Every finding on record at Royal Park Rehabilitation & Health Center

Based on record review and Medical Director, Hospital Urologist, Nurse Practitioner (NP), Resident Representative (RR) and staff interviews, the facility failed to follow hospital discharge orders for a urinary catheter to remain in place for 1 of 5 residents reviewed for urinary catheters (Resident #161). Resident #161 was admitted to the facility from the hospital on 9/18/25 with a urinary catheter due to a diagnosis of hydronephrosis (swelling of the kidneys due to urinary retention). Resident #161's urinary catheter was removed at the facility on 9/19/25 at 6:27 AM and subsequently reinserted at 11:09 PM after the Medical Director reviewed the hospital records which indicated the urinary catheter was to remain in place until follow up with urology. On 9/20/25 Resident #161 was complaining of lower abdominal pain, blood was observed in the catheter tubing, and he was transferred to the emergency department (ED) for further evaluation. The Hospital Urologist noted Resident #161's urinary catheter was not advanced properly, the balloon of the urinary catheter was inflated in the prostate, and during a cystoscopy (insertion of a scope to assist with visual guidance) to insert a 3-way catheter he observed a false passage (tear in the urethral wall). Resident #161 was hospitalized [DATE] through 9/26/25 for CBI (constant bladder irrigation) and antibiotics were administered as a preventative measure. The RR revealed Resident #161 was discharged home on 9/26/25 and was still traumatized by the experience. The findings included:The hospital Discharge summary dated [DATE] at 7:45 PM scanned into the electronic medical record (EMR) revealed Resident #161 was hospitalized [DATE] through 9/18/25 due to a sacral fracture severe bilateral hydronephrosis (swelling of the kidneys due to retention of urine) and was noted to have a history of prostate and bladder cancer, removal of the right lower ureter (tube from the bladder to the kidney) and was tentatively scheduled for surgery to remove a bladder tumor on 10/22/25. The hospital discharge summary further noted that Resident #161's urinary catheter was to remain in place and to schedule a follow up appointment with urology in two weeks.Resident #161 was admitted to the facility on [DATE] and discharged to hospital on 9/20/25. His admitting diagnoses included fracture of the sacrum and malignant neoplasm (cancer) of the prostate and bladder.The nursing admission assessment dated [DATE] completed by Nurse #8 indicated Resident #161 was cognitively intact and had a urinary catheter in place draining clear amber colored urine.Resident #161's physician orders revealed the following orders:9/18/25 remove urinary catheter 9/19/25 for a voiding trial.9/19/25 place a urinary catheter for hydronephrosis.Resident #161's treatment administration record (TAR) indicated the following:9/19/25 removal of the urinary catheter for a voiding trial was documented as completed by Nurse #8 at 6:27 AM.9/19/25 urinary catheter placement was documented as completed by Nurse #8 at 11:09 PM.A nurse's note dated 9/19/25 at 2:32 AM written by Nurse #8 indicated Resident #161 was admitted to the facility for short term rehabilitation due to a sacral fracture and had a history of bladder cancer. Resident #161's urinary catheter was patent and draining clear amber colored urine and per physician's orders a voiding trial was to begin on 9/19/25 at 6:00 AM.A physician's note dated 9/19/25 at 3:32 PM indicated Resident #161 was admitted to the facility following hospitalization due to a sacral fracture and incidentally developed urinary retention which resolved after placement of a urinary catheter. Resident #161's urinary catheter was removed at the facility the morning of 9/19/25, however a review of the hospital records indicated the urinary catheter was to remain in place until a follow up with urology. Nursing staff were notified of new order to reinsert the urinary catheter on 9/19/25. A nurse's note dated 9/19/25 at 5:36 PM written by Nursing Supervisor #1 revealed the Medical Director evaluated Resident #161 and reviewed the hospital records which noted a diagnosis of hydronephrosis and for the urinary catheter to remain in place until a follow up with urology. Resident #161 was informed of new order from the Medical Director to reinsert the urinary catheter to prevent recurrence of hydronephrosis and kidney injury. Resident #161 voiced disappointment due to voiding three times since the catheter was removed this morning but verbalized understanding and agreeable to reinsertion of the urinary catheter. Resident #161 indicated he would notify his RR to schedule a follow up appointment with his urologist. A nurse's note dated 9/20/25 at 7:16 AM written by Nurse #8 revealed Resident #161 tolerated urinary catheter placement with flash of 30 cubic centimeters (ccs) of urine upon insertion, catheter draining clear amber colored urine with total output of 200 ccs by end of shift.A nurse's note dated 9/20/25 at 12:00 PM written by Nurse #9 revealed Resident #161 was observed to have string like blood clots in urinary catheter with complaints of burning and pain. Resident #161 was administered pain medication, the on-call provider was notified, and new orders were received to reposition the urinary catheter and to obtain a urinalysis. When attempting to reposition the urinary catheter blood was observed coming from Resident #161's urethral meatus (external opening at the tip of the urethra) onto the bed sheets as well as in the catheter tubing. Resident #161 expressed pain and was visibly wincing. The on-call provider was again notified and gave an order to transfer Resident #161 to the Emergency Department (ED) for further evaluation. Resident #161's hospital records dated 9/20/25 through 9/26/25 indicated Resident #161 was transferred to the ED from the facility due to lower abdominal pain and blood in his urine. Resident #161's urinary catheter was noted to have been removed and then reinserted at the facility for unknown reasons however hospital records from 9/14/25 through 9/18/25 indicated the catheter was to remain in place until follow up with urology. The Hospital Urologist noted Resident #161's urinary catheter was not advanced properly, and the balloon of the urinary catheter was inflated in the prostate. The Hospital Urologist performed a cystoscopy to insert a 3-way catheter and noted a false passage (tear in the urethral wall) was observed during the procedure. Resident #161 was admitted to the hospital for further monitoring, CBI as initiated and antibiotics were administered as a preventative measure. Resident #161's bleeding and pain related to the urinary catheter resolved and he was discharged home on 9/26/25.A phone interview was conducted with Resident #161's RR on 12/04/25 at 12:29 PM. The RR stated she was present when Resident #161 was admitted to the facility on [DATE]. The RR indicated she did not recall her name but the nurse on duty reviewed the medication and treatment orders that were received from the hospital including an order to remove the urinary catheter. The RR stated she and Resident #161 voiced concern about removing the urinary catheter due to complications that occurred in the hospital and Resident #161's history of prostate and bladder cancer. The RR indicated the nurse informed them the order to remove the urinary catheter was from the hospital, so they proceeded with removing the catheter the next morning. The RR revealed that within hours of the catheter being removed the facility determined it was supposed to remain in place and reinserted the urinary catheter. The RR stated on 9/20/25 Resident #161 was experiencing severe pain and bleeding from the catheter and was transferred to the hospital for further evaluation. The RR indicated the urinary catheter was not positioned properly and the Hospital Urologist had to use a scope to reinsert the catheter. The RR revealed that Resident #161 was hospitalized for approximately a week and was still traumatized by the experience. The RR revealed Resident #161 was able to have surgery to remove a bladder tumor on 10/22/25 and no longer required the urinary catheter. A phone interview conducted with Nursing Supervisor #1 on 12/5/25 at 8:47 AM revealed she received Resident #161's hospital discharge summary from the Assistant admission Director on 9/18/25 at approximately 2:30 PM and called NP #2 to review the discharge summary and verify the medication and treatment orders. She revealed NP #2 verified the discharge summary orders including removal of the urinary catheter for a voiding trial and then she entered the orders into the EMR. Nursing Supervisor #1 stated she was not at the facility when Resident #161 arrived, she did not review the paperwork sent with him from the hospital, however the discharge summary scanned into the EMR was not the one she reviewed with NP #2. Nursing Supervisor #1 indicated Nurse #8 activated and followed the orders she entered in the EMR and removed Resident #161's urinary catheter on the morning of 9/19/25. She stated the afternoon of 9/19/25 the Medical Director evaluated Resident #161 and informed her that he reviewed the hospital records which indicated the urinary catheter was to remain in place and gave an order to reinsert the catheter. She stated she informed Resident #161 of the order to reinsert the urinary catheter and that he was disappointed because he had been voiding with no issue, but voiced understanding as to why the catheter had to be reinserted. A phone interview with the Assistant Admissions Coordinator on 12/05/25 at 10:14 AM revealed when a new resident was admitted to the facility, she would access the hospital EMR system and print records as needed but did not recall printing Resident #161's discharge summary on 9/18/25 and giving it to Nursing Supervisor #1. During a phone interview with Nurse #8 on 12/04/25 at 7:30 AM she revealed she was the assigned nurse to Resident #161 on 9/18/25 from 7:00 PM to 7:00 AM on 9/19/25. She stated Resident #161 was a new admission and arrived at the facility on 9/18/25 around 9:00 PM or 10:00 PM. She indicated Resident #161's medication and treatment orders had been confirmed and entered into the electronic medical record (EMR) by Nursing Supervisor #1 earlier in the day. Nurse #8 indicated a packet of information was sent with Resident #161 from the hospital and she reviewed the discharge summary in the packet however she did not compare the orders on the discharge summary to the orders in the EMR nor did she notice instructions for the urinary catheter to remain in place. She stated Nursing Supervisor #1 had already verified the orders and she had no indication the orders were changed and her responsibility was just to activate the orders in EMR when Resident #161 arrived at the facility. She stated she reviewed the orders in the EMR with Resident #161 and the RR including the order to remove the urinary catheter for a voiding trial. She stated Resident #161 and the RR were concerned about removing the catheter due to complications with bleeding that occurred in the hospital, but when she explained the orders were verified by the facility's provider, they agreed with the removal. Nurse #8 indicated she removed Resident #161's urinary catheter 9/19/25 at approximately 6:00 AM without incident. She stated when she returned to work on 9/19/25 at 7:00 PM, Resident #161 had an order to reinsert the urinary catheter which she completed that night without incident. She stated when she placed the catheter Resident #161 exhibited no signs or symptoms of pain or discomfort and the catheter was draining clear amber colored urine. A phone interview conducted with Nurse #9 on 12/5/25 at 3:57 PM indicated she was assigned to Resident #161 on day shift (7AM to 7 PM) on 9/20/25. She stated Nurse #8 reported at shift change Resident #161's urinary catheter was reinserted without incident and draining urine. Nurse #9 revealed she checked on Resident #161 throughout the morning and there were no concerns related to the catheter until approximately 11:00 AM when he reported pain in his lower abdomen. She indicated Resident #161's lower abdomen was visibly distended, and she observed string like blood clots in the catheter tube. Nurse #9 revealed she administered pain medication to Resident #161 and then notified the on-call provider and received orders to obtain a urinalysis and reposition the urinary catheter. Nurse #9 stated she was going to attempt repositioning the catheter, but when she moved the catheter tubing from the side of Resident #161's leg he winced in pain and a large amount of blood started draining through the catheter tube. Nurse #9 revealed she notified the on-call provider of what occurred and received an order to transfer Resident #161 to the ED for further evaluation.A phone interview was conducted with NP #2 on 12/04/25 at 3:28 PM. NP #2 stated Nursing Supervisor #1 reviewed Resident #161's hospital discharge summary with her by phone to verify the orders. NP #2 revealed she was not aware Resident #161 had a diagnosis of hydronephrosis in the hospital but that would have made her hesitant to approve an order to remove the urinary catheter before a follow up with urology. During a phone interview with the Medical Director on 12/04/25 at 3:03 PM he indicated when evaluating a newly admitted resident he either reviews the hospital records scanned into the facility's EMR or directly through the hospital EMR system, but he did not recall in which system he reviewed Resident #161's records. The Medical Director revealed as stated in his progress note dated 9/19/25, Resident #161 had the urinary catheter removed prior to his visit, however after reviewing the hospital records he noted the catheter was to remain in place and gave an order for the catheter to be reinserted. The Medical Director revealed if changes were made to Resident #161's discharge summary orders provided to the facility prior to Resident #161 arriving then the hospital was responsible for notifying the facility of the changes. The Medical Director indicated the complications Resident #161 encountered related to the urinary catheter and his subsequent hospitalization would have been avoided if the catheter had remained in place. A phone interview was conducted with the Hospital Urologist on 12/05/25 at 9:41 AM. He stated he evaluated Resident #161 on 9/20/25 when he was transferred to the ED from the facility and he presented with significant pain and bleeding related to the urinary catheter. The Hospital Urologist indicated upon assessment of the catheter it was not advanced properly, and the catheter balloon was inflated at the prostate. The Hospital Urologist stated Resident #161 had trauma to his urethra and prostate due to the incorrect placement of the catheter and a false passage was observed. He revealed attempts to reposition the catheter in the ED were unsuccessful and a cystoscopy was performed to insert a 3-way catheter. The Hospital Urologist stated CBI was initiated due to the bleeding and passage of clots, and antibiotics were administered as a preventative measure. He indicated Resident #161 was hospitalized from [DATE] through 9/26/25 and then discharged home. The Hospital Urologist indicated Resident #161's hospital records from 9/14/25 through 9/18/25 clearly ordered the urinary catheter to remain in place and it should not have been removed at the facility. He further stated that Resident #161's significant history of bladder and prostate cancer made him difficult to catheterize, and the facility should have transferred him to the hospital to have the urinary catheter reinserted. An interview with the Director of Nursing (DON) on 12/4/25 at 3:53 PM revealed Nursing Supervisor #1 received Resident #161's hospital discharge summary from the facility's admission department and followed the proper procedure for reviewing and verifying the orders with NP #2. The DON stated the facility had no indication the hospital discharge orders had changed prior to Resident #161 arriving at the facility and Nurse #8 followed the orders that were verified and entered into the EMR. During an interview with the Administrator on 12/04/25 at 4:40 PM she stated the hospital discharge summary orders that were sent with Resident #161 should have been reconciled with the orders that were already entered into the EMR to ensure the orders were correct and no changes had been made.

