Every finding on record at Signature Healthcare of Roanoke Rapids

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of the use of an anticoagulant medication for 1 of 30 residents whose MDS assessments were reviewed (Resident #17).The findings included:Resident #17 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (CVA). Resident #17 had an active physician order dated 4/17/26 for dabigatran (an anticoagulant medication) 150 milligram (mg) capsule; give one capsule twice a day by mouth. The order was noted as on hold for 4/18/26 and 4/19/26. The Medication Administration Record for April 2026 revealed the anticoagulant medication was administered to Resident #17 as ordered twice a day on 4/20/26, 4/21/26, 4/22/26, and 4/23/26. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #17 was not coded for the use of an anticoagulant medication during the 7-day look back period. A telephone interview was conducted with MDS Nurse #2 on 5/07/26 at 10:23 am. MDS Nurse #2 reviewed the electronic health record and confirmed that Resident #17 had been administered the anticoagulant medication during the 7-day look back period of the admission assessment. MDS Nurse #2 stated when she completed the MDS assessment for Resident #17 she missed the use of the anticoagulant medication and did not code the assessment accurately for the use of the medication. The Administrator was interviewed on 5/07/26 at 2:31 pm. The Administrator stated MDS Nurse #2 was responsible for making sure Resident #17's MDS assessment was coded correctly when it was completed.

Based on observations, record review, and staff interviews the facility failed to post cautionary and safety signs indicating the use of supplemental oxygen for 2 of 3 residents reviewed for respiratory care (Resident #1 and Resident #17). The findings included:During the survey entrance conference with the Administrator on 5/04/26 at 10:10 am the Administrator reported the facility was a smoking facility.1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and dependence on supplemental oxygen. Resident #1 had a physician order dated 4/21/26 for oxygen therapy; oxygen via nasal cannula (NC) at 3 liters per minute continuous every shift for hypoxia (low levels of oxygen in the body tissue). Resident #1's census history revealed a room change had occurred on 4/26/26.Observations were conducted on 5/04/26 at 10:46 am and 2:37 pm of Resident #1. Resident #1 was observed in bed with supplemental oxygen in place. Resident #1 did not have the cautionary and safety signage posted that indicated supplemental oxygen was in use.During an interview on 5/07/26 at 9:37 am with Unit Manager #2 confirmed she was responsible for Resident #1's unit. Unit Manager #2 revealed that all residents that used supplemental oxygen should have the safety oxygen in use sign posted on the door frame. Unit Manager #2 stated any staff member was able to put the oxygen in use signage up on Resident #1's door when supplemental oxygen was used. Unit Manager #2 stated that Resident #1 had a recent room change and the safety signage must not have been moved to the new room when the room change was completed. The Director of Nursing (DON) was interviewed on 5/07/26 at 2:03 pm. The DON stated that Resident #1's oxygen in use signage must have been missed when the room change occurred.During an interview on 5/07/26 at 2:29 pm with the Administrator she revealed that when a resident was admitted to the facility and required supplemental oxygen the safety signage should be posted on the residents door. The Administrator stated that nursing administration should follow up and ensure the oxygen in use signs were posted on Resident #1's door. 2. Resident #17 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and dependence on supplemental oxygen.Resident #17 had a physician order dated 4/17/26 for oxygen therapy; oxygen at 2 liters per minute via nasal cannula continuous every shift for hypoxia (low levels of oxygen in the body tissue). Resident #17's census history revealed a room change had occurred on 4/29/26. An observation was conducted on 5/04/26 at 1:51 pm of Resident #17 who was observed to be in bed with supplemental oxygen in place. Resident #17 did not have the cautionary and safety signage posted that indicated supplemental oxygen was in use. An observation and interview were conducted on 5/07/26 at 9:03 am with Unit Manager #1 of Resident #17's room. Unit Manager #1 confirmed the oxygen in use signage was not posted to indicate supplemental oxygen was in use. Unit Manager #1 stated she was not responsible for unit that Resident #17 resided on but she stated that any nurse was able to put the oxygen in use signage on the door when it was needed. During an interview on 5/07/26 at 9:37 am with Unit Manager #2 confirmed she was responsible for Resident #17's unit. Unit Manager #2 revealed that all residents that used supplemental oxygen should have the safety oxygen in use sign posted on the door frame. Unit Manager #2 stated any staff member was able to put the oxygen in use signage up on Resident #17's door when supplemental oxygen was used. Unit Manager #2 stated that Resident #17 had recent room change and the safety signage must not have been moved to the new room when the change was completed. The Director of Nursing (DON) was interviewed on 5/07/26 at 2:03 pm. The DON stated that Resident #17's oxygen in use signage must have been missed when the room change occurred.During an interview on 5/07/26 at 2:29 pm with the Administrator she revealed that when a resident was admitted to the facility and required supplemental oxygen the safety signage should be posted on the residents door. The Administrator stated that nursing administration should follow up and ensure the oxygen in use signs were posted on Resident #17's door.

Based on observations, record reviews, manufacturer recommendations, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 39 opportunities, resulting in a medication error rate of 7.69% for 2 of 4 residents observed during the medication administration observations (Resident #6 and Resident #26).The findings included:1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included vitamin D deficiency and hyperlipidemia (condition of high cholesterol or fats in the blood).A review of Resident #26's current physician's orders revealed a medication order was initiated on 3/25/26 for cholecalciferol (a vitamin supplement to replace Vitamin D) 25 micrograms (mcg) one tablet by mouth one time a day for vitamin deficiency and a medication order initiated on 3/25/26 for fenofibrate 40 milligram (mg) to be given as one tablet by mouth one time a day for hyperlipidemia (condition of high cholesterol or fats in the blood).A review of Resident #26's May 2026 Medication Administration Record (MAR) revealed that the Cholecalciferol and Fenofibrate were scheduled to be administered daily between 7:00 AM and 11:00 AM. On 5/6/26 at 9:03 AM, Nurse #1 was observed as he prepared and administered nine (9) medications to Resident #26. The medications administered to the resident did not include cholecalciferol and Fenofibrate. An interview was conducted on 5/6/26 at 9:22 AM with Nurse #1 with the Assistant Director of Nursing (ADON) present. During the interview, Nurse #1 pulled up Resident #26's May 2026 MAR and reviewed her physician's order for the cholecalciferol and fenofibrate. At that time, Nurse #1 confirmed the order indicated Resident #26 was supposed to receive cholecalciferol 25 mcg once daily and confirmed the order indicated Resident #26 was supposed to receive fenofibrate 40 mg tablet once daily. Nurse #1 stated the stock medication bottle contained cholecalciferol 20 mcg, so he did not administer the cholecalciferol medication. Nurse #1 further stated that the fenofibrate medication was not available for administration and he would follow up with pharmacy to see when medication would be delivered. The ADON stated she would review the orders with the provider for further instructions. An interview was conducted on 5/7/26 at 2:03 PM with the facility's Director of Nursing (DON). The DON stated that staff were to follow up with the pharmacy when medications were not available for administration. The DON stated she expected the staff to notify the provider to see what recommendations they had for the medication order. The DON also stated that she expected staff to notify her of the missing medication, the steps they took, and document that the medication was not given on the MAR.An interview conducted with the Administrator on 05/07/2026 at 2:40 PM revealed medication errors were to be managed by Nursing administration and the DON. The Administrator stated she expected the DON and Nursing administration to ensure medications were available and administered as ordered. The Administrator further stated she expected staff would notify the DON, Unit Manager, and Pharmacy when medications were not available. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe).Fluticasone propion-salmeterol 500-50 micrograms (mcg)/dose is an aerosol powder for inhalation used for the management of chronic obstructive pulmonary disease (COPD) and/or asthma. The manufacturer's Full Prescribing Information that was undated for the Fluticasone propion-salmeterol inhaled medication included Administration Information. These instructions read, in part: After inhalation, the patient should rinse his/her mouth with water without swallowing to prevent thrush (a yeast infection of the mouth). A review of Resident #6's current orders revealed a medication order was initiated on 1/16/26 for 500-50 mcg per actuation of Fluticasone propion-salmeterol aerosol powder to be given as one puff by mouth twice a day for COPD. There was no notation included in the order to rinse mouth and spit after use. On 5/6/26 at 10:11AM, Nurse #6 was observed as she prepared and administered Fourteen (14) medications to Resident #6. The medications administered to the resident included 500-50 micrograms (mcg) per actuation of Fluticasone propion-salmeterol powder given as one puff by mouth. After Resident #6 inhaled one puff of the Fluticasone propion-salmeterol, Nurse #6 collected the inhaler and walked out of the room back to the medication cart. Nurse #6 did not prompt the resident to rinse his mouth with water and then spit the water out after using the inhaled medication. An interview was conducted on 5/6/26 at 10:24 AM with Nurse #6. During the interview, Nurse #6 reviewed the manufacturer's instruction and confirmed the manufacturer's instruction read, in part: After inhalation, the patient should rinse his/her mouth with water without swallowing after use of Fluticasone propion-salmeterol. Nurse #6 pulled up Resident #6's May 2026 Medication Administration Record (MAR) and reviewed his physician's order for the Fluticasone propion-salmeterol. When asked, Nurse #6 stated Resident #6 knew that she was supposed to rinse her mouth out after the Fluticasone propion-salmeterol was administered. Nurse #6 acknowledged she did not prompt Resident #6 to rinse and spit the water out. Nurse #6 stated she would go remind Resident #6 to rinse/spit after using the Fluticasone propion-salmeterol. An interview was conducted on 5/7/26 at 2:03 PM with the facility's Director of Nursing (DON). The DON reported she would expect the nursing staff administering a steroid inhaler to remind the resident to rinse and spit the water out after administering the inhaler.An interview conducted with the Administrator on 05/07/2026 at 2:40 PM revealed medication errors were to be managed by Nursing administration and the DON. She stated she expected the DON and Nursing administration to ensure medications were available and administered as ordered.

Based on record review, and interviews with resident, staff, and pharmacist the facility failed to ensure the accurate documentation and administration of controlled medications (Residents # 1 and # 4) and that the facility's system to account for controlled medications was being followed between shift change and upon receipt and removal of controlled medications in sufficient detail to enable an accurate reconciliation. This was for 3 of 3 sampled residents whose controlled drug records were reviewed for accurate documentation of administration and removal from locked storage (Residents # 1, # 2, and # 4) and for 1 of 1 unit's records reviewed for accounting of controlled medications at shift change and upon receipt or return of controlled medications.The findings included:1. Record review revealed Resident # 1 was admitted to the facility on [DATE] at 6:53 PM and resided there until his discharge on [DATE]. Resident # 1 had diagnoses which included but were not limited to the following: Stage IV basal cell carcinoma with metastatic disease to the lung and bone, open malignant wound to the posterior left shoulder, neuropathy, and a history of cervical and thoracic spine surgery.Review of orders revealed Resident # 1 had an order, dated 3/6/26, for hydrocodone 5-325 mg (milligrams) every four hours as needed for pain.Review of orders revealed additionally Resident # 1 was ordered oxycodone 10 mg every six hours as needed for pain. This was originally ordered on 3/6/26.Review of Resident # 1's March 2026 Medication Administration Record (MAR) revealed Resident # 1 was documented on the MAR to receive hydrocodone 5-325 mg one time while he resided at the facility. This was on 3/10/26 at 9:35 PM and was noted to be administered by Nurse # 5.Review of Resident # 1's hydrocodone-acetaminophen 5-325 mg Controlled Drug Record revealed the hydrocodone-acetaminophen Controlled Drug Record did not reconcile with the MAR. The hydrocodone-acetaminophen was signed out 11 times from storage with no indication it was administered on the MAR. (A Controlled Drug Record sheet is a log on which nurses are to document their signature, date, and time when a controlled medication is removed from locked storage for administration.) The following documentation was on Resident # 1's hydrocodone-acetaminophen Controlled Drug Record:3/6/26 at 2:00 PM-Nurse # 1 signed for a removal of hydrocodone-acetaminophen3/9/26 at 9:00 AM-Nurse # 1 signed for a removal of hydrocodone-acetaminophen3/9/26 at 2:00 PM-Nurse # 1 signed for a removal of hydrocodone-acetaminophen3/10/26 at 1:30 AM Nurse # 6 signed for a removal of hydrocodone-acetaminophen3/10/26 at 8:30 AM Nurse # 1 signed for a removal of hydrocodone-acetaminophen3/10/26 at 2:30 PM Nurse # 1 signed for a removal of hydrocodone-acetaminophen3/11/26 at 6:00 AM Nurse # 5 signed for a removal of hydrocodone-acetaminophen3/11/26 Nurse # 5 signed for a removal of hydrocodone-acetaminophen (no time was documented)3/11/26 Nurse # 5 signed for a removal of hydrocodone-acetaminophen (no time was documented)3/13/26 at 9:00 AM Nurse # 1 signed for a removal of hydrocodone-acetaminophen3/13/26 at 2:00 PM Nurse # 1 signed for a removal of hydrocodone-acetaminophen Review of Resident # 1's March 2026 MAR revealed oxycodone 10 mg was administered 11 times while Resident # 1 resided at the facility. The following was documented on Resident # 1's MAR: 3/6/26 at 9:08 PM Nurse # 7 documented an administered dose of oxycodone3/7/26 at 5:43 AM Nurse # 7 documented an administered dose of oxycodone3/8/26 at 1:12 PM Nurse # 4 documented an administered dose of oxycodone3/8/26 at 10:56 Nurse # 8 documented an administered dose of oxycodone3/11/26 9:35 PM Nurse # 5 documented an administered dose of oxycodone3/12/26 at 10:03 AM MA # 2 documented an administered dose of oxycodone3/13/26 at 9:35 AM Nurse # 1 documented an administered dose of oxycodone3/14/26 at 1:31 PM MA # 4 documented an administered dose of oxycodone3/17/26 at 1:48 AM Nurse # 3 documented an administered dose of oxycodone3/17/26 at 10:08 AM Nurse # 1 documented an administered dose of oxycodone3/18/26 at 4:26 AM Nurse # 9 documented an administered dose of oxycodone Review of Resident # 1's Oxycodone 10 mg Controlled Drug Record revealed the Oxycodone was removed from storage and signed out 13 times but was not initialed on the MAR as administered. The following was documented on Resident # 1's Oxycodone 10 mg Controlled Drug Records: 3/6/26 at 9:00 AM Nurse 10 signed for a removal of oxycodone3/6/26 at 2:00 PM Nurse # 1 signed for a removal of oxycodone3/9/26 at 4:05 AM Nurse # 11 signed for a removal of oxycodone3/9/26 at 10:15 AM Nurse # 1 signed for a removal of oxycodone3/9/26 at 4:20 PM Nurse # 1 signed for a removal of oxycodone3/10/26 at 11:00 AM Nurse # 1 signed for a removal of oxycodone3/11/26 at no documented time Nurse # 5 signed for a removal of oxycodone3/11/26 at no documented time Nurse # 5 signed for a removal of oxycodone3/13/26 at 6:00 PM Nurse # 1 signed for a removal of oxycodone3/14/26 at 2:40 AM Nurse # 2 signed for a removal of oxycodone3/14/26 at 10:45 PM Nurse # 2 signed for a removal of oxycodone3/15/26 at 10:00 AM Nurse # 1 signed for a removal of oxycodone3/16/26 at 1:35 PM Nurse # 1 signed for a removal of oxycodone Nurse # 5 was interviewed on 3/25/26 at 3:46 PM regarding signing out three doses of oxycodone and three doses of hydrocodone-acetaminophen from Resident # 1's supply of controlled medications on 3/11/26 with indication on the MAR that only one dose of oxycodone was administered on that date by him, and no doses of hydrocodone-acetaminophen were administered by him on that date. Nurse # 5 reported the following information. He was scheduled to work at 7:00 PM starting on 3/11/26. He arrived late and he did not think that he and Nurse # 1 counted controlled drugs that night before he took the keys and began work. He was not sure about whether they had or had not. Resident # 1 needed pain medication at 9:34 PM on 3/11/26 and he administered oxycodone for which he signed both on the MAR and the controlled drug record. At 6:00 AM on 3/12/26, Resident # 1 was in pain again. Therefore, he gave him some hydrocodone-acetaminophen but did not put the administration of the hydrocodone-acetaminophen on the MAR. Nurse # 5 also put it on the controlled drug sheet as being removed at 6:00 AM on 3/11/26 and it should have been 6:00 AM on 3/12/26. At the end of his shift at 7:00 AM on 3/12/26, the count was off for both Resident # 1's oxycodone and hydrocodone-acetaminophen. He thought Nurse # 1 had given some doses of both these pain medications on 3/11/26 which she had not signed as removed from storage and it had gone unnoted since they had not counted at 7:00 PM on 3/11/26. Therefore, he signed out two more oxycodone and two more hydrocodone and left the times blank so that Nurse # 1 could come back and fill in the times that the doses were removed by her. He felt he had to do that, or the count would not have been correct. Nurse #5 thought he had talked to Nurse # 12 about this issue. Nurse # 12 was the Unit Manager and had counted with him at 7:00 AM on 3/12/26. The interview further revealed if he had not talked to the Unit Manager about the count being incorrect, then he should have done so. According to the nurse he knew that he was to notify a manager if the count was not correct so that the count could be checked and a notation written about what action was taken. The Unit Manager (Nurse # 12) was interviewed on 3/26/26 at 10:00 AM and reported the following information. The number of controlled medications matched the number recorded on the sheets when she counted with Nurse # 5 at 7:00 AM on 3/12/26 and she had not noticed that Nurse # 5 had signed out for six doses of controlled drugs for Resident # 1 on 3/11/26. At the time of the count, she had been looking to ensure the number of controlled drug pills in storage matched the number on each Controlled Drug Record sheet and they matched which indicated no obvious problems with the count to her. Nurse # 5 had not talked to her about the count being off and that he had signed out extra medication to make the count correct. Nurse # 5 should not have signed out for controlled medications that he himself had not removed from storage. Nurse #12 stated each nurse that removed controlled medications from storage was supposed to sign, date, and time the removal of each individual dose and document the administration on the MAR. Nurse # 1 was interviewed on 3/25/26 at 12:40 PM and reported the following information. She had administered to Resident # 1 all the controlled drugs for which she had signed removal from his supply during his residency. He had experienced pain while he resided at the facility and needed pain medication. Nurse #1 indicated she would get busy with her work and forget to document the administration on Resident # 1's MAR after she removed the doses from locked storage. During a follow up interview with Nurse # 1 on 3/25/26 at 5:30 PM regarding Nurse # 5's comments that he did not think she (Nurse # 1) and he (Nurse # 5) had counted at shift change on 7/11/26 at 7:00 PM and that some of his (Nurse # 5's) removals of oxycodone and hydrocodone-acetaminophen from drug storage was actually meant to reflect Nurse # 1's removal and administration on 3/11/26. During the interview, Nurse # 1 reviewed the count sheet and reported she could not specifically recall if this had been the case, but that it was possible that it had been. Nurse # 6 was interviewed on 3/26/26 at 1:08 PM regarding Resident # 1's dose of hydrocodone-acetaminophen she had removed from controlled drug storage on 3/10/26 at 1:30 AM without documentation of administration to Resident # 1. Nurse # 6 reported she had administered the hydrocodone-acetaminophen but had forgotten to sign for the administration on Resident # 1's MAR. On 3/26/26 at 12:06 PM an attempt was made to interview Nurse # 10 regarding the dose of oxycodone she removed from Resident # 1's controlled drug supply on 3/6/26 at 9:00 AM without documentation of administration. Nurse # 10 could not be reached on that date. On 3/26/26 at 12:00 PM an attempt was made to interview Nurse # 11 regarding the dose of oxycodone she removed from Resident # 1's controlled drug supply on 3/9/26 at 4:05 AM without documentation of administration. Nurse # 11 could not be reached. During interviews with the Director of Nursing (DON) on 3/24/26 at 7:10 PM and again on 3/25/26 at 7:56 PM, the DON reported the following. She would expect that the documentation of removal of controlled substances from locked storage should coincide with documentation of administration to a resident. She recalled speaking directly to Nurse # 5 at one point and did one on one training and educated him that he could not sign out controlled medications for another nurse. She thought this was regarding a problem with documentation related to Resident # 1 but did not recall for sure. The DON was not aware of unaccounted for controlled medications. Interview with the interim Administrator on 3/26/26 at 3:50 PM revealed there should be an accurate accounting of controlled medications, and she was not aware of problems with the accounting of controlled medications. 2. Unit 3's controlled substance count sheet was reviewed for dates and times which began on 3/10/26 at 7:00 PM through 3/19/26 at 7:00 AM. (The controlled substance count sheet is a document on which nurses sign they have reconciled the number of controlled medications between shifts.) The sheet contains columns where an off-going nurse is to sign with an oncoming nurse after they reconcile the count of controlled drugs. There are also columns for the off-going nurse and on-coming nurse to document the total number of cards/containers in the controlled drug storage and the total number of count sheets. (The number of count sheets should coincide with the number of cards/containers of controlled drugs in storage at each accounting between nurses.) There are also columns on the controlled substance count sheet to reflect if controlled medications and their accompanying count sheets have been removed from the total or added to the total during the shift. The columns include a place where nurses are to document a resident's name if a new card/container of medication has been added or subtracted to the number stored, the medication and strength added or subtracted, the number of cards/containers added or subtracted out each shift, the number of sheets added or subtracted out of the count each shift, and columns for two nurses to sign when cards/containers of medications and their accompanying sheets are added or subtracted out of the total count. For Unit 3, between 7:00 PM on 3/10/26 through 7:00 AM on 3/19/26 20, according to the column which noted the number of medication cards added or subtracted to the count, there were twenty (20) medications which were either signed in or out to the total count. For eleven (11) out of these twenty (20) times medications were added in or subtracted out of the total count, there was only one nurse's signature. For seven (7) of the twenty (20) medications added or subtracted out of the total there was no nurse's signature. For two (2) of the twenty (20) medications added in or subtracted out of the total count between 3/10/26 and 3/19/26, there was no notation about what medication was added, for which resident, and by which nurse. (There was just a +1 documented for these two occurrences without any further information.) Further review of Unit 3's controlled substance count sheet for 7:00 PM on 3/10/26 through 7:00 AM on 3/19/26, revealed the documentation did not always reveal which nurse was accountable for the reconciliation of controlled medications between shift changes on multiple days. The number of sheets and the number of cards/containers they counted and reconciled were also not consistently documented during each change of shift. Specifics were as follows: 3/11/26 at 7:00 PM -On-coming Nurse- no documented signature; The number of cards/containers/ medication sheets which were counted and reconciled was blank. (During an interview with Nurse # 5 on 3/25/26 at 3:46 PM, Nurse # 5 reported he was the on-coming nurse, and he thought that he and the off-going nurse had not counted and reconciled the controlled medications.) 3/12/26 at 7:00 AM -Off -going Nurse- no documented signature; The number of cards/containers/ medication sheets which were counted and reconciled was blank. 3/13/26 at 7:00 AM -Off-going Nurse no documented signature 3/14/26 -On-coming Nurse-no documented signature; There was no documented time the changeover and reconciliation occurred. The number of cards/containers/ medication sheets which were counted and reconciled was blank. 3/15/26-completely blank other than the date; This followed the 3/14/26 date which had no time. 3/15/26 at 7:00 PM- Off-going Nurse no documented signature; The number of cards/containers/ medication sheets was blank. 3/16/26 7:00 AM- The number of cards/containers/ medication sheets was blank. Between the 36-hour timeframe of 7:00 AM on 3/16/26 and the next day (3/17/26) at 7:00 PM there was no notation of a count and reconciliation of the controlled medications. During an interview with the DON on 3/25/26 at 7:56 PM, the DON reported that Nurse # 2 had been one of the nurses who had been responsible for the accounting of Unit 3's controlled medications at 7:00 PM on 3/16/26. The DON further reported Nurse # 2 left after midnight on 3/17/26 and the count was reconciled between Nurse # 2 and another staff member in her (the DON's) presence before Nurse # 2 left. According to the DON, the count was initially off and an error in documentation was found by her (the DON) which allowed the controlled substances to be reconciled in her presence. 3/17/26 7:00 PM- Off-going nurse- no documented signature 3/19/26 at 7:00 AM-On-coming nurse- no documented signature During an interview with Unit 3's Unit Manager on 3/26/26 at 10:00 AM, the Unit Manager reported that nurses were to reconcile, count, and sign at each change of shift the controlled medications. If controlled medications were subtracted or added to the total count, then two nurses were to witness and sign for the additions and subtractions. 3. Resident # 2 resided at the facility from 11/7/25 until her discharge on [DATE]. Resident # 2's diagnoses included chronic pain. Review of Resident # 2's medications revealed an order, dated 1/5/26, for Oxycontin 15 mg (milligrams) two times per day. The Pharmacist in charge of the facility's contracted pharmacy was interviewed on 3/26/26 at 11:05 AM regarding Resident # 2's most recent dispensed doses of Oxycontin prior to her discharge and any documentation of returned Oxycontin doses to the pharmacy following Resident # 2's final discharge. The Pharmacist reported the following information after reviewing the records in their pharmacy system. On 2/9/26 the pharmacy received a new Oxycontin prescription for a total of 60 tablets of Oxycontin. The pharmacy sent a 14-day supply which equated to 28 pills on that date (2/9/26). On 2/27/26 their pharmacy system showed that a facility request was submitted to the pharmacy for additional Oxycontin doses for Resident # 2. On 2/28/26 their pharmacy system showed that 17 doses of Resident # 2's Oxycontin dispensed on 2/9/26 was returned. On the same date (2/28/26) their pharmacy system showed a return of 17 doses, their system also showed they sent 28 more Oxycontin doses to the facility for Resident # 2. According to the Pharmacist in charge, the pharmacy was caught up with logging any returns and they did not have any records of returned Oxycontin from Resident # 1's doses sent on 2/28/26. The last return they had logged was on 2/28/26. The Pharmacist was interviewed regarding why the pharmacy's system would show a request of more Oxycontin doses on 2/27/26 while also showing a return of Oxycontin on 2/28/26 for Resident # 1. The Pharmacist in charge acknowledged that the information in their system did not make sense but that was what their system records were showing on the date of interview with the surveyor. According to the pharmacist in charge's records, they were still awaiting Resident # 2's unused Oxycontin from their dispense date of 2/28/26 to be returned to them. On 3/26/26 at 11:55 AM the facility's Corporate Nurse Consultant was interviewed and provided a form entitled. Medication Disposition Record Med Returns to [Name of contracted pharmacy]. The form contained multiple controlled medications for multiple residents which had been returned to the pharmacy. At the top of the form was a scanned date of 3/9/26 and a status notation of in transit. Seventeen doses of Resident # 2's Oxycontin, which was shown to be dispensed by the pharmacy to the facility on 2/9/26, was listed on the return sheet as returned. The Corporate Nurse Consultant also provided the individual Controlled Drug Records for Resident # 1's last two dispensed Oxycontin fills they had received from the pharmacy. The first of these two Oxycontin Controlled Drug Records included a pharmacy sticker which included information that 28 doses were filled on 2/9/26 which left 32 remaining doses on the prescription which could be requested by the facility. A nurse signed on 2/10/26 that the 28 Oxycontin doses were received by the facility. A review of this Controlled Drug Record which was filled on 2/9/26, showed that all 28 doses were used and none were returned. The second of the two Controlled Drug records for Resident # 2's Oxycontin included a pharmacy sticker which included information that 28 doses were filled on 2/28/26 under the same prescription number for Resident # 2, which left four tablets left as available to be filled on the prescription. A nurse's signature, which was not clear, showed these 28 tablets of Oxycontin were received on 2/19/26 by the facility (which was before the pharmacy sticker's fill date.) The Controlled Drug Record for the Oxycontin, which was filled on 2/28/26, showed that 17 doses remained after Resident # 2 was discharged and were returned to the pharmacy on 3/9/26. According to the Corporate Nurse Consultant during an interview on 3/26/26 at 11:55 AM all of Resident # 2's unused Oxycontin was returned upon the resident's discharge, and it did not make sense that the pharmacy's internal records would show the facility returned 17 doses on 2/28/26 when their records showed those 17 doses were used for the resident. According to the Corporate Nurse Consultant, the form showing the return of 17 doses on 3/9/26 was directly taken from the pharmacy's system which they (the facility) could access. The Corporate Nurse Consultant did not understand why the Pharmacist in charge thought that there were still remaining doses of Resident # 2's Oxycontin to be returned since the facility's records showed they had returned all of them and she did not know why the records between the pharmacy and the facility could not be reconciled. 4. Resident # 4 was admitted to the facility on [DATE] and had a diagnosis of vertebrae osteomyelitis (bone infection) and low back pain. Review of orders revealed an order dated 1/1/26 for Oxycontin 10 mg every twelve hours. Resident # 4 also had an order, dated 2/6/26, for oxycodone 5 mg every six hours as needed for breakthrough pain. a. A review of Resident # 4's March 2026 Medication Administration Record (MAR) and Oxycontin Controlled Drug Record revealed on 3/2/26 Nurse # 13 initialed Resident # 4 received his Oxycontin scheduled 10:00 AM dose. A review of Resident # 4's Controlled Drug Record revealed no Oxycontin was signed out of the resident's storage for the administration of the 10:00 AM dose on 3/2/26. Nurse # 13 was interviewed on 3/25/26 at 1:30 PM and reported the following information. She had not administered the 10:00 AM dose of Oxycontin on 3/2/26. The resident appeared sedated. She had already signed on the MAR before she determined it needed to be held and not administered. She was new to the facility's electronic medical system and had been unsure of how to correct MAR to reflect the dose was not actually administered. b. On 3/20/26 at 7:57 PM Nurse # 14 documented on Resident # 4's March 2026 MAR that she administered oxycodone 5 mg per the resident's as needed order. On 3/20/26 Nurse # 14 initialed on Resident # 4's MAR by the 10:00 PM dose of Oxycontin with an asterisk indicating a comment about administration was documented. The comment entered by Nurse # 14 was RC. A review of Resident # 4's Controlled Drug Record revealed no Oxycontin was signed out of the resident's storage for the administration of the 10:00 PM dose on 3/20/26. Nurse # 14 was interviewed on 3/26/26 at 9:10 PM and reported RC meant resident care and did not provide an explanation for why this comment was documented related to the administration or lack thereof of Oxycontin. She recalled that on the evening of 3/20/26 Resident # 4 had complained of pain and she did not realize he had Oxycontin ordered and gave him a dose of Oxycodone which he had ordered as needed. Therefore, she had not administered the Oxycontin but had not entered an explanation to why in the record. During an interview with the DON (Director of Nursing) on 3/25/26 at 7:56 PM, the DON reported she did not know what RC meant under the administration of Resident # 4's 10:00 PM Oxycontin dose on 3/20/26 and did not know by the documentation if the dose had or had not been administered. c. On 3/22/26 Nurse # 15 initialed on Resident # 4's March 2026 MAR by the 10:00 AM dose of Oxycontin that the dose was administered. A review of Resident # 4's Oxycontin Drug Control Record did not reveal a dose of OxyContin was removed from Resident # 4's drug supply for the administration of this dose. Nurse # 15 was interviewed on 3/25/26 at 7:05 PM and reported she could not recall why the MAR reflected that the dose was administered and the Drug Control Record did not reflect it was removed for administration. During an interview with the DON (Director of Nursing) on 3/24/26 at 7:10 PM, the DON reported the following. She would expect that the documentation of removal of controlled substances from locked storage should coincide with documentation of administration to a resident on the MAR.

