Every finding on record at Rocky Mount Rehabilitation Center

Based on observation, record review, and interviews with staff, the facility failed to implement their abuse policy when the facility failed 1) to report to the local law enforcement within 24 hours that Resident # 1 and Resident # 2 were involved in an altercation where staff members reportedly witnessed bodily hits of residents and 2) complete a thorough investigation by ensuring that all witnesses were interviewed. The facility also failed to ensure its Abuse and Neglect Prohibition policy, specified that the Administrator was to be notified immediately of allegations of abuse as required by federal regulations and failed to ensure that immediately following the altercation between Resident # 1 and Resident # 2 that it was clearly communicated to the Administrator that there had been witnessed bodily hits between the residents. This was for 1 of 2 alleged abuse cases reviewed involving Resident # 1 and Resident # 2.The findings included:Review of the facility's Abuse and Neglect Prohibition policy, dated 10/24/22 and revised on 8/2023, revealed the following policy and procedures. The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. Under Reporting and Response, the abuse policy listed 6 items which read, 1) The center will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state/federal agency and law enforcement officials as designated by state/federal law. 2)The center will assure that reporters are free from retaliation 3) The center will post a conspicuous notice of employees rights, including the right to file a complaint with the State Survey Agency if they believe the center has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint. 4)The center will report to the corporate office in accordance with reporting procedures via Risk Guide. 5) The center will report any occurrences of abuse by registered or certified staff to the State Board as required by state law. 6) Policies and procedures will be analyzed and modified as necessary by the QA & A/QAPI Committee (Quality Assurance and Performance Improvement) to meet the full intent of the law. There was no specific policy or procedure referenced in the 8/20/23 revised Abuse and Neglect Prohibition policy which noted what Risk Guide to the Corporate Office entailed, and the Abuse and Neglect Prohibition policy did not specify that the Administrator was to be notified immediately of alleged abuse.On 2/17/26 the facility submitted to the state agency an Initial Allegation Report of alleged abuse which according to the facility's report to the state agency occurred on 2/17/26 and of which they became aware on 2/17/26. In the facility's initial report to the state agency, the facility submitted that Resident # 1 alleged that Resident # 2 swung at her on 2/17/26.Review of the facility's investigative file revealed statements which indicated alleged abuse occurred on 2/14/26 and not on 2/17/26. On 2/22/26, the Administrator signed she completed a five-day Investigation Report which included corrected information and which was submitted to the state agency. The Administrator indicated the following on the five-day investigation report. There had been an altercation between Resident # 1 and Resident # 2 which had occurred on 2/14/26 and the facility became aware of the incident on 2/17/26. The facility's investigation showed that Resident # 2 made contact with Resident # 1's shoulder/chest. Resident # 1 had a bruise on her cheek. There had been no witness that Resident # 1's face had been contacted, but it was thought that the altercation had led to Resident # 1's eye being bruised.Review of statements obtained by the facility regarding the alleged abuse between Resident # 1 and Resident # 2 revealed the following statements.Nurse Aide (NA # 1) wrote the following information in a statement which was dated 2/14/26. She saw Resident # 1 watching television in the activity room. Then she saw Resident # 3 enter the Activity room and sit next to Resident # 1. Then a few minutes later she saw Resident # 2 enter the Activity Room and sit on the other side of Resident # 1. Then she heard yelling and looked up and saw Resident # 2 hitting Resident # 1 and she also heard Resident # 3 saying hit her again. Then Resident # 2 swung at Resident # 1 again. She (NA # 1) entered the activity room with NA # 2 and tried to get Resident # 1 out of the Activity Room, but NA # 2 put Resident # 2 at another table. On 3/4/26 there was an update on the statement by Nurse Aide # 1 which read before [Resident # 1] went to bed she told [Resident # 2] hit her in her eye.NA # 1 was interviewed on 3/4/26 at 5:15 PM and reported the following information. On the evening of 2/14/26 she had been sitting at the nursing desk and had a direct view into the activity room. Resident # 1 entered the activity room first. Resident # 3 then entered the activity room and sat close to Resident # 1. Resident # 2 then entered and sat close to both Resident # 1 and # 3. They were all watching television. Then she heard Resident # 1 yelling, Stop. Leave me alone. She heard Resident # 3 yell, Hit her again. As she (NA # 1) was entering the activity room, she saw Resident # 2 hit Resident # 1 with his fist. He hit her in the face. Resident # 1 was backing away from him. Resident # 2 swung to hit Resident # 1 again but Resident # 1 put her arm up to block his hit. Nurse Aide # 2 was right behind her and entered also. She (NA # 1) never saw Resident # 1 provoke Resident # 2 or hit Resident # 2. She (NA # 1) tried to take Resident # 1 out of the room but Resident # 1 did not want to leave. Resident # 2 was taken and put at a different table. After a few minutes, Resident # 1 wheeled in her wheelchair out of the activity room and left. At the time, Resident # 1 did not have any marks on her face or outward signs of injury. Before Resident # 1 went to bed that night, NA # 1 heard Resident # 1 say, he hit me. She was not assigned to care for Resident # 1 or Resident # 2 on the evening of the incident. NA # 2 had been the assigned Nurse Aide on the residents' hall and therefore NA # 2 had spoken to the Nurse. She did not know what NA # 2 told the nurse regarding what had happened. She (NA # 1) had not spoken to a nurse. She had been asked to write a statement that night and put it under the Administrator's door. She had done so. A couple days later she noticed that Resident # 1 had a black eye. No one had asked her about the incident after the incident occurred until the current day when she was talking to the surveyor. The surveyor was the first person to talk with her about the incident. Resident # 3, who she heard tell Resident # 2 to hit Resident # 1 again during the incident, had always started things. Resident # 3 would tell other residents that Resident # 1 was crazy and other negative remarks about the resident. She had reported Resident # 3's remarks to nurses but had not reported them to the Administrator. The Administrator had not talked to her about the 2/14/26 incident.Review of NA # 2's statement in the facility's investigative file revealed NA # 2 wrote the following information. She (NA # 2) was sitting at the nursing station charting when she heard a loud commotion in the Activity Room. When she got in there to find out what was going on, NA # 1 had separated Resident # 1 and Resident # 2 who were in the middle of a physical altercation. NA # 1 pulled Resident # 1 away and she (NA # 2) asked Resident # 2 to go to another table and he did. She (NA # 2) did not see who passed the first lick but they were both hitting each other.NA # 2 was interviewed on 3/4/26 at 4:45 PM and reported the following information which included differing details of the incident regarding what she heard to prompt her to go into the activity room on 2/14/26 and what she saw. NA # 2 reported the following specific details. She and NA # 1 were at the nursing desk together on the evening of 2/14/26. Resident # 1, # 2, and # 3 were all in the activity room watching television. She did not recall that there were any other residents with them. She heard Resident # 3 yell, They are fighting. They are fighting. She entered with NA # 1 and saw that both Resident # 1 and Resident # 2 were hitting each other but she did not recall where the blows were on each of the resident's bodies. She did not know who had struck the first blow. Neither resident reported how it had started. NA # 1 took Resident # 1 back to her room. Resident # 2 stayed in the activity room. She had not known either resident to fight before and it was a surprise to her that it had occurred. NA # 1 told whoever the nurse on duty was what had occurred. She did not recall which nurse that was. She (NA # 2) was assigned to Resident # 2 but not to Resident # 1. That night Resident # 1's eye was okay but in a couple of days it turned black.Nurse # 1 was interviewed on 3/5/26 at 9:50 AM and reported the following information. On the 3:00 to 11:00 PM shift on 2/14/26, she was the assigned nurse for Resident # 1 and Resident # 2. A Nurse Aide told her that Resident # 1 and Resident # 2 were in an altercation and that Resident # 1 had started hitting Resident # 2. Resident # 2 did not hit back at first and then he did. She did not recall which Nurse Aide had told her about the incident. The incident occurred in the Activity Room. She checked the residents and they had no marks. It was a very busy night, and she did not call the Administrator but knew she should have done so.The Scheduler was interviewed on 3/4/26 at 4:25 PM and reported the following information. She was the Administrator on Duty for the weekend of 2/14/26. She had been in the facility on the evening of 2/14/26 when she heard NA # 1 at the nursing station talking to someone else saying that Resident # 2 had hit Resident # 1. She did not clarify where Resident # 1 had been hit. She went to talk to the nurse on the hall and found out that the nurse was aware of the incident. She went to look at Resident # 1 and did not see any marks on the resident. Resident # 1 told her (the Scheduler) that a man had hit her and described a physical feature of the male resident. She talked to Resident # 2 who said he did not know what she was talking about. She (the Scheduler) called the Administrator and referred to Resident # 1 and Resident # 2 and told the Administrator that Resident # 2 may have hit Resident # 1. Resident # 1 had been assessed and there were no marks. The Administrator told her (the Scheduler) to have NA # 1 write a statement and put it under her door. She made sure the residents were separated. During an interview with the local police department on 3/5/26 at 12:17 PM, it was confirmed that they did not receive a report of alleged assault until 2/17/26 at 12:17 PM.The DON (Director of Nursing) was interviewed on 3/5/26 at 12:15 PM and reported she had been off on 2/14/26 through 2/16/26 and no one had reported any alleged abuse to her. The Scheduler had reported to her on 2/16/26 that Resident # 1's eye was dark underneath the eye. At the time she became aware, the Administrator had already noticed the darkened area also. During interviews with the Administrator on 3/4/26 at 2:00 PM, 3/5/26 at 8:00 AM and 3/5/26 at 11:20 AM, the Administrator reported the following information. The Scheduler had called her at home on the evening of 2/14/26 and told her there was a resident-to-resident altercation between Resident # 1 and Resident # 2. She was told that it was a verbal altercation which was non-physical and no one had been hurt. She was aware that Resident # 1, who was cognitively impaired, had a history of telling other residents things like where they could sit in the common area. She had assumed Resident # 2 was the aggressor in the verbal altercation and told the Scheduler to make sure he was monitored. On 2/15/26 (Sunday) she called and talked to a nursing staff member, who validated Resident # 1 and Resident # 2 were being kept apart, monitored, and there were no problems. On Monday (2/16/26) Resident # 1 was gone for most of the day for dialysis and therefore she did not get an opportunity to talk to her. She did not look at NA # 1's statement until Tuesday (2/17/26). She did not talk to NA # 1 on 2/17/26 and first talked to NA # 1 on 3/4/26 and had her update her statement. On Tuesday (2/17/26) she talked to Resident # 1 and noticed that her eye was darker underneath. She asked her what had happened and Resident # 1 initially told her that a branch had hit her on the way to dialysis. (She had gone to dialysis the previous day). She asked Resident # 1 to think and see if there was anything else that she recalled that might have caused the dark area under her eye. Resident # 1 then said that there was a guy who was going to beat her up. The guy would not do what she asked him to do and then he pushed her. Resident # 1 had pointed to her right anterior shoulder when she said the guy had pushed her. She (the Administrator) then talked to Resident # 2 on 2/17/26 and he said he did not have a problem with anyone. Resident # 2 reported he had not hit anyone, and he wanted to be left alone. Then she had talked to Resident # 3 who had been the only resident who had witnessed the incident. Resident # 3 was cognitively intact, but she (the Administrator) could not voice an opinion on whether the resident was credible or not. Resident # 3 had told her (the Administrator) that Resident # 1 started hitting Resident # 2 when he would not do what she wanted him to do. Resident # 2 had backed up and pushed her away in a defensive manner but had not hit Resident # 1 at all. She (the Administrator) called the police to report the alleged assault on 2/17/26 and found that the family had become aware of the resident's bruising below her eye by someone other than a staff member and had already called the police themselves that day a very short time period before she had done so. She knew there had been different stories told by different individuals and she had not been able to substantiate that abuse had occurred. The Administrator did validate that the incident was not reported to her (as the Administrator) as abuse initially in order that the report to the police and state agency report be initiated per their policy. She also validated that the investigation into the alleged abuse did not begin until 2/17/26 because details had not been communicated clearly to her and she had been busy and not read NA # 1's statement when she returned to work on Monday (2/16/26).

Based on record review and interviews with staff and Physician Assistant, the facility failed to ensure the medical record was complete regarding altercations that had occurred and a Physician Assistant's assessment following an altercation. This was for 2 of 2 sampled residents whose records were reviewed related to an altercation (Residents # 1 and # 2). The findings included:1a. Resident # 1's was admitted to the facility on [DATE] and Resident # 2 was admitted on [DATE].Review of a facility investigative file into alleged abuse which occurred during an altercation on 2/14/26 between Resident # 1 and Resident # 2 revealed written statements from witnesses regarding details of what transpired in the altercation. A review of Nurse Aide (NA #1's) statement revealed she witnessed Resident # 2 hit Resident # 1. A review of NA # 2's statement revealed Resident # 1 and Resident # 2 were both hitting each other.Nurse # 1 had been assigned to care for Resident # 1 and Resident # 2 on 2/14/26. During an interview with Nurse # 1 on 3/5/26 at 9:50, Nurse # 1 reported she did not recall which Nurse Aide had informed her about an altercation, but she had been told that Resident # 1 hit Resident # 2 and then Resident # 2 hit Resident # 1 back. Nurse # 1 further reported she had been very busy, checked the residents, saw no injuries or marks, but did not document in the medical record the altercation or her assessment of the residents.During an interview with the Administrator on 3/5/26 at 3:45 PM, the Administrator reported Nurse # 1 should have made a notation in each resident's record that the residents had been involved in an altercation.1b. On 2/17/26 Resident # 1 was documented on a skin audit report as having bruising to the cheek area below her left eye. Physician Assistant # 1 was interviewed on 3/5/26 at 1:10 PM and reported the following information. She recalled assessing Resident # 1 after Resident # 1 had been involved in an altercation on 2/14/26 and after Resident # 1 was identified to have a bruise below her eye. She did not recall for sure which day this had been but knew it had been after the bruise and altercation had been reported to her from staff. Resident # 1's eye was not painful or shut. Resident # 1 did not have vision problems. Resident # 1 had reported she had been hit in another room and did not give details. She (PA # 1) reported she did not make a notation about her assessment of Resident # 1 in Resident # 1's medical record.During an interview with the Administrator on 3/5/26 at 3:45 PM, the Administrator reported PA # 1 should have made a notation in Resident # 1's record about her assessment of Resident # 1 when she evaluated her for the bruised eye following the altercation.

Based on observations, and staff and Pharmacist interviews the facility failed to (1) remove expired medications from the medication refrigerator in 1 of 1 medication storage room observed (Nursing Station), and (2) remove expired medication and (3) refrigerate medications according to the manufacturer's recommendations for 2 of 3 medication carts reviewed (Hall 100 and Hall 200).The findings included:1. During an observation of the medication refrigerator in the medication storage room (Nursing Station) with the Director of Nursing (DON) on 9/24/25 at 8:32 am the following was observed. The DON confirmed all findings before the removal of the identified items.One box with 5 COVID-19 mRNA vaccine injections with an expiration date of 9/06/25.One open plastic bottle of cephalexin (antibiotic) 250 milligrams per 5 milliliters (mg/ml) oral suspension with an expiration date of 8/31/25.One open plastic bottle of vancomycin hydrochloride (antibiotic) 250 mg/5 ml oral solution with an expiration date of 8/17/25.An immediate interview was conducted with the DON on 9/24/25 at 8:56 am who revealed the Unit Manager was responsible for checking the medication room and removal of expired medications.An interview was conducted with the Unit Manager on 9/24/25 at 8:57 am who revealed she tried to check the medication storage room every few weeks to make sure expired items were removed.2. An observation of the Hall 100 medication cart was conducted on 9/24/25 at 10:28 am with Nurse #1. Nurse #1 confirmed the findings before the removal of the identified item.One fluticasone, furoate, umeclidinium and vilanterol 200 micrograms (mcg)/62.5 mcg/25 mcg inhalation powder (medication used to treat chronic obstructive pulmonary disease (COPD) and asthma) was observed open with an open date of 8/02/25. The outer package of the fluticasone, furoate, umeclidinium and vilanterol inhalation powder read to discard after 6 weeks of opening.An immediate interview was conducted with Nurse #1 on 9/24/25 at 10:32 am who revealed she did not know the medication should have been removed 6 weeks after opening.During an interview on 9/24/25 at 11:24 am with the Director of Nursing (DON) she revealed she was new to the facility and had not yet implemented a process for the medication carts to be checked for expired medications.3. The manufacturer's recommendations for insulin lispro recommended that unopened insulin be stored in the refrigerator at approximately 36 to 46 degrees Fahrenheit.An observation was conducted on 9/24/25 at 9:53 am of the 200 Hall medication cart with Nurse #2. Nurse #2 confirmed the findings before the removal of the identified items.Two insulin lispro (rapid-acting) 100 units per milliliter (ml), 3 ml injector pen was observed unopened with 300 units of the 300 units of insulin remaining. The insulin lispro was in a clear plastic bag with blue lettering which read refrigerate and a label was attached to the injector pens which read refrigerate until opened.An immediate interview was conducted with Nurse #2 on 9/24/25 at 9:56 am who revealed the unopened insulin lispro pens should have been placed in the refrigerator when they were delivered from pharmacy until they were needed. A telephone interview was conducted on 9/24/25 at 3:56 pm with the Pharmacist who revealed the insulin lispro injector pens needed to be stored in the refrigerator until opened. The Pharmacist stated when new insulin pens were sent to the facility they were in a clear plastic bag with the word refrigerate stamped on the bag in large blue letters and a label attached to the pen which read the same. She stated labeling to refrigerate was done to remind the staff to store the medication in the refrigerator until ready to use.An interview was conducted with the Director of Nursing (DON) on 9/24/25 at 11:24 am. The DON revealed the insulin pens should have been placed in the refrigerator as labeled when they were delivered to the facility.

Based on record review, Maryland Board of Nursing (MBON) and North Carolina Board of Nursing (NCBON) verification registries and staff interviews, the facility failed to verify a staff member from another state working as a registered nurse (Staff #1) had an active professional nursing license for 1 of 14 nursing staff reviewed. Staff #1 did not have a professional nursing license and performed the job responsibilities of a nurse from 2/24/25 through 6/15/25. The findings included: A review of Staff #1's employment application with the facility indicated she was hired as a Registered Nurse (RN) on 2/14/25. Her date of birth and middle name were included on her Maryland driver's license. A MBON licensure verification dated 2/14/25 located in Staff #1 's employment folder indicated the same first and last name as Staff #1 was listed as an active RN with a compact state license that included North Carolina. The middle name was not included on the nursing license. Record review indicated Staff #1's nurse competencies were reviewed after hire during her training with another staff member. The record showed this competency verification was completed in full with no areas of concern identified. A review Staff #1's personnel file revealed no evidence of performance issues or disciplinary action. A review of Staff #1's timecard report from 2/14/25 through 6/15/25 recorded Staff #1 worked the following hours as an RN on the following dates: 2/24/25 8:00 am - 12:30 pm, 1:00 pm - 3:00 pm2/25/25 9:01 am - 3:39 pm2/26/25 7:00 am - 3:21 pm3/4/25 7:00 am - 3:16 pm3/6/25 10:44 pm - 7:18 am3/8/25 10:39 pm - 7:49 am3/9/25 10:38 pm - 7:12 am3/10/25 10:43 pm - 7:15 am3/13/25 10:40 pm - 7:35 am 3/17/25 10:45 pm - 7:30 pm3/19/25 10:26 pm - 7:57 am3/20/25 10:40 pm - 7:40 am3/22/25 10:48 pm - 8:00 am3/23/25 10:54 pm - 7:34 am3/24/25 10:44 pm - 7:35 am3/27/25 10:32 pm - 7:35 am3/31/25 10:53 pm - 8:57 am4/2/25 10:43 pm - 8:32 am 4/3/25 10:43 pm - 7:19 am4/4/25 10:52 pm - 7:56 am4/5/25 10:50 pm - 8:14 am4/6/25 10:55 pm - 7:35 am4/7/25 10:47 pm - 7:57 am4/14/25 10:59 pm - 7:19 am4/16/25 10:52 pm - 7:55 am4/17/25 10:46 pm - 7:55 am4/19/25 10:46 pm - 7:45 am4/20/25 10:54 pm - 8:39 am4/24/25 10:42 pm - 7:42 am4/28/25 10:46 pm - 7:34 am4/30/25 10:40 pm - 7:41 am5/1/25 10:45 pm - 7:36 am5/3/25 10:40 pm - 8:08 am5/4/25 10:45 pm - 8:07 am5/5/25 10:44 pm - 7:46 am5/8/25 10:46 pm - 8:06 am5/9/25 10:45 pm - 7:46 am5/12/25 10:44 pm - 7:49 am5/14/25 10:45 pm - 11:15 pm5/21/25 11:28 pm - 7:47 am5/23/25 10: 45 pm - 7:40 am5/26/25 11:10 pm - 8:38 am5/27/25 11:05 pm - 7:38 am5/28/25 11:29 pm - 7:33 am5/29/25 11:39 pm - 7:39 am5/30/25 10:45 pm - 7:45 am5/31/25 10:56 pm - 8:36 am6/1/25 10:47 pm - 7:22 am6/2/25 11:27 pm - 8:05 am6/5/25 11:46 pm - 7:44 am6/9/25 11:38 pm - 7:38 am6/11/25 11:40 pm - 7:46 am6/12/25 11:30 pm - 7:54 am6/14/25 10:40 pm - 7:45 am6/15/25 10:45 pm - 7:37 am The Former Scheduler was interviewed via telephone on 9/23/25 at 12:02 PM. She indicated that she received a call from a Staffing Agency Owner on 7/7/25 asking if Staff #1 currently worked at the facility. Staff #1 no longer worked for the facility at that time and had applied to the Staffing Agency. The Staffing Agency Owner told the Former Scheduler that Staff #1 was not a nurse. She explained that she personally knew the Director of Nursing (DON) at Facility #2 and was aware Staff #1 had worked there in the role of a nurse as well. The Former Scheduler indicated that the Staffing Agency Owner asked her to stay on hold while she called the DON at Facility #2. When taken off hold, the Staffing Agency Owner merged the call with the Former Scheduler and the DON at Facility #2. The Staffing Agency Owner told them that Staff #1 applied at the Staffing Agency and the agency could not find a matching social security number or a valid nursing license for Staff #1 and stated that, therefore, Staff #1 was not a licensed nurse. The Former Scheduler indicated that she did not do anything further with that information. The Staffing Agency Owner was interviewed via telephone on 9/23/25 at 12:04 PM. She stated that Staff #1 never applied to her company, and she denied contacting the facility on 7/7/25. Facility #2's Administrator, the other facility where the Staffing Agency Owner indicated Staff #1 worked, was interviewed via telephone on 9/23/25 at 10:19 AM. She revealed that Staff #1 was hired at Facility #2 as an RN. She indicated when Facility #2's DON performed an independent search to verify Staff #1's credentials, they could not connect her name to the Maryland Nursing and Interstate Compact License because the full name of Staff #1 did not match exactly. When Staff #1 was approached about the questionable search results, she became angry and would not answer any questions. Facility #2's Administrator reported that Staff #1 told her and Facility #2's DON that she was in Nurse Practitioner school at a local community college. During a telephone interview with Facility #2's DON on 9/23/25 at 10:48 AM, she revealed that the Staffing Agency Owner initiated a call between herself and the Former Scheduler of Facility #1 on 7/7/25 at 9:00 PM. The Staffing Agency Owner reported the agency had some concerns about Staff #1, and they were considering hiring her. The Staffing Agency Owner questioned Staff #1's nursing license and background due to 2 different middle names that were being used. On 9/23/25 at 12:22 PM, the North Carolina Board of Nursing License Verification online inquiry revealed that Staff #1's name did not populate in the search. On 9/23/25 at 12:30 PM, the Maryland Board of Nursing License Verification inquiry indicated that a Registered Nurse (RN) with the same first and last name (no middle name listed) as Staff #1 held an active RN license renewed on 12/1/23 and set to expire on 11/28/25. A telephone interview was attempted with Staff #1; however, she could not be reached during the investigation. The Maryland Board of Nursing License Verification inquiry on 9/23/25 indicated Staff #1's had an active Certified Nursing Assistant (CNA) license renewed on 1/22/24 and set to expire on 1/28/26. Her middle name was included in the registry. During a telephone interview with a representative at the Maryland Board of Nursing Complaints Department on 9/23/25 at 1:10 PM, she confirmed that Staff #1 with the correct date of birth and middle name included on her driver's license was registered as an active CNA only. On 9/23/25 an online search on the North Carolina (NC) Health Care Personnel Registry's verification website (a website that provides verification directly from NC registries for Nurse Aides and Medication Aides), revealed no information for Staff #1. The Former DON was interviewed on 9/23/25 at 11:29 AM. She revealed that Staff #1 used to get flustered during her overnight shifts. Staff #1 had a bad night one night, and Staff #1 asked one of the day shift nurses (name unknown) to help her (Staff #1) with paperwork so that she could leave. After Staff #1 left the facility (date unknown), the day shift nurse who helped Staff #1 told the Former DON that this happened all the time with Staff #1. The Former DON indicated that she did not do anything further with the information. An interview was conducted with Human Resources on 9/23/25 at 9:44 AM. She revealed that the hiring process included verification of the driver's license, social security card, background check, and I-9 verified in person (Employment Eligibility Verification). She indicated that Staff #1 was employed as a registered nurse at the facility from 2/24/25 - 6/15/25 and then quit without notice on 6/15/25. Multiple attempts were made to contact Staff #1 on 6/16, 6/18, 6/23 without any answer. The active nursing license that Staff #1 provided was initiated in Maryland (multi-state license) with an expiration date of 11/28/25. Human Resources stated that there were not any issues while Staff #1 was employed at the facility. Her performance did not cause any questions about her competency, and she did not receive any disciplinary action or teachable moments. Human Resources indicated that she heard something about Staff #1 not being a licensed nurse (from who was unknown); however, she stated that was hearsay and did not investigate it further. During an interview with the Former Administrator on 9/24/25 at 10:11 AM, he revealed that he could not recall Staff #1 as a staff member, and no one from the facility spoke to him about her credentials. The [NAME] President of Operations was interviewed on 9/23/25 at 3:25 PM. He revealed that there was a breakdown in the HR process, and Staff #1's complete personnel information should have been validated with the Maryland Board of Nursing.

Based on record review and staff interviews, the facility failed to ensure a medical record was complete and accurate regarding tracheostomy care. This was for 1 of 5 sampled residents whose medical record was reviewed for documentation (Resident #1).Resident #9 was readmitted to the facility on [DATE]. Physician orders for Resident #9 revealed that tracheostomy care every shift and as needed was entered into the electronic medical record on 6/10/25 by the previous Infection Preventionist. During an interview with the Staff Development Coordinator/previous Director of Nursing (from 4/1/25 - 9/9/25) on 9/24/25 at 4:56 PM, she revealed that when the order for tracheostomy care every shift and as needed was entered by the previous Infection Preventionist, she chose the standard option instead of the option that populated onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR). She explained that the standard option only showed in the orders section of the electronic medical record, it did not activate the order to display for nurses to see or record their activity. Resident #9's TAR/MAR from 6/10/25 through 9/24/25 revealed the physician order dated 6/10/25 for tracheostomy care every shift and as needed was not listed. The only order related to Resident #9's tracheostomy that populated on the TAR/MAR was an as needed order for nurses to change Resident #9's tracheostomy and/or tracheostomy collar as needed with a size 6 Shiley (tracheostomy tube size). There was no evidence on the TAR/MAR that tracheostomy collar was changed on 8/27/25. Nurse #7, who worked with Resident #9, was interviewed on 9/24/25 at 2:04 PM. She revealed that she changed the tracheostomy collar on 8/27/25 but forgot to document in the TAR/MAR. Nurse #7 indicated that she did not notice Resident #9 did not have any tracheostomy care orders in the TAR/MAR. An interview was conducted with Nurse #8 on 9/24/25 at 3:16 PM. He worked with Resident #9 during the evening shifts from 3:00 PM - 11:00 PM on 9/22/25 and 9/23/25. Nurse #8 revealed that he usually performed tracheostomy care early in his shift and would normally document this activity in the TAR. However, Nurse #8 stated he did not document tracheostomy care for Resident #9 because there was no order in the TAR/MAR. During a telephone interview with Nurse #4 on 9/24/25 at 4:30 PM, she revealed that she worked with Resident #9 during the night shift from 11:00 PM - 7:00 AM on 9/17/25, 9/22/25, and 9/23/25. Nurse #4 stated that she did perform tracheostomy care for Resident #9, and the tracheostomy care that she performed during her shift. She could not recall there being a section to sign off on in the TAR/MAR for Resident #9's tracheostomy care. When asked why she did not report the order missing from the TAR/MAR, she stated because she just realized now when talking about Resident #9's tracheostomy that there was no section to sign off for care. An interview was conducted with the Director of Nursing on 9/25/25 at 1:38 PM. She revealed that tracheostomy care for Resident #9 was included as a physician order; however, it was not entered properly to populate for nurses to sign off on in the TAR/MAR. The Administrator was interviewed on 9/25/25 at 2:16 PM. When asked to discuss what caused the failure related to complete and accurate medical records for Resident #9, the Administrator did not provide an answer. He stated that the facility will need to review the process to ensure that nurses have access to document the care provided.

Based on record review, and staff, resident and Pharmacist interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 2 of 4 residents reviewed for misappropriation of property (Resident #38 and Resident #83).The findings included:The facility's Abuse and Neglect Prohibition policy last revised 8/2023 indicated that each resident had the right to be free from abuse which included misappropriation of property which was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.a. Resident #38 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, gout, and long-term use of opiate analgesic (a type of opioid pain medication). Resident #38 had a physician order dated 8/21/25 for oxycodone (opioid pain medication) 5 milligrams (mg); one tablet by mouth three times a day for pain.A pharmacy proof of delivery shipment summary dated 8/26/25 revealed a delivery for Resident #38's oxycodone 5 mg tablets with a quantity of 90 tablets (3 medication cards with 30 tablets per card) on 8/27/25. Resident #38's Medication Administration Record (MAR) was reviewed for August 2025 and September 2025 and the oxycodone 5 mg tablet was administered as ordered.An interview was conducted with Resident #38 on 9/21/25 at 11:10 am who revealed she had no concerns related to pain management.b. Resident #83 was admitted to the facility on [DATE] with diagnoses which included chronic pain and peripheral vascular disease.Resident #83 had a physician order dated 8/15/25 for oxycodone 7.5 mg/acetaminophen 325 mg (an opioid pain medication); give one tablet by mouth every 4 hours for chronic pain.A pharmacy proof of delivery shipment summary dated 8/15/25 revealed a delivery for Resident #83's oxycodone 7.5 mg/acetaminophen 325 mg tablets with a quantity of 180 tablets (6 medication cards with 30 tablets per card) on 8/15/25.Resident #83's MAR was reviewed for August 2025 and September 2025 and the oxycodone 7.5 mg/acetaminophen 325 mg tablet was administered as ordered.An interview was conducted with Resident #83 on 9/21/25 at 12:52 pm. Resident #83 stated the facility managed her pain well and she did not have any concerns related to pain management.The initial allegation report completed by the Administrator revealed the facility became aware of misappropriation of resident property on 8/31/25 when the Staff Development Coordinator (SDC) and the Regional Clinical Director notified the Administrator that Resident #38 and Resident #83 had missing narcotics and the medications were unable to be located in the facility. The Administrator submitted an initial report to the Division of Health Service Regulation for misappropriation of resident property for Resident #38 and Resident #83 on 8/31/25. The police department was notified of suspicion of crime on 8/31/25 at 3:53 pm. A review of the 5-day investigation report completed by the Administrator dated 9/05/25 revealed that the allegation of misappropriation of resident property identified two residents (Resident #38 and Resident #83) who were affected and the allegation was not substantiated by the facility. The facility's investigation indicated that Resident #38 had one medication card, which contained 30 tablets, of oxycodone 5 mg tablets and Resident #83 had one medication card, which contained 30 tablets of oxycodone 7.5 mg/acetaminophen 325 mg tablets, that were each unable to be located in the facility. Nurse #11, who was the named agency nurse in the investigation report, was placed on the do not return list. The local police department, Adult Protective Services, and the Drug Enforcement Agency (DEA) were notified of the missing narcotics.Attempts to conduct a telephone interview with Nurse #11 on 9/24/25 at 3:44 pm and 9/25/25 at 9:30 am were unsuccessful.An interview was conducted with Nurse #9 on 9/24/25 at 1:16 pm who revealed she worked on the medication cart utilized for the hall Resident #38 and Resident #83 resided on during the 7:00 am-3:00 pm shift on 8/28/25 and 8/29/25. Nurse #9 stated she arrived to work on 8/29/25 for the 7:00 am-3:00 pm shift and she completed the narcotic count for the medication cart with Nurse #11. Nurse #9 stated when they completed the narcotic count the number of narcotic medication cards in the locked drawer of the medication cart matched the number of the narcotics noted on the controlled drug count record (used to monitor narcotics that were added and removed from the medication cart), which she recalled was noted as 25 narcotic medication cards. Nurse #9 stated she had worked the previous day (8/28/25) and recalled the number of narcotic reconciliation for the medication cart was 27 when she completed her shift at 3:00 pm and she could not recall any of the narcotics being close to empty. Nurse #9 explained that narcotic cards were only removed when discontinued or the pack was empty and she knew nothing was close to empty when she left the previous today. Nurse #9 further explained that she felt like something was off with the narcotic medication card count throughout her shift even though the number of narcotic medication cards and the number of countdown sheets matched. Nurse #9 stated she questioned Nurse #11 about what narcotic medication cards were removed from the narcotic lock box on the medication cart and she stated Nurse #11 denied removing any narcotics. Nurse #9 stated she then left the medication cart to look for the completed narcotic count down sheets or the medication packs that were removed and during that time, Nurse #11 left the facility. Nurse #9 stated when Nurse #10 had arrived at the facility on 8/29/25 for the start of her 3:00 pm-11:00 pm shift she (Nurse #9) asked her (Nurse #10) if she recalled removing any completed narcotics from the medication cart during her shift on 8/28/25 and Nurse #10 stated she did not have to discard any completed narcotic medication cards from the narcotic drawer during her shift. Nurse #9 stated at that point she notified the SDC, who was at the facility at the time, of the possible discrepancy with the medication cart narcotic count. She stated at that time she and the SDC began looking through the medication cart with her to determine if any narcotics were missing. Nurse #9 stated it was found that Resident #38 and Resident #83 each had one narcotic medication pack and countdown sheets for those medication packs missing from the medication cart. A telephone interview was conducted with Nurse #10 on 9/25/25 at 11:36 am who revealed she worked on 8/28/25 and 8/29/25 during the 3:00 pm-11:00 pm shift. She stated she counted the narcotics on the medication cart with Nurse #11 on 8/28/25 at the end of her shift and the count was correct. Nurse #10 stated she could not recall at this time what the count was but she stated there was no discrepancy when she left the facility after her shift on 8/28/25. Nurse #10 stated she recalled that on 8/29/25 when she arrived back to work, Nurse #9 asked her if she had to remove any narcotics from the medication cart during her shift on 8/28/25 and she stated she did not have to remove any narcotic medication cards or complete countdown sheets during her shift. Nurse #10 stated the SDC was present at the facility at this time and the SDC began looking for any medications that may have been removed.A telephone interview was conducted with the Pharmacist on 9/24/25 at 3:46 pm who revealed when controlled substances (such as narcotics) were sent from the pharmacy to the facility the medications were scanned and secured in a delivery bag with a manifest (list of all the controlled substances in the delivery). She stated the delivery driver then delivered the controlled substances and a nurse at the facility had to check the medications to ensure accuracy with the manifest and then sign the manifest confirming the delivery was accurate. The Pharmacist stated that each narcotic medication pack was sent to the facility with an individual count down sheet for each pack, and she stated the medication packs normally had 30 tablets per pack. The Pharmacist stated the facility was to notify the pharmacy of any discrepances related to narcotics once identified and she confirmed the information was received from the facility when the discrepancy was identified.During an interview on 9/23/25 at 12:57 pm with the Previous Director of Nursing (DON) she stated she was not present at the facility during the time the narcotics for Resident #38 and Resident #83 were identified as missing but she stated the Administrator, SDC, and corporate office managed the investigation.An interview was conducted with the Administrator on 9/24/25 at 4:25 pm who revealed he was notified at the end of the day on 8/29/25 that there may have been a narcotic discrepancy with one of the medication carts at the facility but it was not confirmed until 8/31/25. He stated the SDC was present at the facility at the time and began an investigation to locate the missing medications and after a full search of the facility and investigation the missing narcotics were confirmed. The Administrator stated he reported the allegation to the appropriate agencies and the facility replaced the missing narcotics. The Administrator stated the facility was unable to substantiate the allegation and did not report Nurse #11 to the North Carolina Board of Nursing because the facility was unable to speak with Nurse #11 about the missing narcotics. The Administrator confirmed that the facility was unable to locate Resident #38's and Resident #83's missing narcotics, that the narcotics were removed from the facility, and that Nurse #11 was the named nurse in the allegation. The facility provided a plan of correction that was not acceptable to the State Agency as the facility did not report Nurse #11, the nurse suspected of misappropriating the narcotic medications for Resident #38 and Resident #83, to the North Carolina Board of Nursing.