Based on observations, and facility staff, pharmacy staff and Nurse Practitioner (NP) interviews, and record reviews, the facility failed to have effective systems in place for obtaining medications and to ensure they were available to administer to a newly admitted resident in accordance with the physician's orders. This resulted in multiple doses of eleven (11) medications being omitted for 1 of 6 residents (Resident #172) who were reviewed for the availability of their medications.The findings included: Resident #172's resided in the community with a family member prior to her admission to the facility. A physician's Orders Note dated 10/9/24 revealed plans were made to admit Resident #172 to the facility for respite care from 10/18/24 to 10/23/24. Respite care is temporary care given to a person who is unable to care for himself or herself while providing short-term relief for primary caregivers. The Orders Note included a list of the resident's current medications and provider contact information. The resident was admitted to the facility for respite care on 10/18/24. Her diagnoses included end stage renal (kidney) disease with dependence on renal dialysis, glaucoma, gastro-esophageal reflux disease (GERD), and dementia. The resident's admission orders to the facility included the following medications scheduled for administration:--81 milligrams (mg) enteric coated (EC) aspirin to be given as one tablet by mouth one time a day for health maintenance (ordered on 10/18/24 and scheduled for 9:00 AM);--500 mg / 15 milliliters (ml) acetaminophen to be given as 30 ml by mouth two times a day for mild to moderate pain (Ordered on 10/18/24 and scheduled for 9:00 AM and 5:00 PM);--0.2 - 0.5 % brimonidine-timolol solution (an eye drop used to treat glaucoma) to be instilled as one drop in both eyes every 12 hours for glaucoma (Ordered on 10/18/24 and scheduled for 9:00 AM and 5:00 PM);--2% dorzolamide ophthalmic solution (an eye drop medication to treat glaucoma) to be given as one drop instilled in both eyes three times a day for glaucoma (Ordered on 10/18/24 and scheduled for 9:00 AM, 2:00 PM, and 9:00 PM);--0.02 - 0.005% netarsudil - latanoprost solution to be instilled as one drop in both eyes at bedtime for glaucoma (Ordered on 10/18/24 and scheduled for 9:00 PM);--5 mg donepezil (a medication used to treat dementia) to be given as one tablet by mouth at bedtime for dementia (Ordered on 10/18/24 and scheduled for 9:00 PM);--40 mg esomeprazole (a medication used to manage GERD) to be given as one capsule by mouth one time a day for GERD (Ordered on 10/18/24 and scheduled for 9:00 AM);--7.5 mg mirtazapine (an antidepressant) to be given as one tablet by mouth at bedtime (Ordered on 10/18/24 and scheduled for 9:00 PM);--8.6 - 50 mg sennosides - docusate tablet (a combination laxative containing a bowel stimulant and stool softener) to be given as 2 tablets by mouth two times a day for constipation; Hold for diarrhea (Ordered on 10/18/24 and scheduled for 9:00 AM and 5:00 PM);--0.8 grams (g) sevelamer packet (a phosphate binder) to be given as two packets by mouth with meals for chronic renal disease three times daily; mix with 1 - 2 ounces of water (Ordered on 10/18/24);--180 mg diltiazem extended release (ER) capsule (an antihypertensive medication) to be given as one capsule by mouth one time a day for hypertension. (Ordered 10/18/24 and scheduled for 9:00 AM). A Nursing Note dated 10/20/24 at 2:00 PM was authored by Nurse #4. The note reported Nurse #4 contacted a representative of Resident #172's managed care program and made her aware that the resident's medications had not yet been received. The representative reported that their pharmacy (different from the facility's contracted pharmacy) was closed on this date (Sunday) and she would make the pharmacy aware of the situation on Monday morning. Attempts made to contact the managed care program's representative for a telephone interview were unsuccessful. An interview was conducted on 12/3/25 at 2:00 PM with Nurse #4. During the interview, Nurse #4 (a weekend nurse supervisor) stated she did not recall Resident #172. When asked how medications would typically be obtained for a resident admitted for respite care (including participants of the managed care program), the nurse reported that sometimes the resident brought in his/her medications for use at the facility. On 10/21/24 at 4:37 PM, a Nursing Note authored by Nurse #3 indicated both the pharmacy and Nurse Practitioner were notified about the resident's medication status. The note reported that Resident #172 was alert, responsive, and able to make her needs known. Nurse #3 also reported the resident's vital signs were stable and that she denied having pain. Multiple unsuccessful attempts were made to contact Nurse #3 for a telephone interview. A review of Resident #172's Nursing Notes revealed from 10/18/24 to 10/21/24, the resident's vital signs included blood pressure results ranging from 99/71 to 102/76; pulse rate ranging from 72 to 78 beats per minute; respiration rate ranging from 16 to 18 respirations per minute; and, her oxygen saturation rate ranging from 96 - 97% on room air. A Nursing Note dated 10/22/24 at 5:02 PM reported the resident was discharged from the facility and returned home with her family. Resident #172's October 2024 Medication Administration Record (MAR) revealed the following medication doses were not documented as given in accordance with her physician orders. On 10/18/24, the medication doses that were not documented as given included:--1 dose of 0.2-0.5% brimonidine-timolol ophthalmic solution left blank on the MAR;--1 dose of 2% dorzolamide ophthalmic solution held and 1 dose left blank on the MAR;--1 dose of 0.02 - 0.005% netarsudil - latanoprost ophthalmic solution left blank on the MAR;--1 dose of 5 mg donepezil left blank on the MAR;--1 dose of 7.5 mg mirtazapine left blank on the MAR;--1 dose of 0.8 g sevelamer noted as held on the MAR. On 10/19/24, the medication doses that were not documented as given included:--1 dose of 81 mg EC aspirin was left blank on the MAR;--1 dose of 500 mg / 15 ml acetaminophen suspension was left blank and one dose was noted as held on the MAR;--1 dose of 0.2-0.5% brimonidine-timolol ophthalmic solution was left blank and one dose was noted as held on the MAR;--2 doses of 2% dorzolamide ophthalmic solution were left blank and one dose was noted as held on the MAR;--1 dose of 0.02 - 0.005% netarsudil - latanoprost ophthalmic solution was noted as held on the MAR;--1 dose of 40 mg esomeprazole was left blank on the MAR;--1 dose of 8.6-50 mg sennosides - docusate was left blank on the MAR;--2 doses of 0.8 g sevelamer were left blank and one dose was noted as held on the MAR;--1 dose of 180 mg diltiazem ER capsule was left blank on the MAR. On 10/20/24, the medication doses that were not documented as given included:--1 dose of 81 mg EC aspirin was left blank on the MAR;--1 dose of 500 mg / 15 ml acetaminophen suspension was left blank and one dose was noted as other on the MAR;--1 dose of 0.2-0.5% brimonidine-timolol ophthalmic solution was left blank and one dose was noted as other on the MAR;--1 dose of 2% dorzolamide ophthalmic solution was left blank and two doses were noted as other on the MAR;--1 dose of 0.02 - 0.005% netarsudil - latanoprost ophthalmic solution on dose was noted as other on the MAR;--1 dose of 40 mg esomeprazole was left blank on the MAR;--1 dose of 8.6-50 mg sennosides - docusate was noted as other on the MAR;--1 dose of 0.8 g sevelamer was left blank and two doses were noted as other on the MAR;--1 dose of 180 mg diltiazem ER capsules was left blank on the MAR. On 10/21/24, the medication doses that were not documented as given included:--1 dose of 81 mg EC aspirin was noted as refused on the MAR;--1 dose of 500 mg / 15 ml acetaminophen suspension was noted as refused on the MAR;--1 dose of 0.2-0.5% brimonidine-timolol ophthalmic solution was noted as held on the MAR;--2 doses of 2% dorzolamide ophthalmic solution were noted as held on the MAR;--1 dose of 0.02 - 0.005% netarsudil - latanoprost ophthalmic solution; --1 dose of 40 mg esomeprazole was noted as held on the MAR;--3 doses of 0.8 g sevelamer were noted as held on the MAR;--1 dose of 180 mg diltiazem ER capsule was noted as held on the MAR. On 10/22/24 (the date of Resident #172's discharge), no medications were documented as given to Resident #172. An interview was conducted on 12/3/25 at 2:05 PM with Nurse Supervisor #1. During the interview, the supervisor was asked how medications would be obtained for a resident admitted for respite care (including participants in the managed care program). She stated that, generally speaking, his/her medications would be dispensed by the facility's contracted pharmacy. An interview was conducted on 12/3/25 at 2:12 PM with the facility's DON. At that time, the DON reported a resident admitted for respite care (and on a managed care program) would be typically looked at on a case by case basis. The DON indicated that since she started her position in April 2025 (after Resident #172's October 2024 stay at the facility), she would need to review Resident #172's electronic medical record (EMR) to become familiar with the resident's respite admission. A telephone interview was conducted on 12/4/25 at 10:50 AM with a representative of the dispensing pharmacy for Resident #172's managed care program. The representative reported that this pharmacy did not provide medications for its participants admitted to a facility for respite care. A telephone interview was conducted on 12/4/25 at 10:58 AM with the facility's contracted pharmacy. During the interview, the pharmacist reviewed Resident #172's dispensing records. He reported the pharmacy received several medication orders dated 10/18/24 but the medications were marked to be profiled, noting profiled medications were put into the resident's record to be filled later upon request. He stated that none of Resident #172's medications were requested to be filled until 10/21/25. A 2-day supply of the following medications were requested, dispensed, and delivered to the facility for Resident #172 on 10/21/25. These medications included: 0.2-0.5% brimonidine-timolol ophthalmic solution, 2% dorzolamide ophthalmic solution, 0.02 - 0.005% netarsudil - latanoprost ophthalmic solution, 5 mg donepezil, 7.5 mg mirtazapine, 0.8 g sevelamer, and 180 mg diltiazem ER capsules. Upon inquiry, the pharmacist reported that while the facility may have been able to obtain Resident #172's oral medications from their on-site, automated medication dispensing system, the eye drops would not have been available in-house. A telephone interview was conducted on 12/4/25 at 11:28 AM with NP #1. NP #1 was identified as one of Resident #172's managed care program providers. During the interview, the NP was asked how medications would be obtained for the managed care program's participant receiving respite care. She stated the facility's nursing staff was expected to put medication orders into the resident's EMR and request the medications be dispensed and delivered from the facility's contracted pharmacy. When noting that Resident #172's vital signs were reported as stable throughout her respite stay, the NP did not identify any harm caused by missing doses of her medications. A telephone interview was conducted on 12/4/25 at 2:15 PM with the facility's former DON. While the former DON did not recall Resident #172, she did remember running into a problem with obtaining medications for a managed care program's participant who was receiving respite care at the facility. The DON stated this was the first time she had dealt with respite care, and she was not sure of the process that was supposed to be implemented to obtain the resident's medications. The former DON acknowledged that due to the problems encountered with obtaining the resident's medications, there was a delay in care for the resident. A follow-up interview was conducted on 12/4/25 at 12:33 PM with the facility's current DON. At that time, concerns related to the failure of the facility to obtain medications for Resident #172 for 3 days after her admission to the facility were shared. The DON reported that all respite care residents were treated like regular admissions and their medications would be ordered, dispensed, and delivered by the facility's contracted pharmacy. She added that if there was a situation where a resident's medication was not on the medication cart when it was scheduled for administration, the nurses knew to go to the onsite automated dispensing system to obtain it. If that medication was not available on-site, then they needed to call the pharmacy and get that medication from the backup pharmacy or contact the provider for an alternative medication, if needed. When asked if the facility had developed and implemented a plan of correction related to the situation encountered with Resident #172, the DON reported she would need to check. On 12/4/25 at 3:15 PM, the facility provided a plan of correction (POC) for review. The POC indicated the facility's date of compliance was 10/25/24. A follow-up interview was conducted with the DON on 12/4/25 at 3:40 PM to discuss concerns about the facility's failure to continue compliance with their POC as evidenced by the interviews conducted on 12/3/25 with Nurse #4, Nurse Supervisor #1, and herself. At that time, each of the nurses expressed uncertainty as to how medications would be obtained for residents admitted to the facility for respite care. The DON stated the nurses' answers may not have been clear due to nerves. A second attempt to validate the facility's POC began on 12/4/25 at 3:47 PM. When the nurses and medication aide(s) were asked how medications would be obtained for residents admitted to the facility for respite care (including managed care program residents), the responses included the residents bringing his/her own medications from home and/or obtaining them from the facility's contracted pharmacy. Due to the varying responses obtained during the interviews conducted on 12/3/25 and 12/4/25, the facility's POC could not be validated as past non-compliance.

Based on record reviews, observations, and resident and staff interviews, the facility failed to serve food at a palatable temperature, hot foods were served lukewarm or cold and a beverage was served partially frozen for 6 of 6 residents reviewed for food palatability (Resident #8, Resident # 37, Resident #54, Resident #14, Resident #110, and Resident #80).The findings Included:a. Resident 8 was admitted to the facility on [DATE]. Resident #8 had a physician's order dated 2/12/2025 for a cardiac diet with regular texture, a thin consistency, and double portions. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact.An observation and interview of Resident #8 was conducted on 12/01/2025 at 2:14 PM during the lunch meal. Lunch trays arrived at the 200 Hall at 1:50 PM on 12/01/2025 and were delivered to all residents at the 200 Hall by 2:10 PM. Resident # 8 was observed removing the lid of the hot beverage on his lunch tray and no steam was visible. Resident #8 complained the lunch meal was also lukewarm and stated he would like his food and coffee served hot. Staff entered and offered to reheat the plated food and beverage. Resident #8 declined to have food reheated. Resident expressed frustration and stated he felt they intentionally always served hot food cold and was hesitant to eat it some days. b. Resident #37 was admitted to the facility on [DATE].The admission MDS assessment dated on 10/13/2025 revealed Resident #37 was cognitively intact. Resident #37 had a physician's order dated 10/28/2025 for a regular diet with regular texture and consistency.Resident #37 was interviewed and observed on 12/2/2025 at 9:12AM. Resident #37 stated his room was at the end of the hallway, so when his tray was served to him the hot foods were not warm when meal trays are served. Resident #37 stated staff needed to reheat at least 50% of the meals.Resident #37 was interviewed and observed on 12/2/2025 at 9:17 AM when staff brought in the breakfast tray and assisted in the set-up. Resident #37 stated to staff the scrambled eggs were lukewarm. Staff offered to reheat the eggs and Resident #37 declined. Resident #37 stated rewarming eggs dried them out and made them too difficult for Resident #37 to chew and swallow. Staff did not offer Resident #37 a replacement or alternative.c. Resident #54 was admitted to the facility on [DATE].Resident #54 had a physician's order dated 9/11/2025 for a regular diet with pureed texture and a thin consistency ordered.The quarterly MDS assessment dated [DATE] revealed Resident #54 was cognitively intact.When Resident #54 was interviewed on 12/1/2025 at 2:36 PM, Resident #54 complained the food was consistently cold when it arrived and staff repeatedly returned to reheat the meals throughout the day. On 12/2/2025 at 9:05 AM Resident #54 was interviewed and observed checking temperature of pureed scrambled eggs and cheese, pureed hot cereal, and pureed moistened biscuit using his index finger and complained the food was lukewarm. When the plate cover was removed there was no steam and the inside of the plate cover was visibly moist with condensation and did not feel warm to touch. At 9:17 AM, staff entered to deliver the roommate's tray and offered to reheat Resident #54's food. The resident agreed, and staff took the plate to reheat it. d. Resident #14 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] specified Resident #14 was cognitively intact. Resident #14 had a physician's order dated 2/26/2025 for a limited concentrated sweets diet with easy to chew texture and a thin consistency. Resident #14 was interviewed on 12/1/2025 at 11:31 AM and complained the food served was very poor in quality and the options weren't appropriate for a diabetic. Resident #14 stated there were not balanced diet options for diabetics, and the hot foods were cold and the cold foods warm. Resident #14 complained the sandwiches and bread were either soggy or dried out. Resident #14 reported raising her concerns repeatedly for the past 4-5 months to Resident Council and the Administrator without improvement. Resident #14 was interviewed and observed again on 12/3/2025 at 9:32 AM. Resident #14 attempted to eat a hardboiled egg from the tray. Resident #14 stated the items on the breakfast tray were not what she had ordered, tray items were not what was on the ticket, and the ham with gravy and bowl of grits were cold. The ticket listed scrambled eggs, ham, hot cereal, orange juice, hot coffee, and toast, but the tray instead contained chunked ham with gravy, grits, a boiled egg, and toast. NA #3 attempted to resolve the situation by offering another egg or reheating the grits. Resident #14 waved the tray away and became emotional, stating NAs tried to make up for ongoing problems with cold food. e. Resident #110 was admitted to the facility on [DATE]. Resident #110 had a physician's order dated 8/7/2023 for a regular diet with easy to chew texture and thin consistency ordered. A quarterly MDS assessment dated [DATE] specified Resident #10 was moderately cognitively impaired. Resident #110 was interviewed and observed on 12/3/2025 at 8:48 AM seated in the 100-200 Unit Dining Hall at a table. Resident #110 drank from a cup of coffee that was set on the table when he arrived and stated it was cold and asked for some sugar packets for the cup of coffee. There was no lid on the cup, no condiments for the coffee, and no steam was observed coming from the cup. Resident #110 stated breakfast trays often arrived cold, residents waited an hour or more in the dining room for meals, and staff routinely reheated items in the microwave. Staff did not offer to reheat the coffee but brought packets of sugar to Resident #110. The Resident stated he reported cold meals to staff but did not bring concerns to Resident Council because he felt nothing changed when other residents raised food concerns. Resident #110 was again interviewed and observed on 12/4/2025 at 1:35PM at the 200 Unit dining room table while eating lunch. Resident #110 ate 75% of the lunch with no steam observed from the chicken or vegetables. The Resident reported his lunch and dinner on 12/3/2025 were not warm but stated the lunch he was eating was hotter than usual. f. Resident #80 was admitted to the facility 12/31/2024.Resident #80 had a physician's order dated 12/31/2024 for a regular diet with regular texture and thin consistency. The quarterly MDS assessment dated [DATE] specified Resident #80 was cognitively intact.Resident #80 was interviewed on 12/3/2025 at 8:58 AM. Resident #80 stated meal trays were late twice a week, food temperatures were incorrect 9 times out of 10, and meal items often did not match the tray ticket. Resident #80 stated they bring the trays out to the table right when they get on the unit, but food was either too cold or not hot enough. Resident #80 was interviewed and observed on 12/3/2025 at 9:25 AM. Resident #80 complained about frozen juice. Resident #80 complained that the juice containers were frozen. Chunks were observed and slushing heard when Resident #80 used her utensils to break up and mix the partially frozen juice. On 12/4/2025 at 3:15 PM Nurse Aide (NA) #2 was interviewed and revealed each day more than half of the 20 resident dinner trays she delivered to the 200 Hall required reheating. NA #2 stated the nursing staff have made management aware over past several months that dinner trays arrived cold and that it takes extra time for staff to reheat them. A medical records staff member was interviewed and observed on 12/2/2025 at 9:21 AM as she passed out trays on the 200 Unit. The medical records staff member stated when they announced trays have arrived on a unit, she and other administrative staff members were assigned to pass out and set up meal trays on every unit. The medical records staff member revealed food was reheated 4 of 5 days each week for both breakfast and lunch trays for the 4 to 5 residents she delivered to and set-up for. On 12/4/2025 at 3:29 PM the Dietary Manager (DM) was interviewed about residents' concerns with cold food and beverages. The DM stated staff were to offer replacement trays if residents complained of cold food instead of offering to reheat food. The DM stated she worked with nurse management and requested the trays be delivered upon arrival to the unit to prevent a delay. The DM reported the kitchen conducted one test tray every day and found no issues with food palatability. The DM was unable to provide documented evidence of test tray records. On 12/01/2025 at 3:45 PM the Director of Nursing (DON) was interviewed. The DON stated all staff were trained, even administrative staff, to deliver trays and provide assistance with resident feeding.On a follow-up interview with the DON on 12/04/2025 at 4:10 PM it was revealed all staff were expected to report to the units when the announcement goes overhead that trays had arrived on a unit so they can deliver trays quickly. The DON stated that nursing leadership was aware that many staff repeatedly reheated trays upon arrival and delivery to the residents. The DON acknowledged an awareness of multiple residents across the facility had food complaints of unsatisfactory temperatures and stated it had been an issue for several months and stated the nursing staff were delivering the trays within a few minutes of arriving to the units. The DON stated this had been their practice for a few years at the facility. The DON stated they do not allow staff to schedule their breaks during mealtimes, so all staff are available to assist with tray delivery.On 12/4/2025 at 4:00 PM the Administrator was interviewed and reported awareness of food issues and palatability concerns raised at Resident Council meetings and reported to nurse leadership. The Administrator stated the facility was planning to terminate their current food service contract.

Based on observation and staff interviews, the facility failed to label and date food items and discard expired items in 2 of 3 nourishment rooms (300/400 hall nourishment room and 500/600 hall nourishment room). These deficient practices had the potential to affect food served to residents. Findings included:1. Observation and interview conducted with the Dietary Manager on 12/1/25 at 10:25 AM revealed Nourishment room [ROOM NUMBER] (300/400 hall) had: an opened container of coffee creamer that was labeled with a name, but no date. a container with noodles labeled with a resident's name but no date. a gallon of iced tea not labeled with the product or resident name and had the best by date of 11/29/25. an opened bottle of prune juice that was not labeled with a resident's name. The Dietary Manager stated during the observation she expected all items to be labeled and expired items discarded. 2. Observation and interview conducted with the Dietary Manager on 12/1/25 at 10:50 AM revealed Nourishment room [ROOM NUMBER] (500/600 hall) had: a container of leftover pudding that was not dated or labeled.The Dietary Manager stated during the observation she expected all items to be labeled. The Dietary Manager revealed kitchen staff checked the nourishments rooms twice a day. The Dietary Manager stated the Assistant Dietary Manager had checked the nourishment rooms on 11/30/25.An interview conducted with the Assistant Dietary Manager on 12/4/25 at 2:25 PM revealed she had worked on 11/30/25 but failed to check the nourishment rooms. It was further revealed she had worked as a dietary aide that day and forgot to check the nourishment rooms. The Assistant Dietary Manager stated she or the Dietary Manager normally checked the nourishment rooms daily.An interview conducted with the Director of Nursing (DON) on 12/4/25 at 1:40 PM revealed all nursing staff had been educated to label and date residents' items in the nourishment rooms. The DON indicated she expected nursing staff to follow those instructions. The DON stated all staff were educated during orientation.An interview conducted with the Administrator on 12/4/25 at 2:00 PM revealed staff were educated to label residents' items when placed in the nourishment rooms. The Administrator further revealed when new staff were hired, they were taught that residents' items were to be labeled during orientation. The Administrator indicated dietary staff checked the nourishment rooms daily as well and were advised to look for items that were unlabeled.

Based on record review, observations, and staff interviews, the facility failed to store a syringe used for enteral feedings (also known as tube feeding, is a method of delivering nutrition directly into the gastrointestinal tract) dry and with the plunger separated from the syringe and free from moisture for 1 of 3 residents reviewed for enteral feeding management (Resident #73). This practice had the potential for bacterial growth and contamination.Findngs included: Resident #73 was admitted to the facility on [DATE] with diagnoses of diabetes, stroke, hypertension, hemiplegia, malnutrition, difficulty swallowing, esophageal web, gastrostomy status (indicates the presence of a gastrostomy tube, which is surgically placed to provide direct access to the stomach for nutrition and hydration when oral intake is insufficient or unsafe), dysphagia, and oropharyngeal. Review of Resident #73 order dated 03/16/24 revealed the resident was ordered to receive 250 milliliters of Glucerna (tube feeding formula) 1.5 through bolus every 6 hours and to receive water flush of 100 milliliters before and after each bolus feeding. Bolus feeding is a way to give enteral nutrition (tube feeding). Bolus feedings give large doses of formula several times a day. The formula is poured slowly into a syringe attached to a feeding tube.A significant change Minimum Data Set assessment dated [DATE] indicated Resident #73 received 51% of more of her total calories from enteral feedings and 501 milliliters of fluids per day by enteral feedings.Review of the Resident #73's Medication Administration Record (MAR) revealed Nurse #10 had signed off Resident #73's morning medications on 12/02/2025. During an observation on 12/02/2025 at 10:00 AM Resident #73's syringe used for enteral feedings and medication administration was observed with the plunger inside the syringe which was wet with condensation and stored in a plastic bag on the bedside table. During an observation and interview on 12/02/25 at 12:00 PM, Nurse #10 administered the enteral bolus feeding to Resident #73, followed by the water flush. After the feeding was completed Nurse #10 did not separate the plunger from the syringe and wash it. The Nurse placed the syringe in the bag with the residual feeding formula still in it. Nurse #10 stated she normally did not wash Resident #73's syringe after the resident's feeding due to their not being residue on the syringe after the last flush. Nurse #10 stated she was not aware the syringe was required to be dried before placing the syringe back in the storage bag. Nurse #10 indicated she was aware the plastic syringe and plunger should be washed if residue is left in the syringe but was not aware the plunger should be left out to air dry to prevent any bacterial growth in the syringe. Nurse #10 confirmed she had given Resident #73 his medications through his feeding tube earlier this shift. An interview was conducted with the Director of Nursing on 12/04/25 at 1:40 PM and she stated after an enteral feeding the plastic syringe and plunger should be washed and the plunger left out of the syringe to allow it to air dry to prevent any bacterial growth in the syringe. The DON further revealed nurses had been educated on this protocol and all new hires had been educated during orientation.During an interview with the Administrator on 12/04/25 at 2:05 PM she stated Nurse #10 should have washed the plastic syringe and plunger separately to remove any residue and allowed them to dry completely to prevent any bacterial growth.

