Every finding on record at Swannanoa Valley Health and Rehabilitation

Based on observation and staff interviews, the facility failed to remove expired food (walk in cooler #1) and failed to remove perishable food with grey and white fuzz (walk in cooler #2) from 2 out of 2 walk in coolers. This practice had the potential to affect food served to residents. The findings included: a. On 9/29/25 at 10:02 AM an initial tour of the kitchen was conducted with the Dietary Manager (DM). During the initial tour it was observed in the walk in cooler #1 four (4) containers (32 ounces each) of vanilla low fat yogurt that were unopened and had a best if used by date of August 26, 2025. There was also one gallon size container of cottage cheese that was opened, and half of the product was gone with a best if used by date of August 24, 2025. b. On 9/29/25 at 10:02 AM an initial tour of the kitchen was conducted with the DM. In the walk in cooler #2 an observation was made of one container of fresh strawberries. The container had 2 strawberries covered in grey and white fuzz. On 9/29/25 at 10:15 AM an interview was held with the DM. The DM stated that the expired food in both walk in coolers was a visual oversight. The DM stated that it was her responsibility to check the coolers for expired food and she normally checked the entire kitchen for expired food every morning. The DM also stated she had worked at the facility for one month and was training her team to also be checking the dates of all the food before serving and/or getting food out of a container. On 10/2/25 at 1:57 PM an interview was held with the Administrator. The Administrator expected that the kitchen staff would be looking at the dates and getting rid of food as needed especially if past the use by date and/or had signs of spoilage.

Based on observation, record reviews, and staff interviews, the facility failed to implement their infection control hand hygiene policy when the Wound Nurse failed to change gloves and perform hand hygiene after wound care for Resident #30 and Resident #18. This occurred for 1 of 5 staff members observed for infection control practices (Wound Nurse). Findings included: A review of the facility's Hand Hygiene Policy revised 01/01/25 revealed hand hygiene should be completed before donning gloves and immediately after gloves were removed.1a. A continuous observation of wound care for Resident #30 was completed with Wound Nurse Practitioner and Wound Nurse on 10/01/25 from 9:11 AM through 9:25 AM. Resident #30 had a sign on her door which instructed staff to don gloves and a gown for high contact resident care activities which included wound care. Personal protective equipment (PPE) was observed on Resident #30's door. The Wound Nurse Practitioner and Wound Nurse performed hand hygiene and donned gown and gloves. Resident #30 was positioned for wound care and the Wound Nurse Practitioner cleaned and assessed Resident #30's wound to buttocks. The Wound Nurse Practitioner removed gloves and gown, performed hand hygiene, and exited the room. The Wound Nurse then applied calcium alginate (an absorbent dressing), ointment to the wound area and applied a bordered dressing. The Wound Nurse failed to remove gloves which were visibly soiled with ointment. Resident #30 stated she had a new reddened area to her right heel. The Wound Nurse assessed Resident #30's right heel area, and still wearing the same gloves, went to door, grabbed the doorknob and opened the door and asked the Wound Nurse Practitioner for skin prep. The Wound Nurse then applied skin prep to Resident #30's right heel reddened area without changing gloves and performing hand hygiene directly after she performed wound care to the buttocks wound. The Wound Nurse failed to remove her gloves, then rolled absorbent pad under Resident #30 out and replaced the pad underneath Resident #30. The Wound Nurse failed to remove her gloves and then applied Resident #30's socks, opened the closet door, and obtained heel protectors from the closet and applied heel protectors to Resident #30 feet. The Wound Nurse failed to remove gloves and replaced the sheets and blankets on Resident #30 bed and raised the head of the bed when she pressed buttons on the foot of the bed. The Wound Nurse then grabbed the call bell, placed it within reach of Resident #30, and turned off the overhead light by pulling the string, and pushed the bedside table next to the bed without removing her gloves. The Wound Nurse then removed gloves and gown and performed hand hygiene before she exited the room. 1b. A continuous observation of wound care for Resident #18 was completed on 10/01/25 at 11:51 AM through 12:26 PM. Resident #18 had a sign for Enhanced Barrier Precautions (EBP) (type of isolation) on the room door which instructed staff to don gloves and a gown for high contact resident care activities which included wound care. PPE was observed on Resident #18's door. The Wound Nurse performed hand hygiene and donned a gown and gloves. Resident #18 was positioned for wound care and the Wound Nurse cleaned Resident #18's wound to right hip with gauze, applied skin prep, and prepared packing gauze strip for use. The Wound Nurse pulled her gown up and began touching her scrub pockets with the gloved hands and reached into her pockets and verbalized she was looking for her scissors. The Wound Nurse stated the scissors were left on her treatment cart and removed her gown and gloves and performed hand hygiene before exiting the room. The Wound Nurse retrieved scissors from the treatment cart and reentered the room. The Wound Nurse performed hand hygiene, donned a new gown and gloves, and began packing the right hip wound while holding the scissors in her hand. The Wound Nurse covered Resident #18's right hip wound with a bordered dressing. The Wound Nurse removed gloves and performed hand hygiene. The Wound Nurse applied new gloves and Resident #18 was positioned for wound care to his buttocks. The Wound Nurse cleaned Resident #18's buttocks wound with gauze, applied skin prep, packed buttock wound with gauze strip, cut the gauze strip, and applied a bordered dressing over buttocks wound. The Wound Nurse failed to remove gloves and perform hand hygiene after wound care to buttock wound and grabbed Resident #18's walker to move it closer to him. The Wound Nurse failed to remove gloves or perform hand hygiene and assisted Resident #18 to a standing position, retied her gown, and pulled Resident #18's pants up and buttoned them. The Wound Nurse then discarded trash, removed her gloves and gown and discarded PPE. The Wound Nurse performed hand hygiene before she exited the room. An interview with the Infection Preventionist (IP) was conducted on 10/01/25 at 3:46 PM. She stated the Wound Nurse should have changed gloves after wound care was provided to prevent contaminating surfaces.An interview with Wound Nurse was conducted on 10/01/25 at 12:09 PM. The Wound Nurse verbalized understanding that gloves should have been changed after wound care as required by the facility EBP policy. The Wound Nurse stated that she had been educated on EBP when hired and she would normally change gloves and follow EBP policy for wound care. The Wound Nurse reported that due to nervousness, she had forgotten to change gloves and perform hand hygiene after she completed wound care on Resident #30 and Resident #18. The Wound Nurse stated she did not realize she had not changed her gloves or performed hand hygiene before touching multiple surfaces with contaminated gloves.An interview with the Director of Nursing (DON) was conducted on 10/02/25 at 9:52 AM. The DON stated that Resident #30 and Resident #18 required EBP due to wounds. The DON verbalized that staff were expected to follow EBP when wound care was performed per facility's EBP policy. The DON stated that staff should change gloves and perform hand hygiene between wounds and remove soiled gloves and perform hand hygiene after wound care.

Based on record review, and interviews with residents, pharmacy, medical director, nurse practitioner and staff, the facility failed to implement an effective system to ensure the antidiarrheal medication was reordered and available to administer which resulted in 12 missed doses for 1 out of 1 resident reviewed for pharmacy services (Resident #4) The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses of incontinence, end stage renal disease and end stage renal dialysis. The 8/28/25 quarterly Minimum Data Set (MDS) revealed that Resident #4 was cognitively intact. He had a urinary catheter and was always incontinent of bowel. There was a physician order with a start date of 3/18/25 for medication diphenoxylate-atropine (Lomotil)-controlled drug 2.5-0.025 milligrams (MG). Resident #4 was to get 2 tablets four (4) times a day for diarrhea. The September 2025 Medication Administration Record (MAR) showed that Resident #4 was receiving his diphenoxylate-atropine four times a day at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM up until 9/27/25. On 9/27/25 starting with 2:00 AM dose it was recorded that the dose was put on hold. On 9/27/25, 9/28/25 and 9/29/25 each of the 4 doses were recorded either on hold or see nurses note. On 9/30/25 the medication was coded to have been given as ordered. On 10/1/25 at 2:44 PM an interview was held with Medication Aide #2. She stated she worked on 9/26/25 and 9/27/25 from 7:00 PM till 7:00 AM. On 9/27/25 she went to administer the 2:00 AM lomotil medication to Resident #4's and saw that he was out of the medication. Medication Aide #2 reported this to the [NAME] Side Unit Manager. The [NAME] Side Unit Manager told her that she would take care of it. On 10/2/25 at 11:13 AM an interview was conducted with Nurse #4. She stated that she worked on 9/27/25 from 7:00AM until 7:00 PM and when she looked over her medication cart, she noticed that Resident #4 did not have any of his lomotil medication. Medication Aide #2, whose shift was now ending and was giving the keys to the cart to Nurse #4, did not have any information on what was going on with the medication but stated the Medical Director might coming around to do rounds and to ask him about it. Nurse #4 stated that the Medical Director never did come in to do rounds. Nurse #4 said that during her shift she changed Resident #4's dressing and his wound looked good, and he was not experiencing any diarrhea. On 10/1/25 at 3:13 PM an interview was held with the [NAME] Side Unit Manager. She stated that every Friday the facility had a team meeting to go over medications and for the staff to check their medication carts to ensure they have everything needed for the weekend, especially controlled medications. She stated that on the weekend the on call providers get really upset if they are asked to order a controlled medication. So, the facility tries hard not to make this type of call to the weekend on call provider. She stated they had the medication cart meeting on 9/26/25 and the agency nurse who had the west side cart did not report that the lomotil for Resident #4 was low and needed a new order. On Saturday 9/27/24 the [NAME] Side Unit Manager stopped by the facility and when she was at the facility Medication Aide #2 alerted her that there was no more lomotil for Resident #4. The unit manager told Medication Aide #2 that one of the nurses needed to call it in. The Unit Manager also stated she would take care of it and was unsure how she left the conversation for the nurse to take care of it or herself. On 10/2/25 at 9:18 AM an interview was conducted with Nurse #3. Nurse #3 stated she worked the 7:00 AM to 7:00 PM shift on 9/28/25. Nurse #3 stated when she started her shift, she was informed at report that Resident #4's lomotil medication was out. Nurse #3 stated that later that day the west side Unit Manager stopped by and asked if any medications or narcotics needed to be called into the pharmacy and Nurse #3 informed the Unit Manager that Resident #4 needed his lomotil medication. The Unit Manager stated she had already been informed about that medication and that it should be coming in from the pharmacy. During the interview Nurse #3 stated that a nurse can reorder a medication through eMAR but not a narcotic. For a narcotic the nurse would enter the need for a new script in the Nurse Practitioner (NP) book or peel off the medication label on the empty pack and put that in the NP book alerting the NP that it needed to be reordered. Nurse #3 did check Resident #4's skin and spoke to Resident #4 and he knew that he was out of the one medication. Resident #4 was not experiencing diarrhea. On 10/2/25 at 1:17 PM a telephone call was made to the East Side Unit Manager but was unsuccessful. On 10/1/25 at 2:04 PM an interview was held with Medication Aide #1. Medication Aide #1 worked the weekends from 7:00 PM until 7:00 AM. She stated that she worked on Resident #4's hall passing medication on 9/28/25. When she started her shift, she had been informed by a nurse, she could not remember who, that Resident #4 was out of his lomotil medication. Medication Aide #1 stated the nurse told her that the pharmacy had been called to deliver the medication, but by the end of the evening the medication still had not been delivered. Medication Aide #1 stated that as a Medication Aide she can suggest a medication for reorder, but she can't reorder it herself. Medication Aide #1 stated that the assigned Nurse Aide (NA) for Resident #4 informed her that he had a bowel movement and did not mention diarrhea. Medication Aide #1 had also spoken to Resident #4 during her shift, and he had not informed her of any diarrhea. On 10/1/25 at 2:20 PM a telephone call was made to the NA assigned to Resident #4 on 9/28/25 during the 7:00 PM to 7:00 AM shift. Telephone contact was unsuccessful. On 9/30/25 at 9:08 AM an interview was conducted with Resident #4. He stated that on Friday, Saturday and Sunday, meaning this past weekend, he did not receive his anti-diarrhea medication called lomotil. He stated that this was the first and only time the facility ran out of it. He stated that being off the medication for 3 days did not really affect his stools too badly. He stated that he was now back on the medication. On 10/1/25 at 12:11 PM an interview was held with Nurse #2. She stated that she works every other weekend and was working on 9/29/25. She stated that the NP had put the lomotil medication on hold because the facility ran out. Nurse #2 said she called the pharmacy to get a delivery time and the pharmacy told her that it would be delivered sometime that evening. Nurse #2 left her shift at 7:00 PM and the medication had not been delivered. On 10/1/25 at 8:52 AM an interview was conducted with Nurse #1 who was passing out medications on Resident #4's hall. Nurse #1 looked at Resident #4's medication record and stated that it appeared he had run out of the lomotil medication on Saturday 9/27/25. Nurse #1 stated she was unsure what happened but can ensure he currently has plenty of that medication now. Nurse #1 stated that when she was passing out medications and noticed the pill count was low, she reorders the medication right away. She thought the pharmacy delivered to the facility two times a day except on Sunday. On 10/1/25 at 2:23 PM a telephone interview was held with the Pharmacy Representative. The Pharmacy Representative stated that Resident #4's lomotil was delivered to the facility on 9/30/25 at 1:26 AM. The Pharmacy Representative stated that on 9/27/25 there had been a request through the facilities electronic Medication Administration Record (eMAR) by an unknown staff requesting a refill on Resident #4's lomotil medication. Since lomotil was a controlled medication, the pharmacy was unable to fill it without a new order by the provider. The Pharmacy Representative was unable to say if anyone from the pharmacy called to alert the facility that a new order would be needed. The Pharmacy Representative reviewed over their call logs and did not see any telephone calls from the facility to order the lomotil medication. On 10/2/25 at 12:42 PM an interview was conducted with the Director of Nursing (DON). The DON stated that on 9/28/25 the East Side Unit Manager was working, and the East Side Unit Manager called the Medical Director regarding the lomotil medication being out and needing a new script. The Medical Director told the East Side Unit Manager to put the lomotil medication on hold until it came in from the pharmacy. The DON agreed that the nursing staff should know that a controlled medication can't be ordered through eMAR and that a new start date and script would be required. The DON was unsure who tried to order the medication through eMAR on 9/27/25. The DON stated that when staff order medications through eMAR it appears on eMAR that the medication was ordered but it doesn't alert the facility that a new script would be needed. The DON thought staff looked in eMAR and saw that the lomotil was ordered on the 9/27/25 and so the staff was waiting for the pharmacy to deliver. On 10/2/25 at 1:20 PM the Medical Director was interviewed by telephone. He stated that he was notified on 9/28/25 by the East Side Unit Manager that Resident #4's lomotil was out. The Medical Director could not remember what time the conversation happened but stated it was earlier in the day. The Medical Director told the East Side Unit Manager to put the lomotil medication on hold and that it was fine for Resident #4 not to get the medication until Monday when the NP would be in the facility to handle it. The Medical Director did not think it was a significant medication error for Resident #4 missing this medication. The Medical Director stated that Resident #4 had diarrhea all the time and that the lomotil does help but doesn't prevent it. The Medical Director knew that on Monday the NP would be able to get a new script to fill the medication. On 10/1/25 at 11:56 AM an interview was conducted with the Nurse Practitioner (NP). The NP stated that she became aware that Resident #4 had missed doses of his lomotil on Monday 9/29/25. She was unsure what time she was made aware. When staff made her aware she then ordered more of the medication. The NP stated that since the medication was a controlled medication there was a process on how it was ordered, and staff could not just call and get a refill. She stated that she could understand how a nurse may not realize that an antidiarrheal would be a controlled medication. The NP said that Resident #4's diarrhea did come back from not being on the medication, but she did not review it as being a significant medication error. On 10/2/25 at 1:57 PM an interview was held with the Administrator. She stated that did not know much regarding the missed doses of Lomotil and the Administrator was letting the DON handle it.

Based on observations and interviews with staff and residents, the facility failed to ensure a resident's accessibility to the light switch that was located behind the bed for 1 out 1 resident reviewed for accommodation of needs (Resident #44). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses of spinal stenosis. The 7/19/25 quarterly Minimum Data Set (MDS) assessment revealed that Resident #44 was cognitively intact. She had no impairment of her upper or lower extremities and used a wheelchair for mobility. During an observation on 9/29/25 at 11:50 AM the light switch for the over bed light fixture was located behind Resident #44's bed. There was a pull string/cord that was attached with a broken string that was approximately 10 inches long. It was 3 1/2 feet from the floor and 3 feet from the bed. Resident #44 was unable to reach the string/cord from her bed to turn the light on/off when needed. An interview was conducted with Resident #44 on 9/29/25 at 11:55 AM. Resident #44 stated that she had back pain often and so she stayed in her bed much of the time. When asked about the light switch behind her bed Resident #44 stated she would like to use it but couldn't reach it. Resident #44 stated that she had forgotten about the light because the cord had been broken for a long time and could not remember if she had notified the staff when it was first broken. On 10/1/25 at 9:39 AM a follow up interview was conducted with Resident #44. Resident #44 was lying in her bed reading and the room was dimly lit. The light behind the bed was off. Resident #44 was asked if she would like the light on and she stated yes. The light was turned on and she said, that is much better. Resident #44 was again asked if she would like to be able to turn the light on and off herself and she stated she would. On 10/1/25 at 10:00 AM an interview was held with the Maintenance Director. He stated that he and other maintenance staff went around the facility and fixed the light switch cords on a weekly basis because they often broke. The Maintenance Director could not say when or if the light cord for Resident #44's was fixed at the last go around. The Maintenance Director looked at Resident #44's light switch and agreed it needed an extension added to the cord so that Resident #44 could turn the light on/off. On 10/2/25 at 1:05 PM an interview was held with the Director of Nursing (DON) and she stated that any resident that would like to be able to use the pull cord for the light switch should be able to reach it. On 10/2/25 at 2:01 AM an interview was held with the Administrator. She stated that she would expect Resident #44 to have her pull cord available to her but also stated that Resident #44 was able to communicate to staff if she wanted her light on.