Based on record review and staff interviews, the facility failed to ensure the accuracy and completeness of documentation related to bowel movements and/or medication administration. This was for 2 of 4 residents whose medical records were reviewed for documentation of bowel movements and/or medication administration (Residents # 1 and # 4). The findings included:1a. Resident # 1 was admitted to the facility on [DATE] with a diagnosis of Stage IV basal cell carcinoma.A review of Resident # 1's bowel movements which were documented in the resident's medical record revealed three bowel movements during Resident # 1's nineteen-day residency of 3/5/26 through 3/18/26. A medium bowel movement was documented on 3/6/26, a small bowel movement on 3/13/26, and a small bowel movement on 3/18/26.Nurse # 1 was interviewed on 3/24/26 at 1:52 PM and reported the following information. She had routinely cared for Resident # 1, and the medical record was not accurate in reflecting the number of bowel movements Resident # 1 had while he resided at the facility. The system would flag when a resident went without a bowel movement for three days in order that nursing staff administer a medication if needed. She had checked with Resident # 1, and he had more bowel movements than were documented in the medical record. Nurse # 1 specifically remembered Resident # 1 had a large bowel movement she thought on 3/17/26 which was not documented.The DON was interviewed on 3/24/26 at 7:10 PM regarding documentation of only three bowel movements during the resident's residency. The DON reported the resident was at risk for constipation due to pain medications he received for his cancer diagnosis. The DON further reported Resident # 1's record was not complete and did not accurately reflect his status in that the resident had more bowel movements than were documented. The DON reported the number of bowel movements in the medical record should be accurately reflected.1b. Review of orders revealed Resident # 1 had an order, dated 3/6/26, for hydrocodone 5-325 mg (milligrams) every four hours as needed for pain.Review of Resident # 1's March 2026 Medication Administration Record (MAR) revealed no documentation that hydrocodone-acetaminophen was administered to Resident # 1 on 3/6/26 at 2:00 PM, 3/9/26 at 9:00 AM, 3/9/26 at 2:00 PM, 3/10/26 at 8:30 AM, 3/10/26 at 2:30 PM, 3/13/26 at 9:00 AM, and 3/13/26 at 2:00 PM although Nurse # 1 signed for the removal of Resident # 1's hydrocodone-acetaminophen on those dates and times on Resident # 1's Controlled Drug Record.Nurse # 1 was interviewed on 3/25/26 at 12:40 PM and validated Resident # 1's medical record was incomplete because she had given the hydrocodone-acetaminophen on all the dates and times she had removed the hydrocodone-acetaminophen from storage, but she had not documented the administration of the hydrocodone-acetaminophen on the resident's MAR in the resident's record.Review of Resident # 1's March 2026 MAR revealed no documentation that Resident # 1 received hydrocodone-acetaminophen on 3/10/26 at 1:08 PM although there was documentation of its removal from drug storage by Nurse # 6 on this date and time. Nurse # 6 was interviewed on 3/26/26 at 1:08 PM regarding Resident # 1's dose of hydrocodone-acetaminophen she had removed from controlled drug storage on 3/10/26 at 1:30 AM without documentation of administration to Resident # 1. Nurse # 6 reported she had administered the hydrocodone-acetaminophen but had forgotten to sign for the administration on Resident # 1's MAR. Review of orders revealed additionally Resident # 1 was ordered oxycodone 10 mg every six hours as needed for pain. This was originally ordered on 3/6/26.Review of Resident # 1's March 2026 MAR revealed no documentation that oxycodone was administered to Resident # 1 on 3/6/26 at 2:00 PM, 3/9/26 at 10:15 AM, 3/9/26 at 4:20 PM, 3/10/26 at 11:00 AM. 3/13/26 at 6:00 PM, 3/15/26 at 10:00 AM, and 3/16/26 at 1:35 PM although Nurse # 1 signed for the removal of Resident # 1's oxycodone on those dates and times on Resident # 1's Controlled Drug Record.Nurse # 1 was interviewed on 3/25/26 at 12:40 PM and validated Resident # 1's medical record was incomplete because she had given the oxycodone on all the dates and times she had removed the oxycodone from storage, but she had not documented the administration of the oxycodone on the resident's MAR in the resident's record.Interview with the interim Administrator on 3/26/26 at 3:50 PM revealed she expected that medical records would be complete regarding the documentation of bowel movements and the administration of controlled medications.2. Resident # 4 was admitted to the facility on [DATE] and had a diagnosis of vertebrae osteomyelitis (bone infection) and low back pain. Review of orders revealed an order dated 1/1/26 for Oxycontin 10 mg every twelve hours. Resident # 4 also had an order, dated 2/6/26, for oxycodone 5 mg every six hours as needed for breakthrough pain. A review of Resident # 4's March 2026 Medication Administration Record (MAR) and Oxycontin Controlled Drug Record revealed on 3/2/26 Nurse # 13 initialed Resident # 4 received his Oxycontin scheduled 10:00 AM dose. Nurse # 13 was interviewed on 3/25/26 at 1:30 PM and reported the following information. She had not administered the 10:00 AM dose of Oxycontin to Resident #4 on 3/2/26 because the resident appeared sedated. She explained she had already signed on the MAR before she determined it needed to be held and not administered. Nurse # 13 indicated she was new to the facility's electronic medical system and had been unsure of how to correct the MAR to reflect that the dose of Oxycontin was not actually administered. Therefore, Nurse # 13 validated the medical record was not accurate. Interview with the interim Administrator on 3/26/26 at 3:50 PM revealed she expected that medical records would be complete regarding the administration of controlled medications.

Based on record review and interviews with family member and staff, the facility failed to ensure transportation was arranged for a resident's follow-up appointments following his discharge from the hospital and subsequent admission to the facility for his medical care. This was for 1 of 3 residents reviewed for professional standards of practice (Resident # 1).The findings included:Record review revealed Resident # 1 was hospitalized from [DATE] to 3/5/25 and then admitted to the facility on [DATE] with a diagnosis of Stage IV basal cell carcinoma with metastatic disease to the lung and bone. Additionally Resident # 1 had a diagnosis of Stage IV Kidney disease.Review of Resident # 1's hospital Discharge summary dated [DATE] revealed it included information that Resident # 1 had diagnostic and physician appointments scheduled related to his cancer and kidney disease diagnosis for 3/18/26. The first appointment was scheduled at 7:00 AM on 3/18/26 and subsequent appointments had designated times already arranged for that same day. The appointments included such things as a preclinical PET (positron emission tomography scan) and appointments with an oncologist and nephrologist. (A PET scan is a nuclear imaging test that can help stage cancer.) The information in the discharge summary included the department and location of each appointment.A review of facility records revealed a physician's progress note, dated 3/9/26, noting that Resident # 1's family member was present and reporting to the physician that Resident # 1 had an oncology follow up scheduled for 10 days and was questioning if transportation could be arranged.Resident # 1's Family Member was interviewed on 3/24/26 at 12:12 PM and reported the following information. He (the family member) had gone to the oncology appointment on 3/18/26 with plans to meet Resident # 1 there. He thought the facility had arranged Resident # 1's transportation to the appointments. The Family Member indicated Resident # 1 did not show up and his appointments were missed.The Transportation Nurse Aide was interviewed on 3/26/26 at 1:00 PM and reported the following information. When a new resident arrives, the nursing staff read the discharge summary and then give the discharge summary to her so that she can review the information for any appointments on the discharge summary for which transportation needs to be arranged. Resident # 1's discharge summary was not given to her for review, and she did not know anything about his 3/18/26 appointments. The Transportation Nurse Aide also stated no one mentioned the appointments to her. She could have taken Resident # 1 to his 3/18/26 oncology appointments if she had known.The facility Social Worker was interviewed on 3/26/26 at 8:05 AM and reported the following information. She was not aware of any of Resident # 1's missed appointments. The Transportation Nurse Aide routinely checked hospital discharge summaries for pending appointments and arranged to transport residents. If the Transpiration Nurse Aide was absent, she would assist with the process.The Director of Nursing was interviewed on 3/25/26 at 7:56 PM and reported the Transportation Nurse Aide should have been given the discharge summary to arrange Resident # 1's transport to his oncology appointments on 3/18/26, but this had not happened. The Director of Nursing did not report why the Transportation Nurse Aide had not been given the information. She (the DON) had not been aware of the problem until after Resident # 1 missed his appointments. The DON further reported that Resident # 1 was transferred back to the hospital later in the day following his first missed appointment on 3/18/26 and therefore the facility had not had time to arrange for the follow ups to take place.Following the interview with the Transportation Nurse Aide on 3/26/26 at 1:00 PM during which the Transportation Aide reported that nursing staff had not given her Resident # 1's discharge summary in order that she knew to make transportation arrangements, an attempt was made to speak to Resident # 1's admitting nurse. According to an interview with the Corporate Nurse Consultant on 3/26/26 at 1:50 PM Nurse # 1, who had admitted Resident # 1 on 3/5/26, had experienced a personal emergency and was not available for interview.

Based on record review and interviews with staff, family member, and Wound Nurse Practitioner (NP), the facility failed to ensure a resident diagnosed with cancer was administered pain medication when the resident requested. This was for 1 of 3 sampled residents reviewed for pain (Resident # 1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE] at 6:53 PM and resided there until his discharge on [DATE]. Resident # 1 had diagnoses which included stage IV basal cell carcinoma with metastatic disease to the lung and bone, open malignant wound to the posterior left shoulder, neuropathy, and a history of cervical and thoracic spine surgery.Review of physician orders revealed Resident # 1 had orders dated 3/6/26, for hydrocodone (opioid pain medication) 5-325 mg (milligrams) every four hours as needed for pain, oxycodone (opioid pain medication) 10 mg every six hours as needed for pain, and gabapentin (medication used for neuropathic pain) 800 mg three times per day. Review of Resident # 1's admission Minimum Data Set assessment, dated 3/11/26, revealed Resident # 1 was cognitively intact and frequently experienced moderate pain which interfered with his day-to-day activities. During the last five days of the assessment period the resident had reported his highest pain level as a 7 on a scale of 1 to 10 (Zero would indicate no pain and ten would indicate the worst pain imaginable).Resident # 1's care plan, dated 3/16/26, included the information that Resident # 1 had complaints of pain related to his wound and cancer malignancy. Interventions on the care plan included to encourage Resident # 1 to request pain medication as needed and to offer the medication as ordered.During an interview with Resident # 1's family member on 3/24/26 at 12:12 PM, the family member reported the following information. Resident # 1 was alert and could ask for pain medication when he resided at the facility. Resident # 1 had voiced to him (the family member) that he would call for his pain medication, and it would take a couple of hours for the staff to administer pain medication. The family member did not reference a specific date when this had occurred but indicated it was a general problem. Resident # 1's pain was in his back and in his shoulders.On 3/24/26 at 1:17 PM the facility's Physical Therapist and Physical Therapy Assistant # 1 were interviewed together regarding Resident # 1's pain. The Physical Therapist reported Resident # 1 had pain, but he was able to stand on the day of her initial evaluation. Following the initial evaluation, PTA # 1 had then consistently worked with Resident # 1. PTA # 1 reported on her first day the resident pivoted but in following days he did not stand or pivot because pain limited his ability to get out of bed. His pain had been in his neck and upper back area. She therefore worked with him on positioning and saw that he would grimace. He would say that his pain was always a 8, 9, or 10. She (PTA # 1) would report the pain to the nursing staff.Nurse # 1, who had routinely cared for Resident # 1, was interviewed on 3/24/26 at 1:52 PM regarding Resident # 1's pain. Nurse # 1 reported the following information. Resident # 1 had both hydrocodone and oxycodone ordered for pain. The nursing staff would try to administer the hydrocodone first and then the oxycodone if needed. The resident was administered his pain medication when requested and when therapy reported the resident's pain. For the most part the pain medication was effective when administered.The Wound NP was interviewed on 3/26/26 at 10:28 PM about Resident # 1's pain. The Wound NP reported the resident's pain in his shoulder and neck were probably due to radiating cancer pain.Review of assignment sheets revealed Nurse # 2 was assigned to care for Resident # 1 starting at 7:00 PM on 3/16/26.Review of Resident # 1's March 2026 Medication Administration Record (MAR) revealed Resident # 1's evening dose of gabapentin was scheduled to be administered every day between an interval timeframe rather than a scheduled hour. The interval was from 7:00 PM to 11:00 PM. Nurse #2 was responsible for caring for Resident # 1 during this timeframe and Nurse #2's initials did not appear on the MAR by the 3/16/26 evening dose. (A nurse's initials by a medication on the MAR would indicate that nurse was the one to administer medication.) Instead, Nurse # 3's initials appeared by the gabapentin evening dose of 3/16/26 with no indication on the MAR when it was given. Further review of the MAR revealed the first dose of oxycodone on the shift which began at 7:00 PM on 3/16/26 was at 1:48 AM on 3/17/26. This was documented as administered by Nurse # 3 and as removed by Nurse # 3 on 3/17/26 at 2:00 AM from controlled medication storage for administration. There was no documentation Resident # 3 received hydrocodone-acetaminophen on the shift which began at 7:00 PM on 3/16/26. On 3/25/26 Nurse Aide (NA) # 1, who had cared for Resident # 1 on multiple occasions, was interviewed regarding Resident # 1's pain. NA # 1 reported the following information. Resident # 1 always had excess pain, and she knew to be careful with him. She was aware of one instance when he requested pain medication, and he did not receive it for several hours because she could not find the nurse. This was either on 3/16/26 or 3/17/26. She worked with him beginning at 7:00 PM on the night when the pain medication was delayed and she had made initial rounds between 7:00 PM and 7:30 PM. During that time, she had asked Resident # 1 if he needed anything. He had reported that he needed his pain medication, and she told him she would relay the message to the nurse. Resident # 1's Nurse (Nurse # 2) had been at the desk, and she (NA # 1) told Nurse # 2 that Resident # 1 was requesting his pain medication and Nurse # 2 replied she would get to it. Then she (NA # 1) went to attend to other duties. Around 8:30 PM she saw Resident # 1's call light on and he reported again he needed his pain medication and had not received any. She again told the resident that she would check with the nurse. At the time, Nurse # 2's cart was at a particular area in the hallway, and she had not seen it moved up and down the halls. NA #1 recalled she could not find the nurse. That evening Resident # 1 kept calling for his pain medication. He would see her (NA # 1) as she went up and down the halls and yell out to her, I am in pain. Nurse # 1's medication cart continued to stay in the same position throughout the evening, and she did not see her at the cart and could not find her. At some point she saw a Medication Aide (MA) who was assigned to another Unit. She thought it was MA # 1 and she (NA # 1) asked MA # 1 if she had seen Nurse # 2 and let her know she could not find her. She thought MA # 1 went to look for Nurse # 2 outside. At some point she thought she saw Nurse # 2 come back in after she (NA # 1) had mentioned the problem of not being able to locate the nurse, but she did not know what Nurse # 2 did and did not recall speaking to her. Several people called the Director of Nursing (DON) that night and the DON had to come to the facility and direct other staff to administer pain medication to Resident #1. She thought it was midnight or after before Resident # 1 received any pain medication because of this. NA # 1 was interviewed regarding whether Resident # 1 was able to go to sleep without his pain medication that night and reported he had not because he was hurting.Nurse # 3 was interviewed on 3/25/26 at 10:38 AM and reported the following information. She worked from 7:00 PM on 3/16/26 until 7:00 AM on 3/17/26 on Unit 2. Resident # 1 resided on Unit 3 and Nurse # 2 was assigned to care for Resident # 1. Other staff members had alerted her that Nurse # 2 was asleep in her car on the evening of 3/16/26 and that residents on Nurse # 2's unit needed their medications. Nurse # 3 did not specify who alerted her first to the problem. One of the residents, who was in need of medication, was Resident # 1 and he needed his pain medication. Nurse # 2 had the keys to Unit 3's medication cart in her pocket and therefore she (Nurse # 3) could not access Resident # 1's medications to administer the resident any pain medication. She called Nurse # 4, who was the on-call nurse, and requested for help because she had her own residents for whom to care and could not access any pain medication for Resident # 1. Nurse # 4 informed her that he had to work the next day at 7:00 AM and that she needed to go to the car and awaken Nurse # 2. Nurse #3 indicated she called the DON also and alerted her to the problem. Her first call was made at 8:29 PM to the DON and the DON also told her to try to awaken Nurse # 2. Nurse #3 stated she went to the car to awaken Nurse # 2, and two other staff members also went on separate occasions that evening to try to awaken Nurse # 2 that evening. When she (Nurse # 3) went to the car, Nurse # 2 cracked the door, and she did not talk but wiped her face and she never came into the facility. Nurse #2 closed the car door and went back to sleep. She (Nurse # 3) called the DON multiple times to alert her to the problem, and the DON repeatedly told her to try to awaken Nurse # 2. By midnight Nurse # 2 was still asleep in her car, and the DON said she would come to the facility. By referencing her phone regarding phone calls, Nurse # 3 reported that the DON arrived at 12:28 AM and Resident # 1 still had not had his pain medication by that time. The DON got Nurse # 2 out of her car, had her come into the facility and count off (reconcile the controlled substances), and sent Nurse # 2 home. The reconciliation took longer because there was a problem that needed to be found and corrected. After the problem was accounted for, she (Nurse # 3) then started to help administer medications on Unit 3 since the keys could then be accessed to the medication cart. Resident # 1's pain medication had not been given by Nurse # 2. She (Nurse # 3) administered pain medication around 2:00 AM to Resident # 1. At the time Resident # 1 had tears in his eyes and rated his pain level a 20 on a scale of 1-10.MA # 3 was interviewed on 3/25/26 at 9:39 PM. MA # 3 indicated she had been in orientation with Nurse # 3 on the evening of 3/16/26 on Unit # 2 and reported the following information. She had accompanied Nurse # 3 to Unit 3 when the DON arrived on the shift which began at 7:00 PM on 3/16/26 and she had counted (reconciled controlled medications) with Nurse # 2 at that time. After the count was reconciled and Nurse # 2 was sent home, she helped administer medications. She did not recall going into Resident # 1's room when Nurse # 3 went to administer his pain medication. She did see the DON walk around and check on residents but could not attest to which rooms she went into. She (MA # 3) did not hear anyone yelling out or crying in pain while on Unit 3.MA # 1 was interviewed on 3/25/26 at 5:20 PM and reported the following information. She was not assigned to Resident # 1 but needed Nurse # 2 to help with a nursing task that was not related to Resident # 1 on the evening of 3/16/26. She tried to find Nurse # 2 and someone pointed to her that Nurse # 2 was outside. She went outside and found Nurse # 2 in the car. She banged on the door to get her attention and told her there was a resident that needed some assistance which she (MA # 1) could not render as a medication aide. At that point Nurse # 2 came into the facility but she did not know how long she was in the facility or what she did.Nurse # 2 was interviewed on 3/25/26 at 4:12 PM and reported the following information. She had not been feeling well on the evening of 3/16/26 and the DON was aware of this. She had gone to her car for break close to the time the DON came to relieve her. Nurse #2 indicated she was not aware of Resident # 1 being in pain and she had not administered pain medication to him.The DON was interviewed on 3/25/26 at 7:56 PM and reported the following information. She had received a call from Nurse # 3 around 8:00 Pm on 3/16/26 but it was not related to Nurse # 2 being in her car and not giving medications. She first received a call on 3/16/26 at 10:32 PM from Nurse # 3 about Nurse # 2 being asleep in her car. She directed Nurse # 3 to try to awaken Nurse # 2 and also told Nurse # 2 that she (the DON) would also call Nurse # 2. She called Nurse # 2 and told her that staff were reporting she was asleep in her car and Nurse # 2 responded that she was on break. She (the DON) responded to Nurse # 2 that staff were reporting she had been on break longer than her allowed break and she directed Nurse #2 to go back into the facility. At 12 something she received another call from Nurse # 3 saying that Nurse # 2 was back in her car and she went to the facility. The DON indicated she arrived at 12:28 AM and found Nurse # 2 in the car. She made Nurse # 2 get out of the car and went with her into the facility where she then had Nurse # 2 reconcile controlled medications with another staff member. There had been a problem with a controlled substance not being signed out but she (the DON) was able to review the MARs and reconcile where the problem had occurred. After the problem was reconciled, she then sent Nurse # 2 home. The DON stated she checked on all the residents to make sure they were okay. She did not recall exactly what time she had entered Resident # 1's room, but when she checked on him, he was asleep. Prior to coming to the facility, she had dressed quickly and needed to return home to dress in professional attire. She asked that other staff who were present attend to any medications needed while she went home quickly and returned to the facility. The DON was interviewed regarding why NA # 1 and Nurse # 3 would indicate that the resident had not been sleeping and had been in pain and reported she did not know.The interim Administrator was interviewed on 3/25/26 at 10:00 AM and reported the following information. She was aware that Nurse # 2 had gone to her car on the evening of 3/16/26 for a break and fallen asleep. She did not know the details of how long she was in the car or anything about Resident # 1 needing pain medication while the nurse was in the car. She knew the DON had been aware of the situation and had taken care of it.

