Every finding on record at PruittHealth-Trent

Based on record review and resident and staff interviews, the facility failed to provide restorative services as outlined in the plan of care for 1 of 3 residents reviewed for rehabilitation and restorative services (Resident #47).Findings included:Resident #47 was admitted to the facility on [DATE] with active diagnoses that included lumbar spinal stenosis with neurogenic claudication (intermittent leg pain from impingement of the nerves emanating from the spinal cord), hypertension, and diabetes mellitus.Resident #47's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no functional impairment of range of motion to his upper and lower extremities and no contractures.Review of a restorative communication sheet from therapy dated 4/28/26 indicated Resident #47 required Active Range of Motion and Active Assisted Range of Motion to both lower extremities six days per week. The documented goal was to reduce the likelihood of functional loss and prevent skin integrity issues. The interventions instructed staff to place the resident on restorative services for range of motion exercises.Resident #47's care plan dated 5/3/26 indicated Resident #47 required Active Range of Motion and Active Assisted Range of Motion to both lower extremities six days per week. The documented goal was to reduce the likelihood of functional loss and prevent skin integrity issues. The interventions instructed staff to place the resident in the restorative nursing program for range of motion exercises.Resident #47's restorative documentation showed the resident was scheduled to begin restorative programming on 4/29/26 and he received 15 minutes of restorative services on 4/29/26 and another 15 minutes on 5/5/26. No further restorative sessions were documented for Resident #47.During an interview on 5/11/26 at 11:18 AM, Resident #47 stated Restorative Aide #1 currently provided his restorative exercises. He added that he often did not receive restorative care because the aide was assigned to work on the unit and could not come to him. Resident #47 commented that he did not expect to receive restorative care that day because she had another assignment. He reported he did not feel a decline in his range of motion or bed mobility due to the missed sessions.During a follow up interview on 5/12/26 at 3:43 PM, Resident #47 stated he had not received restorative care either that day or the day prior.During an interview on 5/13/26 at 1:50 PM, Restorative Aide #1 stated she was the only restorative aide and was responsible for providing restorative services to Resident #47. Restorative Aide #1 indicated Resident #47 was to get restorative services 6 times a week. She explained she was unable to complete restorative sessions when she was reassigned as a nurse aide, which occurred on 5/11/26 and 5/12/26. She reported she worked on the hall both days and therefore did not conduct restorative programming with Resident #47. She stated the resident began restorative care on 4/29/26 but she could not recall additional dates he may or may not have received services. She added she did not notify anyone when reassigned because management would already know she had been pulled to the floor.During an interview on 5/13/26 at 2:29 PM, the Therapy Director stated therapy added restorative care to Resident #47's care plan requiring services six days per week. She added that a written description of the required restorative activities was provided to the Nurse Navigator, who then distributed the information to the Restorative Aide. She stated it was beneficial for him to receive continued restorative services to maintain his range of motion. During an interview on 5/13/26 at 2:17 PM, the Nurse Navigator stated that when therapy initiated restorative programming, she received written notification from therapy and therapy also updated the care plan. She explained she created a list for the restorative aide outlining each resident's restorative tasks. She stated Resident #47 should have received restorative services six days per week beginning 4/29/26. She confirmed that the resident had received only two restorative sessions since that date and that he was scheduled to receive care on 5/13/26. She concluded the resident should have received significantly more restorative intervention than what was documented.During an interview on 5/13/26 at 2:34 PM, the Administrator stated restorative care must be delivered according to each resident's plan of care. She reported this situation was an unfortunate miss, as alternate staff could have been reassigned to support restorative services when the restorative aide was unavailable. She stated this issue had not been brought to her attention before the survey.

Based on record review, and interviews with staff, Nurse Practitioner, and Physician for Resident # 1, who had a critical blood glucose level the week prior to 1/21/26 without a documented long term plan to address the resident's diabetes after that date, the facility failed to notify the physician regarding all changes in condition observed on 1/21/26 and consult with the physician to determine if an alternate plan of treatment needed to commence to address all the resident's symptoms so that nursing staff would receive physician orders for monitoring the resident's change in condition, monitoring blood glucose, monitoring oxygen saturations, monitoring vital signs and other orders to treat her condition. Interviews with Nurse Practitioner # 2 and Nurse # 2 revealed the provider was notified regarding Resident # 1 having a cough on the morning of 1/21/26, a chest x-ray was requested, and an order was given for the chest x-ray. This was the only communication that day with the medical provider. On 1/21/26 when staff were aware after three consecutive meals the resident had eaten only one bite of food, was not pulling up fluid through a straw when assisted by a Nurse Aide, was observed by multiple staff not responding to staff per her normal baseline, and was observed by a 1/21/26 evening shift Nurse Aide to need total staff assistance to turn in bed which was not her baseline; there was no notification to the physician of the additional symptoms or a consultation with the physician regarding if more diagnostic tests, monitoring, or treatment other than just the x-ray was needed. On 1/22/26 at 5:44 AM Emergency Medical Services (EMS) was dispatched to the resident who was identified by EMS to have a blood sugar reading of high. The resident was transferred to the hospital where she was noted by the Emergency Department (ED) physician to be obtunded (a state of reduced alertness and reduced consciousness), dehydrated, and experiencing agonal breathing (shallow, gasping, irregular breathing pattern which is considered critical). ED labs revealed a blood glucose level result of 882 (life threatening condition that requires immediate medical attention) along with other lab abnormalities. The resident's temperature was 41.7 Celsius (107.06) degrees Fahrenheit). Resident # 1 coded at 6:53 AM on 1/22/26 and expired after unsuccessful attempts were made to resuscitate her. This was for 1 of 3 residents reviewed for notification of physician regarding needed medical care (Resident # 1). Immediate jeopardy began on 1/21/26 when the facility failed to notify the physician that Resident # 1 was not responding to staff per her baseline, eaten one bite in three consecutive meals, a day shift Nurse Aide noted that she could not pull up fluid via way of a straw when she normally ate and drank independently, and an evening shift Nurse Aide observed that she needed total assistance to turn in bed and was no longer talking. Immediate jeopardy was removed on 2/1/26 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place.The findings included:Record review revealed Resident # 1 resided at the facility from 6/19/20 until 1/22/26. Resident # 1 had diagnoses which included diabetes, epilepsy, schizophrenia, schizoaffective disorder, hypertension, muscle weakness, intellectual disability, muscle weakness, a history of metabolic encephalopathy and feeding difficulties in June 2022, hyperlipidemia, vitamin D deficiency, depressive disorder, a history of insomnia, extrapyramidal and movement disorder, kidney disease, and a history of dysphagia.Orders, which originated on 6/19/20 and were in effect until Resident # 1's discharge date , were for Resident # 1 to be a full code.On 1/14/26 at 6:10 PM Nurse # 1 documented the following information in a progress note. She had received a critical blood sugar level of 466 (For adults with diabetes, normal blood sugar targets range from 80 to 130). The nurse rechecked the blood sugar and found it to be currently 496. The resident's vital signs were stable and registered 143/85 blood pressure, 93 heart rate, 16 respirations, and 98.1 temperature. The resident reported she felt sleepy all day. The providers' triage line was consulted and orders received for 10 units of Novolog insulin times one dose and then to recheck the blood sugar in one hour. Review of transcribed communication between Nurse # 1 and the provider via way of their electronic triage communication application revealed the following documentation was sent to the on-call provider on 1/14/26 at 5:54 PM regarding Resident # 1. Received a critical lab of a 466 blood sugar level. I rechecked it and it now shows a reading of 496. Resident just eating dinner that has a hefty amount of carbs (carbohydrates) and sugars. Vitals signs remain stable 143/85 (blood pressure) 93 HR (heart rate) 16 RR (respirations) 98.1 T (temperature). Patient reports feeling sleepy all day. May I have insulin orders? According to the transcribed communication, the rendering provider signed on 1/14/26 at 7:51 PM that the following orders were communicated back. Order Novolog 10 Units SQ (Subcutaneous) X 1 dose now. Recheck glucose in 1 hour. Notify if greater than 450. Place in acute book for PCP FU (primary care provider follow upOn 1/14/26 at 8:06 PM, Nurse # 1 documented a recheck of the resident's blood sugar had been done and the reading was 386. The resident would be monitored for changes.Review of Resident # 1's record revealed no further documented blood sugar checks after the date of 1/14/26 through the resident's discharge and there were no further orders which addressed the resident's blood sugars or other abnormal labs after the orders on 1/14/26.According to staffing sheets, Nurse # 5 had cared for Resident # 1 from 7:00 AM to 11:00 PM on 1/19/26 (Monday) and again on 1/20/26 (Tuesday) from 7:00 AM to 5:00 PM. Nurse # 5 was interviewed on 1/28/26 at 3:00 PM and reported the following information. She routinely cared for Resident # 1 and the resident was normally alert, verbal, and had minimal confusion. Resident # 1 particularly liked a certain type of soft drink and when she (Nurse # 5) entered the room, Resident # 1 would speak up and ask her if she had that particular type of drink for her. The resident had been at her baseline on both days on 1/19/26 and 1/20/26 while she (Nurse # 5) took care of her.According to staffing records, Nurse Aide (NA # 3) had cared for Resident # 1 on the 7:00 AM to 7:00 PM shift on 1/19/26 (Monday) and on the 7:00 AM to 3:00 PM shift on 1/20/26 (Tuesday). NA # 3 was interviewed on 1/29/26 at 11:33 AM and reported the following information. Resident # 1 was usually upbeat, happy, and talkative. She loved a particular type of soft drink, and she would eat and drink independently without any problems. Resident # 1 knew her (NA # 3) by name when she cared for her. She had been fine without any complaints. According to staffing records, NA # 6 had cared for Resident # 1 on 1/20/26 (Tuesday) from 3:00 PM till 7:00 AM on 1/21/26 (Tuesday). NA # 6 was interviewed on 1/28/26 at 4:35 PM and reported the following information. The resident was able to help roll and turn in bed per her normal activity. She normally would talk and was alert enough to remember things that had been in previous conversations. On the evening of 1/20/26 Resident # 1 talked to her (NA # 6) and reported she thought she was getting a cold. She (NA # 6) noticed Resident # 1's voice was deep as if she was getting a cold. She also appeared dark under her eyes and her eyes looked sunken. The resident did not feel warm to the touch as if she might have a fever. She was sleepy but at times she would be in and out. She would routinely drink independently and did not need help that evening drinking fluids. She was able to drink from a straw that evening. Usually, the resident ate well. She (NA #6) thought she had told a nurse about the resident sounding like she was getting a cold, but she could not recall who she had told.Review of nursing progress notes revealed no nursing progress notes for 1/21/26 noting that the physician was notified of any change in condition.There was one order dated 1/21/26 and this was for a chest x-ray which was ordered by NP # 2, verified by Nurse # 2, and placed in the resident's electronic record on 1/21/26 at 11:23 AM by Nurse # 2.On 1/21/26 at 11:07 AM the facility Social Worker noted Resident # 1 had been seen by the psychiatric Nurse Practitioner that morning for medication management.Review of the Psychiatric Nurse Practitioner's note on 1/21/26 revealed in entirety the following documentation: ASSESSMENT AND PLAN 1. Schizoaffective disorder, bipolar type: Chronic and stable. No associated behavioral or psychotic disturbances.Currently on Ingrezza 40mg (milligrams) qd (every day), Oxcarbazepine 300mg twice a day, and Risperidone 1.5mg twice a day. Plan: Continue current medication regimen. Will follow up and continue to monitor patient for changes in cognitive function. (Ingrezza treats movement disorders. Oxcarbazepine is used for mood disorders, and Risperidone is used to treat psychosis.)2. Extrapyramidal and movement disorder: Chronic and mild. Involuntary movement occasional. Plan: Will continue Ingrezza 40mg qd (every day). Will monitor for any changes in EPS or other side effects. Will follow up to reassess condition and medication efficacy.3. Depression: Chronic and stable. No associated behavioral or psychotic disturbances. This can indicate current medication of Venlafaxine ER 75 mg daily is managing symptoms. Plan: Continue current medication regimen. Will follow up and continue to monitor patient for changes in cognitive function.GENERAL Note Medications were reviewed for possible GDR (Gradual Dose Reduction) of psychotropics. Any reduction in regimen is likely to risk decompensation and is not recommended. At this time benefits outweigh risks and there is no clinical indication for any GDR of psychiatric medications. ORDERS Orders (as written) for this Visit no new orders.The Psychiatric NP was interviewed on 1/30/26 at 12:12 PM and reported she did not recall what time of morning she saw Resident # 1. She saw a lot of people and the resident was receiving patient care when she was there. She did not recall any specifics of a conversation with her. The Psychiatric NP explained she sometimes jotted down things that were different about residents, but she did not see anything in her note that she had jotted down that was not ordinary for Resident # 1.NA # 1 had cared for Resident # 1 from 7:00 AM to 7:00 PM on 1/21/26 (Wednesday). NA # 1 was interviewed on 1/28/26 at 4:05 PM and reported the following information. Prior to 1/21/26, she recalled last caring for Resident # 1 on the previous Friday. There was a significant change in Resident # 1 from the previous Friday to the Wednesday of 1/21/26. All day on 1/21/26 she did not pep up and she was sleepy. It was unusual that she would not pep up during the whole shift. She did not eat breakfast, lunch, or her supper meal. It was not unusual for her to not eat breakfast, but she typically ate other meals, and she routinely would feed herself and drink. Usually, Resident # 1 would talk a lot, but that day she did not converse like she usually did. She seemed out of it. If she asked her a question, the resident would answer with a sentence and then not keep talking. Her color also looked darker. She could not get the resident to pull up fluid with a straw which was unusual for her. During the day, the total she was able to get the resident to drink was about one cup of fluid by giving her sips. She recalled she had told Nurse # 2 that the resident did not eat breakfast or lunch, and Nurse # 2 knew she did not feel well. Nurse # 2 had told her (NA #1) that she was going to get a chest x-ray ordered. Nurse # 5 (who took over care of Resident # 1 at 3:00 PM) also knew that Resident # 1 did not eat her supper.Nurse # 2 cared for Resident # 1 on 1/21/26 from 7:00 AM to 3:00 PM. Nurse # 2 was interviewed on 1/29/26 at 8:52 AM and reported the following information. She did not normally care for Resident #1, and it had been about 2 months since she had been assigned to her. The resident looked a little funny to her and she also had a bad cough. Nurses #2 stated she listened to the resident's lungs, and they were coarse (abnormal breath sounds while listening with a stethoscope which can indicate fluid or mucous). She thought something respiratory was going on with the resident. In the morning when she tried to give her medications she was half asleep and she could not get the resident to take medications. She tried at lunch and she was able to get Resident #1 to take the medications at lunch time. The resident said she did not feel good and Nurse #2 asked her what was wrong and she just said she didn't know. Nurse #2 indicated she was able to get one bite of food in Resident # 1 at lunch, and she drank a little bit. She did not see outward signs of dehydration. Given that she had not cared for the resident recently, she talked to Unit Manager # 1 and Nurse Aides to see what was going on with the resident. She looked at Resident # 1's chart and saw that the resident had a high blood sugar the previous week. She thought to herself that she had not even known the resident was a diabetic and as she recalled she had mentioned to Unit Manager # 1 that the resident's blood sugar was crazy days ago. When she was with the resident, the resident did pull up from the straw and NA # 1 had not reported to her at any part of the day that the resident would not pull up fluid through a straw for her (NA #1). She did send a message to a Nurse Practitioner and thought it was NP # 2 that she texted a message to. She let the NP know the resident had a cough and asked if they could get a chest x-ray. The provider responded yes. Nurse #2 explained the information that the resident had a cough and she was requesting a chest x-ray was the only information provided to the NP. She put the order for the chest x-ray into the computer which would have automatically generated the order going to the mobile x-ray company. She also called to verify that they had received it. The mobile x-ray company did not come on her shift, and she passed along to the next nurse that the resident was due for a chest x-ray. During her shift, she (Nurse # 2) took the resident's temperature and may or may not have written it down but as she recalled it was 98.5. She did not take the rest of the resident's vital signs or check her blood sugar. Nurse #2 stated it had been a crazy day with a lot of things going on and she had been very busy all day long.NP # 2 was interviewed on 1/29/26 at 12:05 PM and reported if a resident did not eat for three consecutive meals and had a change from their baseline responsiveness to staff, this was information that should be communicated to the provider. The only notification she was aware that took place on 1/21/26 was in regard to Resident #1's cough and a request for the x-ray.According to the assignments, Nurse # 5 cared for Resident # 1 during the first part of the 3:00 PM to 11:00 PM shift on 1/21/26. During the interview with Nurse # 5 on 1/28/26 at 3:00 PM Nurse # 5 reported the following information. On 1/21/26 during the change of shift report at 3:00 PM she was told that Resident # 1 was not feeling well and that a chest x-ray was ordered. Nurse #5 could not recall the reason that was told in report for why the chest x-ray was ordered. She knew the resident had recently had her COVID vaccine. When she checked on Resident # 1 she was alert and she could tell the resident did not feel well. Resident # 1 did not carry on a conversation in the way she usually did. She (Nurse # 5) asked Resident # 1 if she would like the soft drink that she usually asked for, and the resident said no. She did not want anything. Resident #1 did not eat her supper meal while she (Nurse # 5) was there, and Nurse # 5 did not know if Resident # 1 ate anything after she left that night. Nurse #5 recalled she took the resident's temperature, and it was okay. She did not take the rest of the resident's vital signs or check her blood sugar. She was aware the resident had been put in the physician's book about blood sugars earlier in the month but there had been no order to check her blood sugars. Nurse #5 indicated she only cared for Resident # 1 for a few hours and left around 6:30 PM. During an interview on 1/29/26 at 1:55 PM with Nurse # 5, Nurse # 5 reported she did not notify or consult with the physician on 1/21/26 regarding Resident #1. According to assignment sheets, NA # 5 had cared for Resident # 1 on 1/21/26 (Wednesday) from 7:00 PM to 11:00 PM. NA # 5 was interviewed on 2/3/26 at 2:15 PM and reported the following information. Normally the resident was confused but would talk and converse when a staff member cared for her. The resident was normally very active and would help turn when care was provided during rounds. That night she (NA # 5) changed the resident one time while caring for her and the resident just laid in bed and did not help turn. Therefore, she had to get assistance from NA # 2. The resident did not talk at all. She briefly opened her eyes partially and then closed them again. She did not recall the resident's skin being warm. She knew the resident had recently had a shot and she thought that was why she was different and therefore she did not report it to anyone.Nurse # 4 cared for Resident # 1 on the second half of the 3:00 to 11:00 PM shift on 1/21/26 (Wednesday). Nurse # 4 was interviewed on 1/29/26 at 8:23 AM and reported the following information. One of the Nurse Aides had reported that Resident # 1 seemed a little off. She thought it was NA # 4 who had told her that. She went to check on the resident who appeared to be sleeping. She asked the resident if she was okay and the resident replied yea and the resident opened her eyes some. She (Nurse # 4) touched Resident # 1, and she opened her eyes more. She (Nurse # 4) asked Resident #1 if she was sleeping good and the resident responded with a murmur which indicated yes. To her, it appeared the resident seemed to be getting an attitude about being bothered and it seemed to her (Nurse # 4) that the resident was just sleeping well. Therefore, she did not bother her further. She did call and talk to the nurse before her (Nurse # 5) and Nurse # 5 said that the resident had had a COVID vaccine, had some chest congestion, and there was an x-ray ordered. Nurse # 5 had told her (Nurse # 4) that if the x-ray company did not come by in the morning, then she (Nurse # 5) would follow up with them in the morning. Nurse # 5 also mentioned the resident was not eating as good. She (Nurse # 4) did not check Resident # 1's vital signs or blood sugar and she did not call an update the resident's physician about the resident.NA # 2 had cared for Resident # 1 on 1/21/26 from 11:00 PM to 7:00 AM on 1/22/26 until the time of her discharge. NA # 2 was interviewed on 1/28/26 at 6:58 PM and reported the following information. Prior to 1/21/26, she had last worked with Resident # 1 on the weekend of 1/17/26 and 1/18/26. When she left work on 1/19/26 (Monday) morning at 7:00 AM, Resident # 1 was okay and was watching television and laughing. She came back to work on 1/21/26 at 7:00 PM and learned that the resident was not doing well. Although she did not have her on her assignment starting at 7:00 PM, she looked in on her and the resident was sleeping and not responding as she usually did. If you called her name, the resident would not say anything. Resident #1 would open her eyes a little and then go back to sleep. NA #2 indicated she was assigned to the resident at 11:00 PM and knew she had just recently been changed so she did not change her at that time. At 2:00 PM rounds, she did not need changing. During the next rounds at around 4:00 to 4:30 AM the resident felt warm to the touch and she got the nurse. She took the resident's vital signs, and the nurse (Nurse # 3) wrote them down. She recalled the resident had a high fever and the nurse called EMS (Emergency Medical Services) right away.Nurse # 3 had cared for Resident # 1 on the shift which began at 11:00 PM on 1/21/26 until the resident's discharge to the hospital. Nurse # 3 was interviewed on 1/28/26 at 8:27 PM and again on 2/4/26 at 4:44 PM and reported the following information. Nurse #3 recalled Nurse # 4 had given her report at change of shift at 11:00 PM and there was nothing critical shared with her about Resident # 1. It was passed along in report that Resident # 1 was not eating, and she was due for a chest x-ray. She went in and looked at the resident at the beginning of her shift, and she appeared to be sleeping and breathing okay. She did not awaken the resident to do vital signs or check her blood sugar. Nurse #3 stated she was not aware that anyone had noticed Resident #1 had a change in responsiveness as this had not been reported to her. Later, as she was passing medications around 5:00 AM the assigned Nurse Aide (NA # 2) came to get her and said something was wrong. She went to check on the resident, and her skin was fire hot. Nurse #3 stated she had never felt someone's skin to have ever been as hot as the resident's skin was that night. Her breathing was labored and slow as if she was about to pass away. She told the Nurse Aide to get the resident's vital signs, and she called EMS right away.On 1/22/26 at 5:53 AM Nurse # 3 documented a focused observation note under assessments in the resident's electronic record. Nurse # 3 documented the resident was observed to have labored breathing with a temperature reading of 104.6. The resident was warm, clammy, flushed, with skin turgor slow to return to normal position. The resident was unable to answer related to any pain she might have.On 1/22/26 at 6:00 AM Nurse # 3 completed a Nursing Home to Hospital transfer form and noted the resident was observed with short, labored, breathing, diaphoretic skin (heavy perspiration) and temperature of 104.6.On 1/23/26 at 10:11 AM Nurse # 3 entered a late entry which noted the following information. CNA (certified nursing assistant) assigned alerted nurse to resident's change in condition. Upon entry into resident's room, writer observed her respiratory status as labored and slow. Writer attempted to assess heart rate, but upon touching resident, she was extremely hot. Writer instructed the CNA to get resident's vitals while she contacted EMS for transport to the ER for evaluation. VS: BP 57/32 (hypotension), P-131 (normal range 60 to 100), R-12, T-104.6, O2 (Oxygen saturation) = 89 RA (room air). (Readings below 90% to 92 % are considered low.) EMS arrived shortly after contact, and resident was transported to the [name of hospital] ER. Nurse # 3 also noted she contacted the resident's Responsible party and the DON.Review of EMS notes revealed they were dispatched on 1/22/26 at 5:44 AM and were on the scene at 5:47 AM. The paramedic noted they arrived to find the resident altered with two staff members at the bedside who were unsure how long the resident had been that way and were not able to provide an accurate last known well time. The paramedic did not note in the narrative note portion of the EMS report a further description of altered. In another portion of the EMS report, the paramedic noted the resident was alert. The paramedic further documented the following information in the narrative. The staff reported the resident had a temperature of 104 prior to calling. EMS noted the resident's blood sugar was taken by them (the EMS crew) and that the reading was H (high). The resident's temperature was 103 axillary. (An axillary temperature is taken in the armpit, and the reading is generally one degree less than an oral temperature reading). The resident's first blood pressure registered 154/98 (hypertension), first pulse 120, first oxygen saturation 89 %, and first respirations 18. Oxygen was started and the resident was transported to the hospital and transferred to hospital care at 6:10 AM.Review of hospital 1/22/26 ED records revealed the following information. The physician noted the resident was obtunded upon exam. Her temperature was 41.7 Celsius and blood pressure was 64/31 with tachycardia. She had agonal respirations and was extremely warm to touch. The staff were unable to perform ultrasound guided peripheral access (a technique used to place an intravenous catheter in an arm) due to the severity of her volume status depletion and a central line (an intravenous catheter inserted in a large vein and which goes near the heart) was placed. Large volumes of fluids were infused. Labs drawn at 6:21 AM revealed a blood glucose level of 882, a BUN of 38 (normal 9-23), a Creatinine of 4.58 (normal .55-1.02), a sodium level of 156 (normal 136-145) along with other abnormal lab values. The resident's white blood count was 4.3 (normal 4.8-10.8). Soon after the central line was placed the physician was notified that the resident was becoming bradycardic (low heart rate) and she went into cardiac arrest. CPR (cardiopulmonary resuscitation) was initiated at 6:53 AM but efforts to resuscitate the resident were unsuccessful, and the resident expired.Review of Resident # 1's death certificate reflected the first cause of death was listed as advanced adult failure to thrive which the resident had for weeks and Type 2 diabetes which the resident had for years.The ED physician was interviewed on 1/28/26 at 5:31 PM and reported the following information. The resident arrested very quickly in the ED, and they did not have much time to render treatment before this occurred. She had been very dehydrated when she arrived. He recognized that blood sugars can rise quickly but felt it had taken a couple of days to become as dehydrated as she was. He reported that she was approximately 6 liters of fluid in deficit. The ED physician also reported he felt the resident would not have expired if she had received medical attention sooner.The Director of Nursing was interviewed on 1/29/26 at 9:35 AM. The DON reported the following information. Nurse # 3 had called her on 1/22/26 when Resident # 1 was sent to the hospital, but she did not recall staff mentioned anything to her that Resident # 1 was experiencing any acute problems on 1/21/26 or about communication to the provider prior to her transfer. The facility Administrator was interviewed on 1/29/26 at 10:30 AM and reported the following information. She usually checked on all her residents often, and the facility staff were very good to check on residents as well. They had been very good about communicating with the previous provider and the new providers that had started in January 2026.Resident # 1's physician, who served as the facility's Medical Director, was interviewed on 1/29/26 at 1:40 PM and again 2/2/26 at 3:25 PM and reported the following information. He had not personally seen Resident # 1 since the new providers had assumed care of the resident in January 2026. When NP # 1 saw Resident # 1 on 1/5/26 as a new provider, she was supposed to do a broad overview and he had not seen the resident. Details from interviews which were relayed to the surveyor from staff who had cared for Resident # 1 on 1/20/26 through her transfer on 1/22/26 were shared with the physician. The physician reported that the staff had notified the provider of the chest congestion. The physician was interviewed regarding the importance of the provider knowing that the resident, excluding one bite, had not eaten three consecutive meals, reportedly was not responding to staff per her baseline, and was not able to suction fluid through a straw when assisted by a Nurse Aide. The physician acknowledged that this would have been good information for the provider to have had. As the resident's physician he had not been made aware of any problems with the resident prior to transfer. The physician further reported the following. A resident's blood sugar can rise even though they are not eating when there is a stress response in their body, and this in turn can also lead to dehydration when the individual goes into a hyperosmolar state. Given that facility staff were reporting that the resident had cold symptoms on 1/20/26 and respiratory symptoms on 1/21/26, it appeared the resident had developed an acute rapid onset of respiratory sepsis syndrome which also resulted in the resident having a hyperosmolar syndrome. Therefore, after hearing and reviewing details on 2/2/26 regarding staff reports of the resident having respiratory symptoms prior to the resident's hospital transfer, her death may have not been avoidable. It appeared she had rapidly declined in a 24-hour period's time. In reviewing the resident's hospital BUN and creatinine level results, her elevated levels may have been because there was an insult to her kidneys from an infection. On 1/29/26 at 5:05 PM the Administrator was informed of Immediate Jeopardy.The Administrator presented the following Immediate Jeopardy Removal Plan:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of noncompliance:Resident #1 was a long-term care resident of the facility who was admitted on [DATE] and discharged on 1/22/2026. She had medical diagnoses to include but not limited to Schizophrenia, Epilepsy, and Type 2 Diabetes. On 1/21/2026 Nurse Aide (NA) #1, per surveyor interview, reported that Resident #1 appeared sleepy, did not respond to conversation per baseline, and did not eat her breakfast, lunch, or dinner. Per Nurse #2's interview on 1/29/2026 by the facility Director of Nursing (DON), NA #1 did not communicate this to her (Nurse #2). NA #1 did not verbalize these concerns to the nurse managers, DON, or Administrator either. The facility became aware of NA #1's statement when the surveyor relayed this information to the facility on 1/28/2026. The facility was unable to validate this information due to NA #1 refusing to discuss her interview with the surveyor with the DON on 1/28/2026. This information was not in Resident #1's medical record. On 1/29/2026 one to one education was given to NA #1 on the importance of communicating change(s) of condition timely to the charge nurse by the DON. On 1/21/2026 at approximately 11:00am Nurse #2 assessed the resident for congestion. Nurse #2 was in the room and asked Resident #1 how she was feeling. Nurse #2 identified the congestion independently. Per interview with Nurse #2 by the DON on 1/29/2026, this assessment revealed a moist non-productive cough with coarse breath sounds. Nurse #2 notified the provider of changes and received an order for a chest x-ray. Nurse #2 did not find any signs and symptoms of any other changes in Resident #1's condition. Surveyor interviewed Nurse #2 and she reported she saw the blood sugar in the chart on 1/21/2026. She also reported the Resident #1 did not take her medication at breakfast, but she did take them at lunch. Per Nurse #2's interview, Resident #1's temperature at the time was 98.5 degrees and no blood glucose level was obtained. The x-ray was scheduled for 1/21/2026; however, it was not completed on this date. The x-ray technician arrived at the facility on 1/22/2026 and Resident #1 had already been discharged to the hospital.On 1/22/2026 at approximately 4:00am, NA #2 alerted Nurse #3 that Resident #1 felt extremely hot. Nurse #3 immediately assessed Resident #1 and observed Resident #1 to be in respiratory distress. Abnormal vital signs were obtained and EMS was called. EMS arrived shortly after calling and transferred Resident #1 to hospital. The facility called the hospital for an update on Resident #1's status and was told Resident #1 had coded and expired.On 1/29/2026 after conversation with the surveyor, the surveyor indicated a breakdown in the nurse to provider notification process related to a resident change in condition. Resident #1 experienced an acute change in condition. Nurse # 2 assessed Resident #1 and communicated her findings to the provider (on 1/21/2026) without knowledge of NA #1's observation of Resident #1. On 1/29/2026 an ad hoc Quality Assurance Performance Improvement meeting to include the Medical Director, Administrator, DON, Social Worker,