Based on observations and resident and staff interviews, the facility failed to maintain the commodes free from dirty build-ups around the base for 2 of 2 toilets (rooms [ROOM NUMBERS]) and failed to replace broken blinds with sharp edges in 2 of 2 resident rooms (rooms [ROOM NUMBERS]) reviewed for orderly interior in 2 of 2 halls. The findings included: 1 a. An observation was conducted on 09/15/24 at 1:19 PM of the bathroom in room [ROOM NUMBER] that shared with residents in room [ROOM NUMBER]. The caulking around the base of the commode had fallen off and filled with dark colored build-up approximately 1 centimeter in width around the base of the toilet. Further assessment of the commode revealed it was intact and functional without any broken parts or loosened base. The broken caulking around the base of the commode had trapped a layer of dirty build-up that might consist of urine, mopping water. During an interview conducted on 09/15/24 at 1:20 PM, Resident #36 stated the darkened substances around the base of the commode that had been accumulated for at least 6 months and it disgusted her. b. An observation was conducted on 09/15/24 at 2:48 PM of the bathroom in room [ROOM NUMBER] that share with residents in room [ROOM NUMBER]. The caulking around the base of the commode had fallen off and filled with dark colored build-up approximately 1 to1.5 centimeter in width around the base of the toilet. Further assessment of the commode revealed it was intact and functional without any broken parts or loosened base. The broken caulking around the base of the commode had trapped a layer of dirty build-up that might consist of urine, mopping water, or other unknown substances. During an interview conducted on 09/15/24 at 2:49 PM, Resident #88 stated he had seen the black color build-ups around the base of the commode since he moved into his room in late April. Subsequent observations to Resident #36's and Resident #88's bathroom on 09/16/24 at 2:29 PM and 2:33 PM respectively revealed the base of the commode for both bathrooms remained dirty with broken caulking. During a joint observation conducted with Unit Manager #2 on 09/17/24 at 11:48 AM, she acknowledged that the caulking around the base of both commodes needed to be re-caulked as soon as possible. She explained she rarely went into residents' bathroom, and she expected the housekeepers to report repair needs to the maintenance department in a timely manner. An interview was conducted with Housekeeper #1 on 09/17/24 at 11:57 AM. She stated she noticed the base of both commodes accumulating buildups and recalled she had notified the Maintenance Manager about 2 weeks ago. However, she did not see anything had been done to fix the issues so far. During an interview with the Housekeeping Manager on 09/17/24 at 12:05 PM, he indicated he had just started his role about 2 weeks ago. He acknowledged that the darkened buildup around the base of both commodes needed to be removed and installed with a new caulking. He explained he walked through all residents' room at least twice weekly to ensure cleanliness, but he did not notice the base of both commodes were accumulated with buildups. He expected the housekeeper to notify him and the maintenance department to keep the commodes clean all the time. An interview was conducted on 09/17/24 at 12:12 PM with the Maintenance Manager. He stated he walked through all residents' room including bathroom at least once weekly. He did not notice the broken caulking with dirty build-ups and indicated that it was his oversight. He normally depended on staff reporting of repair needs by dropping the work orders in the mailbox outside of the maintenance office, or by verbal notification. He did not recall receiving any report from nursing or housekeeping staff regarding the broken caulking with dirty buildups for the commodes for both bathrooms so far. He acknowledged that both commodes needed to be cleaned and re-caulked as soon as possible. During an interview conducted on 09/17/24 at 1:18 PM, the Administrator expected all the staff to communicate with each other to report environmental concerns in a timely manner to ensure residents' homes remained clean and in good repair all the time. An interview was conducted with the Director of Nursing on 09/18/24 at 3:55 PM. She expected the facility to keep residents' home clean and in good repair all the time. 41069 2. a. An observation was made in room [ROOM NUMBER] on 9/15/24 at 2:31 PM. The window blinds inside the room were missing three pieces of slat in the middle and had five broken slats at the bottom with sharp edges. During the observation, an interview with Resident #64 who resided in the room stated that the blinds in his room had been like this for two months. A follow-up observation in room [ROOM NUMBER] on 9/17/24 at 9:15 AM revealed three pieces of slat missing in the middle which measured approximately 6 inches long and 12 inches wide, and five broken slats with sharp edges at the bottom of the window blinds. An interview with Housekeeper #2 on 9/18/24 at 7:33 AM revealed she had noticed the broken blinds in room [ROOM NUMBER] for a couple of months, but the Maintenance Manager already knew about them. Housekeeper #2 stated that there was a clipboard on the Maintenance Manager's door for repair requests, but she did not know whether he checked it or not so her supervisor gave them a note pad wherein they could write any repair requests and hand them directly to the Maintenance Manager. An interview with Nurse #4 on 9/18/24 at 11:05 AM revealed she had noticed the broken blinds in room [ROOM NUMBER] which were due to Resident #64 pulling them down. Nurse #4 stated that it had been reported that they needed repair and that they had been broken for a while, but she couldn't remember exactly how long. b. An observation was made in room [ROOM NUMBER] on 9/16/24 at 8:29 AM. The window blinds inside the room had 14 slats that were missing on the left side and made a hole which measured approximately 12 inches in length and 12 inches in width. All of the broken pieces had sharp edges. A follow-up observation and interview with Resident #20 on 9/17/24 at 8:56 AM revealed the blinds in his room had been broken ever since he moved to the room about a month ago. Resident #20 stated that he was not sure how the blinds got broken like that when all they needed to do was to raise it up. He said he was not sure why they had to put a hole in the blinds. He further stated that he was sure they knew that the blinds needed to be replaced or repaired for as long as it had been that way. An interview with the Maintenance Manager on 9/18/24 at 10:29 AM revealed that he had a clipboard on the outside of his door where staff could notify him of any maintenance repair requests. The Maintenance Manager stated that he was in the process of changing the blinds that needed repair. He said that he saw the broken blinds in room [ROOM NUMBER] when he was walking outside the day before, and the blinds in room [ROOM NUMBER] got broken all the time because the resident often messed it. He shared that he had just changed the blinds in room [ROOM NUMBER] two weeks ago, but the problem was that they got rid of the pull cord from the blinds due to it being a choking or hanging hazard so you would need to pull on the blinds when lowering them. An interview with the Administrator on 9/18/24 at 4:47 PM revealed they had been replacing the blinds in room [ROOM NUMBER] because the resident often messed with them, but she was not aware of the broken blinds in room [ROOM NUMBER].

Based on record review, observations, resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of flies on 2 of 4 hallways (West hallways) that affected resident rooms [ROOM NUMBERS], and the dining room. The findings included: A review of the Pest Control Company service specifications and recommendations dated 12/23/22 indicated under Insect Control: Interior - Restrooms, break areas, vending areas, kitchen, dining area, and offices will be inspected and treated as needed monthly. Exterior - Perimeter treatment will be done quarterly at ground level, up to 6 feet out and 2 feet up from structure to control crawling insects. The services accepted (by the facility) included regular pest control, exterior insect control and addition for kitchen cleanout. Fly control was not included in the services. A review of the facility's pest control sheet from May 2024 to September 2024 indicated the pest control issues reported were ants, roach-like bugs, stink bugs, and roaches. No issues regarding flies were reported. A review of the Pest Control service work order invoice dated 7/15/24 indicated a quarterly exterior treatment was done for crawling insects, and rooms [ROOM NUMBERS] were inspected and no pest activity was found. rooms [ROOM NUMBERS] were treated for crawling insects. A review of the Pest Control service work order invoice dated 8/8/24 indicated the nourishment room, and the East and [NAME] nursing stations were treated for roaches. A review of the Pest Control service work order invoice dated 9/13/24 indicated spot treatment was done on crack crevices for roaches. a. An observation of residents in room [ROOM NUMBER] was made on 9/15/24 at 12:33 PM. There were three flies that were flying around, and two flies hovered over the first bed in which a resident was sleeping in. A second observation in room [ROOM NUMBER] was made on 9/16/24 at 8:37 AM. Two flies hovered by the footboard of the first bed. There were no residents in the room at this observation. b. An observation of the 200 hallway (West) was made on 9/15/24 at 1:00 PM. A fly was observed flying around near the hallway door. A fly light was observed positioned on the wall about 1/4 of the way to the nurses' station. c. An observation of room [ROOM NUMBER] was made on 9/16/24 at 3:05 PM. There was a fly noted on the resident's bed. d. An observation of the dining room was made on 9/17/24 at 11:40 AM while the surveyor was heading to the kitchen. A fly was hovering and landed on the surveyor's face. There were no residents in the dining room at this time. An interview with Resident #6 who resided in room [ROOM NUMBER] was conducted on 9/17/24 at 9:41 AM. Resident #6 stated that he had observed at least three flies in his room, and he attributed the presence of flies to urine not being completely cleaned off of his floor when spills occurred. An interview with Housekeeper #2 on 9/18/24 at 7:33 AM revealed she had seen flies all over the facility for about a week, but she did not know where they were coming from. Housekeeper #2 stated she had noticed flies in room [ROOM NUMBER], and had observed flies in the East hallway the past week. She stated she knew a pest control company came to the facility to do treatments, but she was not sure what they did for flies. An interview with Nurse Aide (NA) #1 on 9/18/24 at 11:22 AM revealed she had observed flies all over the facility, but the [NAME] hall was worse compared to the East hall. NA #1 stated that she noticed the presence of flies had gotten worse within the past week, and she had reported this issue to the Maintenance Manager. NA #1 further stated the Maintenance Manager was trying to do something about the flies, but she was not sure what. An interview with Nurse #4 on 9/18/24 at 11:05 AM revealed she had noticed some flies hovering around the nurses' station on the [NAME] hall and in the [NAME] hallway, and the presence of flies had been recently getting worse within the past month. Nurse #4 stated that she had no idea where they were coming from, but she had reported it to the Maintenance Manager. Nurse #4 also stated that she didn't know what the next steps were to control the flies. An interview with the Maintenance Manager on 9/18/24 at 10:29 AM revealed he did rounds every day to check for pests inside the facility and he also had a clipboard on his door where staff could report any pests they observed in the facility. The Maintenance Manager stated that a pest control technician came to the facility on the second Tuesday of each month to spray in the common areas. They also checked the clipboard to address any pests that were reported. The Maintenance Manager stated that he had seen flies inside the facility, but they had fly lights which were posted on each hallway and right by the smoking door. The Maintenance Manager also stated that the presence of flies had been worse this week because it had been wet from the rain. He shared that the flies might have been coming into the building from the smoking door which opened and closed from the smokers coming in and out of this door all the time. An observation of the smoking area on 9/18/24 at 9:40 AM revealed a fly light mounted on the wall on the hallway leading up to the smoking door. It was on and working. However, the smoking door was observed being opened and closed frequently from smokers coming in and out of the facility. No flies were observed in the area. A phone interview was attempted with the Pest Control Technician on 9/18/24 at 4:34 PM. He stated that he provided general pest control for the facility, but he refused to provide additional details, claiming it was due to confidentiality issues. A follow-up interview with the Maintenance Manager on 9/18/24 at 4:05 PM revealed there was nothing else they could do about the flies in the facility besides the use of the fly lights. He stated that the only way to completely get rid of the flies was to fumigate the whole building, which meant evacuating all the residents first. He also checked with the Pest Control Technician who told him the same thing. An interview with the Administrator on 9/18/24 at 4:47 PM revealed the facility had fly lights and she had more on order because during the summer time, the smokers went in and out of the facility several times during the day. They also utilized fly swatters whenever they observed flies. The Administrator stated that they had tried to do a good job with keeping the presence of flies down. A follow-up interview with the Administrator and the Maintenance Manager on 9/18/24 at 5:14 PM revealed they went in to check room [ROOM NUMBER] and observed a fly in the room but it was closer to the window near the second bed. The Administrator stated they checked if there were any openings in the room but couldn't find where they were coming from. The Maintenance Manager stated he put up stickers on the window where they could get stuck if they tried to find somewhere to get out of the room. They stated they would continue to investigate and find out where the flies were coming in from.

Based on record review, observation, and interview with resident and staff, the facility failed to protect a resident's right to be free from physical abuse when a cognitively intact resident (Resident #23) hit a resident with severely impaired cognition (Resident #19) who wandered into his room asking for cigarette. This affected 1 of 4 sampled residents review for abuse. The finding included: Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia and traumatic brain injury. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #19 with severely impaired cognition. He was under Hospice care and utilized wheelchair as the primary mobility device. He weighted 132 pounds and was 5 foot 6 inches tall. He wandered and demonstrated verbal behavioral symptoms directed toward others ,d+[DATE] days during the 7-day assessment period. Resident #23 was admitted to the facility on [DATE] with diagnoses including depression and psychoactive substance dependence. The quarterly MDS assessment dated [DATE] coded Resident #23 with an intact cognition. He was 6 foot 6 inches tall and weighed 222 pounds. He had an acquired absence of left leg above knee and was using wheelchair as the mobility device. A review of nurse's progress notes dated [DATE] revealed Resident #19 entered Resident' #23's room with his wheelchair and had a verbal and physical altercation in that evening. Upon assessment, Resident #19 suffered skin tear to the left brow, bruise and swelling about the size of a marble below the left eye. On [DATE], the Director of Nursing (DON) and Social Service Director (SSD) assessed Resident #19 and noted he was free of distress or mental anguish. Resident #19 denied pain and could not recalled the altercation that occurred with Resident #23 the previous night. The physician's progress notes dated [DATE] revealed Resident #19 went into Resident #23's room and was being slapped and hit by Resident #23. At the time of assessment, Resident #19 appeared calm. He had limited insight into the incident due to his level of dementia and was unable to provide details. The nurse's progress notes dated [DATE] revealed Resident #23 was under one-on-one staff supervision after having a physical altercation with Resident #19. The physician's progress notes dated [DATE] indicated Resident #23 had slapped and punched Resident #19 who went into his room. At the time of assessment, Resident #23 appeared calm and stated when Resident #19 came into his room, he told him to leave even though he was his neighbor. However, Resident #19 would not leave and threw a cup of coffee at him. Resident #23 stated he felt like he had to defend himself by slapping Resident #19. When Resident #19 tried to hit him back, he punched him. Resident #23 denied having issues with his mood or anxiety after the incident during the assessment. He reported he had been eating and sleeping well, and it was confirmed by the staff. The initial report submitted to the Health Care Personnel Registry (HCPR) by the facility on [DATE] indicated it was a resident-to-resident abuse between Resident #19 and Resident #23 which occurred on [DATE] in the evening. The report indicated Resident #19 entered Resident #23's room asking for cigarette. When Resident #23 told him to leave, Resident #19 threw a cup of coffee at Resident #23. Then, Resident #23 slapped Resident #19's. Both residents were placed on one-on-one after the incident. The Hospice nurse, in-house Nurse Practitioner (NP), local police, and Adult Protective Services (APS) were notified. Resident #19 suffered skin tears of approximately 0.5 centimeters (cm) to left brow, a marble size of bruise to left eye with slight swelling. Resident #23 was noted with bruises to his right anterior hand without any mental anguish. Resident #19 could not remember the incident when an administrative staff asked him about 30 minutes after the incident. The investigation report submitted by the facility on [DATE] indicated the allegation of abuse was unsubstantiated. Resident #23 stated Resident #19 did enter his room and could not be redirected. When he told him to leave, Resident #19 threw a cup of coffee at him. Then, Resident #23 struck Resident #19 defensively once to remove him from his room. An attempt to interview Resident #19 on [DATE] at 3:00 PM was unsuccessful. Resident #19 could not recall anything related to the episode of physical altercation with Resident #23 on [DATE]. Observation of Resident #19 revealed he was calm, pleasant, and free of mental anguish. During an interview conducted on [DATE] at 3:05 PM, Resident #23 could not recall the physical altercation with Resident #19 that occurred on [DATE]. Observation of Resident #23's room revealed a Stop sign was in place by the entrance. He sat in the wheelchair and appeared to be calm, friendly, and free of any mental anguish. An interview was conducted with Unit Manager (UM) #1 on [DATE] at 4:23 PM. She stated Resident #19 used to stay at the North side of [NAME] wing. After the physical altercation on [DATE], he was moved to the South side of [NAME] wing. A few days later, he was moved again to the East wing due to changing from rehab to long-term care. Resident #19 always thought his home was at [NAME] wing and wandered to [NAME] wing frequently. She stated that she was not in the facility when both incidents occurred. During an interview conducted on [DATE] at 12:19 PM, UM #2 stated Resident #19 used to be Resident #23's neighbor and sharing the same bathroom. After the incident on [DATE], Resident #19 was moved to the south side of [NAME] wing, separated by the nurse station. Resident #19 was place under one-on-one and Resident #23 under 15 minutes checks for several days. A banner with a Stop sign was placed at the entrance of Resident #23's room. An attempt to conduct a phone interview on [DATE] at 4:39 PM with Nurse #1 who was the hall nurse for Resident #23 on [DATE] was unsuccessful. She did not return the call. During a subsequent interview conducted on [DATE] at 5:53 PM, Resident #23 could not recall any administrative staff had ever educated him to call for help and refrained from using physical force toward any residents when he was provoked. Resident #23 stated he had the right to defense himself when he was provoked or physically attacked by an intruder in his home. An interview was conducted with the DON on [DATE] at 6:48 PM. She stated after the first incident on [DATE], Resident #23 was care planned for his physically aggressive behavior with the goal to control his behavior and seek staff for assistance when he became agitated. She personally educated Resident #23 to refrain from using physical force toward other residents and asked for assistance from the staff. She stated Resident #23 verbalized understanding after receiving the education. She stated the interventions put in place after the first incident were fully implemented and added they were sufficient to prevent any subsequent physical altercation from happen again.

Based on record review, interviews with resident and staff, the facility failed to provide care in a safe manner when a resident fell from her bed during personal care. Resident #29 fell off her bed and hit her nose on an oxygen concentrator positioned next to the bed and subsequently fell to the floor. The resident was sent to the hospital evaluated and returned to the facility the same day with no injuries from the fall. This was for 1 of 5 residents reviewed for the prevention of accidents (Resident #29). Findings included Resident #29 was admitted to the facility on [DATE] with diagnosis that included dementia, respiratory failure, diabetes mellitus Resident #29's care plan prior to the fall read, Resident #29 was at risk for falls related to deconditioning, gait and balance problems (8/30/23). Interventions included risks and injury will be minimized through next review date and use sit to stand lift with transfers if the resident is having fatigue, shortness of breath, or other difficulty transferring. Resident #29's quarterly Minimum data set (MDS) dated [DATE] coded her as cognitively intact. Resident #29 required 1-person maximum assistance with rolling left or right, dependent with 2-person assistance with bathing and with toileting. A review of the incident report dated 11/3/23 at 6:30 PM completed by Nurse #5 read in part: Nurse #5 was called to the resident's room by Nurse Aide (NA) #2. Resident #29 was lying on the floor on her right side with blood on the floor from her nose. The resident was complaining of head pain and right shoulder pain when assessed. Nurse #5 called Emergency Medical Services (EMS) immediately and notified the Director of Nursing (DON), Medical Director (MD), and family. The hospital discharge summary dated 11/3/23 was reviewed. The discharge summary read the resident was seen in the emergency room after a fall. A Computed Tomography (CT) scan of her head showed no intercranial hemorrhage, and x-ray of her right hip and hand showed no evidence of broken bones. Resident #29 was discharged back to the facility with no orders for pain medication. The discharge summary did not include a description of a nose injury or treatments to the nose or other areas of the head or face. A MD progress note dated 11/8/23 was reviewed and read in part: Resident #29 had a fall and was sent to the ER where a CT head scan and an x-ray of her hip and hand were normal. The resident had complained of pain in her head and right arm. The resident received Tylenol and Tramadol for arm pain. Resident #29 was interviewed on 9/15/24 at 10:42 AM. She stated on 11/3/23 she was getting a bed bath from a NA who she couldn't remember. Resident #29 stated she was lying on her right side with the NA standing behind her. The resident stated her legs fell off the bed and she then fell out of the bed and hit her nose on the oxygen concentrator beside her bed before hitting the floor. She stated her left arm was hurting from the fall too. The nurse sent her to the hospital after the fall to check her out and the hospital did not find anything broken or wrong with her. Resident #29 said the hospital did not give her any pain medications and she did not need to take any because her pain wasn't bad. The resident stated she normally had 2 people assist her with bed baths, and there was one NA helping her when she fell from her bed. She also stated she had not fallen from her bed before that incident. Resident #29's assigned Nurse #5 was interviewed on 9/17/24 at 11:30 AM. She stated Resident #29 was receiving a bed bath from NA #2 during the shift change that evening. NA #2 provided the bed bath without assistance from another staff member. Resident #29 required 2-person assistance for all care areas and NA #2 knew Resident #29 required 2-person assistance with bed baths because it had been discussed during the huddle meeting at the beginning of her shift, earlier that day. NA #2 called down the hallway for help, and Nurse #5 quickly went to the resident's room. Nurse #5 stated Resident #29 was seen lying on the floor on her right side, and her nose was bleeding from her nostrils. Resident #29 told Nurse #5 her head was hurting and Nurse #5 provided first aide to the resident's nose, called EMS and then notified the MD, Director of nursing (DON), and family of the incident. NA #2 told Nurse #5 she was giving Resident #29 a bed bath without assistance and the resident was laying on her side and she was behind the resident washing her. Resident #29 rolled out of bed and onto the floor. NA #2 was unavailable for interview. NA #2's written statement dated 11/3/23 read in part: NA #2 was providing a bed bath to Resident #29. Resident #29 was assisting NA #2 with rolling over on her right side. During the bed bath, Resident #29 threw her leg up and over causing her to roll over and out of the bed. NA #2 wrote she tried to stop Resident #29 from rolling out of bed, but Resident #29 continued to move herself. The DON was interviewed on 9/17/24 at 3:05 PM. She stated Resident #29 had previously been a 1-person assist but had a decline before the fall and needed 2-person assistance when providing care and bed baths. The DON said NA #2 did not remember Resident #29 needed 2-person assist when providing a bed bath. Resident #29 was lying on her side when NA #2 was washing her and the resident's legs rolled off the side of the bed, causing the resident to fall to the floor. The DON stated NA #2 was provided education to have 2 -person assistance when providing care with Resident #29. NA #3 was interviewed on 9/18/24 at 2:12 PM, she stated she had been assigned to Resident #29 prior the fall on 11/3/23. NA #3 said Resident #29 had required 2-person assistance for all care including bed baths, and all NA's who provided care for Resident #29 had been informed of her care needs during team huddles at the beginning of each shift. The Administrator was interviewed on 9/18/24 at 4:29 PM. The Administrator stated Resident #29 should have had 2 people providing her a bed bath on 11/3/24, and NA #2 should have found assistance from another NA or Nurse before providing a bed bath.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint and recertification survey that occurred on 11/23/21. The failure was for one deficiency that was originally cited in the area of Food Procurement (F812). The repeat deficiency during two surveys of record shows a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F812: Based on observations and staff interviews the facility failed to ensure staff wore hair coverings when working in food production areas for 1 of 1 meal production observation. This practice had the potential to affect food served to residents. During the recertification and complaint investigation survey conducted 11/23/21, the facility failed to cover, label and date 4 contains of fruit, cover and label a 6-liter container of fruit dated 11/07/21, label, and date 8 small plastic containers with a green food item in them, and label, and date a plastic grocery bag with 2 plastic containers in it in Refrigerator #1, label, and date 2 plastic containers of whipped topping and a container of lunch meat in Refrigerator #2, label, and date an opened container of ice cream, and label, and date a frozen entree in nourishment room Freezer #1 and clean the dust on the intake fan of the dishware air dryer in the kitchen. During an interview with the Administrator on 07/20/23 at 1:43 PM, she reported previously their citation was for uncovered and unlabeled foods and they had done a process improvement plan (PIP), educated, and monitored staff, reported through their QA committee, and had achieved compliance with food storage. She stated this was a new issue and given the staff in the kitchen was new they would need to expand their process to include sanitary conditions in the kitchen and provide additional education to the new staff in the kitchen and again monitor for compliance.