Based on observations, record reviews, and resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 3 residents reviewed for food preferences (Resident #136).Findings included:Resident #136 was admitted to the facility on [DATE].Review of Resident #136's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Review of Resident #136's undated preference sheet revealed that she disliked grits and hot cereal (oatmeal) for breakfast.An interview and observation with Resident #136 on 12/03/25 at 9:15 AM revealed she had received hot cereal for breakfast. Resident #136 stated she disliked hot cereal and had informed both dietary and nursing staff on multiple occasions, expressing a preference for yogurt instead.An interview and observation with Resident #136 on 12/04/25 at 9:00 AM revealed she had received grits for breakfast. Resident #136 reiterated that she disliked grits and had communicated this to dietary and nursing staff multiple times, again expressing a preference for yogurt.An interview with Nurse #1 on 12/04/25 at 10:45 AM revealed that Resident #136 had frequently expressed dissatisfaction with receiving food items she did not prefer. Nurse #1 stated she had communicated this to dietary staff but could not recall to whom she had spoken.An interview with the Dietary Manager on 12/04/25 at 9:45 AM indicated ongoing issues with tracking residents' food preferences due to problems with the facility's meal program software. The Dietary Manager acknowledged that multiple residents had received food items they did not prefer and confirmed that Resident #136 had consistently received items she disliked. She stated that a better system was needed to ensure residents received food items they preferred.An interview with the Director of Nursing (DON) on 12/04/25 at 1:20 PM revealed she was unaware that Resident #136 or other residents had received food items they did not prefer. The DON stated she expected residents to receive food items that matched their preferences.An interview with the Administrator on 12/04/25 at 2:00 PM revealed that residents had not voiced concerns about food preferences to her. The Administrator stated she expected residents to receive food items they preferred.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.5% for 3 of 5 residents (Resident #24, Resident #53, and Resident #168) observed during the medication administration observation.The findings included: 1. Resident #24 was admitted to the facility on [DATE]. Her cumulative diagnoses included end stage renal disease requiring hemodialysis. On 12/3/25 at 4:50 PM, Nurse #2 was observed as she began to prepare medications for administration to Resident #24. The medications were administered at 5:05 PM and included two tablets of 800 milligrams (mg) sevelamer. Sevelamer is a phosphate binder used to control blood phosphorous levels for patients with chronic kidney disease on dialysis. A review of Resident #24's December 2025 Physician Orders included a current order for 800 mg sevelamer to be given as two tablets by mouth with meals for end stage renal disease. The sevelamer was scheduled for administration at 9:00 AM, 1:00 PM, and 6:00 PM. The manufacturer's prescribing information for sevelamer noted this medication should be taken with meals. The facility's schedule for the delivery of meal trays to each of the residents' hallways was reviewed. The schedule indicated the evening dinner meal trays for Resident #24's hall were scheduled to be delivered at 6:35 PM daily. An interview was conducted with Nurse #2 on 12/3/25 at 5:55 PM. As of the time of the interview, no evening meal trays had been delivered to Resident #24's hallway. Upon request, Nurse #2 reviewed Resident #24's medication order which included instructions to administer sevelamer with meals. The nurse stated she thought those instructions just meant that sevelamer should be given with food and added that she had given Resident #24 juice and crackers approximately 10 minutes before the observation of her medication administration. However, Nurse #2 confirmed the resident would still be receiving her evening meal (not yet delivered). The nurse reported she was not aware the medication was intended to be given with meals. 2. Resident #53 was admitted to the facility on [DATE]. On 12/3/25 at 7:50 AM, Nurse #1 was observed as she prepared eight (8) medications for administration to Resident #53. The medications included two tablets of a single ingredient medication with each tablet containing 8.6 milligrams (mg) sennosides (a stimulant laxative) taken from a stock medication bottle stored on the medication cart. The medication was administered to Resident #53. A review of Resident #53's current physician's orders revealed his medication orders included a combination medication containing 8.6 mg sennosides and 50 mg docusate (a stool softener) to be given as two tablets by mouth two times a day for bowel management. Resident #53 did not have a physician's order for the sennosides to be given as a single ingredient medication. An interview was conducted on 12/3/25 at 10:00 AM with Nurse #1. At that time, Nurse #1 reviewed Resident #53's December 2025 Medication Administration Record (MAR) and confirmed a physician order was written to administer a combination medication containing 8.6 mg sennosides and 50 mg docusate to the resident. The nurse pulled the stock bottle containing 8.6 mg sennosides used for the medication administration observation from the medication cart, reviewed its labeling, and acknowledged it contained sennosides but did not include the second ingredient (docusate). Upon further review of the stock medications available on the medication cart, Nurse #1 identified a bottle containing a combination of the two medications (8.6 mg sennosides and 50 mg docusate) as ordered by the physician. The nurse confirmed she should have administered the combination medication (including docusate) instead of a single ingredient medication containing only sennosides. Nurse #1 stated, I've learned something. 3. Resident #168 was admitted to the facility on [DATE]. On 12/3/25 at 8:55 AM, Medication Aide (Med Aide) #1 was observed as she prepared eight (8) medications for administration to Resident #168. The medications included one tablet of a single ingredient medication with each tablet containing 8.6 milligrams (mg) sennosides (a stimulant laxative) taken from a stock medication bottle stored on the medication cart. The medication was administered to Resident #168. A review of Resident #168's current physician's orders revealed her medication orders included a combination medication containing 8.6 mg sennosides and 50 mg docusate (a stool softener) to be given as one tablet by mouth two times a day for constipation. Resident #168 did not have a physician's order for the sennosides to be given as a single ingredient medication. An interview was conducted on 12/3/25 at 10:43 AM with Med Aide #1. Upon request, the medication aide reviewed Resident #168's December 2025 Medication Administration Record (MAR) and confirmed her medication order was for a combination medication containing both sennosides and docusate. When she pulled the stock bottle used to provide the laxative for Resident #168, it was noted that the ingredient label indicated that medication bottle contained 8.6 mg sennosides only. Med Aide #1 then found a different stock bottle stored on the medication cart that contained the sennosides / docusate combination medication ordered for Resident #168. At that time, Med Aide #1 acknowledged she was not previously aware there was a difference between these two stock bottles of medication. She confirmed that she should have administered the combination medication containing 8.6 mg sennosides and 50 mg docusate instead of the single ingredient sennosides to Resident #168. An interview was conducted on 12/4/25 at 12:33 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she would expect nursing staff to look carefully at both the medication and the resident's medication order when passing medications. The DON added that the 6 medication administration rights should always be observed (right patient, right drug, right dose, right route, right time, and right documentation).

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge (Resident #163) and Hospice (Resident #7) for 2 of 29 residents reviewed for accuracy of assessments. The findings included: 1. Resident #163 was admitted to the facility on [DATE]. Review of the discharge MDS assessment dated [DATE] indicated Resident #163 was discharged to home. Review of a nursing progress note dated 9/21/25 indicated Resident #163 was sent to the hospital for evaluation following an episode of sudden confusion and shaking. An interview with the MDS Nurse on 12/4/25 at 1:43 PM was conducted. She stated the discharge MDS for Resident #163 dated 9/21/25 was coded for a discharge to home because Resident #163's Responsible Party (RP) informed the facility that he was sent home from the hospital and would not return to the facility. She stated since Resident #163 ultimately went home, she coded the MDS to reflect his discharge home. An interview with the Director of Nursing (DON) on 12/4/25 at 2:52 PM revealed residents' discharge MDS should accurately reflect their discharge location from the facility. During an interview with the Administrator on 12/4/25 at 3:40 PM she indicated the MDS should be completed accurately. The findings included: 2. Resident #7 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia and rheumatoid arthritis. A Hospice Comprehensive Plan of Care dated 9/11/2025 indicated that Resident #7 was admitted under the care and services of Hospice for end of life on 6/19/2025. Further review of the Hospice Comprehensive Plan of Care for Resident #7 indicated that a recertification of Resident #7's prognosis of 6 months or less was received on 9/11/2025 from the physician. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was severely cognitively impaired and received Hospice services. Resident #7's prognosis of 6 months or less was coded no. An interview on 12/4/2025 at 1:30 PM with the MDS Coordinator revealed she had completed the quarterly MDS dated [DATE] for Resident #7 and coded it incorrectly for the prognosis of 6 months or less which should have been coded yes. The MDS Coordinator stated the incorrect coding was a mistake and the MDS should have been coded correctly. An interview on 12/4/2025 at 3:56 PM with the Administrator indicated that the MDS assessments should be accurate.

Based on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 3 wound care observations on 1 of 2 residents reviewed (Resident #25). The findings included: The facility's policy entitled Hand Hygiene last revised on 10/2022 indicated the following: Specific indications for hand hygiene included after contact with body fluids or excretions, non-intact skin, wound dressings, and after removing gloves. Gloves - If gloves are worn for a procedure, hand hygiene is to be completed before putting on gloves and after removal and deposit of gloves in appropriate container. The use of gloves does not replace hand hygiene. A continuous observation of wound care on 8/7/24 from 9:08 AM through 9:40 AM revealed Nurse #1 applying hand sanitizer to both hands, and putting on gloves and a gown before entering Resident #25's room. She removed the old dressing on Resident #25's wound to her left upper back. The old dressing had a large amount of drainage that was colored green and had a foul odor. Nurse #1 discarded the old dressing and removed her gloves. Without doing hand hygiene, she proceeded to put on a new pair of gloves, and cleaned the wound with a gauze soaked with wound cleanser. Nurse #1 removed her gloves and without doing hand hygiene, she put on a new pair of gloves to both hands. Nurse #1 packed the wound with a medicated packing strip, removed her gloves and put on new gloves. She then applied zinc oxide to the surrounding skin, removed her gloves and put on new gloves. She covered the wound with a dry gauze and a dry bordered dressing. Nurse #1 removed both gloves and without doing hand hygiene, put on a new pair of gloves to both hands. At 9:25 AM, Nurse #1 was observed to clean Resident #25's deep tissue injury to the right heel with a gauze that had been soaked with wound cleanser. She removed her gloves and without performing hand hygiene, she put new gloves on and applied skin prep to Resident #25's right heel. She discarded her gloves and put new gloves on. Nurse #1 proceeded to remove Resident #25's old dressing on her right upper back wound. The old dressing was moderately soaked with serosanguineous drainage (clear serous fluid and blood mixture). Nurse #1 removed her gloves and without doing hand hygiene, put on new gloves. She cleaned the wound with a gauze that had been moistened with wound cleanser and then wiped it with a dry gauze. She removed her gloves and put new gloves on. She packed the wound with a medicated packing strip, removed her gloves and put new gloves on. Nurse #1 applied zinc oxide to the surrounding skin, covered the wound with a dry gauze and a bordered dressing. She discarded any unused supplies including her gown and gloves, and washed her hands. An interview with Nurse #1 on 8/7/24 at 11:48 AM revealed she had been educated to wash her hands before getting started with wound care, and during wound care after changing her gloves. Nurse #1 stated that she knew that she was supposed to sanitize her hands after removing gloves and that she tried to carry a hand sanitizer with her, but she forgot to do so during the wound care observation on Resident #25. A phone interview with the Infection Preventionist (IP) on 8/7/24 at 12:12 PM revealed staff was supposed to wash hands before doing wound care, when removing dressings and after changing gloves. The IP stated that hand hygiene was supposed to be done after each glove change. The IP shared that in-services regarding infection control especially hand hygiene was a continuous process, and he last did an education with all staff on July 2024 wherein he covered topics such as the use of Personal Protective Equipment and handwashing. The IP further shared that he had not observed Nurse #1 perform wound care because she usually did the dressing changes in the early mornings when he was not in the facility, but he had not heard of any issues regarding wound care. He also stated that he had done an education with Nurse #1 on wound care and hand hygiene, but he could not remember the date when he did it. The IP further stated that it was a problem that Nurse #1 did not do hand hygiene in between changing gloves, and that she might have forgotten to do it during the observation. He also stated that if a resident had multiple wounds, he would advise to start with the least infected wound going to the most infected wound to prevent possible cross-contamination. An interview with the Director of Nursing (DON) on 8/7/24 at 11:55 AM revealed staff was supposed to wash their hands or perform hand hygiene every time gloves were removed. The DON stated that they often did education with all their staff regarding infection control and hand hygiene procedures.

Based on observations, record reviews and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 out of 1 sampled resident observed with medications left at bedside (Resident #42). The findings included: Resident #42 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] showed that Resident #42 was cognitively intact. Review of Resident #42's care plan dated 7/29/24 revealed there was no focus area for self-administering medications. Upon review of Resident #42's medical record, there was no Self Administration assessment for any prescribed medications. Resident #42's Medication Administration Record (MAR) revealed that Medication Aide #1 signed off administering the following medications to Resident #42 on 8/5/24 and 8/7/24 at 9:00 AM. Medication Aide #1 administered aspirin 81mg (milligrams), Flomax 0.4mg, loratadine 10mg, potassium chloride, vitamin C 5000mg, vitamin D3 2000 units, zinc 25mg, docusate sodium 100mg, Eliquis 5mg, furosemide 20mg and chlormadinone. On 8/05/24 at 10:41 AM an interview and observation were made of Resident #42. Resident #42 was in his bed, and he had a clear medication cup sitting on his bedside table full of pills. During the conversation Resident #42 picked up the cup and took his pills. Resident #42 stated that sometimes he was not ready to take his medication when the nurse brought them. Resident #42 stated that the nurse left the medicine for him to take. Resident #42 stated he always takes his medication and doesn't throw any out. Resident #42 stated he knows what medicine he takes and when. Resident #42 stated he has lived at the facility for a long time and doesn't remember being assessed to take his medications without supervision. On 8/06/24 at 2:35 PM an interview was conducted with Medication Aide #1. Medication Aide #1 stated that if a resident would like to be independent with medications they would need to get a physician's order from the doctor and would need to be assessed. If the resident refused to take medications the staff would mark refusal in computer. Medication Aide #1 stated that if Resident #42 refused or was not ready to take his medications she would need to hold the medications for a few minutes and then reapproach and offer the medications again. Medication Aide #1 stated that Resident #42 has told her in the past he was not ready for medications, this usually occurred in the morning when he was not awake all the way. When this happened staff would take his medications and hold them and then reapproach. Medication Aide #1 had not left medications with Resident #42 without supervision. Medication Aide #1 stated that currently she has no residents that take medications independently. On 8/07/24 at 9:30 AM a second observation and interview was made with Resident #42. Resident #42 again had a clear pill cup with pills. The cup was in Resident #42's hand. Resident #42 was observed taking his pills. No nurse or medication aide was present in or around the room. On 8/07/24 at 9:36 AM a second interview was conducted with Medication Aide #1. The Medication Aide stated that she remembered Resident #42 bringing the cup up to his mouth and she thought he had taken all his medicine. Medication Aide #1 stated that Resident #42 does need to be observed when taking his medications. Medication Aide #1 stated she should have stayed to make sure Resident #42 took all his medications. On 8/07/24 at 11:01 AM an interview was conducted with the Director of Nursing (DON). The DON stated that for a resident to be able to take medication independently a self-assessment would be completed to see if they can self-administer. The nurses would do the teaching, and the resident would demonstrate. If deemed able to self-administer the nurse staff would keep the medicine on the medication cart. Resident #42 had not been assessed to take his own medications and should be supervised. The staff should not walk away when administering medications.