Based on observation, record review, and resident and staff interviews, the facility failed to follow professional standards of care when the nurse did not remain at the bedside to ensure the resident had taken all the medications. The deficient practice was observed for 1 of 1 resident observed with medications at bedside (Resident #74).The findings included:Resident #74 was admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis.Review of the medical record revealed a physician order dated 2/21/25 for Lanthanum Carbonate 500 milligram (MG) Chewable Tablet (a medication used to decrease the amount of phosphate in the blood caused by kidney disease). Give 3 tablets by mouth before meals.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was cognitively intact.Resident #74's care plan last reviewed 8/18/25 did not include self-administration of medication.There was not an assessment of Resident #74 in the medical record to determine if it was safe for the resident to self-administer medications.On 9/21/25 at 12:37 PM Resident #74 was observed with a large white pill with the number 500 sitting in a cup on her bedside table. Resident #74 reported she took the medication before breakfast, lunch, and dinner daily. Resident #74 reported she was going to take the medication and had placed the medication in the cup on the bedside table.An interview was conducted with Nurse #5 on 09/21/2025 at 1:43 PM. Nurse #5 stated she was supposed to watch the resident take her medication and make sure that she took all the medication before she left the room. Nurse #5 stated Resident #74 normally took all of her medication when given. An interview was conducted with Resident #74 with the Director of Nursing (DON) present on 09/21/2025 at 1:52 PM. Resident #74 stated that she took 2 of the tablets with the nurse there at the bedside. Resident #74 stated she must have forgotten to take the third pill. During an interview with the DON on 9/21/25 at 2:00 PM she stated Nurse #5 should have stayed with Resident #74 and watched her take the medication before exiting the room. An interview was conducted with the Administrator on 9/25/25 at 1:10 PM. The Administrator stated he expected the staff would make sure all medications were taken prior to leaving the resident.

Based on observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 4 residents reviewed with a urinary catheter (Resident #11).The findings included:Resident #11 was admitted to the facility on [DATE]. Her cumulative diagnoses included urostomy, spina bifida, seizures, and chronic kidney disease. Resident #11's care plan included an area of focus related to the resident having an indwelling urinary catheter in place (Initiated on 7/16/25). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severely impaired cognition. She experienced fluctuating disorganized thinking but no rejection of care behaviors. The assessment indicated Resident #11 required substantial/maximal assistance with all activities of daily living (ADL). The MDS reported Resident #11 had an indwelling urinary catheter.An observation was conducted on 9/21/25 at 12:35 PM as Resident #11 was lying in bed with a urinary catheter collection bag hanging from the left side of the bed frame. At the time of this observation, 3 inches of the bottom of Resident #11's urinary catheter bag was on the floor. During an interview on 9/21/25 at 1:29 PM with Nurse Aide #1, who was assigned to Resident #11, she stated that the catheter bag should not be touching the floor. However, when Resident #11's bed went up and down, the catheter bag would touch the floor if the bed was too low. Nurse Aide #1 stated she normally emptied the bag at the end of her shift, so she did not know how long the catheter bag/cover was touching the floor. Nurse Aide #1 then raised Resident #11's bed so that the catheter bag/cover was off the floor. An interview was conducted with the interim Director of Nursing (DON) on 9/24/25 at 9:15 AM. She revealed that the catheter bag should not be touching the floor or hanging above the abdomen. Resident #11's catheter bag should never have been on the floor, and it should have been placed in a location that did not compromise her with a possible infection. The interim Administrator was interviewed on 9/24/25 at 10:23 AM. He revealed that Resident #11's catheter bag should have been hung so when the bed was lowered it did not touch the floor.

Based on observations, record review and staff interviews, the facility failed to provide nutritional support through enteral feeding (a method of delivering nutrition directly into the gastrointestinal (GI) tract, typically through a feeding tube) as ordered by the physician for 1 of 2 residents reviewed for tube feedings (Resident #79).The findings included: Resident #79 was readmitted to the facility on [DATE]. His diagnoses included anoxic brain damage, and dysphagia. The care plan dated 3/13/24 revealed Resident #79 was at risk for malnutrition and dehydration related to a past medical history of aphasia, anoxic brain damage, gastrostomy tube (g-tube) feedings, heart failure, coronary artery disease, hypertension, gastroparesis, epilepsy, colostomy status, quadriplegia, and vitamin D deficiency. There was a need for enteral nutrition and on medications with signs and symptoms of appetite and weight changes. Interventions included: Administer g-tube feedings and water flushes as ordered. Observe for signs and symptoms of dehydration. Monitor and evaluate weight/weight changes. Monitor/record/report signs and symptoms of malnutrition. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79 was severely cognitively impaired and was totally dependent on staff for all activities of daily living (ADL). He had no speech and rarely/never understood/understands. The MDS indicated Resident #79's nutrition was approached with the use of tube feedings, and he received more than fifty one percent of his calories and more than five hundred and one milliliters of fluid intake per day from his tube feedings. The physician order dated 9/5/25 revealed Resident #79 was ordered fortified nutritional supplement at seventy-five milliliters (mL) per hour for twenty-two hours from two o'clock in the afternoon to twelve o'clock in the afternoon via g-tube. Medication Administration Record (MAR) dated September 2025 revealed fortified nutritional supplement at seventy-five milliliters (mL) per hour for twenty-two hours from two o'clock in the afternoon to twelve o'clock in the afternoon via g-tube. Nurse #5 documented on the MAR that the tube feeding was administered on 9/21/25 as scheduled. During a continuous observation on 9/2125 from 11:08 AM until 11:48 AM, Resident #79 was observed lying in bed, and the tube feeding pump screen was black with a green light signifying the battery was charging. The tube feeding formula was hanging with date/time identifiers, and the bottle was just about full (missing 1/8th of the amount). At 11:36 AM on 9/21/25, Nurse #5 was observed walking past Resident #79's room, looking in, and continued down the hall. An interview and observation with Nurse #5 were conducted on 9/21/25 at 11:49 AM. Nurse #5 confirmed that the tube feeding was supposed to be off from 12:00 PM - 2:00 PM every day. She stated she was not aware that Resident #79's tube feeding was not infusing from 11:08 AM - 11:49 AM. Nurse #5 indicated that perhaps Nurse Aide #2 provided care for Resident #79, turned off the tube feeding pump, and forgot to turn it back on. Nurse Aide #2 was interviewed on 9/21/25 at 11:52 AM. She revealed that she provided care to Resident #79 at 7:00 AM the same morning. Normally, when she performed care for Resident #79, she would place the tube feeding pump on hold and then when finished with care, she would unlock the hold. Nurse Aide #2 stated she never turned the tube feeding pump off completely. She further stated that she could not say when she was in the room last but had passed by the room since 7:00 AM and did not notice if the tube feeding pump was off. During an interview with the Director of Nursing (DON) on 9/24/25 at 9:35 AM, she revealed that Resident #79's tube feeding pump should not have been turned off from 11:08 AM - 11:48 AM. Nurse #5 should have followed the physician order to hold the feeding from 12:00 PM until 2:00 PM. The interim DON stated that rounds were performed every two hours by Nurse Aide #2 and anytime Nurse #5 went into the room to give medication. The Administrator was interviewed on 9/24/25 at 10:24 AM. He revealed that the physician's order for Resident #79's continuous tube feeding should have been followed as ordered. Unless care was provided, the tube feeding pump should be kept on.

Based on observation, record review, and staff and Medical Director interviews, the facility failed to have effective systems in place for entering tracheostomy care orders, so they were placed on the Treatment Administration Record (TAR) for completion by nursing staff. Nurse #2 did not provide tracheostomy care consistent with professional standards of practice when she was observed picking up the oxygen tubing off the floor and attaching it to the corrugated tubing connected to the humidifier (adds moisture to the oxygen). In addition, the facility failed to have effective systems in place for identifying an avoidable open moisture-associated skin damage in Resident #9's skin fold on her neck. The deficient practice occurred for 1 of 2 residents reviewed for tracheostomy care (Resident #9). The findings included:Resident #9 was readmitted to the facility on [DATE] with diagnoses that included anoxic brain damage and tracheostomy status. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed that Resident #9 had no speech, rarely/never understood/understands, and was severely cognitively impaired. She was totally dependent on staff for all activities of daily living (ADL) and was coded for tracheostomy care. Review of Resident #9's care plan updated on 5/13/25 revealed that she had impaired gas exchange/ineffective airway clearance related to respiratory failure with brain injury, tracheostomy, and history of COVID. Interventions included tracheostomy care. Review of physician orders dated 6/10/25 revealed that Resident #9 was to receive tracheostomy care every shift and as needed and suctioning as needed for secretions, mucus, and/or increased shortness of breath. The order was entered by the previous Infection Preventionist and there were no specifics regarding tracheotomy care included in the order. Review of a skin assessment dated [DATE] and completed by Nurse #8 revealed that Resident #9 did not have any new skin concerns. Nurse #8 was interviewed on 9/24/25 at 3:16 PM and stated when performing skin checks the areas observed included were the sacrum, heels, and any other bony prominence (normal breakdown spots). He stated that he would only check the head or neck area if nursing staff alerted him of a new skin issue. Review of the June 2025 through September 2025 Treatment Administration Records (TAR) revealed there were no orders for tracheostomy care as the order did not populate on the TAR for completion from 6/10/25 through 9/24/25. A continuous observation of tracheostomy care and interviews were conducted on 9/24/25 from 11:17 AM through 12:12 PM. Nurse #2 was the assigned nurse for Resident #9; however, the facility asked Nurse #1 to perform the tracheostomy care. Nurse #2 stated that she had never performed tracheostomy care at the facility for Resident #9 and wanted to observe Nurse #1 for training. Nurse #2 stated that the overnight shift usually performed the tracheostomy care. At 11:33 AM, Nurse #2 was observed picking up the oxygen tubing off the floor and reattaching it to the corrugated tubing connected to the humidifier. Nurse #1 responded: You can't do that. Nurse #1 then instructed Nurse #2 to retrieve all new oxygen and corrugated tubing that was sterile. The concern of the tubing on the floor was related to infection control purposes. When Nurse #2 returned to the room with the new tubing, she stated that the oxygen tubing often disconnected from the corrugated tubing during her shift, and she normally reconnected the tubing without changing any of the tubing. Nurse #1 stated that Nurse #2 should have disconnected and replaced all tubing when the oxygen tubing was found on the floor. Nurse #2 stated that she thought the opening to the corrugated tubing was not a sterile site. At 12:12 PM, as Nurse #1 was disconnecting the tracheostomy tie on the right side of Resident #9's neck, she noticed an open moisture-associated skin damage (MASD) area within the skin fold. She then took used her sterile gloves and put sterile water on a piece of gauze and treated the area. Bright red blood was found on the used gauze. An interview was conducted with the Wound Nurse on 9/24/25 at 4:48 PM. She revealed that Resident #9's newly discovered skin issue found on 9/24/25 was caused by MASD. Her neck area was moist and sweaty. The Wound Nurse had to open the skin folds on the neck to see it. She stated that she contacted the wound provider, and she wanted to try antifungal powder as well as interdry (moisture wicking fabric with antimicrobial properties) sheets. The Wound Nurse stated that skin areas that hold moisture should have interdry sheets in between. The Wound Nurse indicated when the trach ties were changed, the nurses should inspect in between the skin folds of the neck. Skin assessment entails head-to-toe observation and not only boney prominences. With heavier residents, skin folds need to be assessed every shift or included with weekly skin checks. Nurse #8, who was assigned to Resident #9 during the 3:00 PM to 11:00 PM shift on 9/22/25 and 9/23/25, was interviewed on 9/24/25 at 3:16 PM. Nurse #8 revealed that he had performed Resident #9's tracheostomy care on 9/22/25 and 9/23/25, and he did not observe anything out of the ordinary other than a mild amount of secretions. Normally, he would document completed tracheostomy care in the TAR. However, Nurse #8 stated that he did not document tracheostomy care for Resident #8 because there was no order on the TAR. He stated that he had changed the gauze but not the tracheostomy collar both days collar. Nurse #1 was interviewed on 9/25/25 at 10:14 AM. She revealed the main issues during tracheotomy care for Resident #9 on 9/24/25 was that the tubing needed to be replaced, originally the incorrect inner cannula size was chosen, multiple pairs of sterile gloves ripping, and the discovery of the MASD area on Resident #9's neck. Nurse #1 indicated that she heard Nurse #2 say that she wanted to observe tracheostomy care because she had never performed tracheostomy care at the facility and needed further training. Resident #9's responsible party (RP) was interviewed on 9/24/25 at 3:12 PM. She has had past issues with shearing (when tissue layers shift laterally) on Resident #9's neck when the tracheostomy ties were removed. During an interview with the Staff Development Coordinator/previous Director of Nursing (from 4/1/25 through 9/9/25) on 9/24/25 at 4:56 PM. Physician orders were normally reviewed in the morning clinical meeting the day after (re)admission, and a second review was done with medication reconciliation. The Staff Development Coordinator/previous Director of Nursing stated that tracheostomy care was an order set and then the options would be selected from there. The selected orders should be tracheostomy care, suctioning, site monitoring, and oxygen calibration/monitoring. All orders should be verified with the Medical Director and/or Physician Assistant. She could not recall if Resident #9's orders after readmission on [DATE] were reviewed the next day during the morning meeting; however, that was supposed to be the protocol along with medication reconciliation from the hospital discharge orders. The Staff Development Coordinator/previous Director of Nursing explained when the orders were entered by the previous Infection Preventionist, she chose the standard option instead of MAR or TAR which does not place the order on the MAR/TAR for completion by staff. Further order reviews would not have been performed unless Resident #9 had a change of condition or another readmission. A telephone interview was conducted on 9/24/25 at 3:43 PM with Nurse #3, who worked with Resident #9 during various evening shifts. Nurse #3 stated she was familiar with Resident #9 and verified that she did have a tracheostomy. She further stated that she provided suctioning during her shift of 3:00 PM to 11:00 PM when assigned to Resident #9; however, she did not document this activity in the TAR. She also replaced the gauze dressing around the stoma (opening created by a surgeon) because it was usually soiled. Nurse #3 indicated that she did not provide any other tracheostomy care for Resident #9 because the cleaning of the tracheostomy, changing of the inner cannula, and replacement of ties were done during the night shift from what other staff had told her. She stated that the suctioning of the tracheostomy was documented on the TAR. All oxygen tubing was changed on Sunday during night shift. She stated she did not change the inner canula or check the skin under the collar for any breakdown during the shifts she worked. She stated she was not sure what shift was supposed to change the inner canula or how often the facility expected it to be changed. Nurse #3 confirmed that she did attend the training provided by the Respiratory Therapist on 6/29/26. Nurse #4 was interviewed via telephone on 9/24/25 at 4:30 PM. She revealed that she was an agency nurse, worked the 11:00 PM to 7:00 PM shift at the facility, and picked up shifts every now and then. Nurse #4 stated that she had tracheostomy care experience from her nursing history and she did perform tracheostomy care for Resident #9. The tracheostomy care that she performed during her shift included changing the gauze dressing around the stoma because it was usually soiled. She would remove the soiled dressing and put a clean dressing around the stoma. Nurse #4 stated she did not change the inner canula or check the skin under the collar for any breakdown during the shifts she worked. She indicated that she was not sure what shift was supposed to change the inner canula or how often the facility expected it to be changed. She also stated she would suction the stoma if it was needed but did not otherwise. Nurse #4 could not recall there being a section to sign off this activity on the MAR or TAR. Nurse #4 indicated she did not report the order missing from the MAR because she just realized now when talking about Resident #9's tracheostomy that there was no section to sign off for the care. A telephone interview was conducted with the Respiratory Therapist on 9/24/25 at 2:31 PM. She revealed that she visited the facility weekly, and the last time she saw Resident #9 was on 9/16/25. The Respiratory Therapist stated she did not see anything out of the ordinary on 9/16/25 or any concerns with nursing staff performance to prompt an education opportunity for tracheostomy care. She stated Resident #9 often had secretions and coughed to clear secretions and required suctioning often. Resident #9's gauze must be changed often due to excessive secretions. The Respiratory Therapist stated she documented her activity in the progress notes section of the electronic medical record (EMR). She further stated that tracheostomy care, assessment, and cleaning of the area should be performed every shift and as needed. During a follow up interview with the Respiratory Therapist on 9/25/25 at 10:02 AM, she revealed that routine tracheostomy care included cleaning around the trach, under the flange, and around the neck with sterile water and peroxide. Also, change the inner cannula and place the new drainage sponge (gauze), and change the trach ties as needed every shift and as needed. The Medical Director was interviewed on 9/25/25 at 8:57 AM via telephone. He revealed that the as needed tracheostomy care order for Resident #9 dated 6/10/25 was appropriate. However, the order was for tracheostomy care every shift and as needed. Resident #9 had a long-standing tracheostomy for more than 3 years and had respiratory failure from COVID. The Medical Director stated the order entered on 6/10/25 for tracheostomy care was deescalated from every shift to as needed when Resident #9 returned from the hospital. Only when there was crustiness around the stoma would tracheostomy care be appropriate. The Medical Director indicated that the inner cannula was there to remove if she ever had an obstruction, and for no other reason. He stated that tracheostomy care consisted of sterile water used to clean around the stoma and sterile gauze used to clean the outside of the tracheostomy. The Medical Director further stated that nurses should assess the stoma/area every shift as part of their nursing rounds. The Director of Nursing was interviewed on 9/25/25 at 1:36 PM. She revealed that if the nurses did not see an order for tracheostomy care or suctioning, they should have contacted the provider for proper orders. For a resident that has a tracheostomy, the Director of Nursing stated that nurses should follow physician's orders for caring/monitoring the tracheostomy. Also, Nurse #1 should have never reattached the oxygen tubing when found on the floor but rather replace the oxygen tubing before reattaching. During an interview with the Administrator on 9/25/25 at 2:05 PM, he revealed that the facility would continue to investigate what went wrong with Resident #9's tracheostomy care, and it would be included in the plan of correction.

Based on observations, record review and staff interviews, the facility failed to ensure nursing staff were competent to provide tracheostomy (surgical hole in the windpipe) care when Nurse #2 was observed picking oxygen tubing off the floor and attaching it to the corrugated tubing connected to the humidifier (adds moisture to the oxygen). During interviews Nurse #4 indicated she had not received any education from the facility regarding tracheostomy care and Nurse #7 indicated no one had evaluated her performance for tracheostomy care since her most recent return 2 months ago. In addition, the facility was unable to locate any nursing skills competency check off information for tracheostomy care for any of the nursing staff. The deficient practice occurred for 3 of 8 nursing staff reviewed for tracheostomy care competencies (Nurse #2, Nurse #4, and Nurse #7). The findings included:Review of a competency and training fair held at the facility on 6/29/25 with various specialists to provide education to facility staff revealed that the Respiratory Therapist provided training to nurses about tracheostomy/respiratory care. However, there was no evidence that Nurse #2 and Nurse #4 attended the training. a. A continuous observation of tracheostomy care and interviews were conducted on 9/24/25 from 11:17 AM through 12:12 PM. Nurse #2 was the assigned nurse for Resident #9; however, the facility asked Nurse #1 to perform the tracheostomy care. Nurse #2 stated that she had never performed tracheostomy care at the facility and wanted to observe Nurse #1 for training. She also stated that she did not attend the tracheostomy care training at the facility on 6/29/25 provided by the Respiratory Therapist. At 11:33 AM, Nurse #2 was observed picking up the oxygen tubing off the floor and reattached it to the corrugated tubing connected to the humidifier. Nurse #1 responded: You can't do that. Nurse #1 then instructed Nurse #2 to retrieve all new oxygen and corrugated tubing. When Nurse #2 returned to the room with the new tubing, she stated that the oxygen tubing often disconnected from the corrugated tubing during her shift, and she normally reconnected the tubing without changing any of the tubing. Nurse #1 stated that Nurse #2 should have disconnected and replaced all tubing when the oxygen tubing was found on the floor. b. Nurse #4 was interviewed via telephone on 9/24/25 at 4:30 PM. She revealed that she was an agency nurse, worked the 11:00 PM to 7:00 PM shift at the facility, and picked up shifts every now and then. Nurse #4 stated that she had tracheostomy care experience from her nursing history but had not received any education from the facility regarding tracheostomy care, including the training provided on 6/29/25 by the Respiratory Therapist. She further stated that she did perform tracheostomy care for Resident #9, and the tracheostomy care that she performed during her shift included changing the gauze dressing around the stoma (opening created by a surgeon) because it was usually soiled. c. Nurse #7, who worked with Resident #9 during the day shift from 7:00 AM until 3:00 PM on 9/22/25 and 9/23/25, was interviewed on 9/24/25 at 2:04 PM. She revealed she worked at the facility previously, left about 2 years ago, and returned to the facility 2 months ago. She stated no one had evaluated her performance for tracheostomy care since her most recent return 2 months ago. In the last 2 months since she has been back, there had not been any paper education or any other kind of training provided related to tracheostomy care. A telephone interview was conducted with the Respiratory Therapist on 9/24/25 at 2:31 PM. The Respiratory Therapist stated she last provided tracheostomy care education on 6/29/25 during a skills fair for some of the nurses who dropped in for a 15-minute instruction. There were 2 to 3 nurses at a time that would watch a video about suctioning/tracheostomy care and then performed the same process on a practice dummy. The drop in training was a 4-hour window and was usually provided 1 to 2 times per year and per the facility's discretion. The Respiratory Therapist indicated that the Staff Development Coordinator/previous Director of Nursing helped schedule the drop-in class. If she (the Respiratory Therapist) noticed that a nurse needed extra help, she would notify the DON; however, no nurses needed extra help on 6/29/25. During an interview with the Staff Development Coordinator/previous Director of Nursing (from 4/1/25 through 9/9/25) on 9/24/25 at 4:56 PM, she revealed that she was not aware of the tracheostomy care education protocol. The respiratory skills were included in orientation with a 10-minute video and then time for questions and answers. The Staff Development Coordinator/previous Director of Nursing stated the previous Staff Development Coordinator left abruptly without notice on 6/7/25, and the role had not been filled since then until 9/9/25. She indicated that nurse competencies for tracheostomy care were not performed during this time except for the on-site skills fair on 6/29/25. However, not all nurses attended. The Staff Development Coordinator/previous Director of Nursing stated she was not aware of any tracheostomy care training prior to 6/7/25 and there was no documentation to support that it was provided. During an interview with the [NAME] President of Operations on 9/25/25 at 1:01 PM, he revealed that the facility had high turnover for the Staff Development Coordinator position in a short period of time. He was unable to locate documentation showing tracheostomy competency of nurses or any other training aside from the fair held on 6/29/25. On 9/25/25 at 1:45 PM, the Director of Clinical Services was interviewed. She revealed that on day 3 of nursing orientation or during initial training (within a 30-day period), all nurses including agency staff were supposed to be evaluated with certain skills, including tracheostomy care/monitoring. However, the documentation on this activity could not be found. Also, she indicated that not all nurses attended the documented training provided by the Respiratory Therapist on 6/29/25. The Administrator was interviewed on 9/25/25 at 2:13 PM. He revealed that he began working for the facility on 8/19/25. Since then, he indicated that one orientation for new hires was held on 8/19/25 by a traveling Staff Development Coordinator; however, documented evidence of that training could not be found.

Based on observation, record review, staff and Pharmacist interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 25 opportunities. The 3 medication errors resulted in a medication error rate of 12% for 1 of 4 residents observed during medication administration (Resident #96).The findings included:Resident #96 was admitted to the facility on [DATE].a. An active physician order was in place for cholecalciferol tablet (Vitamin D3) 1000 units give 2 tablets by mouth one time a day for vitamin D deficiency.During a continuous medication administration observation on 9/23/25 at 8:04 am through 8:10 am, Nurse #6 was observed to prepare and administer two vitamin B12 500 microgram (mcg) tablets to Resident #96.An interview was conducted with Nurse #6 on 9/24/25 at 10:39 am who confirmed Resident #96 was administered two vitamin B-12 tablets during the morning medication pass observation. Nurse #6 reviewed the physician order and completed an internet search for the cholecalciferol tablet and confirmed it was a vitamin D3. Nurse #6 stated she thought the vitamin B-12 was the correct medication listed in the order, but she should have checked to make sure before she administered it to Resident #96.A telephone interview was conducted on 9/24/25 at 3:52 am with the Pharmacist who revealed there was no medical concern with Resident #96 being administered the vitamin B-12 instead of cholecalciferol (vitamin D3).During an interview on 9/24/25 at 11:31 am the Director of Nursing (DON) stated Nurse #6 should have checked the order against the pill bottle and if she was still unsure the nurse should have looked up the medication. The DON stated Nurse #6 should not have administered medication to Resident #96 if she was unsure if it was the correct medication.b. An active physician order was in place for fluticasone propionate 50 mcg nasal spray instill one spray per nostril one time a day for allergies.During a continuous medication administration observation on 9/23/25 at 8:04 am through 8:10 am, Nurse #6 was observed to enter Resident #96's room and open the nasal spray and pump the spray to release one dose in the air. Nurse #6 was then observed to administer two sprays per nostril of the fluticasone propionate nasal spray to Resident #96 and exited the room.An interview was conducted with Nurse #6 on 9/24/25 at 8:13 am who revealed sometimes it did not feel like the full dose of medication goes in when she pushed down on the nasal spray pump, so she administered the two sprays to make sure the resident got enough of the medication.A telephone interview was conducted on 9/24/25 at 3:52 am with the Pharmacist who revealed there was no medical concern with Resident #96 being administered two sprays per nostril of the fluticasone propionate nasal spray.During an interview on 9/24/25 at 11:31 am with the Director of Nursing (DON) she revealed Nurse #6 should have administered the medication as ordered by the physician to Resident #96.c. An active physician order was in place for levothyroxine sodium 50 microgram (mcg) tablet give 1 tablet every day in the morning upon rising for hypothyroidism.During a continuous medication administration observation on 9/23/25 at 8:04 am through 8:10 am, Nurse #6 was observed to prepare Resident #96's morning medications which included the one levothyroxine 50 mcg tablet. The medication blister pack card had a yellow sticker which read take on an empty stomach. Resident #96 was observed sitting in a chair eating breakfast with approximately half of her meal remaining. Nurse #6 administered the medications, which included the levothyroxine tablet to Resident #96 and exited the room.An immediate interview was conducted with Nurse #6 on 9/23/25 at 8:13 am who revealed she was aware the medication was supposed to be given on an empty stomach, and she thought it would have been given on the night shift, but the medication was listed for her to administer. Nurse #6 stated she did not check if any medications had to be given before breakfast when she started her shift and she did not think to hold the medication since Resident #96 had already eaten breakfast. Nurse #6 reviewed the blister pack and confirmed the package had a sticker that stated the levothyroxine was to be administered on an empty stomach. A telephone interview was conducted on 9/24/25 at 3:52 pm with the Pharmacist who revealed the levothyroxine medication was recommended to be administered first thing in the morning on an empty stomach because the medication absorbs best on an empty stomach. The Pharmacist stated the medication blister pack had an information label that reminded staff to administer the medication on an empty stomach.An interview was conducted with the Director of Nursing (DON) on 9/24/25 at 11:31 am, she revealed the facility administered medications upon rising which was generally between 7:00 am and 11:00 am unless the medication had specific administration instructions. The DON stated that the levothyroxine was to be administered an empty stomach and Nurse #6 should have administered the medication before Resident #96 ate her breakfast.

Based on record review and staff interviews, the facility failed to provide the resident or Responsible Party (RP) the bed hold policy for 2 of 4 residents reviewed for hospitalization (Resident #12 and Resident #15).The findings included:1a. Resident #12 was admitted to the facility on [DATE].The nursing progress note dated 8/08/25 revealed Resident #12 was sent to the hospital.The medical record indicated Resident #12 was discharged from the facility on 8/08/25 and returned to the facility on 8/13/25.The medical record was reviewed and no documentation was noted that the facility provided Resident #12 or the RP the bed hold policy.b. The nursing progress note dated 8/20/25 revealed Resident #12 was transferred to the hospital.The medical record indicated Resident #12 was discharged from the facility on 8/20/25 and returned to the facility on 8/29/25.The medical record was reviewed and no documentation was noted that the facility provided Resident #12 or the RP the bed hold policy.An interview was conducted with Resident #12 and the RP on 9/21/25 at 2:28 pm. Resident #12 and the RP revealed they did not receive any information regarding the bed hold policy when the resident was transferred to the hospital on 8/08/25 or 8/20/25.An interview was conducted with the admission Director on 9/23/25 at 9:07 am who revealed she was responsible for providing residents and their RP with copies of the bed hold policy when a resident was transferred to the hospital. The admission Director stated she did not normally discuss the bed hold policy when a resident was transferred to the hospital unless she needed to use the room for some reason. The admission Director stated she did not discuss the bed hold policy with Resident #12 or the RP when he transferred to the hospital on 8/08/25 or 8/20/25.During an interview with the [NAME] President of Operations on 9/03/25 at 9:10 am he stated the admission Director was the person that would discuss the bed hold policy for Resident #12. He reported that the facility was unable to locate any documentation that the bed hold policy was discussed for Resident #12's transfers to the hospital.2. Resident #15 was admitted to the facility on [DATE].The nursing progress note dated 9/19/25 revealed Resident #15 was transferred to the hospital.The medical record indicated Resident #15 was discharged from the facility on 9/19/25.The medical record was reviewed and no documentation was noted that the facility provided Resident #15 or the RP the bed hold policy.A telephone interview was conducted with Resident #15's RP on 9/25/25 at 9:18 am who revealed she was not notified about the bed hold policy or procedure when Resident #15 was transferred to the hospital on 9/19/25.During an interview on 9/25/25 at 9:16 am with the admission Director, she revealed she did not contact Resident #15's RP for the 9/19/25 transfer to the hospital to discuss the bed hold policy. The admission Director stated she would not have contacted Resident #15's RP to discuss the bed hold policy unless she needed the room for another resident.An interview was conducted with the [NAME] President of Operations on 9/25/25 at 9:06 am who revealed the facility had no documentation about the bed hold policy communication with Resident #15's RP.

Based on observation, record review and staff interviews, the facility failed to post daily nurse staffing sheets at the beginning of each shift for 1 of 5 days of the survey (9/21/25). In addition, the facility was unable to locate a copy of the daily nurse staffing sheet for 1 of 31 days reviewed (9/20/25).The findings included: An observation on 9/21/25 at 10:14 AM revealed the daily posted staffing sheet posted in the lobby was dated 9/19/25. Review of the facility's daily posted nurse staffing sheets from 8/21/25 through 9/20/25 revealed the 9/20/25 staffing sheet was missing.During an interview with the Scheduler on 9/23/25 at 9:57 AM, she revealed that she was responsible for posting the nurse staffing information. The Scheduler explained she was not aware that she could print the nurse staffing information for the day ahead or the day before but rather only for the current day. The Scheduler stated the previous scheduler told her that she printed out the weekend posting on Friday's and placed the sheets in the medication room for the nurses to display at the front entrance. The interview further revealed the Scheduler could not say if the nurse staffing information was printed and posted during the weekends or the entire month of September. An interview was conducted with the interim Administrator on 9/24/25 at 10:26 AM, and he stated the weekend nursing staff should have access to the nurse staffing information to ensure that it was displayed timely and accurately.

Based on staff interviews and record review, the facility failed to have an accurate facility assessment that recorded the current Administrator, Director of Nursing (DON), Infection Preventionist, Rehabilitation Manager, Staff Development Coordinator, and Maintenance Director. This deficient practice had the potential to affect 109 of 109 residents. The findings included:The facility assessment was reviewed and recorded the last update and review by the facility's quality assurance, performance, and improvement (QAPI) committee occurred on 10/31/24. Page one of the facility assessment recorded the names of the following former staff positions: Administrator, Director of Nursing (DON), Infection Preventionist, Rehabilitation Manager, Staff Development Coordinator, and Maintenance Director.The interim Administrator was interviewed on 9/23/25 at 10:31 AM. He revealed the facility assessment was managed by the Administrator. However, there had been multiple changes in leadership since 10/31/24. He stated the assessment was completed in the last year, and it was due 10/31/25 for all updates. The Administrator indicated that since he began as interim Administrator on 9/9/25, the administrative personnel listed in the facility assessment were not accurate.