Based on record review, and interviews with staff, Nurse Practitioner, Physician, and Consultant Pharmacist, for Resident # 1, the facility failed to 1) ensure comprehensive assessment, monitoring, and treatment of the resident's diabetes and 2) ensure acute monitoring, assessment, and treatment when the resident further developed respiratory symptoms in conjunction with untreated diabetes. On 10/14/25 Resident # 1 had a Hemoglobin A1C collected which showed a result of 8.1 % with a normal range noted on the lab report to be less than or equal to 5.7. (A Hemoglobin A1C measures average blood sugar levels over the past 2-3 months). There was no documented plan to address the resident's elevated Hemoglobin A1C. On 1/14/26 facility staff were made aware of a critically high serum blood glucose level of 466 which had been drawn on 1/13/26. (For adults with diabetes, normal blood sugar targets range from 80 to 130). Upon notification to staff by the lab, a finger stick blood sugar was done on 1/14/26 and revealed a result of 496. Per order, the resident received a one-time order of insulin and one documented repeat finger stick blood sugar check on 1/14/26, which showed a result of 386. Resident # 1 was seen on 1/15/26 by the Nurse Practitioner with no orders or established plan of care for the resident's diabetes initiated. No further blood sugar checks were documented following the result of 386 through the resident's discharge date . On 1/20/26 the resident reported she felt as if she was getting a cold. On 1/21/26 staff reported the following observations and symptoms 1) excluding one bite at lunch, the resident did not eat three consecutive meals 2) the resident appeared sleepy and did not converse and respond to the staff per her baseline 3) she was unable to suction fluid through a straw when a Nurse Aide assisted her although she reportedly normally ate and drank independently 4) she had developed a cough and coarse breath sounds and 5) she did not assist to turn in bed as she usually did during the evening of 1/21/26. Interviews with four nurses who had cared for Resident # 1 beginning at 7:00 AM on 1/21/26 revealed no complete sets of vital signs or blood sugar levels were obtained. On 1/22/26 at 5:44 AM EMS (Emergency Medical Services) was dispatched to the resident who was identified to have a blood sugar reading by paramedics of high. The resident was transferred to the hospital where she was noted by the ED (Emergency Department) physician to be obtunded (a state of reduced alertness and reduced consciousness) and dehydrated. ED labs revealed a glucose result of 882 (life threatening condition that requires immediate medical attention) along with other lab abnormalities. The resident's temperature was 41.7 Celsius (107.06 degrees Fahrenheit). Resident # 1 coded (a medical emergency which is typically a cardiopulmonary arrest) at 6:53 AM and expired after unsuccessful attempts were made to resuscitate her. This was for 1 of 3 residents reviewed for professional standards of practice to address medical conditions (Resident #1).Immediate jeopardy began on 1/15/26 when the facility failed to ensure monitoring and a treatment plan was initiated for Resident # 1, who had a critically high elevated blood glucose level on 1/14/26 after already having an elevated HgBA1C in October 2025. Immediate jeopardy was removed on 2/1/26 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place.Findings included: Record review revealed Resident # 1 resided at the facility from 6/19/20 until 1/22/26. At time of discharge Resident # 1 was [AGE] years of age. Resident # 1 had diagnoses which included diabetes, epilepsy, schizophrenia, schizoaffective disorder, hypertension, muscle weakness, intellectual disability, muscle weakness, a history of metabolic encephalopathy (a disturbance of the brain's functioning from disease) and feeding difficulties in June 2022, hyperlipidemia, vitamin D deficiency, depressive disorder, a history of insomnia, extrapyramidal (problems with muscle tone and muscle movements often caused by antipsychotic medications) and movement disorder, kidney disease, and a history of dysphagia. Orders, which originated on 6/19/20 and were in effect until Resident # 1's discharge date , were for Resident # 1 to be a full code. Orders, which originated on 10/4/22 and were in effect through the resident's discharge date , included that Resident # 1 was to be on a CCHO (Consistent Carbohydrate) /Liberalized diabetic diet. Review of labs revealed Resident # 1 had a HgbA1C (Hemoglobin A1C), which was ordered on 10/14/25, by Nurse Practitioner # 1. The lab report included that the lab was drawn on 10/14/25 at 7:18 AM and the results on 10/15/25 showed a result of 8.1 % with a normal range noted on the lab report to be less than or equal to 5.7. The electronic copy of the lab showed the results were signed by Nurse Practitioner # 1 on 11/5/25. During a 1/29/26 1:40 PM interview with the facility's current Medical Director, who began in his position in January 2026, the Medical Director reported that a goal for diabetic residents was to have a HgbA1C of less than 7.0.On 11/5/25 the Facility's Consultant Pharmacist created a communication sheet to the physician regarding the elevated HgBA1C level and noted the following information and question to the physician in the communication sheet. Resident # 1's Hgb1AC had been elevated in October, and the resident was not receiving any treatment. The pharmacist questioned the provider whether the resident would benefit from either Metformin 500 mg (milligrams) twice per day or Jardiance 10 mg every day. The communication sheet was written by the pharmacist in a way that the provider could check to begin either the Metformin or the Jardiance and sign she agreed and that the order could be written. The provider could also check an alternative response on the form indicating not to start the resident on medication by checking a box titled other and noting a rationale on the form about the provider's response not to start treatment. NP # 1's initials appeared on the form on 11/20/25 with a notation of no change. There was no further documentation by NP # 1 on the form and there was no corresponding progress note on that date. A review of the record revealed no orders for diabetic medication were initiated following 11/5/25 through the resident's discharge date . On 12/15/25 Resident # 1's care plan was reviewed and revised. The care plan included that the resident had suspected intellectual disability. A problem, which originated on 6/19/20 and which noted that Resident # 1 felt tired and had little energy related to her diabetes, remained as an active problem as of the review date of 12/15/25. One of the interventions was to encourage the resident to avoid daytime napping. There were no directions about blood sugar monitoring or a plan for the resident's diabetes. A problem, which originated on 1/29/22 and remained active on 12/15/25, noted Resident # 1 had experienced weight loss/gain secondary to diuretic usage and fluctuating appetite. Directions on the care plan included to provide set up assistance for the resident's meals and assist if needed. Staff were to encourage oral intake of food and fluids and monitor and record the resident's intake of food. On 12/18/25 NP # 1 noted she was seeing Resident # 1 for a regulatory visit and follow-up to chronic medical conditions. NP # 1 documented Resident # 1 reported she felt okay and did not offer any complaints. Under plan for Type 2 Diabetes Mellitus with diabetic chronic kidney disease, NP # 1 did not reference and address the 10/14/25 elevated HgbA1C of 8.1. Instead, NP # 1 documented that the resident's HgbA1C was 6.5 on 9/1/24 and was diet controlled. The plan was to continue a healthy diet. The resident's chronic kidney disease was documented to be mild and as Stage 2 with a glomerular filtration rate of 64 on 7/6/25. (Glomerular filtration rate is a measure of kidney function, which measures how many milliliters of blood the kidneys filter per minute with a normal rate equal to or greater than 90 ml (milliliters per minute). NP # 1 also included within her progress note labs from 7/10/25 which noted that the resident's BUN (Blood Urea Nitrogen) and Creatinine were normal. The resident's BUN was 10 (normal 9-23) and the resident's creatinine was .94 (normal .55-1.02). (Elevated BUN and Creatinine levels can at times signify kidney problems or dehydration.)NP # 1 was interviewed on 1/30/26 at 11:46 AM and reported the following information. She had spoken to Resident # 1 about doing checks of her blood sugar more often and treating her diabetes after the result of the HgBA1C was returned. NP #1 explained the result of 8.1 would have correlated to a daily blood sugar of around 200. NP # 1 indicated the resident was not interested in doing that and wanted to control her blood sugar with diet only. Given the result, she thought that it would be reasonable and then have another evaluation after three months. NP #1 indicated she should have placed the information in her December note that she had talked to the resident but had not done so. The interview further revealed after December NP # 1 did not see Resident # 1 again.On 1/5/26 NP # 2 saw Resident # 1. NP # 2 noted Resident # 1 was being seen for a routine evaluation and management visit of chronic health issues such as hyperlipidemia, hypertension, and vitamin D deficiency. NP # 2 noted the following information. The resident was alert, awake, and cooperative and oriented times three (indicating the resident was oriented to person, place, and time). Within the progress note, NP # 2 included lab values from July 2025. She did not reference the elevated HGBA1C, which had been drawn on 10/14/25. At the bottom of her progress note she addressed three diagnoses with a plan. The three diagnoses were hyperlipidemia, hypertension, and vitamin D deficiency. The progress note did not address a plan of care for the resident's diabetes. NP # 2 noted there was one order for the visit which was for a Vitamin D level.NP # 2 was interviewed on 1/29/26 at 12:05 PM and reported the following information. The date of 1/5/26 was her first visit with Resident # 1 as a provider in a new group of providers that had assumed care at the first of January 2026 for the facility's residents. On 1/5/26 she saw Resident # 1 for chronic problems and to establish the resident with their group. She had picked three diagnoses to concentrate on, and her plan was to pick three more the next month. NP # 2 was interviewed regarding why she picked only three and had not reviewed all of the resident's diagnoses and responded that if she had reviewed all of the diagnoses then it would take forever. She also said that her future plan was to see residents' monthly, which was more often than regulatory and hopefully would provide better resident care since more frequent routine visits would be conducted. NP #2 stated she had not addressed the resident's diabetes on 1/5/26 but planned to do so during a future visit.On 1/9/26 Resident # 1 had a quarterly MDS assessment completed which showed the resident had a Brief Interview for Mental Status Score of 7. (A score of 0 to 7 indicates severe cognitive impairment and a score of 8 to 12 indicates moderate cognitive impairment). She required set-up assistance for eating. Review of orders revealed an order, which originated on 7/9/24, for a CMP (Comprehensive Metabolic Panel) to be done every twelve months.Review of a CMP dated as collected on 1/13/26 at 2:00 AM revealed that the result was reported on 1/14/26 at 5:31 PM. The results showed the following:Glucose 466; noted to be critically high; (normal 74-106)Creatinine 1.15; noted to be high; (normal .55-1.02)Potassium 3.2; noted to be low; (normal 3.5-5.1)Chloride 89; noted to be low; (normal 98-107)Carbon dioxide 31; noted to be high; (normal 20-30)Estimated Glomerular filtration rate 50 noted to be low (normal equal to or greater to 90)Review of transcribed communication between Nurse # 1 and the provider via the facility's electronic triage communication application revealed the following documentation was sent to the on-call provider on 1/14/26 at 5:54 PM regarding Resident # 1. Received a critical lab of a 466 blood sugar level. I rechecked it and it now shows a reading of 496. Resident just eating dinner that has a hefty amount of carbs (carbohydrates) and sugars. Vitals signs remain stable 143/85 (blood pressure) 93 HR (heart rate) 16 RR (respirations) 98.1 T (temperature). Patient reports feeling sleepy all day. May I have insulin orders? According to the transcribed communication, the rendering provider signed on 1/14/26 at 7:51 PM that the following orders were communicated back. Order Novolog 10 Units SQ (Subcutaneous) X 1 dose now. Recheck glucose in 1 hour. Notify if greater than 450. Place in acute book for PCP FU (primary care provider follow up). On 1/14/26 at 6:10 PM Nurse # 1 documented the following information in a nursing progress note. She had received a critical blood sugar level of 466. The nurse rechecked the blood sugar and found it to be currently 496. The resident's vital signs were stable and registered 143/85 blood pressure, 93 heart rate, 16 respirations, and 98.1 temperature. The resident reported she felt sleepy all day. The providers' triage line was consulted and orders received for 10 units of Novolog insulin times one dose and then to recheck the blood sugar in on hour. On 1/14/26 on the 3:00PM to 11:00 PM shift, Resident # 1's Medication Administration Record reflected that Nurse # 4 administered the 10 Units of Novolog Insulin. The MAR reflected the Novolog insulin was administered on the 3:00 to 11:00 PM shift and did not note a specific time of administration. On 1/14/26 at 8:06 PM, Nurse # 1 documented a recheck of the resident's blood sugar had been done and the reading was 386 and that the resident would be monitored for changes.Nurse # 1 was interviewed on 1/28/26 at 4:02 PM and reported the following information. She had not been assigned to the resident that day but was working on the floor and received the call from the lab noting that the resident's blood glucose was high. She went to check the resident who was alert and eating. She reported she had been sleepy that day. She (Nurse # 1) notified the provider. The resident received a dose of insulin, and her blood glucose came down below the parameter set by the provider. The information was placed in the communication book for the provider to review in the morning. On 2/4/26 at 4:44 PM Nurse # 3, who had cared for Resident # 1 beginning at 11:00 PM on 1/14/26, was interviewed. Nurse # 3 could not recall if it was told to her that Resident # 1's blood sugar was high or if she had seen the elevated blood sugar on a written report.Review of Resident # 1's record revealed no further documented blood sugar checks after the date of 1/14/26 through the resident's discharge and there were no further orders which addressed the resident's blood sugars or other abnormal labs after the orders on 1/14/26.On 1/29/26 at 12:40 PM the DON (Director of Nursing) provided a progress note from NP # 2 for a service date of 1/15/26. The DON reported they had not received the progress note when the service visit was completed. It had been received by them that day (1/29/26). Review of the progress note revealed on 1/28/26 NP # 2 signed a progress note which was dated for a service date of 1/15/26. NP # 2 documented the following information in the note. She was seeing Resident # 1 for an acute visit for elevated blood glucose on her labs. Within the note, NP # 2 noted that all the resident's lab work had shown that her labs were at the resident's baseline with the exception of her glucose. NP # 2 did not address the low chloride, potassium, or decreased glomerular filtration rate within her progress note. NP # 2 wrote, Patient seen today on assessment resting in bed, appearing comfortable with NAD (no apparent distress) noted. Patient recently had lab work done where all was at patient's baseline with the exception of her glucose. No leukocytosis noted on CBC (complete blood count) nor S/SX (signs and symptoms) of infection present on exam. Patient is on several antipsychotics which may be contributory due to potential metabolic syndrome with hyperglycemia. Patient also noted to be eating at the time of lab draw as well, which can cause false high readings even in nondiabetic residents. Spoke with upstairs and downstairs unit managers who stated that staff notified triage of the abnormal lab and received an order for 10 U of short acting insulin, that she responded favorably and became euglycemic (normal blood sugars) with her trends. Patient is completely asymptomatic at this time and shows no s/s of infection nor hyperglycemia during assessment. Encouraged staff to monitor for S/S of hyperglycemia and infection, and to take FSBS (Finger Stick Blood Sugar) as well as notify PCP if patient had any status changes. Patient has no other symptoms of hyperglycemia at this time. Additional acute and chronic issues addressed below. MAR (Medication Administration Record), VS (Vital Signs), lab, and full history review performed today. Patient is seen on exam doing well with no acute issues or needs per staff at this time. Will continue to monitor. Within the progress note, NP # 2 listed Resident # 1's past medical history diagnoses and she also included labs from 7/10/25 as part of data within the progress note. There was no mention of the 10/14/25 elevated HgBA1c level of 8.1 within the progress note. Within the 1/15/26 progress note, NP # 2 referenced vital signs from 1/16/26 at 4:17 PM. Under the assessment and plan for diabetes, NP # 2 noted in part that staff were encouraged to take the resident's FSBS, notify the provider if the resident's status changed, and that her HgBA1C would be monitored every 12 months. NP # 2 noted the HgBA1C was ordered for the next lab day. The resident's diabetes was currently diet controlled and she would be monitored for hyperglycemia and signs and symptoms of infection. The goal for the HgBA1C was noted to be less than 6.5. At the end of the diabetes assessment and plan portion of the progress noted, NP # 2 noted risks for Resident # 1 included but were not limited to diabetic ketoacidosis with coma, hyperosmolar hyperglycemic state, blindness, kidney disease, heart attack as well as further decline and rehospitalization if left untreated and unmonitored. (Hyperosmolar Hyperglycemic State is a critical complication of type 2 diabetes marked by extreme blood sugar, severe dehydration, and high blood viscosity which can cause lethargy and confusion.) Review of the record revealed no orders were written for the HgbA1C or Finger Stick Blood Sugars which were mentioned in NP # 2's 1/15/26 progress note.NP # 2 was interviewed in conjunction with the DON being present on 1/29/26 at 12:05 PM. NP # 2 reported the following information. She saw Resident 1 on 1/15/26 and reviewed the lab report from 1/14/26. She had been told that the resident was eating when the lab was drawn and that the FSBS was done. She had talked to the Unit Manager who reported they had rechecked a FSBS and it had come down in the 80s that day. She did not know that there was no order to check FSBSs and thought that the nurses were doing FSBS checks. She had asked if the staff wanted a sliding scale insulin coverage order and was told this might be overkill and the nurses would just watch her.Unit Manager # 1 was interviewed on 1/29/26 at 11:02 AM and reported the following information. Resident # 1's baseline was that she was alert, fed herself and would converse. She knew that Resident # 1 had been placed in the physician's communication book to be seen on 1/15/26 related to an elevated glucose level. That day NP # 2 talked to her about the residents she had seen that day and did not mention anything about Resident # 1. Therefore, she asked NP # 2 if she had seen Resident # 1 since she was on the list to be seen and NP # 2 responded that she had seen the resident and she had it (indicating that she was aware of the resident being on the list and addressing it). After that NP # 2 left the facility. The Unit Manager was interviewed regarding NP # 2 leaving the facility without orders for the resident's blood sugars. Unit Manager # 1 further reported the following information. At times she (the Unit Manager) thought that the NPs, who were part of a new group of providers to the facility, would leave and review records remotely. They also then put in their own orders. At the end of the day, the NP would then send a list of residents she had seen on that day, and the list would include orders that had been given. Resident # 1 was not on the list of residents as being seen by NP # 2 on 1/15/26. Unit Manager # 1 was interviewed why there was no follow up by the facility staff to NP # 2 when they saw that there were no orders about a plan to deal with the resident's diabetes and blood sugars and Unit Manager # 1 reported that it never came back up again.Unit Manager # 2 was interviewed on 1/29/26 at 12:50 PM and reported the following information. No one had ever talked to her on 1/15/26 about a resident on another unit having a high blood sugar. She did not oversee Resident # 1's unit and therefore health issues would not have been addressed with her. On 1/16/26 Nurse # 3 documented a focused observation assessment note in Resident # 1's electronic record, noting that Resident # 1 was alert, responsive, had regular respirations, clear speech, and no cough.On 1/19/26, Resident # 1's Medication Administration Record, reflected that the resident received a Minexpike 2025-2026 (COVID vaccine) on the 7:00 AM to 7:00 PM shift by Nurse # 5. On that date (1/19/26) the resident's temperature registered 97.6 as documented under the vital sign portion of the resident's electronic record. This was the last vital sign under the vital sign portion of the record.The facility's consultant pharmacist was interviewed on 1/29/26 at 11:52 AM regarding any information that accompanied the current COVID vaccines for which staff were to monitor residents. The consultant pharmacist reported the following information. Information from the National Institute of Health and other medical literature journals showed in rare instances there could be severe illness or adverse reactions. In rare cases, it could also cause transient hyperglycemia which tended to resolve in a few days or weeks following vaccination.According to staffing sheets, Nurse # 5 had cared for Resident # 1 from 7:00 AM to 11:00 PM on 1/19/26 (Monday) and again on 1/20/26 (Tuesday) from 7:00 AM to 5:00 PM. Nurse # 5 was interviewed on 1/28/26 at 3:00 PM and reported the following information. She routinely cared for Resident # 1 and the resident was normally alert, verbal, and had minimal confusion. Resident # 1 particularly liked a certain type of soft drink and when she (Nurse # 5) entered the room, Resident # 1 would speak up and ask her if she had that particular type of drink for her. Nurse #5 indicated the resident had received the COVID vaccine and appeared to be at her baseline both days on 1/19/26 and 1/20/26 while she (Nurse # 5) took care of her. According to staffing records, Nurse Aide (NA # 3) had cared for Resident # 1 on the 7:00 AM to 7:00 PM shift on 1/19/26 (Monday) and on the 7:00 AM to 3:00 PM shift on 1/20/26 (Tuesday). NA # 3 was interviewed on 1/29/26 at 11:33 AM and reported the following information. Resident # 1 was usually upbeat, happy, and talkative. She loved a particular type of soft drink, and she would eat and drink independently without any problems. Resident # 1 knew her (NA # 3) by name when she cared for her and she had been fine without any complaints. According to staffing records, NA # 6 had cared for Resident # 1 on 1/20/26 (Tuesday) from 3:00 PM till 7:00 AM on 1/21/26 (Tuesday). NA # 6 was interviewed on 1/28/26 at 4:35 PM and reported the following information. The resident was able to help roll and turn in bed per her normal activity. She normally would talk and was alert enough to remember things that had been in previous conversations. On the evening of 1/20/26 Resident # 1 talked to her (NA # 6) and reported she thought she was getting a cold. She (NA # 6) noticed Resident # 1's voice was deep as if she was getting a cold. She also appeared dark under her eyes and her eyes looked sunken. The resident did not feel warm to the touch as if she might have a fever. She was sleepy but at times she would be in and out. She would routinely drink independently and did not need help that evening drinking fluids. She was able to drink from a straw that evening. Usually, the resident ate well. She (NA #6) thought she had told a nurse about the resident sounding like she was getting a cold, but she could not recall who she had told.There were no nursing progress notes from facility nurses for the date of 1/21/26.On 1/21/26 at 11:07 AM the facility Social Worker noted Resident # 1 had been seen by the psychiatric Nurse Practitioner that morning for medication management.Review of the Psychiatric Nurse Practitioner's note on 1/21/26 revealed in entirety the following documentation: ASSESSMENT AND PLAN 1. Schizoaffective disorder, bipolar type: Chronic and stable. No associated behavioral or psychotic disturbances.Currently on Ingrezza 40mg (milligrams) qd (every day), Oxcarbazepine 300 mg twice a day, and Risperidone 1.5mg twice a day. Plan: Continue current medication regimen. Will follow up and continue to monitor patient for changes in cognitive function. (Ingrezza treats movement disorders. Oxcarbazepine is used for mood disorders, and Risperidone is used to treat psychosis.)2. Extrapyramidal and movement disorder: Chronic and mild. Involuntary movement occasional. Plan: Will continue Ingrezza 40mg qd (every day). Will monitor for any changes in EPS or other side effects. Will follow up to reassess condition and medication efficacy.3. Depression: Chronic and stable. No associated behavioral or psychotic disturbances. This can indicate current medication of Venlafaxine ER 75 mg daily is managing symptoms. Plan: Continue current medication regimen. Will follow up and continue to monitor patient for changes in cognitive function.GENERAL Note Medications were reviewed for possible GDR (Gradual Dose Reduction) of psychotropics. Any reduction in regimen is likely to risk decompensation and is not recommended. At this time benefits outweigh risks and there is no clinical indication for any GDR of psychiatric medications. ORDERS Orders (as written) for this Visit no new orders.The Psychiatric NP was interviewed on 1/30/26 at 12:12 PM and reported she did not recall what time of morning she saw Resident # 1. She saw a lot of people and the resident was receiving patient care when she was there. She did not recall any specifics of a conversation with her. The Psychiatric NP explained she sometimes jotted down things that were different about residents but she did not see anything in her note that she had jotted down that was not ordinary for Resident # 1.NA # 1 had cared for Resident # 1 from 7:00 AM to 7:00 PM on 1/21/26 (Wednesday). NA # 1 was interviewed on 1/28/26 at 4:05 PM and reported the following information. Prior to 1/21/26, she recalled last caring for Resident # 1 on the previous Friday. There was a significant change in Resident # 1 from the previous Friday to Wednesday on 1/21/26. All day on 1/21/26 she did not pep up and she was sleepy. It was unusual that she would not pep up during the whole shift. She did not eat breakfast, lunch, or her supper meal. It was not unusual for her to not eat breakfast, but she typically ate other meals, and she routinely would feed herself and drink. Usually, Resident # 1 would talk a lot, but that day she did not converse like she usually did. She seemed out of it. If she asked her a question, the resident would answer with a sentence and then not keep talking. Her color also looked darker. She could not get the resident to pull up fluid with a straw which was unusual for her. During the day, the total she was able to get the resident to drink was about one cup of fluid by giving her sips. She recalled she had told Nurse # 2 that the resident did not eat breakfast or lunch, and Nurse # 2 knew Resident #1did not feel well. Nurse # 2 had told her (NA #1) that she was going to get a chest x-ray ordered. Nurse # 5 (who took over care of Resident # 1 at 3:00 PM) also knew that Resident # 1 did not eat her supper. The resident's urination appeared to be the same, and her mouth did not look dry. During last rounds before she (NA # 1) left at 7:00 PM, the resident's skin did not feel warm to her.Nurse # 2 cared for Resident # 1 on 1/21/26 from 7:00 AM to 3:00 PM. Nurse # 2 was interviewed on 1/29/26 at 8:52 AM and reported the following information. She did not normally care for Resident #1, and it had been about 2 months since she had been assigned to her. The resident looked a little funny to her and she also had a bad cough. Nurses #2 stated she listened to the resident's lungs, and they were coarse (abnormal breath sounds while listening with a stethoscope which can indicate fluid or mucous). She thought something respiratory was going on with the resident. In the morning when she tried to give her medications she was half asleep and she could not get the resident to take medications. She tried at lunch and she was able to get Resident #1 to take the medications at lunch time. The resident said she did not feel good and Nurse #2 asked her what was wrong and she just said she didn't know. Nurse #2 indicated she was able to get one bite of food in Resident # 1 at lunch, and she drank a little bit. She did not see outward signs of dehydration. Given that she had not cared for the resident recently, she talked to Unit Manager # 1 and Nurse Aides to see what was going on with the resident. She looked at Resident # 1's chart and saw that the resident had a high blood sugar the previous week. She thought to herself that she had not even known the resident was a diabetic and as she recalled she had mentioned to Unit Manager # 1 that the resident's blood sugar was crazy days ago. When she was with the resident, the resident did pull up from the straw and NA # 1 had not reported to her at any part of the day that the resident would not pull up fluid through a straw for her (NA #1). She did send a message to a Nurse Practitioner and thought it was NP # 2 that she texted a message to. She let the NP know the resident had a cough and asked if they could get a chest x-ray. The provider responded yes. Nurse #2 explained the information that the resident had a cough and she was requesting a chest x-ray was the only information provided to the NP. She put the order for the chest x-ray into the computer which would have automatically generated the order going to the mobile x-ray company. She also called to verify that they had received it. The mobile x-ray company did not come on her shift, and she passed along to the next nurse that the resident was due for a chest x-ray. During her shift, she (Nurse # 2) took the resident's temperature and may or may not have written it down but as she recalled it was 98.5. She did not take the rest of the resident's vital signs or check her blood sugar. Nurse #2 stated it had been a crazy day with a lot of things going on and she had been very busy all day long.During the interview with Unit Manager # 1 on 1/29/26 at 11:02 AM, Unit Manager # 1 reported the following. She recalled Nurse # 2 telling her that the resident did not seem herself. She knew that the resident was going to have a chest x-ray. She did not recall Nurse # 2 mentioning to her about the resident having a high blood sugar the previous week. She recalled seeing the resident one time that day when she went into the room to do something for the other resident in the room and the resident looked at her. She (the Unit Manager) did not do an assessment and nothing jumped out to her as being not normal.According to the assignments, Nurse # 5 cared for Resident # 1 duri[TRUNCATED]