Based on record review and interviews with residents, staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 1 resident (Resident #4) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised in February 2024, revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. A review of the physician's order dated 11/22/23 revealed Resident #4 had an order to receive 1 tablet of oxycodone (a semi-synthetic narcotic analgesic for pain) 5 milligrams (mg) by mouth once daily in the morning for knee pain. A review of the medication administration records (MARs) revealed Resident #4 had received 1 tablet of oxycodone 5 mg once daily as ordered throughout the month of November 2023. The initial allegation report dated 11/27/23 revealed the facility became aware of the misappropriation of residents' property on 11/27/23 at 7:00 PM when Resident #4's oxycodone and its controlled medication count sheet could not be found in the medication cart. All medication carts were audited to locate the missing card of oxycodone. All residents were assessed for pain and alert and oriented residents were interviewed for concerns with pain medication administration. A review of the 5-day investigation report dated 12/04/23 revealed on 11/27/23, a blister card contained 24 tablets of oxycodone 5 mg and the controlled medication count sheet for Resident #4 were allegedly removed by Nurse #2. All nursing staff worked with the medication cart in the past 24 hours except Nurse #2 were interviewed and indicated that they did not remove any controlled medication sheet from the medication cart in that time frame. Nurse #2 who worked with the medication cart on the day the prescription numbers were written as being removed from the shift count controlled medication sheet did not return the calls. Several attempts to call Nurse #2 went unanswered. Further investigation by reviewing the camera footage revealed Nurse #2 was seen removing items from the medication cart during her shift on 11/26/23. The allegation of diversion of Residents' drugs was substantiated and Nurse #2 was terminated on 11/27/23. A review of the controlled medication count sheet for medication cart in C-halls indicated Medication Aide (MA) #1 had removed 2 medication cards from the controlled medication compartment during her shift on 11/26/23 with 36 cards remaining in the medication cart. However, further review of the handwriting and signature revealed they were inconsistent with MA #1's other handwriting documented in the controlled medication count sheets. An interview was conducted with the Medical Director on 06/05/24 at 5:01 PM. He stated he was made aware of the alleged drug diversion incident on the same day in November 2023. He added the affected resident (Resident #4) was assessed immediately without any adverse consequences noted. The missing pain medication was obtained from the Pyxis without any delays. He indicated all the missing medications were replaced and paid for by the facility later. During an interview conducted on 06/05/24 at 5:15 PM, Resident #4 stated she was notified of the alleged drug diversion on 11/27/23 and received oxycodone as ordered in a timely manner in that morning. The facility reordered and paid for the missing oxycodone. She did not have problems getting her pain medication as ordered in a timely manner so far. An interview was conducted with Unit Manager (UM) #1 on 06/05/24 at 5:35 PM. She recalled the former Director of Nursing (DON) called her on 11/27/23 morning to assist the investigation related to the alleged drug diversion. After she and the former DON audited all the pertinent pharmacy packing slips, MARs, prescription order tracking records, controlled medication return sheets, and comparing controlled medications in all the medication carts, they concluded that a total of 24 tablets of oxycodone 5 mg for Resident #4 were missing and Resident #4 was the only resident affected by this incident. She assisted the former DON assessing and interviewing residents for potential pain or concerns with medication administration. She did not find any issues for all the residents she handled that day. During a phone interview conducted on 06/05/24 at 6:35 PM, Nurse #1 stated she started her shift on 11/27/23 morning by counting the controlled medications in the double-locked compartment of medication cart with Nurse #2 and found that the quantity of controlled medication sheets and the number of blister card of controlled medications were matched. When she attempted to administer Resident #4's oxycodone around 9 AM, she found that the oxycodone was not in the cart. She could not find the oxycodone even though she had double-checked the entire medication cart. She called the DON and obtained instruction to retrieve 1 tablet of oxycodone 5 mg from the Pyxis. As she thought nurses who worked in the previous week did not re-order oxycodone for Resident #4, she called the pharmacy to reorder and was told that it was too early. When she called MA#1 who worked with the medication cart a day before, MA #1 confirmed a card of at least 20 tablets of oxycodone 5 mg for Resident #4 was in the medication cart when she worked. Then, he called the former DON and was told to recheck her medication cart again and check other medication carts if needed. She recalled she re-checked her entire medication cart again 3 more times and other medication carts at least once without having any success. When she checked the controlled medication count sheet in the narcotic book, she found that the count sheet for Resident #4's oxycodone 5 mg was missing. After she notified the former DON that she could not find the oxycodone and the controlled medication count sheet as well, the former DON told her that she would come to the facility to start the investigation. An interview was conducted with MA #1 on 06/06/24 at 10:19 AM. She recalled Nurse #2 relief her on 11/26/23 around 7:00 PM. When she counted the controlled medications in the medication cart for C-halls with Nurse #2, she recalled Nurse #2 asking her why there were 38 cards in the controlled medication compartment. She explained that the diabetic kit that was stored in the double-locked compartment was also counted as one item. Then both staff signed the controlled medication count sheet, and she handed over the medication cart key to Nurse #2. She did not recall signing out any controlled medications from the medication cart for C-halls that shift. The next day the former DON called her and wanted to know if she had signed out any card from the controlled medication compartment. She denied signing any cards that shift. Later, she found that the handwriting and signature documented in the controlled medication count sheet on 11/26/23 were not written by her. The former DON requested her to write a statement related to this incident. During a phone interview with Nurse #2 on 06/06/24 at 10:43 AM, she denied any involvement in the alleged drug diversion that occurred in November last year. She added the North Carolina Board of Nursing had cleared up the allegation and refused to provide any additional information. A phone interview was conducted with the former DON on 06/06/24 at 10:48 AM. She recalled Nurse #1 called her on 11/27/23 morning reporting problems locating Resident #4's oxycodone. When Nurse #1 called the pharmacy to reorder, she was told that the facility had just received 30 pills of oxycodone 5 mg about 2 weeks ago. She instructed Nurse #1 to check the entire medication cart as Nurse #2 who had worked the prior shift was an agency nurse, and she could have placed the oxycodone in the wrong compartment. When Nurse #1 called again to notify her that she was still unable to find the oxycodone, she told Nurse #1 to get the oxycodone 5 mg from Pyxis and then search all other medication carts with assistance from UM #1. Investigation revealed Nurse #2 had faked MA #1's signature signing out 2 cards. When she audited the pharmacy packing slips, MARs, controlled medication return sheets, prescription numbers, and the compared with the controlled medication in the medication cart, she found that Nurse #2 had taken 24 tablets of oxycodone 5 mg and its controlled medication count sheet at the same time. In addition, when she rolled back the video footage, she observed Nurse #2 took items from the medication cart covered with her clothing and walked out of the building. She interviewed all the nurses who worked 24 hours prior to the incident except Nurse #2 who would not answer or return the calls. She reported the incident to the Department of Health and Human Services (DHHS), law enforcement agent, North Carolina Board of Nursing, and the Adult Protective Services. In addition, the Medical Director, Resident #4, and her family were all notified. The missing oxycodone was reordered and paid for by the facility. All residents were assessed, and alert and oriented residents were interviewed for possible harm. In-service related to narcotic accountability and process was conducted to all the current employees, agency staff, and new hired. She audited at least one medication cart and 5 residents once weekly for 4 weeks and then monthly for 2 months. The audit report was presented to the weekly Quality Assurance Performance Improvement (QAPI) meeting for 3 months. After the incident, she did not recall having any additional incident related to controlled medication discrepancies or drug diversion. The facility provided the following corrective action plan with a completion date of 12/02/23: Corrective action for resident(s) affected by the alleged deficient practice: On 11/27/2023 Nurse #1 notified Director of Nursing that a card of oxycodone 5 milligrams (mg) tablets was missing that were prescribed for Resident #4. Nurse #1 assessed Resident #4 for pain and retrieved Resident #4's 9 am scheduled dose of oxycodone 5 mg from facility Pyxis to administer to Resident #4. The Director of Nursing initiated investigation and began to search for the oxycodone 5 mg medication card with Resident #4's name on the card. The Director of Nursing was unable to locate the narcotic card of Resident #4. Director of Nursing assessed Resident #4 for pain, no issues with pain were noted and she notified Medical Director of alleged narcotic diversion and to request new prescription for oxycodone 5 mg for Resident #4 be sent to pharmacy. Director of Nursing notified the Pharmacy that the facility was not able to locate the narcotic card for Resident #4 and she notified the pharmacy that Medical Director would be sending them a new prescription for oxycodone 5 mg to be filled and sent out with regular delivery on evening of 11/27/2023. Per pharmacy, 30 tablets of oxycodone 5 mg were last delivered on 11/13/2023. The Director of Nursing was able to determine approximately 24 of 30 tablets were missing of oxycodone 5 mg for Resident #4. The Director of Nursing made pharmacy aware to charge medication to the facility. On 11/27/2023, 90 tablets of oxycodone 5 mg were delivered to the facility for Resident #4. On 11/27/2023 at 6:45 pm the Administrator notified the Police Department and Adult Protective Services of alleged narcotic diversion and filed a report. On 11/27/2023 the facility self-reported with a 24-hour/5-day to the North Carolina Department of Health and Human Services of alleged diversion pertaining to Resident #4. Director of Nursing called Nurse #2 who had worked the 7 pm -7 am shift on 11/26/2023 to ask Nurse #2 to come into facility to submit to a drug screen and provide a statement. The Director of Nursing was unable to reach Nurse #2. She reached out to the Staffing Agency to inform them of the alleged drug diversion incident and instruct them to attempt to reach out to Nurse #2 regarding diversion and informed them of Nurse #2 suspension pending investigation. Nurse #2 did not work on or after 11/27/2023 and was deemed a do not return agency employee. On 11/29/2023, the Administrator completed the North Carolina Board of Nursing Complaint Evaluation Tool and submitted a complaint to the North Carolina Board of Nursing for Nurse #2. Corrective action for residents with the potential to be affected by the alleged deficient practice. On 11/27/2023 the Director of Nursing identified residents that were potentially impacted by this practice by completing interviews with residents with a Brief Interview for Mental Status (BIMS) score of 13 or higher and completed a pain assessment for residents with BIMS of 12 or less on all current residents. All narcotics were audited on all medication carts for discrepancies. This was completed on 11/29/2023. The results included: No other residents affected by this deficient practice. All narcotics accounted for on all medication carts. On 11/28/ 2023, incident reviewed with Quality Assurance Team to discuss investigation finding. Findings were medications unable to be accounted for only one resident (Resident #4). No other residents were affected by the alleged deficient practice. Resident #4 did not miss any medications and was not affected by the alleged deficient practice. Facility to monitor 5 residents for narcotic counts weekly for 4 weeks and monthly for 2 months with ongoing education. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: On 11/27/2023, the Director of Nursing began in-servicing for all full-time, part-time and PRN (as needed) registered nurses, licensed practical nurses, and medication aides including agency nursing staff on the Narcotic Process policy. This training included: Misappropriation of Resident Property and the Narcotic Process Policy. The Narcotic Process policy includes ordering, receipt, storage and record keeping of narcotics, this policy also includes systems to assist with prevention and recognition of diversion and what to do once diversion is suspected and corrective actions to take. As of 11/29/2023, 15% of staff members have not attended the in-service. The Director of Nursing will ensure that any of the above-identified staff who did not complete the in-service training by 11/30/2023 will not be allowed to work until the training is completed. This training will be included in the new hire orientation for any newly hired staff. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. Beginning 12/1/2023, The Director of Nursing or designee began monitoring the controlled substance process using the QA Tool for Controlled Substances Process. This was completed weekly for 4 weeks then monthly for 2 months. Reports were presented to the weekly Quality Assurance Performance Improvement (QAPI) Committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and an ongoing auditing program will be reviewed at the Quality Assurance Performance Improvement Weekly Meeting. The weekly QAPI Meeting was attended by the Administrator, Director of Nursing, Unit Managers, Minimal Data Set Coordinator, Therapy Manager, Health Information Manager, and the Dietary Manager. Date of Compliance: 12/02/2023 The facility's corrective action plan with a correction date of 12/02/23 was validated onsite on 06/06/24 by record review, observations, and interviews with nursing staff, DON, and the Administrator. Medication Administration observations were conducted from 06/05/24 through 06/06/24 and it consisted of 28 medications, 4 different residents, and 4 different Nurses. Controlled medication was pulled from the double-locked compartment in the medication cart during the medication pass observation. The nurse documented the retrieval of controlled medication in the controlled medication count sheet properly. Random samples of 3 controlled medications were pulled from each medication cart to verify accuracy and the controlled medication counts were consistent with the records in the count sheets. An observation was conducted during a shift transition. The arriving and the departing nurses started the process by counting the total number of blister cards containing controlled medication in the double-locked compartment to verify the total number of controlled medications in the count sheet. Then, they counted each blister card of controlled medication to ensure the quantity listed in the count sheet was consistent with the actual counts. The departing nurse read out the number of pills for each blister card from the controlled medication count sheets and the arriving nurse pulled the blister card to verify the quantity. After all the counts were completed without any discrepancies, the arriving nurse signed the controlled medication count sheet before the departing nurse passed the medication cart key to her. The nursing staff confirmed during the interviews that they had received in-service training related to Abuse, neglect, misappropriation, reporting, code of ethics, and diversion and The Control Substance Process. They were assigned to review the handouts for the in-service prior to the training. The training was conducted in-person by DON, and it included multiple examples and scenarios. A review of the in-service log revealed a total of 56 nursing staff had completed the training and signed in the in-service records. The training was completed on 11/30/23. A review of the audit records revealed 5 residents receiving controlled medications were randomly audited by the DON or designee once per week for 4 weeks by comparing controlled medication count sheets, MAR, and the controlled medication return sheets. At least one medication cart was randomly audited by the DON or designee once per week for 4 weeks to ensure all controlled medication counts were conducted properly and the count sheets were documented accordingly. In addition, the DON and designee had conducted pain assessments and interviews with 5 residents who receiving pain medication once weekly for 4 weeks to ensure all the pains were addressed and the facility was free of drug diversion. The DON presented the findings of the audit tools to the Quality Assurance Performance Improvement Committee (QAPI) for 3 months. Interview with the Administrator and DON revealed the former DON started the in-service related to controlled medication process and accountability immediately after the incident to re-educate all the licensed nurses and medication aides. The Administrator stated the interventions were successful as the facility did not have any similar drug diversion issues since then. The compliance date of 12/02/23 was validated.