Based on record review and staff, Resident Representative (RR), Nurse Practitioner (NP), and physician interviews, the facility failed to obtain a STAT (immediate or rapid response) mobile x-ray exam when Resident #1 fell and experienced left leg pain for 1 of 3 residents reviewed for falls.Findings included:Resident #1 was admitted to the facility most recently on 02/03/26 with diagnoses that included, in part: End stage renal disease, primary pulmonary hypertension (admission diagnosis), chronic obstructive pulmonary disease, chronic respiratory failure, dependence on renal dialysis, congestive heart failure, paroxysmal atrial fibrillation, sick sinus syndrome, presence of cardiac pacemaker, essential primary hypertension, Type 2 Diabetes Mellitus, poly osteoarthritis, unsteadiness on feet, difficulty in walking, muscle weakness, and limitation of activities due to disability. Review of an admission Minimum Data Set assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She could be understood and did understand others. She had no moods or behaviors. She had impairments to both upper extremities and no impairment to either lower extremity. She had no falls since admission. She received a mechanically altered, therapeutic diet. She had no pressure ulcers. Resident #1 had received anticoagulant medication. She denied pain at the time of the assessment. She received dialysis services. Resident #1 had received Speech Therapy, Occupational Therapy, and Physical Therapy during the assessment look back period. The family of Resident #1 provided the information for the assessment.Review of the care plan for Resident #1 last updated on 02/05/26 revealed the following problem: Resident at risk for falling related to debility and difficulty walking. The category was falls. The goal was for Resident #1 to remain free from falls with major injury with a target date of 05/05/26. Approaches included: 02/17/2026 actual fall, resident sent to emergency room for evaluation and treatment per physician order; therapy evaluation and treat as needed; staff to assist resident with transfers as needed; arrange for a clutter free environment as resident will allow; Keep personal items and frequently used items within reach; encourage and assist resident to assume a standing position slowly; and keep call light in reach.A progress note written by Nurse #2 on 02/16/26 at 7:20 AM was reviewed. Nurse #2 documented she was called to Resident #1's room by the nurse aide where she found Resident #1 laying on the floor. Nurse #2 documented that Resident #1 stated she slid off the bed while trying to sit on the edge. The Resident #1 denied hitting her head or hurting anywhere. The Resident #1 was assessed for any injuries and there were none. She was put back to bed by the nurse aides. Resident #1 was talking about going out to a store shopping during the assessment.An interview was conducted with Nurse #2 on 02/10/26 at 2:15 PM. Nurse #2 stated that she was the wound care nurse; however, staff had called her to Resident #1's room the morning of 02/16/26 because the other nurses were busy elsewhere. She explained Resident #1 was sitting on the floor when she arrived. She assessed the resident including range of motion on all extremities. She found no injury and the resident denied pain. She repeated that there were no indications that the resident had been injured. Nurse #1 recalled Resident #1 was talking about going shopping during the assessment.In a second interview with Nurse #2 on 03/11/26 at 10:05 AM she stated that she had called the RR on the morning of 02/16/26 after Resident #1 fell. Nurse #2 explained she informed the RR that Resident #1 had slid off the bed onto the floor and had not been injured. Nurse #2 stated the RR told her she would be in to see Resident #1 later and she would remind Resident #1 to call for assistance when she wanted to sit on the edge of the bed. Nurse #2 explained that when she documented the fall on the Event Report dated 02/16/2026 she accidently typed that she notified the resident instead of the RR in error.Review of the Event Report dated 02/16/26 for Resident #1 revealed Nurse #2 documented that she had notified Resident #1 of the incident, not the RR. An interview was conducted with Nurse Aide #4 on 03/10/26 at 2:23 PM. She stated she was normally assigned to care for Resident #1. Nurse Aide #4 recalled she had just arrived at work on 02/16/26 at 7:00 AM when she heard Resident #1 holler, Hello.Hello. When she went into the room, Resident #1 was on the floor. Nurse #1 came to the room and assessed Resident #1. Nurse Aide #4 remembered that Resident #1 had not complained of any pain as the nurse assessed her and she was able to move all her extremities.An interview was conducted with Nurse Aide #1 on 03/10/26 at 3:44 PM. She stated she helped to care for Resident #1on 02/16/26 on the day shift. Nurse Aide #1 recalled she and another Nurse Aide #4 found resident #1 on the floor on the morning of 02/16/26. She explained that a third nurse aide on the hall went and got Nurse #1 who came immediately and assessed Resident #1. Once Nurse #1 completed a full body assessment and cleared the resident, she helped put Resident #1 back in bed. Nurse Aide #1 stated Resident #1 was not showing any signs of pain after the fall and she was not aware of any complaints of any pain during the shift on 02/16/26 from 7:00 AM - 7:00 PM while she was working. She recalled after the resident was put back in bed Resident #1 asked Nurse Aide #1 where was breakfast?A progress note was recorded as a late entry on 02/18/2026 at 9:32 AM for 02/16/26 at 11:18 PM by Nurse #1. Nurse #1 documented that she was called to Resident #1's room by the Nurse Aide because the resident had been found on the floor at her bedside facing the foot of the bed. Nurse #1 documented that on assessment Resident #1 denied hitting her head, and had no bruising or bleeding noted. Nurse #1 assessed the resident for range of motion and the resident complained of left leg pain with no deformity noted. Nurse #1 notified the physician on call and received a new order for a STAT x-ray of the left leg and hip. Nurse #1 documented that she called the RR and made her aware of the findings and the new order.The following physician order for Resident #1 was reviewed: Radiology Order: 02/16/26 at 10:18 PM: STAT-immediately; Left Femur; Left Hip related to fall.Nurse #1 was not available for interview.The following progress note was documented by Nurse #3 on 02/17/26 at 4:25 PM: This writer was informed from the (RR) that the resident had a fall over night and asked if the writer could come to help reposition the resident. When helping the resident to get repositioned back in the bed the (RR) stated that the resident stated that she was having pain to the left side of her leg. This writer asked the resident if she could put her hand where the pain was coming from, she then stated that she was not hurting but when being moved the resident did grimace. This writer first palpated the right leg; no pain then proceeded to the left leg the resident did not verbalize any pain but closed her eyes. This writer gave the resident Tylenol for pain. The residents (RR) got (Resident #1) ready for dialysis. The resident then was picked up by medical transport for dialysis. About an hour in a half before the resident was due back from dialysis the x-ray tech came to the unit and stated that she was at the facility to complete an x-ray of the resident left femur and bilateral hips. This writer informed the tech that the resident was out to dialysis and the tech then stated that the x-ray will be rescheduled for later that evening. The resident returned from dialysis about an hour early and was seen by the DON and then the MD (Medical Director). The MD advised that the resident be sent out to the ER (emergency room) for evaluation. (RR) was informed that the resident is being sent out to the ER for evaluation.In an interview with Nurse #3 on 03/11/26 at 2:41 PM she stated on the morning of 02/17/26 she did not complete an assessment on Resident #1 because Nurse #1who was going off shift had reported to her that she had assessed the Resident #1 on her shift and had ordered a STAT x-ray. Nurse #3 stated that no range of motion assessment had been done prior to sending her to dialysis. She recalled that the RR was present on the morning of 02/17/26 and that she had helped the RR get the resident ready to go to dialysis. She helped the RR put a button down shirt on Resident #1 so that dialysis could access her intravenous port easier. Nurse #3 recalled Resident #1 had been sitting on the side of the bed joking with the RR and laughing prior to going to dialysis. Nurse #3 stated that at no time while they were dressing the resident to go to dialysis on the morning of 02/17/26 did the resident indicate she was in pain or even say, ouch, when she was getting ready. Nurse #3 reported that the mobile x-ray technician came to the facility to do the STAT x-ray but Resident #1 had already went to dialysis. Nurse #3 stated that she had called the dialysis unit around 1:30 PM on 02/17/26 to check on Resident #1 because the RR had voiced concern that Resident #1 was in pain and was told by the dialysis nurse that Resident #1slept through her treatment from her arrival until the time she called to inquire. Nurse #3 reiterated that the dialysis nurse did not report to her that the resident was in any pain.An additional interview with Nurse #3 was conducted on 03/11/26 at 3:34 PM at her request. Nurse #3 stated that she did remember that the RR had told her that she thought Resident #1 was in pain around 8:30 AM or 9:00 AM the morning of 02/17/26. Nurse #3 stated she did recall she went to the room and assessed Resident #1. Resident #1 told her she was not in pain. Nurse #3 stated she listened to her lungs, palpated her stomach, palpated both hip areas and moved both of her legs by bending each leg at the knee. She did not note any signs of pain as she assessed Resident #1. She stated it was at that point that she assisted the RR to change the residents shirt. She stated the RR asked her to medicate Resident #1 for pain and she did administer (2) Tylenol 325 Milligram pills to the resident but forgot to record the administration on the Medication Administration Record (MAR). Nurse #3 stated she felt Resident #1 was okay to go to her dialysis appointment.Record review of the February 2026 MAR for Resident #1 showed that no Tylenol medication had been administered to Resident #1 on 02/17/26.In an interview on 03/10/26 at 3:23 PM the Director of Nursing (DON) She stated that Resident #1's RR was at the facility the morning of 02/17/26 and requested that the resident be administered Tylenol for pain prior to going to dialysis. The DON explained that she told the daughter she would assess the resident herself when the resident returned from dialysis and that she would also call the dialysis unit while the resident was there to check her status. She reported that she had called the dialysis facility and was told by the dialysis staff that the resident was fine and was sleeping as usual with no complaints of pain. The DON stated when Resident #1 returned from dialysis she assessed the resident and found that when she attempted to rotate her left leg she grimaced and guarded her leg. The DON reported that she immediately called the provider and obtained an order to send the resident to the emergency room for an evaluation. The DON noted Resident #1 was sent to the emergency room that day at 4:41 PM. She stated she had interviewed Nurse #1 the morning of 02/17/26 and that Nurse #1 told her Resident #1 had been found on the floor the previous evening and when she assessed the resident she found no injury and the resident did not show any signs of pain during range of motion. Nurse #1 explained that she had called the provider and had received an order for a STAT x-ray. The DON stated STAT mobile x-rays were normally completed within 4 hours. She noted that when she called the mobile x-ray provider she was told the provider would have to conduct their own investigation to determine why the STAT x-ray was not completed. The DON explained that she had provided the mobile x-ray technicians with the code to unlock the facility doors but that she learned that the technician who responded to the STAT order was new, did not have the code to the door, and was not able to alert staff that she was there to do the x-ray because after repeated attempts no staff answered the doorbell or the phone. The DON stated that on 02/17/26 when the mobile x-ray technician returned to the facility at 3:01 PM to do the exam, Resident #1 was at dialysis. In an additional interview on 03/11/26 at 1:58 PM, the DON recalled that she had placed a call to the NP on the morning of 02/17/26 and explained that Resident #1 had not received the STAT x-ray that had been ordered the evening of 02/16/26. She reported that the NP told her that if Resident #1 was not in distress that it was okay for her to go to dialysis and get the x-ray later. The DON did not assess Resident #1 for pain at that time because she saw the resident sitting in her wheelchair and laughing as she waited to go to dialysis. She also clarified that she had mistakenly reported that she had called the dialysis unit to check on Resident #1 on 02/17/26 but had delegated the task to the staff nurse.Review of the Dialysis Handoff Communication Form dated 02/17/26 for Resident #1 documented the following problem during dialysis: Continues to complain of left lower extremity pain during dialysis.An interview was conducted with the Dialysis Provider Clinical Coordinator on 03/11/26 at 11:03 AM. She stated on 02/17/26 that Dialysis Nurse #1 documented Resident #1 complained of left lower leg pain and that Resident #1 requested to end her dialysis treatment 2.5 hours into the treatment. The Dialysis Provider Clinical Coordinator explained that Resident #1's normal dialysis treatment was 4 hours. She stated there were no other dialysis nurses notes for 02/17/26. She reported there was no documentation that indicated anyone from the nursing home had called to check on Resident #1 while she was there. She stated that Dialysis Nurse #1 who provided the dialysis treatment to Resident #1 was not available for interview.A Compliant/Grievance Report filed by the RR dated 02/17/26 was reviewed. The concern details were that the RR called with concerns related to Resident #1's falls thinking that all residents are sent to the emergency room after all falls. The DON was assigned to investigate the concern. The findings of the investigation were that the DON called the RR and explained she would herself would call dialysis to check on Resident #1 and would assess Resident #1 herself on return from dialysis. The results of actions taken were that dialysis reported Resident #1 was asleep as usual during treatment with no signs or symptoms of distress. On return Resident #1 was assessed. The physician gave an order to send Resident #1 to the emergency room for evaluation and treatment. The RR was made aware and was thankful. The RR had been contacted by telephone.An interview was conducted with the RR of Resident #1 on 03/10/26 at 11:18 AM. The RR noted that she had been notified of the second fall that had occurred at 10:18 PM on 02/16/26 but not the first fall earlier that day. The RR stated she had asked the nurse to send Resident #1 out to the hospital for evaluation after she fell on [DATE] at 10:18 PM but that the facility staff had not been in agreement to send her out. The RR stated that because it was late when she received the call she told the nurse she would come in the morning to see Resident #1. She explained when she arrived at the facility the next morning on 02/17/26 Resident #1 was moaning in pain and the nurse told her the facility was waiting on a mobile x-ray. The RR stated she asked for Resident #1 to receive Tylenol for pain, and Resident #1 was sent to dialysis. The RR explained that she then called the facility Corporate Complaint line and complained that Resident #1 had not been sent out to have an x-ray done at the hospital after she fell the night before. She stated that later in the day between 4:00 PM and 5:00 PM on 02/17/26 that the Director of Nursing (DON) called her and told her she had assessed Resident #1 and that the resident had been sent to the hospital for an assessment. The RR reported that she went to the hospital and discovered Resident #1 had to have surgery for a hip fracture. The RR stated she felt Resident #1 should have been sent to the hospital after she fell the night before on 02/16/26.An interview was conducted with the NP on 03/11/26 at 9:43 AM. He stated he had assessed Resident #1 on 02/16/26 during the day with the family present. He recalled the focus of the visit was complaints of gout pain in Resident #1's great left toe. The NP also stated he had checked her leg because she had fallen earlier that day and she had normal range of motion with no suspicion of a hip fracture and Resident #1 showed no signs of pain at that time. In an additional interview with the NP on 03/11/26 at 2:40 PM he stated he had not seen or assessed Resident #1 on 2/17/26 after the second fall the previous evening. He noted there were no triage communication notes documented for 02/17/26. He checked his personal cell phone and reported that he had received a call from the facility on 02/17/26 at 10:53 AM but did not recall the conversation. The NP explained had the facility used the preferred method of communication through the physician triage center there would have been a recording of the conversation, but they had contacted him on his personal phone which was not preferred for this reason. He reviewed all the diagnoses for Resident #1 and stated that because she did have a fractured hip when she was transferred to dialysis she was at risk for becoming short of breath or for having a cardiovascular event (heart problem). The NP noted that Resident #1 had not experienced either risk as a result of a delay in treatment for a fractured hip.An interview was conducted with the Medical Director on 03/11/26 at 1:58 PM. He stated that he had not seen or assessed Resident #1 on 02/16/26 or 02/17/26. He explained that a hip fracture could be a life threatening situation but that hip fractures were also sometimes left to heal without surgery in residents with dementia. He stated after reviewing the medical notes he did not feel any further damage had been caused by a delay in treatment in this situation with Resident #1.

Based on record review, and staff, resident, and Medical Director interviews, the facility failed to administer doses of scheduled rapid-acting insulin due to a staffing issue (Resident #1 and Resident #3) and failed to follow up with a pulmonary consultation recommendation to discontinue a steroid medication (Resident #2) for 3 of 3 residents reviewed for significant medication error. The findings included:1a. Resident # 1 was admitted to the facility on [DATE] with diagnoses which included diabetes. Resident #1 had an active physician order dated 9/16/24 for insulin aspart (rapid-acting insulin) 100 units per milliliter (mL). Administer subcutaneous (under skin) as directed three times a day (8:00 am-11:00 am, 11:15 am-3:00 pm, and 5:00 pm-7:00 pm). Give 15 minutes after each meal: 0 units if no food is eaten, 2 units if 25% of meal eaten, 4 units if 50% of meal eaten, 6 units if 100% of meal eaten. The physician order also included to record the blood sugar before insulin was administered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and was coded for hypoglycemic medication which included insulin. The Medication Administration Record (MAR) for 8/14/25 revealed Resident #1 did not receive the scheduled 8:00 am-11:00 am dose of insulin aspart and there was no blood sugar noted. The MAR administration note, written by Nurse #1, revealed the medication was not administered due to overlapping dose from late administration, physician aware. The MAR further noted that Resident #1 received the next scheduled dose of insulin during the scheduled 11:15 am-3:00 pm timeframe for a blood sugar of 238 mg/dl (milligrams per deciliter) by Nurse #1.An interview was conducted with Resident #1 on 12/02/25 at 11:43 am who revealed he did not receive his morning dose of insulin on 8/14/25 after he ate breakfast because the facility did not have a nurse to administer the medication. Resident #1 stated he did not have any adverse events from not having his insulin but he stated he should have been administered his medication as it was ordered. 1b. Resident #3 was admitted to the facility on [DATE] with diagnoses which included diabetes. Resident #3 had a physician order dated 3/18/25 for insulin aspart (rapid-acting insulin) 100 units per milliliter (ml). Administer 13 units subcutaneous (under the skin) twice a day that was scheduled to be administered between 7:00 am-9:00 am and 4:00 pm-5:00 pm. The physician order also included to record the blood sugar before insulin was administered.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 had severe cognitive impairment and was coded for hypoglycemic medication which included insulin. The Medication Administration Record (MAR) for 8/14/25 revealed Resident #3 did not receive the scheduled 7:00 am-9:00 am morning dose of insulin aspart 13 units and there was no blood sugar noted. The MAR administration note, written by Nurse #1 revealed the insulin was not administered due to overlapping dose from late administration and the physician was aware. The MAR noted the next scheduled dose (4:00 pm-5:00 pm) dose was administered for a blood sugar of 512 mg/dl (milligrams per deciliter) by Nurse #1.During an interview with Nurse #1 on 12/02/25 at 3:46 pm he revealed he arrived at the facility on 8/14/25 at approximately 12:30 pm and went directly to his office and began working. Nurse #1 stated that he was notified by the previous Director of Nursing (DON) around 2:00 pm that he needed to pass medications on Unit 1 because the scheduled staff had not shown up for work and the residents had not received their morning medications. He stated that he did not administer Resident #1's or Resident #3's morning insulin aspart doses because by the time he started passing medications it was time for the second doses of insulin aspart to be administered. Nurse #1 stated that the previous DON made the physician aware that the morning doses of insulin were not administered and the physician gave permission to administer the next scheduled doses of insulin aspart for Resident #1 and Resident #3. Nurse #1 stated that all medications that were ordered to be administered daily or twice a day were administered late on that day but he was unable to administer the morning insulin aspart since the next doses were scheduled to be administered.A telephone interview was conducted with the previous Medical Director on 12/03/25 at 10:40 am. The previous Medical Director confirmed he was the physician assigned to Resident #1 and Resident #3 on 8/14/25. He revealed he was notified by the facility that Resident #1 and Resident #3 had not received their morning dose of insulin aspart due to a staffing issue at the facility. The previous Medical Director stated he gave permission to hold the morning insulin aspart since Resident #1 and Resident #3 had additional doses that would have overlapped administration times and told the facility to administer the next scheduled dose. He stated he made the best decision that was possible due to the staffing situation at the facility that morning and Resident #1 and Resident #3 did not have a negative outcome from their missed morning dose of insulin aspart. A telephone interview was conducted with the previous DON on 12/02/25 at 2:15 pm who revealed she did not recall the exact situation that occurred at the facility on 8/14/25 but she stated she did notify the physician that the morning dose of Resident #1's and Resident #3's insulin aspart were not administered. The previous DON stated the physician gave the direction for staff to administer the next scheduled dose of insulin aspart for Resident #1 and Resident #3 and to hold the missed doses that were scheduled to be administered that morning.During an interview on 12/03/25 at 12:46 pm with the Administrator she revealed she was made aware of the staffing issue 8/14/25 and that morning medications were not administered when she arrived at the facility. The Administrator stated the physician was made aware of the what had occurred at the facility by the previous DON. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses which included sarcoidosis of the lung (an inflammatory disease where immune cells form tiny lumps in organs, most commonly in the lungs, lymph nodes, skin, and eyes). Resident #2 had a physician order dated 4/23/25 for prednisone (corticosteroid medication used to reduce inflammation and suppresses the immune system) tablet 2.5 milligrams (mg). Administer 2.5 mg once a day every other day for sarcoidosis until return pulmonology visit. Resident #2's prednisone order was discontinued on 11/11/25. The report of consultation dated 7/30/25 revealed Resident #2 was seen by the pulmonologist for a diagnosis of pulmonary sarcoidosis. The report of consultation further noted to discontinue prednisone, continue budesonide formoterol (inhaled corticosteroid and bronchodilator medication), and monitor for respiratory symptoms. The report of consultation was signed by Unit Manager #1 on 7/30/25.Resident #2's Medication Administration Record (MAR) from July 2025 through November 2025 was reviewed and revealed the prednisone was administered daily every other day until discontinued on 11/11/25.Multiple attempts to conduct a telephone interview with Unit Manager #1 were unsuccessful. An attempt to conduct a telephone interview with the pulmonology office on 12/03/25 at 9:44 am was unsuccessful. A telephone interview was conducted with the previous Medical Director on 12/03/25 at 10:40 am. The previous Medical Director confirmed he was Resident #2's assigned physician at the time the pulmonary consultation occurred. He stated he did not recall the recommendation to discontinue the prednisone for Resident #2 and stated he would have most likely agreed with the recommendation and discontinued the medication. The previous Medical Director stated Resident #2 was ordered a very low dose of prednisone every other day so it would not cause the resident any harm to continue the prednisone until it was discontinued. A telephone interview was conducted on 12/03/25 at 10:49 am with the Medical Director who confirmed they were the assigned physician for Resident #2 since October 2025. The Medical Director stated he was unable to recall if he saw the consultation report from the pulmonology visit in July when he was reviewing the chart or he just decided that the prednisone medication was no longer needed when he discontinued the order for Resident #2. A telephone interview was conducted on 12/02/25 at 2: 15 pm with the previous Director of Nursing (DON) who revealed she was the DON at the time of the pulmonology consultation for Resident #2. The previous DON stated Unit Manager #1 was responsible for reviewing the consultation reports for recommendations, contact the physician to discuss the recommendations, and discontinue the medication if agreed upon by the physician. She stated after the Unit Manager reviewed the consultation report with the provider and made the necessary changes, the report would be reviewed during the morning clinical meeting. She stated she was unable to recall if Resident #2's consultation report from the pulmonology visit was reviewed during the morning clinical meeting at that time. The previous DON was unable to state why Unit Manager #1 would have signed the consultation report but not discussed it with the physician and discontinued the medication as recommended. An interview was conducted with the Administrator on 12/03/25 at 12:46 pm who revealed she was not aware Resident #2's pulmonary visit consultation report was not reviewed with the physician. The Administrator stated the DON was responsible for ensuring the consultation reports were reviewed with providers and any changes that were recommended were implemented.