Based on observations and staff interviews the facility failed to ensure staff wore hair coverings when working in food production areas for 1 of 1 meal production observation. This practice had the potential to affect food served to residents. The findings included: An observation and interview conducted on 07/17/23 at 9:45 AM revealed Dietary Aide #1 did not have a hair covering on while he was preparing food over the stove. The Dietary Aide #1 revealed he had forgotten to put his hair covering on before entering the kitchen. An interview conducted on 07/17/23 at 9:50 AM with the Dietary Manager (DM) revealed he was not aware Dietary Aide #1 was not wearing a hair covering but expected all staff to wear hair coverings in the kitchen. An interview conducted with the Administrator on 07/20/23 at 2:45 PM revealed all kitchen staff were expected to wear hair coverings, and Dietary Aide #1 should have been wearing a hair covering while preparing food.

Based on record review, staff interviews, and observations the facility failed to develop and implement care plan interventions for hearing (Resident #73) and limited Range of Motion (ROM) (Resident #75) for 2 of 4 sampled residents. 1. Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, dementia, and hypertension. Review of Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was moderately cognitively impaired and required supervision for most of activities of daily living (ADL). The MDS further revealed Resident #73 was coded for a hearing aide device. Review of Resident #73's care plan revealed no goals or interventions regarding Resident #73's hearing aids. Review of Resident #73's Physician orders dated 04/03/23 staff were to assist the resident with applying hearing aids in the morning and removing them in the evening. An observation was conducted on 07/17/23 at 3:50 PM and revealed Resident #73 had a sign behind her bed that stated, please assist resident with charging her hearing aids by removing them at night and putting them on charger in box by the refrigerator. The resident's hearing aides were observed to be on the charger and not on the resident. An interview was conducted with Resident #73's family member and revealed she had asked staff multiple times to charge Resident #73's hearing aids but they were always dead when they visited. An observation conducted on 07/18/23 at 2:30 PM revealed Resident #73 sitting up in her bed watching television without her hearing aids in. The hearing aides were observed on Resident #73's charging box. An interview conducted with Nurse #6 revealed she was from an agency and had not worked with Resident #73 often. Nurse #6 further revealed she was not aware Resident #73 had hearing aides and that there was a sign above her bed. Nurse #6 stated she should have offered to assist Resident #73 with her hearing aids. An interview conducted with the MDS Coordinator on 07/20/23 at 9:15 AM revealed Resident #73 did have an order and was coded for hearing aids. The MDS coordinator further revealed she had failed to add hearing aids to Resident #73's care plan. An interview conducted with Director of Nursing (DON) on 07/20/23 at 10:00 AM revealed she was aware Resident #73 had hearing aids and expected nursing staff to assist Resident #73 with her hearing aids. The DON further revealed hearing aid interventions should have been added to the resident's care plan. An interview conducted with the Administrator on 07/20/23 at 2:40 PM revealed Residents #73's order of hearing aides should have been added to the resident's care plan and the interventions should have been followed. 2. Resident #75 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and a disorder that affects movement and muscle tone or posture. Review of Resident #75's quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #75 was severely cognitively impaired and was totally dependent for all Activity's of Daily Living. Review of Resident #75's care plan revised on 04/13/23 revealed Resident #75 had potential impairment to skin integrity due to limited mobility secondary to a disorder that affects movement and muscle tone or posture. The goal was for Resident #75 to maintain or develop clean and intact skin by the review date. Interventions included for Resident #75 to wear palm braces to both hands and remove them once a day or during shower. Physician orders dated 06/08/23, stated Resident #75 was to wear bilateral palm guards as tolerated and to remove them daily to clean the resident's hands. An observation was conducted on 07/17/23 at 2:10 PM revealed Resident #75's hands were contracted and she did not have palm guards placed on her. In addition, no palm guards were observed in Resident #75's room. An interview conducted with Nurse #7 and Nurse Aide (NA) #5 on 07/19/23 at 3:50 PM, revealed they had assisted Resident #75 with her palm guards before but were unsure why they were not present in Resident #75's room. NA #5 further revealed Resident #75 had moved from another hall about two weeks ago and believed her palm guards got lost in the move. An observation and interview were conducted with the facility Occupational Therapist (OT) on 07/19/23 at 4:10 PM and revealed the OT brought new palm guards and put them on Resident #75 on 07/19/23. The OT further revealed he had educated and trained staff on putting palm guards on Resident #75 in April and was unsure why she did not have any in her room. The OT stated Resident #75 had no skin impairment but wanted Resident #75 to wear them as much as possible to prevent skin issues. An interview conducted with the Director of Nursing (DON) on 07/20/23 at 10:00 AM revealed she was not aware Resident #75 did not have palm guards in place but expected for nursing staff to follow Resident #75's care plan and to document if the resident refused. The DON further revealed, therapy educates and trains nursing staff on Range of Motion interventions and she expected nursing staff to follow through with interventions. An interview conducted with the Administrator on 07/20/23 at 2:40 PM revealed Resident #75's palm guards should have been placed on her daily and expected for interventions to be carried out by nursing staff.

Based on record reviews and resident and staff interviews, the facility failed to have a plan in place for providing minimum supervision and assistance with applying a smoking apron for a resident during the hours there was not a staff member assigned to supervise residents in the designated smoking area. Resident #52 was required to wear a smoking apron at all times when he was smoking and was not able to apply it independently. This deficient practice occurred for 1 of 3 residents reviewed for smoking (Resident #52). The findings included: Review of revised facility smoking policy dated 01/27/23 revealed residents who smoke would be assessed using the resident safe smoking assessment during the admission process and during each quarterly or comprehensive Minimum Data Set (MDS) assessment process. The policy also revealed safe smoking privileges would be revoked indefinitely for residents with smoking incidents resulting in a burn to clothing, skin, hair, or other bodily injury not determined by administration to be accidental and failure to smoke in designated smoking area. Resident #52 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes, tremors, muscle weakness, and tobacco use. Review of the resident safe smoking assessment dated [DATE] completed by Director of Nursing (DON) for Resident #52 indicated he did not meet the criteria for a safe smoker and required at minimum supervision while smoking due to having history of smoking-related incidents: burning clothing, dropping ashes on self, and smoking in a non-smoking area. Review of the Administrator progress note dated 04/08/23 revealed she had spoken with Resident #52 about his concerns regarding smoking materials being misplaced. The interdisciplinary team (IDT) met to discuss safety concerns related to Resident #52's care and smoking. Resident #52 would be a supervised smoker going forward. Review of the resident safe smoking assessment dated [DATE] completed by Nurse #5 revealed Resident #52 had a history of smoking related incidents: burning clothing and required at minimum supervision while smoking but was assessed as being able to smoke independently. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was cognitively intact. The revised care plan dated 07/10/23 revealed Resident #52 was an independent smoker, and the goal was he would not have any smoking related incidents through the next review date. Interventions included instructing Resident #52 about the facility policy on smoking: locations, times, safety concerns, notifying charge nurse immediately it suspected Resident #52 had violated facility smoking policy, and Resident #52 was required to wear a smoking apron while smoking. Observation and interview with Resident #52 on 07/18/23 at 10:25 AM revealed him finishing smoking in the designated smoking area, taking off his smoking apron, and placing his lighter back inside his locked box while the facility Smoking Aide was present. He was observed having a burn hole in his shirt and when asked he stated that it was from a past incident where he had dropped ashes on himself. Resident #52 revealed he was able to smoke whenever he wanted but was told he had to wear the smoking apron and staff assisted him with putting apron on. When asked if he was able to apply smoking apron when staff were not present, Resident #52 did not answer and went back inside facility. An interview was conducted with Medication Aide (MA) #1 dated 07/18/23 at 10:25 AM revealed she had been assigned as facility smoking aide and was responsible for providing smoking materials, assistive and safety devices, and supervision of all supervised smokers. She stated unsupervised smokers were allowed to smoke at any time and were assigned a key and locker to keep their smoking materials locked. MA #1 revealed she was familiar with Resident #52, and he was an unsupervised smoker but was required to wear a smoking apron at all times. She stated Resident #52 required assistance with retrieving and applying his smoking apron, but she had not seen any issues with his ability to retrieve his smoking materials or light and smoke his cigarette appropriately. She revealed she had not seen any issues with Resident #52's ability to ash or distinguish his cigarette appropriately since wearing the smoking apron. A telephone interview with Nurse #5 on 07/20/23 at 9:33 AM revealed she had been responsible for completing Resident #52's smoking assessment in May 2023. She stated she was not as familiar with the smoking assessment and had been asked by administration to complete the smoking assessment for Resident #52 and make him an unsupervised smoker. She revealed Resident #52 had a smoking incident the month prior and had been assessed to require supervision while smoking and she assumed that after 30 days he could be assessed as requiring no supervision while smoking as long as he wore a smoking apron at all times. Nurse #5 stated the facility had implemented a Smoking Aide during daytime hours to provide supervision to supervised smokers, but unsupervised smokers were allowed to smoke at any time with no restrictions or supervision. She revealed Resident #52 would be responsible for applying his own smoking apron when the smoking aide was not present, and she was not aware if he was able to apply smoking apron by himself or not. Observation and interview with Resident #52 on 07/20/23 at 10:23 AM revealed him exiting the facility to smoking area unsupervised and retrieving his cigarettes and lighter from his locked box. The box with the smoking apron was located on the wall of the smoking area and Resident #52 was able to open the box and take out smoking apron but was not aware of how to apply the smoking apron and had to be assisted by the Smoking Aide who was present. Resident #52 stated he was aware he had to wear his smoking apron while smoking and required assistance with applying apron from staff outside, when asked if he wore smoking apron when staff were not present, he did not answer. Resident #52 was able to light, smoke, and distinguish cigarettes properly, he did have a burn hole in his shirt, but he stated that was from a past incident. An interview with the Administrator and Director of Nursing (DON) on 07/20/23 at 11:25 AM revealed they were familiar with Resident #52 and he had some issues a few months ago with him not following the smoking policy, he was smoking in non-smoking areas, having smoking materials inside facility, and observations of burn holes in clothing, so he was assessed to require supervision while smoking and his smoking materials were locked and only provided during scheduled smoking times by staff. They stated Resident #52 began having behavioral issues due to the supervised smoking, so they implemented a facility Smoking Aide to work from 7:00 AM to 8:30 PM and his behaviors improved. The Administrator and DON revealed when his last smoking assessment was completed in May 2023, he was assessed to be an unsupervised smoker with the restriction of wearing a smoking apron. They stated although Resident #52 had smoking violations in the past, they felt this would be the least restrictive option for him and the Smoking Aide would be able to assist with him wearing the smoking apron. They revealed they were not able to say for sure if Resident #52 would be wearing smoking apron if smoking aide was not present, and if he would be a safe smoker without smoking apron due to past concerns with him dropping ashes on himself and burning holes in his clothing. The Administrator and DON stated all resident smoking assessments should be completed accurately and reflect all concerns.

Based on record review and interviews with the staff, the Wound Care Nurse Practitioner, and Medical Doctor the facility failed to provide necessary care and services for a newly identified open area on the right heel and failed to accurately complete the weekly skin assessment and shower audit tool for an existing wound on the right heel that developed signs of infection for 1 of 3 residents reviewed for pressure ulcers (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was discharged to the community on 08/29/22. Review of the admitting 3-day skin assessments for Resident #3 revealed on 08/09/22 and 08/10/22 Nurse #1 documented a blanchable open area was present on the right posterior heel. On 08/11/22 Nurse #2 documented a blanchable open area was present on right posterior heal. Review of the bathing records revealed on 08/12/22 Nurse Aide #1 initialed the shower audit tool to indicate Resident #1 received a bed bath and documented the skin was intact and good. Review of Resident #3's weekly skin assessment revealed on 08/15/22 Nurse #3 documented the skin was intact. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed the cognition of Resident #3 as being moderately impaired and indicated extensive assistance was needed with bed mobility, transfers, and toilet use. The MDS indicated Resident #3 was at risk but did not have any unhealed pressure ulcers or other skin conditions and treatments included a pressure reducing device for the bed and chair. Review of a progress note dated 08/17/22 revealed the Wound Care Nurse documented Resident #3 was notified of treatment orders and a plan of care for the right heel. The treatment was to apply an antiseptic solution of [MEDICATION(S)]-iodine and cover with a silicone foam dressing and scheduled to be changed three times a week and as needed when soiled or dislodged for a deep tissue injury (non-blanchable, darkly pigmented skin resulting from prolonged pressure). Review of the document titled; Weekly Pressure Wound Observation Tool signed by the Wound Care Nurse revealed on 08/18/22 the Medical Doctor (MD) or alternate was notified, and the current treatment in place was to clean the right heel with normal saline and apply a nickel thick amount of a [MEDICATION(S)] ointment (removes dead tissue) to the wound bed and cover with a silicone foam dressing. The treatments were scheduled to be changed daily and as needed. An air mattress and heel boots were recommended to offload pressure. The documentation indicated this was the first observation of a pressure ulcer that was present on admission on 08/09/22 and currently measured 2.9 centimeter (cm) in length and 3.2 cm in width and 0 cm in depth with a moderate amount of bloody drainage. Review of the Wound Care Nurse Practitioner (NP) progress note revealed on 08/18/22 the initial exam of Resident #3's right heel identified an unstageable pressure ulcer (a wound obscured by dead tissue) measuring 2.9 cm in length and 3 cm in width and 0 cm in depth. The Wound Care NP recommended to clean the area with normal saline and apply a [MEDICATION(S)] ointment and cover with a silicone foam dressing every day and as needed. Review of the care plan initiated on 08/18/22 identified Resident #3 had the potential for pressure ulcer development related to limited physical mobility, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Care NP progress note dated 08/25/22 revealed the size of right heel pressure ulcer increased to 3.9 cm in length and 3 cm in width and 0.3 in depth with 80 % slough (moist non-viable tissue). The Wound Care NP recommended antibiotics and noted the reason as being increased drainage, odor, pain, and redness. Review of the NP progress note dated 08/25/22 revealed Resident #3 was evaluated for a right heel wound. The note revealed the Wound Care NP reported increased redness and slough with signs of possible infection. The note revealed Resident #3 had no increased pain associated to the worsening wound and remained afebrile (no fever). A wound culture and pain management were ordered. Review of the wound culture report revealed on 08/26/22 a culture was collected. The report revealed the lab received and reported the results on 08/31/22 the specimen was out of stability and no culture was obtained. An interview was conducted on 11/01/22 at 2:43 PM with the Wound Care Nurse. The Wound Care Nurse revealed she first saw Resident #3's wound on 08/17/22 and described it as an unstageable pressure ulcer with eschar (scab like dead skin either black, brown, or tan in color). She cleaned the area and covered it and notified the Wound Care NP. The Wound Care NP assessed Resident #3's pressure ulcer and provided treatment orders on 08/18/22. The Wound Care Nurse confirmed no treatment orders were in place when the wound was first identified on the admitting skin assessments on 08/09/22, 08/10/22, and 08/11/22. During an interview on 11/01/22 at 4:22 PM Nurse #1 confirmed he documented the skin assessments for Resident #3 dated 08/09/22 and 08/10/22. Nurse #1 revealed he didn't verbally report Resident #3 had an open area on the right heel and stated he documented the results on the skin assessments. Nurse #1 stated the Wound Care Nurse reviewed the weekly skin assessments therefore he didn't report the open area on Resident #3's right heel. A second interview was conducted on 11/02/22 at 12:52 PM with the Wound Care Nurse. The Wound Care Nurse revealed she did not review weekly skin assessments for residents unless a concern was communicated to her then she would and physically looked at the area. The Wound Care Nurse revealed when she became aware of the area on the right heel and after reviewing Resident #3's skin assessments she determined the wound was present upon admission. During an interview on 11/02/22 at 1:56 PM Nurse #2 confirmed she documented the skin assessment dated [DATE]. Nurse #2 revealed she would've reported her findings to the Wound Care Nurse but since Resident #3 was admitted on [DATE] and there were 2 previous assessments prior to hers she assumed treatment orders were in place. Nurse #2 revealed she checked treatment orders when she identified an open area on a Resident's skin and if not in place would notify the Wound Care Nurse. When informed no treatments were in place until 08/18/22 Nurse #2 stated something was missed. An interview was conducted with Nurse #3 on 11/02/22 at 9:52 AM. Nurse #3 confirmed she documented the weekly skin assessment for Resident #3 indicating the skin was intact on 08/15/22. Nurse #3 stated she was unsure if the skin was intact since the previous assessments identified an open area on the right heel. Nurse #3 stated she would report to the Unit Supervisor or Wound Care Nurse if a resident had an open area on the heel or skin. An interview was conducted on 11/02/22 at 11:22 AM with the Medical Doctor (MD). The MD revealed Resident #3 was at risk for the development of pressure ulcers due to predisposing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD revealed a delay in treatment would put Resident #3 at risk for developing an infection if an open area on the right heel was identified upon admission and left untreated. An interview was conducted on 11/02/22 at 3:13 PM with Nurse Aide (NA) #1. NA #1 confirmed she documented the shower audit sheet dated 08/12/22 indicating Resident #3's skin was intact and good. NA #1 revealed she documented the skin was good on 08/12/22 meaning there were no open areas or nothing new on the skin she hadn't previously observed. NA #1 stated she would report to the nurse when she identified an open area on the skin. A second interview was conducted on 11/03/22 at 8:04 AM with Nurse #1. Nurse #1 didn't recall providing a treatment to the right heel of Resident #3. Nurse #1 stated he could only recall doing the necessary paperwork for the skin assessment. During an interview on 11/03/22 at 10:40 AM the Wound Care NP revealed her first assessment on 08/18/22 Resident #3 had an unstageable pressure ulcer on her right heel. Resident #3 denied pain to area and there was no odor to indicate infection. On her next visit on 08/25/22 the pressure ulcer presented with increased redness, slough, and had an odor. With Resident #3 having pain to the area and the other changes she noted those were signs of an infection. The Wound Care NP revealed she couldn't say how long the wound was present but if an open area on the right heel was identified on the admission skin assessments and the area was left uncovered or without treatments in place that would increase the risk of a pressure ulcer becoming infected. An interview was conducted on 11/03/22 at 3:08 PM with the Director of Nursing (DON). The DON revealed she expected Nurses to notify the Wound Care Nurse, her, and the MD or NP to ensure concerns related to skin weren't missed and the area was evaluated right away. The DON revealed after her review of the admitting skin assessments she couldn't find any evidence to support the open area to the right heel was reported or a treatment was in place prior to 08/18/22. During an interview on 11/03/22 at 3:31 PM the Administrator revealed the process in place if the Nurse finds something abnormal during a resident's skin assessment, they need to call either the on-call physician or inform NP or MD so treatment orders can be put in place.