Based on observation, record review and Resident, transportation company staff, insurance manager, facility staff, Wound Physician and Medical Director interviews, the facility failed to secure Resident #1 and her wheelchair to the vehicle according to the manufacturer's instructions to prevent her from sliding forward from the wheelchair during a contracted van transport. When the driver applied the brakes in traffic it caused Resident #1 to slide forward from the wheelchair, her face on the back of the driver's seat and pinning her right kneecap on the van floor. Resident #1 was taken to the hospital for evaluation and a computed tomography (CT) scan of her head and spine resulted negative and three x-ray views of the right knee resulted negative. The Resident was returned to the facility the same day. The Resident had moderate to severe pain and her right kneecap developed a blister that resulted in an open wound that continued to require treatment and had not healed as of the survey. This deficient practice had the likelihood of causing serious injury for 1 of 3 residents (Resident #1) reviewed for accidents. The findings included: The undated manufacturer's instructions for the securement system used in the contracted transportation service vans used to transport residents who were seated in the wheelchairs for transports was made up of four retractors, one occupant lap belt, one occupant shoulder belt and floor anchorages. The instructions read in part 9. Non WC19 Wheelchairs (A wheelchair that does not meet a voluntary industry standard that establishes minimum design and performance requirements for wheelchairs that are occupied by users traveling in motor vehicles.): attach shoulder belt pin connector to pin on rear retractor closest to wall. Occupant restraint shoulder and pelvic belt must not be held away from the occupant's body by wheelchair components. 10. Attach the pelvic belt pin connector to pin on rear retractor closest to the aisle. 11. Pull the shoulder belt over occupant's chest and buckle shoulder belt pelvic connector to removable pelvic belt. 12. Adjust shoulder belt height so that shoulder belt rests on shoulder. After the occupant and vehicle are secured, the occupant is ready for transportation. Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident with left side hemiplegia (paralysis of one side of the body) and left above the knee amputation, pain and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had functional impairment of range of motion on one side of her upper and lower extremities. The MDS indicated the Resident also received routine and as needed pain medication. During an interview with Nurse Aide (NA) #5 on 03/20/24 at 11:45 AM the NA explained that she was the one who got Resident #1 ready for her doctor's appointment on 02/06/24 and the Resident had no complaints of feeling dizzy or sick or she would have informed the nurse. The NA continued to explain that she transferred Resident #1 into the manual wheelchair that she normally used when she had out of the facility appointments. A review of a Nurse Progress Note dated 02/06/24 at 1:22 PM written by Nurse #4 revealed, the Resident #1 left out of the facility for appointment in stable condition alert and oriented. An interview was conducted with Nurse #4 on 03/20/24 at 7:45 PM who reported that she was the Nurse on duty on 02/06/24 when Resident #1 went out of the facility for a doctor's appointment via the transportation van. The Nurse explained that she did not remember Resident #1 having any complaints of being dizzy or sick before she left for the appointment. She stated Van Driver #1 was always good about asking if the residents were okay for the transportation before he took them off the floor and she specifically remembered that the Van Driver asked her that day about Resident #1 before he took her off the floor and she told him that Resident #1 was okay to go to her appointment. A review of a written verbal statement from Resident #1 dated 02/08/24 witnessed and signed by the Director of Nursing revealed Resident #1 stated that she was correctly strapped in the wheelchair by the Van Driver. When she was questioned regarding the top strap being pulled across her and being secured in the wheelchair the Resident stated yes, the top strap was fastened and secured. The Resident stated she felt the Van Driver had secured her safely in the wheelchair and van. She stated the wheels were locked on the wheelchair. Resident #1 stated that at no time did she feel dizzy, and she was looking down because she had just made a phone call and was about to make another call. At that moment when she was looking through her contacts the Van Driver slammed on the brakes suddenly causing her to be thrown forward and pinned with the right side of her face hitting the back of the driver's seat. She stated her right knee was pinned on the floor of the van with her right leg turned backwards. The Resident stated she yelled to call 911. She continued, the Owner of the van service was the first to arrive on the scene and the Owner and the Van Driver started conversing in a language she did not understand. She stated the Owner and the Van Driver then cut the seatbelt and shortly after that the paramedics arrived and all of them removed her from the van then lowered her onto the ground and slid her onto the stretcher. The Resident stated the paramedics transported her to the hospital with no further issues. The Resident verbalized discomfort to her right lower extremity and the right side of her face in route to the hospital. On 03/20/24 at 10:00 AM an interview was conducted with Resident #1 who explained that she was being taken to her doctor's appointment by the transportation company van in a manual wheelchair and as far as she knew Van Driver #1 strapped her in with the seatbelt and shoulder harness and buckled the wheelchair down appropriately because she could not tell that anything was different. She stated she had ridden with the Van Driver before and had no problems with the transport, but she always thought that he drove too fast. The Resident continued to explain that she was looking down at her phone to call her family member when all the sudden the Van Driver slammed on the brakes and she and her phone flew up to the front of the van pinning the right side of her face against the back of the driver's seat and her right kneecap against the floor of the van with her leg bent behind her. The Resident stated she did not know why the Van Driver slammed on the brakes because she was looking down and he never said anything before he slammed on the brakes. Resident #1 reported she screamed to call 911 and let them know that she was in an accident, but the Van Driver called his boss (the Owner of the company), and the Owner showed up to the accident before the ambulance got to the accident. She stated they kept pulling on her coat collar saying let me see you, but she could not turn over because she was face forward and still strapped to the wheelchair. She stated the Owner finally cut the seatbelt that released her. The Resident continued to explain that the ambulance got to the accident about 20 minutes later and all the while her right knee was burning while pressing against the van floor. She reported when the ambulance got to the accident, they asked the Owner and Van Driver what happened, and the Owner stated she slid out of her wheelchair and the Van Driver was going to pull over to the side because she complained of being dizzy. She stated she knew that was not true, because why would she end up face forward up front if she just slid out of the wheelchair, but she did not say anything to the contrary. The Resident explained that they sat her up and laid her down and rolled her over on a slide pad then put her onto the stretcher. She stated they took her to the hospital where they did a CT scan of her head and right knee and there were no broken bones. She stated she returned to the facility late that night. Resident #1 reported that she did have pain in her knee and the facility was good to give her pain medication when she requested it to relieve the pain. During an interview with Van Driver #1 on 03/20/24 at 4:45 PM the Van Driver explained that on the afternoon of 02/06/24 he was scheduled to transport Resident #1 to a doctor's appointment and when he went to pick her up, she complained of being dizzy. He stated he checked with the Nurse before he took her off the hall and the nurse reported the Resident was okay to go to the appointment. The Van Driver reported that he secured Resident #1 into the van by the anchors and seatbelts the way he normally secured a resident in the van and started to the doctor's office. About 3 miles away he heard Resident #1 say, Help me and he pulled over off the road and when he got to where he could open the door, he saw that the Resident had slid out of the wheelchair and was pressing her head against the back of the driver's seat and her right leg was extended out to the side. He stated the wheelchair was still attached to her and the wheelchair was still anchored down. The Van Driver stated he called 911 and then he called the Owner of the company who arrived at the van before the emergency services arrived. He stated the Resident would not let them help her up, so the Owner cut the seatbelt off her and moved the wheelchair in order to be able to roll her over onto the stretcher when the emergency services got there. He stated they rolled her onto a cloth then transferred her over onto the stretcher and took her to the hospital. The Van Driver explained the facility immediately suspended the transport services by the company until the van could be inspected and the Van Drivers including the Owner were retrained by a representative of the facility. He indicated they endured weekly audits, and the audits were still going on. At 5:05 PM on 03/20/24 an interview and observation were made of Van Driver who reenacted how he secured Resident #1 into the van on 02/06/24 afternoon. The Van Driver utilized a random individual as a passenger in a wheelchair and secured the wheelchair to 4 floor anchors then applied a seatbelt and the shoulder strap to the individual. The Van Driver rocked the wheelchair to ensure it was safely secured to the anchors and ensured the individual could not slide out from under the seatbelt. When the Van Driver was asked how Resident #1 slid out of the wheelchair if she was securely strapped in the Van Driver brought his hands up to his chest and gestured that he did not know. The Van Driver was asked why he slammed on his brakes, and he stated he did not slam on his brakes because nothing was wrong. The Van Driver stated everything was fine until Resident #1 stated, Help me. When asked about the discrepancies in his explanation of the accident and Resident #1's explanation of the accident the Van Driver again brought his hands up to his chest and stated Ma'am, I don't know. Interviews were conducted with the Owner of the transportation company on 03/20/24 at 3:00 PM and 5:54 PM. The Owner stated that his transportation service for the facility was suspended on 02/06/24 immediately after the van incident for about 3 weeks when Resident #1 slid out of her wheelchair during a transport in one of his vans that was being driven by the Van Driver. He explained that before he could resume transportation for the facility, he along with his Van Drivers had to be retrained and the van that was used during the incident had to be inspected by the facility's Insurance Manager who did not find anything wrong with the seatbelts. He stated all the drivers of the vans had to be randomly audited for loading and unloading the passengers correctly and safely before the facility would reinstate their service and the random audits were still ongoing. The Owner continued to explain that the Van Driver had to perform a reenactment of how he secured Resident #1 in the wheelchair and the Insurance Manager determined that the driver did not secure the Resident in the wheelchair correctly. The Owner stated that he personally felt that the Van Driver secured Resident #1 in the wheelchair correctly because if he did not hook her up correctly, she would have fallen out of the wheelchair as they were driving out of the facility's parking lot because of so many turns they had to make in order to get to the doctor's office. The Owner explained that when he hired Van Driver #1 almost a year ago, the Van Driver was given 3 weeks of training before he was released to transport residents solo and there were no concerns with his performance. The Owner continued to explain that he remembered specifically that he told Van Driver #1 the morning of the transport to make sure Resident #1 was safely strapped in her wheelchair because she had a tendency to take naps and lean forward in the wheelchair. The Resident has even dropped her phone and had tried to pick it up during transport before. When the Van Driver was still at the facility, he called the Owner and reported that Resident #1 looked dizzy, and the Van Driver was told to check with the Nurse before he left with the Resident and the Resident told the Van Driver that she was only tired. Then about 3 miles into the transport the Van Driver called the Owner and reported that Resident #1 stated, Help me, help me and when he looked in the rear-view mirror she had started to slide out of the wheelchair and the Resident stated it was choking her. The Van Driver had to get through the traffic light and pull over. When the Van Driver pulled over, he got out and opened the side door of the van and found Resident #1 had already slid out of her wheelchair. The Van Driver called the Owner who told the Van Driver to call 911 which he did. The Owner stated that he arrived at the scene before the emergency services got there and found Resident #1 lying face forward on the van floor where she landed (she had not been moved from where she landed) and up against the back of the driver's seat and her seat belt was not on her it was lying underneath her. He stated he thought Resident #1 had removed the seatbelt that went across her belly because it was laying underneath her. He stated he had to cut the left front anchor strap to free the Resident up enough for them to roll her over and onto the stretcher. A review of an Incident Report dated 02/06/24 at 1:50 PM completed by Long Term Care Support Nurse revealed the Van Driver called this Nurse to report that while transporting Resident #1 to her doctor's appointment, the Resident complained of not being able to breathe and was feeling dizzy. The Van Driver pulled over and the Resident was leaning over in her chair. The Van Driver had to cut the seat belt to lower the Resident to the floor then called 911. The Resident was taken to the local hospital by ambulance. During an interview with the Long Term Care Support Nurse on 03/20/24 at 4:30 PM the Nurse explained that on the day of the accident she received a phone call from the Owner of the transportation company who reported that he was still trying to figure out what happened but there was a van accident and Resident #1 fell over forward out of her wheelchair and he had to cut the seatbelt because where the seatbelt was positioned on her, it was pressing into her. He said the Resident landed on one side and her knee landed on the floor of the van. The Nurse continued to explain that she immediately reported the accident to the Administrator. The Nurse stated a short while after that the owner of the transportation van came to the facility with the wheelchair that Resident #1 was sent to the appointment in. The Nurse reported the Owner of the transportation company explained that he received a phone call from the driver of the van who reported that he put the brakes on quickly and Resident #1 fell over face first. When the owner arrived at the van, he had to cut the seatbelt off her to relieve the pressure because she complained of the strap hurting her. The Nurse stated when Resident #1 returned to the facility she had a blister on her right kneecap that burst, and she was currently being seen by the Wound Physician. A review of Resident #1's emergency room visit on 02/06/24 3:02 PM revealed a CT scan of her head and spine resulted negative for injury and three x-ray views of the right knee resulted negative for fractures. A review of a Nurse Progress Note dated 02/07/24 at 6:32 AM written by Nurse #5 revealed, Resident #1 returned to the facility at 12:00 midnight via medic transport. The Resident was alert and oriented times three and verbally responsive. She was treated in the emergency room for a fall that included a CT scan of her head and x-ray to her right knee that showed negative fractures. The Resident complained of pain in the right knee of 9/10 with a rating of nine with the highest rating of ten and was relieved after pain medication was given. Her skin assessment revealed fluid filled blisters to her right kneecap and no other new areas noted. Attempts were made to interview Nurse #5, but the attempts were unsuccessful. A review of Resident #1's physician orders revealed: - an order on 02/06/24 for Oxycodone HCL 5 milligrams (mg) by mouth every 12 hours as needed for moderate to severe pain. A review of Resident #1's 02/2024 and 03/2024 Medication Administration Record indicated Resident required the as needed pain medication less than once a day. There were several days in a row when there was no pain medication administered. - an order on 03/06/24 to cleanse right knee with wound cleanser and apply a debriding agent and oil emulsion and cover with gauze border dressing once a day. On 03/20/24 at 10:20 AM an observation was made of Resident #1's right kneecap wound treatment and assessment conducted by the Wound Physician. When the dressing dated 03/19/24 was removed the entire right kneecap was an open wound that had brown necrotic tissue and yellow slough with a small amount of brown drainage. The wound measured 6.9 centimeters (cm) x 8.0 cm x 0.1 cm. The wound bed was 60% with 30% necrosis (dead tissue) and 10% granulation (healthy tissue). An interview was conducted with the Wound Physician on 03/20/24 at 10:30 AM. The Wound Physician explained that Resident #1's wound resulted from a fall that started out as a fluid filled blister and when he first consulted on the wound on 02/07/24 he ordered skin prep to be applied daily and keep pressure off the knee. He stated after a few visits the blister opened to a wound that required a daily dressing change and then required a daily debriding agent to soften the necrotic tissue so that it could be removed easier with the scalpel. During an interview with the Nurse Practitioner (NP) on 03/25/24 at 8:05 AM the NP confirmed that she was informed of the van incident that involved Resident #1 on the evening of 02/06/24. The NP explained that she was told that the Resident was being transported to a doctor's appointment and had come out of her wheelchair in the van and was taken to the emergency room . They determined that she had no fractures, but she had one intact blister to her right kneecap. The blister did eventually open and now she was being followed by the Wound Physician who consulted with her weekly. The NP stated that on 02/29/24 she had to increase Resident #1's pain medication from every 12 hours as needed to every 6 hours as needed and that seemed to manage her pain. An interview was conducted with the Director of Nursing (DON) on 03/20/24 at 3:20 PM. The DON explained that she was notified of the van accident involving Resident #1 by the Long-Term Care Support Nurse. She was told that Resident #1 would be transferred to the hospital for evaluation and that the family member and Physician were already notified. The DON reported that when she spoke with Resident #1 the following day the Resident explained that as far as she knew the van driver had strapped her in the wheelchair correctly but when he suddenly hit the brakes, she fell forward. Then, when she interviewed the Resident again on 02/08/24 for her statement the Resident reported the same thing that she fell forward out of the wheelchair and pinned her head up against the back of the driver's seat and pinned her right knee against the floor of the van. The Resident stated the van Owner was the first one to arrive at the accident and the van Owner cut the seatbelt off her before the emergency services arrived and took her to the hospital. The DON continued to explain that they did scans of her head and right knee and there were no fractures, but she did have a blister on her right kneecap that developed into an open wound and was currently being treated weekly by the Wound Physician. She reported the transportation service with that particular company was immediately halted pending investigation and training for several weeks. During an interview with the Administrator on 03/20/24 at 3:35 PM the Administrator explained that the Owner of the transportation company came into her office on the afternoon of 02/06/24 and reported that he received a phone call from Van Driver #1 who reported that Resident #1 was on the floor of the van, and he instructed the Van Driver to call 911. The Owner informed the Van Driver that he was close by, so the Owner arrived before the emergency services arrived at the scene. The Owner stated that when he arrived Resident #1 was leaning face down on the left side close to the driver's seat and he had to cut the seatbelt off to be able to lay the Resident down to release her from the wheelchair so the emergency services could get her on the stretcher to take her to the hospital. The Administrator stated Resident #1 returned to the facility the same day and did not have any fractures. The Administrator explained the corporate Insurance Manager who conducts the training for our company, conducted the investigation and determined through reenactment that the Van Driver did not properly place the retractors and the seatbelt system was not properly applied to Resident #1 for the transport. The Owner of the company and the Van Driver were retrained correctly on the securement system in the vans and weekly audits were done at random by the facility's medical supply clerk who is trained in van transportation, to ensure loading and unloading the residents were correctly done and was ongoing. The Administrator continued to explain that the residents who were transported by the van company before the incident were interviewed about the safety of the service and there were no complaints from the residents about their being unsafe for their transports. Residents who were currently transported by the transportation service continue to be interviewed about their safety and there have been no concerns brought forward. An interview was conducted with the Insurance Manager on 03/20/24 at 7:00 PM. The Manager explained that he had over [AGE] years of experience of training the company's van drivers as well as the incident investigator. He continued to explain that on 02/08/24 he met with the Owner of the company and the Van Driver and had the Van Driver reenact the incident using the exact same wheelchair that was used during the transport. The Van Driver demonstrated how he secured the resident in the wheelchair by the anchors and the seatbelts, and the Manager stated when the Van Driver finished, he determined that the Van Driver did not apply the seatbelt correctly by the standards of the company and the resident slid out from under the seatbelt. The Manager stated the seatbelt had to be applied correctly in order to restrain an individual in the seat and the individual slid out from under the seatbelt because it was not applied correctly. He stated the Resident did not release the seatbelt, she just slid out from underneath it. After that the Manager stated he showed the Van Driver how to set it up correctly and told the Owner to obtain the instruction manual for the securement system used in the van and retrain the drivers on the correct way to secure the individual in the wheelchair. The Manager explained the transportation service was immediately suspended for at least 3 weeks until they could produce a substantial training log to support the training in the correct way the seatbelt system should be applied, and weekly auditing was still being conducted by the facility. The Manager stated during the reenactment it was determined that the anchors were not placed properly but it did not have anything to do with the incident. The Administrator was informed of immediate jeopardy on 03/21/24 at 11:39 AM. The facility provided the following Corrective Action Plan with a compliance date of 02/16/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 2/6/2024, around 1:25 pm, Facility transport driver (contracted) arrived at the facility to transport with Resident #1 to an endocrinology appointment. Resident was loaded into transport van via wheelchair. Wheelchair was secured, shoulder harness applied in addition the seatbelt was secured to her person. At approximately 1:35 pm, driver left facility with resident in route to appointment. At approximately 1:45 pm, driver slammed on brakes causing resident to fall forward from wheelchair and land in floor with face against back of driver's seat. Immediately driver pulled over vehicle and called emergency medical for assistance. Driver then called transport company and owner arrived and assisted driver in cutting seatbelt to provide resident comfort from seatbelt harness. At approximately 2:50 pm, Emergency Medical Services arrived and transported resident to hospital for evaluation and treatment. On 2/6/2024, the Administrator immediately suspended the transport driver and company pending investigation. During the re-enactment it was discovered that the seatbelt system was not properly applied and the wheelchair retractors were not properly placed. On 2/6/2024, the Director of Nurses notified Resident #1's responsible party and the Medical Director of the van incident. On 2/7/2024, facility scheduled all transports with outside transportation service for the following week. Also, Resident #1's wheelchair was taken out of use and placed in Administrator's office for inspection. On 2/7/2024 at 12:00 midnight, Resident #1 returned to facility with no new orders. On 2/14/2024, transport van and Resident #1's wheelchair was inspected by Risk Management Insurance Manager. The inspection revealed no malfunctioning components of van's seatbelts or wheelchair. On 2/14/2024, transport driver was re-educated on how to properly apply the seatbelt system and the wheelchair retractors according to the Restraint Manufacturer Manual and the need to make sure residents are fully secured prior to transport. On 2/14/2024, Administrator concluded the van incident investigation and based on investigation findings the root cause of incident was due to lack of knowledge of the contracted transport driver and not properly applying the seatbelt system and the wheelchair retractors, this was identified by the Risk Management Insurance Manager During re-enactment. On 2/14/2024, a Quality Assurance and Performance Improvement meeting was held with the Interdisciplinary Team to review findings of investigation with no additional findings. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Beginning 2/7/2024, the Administrator and Director of Nursing identified residents that would be potentially impacted by the deficient practice by completing facility transportation audits for all current resident that had appointments in the past three months that had been transported by the outside transport van and asked if they had any issues or concerns when the transport driver transported them to or from an appointment. The results of the audit revealed no other residents identified with any issues or concerns with transports to or from appointments and that they had been secured with a seatbelt and felt safe. On 2/7/2024, all appointments scheduled for the following week were scheduled with outside transportation service. On 2/14/2024, after concluding investigation, the Quality Assurance Committee convened to discuss the van incident and the status of the investigation. There were no additional findings at that time. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 2/7/2024 the Administrator in-serviced the contracted transport driver on the facility transportation safety education policy and on how to properly apply the seatbelt system and the wheelchair retractors according to the Restraint Manufacturer Manual. On 2/14/2024, skills checkoff includes driver ensuring resident wears seatbelt, and how to apply seatbelt properly according to the facility transport education policy. Inservice was also done on securing the wheelchair and how to attach the retractors as well has how to apply the seatbelt properly this was derived from the Restraint Manufacturer Manual. This was completed with the Owner of the transportation company by our Risk Management Insurance Manager. The transportation company Owner will ensure that any newly hired transportation staff will receive this training prior to transporting residents. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; The Administrator/Designee will monitor 5 residents for safe transports using the Quality Assurance (QA) Tool for Van Safety starting 2/16/2024. This will be completed weekly for 4 weeks and monthly for 2 months. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. Include dates when corrective action will be completed. 2/17/2024 Immediate jeopardy removal date is 2/14/2024. The Administrator is the individual responsible for compliance with this action plan. On 03/21/24 the facility's correction action plan for immediate jeopardy removal was validated by the following: The facility provided documentation to support their corrective action plan including education provided to the transportation owner and van driver that included return demonstration and weekly auditing logs that included safely loading and unloading resident transports. The plan included documentation of resident interviews of safe transport by the transportation company with no concerns identified. The documentation included information submitted to the Quality Assurance Committee and the monitoring is ongoing, which is now on a monthly basis. An observation was conducted of the Van Driver and the Owner of the company who both demonstrated the correct method of securing a wheelchair to the 4-point wheelchair securement system including the seatbelt and shoulder harness. The facility's date of 02/17/24 for the corrective action plan was validated on 03/21/24.

Based on record review, activity calendar and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 7 residents reviewed for activities (Residents #1, #2, #3, #4, #5 and #6). The residents expressed not being able to leave the facility for over a year made them feel like they had lost some of their independence, felt terrible, isolated, confined, sad, trapped, and they missed getting out and socializing with a group and seeing people outside the facility. The findings included: A review of the March 2023 through March 2024 activity calendars revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility for any of these months. Observation on 03/20/24 at 9:30 AM revealed the facility was located within a business and residential area and was within a 1 to 3-mile radius of shopping complexes with various retail stores, restaurants, local and commercial coffee shops, fast food restaurants, grocery stores and a commercial super center. a. Resident #1 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #1 was cognitively intact. An interview with Resident #1 on 03/20/24 at 11:39 AM revealed there had not been a scheduled group activity outside of the facility in years and they had discussed it during resident council meetings each month and were told there was no transportation for the residents to be taken on outings outside the facility. She stated group activities outside of the facility were important to the residents that were able to go and participate because it allowed them some independence, socialization with the group and outside world, and helped with their overall mental and physical health. Resident #1stated not being able to leave the facility in over a year and participate with a group in activities outside the facility had made her feel as though she had lost some of her own independence and was having to rely on someone else to do her personal shopping that she enjoyed doing herself. She further stated she had gone out from time to time on the municipal bus system but it wasn't the same going alone as going with a group and had friends at the facility that wanted to get out as well. Resident #1 said it was very important to her to be able to go out and socialize with a group outside the facility. b. Resident #2 was admitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #2 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #2 was cognitively intact. An interview with Resident #2 on 03/20/24 at 4:29 PM revealed there had not been a scheduled group activity outside of the facility since she had been admitted and they had discussed it during resident council meetings several times and were told there was no transportation for the residents to be taken on outings outside the facility. She stated the residents had been told by administration but could not recall who, if they wanted to go on activities outside the facility, they would have to make the arrangements and secure transportation on their own for the activity. Resident #2 stated not being able to leave the facility since being admitted and participating with a group in activities outside the facility had made her feel sad and like she no longer had any independence in any aspect of her life. She further stated she had gone out from time to time with family but would love to be able to go out with friends at the facility as a group and enjoy the outside world if only for a couple of hours to feel like a normal person. Resident #2 explained that she was one of the younger residents at the facility and it was important to her to get out and shop and socialize with other residents and said it was very important to her to get out of the four walls of the facility and socialize with a group. c. Resident #3 was admitted to the facility on [DATE]. An admission MDS assessment dated [DATE] indicated Resident #3 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #3 was cognitively intact. An interview with Resident #3 on 02/20/24 at 4:00 PM revealed there had not been a scheduled group activity outside of the facility since he had been admitted and said he had attended resident council meetings occasionally and they had discussed it during the meetings and were told there was no transportation. He stated he used to compose music for symphonies all over the world and traveled to lots of different countries to hear his music played by the symphonies. Resident #3 further stated he would love to get out of the facility surroundings and be able to go with a group to a restaurant, movie or to listen to music or anything to get him out of the four walls of the facility. He said it had been difficult to be confined to a small space with four walls after traveling the world and said he was uplifted and encouraged by talking about getting out of the facility and socializing with a group and getting out in the real world with other people. d. Resident #4 was admitted to the facility on [DATE]. An Annual MDS assessment dated [DATE] indicated Resident #4 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #4 was cognitively intact. An interview with Resident #4 on 02/21/24 at 7:35 PM revealed there had not been a group activity outside of the facility in years and said she had attended resident council meetings monthly and they had discussed it during the meetings and were told there was no means of transportation for residents to go on outings. She stated she thought it would be wonderful to go out of the facility on group outings and said she felt like it would lift their spirits to get out of the same four walls they are confined to on a regular basis. Resident #4 further stated it was very important to her to get out and socialize with other residents in a group and was important to her to be able to go outside the facility to socialize with the outside world. e. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE]. An Annual MDS assessment dated [DATE] indicated Resident #5 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #5 was cognitively intact. An interview with Resident #5 on 03/21/24 at 7:00 PM revealed there had not been a group activity outside of the facility in years and said she had attended resident council meetings monthly and they had discussed it during the meetings and were told there was no means of transportation for residents to go on outings. She stated her roommate and she had brought it up themselves several times during meetings and other residents had brought it up as well and nothing had been done. Resident #5 further stated not being able to get out of the facility had made her feel sad and isolated from the outside world and said she would love to get out and go to a restaurant to eat or a coffee shop to have coffee and donuts or do anything just to be outside the facility and socialize with a group. f. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE]. An Annual MDS assessment dated [DATE] indicated Resident #6 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #6 was cognitively intact. An interview with Resident #6 on 03/21/24 at 7:00 PM revealed there had not been a group activity outside of the facility since her admission and said she had attended resident council meetings monthly and they had discussed it during the meetings and were told there was no means of transportation for residents to go on outings. She stated she knew for a fact that she had asked several times during meetings about going out with a group to a movie, coffee shop, or restaurant but said nothing was ever done about taking them out. Resident #6 said she would love to be able to get out and go with a group on an outing and said not being able to do so made her feel terrible and isolated from the outside world. She further stated she would love the opportunity to go out to eat or do anything outside the facility's four walls and would love to be able to do it with a group from the facility. Resident #6 indicated she thought it would be great for all of them mentally and emotionally to get out of the facility and enjoy themselves at a restaurant, theater, or coffee shop. A review of the Resident Council Meeting minutes from October 2023 through March 2024 revealed no indication in the minutes that group outings were discussed during the meetings. An interview with the Activity Director (AD) on 03/21/24 at 9:16 AM revealed she had been the director for 2 years. She stated she oversaw setting up the resident council meetings and usually recorded the minutes for the meeting. The AD stated the resident council met monthly and stated the residents in attendance were very vocal about their issues at the facility and would often seek her out in between meetings to let her know about issues affecting them at the facility. She stated a resident had just recently discussed activities being provided for them outside of the facility with her but it was not during the resident council meeting and she had reported this to the Administrator (could not remember exactly when). She further stated when she discussed it with the Administrator, she gave the AD some ideas for activities to inquire about and told her to let her know what she found out about the suggestions. The AD further said they had looked at activities right around the area where they were and had contacted a playhouse that offered live plays and musicals and were working on planning for the residents to attend an event in May but said none of the details had been finalized for the event. The AD indicated they did not have any activities planned outside of the facility for March or April of 2024, just the one they were working on for May. She further indicated before COVID in 2020 there were group outings outside of the facility at least monthly but since 2020 they had not been outside the facility on a group outing. The AD said there was a van at the facility but she was not sure if it was operational or if they had a driver for the van. She also said some of the residents had expressed an interest in getting out and shopping but said if they needed something she usually collected their money and did their shopping for them. The AD admitted she knew it was not the same but said she ordered out for them monthly at the restaurant of their choice, collected their money, and delivered their meals to them. An interview with the Administrator on 03/21/24 at 9:41 AM revealed she had been the Administrator since August 2023 and said the residents had just recently mentioned wanting to go and see a live play and that they were working on the details of the event in May but all the arrangements had not been finalized. She stated there were no group outings planned on the March or April calendars and to her knowledge had not been any group outings planned since she had been at the facility but said they could try to schedule something for the residents to do in April if they could work out the details. The Administrator further stated they had taken the residents outside but had not taken them off campus yet and said they would have to get consent from family, guardians, power of attorney for the residents that were not their own responsible party to see if they agreed for the residents to go on outings outside of the facility. She indicated it was just recently brought to her attention by one of the residents and the Activities Director that the residents wanted to go on group outings and she had made it a priority to plan a group outing for May. The Administrator further indicated it was her goal to provide the residents with outings of their choice but there were details that had to be resolved. The Administrator stated the facility had a van but she was not sure if it was in proper working condition and if they had a driver for the van and these were some of the details, they had to work out to provide the residents with group outings.