Based on record review and interviews with resident and staff, the facility failed to ensure sufficient nursing staff to provide nursing services to residents when 2 of 3 assigned staff members (Medication Aide #2 and Unit Manager #1) did not report to work as scheduled. This deficient practice resulted in significant medication not being administered as ordered for 2 of 3 residents reviewed for significant medication error (Resident #1 and Resident #3). The findings included:a. Resident #1 was admitted to the facility on [DATE] with diagnoses which included diabetes. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and was coded for hypoglycemic medication which included insulin.The Medication Administration Record (MAR) was reviewed for 8/14/25 and revealed Resident #1 was not administered the scheduled morning dose of insulin aspart (rapid-acting insulin). The MAR administration note, written by Nurse #1, revealed the medication was not administered due to overlapping doses from late administration and the physician was aware.An interview was conducted with Resident #1 on 12/02/25 at 11:43 am who revealed on 8/14/25 he did not receive his morning dose of rapid-acting insulin after he ate his breakfast because the staff member assigned to his care did not come to work. Resident #1 stated he could not remember exactly how he found out what happened that morning, but he stated he probably just went out and asked someone that was working on the unit and was told the staff did not show up for work. b. Resident #3 was admitted to the facility on [DATE] with diagnoses which included diabetes. The MDS quarterly assessment dated [DATE] revealed Resident #3 had severe cognitive impairment and was coded for use of hypoglycemic medication which included insulin. The Medication Administration Record (MAR) was reviewed for 8/14/25 and revealed Resident #3 was not administered the scheduled morning dose of insulin apart was not administered. The MAR administration note, written by Nurse #1, revealed the medication was not administered due to overlapping doses from late administration and the physician was aware. The facility's daily assignment sheet dated 8/14/25 revealed the facility census was 79 and the following staff were scheduled to work during the day shift (7:00 am-3:00 pm) for medication administration. Medication Aide #2 was assigned to work on Unit 1 from 7:00 am-3:00 pm, Nurse #2 was assigned to work on Unit 2 from 7:00 am-3:00 pm, and Unit Manager #1 was assigned to work on Unit 3 from 7:00 am-7:00 pm. The daily attendance reports were reviewed and revealed the following nursing staff attendance time for 8/14/25. Medication Aide #2 had no work hours recorded for 8/14/25, Nurse #2 clocked in for the shift at 6:42 am, and Unit Manager #1 clocked in for the shift at 11:10 am. The daily attendance report dated 8/14/25 further noted that the previous Director of Nursing (DON) clocked in at the facility at 12:10 pm and the Nurse #1, the Infection Preventionist, clocked in at the facility at 12:30 pm. An interview was conducted with the Scheduler on 12/02/25 at 2:48 pm who revealed she arrived at the facility on 8/14/25 at approximately 8:30 am and saw that some staff had not yet shown up for their scheduled work shift. The Scheduler stated she contacted Medication Aide #2 who reported she was enroute to the facility, but she later called and said she was not coming to work. The Scheduler stated Unit Manager #1 was the nurse on call for 8/14/25 and was already scheduled to work on a medication cart due to a known staffing shortage for that day so she should have arrived at the facility as scheduled at 7:00 am. The Scheduler stated she did not follow up with the previous DON about why Unit Manager #1 was late to the facility because Unit Manager #1 did not report to the scheduler and she assumed the previous DON and Unit Manager #1 were in contact with each other. The Scheduler stated she did notify the previous DON when she (previous DON) arrived at the facility and the previous DON reported she was already aware of the staffing issue at the facility on 8/14/25. The Scheduler stated she continued to make phone calls to replace Medication Aide #2 but was unsuccessful to find a replacement so the previous DON sent Nurse #1 was sent to Unit 1 to pass medications. An interview was conducted with Nurse #1 on 12/02/25 at 3:46 pm who revealed he arrived at the facility on 8/14/25 at 12:30 pm due to a previously scheduled appointment and he was not aware staff had not shown to work. Nurse #1 stated he was not notified until approximately 2:00 pm that he needed to take the medication cart on Unit 1 by the previous DON because medications had not yet been administered. He stated he went to Unit 1 and began administering resident medications to the residents, but he stated he was unable to administer the morning insulin for Resident #1 and Resident #3 because he was not present in the facility at the time the insulin was scheduled to be administered. Nurse #1 reported that the previous DON notified the Medical Director of the staffing issue and missed or late medication administration to the residents. An attempt to conduct a telephone interview with Medication Aide #2 on 12/03/25 at 9:43 am was unsuccessful.Multiple attempts to conduct a telephone interview with Unit Manager #1 were unsuccessful. A telephone interview was conducted on 12/03/25 at 2:36 pm with Nurse Aide (NA) #1 who was assigned to Unit 1 on 8/14/25 during the 7:00 am to 3:00 pm shift. NA #1 stated she recalled the facility did not have anyone to administer resident medications in the morning on 8/14/25. NA #1 stated that she did ask Nurse #2, who was working on Unit 2, to come and pass medications because a resident had reported to her that she had not received any medication. NA #1 stated she did not report there was no nurse on Unit 1 to anyone because she was told by other staff that the facility was aware.A telephone interview was conducted on 12/03/25 at 11:17 am with Nurse #2 who worked during the 7:00 am to 3:00 pm shift 8/14/25. Nurse #2 stated when she arrived at work on the morning of 8/14/25 she clocked in and went right back to Unit 2, which was located at the back of the building, and began working. Nurse #2 reported she was not aware no other nursing staff members were in the facility until she was told by NA #1 sometime during the late morning hours. She reported that NA #1 had requested that she administer a resident pain medication because Unit 1 did not have a nurse. Nurse #2 stated she went over and began passing medications to the residents on Unit 1 and she did her best to pass medications to as many residents as she could until Nurse #1 arrived and came to pass medications. A telephone interview was conducted with the previous DON on 12/02/25 at 2:15 pm who revealed she did not recall the exact situation that occurred at the facility on 8/14/25 or if she was notified about a staffing issue at the facility. She reported she was unable to recall at this time why Resident #1 and Resident #3 did not get the insulin as ordered but she did recall speaking to the physician about medications not being administered on time. During an interview on 12/03/25 at 12:46 pm with the Administrator she revealed she was made aware of the staffing issue and that morning medications were not administered when she arrived at the facility on 8/14/25. The Administrator stated the physician was also notified by the previous DON and the staff made the adjustments as approved by the physician. The Administrator stated the facility should have notified her when the staffing issue was identified.

Based on record review, resident interview, staff interview, and nurse consultant interview, the facility failed to perform a transfer from the wheelchair to the bed according to the care plan for one (Resident #1) of three residents reviewed for accidents. Resident #1 sustained a left leg fracture above the knee with extreme pain requiring a visit to the emergency room at the hospital after being transferred without a mechanical lift. Findings included: Resident #1 had resided in the facility since 7/17/2019 and had multiple diagnoses some of which included cerebral vascular accident, hemiplegia, hemiparesis, heart failure, and diabetes mellitus. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed that Resident #1 was coded as cognitively intact and dependent on staff for a chair-to-bed transfer. On the same assessment, she was also coded as having a range of motion impairment on one side of her upper and lower extremities. Documentation on the care plan initiated on 5/6/2024 under the problem area entitled Profile Care Guide revealed Resident #1 required the intervention of a mechanical lift for transfers. During an initial tour on 4/30/2025 at 9:03 AM, Resident #1 provided the following information. Resident #1 indicated a male nurse aide picked her up and threw her on the bed. Resident #1 told the male nurse aide that he couldn't pick her up knowing what she weighed. Resident #1 stated she hit the bed hard, and it hurt. Resident #1 revealed she was in a lot of pain, so she was transported to the hospital where they put a brace on her leg. An interview was conducted with Nurse #2 on 4/30/2025 at 11:09 AM. Nurse #2 was assigned to care for Resident #1 on 3/30/2025 for the 7:00 AM to 7:00 PM shift. Nurse #2 stated on 3/30/2025 after dinner Nurse Aide (NA) #1 put Resident #1 back to bed at the resident's request. Nurse #2 indicated she checked with Resident #1 at the end of her shift before going home and she was asleep. Nurse #2 revealed NA #1 did not tell her he transferred Resident #1 without a lift and Nurse #2 was not told Resident #1 had any pain. Attempts to contact NA #1 via the telephone during the survey were unsuccessful. The facility provided the following statement from NA #1 obtained on 4/1/2025 by the former Director of Nursing: The writer spoke with [NA #1] to obtain the details on what happened with the transfer of [Resident #1] Agency [Certified Nursing Assistant]. [NA #1] was oriented to the facility with the agency orientation binder. [NA #1] worked 3/30/2025 from 7:00 AM to 7:00 PM. [NA #1] was assigned to [Resident #1]. [NA #1] got [Resident #1] up to the wheelchair with no issues noted. Around 5:30 PM [Resident #1] requested to be put back into bed. [NA #1] states at 5:37 PM he performed a one-person assist from the wheelchair to the bed. [NA #1] wheeled the wheelchair beside the bed and locked it into place. The bed was lowered, and he did a single-person lift. The first lift was unsuccessful, so he placed [her] back into the wheelchair. The second lift was successful and placed [Resident #1] into the bed. [Resident #1] was low in the bed. [Resident #1] complained of mild pain. [Resident #1] stated [to NA #1] the pain was relieved with repositioning. [Resident #1] told [NA #1] Don't do that by yourself again. [NA #1] states that he told [Resident #1] he would not attempt again. [NA #1] states that [Resident #1's] leg made no contact with the wheelchair or the bed. [NA #1] states that there was no twisting of [Resident #1's] leg at the time of the transfer. [NA #1] was educated on the proper transfer process and the importance of timely reporting of resident pain. NA #2 was interviewed on 4/30/2025 at 11:32 AM and the following information was provided. NA #2 worked in the same hallway as NA #1 on 3/30/2025 from 7:00 AM to 7:00 PM. NA #1 was an agency nurse aide, so NA #2 specifically instructed NA #1 to transfer Resident #1 with a mechanical lift. NA #1 did not come to NA #2 to request help transferring Resident #1. NA #2 also revealed she told NA #1 she was available to answer questions and help during the shift. NA #2 stated all agency nurse aides are instructed how to use the kiosk with the care plan information for the residents, reiterating she was available to ask during the shift on 3/30/2025 if NA #1 did not know the resident care needs. NA #3 was interviewed on 4/30/2025 at 3:22 PM. NA #3 stated she worked in the facility on 3/30/2025 from 12:00 PM to 7:00 PM. NA #3 explained she was called into Resident #1's room sometime after dinner because NA #1 needed assistance pulling Resident #1 up in the bed. NA #3 indicated Resident #1 was very low in the bed, positioned toward the foot of the bed, and needed to be repositioned toward the head of the bed. NA #3 did not recall Resident #1 complaining of pain before leaving the room after assisting. Documentation in the nursing progress notes dated 3/30/2025 written by Nurse #1 at 10:32 PM revealed, Resident [complained of] left knee pain. Left knee noted with swelling and discomfort. Painful upon assessment. Received [an] order to obtain an x-ray of [the] left knee. Left voicemail for [Responsible party] to return call to facility. Nurse #1 was interviewed on 4/30/2025 at 4:35 PM. Nurse #1 confirmed she was assigned to care for Resident #1 on 3/30/2025 for the 7:00 PM to 7:00 AM shift. Nurse #1 indicated she did not receive any concerns regarding Resident #1 when she received a report regarding the residents from Nurse #2 at the end of her shift. Nurse #1 revealed that as soon as her shift began NA # 4 came to her while she was in another resident's room and requested, she come to see Resident #1. Nurse #1 stated she went immediately to the room of Resident #1 who told her she was thrown into the bed hurting her knee. Nurse #1 stated she assessed the left knee and observed it was swollen, and Resident #1 was in severe pain. Nurse #1 stated she called the resident's physician, and he requested a mobile x-ray of the left knee. Nurse #1 stated she received a call from the Mobile x-ray company stating they would be at the facility at 7:00 AM on 3/31/2025. Nurse #1 stated she gave Resident #1 650 milligrams of Acetaminophen for the pain, but Resident #1 remained awake on and off with complaints of pain. Nurse #1 revealed she called the physician back due to the continued complaints of pain from Resident #1 and the concern of giving her too much Acetaminophen due to her receiving the scheduled 500 mg of Acetaminophen at night as well as receiving the as-needed dose of 650 mg Acetaminophen for the knee pain. Nurse #1 revealed the physician ordered Resident #1 to receive 20 mg of Prednisone daily for pain and swelling for 5 days. Nurse #1 indicated she also put ice on her knee and elevated her left leg. Nurse #1 admitted the measures put in place to help alleviate pain for Resident #1 helped temporarily but Resident #1 was very upset as to what happened and did not get a lot of sleep. Documentation on the medication administration record (MAR) for 4/30/2025, revealed Resident #1 was administered the scheduled 500 mg of Acetaminophen by mouth on the night shift by Nurse #1 and an additional 650 mg of Acetaminophen by mouth on an as-needed basis at 10:36 PM. The 650 mg of Acetaminophen at 10:36 PM were documented as not effective. Nurse #1 documented the pain level for Resident #1 on 4/30/2025 on the night shift was an 8 on a scale from 1 to 10. An interview was conducted with Nurse #2 on 4/30/2025 at 11:09 AM. Nurse #2 revealed when she returned to the facility on [DATE] for her 7:00 AM to 7:00 PM shift, she was informed by Nurse #1 that Resident #1 was transferred by NA #1 without a mechanical lift and Resident #1 had been complaining of pain on and off throughout the night. Nurse #2 additionally found out an x-ray of the left knee of Resident #1 was ordered for 7:00 AM on 3/31/2025 but they never arrived. Nurse #2 stated that Unit Manager #1 obtained orders for Resident #1 to be sent to the emergency department for x-rays due to the delay. Nurse #2 stated Resident #1's pain was relieved with Acetaminophen on the morning of 3/31/2025. Nurse #2 revealed she found out from the responsible party as she was leaving on 3/31/2024 at the end of her shift that Resident #1 had broken her leg and had to keep an immobilizer on her left leg. Documentation on the MAR for 4/31/2025 revealed Nurse #1 administered the scheduled 500 mg of Acetaminophen by mouth to Resident #1 on the day shift. Nurse #1 documented Resident #1's pain level on the day shift as a 3 on a scale of 1 out of 10. Documentation in the nursing progress notes dated 3/31/2025 at 3:39 PM written by Nurse #2 revealed Resident #1 was sent to the emergency room for further evaluation per the Unit Manager and transported via emergency medical services. Documentation on the emergency department course and medical decision-making dated 3/31/2025 revealed the following information. X-rays were obtained of the left knee and femur. Resident #1 sustained a comminuted and displaced fracture of the distal metaphysis of the left femur with some impaction of the fracture fragments. A comminuted and displaced fracture of the distal metaphysis of the left femur means the bone at the lower end of the thighbone (femur) near the knee was broken into multiple pieces (comminuted) and those pieces had shifted out of alignment (displaced). A knee immobilizer was placed to help stabilize her leg if she was being moved. The former Director of Nursing (DON) was interviewed on 4/30/2025 at 2:14 PM. The former DON stated she was a travel DON and was the DON at the facility from 3/10/2025 to 4/7/2025. The former DON confirmed she took immediate action when it was confirmed NA #1 had not used a mechanical lift to transfer Resident #1 resulting in a fracture. The former DON stated she worked closely with the SCC (facility nurse consultant) to provide education and training for the nursing staff to make sure all the residents were being safely transferred. The former DON stated for specific information on the corrective actions taken, the SCC could provide the details because the former DON was no longer in the facility. An interview was conducted with the facility nurse consultant (SCC) on 4/30/2025 at 2:44 PM. The SCC confirmed she assisted the former Director of Nursing with investigating the fracture sustained by Resident #1 on 3/30/2025. The SCC stated NA #1, an agency nurse aide, lifted Resident #1 from the wheelchair under her arms and placed her on the bed. The SCC noted the unit manager had made sure all the agency nurse aides knew how to access the care plans of each resident on the kiosk as well as making sure the agency staff were made aware binders on how to use the kiosk were located at each nursing station. The SCC stated that agency staff could have always asked another nursing staff member if assistance was needed. The SCC stated that NA #1 decided of his own volition that he would transfer Resident #1 without the assistance of a mechanical lift and another nurse aide causing Resident #1 to fracture her leg during a transfer. The SCC stated that the actions taken by NA #1 were not acceptable and he no longer will return to the facility. The facility provided the following corrective action plan with a completion date of 4/4/2025. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 3/30/25 an Agency Certified Nursing Assistant #1 completed a one-person assist transfer with Resident #1, which required a Mechanical Lift. Resident #1 complained of pain during transfer however this was resolved with repositioning. On 3/30/2025 Resident #1 was assessed by Licensed Nurse #1 with noted swelling and 650mg of Acetaminophen was administered for pain with good effects. The Physician and the Responsible party were notified of Resident #1 change in condition and new orders were received for Mobile X-ray. On 3/31/25, the mobile X-ray company called and stated they would arrive at approximately 7:00 AM. On 3/31/25, Resident #1 complained of left knee pain and discomfort. Swelling remained. The Physician was made aware. New orders were received for Prednisone for 5 days and additional Acetaminophen was given with good effects. On 3/31/25 the Facility Mobile X-ray Company called Licensed Nurse #2 and stated there was a delay in their arrival. On 3/31/25 at 3:39 PM, Resident #1 was transported to the local emergency room with left knee pain and swelling. Resident #1 returned on 4/1/25 to the facility with x-ray results, of a closed fracture of the distal end of the femur, with an immobilizer in place. Orders were placed in the chart to assess pain every shift, immobilizer to the affected extremity, in addition to skin and circulation checks to be performed every 4 hours, and follow up appointments made with orthopedics on 4/9/2025 and 4/23/2025 for additional follow-up. On 4/1/25 the Director of Nursing ensured Agency Certified Nursing Assistant #1 was re-educated and placed on the do not return list. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected. On 4/1/25, in-house assessments of all residents with a BIMS (Basic Interview for Mental Status) of 8 or below were completed by Unit Manager #1. No concerns noted. All residents with BIMS above 8 were interviewed by Licensed Social Worker #1 to ensure all residents were treated with dignity and respect and the facility staff were following the care plan, including transfer status. No additional concerns were noted. On 4/4/25, the Clinical Reimbursement Nurse Consultant audited all residents' care assist profiles to ensure all transfer statuses were accurate and present. This was completed on 4/4/25. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 4/1/25 All facility Nurses and Nursing assistants received the training below: All Licensed Nurses and Nursing Assistants should review the resident's transfer status before performing a transfer. This can be found easily in the resident profile in Care Assistance/Matrix Care Electronic Medical Record. If there is no transfer status on the resident see the nurse before attempting to transfer. Also, please be sure to report any complaints of pain, new or otherwise, to the nurse for assessment promptly. A stop and watch (Reporting method for resident changes in conditions) may be coupled with this as well. The Director of Nursing and Staff Development Coordinator made sure all nursing staff received and retained education as of 4/3/25. As of 4/3/25, 100% of Licenses Nurses and Certified Nursing Assistants have received the in-service on the above. The Director of Nursing and Staff Development Coordinator will ensure that any new nursing staff, including agency staff, will be in-serviced and not allowed to work until the training is completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. Quality Assurance Performance Improvement Plan initiated: 4/1/2025 The Facility Nurse Consultant will monitor five randomly selected transfers weekly to ensure proper resident transfers. This will be documented on a facility Quality Assurance tool. This will be completed weekly for 8 weeks, then monthly times 2. Reports will be presented to the weekly Quality Assurance committee by the Administrator or Director of Nursing to ensure corrective action is completed as appropriate. Compliance will be monitored and the ongoing auditing program reviewed at the weekly Quality Assurance Meeting. The weekly Quality Assurance Meeting is attended by the Administrator, Director of Nursing, Minimum Data Set Coordinator, Therapy, Health Information Manager, and Dietary Manager. Compliance date of 4/4/2025 Validation of the corrective action plan was completed on 5/1/2025. The Quality Assessment and Performance Improvement Plan was reviewed with corresponding documentation to support the actions taken by the facility. Interviews were conducted with a sample of nurses and nurse aides from all nursing shifts to verify education was provided for licensed nurses and certified nursing assistants regarding assuring the correct transfer method was being used before performing a transfer, as well as notification of any new changes in pain. The documentation for in-service records was reviewed. Social Worker #1 was interviewed to confirm all alert and oriented residents were interviewed to verify no other inappropriate transfers had occurred. The Clinical Reimbursement Nurse Consultant was interviewed to confirm the transfer status of each resident was present and accurate in each resident care guide. The audits were verified as well as the ongoing monitoring audits to ensure residents were being transferred with the appropriate transfer method for each resident. The compliance date of 4/4/2025 was validated.