Based on record review and interview with staff and Nurse Practitioner, the facility failed to ensure that the medical provider documented a plan to address Resident # 1's diabetes during a required regulatory visit. This was for 1 of 3 residents whose medical records were reviewed related to medical needs (Resident #1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE] with a diagnosis of diabetes.Record review revealed Nurse Practitioner (NP) # 1 documented she was seeing the resident for a regulatory visit on 9/26/25, and Resident # 1's diabetes was diet controlled.Review of labs revealed Resident # 1 had a HgbA1C (Hemoglobin A1C), which was ordered on 10/14/25, by Nurse Practitioner # 1. The lab report included that the lab was drawn on 10/14/25 at 7:18 AM and the results on 10/15/25 showed a result of 8.1 % with a normal range noted on the lab report to be less than or equal to 5.7. (A Hemoglobin A1C measures average blood sugar levels over the past 2-3 months by checking the percentage of hemoglobin coated with sugar and does not require an individual to be fasting when drawn.) The electronic copy of the lab showed the results were signed by Nurse Practitioner # 1 on 11/5/25. Review of the medical record revealed there was no corresponding provider progress note dated 11/5/25.Following 9/26/25, the next documented regulatory visit by a provider was on 12/18/25. On 12/18/25, NP # 1 noted she was seeing Resident # 1 for a regulatory visit and follow-up to chronic medical conditions. NP # 1 documented Resident # 1 reported she felt okay and did not offer any complaints. Under plan for Type 2 Diabetes Mellitus with diabetic chronic kidney disease, NP # 1 did not reference and address the 10/14/25 elevated HgbA1C of 8.1. Instead, NP # 1 documented that the resident's HgbA1C was 6.5 on 9/1/24 and was diet controlled. The plan was to continue a healthy diet. The resident's chronic kidney disease was documented to be mild and as Stage 2 with a glomerular filtration rate of 64 on 7/6/25. (Glomerular filtration rate is a measure of kidney function, which measures how many milliliters of blood the kidneys filter per minute with a normal rate equal to or greater than 90 ml (milliliters per minute). NP # 1 also included within her progress note labs from 7/10/25 which noted that the resident's BUN (Blood Urea Nitrogen) and Creatinine were normal. The resident's BUN was 10 (normal 9-23) and the resident's creatinine was .94 (normal .55-1.02). (Elevated BUN and Creatinine levels can at times signify kidney problems or dehydration.)NP # 1 was interviewed on 1/30/26 at 11:46 AM and reported the following information. She spoke to Resident # 1 about doing checks of her blood sugar more often and treating her diabetes after the result of the 8.1% HgBA1C returned. The result of 8.1 would have correlated to a daily blood sugar of around 200. The resident was not interested in doing that and wanted only to control it with diet. Given the result of 8.1, she thought attempts to control Resident # 1's diabetes with diet would be reasonable and then have another evaluation after three months. NP #1 indicated she should have documented in her December 2025 regulatory visit note that she had talked to the resident about possibly starting treatment for the elevated HGBA1C by doing blood sugar checks and treating any elevated blood sugar results when the checks were done. NP # 1 also indicated within the December 2025 regulatory progress note, she should have documented the resident wanted to try to control her diabetes with diet and that the plan would be evaluated again in three months. After December 2025 she did not see the resident again. NP # 1 confirmed she had not documented the discussion with Resident # 1 and the diabetic plan in her regulatory note and should have done so.Interview with the Administrator on 1/28/26 at 3:35 PM revealed NP # 1 was part of a provider group who had seen residents at the facility through the end of December 2025, and NP # 1 was very good to address problems that the residents might have.

Based on observations and staff interviews, the facility failed to ensure food was sealed when stored, the floor was clean, and food storage shelves were free of grainy food particles for 1 of 1 main facility kitchen. The findings included:During kitchen observations made on 1/30/26 beginning at 7:50 AM the following were observed. In the dry storage room there was a container of multiple large bags of cereal. The top bag was open. The lid to the container was found on the floor underneath another shelving unit in the dry storage room. Grits were on a shelf and not sealed up and closed, rather the top of the grits bag was rolled up. The metal shelf, where the grits were located, had a liner. The liner on this shelf and another kitchen shelf in the dry storage room had very fine grainy particles visible on the liner. Underneath the shelving units in the dry storage room were multiple items and food crumbs which included but were not limited to loose, dry cereal, a dried up orange peeling, two closed packets of cookies, two water bottles, two condiment packets, a carbonated drink, a closed bag of Cheetos, a closed pudding cup, a loose cigarette, and a pair of shoes (sandal slides). Underneath the kitchen oven there was a span of about 12 inches of black, dried-up grease. Dietary Aide # 1 was interviewed at the time of the observation and reported they had to be careful when they cleaned under the oven because part of the bottom of the oven would come off.During the kitchen observations on 1/30/26, which began at 7:50 AM, the Administrator also viewed the dry storage floor and the food items that were not in a sealed bag or container. At 8:50 AM on 1/30/26, the Administrator reported that the former Dietary Manager had walked out in October 2025 without a notice and that the current Dietary Manager worked one to two days per week until a full time Dietary Manager could be hired.The Dietary Supervisor was interviewed on 1/30/26 at 10:40 AM and reported the following information. She would normally seal any opened food items if the kitchen staff forgot and did not seal the food items up. The staff were supposed to sweep and clean nightly before leaving and given the amount of items found on the floor in dry storage during kitchen observations which began on 1/30/26 at 7:50 AM by the surveyor, it would not appear they had not done so. The Dietary Supervisor also reported that there was a cleaning schedule that the kitchen utilized and provided a copy of the cleaning schedule to the surveyor. Review of the cleaning schedule revealed it did not mention the dry storage cleaning.The Dietary Manager was interviewed on 2/2/26 at 2:40 PM and reported the following information. She worked part time at the facility and was usually there one day per week. She tried to be there on weekends and afternoons. The Dietary Manager stated the staff should be cleaning and mopping every night before they leave and instructions had been given to them to do this. All food should be sealed, covered, and dated. The Dietary Manager indicated she had made a new cleaning schedule when she started to work, and it did incorporate the dry storage area, but she had been told that the facility needed to use a corporate cleaning schedule which was not the same as hers and did not include the dry storage room.

Based on observations, and interviews with staff, contracted pest control technicians, and a local health department employee, the facility failed to ensure 1) cleaning practices and food storage practices were carried out in the main kitchen to deter attraction of pests and 2) communicate effectively with pest control technicians to ensure contributing factors to pests could be identified and efforts made to resolve any issues for 1 of 1 main kitchen area in the facility.The findings included:Review of pest control records provided by the facility's corporate office and Health Department records revealed the following information:On 5/19/25 Contracted Pest Control Technician # 1 noted the following in an invoice. A few roaches were found in the kitchen area. The area was inspected and serviced. There were sanitation issues identified in the kitchen which could lead to pest problems. The floor under the cook/steam line was in need of cleaning and there was food or grease build-up observed in the kitchen. The inspection report invoice noted, Please clean regularly.On 7/30/25 Pest Control Technician # 1 noted the following in an invoice report. No pest activity was found.On 8/13/25 the local health department completed a main kitchen review and noted a large amount of roaches were found in an electrical box above the three-compartment sink. The inspector also noted that there were kitchen cleaning issues. Specifically, the inspector noted 1) general floor cleaning was needed and cleaning was needed under food equipment 2) cleaning was needed under shelving in the walk in closet, walk in freezer, and dry storage 3) floor behind the equipment and under three compartment sink was in need of cleaning. Additionally, the inspector noted there was wall damage throughout the kitchen. On 8/26/25 Pest Control Technician # 1 noted the following in an invoice report. They had performed interior rodent service, checked and reset traps. No pest activity was found.On 9/18/25 Pest Control Technician # 1 noted the following in an invoice report. Pest activity was found in the kitchen area. Cockroaches were noted during service coming out of the trash disposal door and other places in the kitchen. The technician noted he would return to do a follow-up service in 7 to 10 days and was looking to do a night service the next Saturday. There were sanitation issues found that could cause pest problems which included that the floor drains needed to be cleaned. There were dirty strainers. The floor was normally wet all the time. The technician wrote for the facility to keep as dry as possible in the kitchen and to clean in and around drains frequently to help prevent pest breeding sites.The facility was not able to provide during the survey a specific date or invoice when the Pest Control Technician returned in September 2025 to do the nightly service they noted they wished to do. Following 9/18/25, the next pest service record provided by the facility was on 10/26/25 which noted no pest activity during service.The next service record following 10/26/25 provided by the facility was on 12/5/25. Pest Control Technician # 1 noted there were no pests but there was sanitation issues found in the kitchen that could cause pest problems in the kitchen. The technician noted there was food debris found during most pest control services and standing water every service. The technician wrote, Please clean regularly.On 1/15/26 the contracted pest control company's Technician # 2 noted the following on an invoice for a service. Roaches were noted during service along wall piping in the kitchen. The area was inspected and serviced. There were structural concerns that could cause pest problems. This included holes and gaps throughout the kitchen and prof peeling (a plastic covering) off the walls. There were sanitation issues. The report noted that food debris was found throughout the kitchen. There was a note, Please clean regularly.During kitchen observations made on 1/30/26 beginning at 7:50 AM the following was observed. There was a dead roach behind the ice machine and another roach in one corner of the kitchen that moved slowly. In the dry storage room there was a container of multiple large bags of cereal. The top bag was open. The lid to the container was found on the floor underneath another shelving unit in the dry storage room. Grits were on a shelf and not sealed up and closed, rather the top of the grits bag was rolled up. The metal shelf, where the grits were located, had a liner. The liner on this shelf and another kitchen shelf in the dry storage room had a very fine grainy substance visible on the liner. Underneath the shelving units in the dry storage room were multiple items and food crumbs which included but were not limited to loose, dry cereal, a dried up orange peeling, two closed packets of cookies, two water bottles, two condiment packets, a carbonated drink, a closed bag of Cheetos, a closed pudding cup, a loose cigarette, and a pair of shoes (sandal slides). Underneath the kitchen oven there was a span of about 12 inches of black, dried-up grease. Dietary Aide # 1 reported they had to be careful when they cleaned under the oven because part of the bottom of the oven would come off. There was a portion of the wall that was peeling off near the sink in more than a foot of area. At the time of the kitchen observations, staff were not observed actively preparing grits and cereal.During the kitchen observations on 1/30/26, which began at 7:50 AM the Administrator also viewed the dry storage floor and the food items that were not closed. At 8:50 AM on 1/30/26, the Administrator reported that the former Dietary Manager had left employment in October 2025 and that the current Dietary Manager worked one to two days per week until a full time Dietary Manager could be hired. In the interim, the Dietary Supervisor also covered. The Administrator stated the pest control company had been in to treat for roaches multiple times at night in January 2026. According to the Administrator, the pest control company had just finished a treatment on the night of 1/29/26.The Dietary Supervisor was interviewed on 1/30/26 at 10:40 AM and reported the following information. She would normally close any opened food items if the kitchen staff forgot. The dietary staff were supposed to sweep and clean nightly before they left and should have swept up the items on the floor in the dry storage room/area. The Dietary Supervisor also reported that there was a cleaning schedule that the kitchen utilized. Review of the cleaning schedule revealed it did not mention the dry storage cleaning. The Dietary Supervisor reported that because of a current physical limitation, she could not see under the stove well enough to view the grease build up, but there were plans to power wash under it. The Dietary Supervisor reported that she had been coming in at night and that the facility's pest control company had been bombing the kitchen recently to alleviate the roaches. The interview further revealed the nightly treatments started after all food preparation activities were completed for the day.The Dietary Manager was interviewed on 2/2/26 at 2:40 PM and reported the following information. She worked part time at the facility and was usually there one day per week. She had done a complete inspection of the kitchen on 1/4/26 and did not see roaches at that time. She tried to be there on weekends and afternoons. The dietary staff should be cleaning and mopping every night before they left, and instructions had been given to them to do this. All food should be sealed, covered, and dated. The Dietary Manager had made a new cleaning schedule when she started to work, and it did incorporate the dry storage area, but she had been told that the facility needed to use a corporate cleaning schedule which was not the same as hers and which did not include the dry storage room. The Dietary Manager stated the grease under the oven should be cleaned but they had to be careful about power washing under the oven because in past times, power washing had caused an electric outlet to not function. She was aware that roaches had been found in the kitchen, the pest control company was performing treatments, and she had instructed the staff to unpack boxes of supplies as soon as possible. She thought some of the bugs that were seen were possibly water bugs and not roaches. The interview further revealed the Administrator was in the kitchen all the time checking on things. Pest Technician # 1 was interviewed on 1/30/26 at 11:30 AM and reported the following information. Staff had reported to him that they saw roaches in the residential part of the facility at times during his visits. While servicing the building he did not see them in the residential part. He did find live roaches in the kitchen, and he thought any sightings in the facility originated from the kitchen. In December 2025 he saw about 15 to 20 live roaches coming from an electrical box in the kitchen. There were a bunch of dead ones also on the glue board he had set out. When he routinely serviced the facility there were sanitation issues in the kitchen and always stuff on the floor such as trash and food particles. He talked to the kitchen staff about it. Also, the floor tended to be wet around the ice machine which could attract the roaches and the bait the pest control company used also needed to be kept dry. In December 2025, he also talked to an employee in the front of the building about servicing the kitchen at night. Pest Technician # 2 was interviewed on 1/30/26 at 11:05 AM and reported the following information. He had treated the kitchen three times in January 2026 at night after all food preparation was finished for the day. On his first visit, which took place on 1/15/26, he had seen about 6 or 7 active roaches. They hid behind some white piping in the kitchen area and in the dishwasher area. When he was there at night there was food still in the food trap from the dishwasher machine and the prep sink had not been rinsed out. Pest Technician #2 explained that food can attract roaches. The prof covering to the wall was coming loose and roaches could hide under the wall covering where it was loose and not adhered to the wall. He felt the treatment he had initially done on 1/15/26 had eradicated probably 85% of any roach population in the kitchen. He had been out three times in January for treatment on 1/15/26, 1/23/26, and 1/28/26. He saw one active roach during his last visit, which he reported to be on the night of 1/28/26. A local Health Department Employee, who had completed the kitchen inspection in August 2025, was interviewed on 2/5/26 at 1:49 PM and again on 2/5/26 at 3:40 PM and reported the following information. He completed the facility's main kitchen's inspection in August 2025 and observed sanitation issues while in the kitchen. He had also seen 10-20 roaches in the kitchen that came from an electrical box in the kitchen. He had spoken to the Administrator during his August 2025 inspection about the issue and the Administrator had said that there were no roaches. Therefore, he took a video of the roaches and showed it to the Administrator. The facility was asked to send evidence they had pest control services to the health department. The Health Department Employee had not returned to the main kitchen since August 2025. He had returned to do an inspection of residential areas which included nourishment rooms in December 2025 and had also been in the facility in residential areas in October 2025 and January 2026 due to complaints of roaches in residential areas. The interview further revealed while in the residential areas, he had not seen roaches.The Business Office Manager and Maintenance Employee # 1 were interviewed on 2/4/26 at 10:33 AM. The Business Office Manager reported the following information. The pest control invoices with notations about pests and structural issues were not given directly to the facility. They (the facility) had to call and obtain reports which were provided to the surveyor, and this was done following the surveyor's request for pest control records during the survey. The facility only had one invoice/report from 12/5/25 and no other report. Maintenance Employee # 1 reported the following information. He thought there was a date the Pest Control Technician returned in December 2025 and saw roaches in the kitchen. At that time a plan was made for another technician to come and do treatment. The technicians had not reported to him any structural issues or sanitation issues that could be causing a problem in managing roaches. He had not been aware of the problem with the kitchen wall facing coming off and did not know what other holes the technicians were referencing in their reports. Normally when the technicians came into the facility, they did not routinely go around and point out problems to the maintenance employees about issues they saw and they sometimes left without giving a report. Maintenance Employee #1 stated the facility also did not receive the invoice reports noting problems that could be contributing to the issues.During a follow up interview with Maintenance Employee # 1 on 2/6/26 at 12:00 PM regarding whether the Pest Control Company had ever done a nightly visit following the September 2025 roach sightings as they had documented in their report. Maintenance Employee #1 reported he was not fully involved until January 2026 with the pest control issues, but it was his understanding that they had returned in September after 9/18/25 and sprayed at night.The Administrator was interviewed on 2/4/26 at 2:56 PM regarding the notations of structural issues and sanitation issues in the pest control invoices and reported the following information. Their pest control company was supposed to come in monthly. She could not find records for November 2025 to validate if they came to the facility. She thought a pest technician had been back in at some point in December 2025 and determined a problem in the kitchen which needed nightly treatments. Since the holidays were near, the timeframe for treatment was set up for January 2026. The Administrator was not clear on what all was found in December 2025 by the technician which prompted the three nightly treatments in January 2026. The Administrator reported the technicians did not always talk to her about sanitation or structural issues that needed to be resolved and did not give her written reports that needed follow up. She recalled the local health department had been in recently and the employee told her he did not find roaches.

Based on record review and staff and Responsible Party (RP) interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record and failed to honor the resident's wishes with regards to code status as expressed by the resident's RP on admission. This was for 1 of 11 residents (Resident #94) reviewed for advanced directives. Findings included: A review of Resident #94's hospital discharge summary dated [DATE] revealed his code status in the hospital was full code (a medical term that indicates a patient wants to receive all available measures to save their life in an emergency). It was initialed by Unit Manager #1 indicating she reviewed the document. Resident #94 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of the facility's admission document titled NC Advanced Directive for Healthcare dated [DATE] and signed by Resident #94's RP and the facility's Admissions Director revealed documentation indicating Resident #94 had previously executed an advanced directive (Living Will or Healthcare Power of Attorney) and would provide a copy to the facility. A review of the facility admission document titled DNR (Do not Resuscitate is a legal order written to respect the wishes of a patient not to undergo cardiopulmonary resuscitation (CPR) if their heart stopped or they were to stop breathing) dated [DATE] and signed by Resident #94's RP and the facility's Admissions Director revealed documentation indicating Resident #94 had a DNR order or MOST (Medical Orders for Scope of Treatment) previously executed on his behalf and a copy would be provided to the healthcare center. A review of Resident #94's physician's orders revealed a code status order for full code dated [DATE] entered by Unit Manager #2. A review of Resident #94's comprehensive care plan revealed a focus area for advanced directives initiated on [DATE] indicating Resident #94's code status was full code. The goal was for Resident #94's wishes and directives to be carried out in accordance with his advanced directives on an ongoing basis. An intervention was to discuss advanced directives with Resident #94 and/or his appointed health care representative. A review of a Social Work (SW) progress note for Resident #94 dated [DATE] at 11:35 AM written Resident #94's SW revealed Resident #94's code status was DNR. A review of Resident #94's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. A review of Resident #94's medical record did not reveal a copy of his advanced directives. On [DATE] at 1:51 PM a telephone interview with Resident #94's RP indicated she completed the admissions paperwork for Resident #94 when he was admitted to the facility as he had not been capable of doing this. She stated Resident #94 had both a living will, and a healthcare power of attorney which listed her as his RP. She reported that she expressed that he had these things when she completed Resident #94's admission paperwork and also expressed that Resident #94's wish for code status was DNR. She stated she had provided the facility with a copy of these documents. She reported no one from the facility had ever let her know they did not have them, or she would have gladly provided them again. Resident #94's RP went on to say she participated in all Resident #94's care plan meetings, but she did not recall Resident #94's code status or advanced directives being discussed there. She stated she was not aware that Resident #94's code status in the facility had been full code since his admission, and this would not be what he wanted. On [DATE] at 2:52 PM an interview with the Admissions Director indicated she completed Resident #94's admission paperwork with his RP. She stated if a resident or RP indicated a resident had advanced directives she checked that box on the admission form. She stated if Resident #94's advanced directives were not in his record, it might be that his RP had not provided it to the facility. She reported she did not follow up after the initial admission paperwork was completed to ensure that the documents were received. The Admissions Director stated for code status, if a resident or RP expressed the wish to be a DNR, she checked that box on the admission form and also put a check in the box in the residents electronic record which caused a DNR flag to appear in the electronic record on the resident's face sheet for the nurses to see. She reported it would then be the nurse's responsibility to get the DNR order. On [DATE] at 8:10 AM an interview with Unit Manager #2 indicated she entered the full code order for Resident #94 into his electronic medical record on [DATE] based on the information she obtained from his hospital discharge summary. She stated Resident #94 was not residing on her unit, so she had not looked for any advanced directive paperwork, or a DNR or MOST form. She stated Unit Manager #1 would have been responsible for this. On [DATE] at 8:16 AM an interview with Unit Manager #1 indicated she did not follow up with residents or their RP's if they indicated the resident had advanced directives such as a living will or a health care power of attorney on admission to ensure a copy was obtained for the residents record. She reported she did recall on Resident #94's admission to the facility, the banner on his electronic record face sheet said DNR, and he had a full code order in place. She went on to say at some point the SW had been doing an audit to ensure resident's face sheet banner code status matched the code status order, and Resident #94's face sheet banner had been changed to full code. She stated she had checked with the SW, and the SW told her Resident #94 was a full code. She reported if a resident's admission paperwork indicated their wish was for a DNR code status, and the physician's order was for a full code status, she did try to clarify with the resident or their RP, but she had not done this for Resident #94. On [DATE] at 8:28 AM an interview with the SW indicated she did not recall why she documented Resident #94's code status was DNR in her progress note dated [DATE]. She stated if a resident had advanced directives paperwork such as a living will or a health care power of attorney, the Admissions Director would let her know and the Admissions Director would get copies of the documents and upload them into the residents medical record. She reported she had completed the audit for ensuring that residents code status physician's order and face sheet code status banner matched and recalled that Resident #94's banner indicated a DNR code status, but the physician's order was for full code. She stated when she didn't see any advanced directive paperwork such as a living will or a healthcare power of attorney in Resident #94's record she told Unit Manager #1 that Resident #94 was a full code. She stated she had not clarified the issue with Resident #94's RP. The SW stated Resident #94's RP did attend his care plan meetings, and she did not recall Resident #94's RP ever telling her he wanted to be a DNR code status. On [DATE] at 9:27 AM an interview with the Director of Nursing indicated if a resident or their RP indicated on admission that the resident had a living will or a health care power of attorney, the Admissions Director should be ensuring there were copies of the documents in the residents medical record. She went on to say if a resident's wishes were to be a DNR code status, that's what their code status should be, and the Unit Managers should be ensuring a goldenrod DNR form or a MOST form were obtained for the resident. On [DATE] at 11:30 AM an interview with the Administrator indicated the facility had a system in place where they asked on admission whether a resident had a living will or a health care power of attorney. She stated if Resident #94's RP indicated he had these, someone should have ensured a copy was obtained and included in Resident #94's medical record. The Administrator reported if a resident or a resident's RP expressed that the resident's wishes were to be a DNR code status, then that's what it should be.

Based on observations, staff interviews, and record review the facility failed to attempt alternatives prior to installing side rails for 2 of 4 residents (Resident #18 and Resident #98) reviewed for side rails. Findings included: 1. Resident #18 was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury. A review of Resident #18's record revealed an assessment titled restraint-adaptive equipment use dated 8/23/24 and completed by Unit Manager (UM) #1 indicated no answer was provided for the question have alternatives to restraint or adaptive equipment been tried in the past?. The choices were yes, no or not applicable. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired. The MDS indicated Resident #18 required substantial to maximum assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #18 had no impairment of both upper and lower extremities. The MDS indicated Resident #18's siderails were not used as a restraint. A care plan with the latest review date of 1/17/25 revealed a problem of use of one quarter side rails for increasing or maintaining current bed mobility. The goal was Resident #18 would remain safe through the next review. The approach was for Resident #18 used one quarter side rails for turning and repositioning during incontinence care. An observation on 2/24/25 at 1:03 PM revealed Resident #18 lying in bed with bilateral one-quarter length side rails in the up position on the bed. An observation on 2/25/2025 at 12:09 PM revealed Resident #18 sitting in her bed with the head raised at a 45-degree angle. The side rails were observed to be in the raised position. An interview with Nurse #1 on 2/25/25 11:58 am revealed the Nurses completed the restraint-adaptive equipment use evaluation on admission and quarterly. Nurse #1 stated this form was used for side rail screening. She further stated she always answered no to the question Have alternatives to restraint or adaptive equipment been tried in the past?. Nurse #1 indicated side rails were on the beds on admission. She further indicated Nursing did not try alternatives to side rails before they were used, and she could not think of alternatives to try instead of using side rails. Nurse #1 was not aware alternatives needed to be tried before using side rails. In an interview with UM #1 on 2/25/25 at 12:03 PM she stated she recalled completing the restraint-adaptive equipment use evaluation for Resident #18. She further stated she was not aware of a time the facility tried alternative side rails. She was not aware alternatives to side rails needed to be attempted before using them, so she did not answer the question. In an interview with the Director of Nursing (DON) on 2/25/25 at 12:09 PM she stated Nursing completed the restraint-adaptive equipment use evaluation on admission and quarterly. She further stated they did not try interventions before using side rails as she was not aware this was a requirement. The DON revealed side rails were always on the beds. If a resident did not need them, then they were kept in the down position. In an interview with the Administrator on 2/25/25 at 12:34 PM she stated alternative interventions to siderails were not tried before implementation as she was unaware that this was a requirement. 2. Resident #98 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) of left side of body following cerebral infarction (stroke). A review of Resident #98's record revealed an assessment titled restraint-adaptive equipment use evaluation dated 10/4/24 and completed by Nurse #1 indicated no alternatives to restraint or adaptive equipment been tried in the past. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #98 was cognitively intact and was dependent on staff for bed mobility. The MDS indicated Resident #98's siderails were not used as a restraint. A care plan with the latest review date 10/21/24 revealed a problem that Resident #98 had one quarter siderails to assist with bed mobility and transfers. The goal was Resident #98 would not obtain any injury from positioning/transfers. The approach stated Resident #98 and staff would use side rails to assist with bed mobility and transfers as needed. An observation on 2/24/25 at 11:15 AM revealed Resident #98 in bed with the one quarter length side rails in the raised position. An observation on 2/25/25 at 11:45 AM revealed Resident #98 in bed with bilateral one-quarter length siderails in the up position on the bed. An interview with Nurse #1 on 2/25/25 11:58 am revealed the Nurses completed the restraint-adaptive equipment use evaluation on admission and quarterly. Nurse #1 stated this form was used for side rail screening. She further stated she recalled completing the form for Resident #98 and she always answered no to the question Have alternatives to restraint or adaptive equipment been tried in the past?. Nurse #1 indicated side rails were on the beds on admission. She further indicated Nursing did not try alternatives to side rails before they were used. Nurse #1 was not aware alternatives were required before using side rails. In an interview with UM #1 on 2/25/25 at 12:03 PM she stated she was not aware of a time the facility tried alternatives to siderails. She was not aware alternatives to side rails needed to be attempted before using them. In an interview with the Director of Nursing (DON) on 2/25/25 at 12:09 PM she stated Nursing completed the restraint-adaptive equipment use evaluation on admission and quarterly. She further stated they did not try interventions before using side rails as she was not aware this was a requirement. The DON revealed side rails were always on the beds. If a resident did not need them, then they were kept in the down position. In an interview with the Administrator on 2/25/25 at 12:34 PM she stated alternative interventions to siderails were not tried before implementation as she was unaware that this was a requirement.