Based on observations, record review, resident and staff interviews, the facility failed to provide podiatry services and/or toenail care for 2 of 2 sampled residents (Resident #3 and Resident #1) reviewed for foot care. Resident #3 reported difficulty getting his socks on every morning and having to walk differently due to the condition of his toenails and reported the big toenails on both feet were ingrown. The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes mellitus type II with complications. Resident #3's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was independent with personal hygiene. Review of a visit summary dated 03/08/24 revealed Resident #3 was not seen by the podiatrist on that date and was not on the list of residents not seen on that date. An observation and interview with Resident #3 on 03/20/24 at 4:00 PM out in the courtyard revealed he needed to be seen by the podiatrist to have his toenails cut. Resident #3 described them as growing over the back of his toes and said he had a difficult time putting on his socks and was walking differently because the toenails were long and bothering the back of his toes. He stated he was admitted to the facility in October of 2023 and had not seen the podiatrist since he had been admitted to the facility. Review of Resident #3's electronic medical record revealed there were no progress notes from podiatry in his chart. An observation of Resident #3 on 03/21/24 at 8:55 AM revealed his toes on the left foot had nails that extended 1/4 inch to 1/2 inch beyond the tip of his toe. The 2nd toenail had grown over the top of the toe and extended into the skin of the back of the toe on both feet. Resident #3 stated he had ingrown toenails of both big toes on both feet that were painful and affected the way he walked. He further stated the condition of his toenails was new since his admission to the facility and had steadily worsened. Observation of his big toes on both feet revealed both big toenails were curving, growing inward on the sides of both big toes and the nails had a yellowish tint. He stated he had mentioned it to the NA who takes care of him but could not recall her name. Resident #3 further stated he would love to see the podiatrist and get his toenails trimmed so he could walk without that pain and the pain from his ingrown toenails. He stated they only hurt when he walked but he still walked because he liked to be out of his room. A telephone interview with NA #3 on 03/21/24 at 6:18 PM who had taken care of Resident #3 on the 7:00 AM to 3:00 PM shift on 03/20/24 and 03/21/24 revealed she had noticed his toenails 2 weeks ago and mentioned it to Nurse #3 who said the podiatrist would be coming soon. NA #3 stated she did not cut anyone's toenails and especially not residents who were diabetic. An interview with Nurse #2 on 03/21/24 at 6:26 PM revealed she was the primary nurse for Resident #3 and frequently took care of him 7:00 AM to 7:00 PM. She stated no one had reported his toenails to her or if they had she couldn't remember it and said she had not noticed them being long. Nurse #2 observed Resident #3's toenails and agreed they needed to be trimmed and he needed to be seen by the podiatrist. She stated she would refer Resident #3 to the podiatrist to be seen on his next visit. A telephone interview with Nurse #3 on 03/21/24 at 6:48 PM revealed she didn't recall anyone mentioning Resident #3's long toenails to her and said if they had she didn't remember it. She stated she had not noticed his toenails or that they needed to be trimmed but said he should be seen by the podiatrist since he was diabetic. An interview with the Director of Nursing (DON) on 03/21/24 at 7:21 PM revealed that she thought it was the responsibility of the Social Worker to put diabetic residents on the list for the podiatrist. She stated these residents should be seen by the podiatrist every 3 months on a routine basis and said she would have expected Resident #3 to have been included on the list to be seen every 3 months. A follow-up telephone interview with the Social Worker on 03/21/24 at 8:11 PM revealed the podiatry office sees all long-term care residents admitted to the facility and accept referrals from nursing and residents who need to be seen. She stated once they are seen the podiatrist puts them in the rotation of residents to be seen every 3 months. The Social Worker stated she could not explain why Resident #3 had been left off the rotation but said she and the Administrator were in the process of setting up a conference call with the podiatry office about their concerns with residents not being seen during visits. An interview with the Administrator on 03/21/24 at 8:34 PM revealed she expected all diabetic residents and other residents with toenail concerns to be seen by the podiatrist. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included peripheral vascular disease, neuropathy, and diabetes mellitus type II with complications. Review of Resident #1's electronic medical record (EMR) revealed a note dated 11/22/23 and signed by the podiatrist on 11/26/23. The resident was seen by the podiatrist on 11/22/23 and he trimmed her nails to patient's tolerance. The note stated there were no signs of infection and non-professional treatment would be hazardous to the resident. There was a recommendation for follow-up as medically necessary but no sooner than 60 days. Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial to maximal assistance of one staff member with personal hygiene. Review of Resident #1's care plan dated 03/07/24 revealed a focus area for the resident having diabetes mellitus type II and being at risk for complications. The interventions included inspecting feet daily for open areas, sores, pressure areas, blisters, edema or redness and report to nurse if noted, among others. Review of Resident #1's electronic medical record revealed she had been seen by podiatry on their visit on 11/22/23 but had not been included on the list of residents seen on 03/08/24 which had been 3 1/2 months since she was last seen by podiatry. Review of a visit summary from the podiatrist dated 03/08/24 revealed Resident #1 was not seen by the podiatrist on that date and was not on the list of residents not seen on that date. An observation of Resident #1 on 03/20/24 at 11:39 AM revealed her lying in bed and her right leg was extended out of the covers and her right foot was observed with the 2nd through 4th toes noted with nails extending 1/4 to 1/2 inch beyond the tip of her toes. The 5th toenail was noted to be so long that it had grown inverted past the front of her toe and onto the skin of her foot. The resident stated she did not feel the toenail digging into her skin because she had neuropathy and could not feel anything on her foot. Resident #1 further stated she had been seen by podiatry services several months ago but had not seen them since and was not sure when they had been back to the facility or why she had not seen by them since 11/22/23. An observation was made of Resident #1 on 03/21/24 at 9:43 AM and she was in bed with a gown on and her toenails remained long and the 5th toenail remained inverted and growing past her toe and onto the skin of the top of her foot. An interview with the Social Worker (SW) on 03/21/24 at 11:00 AM revealed she was responsible for setting up appointments with ancillary services for the residents. She stated the services included podiatry, dental, auditory and optometry. The Social Worker explained that the podiatry office had access to their resident population and diagnoses and devised and sent to her a list of residents that needed to be seen based on their diagnoses. She said she didn't know why Resident #1 had been left off the list but said if nursing had referred the resident to her, she could have added her to the list of residents to be seen but that had not happened before the visit on 03/08/24. The SW indicated once residents were on the list they should be in the rotation to see the podiatrist every 3 months and said she wasn't sure how Resident #1 had been left off the list for 03/08/24 and the list for 03/29/24. A phone interview with NA #2 on 03/21/24 at 6:06 PM revealed she had taken care of Resident #1 on 03/21/24 from 7:00 AM to 3:00 PM and said she saw the resident's foot out of the covers but really didn't notice her toenails. NA #2 stated no one had mentioned her toenails being long and needing cut to her but said she didn't cut toenails and especially not on residents with diabetes. An interview with Nurse #1 on 03/21/24 at 6:40 PM revealed she took care of Resident #1 from 7:00 AM to 7:00 PM on 03/20/24 and 03/21/24 and said no one had mentioned the resident's toenails needing cut to her. She stated they had a podiatrist who came in every 3 months and that Resident #1 should have been seen by the podiatrist since she was diabetic. Nurse #1 observed Resident #1's toenails and agreed they needed to be cut by the podiatrist. She further stated she would make sure the resident got added to the next podiatry visit scheduled. An interview with the Director of Nursing (DON) on 03/21/24 at 7:21 PM revealed that she thought it was the responsibility of the Social Worker to put diabetic residents on the list for the podiatrist. She stated these residents should be seen by the podiatrist every 3 months on a routine basis and said she would have expected Resident #1 to have been included on the list to be seen every 3 months. A follow-up telephone interview with the Social Worker on 03/21/24 at 8:11 PM revealed the podiatry office sees all long-term care residents admitted to the facility and accepts referrals from nursing and residents who need to be seen. She stated once they are seen the podiatrist puts them in the rotation of residents to be seen every 3 months. The Social Worker stated she could not explain why Resident #1 had been left off the rotation but said she and the Administrator were in the process of setting up a conference call with the podiatry office about their concerns with residents not being seen during visits. An interview with the Administrator on 03/21/24 at 8:34 PM revealed she expected all diabetic residents and other residents with toenail concerns to be seen by the podiatrist.

Based on observations, record reviews, resident and staff interviews, and test tray the facility failed to provide palatable food that was appetizing in temperature for 2 of 3 residents on the 500 Hall (Resident #1 and Resident #8) reviewed for food palatability. This practice had the potential to affect other residents on the 500 Hall. The findings included: A kitchen observation of the breakfast meal before being plated on 03/21/24 at 8:15 AM along with the Food Service Director. On 03/21/24 at 8:35 AM the breakfast meal cart was delivered to 500 Hall from the kitchen. The first breakfast tray was removed from the enclosed cart at 8:40 AM and the last breakfast tray removed from the cart at 8:59 AM. The test tray which had an insulated dome lid and bottom was taken to the nearest nourishment room at 9:00 AM. A test tray of grits, scrambled eggs and sausage was tested along with the Food Service Director at 9:00 AM on 03/21/24. Butter was placed on the grits that did not melt. The taste test yielded the food was not hot and at best was room temperature. The Director remarked the food was cold because the food sat on the hall too long before it was passed out by the staff. When the Director was asked what could be done to ensure the food was hot when it was delivered to the residents, she stated the food could be passed out to the residents faster when the meal cart arrived on the halls. 1a. Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's medical record revealed an order dated 06/16/22 for limited concentrated sweets, regular texture and regular liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. On 03/21/24 at 9:18 AM an interview and observation were conducted with Resident #1. The Resident was eating her breakfast of oatmeal in a small ceramic bowl and one fried egg on a plate. The Resident explained that her breakfast did not taste good because it was cold by the time the staff brought her tray to her. She reported that since her oatmeal was cold, she had the staff put some flavored creamer in it to give it flavor. The Resident continued to explain that she received her breakfast cold every morning. 1b. Resident #8 was admitted to the facility on [DATE]. A review of Resident #8's medical record revealed an order dated 08/12/16 for regular diet, regular consistency and regular liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. During an interview with Resident #8 on 03/21/24 at 9:12 AM the Resident was sitting up in bed feeding himself his oatmeal. The Resident explained that his breakfast was cold when he received it. The Resident stated that he felt the meal cart sat on the hall too long before the staff delivered his tray to him. He continued to explain that when the staff brought the meal cart to the hall, they parked it outside his room door, and he could hear them unloading the cart. He stated that because it took the staff so long to deliver his tray was why he thought his meals were almost always cold when he got his tray. An interview was conducted with the Director of Nursing (DON) at 7:15 PM on 03/21/24. The DON explained the nurse aides could have been in resident rooms when the meal cart was brought to the hall, but they should be aware when the meal cart was brought to the hall so that they could deliver the trays while the food was hot. She stated no one should have to eat cold food. During an interview with the Administrator on 03/21/24 at 8:31 PM she explained that she conducted test trays about every other month that included taking food temperatures and taste tests. She stated she had not encountered a problem with the procedure. The Administrator indicated the residents were entitled to receive hot meals.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 11/19/21, and the recertification and complaint investigation survey that occurred on 03/10/23 This failure was for two deficiencies that were originally cited in the areas of Development and Implementation of Comprehensive Care Plans (F656) and Nutritive Value/Appearance, Palatability/Preferred Temperature of Food (F804) and were subsequently recited on the current complaint investigation survey of 03/25/24. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F656: Based on observation, record review, staff and Resident interviews, the facility failed to implement care plan interventions by not serving (Resident #1) her food to her in large bowls for easier management for 1 of 3 residents reviewed for care plans. During the recertification and complaint investigation survey conducted 11/19/21, the facility failed to develop a care plan for right-hand splint management for 1 of 1 resident reviewed for positioning. F804: Based on observations, record reviews, resident and staff interviews, and test tray the facility failed to provide palatable food that was appetizing in temperature for 2 of 3 residents on the 500 Hall (Resident #1 and Resident #8) reviewed for food palatability. This practice had the potential to affect other residents on the 500 Hall. During the recertification and complaint investigation survey conducted 03/10/23, the facility failed to provide meals that were palatable for 5 of 5 residents sampled for food palatability. The residents complained the food was cold, unseasoned, and overcooked. During the recertification and complaint investigation survey conducted 11/19/21, the facility failed to provide food that was appetizing for 8 of 8 residents reviewed for food palatability. The residents complained the food was cold, butter did not melt on food and food was hard. A telephone interview on 03/25/24 at 3:20 PM with the Administrator revealed the QAPI committee meets monthly with department heads, administrative staff, the Medical Director, and at least quarterly the Pharmacist and Registered Dietician attend in person or by phone. She reported she felt like the issues that kept occurring were a result of not having consistent staff in department head positions. The Administrator stated they had changes in administration, in MDS Coordinators and in other leadership positions but that had now stabilized and hopefully the Process Improvement Plans (PIPs) they were putting into place would reflect positive changes moving forward.

Based on observation, record review, staff and Resident interviews, the facility failed to implement care plan interventions by not serving her food to her in large bowls for easier management for 1 of 3 residents reviewed for care plans (Resident #1). The finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (CVA) with left hemiplegia. A review of Resident #1's physician orders revealed an order dated 09/15/22 to have all her meals served in bowls for independence in self-feeding since the Resident was unable to use her left upper extremity. A review of Resident #1's care plan revised on 03/15/23 revealed a self-care deficit related to left hemiplegia with the goal to maintain her current level of functioning. The goal would be attained by utilizing interventions which included allowing the Resident time to complete tasks and having all her meals served in large bowls due to inability to use her left upper extremity. A review of Resident #1's Care Area Assessment for Activity of Daily Living (ADL) dated 09/22/23 revealed the Resident could eat when her meals were served in bowls for independence in self-feeding due to her diagnoses of CVA. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had a functional limitation of range of motion of the upper extremity. The MDS also indicated the Resident required set up and clean up assistance for eating with the Resident completing the activity. A review of Resident #1's meal ticket for breakfast on 03/21/24 revealed all foods served in bowls/food in large bowls printed on the ticket. A review of Resident #1's Kardex (a means of communication specifically for nurse aides to deliver care to the residents) dated 03/21/24 revealed directions I am unable to use my left upper extremity, please deliver all my meals served in bowls for independent in self-feeding. On 03/21/24 at 9:18 AM an interview and observation were conducted with Resident #1. The Resident was eating her breakfast of oatmeal in a small ceramic bowl and one fried egg on a plate. The Resident explained she did not receive her breakfast in large bowls, which was what she needed in order to feed herself. The Resident continued to explain that she could only use one hand and she needed her food put in large bowls with tall sides so that it was easier for her to be able to feed herself her meals. She stated the tall sides of the bowls allowed her to scoop the food on the spoon and it remained there while she brought the spoon to her mouth. The Resident stated it had taken her a while to eat one of the 2 fried eggs she received for breakfast. She stated it was hit or miss as to when she would receive her meals in the large bowls. On 03/21/24 at 9:20 AM an interview was conducted with Cook #1 who plated Resident #1's food on her breakfast tray on 03/21/24. The Cook explained that he was aware that Resident #1 required her meals to be put in large bowls and stated he just missed it that morning and did not put her food in large bowls. The Cook prepared Resident #1 another breakfast tray with large bowls. During an interview with the Assistant Food Service Director on 03/21/24 at 9:23 AM she explained that she was aware that Resident #1 required her meals to be served in large bowls and stated she did not notice that her food was not prepared in the large bowls that morning or she would have reminded the Cook to put her food in the bowls. An interview was conducted with the Occupational Therapist (OT) on 03/21/24 at 4:05 PM. The OT explained that Resident #1 had left sided hemiplegia and therefore could not use both her hands to feed herself therefore having her food served to her in large bowls would enable her to feed herself and increase her self-independence. During an interview with the Minimum Data Set Nurse on 03/21/24 at 4:20 PM the Nurse explained that when the care plan was written the interventions would be put on the Kardex as well and the nurse aides and staff should adhere to the Kardex for Resident #1's care and needs. On 03/21/24 at 5:50 PM during an interview with Nurse Aide (NA) #4 she stated she had only worked at the facility 5 or 6 times and was still getting used to the routine. The NA confirmed that she delivered Resident #1's breakfast tray to her and explained that she did not know that Resident #1 should have her meals served in large bowls. When asked if she read the Resident's meal ticket, the NA stated she had not because she could not rely on what was printed on the meal ticket. An interview conducted with the Director of Nursing (DON) on 03/21/24 at 7:15 PM who explained that she spent a lot of time with Resident #1 and knew that she needed her meals to be served in large bowls for her to be able to feed herself efficiently. The DON indicated if serving the Resident's meals in large bowls was written on the care plan then she expected the care plan to be followed.

Based on observation, record review, staff and Resident interviews the facility failed to serve her food to her in large bowls for easy management for 1 of 3 residents reviewed for choices. The finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (CVA) with left hemiplegia. A review of Resident #1's physician orders revealed an order dated 09/15/22 to have all her meals served in bowls for independence in self-feeding since the Resident was unable to use her left upper extremity due to assist during the task of (eating). A review of Resident #1's care plan revised on 03/15/23 revealed a self-care deficit related to left hemiplegia with the goal to maintain her current level of functioning. The goal wound be attained by utilizing interventions which included allowing the Resident time to complete tasks and having all her meals served in large bowls due to inability to use her left upper extremity. A review of Resident #1's Care Area Assessment for Activity of Daily Living (ADL) dated 09/22/23 revealed the Resident could eat when her meals were served in bowls for independence in self-feeding due to her diagnoses of CVA. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had a functional limitation of range of motion of the upper extremity. The MDS also indicated the Resident required set up and clean up assistance for eating with the Resident completing the activity. A review of Resident #1's meal ticket for breakfast on 03/21/24 revealed all foods served in bowls/food in large bowls printed on the ticket. On 03/21/24 at 9:18 AM an interview and observation were conducted with Resident #1. The Resident was eating her breakfast of oatmeal in a small ceramic bowl and one fried egg on a plate. The Resident explained she did not receive her breakfast in large bowls, which was what she needed in order to feed herself. The Resident continued to explain that she could only use one hand and she needed her food put in large bowls with tall sides so that it was easier for her to be able to feed herself her meals. She stated the tall sides of the bowls allowed her to scoop the food on the spoon and it remained there while she brought the spoon to her mouth. The Resident stated it had taken her a while to eat one of the 2 fried eggs she received for breakfast. She stated it was hit or miss as to when she would receive her meals in the large bowls. On 03/21/24 at 9:20 AM an interview was conducted with Cook #1 who plated Resident #1's food on her breakfast tray on 03/21/24. The Cook explained that he was aware that Resident #1 required her meals to be put in large bowls and stated he just missed it that morning and did not put her food in large bowls. The Cook prepared Resident #1 another breakfast tray with large bowls. During an interview with the Assistant Food Service Director on 03/21/24 at 9:23 AM she explained that she was aware that Resident #1 required her meals to be served in large bowls and stated she did not notice that her food was not prepared in the large bowls that morning or she would have reminded the Cook to put her food in the bowls. An interview conducted with the Director of Nursing (DON) on 03/21/24 at 7:15 PM who explained that she spent a lot of time with Resident #1 and knew that she needed her meals to be served in large bowls for her to be able to feed herself efficiently. The DON stated if it is on her meal ticket then the bowls should have been utilized.