Based on record review and staff interviews, the facility failed to annually review and update the facility assessment, which had the potential to affect 80 of 80 residents in the facility, and to ensure the facility assessment identified and addressed the care required for the population of residents with a tracheostomy (Resident #35 and #56). The findings included: Review of the most recent facility assessment revealed the assessment period was from January 1 through December 31, 2023. This facility assessment indicated there were no residents who required tracheostomy care. A review of the medical records revealed Resident #35 and Resident #56 had tracheostomies and required tracheostomy care. The facility could not provide documents to demonstrate it had reviewed and updated the facility assessment since 2023. An interview conducted with the Administrator on 1/6/25 at 9:42 a.m. revealed it was her responsibility to ensure a review of the facility assessment was conducted annually and updated to reflect accurate information to include the care required for the resident population. She stated she was not aware the facility assessment was not current and forgot to conduct a review of the assessment in 2024.

Based on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of dialysis (Resident #15 and Resident #70), use of a wander elopement alarm (Resident #57), use of hypoglycemic medication (medication that help lower blood sugar levels in people diagnosed with diabetes) (Resident #44), for 4 of 23 residents whose MDS assessments were reviewed. The findings included: 1. Resident # 15 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease and dependence on dialysis (treatment to filter wastes and water from the blood). Review of the hospital discharge summary dated 9/10/24 revealed Resident #15 was hospitalized on [DATE] for acute kidney injury. Resident #15 was seen by the Nephrology (a specialized physician focused on kidney function) and was noted to have improved kidney function and dialysis was discontinued. Resident #15 was discharged back to the facility on [DATE] with no orders for dialysis treatment. Resident #15 had an active physician order dated 9/14/24 to monitor for bruit (a whooshing sound heard at the fistula site with a stethoscope) and thrill (vibration caused by blood flow felt with fingers) to shunt every shift in right arm. A review of Resident #15's medical record revealed no physician order for dialysis. Review of the Nurse Practitioner (NP) progress note dated 10/02/24 revealed Resident #15 was hospitalized on [DATE] through 9/10/24 and was noted to have been seen by nephrology to have improved kidney function and no longer required hemodialysis. The Minimum Data Set (MDS) significant change assessment dated [DATE] and completed by MDS Nurse #1 revealed Resident #15 was coded for dialysis. An interview was conducted on 1/07/25 at 2:44 pm with MDS Nurse #1 who revealed she must have assumed Resident #15 received dialysis treatment because she saw the physician order for monitoring the shunt site. MDS Nurse #1 stated she coded Resident #15's MDS assessment in error. During an interview on 1/07/25 at 12:35 pm the Director of Nursing (DON) revealed Resident #15 had not received dialysis treatments while he resided at the facility and did not have physician orders for dialysis. An interview was conducted with the Administrator on 1/08/25 at 11:28 am who stated the MDS Nurse was responsible to ensure resident assessments were coded accurately. 2. Resident #57 was admitted to the facility on [DATE] with diagnoses which included vascular dementia. Resident #57 had an active physician order dated 6/04/24 for wander guard alarm placement to right wrist. Review of Resident #57's Medication Administration Record (MAR) for December 2024 revealed the wander guard alarm was in place as ordered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #57 was not coded for use of a wander or elopement alarm. An observation on 1/05/25 at 12:59 pm revealed Resident #57 was noted to have a wander guard alarm bracelet on the right wrist. An interview was conducted on 1/07/25 at 2:47 pm with MDS Nurse #1 who revealed she was aware Resident #57 was a wanderer and had a wander guard in place. MDS Nurse #1 stated she just missed it when she completed Resident #57's assessment. An interview was conducted with the Administrator on 1/08/25 at 11:28 am who stated the MDS Nurse was responsible to ensure resident assessments were coded accurately. 3. Resident #44 was admitted to the facility on [DATE] with diagnoses which included diabetes. Resident #44 had an active physician order dated 4/30/24 for insulin glargine (long-acting insulin) 100 units per milliliter (ml). Administer 24 units once a day at bedtime. Resident #44 had an active physician order dated 4/30/24 for insulin glargine100 units per ml. Administer 28 units once a day scheduled to be administered between 7:15 am through 11:00 am. Review of Resident #44's Medication Administration Record (MAR) for October 2024 revealed the insulin glargine was administered as ordered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #44 was not coded for use of hypoglycemic medication. An interview was conducted on 1/07/25 at 2:41 pm with MDS Nurse #1 who revealed the normal process she used to complete the assessment included reviewing the medical record for pertinent information needed to code the assessment. MDS Nurse #1 stated she just missed Resident #44's hypoglycemic medication when she completed the assessment. During an interview with the Administrator on 1/08/25 at 11:28 am who stated the MDS Nurse was responsible to ensure resident assessments were coded accurately. 20710 4. Resident # 70 was readmitted to the facility on [DATE] from a hospital. His cumulative diagnosis included end stage renal dialysis with dependence on renal dialysis. Review of the nurse note dated 11/29/24 revealed Resident #70 was sent to Dialysis this morning and has not returned on his usual schedule. The nurse called the hospital and found out that the resident has been transferred from dialysis and admitted to the hospital for sepsis. The physician was made aware. Resident #70 was discharged back to the facility on [DATE] with no orders for dialysis treatment. Review of Resident #70's Minimum Data Set (MDS) assessment dated [DATE] did not indicate he had end stage renal disease or was receiving renal dialysis services. An interview was conducted on 1/07/25 at 1:50PM with MDS Nurse #1 who revealed the MDS should have been coded to indicate Resident #70 was receiving dialysis. An interview was conducted on 1/07/24 at 3:33 PM with the Director of Nursing who revealed Resident #70, was listed as a resident who received Dialysis. She reported that staff failed to pull the dialysis order back up when he returned from the hospital. An interview was conducted on 1/08/24 at 11:06 PM with the Administrator who stated the MDS Nurse was responsible for ensuring resident assessments were coded accurately.

Based on observations and staff interviews the facility failed to (1) label and date an open insulin injector pen and an open albuterol inhaler (Unit 3) and failed to refrigerate a medication according to the manufacturer's recommendation (Unit 1) for 2 of 2 medications carts reviewed, and (2) failed to ensure 1 of 3 wound treatment carts were secured while unattended (Unit 3). The findings included: 1.a. During an observation of the Unit 3 medication cart with Unit Manager #1 on 1/07/25 at 2:00 pm the following was observed. Unit Manager #1 confirmed all findings before the removal of the items. One insulin lispro (rapid-acting insulin used to manage diabetes) injector pen was in the back of the top drawer, open with no open date noted and no resident identifiers. The label read expires 14-days after opening. The insulin lispro injector pen was not stored in the same location as the current residents insulin injector pens. One albuterol (a medication to relax the muscles in the airways used for asthma and chronic obstructive pulmonary disease) 90 microgram inhaler was observed open, with no open date or resident identifiers. An immediate interview was conducted with Unit Manager #1 who revealed the insulin injector pen should not have been in the medication cart without resident identification and dated when opened. Unit Manager #2 and this surveyor confirmed the insulin lispro injector pen was opened but unused with the orange stopper at the base of the pen below the beginning line of insulin. Unit Manager #1 stated the albuterol inhaler may have been brought in from a resident's home because the facility did not use that type of inhaler, but she stated it should not have been in the medication cart. An interview was conducted on 1/07/25 at 3:41 pm with Nurse #1 who was assigned to Unit 3 medication cart who revealed she did not know the medications were in the cart and she stated she did not use any medications that were not labeled with a resident name. During an interview with the Director of Nursing (DON) on 1/08/25 at 11:44 am she revealed all nurses were responsible for making sure the medication carts did not have medications without resident identifiers and that all medications required an open date. She stated the Unit Managers conduct weekly audits, and the pharmacy also conducted auditing of the medication cart, so she was unable to state how the medications were missed in the cart. b. During an observation of the Unit 1 medication cart with Unit Manager #1 on 1/07/25 at 2:20 pm the following was observed. Unit Manager #1 confirmed the finding before the removal of the item. One squeeze bottle of netarsudil ophthalmic solution (eye drop used to lower pressure inside the eye, used treat glaucoma) unopened with a label on the container that read keep in refrigerator. The manufacturer's storage recommendations for an unopened netarsudil ophthalmic solution were to be stored in the refrigerator at 36 to 46 degrees Fahrenheit. An immediate interview was conducted with Unit Manager #1 who revealed the ophthalmic solution should have been stored in the refrigerator until it was ready to be used. During an interview on 1/08/25 at 11:44 am with the Director of Nursing she revealed the nurses were responsible for checking the medication carts to ensure all medications were stored as recommended. 2. An observation on 1/08/25 at 8:00 am on Unit 3 revealed the wound treatment cart was unattended and unlocked with the lock in the outward position. The wound treatment cart was located across from the nursing station and the facility vending machines. The Administrator and Nurse #2 were observed to be at the nursing station. The Administrator approached this surveyor, and an observation of the wound treatment cart was conducted in the presence of the Administrator. The wound treatment cart was noted to contain resident creams and ointments, medicated dressings, and treatment supplies. The Administrator stated she believed the wound treatment cart was left unlocked for the night shift in the event something was needed but she would check with the Director of Nursing. On 1/08/25 at 8:02 am the Administrator returned to the treatment cart and pushed the lock in to secure the wound treatment cart. The Administrator stated she would try to find out who left the wound treatment cart unlocked. An interview was conducted on 1/08/25 at 8:07 am with Nurse #2 who confirmed she was assigned to Unit 3 on 1/07/25 during the 7:00 pm through 7:00 am shift. Nurse #2 stated she did not use the wound treatment cart during her shift, but she stated another nurse did come over and took something from the wound treatment cart when she started her shift and must have left the cart unlocked. Nurse #2 stated had she had not gone over to the wound treatment cart during her shift and did not notice it was unlocked until reported by this surveyor. During an interview on 1/08/25 at 8:05 am the Director of Nursing (DON) stated the wound treatment cart was to be locked when unattended and all nursing staff knew to lock the cart.

Based on observations, and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent the potential cross contamination of food by failing to clean 1 of 1 plate dispenser and failed to clean the shelf under the steam table for 1 of 1 steam tables observed. These practices had the potential to affect food served to residents. The findings included: 1. During the lunch meal observation on 1/6/25 at 12:14 PM the tray line area was observed. The two-cylinder plate dispenser was observed with dark dried food particles in the bottom of both cylinders and the plate tray had dried liquid stains. An observation on 1/07/25 at 3:14 PM revealed the two-cylinder plate dispenser was observed in the same condition. An interview was conducted with the District Dietary Manager on 1/08/24 at 9:45 AM. She indicated that the two-cylinder plated dispenser was kept plugged in at all times and staff overlooked cleaning inside the cylinders. 2. Observations of the kitchen were conducted on 1/07/25 at 3:14 PM, and 1/08/25 at 9:34 AM, and revealed the 6-foot shelf under the steam table was observed to be covered with dark dried food particles. An interview was conducted on 1/08/25 at 9:48 AM with the Certified Dietary Manager (CDM). She stated she had a weekly cleaning schedule, and the steam table was included in that schedule. An interview was conducted with the District Dietary Manager on 1/08/24 at 9:45 AM. She indicated that the two-cylinder plated dispenser was kept plugged in at all times and staff overlooked the weekly cleaning of the plate dispenser. An interview was conducted on 1/08/25 at 11:02 AM with the Administrator. She stated the dietary staff should keep all areas in the kitchen clean and include the plate dispenser and steam table shelves to the cleaning schedule.

Based on observations, and staff interviews, the facility failed to ensure garbage was contained in a closed dumpster and doors were kept closed for 1of 2 dumpsters observed. The findings included: An observation of the dumpster area was conducted on 1/07/24 at 8:07 AM. Dumpster #1 was observed with a large bag of garbage hanging out of the dumpster lid and 2 disposable gloves were on the ground behind the dumpster. An observation of the dumpster area with the Dietary District Manager was made on 1/07/24 at 3:03 PM. Dumpster #1 lid was open, and the right-side door was open. There were 3 disposable gloves, a soda bottle and straw papers loose on the ground surrounding Dumpster #1. In an interview on 1/07/24 at 3:29 PM the Dietary District Manager revealed the dumpster area had been cleaned that morning and the Waste company had emptied the trash and not picked up what was dropped. In an interview with the Administrator on 1/08/24 at 11:10 AM revealed all staff were responsible for the dumpster area and had been educated to keep the area clean. In an interview on 1/08/24 at 1:28 PM the Corporate Administrator indicated that a staff member should be assigned to inspect the dumpster area daily to keep the area clean and the doors closed.

Based on record review and staff interviews, the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for 1 of 23 residents whose MDS assessments were reviewed (Resident #56). Findings included: Resident# 56 had been admitted to the facility on [DATE] with diagnoses of malignant neoplasm. Resident #56s admission MDS was dated 10/20/24 and identified Resident #56 as cognitively intact had a tracheotomy (a surgical opening in the neck to provide air into the lungs) and revealed she was not receiving hospice services. Review of Resident# 56's medical record revealed a Physician order dated 11/21/24 to admit resident to Hospice related to the terminal diagnosis of malignant neoplasm, if the disease runs normal course life expectancy is 6 months or less. Review of Resident# 56's medical record revealed no documentation that a MDS significant change in status assessment had been completed to reflect Resident #56 was receiving Hospice Services. An interview was conducted on 1/08/24 at 9:00 AM with the MDS Nurse #1 who stated Resident #56 should have had a significant change in status assessment completed when she began Hospice Services. An interview was conducted on 1/08/24 at 11:06 PM with the Administrator who stated the MDS Nurse should have reviewed Resident #56 for a significant change in status assessment when she elected Hospice services.

Based on observations, record review, and staff and Responsible Party (RP) interviews, the facility failed to develop a person-centered care plan for 1 of 1resident reviewed for activities (Resident #44). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses which included stroke and dementia. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] and completed by MDS Nurse #2 revealed Resident #44 had severe cognitive impairment. Resident #44 reported the following activity preferences were very important: books, newspapers, and magazines to read, listen to music, religious services, and be outdoors for fresh air when weather was good. Review of the Life Enrichment Record for October 2024 through January 2025 revealed Resident #44 refused participation in group activites when offered and one to one (1:1) room visits were conducted daily. Resident #44's 1:1 activities included sports and devotionals on television and listening to music. Resident #44's care plan last reviewed on 1/03/25 revealed no care plan related to activity preferences. Observations were conducted of Resident #44 on 1/05/25 at 1:46 pm, 1/06/25 at 1:14 pm, 1/07/25 at 8:07 am and 1:49 pm, and 1/08/25 at 10:30 am. Resident #44 was noted to be in the room with the television on during all observations. During an interview with Resident #44's Responsible Party (RP) on 1/05/24 at 2:41 pm she revealed she was not sure what kind of activities the facility provided for Resident #44. The RP stated she normally visited in the afternoons, and she did not observe Resident #44 involved in any activities when she was at the facility. An interview was conducted with the Activity Director on 1/06/25 at 2:59 pm who revealed she had worked at the facility for over one year. She stated she visited with Resident #44 daily and would offer to participate in the group activities but he would refuse. The Activity Director stated she completed 1:1 room visits for Resident #44 which included sports and devotionals on television, and he enjoyed music. The Activity Director stated she had not done resident care plans since she started working at the facility, but she was just shown how to create a care plan and will start doing the care plans. During an interview on 1/07/25 at 2:44 pm with MDS Nurse #2 who revealed the Activity Director was responsible for implementing the activity focused care plan for Resident #44. An interview was conducted with the Administrator on 1/08/25 at 11:22 am who revealed the Activity Director was responsible for creating the activity care plan for Resident #44, but she expected the MDS Nurses to assist with care plans when needed.

Based on observation, record review, and staff interviews, the facility failed to obtain a physician order for tracheostomy (a surgical opening through the front of the neck into the windpipe for an air passage to help breathe) care for 1 of 2 residents reviewed for tracheostomy (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses which included tracheostomy. The nursing progress note dated 11/23/24 revealed Resident #35 was transferred to the hospital on 11/23/24 and returned to the facility on [DATE]. Resident #35 had a physician order dated 12/04/24 for oxygen via tracheostomy collar at 28% humification with 5 liters per minute continuously. Resident #35 had a physician order dated 12/04/24 to assess for need of suctioning tracheostomy every shift. Review of Resident #35's physician orders revealed no physician order for tracheostomy site care. Review of the Treatment Administration Record (TAR) for December 2024 and January 2025 revealed no documentation for tracheostomy site care for Resident #35. Review of the care plan last reviewed 12/11/24 revealed Resident #35 was at risk for adverse outcomes related to tracheostomy with interventions which included tracheostomy stoma care per physician orders. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #35 was coded for tracheostomy care, suctioning, and oxygen use. An observation was conducted on 1/05/25 at 11:37 am of Resident #35 who was noted to have a tracheostomy opening, without a tracheostomy tube, and oxygen at 5 liters per minute supplied via tracheostomy collar. An interview was conducted with Nurse #5 on 1/05/25 at 1:16 pm who was assigned to Resident #35. Nurse #5 revealed Resident #35 did not use a tracheostomy tube, but she has oxygen to the tracheostomy collar. Nurse #5 stated she provided tracheostomy care to Resident #35 which included cleaning around the tracheostomy site, and she stated the care was provided at least once a shift. Nurse #5 stated Resident #35 also received suctioning of the tracheostomy as needed. An interview was conducted with Nurse #3 on 1/08/25 at 9:21 am who revealed she performed tracheostomy care on her shift for Resident #35 which included cleaning the tracheostomy opening with sterile water and skin care around the tracheostomy site. Nurse #3 stated Resident #35 normally required suctioning once per shift dependent upon the amount of secretions present. During an interview on 1/08/25 at 10:14 am with Unit Manager #1 revealed Resident #35 received tracheostomy care once a shift. Unit Manager #1 confirmed Resident #35 did not have a physician order for the tracheostomy care but stated the order should have been entered when Resident #35 was admitted . Unit Manager #1 reported orders were reviewed in the clinical meetings, but she stated Resident #35's tracheostomy care order was just missed. An interview was conducted on 1/08/25 at 11:50 am with the Director of Nursing (DON) who revealed the Unit Manager was responsible to enter the initial admission orders and the admission packet was then reviewed in the clinical morning meeting. The DON was unable to state how Resident #35's tracheostomy care order was missed.

Based on record review and staff interviews, the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis. This was for 1 of 2 sampled residents reviewed for receiving dialysis. (Resident #70). The findings included: Resident # 70 was admitted to the facility on [DATE] with cumulative diagnosis that included end stage renal dialysis with dependence on renal dialysis. Resident # 70's care plan dated 11/12/24 noted he had a diagnosis of chronic renal failure and has the potential for complications from hemodialysis. Staff were to provide communication with dialysis center regarding medication, diet, and lab results. Coordinate resident's care in collaboration with dialysis center, check shunt site for signs/symptoms of infection, pain, or bleeding daily and as needed, Notify MD (Medical Doctor) to absence of thrill or bruit. Review of the nurse note dated 11/29/24 revealed Resident #70 was sent to Dialysis this morning and had not returned on his usual schedule. The nurse called the hospital and found out that the resident had been transferred from dialysis and admitted to the hospital for sepsis. The physician was made aware. Resident #70's readmission orders dated 12/03/24 did not include an order for dialysis. Review of Resident #70's Minimum Data Set assessment dated [DATE] did not indicate he had end stage renal disease or was receiving renal dialysis services. Review of the nurse's note dated 12/22/24 at 12:24 PM documented Resident #70 returned from dialysis via stretcher with no distress noted. The Resident was safely put back to bed, will continue plan of care. Able to make needs known to staff. An interview with Unit Manager #1 on 1/07/24 at 3:35 PM revealed there was no order for his dialysis. She indicated Resident #70 had gone out to the hospital and on his return his dialysis order was not picked back up. An interview was conducted on 1/07/24 at 3:33 PM with the Director of Nursing who revealed Resident #70, was listed as a Dialysis resident. She reported that staff failed to pull the dialysis order back up when he returned from the hospital. An interview was conducted on 1/08/24 at 11:06 PM with the Administrator who stated staff should have seen Resident #70's physician order for dialysis.