Based on record review and interviews with the staff and Medical Doctor (MD) the facility failed to notify the physician of a newly identified open area on the right heel resulting in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was discharged to the community on 08/29/22. Review of the admitting 3-day skin assessments for Resident #3 revealed on 08/09/22 and 08/10/22 Nurse #1 documented a blanchable open area was present on the right posterior heel. On 08/11/22 Nurse #2 documented a blanchable open area was present on right posterior heal. Review of Resident #3's medical records revealed no evidence or documentation the Medical Doctor (MD) or Nurse Practitioner (NP) were notified of the open area on the right heel identified on the admitting skin assessments. Review of the document titled; Weekly Pressure Wound Observation Tool dated 08/18/22 revealed the MD or NP were notified on 08/18/22 of an unstageable pressure ulcer (a wound obscured by dead tissue) on the right heel of Resident #3. Treatment orders were provided, and the note indicated the wound was acquired on 08/09/22. Review of the Wound Care NP progress note revealed on 08/18/22 an initial exam of Resident #3's right heel identified an unstageable pressure ulcer measured 2.9 cm in length and 3 cm in width and 0 cm in depth. Treatment orders were to clean the area with normal saline and apply a [MEDICATION(S)] ointment and cover with a silicone foam dressing every day and as needed. Review of the Wound Care NP progress note dated 08/25/22 revealed the size of right heel pressure ulcer increased and measured 3.9 cm in length and 3 cm in width and 0.3 in depth with 80 % slough (moist non-viable tissue). The Wound Care NP recommended antibiotics and noted the reason as being increased drainage, odor, pain, and redness. During an interview on 11/01/22 at 2:43 PM the Wound Care Nurse revealed she first saw Resident #3's wound on 08/17/22 and described it as an unstageable pressure ulcer with eschar (scab like dead skin either black, brown, or tan in color). She cleaned the wound and covered it with a dressing and notified the Wound Care NP who saw Resident #3 right heel wound on 08/18/22. The Wound Care Nurse confirmed there were no treatments in place for an open area identified on the admitting skin assessments done on 08/09/22, 08/10/22, and 08/11/22. During an interview on 11/01/22 at 4:22 PM Nurse #1 confirmed he documented the skin assessments for Resident #3 on 08/09/22 and 08/10/22. Nurse #1 revealed he didn't verbally report Resident #3 had an open area on the right heel to the MD or NP. Nurse #1 stated the Wound Care Nurse reviewed the weekly skin assessments therefore he didn't report the open area on Resident #3's right heel. An interview was conducted on 11/02/22 at 11:22 AM with the MD. The MD revealed the skin assessments done on 08/09/22, 08/10/22, and 08/11/22 identified an open area on the right heel he would expect the nurse to notify the physician, or the NP to obtain treatment orders. The MD revealed a delay in treatment would put Resident #3 at risk for developing an infection if the area on the right heel was left untreated. During an interview on 11/02/22 at 1:56 PM Nurse #2 confirmed she documented the skin assessment on 08/11/22. Nurse #2 revealed she didn't report an open area on heel of Resident #3 because there were 2 previous assessments prior to hers and the physician should've already been notified with treatment orders in place. An interview was conducted on 11/03/22 at 3:08 PM with the Director of Nursing (DON). The DON revealed she expected Nurses to notify the Wound Care Nurse, her, and the MD or NP to ensure concerns related to the skin weren't missed and the area was evaluated right away. The DON revealed after her review of the admitting skin assessments she couldn't find any evidence to support the open area to the right heel was reported or a treatment was in place prior to 08/18/22. During an interview on 11/03/22 at 3:31 PM the Administrator revealed the process in place if the Nurse finds something abnormal during a resident's skin assessment, they need to call either the on-call or inform NP or MD so treatment orders can be put in place.

Based on record review and staff interviews the facility failed to accurately assess and document an existing open area was present on the admission Minimum Data Set (MDS) for 1 of 3 residents reviewed for pressure ulcers (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admitting 3-day skin assessments for Resident #3 revealed on 08/09/22 and 08/10/22 Nurse #1 documented a blanchable open area was present on the right posterior heel. On 08/11/22 Nurse #2 documented a blanchable open area was present on right posterior heal. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was at risk but did not have any unhealed pressure ulcers or other skin conditions. Treatments included a pressure reducing device for the bed and chair. During an interview on 11/02/22 at 12:52 PM the Wound Care Nurse revealed when she became aware of the area on the right heel and after reviewing Resident #3's skin assessments she determined the pressure ulcer wound was present upon admission.

Based on record review and staff interviews, the facility failed to follow their abuse policy and procedure by not immediately reporting an allegation of resident-to-resident abuse to the Administrator for 1 of 6 sampled residents reviewed for abuse (Resident #1). Findings included: The facility policy titled, Abuse, Neglect and Exploitation implemented 11/01/20, read in part: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. All alleged violations will be reported to the Administrator within specified timeframes: Immediately, but not later than 2 hours after the allegation is made. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with intact cognition. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #2 with intact cognition. Review of the initial investigative report submitted by the facility to DHSR noted an allegation type of resident abuse involving Resident #1 and Resident #2, a cognitively intact male, on 08/29/22. Review of the facility's investigation summary revealed on 08/29/22 between 10:30 PM and 11:30 PM, Resident #1 reported she was woken from sleep by Resident #2 touching her breasts without her permission. Resident #1 told Resident #2 to leave her room, he left and Resident #1 immediately reported the incident to nursing staff. It was noted the facility was made aware of the allegation on 08/30/22 at 8:30 AM, the initial report was submitted to DHSR via fax transmission on 08/30/22 at 9:25 AM and law enforcement was notified. Resident #1 was out of the facility and unable to be interviewed at the time of this investigation. Resident #2 was discharged to another nursing facility on 09/22/22 and unable to be interviewed. During a telephone interview on 11/02/22 at 9:33 AM, Nurse Aide (NA) #2 confirmed she worked the evening of 08/29/22 and was assigned to provide Resident #1 and Resident #2's care. NA #2 could not recall the exact time but stated when she answered Resident #1's call light and went into her room, Resident #1 stated she had been asleep and woke up to Resident #2 touching her breasts. NA #2 recalled Resident #2 was not in Resident #1's room at the time and Resident #1 stated she had told him to leave. NA #2 stated she immediately reported Resident #1's statement to Nurse #1. During a telephone interview, Nurse #1 confirmed he worked the evening of 08/29/22 and was assigned to provide Resident #1 and Resident #2's care. Nurse #1 recalled around 10:30 PM to 11:00 PM, he was informed by NA #2 that Resident #1 alleged Resident #2 came into her room while she was asleep and touched her breasts. Nurse #1 stated when he spoke to Resident #1 she told him Resident #2 came into her room and was sitting on her bed, she fell asleep and woke up to Resident #2 touching her breasts. Nurse #1 stated Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 could not recall the exact time but stated he notified the Director of Nursing (DON) of the incident via text message the next morning, 08/30/22. Nurse #1 explained when the incident was reported to him on 08/29/22, he did not know an allegation of abuse was supposed to be reported to Administration immediately. During an interview on 11/03/22 at 8:15 AM, the DON confirmed she received a text message from Nurse #1 the morning of 08/30/22, sometime between 7:00 AM and 8:00 AM, while on her way to the facility. When she arrived at the facility, she immediately contacted the Administrator, placed Resident #2 on one-to-one staff supervision and an investigation was initiated. During an interview on 11/03/22 at 3:39 PM, the Administrator confirmed she was notified the morning of 08/30/22 of the resident-to-resident incident that occurred the evening of 08/29/22 involving Resident #1 and Resident #2, the initial report was submitted to DHSR and an investigation was immediately initiated. The Administrator was not sure why Nurse #1 did not contact her or the DON when the allegation was first reported to him by Resident #1 on 08/29/22 and explained all staff were previously educated on the facility's abuse policy which included reporting allegations of abuse immediately. The Administrator added all staff had since been re-educated on the abuse policy.

Based on record review and staff interviews, the facility failed to complete discharge Minimum Data Set (MDS) assessments within 14 days of the discharge date for 3 of 4 sampled residents reviewed for discharge (Residents #2, #10, and #3). Findings included: 1. Resident #2 was admitted to the facility on [DATE]. A Social Worker progress note dated 09/22/22 at 11:30 AM revealed Resident #2 discharged to another nursing facility. Review of Resident #2's medical record revealed the last completed MDS assessment was an admitted d 08/31/22. A discharge MDS assessment dated [DATE] noted a status of in progress. During an interview on 11/03/22 at 10:12 AM, MDS Coordinator #1 revealed she started her employment with the facility in October 2022. MDS Coordinator #1 confirmed a discharge MDS assessment was started for Resident #2 but had not been completed. She was not sure what had happened or how the assessment was overlooked but stated it should have been completed within 14 days of Resident #2's discharge. During an interview on 11/03/22 at 3:39 PM, the Administrator explained for a period of time the facility did not have any full-time MDS Coordinators and MDS assessments got behind. The Administrator stated when the two MDS Coordinators started last month, they prioritized the MDS assessments that needed completed, oldest first, and the discharge assessment for Resident #2 got overlooked. She added discharge MDS assessments should have been completed within 14 days of discharge. 2. Resident #10 was admitted to the facility on [DATE]. A nurse progress note dated 09/20/22 at 11:14 AM revealed Resident #10 discharged to the community. Review of Resident #10's medical record revealed the last completed MDS assessment was an admitted d 09/09/22. A discharge MDS assessment dated [DATE] noted a status of in progress. During an interview on 11/03/22 at 10:12 AM, MDS Coordinator #1 revealed she started her employment with the facility in October 2022. MDS Coordinator #1 confirmed a discharge MDS assessment was started for Resident #10 but had not been completed. She was not sure what had happened or how the assessment was overlooked but stated it should have been completed within 14 days of Resident #10's discharge. During an interview on 11/03/22 at 3:39 PM, the Administrator explained for a period of time the facility did not have any full-time MDS Coordinators and MDS assessments got behind. The Administrator stated when the two MDS Coordinators started last month, they prioritized the MDS assessments that needed completed, oldest first, and the discharge assessment for Resident #10 got overlooked. She added discharge MDS assessments should have been completed within 14 days of discharge. 3. Resident #3 was admitted to the facility on [DATE] and was discharged to the community on 08/29/22. Review of Nurse Practitioner (NP) discharge summary dated 08/26/22 revealed Resident #3 was being evaluated for discharge home. Review of the discharge Minimum Data Set (MDS) assessment for Resident #3 revealed the date of completion was 11/01/22. During an interview on 11/03/22 at 10:12 AM, MDS Coordinator #1 revealed she started her employment with the facility in October 2022. MDS Coordinator #1 confirmed a discharge MDS assessment was completed for Resident #3 on 11/01/22. She stated the discharge MDS assessment should have been completed within 14 days of Resident #3's discharge from the facility. During an interview on 11/03/22 at 3:39 PM, the Administrator explained there was a period of time the facility did not have any full-time MDS Coordinators and MDS assessments got behind. The Administrator stated when the two MDS Coordinators started last month, they prioritized the MDS assessments that needed completed, oldest first, and the discharge assessment for Resident #3 got overlooked. She added discharge MDS assessments should have been completed within 14 days of discharge.

Based on record review and interviews with the staff and the Medical Director, the facility failed to discontinue the previous physician's order for obtaining capillary blood glucose (CBG) testing when a new physician's order was entered for 1 of 1 resident reviewed for professional standards (Resident #2). The findings included: Resident #2 was admitted on [DATE] and discharged on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact for daily decision making and was dependent for bed mobility, transfers, toileting, and personal hygiene. The MDS also indicated he received daily insulin injections. Resident # 2's care plan dated 11/18/2022 revealed a care plan for diabetes with interventions including administering diabetes medication as ordered and checking capillary blood glucose (CBG) as ordered by the physician. Review of Resident #2's Physician's orders revealed an order dated 12/1/2021 for CBG testing twice daily. On 12/6/2021 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Both orders were active at the time of his discharge on 3/30/2022. Resident # 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Regional Clinical Director on 7/20/2022 at 1:00PM. She stated the CBG order from 12/1/2021 for twice daily CBG testing should have been discontinued when the Medical Director entered a new order on 12/6/2021 for every other day testing. In an interview on 7/20/2022 at 6:56 PM the Medical Director stated that in general when a new order is entered it is expected that the previous order is discontinued. He also stated that on 12/6/2021, when he entered the order for every other day CBG testing, the previous order for twice daily CBG testing should have been discontinued. He stated there was a flaw in the electronic medical record software and the system and when a new order for CBG's is entered the previous order should be discontinued automatically. In an interview on 7/20/2022 at 7:20 PM the Administrator stated the twice daily CBG testing order from 12/1/2021 should have been discontinued when the Medical Director entered a new order for every other day CBG testing on 12/6/2021. She also stated new orders were reviewed in the facility morning meeting and the duplication should have been detected and clarified at that point.

Based on record review and interviews with staff the facility failed to include documentation in the resident's medical record to reflect education was provided regarding the benefits and potential side effects associated with vaccines; and failed to include if vaccination was refused or contraindicated for 1 of 5 residents reviewed for COVID-19 vaccination status (Resident #1). The findings included: Review of the facility's policy titled, COVID-19 Vaccination-Resident revised on 03/30/22 read in part: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering residents the COVID-19 vaccine. The facility's policy revealed the resident's medical record was to include the following documentation: education provided to the resident or the resident's representative regarding the risk, benefits, and potential side effects of the vaccine; each dose of the vaccine administered; or if the resident did not receive the vaccine due to medical contraindication or refusal. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was severely impaired. Review of Resident #1's medical records revealed no immunization documentation was included to reflect the Responsible Party (RP) or resident were provided education on the benefits and potential side effects of administering the COVID-19 vaccines or if the vaccine was contraindicated, administered, or refused. An interview was conducted with Regional Director of Clinical Services (RDCS) on 07/20/21 at 4:28 PM. The RDCS stated the medical records should contain documentation to reflect the status of Resident #1's immunizations. The RDCS revealed it was the admitting nurse's responsibility to offer and get consents for the COVID-19 vaccine. An interview was conducted with the designated Infection Preventionist (IP)/Staff Development Coordinator (SDC) on 07/21/22 at 1:34 PM. The IP/SDC revealed he worked fulltime at the facility and was new to the IP position. The IP/SDC revealed he was not the designated IP when Resident #1 was readmitted to the facility and had not followed up on the resident's vaccination status. An interview was conducted with the Administrator on 07/21/22 at 3:11 PM. The Administrator confirmed the medical records did not contain information related to the status of Resident #1's COVID-19 vaccination to reflect education, contraindication, consent, or refusal were obtained or provided by the facility. The Administrator revealed she had attempted several times to contact Resident #1's RP to obtain information related to the COVID-19 vaccine but was unsuccessful. The Administrator revealed the Leadership Team shared the task of obtaining vaccination consents including COVID-19 and the IP, Director of Nursing, and herself oversaw the Infection Prevention Program including the status of vaccinations. The Administrator revealed the COVID-19 vaccination status should be included as part of Resident #1's medical record.

Based on record review and interviews with staff the facility failed to include documentation in the resident's medical record to reflect education was provided regarding the benefits and potential side effects of receiving the influenza and pneumococcal vaccines and failed to include why vaccines were not administered for 1 of 5 residents reviewed for immunizations (Resident #1). The findings included: Review of the facility's policy titled, Infection Prevention and Control Program revised on 10/27/20 revealed the designated Infection Preventionist (IP) was responsible for oversight of the program. The section of the policy titled, Influenza and Pneumococcal Immunizations read in part: Residents would be offered the influenza vaccine each year between October 1st and March 31st, unless contraindicated or received the vaccine elsewhere during this time. Residents would also be offered the pneumococcal vaccines recommended by the Center for Disease Control and Prevention (CDC) upon admission unless contraindicated or received the vaccine elsewhere. Education would be provided to residents and or representatives regarding the benefits and potential side effects of the immunization prior to offering the vaccines. Residents have the opportunity to refuse the immunizations. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations. Resident #1 was readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was severely impaired. The MDS also indicated the influenza vaccine was not received this season and the pneumococcal vaccine was not up to date. The reasons provided on the MDS revealed neither of the vaccines were offered. Review of Resident #1's medical records revealed no immunization documentation was included to reflect the Responsible Party or resident were provided education on the benefits and potential side effects of administering the influenza and pneumococcal immunizations. There was no documentation to reflect the influenza vaccine was contraindicated, administered, or refused during the influenza season from October 2021 through March 2022. There was no documentation to indicate the pneumococcal immunization was contraindicated, administered, or refused upon admission. An interview was conducted with Regional Director of Clinical Services (RDCS) on 07/20/21 at 4:28 PM. The RDCS stated the medical records should contain documentation to reflect the status of Resident #1's immunizations. The RDCS revealed it was the admitting nurses responsibility to offer and get consents for the influenza and pneumococcal immunizations. An interview was conducted with the designated Infection Preventionist (IP)/Staff Development Coordinator (SDC) on 07/21/22 at 1:34 PM. The IP revealed he worked fulltime at the facility and was new to the IP position. The IP/SDC revealed he was not the designated IP during the last influenza season when Resident #1 was admitted to the facility. An interview was conducted with the Administrator on 07/21/22 at 3:11 PM. The Administrator confirmed the medical records for Resident #1 did not contain documentation to reflect education, consent, or refusal were received for either the influenza or pneumococcal vaccines. The Administrator revealed the members of the Leadership Team were assigned residents based on room numbers and were to collect consent forms for immunizations to ensure those were completed. The Administrator stated Resident #1 had frequently changed rooms since her admission and was unable to identify who was responsible for ensuring the documentation for immunizations was offered. The Administrator also revealed the IP/SDC, the Director of Nursing and herself oversaw the Infection Prevention Program including vaccination status.

Based on record review and staff interviews the facility failed to protect a resident right to be free from abuse (Resident #55) from Nurse Aide (NA) #8 for 1 of 3 residents reviewed for abuse. The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was severely cognitively impaired and was totally dependent for majority of activities of daily living (ADL). The MDS further revealed Resident #55 was coded for physical and verbal behaviors directed toward others 1 to 3 days a week through the look back period. Review of the incident report dated 8/28/21 revealed Resident #55 was witnessed getting struck in the stomach by nursing staff during care. Resident #55 did not observe to sustain any injuries after the incident. Review of the investigation completed by the Administrator related to Resident #55's incident revealed the following: - Nurse Aide (NA) #5 statement dated 8/28/21 read in part, NA #8 and I went into Resident #55's room to change him and his bed sheets. While NA #8 and I were changing Resident #55 he began to curse and hit NA #8. NA #8 then slapped Resident #55 on his stomach, and Resident #55 continued to hit NA #8. I then turned around to grab Resident #55 pillow and heard NA #8 get loud with Resident #55 and hit Resident #55 again and when I turned around NA #8 hand was balled in a fist. - Nurse Aide (NA) #8 statement dated 8/28/21 read in part, I went into Resident #55's room to change him with NA #5. Resident #55 was soaked so we had to do a complete bed change and change Resident #55's shirt. Resident #55 was fine the first half then as we had to keep rolling Resident #55, he got more and more aggravated cussing and grabbing at stuff. Resident #55 grabbed my left arm and dug his fingernails in my skin. Before he could break skin, I grabbed his hand to remove it and I got my flat hand pushed it away. Resident #55 grabbed me on my left arm, and I grabbed his hand with my right hand to pull it off then turned my wrist to finish pushing his hand away towards his stomach. I think in the moment I might have had a little too much force and accidently with flat hand barely popped Resident #55 in the belly. I was blocking then Resident #55 punched me in the right arm and I finished fastening his brief, pulled blanket up, grabbed dirty linen and trash, and walked out. - Review of investigative actions dated 8/28/21 revealed employment actions taken was NA #8 was asked to not return to the facility. The facility notified the Medical Director, resident's responsible party, and suspended identified potential suspected perpetrator until investigation was complete. A phone interview conducted with Nurse Aide (NA) #5 on 11/22/21 at 3:10 PM revealed she and NA #8 was giving care to Resident #55 and Resident #55 became aggravated and combative. NA #5 observed NA #8 slapped Resident #55 in the stomach with the back side of her hand and it made a popping sound. NA #5 indicated Nurse #8 continued to give care and shouted to Resident #55 in a loud tone to stop. NA #5 revealed Resident #55 had quit being combative at this time and NA #5 turned her back away from Resident #55 to get a sheet and heard a pop sound and turned to find NA #8 fist balled up like she had punched the resident. NA #5 and NA #8 completed care and left Resident #55's room. NA #5 stated she was training with NA #5 and was educated by other staff members if Resident #55 was combative to step away. NA #5 indicated she was in shock when NA #8 struck at Resident #55 during care and did not know what to do. NA #5 stated she reported the incident to Nurse #8 immediately after leaving the Resident #55 room. A phone interview conducted with NA #8 on 11/19/21 at 10:20 AM revealed she had worked with Resident #55 multiple times and was aware he could be combative during care. It was further revealed NA #8 and NA #5 was giving care to Resident #55 and he became aggravated slapping at NA #8. NA #8 put up her arm blocking Resident #55 and pushed it away. NA #8 indicated Resident #55's arm could have swung back and hit him but could not recall. NA #8 revealed she continued to give care and Resident #55 grabbed NA #8 arm and NA #8 jerked away. NA #8 revealed she jerked away but denied hitting or speaking to Resident #55 in a loud tone. Na #8 indicated she was educated by upper management if Resident #55 had become combative or agitated to rush through care. NA #8 stated he had a bad day and was aggravated but denies hitting or speaking to Resident #55 in a loud tone. An interview conducted with Nurse #8 on 11/19/21 at 11:40 AM revealed NA #5 reported that NA #8 was frustrated when giving care to Resident #55 because the resident had become combative. Nurse #8 further revealed NA #5 witnessed NA #8 hit Resident #55 in the stomach and when NA #5 had turned away and turned back NA #8 had her fist in a ball. Nurse #8 indicated Resident #55 was sometimes combative, but nursing staff was educated to step away and let Resident #55 calm down. Nurse #8 completed a body check and checked for markings all over Resident #55 and did not observe any marks or bruises. Nurse #8 stated she contacted the DON right after the incident occurred. An interview was conducted with the Director of Nursing (DON) on 11/19/21 at 2:53 PM revealed Nurse #8 contacted her right after the incident occurred, and the DON contacted the Administrator immediately. The DON indicated Resident #55 was combative at time with care, but nursing staff was educated to step away to deescalate the situation. The DON further revealed she had no prior issues with NA #8 and feels that she did not hit Resident #55. An interview conducted with the Administrator on 11/19/21 at 1:08 PM revealed Resident #55 could be combative during care, but staff was educated to stay calm and back away if they need too. It was further revealed when the incident was reported by the DON she immediately went to the facility to investigate. The Administrator indicated she spoke to all staff involved and did not substantiate because it was he said she said, and Resident #55 sustained no injuries. The Administrator revealed NA #8 was asked to not come back and work until the investigation was over.