Based on record review, and staff, Physician Assistant and Medical Director interviews, the facility failed to implement physician orders for diabetes care for Resident #22 who was diagnosed with diabetes prior to contacting emergency medical services (EMS) for a change in condition and ensuring immediate action was taken for a resident who required emergent medical care. Physician orders were available regarding checking blood sugar for hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard range), acting on low blood sugar, administering medications to quickly treat hypoglycemia and notifying the physician. On 12/15/24 at approximately 8:00 AM/8:15 AM, Resident #22 had slurred speech and was unable to sit up on the side of the bed followed by a change in level of consciousness. Nurse #1 did not know Resident #22 had diabetes. Nurse #1 did not assess Resident #22 for signs and symptoms of hypoglycemia. Nurse #1 did not check Resident #22's blood sugar. Nurse #1 did not administer any medication to Resident #22 to reverse the effects of low blood sugar. Failure to act on the existing diabetes care physician orders resulted in a delay in treating Resident #22's hypoglycemia. Nurse #1 notified EMS at 8:51 AM about Resident #22's change in the level of consciousness and told EMS the resident did not have diabetes. Resident #22 was unresponsive upon EMS arrival. EMS determined Resident #22 s blood glucose was critically low. EMS administered dextrose and Resident #22 became alert and started to speak. This deficient practice was identified for 1 of 4 residents reviewed for diabetes care (Resident #22). Immediate jeopardy began on 12/15/24 when Nurse #1 failed to recognize and treat signs and symptoms of hypoglycemia. Immediate jeopardy was removed on 1/8/25 when the facility implemented a credible allegation of Immediate jeopardy removal. The facility still remains out of compliance at a lower scope and level of severity D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included transient ischemic attack, chronic kidney disease and diabetes mellitus (DM) type 2. Review of physician orders dated 12/3/24 included: - Januvia Oral Tablet 25 milligrams (mg)- Give 1 tablet by mouth one time a day for DM -Glipizide Extended-Release Oral Tablet 24 Hour 10 milligrams (mg)- Give 1 tablet by mouth one time a day for DM Review of physician orders dated 12/5/24 included: - Fingerstick as needed for signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. - If finger stick blood sugar is less than 70 and the resident is alert and responsive, give milk and graham cracker or instant glucose. Recheck blood sugar in 15 minutes. If blood sugar remains low or resident declines taking milk and graham cracker, give insta-glucose gel (used to raise dangerously low blood glucose concentration) as ordered. - Glucagon- Inject 1 mg intramuscularly (This injection is administered to quickly treat patients with diabetes who experience unexpected episodes of severe hypoglycemia.) as needed for low blood sugar one time only. If unconscious &/or unable to swallow and blood sugar is below 40. - Oral Glucose Gel- Give 1 application by mouth as needed for low blood sugar one time only. If the resident is symptomatic, alert and responsive &/or able to swallow and blood sugar is below 70. -Notify provider for additional orders if fingerstick blood sugar remains less than 70 or greater than 400 after current orders being followed The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. The diagnoses included diabetes mellitus. He was coded as receiving hypoglycemic medication during the assessment period. The care plan initiated on 12/9/24 revealed Resident #22 had an altered endocrine system status related to diabetes. The goal was for Resident #22 to have decreased risk of complications related to altered endocrine system. The interventions included: Observe signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Observe for signs and symptoms of behavioral changes: nervousness, increased irritability, insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. An interview was conducted with Nurse Aide (NA) #1 on 1/8/25 at 11:35 AM. NA#1 stated she was assigned to Resident #22 on 12/15/24 from 7:00 AM to 3:00 PM. NA#1 stated she went in to assist Resident #22 with getting setup for breakfast and sitting on side of the bed. She reported Resident #22 had slurred speech, facial drooping and he was unable to sit up on the side of bed. NA# 1 stated she went to get Nurse #1 immediately. An interview was conducted with Nurse #1 on 1/8/25 at 6:15 AM. Nurse #1 stated she was the primary nurse on the East Hall where Resident #22 resided and was assigned to the resident on 12/14/24 at 11:00 PM until 7:00 AM on 12/15/24 and also from 7:00 AM to 3:00 PM on 12/15/24. Nurse #1 stated she was called to Resident #22's room at approximately 8:00/8:15 AM, close to shift change. Nurse #1 stated she observed Resident #22 had a change in his level of consciousness and called EMS. Nurse #1 stated she assessed Resident #22 was having difficulty speaking and appeared to be in a semiconscious state. She reported vital signs were obtained but no blood glucose was done. Nurse #1 stated she did not know Resident #22 had a diagnosis of diabetes. Nurse #1 reported Resident #22 had been fine and there were no issues during the 11:00 PM - 7:00 AM shift. Nurse #1 stated she did not inform the physician of Resident #22's change in status because she was concerned the resident was exhibiting signs and symptoms of a stroke and wanted to get EMS on the way. Nurse #1 stated when EMS arrived, they got a set of vital signs and a blood glucose which indicated Resident #22 had a critically low glucose reading. Nurse #1 stated when EMS treated Resident #22 with dextrose via IV, he became alert and began talking. Nurse #1 further stated Resident #22 refused to be transported to the ER. Nurse #1 stated she reported to Nurse #2 that Resident #22 had low blood glucose and EMS was called. Nurse #1 stated to EMS that Resident #22 was not a diabetic. The medical record revealed no documentation in the nurses' notes for 12/15/24 from 7:00 AM to 3:00 PM. Further review of the medical record revealed no documentation for the entire date of 12/15/24. The Emergency Medical Services (EMS) patient care record report dated 12/15/24 revealed they were contacted at 8:51 AM for a male patient with a possible stroke. The EMS report revealed they arrived on scene at 8:58 AM and to Resident #22's bedside at 8:59 AM. Facility staff were asked if the resident was diabetic and staff responded that resident was not. The onset of symptoms was reported as probably 20 minutes prior and staff stated Resident #22 had a history of stroke. The report revealed when EMS arrived at the facility, they found Resident #22 lying in bed with his eyes closed and not responding when spoken to. The resident's breathing was normal, and he had a strong radial pulse. Resident #22's blood glucose was obtained, and he had a blood glucose level of 46. The staff was informed of Resident #22's critically low blood glucose and asked about his medical history and medications. Staff retrieved Resident #22's medical record paperwork and stated he was on two diabetes medications which were taken by mouth, but his blood glucose was not being monitored. EMS established an IV (intravenous) access and Resident #22 was administered dextrose 10% 100 milliliters via IV. At 9:06 AM Resident #22 became alert and started to speak. Staff brought a tray with Resident #22' s breakfast and after assuring he was alert and able to answer all questions, he was given his food which he ate. Resident #22's blood glucose was rechecked prior to him eating and his blood glucose was 169. Resident #22 refused to be transported to the Emegency Room (ER). EMS Paramedic #1 who assisted on 12/15/24 was not available for interview. An interview was conducted with Physician Assistant #1 on 1/8/25 at 10:22 AM. PA #1 stated she was aware that Resident #22 had an incident of hypoglycemia. The PA stated Resident #22 would not have had scheduled glucose monitoring due to his hemoglobin A1C (a measure of the average glucose reading over a 3-month period) being at 6.2 (normal range is below 5.7%). The PA stated she did expect the nurse would have recognized the signs and symptoms of hypoglycemia. An interview was conducted with the Director of Nursing on 1/8/25 at 9:46 AM. The Director of Nursing reviewed the nurse progress notes for 12/15/24. The DON confirmed there was no documentation for the 7:00 AM to 3:00 PM shift on 12/15/24. The DON stated she had not been notified that Resident #22 had low blood glucose and EMS was called to the building. The DON stated Nurse #1 should have assessed Resident #22 and recognized the signs and symptoms of hypoglycemia. The DON further stated Nurse #1 should have notified her of the incident and written a note in the resident's medical record. The DON stated since there was no documentation, the information was not part of the 24-hour summary report. The DON stated Nurse #1 should have notified the physician and followed up with her. An interview was conducted on the Medical Director on 1/8/25. The Medical Director stated a diagnosis of diabetes was part of the report process and he expected that Nurse #1 would have recognized the signs and symptoms of hypoglycemia. The Administrator was notified of immediate jeopardy on 1/8/24 at 12:30 PM. The facility provided the following immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance On 12/15/2024 at 8:00 /8:15 am, Resident #22 was noted by CNA #1 to have slurred speech and was unable to sit up on the side of bed as he normally did. CNA #1 immediately went to get Nurse #1 who came to the resident ' s room to assess the resident. Nurse #1 immediately went to assess the resident; the nurse observed the resident to have slurred speech and facial droop. A blood glucose level was not obtained. Nurse #1 called EMS at 8:51am. EMS arrived at 8:58 am. EMS asked Nurse #1 if resident was a diabetic and she stated that he was not. Staff retrieved paperwork and stated that he was on two diabetic medications. EMS checked Resident #22 ' s blood sugar which was 46. At 9:06am EMS initiated an IV on Resident #22 and gave 10% Dextrose 100 milliliters via IV and resident became alert and started to speak. At 9:30am EMS rechecked Resident #22 ' s blood sugar which was 169. Resident #22 returned to baseline and was alert and oriented to person, place, and time, answered all questions appropriately per EMS documentation dated 12/15/24. Resident #22 was able to eat breakfast without difficulty. Resident #22 refused to go to the hospital for further evaluation. EMS left the facility at 0936 per EMS documentation 12/15/24. An Ad Hoc (Quality Assurance Performance Improvement) QAPI meeting was conducted on 1/7/2025 by the QAPI Committee (Administrator, Director of Nursing (DON), Medical Director, Infection Preventionist, Activities Director, Admission Director, Social Service Director, Medical Records Director, and Director of Therapy). Based upon record review and staff interview(s) the QAPI Committee has identified the following root cause of the event: - Nurse #1 failed to recognize and treat the signs and symptoms of hypoglycemia and notify the Medical Provider. - Nurse 1 communicated to EMS that she was unaware that the resident was diabetic, which potentially delayed treatment even further. The nurse failed to review the resident Diagnosis list. On 1/7/25 an audit of all current residents with a diagnosis of diabetes was performed by the Director of Nursing to ensure diabetic orders were in place. The audit also included: - On 1/7/25 a review of the last 14 days of the 24-hour summary was completed by the Director of Nursing to identify any change in condition with MD/RP notification to ensure that medical treatment was provided timely. The audit did not identify any residents that did not receive medical treatment timely. - On 1/7/25 a review of the last 14 days of blood sugars that were below 70 or greater than 400 was performed by the Director of Nursing to ensure appropriate interventions and notifications were completed. The audit did not identify any residents that did not receive appropriate interventions or notification was not completed. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 1/7/25 Nurse #1 was given immediate education on diabetic protocol and change in condition with MD notification by Director of Nursing. The education also included reviewing resident medication administration record and diagnosis list to determine residents with Diabetes Mellitus. On 1/7/2025, education was initiated by the Director of Nursing to Licensed Nurses, including agency licensed nurses, related to the facility policy on hyperglycemia and hypoglycemia. To include obtaining blood glucose levels as needed for signs and symptoms of hypo/hyperglycemia. The education also included reviewing resident medication administration record and diagnosis list to determine residents with Diabetes Mellitus. - If signs and symptoms of Hyperglycemic or hypoglycemic are identified immediate action is required. - When EMS is called to the facility it is vital that accurate information is communicated to EMS, to include if resident is Diabetic. - Parameters for MD notification and follow-up for diabetic residents. - Insulin hyperglycemic and hypoglycemic orders to include monitoring and when to obtain a re-check of blood glucose level per facility policy and/or physician order: - Blood glucose levels as needed for signs and symptoms of hypo/hyperglycemia - Monitor/document/report to provider PRN s/s of hypoglycemia: Shakiness, nervousness, irritability, anxiety, or changes in the personality. Confusion including delirium, rapid/fast heartbeat, weakness, lightheaded, dizziness, or faintness, hunger or excessive eating, or nausea, blurred or impaired vision, tingling or numbness in the lips or tongue, trembling or tremors, headaches, anger or stubbornness, lack of coordination, weakness or fatigue, not able to wake up or appears to be in a coma, unconscious, or partially unconscious or (stupor), seizures. Hyperglycemic and hypoglycemic orders to include monitoring and when to obtain a re- check of blood glucose level per facility policy and /or physician order - If resident is symptomatic, conscious, and able to shallow: Give the resident 15-20 grams of glucose or simple carbohydrates Then recheck your blood glucose after 15 minutes. If hypoglycemia continues, repeat steps. - If the resident responds immediately and is able to swallow, follow up with food if it is more than 30 minutes until the next meal. These are considered additional snacks and are not to be deducted from the next meal. Once blood sugar returns to normal, eat a small snack if the meal or snack is more than an hour or two away. Call the physician for further orders. a. Follow orders. b. Repeat blood glucose level 15-30 minutes after food is consumed. If the resident is semi-conscious, use some form of instant glucose or I.M. Glucagon, based on physician orders. When the resident can swallow 15-20grams of glucose or simple carbohydrates. Document on the resident ' s record. Licensed staff and agency staff that don't receive the education on 1/7/24 will receive it prior to working the next scheduled shift. The Director of Nursing will track the training to ensure all staff are educated. Newly hired licensed staff will receive training during orientation by Director of Nursing. The facility alleged immediate jeopardy removal 1/8/25. The immediate jeopardy removal date of 1/8/25 was validated on 1/8/25. Review of staff education materials and sign-in sheets for the education were reviewed to determine that education was provided to Nurse #1. The facility staff nurses and NAs were interviewed and demonstrated they had been trained on the topics of Diabetic protocol, Change in Condition with physician notification, facility policy on hypoglycemia and hyperglycemia, Review of resident medication administration record and diagnosis list to determine residents with diabetes mellitus. Review of the facility documents revealed audits were done per the facility ' s plan of correction. The immediate jeopardy was removed on 1/8/25.

Based on record review, and staff, Medical Director, and Physician Assistant interviews the facility failed to notify the physician that Resident #22 had a critically low blood glucose requiring Emergency Medical Services (EMS) intervention for 1 of 4 residents reviewed for notification of change in condition (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. He was coded as receiving hypoglycemic medication during the look back period. Review of the Emergency Medical Services (EMS) patient care record report dated 12/15/24 revealed they were contacted at 8:51 AM for a male patient with a possible stroke. The EMS report revealed they arrived on scene at 8:58 AM and to Resident #22's bedside at 8:59 AM. Resident #22's blood glucose was obtained, and he had a blood glucose of 46 (normal blood glucose level is 70-100 milligrams per deciliter [mg/dL]). Resident #22 was administered dextrose 10% 100 milliliters via IV (intravenous). At 9:06 AM Resident #22 became alert and started to speak. Resident #22 refused to be transported to the emergency room (ER). Review of the medical record revealed no documentation in the nurses notes for notification of the physician on 12/15/24 (Sunday). An interview was conducted with Nurse #1 on 1/8/25 at 6:15 AM. Nurse #1 stated she was the primary nurse on the East Hall where Resident #22 resided on 12/15/24. Nurse #1 stated she was called to Resident #22's room and observed he had a change in his level of consciousness. Nurse #1 stated she called 911. Nurse #1 stated she did not call the physician because her priority was to take care of the resident. Nurse #1 stated she never called the physician to report the critically low blood glucose level. An interview was conducted with Nurse #2 on 1/7/25 at 4:03 PM. Nurse #2 stated she worked 3:00 PM to 11:00 PM on 12/15/24 and was informed about Resident #22 having a low blood glucose during the morning shift and EMS being called. She indicated she notified the on-call physician during her shift to get an order for blood glucose checks four times a day. An interview was conducted with Physician Assistant #1 on 1/8/25 at 10:22 AM. PA #1 stated she was aware that Resident #22 had an incident of hypoglycemia. PA #1 further stated she was unsure of whether she had been made aware of the incident directly. PA #1 stated she received report from the weekend provider that Resident #22 had a low blood glucose. She stated she did not recall being notified that EMS was called. PA #1 stated she would have expected Nurse #1 to make the physician aware of the change in resident condition. An interview was conducted with the Medical Director on 1/8/25 at 11:07 AM. The Medical Director confirmed Nurse #1 did not notify the physician of Resident #22's change in status that required EMS intervention. An interview was conducted with the Director of Nursing on 1/8/25 at 9:46 AM. The DON stated she had not been notified that Resident #22 had low blood glucose and EMS was called to the facility. The DON stated Nurse #1 should have notified the physician and followed up with her.

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record by failing to document a resident ' s change in condition requiring Emergency Medical Services interventions for 1 of 4 residents reviewed for accuracy of medical records. (Resident #22) The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2. Review of the Emergency Medical Services (EMS) patient care record report dated 12/15/24 revealed they were contacted at 8:51 AM for a male patient with a possible stroke. The EMS report revealed they arrived on scene at 8:58 AM and to Resident #22 ' s bedside at 8:59 AM. Resident #22 ' s blood glucose was obtained, and he had a blood glucose of 46. Resident #22 was administered dextrose 10% 100 milliliters via IV (intravenous). At 9:06 AM Resident #22 became alert and started to speak. Resident #22 refused to be transported to the emergency room (ER). Review of the medical record revealed no documentation in the nurses notes of Resident #22 having a critically low blood glucose (normal blood glucose level is 70-100 milligrams per deciliter [mg/dL]) or notification of EMS for treatment on 12/15/24. An interview was conducted with Nurse #1 on 1/8/25 at 6:15 AM. Nurse #1 stated she was the primary nurse on the East Hall where Resident #22 resided on 12/15/24. Nurse #1 stated she was called to Resident #22 ' s room and observed he had a change in his level of consciousness. Nurse #1 stated she called 911. Nurse #1 stated she did not document the incident in the electronic medical record because she got sidetracked and forgot. An interview was conducted with the Director of Nursing on 1/8/25 at 9:46 AM. The Director of Nursing reviewed the nurse progress notes for 12/15/24. The DON confirmed there was no documentation for the 7:00 AM to 3:00 PM shift on 12/15/24. The DON stated Nurse #1 should have documented in the nurse progress notes that Resident #22 had a low blood glucose and EMS was called for intervention.

Based on record review, resident, family, staff interview, Nurse Practitioner, and Medical Doctor interview the facility failed to 1)ensure effective communication amongst the nursing staff and with the provider in order that a resident, who was receiving anticoagulation medication, be sent to the hospital when she first experienced post-operative bleeding to the degree that the bleeding soaked her sheets 2) failed to recognize they should communicate with the physician about anticoagulant medication before continuing to give the anticoagulant medication after the resident was observed bleeding post-operatively 3) failed to identify a need for a higher level of care 4) failed to assess vital signs and 5) failed to perform treatments as ordered. Resident #1 was transported to the emergency room , required a blood transfusion for low hemoglobin, and was admitted to the hospital for two days. This was for one (Resident #1) of three residents reviewed for professional standards. Findings included: Resident #1 was originally admitted to the facility on [DATE] and had a discharge to the hospital on 10/22/2024 with a readmission on 10/25/2024. Resident #1 had diagnoses of deep vein thrombosis (2019), pulmonary embolism (2019), anemia, and peripheral vascular disease. Deep vein thrombosis is a blood clot that forms in a large vein deep within the body, typically in the lower leg or thigh. A pulmonary embolism is a condition in which one or more arteries in the lungs become blocked by a blood clot. Peripheral vascular disease is a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs. An annual Minimum Data Set assessment dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status assessment of 13 out of 15, indicating she was cognitively intact. Resident #1 was also coded as dependent for rolling from left and right in bed and transfers. Resident #1 was coded as receiving an anticoagulant. Review of the electronic medical record revealed Resident #1 had recent micrographically oriented histographic surgery (Mohs) surgery on her left lower extremity for non-melanoma skin cancer on 10/17/2024. [NAME] surgery is a surgical procedure that removes skin cancer lesions by gradually removing thin layers of tissue and examining each layer under a microscope for cancer cells. Wound care instructions from the dermatologist were as follows: After 48 hours, remove the bandage. Clean the wound with 1/2 tap water and 1/2 peroxide and apply Vaseline (or prescribed antibiotic ointment). After [the] first 48 hours you may shower, and the wound site can get wet unless otherwise instructed. Cover the wound with a non-stick gauze pad (Telfa) and micropore paper tape. A.Resident #1 had a physician's order, initiated on 7/21/2024, for 5 milligrams (mg) Eliquis to be administered by mouth two times a day for blood thinner with monitoring for bleeding and bruising. Documentation on the care plan last reviewed on 10/8/2024 revealed Resident #1 had a focus area for alteration in hematological status relative to anemia, anticoagulant side effects and thrombosis. Resident #1 had an additional focus area for anticoagulant therapy for her use of Eliquis. Some of the care plan interventions were to monitor for side effects of anemia and signs/symptoms of anticoagulant complications. Documentation in the nursing progress notes dated 10/22/2024 at 11:08 PM written by Nurse #3 revealed, This writer walked in resident room to administer medicine and upon walking in resident room her bedsheet had blood and upon checking the dressing on left leg was saturated with blood. This writer cleaned the area on left leg following the instructions on the TAR (treatment administration record) for dressing change and applied gauze, ABD (abdominal) pad and applied pressure and wrapped with kerlix to stop bleeding, which was controlled at the moment. (An ABD pad is a gauze dressing used to absorb fluid from large or heavily draining wounds.) Minutes later going back to check on resident, the dressing was saturated again. MD (medical doctor) on call was notified and gave orders to give Bumex 2 mg and rewrap the wound and apply pressure and monitor, the resident was notified, and stated she wants to go to ED (emergency department) for evaluation. (Bumex is used to treat fluid retention (edema) and high blood pressure.) MD was called back and notified of resident request, non-emergency transport was called, resident transferred to [Hospital name] ED. Son [Name], daughter [Name] and DON (Director of Nursing) notified. An interview was conducted with Resident #1 on an initial tour on 11/14/2024 at 9:36 AM and again at 10:39 AM. Resident #1 provided the following information. Resident #1 revealed she had told Nurse #4, the assigned nurse for the evening shift, to not come into her room anymore. Resident #1 had surgery on her leg for skin cancer and when it was time to change the bandage, Nurse #3 came to change the bandage. Resident #1 had never seen or met Nurse #3 before. Resident #1 revealed Nurse #3 began to change the bandage on her leg, she ripped it off quickly, and it began to bleed. Resident #1 explained she received a medication that was a blood thinner. Nurse #3 called for assistance from a nurse aide in the hallway, and eventually because the bleeding would not stop, she was sent to the hospital. Resident #1 stated it was very scary in the hospital emergency room because she almost passed out from her blood pressure dropping and had to be given blood. Documentation in the physician's orders revealed Resident #1 had an order initiated on 10/22/2024 at 9:15 PM for 2 mg of Bumex to be administered by mouth one time only for edema. An interview was conducted with Nurse #3 on 11/14/2024 at 3:15 PM. Nurse #3 stated she was not assigned to care for Resident #1 on 10/22/2024 but was asked to come to the hall on which Resident #1 resided because Nurse #4 could not go into the room of Resident #1. Nurse #3 provided the following sequence of events. Nurse #3 was working on the 2:45 PM to 11:15 PM shift on 10/22/2024. After the evening meal Nurse #3 went to the hallway Resident #1 resided to give medications to Resident #1. Nurse #3 prepared the medications for Resident #1 and asked NA #1 to go into the room of Resident #1 with her because she did not know this resident and she was meeting her for the first time. Nurse #3 stated she observed blood on top of the sheet and when she pulled back the sheet, she observed the dressing on the left lower leg of Resident #1 was saturated. Nurse #3 returned to the medication cart, put the medications back into the drawer, locked the medication cart, and went to obtain the treatment cart. Nurse #3 removing the saturated dressing from the lower leg of Resident #1 with gloved hands. Nurse #3 washed her hands, put on another pair of gloves and attempted to stop the bleeding of the wound with gauze, ABD pads and Kerlix. Nurse #3 then followed the wound care orders mixing 1/2 tap water with 1/2 hydrogen peroxide, cleaned the wound, applied Vaseline, several nonstick gauze pads, an ABD pad and wrapped with Kerlix again. At that point the bleeding seemed under control. Nurse #3 removed her gloves, washed her hands, and went to obtain the medications for Resident #1. Nurse #3 asked Resident #1 if she wanted to take her Eliquis that evening, explaining it was a blood thinner. Resident #1 agreed to take Eliquis. Nurse #3 then went to Nurse #4 and explained to her about the blood on the sheets and performing the wound care as well as medication administration to Resident #1. Nurse #3 tried to call the first contact on the family list for Resident #1 and was not able to reach him so, she contacted the second family member on the list. Nurse #1 relayed the information to the family of Resident #1 about the bleeding of her leg. Nurse #3 then went back to her hall to take care of the needs of her residents on her hallway. Nurse #3 was unsure how long she was performing nursing duties for her hallway as she had several tasks to perform. As Nurse #3 approached the room of Resident #1, NA #1 came out of the room and told her about the bandage on Resident #1's leg being soaked with blood again. Nurse #3 went to call the on-call physician. Nurse #4 was at the nursing station when Nurse #3 telephoned the on-call physician and handed the phone to Nurse #4 because she knew Resident #1 better than her and could provide more details about the resident. Nurse #4 explained to the on-call physician that Resident #1 had edematous legs. Nurse #3 did not recall if it was explained to the on-call physician about the bloody sheets/dressing and the resident being on Eliquis. Nurse #3 was sure she explained to Nurse #4 about the dressing that was found to have bled through for the second time. The physician ordered Nurse #4 to administer a one-time dose of 2 mg of Bumex and to reinforce the dressing. Nurse #3 went back to Resident #1 and asked her if she wanted the 2 mg of Bumex and the reinforced dressing. Resident #1 stated she wanted to call a family member to ask what to do and after talking with her family she decided she wanted to go out to the hospital. Nurse #3 called the on-call physician back and obtained an order to send Resident #1 to the emergency room . Nurse #3 called for non-emergency transport and prepared the paperwork to send the resident out to the emergency room . Nurse #3 then obtained more supplies to reinforce the dressing but was unable to do so because emergency medical services arrived. Nurse #3 stated Resident #1 was alert and talking prior to leaving and she thought she gave her Tylenol for pain. Nurse #3 stated she did update the family of Resident #1 and called the DON to let her know Resident #1 was sent to the ER. Nurse #3 was interviewed again on 11/18/2024 at 2:57 PM. Nurse #3 could not remember if the leg of Resident #1 was elevated. Nurse #3 stated after changing all of the sheets of Resident #1 after performing wound care, she stayed with Resident #1 to assure her leg wound did not continue to bleed. Nurse #3 stated she told NA #1 that if there was any more bleeding before she returned to check on Resident #1, to come to her hallway to get her. An interview was conducted with Nurse Aide (NA) #1 on 11/14/2024 at 2:03 PM. NA #1 confirmed she was the nurse aide assigned to care for Resident #1 on the 3:00 PM to 11:00 PM shift on 10/22/2024. NA #1 stated she was completing her nursing rounds after the evening meal on 10/22/2024 and when she went into the room of Resident #1 observed her sheets were all bloody. NA #1 reiterated it was a lot of blood. NA #1 stated she went to the nurse assigned to the hall, Nurse #4, and was told by Nurse #4 she was not allowed into the room of Resident #1. Nurse #4 went to get Nurse #3. NA #1 stated that Nurse #3 then came to the room and NA #1 stated she held the leg of Resident #1 as Nurse #3 rewrapped the leg. NA #1 stated she then went back later and observed that the leg of Resident #1 was bleeding again so she went back to Nurse 4, who went to get Nurse #3. NA #1 was unable to give a time frame for the events and those were her only recollections of the events. An interview was conducted with NA #2 on 11/14/2024 at 2:42 PM. NA #2 confirmed she was an orientee assigned to work with NA #1 on 10/22/2024 for the 3:00 PM to 11:00 PM shift. NA #2 recalled that she peeked into the room of Resident #1 and saw the bloody sheets on her bed. NA #2 stated at that time NA #1 was assisting Nurse #3 as she bandaged the leg of Resident #1. NA #2 stated that later she went into the room to check on Resident #1 and Resident #1 was on a video call with a family member. NA #1 explained that the family member requested to see the leg and bed of Resident #1 on the video call, so NA #2 took the phone of Resident #1 and showed the family member the bloody sheets that were soaked through and the bloody bandage of Resident #1. NA #2 revealed the family member stated Resident #1 needed to go to the hospital. NA #2 revealed she knew Nurse #3 had already called the doctor and was not able to get an order to send Resident #1 to the hospital. NA #2 indicated she was unable to give a time frame for any of the events and those were her only recollections of the events as it was a fast-paced evening. An interview was conducted with Nurse #4 on 11/14/2024 at 4:10 PM. Nurse #4 provided the following information. Nurse #4 was assigned to the hallway which Resident #1 resided on 10/22/2024 for the 2:45 PM to 11:15 PM shift. Nurse #4 routinely works on this hall, and it has been her assigned hallway for the last year. Nurse #4 stated on 10/22/2024 she was told by Resident #1 she was to no longer come into her room. Nurse #3 came to the hallway to take care of the nursing needs of Resident #1. Nurse #3 told Nurse #4 the leg of Resident #1 was draining heavy. Nurse #3 did not recall being told anything about blood and only about drainage. Nurse #3 did not see the legs of Resident #1, did not enter the room of Resident #1, and did not talk to the family of Resident #1 on 10/22/2024. Nurse #3 called the on-call physician and Nurse #4 did get on the phone with the on-call physician. Nurse #4 revealed she relayed to the on-call physician that Resident #1 got out of the hospital two or three months ago with swelling in her legs. Nurse #4 confirmed she was aware Resident #1 had recent [NAME] surgery due to lesions on her legs and that Resident #1 was on Eliquis. Nurse #4 reiterated she was not aware of any bleeding but only drainage, so she did not provide the information to the on-call physician about the [NAME] surgery on 10/17/24 or that the resident was on a blood thinner. The physician ordered Nurse #4 to administer a one-time dose of 2 mg of Bumex and to reinforce the dressing, which she passed on to Nurse #3. Nurse #4 stated the family of Resident #1 wanted her to be sent to the emergency room so, Nurse #3 called the physician back and had her sent to the emergency room . An interview was conducted with a family member for Resident #1 on 11/14/2024 at 11:24 AM. The family member revealed he was notified by another family member at approximately 6:30 PM on 11/22/2024 that the facility had called because the leg of Resident #1 was bleeding heavily. The family member noted he had missed a phone call from the facility. The family member revealed he called the facility to find out what was going on but was told the nurse assigned to the hall was unable to come to the phone. The family member stated he waited for a phone call back. The family member stated he was on a video call with Resident #1 when he was shown by one of the nurse aides the bloody sheets and bloody dressing on the leg of Resident #1. The family member stated he was able to see on the video call that both the top and bottom sheet of Resident #1 was saturated with blood. The family member stated he took pictures of the bloody sheets with his phone and recorded the time to be 9:36 PM. The family member stated Resident #1 was told the physician was called and Bumex was ordered for the bleeding. The family member stated he did not understand why Bumex was ordered for the bleeding. The family member stated Resident #1 was on the blood thinner Eliquis and he was concerned about all the blood he saw on the sheets. The family member stated he told Resident #1 to request to go to the emergency room . An interview was conducted with the on-call physician, Nurse Practitioner (NP) #1, on 11/14/2024 at 5:10 PM. NP #1 explained that she worked as an on-call provider for the facility every eight to ten weeks on a rotational basis and did not know or visit the residents in the facility. NP #1 stated she vaguely recalled the phone call she received on the evening of 10/22/2024 regarding Resident #1. NP #1 stated that if she ordered for a one-time dose of Bumex to be administered it was likely she was told Resident #1 had edema in her leg. NP #1 stated if she had been told Resident #1 was on a blood thinner, had recent [NAME] surgery, and had bled through the bandage, she would have requested Resident #1 be sent to the emergency room for evaluation. NP #1 stated she relied on the nursing staff to provide her with the relevant information so she can ask relevant questions and give relevant orders. Documentation on an Emergency Medical Services (EMS) patient care record dated 10/22/2024 revealed EMS was called to the facility at 9:43 PM because Resident #1 was hemorrhaging/bleeding. Vital signs taken by the EMS on 10/22/2024 at 10:06 PM revealed Resident #1 had a blood pressure of 148/76, Pulse 86, Respiratory rate 19 and saturation of peripheral oxygen 97. The narrative on the EMS record stated, Upon arrival [Resident #1] was found lying supine in her bed with a sheet over her that was covered in blood. [Resident #1] was alert and oriented and not in any distress. RN came in and stated that [Resident#1] had been bleeding for about 45 minutes and could not control the bleeding. [Resident #1] stated she has skin cancer and had surgery done on her left leg, on Saturday [Resident #1's] dressing got changed and again on Tuesday only this time when the bandage was removed it caused [Resident #1] a lot of pain and she stated it felt like they ripped her skin off and that's when it began to bleed uncontrollably. [Resident #1] is on a blood thinner. RN packed the wound and applied pressure prior to our arrival but the wound kept bleeding. RN wrapped the wound up thinking it would stop bleeding, and it did not. Blood was seeping through bandages and sheets. Pt was moved over to stretcher via sheet method and taken out to unit where vitals were taken, and radio report was given. It was noted the condition at the emergency room destination was worse. Documentation in a discharge summary for Resident #1's emergency room visit on 10/22/2024, hospitalization , and discharge on 10/25/2024 revealed the following information. Resident #1 was seen in the emergency room for postoperative bleeding of a 4 X 4 biopsy site on the left lower extremity. The medical decision-making portion of the emergency room notes stated, Patient has a large skin biopsy site to the left anterior shin that does have a clot and is only mildly oozing over the superior aspect. There is no good place to place a stitch as I do not want to pull off the whole clot and make the whole wound start bleeding. I placed combat gauze, and a pressure dressing and bleeding has been controlled. emergency room laboratory values revealed Resident #1 had anemia with a hemoglobin level of 7.3 g/dL (grams per deciliter) at 12:14 PM on 10/23/24 that dropped from 9.9 g/dl taken at 10:56 PM on 10/22/24. The normal range for a hemoglobin is 12.0 to 15.5 g/dL. Resident #1 had a near syncopal episode in the emergency room with the dropping of her blood pressure from 110 systolic to 90, oxygen saturation, and hemoglobin as the emergency room attempted suture ligation of the bleeding. Resident #1 received a blood transfusion of one unit of packed red blood cells and was hydrated aggressively with intravenous fluids. Resident #1 was admitted to the hospital for monitoring and a surgery consultation was ordered in case of continued bleeding. An interview was conducted simultaneously with the DON and the facility Administrator on 11/14/2024. The DON and Administrator agreed Nurse #4 should not have entered the room of Resident #1 unless there was an emergency, as the requests of the residents should always be honored. The DON confirmed there was no documentation of vital signs taken prior to the arrival of EMS for Resident #1. The DON indicated Resident #1 could have been sent to the emergency room immediately. An interview was conducted with the physician (MD #1) for Resident #1 on 11/18/2024 at 2:49 PM. MD #1 revealed the physician who performed the [NAME] surgery on Resident #1 did not request for the Eliquis to be stopped prior to the surgery nor after the surgery. MD #1 stated the wound was very superficial and the nurses who cared for Resident #1 on 10/22/2024 should be commended for attempting to stop the bleeding and sending her to the hospital when they identified the bleeding was not stopping. MD #1 stated Nurse #3 should have given the Eliquis, and he would not have told her to hold the Eliquis on 10/22/2024. MD #1 revealed he agreed with the order for Bumex because Resident #1 had a history of edema. MD #1 also revealed the best treatment for a low hemoglobin was a transfusion and he agreed with all the interventions provided by the hospital. MD #1 summarized his thoughts by saying he felt the facility had done everything appropriately for Resident #1 on 10/22/2024. B. Documentation on a physician's order dated as initiated on 10/19/2024 for Resident #1 revealed the left lower leg was to be cleaned with 1/2 tap water and 1/2 peroxide, Vaseline (or prescribed antibiotic ointment) applied, covered with a non-stick gauze pad (Telfa), and micropore paper tape. The wound care was to be completed daily every evening shift. Documentation on the October treatment administration record (TAR) for Resident #1 revealed the dermatology order for wound care after the [NAME] surgery was initiated on 10/19/2024 and was completed by Nurse # 6 on 10/19/2024 and 10/20/2024. Nurse #6 was interviewed on 11/14/2024 at 5:00 PM. Nurse #6 stated when she completed wound care for Resident #1 on 10/19/2024 and 10/20/2024 she had all the supplies she needed except for hydrogen peroxide. Nurse #6 revealed she did look in the nursing supply room but was unable to locate any hydrogen peroxide in the building that weekend. Nurse #6 stated she used standard nursing practice and cleaned the wound with normal saline instead of using 1/2 tap water and 1/2 hydrogen peroxide. Nurse #6 indicated she was very familiar with performing wound care and the wound had pink granulation tissue with only slight bleeding. An interview was conducted with the Director of Nursing on 11/14/2024 at 12:08 PM. The Director of Nursing confirmed that Nurse #6 was unable to locate the hydrogen peroxide in the facility as it was not a product usually used in wound care in the facility. The Director of Nursing indicated the facility did have hydrogen peroxide, but Nurse #6 was not able to locate it that weekend. The Director of Nursing stated that Nurse #6 should have called the physician to let them know the hydrogen peroxide was not available and obtain alternate orders for wound care. An interview was conducted with the physician (MD #1) for Resident #1 on 11/18/2024 at 2:49 PM. MD #1 stated that there was no difference in using normal saline versus using 1/2 tap water and 1/2 hydrogen peroxide to clean the wound other that it might have been easier to take off the bandage if hydrogen peroxide and tap water was used.