Based on record review, facility staff, Emergency Department Physician's Assistant, Outpatient Clinic Nurse, [CONDITION(S)] Nurse Manager, and Medical Director interviews, the facility failed to control the presence of flies in the facility resulting in a maggot infestation of a resident's wound for 1 of 6 residents (Resident #263) reviewed for wound care. On 7/30/22 Resident #263's left lower leg wound was infested with maggots. She presented to the emergency department with approximately 60-65 maggots in her left lower extremity wound. The findings include: Resident #263 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] (receiving [CONDITION(S)] 3 times weekly), [CONDITION(S)] (skin infection) of the left lower extremity, diabetes, and peripheral vascular disease (reduced blow flow to limbs). A progress note dated 7/11/22 at 12:35 pm written by Nurse #3 revealed Resident #263 was transported to the emergency department for evaluation of altered mental status. A review of the Pest Control Logs indicated the Pest Control Company visited the facility on 7/18/22. All fly traps in resident hallways were checked. No abnormal findings were noted during the service call. A progress note dated 7/20/22 at 5:40 pm written by the facility's Corporate Nurse Consultant revealed Resident #263 was admitted back to the facility with an order for a cardiology appointment on 7/29/22. A Physician's order dated for 7/20/22 revealed an order to cleanse left lower extremity with an antiseptic cleaner, pat dry, apply a petroleum-based dressing to wound bed, and wrap with rolled dressing daily. The 5-day Minimum Data Set (MDS) assessment dated for 7/27/22 indicated Resident #263 was moderately impaired for cognition and required extensive assistance from 1-2 facility staff members to complete activities of daily living. The Resident was coded as receiving [CONDITION(S)] during the MDS assessment period. She was also coded as being diagnosed with venous ulcers (open areas on skin due to abnormal vein function). Resident #263's July 2022 Medication Administration Record revealed the wound dressing treatment for the left lower extremity was signed off by the Resident's assigned nurse once daily as ordered by the Physician from 7/20/22-7/30/22. An interview was completed on 8/24/22 at 3:00 pm with Nurse #4. She indicated she was assigned to Resident #263 on dayshift on 7/28/22. The Nurse stated she provided wound care as prescribed to the Resident's left lower extremity. She revealed she did not observe maggots in the wound during the dressing change. Nurse #4 revealed she did observe 2 flies in Resident #263's room. The Nurse stated she did not observe them in the room during the dressing change. She stated she made the Assistance Maintenance Director aware of the discovery after observing the flies. The Nurse stated he visited the room and used a fly swatter to get rid of them. An interview was completed on 8/24/22 at 3:06 pm with the Assistant Maintenance Director. He indicated he recalled a Nurse (Nurse #4) notifying him of flies in a resident's room around the week of 7/28/22. The Assistant Maintenance Director stated he went to the resident's room and used a fly swatter to rid the room of flies. He was unable to recall what room it was in. He further stated if there had been an abundance of flies, the facility would have had contacted pest control immediately to come into spray. An interview was completed on 8/22/22 at 11:05 am with Nurse #1. She revealed the nurses assigned to Resident #263 completed the Resident's daily wound dressing treatments because the facility did not have a Wound Treatment Nurse. Nurse #1 stated she completed the Resident's scheduled wound dressing treatment on 7/29/22 during the day shift. The Nurse revealed she did not observe maggots in the Resident's wound during the dressing change. She indicated the previous wound dressing was always intact and never loose prior to removing it to apply a new dressing. She further stated the wound bed contained dark colored tissue with minimal amount of drainage. She indicated she did not observe any flies in the room during the Resident's dressing change. Nurse #1 stated it took her approximately 10 minutes to complete the dressing change to Resident #263's left lower extremity. Nurse #1 stated when she provided wound care to the Resident, she had all supplies needed in the Resident's room, and closed the door during the dressing change. She indicated she observed the Resident's room prior to starting wound dressing changes for flies. The Nurse further stated Resident #263 only left her room to attend appointments or go to [CONDITION(S)]. Nurse #1 revealed the facility provided fly swatters at the nurse's station if needed. An interview was completed on 8/22/22 at 2:28 pm with Nurse #6. The Nurse indicated she was assigned to provide care to Resident #263 during nightshift beginning on 7/29/22 and ending in the morning on 7/30/22. She revealed when she prepared the Resident for transport to [CONDITION(S)] on the morning of 7/30/22 Resident #263's left lower extremity dressing was dry, intact, and secure prior to her leaving the facility. Nurse #6 indicated she did not observe flies in the Resident's room during her shift. She revealed the facility has fly swatters available throughout the facility to use if 1-2 flies are observed. Nurse #6 stated if an increase in flies were observed she notified the Administrator and placed the location in the Pest Control Company's logbook (binder located at each Nurse's station the Pest Control Technician checks each visit for any insect/pest activity). A progress note dated 7/29/22 at 4:04 pm written by Nurse #1 indicated the Resident was out of the facility at a Vascular appointment. An interview was completed on 8/23/22 at 9:30 am with a Nurse from a Heart and Vascular Care outpatient clinic. She indicated Resident #263 had an appointment on 7/29/22. The Nurse further revealed the Resident was being seen for a cardiology appointment. She stated Resident #263's wound was not visualized by the Physician. A progress note on 7/30/22 at 1:07 pm written by Nurse #3 revealed while prescribed wound dressing treatment was being provided larva (immature form of insect) was observed. The Physician was notified and advised the Nurse to call emergency medical services and send Resident #263 to the emergency department for evaluation and treatment. An interview was completed on 8/23/22 at 11:11 am with Nurse #3. She indicated she was assigned to provide care to Resident #263 during dayshift on 7/30/22. She stated after Resident #263 returned from [CONDITION(S)]; she went in to change her dressing. Nurse #3 indicated the previous wound dressing to the left lower extremity was dry, intact, and secure and stated when she removed the dressing, she observed 2-3 maggots in the wound bed. The Nurse revealed she cleaned the wound, provided the prescribed wound treatment, and contacted the Physician to make him aware of the Resident's change in condition. The Nurse stated the Physician gave her an order to send the Resident to the emergency department for evaluation and treatment. Nurse #3 indicated she had not observed flies in the Resident's room during her shift. A review of Resident #263's emergency room record revealed a progress note dated 7/30/22 indicating maggot infestation present to her left lower extremity wound. Resident #263 was treated at the hospital for an infection of the left lower extremity wound with intravenous fluids and antibiotics. An interview was completed on 8/22/22 at 7:30 pm with the admitting Physician Assistant (PA) at the emergency department. The PA indicated Resident #263 arrived at the emergency department with her bilateral wounds covered with dry, intact dressings. He stated when the dressings were removed 60-65 maggots were observed in the left lower extremity wound. The PA stated the maggots were removed, the wound was cleaned, and a wound dressing was applied. He indicated maggots invading a wound had the potential to cause an infection. A review of the Pest Control Logs indicated the Pest Control Company visited the facility on 8/1/22. The log indicated a fly spray was applied to all entrance/exit doorways and facility hallways. No sanitation issues or pest control concerns were noted during the visit. An interview was completed on 8/23/22 at 2:16 pm with the Administrator. She indicated the pest control company was contacted the next business day to visit to spray for flies. She stated the company visited on 8/1/22 and sprayed all entrance/exit doorways and facility hallways. The Administrator revealed the Pest Control company last visited on 7/18/22. The technician checked all fly traps in resident hallways. No abnormal findings were noted during the service call. She further indicated the pest control company was contracted to visit the facility monthly to spray for pests. The Administrator stated the facility hallways have fly lights located on all the hallways that attract and trap flies and fly swatters for immediate use. She indicated the facility management staff were assigned resident rooms and complete daily morning room rounds. The Administrator stated staff had been educated to immediately notify maintenance and herself of any increase in fly activity. She revealed these rounds consist of checking for insects and any items that would attract insects. The Administrator stated the findings from the room rounds were discussed during the facility's morning meeting and any concerns were handled immediately. An interview was completed on 8/23/22 at 4:47 pm with the Medical Director. He indicated Resident #263 was admitted to the facility with [CONDITION(S)] (skin infection) in her left lower extremity and bilateral lower extremity venous ulcers. The Medical Director stated the left lower extremity wound had an odor and he felt this and the multiple trips the Resident made to [CONDITION(S)], a fly may have been attracted to the dressing and flown under it. He further stated the Resident was diagnosed with venous and arterial insufficiency that had impeded the healing of the wound. The Medical Director indicated he felt the facility had provided proper wound care and had notified him of all changes in the wound and in the Resident's health. An interview was completed on 8/24/22 at 9:20 am with Nurse #5. She indicated she had observed Resident #263's dressing to her left lower extremity appeared loose once after receiving a [CONDITION(S)] treatment, but she stated it was not recently and was unable to recall the dates. Nurse #5 stated she had never observed the wound being exposed when she returned from [CONDITION(S)]. The Nurse continued to state she reinforced the dressing if she was able or removed the loose dressing and applied a new one. The Nurse indicated the Resident did not touch or attempt to remove her dressing. Nurse #5 stated she had never observed flies in Resident #263's room. An interview was completed on 8/22/22 at 4:28 pm with the [CONDITION(S)] Nurse Manager. The Nurse indicated she had been able to observe the dressings to Resident #263's bilateral lower extremities during her [CONDITION(S)] treatments. She indicated the dressings were always dry, intact, and secure. The Nurse further stated due to the [CONDITION(S)] process, the Resident's swelling in her lower extremities lessens and may cause the dressings to loosen. She continued to state the wounds were never exposed during her [CONDITION(S)] treatments and she never observed the dressing to be loose. A review of Resident #263's electronic medical record revealed she resided on the 300 hall during her stay at the facility. An observation was completed on 8/25/22 at 12:05 pm and revealed it was located across from an entrance/exit door. An observation was completed on 8/25/22 at 12:10 pm of the fly fan above the entrance/exit door located across from the room Resident #263 resided. The fan was blowing out. An interview was completed on 8/22/22 at 3:30 pm with Resident #53. He indicated there were 2-3 days in the last month that 1-2 flies were in his room. He stated he did not notify staff because he felt it was not a problem. An interview was completed on 8/23/22 at 8:39 am with Resident #44. She stated she had 1-2 flies in her room in the last 1-2 months. The Resident indicated facility staff had a fly swatter to get rid of the fly. An observation was completed on 8/24/22 at 9:30 am of a fly flying out of room 300. A second fly was also observed flying in the Resident hallway. A facility staff member was observed going to get a fly swatter to attend to the fly. An observation was completed on 8/25/22 at 1:40 pm of a fly swatter located at the 200 hall nurse's station and 300 hall nurse's station. During an interview on 8/24/22 at 3:06 pm with the Assistant Maintenance Director. The Assistant Maintenance Director stated the flies entered the facility through the entrance/exit doors. He indicated fly lights were located on all facility hallways and fly fans were placed above entrance/exit doors. The Assistant Maintenance Director revealed the Pest Control company visited monthly to inspect the fans and lights. He stated fly swatters were located throughout the facility for staff to use when needed. An interview was completed on 8/24/22 at 4:25 pm with the Regional Plant Operations Manager. He indicated fly lights were located on each resident hallway. He further stated pest control checks the traps when they visit monthly to determine if any additional spaying for insects needed to be performed during that visit. The Administrator was notified of Immediate Jeopardy on 8/24/22 at 8:44 am. The facility provided the following corrective action plan with a completion date of 8/3/22. On 7/30/22, Resident noted with foreign matter to the left leg wound bed that appeared to possibly be maggots. Resident had a cardiology appointment on 7/29/22 that she was transported to and from. Resident returned to the facility after the appointment with a progress note related to the visit with no documentation of any maggots being found during the examination. The Resident also goes out for [CONDITION(S)] treatments three days per week. Element 1 - (Resident(s) Affected) - On 07/30/22 this Resident had left lower extremity wound cleansed per Licensed Nurse, MD notified of findings and ordered resident to be examined at hospital. Resident was sent to the hospital as ordered on 07/30/22. The resident did not return to this facility. Element 2 - (Other Residents who could have been affected) a) On 07/30/22 current facility residents received a skin check and residents with skin integrity issues were assessed by licensed staff to visibly observe for any presence of foreign matter present to the impaired skin integrity areas. No concerns were identified. On 07/31/22 and again on 08/01/22 current facility residents received an additional skin check and residents with skin integrity issues were assessed by licensed staff to visibly observe for any presence of foreign matter present to the impaired skin integrity areas. No concerns were identified. b) On 07/30/22 the provision of treatments was validated through direct observation, by licensed staff for the current resident population who had skin integrity issues had treatment completed and ordered dressings intact. No concerns were identified. This was observations validated by the Director of Nursing, Assistant Director of Nursing, and the Unit Manager. Element 3 - (Action the entity will take to alter the process or system) a) Pest Control arrived at the facility per request of the facility Administrator for additional prophylactic treatment on 8/1/22. Pest Control did not find any pest activity during the onsite visit on 8/1/22. They also documented there were no sanitation issues that could cause pest control issues. Pest Control comes to the facility monthly for pest control inspection and treatment that is for flies and other insects and or pests. b) Education was provided to full-time, part time, agency, and as needed staff on 07/30/22 regarding the following: If anyone notices an abundance / increase (such as droppings, infestations, swarms) of insects, flies, gnats will notify maintenance and place in the pest control book and make the Administrator aware. Also, education was provided to full-time, part time, agency, and as needed staff regarding ensuring all foods are closed in containers or in plastic bags and education was provide on the origin of where maggots come from (flies laying eggs) and that it only takes one fly to cause maggots in a wound. This education was provided by the Director of Nursing, the Assistant Director of Nursing, and the Unit Manager. The pest control book is a book located on nursing station one that staff are to log information on any increased pest activity. The staff will log the pest, location, time, and person reporting. The pest control service looks at this book at each visit. Air curtains were already in place at the facility along with fly lights and fly traps. Element 4 - (Quality Assurance and Performance Improvement) a) Ad Hoc QAPI completed with Medical Director and the facility Administrator, Director of Nursing, and the Unit Manager on 08/01/22. b) Administrator reviewed audits of skin checks that were done on 07/30/22, 07/31/22, and 08/01/22. No concerns identified. c) The QAPI team, during monthly QAPI meetings, will discuss any concerns that arise related to (r/t) any maggots being observed or found in the facility and any pest control issues observed or voiced. d) All staff are alert for monitoring fly presence and will utilize the pest control book and notify the Administrator if any concerns are noted with fly presence. e) Pest Control comes to the facility monthly. During the monthly pest control visits the pest control service provides the following services r/t flies: observes and changes out the fly lights, observes and changes out glue boards, monitors for any increased sign of flies. The facility Administrator is responsible for implementing this plan. Alleged Date of compliance: 08/03/22 Onsite validation was completed on 8/25/22 through staff interviews, observations, and record reviews. Inservice was confirmed to be provided on identification of flies and areas of concern that would attract flies and notification process. Staff were interviewed to validate the in-service was completed on insect control. Review of education conducted with Nurse #7 regarding steps to take if an increase in flies were observed and what were areas in the facility that may attract flies was completed. Skin checks of residents on 7/30/22, 7/31/22, 8/1/22 were reviewed with no concerns noted. A review of the wound treatment audit completed on 7/30/22 revealed no concerns. An interview was completed on 8/25/22 at 10: 30 am with Nurse #8. She indicated if she observed a fly in a resident's room, she would use attempt to use a fly swatter to get rid of the fly, notify the maintenance department, and the Administrator. An interview was completed on 8/25/22 at 2:10 pm with Nursing Assistant #1. She stated the facility had fly swatters available for use. NA #1 indicated if she observed flies in the facility, she would immediately let the Administrator and the maintenance department know and write the location of the flies in the pest control logbook. An observation was completed on 8/25/22 at 3:00 pm of hallway 300. Fly lights were located on hallway and in working order. An observation was completed on 8/25/22 at 3:10 pm of hall 100's entrance/exit door. A fly fan was observed attached above the door and blowing out. An observation was completed on 8/25/22 at 3:15 pm of the Pest Control Logbook located at the 100 hall nurse's station. An interview was completed on 8/25/22 at 4:08 pm with Nurse #7. She indicated if she observed flies in a resident's room, she would immediately contact the maintenance department. Nurse #7 stated she would then attempt to locate the source that was attracting the flies (open food, drink) and attempt to remove it. The Nurse stated fly swatters were available for use to immediately get rid of the flies. Nurse #7 stated prior to completing a wound dressing change she would observe the room for flies and get rid of them if some were observed. The Nurse also stated she always closed the door during wound dressing changes. The facility's corrective action plan was validated to be completed as of 8/3/22.

Based on observation, record review, physician and staff interviews, the facility failed to follow physician's orders to administer scheduled pain medication every 4 hours to control a resident's pain for 1 of 1 resident reviewed for pain management (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set Assessment (Quarterly) dated 4/16/21 revealed the resident was cognitively intact, had no behaviors and required extensive assistance with bed mobility, transfers, ambulation, dressing and personal hygiene and total assistance with toileting. The MDS noted the resident had pain occasionally that did not prevent the resident from sleeping or interfere in day-to-day activities. The MDS noted the resident received an opioid (pain) medication 7 days during the 7 day assessment period. The resident's Care Plan last reviewed on 4/20/21 noted a focus area of Pain and noted the resident reported general body/joint pain as well as diabetic [CONDITION(S)]. The interventions included the following: Monitor side effects of pain. Report to the physician if the resident does not experience reduction or relief of pain after one hour or resident's prescribed interventions. Observe effectiveness of pain medication. Administer pain medication per physician's orders. Review of the physician's orders revealed an order with a start date of 11/16/20 that read as follows: Oxycodone/Acetaminophen 10-325 mg (milligrams) every 4 hours scheduled for pain. Oxycodone is a narcotic pain medication used to treat moderate to severe pain. 1a. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On June 1, 2021 there was a notation on the MAR for 10:00 AM, 2:00 PM and 6:00 PM that read: Not Administered: Drug/Item Unavailable and signed by Nurse #4. The only other pain medication ordered for the resident was Acetaminophen 650mg with an order date of 10/12/20 to be given every 4 hours as needed for pain. On 6/1/21 the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/17/21 at 8:32 AM an interview was conducted with Nurse #4 who stated on June 1, 2021 the Oxycodone had been ordered from the pharmacy and the pharmacy told her they were waiting on a prescription from the doctor and the medication was delivered to the facility on the night of 6/1/21. The Nurse further stated she gave the resident his PRN (as needed) Acetaminophen. The Nurse stated they had Oxycodone 5/325mg in the emergency medication kit but did not have Oxycodone 10/325mg. The Nurse continued and stated the resident did not say he was in pain and she did not call the doctor to let him know the medication was not available. Review of the nursing progress notes for Resident #41 revealed no information that the physician was notified of the Oxycodone not being available. On 6/17/21 at 10:17 AM an interview was conducted with Resident #41. When asked if he received his pain medications regularly the resident stated: Sometimes they are out of it. The resident was asked what he said to the nurse when told they were out of his pain medications and he stated he said Okay. When asked how much pain he had when he did not get his pain medications, Resident #4 stated: Oh, intolerable and stated his pain level went up to a 9-10. On a pain scale, 0 is no pain and 10 is unbearable pain. The resident was observed to be very stoic and did not complain about the facility not having his medication. On 6/17/21 at 10:50 AM, Resident #41 was interviewed in the presence of the Director of Nursing (DON). The DON asked the resident what his pain level was when he did not get his pain medication and the resident stated 8-9 and when he did get his pain medication his pain was 8-9. The Resident stated he had [CONDITION(S)] [CONDITION(S)] and was very stiff and when he got the pain medication the pain was tolerable but when he did not get the pain medication the pain was intolerable. On 6/17/21 at 11:58 AM an interview was conducted with the resident's Physician who stated no one had called him about the resident's pain medication this month. The Physician further stated the resident was very stoic and did not complain about anything. The Physician continued and stated he had tried to educate the facility on not running out of medications and when he was in the facility, he tried to be proactive and ask the nurses if they need written prescriptions for any controlled medications. The Physician further stated they have a back-up pharmacy in town and if the nurse had called him, he could have called the prescription in to the pharmacy and the staff could have gone to pick it up. The Physician continued and stated the facility had an emergency medication kit and they could add any medication they wanted to the emergency kit. On 6/18/21 at 10:29 AM the Physician stated in an interview that all prescriptions (including narcotics) could be done electronically in the state of North [NAME] and he wrote prescriptions seven days a week. On 6/18/21 at 12:11 PM the Director of Nursing stated in an interview that it was her expectation that the nurse notified the physician of any medication that was not available. The DON stated in this case, in order to obtain a narcotic medication for the resident from the emergency kit or from the back-up pharmacy, the physician would need to be called. The DON stated the Oxycodone 10/325mg was not a medication that was currently stocked in the emergency medication kit. 1b. Review of the June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On June 7, 2021 there was a notation on the MAR for 10:00 AM, 2:00 PM and 6:00 PM that read: Not Administered: Drug/Item Unavailable and signed by Nurse #3. The only other pain medication on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/17/21 at 7:58 AM an interview was conducted with Nurse #3 who stated when she started her shift Resident #41 had no Oxycodone on the cart and the pharmacy was supposed to deliver the medication the night before. The Nurse stated she called the pharmacy and was told they would bring the medication at lunch time and the medication was not delivered so she called the pharmacy back and the medication was delivered that night. The Nurse stated they have Oxycodone 5/325mg in their emergency medication kit but they did not have Oxycodone 10/325mg in the kit. The Nurse further stated the resident did not say he was in pain and she did not call the physician to let him know they were out of the resident's pain medication. Review of the progress notes for Resident #41 revealed no documentation the physician was notified that the resident was out of the pain medication. On 6/17/21 at 10:17 AM an interview was conducted with Resident #41. When asked if he received his pain medications regularly the resident stated: Sometimes they are out of it. The resident was asked what he said to the nurse when told they were out of his pain medications and he stated he said Okay. When asked how much pain he had when he did not get his pain medications, Resident #4 stated: Oh, intolerable and stated his pain level went up to a 9-10. On a pain scale, 0 is no pain and 10 is unbearable pain. The resident was observed to be very stoic and did not complain about the facility not having his medication. On 6/17/21 at 10:50 AM, Resident #4 was interviewed in the presence of the Director of Nursing (DON). The DON asked the resident what his pain level was when he did not get his pain medication and the resident stated 8-9 and when he did get his pain medication his pain was 8-9. The Resident stated he had [CONDITION(S)] [CONDITION(S)] and was very stiff and when he got the pain medication the pain was tolerable but when he did not get the pain medication the pain was intolerable. On 6/17/21 at 11:58 AM an interview was conducted with the resident's Physician who stated no one had called him about the resident's pain medication this month. The Physician stated the resident was very stoic and did not complain about anything. The Physician stated he had tried to educate the facility on not running out of medications and when he was in the facility, he tried to be proactive and ask the nurses if they need written prescriptions for any controlled medications. The Physician further stated they have a back-up pharmacy in town and if the nurse had called him, he could have called the prescription into the pharmacy and the staff could have gone to pick it up. The Physician continued and stated the facility had an emergency medication kit and they could add any medication they wanted to the emergency kit. On 6/18/21 at 10:29 AM the Physician stated in an interview that all prescriptions (including narcotics) could be done electronically in the state of North [NAME] and he wrote prescriptions seven days a week. On 6/18/21 at 12:11 PM the Director of Nursing stated in an interview that it was her expectation that the nurse notified the physician of any medication that was not available. The DON stated in order to obtain a narcotic medication for the resident from the emergency medication kit or from the back-up pharmacy, the physician would need to be called. The DON stated the Oxycodone 10/325mg was not a medication that was currently stocked in the emergency medication kit.