Based on observations, record review, and resident, staff and Nurse Practitioner (NP) interviews, the facility failed to assess whether the self-administration of medication was clinically appropriate before leaving medication at the bedside. This was for 1 of 5 residents (Resident #87) reviewed for medication administration. Findings included: Resident #87 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath). A review of Resident #87's medical record did not reveal a self-administration of medication assessment. A review of Resident #87's physician's orders did not reveal a physician's order to self-administer any medication. A physician's order dated 8/15/24 revealed Trelegy Ellipta (a long term medication to treat COPD) blister with device; 100-62.5-25 microgram (mcg) administer one puff inhalation once daily at 9:00 AM for COPD. A review of Resident #87's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of Resident #87's comprehensive care plan dated last reviewed on 2/12/25 did not reveal any evidence Resident #87 self-administered medication. On 2/24/25 at 10:42 AM Resident #87 was observed in bed. She had her Trelegy Ellipta inhaler on her bedside table. An interview with Resident #87 at that time indicated she did not usually keep the medication at her bedside. She stated this medication was for her breathing and she took one inhalation daily each morning. She reported she must have been asleep when Nurse #3 brought the medication earlier and she had not taken the inhaler yet that morning. Resident #87 was then observed to administer one inhalation from the inhaler to herself. A review of Resident #87's February 2025 Medication Administration Record (MAR) revealed documentation by Nurse #3 on 2/24/25 indicating she administered one inhalation of Resident #87's Trelegy Ellipta inhaler to her at 9:00 AM that morning. On 2/25/25 at 12:05 PM an interview with Nurse #3 indicated she was assigned to care for Resident #87 on 2/24/25 from 7:00 AM to 3:00 PM. She stated she was familiar with Resident #87 and had cared for her before. She reported Resident #87 did not self-administer any medication. Nurse #3 stated she administered one inhalation of Resident #87's Trelegy Ellipta inhaler to her on 2/24/25 at 9:00 AM and then must have inadvertently left the inhaler at Resident #87's bedside. She reported that if Resident #87 had taken another dose of the medication on 2/24/25 at 10:42 AM, this would have been a medication error. On 2/27/25 at 9:01 AM an interview with the Director of Nursing (DON) indicated Resident #87 should not have any medication left at her bedside without a self-administration of medication assessment indicating this was appropriate for Resident #87, and a physician's order to self-administer the medication. On 2/27/25 at 9:51 AM an interview with Resident #87's NP #1 indicated that while taking an additional dose of Trelegy Ellipta inhaler medication on 2/24/25 would not have caused any harm to Resident #87, the medication should not have been left at her bedside. On 2/27/25 at 11:30 AM an interview with the Administrator indicated Nurse #3 was a very experienced nurse. She stated leaving medication at a resident's bedside would be very unusual for Nurse #3. The Administrator reported she felt this was just a one-time mistake.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls for 1 of 5 residents reviewed for accidents (Resident #87). Findings included: Resident #87 was admitted to the facility on [DATE]. A review of a nursing progress note for Resident #87 dated 1/25/25 at 4:45 PM written by Nurse #2 revealed Resident #87 had a fall from her bed. Resident #87 had no skin tears, limited range of motion or dizziness after her fall. Resident #87 was complaining of mild pain to her right hip and right knee. A review of Resident #87's quarterly MDS assessment dated [DATE] revealed she had no falls since her prior MDS assessment. On 2/26/25 at 12:46 PM an interview with Nurse #2 confirmed Resident #87 had a fall from her bed on 1/25/25. On 2/26/25 at 1:13 PM in an interview the MDS Coordinator stated she coded the falls section of Resident #87's MDS assessment dated [DATE]. She reported she normally looked at progress notes for information when coding this section. She went on to say the date of Resident #87's prior MDS assessment was 1/21/25, so the fall Resident #87 experienced on 1/25/25 should have been captured on Resident #87's 2/12/25 MDS assessment. She reported it was an oversight on her part. On 2/27/25 at 9:01 AM an interview with the Director of Nursing indicated resident's MDS assessments should accurately reflect their status. On 2/27/25 at 11:30 AM an interview with the Administrator indicated resident's MDS assessments should be coded accurately.

Based on observation, record review and staff interview, the facility failed to follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter when Nurse Aide (NA) #1 and NA #2 provided a bed bath without wearing gowns for 2 of 20 staff observed for infection control (NA #1 and NA #2). Findings included: The facility policy titled Enhanced Barrier Precautions (EBP) dated 4/30/24 stated in part: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gowns and gloves use during high contact resident care activities for residents with indwelling medical devices. The policy gave the example of bathing and dressing as a high contact activity. Observation of Resident #103's door on 2/26/25 at 9:03 AM revealed signage for EBP. The signage indicated that staff providing high contact care to Resident #103 were required to wear gowns and gloves. Further observation revealed a caddy outside Resident #103's room that contained Personal Protective Equipment (PPE) including gowns and gloves. An observation of NA #1 and NA #2 providing a bed bath and dressing Resident #103 was conducted on 2/26/25 at 9:05 AM. NA #1 and NA #2 were observed performing hand hygiene and donning gloves before providing the care. Resident #103 was observed to have a hemodialysis catheter (a tube with connectors) inserted in his right upper chest area. Neither NA #1 nor NA #2 donned gowns before providing high contact care to Resident #103. An interview was conducted with NA #1 and NA #2 on 2/26/25 at 9:30 AM. Both NAs stated they thought the EBP sign on the door was for Resident 103's roommate. When asked to give examples of who should be on EBP they stated residents with wounds, intravenous lines and urinary catheters. They could not recall other reasons a resident would require EBP for high contact care and did not think a hemodialysis catheter was included in reasons to require EBP. NA #1 and NA #2 both stated they had training on EBP at least one time. An interview was conducted with the Infection Preventionist on 2/26/25 at 9:34 AM. The Infection Preventionist stated all residents with an indwelling medical device, which included a hemodialysis catheter, would require EBP for high contact care such as bathing and dressing. The Director of Nursing (DON) was interviewed on 2/26/25 at 9:46 AM. The DON stated she was unaware a hemodialysis catheter required EBP for high contact care. Unit Manager (UM) #2 was interviewed on 2/26/25 at 10:05 AM. UM #2 stated a hemodialysis catheter did not require EBP for high contact care. In an interview with the Administrator on 2/26/25 at 10:38 AM she stated EBP was required for any resident with an indwelling medical device such as a hemodialysis catheter when staff were providing high contact care. She further stated staff were trained on EBP upon hire and annually.

Based on observation of pressure ulcer care, staff interviews and record reviews, the facility failed to perform hand hygiene after removing wound dressings, before cleaning the wound, applying the new treatments and when moving from one wound to another for 2 of 2 residents (Residents #1 and #3). Additionally, the facility failed to clean scissors before and after use for 1 of 2 residents (Residents #3) reviewed for pressure ulcer care. The findings included: The facility's policy titled, Guidelines for Cleansing and Observing a Wound, last reviewed on 07/28/2023, revealed as soon as you have finished removing the soiled dressing and cleansing the wound, remove and discard your gloves. Otherwise, everything you touch, including the faucet and handles, will be contaminated by microorganisms on your gloves. Your bandage scissors may transfer pathogens from one resident to th next, as well as to your own hands and pockets. To prevent this, wash your scissors with an alcohol product or soap and water before and after each use. Wash your hands (or use an alcohol cleanser) after removing and discarding the existing dressing. Put on clean (or sterile) gloves before applying new dressing. Be sure the soiled supplies do not come into contact with clean supplies. 1a. A pressure ulcer wound care treatment of Resident #3 was observed on 3/26/24 at 2:05 PM. Treatment Nurse #1 placed a paper barrier with clean supplies on the bedside table, donned gloves, and removed the dressing from the left and then right buttocks. The soiled dressing was placed on the bedside table next to the clean barrier. Treatment Nurse #1 proceeded to clean the left buttock with cleaner on gauze, obtained another wound cleaner saturated gauze and continued to the right buttock. Treatment Nurse #1 completed these tasks without changing gloves and performing hand hygiene. The used gauze was placed on the bedside table. Treatment Nurse #1 removed scissors from his pocket and cut the silver alginate package in half. The scissors were returned uncleaned into the pocket. The silver alginate was applied to the left buttock and covered with a clear transparent dressing. Treatment Nurse #1 then scratched his face with his left gloved hand, removed the glove, and put it on the bedside table. With the gloved right hand, Treatment Nurse #1 lifted the right buttock and with the ungloved left hand pressed the clean transparent film dressing in place with the back of his hand. Treatment Nurse #1 removed the right glove and gathered the soiled dressing and gloves in the paper barrier with his bare hands and walked out of Resident #3's room and discarded it into the trash bin on the side of the wound care treatment cart. He used hand sanitizer then pushed the cart to the next room. 1b. An observation of pressure ulcer wound care treatment for Resident #1 was conducted on 3/26/2024 at 2:14 PM. Treatment Nurse #1 placed a paper barrier on the bedside table. He placed acetic acid moistened gauze, dressing supplies, clean gloves, and a crushed metronidazole tablet in a medicine cup on the barrier. He cleansed his hands with antimicrobial foam and donned a pair of clean gloves. A new skin tear was noted on Resident #1 right shoulder. Treatment Nurse #1 removed the soiled dressing from the pressure ulcer on the sacrum and put it in the trash. Treatment Nurse #1 cleansed the right shoulder wound and applied petroleum gauze with a foam dressing to the right shoulder. Without changing gloves, Treatment Nurse #1 cleansed the wound on the buttocks with wound cleanser. The crushed metronidazole tablet was sprinkled in the wound, and the acetic acid moistened gauze was placed in the center of the wound and covered with a foam dressing. An interview on 3/26/24 at 3:10PM was conducted with Treatment Nurse #1. He stated that he was nervous, and he forgot to wash his hands and change his gloves. He indicated that he had been trained in wound care and hand hygiene. He stated that he didn't recall touching Resident #3 without gloves. He stated that he didn't think to clean his scissors from his pocket before using them to cut the calcium alginate. He stated he used scissors to cut the dressing packaging and not for patient care. He stated he was not sure why he didn't change his gloves and use hand hygiene between wounds or between the dirty dressing removal or before the clean dressing was applied. He forgot to clean his scissors. An interview on 3/26/24 at 4:00 PM with the Director of Nursing revealed that Treatment Nurse #1 was a competent nurse. She stated that all staff were trained in handwashing. She indicated nursing staff were to follow infection control procedures for wound care.

Based on observations and staff interviews the facility failed to label and date resident's personal food items stored in a nursing unit nourishment refrigerator. This was for 1 of 2 nursing unit nourishment refrigerators (First-Floor) observed. Findings included: On 1/10/24 at 11:24 AM an observation of the First-Floor nursing unit nourishment refrigerator with Nurse #2 revealed the following: a. two unlabeled and undated cardboard pizza boxes containing pizza. b. an unlabeled and undated brown paper bag containing tortilla chips and an unlabeled and undated cup of red liquid. c. an unlabeled and undated plastic food storage container of fried chicken, collard greens, and macaroni and cheese. d. an unlabeled and undated plastic food storage container containing corn bread and black-eyed peas. e. an unlabeled and undated plastic food storage container of green beans and black-eyed peas. In an interview at the time of the observation, Nurse #2 stated she was sure the unlabeled and undated food items in the refrigerator belonged to residents. She stated she had not placed the food items in the refrigerator, and she did not know who had. She went on to say she was not sure how long the items had been in there. She further indicated residents and family members were unable to place items in this refrigerator as it was behind the nurses station. Nurse #2 stated food items had to be given to a staff member. Nurse #2 stated staff were supposed to label items with the resident's name or room number and the date when items were placed in the refrigerator. Nurse #2 stated everyone tried to keep up with this. She went on to say she would need to discard the items because they were not labeled, she was not sure who they belonged to, and she did not know how long they had been in there. On 1/10/24 at 2:46 PM an interview with the Director of Nursing indicated Nurse Aide (NA) #2 was responsible for checking this refrigerator daily Monday through Friday and discarding any items that were not labeled and dated. She stated any staff member who placed an item in this refrigerator should be labeling the item with the resident's name and the date the item was put in the refrigerator. On 1/10/24 at 2:51 PM an interview with NA #2 indicated she was responsible for checking the First-Floor nursing unit nourishment refrigerator daily Monday through Friday to be sure all food items were labeled and dated. She stated she normally checked the refrigerator in the morning when she came in and, in the evening, before she left for the day. She went on to say she had checked the refrigerator on 1/9/24. She further indicated any item that was not labeled and dated was to be discarded. NA #2 stated she had not checked the refrigerator yet on 1/10/24, as she had been out of the facility on a transportation appointment.

Based on observations, staff interviews, and record review the facility failed to speak respectfully to a resident during an interaction (Resident #22) and failed to have a privacy cover on a resident's catheter bag (Resident #37) and for 2 of 6 resident reviewed for dignity. Findings included: 1. Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. His hearing was adequate. He exhibited no hallucinations, psychosis, behaviors, or rejection of care during the assessment period. A review of Resident #22's comprehensive care plan revealed in part a problem area initiated on 1/26/23 of behavior symptoms related to verbal behaviors directed towards others that included Resident #22 calling staff names such as stupid and dumb. An intervention was to maintain a calm environment and approach to Resident #22. On 1/10/24 at 11:13 AM an interview with Resident #22 indicated Receptionist #1 was rude to him. He stated a few months ago, in August 2023, he was at the front desk and Receptionist #1 asked him to move away from the desk because she was talking on the phone. Resident #22 stated he didn't want to move, and she told him he was acting like a butthole. He went on to say he had not mentioned this to anyone because he didn't want to start any trouble. He stated this had made him angry and hurt his feelings at the time. On 1/10/24 at 1:23 PM an interview with Receptionist #1 indicated she recalled an instance with Resident #22 where he was sitting at the front desk while she was talking on the phone. She stated at times needed to have confidential conversations with families or funeral homes. She went on to say she had asked Resident #22 to sit somewhere else while she was on the phone, and he had gotten upset. Receptionist #1 stated Resident #22 told her she was acting like an old butthead and she told him he must have been talking about himself. She further indicated she probably should have handled the situation differently. On 1/10/24 at 1:40 PM an interview with the Administrator indicated she had not been aware of this interaction between Resident #22 and Receptionist #1. She stated Receptionist #1 should not have responded in this way to Resident #22. She went on to say if Receptionist #1 had not agreed with what Resident #22 was saying, she should have just not said anything. 37468 2. Resident #37 was admitted to the facility on [DATE]. His active diagnoses included chronic kidney disease, autonomic neuropathy in diseases classified elsewhere, difficulty in walking, neuromuscular dysfunction of bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #37's minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no behaviors and used an indwelling catheter. During observation on 1/8/24 at 2:00 PM Resident #37 was observed in bed with no cover observed on his catheter bag. The catheter bag was on the side of the bed that faced the door. His roommate's bed blocked the view of the catheter bag from the hall, but Resident #37's urine was visible to anyone in the resident's room. During observation on 1/9/24 at 8:31 AM Resident #37 was observed to have no cover on his catheter bag and urine was visible to anyone in Resident #37's room. During an interview on 1/9/24 at 8:32 AM Resident #37 stated his catheter bag had a cover. When told the catheter bag did not have a cover, he stated he would like a cover on his catheter bag. During an interview on 1/9/24 at 8:36 AM Nurse Aide #1 stated Resident #37 had a catheter bag privacy cover on 1/7/24 and did not know why it was not on today and he should have a cover for his catheter bag for dignity. She did not notice this morning that he did not have a catheter cover and she would go get one now. During an interview on 1/9/24 at 8:42 AM the Director of Nursing stated they had issues with the supply company getting catheter bags with built-in covers. She stated residents should have a cover for dignity, and the facility had covers for bags that did not have built in covers and staff sometimes forget to move the catheter bag cover with the catheter bag during transfers from the wheelchair chair to bed. She concluded he should not have gone since yesterday without a catheter bag cover for dignity.

Based on observations and staff interviews the facility failed to keep medications in a locked medication cart for 1 of 4 medication carts observed (Medication Cart #1). Findings included: During observation on 1/8/24 at 2:34 PM Medication Cart #1 was found by the surveyor to be unlocked and unattended outside the nursing station. Two nurse aides were inside the nurse's station and two cognitively impaired residents were observed near the unlocked medication cart. At 2:36 PM Nurse #1 returned to the unlocked medication cart. During an interview on 1/8/24 at 2:37 PM Nurse #1 stated medication carts were to be locked when unattended and she should have locked the medication cart prior to taking medications to a resident. During an interview on 1/9/24 at 8:42 AM the Director of Nursing stated medication carts were to be locked when unattended for resident safety.

Based on record review, staff and Nurse Practitioner, and Pharmacist interviews, the facility failed to obtain a pain medication from the pharmacy for 1 of 1 resident (Resident #1) reviewed for medications. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus and dementia. Nurse Practitioner (NP) order dated 8/29/23 read Dilaudid (hydromorphone) (an opioid pain medication) 2 milligram (mg) tablet every 4 hours for terminal pain. The start date was 8/29/23. The order was discontinued 10/26/23 and the end date was 10/26/23. Review of the October 2023 Medication Administration Record (MAR) revealed the Dilaudid 2 mg tablet was documented as not administered as follows: - 10/19/23 2:00 AM - Not Administered: Drug/Item Unavailable - 10/19/23 6:00 AM - Not Administered: Drug/Item Unavailable - 10/25/23 6:00 AM - Not Administered: Drug/Item Unavailable Further review of the October 2023 MAR revealed no order for Dilaudid liquid until October 26, 2023. The Controlled Drug Record date received 8/10/23 for Resident #1's Hydromorphone liquid 1 mg/milliliter (ml) revealed Nurse #1 signed out 3 ml on 10/19/23 at 2:00 AM and 10/19/23 at 6:00 AM. There was no dose signed for 10/25/23 at 6:00 AM. An interview on 11/1623 at 12:14 PM with Nurse #1 revealed the facility had run out of Resident #1's Dilaudid 2 mg tablets and she had given him Dilaudid liquid instead. She stated she had done this on 10/19/23 for both his 2:00 AM and 6:00 AM doses and again on 10/25/23 at 6:00 AM. She stated she put a paper notice in the NP's box to notify her about the medication form change. She was unable to explain why she gave Dilaudid 3 mg dose instead of the ordered 2 mg dose. She was unable to explain why she had not signed on the Controlled Drug Record for the 10/25/23 6:00 AM dose. An interview on 11/16/23 at 2:38 PM with the NP revealed she remembered being notified of the Dilaudid form change. She stated that Resident #1 had previously been on Dilaudid 3 mg dose in August 2023 and felt the resident had no adverse effects from the dose given. An interview on 11/16/23 at 3:01 PM with the Pharmacist revealed that a new prescription for Resident #1's Dilaudid 2 mg tablet had been requested on 10/19/23 and received at the pharmacy on 11/01/23.

Based on record review, resident and staff interviews the facility failed to obtain a follow up dental care appointment with a dentist for 1 of 3 residents (Resident #13) reviewed for dental. Resident #13 had complaints of teeth and gum pain from as documented in the care plan from 9/20/22 and to have a follow up with a dentist for a complete exam and x-rays after 10/17/22 dental visit. Findings included: Resident #13 was admitted to the facility on [DATE] with multiple diagnoses that included multiple sclerosis and acute kidney failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact and was documented for a mechanically altered diet. There was no documentation for gum or teeth issues. Resident #13's care plan dated 9-20-22 revealed the resident had discomfort or difficulty chewing related to poor dental status and required a puree consistency diet. The goal for Resident #13 was she would not exhibit signs of malnutrition or dehydration. The interventions for the goal were to avoid foods that were difficult to chew, inspect mouth for oral abscesses, broken, loose or missing teeth. Review of Resident #13's dental visit dated 10-17-22 at the dental school revealed the resident had a cleaning with instructions for the facility to make an appointment for Resident #13 to have a complete exam, x-rays and follow up with the dentist. Resident #13 was observed and interviewed on 12-5-22 at 8:10am. The resident stated she was not doing well and explained her gums and teeth were hurting. She stated she had gone to the dentist a couple months ago and was supposed to have a follow up but said no one had let her know when she was going back. Resident #13 stated she thought she may have an infection in her gums because they hurt. Upon observing Resident #13's teeth and gums, there were no signs of an infection such as swelling, discoloration or drainage. During an interview with the Appointment Scheduler on 12-5-22 at 4:12pm, the Appointment Scheduler explained when a resident went out for an appointment, a form was sent with them for the Physician to write any orders or follow up appointments. She stated when the resident returned from the appointment, the form was given to the nurse who transcribed any orders then gave her the form to make any follow up appointments. The Appointment Scheduler stated she had never received a form from Resident #13's dental appointment on 10-17-22 so she did not know the resident required a follow up appointment and she did not make Resident #13 a follow up appointment. Nurse #3 was interviewed on 12-5-22 at 4:25pm. The nurse explained when a resident returned from an outside appointment, the nurse would be provided the form the resident took with them with any orders or follow up appointments. She stated the nurse would enter any orders into the computer system and write any follow up appointments needed in the appointment book for the Appointment Scheduler. Nurse #3 stated she was not aware of any needed dental follow up for Resident #13. Review of the appointment book revealed no documentation of a needed dental follow up for Resident #13. An interview with Nursing Assistant (NA) #4 occurred on 12-6-22 at 8:40am. The NA stated she had not seen any swelling or drainage from Resident #13's gums but said the resident complained of pain and tenderness when brushing her teeth. NA #4 stated she had informed the nurse (Nurse #4) assigned to Resident #13. During an interview with Nurse #4 on 12-6-22 at 8:44am, the nurse stated Resident #13 often complained of pain to her gums. She stated the Physician had ordered Resident #13 a medicated gel to help relieve her pain and said she had provided the medicated gel to Resident #13. The Administrator was interviewed on 12-8-22 at 9:50am. The Administrator stated when a resident goes out for a dental appointment, the dental office would call to schedule a follow up appointment. She stated after Resident #13 returned from her dental appointment on 10-17-22, the dental office did not call for a follow up. The Administrator stated on 12-6-22 Resident #13 had been made a follow up appointment with the Dentist.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for Preadmission Screening and Resident Review (Residents #5, #44 and #45) oxygen use (Resident #83) and vision (Resident #2) for 6 of 30 resident records reviewed for MDS accuracy. Findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia. Resident #5's Preadmission Screening and Resident Review (PASRR) Level II determination letter dated 10/26/22 revealed he had a Level II determination with no expiration date. The annual Minimum Data Set, dated dated dated [DATE] revealed Resident #5 was coded as no in the Level II PASRR determination section. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the PASRR section of the MDS. She confirmed that Resident #5 should have been coded as a Level II PASRR on the MDS and had not done so. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 2. Resident #44 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Resident 44's Preadmission Screening and Resident Review (PASRR) Level II determination letter dated 6/16/22 revealed he had a Level II determination with an expiration date of 7/16/22. The admission Minimum Data Set, dated dated dated [DATE] was coded as no in the Level II PASRR determination section. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the PASRR section of the MDS. She confirmed that Resident #44 should have been coded as a Level II PASRR on the MDS and had not done so. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 3. Resident #45 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia. Resident #45's Preadmission Screening and Resident Review (PASRR) Level II determination letter was not available for review but based on the applicant lookup information in the North Carolina Medicaid Uniform Screening Program PASRR history detail, starting on 8/23/22 he was given a Level II determination with an expiration date of 11/21/22. The admission Minimum Data Set, dated dated dated [DATE] was coded as no in the Level II PASRR determination section. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the PASRR section of the MDS. She confirmed that Resident #45 should have been coded as a Level II PASRR on the MDS and had not done so. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 4. Resident #83 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and acute and chronic respiratory failure. Review of physician's orders revealed an order dated 10/29/22 for oxygen at 2 liters per minute via nasal cannula continuous. The admission Minimum Data Set, dated dated dated [DATE] was not checked as receiving oxygen therapy while a resident section. Review of physician's orders revealed an order dated 10/29/22 for oxygen at 2 liters per minute via nasal cannula continuous. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the oxygen section of the MDS. She confirmed that Resident #83 should have been coded as using oxygen on the MDS. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 37468 5. Resident #76 was admitted to the facility on [DATE]. Her active diagnoses included cerebral infarction due to embolism of left middle cerebral artery and diabetes mellitus. Resident #76's minimum data set assessment dated [DATE] revealed she was assessed to have received insulin injections 7 days of the 7 day lookback period. Resident #76's medication administration record for 10/13/22 through 10/20/22 revealed Resident #76 did not receive any insulin injections. During an interview on 12/5/22 at 1:28 the MDS Coordinator stated Resident #76 did not receive insulin during the lookback period of the minimum data set assessment dated [DATE] and it was marked in error. During an interview on 12/5/22 at 1:39 PM the Administrator stated the minimum data set assessments should accurately reflect the resident's use of insulin. 32503 6) Resident #2 was admitted to the facility on [DATE]. Her diagnoses included degenerative myopia bilaterally, macular degeneration and corneal scar and opacity. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was coded as having adequate vision. She was coded as severely cognitively impaired (BIMS score of 04). Resident #2 care plan most recently revised on 11/06/22 by the MDS Coordinator revealed a problem of visual function noting she has side vision problems (decreased peripheral vision) related to degenerative myopia bilateral. On 12/5/22 at 11:43 AM Resident #2 was observed turning pages in a book which was on her over the bed table. The book was noted to be upside down. Resident #2 was not aware the book was upside down. On 12/7/22 at 2:30 PM Nurse #4 said there were times during medication pass when Resident #2 would attempt to reach for the cup of water she was offering but would not reach in the correct direction and would reach toward the nurse's voice instead of toward the cup. During an interview on 12/08/22 at 9:11 AM, the MDS Coordinator said she conducted the vision assessment for Resident #2. She said she asked her questions about items in the room such as the sink, the clock on the wall or the dresser. She said she was unsure if Resident #2 used glasses but had noted she had adequate vision. The MDS Coordinator explained she asked other MDS nurses how they completed the assessments and did not consult the RAI (Resident Assessment Instrument -manual with MDS instructions). The MDS Coordinator explained she may need to do more or different testing and should have asked her about seeing fine details.