Based on record review, staff interview, nurse practitioner, and physician interview the facility failed to notify the physician when a resident who was prescribed an anticoagulant experienced post-operative bleeding that soaked her sheets and failed to recognize the need to consult a medical provider for guidance before administering an anticoagulant to a resident with significant post-operative bleeding for one (Resident #1) of one resident reviewed for notification of physician. Findings included: Resident #1 was originally admitted to the facility on [DATE] and had a discharge to the hospital on 10/22/2024 with a readmission on 10/25/2024. Resident #1 had diagnoses of deep vein thrombosis (2019), pulmonary embolism (2019), anemia, and peripheral vascular disease. Deep vein thrombosis is a blood clot that forms in a large vein deep within the body, typically in the lower leg or thigh. A pulmonary embolism is a condition in which one or more arteries in the lungs become blocked by a blood clot. Peripheral vascular disease is a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs. Review of the electronic medical record revealed Resident #1 had recent [NAME] surgery on her left lower extremity for non-melanoma skin cancer on 10/17/2024. [NAME] surgery is a surgical procedure that removes skin cancer lesions by gradually removing thin layers of tissue and examining each layer under a microscope for cancer cells. Resident #1 had a physician's order, initiated on 7/21/2024, for 5 milligrams (mg) Eliquis to be administered by mouth two times a day for blood thinner with monitoring for bleeding and bruising. Documentation in the nursing progress notes dated 10/22/2024 at 11:08 PM written by Nurse #3 revealed, This writer walked in resident room to administer medicine and upon walking in resident room her bedsheet had blood and upon checking the dressing on left leg was saturated with blood. This writer cleaned the area on left leg following the instructions on the TAR (treatment administration record) for dressing change and applied gauze, ABD (abdominal) pad and applied pressure and wrapped with kerlix to stop bleeding, which was controlled at the moment. (An ABD pad is a gauze dressing used to absorb fluid from large or heavily draining wounds.) Minutes later going back to check on resident, the dressing was saturated again. MD (Medical Doctor) on call was notified and gave orders to give Bumex 2 mg and rewrap the wound and apply pressure and monitor, the resident was notified, and stated she wants to go to ED (emergency department) for evaluation. MD was called back and notified of resident request, non-emergency transport was called, resident transferred to [hospital name] ED. Son [Name], daughter [Name] and DON (Director of Nursing) notified. An interview was conducted with Nurse #3 on 11/14/2024 at 3:15 PM. Nurse #3 stated she was not assigned to care for Resident #1 on 10/22/2024 but was asked to come to the hall on which Resident #1 resided because Nurse #4 could not go into the room of Resident #1. Nurse #3 provided the following information. Nurse #3 revealed she was working on the 2:45 PM to 11:15 PM shift on 10/22/2024. Nurse #3 went to the hallway Resident #1 resided to give medications to Resident #1. Nurse #3 stated she observed blood on top of the sheet and when she pulled back the sheet, she observed the dressing on the left lower leg of Resident #1 was saturated. Nurse #3 went to obtain the treatment cart to gather wound care supplies. Nurse #3 went back to the room of Resident #1 to change the lower left leg dressing. Nurse #3 applied pressure to the area and the bleeding stopped. Nurse #3 applied a new dressing with re-enforced pads. At that point the bleeding seemed under control. Nurse #3 asked Resident #1 if she wanted to take her Eliquis that evening, explaining it was a blood thinner. Resident #1 agreed to take Eliquis. Nurse #3 then went to Nurse #4 and explained to her about the blood on the sheets and performing the wound care as well as medication administration to Resident #1. Nurse #3 then went back to her hall to take care of the needs of her residents on her hallway. When Nurse #3 approached the room of Resident #1 to check on her again later that evening, NA #1 came out of the room and told her about the bandage on Resident #1's leg being soaked with blood again. Nurse #3 went to call the on-call physician. Nurse #4 was at the nursing station when Nurse #3 telephoned the on-call physician and handed the phone to Nurse #4 because she knew Resident #1 better than her and could provide more details about the resident. Nurse #4 explained to the on-call physician that Resident #1 had edematous legs. Nurse #3 did not recall if it was explained to the on-call physician about the bloody sheets/dressing and the resident being on Eliquis. Nurse #3 was sure she explained to Nurse #4 about the dressing that was found to have bled through for the second time. The physician ordered Nurse #4 to administer a one-time dose of 2 mg of Bumex and to reinforce the dressing. Nurse #3 went back to Resident #1 and asked her if she wanted the 2 mg of Bumex and the reinforced dressing. Resident #1 stated she wanted to call a family member to ask what to do and after talking with her family she decided she wanted to go out to the hospital. Nurse #3 called the on-call physician back and obtained an order to send Resident #1 to the emergency room . Nurse #3 was interviewed again on 11/18/2024 at 2:57 PM. Nurse #3 could not remember if the leg of Resident #1 was elevated. Nurse #3 stated after changing all the sheets of Resident #1 after performing wound care, she stayed with Resident #1 to assure her leg wound did not continue to bleed. Nurse #3 stated she told the resident's nurse aide that if there was any more bleeding before she returned to check on Resident #1, to come to her hallway to get her. Nurse #3 did not feel the physician needed to be notified because the bleeding was under control at that point. An interview was conducted with Nurse #4 on 11/14/2024 at 4:10 PM. Nurse #3 called the on-call physician and Nurse #4 did get on the phone with the on-call physician. Nurse #4 revealed she relayed to the on-call physician that Resident #1 got out of the hospital two or three months ago with swelling in her legs. Nurse #4 confirmed she was aware Resident #1 had recent [NAME] surgery due to lesions on her legs and that Resident #1 was on Eliquis. Nurse #4 reiterated she was not aware of any bleeding but only drainage, so she did not provide the information to the on-call physician about the [NAME] surgery on 10/17/24 or that the resident was on a blood thinner. The physician ordered Nurse #4 to administer a one-time dose of 2 mg of Bumex and to reinforce the dressing, which she passed on to Nurse #3. Nurse #4 stated the family of Resident #1 wanted her to be sent to the emergency room so, Nurse #3 called the physician back and had her sent to the emergency room . An interview was conducted with the on-call physician, Nurse Practitioner (NP) #1 on 11/14/2024 at 5:10 PM. NP #1 explained that she works as an on-call provider for the facility every eight to ten weeks on a rotational basis and does not know or visit the residents in the facility. NP #1 stated she vaguely recalled the phone call she received on the evening of 10/22/2024 regarding Resident #1. NP #1 stated that if she ordered for a one-time dose of Bumex to be administered it was likely she was told Resident #1 had edema in her leg. NP #1 stated if she had been told Resident #1 was on a blood thinner, had recent [NAME] surgery, and had bled through the bandage, she would have requested Resident #1 be sent to the emergency room for evaluation. NP #1 stated she relied on the nursing staff to provide her with the relevant information so she can ask relevant questions and give relevant orders. An interview was conducted with the physician (MD #1) for Resident #1 on 11/18/2024 at 2:49 PM. MD #1 stated he did not think a physician needed to be notified when Resident #1 initially started bleeding from her [NAME] surgical site on 10/22/2024 nor prior to administration of the blood thinner Eliquis. MD #1 did not think there was any reason to stop the administration of Eliquis for Resident #1 on the evening of 10/22/2024. MD #1 stated the initial order for Bumex was appropriate because Resident #1 had a history of edematous legs. MD #1 felt it was also appropriate for the nursing staff to send the resident to the hospital for which the on-call practitioner was notified of.

Based on observation, staff interview, record review, resident interview, Vice President of Clinical Services interview, and Regional Clinical Director interview the facility failed to maintain a systematic approach to identify residents as smokers, failed to assess smoking safety ability on a routine basis, failed to follow the smoking policies and procedures, and failed to provide supervision of residents smoking in the smoking area for two (Residents #1 and Resident #3) of three residents who were identified as smokers on [DATE]. Resident #1 caught herself on fire in her room on [DATE] sustaining second and third degree [CONDITION(S)] on her body. Resident #1 expired as a result of this incident. Findings included: Documentation on the facility smoking policy and procedure dated as last revised on [DATE] stated in part, Residents that are active smokers will be identified on admission and reviewed when there is a significant change of status, quarterly, and annually thereafter. Documentation in the smoking procedure in the same document stated in part, All smoking materials will be stored by staff (e.g., Cigarettes, pipes, lighters, matches, e-cigarettes, etc.) Smoking materials found in residents' rooms, or on their person will be confiscated and stored appropriately. An additional procedure in the same document stated, Residents are instructed not to share any smoking materials or lighted cigarettes with other residents. 1. Resident #1 was originally admitted to the facility on [DATE] with multiple diagnoses which included dementia. Documentation on the most recent safe smoking evaluation dated [DATE] revealed Resident #1 was a safe smoker. Documentation on the most recent annual MDS assessment dated [DATE] coded Resident #1 as not using tobacco. Documentation on the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as having moderately impaired cognition. Resident #1 was also coded as independent with locomotion on the unit with no range of motion impairment. Resident #1 was assessed as using a wheelchair. The care plan for Resident #1, dated as initiated on [DATE], had a focus area for the resident being an unsafe smoker. The care plan focus area for unsafe smoking was last updated on [DATE] when the Director of Nursing added the intervention of education of the patient not to smoke in her room. Additional interventions under the same focus area included the provision of protective equipment referring to a smoking apron, orientation to the facilities designated smoking area and times, scheduled smoking times per facility protocol, and review of the smoking policy with the resident and the responsible party. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:02 PM. The DON stated she was only aware of one time a long time ago when the husband of Resident #1 brought cigarettes for Resident #1 and the receptionist stopped it. The DON indicated she had no knowledge of a recent time, within the last year, when Resident #1 was found with cigarettes or a lighter on her person inside the building. The DON stated if the smoking policy was followed Resident #1 would not have been left alone to smoke with her husband and Resident #1 absolutely should have been monitored more closely. An interview was conducted with the Vice President of Clinical Services on [DATE] at 1:10 PM. The Vice President of Clinical Services revealed she had previously questioned the Director of Nursing (DON) as to why she had updated the care plan of Resident #1 on [DATE] with the intervention to educate the patient not to smoke in her room. The Vice President of Clinical Services revealed the DON had explained to her that on [DATE] she had found Resident #1 with an unlit cigarette in her hand and a lighter in her room but was not actually smoking. The DON further explained to the Vice President of Clinical Services she had removed the cigarette and the lighter from the possession of Resident #1 and added the education intervention to the care plan. The DON did not respond to interview requests to verify this information from the Vice President of Clinical Services. The MDS nurse was interviewed on [DATE] at 1:27 PM. The MDS nurse confirmed Resident #1 was a smoker and her smoking ability was reviewed at every care plan meeting she had with each MDS assessment. The MDS nurse stated that per the smoking policy Resident #1 was not allowed to have cigarettes or a lighter in her possession and was to have these items locked up at the nursing station. The MDS nurse explained it was her understanding the smoking residents, to include Resident #1, would meet a staff member at the nursing station who would obtain smoking supplies from the locked drawers and then go to the smoking courtyard with the residents. Documentation on the Resident Smoking Support schedule, dated as effective [DATE], listed the following smoking times and departmental coverage for Mondays, the day of the week on [DATE]: 9:30 AM -9:45 AM - Admissions, 11:00 AM -11:15 AM- Scheduler/Central Supply, 1:15 PM-1:30 PM- Nursing Management, 3:,d+[DATE]:45 PM - Food Services, 6:30 PM -6:45 PM - Nursing, 8:,d+[DATE]:45 PM - Nursing. An interview was conducted with the Admissions Director on [DATE] at 10:13 AM. The Admissions Director explained she was aware of the smoking policy and procedures. The Admissions Director admitted she was not following the resident smoking support schedule prior to [DATE] and she was not monitoring the residents who smoked when she was on the schedule to do so. The Admissions Director also admitted she did not monitor the smoking residents on Monday, [DATE] at 9:30 AM to 9:45 AM as stipulated by the schedule. The Admissions Director indicated she did not know if Resident #1 was outside smoking at 9:30 AM to 9:45 AM on [DATE]. An interview was conducted with the Staff Scheduler on [DATE] at 10:02 AM. The Staff Scheduler explained that she was not following the smoking support schedule and monitoring the residents who smoked at her appointed time and day of the week. The Staff Scheduler explained that the only resident who smoked and needed monitoring was Resident #2 and he was monitored continuously one on one already, therefore she did not need to do so. The Staff Scheduler did not know if Resident #1 was outside smoking unsupervised on [DATE] at 11:00 AM to 11:15 AM. An interview was conducted with the Vice President of Clinical Services on [DATE] at 9:22 AM. The Vice President of Clinical Services revealed the DON was the staff member responsible for the scheduling of a nursing staff member to monitor the smoking residents in the smoking courtyard when the nursing department was scheduled to do so. The Vice President of Clinical Services acknowledged that prior to [DATE], the nursing department did not have anybody scheduled to supervise the smoking residents when it was assigned to nursing on the smoking support schedule on Monday, [DATE] at 1:15 PM - 1:30 PM, 6:30 PM - 6:45 PM, and 8:30 -8:45 PM. An interview was conducted with the Dietary Manager on [DATE] at 11:04 AM. The Dietary Manager stated that she appointed the evening cook to the 3:30 PM to 3:45 PM time slot on the resident smoking support schedule when Food Services was listed to monitor the smoking residents on Mondays. The evening cook (Cook #1) was interviewed on [DATE] at 12:20 PM. Cook #1 confirmed she was aware of the smoking policies and procedures and she had been monitoring the smoking residents per the resident smoking support schedule but had stopped probably around [DATE]. Cook #1 indicated she was not aware if Resident #1 was smoking in the smoking courtyard at 3:30 PM to 3:45 PM on [DATE]. Documentation in a nursing note written by Nurse #5 in the electronic medical record of Resident #1 dated [DATE] at 8:20 PM stated, Nurse was on hall passing out her medications. This nurse overheard someone yelling help, help. This nurse turned around and started walking towards [where] the yelling was coming from. This nurse observed resident rolling out her room in her wheelchair. Resident was engulfed in flames. While on fire resident was continuously yelling help, help. this nurse immediately grabbed fire extinguisher from wall and immediately paged over the intercom to alert staff for help. This nurse observed other staff coming down the hall with fire extinguisher also. The fire was immediately put out by staff and resident was immediately wrapped in a blanket. Other staff was down the hall on the phone calling on phone for 911. An interview was conducted with Nurse #5 on [DATE] at 5:28 PM. Nurse # 5 stated she routinely worked on Resident #1's hallway during the 3:00 PM to 11:00 PM shift. Nurse #5 revealed she had seen Resident #1 with cigarettes in her black bag she carried with her but that had been a while ago. Nurse #5 explained the following details occurring on [DATE] regarding Resident #1. Nurse #5 stated she started her nursing shift at 3:00 PM and noted Resident #1 was outside in the smoking area with her husband. Nurse #5 noted Resident #1 and her husband returned from the smoking area to her room at the time the evening meal was being served. Nurse #5 indicated she noted Resident #1 had her black bag with her when she returned to the room with her husband but could not recall when the husband of Resident #1 left the facility. Nurse #5 stated at approximately 8:05 PM she was at her medication cart at the end of the hallway Resident #1 resided. Nurse Aide (NA) #3 had told Nurse #5 she was going to the employee break room. NA #1 told Nurse #5 she would be in the activity room documenting on her residents but was in view of the hall if she was needed. NA #2 told Nurse #5 he was going to the South hallway, another hallway, to assist other residents he was assigned to. Nurse #5 stated at about 8:15 PM she heard a resident calling out for help and she headed toward the sound. Nurse #5 observed Resident #1 wheeling out of her room engulfed in flames. Nurse #5 stated she paged overhead there was fire on her hall and went to grab a fire extinguisher. Before she could operate the fire extinguisher, NA #2 ran onto the hall, grabbed a fire extinguisher, and sprayed Resident #1 with the extinguisher. Nurse #5 explained Resident #1 had her clothes burned off and was in extreme pain but coherent and talking. Resident #1 promised she was not smoking in her room. Nurse #5 stated other staff members acted to close resident doors, call 911, and bring blankets. Nurse #5 saw Resident #1 had a blue lighter in her hand and after the fire department and emergency medical services left with Resident #1, she took the black bag and the blue lighter to the nursing station. Nurse #5 stated she did not think anyone needed to watch Resident #1 when she was smoking and knew Resident #1 would smoke with her husband outside in the smoking area. Nurse #5 revealed she knew the husband of Resident #1 would bring her cigarettes without telling anybody. NA #2 was interviewed on [DATE] at 3:16 PM. NA #2 indicated he routinely worked on Resident #1's hallway during the 3:00 PM to 11:00 PM shift. NA #2 explained that he did not usually go out to the smoking area to monitor the smoking residents because none of the residents on his hall smoked and needed monitoring. NA #2 stated on [DATE] he was getting ready to provide care to a resident on another hall prior to the evening meal tray delivery and as he closed the blinds, he saw Resident #1, the husband of Resident #1, and Resident #3 in the smoking courtyard together without any staff member present. NA #2 stated he observed Resident #1 was smoking at that time in the courtyard with her husband. NA #2 stated he saw Resident #1 and her husband return from the smoking courtyard at approximately 5:20 PM, when he delivered the evening meal tray to Resident #1 in her room but did not know what time her husband left the building. NA #2 stated he saw Resident #1 had her black bag with her but did not note any smoking material in her possession when he delivered her meal tray. NA #2 stated he saw Resident #1 again that evening after the meal service when he was charting in the dining room. NA #2 explained Resident #1 let herself back into the building from the smoking courtyard and she had her black bag. NA #2 did not know if Resident #1 had been smoking in the courtyard at that point. NA #2 stated later, after 8:00 PM, he was on the South hall when he heard an overhead page by Nurse #5 there was an emergency on West hall. NA #2 stated he ran to West hall, visualized Resident #1 sitting in the hallway in her wheelchair in flames. NA #2 stated upon Resident #1 visualizing NA #2 she cried out, Help Me [NA #2] I'm on fire! NA #2 revealed he grabbed the fire extinguisher and sprayed her entire body with the fire extinguisher. NA #2 indicated Resident #1 had her clothes burned off her and her entire front arms, torso, and legs were burned red, so he pulled her wheelchair into her room out of the hallway. NA #2 stated Resident #1 told him, [NA #2] I promise I was not smoking. I swear I wasn't smoking. NA #2 observed Resident #1 had her hand closed tight and asked her what she had in her hand. When NA #2 opened the hand of Resident #1 inside was a blue lighter. NA #2 stated he put the blue lighter on the bed side table. NA #2 explained then NA #8 observed the chair of Resident #1 was still smoking and he grabbed the fire extinguisher spraying her an additional time to put out any lingering flames. NA #2 stated that at that point the fire alarm went off and the doors closed to the hallway. An interview was conducted with NA #1 on [DATE] at 1:48 PM. NA #1 stated she was assigned to care for Resident #1 on [DATE] and routinely worked on Resident #1's hallway during the 3:00 PM to 11:00 PM shift. NA #1 explained on [DATE] she worked the 7:00 AM to 3:00 PM shift and the 3:00 PM to 11:00 PM shift on the hall Resident #1 resided. NA #1 revealed the following events on [DATE]. Resident #1 and her husband returned from being outside in the smoking courtyard at about 5:30 PM as the evening meal was being served. NA #1 heard the husband of Resident #1 tell Resident #1 he would be leaving and would return the next day. NA #1 saw Resident #1 had her black bag with her but did not see the contents of the bag or any smoking materials in her room. NA #1 was busy assisting residents with eating and when the evening meal service was over, Resident #1 was not in her room. NA #1 went to the activity room to chart on her residents at approximately 7:45 PM. NA #1 saw Resident #1 propel her wheelchair by her coming from the outside smoking courtyard and she spoke to her telling her she would soon come on the hall to assist her to bed and check on her. Twenty minutes later NA #1 heard an overhead page of an emergency on her hallway. NA #1 went to the hallway and observed Resident #1 on fire in the hallway with NA #2 and Nurse #5 with fire extinguishers. NA #2 went to the nursing station and called 911 and then the Maintenance Director. The Maintenance Director told NA #2 the fire alarm would not stop until the smoke cleared and directed her to tell everyone to keep the doors closed to the rooms and to open the windows. NA #2 opened the door for the emergency medical services and led them to Resident #1. An interview was conducted with NA #3 on [DATE] at 4:03 PM. NA #3 stated she routinely worked on Resident #1's hallway during the 3:00 PM to 11:00 PM shift. NA #3 stated she saw Resident #1 with a lighter a couple of days before [DATE] but could not be certain which day it was on the week prior. NA #3 revealed Resident #1 removed the lighter from her black bag and she happened to notice. NA #3 asked Resident #1 why she had a lighter and Resident #1 replied that it was to light cigarettes. NA #3 noted Resident #1 was on her way to the smoking courtyard. NA #3 stated she did not tell anyone because she had heard previously from other people Resident #1 kept cigarettes and a lighter in her purse although she had never seen it before that day. NA #3 said she saw Resident #1 when she picked up her evening meal tray on [DATE]. NA #3 stated she did not see any lighter or cigarettes at that time and the husband of NA #3 was not with her at that time. NA #3 revealed at 8:02 PM she punched out and went for a break in the employee break room on the service hall. NA #3 stated she heard the overhead page of an emergency on her hall, so she headed toward the hall. NA #3 explained she saw only dust from the fire extinguisher before she even came around the corner. An interview was conducted with NA #4 on [DATE] at 4:45 PM. NA #4 stated on [DATE] she was assigned to monitor Resident #2 one on one due to wandering/behavior concerns on the 3:00 PM to 11:00 PM shift. NA #4 confirmed Resident #2 was a resident who smoked which required her to monitor him while he smoked but she was never instructed or assigned to monitor anybody else who was smoking. NA #4 stated on [DATE] she went with Resident #2 to the smoking area and saw Resident #1, the husband of Resident #1, and Resident #3 already smoking with lit cigarettes. She stated they were all sitting at the table smoking and she was the only staff member present as she entered the smoking area with Resident #2. NA #4 revealed she lit two cigarettes for Resident #2 and then NA #4 and Resident #2 left the smoking courtyard and returned inside. NA #4 indicated Resident #1, the husband of Resident #1, and Resident #3 remained outside in the smoking courtyard unsupervised. NA #4 also revealed she never saw the residents wearing smoking aprons while smoking and she had never been given any instruction they were required to do so. Nurse #1, the Unit Coordinator, was interviewed on [DATE] at 2:30 PM. Nurse #1 stated on [DATE] she was notified by phone of the fire at the facility and when she came to the facility the fire department personnel were still in the building but Resident #1 had been taken by ambulance to the hospital. Nurse #1 explained the black bag of Resident #3 was opened at the nursing station and the contents verified in the presence of Nurse #3. Nurse #1 stated that inside the bag were six unopened packages of cigarettes and two lighters (one red and one blue). Nurse #1 stated the black bag was locked up in a file cabinet in her office after the contents were verified. Nurse #3, the Regional Clinical Director, was interviewed on [DATE] at 3:49 PM. Nurse #3 stated the DON called her on the evening of [DATE] and notified her of the fire at the facility. Nurse #3 stated when she arrived at the facility on [DATE] Resident #1 was no longer at the facility. Nurse #3 stated she verified the contents of the black bag of Resident #1 at the nursing station in the presence of Nurse #1. Nurse #3 confirmed in the black bag of Resident #1 were six unopened packages of cigarettes and two lighters. An interview was conducted with the Administrator on [DATE] at 11:40 AM. The Administrator stated she thought the facility staff were following the smoking policies and procedures prior to [DATE]. The Administrator stated it was her understanding that the nursing staff were assigning someone to watch the smoking residents after the administrative staff had left for the day and she had never been told anything different. The Administrator revealed that none of the staff or the residents had alerted her to any issues with residents handling of smoking materials or issues with the smoking support schedule. The Administrator acknowledged the facility was not following the smoking policies and procedures which led to the fire. Documentation on an emergency medical services report dated [DATE] initiated at 8:42 PM revealed in the narrative Resident #1 was found to have severe [CONDITION(S)] to the front of her body including her face. Due to the environment and the severity of the residents condition the decision was made to get the resident out of the facility before completing a full assessment. Resident #1 was noted to be in severe pain with second degree [CONDITION(S)] to her face, neck, chest, abdomen, both arms, both hands, and both legs. Resident #1 was documented as having third degree [CONDITION(S)] to both her forearms, her left hand, her abdomen, and the inside of her thighs. Resident #1 was administered [MEDICATION(S)] intravenously for pain management while in route to the hospital. Documentation in a hospital discharge summary revealed Resident #1 was admitted to the Burn and Critical care unit of the hospital on [DATE] with second and third degree [CONDITION(S)] to her face, neck, trunk, bilateral upper extremities, and bilateral lower extremities. Resident #1 was determined to not be a good surgical candidate, palliative care was consulted, and she expired on [DATE]. 2. The most recent admission of Resident #3 was on [DATE]. Resident #3 had multiple diagnoses one of which included [CONDITION(S)], or a severe loss of strength on the dominant right side. Documentation in the most recent Admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3 as being cognitively intact and currently using tobacco. There was no documentation of a safe smoking evaluation for Resident #3 for his [DATE] admission. Documentation on the care plan dated [DATE] revealed Resident #3 had a focus area for being an un-safe smoker. The interventions included supervised smoking, use of a smoking apron while smoking, orientation to the facilities designated smoking areas and times, and review of the smoking policy with the resident and/or family. Documentation on the Resident Smoking Support schedule, dated as effective [DATE], listed the following smoking times and departmental coverage for Mondays, the day of the week on [DATE]: 9:30 AM -9:45 AM - Admissions, 11:00 AM -11:15 AM- Scheduler/Central Supply, 1:15 PM-1:30 PM- Nursing Management, 3:,d+[DATE]:45 PM - Food Services, 6:30 PM -6:45 PM - Nursing, 8:,d+[DATE]:45 PM - Nursing. An interview was conducted with the Admissions Director on [DATE] at 10:13 AM. The Admissions Director explained she was aware of the smoking policy and procedures. The Admissions Director admitted she was not following the resident smoking support schedule prior to [DATE] and she was not monitoring the residents who smoked when she was on the schedule to do so. The Admissions Director also admitted she did not monitor the smoking residents on Monday, [DATE] at 9:30 AM to 9:45 AM as stipulated by the schedule. An interview was conducted with the Staff Scheduler on [DATE] at 10:02 AM. The Staff Scheduler explained that she was not following the smoking support schedule and monitoring the residents who smoked at her appointed time and day of the week to do so. The Staff Scheduler explained that the only resident who smoked and needed monitoring was Resident #2 and he was monitored continuously one on one already, therefore she did not need to do so. The Staff Scheduler stated that Resident #3 was never in the smoking area and she never saw him smoking. An interview was conducted with the Vice President of Clinical Services on [DATE] at 9:22 AM. The Vice President of Clinical Services revealed the DON was the staff member responsible for the scheduling of a nursing staff member to monitor the smoking residents in the smoking courtyard when the nursing department was scheduled to do so. The Vice President of Clinical Services acknowledged that prior to [DATE], the nursing department did not have anybody scheduled to supervise the smoking residents when it was assigned to nursing on the smoking support schedule on Monday, [DATE] at 1:15 PM - 1:30 PM, 6:30 PM - 6:45 PM, and 8:30 -8:45 PM. An interview was conducted with the Dietary Manager on [DATE] at 11:04 AM. The Dietary Manager stated that she appointed the evening cook to the 3:30 PM to 3:45 PM time slot on the resident smoking support schedule when Food Services was listed to monitor the smoking residents on Mondays. The evening cook (Cook #1) was interviewed on [DATE] at 12:20 PM. Cook #1 confirmed she was aware of the smoking policies and procedures and she had been monitoring the smoking residents per the resident smoking support schedule but had stopped probably around [DATE]. Cook #1 confirmed she was not monitoring the smoking residents on [DATE] at 3:30 PM to 3:45 PM and did not know if there was anybody in the smoking courtyard during that time frame. Documentation on the smoking support schedule dated [DATE] listed the Activity Department was to cover the smoking time of 11:00 AM to 11:15 AM on Wednesdays and 3:30 PM to 3:45 PM on Fridays. An interview was conducted with the Activities Manager on [DATE] at 10:24 PM. The Activity Manager stated she was aware of the smoking policies and procedures prior to [DATE] and she did adhere to the resident smoking support schedule. The Activities Manager stated she never saw Resident #3 in the smoking area, and she did not know he smoked. Documentation on the smoking support schedule dated [DATE] listed the Business Office was to cover the smoking time of 9:30 AM to 9:45 AM on Tuesdays. An interview was conducted with the Business Office Manager on [DATE] at 10:35 AM. The Business Office Manager indicated Resident #3 had not been in the facility for a long time and she did not know that he smoked until [DATE]. An interview was conducted with NA #4 on [DATE] at 4:45 PM. NA #4 stated on [DATE] she was assigned to monitor Resident #2 one on one for a wandering/behavior concern on the 3:00 PM to 11:00 PM shift. NA #4 confirmed Resident #2 was a resident who smoked which required her to monitor him while he smoked but she was never instructed or assigned to monitor anybody else who was smoking. NA #4 stated on [DATE] she went with Resident #2 to the smoking area and saw Resident #1, the husband of Resident #1, and Resident #3 already smoking with lit cigarettes. She stated they were all sitting at the table smoking and she was the only staff member present as she entered the smoking area with Resident #2. NA #4 revealed she lit two cigarettes for Resident #2 and then NA #4 and Resident #2 left the smoking courtyard and returned inside. NA #4 indicated Resident #1, the husband of Resident #1, and Resident #3 remained outside in the smoking courtyard unsupervised. NA #4 also revealed she never saw the residents wearing smoking aprons while smoking and she had never been given any instruction they were required to do so. An interview and observation were conducted with Resident #3 while he was in his room on [DATE] at 2:30 PM. The outside door frame to the room in which Resident #3 resided had a sign designating it as a room in which oxygen was used. It was also observed at the time of the interview Resident #3 had an oxygen concentrator in his room that was not in use at that time. Resident #3 explained that his usual smoking habits in the facility were to smoke at 6:00 AM, after breakfast, after lunch, and after dinner. Resident #3 stated he had been in the facility for rehabilitation services on multiple occasions and had always kept his cigarettes and lighter in a drawer in his room, going out to smoke whenever he wanted to until [DATE]. Resident #3 stated that prior to [DATE] he had never had a smoking evaluation, never told to wear a smoking apron, was never told he could not keep a lighter or cigarettes in his room. Resident #3 indicated he was able to come and go as he pleased, smoking whenever he wanted for as long as he wanted while he was in the facility on each of his admissions. Resident #3 confirmed he did not smoke in his room on any of his admissions. Resident #3 revealed the smoking residents and family members, prior to [DATE], would give cigarettes to each other or a lighter whenever they needed or desired them while in the smoking courtyard. An interview was conducted with the facility Administrator on [DATE] at 2:40 PM. The facility Administrator stated she did not know Resident #3 had been keeping his cigarettes and lighter in his room prior to [DATE]. The Administrator stated she thought the facility policy to keep lighters and cigarettes under lock and key with them only being obtained by the facility staff at appointed times was being followed. The Administrator thought all the smoking materials were always kept locked up at the nursing station and the smoking support schedule was being followed. The Administrator indicated she wished Resident #3 had told her he was keeping smoking supplies in his room but acknowledged the staff should have recognized the smoking policies and procedures were not being followed with regard to assessment of smoking ability, securing smoking materials, and monitoring of residents who smoked. The facility provided the following corrective action plan with a completion date of [DATE]. The facility did not evaluate residents for smoking. The facility did not adhere to the supervised smoking schedules. The facility did not ensure safe keeping of resident smoking materials. The facility failed to ensure the implementation and staff understanding of the smoking policy. Resident #1 was discharged to the hospital on [DATE] and did not return. Resident #3 was evaluated for safe smoking on [DATE] and deemed an unsafe smoker. A room sweep was conducted in Resident #3 room to ensure no smoking materials were in the room. Resident #3 smoking materials were removed and locked for safe keeping. Resident #3 was re-educated regarding the smoking policy on [DATE]. Resident #3 signed a safe smoking agreement on [DATE]. On [DATE] a QAPI was initiated for the smoking policy and procedure to ensure residents who wish to smoke can do so safely following the guidelines outlined in the facility policy and procedure. An ad hoc QAPI meeting was held on [DATE] at 1:45am. The following immediate actions that occurred after the incident were reviewed by the committee to include room sweeps on all residents who smoke to verify no unsafe materials were present, review of the designated resident smoking courtyard verifying the proper fire blanket, fire extinguisher, ashtrays, waste receptacles and smoking aprons were in place, posting of the smoking schedule, verification of secured storage area for smoking materials at the nurses station, education for all staff on the smoking policy and procedure, smoking evaluation, care plan updates, and resident / resident representative education for residents who smoke to be completed in am when they are awake. Immediate education to staff on the smoking policy and procedure was initiated on [DATE] after the incident and continued until all staff received the education by [DATE]. The education included detailed review of the smoking policy and procedure with a posttest to verify understanding. On [DATE] additional retention questions were performed randomly to validate continued understanding on the policy and procedure and are continuing as part of the QAPI monitoring. On [DATE] additional retention questions for nurses were performed randomly to validate continued understanding of the documentation associated with the smoking policy and procedure and are continuing as part of the QAPI monitoring. Staff did not work unless they received the education. On [DATE] the Guardian Angel program was educated to the participating managers to ask residents permission to randomly look for any unsafe materials in their rooms or on their person and document this review on their guardian angel form for any assigned residents who smoke. An audit to review the guardian angel reports was initiated on [DATE] and continues as part of the QAPI monitoring. Administrator is designated to review the reports. On [DATE] the residents who smoke were re-evaluated using the safe smoking evaluation. The smoking schedule was reviewed and revised on[DATE] to reflect the evaluations. The care plan for residents who smoke was updated to reflect the results of the resident's evaluation on [DATE]. All residents who smoke resigned [TRUNCATED]

Based on observation, staff interview, record review, resident interview, Vice President of Operations interview, Vice President of Clinical Services interview, and Regional Clinical Director interview the facility administration failed to implement and monitor systems for keeping smokers safe for two (Residents #1 and Resident #3) of three residents who were identified as smokers on [DATE]. Resident #1 caught herself on fire in her room on [DATE] sustaining second and third degree [CONDITION(S)] on her body. Resident #1 expired as a result of this incident. Findings included: Cross Refer: F689 Based on observation, staff interview, record review, resident interview, Vice President of Clinical Services interview, and Regional Clinical Director interview the facility failed to maintain a systematic approach to identify residents as smokers, failed to assess smoking safety ability on a routine basis, failed to follow the smoking policies and procedures, and failed to provide supervision of residents smoking in the smoking area for two (Residents #1 and Resident #3) of three residents who were identified as smokers on [DATE]. Resident #1 caught herself on fire in her room on [DATE] sustaining second and third degree [CONDITION(S)] on her body. Resident #1 expired as a result of this incident. An interview was conducted with the Vice President of Operations and the Vice President of Clinical Services on [DATE] at 3:59 PM. The Vice President of Operations and the Vice President of Clinical Services explained how they addressed the entire administrative team on the responsibilities of the administration to work together to protect the residents. The Vice President of Operations stated he specifically addressed the Administrator and the Director of Nursing on communication and the systematic approach required to address the needs of the smoking residents. The facility provided the following corrective action plan with a completion date of [DATE]. The facility Administrator and Director of Nursing failed to ensure the implementation and staff understanding of the smoking policy as evidenced by the facility did not: evaluate the residents for smoking, adhere to the supervised smoking schedule, ensure safe keeping of resident smoking materials. Resident #1 was discharged to the hospital on [DATE] and did not return. Resident #3 was evaluated for safe smoking on [DATE] and deemed an unsafe smoker. A room sweep was conducted in Resident #3 room to ensure no smoking materials were in the room. Resident #3 smoking materials were removed and locked for safe keeping. Resident #3 was re-educated regarding the smoking policy on [DATE]. Resident #3 signed a safe smoking agreement on [DATE]. On [DATE] a QAPI was initiated for the smoking policy and procedure to ensure residents who wish to smoke can do so safely following the guidelines outlined in the facility policy and procedure. An ad hoc QAPI meeting was held on [DATE] at 1:45am. The following immediate actions that occurred after the incident were reviewed by the committee to include room sweeps on all residents who smoke to verify no unsafe materials were present, review of the designated resident smoking courtyard verifying the proper fire blanket, fire extinguisher, ashtrays, waste receptacles and smoking aprons were in place, posting of the smoking schedule, verification of secured storage area for smoking materials at the nurses station, education for all staff on the smoking policy and procedure, smoking evaluation, care plan updates, and resident / resident representative education for residents who smoke to be completed in am when they are awake. Immediate education to staff on the smoking policy and procedure was initiated on [DATE] after the incident and continued until all staff received the education by [DATE]. The education included detailed review of the smoking policy and procedure with a posttest to verify understanding. On [DATE] department manager training was conducted by VP of Operations and VP of Clinical Services and included the DON and Administrator regarding the policy and procedure and oversight of supervision of the policy. On [DATE] additional retention questions were performed randomly to validate continued understanding on the policy and procedure and are continuing as part of the QAPI monitoring. On [DATE] additional retention questions for nurses were performed randomly to validate continued understanding of the documentation associated with the smoking policy and procedure and are continuing as part of the QAPI monitoring. Staff did not work until they received the education. On [DATE] the Guardian Angel program was educated to the participating managers to ask residents permission to randomly look for any unsafe materials in their rooms or on their person and document this review on their guardian angel form for any assigned residents who smoke. An audit to review the guardian angel reports was initiated on [DATE] and continues as part of the QAPI monitoring. Administrator is designated to review the reports. On [DATE] the residents who smoke were re-evaluated using the safe smoking evaluation. The smoking schedule was reviewed and revised on [DATE] to reflect the evaluations. The care plan for residents who smoke was updated to reflect the results of the resident's evaluation on [DATE]. All residents who smoke resigned their smoking agreements on [DATE]. Residents that smoke and their representatives were educated on the smoking policy and procedure on [DATE]. A secondary education to residents who smoke was completed on [DATE] to include smoking times under staff supervision, staff maintaining smoking materials, and use of a smoking apron. Residents that smoke will continue to receive quarterly safe smoking evaluations using the nursing data set evaluation in conjunction with their quarterly MDS. On [DATE] licensed nurses were educated that they will evaluate resident who smoke upon admission, quarterly, and with significant changes in condition using the nursing data set or safe smoking evaluation form. On [DATE] an audit was conducted to validate if any resident has a desire to smoke now or potentially in the future to ensure that they are aware that we must evaluate the resident prior to them being allowed to participate in the designated smoking times. No other residents were identified as wishing to smoke at this time. On [DATE] an audit to evaluate the smoking policy and procedure was implemented as described in the policy and procedure for new admissions who wish to smoke was completed and continues as part of the QAPI monitoring. On [DATE] a sign was posted at the facility entrance reminding staff, visitors, and residents that no smoking is permitted in the facility and please do not provide any resident smoking materials to include cigarettes, lighters, electronic cigarettes, or other tobacco products. A current list of the smokers and their status of safe or unsafe smoker was reviewed and revised on [DATE] and will be maintained and updated as needed and is located with the smoking materials. On [DATE] an audit tool to review the supervision provided and management of smoking materials by staff was initiated and continues ongoing as part of the QAPI monitoring. Administrator is responsible for reviewing this audit tool. Onsite validation was completed on [DATE] through record review, observation, resident interview, and staff interviews. Observations were made on [DATE] at 9:00 AM of a sign on the front door of the facility alerting visitors of the smoking policy and procedures within the building and warning visitors to not give lighters or cigarettes to the residents. Observations were made on [DATE] at 1:29 PM and [DATE] at 9:47 AM of the signage at the nursing station cabinet for smoking materials and the smoking courtyard area. The top of the cabinet for the smoking materials was observed to be have the list of smoking residents, reminders of the smoking procedures, and a smoking schedule. The cabinet with the smoking materials was observed to be kept locked with a key. Inside the cabinet were bins for each resident with their smoking materials. During both observations the residents were observed to be supervised by a staff member who obtained smoking materials from the locked cabinet at the nursing station, assured residents were wearing smoking aprons, and lit the cigarettes for the residents. The residents had large metal ashtrays for their use at the table. In the smoking courtyard area was a fire blanket and a fire extinguisher readily available. Observations were made on [DATE] beginning at 9:01 AM to verify signage was in place on all the doors of the residents who used oxygen. Interviews were conducted on [DATE] and [DATE] with staff members to determine if training was performed and knowledge retained on smoking policies and procedures. These interviews confirmed staff had received training and were knowledgeable regarding policies and procedures. An interview was conducted with an alert and oriented resident who smoked cigarettes on a routine basis to verify education, smoking assessments, and the smoking policies and procedures being followed as of [DATE]. Interviews were conducted with the Regional Clinical Director and the Director of Nursing to confirm education regarding smoking policies and procedures were conducted with all staff members by [DATE]. The following documentation was provided by the facility and was reviewed. Documentation was reviewed of a Quality Assurance and Improvement Plan for smoking policies and procedures dated [DATE] and [DATE]. Documentation was reviewed of room sweeps conducted on [DATE] during which two additional residents were added to the list of residents who smoked. The facility provided an oxygen sign audit dated [DATE], resident council minutes dated [DATE], resident smoking evaluations and acknowledgments, resident smoking schedule dated [DATE], updated care plans for residents who smoke dated [DATE], resident/family education dated [DATE], and resident safe smoking agreements dated [DATE]. The facility provided documented evidence 100% of the staff in the facility were provided education on the facility policies and procedures for smoking with the focus on notification of administration if the procedures were not being followed. Documentation of education on updated guardian angel round forms for observation of smoking supplies in resident rooms was dated [DATE]. Resident intention to smoke and supervised smoking area audits were initiated on [DATE]. The facility's corrective action plan was validated to be completed on [DATE].