Based on record reviews, staff interviews, and physician interviews, the facility failed to provide a comprehensive approach to pressure ulcers as evidenced by lack of assessments, lack of documentation, and lack of treatments for 1 or 3 residents reviewed for care and services for pressure ulcers. Resident # 1 was admitted on [DATE] with no skin breakdown and was identified on 1/19/21 with an unstageable pressure ulcer to the coccyx, and on 1/20/21 a deep tissue injury to the left heel, left posterior ankle, and left plantar foot. Immediate Jeopardy began on 1/8/2021 a nurse aide identified an open area on the sacral area and a nurse did not perform a complete assessment until 1/19/21, and at that time it was unstageable. Immediate jeopardy was removed on 2/28/2021 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems are in place are effective for the provision of a comprehensive approach to pressure ulcer care. Findings included: Resident #1 was admitted to the facility from the hospital on [DATE] and resided there until his discharge on 1/27/2021. The resident had a [DIAGNOSES REDACTED]. The discharge summary from the hospital dated 1/1/2021 revealed Resident #1 had to wear a neck brace continuously, had unremarkable laboratory values except for [MEDICAL CONDITION], and had no skin breakdown but was at high risk for pressure injuries. The nursing admission observation form check off sheet with skin as one of the categories, dated 1/1/2021 indicated Resident #1 had warm, dry, normal color, normal turgor, and no alterations to his skin. A Braden scale for predicting pressure sore risk dated 1/1/2021 revealed Resident #1 was at high risk for pressure sores due to completely limited sensory perception, occasionally moist skin, bedfast, completely immobile, adequate nutrition, and a friction problem. A nutrition risk assessment dated [DATE] revealed Resident #1 was assessed on 1/1/2021 as being 300 pounds and 6 foot 2 inches tall. Physical therapy notes dated 1/5/2021 stated collaboration was made with the facility social worker, director of nursing, and the unit manager regarding Resident #1 requiring total dependence on care givers for all activities of daily living, the need for an air mattress, as well as the need to establish repositioning schedule every 2 to 3 hours for pressure redistribution and maintenance of skin integrity. An interview with the interim Director of Nursing (DON) was conducted on 2/11/2021 at 3:16 PM. The DON confirmed the air mattress was ordered for Resident #1 as a result of the recommendation of physical therapy. The DON explained all the beds in the facility were pressure redistributing mattresses while Resident #1 obtained a low air loss mattress on 1/7/2021 as evidenced by an invoice with his name on it. A nursing progress note dated 1/8/2021 at 12:54 PM written by the MDS (minimum data set) nurse (Nurse #6) and entered as a late entry on 1/13/2021 stated, Resident (#1) observed on an air mattress. An admission MDS dated [DATE] coded Resident #1 as having a moderately impaired cognition, no rejection of care, and dependent on two people for all activities of daily living. Resident #1 was coded as having an indwelling catheter and always incontinent of bowel. Resident #1 was coded as having no pressure sores, on a pressure reducing device for the bed, application of ointments other than to feet, and was not on a turning and repositioning schedule. The unit manager (Nurse #1) was interviewed on 2/10/2021 at 1:57 PM, 2/10/2021 at 4:15 PM, and again on 2/12/2021 at 10:50 AM. Nurse #1 stated a nurse aide approached her on 1/08/2021 because Resident #1 had an open area on the left buttock. Nurse #1 stated she observed a shearing of the skin of the left buttock on Resident #1. Shearing is a gravity force pushing down on the patient's body with resistance between the patient and the chair or bed. Nurse #1 described the area as a reddened area. Nurse #1 stated she did assess the skin of Resident #1, but she did not document her observations. Nurse #1 stated she did not know why she did not record any documentation of the skin assessment of Resident #1 on 1/08/2021. Nurse #1 called the resident's physician and obtained orders for treatment. A physician's order was initiated on 1/8/2021 for a treatment of [REDACTED].#1. The order stated the wound was to be cleaned with wound cleanser, patted dry, [MEDICATION NAME], a medicinal honey with antimicrobial properties, promotes debridement, stimulates wound tissue, and promotes a moist wound bed, applied, covered with foam, and padded well daily. Review of the treatment administration record (TAR) revealed documentation of ordered treatment to the sheer wound on the left buttock for Resident #1 was initiated on 1/9/2021. The TAR indicated the treatment was not performed as ordered on [DATE], 1/15/2021, 1/16/2021, 1/19/2021, and 1/20/2021. Documentation on the TAR for treatment for [REDACTED].#1 on 1/12/2021 was left blank and no explanation was given. Nurse #8, assigned to provide care on the day shift on 1/12/2021 to Resident #1, was interviewed on 2/23/2021 at 3:26 PM. Nurse #8 stated she did not recall if she did the treatment or if a treatment nurse did the wound care. Nurse #8 did not recall what the wound looked like or who Resident #1 was. Documentation on the TAR for the treatment for [REDACTED].#1 on 1/15/2021 stated under comments the treatment was, not administered: other. A Medication Aide (Med Aide #1), who signed the TAR on 1/15/2021 for the left buttock treatment, was interviewed on 2/23/2021 at 2:10 PM. Med Aide #1 stated she did not remember what had occurred on 1/15/2021 because she was assigned to give medications to Resident #1 but could not provide wound treatments to residents. Med Aide #1 revealed she signed the TAR as not administered because she could not provide the treatment and required the assistance of a nurse. Med Aide did not recall or did not know if a nurse provided the treatment for [REDACTED]. Documentation on the TAR for the treatment for [REDACTED].#1 on 1/16/2021 was left blank and no explanation was given. Nurse #9, assigned to Resident #1 on the day shift on 1/16/21, was interviewed on 2/23/2021 at 3:11 PM. Nurse #9 stated on 1/16/2021 the facility had 2 nurses and one medication aide for the entire building. Nurse #9 indicated she was assigned to care for approximately 85 residents, was able to provide medications, but was unable to perform treatments as required on her shift. Nurse #9 stated she requested the evening shift perform the treatment for [REDACTED]. Nurse #9 acknowledged she may have performed wound care for Resident #1 on other days, but she did not recall what his wound looked like or what the wound care orders were in January 2021. Nurse #10, the evening shift nurse assigned to Resident #1 on 1/16/2021, was interviewed on 2/23/2021 at 4:24 PM. Nurse #10 revealed she remembered 1/16/2021 very clearly. Nurse #10 stated she recalled giving medications to Resident #1 but was told she tested positive for Covid-19 on her nursing shift and she left the building, not going in any other resident rooms. Nurse #1 stated she did not perform a wound treatment on Resident #1 on 1/16/2021. Documentation on the TAR for the treatment for [REDACTED].#1 on 1/19/2021 stated under comments Resident #1 received, Late Administration: Other comment: patient care. Nurse #11, who signed the TAR on 1/19/21 for the left buttock treatment for [REDACTED]. Nurse #11 revealed on 1/19/2021 she was assisting the nurse aides with patient care. Nurse #11 stated she did not have time to perform a treatment for [REDACTED]. She stated she documented on the TAR for Resident #1 she was doing patient care instead of doing his treatment. Documentation on the TAR for the treatment for [REDACTED].#1 on 1/20/2021 stated under the comments the treatment for [REDACTED]. Nurse #12, who signed the TAR on 1/20/2021 for the left buttock treatment for [REDACTED]. A care plan was initiated on 1/13/2021 which stated, (Resident #1) has impaired skin integrity- sheer wound to buttock. The approaches were to analyze the wound(s) to determine pattern/trend; avoid shearing resident's skin during positioning, transferring, and turning; measure and record description of area; monitor and report signs of localized infection; and treat per physician order. An additional care plan problem area was initiated on 1/13/2021 for Resident #1's risk for pressure ulcers relative to immobility, [DIAGNOSES REDACTED]. The interventions also included turning and repositioning every 2 hours and perform weekly skin assessments. An interview was conducted with NA #1 on 2/10/2021 at 11:54 AM. NA #1 stated she worked in the facility on the 7:00 AM to 3:00 PM shift. NA #1 indicated she was always able to find assistance to turn and reposition Resident #1 every two hours. NA #1 maintained Resident #1 was turned and repositioned every two hours when he was on her assignment. Review of the medical record revealed no documentation of skin assessments being done on Resident #1 from the date of 1/8/2021 when a shearing wound was identified on the left buttock of Resident #1 until 1/19/2021. The first documentation of a skin/wound assessment for Resident #1 since admission was on 1/19/2021 by the wound care nurse (Nurse #2). Resident #1 was identified as having an unstageable deep tissue pressure ulcer on his coccyx measuring 11 centimeters (cm) in length, 14 cm in width, and a depth unmeasurable on 1/19/2021. A nursing progress note written by Nurse #2 dated 1/20/21 at 3:44 PM stated, Resident (#1) seen by inhouse wound doctor for sacral wound and left heel. New orders received to begin Santyl to wound, apply Dakin's soak gauze and cover with gauze island (dressing) daily. Left Heel has (deep tissue injury) new order for [MEDICATION NAME] to affected area and wrap with Kerlix daily. (Responsible party) aware of above new wounds and orders. There was no corresponding wound physician note for Resident #1 dated 1/20/2021. There was no skin assessment on 1/20/2021 of Resident #1's heel to indicate the extent of skin area injured. The care plan for Resident #1 was updated on 1/20/2021 for the pressure ulcer on the sacrum. An additional problem area on the care plan was added on 1/20/2021 for a deep tissue injury to the left posterior ankle and left plantar foot relative to immobility and paralysis. This was the first mention in the medical record of Resident #1 having deep tissue injuries to the left posterior ankle and left plantar foot. There was no wound/skin assessment of the left posterior ankle or the left plantar foot on 1/20/2021 to indicate the extent of the skin area injured. There were no physician orders for the treatment and no documentation on the TAR of any treatment given to the left posterior ankle wound from 1/20/2021 to the resident's discharge on 1/27/2021. A physician's order was initiated on 1/21/2021 for an unstageable pressure ulcer in the sacral region of Resident #1. The order stated the sacrum was to be cleansed with wound cleanser, wound prep to the peri wound, Santyl applied, covered with Dakin's soaked gauze, covered with ABD (abdominal) pads, and secured with retention tape. A physician's order was initiated on 1/21/2021 for pressure ulcer monitoring of the sacrum of Resident #1 every shift. Documentation on the TAR revealed Resident #1 received the treatment for [REDACTED]. Documentation on a skin/wound assessment dated [DATE] revealed Resident #1 had a left heel pressure area identified. The unstageable deep tissue injury with necrotic tissue was 2.5 cm in length, width of 1 cm, and an unmeasurable depth. A physician's order was initiated on 1/21/2021 for the left heel of Resident #1. The order stated the left heel was to have [MEDICATION NAME] soaked gauze applied and wrapped with Kerlix every day on Monday, Wednesday, and Friday. A physician's order was initiated on 1/21/2021 for pressure ulcer monitoring of the left heel of Resident #1 every shift. Documentation on the TAR revealed Resident #1 received the treatment for [REDACTED]. Documentation on a physician physical medicine consultation report dated 1/21/2021 revealed Resident #1 had a physical medical appointment outside the facility. The recommendations/new orders from the consultation stated a recommendation for a wound referral, a low air loss mattress, turning schedule every two hours, and range of motion exercises to upper and lower extremities daily. Documentation on the report stated, Sacral decubitus not evaluated. A nursing progress note dated 1/22/2021 at 2:06 PM, written by the Facility Nurse Consultant read in part, Resident returned from MD appointment on 1/21/21 with the following orders: recommend wound referral, needs low air loss mattress, turning schedule every 2 hours, and recommend (range of motion) upper and lower extremities daily. Attempted to schedule resident an appointment at wound clinic with an appointment initially given for 1/29/21 at 11:00 AM. When representative inquired about Covid-19 status of facility, resident appointment was changed to 2/5/21 at 1:00 PM with potential to be changed depending on the Covid-19 status of the facility closer to the appointment date. Until that time, resident will continue to be seen by the facility wound doctor. Resident is already positioned on a low air loss mattress, A turning schedule will be implemented for the resident. Per the rehab manager, the resident will be re-evaluated by PT (physical therapy) and OT (occupational therapy). Responsible party notified of the above recommendations and actions taken. An interview was conducted with Facility Nurse Consultant on 2/10/2021 at 1:53 PM. She stated she was in the facility in January 2021 due to the Director of Nursing leaving her employment with the facility. She reported she conducted an investigation into concerns regarding the development of pressure sores on Resident #1. She stated as a part of her investigation she interviewed staff members who told her Resident #1 had been turned and repositioned every two hours on all shifts. The Facility Nurse Consultant indicated the resident was already on a low air loss mattress and a larger bed had been obtained to accommodate his size and length. She explained Resident #1 required an extension on his bed to accommodate his height. She stated she initiated a form that was posted outside the door of Resident #1 on which the staff members who turned and repositioned Resident #1 had to document when they did this on each shift. The Facility Nurse Consultant revealed she did not know when she initiated this. She stated she felt like the pressure areas were unavoidable for this resident and there was nothing else the facility could have done. Documentation on a facility skin/wound assessment by Nurse#2 dated 1/27/2021 revealed an additional assessment of the left heel pressure ulcer. The left heel ulcer had increased in size to 3.5 cm in length, 2 cm in width with an unmeasurable depth. Documentation on a facility skin/wound assessment by Nurse #2 dated 1/27/2021 revealed an initial assessment of a wound on the plantar left bottom foot of Resident #1. It was assessed as 2.5 cm in length, 2 cm in width, and unmeasurable in depth. This was the first documentation of an assessment of the plantar left bottom foot first mentioned on a care plan initiated 1/20/2021. Documentation on the physician orders revealed treatment orders were initiated on 1/27/2021 for the left plantar foot of Resident #1 with instructions to paint the area and the surrounding tissue with [MEDICATION NAME] daily. The TAR revealed Resident #1 received the treatment for [REDACTED]. Documentation on an initial evaluation of the wounds of Resident #1 by the telehealth Wound Care Physician (MD #2) dated 1/27/2021 revealed initial assessments of an unstageable sacrum wound, unstageable deep tissue injury of the left posterior ankle, and the unstageable deep tissue injury of the left plantar foot. The left posterior ankle wound was assessed as 3.5 cm in length, 2 cm in width, and unmeasurable in depth. The evaluation of the ankle indicated the treatment plan of [MEDICATION NAME] was to be applied daily. A nursing progress note dated 1/27/2021 at 2:44 PM by Nurse #2 read in part: Resident (#1) seen by inhouse wound doctor for sacral wound. New orders received to send resident out to emergency department for evaluation for urgent debridement and antibiotic therapy for sacrum. Labs WBC (white blood cell), [MEDICATION NAME], CRP (c-reactive protein) and ESR (erythrocyte sedimentation rate) all returned with abnormal values. RP aware of above new wounds and orders. Resident dressing changed and prepared for transport. Nurse #2 was interviewed on 2/10/2021 at 2:18 PM and on 2/10/2021 at 4:20 PM. Nurse #2 revealed the wound care nurse for the facility left employment with the facility and the wound care physician was unable to provide services in January 2021. Nurse #2 stated she and a telehealth physician were hired to provide wound care for the facility beginning on 1/1/2021. Nurse #2 explained it took her a couple of weeks to get a system for wound care in place. Nurse #2 stated there was a standing order for weekly skin assessments to be completed for all residents admitted to the facility. Nurse #2 stated on 1/19/2021 and 1/20/2021 she did assessments of the skin of all the residents in the facility so she could get the full picture of the wound care required in the facility. She stated she was able to initiate standing orders for any wounds that fit the parameters of the standing wound care orders. Nurse #2 stated when she observed the skin of Resident #1 on 1/19/2021 she knew she would have to obtain orders from the telehealth wound physician because the wound was covered with a cap of eschar and did not fit in any of the standing orders for wound care. Eschar is dead tissue that fall off from healthy skin. Nurse #2 stated on 1/20/2021 she contacted the wound care physician and he gave her orders for the sacral and left heel deep tissue wounds on Resident #1. Nurse #2 revealed the wound care doctor stated he wanted to initiate wound care orders and order laboratory tests to get a more complete picture of the health of the resident. Nurse #2 stated she initiated the new orders and scheduled Resident #1 to be seen by the telehealth physician on 1/27/2021. Nurse #2 obtained the wound care orders for Resident #1 because from her observation of the wound the treatment needed to change to a different [MEDICATION NAME] agent. Nurse #2 described the wounds to the wound care MD on 1/20/21. It was not the day set up for a telehealth visit. She obtained orders. Nurse #2 confirmed she obtained a physician's order initiated on 1/21/2021 for an unstageable pressure ulcer in the sacral region of Resident #1. The order stated the sacrum was to be cleansed with wound cleanser, wound prep to the peri wound, Santyl applied, covered with Dakin's soaked gauze, covered with ABD (abdominal) pads, and secured with retention tape. Nurse #2 confirmed she obtained a physician's order initiated on 1/21/2021 for the left heel of Resident #1. The order stated the left heel was to have [MEDICATION NAME] soaked gauze applied and wrapped with Kerlix every day on Monday, Wednesday, and Friday. Nurse #2 related she made sure Resident #1 was the first resident to be seen on 1/27/2021 during the telehealth visit by the wound care physician due to the condition of his sacral wound. Nurse #2 stated all laboratory data was faxed to the wound care physician in preparation for the wound care telehealth visit on 1/27/2021 because of the state Resident #1 was in. The date 1/27/2021 was the first official wound care assessment day with the telehealth wound care physician for the facility. Nurse #2 stated as soon as the wound care physician saw the wounds of Resident #1, the telehealth visit stopped, EMS (emergency medical services) was called, paperwork was prepared for EMS, and he was sent to the hospital. The telehealth Wound Care Physician (MD #2) was interviewed on 2/12/2021 at 12:11 PM. MD #2 stated he only saw Resident #1 one time on 1/27/2021. MD #2 stated as soon as he saw the pressure wound on the coccyx of Resident #1 on the telehealth visit, he told Nurse #2 to immediately send him to the emergency room . MD #2 stated the laboratory values indicated Resident #1 was in the early stages [MEDICAL CONDITION] and the wound looked infected. MD #2 stated Resident #1 needed emergency debridement of the wound and he needed intravenous antibiotics immediately. He reported he did not take the time to review the chart of Resident #1 and he knew immediate action needed to be taken by Nurse #2 to get him to the hospital because he was in a life-threatening situation. MD #2 stated weekly skin assessments are the standard in all long-term care facilities so that new areas can be identified and treated immediately. MD #2 stated once a skin breakdown develops it is likely additional areas will form. MD #2 stated skin breakdown must be measured and assessed so risk/benefits of treatment can be determined. MD #2 stated it was hard for him to comment on if the skin breakdown on Resident #1 was avoidable because he did not review the resident's medical chart, but it was his opinion some turning, and repositioning was missed somewhere for this resident for the pressure area to develop so quickly. Documentation on a hospital record for the 1/27/2021 admission for Resident #1 revealed he was admitted for emergency debridement for a necrotic blackened sacral decubitus with an infection. After debridement the sacral decubitus was assessed as a Stage 4. Resident #1 was started on intravenous antibiotics. The facility interim Director of Nursing (DON) was interviewed on 2/11/2021 at 3:16 PM. The DON stated she was not the DON when Resident #1 was in the facility. The DON acknowledged the facility had no skin assessments for Resident #1 from 1/8/2021 to 1/19/2021. The DON was unsure of the facility policy on skin assessments but acknowledged the facility staff should be checking the resident's skin for breakdown. The primary care physician (MD #1) for Resident #1 was interviewed on 2/11/2021 at 4:50 PM. MD #1 stated he thought the pressure areas developed on Resident #1 due to physician visits outside the facility where he was laying on a stretcher for an extended period, but he could not say for certain what caused the wounds. (Documentation in the nursing notes revealed Resident #1 left the facility for medical appointments on 1/21/2021 and 1/25/2021.) MD #1 stated the facility should have been doing weekly skin assessments from the first day of admission. MD #1 stated the facility obtained an air mattress for the resident and performed turning and repositioning so there was nothing else that could have been done to prevent the pressure ulcers on Resident #1. The facility Administrator was notified of the immediate jeopardy on 2/26/2021 at 4:30 PM. The facility provided a credible allegation of immediate jeopardy removal: Allegation of Compliance It is alleged that the facility failed to provide ongoing skin assessments for identification and treatment of [REDACTED]. The facility also failed to provide treatment and services for identified pressure areas and/or skin breakdown for Resident #1. 1. The facility identified the deficient practice for Resident #1 on 1/18/2021 and took the following action: A. Investigation was initiated by the Signature Care Consultant (SCC) and Administrator on 1/18/2021. B. Statements were obtained by SCC from staff members who had been taking care of resident #1. C. SCC notified Regional Vice President and Vice President of Clinical Operations on 1/20/2021 of investigation findings. It was decided at this time to temporarily place a hold on new admissions. The admission hold was in place until 2/1/2021. D. A facility wide skin sweep was initiated on 1/19/21 and completed on 1/20/21 by SCC, two LPNs and a RN from sister facilities. E. An audit was completed on 1/21/2021 of all newly identified wounds from the skin sweep completed on 1/20/21 and on all previously identified wounds, by SCC and facility wound nurse, to ensure a treatment was ordered and in place. Resident #1 had new area identified on 1/20/21, left posterior ankle (this is the left heel wound). There is an order for [REDACTED]. No other missing skin assessments identified. F. Education was completed for licensed nurses by the SCC and Assistant Director of Nursing by 1/28/2021 on the Skin Observation/Evaluation and Prevention Policy. Education included completing a thorough skin assessment upon admission, completing the Braden assessment, Documentation of new skin alteration findings, MD notification, obtaining a treatment order, family/POA notification, weekly skin assessment, documentation of skin assessments, weekly documentation of pressure ulcer assessments, preventative skin care, and completion of wound treatments. Direct care licensed nurses to complete weekly skin assessments, assess and document the wounds each week, request a treatment for [REDACTED]. The wound nurse completed audits to ensue assessments have been completed, treatment orders are received and in place, and that weekly skin assessments are being completed and documented. G. Education completed with licensed nurses and nurse aides by SCC and Assistant Director of Nursing by 1/28/2021 on process for reporting new skin concerns to the physician for a treatment order, and the family/responsible party, per the Skin Observation/Evaluation and Prevention Policy. H. Facility secured a full-time wound nurse, who started on 2/17/2021. I. Starting on 1/21/2021, audits of the following have been conducted weekly by the facility wound nurse, and discussed in the Clinical White Board Meeting five times weekly: a. Current orders in chart and same on TAR and are in place. b. Orders are changed as appropriate c. Pressure ulcer treatments are being signed out timely when due d. Wound documentation and weekly skin assessments are being completed on every resident. J. A QAPI meeting was held on 1/20/21 to discuss the above stated plan and request further recommendations. The meeting was attended by the facility administrator, SCC, department heads, nursing administration team and Medical Director. There were no further recommendations. On March 1, 2021 at 1:55 pm, the administrator sent this e-mail to the surveyor: After careful review of the documentation that we currently have we have not found that we provided the detailed education as outlined in the immediate jeopardy document prior to the entrance of the surveyor on 02/10/2021. As a result, we will be submitting another AOC with an alleged compliance date of 02/28/2021. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: 1. Resident #1 suffered from the deficient practice and was discharged from the facility on 1/27/2021. K. A facility wide skin sweep was initiated on 2/26/21 and completed on 2/26/21 by the Signature Care Consultant (SCC), Interim DON, Assistant Directors of Nursing, Wound Care Nurse, and Unit Manager. This was completed to identify any further residents with potential to have been affected. One additional resident was found to have been affected. L. An audit was completed on 02/26/2021 of all in-house wounds, to ensure a treatment was ordered and in place. No further residents were found to have been affected. M. Education for all licensed nurses was initiated 2/27/2021 and completed on 2/28/21 by the SCC, Interim DON, and RN Supervisor. Education was on the Skin Observation/Evaluation and Prevention Policy. Education included completing a thorough skin assessment upon admission, completing the Braden assessment, Documentation of new skin alteration findings, MD notification, obtaining a treatment order, family/POA notification, weekly skin assessment, documentation of skin assessments, weekly documentation of pressure ulcer assessments, preventative skin care, completion of wound treatments, wound staging, identifying when a wound is declining and MD notification. Nurse aides and licensed nurses were educated on the importance of frequent turning and repositioning and the importance of ensuring specialty mattresses are size appropriate and notifying the DON if a change is needed. All current agency staff have been educated and all facility new hires and new agency staff will receive education prior to working their first shift. The Director of Nursing and/or Assistant Director of Nursing will be responsible to provide this education and they were informed on 2/28/21. This was completed 2/28/21. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: N. Wound documentation and weekly skin assessments are being completed on every resident. Direct care licensed nurses will complete weekly skin assessments, assess and document the wounds each week, request a treatment for [REDACTED]. The wound nurse will be completing audits to ensure assessments have been completed, treatment orders are received and in place, and that weekly skin assessments are being completed and documented. This process began on 1/21/2021 and continues. O. Beginning the week of 3/1/2021, all wounds will be discussed in the weekly Skin Nutrition At Risk meeting with the RD in attendance. Date of IJ removal: 2/28/2021 The credible allegation of IJ removal was verified on 3/4/2021 at 12:15 PM as evidenced by observations, interviews, and record review. Interviews were conducted with licensed nursing staff, to include agency licensed nurses, verifying they received training on admission skin assessment; Braden assessment of wounds; documentation on new skin alteration findings; physician notification; obtaining treatment orders; family/power of attorney notification; weekly skin assessments; weekly documentation of pressure ulcer assessments; preventative skin care; completion of wound treatments; wound staging; identifying a wound decline; turning/repositioning requirements; and importance of ensuring correct mattress/bed size. Interviews were conducted with nurse aides to confirm education was provided on the importance of turning and repositioning residents, notification of nursing staff of new skin issues identified on residents, and importance of ensuring mattress/bed size was appropriate for the resident. Observations were made of the skin integrity books, containing wound care policies and procedures, at Nursing stations 1 and 2. Documentation was reviewed of the skin sweep, audits of treatment orders and education records for licensed and unlicensed nursing staff. Education records revealed skin care alerts, turning and repositioning requirements, identification of new skin conditions, identification/notification of bed size requirement changes, wound standing orders, wound stagi (TRUNCATED)

Based on record review and staff interviews the facility failed to provide sufficient nursing staff to ensure wound care treatments were performed as ordered by a physician for 1 (Resident #1) of 3 residents reviewed for pressure sores. The facility also failed to provide sufficient staff to ensure an assessment was completed, blood sugars were monitored as ordered, and medical attention was sought for a change in condition for 1 (Resident #9) of 3 residents reviewed for the provision of care according to professional standards. Findings included: 1. A physician's orders [REDACTED].#1. The order stated the wound was to be cleaned with wound cleanser, patted dry, [MEDICATION NAME], a medicinal honey with antimicrobial properties, promotes debridement, stimulates wound tissue, and promotes a moist wound bed, applied, covered with foam, and padded well daily. Review of the treatment administration record (TAR) revealed documentation of ordered treatment to the sheer wound on the left buttock for Resident #1 was initiated on 1/9/2021. The TAR indicated the treatment was not performed as ordered on [DATE], 1/15/2021, 1/16/2021, 1/19/2021, and 1/20/2021. Documentation on the TAR for the treatment for [REDACTED].#1 on 1/16/2021 was left blank and no explanation was given. Nurse #9, assigned to Resident #1 on the day shift on 1/16/21, was interviewed on 2/23/2021 at 3:11 PM. Nurse #9 stated on 1/16/2021 the facility had 2 nurses and one medication aide for the entire building. Nurse #9 indicated she was assigned to care for approximately 85 residents, was able to provide medications, but was unable to perform treatments as required on her shift. Nurse #9 stated she requested the evening shift perform the treatment for [REDACTED]. Nurse #10, the evening shift nurse assigned to Resident #1 on 1/16/2021, was interviewed on 2/23/2021 at 4:24 PM. Nurse #10 revealed she remembered 1/16/2021 very clearly. Nurse #10 stated the facility was short a nurse on 1/16/2021, with only 3 nurses working when 4 nurses were needed. Nurse #10 indicated it was all she could do to get the resident medications administered and she had no time to do any other nursing tasks. Nurse #10 stated she recalled giving medications to Resident #1 but was told she tested positive for Covid-19 on her nursing shift and she left the building, not going in any other resident rooms. Nurse #1 stated she did not perform a wound treatment on Resident #1 on 1/16/2021. Documentation on the TAR for the treatment for [REDACTED].#1 on 1/19/2021 stated under comments Resident #1 received, Late Administration: Other comment: patient care. Nurse #11, who signed the TAR on 1/19/21 for the left buttock treatment for [REDACTED]. Nurse #11 revealed on 1/19/2021 she was assisting the nurse aides with patient care. Nurse #11 stated she did not have time to perform a treatment for [REDACTED]. She stated she documented on the TAR for Resident #1 she was doing patient care instead of doing his treatment. An interview was conducted with the Interim Director of Nursing on 2/11/2021 at 2:30 PM. The DON stated it was her expectation the nursing staff follow physician orders. The DON indicated it was also her expectation the nurses reach out to who ever is on call if they need help. The DON stated she was on call 24 hours 7 days a week to help at the facility. The DON stated the priority was taking care of the residents in the facility. 2. This tag has been cross referenced to F684. Based on record review, staff interview, family interview, and physician interview the facility failed to assess a resident and seek medical attention for a change in condition and monitor the blood sugars as ordered by the physician for 1 of 4 residents reviewed for providing care according to professional standards (Resident #9). After the family of Resident #9 called EMS (emergency medical services), Resident #9 was assessed by EMS as having a finger stick blood sugar of 443 mg/dl (Normal 72 to 99 mg/dl) with altered mental status and diabetic symptoms.