Based on record review and staff interviews the facility failed to hold a quarterly care plan meeting and failed to update the care plan for 2 of 2 residents reviewed for care planning (Resident #84 and Resident #37). Findings included: 1. Resident #84 was admitted to the facility on [DATE]. Resident #84's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and had no behaviors. A review of Resident #84's chart revealed Resident #84's last care plan meeting was on 5/31/22. During an interview on 12/4/22 at 11:01 AM Resident #84 stated she had not attended a care plan meeting since the end of spring or early summer. During an interview on 12/6/22 at 12:04 PM the MDS Coordinator stated the Social Worker sent out an invitation a week before care plan meeting to invite residents and families. Care plan meetings were to be done every 90 days. She concluded the Social Worker might have more information on if Resident #84 had a care plan meeting since 5/31/22. During an interview on 12/7/22 at 11:31 AM the Social Worker stated the last care plan meeting for Resident #84 was 5/31/22 and Resident #84's next care plan meeting was set for 12/13/22. She concluded she should have had one prior to 12/13/22 but the Social Worker was behind on care plan meetings. During an interview on 12/7/22 at 11:37 AM the Administrator stated care plan meetings should be held quarterly. 38920 2. Resident #37 was admitted to the facility on [DATE] with multiple diagnoses that included dementia and unsteadiness on feet. Resident #37's active care plan dated 10-29-22 revealed a problem of the resident having a history of falling due to muscle weakness. The goal documented was Resident #37 would remain free from injury. The interventions were for Resident #37 to wear non-skid socks during the night while in bed and remind the resident to wear both shoes when ambulating. A second goal was added on 12-5-22 for the resident to meet therapy goals. The interventions for the goal were to monitor Resident #37's progress and response to therapy. Review of Resident #37's event report dated 11-7-22 revealed Resident #37 had a fall in the facility's dining room while trying to ambulate. The fall was documented as unwitnessed, and Resident #37 complained of mild pain to his left hip. The event report documented staff assisted resident back into his wheelchair. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 was severely cognitively impaired. The MDS also documented the resident needed a wheelchair for ambulation and was documented as having falls, one with a major injury. Nurse #2 was interviewed on 12-7-22 at 12:37pm. Nurse #2 stated she was familiar and usually was assigned to Resident #37. She explained she had not seen any updated interventions on Resident #37's care plan since his fall on 11-7-22 but stated typically the interventions for a resident who falls was for their call bell to be in reach, make sure the resident wears non-skid socks, keep their bed in a low position and increase frequency of rounds. Nurse #2 stated since Resident #37's fall he had not been out of bed, but she had made sure his bed was in a low position and his call light was within reach. The Director of Nursing (DON) was interviewed on 12-7-22 at 1:03pm. The DON explained the management team met every morning and discussed any falls that had taken place the previous day. She said the discussion included making any fall intervention revisions or updates to the resident's care plan. The DON reviewed Resident #37's care plan and stated the only update was made on 12-5-22 for therapy. She further stated Resident #37 should have had revisions or an update made for fall prevention. During an interview with the MDS Coordinator on 12-7-22 at 1:08pm, the MDS Coordinator explained the nurses were responsible for updating the care plan after a resident fall. She further explained she tried to review the care plan during morning meetings to ensure the care plan had been updated but she had not reviewed Resident #37's care plan and was not aware the care plan had not been updated from his fall on 11-7-22. The Administrator was interviewed on 12-8-22 at 9:50am. The Administrator stated she had been aware of the care plan issues and that Resident #37's care plan had not been updated to reflect his fall on 11-7-22. She further stated she expected care plans to be completed timely, be accurate and individualized.

Based on observations and staff interviews the facility administration failed to provide oversight and leadership to ensure the facility maintained the walk-in freezer in proper working condition to prevent structural damage of the freezer door and the accumulation of ice in the freezer for 8 months. The findings included: This tag is cross referenced to: F 908: Based on observations and interviews with facility staff the facility failed to maintain the walk-in freezer in proper working condition when the exterior door malfunctioned and created the accumulation of ice and ice crystals inside the walk-in freezer for the last eight months for 1 of 1 walk-in freezer. On 12/06/22 at 4:30 PM the Administrator provided a copy of the email verification dated 12/06/22 from the Maintenance Director via the computerized maintenance log system of the approved authorization for repair of the walk-in freezer door separating at the bottom. She was unable to state why it had taken 8 months to receive the authorization to repair the walk-in freezer door.

Based on staff, physician, nurse practitioner, and police officer interviews, and record review the facility failed to notify the physician of an open wound that progressively deteriorated from [DATE] through [DATE]. This failure resulted in the resident receiving no physician evaluation of the wound and no physician ordered treatments to the wound. Resident #200 was identified by Emergency Medical Services (EMS) and police on [DATE] to have a large tunneling wound under his left arm at the time of death with no observed dressing present. This was for 1 of 3 residents reviewed for wound care (Resident #200). Immediate Jeopardy began on [DATE] when Resident #200's wound to his left axillary (armpit) opened and the Wound Care Nurse failed to notify the physician or nurse practitioner. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #200 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200's quarterly minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He required extensive assistance with bed mobility and toilet use. He was totally dependent on staff for dressing and personal hygiene. He had two stage II pressure ulcers present upon admission. He had application of non-surgical dressings, pressure ulcer care, and a pressure reducing device to bed and chair. He also had application of ointment and treatments. Review of Resident #200's Treatment Orders and Treatment Administration Records from [DATE] through [DATE]th, 2021 revealed on [DATE] the physician ordered to have Resident #200's left inner armpit cyst, related to hidradenitis, cleansed with normal saline and apply a dry dressing every day. This order was discontinued on [DATE] by Physician #1 and was transcribed by the Wound Care Nurse. A physician note dated [DATE] by Physician #1 revealed Resident #200's hidradenitis had improved with a course of antibiotics and they would resume antibiotics if the inflammation reoccurred. Review of physician and nurse practitioner notes from [DATE] through [DATE] revealed no mention of any wound to Resident #200's left armpit. Review of Resident #200's chart revealed between the time of [DATE] through [DATE] no communication was documented between the facility staff and Physician #1 or Nurse Practitioner #1 related to a wound to Resident #200's left armpit. The EMS record dated [DATE] indicated EMS was dispatched to the facility for Resident #200. He was observed with a large gaping hole in his left armpit that was bleeding. The police case narrative dated [DATE] revealed Police Officer #1 arrived at the facility in response to a death in the facility on [DATE]. Police Officer #1 documented he was informed by EMS upon arrival that it appeared to be a case of neglect based on the deceased 's condition and EMS personnel wanted to ensure a report was on file. Resident #200 had one large open wound under his left arm that was several inches wide and extended up inside his body. The officer documented the open wound that was not bandaged and showed no signs of care. There were additional sores on the resident's side that were smaller but were still noticeable. The officer photographed the body. There were abrasions and sores under his right arm as well though not as pronounced. During an interview on [DATE] at 6:20 PM Police Officer #1 stated he was contacted by his dispatch that EMS had requested an officer respond for an unattended death at the facility. He stated he arrived at 5:03 AM on [DATE] and EMS informed him Resident #200 had several open sores on his body that they discovered when they took off his gown. The most notable sore was to his left armpit. The officer observed the area. The gown that was around that area was soaked in a pink fluid. The wound was approximately two inches wide and three inches long. The wound continued into Resident #200's body towards his head which was open and large enough of a cavity that he could visualize inside the resident's body under his armpit. It was approximately 4 inches deep to his collarbone and was approximately 1.5 inches wide. The cavity ran along the outside of his rib cage and ended at his collarbone. The flesh that was visible in the cavity was a whitish pink. There were additional smaller sores located around the wound. He was informed by EMS that this wound did not have any dressing present when they arrived. He stated the staff could not explain why the wound was not cared for at that time. Review of the police report photographs taken on [DATE] at 5:28 AM at the time of Resident #200's death provided to the surveyor by Police Officer #1 revealed Resident #200 had an open wound under his left armpit. The wound could be observed to be approximately 1.5 inches wide and 2 inches long. Tunneling (Tunneling is when a wound has formed passageways underneath the surface of the skin.) could be observed at 12 o'clock. The tunneling was approximately 0.5 inches in diameter from medial (towards the center of the body) to lateral (away from the center of the body) edges of the tunneling and 1 inch in diameter from anterior (towards the front of the body) to posterior (towards the back of the body) edges of the tunneling. This tunneling extended up under his armpit an indeterminant length as the end of the tunneling was outside of the view of the camera. The wound presented as pale pink and the wound bed had yellow slough present (yellow/white material in the wound bed; usually wet but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound drainage.). During an interview the Wound Care Nurse on [DATE] at 9:43 AM stated she remembered Resident #200. She stated she was the Wound Care Nurse at the time he was at the facility, and he was on her caseload. She further stated on [DATE] the treatment was discontinued to the wound in his left armpit. The Wound Care Nurse stated she informed Nurse Practitioner (NP) #1 Resident #200's wound was not healed, that she was completing the treatment without an order, and that the dressing she was using on the wound would not stay on due to the drainage from the wound. This information was from her recollection and she could not recall the exact timeframe she notified NP #1 of this information. The Wound Care Nurse indicated NP #1 informed her (unable to recall a specific date) to keep an eye on the wound and keep her up to date with any changes, but she had not ordered any treatment. She stated that she recalled notifying NP #1 at some point in [DATE] that the wound continued to not heal. The Wound Care Nurse reported she observed Resident #200's wound and provided the non-ordered treatment to his left armpit up until his death ([DATE]) and it progressively deteriorated. She indicated that a couple of days before Resident #200's death, his left armpit wound had developed an odor. She indicated the wound was the size of a nickel and was about 0.1 centimeters deep. The Wound Care Nurse reported that she told NP #1 about the size and the odor that had developed. She stated it was concerning to her that the wound had deteriorated in size and developed an odor, yet NP #1 had not ordered any care for the wound. She indicated she had not shared this concern with any other staff at the facility. The Wound Care Nurse revealed she had no documentation of any communication with NP #1 related to Resident #200's left armpit wound from [DATE] through [DATE], and she was unable to provide a date of the last time she visualized the wound. During an interview on [DATE] at 10:50 AM Nurse Practitioner #1 stated she remembered Resident #200. She further stated she remembered he had hidradenitis suppurativa especially under his arms. She stated Resident #200 had been given antibiotics a couple of different times when the [CONDITION(S)] were infected. She further stated these areas did not typically open very much and were usually raised with a small area that was draining. She continued to state in [DATE] at the conclusion of his antibiotic treatment she had been told the wounds had gotten better. The Wound Care Nurse's interview that indicated she informed Nurse Practitioner #1 she was completing treatments without an order and that the wound had opened and deteriorated was shared with Nurse Practitioner #1. Nurse Practitioner #1 denied ever being notified after [DATE] by the Wound Care Nurse or any other staff at the facility that the wound to Resident #200's left armpit had opened, deteriorated, or was receiving treatments without orders. She stated if the resident's wound under his left arm had opened, she should have been notified and she would have ordered another round of antibiotic treatment and possible referral to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Practitioner #1 provided a signed statement dated [DATE] which again attested Nurse Practitioner #1 was not aware or notified by any staff that [Resident #200's] wound had opened up or gotten worse since the completion of antibiotics in [DATE]. During an interview on [DATE] at 8:58 AM Physician #1 stated Resident #200 had a condition of hidradenitis which was a chronic problem that was very difficult to control. He further stated the areas to Resident #200's underarms would close and then would rupture and drain. He further stated if one of the wounds was open, he would want to be made aware that the wound was open. The physician indicated he would order antibiotics to attempt to provide treatment to the area and he would leave the area open to allow it to drain better. He stated he was not made aware of any open areas to Resident #200's left armpit and did not know there was a wound to Resident #200's left armpit after [DATE]. During an interview on [DATE] at 1:35 PM the Director of Nursing stated if a wound was open or required treatment the wound should be reported to the nurse practitioner or doctor. She further stated if the Wound Care Nurse had concerns about wound treatments, lack of response from the nurse practitioner or physician, or concerns about wound care in general the Wound Care Nurse could and should inform the Director of Nursing and escalate her concerns with the wound in question. She further stated to her knowledge, Resident #200 was admitted with wounds to his right underarm which eventually closed in September of 2020. He also developed an area under his left arm during his stay that to her knowledge was closed and treatment was completed in September of 2020. She further stated up until his death on [DATE] she was not made aware of any concerns about the skin status of his left armpit. Upon viewing the photographs of Resident #200 supplied by the local police department the Director of Nursing stated a wound of the severity pictured should have been reported to herself as well as the physician or Nurse Practitioner and she was not made aware of the presence of that wound. During an interview on [DATE] at 4:17 PM the Administrator stated she was not aware of any wounds to Resident #200's left armpit. She further stated the Wound Care Nurse was to notify the physician or nurse practitioner of changes to wounds or the presence of new wounds. She stated if the Wound Care Nurse had concerns that a wound was not receiving attention from the physician or nurse practitioner, she should have escalated her concerns to the Administrator and Director of Nursing. She stated the Wound Care Nurse never shared such concerns nor documented such concerns with Resident #200. The Administrator was notified of the immediate jeopardy on [DATE] at 11:03 AM. On [DATE] at 2:02 PM the facility provided the following credible allegation of immediate jeopardy removal. The Removal Plan: F580 · Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On [DATE] the Director of Nursing was notified by the State Surveyor that Resident #200 (whom expired [DATE]) had a wound under his axilla area (armpit) that the Wound nurse stated she had been treating without an order from [DATE] through [DATE]. The Wound nurse stated that she notified the Nurse Practitioner regarding Resident #200's open axilla area and the Nurse Practitioner allegedly stated to the Wound nurse to continue treatments with no order being provided for the treatments. The Wound nurse was unable to provide a date for this notification. The Wound nurse indicated she provided wound treatments to Resident #200 without an order from [DATE] through [DATE]. The Nurse Practitioner stated that she was never notified of any information related to the open axilla area by the facility staff from [DATE] through [DATE] for Resident #200. When the wound nurse was asked where the documentation regarding treatments and Nurse Practitioner notifications were located the wound nurse stated there was none, she did not document and there was not an order to treat from [DATE] through [DATE]. The wound Nurse failed to complete the weekly body observations that included wound assessments and measurements of the wound status for this same period of time. There is no documentation that the wound nurse notified the Nurse Practitioner related to the order or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unaware of the wound nurse was providing treatment without a Physician order. The facility was unaware of the Wound nurse's lack of documentation of assessment, measurements of the wound progression, the Wound nurse was providing treatments without orders, and the lack of notification to the physician/nurse practitioner. Upon arrival to facility on [DATE] the EMS /police noted the resident's axilla area wound condition as a large open wound under left arm that was extended up inside his body. Officer documented he could see ribs and collar bone through the body that was not bandaged. Resident #200 expired on [DATE]. All residents have the potential to suffer a serious adverse outcome as a result of this noncompliance. · 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. The Director of Health Services initiated 100% body audits on all residents within the facility on [DATE]. This audit reveals no wounds without physician/physician extender notification. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding notification to physician and/or physician extender regarding newly identified skin impairments and/or worsening skin impairments for wound treatment orders or all change in conditions (utilizing the Situation, Background, Assessment, Recommendation form when a change in skin impairment or change of condition is noted. This education has been added the Licensed Nurse general orientation upon hire. License Nurses not educated by [DATE] will be educated prior to their next scheduled shift. The Director of Health Services and Nurse Managers educated the Certified Nursing Assistants on daily skin checks during personal care. This education includes notification to the nurse of any skin impairment and/or new dressing noted on resident's skin. The Certified Nursing assistant will utilize a body diagram for nurse notification. This education has been added to the Certified Nursing Assistant general orientation upon hire. Certified Nursing Assistants not educated by [DATE] will be educated prior to their next scheduled shift. Alleged date of IJ Removal [DATE] The credible allegation for Immediate Jeopardy removal was validated on [DATE] which removed the Immediate Jeopardy on [DATE], as evidenced by staff interviews, in-service record reviews, and observation. The in-services included information on notifying the physician about newly identified skin concerns and worsening of known wounds. The facility's Immediate Jeopardy removal date of [DATE] was validated.

Based on staff, physician, nurse practitioner, police officer and emergency medical technician (EMT) interviews, and record review the facility neglected to provide necessary care and services to a resident by failing to effectively assess and monitor an open wound, failing to obtain physician's orders prior to treating the wound, and failing to notify the physician of an open wound that progressively deteriorated from [DATE] through [DATE]. Resident #200 was observed by Emergency Medical Services (EMS) on [DATE] with a large tunneling wound under his left arm at the time of death. This was for 1 of 3 residents reviewed for wound care (Resident #200). Immediate Jeopardy began on [DATE] when the Wound Care Nurse failed to notify the physician of the presence of an open wound to Resident #200's left axillary (armpit), administered a discontinued treatment to the wound, and failed to assess and document the status of the wound. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #200 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200's quarterly minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He required extensive assistance with bed mobility and toilet use. He was totally dependent on staff for dressing and personal hygiene. He had two stage II pressure ulcers present upon admission. He had application of non-surgical dressings, pressure ulcer care, and a pressure reducing device to bed and chair. He also had application of ointment and treatments. Resident #200's care plan dated [DATE] revealed he was care planned to have a pressure ulcer to his sacral area, right axilla, and left and right buttock. There was no mention of a wound to his left armpit. He was also care planned to resist wound treatment care. The interventions included to reiterate the purpose and advantages of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #200's Treatment Orders and Treatment Administration Records from [DATE] through [DATE]th, 2021 revealed on [DATE] the physician ordered to have Resident #200's left inner armpit cyst, related to hidradenitis, cleansed with normal saline and apply a dry dressing every day. The treatments were performed per orders and he refused on ,d+[DATE] through ,d+[DATE] of 2020 and again on ,d+[DATE] through ,d+[DATE] of 2020. This order was discontinued on [DATE] by Physician #1 and was transcribed by the Wound Care Nurse. A physician note dated [DATE] by Physician #1 revealed Resident #200's hidradenitis had improved with a course of antibiotics and they would resume antibiotics if the inflammation reoccurred. Review of physician and nurse practitioner notes from [DATE] through [DATE] revealed no mention of any wound to Resident #200's left armpit. Review of Resident #200's chart revealed between the time of [DATE] through [DATE] no communication was documented between the facility staff and Physician #1 or Nurse Practitioner #1 related to a wound to Resident #200's left armpit. A review of Resident #200's weekly skin assessments from [DATE] to his time of death ([DATE]) revealed no documentation of a wound to his left armpit. There was no documentation of skin check refusals during this time on the skin check assessments. A nursing note dated [DATE] revealed at 4:45 AM Nurse #5 was alerted by Nurse Aide #3 of a change in Resident #200's breathing. The nurse immediately responded and observed Resident #200 in his usual (due to contractures) fetal position, shallow respirations, unresponsive, and with a faint pulse. 911 was notified by the nurse. Resident #200 was found to be without signs of life, cessation of breathing, and no pulse. Cardiopulmonary Resuscitation (CPR) was initiated. EMS arrived at the facility and called time of death at 5:02 am at the facility. The EMS record dated [DATE] indicated EMS was dispatched to the facility and when they arrived on the scene, they found Resident #200 in bed with caregiver providing CPR. He was pulseless and apneic (cessation of breathing) and was warm to the touch. The nurse (Nurse #5) indicated she found Resident #200 not breathing but with a weak pulse. She called another nurse (Nurse #6) from the downstairs unit (the facility had two stories) to stay with Resident #200 while she called 911. Prior to EMS arrival the resident lost his pulse and CPR was initiated by the staff. He had a large gaping hole in his left armpit that was bleeding. It was agreed by EMS personnel to discontinue CPR and call time of death in the facility at 5:02 AM. The local police department was notified. During an interview on [DATE] at 1:03 PM Emergency Medical Technician (EMT) #1 stated he was at the facility on [DATE] for Resident #200. EMT #1 further stated the resident had a gaping, open wound to his left underarm and chest which was about three inches in length and two inches in width. He stated there was some drainage from the wound and it presented as an old wound. He stated the wound was not a fresh laceration but had the appearance of being a wound that had been present prior to the initiation of CPR and had been present for some time. This wound was not bandaged and was wide open. He continued to state even with Resident #200's left arm being held against his body the wound would have been visible to an observer. During an interview on [DATE] at 2:00 PM EMT #2 stated he was dispatched to the facility on [DATE] for a [CONDITION(S)] for Resident #200. The EMTs identified a wound to his left armpit that was in-between a golf ball and baseball sized opening. He stated he did not remember the diameter of the tunneling but that the tunneling could be observed. He stated at the very least there was two inches of depth to this wound's tunneling and noted some green pus drainage to the wound as well as bloody clear pink fluid that was on the blanket that had covered the wound as well. He further stated the wound was not an acute laceration and did not present as having acute trauma as a result of CPR. He further stated it had the appearance of a wound that had been present for quite some time. He stated he did not remember any dressing being in place to the wound on his left armpit. He could not recall if there was an odor to that wound. During an interview on [DATE] at 2:00 PM EMT #3 stated she remembered walking in Resident #200's room on the morning of [DATE]. EMT #3 stated she recalled he had a wound to his left armpit and chest area. The EMT stated a golf ball would have fit the wound due to the depth and size of the wound. She further stated she did not remember if the wound to the underarm was bandaged or not. She stated the wound had some drainage, and the wound had some depth but could not recall exactly how deep or the amount of tunneling if any. EMT #3 concluded based on the appearance of the wound to his underarm she did not believe the wound was a result of CPR and had the appearance of a wound that had been present on Resident #200 for some time. The police case narrative dated [DATE] revealed Police Officer #1 arrived at the facility in response to a death in the facility on [DATE]. Police Officer #1 documented he was informed by EMS upon arrival that it appeared to be a case of neglect based on the deceased 's condition and EMS personnel wanted to ensure a report was on file. Resident #200 had one large open wound under his left arm that was several inches wide and extended up inside his body. The officer documented the open wound that was not bandaged and showed no signs of care. There were additional sores on the resident's side that were smaller but were still noticeable. The officer photographed the body. There were abrasions and sores under his right arm as well though not as pronounced. During an interview on [DATE] at 6:20 PM Police Officer #1 stated he was contacted by his dispatch that EMS had requested an officer respond for an unattended death at the facility. He stated he arrived at 5:03 AM on [DATE] and EMS informed him Resident #200 had several open sores on his body that they discovered when they took off his gown. The most notable sore was to his left armpit. The officer observed the area. The gown that was around that area was soaked in a pink fluid. The wound was approximately two inches wide and three inches long. The wound continued into Resident #200's body towards his head which was open and large enough of a cavity that he could visualize inside the resident's body under his armpit. It was approximately 4 inches deep to his collarbone and was approximately 1.5 inches wide. The cavity ran along the outside of his rib cage and ended at his collarbone. The flesh that was visible in the cavity was a whitish pink. There were additional smaller sores located around the wound. He was informed by EMS that this wound did not have any dressing present when they arrived. He stated the staff could not explain why the wound was not cared for at that time. Review of the police report photographs taken on [DATE] at 5:28 AM at the time of Resident #200's death provided to the surveyor by Police Officer #1 revealed Resident #200 had an open wound under his left armpit. The wound could be observed to be approximately 1.5 inches wide and 2 inches long. Tunneling (Tunneling is when a wound has formed passageways underneath the surface of the skin) could be observed at 12 o'clock. The tunneling was approximately 0.5 inches in diameter from medial (towards the center of the body) to lateral (away from the center of the body) edges of the tunneling and 1 inch in diameter from anterior (towards the front of the body) to posterior (towards the back of the body) edges of the tunneling. This tunneling extended up under his armpit an indeterminant length as the end of the tunneling was outside of the view of the camera. The wound presented as pale pink and the wound bed had yellow slough present (yellow/white material in the wound bed; usually wet but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound drainage.). During an interview on [DATE] at 4:46 PM Nurse #6 stated she remembered Resident #200. She stated he refused a lot of care, but she did not have him on her caseload often. She further stated she did not really remember the morning when she initiated CPR ([DATE]) on Resident #200 or him passing away. She stated she did not remember [CONDITION(S)] under his arms or if they started bleeding while she provided CPR. During an interview on [DATE] at 3:17 PM Nurse #5 stated she remembered Resident #200. She further stated he was a very quiet gentleman who did not like to be bothered. She further stated she did not specifically remember him passing away on her shift or details of that night ([DATE]). She further stated Resident #200 had open wounds under his arm but could not remember if it was both arms or one arm. She concluded she could not remember the wound's appearance under his arm or arms. During an interview the Wound Care Nurse on [DATE] at 9:43 AM stated she remembered Resident #200. She stated she was the Wound Care Nurse at the time he was at the facility, and he was on her caseload. She indicated he refused care at times, explaining he would not allow them to do anything on certain days and other days he would allow treatment to be provided. She indicated she was providing wound care to his left underarm and on [DATE] the treatment was discontinued. She revealed she continued to provide care to the wound because it was open. She was unable to recall why the treatment was discontinued by the Nurse Practitioner as the wound had not improved and had not healed at that time. She further revealed that until Resident #200's death ([DATE]) she continued to provide the discontinued treatment without orders. She stated she had not documented this treatment to the left armpit wound in the medical record from [DATE] through [DATE]. The Wound Care Nurse spoke about the treatment she provided. She indicated she cleaned the wound with skin integrity wound cleanser and patted dry and applied a dry dressing. She placed an adhesive foam dressing over this due to the fact it drained a lot. She explained he had purulent drainage and weeping from the wound under his left arm. She further explained the dressing would not stay on due to the drainage from the wound. She revealed she had not completed any assessments or wound measurements of the left armpit wound for Resident #200 from [DATE] through [DATE]. The Wound Care Nurse stated she informed Nurse Practitioner (NP) #1 Resident #200's wound was not healed, that she was completing the treatment without an order, and that the dressing she was using on the wound would not stay on due to the drainage from the wound. This information was from her recollection and she could not recall the exact timeframe she notified NP #1 of this information. The Wound Care Nurse indicated NP #1 informed her (unable to recall a specific date) to keep an eye on the wound and keep her up to date with any changes, but she had not ordered any treatment. She stated that she recalled notifying NP #1 at some point in [DATE] that the wound continued to not heal. She reported NP #1 saw the resident in [DATE] but had not visualized the wound to his left armpit as it had a dressing over it. The Wound Care Nurse reported she observed Resident #200's wound and provided the non-ordered treatment to his left armpit up until his death ([DATE]) and it progressively deteriorated. She indicated that a couple of days before Resident #200's death, his left armpit wound had developed an odor. She indicated the wound was the size of a nickel and was about 0.1 centimeters deep. The Wound Care Nurse reported that she told NP #1 about the size and the odor that had developed. She stated it was concerning to her that the wound had deteriorated in size and developed an odor, yet NP #1 had not ordered any care for the wound. She indicated she had not shared this concern with any other staff at the facility. The Wound Care Nurse revealed she had no documentation of any communication with NP #1 related to Resident #200's left armpit wound from [DATE] through [DATE], and she was unable to provide a date of the last time she visualized the wound. This interview with the Wound Care Nurse ([DATE] at 9:43 AM) continued. The Wound Care Nurse indicated she worked every Monday through Friday and every other weekend. Nurses for the unit would do the wound care when she was not working. She revealed because there was no physician's order for treatment to Resident #200's open left armpit wound from [DATE] through [DATE], the staff working when she was not in the facility would not have provided him with treatment. She explained she had not verbally gone to the nurses and informed them of the dressing change she was doing for Resident #200's left armpit wound that was not ordered by the physician. During an interview on [DATE] at 10:50 AM Nurse Practitioner #1 stated she remembered Resident #200. She further stated she remembered he had hidradenitis suppurativa especially under his arms. She stated Resident #200 had been given antibiotics a couple of different times when the [CONDITION(S)] were infected. She stated he had some scarring which she believed had been from a past surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated when he first arrived at the facility in June through September of 2020, he always had an odor from those wounds under his arms and the times he did allow her to visualize the wounds, they had drainage. She stated at those times she had put him on antibiotics. She stated he received [MEDICATION(S)] [DATE] through [DATE]. He had [MEDICATION(S)] [DATE] through [DATE]. [MEDICATION(S)] [DATE] through [DATE]. [MEDICATION(S)] [DATE] through [DATE]. [MEDICATION(S)] [DATE] through [DATE]. She further stated these areas did not typically open very much and were usually raised with a small area that was draining. She stated she did not order the wound treatment to be discontinued due to his refusals. She stated even if a resident refused something every day, she would ensure staff were offering the treatment and would not discontinue it. She continued to state in [DATE] at the conclusion of his antibiotic treatment she had been told the wounds had gotten better. The Wound Care Nurse's interview that indicated she informed Nurse Practitioner #1 she was completing treatments without an order and that the wound had opened and deteriorated was shared with Nurse Practitioner #1. Nurse Practitioner #1 denied ever being notified after [DATE] by the Wound Care Nurse or any other staff at the facility that the wound to Resident #200's left armpit had opened, deteriorated, or was receiving treatments without orders. She stated if the resident's wound under his left arm had opened, she should have been notified and she would have ordered another round of antibiotic treatment and possible referral to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Practitioner #1 provided a signed statement dated [DATE] which again attested Nurse Practitioner #1 was not aware or notified by any staff that [Resident #200's] wound had opened up or gotten worse since the completion of antibiotics in [DATE]. During an interview on [DATE] at 8:58 AM Physician #1 stated Resident #200 had a condition of hidradenitis which was a chronic problem that was very difficult to control. He further stated the areas to Resident #200's underarms would close and then would rupture and drain. He further stated if one of the wounds was open, he would want to be made aware that the wound was open. The physician indicated he would order antibiotics to attempt to provide treatment to the area and he would leave the area open to allow it to drain better. He stated he was not made aware of any open areas to Resident #200's left armpit and did not know there was a wound to Resident #200's left armpit after [DATE]. During a follow up interview on [DATE] at 12:33 PM Physician #1 stated upon review of the photographs supplied by the local police department of the wound to Resident #200's left armpit that he or his nurse practitioner should have been made aware of the presence and severity of such a wound. He further indicated he could not say how quickly a wound such as the one in the photograph could take to develop. He further stated he did not recall discontinuing Resident #200's orders for treatment to his wound on his left armpit but if the nurse had made the recommendation to discontinue the treatment he would have signed off on their recommendation. He further stated he would not have told the Wound Care Nurse to continue administering a discontinued treatment and did not believe Nurse Practitioner #1 would have requested the Wound Care Nurse to continue administering a discontinued treatment as well. He further stated he did not understand why the Wound Care Nurse would not have gotten an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician stated he felt the wound had a severe appearance in the photographs and did not know why the Wound Care Nurse did not have measurements, treatment records, and weekly wound assessments if she was following the wound. He stated due to the lack of documentation it was impossible to know if or when the wound was or was not present or the severity of the wound until the time of the photographs by the police department. He stated wounds should be documented and reported to him or the nurse practitioner if there was a need for wound treatment. He expressed he was at a loss as to why the Wound Care Nurse did not request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 11:34 AM Nurse Aide #5 stated she remembered Resident #200. She stated he required total care, and he did not speak much but he was able to make his needs known when he wanted to. She further stated he would let staff provide activities of daily living care, but he did not like to be bothered most of the time. She continued to state he did have open wounds in one or both underarms and nursing was aware of those wounds. She stated during morning care she was aware of those wounds because she had to take care while cleansing around the wound area. She could not remember if there were ever dressings on his wound under his arm or not. During an interview on [DATE] at 8:42 AM Nurse Aide #1 stated she remembered caring for him leading up to his death. She recalled a wound to one of his armpits that was oozing something like pus. The nurse aide reported she notified Nurse #5 on multiple occasions (unable to recall specific dates) of the oozing and the nurse went and looked at the wound when notified. She reported she had not recalled seeing the left arm pit wound with a dressing on it at any point in the weeks leading up to his death. During an interview on [DATE] at 11:56 AM Nurse Aide #2 stated she remembered Resident #200 had a wound under one of his arms. She did not remember if there were ever any dressings to the wound she noted under his arm. She stated the area was about the size of a dime with no depth and it had some drainage that was like pus. This wound was present through the end of his stay in the facility to her knowledge. During an interview on [DATE] at 1:35 PM the Director of Nursing stated if a wound was open or required treatment the wound should be reported to the nurse practitioner or doctor. The doctor had to sign off on all treatments so he would be made aware of treatments. She further stated wound treatment should not be done without an order and if the Wound Care Nurse deemed a wound needed to have continued treatment, she should request the order be continued or changed depending on the situation. She further stated if the Wound Care Nurse had concerns about wound treatments, lack of response from the nurse practitioner or physician, or concerns about wound care in general the Wound Care Nurse could and should inform the Director of Nursing and escalate her concerns with the wound in question. She stated to her knowledge, Resident #200 was admitted with wounds to his right underarm which eventually closed in September of 2020. He also developed an area under his left arm during his stay that to her knowledge was closed and treatment was completed in September of 2020. She further stated up until his death on [DATE] she was not made aware of any concerns about the skin status of his left armpit. She stated the Wound Care Nurse according to the records had discontinued the order to the left armpit as of [DATE] and did not document a reason. Upon viewing the photographs of Resident #200 supplied by the local police department the Director of Nursing stated a wound of the severity pictured should have been reported to herself, the physician or Nurse Practitioner, and responsible party and she was not made aware of the presence of that wound. She stated that identified wounds were to be assessed, monitored, and documented. She concluded wound measurements were part of the assessments to follow the wound progress. During an interview on [DATE] at 4:17 PM the Administrator stated she was not aware of any wounds to Resident #200's left armpit. She further stated the Wound Care Nurse should not provide treatments without orders. She stated the Wound Care Nurse should acquire wound care orders when she deemed wound treatment was needed. She stated if the Wound Care Nurse had concerns that a wound was not receiving attention from the physician or nurse practitioner, she should have escalated her concerns to the Administrator and Director of Nursing. She stated the Wound Care Nurse never shared such concerns nor documented such concerns about Resident #200. The Administrator was notified of the immediate jeopardy on [DATE] at 9:21 AM. On [DATE] at 2:09 PM the facility provided the following credible allegation of immediate jeopardy removal. The Removal Plan: F600 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On [DATE] the Director of Nursing was notified by the State Surveyor that Resident #200 (whom expired [DATE]) had a wound under his axilla area (armpit) that the Wound nurse stated she had been treating without an order from [DATE] through [DATE]. The Wound nurse stated that she notified the Nurse Practitioner regarding Resident #200's open axilla area and the Nurse Practitioner allegedly stated to the Wound nurse to continue treatments with no order being provided for the treatments. The Wound nurse was unable to provide a date for this notification. The Wound nurse indicated she provided wound treatments to Resident #200 without an order from [DATE] through [DATE]. The Nurse Practitioner stated that she was never notified of any information related to the open axilla area by the facility staff from [DATE] through [DATE] for Resident #200. When the wound nurse was asked where the documentation regarding treatments and Nurse Practitioner notifications were located the wound nurse stated there was none, she did not document and there was not an order to treat from [DATE] through [DATE]. The wound Nurse failed to complete the weekly body observations that included wound assessments and measurements of the wound status for this same period of time. There is no documentation that the wound nurse notified the Nurse Practitioner related to the order or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unaware of the wound nurse was providing treatment without a Physician order. Weekly skin assessments from [DATE] through [DATE] failed to identify Resident #200's open wound to the axilla area. The facility was unaware of the Wound nurse's lack of documentation of assessment, measurements of the wound progression, the Wound nurse was providing treatments without orders, and the lack of notification to the physician/nurse practitioner. The facility was unaware of the failure of nurses to identify the open wound during weekly skin assessments from [DATE] through [DATE]. Upon arrival to facility on [DATE] the EMS /police noted the resident's axilla area wound condition as a large open wound under left arm that was extended up inside his body. Officer documented he could see ribs and collar bone through the body that was not bandaged. Resident #200 expired on [DATE]. All residents have the potential to suffer a serious adverse outcome as a result of this noncompliance. 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 The Administrator completed a 24-hour report to the State Agency regarding neglect on [DATE] when she was notified of the concern regarding the axilla (armpit) wound and no documentation of same. The Wound Nurse was suspended pending investigation on [DATE] and terminated on [DATE]. The wound Nurse was reported to the North Carolina Board of Nursing on [DATE] for professional standards violations. The Clinical Competency Coordinator and/or Nurse Management began education on [DATE] for Licensed Nurses regarding abuse and neglect with emphasis on provision of care and services, wound care including assessment, measurement, and notification to physician/physician extender. This education included that treatments were not to be provided without a physician's order and that all provided treatments were to be documented. This education included that the failure of the facility, its employees, or service providers to provide the care necessary to avoid physical harm constitutes neglect. The Licensed Nurses not educated by [DATE] will be educated prior to their next scheduled shift. This education has been added to the general orientation upon hire. The Clinical Competency Coordinator and/or Nurse Managers began educating the Certified Nursing Assistants that the failure of the facility, its employees, or service providers to provide the care necessary to avoid physical harm constitutes neglect. The Certified Nursing Assistants not educated by [DATE] will be educated prior to their next scheduled shift. This education has been added to the general orientation of certified Nursing Assistants. The Director of Health Services initiated 100% body audits on all residents within the facility on [DATE]. This audit reveals no wounds without orders or without physician/physician extender notification. If any resident is noted without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and/or Nurse Managers have reviewed the wound audit conducted on [DATE] and reviewed the documentation to ensure residents with skin impairments had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and Nurse Managers reviewed residents with wounds to ensure weekly documentation including ongoing assessments with wound measurements are currently in place, documented accurately and physician / physician extender notification. Review of documentation identified no residents without wound documentation at this point in time and the current wound observations are accurate. The Director of Health Services and Nurse Managers educated the Licensed Nurses regarding accuracy of weekly body observations to include identification of any dressing noted or skin impairment noted on the resident body. This education has been added the License Nurse general orientation upon hire. License Nurses not educated by [DATE] will be educated prior to their next scheduled shift. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding notification to physician and/or physician extender regarding newly identified skin impairments and/or worsening skin impairments for wound treatment orders. This education has been added the License Nurse general orientation upon hire. License Nurses not educated by [DATE] will be educated prior to their next scheduled shift. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding notification to Resident responsible party regarding newly identified skin impairments and/or worsening skin impairments and new wound treatment orders. This education has been added the License Nurse general orientation upon hire. License Nurses not educated by [DATE] will be educated prior to their next scheduled shift. The Director of Health Services and Nurse Managers educated the Certified Nursing Assistants on daily skin checks during personal care. This education includes notification to the nurse of any skin impairment and/or new dressing note [TRUNCATED]