Based on record review, staff interviews and observation, the facility failed to supervise nurse aides (NA) to ensure the nurse aides read and followed the Kardex, a resident care guide, which was based on the most recent care plan prior to providing resident care and indicated the amount of assistance required for the delivery of activities of daily living (ADL) for two of three residents reviewed for falls. (Resident #1, Resident #2). Resident #1 and Resident #2 fell from their raised beds when only one NA provided ADL care, and Resident #1 and Resident #2 were care planned requiring assistance from two nurse aides for bed mobility. Resident #1 received daily anticoagulant therapy that increased risks from falls. Immediate Jeopardy began on 10/16/21 when NA #1 did not provide the level of assistance during ADL care as indicated on the resident ' s care plan. Resident #1 fell from his bed during incontinent care provided by NA #1. This fall resulted in lacerations, right hand fracture, nasal fracture, maxilla fracture and a left subdural hematoma. Resident #1 required hospitalization at a trauma center. The Immediate Jeopardy was removed on 10/30/2021 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level for an G (Actual harm that is not immediate) to implement a plan of correction for Resident #2 and ensure monitoring systems put into place are effective. Resident #2 fell from the bed during ADL care provided by NA #2. Resident #2 sustained a small soft tissue hematoma to the back of her head. Findings included: 1. Resident #1 was admitted to the facility on [DATE]. Diagnoses included history of falls, displaced fracture of second cervical vertebra, stroke and [CONDITION(S)] affecting the left non-dominant side. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance of one person with bed mobility and toileting. The MDS indicated Resident #1 had no upper or lower impairments to the extremities and was frequently incontinent of urine. The MDS further revealed Resident #1 received anticoagulants, a medication to prevent blood from clotting and experienced a fall prior to admission that resulted in a fracture. Resident #1 was readmitted to the facility on [DATE]. Diagnoses included history of falls, displaced fracture of second cervical vertebra, stroke and [CONDITION(S)] affecting the left non-dominant side. Physician orders dated 10/13/2021 revealed Resident #1 was ordered [MEDICATION(S)], an anticoagulant medication, five milligram tablet twice a day. The Resident Data Set assessment, a nursing assessment utilized by the facility for admissions and readmissions, completed by Nurse #3 dated 10/13/2021 indicated Resident #1 was cognitively intact and required one-person assistance with incontinent care and bed mobility. On 10/25/2021 at 2:56 p.m. in an interview with Nurse #3, she stated she conducted the facility ' s Resident Data Set assessment on re-admission for Resident #1. She stated Resident #1 wore a neck brace and could turn with one-person assistance because he would use his hands to support himself. She stated Resident #1 had no one sided weakness or contractures to the hands and was able to use his telephone and bed control remotes. She stated the Resident Data Set Assessment generated the admission care plan and the ADL resident care guide initially, and they were updated by the MDS nurse as needed. The revised care plan dated 10/14/2021 revealed Resident #1 required extensive to total assistance for two persons to assist with bed mobility and total assistance of one person to assist with toileting. On 10/26/2021 at 1:59 p.m. in an interview with the MDS nurse, she stated based on the Resident Data Set assessment on re-admission to the facility on [DATE] Resident #1 required one-person assistance with activities of daily living (ADL) and bed mobility. She stated she updated the care plan to total assistance of two-persons for bed mobility on 10/14/2021 after receiving information from the interdisciplinary team meeting held on 10/14/2021. She stated the Kardex automatically updated when changes in the care plan were made for ADLs. The updated Kardex for Resident #1 reflected the revisions in the care plan created on 10/14/2021 for bed mobility. The Kardex indicated Resident #1 required total assistance of two person with bathing, personal hygiene, bed mobility, transfers and toileting. On 10/27/2021 at 11:13 a.m. in an interview with NA #3, she stated she had worked with Resident #1 previously, and she reviewed the Kardex after his re-admission, and Resident #1 required one-person assistance for ADL care and bed mobility. She stated during the day shift on 10/15/2021 she provided Resident #1 his ADL care and used one-person assistance to turn Resident #1. On 10/27/2021 at 11:47 a.m. in an interview with NA #4, she stated during the evening shift on 10/15/2021 she assisted Resident #1 with turning without the assistance from other nursing staff. She stated on 10/14/2021 when assigned to Resident #1 she had checked the Kardex that indicated he required one-person assistance with bed mobility. She further stated she had no recollection of the report to NA #1 at the change of shift on 10/15/2021. On 10/27/2021 at 7:51 a.m. in an interview with NA #1, she stated she was familiar with the computer program the facility used to document care and locate the Kardex, a resident ' s care guide. She stated the night shift on 10/15/2021 was the first time she had worked with Resident #1 and stated she did not look at the Kardex for Resident #1 because the NA #4 reported at the change of shift Resident #1 wore a neck brace and adult briefs and needed assistance with turning. She stated assistance with turning meant one person to her. Nursing documentation completed by Nurse #1 revealed on 10/16/2021 at 6:15 a.m. NA #1 notified Nurse #1 Resident #1 was on the floor. Nurse #1 entered the room and found Resident #1 on the floor. Nursing documentation revealed while NA #1 was providing morning care Resident #1 reached for his remote and fell off the opposite side of the bed. Nurse #1 assessed Resident #1 with a laceration to the head, nose and face and notified the on-call physician. Resident #1 was transported by Emergency Medical Services (EMS) to the hospital. On 10/26/2021 at 12:12 p.m. in an interview with Nurse #1, she stated Resident #1 was found on the floor lying on the right side of the bed with a laceration to the forehead. She stated Resident #1 had reached for his bed control to raise his head while NA#1 was washing him, and he fell out of the bed. Nurse #1 stated when she asked NA #1 why she didn ' t get help to turn Resident #1, NA #1 stated, Resident #1 required only one person assistance with turning. Nurse #1 stated NA #1 should have had a second person to provide care to Resident #1 because Resident #1 wore a neck immobilizer and was a two-person assistance with turning. Hospital records revealed Resident #1 was admitted to the Emergency Department (ED) on 10/16/2021 at 7:37 a.m. neurologically intact with baseline left sided weakness. The hospital ED record documented Resident #1 stated the nursing staff at the facility was turning him in the bed to clean and change him, and he accidentally fell face forward onto the ground. The hospital ED record revealed the repair of a forehead laceration and a nasal fracture, a fractured right hand, a known previous cervical -2 fracture with an abnormal ligament of the posterior arch of the cervical -1 and cervical -2 vertebra and a left subdural acute hemorrhage with possible superimposed acute hemorrhage. Resident #1 was treated with [MEDICATION(S)], a reverse agent to anticoagulants, and was transferred and admitted to a trauma facility. A review of the hospital records at the trauma facility dated 10/16/2021 revealed Resident #1 experienced low blood pressure after receiving [MEDICATION(S)], the reversal agent for anticoagulants, but the low blood pressure was resolved with intravenous fluids. Further diagnostic tests were conducted and revealed a fracture to the upper jawbone, decreased subdural collection of fluid and no evidence of an acute cerebral contusion or subarachnoid hemorrhage. Admitting diagnoses included subdural hematoma, laceration to the face, a closed fracture of right fifth metacarpal (bone in the hand), accidental fall and cervical-2 fracture. Resident #1 remains a patient in the trauma facility. On 10/27/2021 at 1:20 p.m. in an interview with the Director of Nursing (DON) and in a follow up interview on 10/28/2021 at 12:30 p.m., she stated the facility ' s Resident Data Set assessment conducted on re-admission generated Resident #1 ' s care plan, and the care plan generated the Kardex and guided nursing staff in performing ADL care to Resident #1. She stated changes in the care plan were communicated to the nursing staff by the DON or MDS nurse and placed on the dashboard of the Kardex for staff to review. She stated NAs were required to access the Kardex to review the resident care guide before providing care to residents, and NAs used interventions for bed mobility when turning a resident. She stated NA #1 should not have provided care to Resident #1 without assistance if the Kardex indicated Resident #1 required two-person assistance with bed mobility. The Administrator ' s written statement dated 10/17/2021 at 11:20 a.m. with NA #1 revealed NA #1 stated Resident #1 required one-person assistance and no one had told her he required two-person assistance. NA #1 stated she was standing on Resident #1 ' s right side of the bed that was raised waist high. Resident #1 was positioned on his back with his head lowered. She had opened the adult brief getting ready to change Resident #1 when he asked for his remote and threw the right leg over his left leg and fell toward the window off the left side of the bed. On 10/27/2021 at 2:32 p.m. in an interview with the Administrator and follow up interviews, he stated falls were discussed in interdisciplinary morning meetings, and new interventions were activated as needed and placed on the Kardex during the meeting. He stated he did not recollect what Resident #1 ' s Kardex indicated for bed mobility directly after the fall. He stated if the Kardex stated Resident #1 required two-person assistance for resident care, one person should not perform the care, and NA #1 should have waited until two persons were available to perform Resident #1 ' s care. On 10/29/2021 at 9:25 a.m., the Administrator was notified of the immediate jeopardy by phone and email. On 10/29/2021 at 8:30 p.m., the facility ' s credible allegation for the removal of immediate jeopardy was reviewed and accepted. The facility ' s credible allegation for removal of the immediate jeopardy for providing supervision to prevent accidents included the following: Rocky Mount Rehabilitation removal plan includes the identification of residents who may have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The failure to supervise nurse aides to ensure the nurse aides read the care guide prior to delivery of care is addressed by the facility with the following actions. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was transferred to the hospital and did not return to the facility. Resident #2 was transferred to the hospital for evaluation and was readmitted with no further incidents since re-admission. She remains at the facility. 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. Immediate Jeopardy Plan 1. 10/17/21- Licensed and non-licensed staff, to include agency staff were educated by NHA/ Nurse Management Team regarding following care plan and Kardex for interventions. Staff were educated prior to working their next scheduled shift. The education was completed by 10/22/2021. 100% of staff have been educated. 2. 10/18/21- An Ad hoc QAPI was conducted with Medical Director via phone, NHA, DON and 5 other team members participated. The team reviewed the 10/16/2021 incident investigation and immediate interventions that were initiated. The initial QAPI was reviewed and discussed. The interventions included Resident #1 was transferred to the ER, staff education regarding utilizing the Kardex prior to providing care, an audit to be conducted of Kardexes and care plans to ensure the residents ' current ADL Care needs are accurate. The root cause was determined to be that the C.N.A did not review the Kardex prior to providing care. There were no further recommendations at that time. 3. 10/18/21- Current residents ' care plans and Kardex-102 total were audited by the MDS Coordinator for assistance needed for ADLs to ensure assistance needed is accurate and completed. An audit of current residents ' MDS assessments comparing to the Kardex will be completed by Nurse Management Team by 10/30/2021. 4. Falls as of 10/16/2021 were reviewed by the Nurse Management Team to ensure an investigation and root cause analysis were completed. An audit of residents at risk for falls was completed on 10/29/2021 by the DON. 8 residents were noted with falls and no issues were identified. This audit will be on-going and a part of the daily clinical meeting. 5. Newly hired staff and agency staff will receive education regarding checking the Kardex for the type of ADL assistance a resident needs and how many staff should provide the care prior to delivering the care as part of their new hire and agency orientation process. There have been no newly hired CNAs since 10/16/2021. 6. Random daily audits will be conducted on each shift by the Nurse Management Team/designee to observe C.N.A ' s accessing the Kardex for resident care needs prior to resident care and ensure they follow through with the delivery of care according to the Kardex. The audits will be conducted daily times 2 weeks, 2 times a week times 4 weeks, weekly times 4 weeks. Audits started 10/29/2021. Rocky Mount Rehabilitation Center alleges immediate jeopardy was removed on 10/30/2021. On 10/29/2021 at 8:30 p.m., the facility ' s credible allegation for the removal of immediate jeopardy was reviewed and accepted. On 11/2/2021 at 9:30 a.m., an onsite extended survey and the validation of the credible allegation was started. The onsite site extended survey consisted of record review, observations, resident interviews and staff interviews. The Sufficient and Competent Nurse Staffing Review Facility Task and the Quality Assessment and Assurance (QAA) and the Quality Assurance and Performance Improvement (QAPI) Plan Review Facility Task were completed with no concerns which may have contributed to the substandard care identified on the complaint investigation survey. There were also no concerns identified related to Physician Services, Administration and Training Requirements. A review of the education records revealed the facility had provided educational training to the nurses and nurse aides on how to review and follow resident ' s care plans and the Kardex prior to administration of resident care. Interviews with nurses and nurse aides validated they had attended in-services training regarding the use of the Kardex and the care plan, and they were observed accessing the Kardex for information on the level of assistance required to perform resident care. Observations revealed beds were in low position, use of fall mats, call bell were within reach, and residents were positioned in the middle of the beds. Interviews with random residents dependent on the staff for one person assistance and two-person assistance with ADL care revealed the residents felt the nursing staff were competent in providing ADL care and felt safe when the nursing staff were assisting the resident with turning and repositioning in the bed. A review of QAPI meeting dated 10/18/2021 revealed the root call analysis for fall on 10/16/2021 was the nurse aide did not review the Kardex prior to providing care to the resident to determine level of assistance required for bed mobility. The facility provided documented evidence of the following audits completed as stated in the credible allegation of compliance: Kardex and care plan audit, MDS assessments and Kardex audits, review of falls since 10/16/2021 for an investigation and root cause analysis, all residents at risk for falls, list of newly hired nursing staff since 10/16/2021 and their orientation packet and daily audits for each shift observing nurses and nurse aides using the Kardex prior to providing resident care. On 11/2/2021 at 2:30pm, the facility ' s credible allegation of compliance was validated for the date of 10/30/2021. 2. Resident #2 was admitted to the facility on [DATE]. Her diagnoses included postural kyphosis, curvature of the spine, nontraumatic intracerebral hemorrhage and [CONDITION(S)] affecting the right dominant side. The fall assessment dated [DATE] indicated Resident #2 was at high risk for falls. Resident #2 ' s care plan dated 2/3/2021 indicated Resident #2 was a risk for falls and was unable to perform self-care due to impaired physical mobility. Interventions included Resident #2 required two-person assistance with bathing and bed mobility. The quarterly MDS assessment dated [DATE] indicated Resident #2 was severely cognitively impaired and required two persons for total assistance with bed mobility and total assistance of one person to perform a bath. The MDS indicated upper and lower impairments to one side of Resident #2 ' s body. On 10/25/2021 at 3:25 p.m. in an interview with NA #5, she stated Resident #2 did not move without assistance and provided little assistance when turning. She stated she provided one-person assistance ADL care to Resident #2, but some NAs used two-person assistance when turning. NA #2 stated she did not know what the Kardex or care pan indicated for the level of assistance required for bed mobility or ADL care for Resident #2. A review of the written statement by NA #2 dated 5/4/2021 reported Resident #2 was receiving ADL care and became upset because her sheets were changed. NA #2 wrote Resident #2 was agitated, jerked and fell off the bed. She further wrote she had provided ADL care to Resident #2 for six months and used two-person assistance for transfers. On 10/26/2021 at 12:00 p.m. in an interview with NA #2, she stated she had worked at the facility almost a year, and she was trained Resident #2 only required one-person assistance with ADL care. NA #2 stated on 5/4/2021 Resident #2 was repositioned on her right side and while washing Resident #2 ' s back side during ADL care, Resident #2 fell out of the raised bed onto the floor. NA #2 stated she had been providing one-person assistance for Resident #2 ' s ADL care as she was trained. She stated she knew about the Kardex prior to the fall incident but did not recall being trained on how to use the Kardex prior to the fall. NA#2 stated after the fall incident she received training on how to use the Kardex to document resident care and to check the resident ' s required level of assistance prior to care. Nursing documentation dated 5/4/2021 at 2:00 p.m. revealed Nurse #2 responded to a code orange, a resident fall, in Resident #2 ' s room and found Resident #2 lying face up on her back on the floor between the two beds. Nursing documentation recorded NA #2 was providing ADL care to Resident #2 when she rolled off the bed to the floor. Nurse #2 assessed Resident #2 with no visible injury, but Resident #2 ' s family requested she be sent to the hospital for an evaluation. On 10/25/2021 at 3:05 p.m. in an interview with Nurse #2, she stated she heard the call for help and entered Resident #2 ' s room and observed Resident #2 lying face up on her back on the floor between the two beds on 5/4/2021. She stated Resident #2 was assessed with no obvious injury noted. The physician and family were notified, and Resident #2 was sent to the ED for an evaluation. She stated Resident #2 ' s bed was a small regular bed with no bed rails, and Resident #2 did not move independently. She stated based on the Kardex, Resident #2 was a two-person assistance with ADL care, and NA #2 was providing one-person assistance ADL care. Nurse #2 further stated she had never looked at a care plan but knew resident care plans were available and had assisted Resident #2 with ADL care before providing only one-person assistance. A change in condition report completed on 5/4/2021 for Resident #2 indicated Resident #2 fell , and pain was indicated by facial grimacing. Hospital records dated 5/4/2021 revealed Resident #2 fell out of her bed onto the right side and presented with right arm in a flexed (bent) position and refused to move the right arm into any other position. Diagnostic tests revealed a small hematoma to the back of the head, no intracranial bleeding and no fractures. Resident #2 was admitted to the hospital, and diagnoses included fall, urinary tract infection and hypertension. Physician progress notes dated 5/10/2021 recorded Resident #2 rolled out of the bed onto the floor while receiving personal care by NA #2. The progress note revealed Resident #2 was aphasic, unable to speak and could not verbalize pain but was yelling when right arm and right hand was touched. Resident #2 was transferred to the hospital for an evaluation. On 10/26/2021 at 10:14 a.m. in an interview with the former DON, she stated she responded to the Code Orange, facility ' s code for a resident fall, on 5/4/202, and the resident was observed lying between the two beds in the room on the floor on her back. She stated when NA #2 rolled Resident #2 over to her side during the bath, Resident #2 kept rolling and she was unable to stop her from falling out of the bed. The former DON stated Resident #2 was a two-person assistance with ADL care. In another interview on 10/28/2021 at 12:27 p.m. she stated the use of the Kardex was part of the facility ' s orientation process, but NA #2 was not familiar with the how to use the Kardex. She further stated staffing was not an issue on 5/4/2021 and NA #2 was trying to complete ADL care for Resident #2 without the assistance of another staff member. On 10/26/2021 at 1:43 p.m. in an interview with the former Administrator, she stated Resident #2 ' s fall on 5/4/2021 was a single isolated incident, and the staff member was re-educated on the use of the Kardex to review the level of assistance required for ADL care. She stated Resident #2 was also moved to a private room and placed on a bigger bed. On 10/27/2021 at 1:20 p.m. in an interview with the current DON and in a follow up interview on 10/28/2021 at 12:30 p.m., she stated she started employment with the facility in June 2021. She stated based on the Kardex, Resident #2 required two-person assistance for bed mobility on 5/4/2021. She stated NAs were to follow Resident #2 ' s care plan and Kardex and two persons needed to be in the room when providing ADL care to Resident #2. On 10/28/2021 at 1:44 p.m. in an interview with the current Administrator, he stated falls were discussed in interdisciplinary morning meetings, and new interventions were activated as needed and placed on the Kardex during the meeting. He stated if the Kardex indicated residents required two-person assistance for resident care, one person should not perform the care, and NAs should wait until two-person assistance was available to perform resident care. On 10/25/2021 at 4:30 p.m., NA #5 and NA #6 were observed standing on opposite sides of the bed while providing incontinent care and repositioning Resident #2.

Based on staff, physician and family interviews and record review, the facility failed to notify the physician of a change in condition for one of three residents reviewed (Resident #3) for notification, when Resident #3 had recurring low blood sugars over a period of 24 hours; and the facility failed to notify a resident's Responsible Party (Resident #6) when the Resident was sent to the hospital, for one of three residents reviewed for notification. The Immediate Jeopardy began 9/4/2017 at 1:06 AM when Nurse #2 checked Resident #3's blood sugar and documented the reading as 39. The Immediate Jeopardy was removed on 10/13/2017 at 7:15 PM when the facility provided a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education to ensure monitoring systems are in place that are effective. Example #2 for Resident #6 is no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is isolated (D). Findings included: 1.A review of the medical record revealed Resident #3 was admitted from the local hospital on [DATE] with [DIAGNOSES REDACTED]. A review of the signed physician orders [REDACTED]. Also listed was a standing order for [MEDICATION NAME] (rapid acting insulin) to be injected three times daily before meals with the dose depending on a blood sugar check and ordered by a sliding scale (blood sugar 0-199 = 0 units insulin and blood sugar < 60 call MD, 200 - 300 = 5 units insulin; 301 - 400 = 10 units insulin; 401 - 450 =15 units insulin, 451 - 500 = 20 units insulin; > 500 Call MD. A review of progress notes revealed a note on 9/4/2017 at 1:06 AM which stated Resident #3 complained of weakness. Resident's blood sugar was checked and documented at 39 milligrams per deciliter (mg/dl). Documentation indicated Resident #3 was given 2 cups apple juice and pudding and the blood sugar would be rechecked. This note was written by Nurse #2. A review of a Medication Administration Note written by Nurse #1 on 9/4/2017 at 8:05 AM noted 240 cubic centimeters (cc) orange juice with sugar was given and documented in the note was the 8:30 AM blood sugar was rechecked to be 59 mg/dl. A review of Medication Administration Note dated 9/4/2017 at 9:10 AM indicated long acting insulin was not administered due to blood sugars of 39 - 59. Documentation was by Nurse #1. A review of a Daily Skilled Note written by Nurse #1, on 9/4/2017 at 4:00 PM revealed documentation of Resident #3 had blood sugar checks 4 times and no insulin coverage. Nurse #1 noted the blood sugar at 8:30 AM was 82 mg/dl and was rechecked to register 59 mg/dl and orange juice with sugar was given. The note also documented Resident #3 had a blood sugar of 81 mg/dl at 11:30 AM and another check at 1:00 PM noted the blood sugar was 53 mg/dl and orange juice with sugar was documented as given and blood sugar noted to be up to 64 mg/dl and Nurse #1 indicated Resident #3 was alert and oriented. A review of a Medication Administration Note dated 9/4/2017 at 5:00 PM and written by Nurse #3 revealed documentation the [MEDICATION NAME] 500 mg had been held due to a low blood sugar of 60 mg/dl and it was indicated Resident #3 was given orange juice and sugar. A Health Status note was reviewed, dated 9/4/2017 at 5:32 PM by Nurse #3. The note indicated Resident #3's blood sugar was 60 mg/dl at 4:30 PM. The note described the resident as alert, verbal with the complaint of feeling bad. The note also indicated Resident #3 was talking on the phone with a family member. The on-call Physician was notified and an order was obtained to administer [MEDICATION NAME] for blood sugar less than 60 mg/dl. The note further indicated Resident #3 was notified of the order. An additional Health Status note was reviewed, written by Nurse #3, on 9/4/2017 at 11:44 PM. The note stated Resident #3's blood sugar was 50 mg/dl at 8:00 PM. [MEDICATION NAME] was given one time Intra Muscular (IM) and at 10:00 PM Resident #3's blood sugar was 60 mg/dl. This note also documented Resident #3 as being alert and verbal and having skin warm and dry to touch. The note indicated a fax was sent to the physician with information about Resident #3 having low blood sugars. A Health Status note written on 9/5/2017 at 2:07 AM by Nurse #6 was reviewed and revealed documentation that a nurse entered Resident #3's room and called to Resident #3 who did not respond. The note indicated the blood sugar was checked at 12:35 AM and was 36 mg/dl. Also noted was the Nurse called for assistance and another nurse administered [MEDICATION NAME] at 12:37 AM and Resident #3's blood sugar was documented at 54 mg/dl. Nurse #6 also documented a nurse called 911, the physician was notified and a code was initiated. It was indicated in the note Emergency Medical Services (EMS) arrived and assumed care at approximately 12:50 AM. Documentation indicated the EMS noted the time of death at 12:53 AM. The Admission Minimum Data Set ((MDS) dated [DATE] was partially completed and noted Resident #3 was not assessed for cognition and needed extensive to total assistance for Activities of Daily Living. Resident #3 could eat independently after the tray was set up. The care plan dated 9/5/2017 noted a focus of risk of hypo / [MEDICAL CONDITION]. One of the interventions was: Orange juice / honey / sugar / milk etc. to counteract hypoglycemic reaction & notify MD. On 10/11/2017 at 8:50 AM in a telephone interview, Resident #3's family member stated Resident #3 had lived with her for ten years and she was the care giver for Resident #3. The family member stated Resident #3 was completely alert and oriented, could feed herself and could tell you how she was feeling. The family member also stated Resident #3 could perform a lot of her own care before she fell and fractured her back. On 10/12/2017 at 12:20 PM in a telephone interview, Nurse #1 stated she did not get report from the 11 PM to 7 AM nurse on 9/4/2017. Nurse #1 stated when she got the low blood sugar reading on Resident #3 she asked the RN Supervisor if she should call the physician, and was told the blood sugar for Resident #3 had gone up and down since admission and to give Resident #3 orange juice with sugar to try and raise the blood sugar. In a telephone interview with the RN Supervisor on 10/12/2017 at 2:15 PM, the Supervisor stated she did not remember Resident #3 or anything about low blood sugar. The RN Supervisor stated if she had been told about a blood sugar of 39 mg/dl, she would have said to call the physician immediately. On 10/12/2017 at 3:20 PM in an interview, Nurse #3 stated when she checked Resident #3's blood sugar at 4:30 PM on 9/4/2017, and it was 60, she called the on-call physician and got an order for [REDACTED].#3 stated she did not give the [MEDICATION NAME] because the blood sugar was 60. When the blood sugar was checked at 8:00 PM and noted to be 50 mg/dl, Nurse #3 stated the [MEDICATION NAME] was given one time and the blood sugar was checked again at 10:00 PM and was 60 mg/dl. Nurse #3 stated she faxed information about Resident #3's low blood sugars to the physician, so that he would know Resident #3 was having low blood sugar readings. On 10/12/2017 at 5:01 PM, in a telephone interview, Nurse #2 stated he had no recollection of the low blood sugar for Resident #3 on 9/4/2017 at 1:06 AM. Nurse #2 stated he was sure that he rechecked the blood sugar after one or two hours, but failed to record it. In an interview by telephone on 10/13/2017 at 2:05 PM, the physician stated he did not have any records there in front of him but recalled Resident #3 as having some fractured vertebrae with a lot of pain, [MEDICAL CONDITION] and possible pneumonia and Diabetes. The physician stated he would expect to be called if Resident #3 had a blood sugar of 39 mg/dl and he expected a recheck would be done. The physician stated he had no recollection of being called at any time about Resident #3's low blood sugar. The physician stated someone should be called whether it was the on-call physician or not. The Administrator was notified of the Immediate Jeopardy on 10/13/2017 at 1:25 PM. The facility provided a credible allegation of immediate jeopardy removal on 10/13/2017 at 6:43 PM. The Credible Allegation of immediate jeopardy removal indicated: The procedure for implementing the acceptable plan of correction for the specific deficiency cited; An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 10/11/17 and included the Administrator, Director of Nursing, Staff Development Coordinator, Unit Manager and Physician's Assistant, to analyze incident occurring on 9-4-2017. Licensed nurse re-education regarding Notification of changes on 10/11/2017 and continued until 100% of the nurses were educated on 10/13/2017. An Ad Hoc QAPI meeting was conducted on 10/13/2017 and included the Administrator, Director of Nursing, Staff Development Coordinator for Notification of Change and Following MD orders. The Ad hoc committee reviewed F157 IJ and allegation of compliance. On 10-13-2017 progress notes were reviewed for any changes and contact was made to the MD and RP were necessary. In-servicing of 100% of all licensed nurses regarding the facility policy on following Physician order [REDACTED]. The education consisted of the fundamental information necessary for transcribing and following physician orders. Any licensed nurse who was not in-serviced will not work and will be removed from the schedule until this in-servicing is completed with them. The certified nursing assistance were educated on reporting notification of change and s/s of [DIAGNOSES REDACTED] to the licensed nurse this started on 10/13/17 and will continue until all staff educated by the DON. These in-services will be added to the general orientation of all licensed nurses from this point forward. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; To remain in compliance and under the direction of the Administrator, beginning 10-13-17; The unit managers will review physician order [REDACTED]. Director of nursing will audit physician order [REDACTED]. Director of Nursing, Unit Managers, Staff Development and Weekend Supervisor will validate the staff's retention of the education presented by conducting education validation audits randomly throughout all three shifts including weekends. Those noted with opportunities will be immediately re-educated. The Administrator and/or Staff Development Coordinator will review these audits weekly for 12 weeks. The title of the person responsible for implementing the acceptable plan of correction: Administrator. The Credible Allegation was validated by: The survey team reviewed the in-service documentation conducted by the RN Consultant and the Director of Nursing. Licensed Nurses were interviewed and confirmed the in-service information on notification of change and procedure for response to [DIAGNOSES REDACTED] had been provided and demonstrated their knowledge of the in-service information. The survey team reviewed the documentation of in-service to all Nursing Assistants on signs and symptoms of [DIAGNOSES REDACTED] with signs and symptoms listed and to report these to the nurse. Nursing Assistants in the facility were interviewed and confirmed the in-service regarding signs and symptoms of [DIAGNOSES REDACTED] had been provided and they could demonstrate the in-service information. 2-Record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] indicated the resident was moderately cognitively impaired and required extensive assistance of one person for all activities of daily living (ADLs). Record review of the Physicians orders for Resident #6 revealed an order dated 9/27/2017 to send the resident to the Emergency Department (ED) for evaluation. Record review of the nursing notes included an entry by Nurse #5 on 9/27/2017 at 4:38 PM. The note revealed Resident #6 was sent to the hospital per the physician orders [REDACTED]. An interview was conducted with Resident #6's responsible party (RP) on 10/13/2017 at 10:20 AM. The RP indicated the resident was sent to the hospital on the evening of 9/27/2017. The RP stated she was not notified of the resident being sent to the hospital until the following morning. The RP indicated she was very involved in the resident's care, visited almost daily and was upset because she was not notified when the resident was sent out of the facility. The RP indicated the nursing staff were very aware of the interest she had in the resident's care and knew she was to be notified when the resident was sent to the hospital. An interview was conducted with Nurse #5 on 10/13/2017 at 11:00 AM. Nurse #5 reported she was Resident #6's primary nurse the evening of 9/27/2017. Nurse #5 indicated shortly after she arrived for her shift on the evening of 9/27/2017, the physician called and ordered to send the resident to the ED for evaluation due to some abnormal laboratory results which were sent to his office earlier in the day. Nurse #6 indicated it was an extremely busy evening and she did not remember to call and notify the resident's RP when the resident was sent to the hospital. Nurse #5 stated she knew part of the process for sending any resident to the hospital included notifying the RP. Nurse #5 indicated she worked a double shift on 9/27/2017 and remembered in the early morning hours of 9/28/2017 that the RP was not notified when Resident #6 was sent to the hospital. Nurse #5 indicated she waited until 7:00 AM to call the RP. Nurse #5 stated the RP was very upset that the resident was sent to the hospital at 4:30 PM the day before and no one notified her. An interview was conducted with the Director of Nursing (DON) on 10/13/2017 at 2:45 PM. The DON indicated she was unaware of any residents being sent to the ED and the RP not notified until the next day. The DON further indicated it was not an acceptable facility practice for the RP not to be notified at the time a resident is sent out for evaluation. The DON stated the expectation was for the responsible party to be notified at the time a resident was sent out of the facility.