Based on record review and staff, resident, Nurse Practitioner, and Physician interviews, the facility failed to ensure a resident was free from a significant medication error when staff failed to administer an oral anti-diabetic medication for 1 of 3 residents reviewed for significant medication errors (Resident #5). This failure resulted in Resident #5 missing a daily dose of an oral anti-diabetic medication for 6 consecutive days. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included diabetes. An annual Minimum Data Set, dated dated dated [DATE] for Resident #5 revealed she was cognitively intact with no behaviors or rejection of care. A care plan for Resident #5 revised on 7/16/23 revealed the resident was care planned for diabetes with risk for complications. The interventions included diabetes medication as ordered by doctor. Report hypo/hyperglycemic episodes to the MD as needed. Report to the nurse any of the following signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, acetone breath (smells fruity), stupor, or coma. Physician's orders for Resident #5 revealed the following: Glimepiride Tablet 4 milligrams (mg). Give 1 tablet by mouth once a day for diabetes. Take with a meal, initiated on 1/5/23. Finger stick blood sugar three times a day (TID). Call the Nurse Practitioner if the blood sugar is greater than 300 or less than 120, initiated on 12/14/22. Resident #5's blood glucose readings from 6/3/23 through 6/9/23 ranged from 123-309. The electronic Medication Administration Record (eMAR) for Resident #5 revealed a medication Glimepiride 4mg was not administered on June 10th, 11th, 12th, 13th, 14th or 15th. On June 10th through the14th the administration was coded as #9. #9 chart code read, other/see nurse notes. On June 15th the administration was coded as #5. #5 chart code read hold/see nurse notes. An eMAR medication administration note for Resident #5's Glimepiride dated 6/10/23 at 2:24 PM was documented by Nurse #6, the note did not record a reason for the missed dose. Resident #5's blood glucose readings for 6/10/23 revealed blood glucose levels of 155, 221, and 179 on that day. During the investigation multiple unsuccessful attempts were made to contact Nurse #6. An eMAR medication administration note for Resident #5's Glimepiride dated 6/11/23 at 1:16 PM was documented by Nurse #5 and read: medication not available. Resident #5's blood glucose readings for 6/11/23 revealed blood glucose levels of 152 and 189 on that day. During an interview on 10/3/23 at 4:58 PM Nurse #5 revealed she worked for an agency and had only worked at the facility one time. She recalled caring for Resident #5. She stated the Glimepiride for resident #5 was not in the cart. She stated she checked the entire cart but could not find the medication. She did not recall ordering the medication or notifying the provider. An eMAR medication administration note for Resident #5's Glimepiride dated 6/12/23 at 11:44 AM was documented by Nurse #4 and read: awaiting delivery. Resident #5's blood glucose readings for 6/12/23 revealed blood glucose levels of 173, 292, and 211 on that day. During an interview on 10/3/23 at 4:14 PM Nurse #4 revealed she worked for an agency and had only provided care to Resident #5 once or twice. She did not recall a shift when Resident #5 missed her Glimepiride An eMAR medication administration note for Resident #5's Glimepiride dated 6/13/23 at 4:26 PM was documented by Unit Manager (UM) #1 and read: call pharmacy. Resident #5's blood glucose readings for 6/13/23 revealed a blood glucose levels of 221, 359, and 191 on that day. An interview on 10/3/23 at 2:16 PM with UM #1 revealed she worked on the cart for the hall where Resident #5 resided on a shift in June when there was a call out. She further revealed Resident #5 could voice her concerns. She recalled that Resident #5 did not have a medication card for glimepiride on the cart. Resident #5 told her she had not received the medication for a couple of days, and she had asked the other nurses about it. Resident #5 told UM #1 she was told by another nurse that the medication was already ordered. An eMAR medication administration note for Resident #5's Glimepiride dated 6/14/23 at 9:47 AM was documented by Medication Aide (MA) #1, the note did not record a reason for the missed dose. Resident #5's blood glucose readings for 6/14/23 revealed blood glucose levels of 126, 248, and 192 on that day. During the investigation multiple unsuccessful attempts were made to contact MA #1. An eMAR medication administration note for Resident #5's Glimepiride dated 6/15/23 at 11:45 AM was documented by Nurse #7 and read: medication on order. Resident #5's blood glucose readings for 6/15/23 revealed blood glucose levels of 193, 206, and 149 on that day. During the investigation multiple unsuccessful attempts were made to contact Nurse #7. During an interview on 10/3/23 at 11:54 AM Resident #5 revealed some time back in June of 2023 she missed her diabetic medication called Glimepiride. She stated during that time her regular nurse was out on leave related to a family emergency and the nurses that were working the cart were either agency staff or nurses that usually worked on other halls. She explained she was familiar with her medications and knew what they looked like. She thought the first day she noticed the Glimepiride was missing was a Saturday. She mentioned it to the nurse and the nurse told her there was none left on the cart. Resident #5 stated she mentioned her missing Glimepiride to each nurse that brought her medications for the 6 days. Resident #5 revealed during the days she missed her Glimepiride she did not feel sick. She further revealed when she was not receiving her Glimepiride she did not eat any of the carbohydrates on her meal trays. She did not want her blood sugars to become very elevated. An interview was conducted on 10/4/23 at 1:30 PM with the Nurse Practitioner (NP). The NP stated one day in June when she was in the facility a nurse told her Resident #5 was out of her Glimepiride. She further stated she thought the resident had already missed 2 or three doses when she was notified. Staff assured her the medication had been ordered and the resident would receive her next dose. She later learned the resident had missed six doses before receiving the medication. She did feel Resident #5 had any adverse effects from her missed doses of Glimepiride. The NP indicated if staff cannot obtain a medication for a resident or if a resident missed a medication dose, they should notify her as soon as possible. During an interview on 10/3/23 at 5:27 PM the former Medical Director revealed she did not recall Resident #5 not receiving her Glimepiride and she could not say whether she was notified or not. She stated although Resident #5 did not experience any adverse effects, a resident not receiving their Glimepiride for 6 consecutive doses could potentially cause continuous elevated glucose levels and those glucose levels could potentially have significant effects, such as polyuria (abnormal production of large amounts of urine > 3 liters a day), and a hyperosmolar state (a complication of diabetes that occurs when the blood glucose is elevated for long periods of times leading to dehydration and confusion). Staff should administer all medications as they are ordered and notify her if they were unable to do so. During an interview on 10/4/23 at 12:30 PM the DON revealed she was not aware of a time when Resident #5 ran out of her medication Glimepiride. The DON further stated staff should always notify the provider if the Resident missed a medication.

Based on record review and staff, resident interview, Pharmacy Technician, Nurse Practitioner, and Physician interviews, the facility failed to acquire and provide medication to a resident as ordered by the Physician when staff failed reorder and administer an oral anti-diabetic medication for 1 of 3 residents reviewed for pharmaceutical services (Resident #5). This failure resulted in Resident #5 missing a daily dose of an oral anti-diabetic medication for 6 consecutive days. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included diabetes, An annual Minimum Data Set, dated dated dated [DATE] for Resident #5 revealed she was cognitively intact with no behaviors or rejection of care. Physician's orders for Resident #5 revealed Glimepiride Tablet 4 milligrams (mg). Give 1 tablet by mouth one time a day for diabetes. Take with a meal, initiated on 1/5/23. The electronic Medication Administration Record (eMAR) for Resident #5 revealed a medication Glimepiride 4mg was not administered on June 10th,11th,12th,13th,14th or 15th. On June 10th through the14th the administration was coded as #9. #9 chart code read, other/see nurse notes. On June 15th the administration was coded as #5, #5 chart code read hold/see nurse notes. Review of an eMAR medication administration note for Resident #5's Glimepiride dated 6/10/23 at 2:24 PM was documented by Nurse #6, the note did not record a reason for the missed dose. During the investigation multiple unsuccessful attempts were made to contact Nurse #6. Review of an eMAR medication administration note for Resident #5's Glimepiride dated 6/11/23 at 1:16 PM was documented by Nurse #5 and read: medication not available. During an interview on 10/3/23 at 4:58 PM Nurse #5 revealed she worked for an agency and had only worked at the facility one time. She recalled caring for Resident #5. She stated the Glimepiride for Resident #5 was not in the cart. She stated she checked the entire cart but could not find the medication. She did not recall ordering the medication or notifying the provider. Review of an eMAR medication administration note for Resident #5's Glimepiride dated 6/12/23 at 11:44 AM was documented by Nurse #4 and read: awaiting delivery. During an interview on 10/3/23 at 4:14 PM Nurse #4 revealed she worked for an agency and had only provided care to Resident #5 once or twice. She did not recall a shift when Resident #5 missed her Glimepiride. She further stated she would document awaiting delivery if a medication had already been ordered and she was waiting for it to be delivered. Review of an eMAR medication administration note for Resident #5's Glimepiride dated 6/13/23 at 4:26 PM was documented by Unit Manager (UM) #1 and read: call pharmacy. An interview on 10/3/23 at 2:16 PM with UM #1 revealed she worked on the cart for the hall where Resident #5 resided on a shift in June when there was a call out. She further revealed Resident #5 could voice her concerns. She recalled that Resident #5 did not have a medication card for glimepiride on the cart. Resident #5 told her she had not received the medication for a couple of days, and she had asked the other nurses about it. Resident #5 told UM #1 she was told by another nurse that the medication was already ordered. UM #1 revealed she checked the other carts and could not find the medication; she then called the pharmacy. She was told by the pharmacy; they did not see where the medication had been ordered. UM #1 explained she ordered the medication, but it was not delivered on her shift. Pharmacy deliveries arrived on the evening shift. She stated she reported this to the Director of Nursing (DON) and the Nurse Practitioner. Review of an eMAR medication administration note for Resident #5's Glimepiride dated 6/14/23 at 9:47 AM was documented by Medication Aide (MA) #1, the note did not record a reason for the missed dose. During the investigation multiple unsuccessful attempts were made to contact MA #1. Review of an eMAR medication administration note for Resident #5's Glimepiride dated 6/15/23 at 11:45 AM was documented by Nurse #7 and read: medication on order. During the investigation multiple unsuccessful attempts were made to contact Nurse #7. During an interview on 10/3/23 at 11:54 AM Resident #5 revealed some time back in June of 2023 she missed her diabetic medication called Glimepiride. She stated during that time her regular nurse was out on leave related to a family emergency and the nurses that were working the cart were either agency or nurses that usually worked on other halls. She explained she was familiar with her medications and knew what they looked like. She thought the first day she noticed the Glimepiride was missing was a Saturday. She mentioned it to the nurse and the nurse told her there were none left. Resident #5 did not recall the name of the nurse, she thought she was from an agency. The nurse did not tell her if she ordered the medication or not. Resident #5 stated she mentioned this to each nurse that brought her medications for the 6 days. When she mentioned the missing medication, she was told they could not find it, or she they were waiting for pharmacy to send the medication. She revealed UM #2 told her she had ordered the medication, and it was supposed to be delivered that night. She stated the following day she did not think staff checked the pharmacy delivery because she did not receive her medication on that day either. The following day she received her Glimepiride. An interview on 10/3/23 at 4:56 PM with UM #2 revealed she was the UM for the unit where Resident #5 resided. She did not recall a time when Resident #5 ran out of Glimepiride or calling pharmacy about it. She stated if a resident was missing a medication in the cart, staff should look through the cart and in other carts, call the pharmacy to order the medication, use their back up pharmacy if needed and call the provider. During an interview on 10/3/23 at 5:09 PM the Certified Pharmacy Technician from the Pharmacy that serviced the facility revealed there was an order entered into the system for Glimepiride 4mg for Resident #5 on 6/13/23. The medication was delivered to the facility on [DATE]. She stated she could not see the details of who entered the order. An interview was conducted on 10/4/23 at 1:30 PM with the Nurse Practitioner (NP). The NP stated one day in June when she was in the facility a nurse told her Resident #5 was out of her Glimepiride. She further stated she thought the resident had already missed two or three doses when she was notified. Staff assured her the medication had been ordered and the resident would receive her next dose. She later learned the resident had missed six doses before receiving the medication. The NP indicated if staff cannot obtain a medication for a resident or if a resident missed a medication dose, they should notify her as soon as possible. During an interview on 10/3/23 at 5:27 PM the former Medical Director revealed she did not recall Resident #5 not receiving her Glimepiride and she could not say whether she was notified or not. She stated a resident not receiving their Glimepiride for 6 consecutive doses could cause continuous elevated glucose levels and those glucose levels could potentially have significant effects, such as polyuria, and a hyperosmolar state (a complication of diabetes that occurs when the blood glucose is elevated for long periods of times leading to dehydration and confusion). She further stated she expected staff to order medication from the pharmacy, use the backup pharmacy if needed. Staff should administer all medications as they are ordered and notify her if they were unable to do so. During an interview on 10/4/23 at 12:30 PM the DON revealed she was not aware of a time when Resident #5 ran out of her medication Glimepiride. She did not recall anyone reporting this to her. The DON further revealed when the nurse removes the medications from the card appropriately there will be a blue strip on the card as a reminder to reorder. She stated if a resident's medication is not in the cart the nurses should ensure the entire cart is checked, they should also check other carts. If the medication was not found, they should reorder the medication from the Pharmacy. They should check to see if the medication could be pulled from their automated medication dispensing machine. If the medication could not be pulled from the pyxis and they were waiting for the medication to be delivered the staff should utilize the backup pharmacy. The DON further stated staff should always notify the provider if the Resident missed a medication.