Based on staff, physician, nurse practitioner, police officer and emergency medical technicians (EMT) interviews, and record review the facility failed to obtain physician's orders prior to treating a wound and failed to identify, assess, and monitor a wound to determine the need for medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200 was identified by Emergency Medical Technicians (EMT) and police on [DATE] to have a large tunneling wound under his left arm at the time of death with no observed dressing present. This was for 1 of 3 residents reviewed for wound care (Resident #200). Immediate Jeopardy began on [DATE] when Resident #200's wound to his left axillary (armpit) opened and the Wound Care Nurse administered a discontinued treatment to the wound and failed to assess and document the status of the wound. During this time, staff failed to identify, report, and document this wound on weekly skin assessments. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #200 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200's quarterly minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He required extensive assistance with bed mobility and toilet use. He was totally dependent on staff for dressing and personal hygiene. He had two stage II pressure ulcers present upon admission. He had application of non-surgical dressings, pressure ulcer care, and a pressure reducing device to bed and chair. He also had application of ointment and treatments. Resident #200's care plan dated [DATE] revealed he was care planned to have a pressure ulcer to his sacral area, right axilla, and left and right buttock. There was no mention of a wound to his left armpit. He was also care planned to resist wound treatment care. The interventions included to reiterate the purpose and advantages of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #200's Treatment Orders and Treatment Administration Records from [DATE] through [DATE]th, 2021 revealed he was ordered on [DATE] to have his left inner armpit cyst, related to hidradenitis, cleansed with normal saline and apply a dry dressing every day. This order was discontinued on [DATE]. The order was discontinued by Physician #1 and transcribed by the Wound Care Nurse. A review of the physician and Nurse Practitioner (NP) notes from [DATE] through [DATE] revealed no reference to Resident #200's left armpit wound. Further review of the medical record revealed no documentation of the wound to his left armpit from [DATE] through [DATE]. There were no assessments or measurements of the wound. A review of Resident #200's weekly skin assessments from [DATE] to his time of death ([DATE]) revealed no documentation of a wound to his left armpit. There was no documentation of skin check refusals during this time on the skin check assessments. On [DATE] a skin check completed by Nurse #1 indicated Resident #200 had alterations in skin. There was no further documentation. On [DATE] a skin check completed by Nurse #3 indicated Resident #200 had alterations to his skin. The comment note indicated the skin alteration was to the resident's sacrum. On [DATE] a skin check completed by Nurse #4 indicated Resident #200 had no alterations to his skin. A nursing note dated [DATE] revealed at 4:45 AM Nurse #5 was alerted by Nurse Aide #3 of a change in Resident #200's breathing. The nurse immediately responded and observed Resident #200 in his usual (due to contractures) fetal position, shallow respirations, unresponsive, and with a faint pulse. 911 was notified by the nurse. Resident #200 was found to be without signs of life, cessation of breathing, and no pulse. Cardiopulmonary Resuscitation (CPR) was initiated. EMS arrived at the facility and called time of death at 5:02 AM at the facility. The EMS record dated [DATE] indicated EMS was dispatched to the facility for Resident #200. He had a large gaping hole in his left armpit that was bleeding. It was agreed by EMS personnel to discontinue CPR and call time of death in the facility at 5:02 AM. The local police department was notified. During an interview on [DATE] at 1:03 PM Emergency Medical Technician (EMT) #1 stated he was at the facility on [DATE] for Resident #200. EMT #1 further stated the resident had a gaping, open wound to his left underarm and chest which was about three inches in length and two inches in width. He stated there was some drainage from the wound and it presented as an old wound. He stated the wound was not a fresh laceration but had the appearance of being a wound that had been present prior to the initiation of CPR and had been present for some time. This wound was not bandaged and was wide open. He continued to state even with Resident #200's left arm being held against his body the wound would have been visible to an observer. During an interview on [DATE] at 2:00 PM EMT #2 stated he was dispatched to the facility on [DATE] for a [CONDITION(S)] for Resident #200. The EMTs identified a wound to his left armpit that was in-between a golf ball and baseball sized opening. He stated he did not remember the diameter of the tunneling but that the tunneling could be observed. He stated at the very least there was two inches of depth to this wound ' s tunneling and noted some green pus drainage to the wound as well as bloody clear pink fluid that was on the blanket that had covered the wound as well. He further stated the wound was not an acute laceration and did not present as having acute trauma as a result of CPR. He further stated it had the appearance of a wound that had been present for quite some time. He stated he did not remember any dressing being in place to the wound on his left armpit. He could not recall if there was an odor to that wound. During an interview on [DATE] at 2:00 PM EMT #3 stated she remembered walking in Resident #200's room on the morning of [DATE]. EMT #3 stated she recalled he had a wound to his left armpit and chest area. The EMT stated a golf ball would have fit the wound due to the depth and size of the wound. She further stated she did not remember if the wound to the underarm was bandaged or not. She stated the wound had some drainage, and the wound had some depth but could not recall exactly how deep or the amount of tunneling if any. EMT #3 concluded based on the appearance of the wound to his underarm she did not believe the wound was a result of CPR and had the appearance of a wound that had been present on Resident #200 for some time. The police case narrative dated [DATE] revealed Police Officer #1 arrived at the facility in response to a death in the facility on [DATE]. Police Officer #1 documented he was informed by EMS upon arrival that it appeared to be a case of neglect based on the deceased 's condition and EMS personnel wanted to ensure a report was on file. Resident #200 had one large open wound under his left arm that was several inches wide and extended up inside his body. The officer documented the open wound that was not bandaged and showed no signs of care. There were additional sores on the resident's side that were smaller but were still noticeable. The officer photographed the body. There were abrasions and sores under his right arm as well though not as pronounced. During an interview on [DATE] at 6:20 PM Police Officer #1 stated he was contacted by his dispatch that EMS had requested an officer respond for an unattended death at the facility. He stated he arrived at 5:03 AM on [DATE] and EMS informed him Resident #200 had several open sores on his body that they discovered when they took off his gown. The most notable sore was to his left armpit. The officer observed the area. The gown that was around that area was soaked in a pink fluid. The wound was approximately two inches wide and three inches long. The wound continued into Resident #200's body towards his head which was open and large enough of a cavity that he could visualize inside the resident's body under his armpit. It was approximately 4 inches deep to his collarbone and was approximately 1.5 inches wide. The cavity ran along the outside of his rib cage and ended at his collarbone. The flesh that was visible in the cavity was a whitish pink. There were additional smaller sores located around the wound. He was informed by EMS that this wound did not have any dressing present when they arrived. He stated the staff could not explain why the wound was not cared for at that time. Review of the police report photographs taken on [DATE] at 5:28 AM at the time of Resident #200's death provided to the surveyor by Police Officer #1 revealed Resident #200 had an open wound under his left armpit. The wound could be observed to be approximately 1.5 inches wide and 2 inches long. Tunneling (Tunneling is when a wound has formed passageways underneath the surface of the skin.) could be observed at 12 o'clock. The tunneling was approximately 0.5 inches in diameter from medial (towards the center of the body) to lateral (away from the center of the body) edges of the tunneling and 1 inch in diameter from anterior (towards the front of the body) to posterior (towards the back of the body) edges of the tunneling. This tunneling extended up under his armpit an indeterminant length as the end of the tunneling was outside of the view of the camera. The wound presented as pale pink and the wound bed had yellow slough present (yellow/white material in the wound bed; usually wet but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound drainage.). During an interview on [DATE] at 9:43 AM the Wound Care Nurse stated she remembered Resident #200. She stated she was the wound care nurse at that time, and he was on her caseload. She indicated she was providing wound care to his cyst to his left underarm and on [DATE] the treatment was discontinued but she continued to provide care to the wound because it was open. She was unable to recall why the treatment was discontinued by the Nurse Practitioner on [DATE] as the wound had not improved and had not healed at that time. She revealed that until his death ([DATE]) she continued to provide the discontinued treatment without orders. She stated she had not documented this treatment to the wound in the medical record from [DATE] through [DATE]. She indicated she had not completed any assessments or wound measurements from [DATE] through [DATE]. She visualized the wound and provided the non-ordered treatment to his left armpit up until his death and it was progressively deteriorating till his death on [DATE]. The Wound Care Nurse indicated she worked every Monday through Friday and every other weekend and the nurses for the unit complete the wound care when she was not working. She stated because there was no physician's order for the treatment the staff working when she was not in the facility would not have known to do the dressing change to the left armpit of Resident #200. She stated she had not verbally gone to the nurses and informed them of the dressing change she was doing for him that was not ordered by the physician. She stated a couple of days before his death his left armpit wound had developed an odor. She stated it was concerning to her that the wound had deteriorated in size and developed an odor and she notified Nurse Practitioner #1 verbally, but Nurse Practitioner #1 did not write a new order or do anything for the wound. She stated she did not share this concern with anyone or document the interactions or concerns. During an interview on [DATE] at 10:50 AM Nurse Practitioner #1 stated she remembered Resident #200. She stated in [DATE] Resident #200 completed antibiotic treatment and she had been told the wounds had gotten better. She indicated she had not known Resident #200's wound progressively deteriorated from [DATE] through [DATE] nor had she known the Wound Care Nurse was completing treatments without orders. She stated that orders were to be obtained prior to treatments being completed. The Wound Care Nurse's interview that indicated she informed NP #1 she was completing treatments without an order and that the wound had opened and deteriorated was shared with NP #1. She denied ever being notified after [DATE] by staff at the facility that the wound to Resident #200's left armpit had opened, deteriorated, or was receiving treatments without orders. NP #1 was informed that no assessments or measurements of the wound were completed from [DATE] through [DATE] despite the Wound Care Nurse being aware of the wound. She stated that identified wounds were to be assessed and monitored. She indicated without documented assessments there was no way to ascertain if there were changes in the wound that would require a change in the treatment plan. During an interview on [DATE] at 12:33 PM with Physician #1 the Wound Care Nurse's interview in which she reported that she completed treatments with no physician's order from [DATE] through [DATE] as well as her statement that she completed no assessments or measurement of the wounds throughout this same time period were reviewed with the physician. He stated that orders were to be obtained prior to treatments being completed and identified wounds were to be assessed, monitored, and documented. He stated wound measurements were part of the assessment. He indicated without assessments and measurements there was no way to determine if there were changes in the wound that would require a change in the treatment plan. He further stated he was unable to understand why the Wound Care Nurse would not have gotten an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He indicated that neither he nor the nurse practitioner would ever deny an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 during interview. He stated he was unsure if the wound could have developed after his death or how long it would have taken to develop such a wound. The Physician stated he felt the wound had a severe appearance in the photographs and had reiterated he had not known why the wound care nurse had no measurements, treatment records, or weekly wound assessments if she was following the wound. He stated due to the lack of documentation it was impossible to know if and when the wound was or was not present or the severity of the wound until the time of the photographs by the police department. During an interview on [DATE] at 1:35 PM the Director of Nursing stated wound treatment should not be done without and order and if the wound care nurse deemed a wound needed to have continued treatment, she should request the order be continued or changed depending on the situation. Identified wounds were to be assessed, monitored, and documented. She concluded wound measurements were part of the assessments in order to follow the wound progress. During an interview on [DATE] at 10:32 AM Nurse #1 stated she did skin check for Resident #200 but did not remember him very well. She stated from [DATE] through [DATE] Resident #200 was on her assignment for weekly skin checks. She stated she did not remember why she checked yes for skin alteration on [DATE]. She stated she did not identify any wounds under his arms during her skin assessments of the resident and if she had noted any wounds to his armpits, she would have documented it and notified the wound nurse. She stated if he had refused his weekly skin assessments, she would have documented the assessment as refused, therefore he did not refuse his weekly skin assessments as she had documented them as completed. She stated a full head to toe skin check included observing the skin of a resident from top to bottom and then turning the resident to check the skin on their back. She stated she usually observed under the arm for skin assessments but could not remember in Resident #200's case if she observed under his arm during his skin assessment. During an interview on [DATE] at 11:44 AM Nurse #3 stated she did remember Resident #200. She stated she did a skin check on [DATE] and noted he had a pressure ulcer wound to his sacrum. Resident #200 was able to raise his arms and she did not identify any wound under his left arm. She further stated had she identified any alterations to his skin under his left arm and armpit she would have documented it on her skin assessment and notified the wound care nurse. The nurse stated if Resident #200 had refused his skin check she would have documented the skin check as refused. She stated because she documented his skin check as complete, he did not refuse his skin assessment on [DATE]. During an interview on [DATE] at 12:30 PM Nurse #4 stated she did a skin check on Resident #200. She stated she could not remember the date but if the documented date was [DATE] then that was when she did the skin check. She stated if she documented no alterations in skin that meant that he did not have any wounds present. She further stated she did not identify any wound to his left underarm or she would have documented the wound and notified the wound care nurse. She stated she could not remember if there were dressings on his left armpit or not but if she saw issues with his skin, she would have documented them. She stated he did not refuse the skin assessment, or she would not have documented the skin check as complete. During an interview on [DATE] at 9:55 AM The Director of Nursing stated if a wound was present under Resident #200's arm at the time they did their skin assessments, it should have been documented and reported to the wound care nurse and nurse on the hall who would be responsible for notifying the Physician, responsible party, and Director of Nursing. If the wound was present at the time of these skin checks she did not know why they did not identify the wound. The Administrator was notified of the immediate jeopardy on [DATE] at 2:49 PM. On [DATE] at 12:51 PM the facility provided the following credible allegation of immediate jeopardy removal. The Removal Plan: F684 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance, and. On [DATE] the Director of Nursing was notified by the State Surveyor that Resident #200 (whom expired [DATE]) had a wound under his axilla area (armpit) that the Wound nurse stated she had been treating without an order from [DATE] through [DATE]. The Wound nurse stated that she notified the Nurse Practitioner regarding Resident #200's open axilla area and the Nurse Practitioner allegedly stated to the Wound nurse to continue treatments with no order being provided for the treatments. The Wound nurse was unable to provide a date for this notification. The Wound nurse indicated she provided wound treatments to Resident #200 without an order from [DATE] through [DATE]. The Nurse Practitioner stated that she was never notified of any information related to the open axilla area by the facility staff from [DATE] through [DATE] for Resident #200. When the wound nurse was asked where the documentation regarding treatments and Nurse Practitioner notifications were located the wound nurse stated there was none, she did not document and there was not an order to treat from [DATE] through [DATE]. The wound Nurse failed to complete the weekly body observations that included wound assessments and measurements of the wound status for this same period of time. There is no documentation that the wound nurse notified the Nurse Practitioner related to the order or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unaware of the wound nurse was providing treatment without a Physician order. The facility was unaware of the Wound nurse's lack of documentation of assessment, measurements of the wound progression, the Wound nurse was providing treatments without orders, and the lack of notification to the physician/nurse practitioner. Upon arrival to facility on [DATE] the EMS /police noted the resident's axilla area wound condition as a large open wound under left arm that was extended up inside his body. Officer documented he could see ribs and collar bone through the body that was not bandaged. Resident #200 expired on [DATE]. All residents have the potential to suffer a serious adverse outcome as a result of this noncompliance. 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 completed a 24-hour report to the State Agency regarding neglect on [DATE] when she was notified of the concern regarding the axilla wound and no documentation of same. The Wound Nurse was suspended pending investigation on [DATE] and terminated on [DATE]. The wound Nurse was reported to the North Carolina Board of Nursing on [DATE] for professional standards violations. The Director of Health Services initiated 100% body audits on all residents within the facility on [DATE]. This audit reveals no wounds without physician/physician extender notification. If any resident is noted without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and/or Nurse Managers have reviewed the wound audit conducted on [DATE] and reviewed the documentation to ensure residents with skin impairments had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documentation identified no residents without documentation at this point in time. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding weekly skin observations and documentation in the electronic health record of same. When a new skin impairment is noted, the Licensed nurse will complete the wound documentation in the electronic medical record that includes description and measurement of area ,and contact the physician/physician extender for orders, regarding newly identified skin impairments and/or worsening skin impairments for wound treatment orders. This includes that the assessments and measurements were necessary as a monitoring tool to determine if there are any changes in the wound that would require a change in the treatment plan. This education has been added to the License Nurse general orientation upon hire. Any Licensed Nurse will not be allowed to work after [DATE] until they receive the education. The new Wound Nurse and the Nurse Practitioner are meeting weekly to discuss and review all residents with wounds. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding completing weekly skin observation and wound management notes including description and measurements of skin impairments weekly. This education has been added the License Nurse general orientation upon hire. Any Licensed Nurse will not be allowed to work after [DATE] until they receive the education. The Director of Health Services and Nurse Managers educated the Certified Nursing Assistants on daily skin checks during personal care. This education includes notification to the nurse of any skin impairment and/or new dressing noted on resident ' s skin. The Certified Nursing assistant will utilize a body diagram for nurse notification. This education has been added to the Certified Nursing Assistant general orientation upon hire. Any Certified Nursing Assistant will not be allowed to work after [DATE] until they receive the education. The Clinical Competency Coordinator/RN is responsible for ensuring education is completed prior to the start of any Licensed Nurse and/or Certified Nursing Assistant working the floor after [DATE]. Alleged date of IJ Removal [DATE] The credible allegation for Immediate Jeopardy removal was validated on [DATE] which removed the Immediate Jeopardy on [DATE], as evidenced by staff interviews, in-service record reviews, and observation. The in-services included information on providing wound care treatments according to physician orders, wound assessments, wound measurements, and identification of new wounds and skin assessments. The facility's Immediate Jeopardy removal date of [DATE] was validated.