Based on family, staff and physician interview and record review, the facility failed to provide interventions to manage diabetic care for one of one residents reviewed with Diabetes (Resident #3) when the Resident had recurring low blood sugars over a 24-hour period. The Resident expired in the facility. Immediate Jeopardy began [DATE], when Nurse #2 noted Resident #3 complained of weakness. Nurse #2 checked Resident #3's blood sugar and documented it as 39 milligrams per deciliter (mg/dl) and would be rechecked. Resident #3's blood sugar was not documented as rechecked. Resident #3 expired in the facility on [DATE]. Immediate Jeopardy was removed on 10//,[DATE], when the facility provided a Credible Allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and to ensure monitoring systems are in place that are effective. Findings included: A review of the medical record revealed Resident #3 was admitted to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] was reviewed and revealed Resident #3 was noted to have documented [DIAGNOSES REDACTED] and [MEDICATION NAME] (long acting insulin) on hold. Included in the discharge summary was information stating [MEDICATION NAME] (oral medication for Type II diabetes control) was discontinued. The admission assessment dated [DATE] noted Resident #3 understands and is understood. Resident is alert. Resident needed set up help only for eating. There was no interim care plan noted. A review of the signed physician orders [REDACTED]. Also listed was a standing order for [MEDICATION NAME] (rapid acting insulin) to be injected three times daily before meals with the dose depending on a blood sugar check and ordered by a sliding scale (blood sugar ,[DATE] = 0 units insulin and blood sugar below 60 call physician (MD), 200 - 300 = 5 units insulin; 301 - 400 = 10 units insulin; 401 - 450 =15 units insulin, 451 - 500 = 20 units insulin; above 500 Call MD. Progress notes were reviewed for Resident #3 and revealed a Medication Administration Note dated [DATE] which indicated [MEDICATION NAME] 3 mg was on order. A review of the Medication Administration Record [REDACTED]. Documentation in the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On the MAR indicated [REDACTED]. The MAR further indicated Resident #3 refused the [MEDICATION NAME]on [DATE], the MAR indicated [REDACTED]. According to the MAR indicated [REDACTED]. [MEDICATION NAME] was indicated in the MAR indicated [REDACTED]. A review of progress notes revealed a note on [DATE] at 1:06 AM which stated Resident #3 complained of weakness. Resident's blood sugar was checked and documented at 39 milligrams per deciliter (mg/dl). Documentation indicated Resident #3 was given 2 cups apple juice and pudding and the blood sugar would be rechecked. This note was written by Nurse #2. On [DATE] at 5:01 PM, in a telephone interview, Nurse #2 stated he had no recollection of the low blood sugar for Resident #3 on [DATE] at 1:06 AM. Nurse #2 stated he was sure that he rechecked the blood sugar after one or two hours, but failed to record it. Nurse #2 stated the blood sugar must have been normal when he rechecked it or he would have called the physician. A review of a Medication Administration Note written by Nurse #1 on [DATE] at 8:05 AM noted 240 cubic centimeters (cc) orange juice with sugar was given and documented in the note was the 8:30 AM blood sugar was rechecked to be 59 mg/dl. On [DATE] at 12:20 PM in a telephone interview, Nurse #1 stated she did not get report from the 11 PM to 7 AM nurse on [DATE]. Nurse #1 stated when she got the low blood sugar reading on Resident #3, which was documented to be 52 mg/dl at 8:30 AM on [DATE], she asked the RN Supervisor if she should call the physician, and was told the blood sugar for Resident #3 had gone up and down since admission and to give Resident #3 orange juice with sugar to try and raise the blood sugar. Nurse #1 stated she did not call Resident #3's MD to report the Resident's blood sugar was below 60 mg/dl on [DATE] at 8:30 AM. A review of a Medication Administration Note dated [DATE] at 9:10 AM indicated long acting insulin was not administered due to blood sugars of 39 - 59. Documentation was by Nurse #1. A review of a Daily Skilled Note written by Nurse #1, on [DATE] at 4:00 PM revealed documentation of Resident #3 had blood sugar checks 4 times and no insulin coverage. Nurse #1 noted the blood sugar at 8:30 AM was 82 mg/dl and was rechecked to register 59 mg/dl and orange juice with sugar was given. The note also documented Resident #3 had a blood sugar of 81 mg/dl at 11:30 AM and another check at 1:00 PM noted the blood sugar was 53 mg/dl and orange juice with sugar was documented as given and the blood sugar was noted to be up to 64 mg/dl and Nurse #1 indicated Resident #3 was alert and oriented. A review of a Medication Administration Note dated [DATE] at 5:00 PM written by Nurse #3 revealed documentation the [MEDICATION NAME] 500 mg had been held due to a low blood sugar of 60 mg/dl. and indicated Resident #3 was given orange juice and sugar. A Health Status note was reviewed, dated [DATE] at 5:32 PM by Nurse #3. The note indicated Resident #3's blood sugar was 60 mg/dl at 4:30 PM. The note described the resident as alert, verbal with the complaint of feeling bad. The note also indicated Resident #3 was talking on the phone with a family member. The on-call Physician was notified and an order was obtained to administer [MEDICATION NAME] for blood sugar less than 60 mg/dl. The note further indicated Resident #3 was notified of the order. An additional Health Status note was reviewed, written by Nurse #3, on [DATE] at 11:44 PM. The note stated Resident #3's blood sugar was 50 mg/dl at 8:00 PM. [MEDICATION NAME] was given one time Intra Muscular (IM) and at 10:00 PM Resident #3's blood sugar was 60 mg/dl. This note also documented Resident #3 as being alert and verbal and having skin warm and dry to touch. The note indicated a fax was sent to the physician with information about Resident #3 having low blood sugars. A Health Status note written by Nurse #4 on [DATE] at 2:07 AM was reviewed and revealed documentation that a nurse entered Resident #3's room and called to Resident #3 who did not respond. The note indicated the blood sugar was checked at 12:35 AM and was 36 mg/dl. Also noted was the Nurse called for assistance and another nurse administered [MEDICATION NAME] at 12:37 AM and Resident #3's blood sugar was documented at 54 mg/dl. Nurse #4 also documented a nurse called 911, the physician was notified and a code was initiated. It was indicated in the note Emergency Medical Services (EMS) arrived and assumed care at approximately 12:50 AM. Documentation indicated the EMS noted time of death at 12:53. A review of the Emergency Medical Services report dated [DATE] revealed Resident #3 was pulseless and had no respirations when they arrived. The EMS documented leads were applied to Resident #3's chest to record heartbeat, but no heartbeat was present and extremities were cold. The report noted Resident #3 was not transported to the hospital and the physician was notified to allow EMS to pronounce Resident #3 dead. The report indicated the facility would contact the funeral home to transport the body. On [DATE] at 8:50 AM in a telephone interview, Resident #3's family member stated Resident #3 had lived with her for ten years and she was the care giver for Resident #3. The family member stated Resident #3 was completely alert and oriented, could feed herself and could tell you how she was feeling. The family member also stated Resident #3 could perform a lot of her own care before she fell and fractured her back. The family member stated Resident #3 was interested in lots of different things and was not like most people of the same age. The family member stated Resident #3 would refuse her diabetic medication in the facility because it had been discontinued when she was at home. Resident #3's family member stated when Resident #3 had low blood sugar, she would sometimes, have cold sweat on her skin, or may act as though she was sleepy while having a conversation. On [DATE] at 2:15 PM a telephone interview was conducted with the RN Supervisor who worked on [DATE] during the 7:00 AM to 3:00 PM shift. The RN Supervisor stated she did not remember Resident #3 or anything about low blood sugar. The RN Supervisor stated if she had been told about a blood sugar of 39, she would have said to call the physician immediately. On [DATE] at 3:20 PM in an interview, Nurse #3 stated when she checked Resident #3's blood sugar at 4:30 PM on [DATE], and it was 60 mg/dl, she called the on-call physician and got an order for [REDACTED].#3 stated she did not give the [MEDICATION NAME] because the blood sugar was 60. When the blood sugar was checked at 8:00 PM and noted to be 50 mg/dl, Nurse #3 stated the [MEDICATION NAME] was given one time and the blood sugar was checked again at 10:00 PM and was 60 mg/dl. Nurse #3 stated she faxed information about Resident #3's low blood sugars to the physician, so that he would know Resident #3 was having low blood sugar readings. Nurse #3 stated she did not know if a response was received from the MD. In an interview by telephone on [DATE] at 2:05 PM, the physician stated he did not have any records there in front of him but recalled Resident #3 as having some fractured vertebrae with a lot of pain, [MEDICAL CONDITION] and possible pneumonia and Diabetes. The physician stated he would expect to be called if Resident #3 had a blood sugar of 39 mg/dl and he expected a recheck would be done. The physician stated he had no recollection of being called at any time about Resident #3's low blood sugar. The physician stated someone should be called whether it was the on-call physician or not and he expected to be called if a blood sugar was below 60 mg/dl. The Administrator was notified of the Immediate Jeopardy on [DATE] at 1:25 PM. The facility provided a credible allegation of immediate jeopardy removal on [DATE] at 6:28 PM. The credible allegation of immediate jeopardy removal indicated: The procedure for implementing the acceptable plan of correction for the specific deficiency cited; An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE] and included the Administrator, Director of Nursing, Staff Development Coordinator, Unit Manager and Physician's Assistant, to analyze incident occurring on [DATE]. Licensed nurse re-education regarding Diabetic Management began on [DATE] and continued until 100% of the nurses were educated on [DATE]. An Ad Hoc QAPI meeting was conducted on [DATE] and included the Administrator, Director of Nursing, Staff Development Coordinator for Notification of Change and Following MD orders. The Ad hoc committee reviewed F309 IJ and allegation of compliance. On [DATE] and [DATE] residents residing in the facility were assessed to ensure adequate orders for diabetic management as it relates to outlined parameters and MD notification completed by DON and nursing management. Residents with diabetes were also reviewed to ensure that orders were in place for interventions to be initiated if and when their blood sugar level was found to be in non-therapeutic range. In-servicing of 100% of all licensed nurses regarding the facility policy on following Physician Orders, Notification of Change, and [DIAGNOSES REDACTED] was completed on[DATE], by the Staff Development Coordinator and the Director of Nursing. The education consisted of the definition of significant change: Significant change is defined as a decline in the resident's medical status to include decline in cognition, decline in activities of daily living, and any condition causing further impairment. The licensed nurses were also in-serviced regarding the process for transcribing physician orders [REDACTED]. Any licensed nurse who was not in-serviced will not work and will be removed from the schedule until this in-servicing is completed with them. The certified nursing assistance were educated on reporting notification of change and s/s of [DIAGNOSES REDACTED] to the licensed nurse this started on [DATE] and will continue until all staff educated by the DON. These in-services will be added to the general orientation of all licensed nurses from this point forward. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; To remain in compliance and under the direction of the Administrator, beginning [DATE]; The unit managers will review progress notes daily to capture any significant changes and ensure there is MD/RP notification. DON will audit progress notes twice weekly for 12 weeks to validate notification and documentation of assessments. DON will pull report of all diabetic blood sugar readings daily to ensure that any levels that are not therapeutic have MD notification and interventions in place. The licensed nurse has had disciplinary action in place of [DATE]. Director of Nursing, Unit Managers, Staff Development and Weekend Supervisor will validate the staff's retention of the education presented by conducting education validation audits randomly throughout all three shifts including weekends. Those noted with opportunities will be immediately re-educated. The Administrator and/or Staff Development Coordinator will review these audits weekly for 12 weeks. The title of the person responsible for implementing the acceptable plan of correction: Administrator. The credible allegation was validated by: The survey team reviewed the documentation for in-service for licensed nurses began on [DATE] and is ongoing. The in-service included: Signs and symptoms of [DIAGNOSES REDACTED] (this was in-serviced to facility Nursing Assistants and validated via interviews by the survey team.) Procedure was explained for testing blood sugar, treating the immediate need for glucose and notification of the physician. The survey team reviewed the in-service documentation conducted by the RN Consultant and the Director of Nursing. Licensed Nurses were interviewed and confirmed the in-service information on diabetic management and procedure following identification of [DIAGNOSES REDACTED] by interviews with licensed nurses who could demonstrate knowledge of the information provided by the in-service on diabetic management and treatment procedures for [DIAGNOSES REDACTED].

Based on staff interview and record review the facility failed to ensure that staff followed turning and positioning guidelines on the Resident Care Card which resulted in 1 of 3 sampled residents (Resident #1), who experienced falls, sustaining a left femur fracture. Findings include: Resident #1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] and 08/10/12. The resident's documented [DIAGNOSES REDACTED]. Review of Resident #1's undated Care Card revealed it documented the resident was total assist for bathing, required a lift for transfers, required two staff members for mobility, required an assist of two staff members for positioning every two to three hours, and was confused. Under "Other" the card documented, "Assist of 2 for T & P (turning and positioning)." The resident's 07/20/12 Quarterly Minimum Data Set (MDS) documented she was severely cognitively impaired, was totally dependent on one staff member for bed mobility/hygiene/bathing, and was totally dependent of two staff members for transfers. Review of the facility's Falls Detail Reports revealed Resident #1 had not experienced a fall in the facility since her admission. A 08/10/12 hospital Discharge Summary documented Resident #1 was admitted to the hospital on [DATE] for uncontrolled diabetes, altered mental status, and failure to thrive. The report documented x-rays obtained in the hospital revealed the resident had osteoporosis, flexure contractures, and a new right femur fracture with placement of a rod in the right femur. A 08/10/12 nursing readmission assessment documented in a fall risk scale that Resident #1 had no history of falling, had no secondary [DIAGNOSES REDACTED]. A 09/07/12 11:13 AM electronic Resident Progress Note documented, "This nurse called to room at approximately (10:00 AM). Noted resident on floor between air conditioner and bed. Resident lying on left side with head resting on floor. Additional staff paged to room for assistance. Resident assisted back to bed with 3 person transfer. Nursing assistant stated that resident rolled off backside of bed while she was attempting to bathe and (provide incontinent care)..... EMS (emergency medical services) arrived at (10:30 AM) to transport resident to ER (emergency room )...." A 09/07/12 11:13 PM electronic Resident Progress Note documented, "Resident returned to facility approx (approximately) (6:00 PM). According to report Head CT (computed tomography) scan was negative, no other injuries noted..." Resident #1's care plan was updated immediately after the fall (without date provided), according to an interview with the Director of Nursing (DON) on 09/25/12 at 8:57 AM. The problem of "___ (name of resident) had an actual fall with no injury, r/t (in regard to) poor balance, poor communication/comprehension, functional problem, disease process/condition: dementia" was identified as a problem. Interventions for this problem included "assist 2 for all turning and positioning." Review of electronic Resident Progress Notes from 09/08/12 through mid-day 09/10/12 revealed Resident #1 did not exhibit any signs of pain or discomfort. A 09/10/12 3:33 PM electronic Resident Progress Note documented that Resident #1's facial expressions were indicative of pain when her left leg was moved. The resident's primary physician was notified, and x-rays of the resident's upper and lower legs were ordered. 09/10/12 mobile x-rays of Resident #1's bilateral hips revealed osteoporosis was present, and there were old fractures of both hips. X-rays of the resident's right femur revealed osteoporosis and an old fracture. X-rays of the resident's left femur revealed osteoporosis and an "acute" fracture. A 09/11/12 physician's orders [REDACTED]. The 09/11/12 hospital x-rays of Resident #1's right femur documented the presence of a rod with more displacement of the fracture fragments within the right femur when compared with x-rays from 08/04/12. The 09/11/12 hospital x-rays of the resident's left femur documented the presence of osteopenic bones and a fracture. At 2:13 PM on 09/24/12 Nurse #1, who cared for Resident #1 on first shift stated Resident #1 was dependent on the staff for her activities of daily living (ADLs), was very cognitively impaired, and had no history of falls prior to her fall on 09/07/12. Thus, she reported no fall interventions were in place for the resident prior to 09/07/12. However, Nurse #1 commented even prior to the resident's fracture of the right femur (08/10/12), two staff members were supposed to provide care and transfers for the resident because of her osteoporosis diagnosis. According to Nurse #1, the two fractures did not seem to change the resident's level of cognitive and physical functioning, other than the resident exhibiting more signs of pain. At 2:23 PM on 09/24/12 NA #1, who reported caring for Resident #1 before the fracture to her right femur (08/10/12) and several times about two weeks after that fracture, stated no one had ever told her that two staff members needed to be present when bathing and providing incontinent care to Resident #1. She reported she knew the resident well, and felt comfortable providing baths and caring for the resident by herself. According to NA #1, the resident was total care and was very confused. She reported the resident was transferred by two staff members using a lift. After the resident was discharged from the hospital on [DATE] with a right femur fracture, the NA commented the only time she asked another staff member to help her bathe or provide care for the resident was when the resident exhibited signs of pain. NA #1 stated if she was unsure of how to care for residents she asked the hall nurse or referred to the Resident Care Card. At 2:40 PM on 09/24/12 NA #2, who reported she cared for Resident #1 before the fracture to the right femur (08/10/12) and assisted with care occasionally after that fracture, stated no one had ever told her that two staff members needed to be present when bathing and providing incontinent care to the resident. However, she commented she knew the resident's family was very particular so she felt more comfortable asking for another NA to assist her any time she was providing care to this resident. She reported after Resident #1's fractures the resident was more confused and experienced more pain. According to NA #2, Resident #1 was transferred using a lift. She stated the resident was unable to provide any assistance during turning and repositioning. NA #2 reported if she was unsure of how to care for residents she asked the hall nurse or referred to the Resident Care Card. At 3:43 PM on 09/24/12 NA #3, who cared for Resident #1 after her right femur fracture (08/10/12), stated the resident never had a fall until 09/07/12. She reported after the right femur fracture (08/10/12) the DON reviewed with her that anytime care was provided to the resident, that involved turning and positioning, two staff members had to be present. According to NA #3, the DON also showed her notations on the Resident Care Card which documented this information. She explained that before the right femur fracture (08/10/12), it had not been necessary to always have two staff members present to bathe or provide incontinent care to Resident #1. The NA stated if she was unsure of how to care for residents she asked the hall nurse or referred to the Resident Care Card. At 3:52 PM on 09/24/12 Nurse #2, who cared for Resident #1 on second shift, stated Resident #1 did not have any falls until 09/07/12. He reported even before the resident returning to the facility on [DATE] with a right femur fracture, the staff had been instructed to always have two people present during Resident #1's care. After the right femur fracture (08/10/12), the nurse commented the resident was temporarily more lethargic. He also reported Resident #1 did not exhibit any signs and symptoms of pain from her 09/07/12 fall until 09/10/12. At 4:32 PM on 09/24/12 the facility's Staff Development Coordinator (SDC) reported after Resident #1's 09/07/12 fall in-servicing began on 09/08/12 about abuse and use of Resident Care Cards and turning and repositioning. She stated all staff were being in-serviced on abuse, but she still had between 15 and 20 staff, many of whom worked on the weekend, who had not yet received the abuse in-service. According to the SDC, only NAs were being in-serviced about Resident Care Cards/turning and positioning, but she still had 12 NAs, including two new hires, that still needed this in-servicing. At 5:17 PM on 09/24/12 the DON stated Resident #1 had required extensive assistance or had been totally dependent on the staff for her ADLs even prior to her femur fractures. However, she explained that she made it mandatory for two staff members to turn and reposition this resident after the fracture of her right femur (08/10/12). After Resident #1 returned from the hospital on [DATE], she reported the resident's Care Card was revised to reflect the new requirement. She explained the NA, who on 09/07/12 did not follow these instructions, was terminated. She explained bathing and incontinent care involved turning and positioning Resident #1, and the 09/07/12 NA attempted to provide these services alone. According to the DON, even though Resident #1 sustained bilateral femur fractures, there was no change in her mental or physical functioning after the fractures. At 8:57 AM on 09/25/12 the DON clarified that the facility did not provide in-servicing to all staff about Resident Care Cards or the need to turn and reposition Resident #1 after the resident returned to the facility on [DATE]. However, she reported she went individually to those staff who would be caring for Resident #1, and reviewed the new requirement to have two staff present any time the resident was turned and repositioned. She also commented she showed these staff this revision of Resident #1's Care Card. At 12:34 PM on 10/05/12 a telephone interview was conducted with NA #4 who was providing care to Resident #1 on 09/07/12 by herself when she reported the resident had to be lowered to the floor. She explained as she turned back toward Resident #1 after obtaining a wash cloth she saw the resident falling, attempted to catch her legs, but the resident was too heavy, and slid to the floor. The NA stated she was aware the Resident Care Cards contained information about how to care for residents. She reported she was pulled form another hall to provide baths on Resident #1's hall. She commented she had not worked with Resident #1 in a long time, but the last time she had worked with the resident only one staff member was needed to bathe her. According to NA #4, she was in a hurry so she did not refer to Resident Care Cards on 09/07/12, but no other staff members provided her with the Care Cards or told her that Resident #1 now required two staff for tasks involving turning and repositioning. At 12:47 PM on 10/05/12 a telephone interview was conducted with Physician #1 who reviewed the 09/11/12 x-ray of Resident #1's left femur. He reported no x-ray of Resident #1's left femur was taken during her 07/30/12 to 08/10/12 hospitalization , which could be compared to the 09/11/12 hospital x-ray of the left femur. After review of the 09/11/12 x-ray of the resident's left femur, Physician #1 stated he could not say with 100% assurance that the left femur fracture was not pathological. However, he reported the fracture occurred as the result of hitting or touching. According to Physician #1, he could not say for sure that the left femur fracture captured on the 09/11/12 x-ray was the result of Resident #1's fall on 09/07/12.

Based on interviews and record review the facility failed to provide a notice of discharge to a family member and failed to document for 1 of 3 discharged residents (Resident # 3). Resident # 3 was admitted on [DATE] for rehabilitation services. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance of 1 person for bed mobility, transfers toileting and bathing. Review of the Nursing Home Notice of Transfer/discharge date d 10/24/11 read, in part: the date of transfer/discharge hand written on the notice was 11/23/11; the reason for the notice was hand written as " you have failed after reasonable and appropriate notice to pay for your stay at this facility " . The section where anyone else who was notified would be listed was left blank, indicating the Responsible Party or other family members were not notified of the impending transfer/discharge. " The discharge location was listed as another facility. Review of the Medical Record from 10/6/11 - 11/23/11 revealed no notation regarding the resident or having received the " Notice of Transfer/Discharge " or of being aware of an impending discharge transfer to another facility or to home. There was also no documentation regarding discharge planning or whether the RP had been informed of the impending transfer/discharge to another facility or to home. Review of the Nursing Notes from 10/6/11 - 11/23/11 did reveal that the RP was consistently informed of changes in condition. Review of Resident #3 ' s care plan revealed she was care planned for Nutrition Risk and it was last updated on 11/16/11. There were no discharge plans or other care plan items noted on the medical record. The Nursing Note dated 11/23/11 at 1800 read " Resident alert and verbal. Order to D/C home. Meds (medications) discussed with resident and son. Meds sent home (with) resident. (Name of Medical Supply company) called concerning O2 (oxygen), reported that resident has concentrator at home. Also RT (Respiratory Therapy) will see resident tomorrow in AM. Resident left facility accompanied by (RP and another family member). O2 tank from facility (with) resident. (RP) will return? " During an interview with the Administrator on 2/17/12 at 3:10 PM, he stated that Resident #3 was discharged for non-payment and that he had spoken to her about it but she refused to pay her bill. He said that the 30 day discharge notice listed another facility as the discharge location but then it was changed because Resident #3 did not want to go there, she wanted to go home. When he was asked if the other facility had agreed to admit Resident #3 he indicated they had, as when Resident #3 was first discharged from the hospital, the other facility had also made a bed offer for her. Interview with the Social Worker on 2/17/12 at 3:15 PM revealed that Resident #3 was sent a 30 day discharge notice from the facility for non payment and that the discharge location was home to her son ' s apartment. She stated that she arranged for a high back w/c to be delivered to the home. She added that Resident #3 was discharged home with a facility w/c and a facility portable oxygen tank to use until the ordered medical equipment arrived. The Social Worker stated she also arranged for home care services and faxed the referral on the date of discharge which was 11/23/11. She said she spoke to Resident #3 about discharge home a couple of days before she went as she did not want to go to another facility. She also reported that she tried to talk to the RP about how Social Security works as he thought Medicaid paid everything, but he still did not want to use her checks to pay the bill. The Social Worker was asked to provide any notes she had regarding these conversations as they were not documented in the medical record but documentation was not available. On 2/17/12 at 3:35 PM the Social Worker and Business Office manager provided a copy of the 30 day discharge notice (Nursing Home Notice of Transfer Discharge). The discharge location was not listed as home it was another facility. Telephone interview with a family member (Family #1) of Resident #3, on 3/2/12 at 11:37 AM, revealed that she had come to the home of the RP to visit over Thanks Giving. She stated that the family was under the impression that the resident was just leaving the facility for a visit over the Thanks Giving weekend and then returning to the facility. On 2/17/12 at 5:15 PM a telephone interview with Resident # 3 revealed she remembered the Social Worker telling quite some time her before discharge that she would be eligible for 3 hours a week of home care and when Resident #3 asked what she needed home care for, the Social Worker said because you ' re having problems with money and you need to pay if you ' re going to stay here. Resident #3 denied ever being told she was going to be discharged to another nursing home and denied ever receiving any paperwork regarding discharge. She did recall being given the bill with the amount of money she owed. She stated that on the day she was discharged she had told the Administrator that she wanted to go home for Thanks Giving and was going to come back after and he told her that she was going on the 26th anyway, so if she went she couldn ' t come back. Resident #3 stated that the Administrator said she needed to pay $6,000 or she had to leave. She said that she asked him if there was anywhere else she could go because she wasn ' t well enough to be discharged and that his reply was that he didn ' t think anyone else would take her. Resident #3 stated that the day of discharge was the first time day she became aware that she was being discharged from the facility. She also said that her son was told that day that he would have to pay $1,000 and something for Resident #3 to be able to stay, which she said was different from what she was told. She did not believe anyone have spoken with the RP prior to 11/23/11 regarding being discharged home. Several attempts were made to interview the RP but he could not be reached for interview.

Based on interviews and record review the facility failed to develop a discharge plan and failed to ensure home care could meet the needs of the resident prior to discharge for 1 of 3 discharged residents (Resident # 3). Resident # 3 was admitted on [DATE] for rehabilitation services. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance of 1 person for bed mobility, transfers toileting and bathing. She required limited assistance with a one person physical assist for walking and for personal hygiene and could eat independently with set up help. The MDS also indicated that Resident #3 did not have steady balance during transitions or walking and was only able to stabilize with human assistance. Resident #3 had upper and lower extremity impairment on one side and used a wheelchair (w/c) and walker for mobility. She was coded on the MDS as being occasionally incontinent of bowel and bladder (B & B). The MDS also revealed Resident # 3 had been receiving [MEDICAL CONDITION] and oxygen therapy while she was a resident of the facility. Review of the Nursing Notes from 10/6/11 - 10/10/11 revealed, in part: 10/6/11 2:30 PM - " Last day of [MEDICAL CONDITION] treatments. " " ADL care provided by nursing staff. " 10/9/11 7 AM - 7 PM - " Resident (up) to w/c with assistance of 1 staff. " 10/10/11 9:30 PM - " Resident had forgotten that medication was given to her earlier. " 10/10/11 11 Pm - " assisted with PM care by two (NAs). " Review of the Psychiatric Evaluation dated 10/10/11 revealed " staff reports VH (visual hallucinations " and paranoia. Pt endorses VH at night. (?) 2? (secondary) to [DIAGNOSES REDACTED]/ sx (symptoms)/[MEDICAL CONDITION]. No recent labs (laboratory results). " Under mental status the items checked included: unfocused, drowsy, orientation to place/person (time was not checked), slow speech, constricted and sad affect, tangential thought process, visual hallucinations, and paranoid. On a scale of unable to participate, poor, fair and good Resident #3 was checked off as fair for all of the following: short term memory, long term memory, concentration, insight and judgment. The recommendations of the evaluation included adding [MEDICATION NAME] 0.5 mg (milligrams twice a day and the diagnostic code identified was 298.9 (unspecified [MEDICAL CONDITION]). 10/17/11 12:40 PM - " Resident had a [MEDICAL CONDITION] while eating lunch in the day room. Brought back to room in geri-chair. [MEDICAL CONDITION] was over in a few seconds. " 10/19/11 3:15 PM - " ADLs per staff. " 10/19/11 10 PM - " Resident is a total assist. " 10/21/11 6:15 AM - ' Pt (patient) total care with ADLs. " 10/23/11 7:15 AM - " ADLs care provided per staff. Incontinent of B & B. " 10/23/11 10 PM - " Up in w/c much of the day. Alert with periods of confusion. " Review of the Nursing Home Notice of Transfer/discharge date d 10/24/11 read, in part: the date of transfer/discharge hand written on the notice was 11/23/11; the reason for the notice was hand written as " you have failed after reasonable and appropriate notice to pay for your stay at this facility " . The section where anyone else who was notified would be listed was left blank, indicating the Responsible Party or other family members were not notified of the impending transfer/discharge. " The discharge location was listed as another facility. Further review of the Medical Record Nursing revealed no notation regarding the resident having received the " Notice of Transfer/Discharge " or of being aware of an impending discharge transfer to another facility or to home. There was also no documentation regarding whether the RP had been informed of the impending transfer/discharge to another facility or to home. Review of the Nursing Notes did reveal that the RP was consistently informed of changes in condition. Review of the Nursing Notes from 10/24/11 - 10/31/11 also revealed , in part: 10/26/11 - " Resident incontinent of B & B. Assisted with ADL ' s total assist. " 10/27/11 - " CNAs (Nursing Assistants NAs) in feeding pt. " Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and her functional status and level of assistance required to complete activities of daily living (ADLs) had not changed since the 8/24/11 review. Resident #3 was only able to stabilize while walking or during transitions with human assistance and had upper and lower extremity impairment on one side. She was coded on the MDS as being occasionally incontinent of bowel and bladder. The MDS also revealed Resident # 3 had been receiving [MEDICAL CONDITION] and oxygen therapy while she was a resident of the facility. Review of Resident #3 ' s care plan revealed she was care planned for Nutrition Risk and it was last updated on 11/16/11. Under " Resident at risk for nutritional decline related to " the contributing factors checked off included: " variable intakes of food/beverages " , " restrictive or mechanically altered diet " , and " decreased self feeding " , and " requires assistance " was hand written. There was not a care plan for discharge planning and there were no other care plan items noted on the medical record. Review of a faxed communication from the Social Worker to the attending physician dated 11/22/11 read, in part, " Resident to D/C (discharge) home (with) home health. " " Medications need to be called into (name and of pharmacy). " The home health services and equipment needed were listed. On an attached page under Homebound Status it read: " considerable and taxing effort to leave home cognitive impairments mobility problems. " It was signed in the physician signature section and dated 11/23/11. The Nursing Note dated 11/23/11 at 1800 read " Resident alert and verbal. Order to D/C home. Meds (medications) discussed with resident and son. Meds sent home (with) resident. (Name of Medical Supply company) called concerning O2 (oxygen), reported that resident has concentrator at home. Also RT (Respiratory Therapy) will see resident tomorrow in AM. Resident left facility accompanied by (RP and another family member). O2 tank from facility (with) resident. (RP) will return? " Review of the Occupational Therapy Discharge Summary dated 11/24/11 indicated that Resident #3 was discharged to a private residence. It also revealed, in part, that Resident #3 made progress with alertness and orientation but required maximum to moderate assistance with all activities of daily living as well as verbal cues to attend to task. One comment read: " Pt does require 24 hour assist (secondary) L hemi (left [MEDICAL CONDITION]) and (decreased) safety. Pt was continuing to make progress with ADLSs. " The discharge recommendations included: Home Health: OT (occupational therapy)/PT (physical therapy)/Nurse/NA Adaptive Equipment: 3 in 1 commode, bathroom grab bars, long handled shower head, reacher, sock aide, long handled shoe horn, long handled sponge Assistance with: cleaning, laundry, cooking, grocery shopping, transportation and medication routine. The discharge summary indicated that a home environmental survey was not completed as this item was not checked off. Review of the Home Care provider ' s Referral Form dated 11/23/11 revealed that the D/C from the facility date was written as 11/23/11 and the SOC (start of service date for Home Care services was written 11/28/11. Under additional comments the following was hand written: " Informed (name of Social Worker at facility) we need H & P (History and Physical) on pt. Also informed her pts home # disconnected. " Review of the Interdisciplinary Discharge Summary dated 11/29/11 indicated the resident was discharged home in stable condition with home health nursing, PT, OT and medications at her request. Under discharge potential it read, in part, " ST (short term) D/C home. " In the Activities section it read, in part, " confusion present, unable to recall actual facts and events. " Review of the Home Care provider ' s Case Communication form dated 11/28/11 revealed " Multiple failed attempts to reach pt # (number) disconnected. NKO (no new number) listed. SN (staff nurse) drove by and (no) # listed for apartment #. 8 males standing around in yard. (Not) safe environment to stop. (Illegible) made aware. " Review of the Home Care provider ' s Case Communication form dated 11/29/11 revealed " SN (Staff Nurse) went to patient home to set-up home health services; explained in detail to family the services provided; also explained that patient needed around the clock care; SN took patient VS (vital signs) 102 - 100 - 36 12/20; patient filled of congestion. SN called EMS to have patient to be evaluated by MD (Medical Doctor). SN also explained to family if they could not provide around the clock care for patient; that the patient does not need to come back home until they get everything in place like it should be for patient; patient admitted to hospital. " The Home Care Provider ' s Comprehensive Adult Assessment form dated 11/29/11 revealed Resident #3 was not admitted to home care but was sent to hospital. There was also a hand written note stating Resident #3 had not eaten for two days and had diarrhea. Review of the Hospital History and Physical revealed Resident #3 was sent to the Emergency Care Center for evaluation of shortness of breath, wheezing and fever. A chest x-ray showed left lower lobe pneumonia and she was admitted to the hospital for treatment. Interview with Nurse #1 on 2/17/12 at 1:20 PM revealed that Resident #3 was getting better at one point and it seemed like she didn ' t need Nursing Home placement anymore, but then she got worse and needed feeding assistance. Nurse #1 indicated that at one point Resident #3 was discharged home. She stated that she was not aware of any discharge plans that had been put in place for the resident and that on 11/23/11 Resident #3 had left on first shift, so she was already gone when Nurse #1 came to work. She added that she was at the facility during second shift when the RP arrived to pick up the resident ' s belongings but she did not speak with him. On 2/17/12 at 2:00 PM Regional Staff Member #1 indicated that the Nurse who was assigned to Resident #3 at the time of discharge, and who completed discharge, no longer worked at the facility and was not available for interview. During an interview with the Administrator on 2/17/12 at 3:10 PM, he stated that Resident #3 was discharged for non-payment and that he had spoken to her about it but she refused to pay her bill. He said that the 30 day discharge notice listed another facility as the discharge location but then it was changed because Resident #3 did not want to go there, she wanted to go home. When he was asked if the other facility had agreed to admit Resident #3 he indicated they had, as when Resident #3 was first discharged from the hospital, the other facility had also made a bed offer for her. Interview with the Social Worker on 2/17/12 at 3:15 PM revealed that Resident #3 was sent a 30 day discharge notice from the facility for non payment and that the discharge location was home to her son ' s apartment. She stated that she arranged for a high back w/c to be delivered to the home. She added that Resident #3 was discharged home with a facility w/c and a facility portable oxygen tank to use until the ordered medical equipment arrived. The Social Worker stated she also arranged for home care services and faxed the referral on the date of discharge which was 11/23/11. She said she spoke to Resident #3 about discharge home a couple of days before she went as she did not want to go to another facility. When asked if she had confirmation back from the Home Care provider that services could be arranged on short notice over the Thanks Giving holiday and weekend, she stated that if they couldn ' t she should have heard back from them. She then said that she did know that the medical equipment had arrived on the day of discharge. She also reported that she tried to talk to the RP about how Social Security works as he thought Medicaid paid everything, but he still did not want to use her checks to pay the bill. The Social Worker was asked to provide any notes she had regarding these conversations as they were not documented in the medical record but documentation was not available. On 2/17/12 at 3:35 PM the Social Worker and Business Office manager provided a copy of the 30 day discharge notice (Nursing Home Notice of Transfer Discharge). The discharge location was not listed as home it was another facility. On 2/17/12 at 3:45 PM telephone interview with a staff member of the Home Care Company (Home Care #1) revealed that they received the referral on 11/23/11 and the start of service date was listed as 11/28/11. He stated that the documentation they had indicated that on 11/28/11 the visit was not done as the phone was disconnected, the number to identify which home was the correct one was not visible, and the location appeared unsafe to go searching alone. Home Care #1 said that according to her notes, when the Nurse went to do the assessment on 11/29/11 Resident #3 was not admitted to Home Care as she was not safe to be at home, she had a temperature and had not eaten for two days. He added that Resident #3 needed around the clock care and was sent to the hospital and admitted . Telephone interview with a family member (Family #1) of Resident #3, on 3/2/12 at 11:37 AM, revealed that she had come to the home of the RP to visit over Thanks Giving. She stated that the family was under the impression that the resident was just leaving the facility for a visit over the Thanks Giving weekend and then returning to the facility. Family #1 stated she and Family #2 (not the RP) went to pick up the resident for the visit but when they got there, all of Resident #3 ' s belongings were packed. Family # 1 stated they asked Resident #3 why all her things were packed and Resident #3 said that they were putting her out of the Nursing Home because she had not paid her bill. Family #1 said that another family member was handling the resident ' s Social Security check and the resident wasn ' t capable of sorting it out herself due to her condition. Family #1 also said that they were told that home care would be coming out on Monday (11/28/11) but then added that no one showed up on Monday. Telephone interview with the Home Care provider staff member who received the referral from the facility (Home Care #2), on 3/2/12 at 11:42, that she received the faxed referral just before 1:40 PM on 11/23/11. She stated that every morning she receives a staffing report and that the report that morning showed that there was no staff available to provide services over the Thanks Giving holiday or weekend, so services could not start until 11/28/11. She stated that whenever she gets a referral she tries to reach the patient and family to let them know when services will start and what to expect. She stated that she was unable to reach Resident #3 as the phone was disconnected. She said she also lets the facility know up front when services can start and that she told the facility Social Worker on the telephone that the earliest available start of service date was 11/28/11 and that if another start date was required she should send the referral to another agency. Home Care #2 stated that the Social Worker indicated that start of service date of 11/28/11 was acceptable. In second telephone interview with Family #1 on 3/2/12 at 11:47 AM she added that the Nursing Home did not give the Resident a chance to pay her bill and " all the Social Worker had to do was have her Social Security check pulled like the other Nursing Home did. We would have let her do that. " Family #1 said that she did not believe the RP was aware that the resident was being discharged home or that there had been a plan to discharge her to another Nursing Home facility. She did say that he had been told that they were going to send her to a psychiatric facility at one time. She also stated that the RP lived in the home but was not there 24 hours a day and Resident #3 was to sick to be discharged from the facility as she was not talking, moving around or eating while at home. On 2/17/12 at 5:15 PM a telephone interview with Resident # 3 revealed that she recalled talking with someone early in her stay at the facility and telling them she could not use her Social Security check to pay her bills at the facility because she wanted to keep her apartment so she could go back home in a year or so. She also stated that she remembered the Social Worker telling quite some time her before discharge that she would be eligible for 3 hours a week of home care and when Resident #3 asked what she needed home care for, the Social Worker said because you ' re having problems with money and you need to pay if you ' re going to stay here. Resident #3 denied ever being told she was going to be discharged to another nursing home and denied ever receiving any paperwork regarding discharge. She did recall being given the bill with the amount of money she owed. She stated that on the day she was discharged she had told the Administrator that she wanted to go home for Thanks Giving and was going to come back after, and he told her that she was going on the 26th anyway, so if she went she couldn ' t come back. Resident #3 stated that the Administrator said she needed to pay $6,000 or she had to leave. She said that she asked him if there was anywhere else she could go because she wasn ' t well enough to be discharged and that his reply was that he didn ' t think anyone else would take her. Resident #3 said that there were a couple of nurses and Supervisors in the room during the conversation. She said that after that her RP came to take her home (attempts to reach the RP but he could not be contacted for interview). She said that she was feeling sick that day and had diarrhea and that she continued to have diarrhea while she was at home. When questioned about what happened at home she didn ' t really remember a lot and did not recall being told about home care services on the day of discharge. Resident #3 said she was at her own apartment where she and her RP lived. She said family members told her they brought her food but she doesn ' t remember and then she ended up in the hospital with pneumonia.