Based on record review and family and staff interviews the facility failed to prevent a resident from falling off the bed during a bed bath for 1 of 3 residents sampled for supervision to prevent accidents (Resident #1). The resident required two person assistance for bed bath, however, one nursing assistant provided the bed bath. Resident #1 was turned on his side during the bed bath and proceeded to roll out of the bed to the floor face first. Review of hospital records indicated that Resident #1's fall resulted in a left orbital floor fracture, subarachnoid hemorrhage, and questionable left lower extremity injury. The finding included: Resident #1 was admitted to the facility initially on 03/19/13 and most recently was readmitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of a care plan, initiated on 01/06/14 and most recently revised on 10/12/17, revealed, Resident #1 had an activities of daily living (ADL) self-care performance deficit related to the [DIAGNOSES REDACTED]. The goal of the care plan was: Resident #1 would remain clean, odor free, and neatly dressed through staff anticipation and providing ADL care x 90 days. The interventions included: Resident #1 required total staff assistance to reposition and turn in bed. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #1 had long/short term memory problems and was severely cognitively impaired for daily decision making. The MDS further revealed that Resident #1 required extensive assistance of 2 persons for bed mobility, transfers, and bathing. The MDS also indicated that Resident #1 had impairments to bilateral upper/lower extremities and no falls were identified on the MDS. Review of the MDS Kardex (a system to identify important information about a resident) for Resident #1 dated 07/06/17 revealed that Resident #1 required extensive assistance of 2 staff members with bed mobility and was totally dependent on 2 staff members for bathing. Review of a nurses note, written by Nurse #1 and dated 10/11/17 revealed this nurse was called to Resident #1's room by a nursing assistant (NA) who stated you need to come to room ASAP (as soon as possible). This nurse entered the resident's room and noted the resident lying on the floor on his left side with his nose bleeding and a cut over his left eye. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Nurse Practitioner (NP) were made aware and orders were received to transfer the resident to the hospital for evaluation. The nurse placed a phone call to the family and to 911. The resident was transported to the hospital by Emergency Medical Services (EMS). Review of an incident report dated 10/11/17 revealed NA reported that a nurse was needed immediately in room 203 B. The nurse entered the room and observed Resident #1 lying on the floor on his left side. Resident #1 had a nose bleed and a cut over his left eye. Resident #1 was groaning on and off. He did not say anything. Resident #1 was assessed for any other injuries and none was noted. Fall mats were in place at bedside. Medical Doctor (MD) and family were notified. Immediate action taken read in part, DON and ADON were made aware. Resident #1 was made comfortable on the floor while the physical assessment could be done by the nurses. Resident #1 was in a partial fetal position and care was taken to establish his baseline movements of his arms and legs. Nurse noted no open areas to the hands, feet or the back of the head. Resident #1 had a halo assist rail in place in the active position at the head of the bed. Review of a hospital History and Physical dated 10/12/17 revealed that as a result of the fall that occurred on 10/11/17 Resident #1 had suffered a left orbital floor fracture (fracture of the bottom of the eye orbit), subarachnoid hemorrhage (brain bleed), and questionable left lower extremity injury. Review of the Care plan Kardex that was printed 10/17/17 revealed Resident #1 was totally dependent on staff for repositioning and turning in bed. Two or more staff assistance were recommended for turning and repositioning. An interview was conducted with NA #2 on 10/17/17 at 11:09 AM. NA #2 stated that she routinely cared for Resident #1 on the 3rd shift. She added that Resident #1 had to be turned, changed and the staff was supposed to have 2 people when they performed care to Resident #1 due to his size. She added that Resident #1 used to try and hit the staff but lately he had calmed down. NA #2 stated that Resident #1 was very stiff and contracted but at times in the past he would try to swing at staff. NA #2 again stated that she was informed by her nurse to always have 2 people when caring for Resident #1 even before his fall on 10/11/17. An interview was conducted with Nurse #1 on 10/17/17 at 11:38 PM. Nurse #1 stated that on 10/11/17 at approximately 9:50 AM she was providing care to another resident and a NA came to the door and stated she needed her and it was an emergency. Nurse #1 stated she entered Resident #1's room and observed him lying on the floor on his left side with a pillow under his head and observed blood on the pillow. Nurse #2 was already in the room and asked what happened. Nurse #1 stated she was told that NA #1 was giving Resident # 1 a bed bath and when NA #1 turned him on his right side he just kept going. NA #1 lost contact with him and he fell to the floor. Nurse #1 stated she instructed the staff to leave him where he was and she went to get the DON and management team while Nurse # 2 stayed with the resident. Nurse #1 stated when she returned to the room they were trying to get a Hoyer lift pad under him to get him back in the bed and were having trouble doing that. The DON came in the room and said to put a sheet under him and perform an 8 man lift to get him back in the bed and that was what they did. Nurse #1 stated that at that time she noticed some nasal bleeding and a laceration over his left eye. The ADON instructed Nurse #1 to call the family and the ADON stated she would call the NP who was on call. Nurse #1 stated she informed Resident #1's family he would be going out via 911 for evaluation and then went ahead and called 911 and they arrived within 10 minutes. They picked him up at 10:20 AM. Nurse #1 stated that Resident #1 was moaning while they were lifting him to the bed and she notified the medics that was not normal for him to moan. Nurse #1 stated she could not asses Resident #1's range of motion (ROM) due to his contractures but could visibly see the bloody nose and laceration over the left eye and his vital signs were stable. Nurse #1 stated that all the NAs had been informed that Resident #1 was to have 2 people when providing care per the family request but sometimes it was impossible to find a 2nd person. An interview was conducted with NA #1 on 10/17/17 at 12:43 PM. NA #1 confirmed that on 10/11/17 she was responsible for Resident #1. NA # 1 stated that she had cared for Resident #1 several times and had always completed his care by herself. NA #1 stated that some of the NAs were not comfortable with him and they would get someone to help them but I am very comfortable providing care to him by myself. She added if the family member or the sitter were present sometimes they would help her. NA #1 stated that on 10/11/17 the sitter and family member were not present in the room. She stated that right after breakfast she went to Resident #1's room and started to bathe him. She stated she raised the bed to approximately 4 to 4.5 feet high and removed his clothes and started bathing him. She stated she had bathed his front side and she used his pad and pulled him close to the side of the bed and turned him on his right side. NA #1 stated Resident #1 was resting on his right side and she had reached for the wash rag and when she turned back to him he was going over the side of the bed and she could not reach him. NA #1 stated that he was on a blow up (air mattress) mattress. NA #1 denied hearing the mattress inflate/deflate or make any noise but the weight of Resident #1 on his side could have shifted the air inside the mattress causing him to turn on over and fall to the floor. NA #1 stated her first response was oh my God and ran to the other side of the bed. Resident #1 was contracted lying face down with his head resting against the night stand. NA #1 stated she grabbed a pillow and put it between the night stand and Resident #1's face. She added she could not turn him due to his size but she could turn his head to one side and then ran to the hall to summons help. NA #1 stated she saw NA #2 and told her to go find Nurse #1. NA #1 stated she saw Nurse #2 at the other end of the hall and summoned her to the resident's room. When Nurse #2 arrived to the room she moved the dresser so they could turn Resident #1. Nurse #1 had gone to get the management team. NA #1 stated that Resident #1 moaned a little when they lifted him from the floor to the bed. The DON suggested to put a sheet under him and lift him to the bed and that was what they did and then they waited on the ambulance. NA #1 stated she got him dressed because he was naked except for his brief. NA #1 stated there was a small amount of blood coming from his nose and cut above his left eye. NA # 1 stated she was a floater and worked all over the building and if she was not familiar with a resident she could review the resident's care plan and Kardex. NA #1 stated she had never reviewed Resident #1's Kardex or care plans. An interview was conducted with Nurse #2 on 10/17/17 at 1:09 PM. Nurse #2 stated she was summoned to Resident #1's room on 10/11/17 by NA #1. Nurse #2 state that when she entered his room, Resident #1 was lying on the floor on his side with his head against the night stand and a pillow was between his head and the night stand. Nurse #2 stated Resident #1 was bleeding from his nose but there were no visible open areas or cuts on his face. She stated she asked what happened and NA #1 stated she was bathing Resident #1 and had turned him over to his right side to wash his back and he just kept going and fell to the floor. Nurse #2 stated that Resident #1's bed was approximately 4 foot high and he was resting in a ball on his side due to his contractures. Nurse #2 stated that while Nurse #1 went to get the management team she assisted Resident #1 to his back to assess him visually because he was nonverbal. Nurse #2 stated she assessed him for any cuts, bruises or swelling and noted the left side of his face was swollen. When the management team came into the room Nurse #2 stated she went to look for a lift and when she returned without the lift the staff in the room had already gotten Resident #1 back into bed. She was not sure how they did that and she asked Nurse #1 if she needed any further help and Nurse #1 stated no. So Nurse #2 returned to her assigned area while Nurse #1 waited for the medics to arrive to transport Resident #1 to the hospital. Nurse #2 stated that Resident #1 needed total assistance from staff with all ADLs and required the assistance of 2 persons with transfers. Nurse #2 stated that the NAs could look at the care plan or Kardex which would tell them how many staff were needed for care. An interview was conducted with the DON on 10/17/17 at 2:42 PM. The DON stated that on the morning of 10/11/17 she was in the facility's morning meeting and was told there had been a fall in Resident #1's room. The DON stated she immediately went to his room and staff were trying to get Resident #1 from the floor to his bed with the use of a mechanical lift. She stated that she asked what happened and what she gathered from the staff in the room was that NA #1 was trying to pull the fitted sheet onto the mattress and this caused the resident to roll and NA #1 could not hold him and he rolled off the bed. She added that Resident #1 had a fall mat to the floor and he had landed on that. She stated that when she entered Resident #1's room he was lying on his right side and they were trying to get the lift pad under him but due to his contractures they were unable to get the pad between his legs. The DON stated that the staff got a sheet and rolled it under him and then 5 or 6 staff members safely transferred Resident #1 back in to the bed. The DON stated that Resident #1's care could be completed with 1 person but since the fall on 10/11/17 the facility determined he would require 2 person assistance. The DON stated that if the MDS and the Kardex indicated that Resident #1 required 2 person assistance then she would expect the staff to use 2 person assistance. An interview was conducted with Resident #1's family member on 10/18/17 at 12:37 PM. The family member stated Resident #1 had resided at the facility for a number of years and had required 2 person assistance with his care for well over a year or so due to his size and his contractures. An interview was conducted with NA #3 on 10/18/17 at 2:17 PM. NA #3 stated that she routinely cared for Resident #1 on the 3rd shift and stated that she had to provide all his personal care for him. NA #3 stated that on her shift she would change him and turn him routinely and he always required 2 person assistance especially with turning from side to side. NA #3 added that Resident #1 also required 2 person assistance with incontinent care and she generally had no trouble finding someone to assist her with providing care to Resident #1. An interview was conducted with NA #4 on 10/18/17 at 2:28 PM. NA #4 stated she cared for Resident #1 at times on 3rd shift and 2nd shift. NA #4 stated that on 3rd shift she assisted the other NA with incontinent care and turning him side to side. NA #4 stated that on 2nd shift she would provide Resident #1 with a shower and that also required 2 person assistance. She added that to her knowledge Resident #1 always required 2 person assistance when providing any type of care to him. An interview was conducted with NA #5 on 10/18/17 at 2:40 PM. NA #5 stated that on 10/11/17 she was walking down the hall and NA #1 hollered for help. She stated that when she entered Resident #1's room he was lying on his side on the floor with a pillow under his head. She stated she noticed some blood on his pillow and could see a cut to the left eye area. NA #5 stated that when she cared for Resident #1 she had 2 people at the request of the family and she always did what was asked of her. She added that once Resident #1 was in the bed she assisted NA #1 with getting him dressed and waited for the medics to arrive. A follow up interview was conducted with the DON on 10/18/17 at 2:58 PM. The DON stated that there was a disconnect in what she stated had occurred on 10/11/17 and what the other staff stated had occurred on 10/11/17. She added that she had gathered that Resident #1 had unpredictable movements during care on 10/11/17 that NA #1 did not observe before. There was no way to stop him from falling once he started to roll off the bed. The DON stated that even if there had been 2 people in the room, because of the position of the staff and the unpredictable movements, Resident #1 may still have fallen. An interview was conducted with NA #6 on 10/18/17 at 3:28 PM. NA #6 stated she routinely cared for Resident #1 on the weekends. NA #6 stated that he always required 2 people assistance to render care to him. NA #6 stated that on the assignment sheet they would assign Resident #1 to 1 NA and then indicate another NA to assist as needed. She added that she always had 2 person assistance with Resident #1 due to his size and his contractures. An interview was conducted with NA #7 on 10/18/17 at 4:10 PM. NA #7 stated she routinely cared for Resident #1 and that during her orientation at the facility the nurse and the other NAs had instructed her to never provide care to Resident #1 with 1 person. She added that any time she provided care to Resident #1 she always had 2 person assistance. She stated that she reviewed Resident #1 care plan and Kardex regularly but could not recall what information it contained but she recalled being told by several staff members to always have 2 people while providing care to Resident #1. An interview was conducted with Resident #1's family member on 10/19/17 at 9:30 AM. The family member indicated that she visited the facility every day while the resident was at the facility for a number of years. The family member indicated that she attended regular care plan meetings and had always been told that her family member required 2 person assistance with his care. The family member further stated that Nurse #1 had indicated to her on numerous occasions that Resident #1 required 2 person assistance and the staff was directed as such.

Based on staff interviews and medical record review, the facility failed to notify the physician of a change in skin condition for 1 of 3 (Resident #61) sampled residents reviewed for pressure ulcers. The findings include: A facility policy entitled "General Treatment Guidelines" revision date 03/2010 indicated to notify the physician (MD) of all wounds and any time a wound shows no evidence of healing, worsening or signs of infection in 2 weeks. Resident #61 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].#61 had cognitive impairment, required total-extensive assistance with activities of daily living (ADL) and was at risk for pressure ulcer development. The MDS did not indicate the presence of any pressure ulcers. A plan of care dated 05/22/13 documented a risk for skin breakdown and indicated an intervention of skin audit weekly and report changes. Review of Resident #61's weekly skin assessment risk factors sheet dated 04/17/13 indicated heels were red and to keep elevated on pillows. Review of Resident # 61's physician (MD) orders revealed a 04/23/13 order for skin prep to heels twice daily (bid) to maintain skin integrity. Review a weekly skin assessment dated [DATE] indicated to keep the heels elevated on pillows A nurse's note dated 04/30/13 indicated Resident 61's left heel was reddish black, soft to touch and the wound nurse was notified. The note indicated the wound nurse ordered to clean heels with skin prep and elevate on pillow. A weekly skin assessment dated [DATE] indicated the left heel area was red and purple and to continue with skin prep to bilateral heels as well as elevating the heels off the bed. A nurse's note dated 05/19/13 indicated Resident #61's left heel with moderate amount of brown colored drainage. The note indicated while applying skin prep the top layer which was a dark colored area sloughed off with pink colored skin noted below and an email was sent to the wound nurse. A review of the June 2013 weekly skin assessment sheet revealed no documentation of changes in Resident #61's skin integrity to the left heel. A review of Resident #61's nurse's notes from 04/09/13 to 06/14/13 made no mention of the physician being notified of a change in skin integrity. A physician progress notes [REDACTED]. A wound consultant report dated 06/28/13 indicated a pressure area to the left heel measuring 4.3x3.2 with an estimated depth of 0.4 centimeters (cm). The left heel was documented with excessive necrotic tissue black in color and mild serous drainage. The report indicated the clinical stage was unstageable. The report indicated the eschar was loosening and starting to drain with need for consent for debridement. Review of the weekly skin assessment sheet for July revealed an assessment dated [DATE]which indicated an open area to the left heel. Review of the physician communication log from April to July revealed no communication regarding a change in Resident #61's skin integrity. During an interview with the treatment nurse on 07/31/13 at 11:36AM, the treatment nurse explained as part of her duties she would monitor wounds weekly for improvement or worsening and report that in a weekly quality report. The treatment nurse also explained all wounds were placed on that report regardless of stage. The treatment nurse added when the staff notified her of any new areas she would notify the physician, order consultation as needed, inform the dietician for supplementation and enter it on the weekly wound report. During a follow -up interview with the treatment nurse on 07/31/13 at 5:47PM, the treatment nurse stated she did not recall if the left heel area was blanchable on the 17th of April and was not aware if it was ever communicated to the physician. The treatment nurse also stated she could not recall when the area became a blister but thought it was in May. The treatment nurse also stated it was her mistake but Resident #61's left heel wound was never measured or added to the weekly wound monitoring report. During an interview with Nurse #3 on 08/01/13 at 8:36 AM, who functioned in a supervisory role, Nurse #3 explained the nurses and/or the nurse aides brought it to her attention on 06/21/13 that Resident #61's left heel wound looked worse and the Nurse Practitioner (NP) was notified. Nurse #3 added the NP observed the wound and based on the characteristics the NP ordered to consult the wound physician. The Nurse also mentioned that prior to the 21st of June she was aware the nurses had been applying skin prep to Resident #61's heels but was unaware what the area looked like. An interview was conducted on 08/01/13 at 11:03AM with the Nurse Practitioner (NP). The NP explained she was unaware of any pressure area to the left heel prior to 06/21/13. The NP added when she observed the left heel on 06/21/13 it was necrotic and dry and warranted consultation from the wound physician due to the necrosis. The NP added she would have expected to be notified when the wound was originally noted to assess the area and review the treatment protocol. The NP also added re-notification was expected when the area started to worsen so the area could have been reassessed, labs ordered, wound physician consulted and a nutritional review conducted. During an interview with Nurse #1 on 08/02/13 at 11:39AM, Nurse #1 explained the MD and DON probably should have been notified. Nurse #1 added the treatment nurse was contacted and she was the first line of defense, she was the most knowledgeable person. Finally the Nurse stated she did not usually contact the MD with changes in skin condition but contacted the treatment nurse. Interview with the Director of Nursing (DON) on 08/02/13 at 3:22 PM revealed the nurses were expected to notify the physician via the MD communication book with all changes in condition. The DON added that the wound nurse should be notified but the physician should have also been notified. .

Based on observations, staff interviews and medical record review, the facility failed to assess, monitor and implement appropriate treatment for [REDACTED].#61) sampled residents reviewed for pressure ulcers. The findings include: A facility policy entitled "General Treatment Guidelines" revision date 03/2010 indicated: 1. All pressure ulcers to be reviewed in the Quality of Life Committee initially and with any signs of non-healing/ worsening 2. treatment of [REDACTED]. 3. Notify the physician (MD) of all wounds and any time a wound shows no evidence of healing, worsening or signs of infection in 2 weeks. Resident #61 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].#61 had cognitive impairment, required total-extensive assistance with activities of daily living (ADL) and was at risk for pressure ulcer development. The MDS did not indicate the presence of any pressure ulcers. A plan of care dated 05/22/13 documented a risk for skin breakdown and indicated an intervention of skin audit weekly and report changes. Review of Resident #61's weekly skin assessment risk factors sheet dated 04/17/13 indicated heels were red and to keep elevated on pillows. Review of Resident # 61's physician (MD) orders revealed a 04/23/13 order for skin prep to heels twice daily (bid) to maintain skin integrity. Review a weekly skin assessment dated [DATE] indicated to keep the heels elevated on pillows A nurse's note dated 04/30/13 indicated Resident 61 ' s left heel was reddish black, soft to touch and the wound nurse was notified. The note indicated the wound nurse ordered to clean heels with skin prep and elevate on pillow. A weekly skin assessment dated [DATE] indicated the left heel area was red and purple and to continue with skin prep to bilateral heels as well as elevating the heels off the bed. A nurse's note dated 05/19/13 indicated Resident #61's left heel with moderate amount of brown colored drainage. The note indicated while applying skin prep the top layer which was a dark colored area sloughed off with pink colored skin noted below and an email was sent to the wound nurse. A review of the June 2013 weekly skin assessment sheet revealed no documentation of changes in Resident #61's skin integrity to the left heel. A physician progress notes [REDACTED]. A wound consultant report dated 06/28/13 indicated a pressure area to the left heel measuring 4.3x3.2 with an estimated depth of 0.4 centimeters (cm). The left heel was documented with excessive necrotic tissue black in color and mild serous drainage. The report indicated the clinical stage was unstageable. The report indicated the eschar was loosening and starting to drain with need for consent for debridement. Review of the weekly skin assessment sheet for July revealed an assessment dated [DATE]which indicated an open area to the left heel. A 07/12/13 physician order [REDACTED]. A 07/26/13 wound consultation report indicated the left heel wound was less necrotic and likely developing undermining as the necrotic tissue had been removed. The report indicated a clinical Stage 4 with wound measurements of 4.9x 3.6x 0.6cm. A weekly wound review report dated 07/31/13 indicated no location or Stage for the pressure ulcer. The weekly report indicated under additional documentation a late entry note dated 06/21/13. The note indicated on 06/21/13 an order was received for evaluation of the left heel wound by the wound physician related to the status of the left heel. Heelz up (positioning device) was added on 06/19/13 to aide in offloading the heel. Prior necrosis was noted on the heel. Red heels were initially noted in late April and a blistered area to the left heel was noted in early May (stage 2). In mid May the top layer sloughed off revealing pink colored skin. Review of the Treatment Administration Record (TAR) for April 2013 to July 2013 revealed skin prep was applied to bilateral heels from April 23rd until July 13th. Review of the treatment standing orders revealed a Stage 1 pressure ulcers were to be treated with [MEDICATION NAME] as indicated; a Stage 2 pressure ulcer if shallow then apply a moisture barrier and if the wound had light drainage use hydrogel and a Stage 3 or 4 pressure ulcer if the area was necrotic then use an autolytic [MEDICATION NAME] agent. An observation of Resident #61 's left heel wound was made on 07/31/13 at 11:25AM. The observation revealed the left heel ulcer approximately 5x4x 0.2 cm encompassing the entire heel, with necrotic edges and a beefy red colored center with yellowish slough. When the soiled dressing was removed it contained a moderated amount of blackish, red colored drainage with no odor noted. Interview with nurse aide (NA) #1 on 07/31/13 at 9:52AM, NA #1 stated she reported redness to the left heel a couple of months ago and was told to continue to turn and reposition and elevate the heels on the pillow. The NA stated the left heel then became a grayish blister and was filled with fluid and mushy. The NA added when it started getting worse she reported it to the nurses and was told to continue elevating the feet but the nurse did not look at the area and stated they would have the wound nurse look at the heel. During an interview with the treatment nurse on 07/31/13 at 11:36AM, the treatment nurse explained as part of her duties she would monitor wounds weekly for improvement or worsening and report that in a weekly quality report. The treatment nurse also explained all wounds were placed on that report regardless of stage. The treatment nurse added when the staff notified her of any new areas she would notify the physician, order consultation as needed, inform the dietician for supplementation and enter it on the weekly wound report. Review of the weekly wound quality report from April 29th through July 1st. indicated Resident #61 was not listed on the report. During a follow -up interview with the treatment nurse on 07/31/13 at 5:47PM, the treatment nurse stated she did not recall if the left heel area was blanchable on the 17th of April and was not aware if it was ever communicated to the physician. The treatment nurse also stated she could not recall when the area became a blister but thought it was in May. The treatment nurse also stated it was her mistake but Resident #61's left heel wound was never measured or added to the weekly wound monitoring report. An interview with Nurse #4 on 07/31/13 at 6:22 PM, Nurse #4 explained when the skin prep was first started the area was not open but was a fluid filled area and the area was noted to change and went from a blister to an open area. The nurse added when the blister opened it was bleeding and pinkish. Nurse #4 added before the dressing was changed on 07/12/13 skin prep was being applied and the area was a little blackish. Nurse #4 further explained the treatment nurse was notified of the changes to the left heel. During an interview with Nurse #1 on 08/01/13 at 10:33 AM, Nurse#1 explained the left heel was a blistered area that became dark and skin prep was being applied. Nurse #1 added the area finally opened sometime in May. The nurse explained a black layer of dark old blood came off and foul smelling dark blackish blood oozed out. Nurse # 1 stated she emailed the wound nurse because she felt the skin prep could no longer be used as the area was now open and applying skin prep would be painful. An interview was conducted on 08/01/13 at 11:03AM with the Nurse Practitioner (NP). The NP explained she was unaware of any pressure area to the left heel prior to 06/21/13. The NP added when she observed the left heel on 06/21/13 it was necrotic and dry and warranted consultation from the wound physician due to the necrosis. The NP added she would have expected to be notified when the wound was originally noted to assess the area and review the treatment protocol. The NP also added re-notification was expected when the area started to worsen so the area could have been reassessed, labs ordered, wound physician consulted and a nutritional review conducted. During an interview with the Director of Nursing (DON) on 08/01/13 at 12:07 PM, the DON explained he was unaware of the pressure area to Resident #61's left heel until yesterday. The DON further explained wounds were discussed daily in morning meeting and weekly in a quality meeting which the treatment nurse attended and had never mentioned Resident #61's wound. The DON added he would have expected the treatment nurse to have followed-up on the wound checking on it at least weekly and reporting on the worsening condition. During an interview with the Wound Physician on 08/02/13 at 8:16 AM, the wound physician stated when he assessed the wound on the 28th of June it was an evolving necrosis and was not dry but hard and softening with some slight odor and drainage. The wound physician added he was unaware of the history of the wound. The wound physician did explain that skin prep should not be used once an area was open because it would be painful on a raw surface. He explained once a blister ruptured the treatment should be changed to something more gentle such as hydrogel or xeroform. During a telephone interview with the medical Director on 08/02/13 at 2:51 PM, the Medical Director stated he believed that Resident #61 was on a slow decline in December of 2012 and continued to be on a decline.