Based on staff, physician, nurse practitioner, police officer and emergency medical technician (EMT) interviews, and record review the facility nursing staff failed to demonstrate competency and skill sets to effectively manage a resident ' s wound and to report a change in wound condition to the physician for evaluation of a wound that progressively deteriorated for more than a 3-month period of time. Resident #200 was identified by Emergency Medical Technicians (EMT) and police on [DATE] to have a large tunneling wound under his left arm at the time of death with no observed dressing present. This was for 1 of 3 residents reviewed for wound care (Resident #200). Immediate Jeopardy began on [DATE] when Resident #200's wound to his left axillary (armpit) opened and the Wound Care Nurse administered a discontinued treatment to the wound and failed to assess and document the status of the wound according to her training. During this time, staff trained on skin assessments failed to identify, report, and document this wound on weekly skin assessments. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: This tag is cross referenced to: Tag F580 - Based on staff, physician, nurse practitioner, and police officer interviews, and record review the facility failed to notify the physician of an open wound that progressively deteriorated from [DATE] through [DATE]. This failure resulted in the resident receiving no physician evaluation of the wound and no physician ordered treatments to the wound. Resident #200 was identified by Emergency Medical Services (EMS) and police on [DATE] to have a large tunneling wound under his left arm at the time of death with no observed dressing present. This was for 1 of 3 residents reviewed for wound care (Resident #200). Tag F600 - Based on staff, physician, nurse practitioner, police officer and emergency medical technician (EMT) interviews, and record review the facility neglected to provide necessary care and services to a resident by failing to effectively assess and monitor an open wound, failing to obtain physician ' s orders prior to treating the wound, and failing to notify the physician of an open wound that progressively deteriorated from [DATE] through [DATE]. Resident #200 was observed by Emergency Medical Services (EMS) on [DATE] with a large tunneling wound under his left arm at the time of death. This was for 1 of 3 residents reviewed for wound care (Resident #200). Tag F684 - Based on staff, physician, nurse practitioner, police officer and emergency medical technicians (EMT) interviews, and record review the facility failed to obtain physician ' s orders prior to treating a wound and failed to identify, assess, and monitor a wound to determine the need for medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200 was identified by Emergency Medical Technicians (EMT) and police on [DATE] to have a large tunneling wound under his left arm at the time of death with no observed dressing present. This was for 1 of 3 residents reviewed for wound care (Resident #200). During an interview on [DATE] at 3:26 PM Nurse #3 stated when she was hired, she was trained on weekly skin checks. She further stated they were to do a head-to-toe assessment. She stated she would start with the resident ' s head and observe the integrity of the skin to the resident ' s head. She stated while checking their head she would palpate their neck to check their glands. She stated and then they would have the resident raise their arms and observe the skin under their arms. Then she would inspect their chest and then peri-area and groin. Then she would check legs and feet. Then the resident would be turned over and they would check the back and the gluteal fold and legs. She stated she performed the skin assessment on [DATE] and noted his skin issue to Resident #200 ' s sacrum. Upon being informed of the wound care nurse ' s description of the wound as well as the description by police and EMT at the time of his death she stated she did not recall identifying such a wound. She further stated she could not explain why the wound would not have been documented in her assessment if it had been present. She denied having any knowledge of the presence of or beginning of a wound to his left underarm in her skin assessment she completed on [DATE]. During an interview on [DATE] at 4:42 PM Nurse #4 stated she was trained how to complete head to toe skin assessments. She further stated she would start with observations of the head, and then move to the front of the resident, then shoulders, then back, then legs and feet, and finally arms and hands. She stated she would have documented if Resident #200 refused to raise his arms so if she did not document refusal, she would have observed under his arms for skin integrity. She further stated she had no idea how she could have missed a wound as it was described by the wound care nurse, EMTs, and responding police officer. She stated the only wound she identified Resident #200 with on [DATE] was the wound under his buttock which she would not note this wound in her skin assessment because it was a pressure ulcer already being treated and it was up to the wound care nurse to document those measurements and treatments. During an interview on [DATE] at 10:24 AM the Wound Care Nurse indicated she began working with wounds at the facility in [DATE]. She indicated she received training at the facility on how to identify, assess, evaluate, monitor, and document skin conditions. This training was completed for her in ,d+[DATE] when she took the position of wound care nurse. When asked why she had not implemented this training for Resident #200 ' s left arm pit wound she indicated she had no reason she chose not to. She acknowledged that she should have assessed and evaluated the open wound to his left armpit, monitored the wound ' s status, and documented this in the medical record in accordance with her training. The Wound Care Nurse reported she was trained to acquire orders for wound care prior to providing treatment. She stated she had no reason why she provided the treatment without an order. She revealed she had not asked the physician or nurse practitioner for orders and that she knew she should have. She stated she was aware she should have completed all these steps due to her training at the time it was happening and had no reason she did not follow her training. The skin assessments completed from the [DATE] through [DATE] that all failed to identify Resident #200 ' s left arm pit wound were reviewed with the Wound Care Nurse. The Wound Care Nurse stated she would have identified a wound of that size on a skin assessment but could not speak to how the other nurses missed the wound. During an interview on [DATE] at 1:28 PM Staff Development Coordinator #1 stated she was the Staff Development Coordinator (SDC) from 2019 through [DATE]. When staff were hired, they were provided education on wound treatments and documentation of treatments. She stated they had a skills observation checkoff for skin assessments that were done with staff upon orientation as well. Staff were educated on notification of changes of residents to the physician and responsible party to include incidents involving skin concerns on an as needed basis. They also educated staff on not providing treatments without orders, not obtaining orders for needed skin treatments, and education on wound care documentation on an as needed basis. She stated she believed the last time any of these issues were needed to be in-serviced was back in 2019 and did not have those records immediately available. She stated the new SDC had done some in-services since [DATE] on the topic of wound care. This in-service was due to a new policy that had been initiated by corporate and did not have anything to do with any concerns identified with the care provided in the facility. During an interview on [DATE] at 1:35 PM Staff Development Coordinator #2 stated she had provided in-services since [DATE] on the topic of wound care. This in-service was due to a new policy that had been initiated by corporate and did not have anything to do with any concerns identified with the care provided in the facility. During an interview on [DATE] at 9:32 AM the Administrator stated it was her expectation that staff would follow their training to perform full head to toe skin assessments and that they would identify, and report concerns of skin integrity. During an interview on [DATE] at 9:55 AM The Director of Nursing stated nursing staff were trained on skin checks and Nurse #1, Nurse #3, and Nurse #4 received skin assessment training. She further stated if a wound was present under Resident #200 ' s arm at the time they did their skin assessments, it should have been documented and reported to the Wound Care Nurse and nurse on the hall who would be responsible for notifying the Physician, responsible party, and Director of Nursing. If the wound was present at the time of these skin checks she did not know why they did not identify the wound. The Wound Care Nurse had been trained that identified wounds were to be assessed, monitored, documented, and treatment was to be provided according to physician ' s orders. She did not understand why the wound care nurse did not follow her training. The Administrator was notified of the immediate jeopardy on [DATE] at 9:36 AM. On [DATE] the facility provided the following credible allegation of immediate jeopardy removal. The Removal Plan: F726 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On [DATE] the Director of Nursing was notified by the State Surveyor that Resident #200 (whom expired [DATE]) had a wound under his axilla area (armpit) that the Wound nurse stated she had been treating without an order from [DATE] through [DATE]. The Wound nurse stated that she notified the Nurse Practitioner regarding Resident #200 ' s open axilla area and the Nurse Practitioner allegedly stated to the Wound nurse to continue treatments with no order being provided for the treatments. The Wound nurse was unable to provide a date for this notification. The Wound nurse indicated she provided wound treatments to Resident #200 without an order from [DATE] through [DATE]. The Nurse Practitioner stated that she was never notified of any information related to the open axilla area by the facility staff from [DATE] through [DATE] for Resident #200. When the wound nurse was asked where the documentation regarding treatments and Nurse Practitioner notifications were located the wound nurse stated there was none, she did not document and there was not an order to treat from [DATE] through [DATE]. The wound Nurse failed to complete the weekly body observations that included wound assessments and measurements of the wound status for this same period of time. There is no documentation that the wound nurse notified the Nurse Practitioner related to the order or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unaware of the wound nurse was providing treatment without a Physician order. Weekly skin assessments from [DATE] through [DATE] failed to identify Resident #200 ' s open wound to the axilla area. The facility was unaware of the Wound nurse ' s lack of documentation of assessment, measurements of the wound progression, the Wound nurse was providing treatments without orders, and the lack of notification to the physician/nurse practitioner. The facility was unaware of the failure of nurses to identify the open wound during weekly skin assessments from [DATE] through [DATE]. Upon arrival to facility on [DATE] the EMS /police noted the resident ' s axilla area wound condition as a large open wound under left arm that was extended up inside his body. Officer documented he could see ribs and collar bone through the body that was not bandaged. Resident #200 expired on [DATE]. All residents have the potential to have suffered a serious outcome as a result of this noncompliance. 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 completed a 24-hour report to the State Agency regarding neglect on [DATE] when she was notified of the concern regarding the axilla wound and no documentation of same. The Wound Nurse was suspended pending investigation on [DATE] and terminated on [DATE]. The wound Nurse was reported to the North Carolina Board of Nursing on [DATE] for professional standards violations. The Director of Health Services initiated 100% body audits on all residents within the facility on [DATE]. This audit reveals no wounds without physician/physician extender notification. If any resident is noted without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and/or Nurse Managers have reviewed the wound audit conducted on [DATE] and reviewed the documentation to ensure residents with skin impairments had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Health Services and Nurse Managers reviewed residents with wounds to ensure weekly documentation including ongoing assessments with wound measurements are currently in place, documented accurately and physician / physician extender notification. Review of documentation identified no residents without wound documentation at this point in time and the current wound observations are accurate. The Director of Health Services and Nurse Managers educated the Licensed Nurses regarding accuracy of weekly body observations to include identification of any dressing noted or skin impairment noted on the resident body. This education has been added the License Nurse general orientation upon hire. License Nurses not educated by [DATE] will be educated prior to their next scheduled shift. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding weekly skin observations and documentation in the electronic health record of same. When a new skin impairment is noted, the Licensed nurse will complete the wound documentation in the electronic medical record that includes description and measurement of area ,and contact the physician/physician extender for orders, regarding newly identified skin impairments and/or worsening skin impairments for wound treatment orders. This includes that the assessments and measurements were necessary as a monitoring tool to determine if there are any changes in the wound that would require a change in the treatment plan. This education has been added to the License Nurse general orientation upon hire. Any Licensed Nurse will not be allowed to work after [DATE] until they receive the education. The new Wound Nurse and the Nurse Practitioner are meeting weekly to discuss and review all residents with wounds. The Director of Health Services and/or Nurse Managers began education on [DATE] regarding completing weekly skin observation and wound management notes including description and measurements of skin impairments weekly. This education has been added the License Nurse general orientation upon hire. Any Licensed Nurse will not be allowed to work after [DATE] until they receive the education. The Director of Health Nursing and/or RN Nurse Managers have validated, (by observation) the [DATE] skin observations completed by the License Nurses for comprehensive assessment and accuracy. No discrepancies where identified. The Clinical Competency Coordinator, Director of Health Services and RN Managers are observing all Licensed Nurse ' s on [DATE] complete skin observation to validate competency of the comprehensive assessment and for accuracy of the assessment. Licensed Nurses not deemed competent will be re-educated and reevaluated to validate competency prior to completing further skin assessments. Licensed Nurse will not be allowed to work after [DATE] until they have been observed and validated for competency of the comprehensive assessment and for accuracy of the assessment . The Clinical Competency Coordinator/RN is responsible for ensuring education and evaluation of competency is completed prior to the start of any Licensed Nurse and/or Certified Nursing Assistant working the floor after [DATE]. Alleged date of IJ Removal [DATE] The credible allegation for Immediate Jeopardy removal was validated on [DATE] which removed the Immediate Jeopardy on [DATE], as evidenced by staff interviews, in-service record reviews, and observation. The in-services included information on providing wound care treatments according to physician orders, wound assessments, wound measurements, and identification of new wounds and weekly skin assessments. The facility ' s Immediate Jeopardy removal date of [DATE] was validated.

Based on record review, resident, nurse practitioner, physician, and staff interviews the facility failed to notify the physician for one (1) of five (5) sampled residents (resident #1) that repeatedly complained of pain, had a change in condition, and repeatedly requested to go to the emergency room . Immediate Jeopardy began on 2-3-2012 and was identified on 2-15-2012 at 4:25 pm. Immediate Jeopardy was removed on 2-16-2012 at 7:45 pm. 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, while the facility monitors the completed in-services to ensures appropriate notification of the physician. Resident #1 was originally admitted to the facility on [DATE] and readmitted last on 2-16-2012 with cumulative [DIAGNOSES REDACTED]. After 2-3-2012 admission to the hospital the [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] indicated resident #1 was able to understand and to be understood with clear speech, was moderately cognitively intact, had no behavioral or mood concerns, needed extensive assist of staff with bed mobility, dressing, eating, toilet use, personal hygiene, and was totally dependent on staff for transfer and locomotion. The MDS indicated resident #1 had a pain assessment done with no complaints of pain. Review of the Care Plan (CP) last updated 2-9-2012 indicated resident #1 had a concern area of oxygen use related to the resident ' s [DIAGNOSES REDACTED].#1 ' s condition. A second concern area of pain related to the resident ' s [DIAGNOSES REDACTED]. A review of the physician ' s progress notes dated 2-2-2012 (with no time noted) indicated resident #1 was seen by the Nurse Practitioner for a productive cough. The Nurse Practitioner had ordered new medications for resident #1 that included, a breathing treatment of [REDACTED]. decrease fluid in the body), then [MEDICATION NAME] 20 milligrams by mouth daily which was started on 2/2/2012, [MEDICATION NAME] 750 milligrams by mouth daily for 7 days (an antibiotic to help with an infection) which started on 2-1-2012, and a chest xray. Resident had an order for [REDACTED]. A review of the nurse ' s note dated 2-3-2012 at midnight (written by nurse #1) stated " at midnight resident c/o (complaint of) pain in arms and shoulder. She was medicated with prn (as needed) meds (medications) per orders. She continued to ask for pain medication and to request to be sent to ER (emergency room ). At 2:00 am she called her significant other (family member) and asked me to come and to talk to him. I did explain to him that I had given her, her meds (medications). I also explained to him that we cannot give her more pain meds (medications) because of her order. " The nurse ' s note indicated that at 4:00 am that resident #1 ' s oxygen level fell below the therapeutic level to 89%, due to the oxygen tubing had come off the oxygen concentrator. The note indicated resident #1 complained of feeling short of breath, having difficulty breathing, and had complaint of pain. The nurse ' s note indicated at 4:00 am Nurse #1 replaced the oxygen tubing, placed the head of bed up to 90 degrees to facilitate easier breathing, and gave more pain medication to resident #1. The nurse ' s note indicated at 8:00 am resident #1 had no complaints of shortness of breath, had her eyes closed, respirations were even and unlabored and had no distress noted. The nurse ' s note had no documentation to indicate that the physician had been notified of the resident ' s repeated complaints of pain and request to go to the emergency room . On 2-15-2012 at 2:00 pm an interview with Nurse #1 (nurse assigned to resident #1 from 11:00 pm on 2-2-2012 through 8:00 am on 2-3-2012) indicated on 2-3-2012 resident #1 complained of pain to top of her shoulder and was medicated with [MEDICATION NAME]/Tylenol 5/500 milligram one tab for pain. Nurse #1 indicated resident #1 rang bell again in 30-35 minutes and asked for more pain medication. Nurse #1 indicated she had informed resident #1 to give more time for the pain medication to work, obtained vital signs of blood pressure of 159/80, heart rate of 82, respirations of 22, and temperature of 97.8. Nurse #1 indicated the resident had asked to go to the emergency room for pain in her shoulder. Nurse #1 indicated that resident #1 had been using her accessory muscles to breathe. Nurse #1 indicated resident #1 had continued to complain of pain in her shoulder and was given more [MEDICATION NAME]/Tylenol 5/500 milligram tablet at 4:00 am. Nurse #1 indicated she had reported resident #1 ' s complaint of pain verbally to the day shift nurse and placed the information on the 24 hours nurse report sheet. Nurse #1 stated " I did not see that she (resident #1) was in immediate distress. " Nurse #1 indicated she had not informed the physician of resident #1 ' s repeated complaints of pain or her requests to be sent to the emergency room . A review of the physician ' s progress notes dated 2-3-2012 (with no time noted) indicated resident #1 was seen by the Nurse Practitioner as a follow up and stated " pt (patient) seen state she feels " a little better, but I had a rough night. " The Nurse Practitioner note indicated resident #1 ' s had chest xray done on 2-2-2012 which was normal, that resident #1 had wheezes in her lungs, a regular cardiac rhythm, and decreased [MEDICAL CONDITION] in bilateral lower extremities from 2-2-2012. A review of the nurse ' s note dated 2-3-2012 at 11:30 am (written by nurse #2) indicated she had not seen resident #1 prior to the resident going to physical therapy. Nurse #2 indicated when resident #1 returned from physical therapy at 11:30 am on 2-3-2012 she was short of breath. Nurse #2 indicated she had given resident #1 a breathing treatment with no improvement in resident #1 ' s breathing. Nurse #2 indicated at 12:00 noon she obtained orders from the Nurse Practitioner to send resident #1 to the emergency room for evaluation, and to increase resident #1 ' s oxygen to 4 liters via nasal cannula. Nurse #2 indicated resident #1 ' s blood pressure was 186/112, respirations were 26, heart rate was 121, oxygen saturation was 87%, and temperature was 97.4. Nurse #2 indicated she had called an ambulance transport company to transport resident #1 to the emergency room at 12:00 noon. Nurse #2 indicated resident #1 became diaphoretic (cool and moist skin), and her oxygen saturation fell below the therapeutic range to 78% prior to transport arrival. Nurse #2 indicated she had placed a non-rebreather (oxygen mask that delivers higher concentration of oxygen) to resident #1. Nurse #2 indicated the ambulance transport company arrived and transported resident #1 to the emergency roiagnom on [DATE] at 1:00 pm. Review of the medical record indicated resident #1 was hospitalized from 2-3-2012 through 2-9-2012. On 2-23-2012 at 4:03 pm a telephone interview with Nurse #2 indicated she had called the ambulance transport service at 12:00 noon per the NP order. Nurse #2 indicated the ambulance transport company arrived to the facility within 10 minutes from time of the request, with a paramedic. Nurse #2 indicated the resident was seen by the NP at 11:30 am on 2-3-2012. Nurse #2 indicated if a resident had a non life changing emergency the ambulance transport company was called. Nurse #2 indicated if a resident had a life changing emergency, 911 (emergency services) was called. Nurse #2 indicated at the time of the call for transport for resident #1, the residents condition was thought to be an anxiety attack, it was not thought to be a life changing emergency. Nurse #2 indicated resident #1 had an increase in respiratory distress prior to the transport company arrival. Nurse #2 indicated the transport company informed her that they could transport the resident to the hospital with appropriate trained staff. A review of the medical record revealed the hospital admission history and physical report dated 2-3-2012 indicated the resident was admitted to the hospital with [REDACTED].#1 was a full code. On 2-16-2012 at 10:46 am an interview with the Nurse Practitioner (NP) indicated her expectation was that nurses would call her or the physician with any concerns about a resident. The NP indicated her expectation of nursing staff would have been for the nurse to notify the NP/Physician if a resident had requested to be sent to the emergency room . The NP stated " my answer is always send them if a resident ask to go to the emergency room . " The NP indicated she had seen resident #1 at 11:30 am on 2-3-2012 and resident #1 told her she had a bad night, but was feeling better. The NP indicated she was not notified by nurse #1 about resident #1 ' s condition throughout the night. The NP indicated she was informed by nurse #2 at 12:00 noon on 2-3-2012 that resident #1 had difficulty breathing and had given an order to send resident #1 to the hospital for evaluation. On 2-16-2012 at 1:25 pm an interview with resident #1 ' s physician in the facility indicated that his expectation from the facility nurse was for him to have been notified of resident #1 ' s complaint and for her request to be sent to the emergency room . The physician indicated his expectation from the facility nursing staff was for them to call him whenever necessary with any concerns with a resident ' s health. The physician indicated he had not been notified about resident #1 ' s complaints of pain or request to go to the emergency room . On 2-16-2012 at 4:45 pm Resident #1 stated (about the night of 2-3-2012), " I was in pain and told her the person who came to the door and answered my bell that I had chest pain, I asked 3-4 times to go to the hospital, she told me I could not go because my doctor wasn ' t here. That is why I called him (resident pointed to her family member at the bedside). I was sick, I suffered for hours. " Resident #1 said " I did not like it, they did not believe me, they should know when I say I hurt, I hurt, I don ' s say it if I don ' t hurt. " Resident #1 stated " I just wanted relief that night eventually I did get it, I went to therapy even the next day then couldn ' t breath and was sent to the hospital. " On 2-24-2012 at 11:44 am a telephone interview with the Nursing Assistant #1 (NA) (assigned to resident #1 on 2-3-2012 from 7:00 am through 3:00 pm) indicated the resident #1 had indicated she did not feel good throughout the night but had stated that she felt better during the morning care. NA #1 indicated the resident had no shortness of breath, had no signs or symptoms of distress, was alert and oriented, and had no concerns during morning bathing. NA #1 indicated the resident had been placed in her wheel chair and ate her breakfast on her own. NA #1 indicated the physical therapy department staff took resident #1 to the therapy department. NA #1 indicated resident #1 had her nasal cannula oxygen at 2 liters on. On 2-24-2012 at 12:02 pm a telephone interview with the Physical Therapist (PT) indicated on 2-3-2012 she was informed by the nurse #2 on 2-3-2012 prior to the morning physical therapy session that resident #1 had bilateral upper extremity soreness and to inform the nurse #2 when resident #1 had returned. The PT indicated resident #1 was in therapy for one hour and had no increased shortness of breath, no signs and symptoms of distress, nothing out of the ordinary for resident #1. The PT indicated resident #1 had 2.5 liters of nasal cannula oxygen on during the therapy session and that resident #1 ' s oxygen saturation was 94%. The PT indicated she had informed nurse #2 that the resident had returned to her room. On 2-24-2012 at 1:04 pm an interview with the Administrator indicated he expected the nurses to assess the vital signs, source of pain, or any signs and symptoms of distress in a resident and to notify the physician. The Administrator indicated that his expectation was that all nurses would call 911 and send residents to the emergency room at anytime a resident is in distress On 2-15-2012 at 4:25 pm the Administrator, Area Assistant Vice President (of the facility), Senior Nurse Consultant, and the Director of Nursing were notified of the Immediate Jeopardy. The Allegation of Compliance indicated: ALLEGATION OF COMPLIANCE WITH THE REMOVAL OF IMMEDIATE JEOPARDY Two Rivers Trent ? Regarding resident (#1), on [DATE] at 12 midnight complained of pain in arm and left shoulder and she was medicated at this time. Resident continued to request pain meds and requested to go to the ER. Resident had called her husband at 2 am and requested the nurse to speak with him. Explained to significant other that the nurse was unable to give anymore pain meds at this time because of the order. At 4am the resident de-sated to 89% due to the 02 tubing slipping off concentrator. 02 replaced complained of shortness of breath and having difficultly breathing. Resident was repositioned and head of bed elevated 90 degrees to facilitate easier breathing. Requested something for pain PRN medication given Oxygen sat 94%. At 8am no complaint of shortness 0 breath eyes closed respiration even an unlabored. Resident attended therapy on 2/3/12 received AAROm and AROM was on PT for 54 min and OT 50 min. Resident was also seen by the NP on 2/2/12 for a productive cough new orders for nebulizer scheduled QID x 7 days, steroid burst times 6 days, and chest x-ray. For the [MEDICAL CONDITION] in lower ext new order for [MEDICATION NAME] 40mg times 7 day then back to [MEDICATION NAME] 20mg QD. Was seen again on 2/3/12 results of chest x-ray was negative; [MEDICAL CONDITION] was decreased, and cardiac regular rhythm. Resident stated she feels "little better". Patient went to therapy around lOam and tolerated well for approximately 2 hours, shortly upon return from therapy increased respirations, BP 186/112, pulse 121, 02 sats 87%- neb tx administered, oxygen increased to 4liters/nasal canula verbal order from NP ( present in facility). Denied chest pain, diaphoretic, 02 SATS 78%, switched to 02 mask, order to transport to hospital.Pt readmitted to facility on February 9th at 3:45pm with [DIAGNOSES REDACTED].?morbidities. ? Nurse on duty was disciplinary action on February 15, 2012 and was suspended on February 16, 2012 pending investigation. ? Pain assessments were completed on 100% of the residents by the DHS (Director of Health Service)/CCC(Clinical Competency Coordinator)/UM(Unit Manager)/SNC (Senior Nurse Consultant). Assessment included looking at [DIAGNOSES REDACTED]. Any identified pain issues will be addressed immediately by the NP and/or MD. Completed on 2/16/12. ? Residents Potentially Affected ? Pain assessments were completed on 100% of the residents by the DHS (Director of Health Service)/CCC(Clinical Competency Coordinator)/UM(Unit Manager)/SNC (Senior Nurse Consultant). Assessment included looking at [DIAGNOSES REDACTED]. Any identified pain issues will be addressed immediately by the NP and/or MD. Completed on 2/16/12. ? Residents identified with [DIAGNOSES REDACTED]. ? condition every shift by licensed staff for any change of condition and doctor will be notified and treatment initiated as ordered. ? Resident council was conducted by the CCC and Social Worker and Administrator on February 16, 2012 at 3pm to review Resident Rights. Any residents not attending the resident council meeting the Social worker, CCC, and Administrator will go to the room and review residents rights. ? In-services were begun immediately Licensed staff on February 15, 2012 and completed on February 16, 2012, conducted by the DHS (Director of Heath Services) and CCC (Clinical Competency Coordinator) on: ? Pain Management (elaborate - when appropriate to give pain med and when not, further assessment necessary) ? ? Notification of MD (for which changes in condition) ? Change of Condition (covers any change in condition, ineffective PRN Pain management, Signs and symptoms of [MEDICAL CONDITION]. [MEDICAL CONDITION], MI) ? ? Resident rights (related to resident request to be transferred to Hospital) ? ? Signs and symptom of [MEDICAL CONDITIONS] ? ** Licensed Staff, who are PRN, or week-end only, out on sick or personal leave, will not be permitted to work until in-services are complete .. ? As a facility practice and as a systematic approach to ensure the staff at the facility has knowledge of and understands the regulations related to Resident Rights, the healthcare center will have mandatory training of all new staff members during orientation and at least annually with all staff Licensed and non licensed staff. In-servicing will also be completed when needs are identified by facility management. ? MARs will be reviewed by the DHS/UM/CCC/ Week end manager Q 3 days for PRN pain med use. Any residents with increase use of pain medications will be addressed with NP and/or MD. Audit will be conducted by the DHS/UM/CCC/ Week-end manager every 3 days and reviewed in the weekly pain meeting. DHS will bring trends and any issues identified to the Performance Improvement meeting monthly. SNC/AVP will review audit during weekly visits times 4 weeks then monthly during visits. DHS will bring finds from the SNC/AVP audit to the Performance Improvement meeting monthly. ? 24 hour reports will be monitored daily by the DHS/CCC/UM/Week end manager to review for increase in pain and any change in condition signs and symptoms of [MEDICAL CONDITION]; [MEDICAL CONDITION] and [MEDICAL CONDITION] infarct. Any identified issues will be reviewed to ensure follow -up was conducted. DHS will bring findings and trends to the monthly Performance Improvement meeting. SNC/AVP will review audit during weekly visits times 4 weeks then monthly during visits. DHS will bring finds from the SNC/AVP audit to the Performance Improvement meeting monthly. ? Prevention of Reoccurrence: ? MARs will be reviewed by the DHS (Director of Health Service}jCCC (Clinical Competency Coordinator}/UM(Unit Manager}jWeek end manager Q 3 days for PRN pain med use. Any residents with increase use of pain medications will be addressed with NP andjor MD. Audit will be conducted by the DHSjUMjCCCj Week-end manager every 3 days and reviewed in the weekly pain meeting. DHS will bring trends and any issues identified to the Performance Improvement meeting monthly. SNC (Senior Nurse Consultant}jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS will bring finds from the SNCjAVP audit to the Performance Improvement meeting monthly. ? 24 hour reports will be monitored daily by the DHS (Director of Health Service}jCCC(Clinical Competency Coordinator}jUM(Unit Manager}jWeek end manager to review for increase in pain and any change in condition including [MEDICAL CONDITION]; [MEDICAL CONDITION] and cardiac issues. Any identified issues will be reviewed to ensure follow -up was conducted. DHS (Director of Health Services) will bring findings and trends to the monthly Performance Improvement meeting. SNC(Senior Nurse Consultant)jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS (Director of Health Services) will bring finds from the SNC(Senior Nurse Consultant}jAVP (Area Vice President) audit to the Performance Improvement meeting monthly. ? Monitoring Compliance: ? PRN Medication Audit will be conducted by the DHS (Director of Health Service}jCCC(Clinical Competency Coordinator}jUM(Unit Manager}jWeek-end manager every 3 days and reviewed in the weekly pain meeting. DHS will bring trends and any issues identified to the Performance Improvement meeting monthly. SNC (Senior Nurse Consultant}jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS (Director of Health Services) will bring finds from the SNC(Senior Nurse Consultant}jAVP (Area Vice President) audit to the Performance Improvement meeting monthly. ? 24 hour reports will be monitored daily by the DHS (Director of Health Service}jCCC(Clinical Competency Coordinator}jUM(Unit Manager}jWeek end manager to review for increase in pain and any change in condition including signsjsymptoms of [MEDICAL CONDITION]; [MEDICAL CONDITION] and cardiac issues. Any identified issues will be reviewed to ensure follow -up was conducted. DHS (Director of Health Services) will bring findings and trends to the monthly Performance Improvement meeting. SNC(Senior Nurse Consultant}jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS (Director of Health Services) will bring finds from the SNC(Senior Nurse Consultant}j AVP (Area Vice President) audit to the Performance Improvement meeting monthly. ? Residents sent to the hospital will have a chart review for the last 3 days including nurses notes, MARS, physician orders, labs, and physician progress notes [REDACTED]. completed for a change in condition. This review will be completed by the DHS (Director of Health Services) findings will be taken to the monthly Performance Improvement meeting. Allegation of compliance: [DATE] Surveyor ' s validated through observation, record review and interviews the facility compliance with the Credible Allegation and the Jeopardy was removed on 2-16-2012 at 7:45 pm.