Based on observations, staff and resident interviews and record reviews, the facility failed to provide the ordered treatment on a pressure ulcer and/or failed to report the reassessment of a pressure ulcer for 1 of 2 sampled residents (Resident # 9) whose pressure ulcer was reviewed. Findings include: Resident # 9 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Nursing Admission Assessments, dated [DATE], indicated Resident # 9 had pressure ulcers on his sacrum and his left hip area. The Weekly Pressure Ulcer Condition Report, dated [DATE], indicated a left trochanter pressure ulcer that measured 2 centimeters by 1 centimeter. The treatment nurse indicated the ulcer was a healing Stage IV. Undermining was documented as 0.5 centimeters. Necrotic tissue covered less than 25% of the wound bed. The care plan for Resident # 9, with an onset date of [DATE], indicated impairment of his skin integrity. Approaches to prevent new skin breakdown included turning and positioning often, use of positioning and pressure relieving devices and skin checks weekly. Review of the [DATE] Treatment Record indicated Resident # 9 received pressure ulcer treatments to both his sacrum and his left trochanter. There was an entry for weekly skin checks that directed the nurses to document positive findings with a plus mark (+) and negative findings with a dash (-). Positive findings were to be reported to the treatment nurse and documented in the nurse's notes. There was no indication of assessment on the treatment sheet for weekly skin checks. Pressure ulcer dressings were undocumented for 1 day from Resident # 9's [DATE] to [DATE]. No explanation for the lack of initials was documented. The Treatment Record for [DATE] indicated a weekly skin check for Resident # 9 had been completed only once for the month. Pressure ulcer treatments to his sacrum and/or his left trochanter had been undocumented twice. No explanation was given on the treatment sheet or in the nurse's notes for the lack of documentation. The [DATE] Weekly Pressure Ulcer Condition Report indicated the wound had been debrided the week before. Measurements were listed as 2.5 centimeters by 1.5 centimeters with 4.5 centimeters of tunneling in the 3:00 PM position. Resident # 9's Quarterly Minimum Data Set (MDS), dated [DATE], coded the resident as cognitively intact. The MDS also indicated Resident # 9 was dependent on staff for transfer, personal hygiene, dressing and toilet use and required extensive assistance for bed mobility. The MDS did not indicate Resident # 9 rejected care. The assessment was coded to reflect 2 - Stage IV pressure ulcers with the largest measuring 4 centimeters (cm) by 4 cm by 4 cm with slough present. Skin and ulcer treatments included nutrition or hydration intervention, ulcer care, application of non-surgical dressings and applications of ointments and medications. The [DATE] Treatment Record indicated the sacral treatment was ordered every 3 days. Review of the record indicated the treatment was completed on [DATE] and then not documented as done again until [DATE]. On [DATE], the sacral treatment was not documented as completed. The treatment nurse documented the reason for not completing the pressure ulcer treatment as "already up in motorized wheelchair." The treatment to the left trochanter was not documented as completed on [DATE] and [DATE] with no reason given. The treatment was not documented as completed to the left trochanter on [DATE] because the resident was not in bed. Weekly skin checks were not entered on the treatment sheet for the month of July. Physician orders [REDACTED]. Orders indicated this treatment order was good for 30 days, then reassessment would be completed. The physician's orders [REDACTED]. The discontinuation date was listed on the treatment sheet as [DATE]. Review of the [DATE] Treatment Record indicated weekly skin checks were completed as ordered. The Treatment Record indicated the sacral pressure ulcer healed on [DATE]. Daily care was provided to the left trochanter pressure ulcer. A plastic surgery consult, dated [DATE], indicated the left hip (trochanter) pressure ulcer presented with a small amount of yellow drainage, The consult also indicated while there was no odor and a decrease in size, the tunneling remained unchanged. The consult also indicated the dressing should continue and a [DEVICE] should be considered. There was no corresponding nurse's note or order that indicated this information was relayed to Resident # 9's attending physician. physician's orders [REDACTED]. A Physician's Progress Note, dated [DATE] indicated Resident # 9 was assessed The physician documented Resident # 9 received [MEDICATION NAME] for his left trochanter osteo[DIAGNOSES REDACTED]. There was no mention of continuing the treatment to the left trochanter. On [DATE], the Treatment Nurse measured the left trochanter wound as 4 cm x 2.5 cm with 5 cm tunneling. Necrotic tissue was documented as not visible. Drainage was described as bloody. On the back of the form where the treatment nurse wrote a narrative was written, "cleansed with NS (normal saline, wet to dry dressing reapplied. Daily drsg (dressing) (symbol for change)." There was no mention of physician notification or receiving new orders. Review of the [DATE] Treatment Sheet for Resident # 9 indicated the entry for the left trochanter pressure ulcer care. The order ended with [DATE] with the remainder of the month X'd out. The last day documented as the treatment being completed was [DATE]. Review of nurse's notes from [DATE] through [DATE] did not indicate the assessment of Resident # 9's left trochanter pressure ulcer was reported to the physician. Notes did not indicate new orders had been received for the continued treatment of [REDACTED]. another medical problem. No mention was made and no order received for the continued treatment of [REDACTED]. On [DATE], an order was written that indicated the dressing to Resident # 9's left trochanter was to continue as previously ordered. Above the order, was written, late entry for [DATE]. Initial observation of the order, on [DATE] prior to the dressing change did not indicate the late entry notation. An observation was made on [DATE] at 11:15 AM of Resident # 9 receiving left trochanter pressure ulcer treatment from Nurse # 4. Nurse # 4 removed the soiled dressing with a date of [DATE] and the initials of the nurse that had changed the dressing. The wound bed had approximately 10 % slough at the top edge with approximately 90 % of the wound bed appearing beefy red. The wound had a 5 cm tunnel in the 3:00 PM position. The wound was cleansed around the circumference then Nurse # 4 was observed to clean the middle. After cleansing the wound, Nurse # 4 removed the soiled gloves. Normal saline moistened gauze was placed in the tunnel using a cotton swab to pack the area. The wound was covered with a larger gauze and secured with tape. Nurse # 4 was interviewed on [DATE] at 3:30 PM. She stated she did not complete the left trochanter pressure ulcer dressing for Resident # 9 on [DATE] because he refused to go back to bed to have the dressing changed. Resident # 9 was interviewed on [DATE] at 10:10 AM. He stated the dressing to his left trochanter wound had not been changed on Monday, [DATE]. He stated the staff told him there was not enough help that day to get the dressing change completed. He did not identify which staff member had relayed this information. Resident # 9 stated he did not refuse to go back to bed and no staff person had offered to change his dressing. Review of the nurse's notes from [DATE] through [DATE] did not indicate Resident # 9 had refused care including pressure ulcer care. On [DATE] at 3:15 PM, Nurse # 4 indicated she did not change Resident # 9's dressing on [DATE] because she thought the order had been discontinued or the area had healed.. She added she had not checked with the Treatment Nurse to see if the wound on the resident's left trochanter had been reassessed and she did not check for a new order. She added the dressing change on [DATE] must have been completed without a valid order. Nurse # 4 added on [DATE] prior to the observed dressing change, the Treatment Nurse passed her a current order for the left trochanter pressure ulcer. Nurse # 4 added Resident # 9 did not refuse to go back to bed on [DATE] as she previously reported. A telephone interview was held with Nurse # 5 on [DATE] at 6:25 PM. She stated she had changed the dressing on Sunday, [DATE] for Resident # 9. She was unsure if she had changed the dressing on [DATE] and stated she needed to review the treatment book. On review of the treatment book, Nurse # 5 acknowledged there was no documentation the treatment was done on [DATE]. She stated the order had expired on [DATE]. Nurse # 5 stated she knew to change Resident # 9's left trochanter dressing because it was "routine" adding she had not checked the treatment book prior to changing the dressing. The nurse stated she had not called the physician for new orders because that was the responsibility of the treatment nurse that worked during the week. Nurse # 5 stated she was unaware the treatment for [REDACTED]. She stated Resident # 9 being out of bed was not a reason not to do his treatment. The nurse added the resident liked to get up early, but no one had mentioned either doing the treatment before he got up or after he went back to bed. On [DATE] at 10:15 AM, an interview was held with the Director of Nursing (DON). The expectation was for the Treatment Nurse to reassess and receive a new treatment order prior to the expiration of the previous treatment. She added that treatments were noted as completed by the initials by the treatment book entry . If a blank was on the treatment sheet, that meant the treatment had been skipped. The DON reviewed the treatment record for Resident # 9 and acknowledged he had treatments missing, weekly skin checks by hall nurses had not been completed and orders had not been received for continuing the left trochanter treatment prior to expiration of the previous treatment. The DON stated not doing a treatment because the resident was out of bed was not an acceptable excuse, adding it could be done prior to rising or after returning to bed. Telephone calls and messages with a return number were left for the Treatment Nurse on [DATE] and [DATE]. No call back was received. Calls were placed to the resident's physician on [DATE] with no return call received.

Based on staff interviews, physician interviews, facility guideline review and record review the facility failed to notify the physician of noted new onset abdominal/rectal pain with associated constipation for 1 of 6 sampled residents (Resident #1). The facility failed to notify the physician of a sub-therapeutic (low) International Normalization Ratio (INR) level for 1 of 3 sampled residents (Resident #11) Immediate Jeopardy (IJ) began on [DATE] for resident #1. The immediate jeopardy was identified on [DATE] and was removed on [DATE] (for resident #1), when the facility demonstrated it had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that completion of staff in-services and incorporation of monitoring systems could be accomplished and included in the Quality Assurance Program. Findings include: Review of the facility "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents", dated [DATE], revealed, for abdominal pain, if the resident had abrupt onset of severe pain or distension, or vomiting and fever the physician should be notified within 1 hour. If the resident had moderate diffuse or localized pain, unrelieved by antacids or laxatives the physician should be notified within ,[DATE] hours, and no later than the next business day. If the resident had mild to moderate discomfort, without associated symptoms the physician could be notified at the next regular visit or phone conversation within one day to 72 hours. 1.Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated, unsigned "Pain Assessment" had the following handwritten in the "location" section, "No c/o (complaint) pain - on admission soreness R (right) hip." The "severity" section was not completed. Further review revealed the "pain type/intensity" , "other non-verbal", "quality of life/activities of daily living", "cause of pain", "relief of pain" and "conclusion" sections were not completed. Nurse #2 was interviewed on [DATE] at 3:30PM. Nurse #2 admitted the resident to the facility on [DATE]. She indicated the resident wasn't having a whole lot of pain in the first day. Then around the second or third day she would just scream when you touched her. The staff was not sure if maybe the resident did not want to go to therapy and that was the reason for her behavior. Therapy would come to work with the resident and she would just scream. The nurse stated she was responsible for the initial pain assessment and could not provide a reason for the incomplete pain assessment. Resident #1's physician orders [REDACTED]. The resident was also ordered [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5mg/325mg 1 tab every 4 hours as needed. Review of the nurse's notes, dated [DATE] through [DATE] revealed the resident had complaints of right hip pain and "pain." She was receiving as needed pain medication ([MEDICATION NAME]). Review of the resident's "Bowel Record" for ,[DATE] shift revealed she had no noted bowel movements on [DATE] and [DATE]. The resident had 2 medium soft bowel movements on dayshift of [DATE]. Review of the resident's "Bowel Record" for ,[DATE] shift revealed she had no noted bowel movements on [DATE]. The resident had one medium soft bowel movement on [DATE] and [DATE] during dayshift. Resident #1 received a [MEDICATION NAME] at 4:55AM on [DATE] for complaint "pain." There was no follow up to evaluate the effectiveness of the medication. The MAR indicated [REDACTED]. The effectiveness of the medication was not evaluated. The MAR indicated [REDACTED]. It was noted as being "effective." On [DATE] at 12:50PM the nurse's notes reflected the resident was complaining of hemorrhoids hurting. A verbal order was received from the physician assistant for "Annusal HC ([MEDICATION NAME] Cream) suppository 1 to 2 pr (per rectum) TID (three times daily) for [MEDICATION NAME] pain prn (as needed)." The resident received a [MEDICATION NAME] and [MEDICATION NAME] HC for "rectal" pain at 12PM. There was no evaluation on the effectiveness of either medication. Resident #1 had a small soft bowel movement on [DATE]. The MAR indicated rectal" pain at 4PM. There was no evaluation on the effectiveness of either medication. The nurse's note dated ,[DATE] at 6:50PM noted the resident had received an [MEDICATION NAME] HC suppository per rectum and [MEDICATION NAME] for [MEDICATION NAME] pain. There was no mention of whether or not there was stool present in the rectum when the [MEDICATION NAME] suppositories were inserted. No assessment of the hemorrhoids or the abdomen was noted. The MAR indicated pain across top buttock." A verbal order dated [DATE] at 11PM read in part, "[MEDICATION NAME] 30cc (cubic centimeter) po (by mouth) daily, [MEDICATION NAME] 1 po daily." On [DATE] at 6:15AM the nurse's note reflected the resident had been medicated with [MEDICATION NAME] HC per rectum (at 5:30AM) and [MEDICATION NAME] for complaint [MEDICATION NAME] pain (at 3:35AM). The physical therapy (PT) notes for [DATE] noted the resident stated she could not participate in therapy. The therapist noted the resident had "decreased motivation." The PT noted the resident had pain in her abdomen and right hip. Pain medications were given and the nurse was aware. Review of the MAR for [DATE] reflected the resident received a Fleets enema x 1. The enema was not documented on the "Nurse's Medication Notes" or in the nurse's notes. Review of the "Bowel Record" for [DATE] noted "0" for the amount of bowel movements on ,[DATE], ,[DATE], and ,[DATE] shifts. Review of the nurse's notes, dated [DATE] revealed no indication of physician notification regarding the in-effective enema. The PT notes for [DATE] revealed the resident said "I can't do it." (in regards to therapy) Resident #1 had pain in her right lower extremity and rectum pain. Pain medications were received and the nurse was aware. The resident had 1 medium hard bowel movement during dayshift on [DATE]. The nurse's note (done by nurse #2), dated [DATE] at 8:30PM revealed the resident would not attempt to walk and her appetite was poor. A moderate amount of soft stool was removed manually from the resident's rectum before inserting a [MEDICATION NAME] suppository. [MEDICATION NAME] 30 cc was given by mouth. The resident was taking a "fair" amount of liquids. Another nurse's note from [DATE] reflected at 9:30PM the resident was assisted to the toilet. The note read in part, "will not try to expel (push out) stool." States, "I can't get it to move." There was no indication of physician notification in regards to the resident's status. During an interview on [DATE] at 3:30PM nurse #2 indicated she believed she checked the resident's rectum once manually and did not feel any stool. Of course the resident was on a narcotic pain medication and that could be constipating. Review of the MAR indicated [REDACTED]. Both enemas were documented on the "Nurse's Medication Notes" as "not effective." There was no indication of physician notifcation in regards to the lack of effectiveness of the enemas. A nurse's note on [DATE] at 4PM revealed the resident received [MEDICATION NAME] HC per rectum at 9AM and 2PM with minimal pain relief voiced per resident. The nurse noted before inserting the suppositories she felt "gummy pasty like fecal matter" and she removed a "fistful amt (amount) of stool." On [DATE] at 10PM the nurse noted the resident remained in bed and "continues not helping herself." Her appetite was poor and she was given [MEDICATION NAME] for "discomfort." There was no evidence of physician notification. The "C.N.A. Flow Record" had a section for "Behaviors observed." It was noted on the ,[DATE] shift on [DATE] the resident had "Continuous yelling/screaming." No other behaviors were noted on the flow record. The "C.N.A. Flow Record" contained a narrative note dated [DATE] (no time) that read in part, "Resident having problems with having BM (bowel movement) the nurse gave her something. She didn't eat much." An interview was conducted on [DATE] 2:43PM with NA #2. The NA stated resident #1 complained about not being able to have a bowel movement and having pain (stomach) because she could not go to the bathroom. The nurse (#1) gave the resident an enema and a little bit of "mushy" stool came out. Another note dated [DATE] (11pm-7am) noted the resident had been removing stool from her rectum and had put it all over her bedding. The resident complained of pain in her rectum. The NA informed the nurse. During an interview, on [DATE] at 3:06PM, NA #4 indicated the resident was a very anxious about her care. The NA stated the resident was "always wanting laxatives" and trying to manually remove stool out of her rectum with her fingers. The nurse's were aware of the resident's behavior and it was something she did throughout her stay. The PT notes for [DATE] read in part, "I am hurting so bad (resident)." The resident complained of pain in her rectum. The nurse was aware and pain medications were received. Resident #1 had only 1 noted bowel movement on the ,[DATE] shift, a small soft one on [DATE]. Review of the resident's "Bowel Record" for ,[DATE] shift revealed she had no noted bowel movements on [DATE] and [DATE]. The nurse's note dated [DATE] at 6:45AM noted the resident had been requesting the bed pan most of the night. She had a medium brown stool and continued to insert her fingers into her rectum to try to remove stool. Resident #1 told PT she was sick on [DATE]. The daily PT note dated [DATE] revealed the resident had abdominal pain secondary to no bowel movement. A nurse's note for [DATE] at 12:30PM noted the resident was being sent to the emergency room for "altered mental status." The resident stated "I don't feel good." Her vital signs were; temperature 97.3 degrees Farenheit, pulse 69, respirations 12 and blood pressure was ,[DATE]. The MAR indicated [REDACTED]. She received one dose on [DATE]. From [DATE] to [DATE] the resident received 2 doses daily of the [MEDICATION NAME]. On [DATE] she had four doses of [MEDICATION NAME] ( 4AM, 12PM, 4PM, and 8pm). The resident had two doses daily of the [MEDICATION NAME] on [DATE] and [DATE]. She received three doses of the [MEDICATION NAME] on [DATE] (times not documented) and 2 doses on [DATE]. Resident #1 was receiving the [MEDICATION NAME] twice daily and the [MEDICATION NAME] twice daily. Record review of the hospital records dated, [DATE], noted the resident presented to the emergency department with complaint of abdominal pain, fatigue, poor oral intake, and [MEDICAL CONDITION]. The resident was given several enemas and manual disimpaction of stool on [DATE]. The facility and family member reported "Very poor oral intake for past ,[DATE] days." The abdominal exam noted the abdomen was "distended, diffusely tender with hypoactive BS (bowel sounds), rectal with gross heme + stool (positive for blood)." The CT (computed tomography) of the abdomen and pelvis, done on [DATE], read in part, "A rather marked amount of retained stool is noted in the rectum and rectosigmoid (colon) compatible with clinical [DIAGNOSES REDACTED]." Resident #1 expired on [DATE] at the hospital with final primary [DIAGNOSES REDACTED]. The rehabilitation interim manager was interviewed on [DATE] at 12:05PM. She indicated she had worked with resident #1. She remembered the resident did "pretty good" the first time she worked with her. Then she was off for a few days, a weekend she thinks, and when she came back the resident was "different." The resident was complaining of trouble with her stomach. The rehab interim manager remembered assisting the resident to the toilet with nursing because they thought that might help her move her bowels. The resident stated she just could not do it, she couldn't push. She indicated as the resident's stay progressed she was significantly different. It was not the whole stay but like ,[DATE] days towards the end. An interview was conducted on [DATE] at 12:15PM with nurse #1. The nurse had cared for resident #1 frequently (8 out of 10 days) during her stay. Nurse #1 indicated the resident came in for rehab; she had a right [MEDICAL CONDITION]. She did complain of pain. She had a PRN pain medication and nurse #1 gave the medication as ordered. Nurse #1 indicated some of the side effects of a narcotic pain medication were constipation, lethargy and drowsiness. The nurse stated she did not have any conversations with the physician in regards to the pain med and possible/potential connection to the resident's constipation and abdominal pain. She noted the facility had a BM protocol. The protocol was like a standing order and the nurses would follow the protocol. The nurse would not contact the physician until they had gone all the way thru the protocol and had no results (bowel movements), but that hardly ever happened. Nurse #1 stated she last assessed the resident's abdomen on [DATE] and it was "soft, wasn't really hard" and her bowel sounds were hyperactive. During an interview on [DATE] at 2:37PM, NA #1 indicated she took care of the resident during her stay. The NA stated the resident was "total care" meaning the staff had to assist her with her activities of daily living. The resident did complain that she could not have a bowel movement. NA #1 reported the resident's concern to the nurse (#1). The NA indicated nurse #1 gave the resident an enema, but she could not recall the exact date. She stated the resident just had "a little watery type" of results from the enema. The resident did not express any relief from receiving the enema. The last time the NA worked with the resident was [DATE]. The resident kept putting on the call light because she could not move her bowels. An interview was conducted on [DATE] at 4:33PM with the DON, the administrator and facility consultant #1. The DON indicated when she assessed the resident on [DATE] she was in no apparent distress. The DON did not document the assessment in the resident's medical record. Facility consultant #1 stated the staff would not be expected to phone the physician until the bowel protocol was completely done. The reason they had the protocol was so the staff would not have to call the doctor. However, if the resident had severe abdominal pain then she would expect the nurse to phone the physician. During an interview on [DATE] at 5:45PM physician #1 (medical director) stated if the facility was having trouble contacting an attending physician then they could always contact him. He would then call the doctor himself. He stated it was a small community and he knew most of the physicians in the immediate area. If the facility had an acute issue/concern then he (as the medical director) would handle it immediately then get in touch with the attending physician. Physician #2 was interviewed on [DATE] at 11:28AM. Physician #2 was at the hospital during the time of the interview and referenced the resident's hospital records prior to her coming to the facility. He indicated she had a [MEDICAL CONDITION]. Physician #2 stated some residents might have been on pain medications all their lives. Sometimes a PRN pain medication becomes a routine medication. The physician indicated he expected the staff would call him or his PA if a resident was utilizing their PRN medication on a routine basis and they would do an evaluation. The physician and/or his PA would try to determine if the medication was effective at relieving the resident's pain. Physician #2 expected if a resident did not have a bowel movement after ,[DATE] days the staff would call and inform him or the PA. He does not remember receiving a call or a fax regarding this resident and her being constipated or having increased pain or a change in the location of her pain. During an interview on [DATE] at 11:43AM, physician's assistant (PA) #1 indicated if the staff did get in touch with him in regards to resident #1 (and orders for [MEDICATION NAME]/[MEDICATION NAME]) it was probably via fax. He stated he really could not recall/remember anything off hand about the resident. A follow up interview was conducted with physician #2 on [DATE] at 10AM. Physician #2 indicated if a resident developed a new problem such as rash, fever, cough, or pain "of course" the physician would want to be notified. He also emphasized when a resident was new to the facility and the physician group did not know them well, they would want them sent to the emergency room for things new onset abdominal pain. If the physician had seen the resident then he would be able to give orders to treat at the facility if able. Physician #2 stated the facility staff should keep trying until they reached either him or the PA. He indicated the evidence of the facility contacting him or the PA would be a fax with a date, signature and instructions on it or if they called him a verbal order with instructions. Physician #2 stated three of the biggest concerns he saw were pain, constipation and dehydration. He indicated constipation was a problem especially with narcotic pain medication administration. The administrator was notified of the I.J. on [DATE] at 12:10PM. The facility provided an acceptable credible allegation of compliance on [DATE] at 12:08PM. The following interventions were put in place: Resident Specific Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her medications included [MEDICATION NAME], Mirtazepine, [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. She received [MEDICATION NAME] for right hip pain once on ,[DATE], twice on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. She received [MEDICATION NAME] three times on [DATE]. She also experienced hemorrhoid pain on [DATE] and an order was received for Annusol suppositories three times per day as needed. Resident received [MEDICATION NAME] 100mg two times per day since admission. On [DATE], [MEDICATION NAME] 30cc daily was added to her medication regimen for constipation. On [DATE], [MEDICATION NAME] was added one tablet daily for constipation. Resident received Fleets enemas on [DATE] (one) and [DATE] (two). On [DATE], both the resident and her brother requested she be sent to the emergency room for evaluation. She stated, "I don't feel good." Attending physician was notified and order received for resident to be transported to the emergency room . Vital signs were: temperature 97.3, pulse 69, respirations 12, and blood pressure ,[DATE]. Resident had documented bowel movements as follows: [DATE]-two soft, medium bowel movements [DATE]-one soft, medium bowel movement [DATE]-one soft, medium bowel movement [DATE]-one soft, small bowel movement [DATE]-[MEDICATION NAME] one tablet daily was added for constipation; one Fleet's enema [DATE]-one hard, medium bowel movement [DATE]-one soft, small bowel movement [DATE]-two Fleets enemas given with no results documented Resident passed away in the hospital on [DATE]. All Other Residents 1. (A) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) performed pain assessments on all residents in house to identify residents with pain. (B) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) performed bowel record review for residents of the facility to also include the look back period to the last documented bowel movement to identify residents with no bowel movement in three days. 2. (A) The resident's primary licensed nurse will be responsible for physician notification via telephone when a residents with a score of 3 or higher on a scale of 1(mild)-10 (continuous/severe) on the pain assessment form, with new orders implemented and care planned by MDSC and or primary licensed nurse, at the time of pain onset. The IDT (Interdisiplinary Team) will validate this process at least 5 times weekly in Clinical Morning Review. Responsible Party(s) will be notified of new medications or change in dosage of current medication as needed. (B) Bowel Protocol was initiated by the Nurse Management Team, consisting of the Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) for residents noted with no bowel movement in three days. Bowel Protocol states: ? On third day with no documented bowel movement give [MEDICATION NAME] 30 cc po (by mouth) or via tube ([MEDICAL CONDITION] or peg) prn (as needed) ? On fourth day with no documented bowel movement and no results from [MEDICATION NAME] give [MEDICATION NAME] supp (suppository) pr (per rectum) prn (as needed) ? On fifth day with no documented bowel movement and no results from [MEDICATION NAME] or [MEDICATION NAME] give Fleets Enema pr (per rectum) prn (as needed) ? Notify attending physician if no results within 30 minutes of Fleets enema administration. 1. (A) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) implemented, evaluated and / or updated resident care plans to reflect pain as needed concerning all residents in the facility. Careplans are made accessible through the resident's medical record for the licensed nurses and the nursing assistant will obtain any careplan updates in shift report from the licensed nurse on an as needed basis on-going. Pain care plan is inclusive of: ? Pain type, chronic, acute, breakthrough, phantom ? Pain symptoms: crying / moaning, facial grimace, guarding, complaints of pain, decrease in functional level, inability to sleep, limiting activities, not eating ? Licensed Nursing Staff monitoring residents for pain each shift. Attending physicians when signs and symptoms of pain, worsening pain, reporting changes in pain location / type / frequency / intensity of pain to physician ? Providing non-pharmacological comfort measures including relaxation techniques, deep breathing, repositioning, activities as appropriate ? Monitoring for side effects including Licensed Nurses to monitor for signs and symptoms of constipation, Licensed Nurses and Certified Nursing Assistants monitoring and documenting bowel movements ? Administering and monitoring for effectiveness and for possible side effects from pain medication ? Pain Assessment to be completed on admission, quarterly and with significant change in status ? Education with resident and family members as needed about comfort measures, [MEDICATION NAME] medications, fear and concerns regarding pain ? Certified Nursing Assistants will verbally notify licensed nurse if resident has no bowel movement in three days ? Certified Nursing Assistants will document notification on bowel record and licensed nurses will review the bowel record flow book the beginning of each shift. ? Licensed Nurses administering stool softeners and laxatives per MD orders ? Licensed Nurses encouraging fluid and fiber ? Certified Nursing Assistant encouraging resident to follow prescribed diet (B) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) implemented, evaluated and / or updated resident care plans related to constipation as needed. Constipation care plan is inclusive of: ? Certified Nursing Assistants monitoring and documenting bowel movements every shift ? Certified Nursing Assistants will verbally notify licensed nurse if resident has no bowel movement in three days ? Certified Nursing Assistants will document notification on bowel record and licensed nurses will review the bowel record flow book the beginning of each shift. ? Licensed Nurses administering stool softeners and laxatives per MD orders ? Licensed Nurses encouraging fluid and fiber as appropriate ? Certified Nursing Assistant encouraging resident to follow prescribed diet ? Notification of Registered Dietician for evaluation of diet and fluid intake / offerings, resident likes and dislikes, and recommendations for food and /or fluids to promote regular bowel elimination 1. Education was initiated by: a) Staff Development Coordinator inserviced current licensed nursing staff on [DATE] and will repeat in-service on-going for newly hired licensed nurses during orientation, licensed nurses returning from vacation and leave of absence with regard to pain policy to include: ? Assessment of resident pain including location, duration, frequency, time of day pain generally occurs, feeling of pain (internal, external, acute, chronic), severity of pain verbal pain scale (if resident able to respond) and non-verbal pain scale, pain type / intensity, other non-verbal cues (facial expressions, vocalizations, body actions / observed behaviors), pain affecting resident's quality of life / activities of daily living, cause of pain, relief of pain ? Initiation of pain care plan as needed ? Implementation of pain care plan ? Monitoring frequency of use of [MEDICATION NAME] medication ? Notifying the attending MD of pain requiring prn (as needed) medication for greater than three consecutive days ? Notifying the attending MD of unrelieved pain of 3 or higher on a scale of 1(mild)-10 (continuous/severe) on the pain assessment form ? Initiation and implementation of constipation care plan a) Staff Development Coordinator inserviced current Certified Nursing Assistants on [DATE] and will repeat in-service on-going for newly hired Certified Nursing Assistants during orientation, Certified Nursing Assistants returning from vacation and leave of absence with regard to: ? Pain policy to include reporting to Licensed Nurse when resident experiences pain ? Implementation of pain care plan including Certified Nursing Assistants monitoring frequency and amount of bowel movement and documenting accordingly ? Certified Nursing Assistants notifying licensed nurse if resident has no bowel movement in three days ? Certified Nursing Assistants will document notification on bowel record and licensed nurses will review the bowel record flow book the beginning of each shift ? Certified Nursing Assistants encouraging resident to follow prescribed diet. Systemic Changes: 1. Pain assessments will be completed by the licensed nurse for all newly admitted residents, all readmitted residents, residents admitted for rehabilitation therapy, and residents admitted with pain medications on admission and daily for three days following admission to ensure residents experiencing pain are identified. Pain assessments will also be initiated with the onset of new pain by the licensed nurse caring for the resident at the time the pain is identified. Pain assessments will be performed quarterly and with significant change resulting in pain. 2. Pain monitoring added to the Medication Administration Records for all residents. Residents will be assessed for pain each shift by the licensed nurse and care planned interventions implemented as needed. If pain medication is indicated and the resident has no order for pain medication, the licensed nurse will notify the physician of the new onset of pain and request pain medication. If the resident is experiencing pain at a level 3 with no relief with current plan of care, the assessing nurse will notify the physician for a pain medication order or adjustment of current pain medication dosage as indicated. The nurse initiating the physician notification will document the resident ' s pain and pending physician notification on the 24 hour report log. The resident will remain on the 24 hour report book until physician has responded. 3. Care plans will be initiated for all residents with pain. The care plan will include medication interventions as well as non-pharmacological interventions to be attempted prior to medication. Care plans will be revised and evaluated quarterly and with change of condition. 4. Nursing assistants will document bowel movements on bowel monitoring flow sheet. At the end of each shift, the nursing assistants will report off to their supervising licensed nurse for validation the flow book documentation has been completed. Licensed nurses working 7a-3p will review the bowel monitoring flow books and identify residents with no bowel movement in 3 days. These residents will be added to the laxative list for a laxative to be administered on the 3p-11p shift. The laxative list will be passed on to the 11p-7a shift for laxative results to be documented. If results are not achieved within thirty minutes after Fleets enema is administered per bowel protocol, the attending physician or physician on call will be notified for further orders. Once the bowel protocol is implemented, the 24 hour report log will be updated to indicate the bowel protocol has been initiated. The resident will remain on the 24 hour report until the constipation is relieved. 5. Interim Director of Nursing Services (I-DNS), or SDC will review laxative lists daily ongoing to validate laxatives were administered as appropriate and results documented. In the absence of the Interim Director of Nursing Services (DNS) and SDC, the ,[DATE] West Hall Licensed Nurse will review laxative lists daily ongoing to validate laxatives were administered as appropriate and results documented. Completion date of credible allegation is [DATE]. Quality Assurance: The Interim Director of Nursing Services (I-DNS) or SDC will review medical records of newly admitted or readmitted residents daily for three days following admission to validate pain assessments are accurately completed, care plans for pain are implemented as necessary, and residents experiencing pain have pain medication prescribed either PRN or scheduled. These reviews will continue on an ongoing basis. Interim Director of Nursing Services (I-DNS), or SDC will review 24 hour report book daily ongoing to identify residents with new onset of pain. These residents ' medical records will be reviewed as well to validate pain assessments are accurately completed, care plans for pain are implemented as necessary, and the physician was notified for pain medication order as needed. Interim Director of Nursing Services (I-DNS), or SDC will audit laxative lists each morning and validate laxatives were given as indicated and results were documented. In the absence of the Interim Director of Nursing Services (I-DNS) and SDC on the weekends and holidays, the ,[DATE] North Hall Licensed Nurse will review laxative lists daily ongoing to validate laxatives were administered as appropriate and results documented. Results of these audits and medical record reviews will be reported to the facility ' s Performance Improvement Committee monthly x 6 months for review, evaluation and further recommendation. Verification of the credible allegation was evidenced by interviews of direct care staff relating to training and in-services received regarding pain assessment, bowel management and physician notification. All direct care staff interviewed on [DATE] were knowledgeable about the facility's bowel protocol, how resident changes are to be communicated and reported (to each other and the physician). The monitoring tools included a skills validation form which included pain management and the bowel protocol and a form to document audits and corrective measures taken when negative findings are noted during facility audits. 2. Resident #11 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].