Based on record reviews, resident, staff, former Nurse Practitioner (NP) and Medical Director interviews, the facility failed to prevent a medication error by not administering [MEDICATION(S)] (a mood stabilizer medication that works in the brain) to a resident (Resident #12) for four consecutive days resulting in increased anxiety for the resident and feeling of being all to pieces without the medication. The findings included: Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact for daily decision making and was on antianxiety and antidepressant medications daily. Review of a psychotherapy progress noted dated 08/04/21 revealed the following under patient objective quote: They ran out of my [MEDICATION(S)] again. I'm all to pieces. The note further revealed under patient reports and progress observed: Patient was assured this provider would consult with Nurse Practitioner (NP) to assist the patient to access her medication in a timely manner. NP was consulted and she stated she would attempt to source the medication from a local pharmacy to assist the patient. Review of a [MEDICATION(S)] lab drawn on 11/08/21 and reported on 11/09/21 revealed a [MEDICATION(S)] level of 0.50 millimoles per liter (mmol/L) with a therapeutic range of 0.50 to 1.20. Review of Resident #12's care plan dated 11/13/21 revealed a plan of care for impaired cognitive function/impaired thought processes related to unspecified [CONDITION(S)] disorder. The interventions included administer medications as ordered and monitor/document for side effects and effectiveness. Observation and interview on 11/18/21 at 2:45 PM revealed Resident #12 in her wheelchair attending the Resident Council meeting. Resident #12 stated she had missed 4 days of her [MEDICATION(S)] about 3 to 4 months ago. Resident #12 further stated being without her [MEDICATION(S)] made her feel crazy and said she knew she acted different. Review of Resident #12's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's nursing progress notes revealed notes written on 07/30/21, 07/31/21, and 08/01/21 indicating awaiting arrival of medication. Interview on 11/19/21 at 10:14 AM with Nurse #2 assigned to care for the resident on 07/31/21 and 08/01/21 revealed Resident #12 was out of her [MEDICATION(S)] those days and it was not given. Nurse #2 stated usually if medication is ordered before 5:00 PM it was delivered the evening on the same day. She further stated sometimes they had to call several days to get medications and it just depended on the medication as to how long it would take to be delivered. Nurse #2 indicated she was not aware if there was a contract with a local pharmacy for emergency dispensing of medications. She stated the resident was on [MEDICATION(S)] and took 3 capsules daily. According to Nurse #2 she remembered calling about the [MEDICATION(S)] both days she worked but couldn't recall if the pharmacy had received the original refill request so she stated she sent the refill request again for the [MEDICATION(S)]. Nurse #2 indicated she remembered Resident #12 being upset at the time and anxious but said she was not sure if it was because she had not taken her meds or because her room was being changed. Phone interview on 11/19/21 at 10:54 AM with the former NP for the facility revealed she recalled the psychotherapist had called her because she was concerned about Resident #12 not receiving her [MEDICATION(S)]. The NP further revealed the psychotherapist was concerned if the resident did not get her [MEDICATION(S)], she could easily decompensate so the NP stated she called the pharmacy directly and the medication was delivered. The NP agreed that it could be concerning for the resident to decompensate if she did not receive her [MEDICATION(S)] and it was not ideal for her to go days without the [MEDICATION(S)]. Phone interview was attempted with the Psychotherapist, but she was out of the country and could not be reached. Phone interview on 11/19/21 at 1:00 PM with the Medical Director (MD) revealed Resident #12 missing doses of her [MEDICATION(S)] was familiar and remembered the resident mentioning to him her medication had run out but could not recall if the facility had notified him of the resident missing 4 consecutive doses. The MD stated in an unstable resident missing 4 consecutive doses of [MEDICATION(S)] could potentially present a problem but said Resident #12 was stable and had been on the medication for a long time. He further stated he was not terribly concerned about her missing the doses of [MEDICATION(S)] but said he would prefer residents received their medications as ordered.

Based on observations, record reviews, and interviews with residents and staff, the facility failed to maintain sufficient nursing staff to assure preferred choices were honored for showers and transfer in and out of bed; failed to assure dependent residents received weekly bathing and timely assistance with incontinence care, nail care, and grooming for 12 of 22 residents reviewed for dignity and respect, choices, and activities of daily living (Resident #7, Resident #8, Resident #9, Resident #13, Resident #23, Resident #26, Resident #27, Resident #45, Resident #50, Resident #54, Resident #81, and Resident #82). The findings included: This tag was cross-referred to: F-550: Based on record reviews, observations, staff interviews, and resident interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, and incontinence care resulting in residents feeling like a homeless person, like staff did not like them, dirty and embarrassed, uncomfortable, and dirty. This affected 3 out of 6 (Resident #27, Resident #13, and Resident #50) sampled residents. F-561: Based on observations, record review and resident, family, and staff interviews, the facility failed to provide residents with their preference for a shower instead of a partial bed bath (Residents #7 and #9) and accommodate resident requests to be assisted to and from bed when requested (Residents #27 and #8) for 5 of 14 residents reviewed for choices. F-677 Based on record reviews, resident, and staff interviews the facility failed to provide showers or complete bed baths for 6 of 18 residents (Resident #27, Resident #26, Resident #81, Resident #82, Resident #13, and Resident #50) and failed to provide nail care and grooming for 3 of 18 residents (Resident #54, Resident #23, and Resident #45) reviewed for activities of daily living (ADL). Resident #27 stated because of not getting her showers, her hair was matted to her head, and she could smell her own body odor and it made her feel degraded and like a homeless person. During an interview on 11/15/21 at 3:20 PM Nurse #9 explained she had approximately 26 residents and was working with NA #9 who had the same assignment. Nurse #9 stated weekend staffing was harder due to no support help from the management team who help pass meal trays, answer call lights and the phone. Nurse #9 revealed agency staff picked up what they want and usually don't want the weekend shift. During an interview on 11/15/21 at 3:38 PM NA #9 revealed her assignment included 5 residents needing total assistance using a mechanical lift, 1 resident needing total assistance with feeding and 10 residents that were incontinent. NA #9 revealed her assignment was to provide care for approximately 26 residents and she hadn't been able to provide residents with their scheduled showers at this time. An interview was conducted on 11/17/21 at 9:40 AM with the Staffing Scheduler (SS). The SS revealed he judged the number of nursing staff needed based on the number of residents, their acuity and/or complexity of care needs discussed with him during meetings with the Interdisciplinary Team. The SS stated there were days the facility was short of nursing staff and one Nurse Aide (NA) would be assigned to provide care for 20 or more residents. The SS revealed residents have told him they didn't get a shower and he tried to ensure it would be done that day or the next. The SS used multiple agency staffing companies and his goal was to have 5 nurses working the day shift and 4 for the evening shift and 3 for the night shift. The SS revealed the goal for NA staff was to have 6 working during the day and evening shifts and 5 working on the night shift. The SS revealed the facility census hovered around 90 residents and if he couldn't find staff coverage leadership personnel came in to cover the shift and were on call 24 hours 7 days a week. The SS revealed the facility offered $50 or $100 bonuses for staff who pick up shifts and a list of shifts needing coverage was provided to nursing staff. During an interview on 11/22/21 at 3:45 PM the Director of Nursing (DON) revealed there had been times the facility was short of staff. Bonuses were provided when staff come in to cover shifts and the SS, Unit Manager, and herself have covered when unable to find coverage. The DON explained the hiring process was ongoing, and the facility was actively trying to recruit new staff and offered sign-on bonuses but was hit or miss with applicants and the facility was doing their best to get positions filled. During an interview on 11/22/21 at 4:12 PM the Administrator revealed she received reports from staff they couldn't get their work completed or showers done due to working short staffed. The Administrator revealed the facility currently worked with 5 different staffing agencies to supplement the schedule but there were times when call outs occurred and nursing worked short of staff. Bonuses were offered when staff pick up shifts but if unable to get anyone to cover, the Administrator revealed she would come in and help out on the floor as a Personal Care Aide along with other administrative staff and understood staffing was a concern and stated they were doing the best they could with staffing.