Based on record review, staff interview, family interview, and physician interview the facility failed to assess a resident and seek medical attention for a change in condition and monitor the blood sugars as ordered by the physician for 1 of 4 residents reviewed for providing care according to professional standards (Resident #9). After the family of Resident #9 called EMS (emergency medical services), Resident #9 was assessed by EMS as having a finger stick blood sugar of 443 mg/dl (Normal 72 to 99 mg/dl) with altered mental status and diabetic symptoms. Findings included: Resident #9 was admitted to the facility on [DATE] with a medical history of [REDACTED]. Resident #9 received [MEDICAL TREATMENT]. The most recent quarterly Minimum Data Set assessment dated [DATE] coded Resident #9 as having moderately impaired cognition, no moods, no behaviors, and no rejection of care. He required supervision of one person with bed mobility, transfers, and personal hygiene. He required supervision and set up help with dressing and eating. Resident #9 was independent with walking, toilet use, and bathing. He received insulin injections six of the seven days of the assessment period. Resident #9 was coded as receiving [MEDICAL TREATMENT]. The care plan had a problem area dated 1/19/2021 for Cardiovascular and diabetes complications for Resident #9. Some of the approaches were to administer medications as ordered, observe for weakness, monitor blood glucose as ordered, and routine vital signs. Resident #9 had physician orders [REDACTED]. Documentation on the Medication Administration Record [REDACTED]. Documentation in the nursing progress notes dated 1/26/2021 at 8:00 AM for Resident #9 stated, (Certified Nursing Assistant) on duty notified nursing staff that resident was unresponsive. This writer responded to his room and checked on the resident. Resident was not his usual self and his CBG (capillary blood glucose) was taken because he is diabetic, and it was 51. He was continuously given a sternum rub in which he was responsive to. He was also given a [MEDICATION NAME] 1 mg (milligram) in each deltoid and CBG did go up to 55 and 15 minutes later to 148. Coworkers called 911 services and they did arrive on the scene with action in progress. CBG began to decline to 145 and resident was sent out for safety because he could not swallow and did have a protruding tongue. (Management) aware and (Physician name) was notified. Resident #9 returned to the facility from the hospital on [DATE]. The Admission Observation form dated 2/4/2021 at 6:35 PM by the unit manager (Nurse #1) revealed Resident #9 was assessed as alert but sluggish in responses and bowel incontinence since hospitalization due to a new [DIAGNOSES REDACTED]. Hospital discharge orders dated 2/4/2021 revealed Resident #9 was to have insulin administered subcutaneously with meals and at bedtime based on a sliding scale of blood glucose monitoring. The physician was to be notified if blood glucose levels dropped below 90 or were above 500. Documentation in a nursing progress note written by Nurse #1 for Resident #9 dated 2/4/2021 at 4:56 PM stated, Resident arrived at 3:59 PM from (Hospital name). Resident alert oriented to self and knows some staff members by face and name. Resident verbally slow to respond. Resident expressed understanding re: diet, medication changes and ability OOB (out of bed) to wheelchair. Resident with no skin issues with exception of peeling dried skin to sternal area. Appearance of drying burn. No apparent distress. Nursing progress notes dated 2/4/2021 at 4:03 PM, written by Nurse #1, stated the finger stick blood sugar monitoring frequency for Resident #9 was increased to every 4 hours until further physician orders. Nurse #1 was interviewed on 2/16/2021 at 10:30 AM. Nurse #1 related she was in communication with the hospital prior to the arrival of Resident #9 coming back to the facility on [DATE]. Nurse #1 was told by the hospital nurse of Resident #9 being unresponsive for several days in the hospital and he had declined in cognition. Nurse #1 explained that in the clinical nursing meeting at the facility it was discussed how Resident #9 would need monitoring through out the night due to his blood sugar dropping. Nurse #1 further explained that it was decided in the morning facility clinical meeting, with the administrative nursing staff members, it would be best for the resident to have his blood sugars monitored every 4 hours and an order was obtained from his physician (MD #1). Nurse #1 revealed she had confirmation of the agreement of MD #1 with the blood sugar monitoring of every 4 hours for Resident #9 through a text message. Nurse #1 indicated MD #1 came to the facility twice a week to see his patients but Resident #9 was not in the facility long enough after his arrival from the hospital on the 2/4//2021 for MD #1 to see him. Review of the MEDICATION ORDERS FOR [REDACTED]. The physician was to be notified if the blood sugar was less than 90 or greater than 500. Resident #9 had an additional order for vital signs to be taken every shift for 72 hours after admission, day and night. Documentation on the MAR from 2/4/2021 at 4:00 PM to 2/7/2021 at 4:00 AM revealed blood sugar monitoring and administration of insulin were completed as ordered when Resident #9 was in the facility and not at [MEDICAL TREATMENT]. There were no abnormal blood sugar readings that went beyond the sliding scale for which the physician of Resident #9 would have to be notified during that time period. Documentation on the MAR for 2/7/2021 revealed blood sugar monitoring and administration of insulin was not competed at 8:00 AM and 12:00 PM as ordered. The reasons/comments on the MAR indicated [REDACTED]. Documentation on the MAR under vital signs every shift was not completed for Day on 2/7/2021 with the reason/comment being the, Resident Unavailable. An interview was conducted on 2/10/2021 at 11:02 AM with a family member who was waiting outside the facility to see Resident #9 on 2/7/2021. The family member stated she went to the facility on [DATE] to check on Resident #1 because he had been having episodes of low blood sugars with several hospital visits, and she was concerned the facility was not monitoring him. The family member stated after the request to see Resident #1 was made, an hour went by and nobody was telling them what was going on. The family member stated her concern grew to the point she called the police to check on the resident. An interview was conducted with NA #8 on 3/4/2021 at 10:41 AM. NA #8 confirmed she was the nurse aide assigned to Resident #9 on 2/7/2021 on the 7:00 AM to 3:00 PM shift. NA #8 stated on the morning of 2/7/2021 Resident #9 was very lethargic and she had to feed him at breakfast. NA #8 revealed she told Nurse #4 several times something was very seriously wrong with Resident #9. NA #8 further revealed it became apparent Nurse #4 was not going to do anything to help Resident #9, so she filled out a Stop and Watch form to protect herself if anything were to happen to Resident #9. A Stop and Watch form is an early warning tool used by the nurse aides to document when they see a change in a resident while caring for them. An interview was conducted with NA #9 on 3/4/2021 at 11:00 AM. NA #9 stated she was a restorative nurse working on the hallway on for which Resident #9 resided on the morning of 2/7/2021. NA #9 stated she saw Resident #9 on 2/7/2021 and described him as looking awful and not his usual self at all. NA #9 revealed Resident #9 was not conscious enough to respond to questions. NA #9 described the resident as having his eyes closed looking weak and lifeless. NA #9 indicated she told Nurse #4 the concern she had for the well being of Resident #9. NA #9 stated Nurse #4 told her it was the New Normal for Resident #9. A nursing progress note dated 2/7/2021 written by Nurse #4 at 5:41 PM stated, Around 1:30 PM family of resident came to facility voicing the need to have a visit with resident. Resident voiced desire to visit but was not able to stay alert long enough to have a visit. Resident would answer questions correctly but needed sternal rubs to maintain alertness. Family members called for a wellness check in which the police officers came to see for themselves and reported back to the family. Daughter requested that resident be sent to ER (emergency room ) for evaluation and called EMS (emergency medical services) herself. EMS arrived and exited with resident to (hospital name) at 2:00 PM. Nurse #4 was interviewed on 2/11/2021 at 12:20 PM. She was working a 7:00 AM to 7:00 PM shift on 2/7/2021. Nurse #4 explained when she arrived the facility was short a nurse and she was asked to be responsible for her one medication cart on a hallway and half of another medication cart for another hallway. Nurse #4 recalled she started to administer medications on the hallway she was most unfamiliar with first. She started on one end of the hallway and worked her way up. Nurse #4 indicated both hallways had residents who needed blood glucose monitoring. She explained she went from resident to resident going up the hallway administering medications and checking blood glucose levels as needed when she came to a diabetic resident. The facility had a lot of room changes recently and she indicated she was not able to get all the blood glucose monitoring done prior to the service of breakfast due to having responsibility for two medication carts. She did check the blood glucose of Resident #9 sometime in between breakfast and lunch and she did administer insulin at that time. Nurse #4 did not recall what the blood glucose level of Resident #9 was or how much insulin was administered. She was unaware Resident #9 was back from the hospital at the start of her shift and she was not aware the orders for blood glucose monitoring had switched to every 4 hours for Resident #9. She had not been notified Resident #9 had a level of acuity change after returning from the hospital. If she had known Resident #9 had increased confusion and couldn't even hold his head up, she would have started on his end of the hall. She did not have time to call the physician for Resident #9 because the family called the police and emergency medical services. Nursing assistants on the hallway were monitoring the residents while she was giving medications on the other hallway. Nurse #4 stated a nursing assistant took the vitals of Resident #9 and wrote it down on a piece of paper but due to the computer not working she did not put the vitals into the MAR. Nurse #4 did not check the blood sugar of Resident #9 prior to leaving with EMS. There was no documentation on the MAR indicated [REDACTED]. A nursing progress note dated 2/7/2021 written by Nurse #5 at 2:10 PM stated, Notified family called police and EMS to facility. Police arrived to building and performed a wellness check. (Responsible Party for Resident #9) requested that resident be sent to ER to be evaluated. Nurse #5 was interviewed on 2/11/2021 at 1:40 PM. She was the nursing supervisor on 2/7/2021 but she had her own 25 patients and a nursing medication cart she was responsible for. Nurse #5 confirmed she was available to assist other nurses in the facility on 2/7/2021 if an emergency occurred. Nurse #5 recounted the assistant business office manager came to her and told her family members of Resident #9 were at the front door requesting to see him. Nurse #5 explained she asked why Resident #9 could not be brought to the front to see his family. She went to the other hallway to see Resident #9. Nurse #5 related everything happened very quickly because the family of Resident #9 called the police. Nurse #5 further explained she asked Resident #9 if he wanted to see his family and he very slowly acknowledged he did want to see his family. Nurse #4 and herself attempted to get Resident #9 prepared to see his family but he was not his normal self, he was drifting in and out. He was only aroused with a sternal rub and he was not safe to sit up in a wheel chair. At that point the police arrived in the room and wanted to know what was going on. Nurse #5 indicated the police asked questions of Resident #9 and he slowly responded drifting in and out of consciousness. She and Nurse #4 accompanied the police to the front door to talk to the family of Resident #9. EMS arrived at the front door because they had been called by the family of Resident #9. The family requested Resident #9 be transported to the hospital and the paperwork for his discharge was prepared. Documentation in an emergency medical services report dated 2/7/2021 revealed Resident #9 had a finger stick blood sugar of 443 mg/dl (Normal 72 to 99 mg/dl) with altered mental status with diabetic symptoms. An interview with the Director of Nursing (DON) was conducted on 2/11/2021 at 2:30 PM. The DON stated it was her expectation that for any change in a resident's condition the resident's physician be notified. The DON stated it was also her expectation physician orders [REDACTED]. An interview was conducted with the physician for Resident #9 (MD #1) on 2/11/2021 at 4:50 PM. MD #1 stated Resident #9 received [MEDICAL TREATMENT] services and his blood sugars were all over the place. MD #1 stated he would never have written an order for [REDACTED].

Based on observations, interviews with the resident, Responsible Party (RP), primary care physician (PCP) and staff, and record review the facility failed to clarify a medication allergy for 1 of 3 sampled residents (Resident #1) reviewed for medication interaction which resulted in the resident being hospitalized . Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A laboratory report, dated 2/11/16, had a hand written note, signed by the PCP, indicating Resident #1 had an allergy to medications containing Sulfa. While the PCP had signed the lab work, the handwriting for the sulfa allergy was different than the PCP ' s signature. Review of a 2/21/16 hospital discharge summary did not list sulfa as an allergy for Resident #1. Review of dictated physician progress notes [REDACTED]. The quarterly Minimum Data Set (MDS) for Resident #1, dated 6/10/16, indicated she was moderately cognitively impaired. The MDS also coded Resident #1 as requiring extensive assistance with transfers, bed mobility, toilet use and personal hygiene. Resident #1 was identified at risk for pressure ulcers, but at the time of assessment had no pressure ulcers, rashes or open [MEDICAL CONDITION]. The resident was coded as having skin tears. Nurse ' s notes dated 6/30/16 at 9:11 PM, indicated Resident #1 had increased confusion. The PCP was called, laboratory tests were ordered including a urine for culture and sensitivity. Initially, the physician ordered [MEDICATION NAME] (an antibiotic) 875 milligrams (mgs) twice daily to treat Resident #1 ' s urinary tract infection. Lab results with a status of final report was called to the MD on 7/6/16. The urine culture revealed greater than 100,000 colony forming units per milliliter of urine of Staphylococcus Haemolyticus (type of bacterial organism) that was susceptible to Bactrim DS (another type of antibiotic that contains sulfa). The physician ordered the [MEDICATION NAME] discontinued and ordered Bactrim DS to be given twice daily for 10 days. On 7/6/16 at 12:55 AM, nurse ' s notes indicated Resident #1 had fallen, been sent to the hospital for evaluation and had returned to the facility. There was no indication of red skin, whelps or blotches noted. Review of the July 2016 Medication Administration Record [REDACTED]. On 7/9/16 at 7:26 AM, the nurse documented Resident #1 had red areas on her legs and arms. The PCP was made aware and orders were received to discontinue the Bactrim and start [MEDICATION NAME] (another type of antibiotic). One dose of [MEDICATION NAME] (a steroid medication) was given along with orders to monitor the resident. At 8:29 PM, the nurse ' s notes indicated the red areas to Resident #1 ' s legs were fading. Nurse ' s notes written on 7/11/16 indicated Resident #1 had scattered red patches over her body that were inflamed and were scratched until one area on her lower right posterior thigh opened. The nurse documented the PCP was called. Orders were received for [MEDICATION NAME] (a type of steroid medication) be given in addition to [MEDICATION NAME] (an anti-[MEDICATION NAME] medication). On 7/13/16 at 7:59 PM, nurse ' s notes documented Resident #1 was noted to have an open area to her back where she had broken out from an allergic reaction. The nurse documented she would make the PCP aware. Review of nurse ' s notes dated 7/14/16 at 8:23 AM, indicated a message had been left for the PCP related to the open areas Resident #1 had on her back and redness in her oral cavity. The nurse documented she had made the on-coming nurse aware. The hospital history and physical, dated 7/14/16, indicated Resident #1 had taken several different antibiotics for a urinary tract infection, developed an [DIAGNOSES REDACTED]tous (red) rash on her torso and extremities over the past few days and had been given steroids without complete resolution of the symptoms. The physician documented the resident had no fever, chills, nausea, vomiting or abdominal pain. The plan of action to resolve the resident ' s skin condition was receiving intravenous steroids. A hospital wound consult note, dated 7/15/16, indicated Resident #1 had multiple open sores involving her back, lower extremities and left breast and chest that has arisen spontaneously within the past several days during which time she received several different antibiotics for an infection. Sulfa was listed as an allergy with an onset date of 7/14/16. Under Impression, the hospital physician documented diffuse open sores of the chest back and lower extremities equivalent to second [MEDICAL CONDITION] had the appearance of Stevens-Johnso[DIAGNOSES REDACTED]. The hospital discharge summary dated 7/18/16 indicated Resident #1 had a [DIAGNOSES REDACTED]. The Nursing Admission Information sheet, dated 7/19/16 revealed the resident was alert and oriented to person, place, time and situation. Documentation indicated the resident had scattered bruises and blisters all over her body. Resident #1 and a family member were interviewed on 7/25/16 at 2:07 PM. The resident stated she had been in the hospital the previous weekend with a reaction to Bactrim. The resident and the family member stated they had been unaware of the Bactrim allergy, adding she had taken the medication previously with no reaction. The Responsible Party was interviewed by telephone on 7/25/16 at 2:45 PM. She stated she was unaware Resident #1 had an allergy to any medications. She stated on Tuesday, July 12, 2016, she visited Resident #1 and saw red spots on her skin. On return, 2 days later, Thursday, July 14, 2016, Resident #1 had blisters, some that had popped, covering her back, shoulders, legs and in her mouth. Nurse #1 was interviewed on 7/26/16 at 10:34 AM. She confirmed she had written the 7/14/16 at 7:40 PM note. The nurse stated if a resident had an allergy, it was listed on the resident ' s medical chart and was found in the computer system. She added when a physician's order [REDACTED]. Nurse #1 stated she was familiar with Resident #1 and knew the resident had received Bactrim for an infection. The nurse stated at first, when the resident ' s skin started turning red, was hard to tell if Resident #1 was having a medication reaction because she had a habit of picking and scratching her skin. Nurse #1 described Resident #1 ' s skin as pale with a darker colored tongue, describing her tongue as deep, dark red infused with pink and purplish colors. Nurse #1 stated the resident ' s tongue did not swell and she was never in any respiratory distress. At that point, staff or the PCP suggested a hospital evaluation because everyone thought giving the resident [MEDICATION NAME] would resolve the symptoms. The nurse added after receiving the [MEDICATION NAME], Resident #1 had no more discoloration of her tongue. Nurse #1 stated after Resident #1 had received the [MEDICATION NAME], she had been off work for a few days. On returning to work, she had been told by the night nurse that Resident #1 had developed blisters and open areas during the 7/13/16 night shift. The night nurse informed Nurse #1 she was waiting for the PCP to return her call. Nurse #1 stated after receiving report from the night nurse, she paged the PCP between 7:00 AM and 8:00 AM with the PCP returning her call before 9:00 AM. Orders were received for aloe vera gel and she had been instructed to treat the resident as if she had a sun burn. The nurse added when she saw Resident #1 she found the areas on her skin to be red, but not hot to touch. She added Resident #1 ' s skin was tender and she hollered out during care. Nurse #1 added when the resident received the Bactrim ordered on [DATE], the chart did not contain the Bactrim allergy and she was unaware Bactrim had been listed on the lab or in the physician ' s notes as an allergy. The Assistant Director of Nursing (ADON) #1 was interviewed on 7/26/16 at 11:20 AM. The ADON stated she had reviewed the laboratory results for February 2016, but denied she was the one that had written sulfa allergy on the lab. She verified the PCP had signed the lab results, but was unable to identify the handwriting of the person who had written sulfa allergy on the lab report. The ADON stated she saw the resident around 5:15 PM when she was transferred to the hospital. She stated while the resident was uncomfortable, she was in bed watching television and in no acute distress. The ADON verified she was the nurse that had written the 7/6/16 Bactrim order, but was unaware the physician ' s progress notes had both no known allergy and allergy to Sulfa written. Told by the nurses the resident had an allergic reaction and asked what med. The ADON during morning report, on Monday, July 11, 2016, she had informed staff thought Resident #1 was having a medication reaction. She added when she had assessed Resident #1 she had observed flat red spots on Resident #1 ' s arms, legs and back. She added on Tuesday, the spots had started to blister. The ADON stated she checked the MAR indicated [REDACTED]. The ADON stated she had assessed Resident #1 on the day she went to the hospital at approximately 5:15 PM and found the resident in bed watching television. The ADON stated if she had been aware Resident #1 had a Bactrim allergy she would not have written the 7/6/16 order for Bactrim. On 7/26/16 at 12:08 PM, Nurse #2 was interviewed. The nurse stated she entered Bactrim into the computer system and added it to Resident #1 ' s chart as an allergy after the facility realized she had an allergy to the Bactrim. Prior to Resident #1 having the current reaction to Bactrim, the nurse stated she was unaware of the resident ' s Bactrim allergy. Nurse #2 stated after the allergic reaction she had reviewed Resident #1 ' s chart and had found no information regarding a Bactrim allergy. She was unaware of the February 2016 lab result or the physician ' s progress notes that indicated a potential sulfa allergy. Nurse #2 was unable to identify the handwriting of the person that had written sulfa allergy on the lab report. A telephone interview was held with Resident #1 ' s PCP on 7/26/16 at 1:49 PM. The PCP stated Resident #1 recently had an episode of Stevens-Johnso[DIAGNOSES REDACTED] caused by taking Bactrim. The PCP stated previously Resident #1 had discontinued Bactrim herself because of a gastrointestinal intolerance, but it was not a true allergy. The PCP added Resident #1 had previously taken Bactrim prescribed by him with no side effects or allergic reaction. The PCP stated he had not written the sulfa allergy notation on the February 2016 lab and had no idea who had placed the notation on the lab. The PCP gave no explanation why progress notes, dictated by him, contained conflicting information regarding no known allergies followed by sulfa allergy. He added allergic reactions were unpredictable and could result in violent reactions, which Resident #1 experienced this time. The PCP stated with the Stevens-Johnso[DIAGNOSES REDACTED] there could be a delayed onset, such as Resident #1 experienced. The PCP added when he had last assessed her Resident #1, she had a mild rash; adding the facility kept him well informed of the changes Resident #1 experienced. The PCP stated the facility had acted appropriately with the information they had. On 7/26/16 at 2:27 PM, the Director of Nursing (DON) was interviewed. The DON stated if a resident had an allergy to a medication, staff were expected to notify the PCP. She reviewed the MD progress notes and stated the notes were confusing with the PCP documenting no allergies and then writing Sulfa. The DON added she and the PCP had spoken after Resident #1 ' s reaction and he had told her the resident ' s record had not indicated she had an allergy to sulfa medications. She stated she was unaware how Sulfa got written as an allergy on the lab slip and was unable to identify the hand writing. With documentation on the lab report and the PCP progress notes, the DON stated she would have expected the nurses to notify the PCP and clarify the allergy information for Resident #1. The DON stated the reaction experienced by Resident #1, while blamed on the Bactrim, could have been any of the antibiotics she received during that week or a combination of several medications.