Based on staff interviews, family interviews, physician interviews and record review the facility failed to assess new onset abdominal pain with associated constipation and failed to assess the resident's pain management program for 1 of 4 sampled residents (Resident #1) resulting in hospitalization . Furthermore, the facility failed to monitor the bowel movements and implement their bowel protocol as written to prevent constipation for 1 of 4 sampled residents (Residents #8). The facility failed to assess and recognize the relationship between a new onset of behaviors and clinical change in condition for 1 of 1 sampled resident (resident #3). Immediate Jeopardy (IJ) began on [DATE]* for resident #1. The immediate jeopardy for resident #1 was identified on [DATE] and was removed on [DATE], when the facility demonstrated it had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that completion of staff in-services and incorporation of monitoring systems could be accomplished and included in the Quality Assurance Program. Findings include: The facility "Bowel Protocol" dated ,[DATE] read in part, "1. [MEDICATION NAME] 30cc (cubic centimeters) on 3rd day with no BM (bowel movement). 2. [MEDICATION NAME] Suppository PR (per rectum) on 4th day with no BM and no results from Milk of Magnesia. 3. Fleets enema PR on 5th day with no BM and no results from Milk of Magnesia or [MEDICATION NAME] Suppository." 1.Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated, unsigned "Pain Assessment" had the following handwritten in the "location" section, "No c/o (complaint) pain - on admission soreness R (right) hip." The "severity" section was not completed. Further review revealed the "pain type/intensity" , "other non-verbal", "quality of life/activities of daily living", "cause of pain", "relief of pain" and "conclusion" sections were not completed. Nurse #2 was interviewed on [DATE] at 3:30PM. Nurse #2 admitted the resident to the facility on [DATE]. She indicated the resident wasn't having a whole lot of pain in the first day. Then around the second or third day she would just scream when you touched her. The staff was not sure if maybe the resident did not want to go to therapy and that was the reason for her behavior. Therapy would come to work with the resident and she would just scream. The nurse stated she was responsible for the initial pain assessment and could not provide a reason for the incomplete pain assessment. Review of the undated care plans found no plan of care for pain or potential side effects from narcotic pain medication (constipation). Review of her hospital records prior to her admission to the facility found no noted issues with constipation. Resident #1's physician orders [REDACTED]. The resident was also ordered [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5mg/325mg 1 tab every 4 hours as needed. Lexi-Comp's Geriatric Dosage Handbook, 15th edition, revealed [MEDICATION NAME] was an Opioid narcotic for treatment of [REDACTED]. The section "Special Geriatric Considerations" it was noted the elderly might be particularly susceptible to the CNS (central nervous system) depressant action (sedation, confusion) and the constipating effects of narcotics. [MEDICATION NAME] was used to prevent iron-deficiency [MEDICAL CONDITION]. Under the "Adverse Reactions - Gastrointestinal" section the following were noted, constipation, dark stools, [MEDICAL CONDITION] pain, GI irritation, nausea and stomach cramping, Review of the nurse's notes, dated [DATE], revealed at 3PM the resident was "alert and oriented." Her abdomen was soft with bowel sounds in all four quadrants. Later on [DATE] at 9:30PM the resident requested a [MEDICATION NAME] for pain in her right hip. The effectiveness of the pain medication was not evaluated. Review of the resident's "Bowel Record" for ,[DATE] shift revealed she had no noted bowel movements on [DATE] and [DATE]. On [DATE] at 6AM it was noted the resident was awake, alert and voiced no complaints. A note on the same day at 4:20PM noted the resident had requested a [MEDICATION NAME] with "effective" results. The nurse's note at 10PM that day revealed the resident rested in bed and was able to make her needs known. She requested a [MEDICATION NAME] at bedtime for right hip discomfort. The effectiveness of the pain medication was not evaluated. The resident had 2 medium soft bowel movements on dayshift of [DATE]. Resident #1 received a dose of [MEDICATION NAME] on [DATE] during the dayshift. The reason for the dose, the time of the dose, and the effectiveness of the medication were not noted. A nurse's note dated [DATE] at 10PM noted the resident remained, alert, able to make needs known, pleasant and cooperative. She requested a [MEDICATION NAME] at bedtime. The effectiveness of the pain medication was not evaluated. The reason for the medication was not noted. The nurse's notes, dated [DATE] revealed no concerns with pain or discomfort. However, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. One was on dayshift at an unknown time for an unknown reason. The effectiveness was not evaluated. At 8:30PM resident #1 was medicated with [MEDICATION NAME] for right hip pain. The effectiveness was not evaluated. Review of the resident's "Bowel Record" for ,[DATE] shift revealed she had no noted bowel movements on [DATE]. A nurse's note dated [DATE] at 4PM reflected a family member informed the staff the resident was "hurting" and could not tolerate sitting in her wheelchair. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The dose and time were not noted on the back of the MAR. The effectiveness was not evaluated. The MAR indicated [REDACTED]. The effectiveness of the medication was not evaluated. The resident had one medium soft bowel movement on [DATE] and [DATE] during dayshift. Resident #1 received a [MEDICATION NAME] at 4:55AM on [DATE] for complaint "pain." There was no follow up to evaluate the effectiveness of the medication. On [DATE] at 1:30PM the resident was alert and responsive, with no distress noted, per the nurse's note. The MAR indicated [REDACTED]. The effectiveness of the medication was not evaluated. The MAR indicated [REDACTED]. It was noted as being "effective." On [DATE] at 12:50PM the nurse's notes reflected the resident was complaining of hemorrhoids hurting. A verbal order was received from the physician assistant for "[MEDICATION NAME] HC ([MEDICATION NAME] Cream) suppository 1 to 2 pr (per rectum) TID (three times daily) for [MEDICATION NAME] pain prn (as needed)." The resident received a [MEDICATION NAME] and [MEDICATION NAME] HC for "rectal" pain at 12PM. There was no evaluation on the effectiveness of either medication. Resident #1 had a small soft bowel movement on [DATE]. The MAR indicated rectal" pain at 4PM. There was no evaluation on the effectiveness of either medication. The nurse's note dated ,[DATE] at 6:50PM noted the resident had received an [MEDICATION NAME] HC suppository per rectum and [MEDICATION NAME] for [MEDICATION NAME] pain. There was no mention of whether or not there was stool present in the rectum when the [MEDICATION NAME] suppositories were inserted. No assessment of the hemorrhoids or the abdomen was noted. The MAR indicated pain across top buttock." The effectiveness of the medication was not evaluated. A verbal order dated [DATE] at 11PM read in part, "[MEDICATION NAME] 30cc (cubic centimeter) po (by mouth) daily, [MEDICATION NAME] 1 po daily." The five day medicare minimum data set ((MDS) dated [DATE] revealed the resident was moderately impaired cognitively. She required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. She was continent of bowel and bladder. Resident #1 was noted to have frequent pain in the five days prior to the MDS. The pain was noted to have limited her day to day activities. The numeric rating the resident gave was "7" on a scale of ,[DATE] with 10 being the worst pain you can imagine. The pain was noted as "moderate." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 6:15AM the nurse's note reflected the resident had been medicated with [MEDICATION NAME] HC per rectum (at 5:30AM) and [MEDICATION NAME] for complaint [MEDICATION NAME] pain (at 3:35AM). The effectiveness of the medication was not evaluated. The physical therapy (PT) notes for [DATE] noted the resident stated she could not participate in therapy. The therapist noted the resident had "decreased motivation." The PT noted the resident had pain in her abdomen and right hip. Pain medications were given and the nurse was aware. The 10PM nurse's note from [DATE] revealed the resident rested in bed and was medicated with [MEDICATION NAME] for right hip pain (at 8PM).The effectiveness was not evaluated. Review of the MAR for [DATE] reflected the resident received a Fleets enema x 1. The enema was not documented on the "Nurse's Medication Notes" or in the nurse's notes. Review of the "Bowel Record" for [DATE] noted "0" for the amount of bowel movements on ,[DATE], ,[DATE], and ,[DATE] shifts. The PT notes for [DATE] revealed the resident said "I can't do it." (in regards to therapy) Resident #1 had pain in her right lower extremity and rectum pain. Pain medications were received and the nurse was aware. The resident had 1 medium hard bowel movement during dayshift on [DATE]. The nurse's note (done by nurse #2), dated [DATE] at 8:30PM revealed the resident would not attempt to walk and her appetite was poor. A moderate amount of soft stool was removed manually from the resident's rectum before inserting a [MEDICATION NAME] suppository. [MEDICATION NAME] 30 cc was given by mouth. The resident was taking a "fair" amount of liquids. Another nurse's note from [DATE] reflected at 9:30PM the resident was assisted to the toilet. The note read in part, "will not try to expel (push out) stool." States, "I can't get it to move." During an interview on [DATE] at 3:30PM nurse #2 indicated she believed she checked the resident's rectum once manually and did not feel any stool. Of course the resident was on a narcotic pain medication and that could be constipating. Review of the MAR indicated [REDACTED]. Both enemas were documented on the "Nurse's Medication Notes" as "not effective." A nurse's note on [DATE] at 4PM revealed the resident received [MEDICATION NAME] HC per rectum at 9AM and 2PM with minimal pain relief voiced per resident. The nurse noted before inserting the suppositories she felt "gummy pasty like fecal matter" and she removed a "fistful amt (amount) of stool." The resident continued to refuse to ambulate with PT. She was encouraged to drink water. On [DATE] at 10PM the nurse noted the resident remained in bed and "continues not helping herself." Her appetite was poor and she was given [MEDICATION NAME] for "discomfort." There was no follow up to evaluate the effectiveness of the pain medication. The "C.N.A. Flow Record" had a section for "Behaviors observed." It was noted on the ,[DATE] shift on [DATE] the resident had "Continuous yelling/screaming." No other behaviors were noted on the flow record. The "C.N.A. Flow Record" contained a narrative note dated [DATE] (no time) that read in part, "Resident having problems with having BM (bowel movement) the nurse gave her something. She didn't eat much." An interview was conducted on [DATE] 2:43PM with NA #2. The NA stated resident #1 complained about not being able to have a bowel movement and having pain because she could not go to the bathroom. The nurse (#1) gave the resident an enema and a little bit of "mushy" stool came out. Another note dated [DATE] (11pm-7am) noted the resident had been removing stool from her rectum and had put it all over her bedding. The resident complained of pain in her rectum. The NA informed the nurse. During an interview, on [DATE] at 3:06PM, NA #4 indicated the resident was a very anxious about her care. The NA stated the resident was "always wanting laxatives" and trying to manually remove stool out of her rectum with her fingers. The nurse's were aware of the resident's behavior and it was something she did throughout her stay. The PT notes for [DATE] read in part, "I am hurting so bad (resident)." The resident complained of pain in her rectum. The nurse was aware and pain medications were received. Resident #1 had only 1 noted bowel movement on the ,[DATE] shift, a small soft one on [DATE]. Review of the resident's "Bowel Record" for ,[DATE] shift revealed she had no noted bowel movements on [DATE] and [DATE]. The nurse's note dated [DATE] at 6:45AM noted the resident had been requesting the bed pan most of the night. She had a medium brown stool and continued to insert her fingers into her rectum to try to remove stool. Resident #1 told PT she was sick on [DATE]. The daily PT note dated [DATE] revealed the resident had abdominal pain secondary to no bowel movement. A nurse's note for [DATE] at 12:30PM noted the resident was being sent to the emergency room for "altered mental status." The resident stated "I don't feel good." Her vital signs were; temperature 97.3 degrees Fahrenheit, pulse 69, respirations 12 and blood pressure was ,[DATE]. The MAR indicated [REDACTED]. She received one dose on [DATE]. From [DATE] to [DATE] the resident received 2 doses daily of the [MEDICATION NAME]. On [DATE] she had four doses of [MEDICATION NAME] ( 4AM, 12PM, 4PM, and 8pm). The resident had two doses daily of the [MEDICATION NAME] on [DATE] and [DATE]. She received three doses of the [MEDICATION NAME] on [DATE] (times not documented) and 2 doses on [DATE]. Resident #1 was receiving the [MEDICATION NAME] twice daily and the [MEDICATION NAME] twice daily. Resident #1 had no noted bowel movements on the ,[DATE] shift from [DATE] to [DATE]. Record review of the hospital records dated, [DATE], noted the resident presented to the emergency department with complaint of abdominal pain, fatigue, poor oral intake, and [MEDICAL CONDITION]. The resident was given several enemas and manual disimpaction of stool on [DATE]. The facility and family member reported "Very poor oral intake for past ,[DATE] days." The abdominal exam noted the abdomen was "distended, diffusely tender with hypoactive BS (bowel sounds), rectal with gross heme + stool (positive for blood)." The CT (computed tomography) of the abdomen and pelvis, done on [DATE], read in part, "A rather marked amount of retained stool is noted in the rectum and rectosigmoid (colon) compatible with clinical [DIAGNOSES REDACTED]." Resident #1 expired on [DATE] at the hospital with final primary [DIAGNOSES REDACTED]. During an interview, on [DATE] at 10:26AM, the Director of Nursing (DON) indicated she had assessed resident #1 either the day she went out to the hospital or the day before, she was not quite sure. She stated the resident's abdomen was slightly distended but soft. She indicated she did hear bowel sounds. The primary nurse informed the DON the resident was having issues with constipation. The primary care nurse had informed the DON that an enema had been given. The resident expressed to the DON she felt she had to go to the bathroom. The DON stated the pain assessment form should be completed in its entirety on admission. She reviewed the form completed for the resident and indicated once the resident started using pain medicine on a routine basis someone should have completed a new pain assessment form. The DON indicated a side effect of taking narcotic pain medication was constipation. An interview was conducted on [DATE] at 12:15PM with nurse #1. The nurse had cared for resident #1 frequently (8 out of 10 days) during her stay. Nurse #1 indicated the resident came in for rehab; she had a right [MEDICAL CONDITION]. She did complain of pain. She had a PRN pain medication and nurse #1 gave the medication as ordered. The nurse was not sure why the pain assessment form was not completely filled out on admission. She did not do the assessment. The nurse indicated she was not sure if she was allowed to go back and complete the pain assessment or start a new one once she determined the resident had pain on a daily basis. The nurse stated some residents have a pain scale chart on their MARs and some do not (this resident did not). She was not sure what determined who got the pain scale and who did not. It just came that way from the pharmacy. She stated an RN (registered nurse) had to complete/initiate the care plan. Nurse #1 indicated some of the side effects of a narcotic pain medication were constipation, lethargy and drowsiness. The nurse stated she did not have any conversations with the physician in regards to the pain med and possible/potential connection to the resident's constipation and abdominal pain. She noted the facility had a BM protocol. The protocol was like a standing order and the nurses would follow the protocol. The nurse would not contact the physician until they had gone all the way through the protocol and had no results (bowel movements), but that hardly ever happened. Nurse #1 stated she last assessed the resident's abdomen on [DATE] and it was "soft, wasn't really hard" and her bowel sounds were hyperactive. The nurse was trying to encourage water intake. She pointed to a clear cup and indicated she would fill it to the 8 ounce line and offer the resident two 8 ounce cups of water during her shift. During an interview on [DATE] at 2:37PM, NA #1 indicated she took care of the resident during her stay. The NA stated the resident was "total care" meaning the staff had to assist her with her activities of daily living. The resident did complain that she could not have a bowel movement. NA #1 reported the resident's concern to the nurse (#1). The NA indicated nurse #1 gave the resident an enema, but she could not recall the exact date. She stated the resident just had "a little watery type" of results from the enema. The resident did not express any relief from receiving the enema. The last time the NA worked with the resident was [DATE]. The resident kept putting on the call light because she could not move her bowels. An interview was conducted on [DATE] at 4:33PM with the DON, the administrator and facility consultant #1. The DON indicated when she assessed the resident on [DATE] she was in no apparent distress. The DON did not document the assessment in the resident's medical record. The DON did not recall discussing resident #1's pain or constipation during daily rounds. Facility consultant #1 stated the staff would not be expected to phone the physician until the bowel protocol was completely done. The reason they had the protocol was so the staff would not have to call the doctor. However, if the resident had severe abdominal pain then she would expect the nurse to phone the physician. During an interview on [DATE] at 5:40PM, nurse #1 indicated she gave the resident the enemas because she was "at that step" on the bowel protocol. The nurse stated she did assess the resident's abdomen each time she gave the enemas she just forgot to chart it. Each time resident #1's stomach was soft and flat with good bowel sounds. She did check the resident's hemorrhoids and did not notice any bleeding. She stated she did not correlate the hemorrhoids and the constipation. Resident #1's decreased appetite had not been reported to her. The nurse stated the ward clerk was responsible for reviewing the BM books. Nurse #1 indicated she did not look at the BM books. Usually the NAs would come and inform her if a resident had not moved their bowels in a couple of days. During an interview on [DATE] at 8:30AM, ward clerk #1 indicated she would review the BM (bowel movement) books. She would give a copy of the BM sheets to the (former) DON and she would write on a sticky note who had not had a bowel movement in 3 days. She would then give the sticky notes to the hall nurses responsible for the residents. Once the (former) DON and nurse's got the list of the resident's needing laxatives they were supposed to document on the BM sheets who received a laxative. Ward clerk #1 was not informed she needed to do any type of follow up. She indicated she did not keep any copies of the sticky notes she gave to the nursing staff. The interim DON was interviewed on [DATE] at 9:15AM. She stated the NA were supposed to be keeping tract of the bowel movements a resident had and the nurses should be looking at the BM book. The interim DON's goal would be for the NAs to improve their communication with the nurse's and for the nurse's to follow up on concerns brought forth by the NAs in regards to the residents. Physician #2 was interviewed on [DATE] at 11:28AM. Physician #2 was at the hospital during the time of the interview and referenced the resident's hospital records prior to her coming to the facility. He indicated she had a [MEDICAL CONDITION]. Physician #2 stated some residents might have been on pain medications all their lives. Sometimes a PRN pain medication becomes a routine medication. The physician indicated he expected the staff would call him or his PA if a resident was utilizing their PRN medication on a routine basis and they would do an evaluation. The physician and/or his PA would try to determine if the medication was effective at relieving the resident's pain. Physician #2 expected if a resident did not have a bowel movement after ,[DATE] days the staff would call and inform him or the PA. He does not remember receiving a call or a fax regarding this resident and her being constipated or having increased pain or a change in the location of her pain. During an interview on [DATE] at 11:43AM, physician's assistant (PA) #1 indicated if the staff did get in touch with him in regards to resident #1 (and orders for [MEDICATION NAME]/[MEDICATION NAME]) it was probably via fax. He stated he really could not recall/remember anything off hand about the resident. A follow up interview was conducted with physician #2 on [DATE] at 10AM. Physician #2 indicated if a resident developed a new problem such as rash, fever, cough, or pain "of course" the physician would want to be notified. He also emphasized when a resident was new to the facility and the physician group did not know them well, they would want them sent to the emergency room for things new onset abdominal pain. If the physician had seen the resident then he would be able to give orders to treat at the facility if able. Physician #2 stated the facility staff should keep trying until they reached either him or the PA. He indicated the evidence of the facility contacting him or the PA would be a fax with a date, signature and instructions on it or if they called him a verbal order with instructions. Physician #2 stated three of the biggest concerns he saw were pain, constipation and dehydration. He indicated constipation was a problem especially with narcotic pain medication administration. The administrator was notified of the I.J. on [DATE] at 12:10PM. The facility provided an acceptable credible allegation of compliance on [DATE] at 12:08PM. The following interventions were put in place: Resident Specific Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her medications included [MEDICATION NAME], Mirtazepine, [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. She received [MEDICATION NAME] for right hip pain once on ,[DATE], twice on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. She received [MEDICATION NAME] three times on [DATE]. She also experienced hemorrhoid pain on [DATE] and an order was received for [MEDICATION NAME] suppositories three times per day as needed. Resident received [MEDICATION NAME] 100mg two times per day since admission. On [DATE], [MEDICATION NAME] 30cc daily was added to her medication regimen for constipation. On [DATE], [MEDICATION NAME] was added one tablet daily for constipation. Resident received Fleets enemas on [DATE] (one) and [DATE] (two). On [DATE], both the resident and her brother requested she be sent to the emergency room for evaluation. She stated, "I don't feel good." Attending physician was notified and order received for resident to be transported to the emergency room . Vital signs were: temperature 97.3, pulse 69, respirations 12, and blood pressure ,[DATE]. Resident had documented bowel movements as follows: [DATE]-two soft, medium bowel movements [DATE]-one soft, medium bowel movement [DATE]-one soft, medium bowel movement [DATE]-one soft, small bowel movement [DATE]-[MEDICATION NAME] one tablet daily was added for constipation; one Fleet's enema [DATE]-one hard, medium bowel movement [DATE]-one soft, small bowel movement [DATE]-two Fleets enemas given with no results documented Resident passed away in the hospital on [DATE]. All Other Residents 1. (A) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) performed pain assessments on all residents in house to identify residents with pain. (B) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) performed bowel record review for residents of the facility to also include the look back period to the last documented bowel movement to identify residents with no bowel movement in three days. 2. (A) The resident's primary licensed nurse will be responsible for physician notification via telephone when a residents with a score of 3 or higher on a scale of 1(mild)-10 (continuous/severe) on the pain assessment form, with new orders implemented and care planned by MDSC and or primary licensed nurse, at the time of pain onset. The IDT (Interdisciplinary Team) will validate this process at least 5 times weekly in Clinical Morning Review. Responsible Party(s) will be notified of new medications or change in dosage of current medication as needed. (B) Bowel Protocol was initiated by the Nurse Management Team, consisting of the Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) for residents noted with no bowel movement in three days. Bowel Protocol states: ? On third day with no documented bowel movement give [MEDICATION NAME] 30 cc po (by mouth) or via tube ([MEDICAL CONDITION] or peg) prn (as needed) ? On fourth day with no documented bowel movement and no results from [MEDICATION NAME] give [MEDICATION NAME] supp (suppository) pr (per rectum) prn (as needed) ? On fifth day with no documented bowel movement and no results from [MEDICATION NAME] or [MEDICATION NAME] give Fleets Enema pr (per rectum) prn (as needed) ? Notify attending physician if no results within 30 minutes of Fleets enema administration. 1. (A) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) implemented, evaluated and / or updated resident care plans to reflect pain as needed concerning all residents in the facility. Careplans are made accessible through the resident's medical record for the licensed nurses and the nursing assistant will obtain any careplan updates in shift report from the licensed nurse on an as needed basis on-going. Pain care plan is inclusive of: ? Pain type, chronic, acute, breakthrough, phantom ? Pain symptoms: crying / moaning, facial grimace, guarding, complaints of pain, decrease in functional level, inability to sleep, limiting activities, not eating ? Licensed Nursing Staff monitoring residents for pain each shift. Attending physicians when signs and symptoms of pain, worsening pain, reporting changes in pain location / type / frequency / intensity of pain to physician ? Providing non-pharmacological comfort measures including relaxation techniques, deep breathing, repositioning, activities as appropriate ? Monitoring for side effects including Licensed Nurses to monitor for signs and symptoms of constipation, Licensed Nurses and Certified Nursing Assistants monitoring and documenting bowel movements ? Administering and monitoring for effectiveness and for possible side effects from pain medication ? Pain Assessment to be completed on admission, quarterly and with significant change in status ? Education with resident and family members as needed about comfort measures, [MEDICATION NAME] medications, fear and concerns regarding pain ? Certified Nursing Assistants will verbally notify licensed nurse if resident has no bowel movement in three days ? Certified Nursing Assistants will document notification on bowel record and licensed nurses will review the bowel record flow book the beginning of each shift. ? Licensed Nurses administering stool softeners and laxatives per MD orders ? Licensed Nurses encouraging fluid and fiber ? Certified Nursing Assistant encouraging resident to follow prescribed diet (B) On [DATE], Nurse Management team, consisting of Interim Director of Nursing Services (I-DNS), Staff Development Coordinator (SDC) and Minimum Data Set Coordinators (MDSC) implemented, evaluated and / or updated resident care plans related to constipation as needed. Constipation care plan is inclusive of: ? Certified Nursing Assistants monitoring and documenting bowel movements every shift ? Certified Nursing Assistants will verbally notify licensed nurse if resident has no bowel movement in three days ? Certified Nursing Assistants will document notification on bowel record and licensed nurses will review the bowel record flow book the beginning of each shift. ? Licensed Nurses administering stool softeners and laxatives per MD orders ? Licensed Nurses encouraging fluid and fiber as appropriate ? Certified Nursing Assistant encouraging resident to follow prescribed diet ? Notification of Registered Dietician for evaluation of diet and fluid intake / offerings, resident likes and dislikes, and recommendations for food and /or fluids to promote regular bowel elimination 1. Education was initiated by: a) Staff Development Coordinator inserviced current licensed nursing staff on [DATE] and will repeat in-service on-going for newly hired licensed nurses during orientation, licensed nurses returning from vacation and leave of absence with regard to pain policy to include: ? Assessment of resident pain including location, duration, frequency, time of day pain generally occurs, feeling of pain (internal, external, acute, chronic), severity of pain verbal pain scale (if resident able to respond) and non-verbal pain scale, pain type / intensity, other non-verbal cues (facial expressions, vocalizations, body actions / observed behaviors), pain affecting resident's quality of life / activities of daily living, cause of pain, relief of pain ? Initiation of pain care plan as needed ? Implementation of pain care plan ? Monitoring frequency of use of [MEDICATION NAME] medication ? Notifying the attending MD of pain requiring prn (as needed) medication for greater than three consecutive days ? Notifying the attending MD of unrelieved pain of 3 or higher on a scale of 1(mild)-10 (continuous/severe) on the pain assessment form ? Initiation and implementation of constipation care plan a) Staff Development Coordinator inservi

Based on staff interviews and record review the facility failed to provide catheter care as ordered by the physician, failed to assess the urinary drainage system and failed to detect blockage of the urinary drainage system for 1 of 4 sampled residents. (Resident #2) Findings include: 1.Resident #2 was last re- admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Assessment Protocol (RAPS), dated 7/21/10, revealed a concern with urinary incontinence. The resident was not able to voice her needs and was incontinent of bowel and bladder. An undated care plan revealed a problem with urinary output related to the need for an indwelling catheter due to persistent overflow incontinence with symptomatic infections. The goal was for the resident to not develop any symptomatic urinary tract infections [MEDICAL CONDITION] and/or catheter related complications. The interventions included, provide catheter care per facility protocol to prevent infection and/or reduce irritation. Observe and report signs and symptoms of UTI (including cloudy urine, sediment in urine, discolored tubing or drainage bag, complaints of burning and/or suprapubic tenderness, dark concentrated urine, hematuria, fever, cognitive changes and foul smelling urine.). Observe and report any signs/symptoms of catheter related complications (including blocked catheter). Resident #2's monthly physician orders [REDACTED]. Resident #2 had labs collected on 1/3/11. Her BUN (blood urea nitrogen- a test that revealed important information about how well her kidneys and liver were working) was 40 (range was 6-23) and her creatinine (a test used to diagnose impaired kidney function and to determine kidney damage) was 1.36 (range was 0.40-1.20). Review of the " C.N.A. Flow Record " revealed on 1/9/11 the resident had 200 cc (cubic centimeters) of yellow urine documented on the 11-7 shift. No other shifts had documented the resident's urine ouput.Review of the " C.N.A. Flow Record " revealed on 1/12/11 she had 400cc of yellow urine documented on the 11-7 shift. No other shifts had documented the resident's output. There were no other urinary outputs documented until 1/21/11. Resident #2 was seen by the physician on 1/13/11. The physician noted her respirations were between 16-24 and irregular. She had a [MEDICAL CONDITION] bladder and end stage [MEDICAL CONDITION]. A nurse's note dated 1/15/11 revealed the urine in the resident's drainage bag was "turbid & amber colored." The on call physician was contacted and gave no orders because the resident was not running a fever and was "probably colonized" due to having the indwelling catheter. The nurse's note for 1/16/11 revealed the catheter was found lying between the resident's legs with the balloon fully inflated. A moderate amount of bleeding was noted. A new indwelling catheter was inserted and was draining blood tinged urine. A basic metabolic panel (BMP/lab) was drawn on 1/19/11. Resident #2's BUN was 56 (range was 6-23) and her creatinine was 1.49 (range was 0.40-1.20). The potassium level was 4.1 (range 3.5-5.3). A note from a nurse was left for the physician on 1/19/11. The resident was noted to have blood in indwelling catheter. The physician responded the same day to obtain a UA (urinalysis) and a PT ([MEDICATION NAME] Time) with INR (International Normalized Ratio). The resident was taking [MEDICATION NAME] 4mg (milligrams) everyday. A verbal order was written to obtain the UA and PT/INR on 1/20/11. The results of the PT/INR on 1/20/11 were as follows, PT= 26.4 seconds (range 11.6 - 15.2) and INR= 3.47 (therapeutic range normally between 2-3). Review of the " C.N.A. Flow Record " reflected an output of 400cc on 1/21/11 with no description of the urine and no details to indicate if it was for one shift or the entire day. The physician visited the resident on 1/21/11 noted questionable hematuria (bloody urine) versus amber colored urine. He noted the urine drainage bag was clear at the time of his assessment with no signs of blood. The physician wanted the UA results faxed to him when available. On 1/25/11 the resident was started on [MEDICATION NAME] 100 mg twice daily for 7 days. Review of the " C.N.A. Flow Record " reflected an output of 450cc for 2nd shift and 300cc for 3rd on 1/25/11 with no description of the urine. Review of the " C.N.A. Flow Record " reflected an output of 250cc for 2nd shift on 1/26/11 with no description of the urine. The nurse's note dated , 1/27/11 at 11:30AM revealed the catheter was draining yellow urine. No amount listed. Review of the " C.N.A. Flow Record " reflected an output of 450cc for 2nd shift on 1/27/11 with no description of the urine. A nurse's note dated 1/29/11 at 7:30AM, noted her indwelling catheter was intact with clear amber urine. No amount of output was noted. On 1/30/11 at 11:30AM nurse #6 was called to the resident's room by the NA (nursing assistant). The resident was breathing heavily and grimacing. She was medicated for pain due to the facial grimacing. The resident was suctioned with no results, her lungs were clear to auscultation bilaterally. Review of the nurse's notes, dated 1/30/11 at 2:35PM revealed the resident continued to have labored breathing. Her vitals were, temperature 98.2 Fahrenheit, pulse 68, respirations 20, and blood pressure was 85/62. She was on 1.5 liter of nasal cannula oxygen and her oxygen saturation was 95%. A " scant " amount of amber colored urine was noted as output since 7AM. An assessment of the resident's abdomen was not noted. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. " Handwritten on the MAR indicated (shift). No other shifts were noted on the MAR. Catheter care was documented as being done on the 7-3 shift seventeen times.No other shifts were noted catheter care as being done. Catheter care was not noted as being done on 1/29/11,1/30/11 or 1/31/11. The resident was sent to the emergency department (ED) for evaluation and treatment on 1/30/11 per the nurse's notes (2:35PM). Review of the hospital records revealed, resident #2 was sent to the hospital on [DATE]. The chief complaint was " abnormal breathing. " Review of the ED notes revealed the resident was also sent to the ED for evaluation of low blood pressure. The resident had been grimacing more and appeared in pain. The resident was currently being treated for [REDACTED]. " The nurse's note reflected the resident arrived with an indwelling catheter in place. The " tubing noted to be dry, no urine in tubing, sediment noted along entire tubing, less than 100 ml (milliliters) dark urine noted in bag. " The indwelling catheter was replaced and an " immediate return of 600ml bloody urine with clots noted. " The history and physical read in part, " she was found to have a very dirty and clogged up Foley catheter. Her basic lab work showed acute [MEDICAL CONDITION] from serum creatinine jumping from 1 to about 5 and she was also hyperkalemic (elevated potassium of 6.9). She had a CT (computed tomography) scan of the abdomen and pelvis, which showed hydro[DIAGNOSES REDACTED] (swelling of a kidney due to back up of urine), bilateral dilated ureters and distended bladder even though the Foley is in place. Obviously, this is a Foley catheter that was clogged. " Resident #2's admitting [DIAGNOSES REDACTED]. During an interview on 2/17/11 at 11:47AM nurse #3 indicated indwelling catheter care should be done every shift. The NA's should report things like bloody urine to the nurse and the nurse should then inform the physician. An interview was conducted on 2/17/11 at 11:53AM with nurse #4. The nurse stated resident's with indwelling catheters should have catheter care every shift. The staff (nurses and NAs) should be monitoring intake and output and changes in the urine (color consistency). NA #2 was interviewed on 2/17/11 at 2:43PM. The NA indicated catheter care should be done " everyday " and sometimes it was done more than once a day. NA #2 worked regularly with resident #2. The resident was usually " neat and clean " in regards to her personal hygiene. She was totally dependent on staff for personal hygiene and toileting. The NA did not recall the resident having any problems (bloody urine, decreased output) with her indwelling catheter. During an interview on 2/17/11 at 3:06PM, NA #3 indicated the resident was totally dependent on the facility staff for her activities of daily living (personal hygiene, toileting). NA #3 stated catheter care should be done everyday. She did not recall the resident having bloody urine (hematuria) when she took care of her. An interview was conducted with the DON on 2/17/11 at 4:33PM. The DON indicated the facility recently switched documenting catheter care from the treatment record to the medication administration record. The DON stated this could be a reason the staff was not keeping track of the times they did catheter care. The DON expected the facility staff to do catheter care every shift. It should be documented as being done. The DON expected staff to report changes in the urine such as blood or decreased output. The resident's physician was interviewed on 2/17/11 at 5:45PM. The physician indicated the resident did have periods of hematuria, but not consistent hematuria. The staff did report a change in the color of the urine from yellow to bloody. The physician expected the facility staff to be caring for the indwelling catheter per their policy and procedure.

Based on record review, facility policy review and staff, family and physician interview, the facility failed to ensure the physician and responsible party were notified of a change in condition for 1 of 3 sampled residents (Resident #2). The findings included: The facility policy dated 10/31/07 R entitled "Notifications" read in part, "Staff informs the resident, consults with their attending physician, and notifies the resident's surrogates when: "A significant change occurs in the resident's physical, mental or psychosocial status." Resident #2 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment, dated 8/12/10, indicated that Resident #2 rarely/never understood others nor was understood by others and was totally dependently for all activities of daily living. Nurses' notes, written by Nurse #1 dated 11/25/10, revealed that Resident #2 had a new onset of vaginal bleeding. The notes had no documentation that either the physician or responsible party was notified. No physician orders were dated for 11/25/10. During an interview on 12/29/10 at 2:53 PM, Nurse #1 indicated that he had called the physician and the responsible party about Resident #2's vaginal bleeding on 11/25/10. Nurse #1 said that Resident #2 had subsequent episodes of vaginal bleeding and that each time he notified the physician and responsible party. Nurse #1 stated that he documented on the nurses' notes whenever he notified the responsible party of a change in condition, and documented on the physician orders or in the nurses' notes when he notified the physician of a change in condition. Review of the nurses' notes revealed no notes between 11/25/10 and 12/9/10. On 12/10/10, Nurse #2 documented that the physician and responsible party were notified of Resident #2's change in condition. During an interview on 12/29/10 at 4:14 PM, the physician indicated that he could not recall specifically if he was notified of Resident #2's vaginal bleeding. The physician indicated that he would have ordered a gynecological consult if he had been notified. Review of physician orders for Resident #2 revealed no order for a gynecological consult. During an interview on 12/30/10 at 10:15 AM, the responsible party indicated he was not aware of Resident #2's vaginal bleeding until she was admitted to the hospital on [DATE]. During an interview on 12/30/10 at 8:49 AM, the Director of Nursing indicated that the physician and responsible party should have been notified when Resident #2 began to have vaginal bleeding, and that notification should be documented on the clinical record.

Based on observation, facility policy review, resident record review and staff interview, the facility failed to provide proper indwelling catheter care as evidenced by (1) cleaning upward from vaginal to urethral area and failing to clean the catheter during catheter care and (2) failing to anchor the catheter for 1 of 2 residents (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE]. The resident's cumulative [DIAGNOSES REDACTED]. A review of Resident #5's admission care plan dated 12/8/10, indicated Resident #5 had a urinary catheter in place. One of the goal/approaches listed on this care plan was for Resident #5 to have her urinary catheter anchored securely. A review of Resident #5's most recent Minimum Data Set ((MDS) dated [DATE], indicated Resident #5 had severely impaired cognition with short and long term memory problems. The MDS further indicated Resident #5 had an indwelling urinary catheter in place. A review of a facility policy dated 4/28/10 entitled "Indwelling Urinary Catheter Care" read in part: "9. Wash perineum beginning at the junction of the catheter tubing and meatus working outward to the surrounding perineal structures with soap and warm water or a no rinse cleansing solution and cleaning from front to back." "13. Validate the catheter is anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter." On 12/28/10 at 4:22 PM, Nursing Assistant #1 (NA) was observed providing Resident #5 catheter care following an episode of stool incontinence. The catheter was not secured in place. NA #1 used a downward motion to wipe the inner right labium past the urethra and vagina, then turned the washcloth over and wiped upward on the left labium from the vagina past the urethra. At no point during the care was the catheter cleansed. During an interview on 12/28/10 at 4:35 PM, NA #1 indicated that she had been taught to wipe from top to bottom of labial area and did not realize she was wiping upward. NA #1 indicated that she had been taught to wash off the catheter if there was visible stool on it. NA#1 also stated that she had never seen any type of anchor used for Resident #5's catheter. On 12/29/10 at 11:15 AM, NA #2 was observed providing catheter care to Resident #5. This observation revealed that the catheter tubing was not secured to the resident with a leg band. During an interview with NA#2 on 12/29/10 at 11:15AM, she stated that Resident #5 should have a catheter leg band on to keep the catheter in place, and she would let the nurse know that Resident #5 needed one. During an interview on 12/30/10 at 8:49 AM, the Director of Nursing (DON) indicated that her expectation was for all residents' catheters to be anchored securely and for catheter care to be performed by cleaning from the catheter outward, and then cleaning the catheter itself from urethra outward.