Based on record reviews, resident, and staff interviews the facility failed to provide showers or complete bed baths for 6 of 18 residents (Resident #27, Resident #26, Resident #81, Resident #82, Resident #13, and Resident #50) and failed to provide nail care and grooming for 3 of 18 residents (Resident #54, Resident #23, and Resident #45) reviewed for activities of daily living (ADL). Resident #27 stated because of not getting her showers, her hair was matted to her head, and she could smell her own body odor and it made her feel degraded and like a homeless person. The findings included: 1. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's most recent quarterly MDS dated [DATE] revealed she was cognitively intact for daily decision making, had no behaviors for refusal of care, and required total assistance of 2 staff for bathing. Review of Resident #27's care plan dated 11/11/21 revealed a plan of care for ADL self-care performance deficit related to debility, disease process, fatigue, chronic respiratory failure and pain. The interventions included the resident requires extensive assistance of 2 staff with bathing/showering on preferred shower days and as necessary, the resident requires extensive assistance of 1 staff with personal hygiene and oral care, the resident requires total assistance of 2 staff to move between surfaces as necessary and monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course or declines in function. Observation and interview on 11/15/21 at 2:38 PM of Resident #27 revealed her lying in bed in her room watching her TV. Resident #27 stated she had a shower yesterday and it was the first one she had in 3 weeks. Resident #27 further stated her hair was matted to her head and she could smell her own body odor and it made her feel degraded and like a homeless person. Resident #27 indicated there was not enough staff at the facility to properly care for the residents and make sure their needs were met. Review of the master shower schedule revealed Resident #27 was scheduled for showers on Sunday and Wednesday on 2nd shift (3:00 PM to 11:00 PM or 7:00 PM to 7:00 AM). Review of the documented bathing for Resident #27 August through November 2021 revealed the following: ·August: 08/04/21 (SH), 08/09/21 (SH), 08/19/21 (SH), 08/20/21 (SH) 08/21/21 (BB), 08/24/21 (SH), 08/27/21 (BB) and 08/30/21 (BB) and there were 2 missed showers/bed baths that were not documented as completed. ·September: 09/08/21 (BB), 09/10/21 (SH), 09/28/21 (SH) and 09/30/21 (BB) and there were 6 showers/bed baths that were not documented as completed. ·October: 10/25/21 (SH) and 10/26/21 (BB) and there were 7 missed showers/bed baths that were not documented as completed. ·November: 11/14/21 (SH) and there were 3 missed showers/bed baths that were not documented as completed. Interview on 11/18/21 at 11:16 AM with Nurse Aide (NA) #1 revealed Resident #27 required 2 staff to transfer her in and out of bed but once in the shower room she could be assisted by one staff member. NA #1 stated there were only 2 NAs on the hallway and they usually had 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. NA #1 further stated residents had not been receiving their showers as scheduled because it was all they could do to keep them clean, dry, and safe. Interview on 11/18/21 at 1:45 PM with NA #2 revealed Resident #27 has missed showers and bed baths due to the workload of the NAs. NA #2 stated Resident #27 required 2 staff to get her on the shower bed and into the shower room which took both NAs off the floor for a period of time. NA #2 further stated when she was in the shower the NA assigned to her had to remain with her through the entire shower which left only one NA on the floor for the rest of the 30 plus residents. NA #2 indicated it was impossible to get all the showers done due to staffing. Interview on 11/18/21 at 3:38 PM with Nurse #1 revealed Resident #27 had missed showers/bed baths due to the number of residents the NAs had to provide care. Nurse #1 stated it was impossible for 2 NAs to do showers, vitals, turning and repositioning and incontinence care for 18-20 residents each and be able to complete their work and documentation. Nurse #1 further stated the nurses were so busy with medications, orders and required charting that it was difficult for them to provide any assistance to the NAs with resident care. Interview on 11/19/21 at 3:32 PM with the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's most recent admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact for daily decision making and displayed no behaviors for refusal of care. The resident's MDS also revealed bathing coded as not being provided; however, the resident required total assistance of 1 to 2 staff members with all ADL except eating. Review of Resident #26's care plan dated 09/28/21 revealed a plan of care for ADL self-care deficit related to activity intolerance, disease process, impaired balance, impaired mobility and generalized weakness. The interventions included the resident required total assistance of 2 staff with personal hygiene, oral care, and bathing, praise all efforts at self-care, monitor/document/report any changes, any potential for improvement, reasons for self-care deficit, expected course or declines in function, encourage resident to participate to the fullest extent possible with each interaction. Review of a wound note dated 11/11/21 written by the wound care Nurse Practitioner (NP) read in part: Treatment recommendations: #1 Moisture associated skin damage (MASD) buttocks bilaterally - instruction: shower 3 times weekly, no brief while in bed. Apply antifungal and skin prep barrier two times daily (bid). Keep buttocks area clean and dry. Recommend no briefs in bed and optimize nutrition. Plan of care discussed with facility staff. Observation and interview on 11/15/21 at 2:09 PM with Resident #26 revealed he was not getting bathed as often as he should and had missed some baths since being admitted to the facility. The resident stated the facility was not equipped with a shower chair or bed to accommodate his size. The facility had told Resident #26 they were looking into getting a shower bed to accommodate his height but said he was not aware a shower bed had been purchased. Observation on 11/17/21 at 10:30 AM with the wound care Nurse Practitioner and wound treatment nurse of Resident #26's area on his buttocks revealed areas on both buttocks that were red and not open. As the resident was turned over there was stool on the resident's skin and on his draw sheet. The NP asked the wound treatment nurse if the resident was due for a shower on 11/17/21 and the wound care nurse responded she did not know but would check the schedule. The NP after removing her gloves and sanitizing her hands put on the resident's call light so he could be cleaned. The NP commented the wounds looked better and seemed to be healing but it was important for staff to keep the area clean and dry. Review of the master shower schedule revealed Resident #26 was scheduled for showers on Tuesdays and Fridays on day shift (7:00 AM to 3:00 PM or 7:00 AM to 7:00 PM). Review of the documented bathing for Resident #26 for September through November 2021 revealed the following: ·September: 09/01/21 shower (SH), 09/07/21 bed bath (BB), 09/08/21 (BB), 09/10/21 (SH), 09/20/21 (BB) and 09/28/21 (SH) and there were 4 missed showers/bed baths that were not documented as completed. ·October: 10/15/21 (BB) and 10/26/21 (BB) and there were 7 missed showers/bed baths that were not documented as completed. ·November: 11/09/21 (BB) and 11/12/21 (BB) and there were 2 missed showers/bed baths that were not documented as completed. Interview on 11/17/21 at 3:58 PM with Nurse Aide (NA) #3 revealed she was not aware Resident #26 had physician ordered showers three times weekly. NA #3 stated Resident #26 received bed baths because he was too long or too tall for the shower bed and was afraid it would not support him in the shower room to get a shower. NA #3 further stated the facility was supposed to be getting another shower bed that would support him so he could get the showers he preferred but said she had not seen it yet. NA #3 indicated it was impossible to get all the showers done with only 2 NAs on the hall. Interview on 11/17/21 at 4:41 PM with NA #4 revealed she was not aware Resident #26 had physician ordered showers three times weekly. NA#4 stated Resident #26 was difficult to get into the shower room and was not comfortable with the shower chair or shower bed the facility currently had for residents. NA #4 further stated Resident #26 was receiving bed baths instead of showers but was only scheduled for 2 per week. NA #4 indicated the facility was supposed to be purchasing a shower bed to accommodate Resident #26 but said it had not been brought to their attention that the bed had been delivered to the facility. She further indicated she was not sure how they would be able to provide Resident #26 3 bed baths or shower per week because it was impossible to get all the showers done with only 2 NAs on the hallway. Interview on 11/18/21 with Nurse #1 revealed she was not aware Resident #26 had physician ordered showers three times weekly. Nurse #1 stated Resident #26 was afraid to get up in the shower chair or onto the shower bed at the facility because he didn't think the chair or bed would support him due to his size. Nurse #1 further stated showers three times weekly were not possible and the NP probably needed to re-evaluate the order. Nurse #1 indicated the staff was having a hard time even getting 2 showers done on residents each week and 3 showers may not be possible especially for Resident #26 because it took 2 staff to provide his bed bath. Interview on 11/19/21 at 3:32 PM with the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident ' s shower on their scheduled day, she expected the NAs to let the resident know and provide them a make up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 3. Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's most recent admission MDS dated [DATE] revealed he was cognitively intact for daily decision making, communicated via a dry erase board, and required extensive to total assistance with all activities of daily living (ADL). Review of Resident #54's care plan dated 10/05/21 revealed a plan of care for ADL self-care performance deficit related to activity intolerance, external devices, fatigue, impaired balance, limited mobility and pain. The interventions included the resident required extensive assistance by 1 to 2 staff with bathing/showering on preferred shower days and as necessary, the resident requires extensive assistance by 1 to 2 staff with personal hygiene and oral care, encourage resident to use bell to call for assistance, resident requires a white board to communicate and ensure availability and functioning of adaptive communication equipment and monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function. Observation and interview on 11/15/21 at 10:47 AM revealed Resident #54 lying in bed with head of bed elevated 45 degrees. The resident was able to shake his head to yes/no questions and mouthed he was not feeling well today. There was a white board with dry erase markers available on his overbed table to enable him to communicate with staff. It was noted he had written on his board I would please like for my fingernails to be trimmed. Observation of his fingernails revealed they were ¼ to ½ inch beyond the end of his fingers. There was a message written across the room on another white board for staff to please provide oral care. Observation and interview on 11/16/21 at 10:34 AM revealed Resident #54 with the message about his fingernails still on his white board and his fingernails remained ¼ to ½ inch beyond the end of his fingers. Resident once again mouthed he was not feeling well today. Interview on 11/17/21 at 3:58 PM with NA #3 revealed had not noticed the message on Resident #54's white board about wanting his fingernails trimmed. NA #1 stated since he had diabetes, the NAs were not allowed to trim his nails but said she had not reported the message to the nurse assigned to the resident. Observation and interview on 11/18/21 at 10:29 AM revealed Resident #54 resting in bed. He mouthed he finally got his nails trimmed and mouthed in a whisper they felt much better since being trimmed. Interview on 11/18/21 at 11:16 AM with NA #1 revealed had not noticed the message on Resident #54's white board about wanting his fingernails trimmed. NA #1 stated since he had diabetes, the NAs were not allowed to trim his nails, but the nurse would be able to trim them. Interview on 11/18/21 at 1:45 PM with NA #2 revealed had not noticed the message on Resident #54's white board about wanting his fingernails trimmed. NA #2 stated would not be able to trim his nails because the resident had diabetes but stated the nurse would be able to trim them. NA #2 further stated had not reported the message on the board to the nurse or noticed the resident's fingernails. Interview on 11/18/21 at 3:38 PM with Nurse #1 revealed she had not noticed the message on his white board about wanting his fingernails trimmed but stated the wound care nurse had brought it to her attention after she saw it and had trimmed his nails. Interview on 11/19/21 at 3:32 PM with the Director of Nursing (DON) revealed nail care was to be provided to residents on shower days and as needed. The DON stated she would have expected someone to have looked at the message on the white board and provided Resident #54 nail care as soon as the note was written. The DON further stated it was her expectation that resident's nails be checked on every shower day and be trimmed and filed as needed or requested. 4. Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #82 had severe impairment in cognition for daily decision making and required total assistance of 1 staff member with bathing. Review of Resident #82's care plans, last reviewed/revised on 11/17/21, revealed a plan of care that addressed an ADL self-care performance deficit related to activity intolerance, fatigue and was at risk for changes and decline in functional status related to the disease process. Interventions included extensive assistance by 1 to 2 staff members with bathing/showering on preferred shower days and as necessary, personal hygiene and oral care, and moving between surfaces as necessary. Review of the master shower schedule revealed Resident #82 was to receive showers on Wednesday and Saturday on the evening shift during the hours of 3:00 PM to 11:00 PM or 7:00 PM to 7:00 AM. Review of the Nurse Aide (NA) bathing documentation reports for Resident #82 for the months of October 2021 and November 2021 revealed the following: · October: Partial bed baths were documented as provided on 10/02/21, 10/03/21, 10/04/21, 10/05/21, 10/07/21, 10/08/21, 10/13/21, 10/14/21, 10/16/21, 10/22/21, 10/23/21, 10/24/21, 10/27/21, and 10/28/21. Showers were documented as provided on 10/11/21, 10/15/21, 10/25/21, 10/26/21, and 10/30/21. · November: Partial bed baths were documented as provided on 11/01/21, 11/02/21, 11/04/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, and 11/11/21. Showers were documented as provided on 11/13/21 and 11/17/21. Review of the nurse progress notes for the months of October 2021 and November 2021 revealed no entries related to Resident #82 refusing bathing assistance. During an interview on 11/18/21 at 11:16 AM, NA #1 revealed Resident #82 required staff assistance with bathing needs and on occasion, would refuse to take a shower. NA #1 revealed if the documentation stated partial bed baths were provided that meant he only cleaned the underarms and the genital and buttock areas. NA #1 confirmed resident showers were not being provided as scheduled and explained there were only 2 NAs assigned to Resident #82's hall with 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. During an interview on 11/18/21 at 1:45 PM, NA #2 stated when there were only 2 NAs assigned to Resident #82's hall with 19 to 20 residents each, he wasn't able to provide resident showers as scheduled. NA #2 revealed he had not provided Resident #82 with a shower during the months of October 2021 and November 2021; however, in lieu of a shower, he provided him with a partial bed bath which he described as lathering with soap and water and washing the hair, face, and neck. NA #2 stated Resident #82 wanted to take a shower and would be cooperative with taking one if the NAs had time to provide. During an interview on 11/19/21 at 3:32 PM, the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 5. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #81's care plans, last reviewed/revised on 09/01/21, revealed a plan of care that addressed an ADL self-care performance deficit related to activity intolerance, [CONDITION(S)] disease, impaired balance and limited mobility. Interventions included extensive assistance by 1 to 2 staff members with bathing/showering on preferred shower days and as necessary. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #81 had intact cognition and required extensive assistance of one staff member with bathing. Review of the master shower schedule revealed Resident #81 was to receive showers on Monday and Thursday on the day shift during the hours of 7:00 AM to 3:00 PM or 7:00 AM to 7:00 PM. Review of the Nurse Aide (NA) bathing documentation for Resident #81 for the months of October 2021 and November 2021 revealed the following: · October: Partial bed baths were documented as provided on 10/02/21, 10/05/21, 10/07/21, 10/08/21, 10/11/21, 10/12/21, 10/14/21, 10/15/21, 10/16/21, 10/22/21, 10/23/21, 10/24/21, 10/26/21, 10/27/21, and 10/28/21. Showers were documented as provided on 10/01/21, 10/13/21, 10/25/21, and 10/30/21. · November: Partial bed baths were documented as provided on 11/01/21, 11/02/21, 11/04/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, and 11/11/21. A shower was documented as provided on 11/16/21. Review of the nurse progress notes for October 2021 and November 2021 revealed no entries related to Resident #81 refusing bathing assistance. During an interview on 11/15/21 at 2:44 PM Resident #82 stated he needed staff assistance with bathing but it was hard to get help from staff. Resident #81 added he would like to have a shower but hadn't had one in 8 days. During an interview on 11/18/21 at 11:16 AM, NA #1 revealed Resident #81 never refused bathing assistance and would take a shower every day if he could. NA #1 revealed if the documentation stated partial bed baths were provided that meant he only cleaned the underarms and the genital and buttock areas. NA #1 confirmed resident showers were not being provided as scheduled and explained there were only 2 NAs assigned to Resident #81's hall with 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. During an interview on 11/18/21 at 1:45 PM, NA #2 stated when there were only 2 NAs assigned to Resident #81's hall with 19 to 20 residents each, he wasn't able to provide resident showers as scheduled. NA #2 revealed he had not provided Resident #81 with a shower during the months of October 2021 and November 2021; however, in lieu of a shower, he provided him with a partial bed bath which he described as lathering with soap and water and washing the hair, face, and neck. NA #2 stated Resident #81 wanted to take a shower and would be cooperative with taking one if the NAs had time to provide. During an interview on 11/19/21 at 3:32 PM, the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 6. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact and required physical assistance of one person for bathing and transfers. Review of the shower schedule revealed Resident #13 was scheduled for showers on Tuesday and Fridays during evening shift. Resident #13's shower schedule for October and November 2021 revealed a shower or bath was not documented as given on 10/1/21, 10/5/21, 10/12/21, 10/19/21, 10/22/21, 11/5/21, and 11/12/21. An observation was conducted on 11/15/21 at 10:35 AM revealed Resident #13 hair appeared to be oily and unbrushed. An interview conducted with Resident #13 on 11/15/21 at 10:37 AM revealed multiple showers had been missed the last two months due to staff quitting. Resident #13 further revealed her shower schedule was on Tuesday and Fridays but stated she rarely received a bed bath or shower on her scheduled days. An interview conducted with Nurse Aide (NA) #2 on 11/18/21 at 1:32 PM revealed there has not been enough staff to complete showers as scheduled in the past few months. NA #2 further revealed they had worked evening shifts multiple times and Resident #13 had not received a shower or bath because there was a staff shortage. NA #2 indicated that showers and baths had been missed often. An interview conducted with Nurse #1 on 11/18/21 at 2:44 PM revealed Resident #13 had never refused showers or care. Nurse #1 further revealed Resident #13's scheduled showers and baths had been missed due to not having enough staff during evening shifts. Nurse #1 stated she had worked evening shifts multiple times and it was hard to give 100% care to the residents in a timely manner. An interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further revealed if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like showers had not been provided as scheduled due to staffing. 7. Resident #50 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #50 was cognitively intact and was total dependent of two staff for bathing and transfers. Review of the shower schedule revealed Resident #50 was scheduled for showers on Tuesday and Fridays during day shift. Resident #50's shower schedule for October and November 2021 revealed a shower or bath was not documented as given on 10/1/21, 10/5/21, 10/8/21, 10/15/21, 10/19/21, 10/22/21, 10/26/21, and 11/5/21. An observation was conducted on 11/15/21 at 10:35 AM revealed Resident #50's hair appeared to be disheveled and flakey with dandruff. An interview conducted with Resident #50 on 11/15/21 at 10:40 AM revealed most scheduled shower days Resident #50 had not received a bath or shower consistently in several weeks. Resident #50 further revealed she preferred and loved her showers and would never refuse them. Resident #50 indicated scheduled showers had been missed weekly due to shortage of staff. An interview conducted with Nurse Aide (NA) #1 on 11/18/21 at 10:55 AM revealed Resident #50 had never refused care or showers. NA #1 further stated Resident #50's showers had been missed due to staff shortages. NA #1 indicated Resident #50 required extensive assistance and there had not been staff to assist with showers. An interview conducted with Nurse #1 on 11/18/21 at 2:44 PM revealed Resident #50 preferred showers and recalled Resident #50 missing scheduled bath days. Nurse #1 further revealed scheduled showers and baths had been missed due to not having enough staff and would be pushed to the next shift but rarely got done. Nurse #1 stated it was hard to give 100% care to the residents in a timely manner. An interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further revealed if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like showers had not been provided as scheduled due to staffing. 8. Resident #23 was admitted to the facility 10/21/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was severely cognitively impaired and was totally dependent on staff assistance for bathing. The care plan for activities of daily living (ADL) last updated 09/06/21 revealed Resident #23 had an ADL self-care performance deficit related to activity intolerance and dementia. Interventions included extensive assistance of 1 to 2 staff members with bathing/showering on shower days and as necessary and encouraging Resident #23 to participate to the fullest extent possible with each interaction. An observation of Resident #23 on 11/16/21 at 8:44 AM revealed she was lying in bed with uncombed hair and jagged edges to her fingernails. An observation of Resident #23 on 11/18/21 at 8:42 AM revealed she was lying in bed with uncombed hair. Brown material was noted under Resident #23's fingernails and her fingernail edges remained jagged. An observation of Resident #23 on 11/19/21 at 8:29 AM revealed she was in bed feeding herself. Resident #23's hair was uncombed, brown material was noted under her fingernails, and her fingernails had jagged edges. Review of the master shower schedule revealed Resident #23 was scheduled to receive her shower on Tuesdays and Fridays on the 3:00 PM to 11:00 PM shift. Review of bathing documentation for Resident #23 for October 2021 and November 2021 is as follows: October: Partial bed baths were documented as performed 10/22/21, 10/23/21, 10/27/21, 10/28/21. Showers were documented as being provided 10/25/21, 10/26/21, and 10/30/21. November: Partial bed baths were documented as being provided 11/01/21, 11/02/21, 11/04/21, 11/05/21, 11/06/21, 11/07/21, 11/10/21, and 11/11/21. No showers were documented as being provided in November. An interview with Nurse Aide (NA) #7 on 11/17/21 at 3:46 PM revealed when there were only 2 NAs assigned to Resident #23's hall she was unable to get all her showers or nail care done. She stated when she wasn't able to complete the scheduled showers or nail care she notified the nurse on the hall. An interview with NA #2 on 11/18/21 at 1:32 PM revealed when there were only 2 NAs scheduled for Resident #23's hall he was not able to get all his showers or nail care done. He explained that when a partial bed bath was documented that meant the resident received cleaning assistance with the underarm, genitals, and buttock areas. An interview with the Director of Nursing (DON) on 11/19/21 at 3:31 PM revealed if residents were scheduled for 2 showers a week she liked for residents to receive 2 showers a week. She stated staffing was the reason showers were not getting done as scheduled. The DON stated when possible an effort was made to make up a missed shower the next day but that did not always happen. She stated nail care should be done if needed when showers were given. An interview with the Administrator on 11/22/21 at 12:13 PM revealed she was aware of the residents not receiving their showers as scheduled. She explained showers were not getting done due to lack of staff. The Administrator stated staff did make every effort to get showers done when possible. She stated nail care should be performed when showers were done or when needed. 9. Resident #45 was admitted to the facility 10/8/19 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the activity of daily living (ADL) care plan revised on 9/29/21 identified Resident #45 as having an ADL self-care performance deficit with the goal to maintain the current level of ADL function through the review date. Interventions included provide limited to extensive assistance by 1 or 2 staff with bathing and/or showering on preferred shower days and as necessary and provide limited assistance with personal hygiene. A review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #45's cognition as being moderately impaired. The MDS assessment of functional status revealed Resident #45 required supervision with 1-person assist with personal hygiene and was totally dependent on staff for bathing. The MDS assessment of behaviors revealed no rejection of care. A review of the shower schedule revealed Resident #45 was scheduled to receive a shower on Sunday and Thursday. The last shower documented was provided by Nurse Aide #2 on 11/14/21. An observation on 11/16/21 at

Based on record reviews, observations, staff interviews, and resident interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, and incontinence care resulting in residents feeling like a homeless person, like staff did not like them, dirty and embarrassed, uncomfortable, and dirty. This affected 3 out of 6 (Resident #27, Resident #13, and Resident #50) sampled residents. 1. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact for daily decision making, had no behaviors for refusal of care, and required total assistance of 2 staff for bathing and toileting. Observation and interview on 11/15/21 at 2:38 PM of Resident #27 revealed her lying in bed in her room watching her TV. Resident #27 expressed concerns about not being provided incontinence care until she had wet through her clothing down to her knees and wet the linens on her bed. Resident #27 stated just yesterday on 11/14/21 she had been told by Nurse Aide (NA) #3 she would have to wait for care until NA #3 completed her charting. She stated she had a shower yesterday and it was the first one she had in 3 weeks. Resident #27 further stated her hair was matted to her head and she could smell her own body odor and it made her feel degraded and like a homeless person. Resident #27 indicated there was not enough staff at the facility to properly care for the residents and make sure their needs were met. Resident #27 revealed it made her feel like the NAs did not like her or like taking care of her because of her size and she depended on them for her care. Observation on 11/17/21 at 2:42 PM of incontinence care on Resident #27 revealed the resident in bed with brief on with large amount of urine in the brief. NA #3, with gloved hands, cleaned the resident and applied a new brief. Resident #27 requested her draw sheet be changed because she could feel on her legs that it was wet. NA #3 felt of the draw sheet with gloves on and the resident said to her you can't feel the wetness with gloves on. NA #3 proceeded to change the draw sheet and then took the dirty linens and trash out of the room. Resident #27 then said to the surveyor NA #3 would not have changed my draw sheet if you had not been in here. Interview on 11/17/21 at 3:58 PM with NA #3 revealed she frequently worked from 7:00 AM to 3:00 PM or 7:00 AM to 7:00 PM on Resident #27's hall. NA#3 stated she had worked on 11/14/21 and recalled telling Resident #27 she would be right with her as soon as she finished charting on another resident. She stated she did not want to get in trouble for not getting her charting done and sometimes it was hard when you had so many residents to provide care. NA #3 further stated she probably should not have said that to Resident #27. NA #3 indicated she should not have tried to feel wetness on the resident's draw sheet and should have just changed it as the resident requested. NA #3 further indicated she was usually only able to provide 2 incontinence rounds to the residents in an 8-12-hour shift and said it was difficult to do more. Interview was conducted on 11/18/21 at 11:16 AM with NA #1 who worked 7:00 AM to 3:00 PM most of the time and sometimes stayed over to 7:00 PM to help cover the schedule. NA #1 stated had cared for Resident #27 and said it was difficult with 18 to 20 residents to get incontinence care done every 2 hours. NA #1 further stated they did the best they could and worked together to provide incontinence care to residents that require 2 staff. NA #1 indicated it was hard to do residents that require 2 staff every 2 hours because you had to wait until someone was available to assist with care. NA #1 revealed Resident #27 required 2 staff to transfer her in and out of bed but once in the shower room she could be assisted by one staff member. NA #1 stated there were only 2 NAs on the hallway and they usually had 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. NA #1 further stated residents had not been receiving their showers as scheduled because it was all they could do to keep them clean, dry, and safe. Interview was conducted on 11/18/21 at 11:16 AM with NA #2 who worked 7:00 AM to 3:00 PM most of the time and sometimes stayed over to 7:00 PM to help cover the schedule. NA #2 stated had cared for Resident #27 and said it was difficult with 18 to 20 residents to get incontinence care done every 2 hours and sometimes were only able to complete care 2 times a shift. NA #2 further stated they did the best they could and worked together to provide incontinence care to residents that require 2 staff. NA #2 indicated it was hard to do residents that require 2 staff every 2 hours because you had to wait until someone was available to assist you with the care. NA #2 further indicated the nurses were not always able to assist you because they were busy with their duties, and you just had to wait on someone. NA #2 revealed Resident #27 has missed showers and bed baths due to the workload of the NAs. NA #2 stated Resident #27 required 2 staff to get her on the shower bed and into the shower room which took both NAs off the floor for a period of time. NA #2 further stated when she was in the shower the NA assigned to her had to remain with her through the entire shower which left only one NA on the floor for the rest of the 30 plus residents. NA #2 indicated it was impossible to get all the showers done due to staffing. Interview on 11/19/21 at 3:32 PM with the Director of Nursing revealed she expected residents to receive incontinence care at least every 2 hours and as needed. The DON stated she knew there were staffing concerns and they were working on trying to hire more staff and were offering sign on bonuses to try to recruit staff and using agency staff. She further stated if staff were having difficulties providing care, she would expect them to ask the nurses or administrative nurses for assistance. The Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact and required physical assistance with one staff for bathing and transfers. An observation conducted on 11/15/21 at 10:35 AM revealed Resident #13's hair appeared to be oily and unbrushed. An interview conducted with Resident #13 on 11/15/21 at 10:37 AM revealed staff stated to Resident #13 showers and baths were being missed due to staff quitting. Resident #13 further revealed her shower schedule was on Tuesday and Fridays but rarely received a bed bath or shower on her scheduled days. Resident #13 indicated she felt dirty and was embarrassed that her hair was oily and nasty. An interview conducted with Nurse Aide (NA) #1 on 11/18/21 at 10:55 AM revealed Resident #13's showers had been missed due to staff shortages for the last four to five months. NA #1 indicated Resident #13 needed limited assistance with showers and transfers. NA #1 indicated Resident #13 had complained about missing showers and Resident #13 had stated she felt dirty and unclean. An Interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further she felt like showers had not been provided as scheduled due to staffing. The DON revealed she could not recall if Resident #13 had missed showers or baths, but indicated many residents had. 3. Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #50 was cognitively intact and was totally dependent with two person staff assistance for bathing and transfers. An observation was conducted on 11/15/21 at 10:35 AM revealed Resident #50's hair appeared to be disheveled with white flakes throughout the hair. An interview conducted with Resident #50 on 11/15/21 at 10:40 AM revealed staff had stated to Residents #50's scheduled showers had been missed due to a shortage of staff the last few months. Resident #50 indicated she felt uncomfortable and dirty when her scheduled shower days were missed. An interview conducted with Nurse Aide (NA) #1 on 11/18/21 at 10:55 AM indicated Resident #50 required extensive assistance and there had not been staff to assist with Resident #50's showers. NA #1 further revealed Resident #50 had complained about not receiving a shower or bath on scheduled days and indicated she felt dirty and was mad. An interview conducted with direct care Nurse #1 on 11/18/21 at 2:44 PM revealed scheduled showers and baths had been missed due to not having enough staff. Nurse #1 stated Resident #50 had complained about not receiving a shower or bath on schedule days and Resident #50 stating she felt gross and dirty. An Interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further she felt like showers had not been provided as scheduled due to staffing. The DON revealed she could not recall if Resident #50 had missed showers or baths, but indicated many residents had.