Based on record review, resident, nurse practitioner, physician, and staff interviews the facility failed to identify the need for medical treatment and failed to initiate emergency medical services for one (1) of five (5) sampled residents (resident #1) that repeatedly complained of pain, had a change in condition, and repeatedly requested to go to the emergency room . Immediate Jeopardy began on 2-3-2012 and was identified on 2-15-2012 at 4:25 pm. Immediate Jeopardy was removed on 2-16-2012 at 7:45 pm. 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, while the facility monitors the completion and accuracy of resident assessments and ensures appropriate interventions to prevent negative outcomes for residents who have pain, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] indicated resident #1 was able to understand and to be understood with clear speech, was moderately cognitively intact, had no behavioral or mood concerns, needed extensive assist of staff with bed mobility, dressing, eating, toilet use, personal hygiene, and was totally dependent on staff for transfer and locomotion. The MDS indicated resident #1 had a pain assessment done with no complaints of pain. Review of the Care Plan (CP) last updated on 2-9-2012 indicated resident #1 had a concern area of oxygen use related to the resident ' s [DIAGNOSES REDACTED].#1 ' s condition. A second concern area of pain related to the resident ' s [DIAGNOSES REDACTED]. A review of the physician ' s progress notes dated 2-2-2012 (with no time noted) indicated resident #1 was seen by the Nurse Practitioner for a productive cough. The Nurse Practitioner had ordered new medications for resident #1 that included, a breathing treatment of [REDACTED]. decrease fluid in the body), then [MEDICATION NAME] 20 milligrams by mouth daily which was started on 2/2/2012, [MEDICATION NAME] 750 milligrams by mouth daily for 7 days (an antibiotic to help with an infection) which started on 2-1-2012, and a chest xray. Resident had an order for [REDACTED]. A review of the nurse ' s note dated 2-3-2012 at midnight (written by nurse #1) stated " at midnight resident c/o (complaint of) pain in arms and shoulder. She was medicated with prn (as needed) meds (medications) per orders. She continued to ask for pain medication and to request to be sent to ER (emergency room ). At 2:00 am she called her significant other and asked me to come and to talk to him. I did explain to him that I had given her, her meds (medications). I also explained to him that we cannot give her more pain meds (medications) because of her order. " The nurse ' s note indicated that at 4:00 am that resident #1 ' s oxygen level fell below the therapeutic level to 89%, due to the oxygen tubing had come off the oxygen concentrator. The note indicated resident #1 complained of feeling short of breath, having difficulty breathing, and had complaint of pain. The nurse ' s note indicated at 4:00 am Nurse #1 replaced the oxygen tubing, placed the head of bed up to 90 degrees to facilitate easier breathing, and gave more pain medication to resident #1. The nurse ' s note indicated at 8:00 am resident #1 had no complaints of shortness of breath, had her eyes closed, respirations were even and unlabored and had no distress noted. A review of the medical record revealed the 24 hour nurse report sheet dated 2-2-2012 for the 11:00 pm to 7:00 am on 2-3-2012 shift (written by nurse #1) stated, " awaken all night med x2 (medicated times 2) for pain, she called her family @ 2a (2:00 am) and told him I would not give her meds (medications). " On 2-15-2012 at 2:00 pm an interview with Nurse #1 (nurse assigned to resident #1 from 11:00pm on 2-2-2012 through 8:00 am on 2-3-2012) indicated on 2-3-2012 resident #1 complained of pain to top of her shoulder and was medicated with [MEDICATION NAME]/Tylenol 5/500 milligram one tab for pain. Nurse #1 indicated resident #1 rang bell again in 30-35 minutes and asked for more pain medication. Nurse #1 indicated she had informed resident #1 to give more time for the pain medication to work, obtained vital signs of blood pressure of 159/80, heart rate of 82, respirations of 22, and temperature of 97.8. Nurse #1 indicated the resident had asked to go to the emergency room for pain in her shoulder. Nurse #1 indicated that resident #1 had been using her accessory muscles to breathe. Nurse #1 indicated resident #1 had continued to complain of pain in her shoulder and was given more [MEDICATION NAME]/Tylenol 5/500 milligram tablet at 4:00 am. Nurse #1 indicated she had reported resident #1 ' s complaint of pain verbally to the day shift nurse and placed the information on the 24 hours nurse report sheet. Nurse #1 stated " I did not see that she (resident #1) was in immediate distress. " Nurse #1 indicated she had not informed the physician of resident #1 ' s complaints of pain or her request to be sent to the emergency room . On 2-24-2012 at 11:44 am a telephone interview with the Nursing Assistant #1 (NA) (assigned to resident #1 on 2-3-2012 from 7:00 am through 3:00 pm) indicated the resident #1 had indicated she did not feel good throughout the night but had stated that she felt better during the morning care. NA #1 indicated the resident had no shortness of breath, had no signs or symptoms of distress, was alert and oriented, and had no concerns during morning bathing. NA #1 indicated the resident had been placed in her wheel chair and ate her breakfast on her own. NA #1 indicated the physical therapy department staff took resident #1 to the therapy department. NA #1 indicated resident #1 had her nasal cannula oxygen at 2 liters on. On 2-24-2012 at 12:02 pm a telephone interview with the Physical Therapist (PT) indicated on 2-3-2012 she was informed by the nurse #2 on 2-3-2012 prior to the morning physical therapy session that resident #1 had bilateral upper extremity soreness and to inform the nurse #2 when resident #1 had returned. The PT indicated resident #1 was in therapy for one hour and had no increased shortness of breath, no signs and symptoms of distress, nothing out of the ordinary for resident #1. The PT indicated resident #1 had 2.5 liters of nasal cannula oxygen on during the therapy session and that resident #1 ' s oxygen saturation was 94%. The PT indicated she had informed nurse #2 that the resident had returned to her room. A review of the physician ' s progress notes dated 2-3-2012 (with no time noted) indicated resident #1 was seen by the Nurse Practitioner as a follow up and stated " pt (patient) seen state she feels " a little better, but I had a rough night. " The Nurse Practitioner note indicated resident #1 ' s had chest xray done on 2-2-2012 which was normal, that resident #1 had wheezes in her lungs, a regular cardiac rhythm, and decreased [MEDICAL CONDITION] in bilateral lower extremities from 2-2-2012. A review of the nurse ' s note dated 2-3-2012 at 11:30 am (written by nurse #2) indicated she had not seen resident #1 prior to the resident going to physical therapy. Nurse #2 indicated when resident #1 returned from physical therapy at 11:30 am on 2-3-2012 she was short of breath. Nurse #2 indicated she had given resident #1 a breathing treatment with no improvement in resident #1 ' s breathing. Nurse #2 indicated at 12:00 noon she obtained orders from the Nurse Practitioner to send resident #1 to the emergency room for evaluation, and to increase resident #1 ' s oxygen to 4 liters via nasal cannula. Nurse #2 indicated resident #1 ' s blood pressure was 186/112, respirations were 26, heart rate was 121, oxygen saturation was 87%, and temperature was 97.4. Nurse #2 indicated she had called an ambulance transport company to transport resident #1 to the emergency room at 12:00 noon. Nurse #2 indicated resident #1 became diaphoretic (cool and moist skin), and her oxygen saturation fell below the therapeutic range to 78% prior to transport arrival. Nurse #2 indicated she had placed a non-rebreather (oxygen mask that delivers higher concentration of oxygen) to resident #1. Nurse #2 indicated the ambulance transport company arrived and transported resident #1 to the emergency roiagnom on [DATE] at 1:00 pm. Review of the medical record indicated resident #1 was hospitalized from 2-3-2012 through 2-9-2012. On 2-15-12 at 1:15 pm an interview with Nurse #2 (nurse assigned to resident #1 on 2-3-2012 7:00 am through 3:00 pm) indicated resident #1 had been seen by the Nurse Practitioner (NP) on 2-2-2012 and was started on medication for a cough. Nurse #2 indicated on 2-3-2012 she did not see resident #1 prior to her going to physical therapy, but when resident #1 returned to her room resident #1 was short of breath. Nurse #2 indicated she had given resident #1 a nebulizer (a inhaled medication to assist with breathing) treatment. Nurse #2 indicated resident #1 had no relief from the nebulizer treatment and she notified the NP and received an order to send resident #1 to the hospital for evaluation and to increase her oxygen level to 4 liters via nasal cannula. Nurse #2 indicated report from Nurse #1 had been that resident #1 had a restless night and that her oxygen saturation (measures level of oxygen in the body) was down due to resident #1 oxygen tubing had been undone from the oxygen concentrator. Nurse #2 indicated that resident #1 had been alert and oriented, had been able to make her needs known, had not been a resident who had made complaints, had been a resident who was eager to get better and worked hard to make progress in physical therapy. Nurse #2 indicated that resident #1 had become diaphoretic (cool and moist skin) and oxygen saturation dropped to 78% while waiting for the ambulance to arrive, and she had placed a non-rebreather (an oxygen mask that delivers higher level of oxygen) on resident #1. On 2-23-2012 at 4:03 pm a telephone interview with Nurse #2 indicated she had called the ambulance transport service at 12:00 noon per the NP order. Nurse #2 indicated the ambulance transport company arrived to the facility within 10 minutes from time of the request, with a paramedic. Nurse #2 indicated the resident was seen by the NP at 11:30 am on 2-3-2012. Nurse #2 indicated if a resident had a non life changing emergency the ambulance transport company was called. Nurse #2 indicated if a resident had a life changing emergency, 911 (emergency services) was called. Nurse #2 indicated at the time of the call for transport for resident #1, the residents condition was thought to be an anxiety attack, it was not thought to be a life changing emergency. Nurse #2 indicated resident #1 had an increase in respiratory distress prior to the transport company arrival. Nurse #2 indicated the transport company informed her that they could transport the resident to the hospital with appropriate trained staff. A review of the medical record revealed the hospital admission history and physical report dated 2-3-2012 indicated the resident was admitted to the hospital with [REDACTED].#1 was a full code. On 2-16-2012 at 10:46 am an interview with the Nurse Practitioner (NP) indicated her expectation was that nurses would call her or the physician with any abnormal vital signs, abnormal labs, or any concerns about a resident. The NP indicated her expectation of nursing staff would have been for the nurse to notify the NP/Physician if a resident had requested to be sent to the emergency room . The NP stated " my answer is always send them if a resident ask to go to the emergency room . " On 2-16-2012 at 1:25 pm an interview with resident #1 ' s physician in the facility indicated that his expectation from the facility nurse was for him to have been notified of resident #1 ' s complaint and for her request to be sent to the emergency room . The physician indicated his expectation from the facility nursing staff was for them to call him when ever necessary with any concerns with a resident ' s health. On 2-16-2012 at 4:45 pm an interview with resident #1 stated (about the night of 2-3-2012), " I was in pain and told her the person who came to the door and answered my bell that I had chest pain, I asked 3-4 times to go to the hospital, she told me I could not go because my doctor wasn ' t here. That is why I called him (resident pointed to her family member at bedside). I was sick, I suffered for hours. " Resident #1 said " I did not like it, they did not believe me, they should know when I say I hurt, I hurt, I don ' t say it if I don ' t hurt. " Resident #1 stated " I just wanted relief that night eventually I did get it, I went to therapy even the next day then couldn ' t breath and was sent to the hospital. " On 2-24-2012 at 1:04 pm an interview with the Administrator indicated he expected the nurses to assess the vital signs, source of pain, or any signs and symptoms of distress in a resident and to notify the physician. The Administrator indicated that his expectation was that all nurses should call 911 and send residents to the emergency room at anytime a resident is in distress. On 2-15-2012 at 4:25 pm the Administrator, Area Assistant Vice President (of the facility), Senior Nurse Consultant, and the Director of Nursing were notified of the Immediate Jeopardy. The Allegation of Compliance indicated: ALLEGATION OF COMPLIANCE WITH THE REMOVAL OF IMMEDIATE JEOPARDY Two Rivers Trent ? Regarding resident (#1), on [DATE] at 12 midnight complained of pain in arm and left shoulder and she was medicated at this time. Resident continued to request pain meds and requested to go to the ER. Resident had called her husband at 2 am and requested the nurse to speak with him. Explained to significant other that the nurse was unable to give anymore pain meds at this time because of the order. At 4am the resident de-sated to 89% due to the 02 tubing slipping off concentrator. 02 replaced complained of shortness of breath and having difficultly breathing. Resident was repositioned and head of bed elevated 90 degrees to facilitate easier breathing. Requested something for pain PRN medication given Oxygen sat 94%. At 8am no complaint of shortness 0 breath eyes closed respiration even an unlabored. Resident attended therapy on 2/3/12 received AAROm and AROM was on PT for 54 min and OT 50 min. Resident was also seen by the NP on 2/2/12 for a productive cough new orders for nebulizer scheduled QID x 7 days, steroid burst times 6 days, and chest x-ray. For the [MEDICAL CONDITION] in lower ext new order for [MEDICATION NAME] 40mg times 7 day then back to [MEDICATION NAME] 20mg QD. Was seen again on 2/3/12 results of chest x-ray was negative; [MEDICAL CONDITION] was decreased, and cardiac regular rhythm. Resident stated she feels "little better". Patient went to therapy around lOam and tolerated well for approximately 2 hours, shortly upon return from therapy increased respirations, BP 186/112, pulse 121, 02 sats 87%- neb tx administered, oxygen increased to 4liters/nasal canula verbal order from NP ( present in facility). Denied chest pain, diaphoretic, 02 SATS 78%, switched to 02 mask, order to transport to hospital.Pt readmitted to facility on February 9th at 3:45pm with [DIAGNOSES REDACTED].?morbidities. ? Nurse on duty was disciplinary action on February 15, 2012 and was suspended on February 16, 2012 pending investigation. ? Pain assessments were completed on 100% of the residents by the DHS (Director of Health Service)/CCC(Clinical Competency Coordinator)/UM(Unit Manager)/SNC (Senior Nurse Consultant). Assessment included looking at [DIAGNOSES REDACTED]. Any identified pain issues will be addressed immediately by the NP and/or MD. Completed on 2/16/12. ? Residents Potentially Affected ? Pain assessments were completed on 100% of the residents by the DHS (Director of Health Service)/CCC(Clinical Competency Coordinator)/UM(Unit Manager)/SNC (Senior Nurse Consultant). Assessment included looking at [DIAGNOSES REDACTED]. Any identified pain issues will be addressed immediately by the NP and/or MD. Completed on 2/16/12. ? Residents identified with [DIAGNOSES REDACTED]. ? condition every shift by licensed staff for any change of condition and doctor will be notified and treatment initiated as ordered. ? Resident council was conducted by the CCC and Social Worker and Administrator on February 16, 2012 at 3pm to review Resident Rights. Any residents not attending the resident council meeting the Social worker, CCC, and Administrator will go to the room and review residents rights. ? In-services were begun immediately Licensed staff on February 15, 2012 and completed on February 16, 2012, conducted by the DHS (Director of Heath Services) and CCC (Clinical Competency Coordinator) on: ? Pain Management (elaborate - when appropriate to give pain med and when not, further assessment necessary) ? Notification of MD (for which changes in condition) ? Change of Condition (covers any change in condition, ineffective PRN Pain management, Signs and symptoms of [MEDICAL CONDITION]. [MEDICAL CONDITION], MI) ? Resident rights (related to resident request to be transferred to Hospital) ? Signs and symptom of [MEDICAL CONDITIONS] ? ** Licensed Staff, who are PRN, or week-end only, out on sick or personal leave, will not be permitted to work until in-services are complete .. ? As a facility practice and as a systematic approach to ensure the staff at the facility has knowledge of and understands the regulations related to Resident Rights, the healthcare center will have mandatory training of all new staff members during orientation and at least annually with all staff Licensed and non licensed staff. In-servicing will also be completed when needs are identified by facility management. ? MARs will be reviewed by the DHS/UM/CCC/ Week end manager Q 3 days for PRN pain med use. Any residents with increase use of pain medications will be addressed with NP and/or MD. Audit will be conducted by the DHS/UM/CCC/ Week-end manager every 3 days and reviewed in the weekly pain meeting. DHS will bring trends and any issues identified to the Performance Improvement meeting monthly. SNC/AVP will review audit during weekly visits times 4 weeks then monthly during visits. DHS will bring finds from the SNC/AVP audit to the Performance Improvement meeting monthly. ? 24 hour reports will be monitored daily by the DHS/CCC/UM/Week end manager to review for increase in pain and any change in condition signs and symptoms of [MEDICAL CONDITION]; [MEDICAL CONDITION] and [MEDICAL CONDITION] infarct. Any identified issues will be reviewed to ensure follow -up was conducted. DHS will bring findings and trends to the monthly Performance Improvement meeting. SNC/AVP will review audit during weekly visits times 4 weeks then monthly during visits. DHS will bring finds from the SNC/AVP audit to the Performance Improvement meeting monthly. ? Prevention of Reoccurrence: ? MARs will be reviewed by the DHS (Director of Health Service}jCCC (Clinical Competency Coordinator}/UM(Unit Manager}jWeek end manager Q 3 days for PRN pain med use. Any residents with increase use of pain medications will be addressed with NP andjor MD. Audit will be conducted by the DHSjUMjCCCj Week-end manager every 3 days and reviewed in the weekly pain meeting. DHS will bring trends and any issues identified to the Performance Improvement meeting monthly. SNC (Senior Nurse Consultant}jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS will bring finds from the SNCjAVP audit to the Performance Improvement meeting monthly. ? 24 hour reports will be monitored daily by the DHS (Director of Health Service}jCCC(Clinical Competency Coordinator}jUM(Unit Manager}jWeek end manager to review for increase in pain and any change in condition including [MEDICAL CONDITION]; [MEDICAL CONDITION] and cardiac issues. Any identified issues will be reviewed to ensure follow -up was conducted. DHS (Director of Health Services) will bring findings and trends to the monthly Performance Improvement meeting. SNC(Senior Nurse Consultant)jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS (Director of Health Services) will bring finds from the SNC(Senior Nurse Consultant}jAVP (Area Vice President) audit to the Performance Improvement meeting monthly. ? Monitoring Compliance: ? PRN Medication Audit will be conducted by the DHS (Director of Health Service}jCCC(Clinical Competency Coordinator}jUM(Unit Manager}jWeek-end manager every 3 days and reviewed in the weekly pain meeting. DHS will bring trends and any issues identified to the Performance Improvement meeting monthly. SNC (Senior Nurse Consultant}jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS (Director of Health Services) will bring finds from the SNC(Senior Nurse Consultant}jAVP (Area Vice President) audit to the Performance Improvement meeting monthly. ? 24 hour reports will be monitored daily by the DHS (Director of Health Service}jCCC(Clinical Competency Coordinator}jUM(Unit Manager}jWeek end manager to review for increase in pain and any change in condition including signsjsymptoms of [MEDICAL CONDITION]; [MEDICAL CONDITION] and cardiac issues. Any identified issues will be reviewed to ensure follow -up was conducted. DHS (Director of Health Services) will bring findings and trends to the monthly Performance Improvement meeting. SNC(Senior Nurse Consultant}jAVP (Area Vice President) will review audit during weekly visits times 4 weeks then monthly during visits. DHS (Director of Health Services) will bring finds from the SNC(Senior Nurse Consultant}j AVP (Area Vice President) audit to the Performance Improvement meeting monthly. ? Residents sent to the hospital will have a chart review for the last 3 days including nurses notes, MARS, physician orders, labs, and physician progress notes [REDACTED]. completed for a change in condition. This review will be completed by the DHS (Director of Health Services) findings will be taken to the monthly Performance Improvement meeting. Allegation of compliance: [DATE] Surveyor ' s validated through observation, record review and interviews the facility compliance with the Credible Allegation and the Jeopardy was removed on 2-16-2012 at 7:45 pm.

Based on record review, resident and staff interviews, the facility failed to provide a 2-person assistance with repositioning and failed to use half side rails when in bed resulting in a fall from the bed for 1 of 3 (Resident #1) sampled residents reviewed for falls Findings include: Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/25/11, identified the resident as being cognitively intact and able to make her needs known based on the Brief Interview for Mental Status (BIMS) assessment. Resident #1 ' s Functional Status was assessed as requiring extensive, two-person physical assistance in bed mobility, which included turning side to side and positioning her body in bed. Resident #1 was also assessed as having impairment on both sides of her upper and lower extremities. Resident #1 was lifted using a mechanical lift and totally dependent on staff for transferring. In reviewing the resident ' s Care Area Assessments worksheet, dated 1/25/11, the following Problem Areas triggered: Falls and ADL (Activities of Daily Living) Potential. Falls triggered due to the resident having difficulty standing and impaired balance during transitions related to her [DIAGNOSES REDACTED]. ADLs triggered because the resident needed extensive to total assistance with ADLs related to the bilateral leg amputations and Arthritis in fingers of both hands. Review of Resident #1 ' s most recent Care Plan, dated 5/18/10 and updated most recently on 3/25/11 read that Resident #1 is not independent with daily ADLs and requires total to extensive assistance with daily care. A listed " Approach " to meeting the goal of minimizing further decline in the resident ' s level of independence was " half side rails up when in bed to promote independence with bed mobility. " Review of the Care Plan for Falls, dated 5/18/10 and most recently updated on 3/25/11 read that the resident had a potential for falls and noted on the Care Plan were the words, " Bilat BKA " (bilateral below the knee amputation). Review of Resident #1's CNA (Certified Nursing Assistant) Care Record, used by nursing assistants (NAs) for resident care needs, revealed the section designated for " Reposition - assist of one; Restraints/Safety Devices - Siderails: half x 2 (times two) head of bed. " A review of the facility Incident Report, dated 6/20/11 at 10:45AM, documented that Resident #1 rolled from the bed to the floor while a treatment was being performed. It read that the resident was placed on her left side by the staff; she was on a low air loss mattress and an electric bed. Also documented was that the resident was holding onto the top rail and lost her balance rolling over the side of the bed. The resident went down on her bilateral stumps of her legs. In a review of the Nursing Notes, dated 6/20/11, documentation revealed that the nurse was called to the resident ' s room and observed Resident #1 sitting on her buttocks on the floor. Further documentation read that during treatment the resident was placed on her left side by staff. The resident lost her balance and rolled over the side of the bed. The note documents that the nurse in the room during the treatment tried to stop the fall, but was unable to do so. Resident #1 complained of pain, the Physician was notified, an X-ray was ordered and pain medication given. Resident #1 was sent to the emergency room for evaluation. Review of the physician's order [REDACTED]. Splint at all times. " During an interview with Resident #1 on 6/29/11 at 10:10AM, she stated that on the day of the fall she was in an electric bed that had smaller, short rails at the top of the bed near to her head. She stated that the bed was pulled away from the wall because when she is rolled over on her left side her right knee would hit the wall if the bed is not pulled away. She stated that she was going to receive treatment to her thigh area and she had been rolled to her left side by the nurse. Resident #1 said that she stated, " I ' m going down, " but the nurse did not understand her and said, " what? " Resident #1 said she stated it again but the nurse must not have understood what I meant. She stated that " it all happened so fast " and the nurse tried to stop me but I hit the floor. She continued by saying she thought she was just rolled over too far and usually she can hold onto the rail. During an interview with Nurse #1 on 6/29/11 at 10:30AM, she stated that on the day of the fall the resident had her bath and she went into the room to do her treatment because she is the only one the resident will allow to do her treatments. She stated that she pulled the bed away from the wall, because that is how the resident likes it during the treatment, and rolled the resident to her left side. She stated she was the only person doing the treatment. She stated the bed was approximately three (3) feet from the wall, a little more than usual. She stated that she was putting cream on the resident ' s back from her neck to her legs when the resident stated, " oh. " The nurse then asked the resident, " what is it? " Nurse #1 stated that ' s when she noticed the resident was " going over the side of the bed. " Nurse #1 stated that at the point she moved quickly to the left hand side of the bed and put her arms around the resident and tried to stop the fall, but could not. Nurse #1 stated that " because of the resident ' s size there was no way I could stop the fall. I had cream all over my gloves and she was covered in cream. I grabbed her body and let her slide to the ground, but she hit her knees. She really did not have enough support to help hold her and she just rolled out of the bed. " The nurse also stated that Resident #1 usually places her arm over the side rail to help keep her balance while on her side. She stated we could look at the type of bed the resident had when she fell in another resident ' s room. During an observation on 6/29/11 at 10:35AM with Nurse #1 of the type of electric bed that Resident #1 had at the time of the fall on 6/20/11 revealed that the side rails were observed to be made of a white, plastic material and were quarter rails positioned bilaterally at the head of the bed. During an interview with the Administrator on 6/29/11 at 10:45AM she stated that Resident #1 ' s non-electric bed had broke and it was replaced with an electric bed. She stated that if two persons would have been assisting during the treatment the fall could have been avoided. During an interview with NA #1 on 6/29/11 at 11:05AM, she stated that she works with Resident #1 often. She stated that the resident had a non-electric bed with half rails but the bed broke and was switched out to an electric bed with little, white plastic rails at the top of the bed. NA #1 stated that the resident likes the bed pulled away from the wall during care because her knee will hit the wall if it is not pulled away. She further stated that on the day of the incident, she had given the resident a bath and left her on her back for the nurse. She also stated that Resident #1 is rolled using a draw sheet. During an interview on 6/29/11 at 1:15PM with the Minimum Data Set (MDS) Nurse, she stated that she was unaware that the resident did not have half rails until after the fall. She also stated that she did assess the resident as needing extensive 2-person assistance during care and this should have been placed on the Nursing Assistant care record. The MDS nurse and the surveyor walked to room 103 and observed the size of the electric bed side rails and the MDS Nurse stated that they are much smaller and not in the middle of the bed and could see how Resident #1 could have fallen. During an interview with the Maintenance Department on 6/29/11 at 1:40PM, it was stated that the electric beds have quarter side rails near the head of the bed. During an interview with the Director of Nursing on 6/29/11 at 1:50PM, she stated that Resident #1 had half rails on her crank bed, but that during the time of the fall, Resident #1 had quarter rails on the electric bed. During an interview with the Administrator on 6/29/11 at 1:55PM, she stated that Resident #1 ' s crank bed broke on 6/15/11 and was replaced around 5:00PM that evening with an electric bed. She stated after the fall on 6/20/11 the electric bed was removed from the room and it was replaced with the crank type bed. She stated that the facility identified the difference in the side rail size after the fall.