Based on record review, Hospital Risk Manager, Medical Director, resident, and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for an evaluation using the resident's behaviors prior to transfer as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Resident #1). This resulted in Resident #1 remaining in the Emergency Department (ED) for an extra 14 days without skilled nursing services. Resident #1 voiced anger about not being allowed to be readmitted to the facility and stated he felt like he had been treated like an animal. Immediate Jeopardy began on 11/09/19 when the facility refused to allow Resident #1 to return to the facility after he was medically and psychiatrically cleared by the hospital physicians to return to the facility which resulted in Resident #1 remaining in the ED for 14 additional days until placement for him was arranged at another skilled nursing facility on 11/22/19. Immediate Jeopardy was removed on 11/26/19 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Review of the facility's policy titled Readmission to the Facility that was last revised (MONTH) (YEAR), read in part, A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident: a) requires the services provided by the facility, b) meets the admission criteria as outlined in facility policy, c) was not discharged for any reason outlined in the Transfer or Discharge Notice policy, and d) is eligible for Medicaid nursing facility services. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #1 with intact cognition. The MDS indicated Resident #1 displayed delusions and verbal behavior directed toward others 4 to 6 days during the MDS assessment period. The nurse progress notes for Resident #1 revealed the following entries: · 11/08/19 at 10:50 AM read in part, Resident #1 can be heard screaming from the Director of Nursing (DON) office. Resident #1 has had his morning medications but is upset and screaming loudly. · 11/08/19 at 12:49 PM read in part, Resident #1 was witnessed repeatedly yelling profanities at staff this shift, verbally abusing staff every time they entered his room. Other residents were complaining about Resident #1's yelling and were scared and anxious to situation. Resident #1 was overheard stating, I am going to kill the Administrator. She is a crook and steals everyone's money. A physician's orders [REDACTED].#1 read in part, send to hospital for a Psychiatric evaluation. The hospital records for Resident #1 included progress notes for the following psychiatric evaluations: · 11/08/19 at 8:44 PM, written by hospital Physician #1, read in part, presents under Involuntary Commitment (IVC) due to threats to hurt the nurses at his facility. The patient appears manic and potentially delusional. He has reported history of [MEDICAL CONDITION] and [MEDICAL CONDITION], which may contribute to his current presentation. I do not believe he is safe for others given his preoccupation with the staff and the statements that he would hurt the staff that would put their hands on him. [DIAGNOSES REDACTED]. The patient meets psychiatric admission criteria but no psych beds are currently available. We will seek appropriate services at a regional facility. Uphold the IVC. · 11/09/19 at 10:40 AM, written by hospital Physician #2, read in part, The patient's non-psychiatric medical conditions have continued to be monitored after initial medical evaluation and stabilization by the emergency medicine team and remain stabilized. The patient has no clear or compelling evidence of imminent risk of harming self or others and does not meet IVC criteria. The patient is now reasonably and adequately stabilized for discharge to outpatient services. No emergency or psychiatric medical or psychiatric condition was identified. · 11/09/19 at 11:28 AM, written by hospital Physician #3, read in part, the patient's medical record has a well-documented history of personality disorder and associated behavior with previous statement about wanting to harm people when his standards are not met. He does not have a history of violent behavior that can be identified. The patient does not have symptoms of a major mood disorder and does not have [MEDICAL CONDITION] disorder. He is not psychotic appearing. His pressured speech appears related to personality structure and may possibly be related to his prior [MEDICAL CONDITION]. He does not meet IVC criteria or need inpatient hospitalization at this time. Will release from IVC and discharge. During a phone interview on 12/06/19 at 12:00 PM, Hospital Physician #1 confirmed she conducted a psychiatric evaluation of Resident #1 on 11/08/19. She recalled, during her evaluation, Resident #1 presented as very frustrated with the skilled nursing facility and made statements that he would hurt whomever placed their hands on him. She explained an IVC was not automatically upheld due to a [DIAGNOSES REDACTED]. Hospital Physician #1 stated the main reason she upheld the IVC and recommended a psychiatric admission for Resident #1 was due to the report received from the facility of the threats and potential harm he made toward staff as well as the similar comments he made during his evaluation. She added it was entirely possible for someone in an agitated state, such as Resident #1, to make comments in the heat of the moment who became calmer as time elapsed causing their disposition (outlook) to change and present more appropriate. She indicated in those cases, the individual would no longer present as an immediate danger to themselves or others and would be considered safe returning to the skilled nursing facility. Telephone attempts to speak to hospital Physician #2 who evaluated Resident #1 was unsuccessful. The hospital records for Resident #1 also included a medical evaluation progress note dated 11/09/19 at 3:31 PM, written by hospital Physician #4, and read in part, Agitation - although he has reportedly been significantly agitated and belligerent in the ED, he was relatively pleasant during exam though he did perseverate (repetitive behavior) about his grievances against the nursing facility. In any event, there is no indication at all for hospital admission. The ED report dated 11/12/19 at 10:29 PM, written by hospital Physician Assistant #1 and co-signed by hospital Physician #5, read in part, Resident #1 was discharged from the ED just prior to being sent back by his skilled nursing facility who refused to take him back into their care. Prior to this, he remained in the ED for 4 days and was cleared both medically and psychiatrically for return to the skilled nursing facility. Patient is without complaint upon return to ED. No indication for further medical or psychiatric work-up at this time. Medications ordered per his medication list. Vitals stable. Social Worker will likely need to see patient in the AM (morning) and may need to file report regarding skilled nursing facility refusing to take him back despite his desire to return and no contraindication (condition, symptom or circumstance that makes treatment or interventions risky) medically or psychiatrically to his return. The ED report dated 11/12/19 at 11:11 PM, written by hospital Physician #5, read in part, Resident #1 was discharged per his request back to his nursing home. They refused to take him back. Patient is very upset and disappointed by this development as he very much wanted to go home. He has no acute psychiatric or medical issues. An ED report dated 11/16/19 at 11:08 AM, written by hospital Physician Assistant #2, read in part, Resident #1 presented to the ED on 11/12/19 after being evicted from a skilled nursing facility for violent behavior. Patient is awaiting placement in a new facility. Vital signs are reviewed and are stable. There are no medical issues at this time .remains medically clear. The discharge MDS dated [DATE] for Resident #1 was coded as return not anticipated. The MDS noted the discharge was unplanned to an acute hospital. An ED report dated 11/22/19 at 2:28 PM, written by hospital Nurse Practitioner #1, read in part, Resident #1 was evaluated in the ED just prior to PM transfer. At first the patient was refusing transfer but after the ED Manager spoke with him he did agree to transfer. The patient is in his normal state where he is quite talkative with rambling speech and tangential in his thoughts. He is denying any acute (sudden onset or of short duration) changes to his medical state. There is no report from the nursing staff of any concerns about this patient. Discharge order entered and medication prescription issued for his nursing home. During a phone interview on 11/25/19 at 2:00 PM, Resident #1 confirmed he was taken from the facility to the hospital via IVC on 11/08/19 for a psychiatric evaluation. Resident #1 shared he remained at the hospital in the ED until he was sent to another skilled nursing facility on 11/22/19. Resident #1 stated he wanted to return to the facility where all his belongings were but was informed by hospital staff he either had to go to the skilled nursing facility located in [NAME]ville or be arrested and go to jail. Resident #1 stated he agreed to go to the other skilled nursing facility but was not happy about any of it. Resident #1 verified he did not receive a 30-day discharge notice or bed hold policy from the facility when he was transferred to the hospital and added they just kicked me out. Resident #1 voiced anger over the situation and stated he felt like he had been treated like an animal. During a phone interview on 11/25/19 at 1:20 PM, the Hospital Risk Manager (HRM) confirmed Resident #1 was transported to the hospital on [DATE] for an IVC due to threats he made toward facility staff. The HRM explained Resident #1 was cleared medically and psychiatrically by hospital physicians for return to the facility but when hospital staff contacted the facility on 11/09/19 they were informed Resident #1 would not be allowed to return to the facility. The HRM stated that starting on 11/11/19, she had multiple conversations with the facility's Administrator, Director of Nursing, and Corporate Representatives to discuss Resident #1 returning to the facility. She indicated she explained that the hospital physicians who had evaluated Resident #1 on 11/09/19 indicated his behaviors were due to a personality disorder and would not improve with medication or inpatient psychiatric treatment but the facility repeatedly refused to allow him to return. She added the facility was also informed during the conversations that Resident #1 remained in the ED, which was an unsafe setting for him, because he had no emergent issues that warranted a hospital admission and told them she felt they were dumping Resident #1 on the hospital by refusing to accept him back. The HRM reverified Resident #1 was not admitted to the hospital for medical or psychiatric treatment and remained in the ED until 11/22/19 when placement at another skilled nursing facility was arranged. The HRM stated Resident #1 voiced wanting to return to the facility where he had resided for the past year and was not happy about going to a skilled nursing facility located in [NAME]ville. During an interview on 11/25/19 at 4:30 PM, the facility's Admissions Director (AD) revealed she received and reviewed referrals sent from the hospital for residents needing skilled nursing placement. She added when a resident of the facility was sent out to the hospital, the referral received from the hospital was automatically approved for the resident to return to the facility when cleared for discharge. The AD confirmed she received a referral from the hospital for Resident #1 on 11/11/19 and notified the Administrator and Director of Nursing (DON). The AD added upon direction from the Administrator, she notified the hospital Resident #1 would not be allowed to return to the facility due to his verbal and threatening behaviors prior to his transfer to the acute hospital. During an interview on 11/25/19 at 5:31 PM, the DON revealed she was informed by the Administrator on 11/08/19 that per the Corporate Office, Resident #1 would not be allowed to return to the facility when he was sent to the hospital on [DATE]. She explained it was the second time Resident #1 was IVC due to communicating threats. The DON admitted she never read the hospital referral for Resident #1 received on 11/11/19 and when notified he was ready to return to the facility, told the AD you know we aren't taking him back. The DON added, I understand his rights were violated and confirmed the decision not to allow Resident #1 to return to the facility was based on his behaviors while at the facility prior to his transfer to the acute care hospital on [DATE]. During an interview on 11/25/19 at 5:58 PM, the Administrator confirmed she was aware of the regulation and admitted when Resident #1 was transported to the acute care hospital on [DATE], she knew he was not safe to return to the facility and would not be allowed back. She stated she was informed by hospital staff beginning on 11/09/19 that Resident #1 was stable to return to the facility but had disagreed with them based on the initial psychiatric evaluation dated 11/08/19 and the fact that he had not received any psychiatric treatment while at the hospital. The Administrator confirmed she informed the hospital starting on 11/09/19 that Resident #1 would not be allowed to return to the facility and explained their decision not to allow him to return was based on the intense verbal and threatening behaviors he displayed while residing at the facility and up to the day of his IVC on 11/08/19. During an interview on 11/26/19 at 2:30 PM, the Medical Director (MD) confirmed Resident #1 was sent to the acute care hospital on [DATE] after threatening the Administrator's life. He stated he felt Resident #1 was at the tipping point and was a safety risk to the Administrator based on the escalating behaviors he displayed while at the facility. He explained Resident #1 had borderline personality disorder, was very resourceful and could be a danger to others despite not being able to transfer on his own as he had decreased range of motion but good upper body strength. The MD confirmed he discussed his concerns with the ED Physician and informed him that Resident #1 would not be allowed to return to the facility. On 11/26/19 at 1:49 PM the Administrator, DON and Regional Clinical Consultant (RCC) were notified of Immediate Jeopardy. On 11/26/19 the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 11/08/19 Resident #1 was transported to Mission Hospital for Involuntary Commitment (IVC) due to threats he made toward facility staff. Resident #1 was evaluated in the emergency room for an initial psychiatric evaluation and was found not to be safe to return to the nursing facility. Resident #1 was given the [DIAGNOSES REDACTED]. On 11/09/19 Resident #1 received a follow up evaluation from psychiatric at which time psychiatry stated that Resident #1 was stable and was no clear or compelling evidence of imminent risk of harming himself or others and that Resident #1 did not meet IVC criteria. The facility was notified on 11/09/19 that Resident #1 was ready to return. The facility Administrator spoke with the hospital and shared her concerns about the safety of her staff and other residents. The hospital did not change any medications or modify the plan of care for Resident #1. Therefore, both residents and staff would remain at risk for both physical and emotional harm by Resident #1. Since the hospital did not change Resident #1 plan of care, the Administrator and Director of Nursing made the decision not to allow him to return based on his unsafe behavior demonstrated while in the facility. The facility had made multiple attempts to improve the setting of care for Resident #1. Resident #1 refused consistently to see or meet with psychiatrists or social workers but did agree to see Dr. #1 on 9/22/19. Dr. #1 made repeated attempts to communicate with the hospital during this hospitalization but was unable to get calls returned. Dr. #1 advised strongly that it was unsafe for Resident #1 to return to this facility. Staff had been trained by a PhD psychologist on 6/21/19 in managing Resident #1 behavior which was reportedly associated with a personality disorder with narcissism. Staff was advised to provide care in pairs, not to engage in resident #1's abusive language about other staff and residents, to assure Resident #1 was safe then excuse themselves stating they would return when resident #1 was calm in 15 minutes when Resident #1 became abusive with them. Resident #1 had faced charges when he ran his wheelchair into a nurse causing her injury which he now reports as her abuse toward him and his accidentally bumping into her. Resident #1 is well known to the magistrate and the court system in the community because of a violent history the facility did not have access to at the point of admission. Recommendations were consistently made by psychiatry, psychology, and the Medical Director that the nursing home setting was not an appropriate environment for Resident #1 and that this nursing home had become a toxic environment for the resident despite the efforts of staff to improve it. Based on Resident #1's history of [MEDICAL CONDITION], his impulsivity, his threats of violence against others and his physical acts against others and the open statement of intended violence against the staff made to the initial psychiatrist at the hospital on [DATE], the Administrator determined the facility was unable to meet Resident #1's clinical needs and denied his readmission. Resident #1 was not permitted to return to his bed or the first available following his hospitalization due to his clinical and behavioral status endangered the safety of individuals within the facility. Since 11/08/19 no other residents have been admitted with [MEDICAL CONDITION] or that endanger the safety of other individuals within the facility. A bed offer will be made on 11/26/19 to Resident #1 to return to the facility. 2. 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: A review of the last 30 days of discharges and readmissions was completed by the Director of Nursing on 11/26/19 and no other residents were found to be affected by this practice. On 11/26/19 The Regional Clinical Consultant re-educated the Administrator, Director of nursing, East Unit Manager, Social Services, Business Office Manager, and the Admissions coordinator on the following policies; Discharge, bed hold and readmission process and F tag 626 requirements. The facility alleges the removal of the Immediate Jeopardy on 11/26/19. The Administrator is responsible for assuring corrective actions are sustained. Immediate Jeopardy was removed on 11/26/19 at 9:00 PM when the credible allegation was verified. Administrative staff were interviewed and confirmed they received training from the RCC on the regulatory requirements pertaining to discharge and transfers, bed hold policy and 30-day notice of discharge. Administrative staff all voiced understanding of the requirements for each of the regulations. A review of the residents who discharged to the hospital during the past 30 days revealed all but one resident (who was still in the hospital) had returned to the facility following their hospitalization . On 11/26/19 at 8:36 PM, Resident #1 confirmed he was contacted by the facility and had declined their bed offer for him to return to the facility.

Based on record review, staff, family, Physician, Nurse Practitioner, and Emergency Medical Service interviews the facility failed to provide basic and expected nursing care for a resident who was experiencing shortness of breath and assessed with [REDACTED]. The resident was sent to the emergency room for evaluation and treatment of [REDACTED]. Immediate Jeopardy began on [DATE] when Nurse #1 neglected to raise the head of the bed and administer oxygen for Resident #1 who was experiencing shortness of breath and a decreased oxygen saturation of 78%. The resident was sent out to the emergency room for evaluation and treatment of [REDACTED]. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility Standing Orders updated ,[DATE] revealed the following for acute shortness of breath: a. Elevate head of bead. b. Check oxygen saturation on room air before application of oxygen. c. Apply oxygen to get oxygen saturation to 90%. d. Obtain and monitor vital signs (temperature, heart rate, respirations) and check oxygen saturation after application of oxygen. e. Notify physician after above completed. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired and required limited to extensive assistance with most activities of daily living. The MDS was not coded for oxygen use for Resident #1. Review of the care plan dated [DATE] revealed Resident #1 had altered respiratory status/difficulty breathing related to [MEDICAL CONDITION] and a history of pneumonia. The goal was for Resident #1 to maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date and his pulse oximetry will remain greater than 90% through the review date. The interventions included: Monitor for signs and symptoms of respiratory distress and report to MD as needed. Monitor pulse oximetry as needed. Review of the nurse's notes dated [DATE] revealed the following note was written by Nurse #1 at 1:20 AM: Resident #1 was moaning intermittently and restless, he indicated left flank, side, pain when asked where he hurt. Resident #1 appeared to doze for short periods while sitting up and his oxygen saturation would drop, then rise again once he roused. Adventitious, abnormal sounds heard over a patient's lungs and airways, lung sounds. The Family Nurse Practitioner (FNP) had ordered lab work, urinalysis with a culture and sensitivity, and a chest x-ray. Resident #1's family member, stated she wanted him sent to the emergency room (ER) for evaluation and treatment, stating she thought he was having a [MEDICAL CONDITION]. The on- call FNP was contacted via telephone at 6:20 PM and agreed to have Resident #1 sent to the ER. The Director of Nursing (DON) was notified via telephone. Emergency Management System (EMS) was contacted via telephone for pickup. Resident #1 departed the facility at 6:45 PM. Vital signs were blood pressure - ,[DATE], pulse - 113, respirations - 28, temperature - 98.1 (orally), oxygen saturation 78% on room air. Nurse #1 contacted the ER at 11:00 PM and was informed that Resident #1 had been admitted to the hospital for pneumonia. The DON was notified via telephone at 11:10 PM. Review of the Emergency Medical Services (EMS) run report dated [DATE] revealed they were called by the facility at 6:27 PM for transport of a resident having difficulty breathing to the emergency room (ER). The EMS report revealed they arrived at the facility at 6:41 PM and to Resident #1's bedside at 6:44 PM. They departed the facility for the ER at 7:04 PM and arrived at the hospital at 7:35 PM. The report further revealed when they arrived at the facility they found Resident #1 lying flat on his bed with adventitious lung sounds. His family member was at the bedside and stated he had some congestion lately but was worse today. They sat Resident #1 up in bed and he was able to pivot with assistance to the gurney. Physical exam revealed lower extremity swelling, lung sounds full of fluid throughout, and skin was cool and clammy. Review of the oxygen saturation readings on the EMS report revealed the following: 6:57 PM - 69%, 6:59 PM - 73%, 7:00 pm - 89%, 7:07 PM - 80%, 7:17 - 92 %, 7:24 - 91%, and 7:32 PM - 93%. Oxygen via nasal cannula was applied at 7:01 PM and a [MEDICAL CONDITION], continuous positive airway pressure is a form of positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in people who are able to breathe spontaneously on their own, was applied at 7:03 PM. Review of the hospital discharge summary dated [DATE] revealed Resident #1 likely expired due to his severe pneumonia, which may have been a result of aspiration and was significantly affected by his [MEDICAL CONDITION]. Review of the death certificate for Resident #1 revealed he expired on [DATE] from pneumonia. An interview conducted on [DATE] at 12:10 PM with Nurse #2 stated she observed Resident #1 on [DATE] on the 7:00 AM to 3:00 PM shift and he was drowsier than usual and acting different. She stated she reported it to the FNP and she ordered lab work and a chest x-ray. Nurse #2 further stated she reported to Nurse #1 about Resident #1 being drowsier and acting different and that the FNP had ordered lab work and a chest x-ray earlier that day. An interview conducted on [DATE] at 1:39 PM with the Nurse Practitioner stated she saw Resident #1 on [DATE] at 11:15 AM per his family member and Nurse #2's request due to being resistive to care and having an increase in agitation. She stated he was not congested or having shortness of breath (SOB) or difficulty breathing when she assessed him. She stated he had complaints of pain at the site of his broken rib and she ordered a chest x-ray per the family's request. She reported Nurse #1 called her that evening around 6:15 PM and reported Resident #1 was SOB and had a low oxygen saturation and she gave the order to send him to the ER for evaluation. She stated she was not informed Resident #1's oxygen saturation was 78% and would have expected staff to raise the head of the bed and provide oxygen per standing orders to bring his oxygen level back up. An interview conducted on [DATE] at 11:17 AM with Nurse Aide (NA) #1. NA #1 stated he was at the nurses desk on the East Hall the evening of [DATE] when the EMS arrived and told Nurse #1 they were there for Resident #1 and asked where his room was and if anyone was in the room with him, he heard the nurse say no and pointed in the direction of Resident #1's room. NA #1 stated he offered to take the EMS workers to Resident #1's room. He stated when they walked in the room Resident #1 was lying flat in bed and he could hear him trying to breathe, he sounded very congested and short of breath. NA #1 stated Resident #1 didn't have any oxygen on and there wasn't an oxygen concentrator or oxygen tank in the room. NA #1 further stated he was not assigned to Resident #1 that evening and had not seen him before taking EMS personnel to his room around 6:45 PM. An interview was conducted on [DATE] at 12:05 PM with EMS Worker #1. She stated when they arrived at the facility the nurse was at the desk and she told him they were there for Resident #1 for a respiratory distress call and he pointed down the hall, she asked if someone was with him and he said no, she told him she needed report and he continued to sit at the desk and do paperwork. She stated NA #1 told her he would take them to Resident #1's room, she reported when they walked into Resident #1's room he was lying flat in bed, with no oxygen on, and she could hear him trying to breathe. EMS Worker #1 stated there were no staff present in Resident #1's room when they arrived and she didn't see an oxygen tank or concentrator in the room. She further stated Resident #1's family member was in the room with him and she was crying, when she asked her why she told her she thought he was having a [MEDICAL CONDITION] and he was going to die. An interview conducted on [DATE] at 12:15 PM with Nurse #1, who worked with Resident #1 on the 3:00 PM to 11:00 PM shift on [DATE], revealed he was in the middle of his medication pass and Resident #1's family member asked him to assess Resident #1 because he was having difficulty breathing and pain in his chest around 6:00 PM. Nurse #1 stated he went to Resident #1's room and assessed him while NA #2 obtained his vital signs. Nurse #1 stated Resident #1's oxygen saturation was 78% at that time. Nurse #1 stated the resident pointed to his ribs and not his heart when he asked him where his pain was but his family was insistent that he be sent to the ER. Nurse #1 stated he went to the nurse's desk to call the on-call provider for order's and start the transfer paperwork and thought he told NA #2 to put oxygen on Resident #1 per facility standing orders due to his oxygen saturation being 78% when the vital signs were checked but did not think about raising the head of the bed. Nurse #1 stated he called the FNP, DON and the EMS and started the paperwork for the transfer and he did not go back and assess Resident #1 due to trying to get the paperwork completed and did not go with the EMS to his room when they arrived because he wasn't finished with the paperwork. An interview conducted with the Director of Nursing revealed Nurse #1 called her on [DATE] and informed her he was sending Resident #1 to the ER per his family's request. She stated she was not informed Resident #1's oxygen saturation was 78%. She stated all nurses were trained on standing orders and there was a copy of the standing orders on every medication administration book and her expectation was for all nurses to follow the facility standing orders and raise the resident's head of bed and apply oxygen to get the oxygen saturation back to 90%. She further stated Nurse #1 should have followed the facility standing orders and administered oxygen and raised the head of the bed for Resident #1. An interview conducted on [DATE] 3:16 PM with Resident #1's family member revealed she was with Resident #1 all day on [DATE] because he asked her to stay with him. She stated he complained of chest pain and the FNP saw him that day and ordered lab work and a chest x-ray to be done. The family member reported Resident #1 started having difficulty breathing that evening and she checked his oxygen saturation with her own machine and showed it to NA #2 who checked it with the facility machine. She stated NA #2's oxygen saturation reading was 78% around 6:00 PM and she reported it to Nurse #1. Resident #1's family member stated Nurse #1 did not assess Resident #1 but he did come to the door of his room and ask her if she wanted him sent to the ER. She further stated she asked staff to give Resident #1 oxygen due to his shortness of breath and difficulty breathing but no one ever did until the EMS arrived around 6:30 PM and they provided oxygen for him. An interview conducted on [DATE] 3:07 PM NA #2 revealed Resident #1's family member called her to his room on [DATE] around 6:00 PM and showed her the oxygen saturation reading she got on her own private machine and it was 75%. NA #2 stated she checked Resident #1's oxygen saturation with the facility machine and got a reading of 78% and immediately informed Nurse #1. She stated Nurse #1 assessed Resident #1 and she took oxygen into the room for him to put on Resident #1. She stated she didn't see Nurse #1 put the oxygen on Resident #1 and she didn't return to the room after she took the oxygen to the room. She further stated Resident #1 was lying flat in bed and he was having difficulty breathing. An interview conducted on [DATE] at 9:00 AM with the facility Physician revealed it was his expectation for a resident who was short of breath and had an oxygen saturation of 78% to have oxygen applied and the head of the bed raised per facility standing orders. He further stated the on-call provider should be called immediately. On [DATE] at 4:45 PM the Administrator and the DON were notified of Immediate Jeopardy. On [DATE] at 2:44 PM the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: (1) Plan for correcting specific area of concern identified, include the process that led to the concern: It was observed that on [DATE] that LPN #1 failed to ensure the delivery of quality care or to ensure the highest practicable physical, mental, and psychosocial well-being. The process breakdown that lead to the concern was as follows: 5.28.18 (11:37pm) LPN #1 documented agitation and verbal aggression as well as [MEDICAL CONDITION]. [MEDICATION NAME] IM given. 5.29.18 Patient seen by Nurse Practitioner related to increased agitation, [MEDICAL CONDITION], and flank pain. No documented fever, dyspnea, cough. Order for chest x-ray, urinalysis, CMP, and left rib x-ray given by nurse practitioner. Respiratory assessment by nurse practitioner shows poor compliance and diminished without wheezes, rales, or rhonchi. New orders for [MEDICATION NAME] as requested for pain. 5.29.18 (6:19pm) LPN #1 documented change of condition assessment related to shortness of breath, oxygen saturation of 78% on room air. Orders noted to send to emergency room . 5.29.18 (6:35pm) LPN #1 completed transfer form. Oxygen was not documented as an intervention at this time. Per the transfer form to the hospital - - O2: 78%, Res: 28, Pulse: 113, B/P: ,[DATE]. Pain eval conducted; rated as 4 of 10. Known d/x of [MEDICAL CONDITION] and [MEDICAL CONDITION] Statements from EMS surrounding this event revealed that no staff member was present in room with Resident #1 and head of bed not elevated at time EMS arrived and that oxygen was not being administered. 5.30.18 (01:22pm) LPN #1 documented nurses note related to change of condition and orders to send to hospital. Attending physician notified and sister aware and in room. Resident left facility at 6:45pm. At, 11:00pm facility was notified that resident was admitted to the hospital related to pneumonia. 6.28.18 (08:00) NC Department of Health and Human Services arrive to facility to investigate complaint of event on [DATE]. Facility was cited with F684 for Quality of Care. Upon review of the aforementioned event, there is evidence that LPN #1 did not follow facility procedures when addressing Resident #1's change of condition including implementation of interventions for low oxygen saturation levels (78%) and shortness of breath, which subsequently resulted in failure to deliver an acceptable level of quality care or to ensure the highest practicable physical, mental, and psychosocial well-being of the resident. Interview with LPN #1 states that nurse had instructed CNA #1 to get oxygen while he was completing documentation to send Resident #1 to hospital. Per LPN #1, he believed that Resident #1 was sitting on edge of bed, and thus could not raise the head of bed. LPN #1 also believe that CNA #1 was applying O2 to resident. Interview with LPN #1 revealed that he understood that setting up O2 was out of CNA scope of practice, but was trying to save time in light of Resident #1's change of condition. Resident #1's O2 saturation rate was 78% which justified supplemental oxygen and monitoring until baseline O2 saturation rate is achieved The plan to correct this identified concern includes the completion of a thorough investigation surrounding the event on [DATE], completion of a Root Cause Analysis to identify the variables that led to the process failure, house-wide education and in-service training to appropriate staff on areas for opportunity to include topics of Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plans. The facility will also implement monitoring measures and random audits spread over the course of the next 90 days to ensure compliance and efficacy of this plan. Lastly, all audit results will be shared with the facility Quality Assurance Performance Improvement team and the Medical Director no less than monthly for review. All negative audit results will be immediately brought before the QAPI team and Medical Director for immediate review and remedy. The root cause of this event was that that LPN #1 made a poor judgment call and requested another staff member (who was not a licensed nurse) to retrieve and set up oxygen for a resident and it was ultimately not administered. LPN #1 failed to ensure that they, the licensed nurse assigned to the patient, administered oxygen and monitored resident until O2 saturation baseline was achieved which is facility protocol. (2) The procedure for implementing the acceptable plan of correction for the specific deficiency cited: On [DATE], the Director of Nursing immediately suspended LPN #1 pending investigation regarding failure to provide quality of care. If investigation is substantiated, facility will follow policy of terminating LPN #1's employment and reporting event to required agencies and licensing boards, as appropriate. On [DATE], the Director of Nursing, Staff Development Coordinator, MDS nurse, and Assistant Director of Nursing created a timeline of events surrounding the [DATE] occurrence in order to successfully conduct a Root Cause Analysis of the process failure. Process failure was determined after reviewing timeline by DON and Administrator on [DATE]. The failed process identified was that LPN #1 did not follow facility O2 protocols when he observed resident with 78% O2 saturation rate. At the time a low saturation rate was observed, LPN #1 should have placed resident on supplemental Oxygen, elevated head of bed, and remained with resident until resident could reach a baseline O2 saturation rate, which LPN #1 failed to do. On [DATE], the Director of Nursing conducted 100% chart audit of other residents discharged from facility (either due to death or hospitalization ) within the last 90 days to review for vital sign monitoring, change of condition, and following of standing orders. Area for opportunity was self-identified in 1 of 15 residents with no negative outcomes noted as a result. However, these audit findings were added to ongoing Quality Assurance / Performance Improvement plan and discussed with IDT / Medical Director on [DATE]. On [DATE], the facility's Staff Development Coordinator gathered the facility's policies and procedures regarding Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plan. SDC, MDS, DON, and ADON began 100% in-service education of all clinical staff (LPN, RN, CNA, contract therapy) on this topic with post - test administered. Starting on [DATE], no clinical staff is permitted to work until education is received and post -test completed. Staff education to be completed by [DATE] regarding Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plan. All staff who have not completed in-person / over the phone education and post-tests will be mailed a copy of each via USPS Certified Mail and will not be permitted to work until this education and post-test is completed. Compliance will be ensured and tracked by each employee's respective department manager. This training included: 1. MD Orders / Standing Orders - Educated on process including explanation that there are hard copies orders for all residents in the narcotics book. When a nurse needs to implement a Standing order, facility requires nurse to place that order in the computer (EMR), and complete an E-Interact change of condition form along with that order, and to also document communication in the MD communication book. The expectation is that MD orders will be followed at all times. 2. Interventions for respiratory distress / low O2 levels - facility processes include: Staff member is to be present if resident is noted to be in distress and have a low O2 saturation, Nurse will request that another staff member go and retrieve O2 concentrator or tank with tubing. Staff will follow protocol for administering Oxygen, and how to observe oxygen saturation by using Pulse Ox per protocol. Nurses will delegate to other staff to stay with resident once resident is stable. After resident is stable the nurse is to call MD for orders. Nurse will place all orders into the computer including orders implemented from Standing orders (ex: oxygen placement and settings. Refer to Order/care plan guide for items to include in orders). Nurse will then start completing the required paper work to transfer out if order received. Paperwork includes E-interact Change of Condition, and transfer form. If in an emergent situation arises and the nurse does not feel that the resident is stable, nurse will instruct another staff member to call 911 and help gather the required paperwork. 3. Change of Condition / MD Notification / Resident Assessment- With any change of condition, vital signs need to be obtained appropriately, and frequently, vital signs should be taken at time of incident. If any abnormal VS, vitals need to be obtained at a minimum of every 4 hours until VS stable per baseline. Oxygen - the resident should not be left alone until O2 is at an acceptable level (at acceptable baseline), continue to monitor. Blood pressure- if you have an abnormal blood pressure for the resident, you are to notify the MD immediately and obtain orders, continue to monitor. Pulse- if you have an abnormal pulse for the resident, you are to notify the MD immediately and obtain orders, continue to monitor. Respirations- encourage resident to purse lip breath. In through their nose out through their mouth. Slow, deep and steady. Temperature- Administer medications per standing orders, notify MD, and continue to monitor. 4. Updating / Following of Care Plan - It is the expectation of the facility that nursing staff will follow and / or update each resident's specific plan of care. On [DATE], the Staff Development Coordinator, Director of Nursing, MDS Nurse, and ADON began 100% in-service education with nursing staff that the on-call nurse is to be notified immediately with any and all resident changes in condition. (3) The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and / or in compliance with regulatory requirements: Starting on [DATE], each unit's 24-hour report and available push reports will be reviewed daily (M-F) in clinical meeting to validate identified at-risk residents' vitals are within normal limits, care plans are followed, code statuses honored, and appropriate O2 protocol is being followed as appropriate. On [DATE], the Regional Nurse Consultant developed a monitoring flow sheet to check and validate at-risk residents as identified by the 24-hour report or available push report. This flow sheet includes assessment of abnormal vitals, honoring of code status and care plans, and oxygen protocol being followed as indicated. Starting [DATE], this flow sheet will be populated and reviewed daily (M-F) in morning clinical meeting to review and track at-risk residents over the previous 24 hours (72 hours if weekend). Starting on [DATE], the DON, ADON, SDC, MDS, Regional Nurse, or designated nurse manager will conduct (3) random audits of patient charts to review vitals, code status changes, incident reports, orders, change of condition and required notifications therein, as well as care plans 5x weekly for 4 weeks, then 3x weekly for 4 weeks, then weekly for 4 weeks to monitor delivery of quality care. Any noted issues from audits will be discussed with the IDT and QA committee and addressed immediately. Starting [DATE], the Inter Disciplinary Team and Medical Director will attend QAPI meeting to review the efficacy of the aforementioned plan weekly x 4 weeks, then bi-weekly x 1 month, and then monthly thereafter to ensure continued compliance with the requirements of participation. The IDT includes the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admissions Coordinator, Staff Development Coordinator, Housekeeping Director, Maintenance Director, MDS Nurse, Dietary Director, Medical Director, and Pharmacist. (4) The title of the person responsible for implementing the acceptable plan of correction: The individual responsible for implementing the credible plan of correction is the Administrator. Immediate Jeopardy was removed on [DATE] at 3:35 PM when the facility staff were interviewed and demonstrated they had been trained on the topics of Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plan.

Based on record review, staff, family, Physician, Nurse Practitioner, and Emergency Medical Service interviews the facility neglected to stay with the resident, administer oxygen, and raise the head of the bed for a resident who was experiencing shortness of breath and assessed with [REDACTED]. The resident was sent to the emergency room for evaluation and treatment of [REDACTED]. Immediate Jeopardy began on [DATE] when Nurse #1 neglected to raise the head of the bed and administer oxygen for Resident #1 who was experiencing shortness of breath and a decreased oxygen saturation of 78%. The resident was sent out to the emergency room for evaluation and treatment of [REDACTED]. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility Standing Orders updated ,[DATE] revealed the following for acute shortness of breath: a. Elevate head of bead. b. Check oxygen saturation on room air before application of oxygen. c. Apply oxygen to get oxygen saturation to 90%. d. Obtain and monitor vital signs (temperature, heart rate, respirations) and check oxygen saturation after application of oxygen. e. Notify physician after above completed. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired and required limited to extensive assistance with most activities of daily living. The MDS was not coded for oxygen use for Resident #1. Review of the care plan dated [DATE] revealed Resident #1 had altered respiratory status/difficulty breathing related to [MEDICAL CONDITION] and a history of pneumonia. The goal was for Resident #1 to maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date and his pulse oximetry will remain greater than 90% through the review date. The interventions included: Monitor for signs and symptoms of respiratory distress and report to MD as needed. Monitor pulse oximetry as needed. Review of the nurse's notes dated [DATE] revealed the following note was written by Nurse #1 at 1:20 AM: Resident #1 was moaning intermittently and restless, he indicated left flank, side, pain when asked where he hurt. Resident #1 appeared to doze for short periods while sitting up and his oxygen saturation would drop, then rise again once he roused. Adventitious, abnormal sounds heard over a patient's lungs and airways, lung sounds. The Family Nurse Practitioner (FNP) had ordered lab work, urinalysis with a culture and sensitivity, and a chest x-ray. Resident #1's family member, stated she wanted him sent to the emergency room (ER) for evaluation and treatment, stating she thought he was having a [MEDICAL CONDITION]. The on- call FNP was contacted via telephone at 6:20 PM and agreed to have Resident #1 sent to the ER. The Director of Nursing (DON) was notified via telephone. Emergency Management System (EMS) was contacted via telephone for pickup. Resident #1 departed the facility at 6:45 PM. Vital signs were blood pressure - ,[DATE], pulse - 113, respirations - 28, temperature - 98.1 (orally), oxygen saturation 78% on room air. Nurse #1 contacted the ER at 11:00 PM and was informed that Resident #1 had been admitted to the hospital for pneumonia. The DON was notified via telephone at 11:10 PM. Review of the Emergency Medical Services (EMS) run report dated [DATE] revealed they were called by the facility at 6:27 PM for transport of a resident having difficulty breathing to the emergency room (ER). The EMS report revealed they arrived at the facility at 6:41 PM and to Resident #1's bedside at 6:44 PM. They departed the facility for the ER at 7:04 PM and arrived at the hospital at 7:35 PM. The report further revealed when they arrived at the facility they found Resident #1 lying flat on his bed with adventitious lung sounds. His family member was at the bedside and stated he had some congestion lately but was worse today. They sat Resident #1 up in bed and he was able to pivot with assistance to the gurney. Physical exam revealed lower extremity swelling, lung sounds full of fluid throughout, and skin was cool and clammy. Review of the oxygen saturation readings on the EMS report revealed the following: 6:57 PM - 69%, 6:59 PM - 73%, 7:00 pm - 89%, 7:07 PM - 80%, 7:17 - 92 %, 7:24 - 91%, and 7:32 PM - 93%. Oxygen via nasal cannula was applied at 7:01 PM and a [MEDICAL CONDITION], continuous positive airway pressure is a form of positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in people who are able to breathe spontaneously on their own, was applied at 7:03 PM. Review of the hospital discharge summary dated [DATE] revealed Resident #1 likely expired due to his severe pneumonia, which may have been a result of aspiration and was significantly affected by his [MEDICAL CONDITION]. Review of the death certificate for Resident #1 revealed he expired on [DATE] from pneumonia. An interview conducted on [DATE] at 12:10 PM with Nurse #2 stated she observed Resident #1 on [DATE] on the 7:00 AM to 3:00 PM shift and he was drowsier than usual and acting different. She stated she reported it to the FNP and she ordered lab work and a chest x-ray. Nurse #2 further stated she reported to Nurse #1 about Resident #1 being drowsier and acting different and that the FNP had ordered lab work and a chest x-ray earlier that day. An interview conducted on [DATE] at 1:39 PM with the Nurse Practitioner stated she saw Resident #1 on [DATE] at 11:15 AM per his family member and Nurse #2's request due to being resistive to care and having an increase in agitation. She stated he was not congested or having shortness of breath (SOB) or difficulty breathing when she assessed him. She stated he had complaints of pain at the site of his broken rib and she ordered a chest x-ray per the family's request. She reported Nurse #1 called her that evening around 6:15 PM and reported Resident #1 was SOB and had a low oxygen saturation and she gave the order to send him to the ER for evaluation. She stated she was not informed Resident #1's oxygen saturation was 78% and would have expected staff to raise the head of the bed and provide oxygen per standing orders to bring his oxygen level back up. An interview conducted on [DATE] at 11:17 AM with Nurse Aide (NA) #1. NA #1 stated he was at the nurses desk on the East Hall the evening of [DATE] when the EMS arrived and told Nurse #1 they were there for Resident #1 and asked where his room was and if anyone was in the room with him, he heard the nurse say no and pointed in the direction of Resident #1's room. NA #1 stated he offered to take the EMS workers to Resident #1's room. He stated when they walked in the room Resident #1 was lying flat in bed and he could hear him trying to breathe, he sounded very congested and short of breath. NA #1 stated Resident #1 didn't have any oxygen on and there wasn't an oxygen concentrator or oxygen tank in the room. NA #1 further stated he was not assigned to Resident #1 that evening and had not seen him before taking EMS personnel to his room around 6:45 PM. An interview was conducted on [DATE] at 12:05 PM with EMS Worker #1. She stated when they arrived at the facility the nurse was at the desk and she told him they were there for Resident #1 for a respiratory distress call and he pointed down the hall, she asked if someone was with him and he said no, she told him she needed report and he continued to sit at the desk and do paperwork. She stated NA #1 told her he would take them to Resident #1's room, she reported when they walked into Resident #1's room he was lying flat in bed, with no oxygen on, and she could hear him trying to breathe. EMS Worker #1 stated there were no staff present in Resident #1's room when they arrived and she didn't see an oxygen tank or concentrator in the room. She further stated Resident #1's family member was in the room with him and she was crying, when she asked her why she told her she thought he was having a [MEDICAL CONDITION] and he was going to die. An interview conducted on [DATE] at 12:15 PM with Nurse #1, who worked with Resident #1 on the 3:00 PM to 11:00 PM shift on [DATE], revealed he was in the middle of his medication pass and Resident #1's family member asked him to assess Resident #1 because he was having difficulty breathing and pain in his chest around 6:00 PM. Nurse #1 stated he went to Resident #1's room and assessed him while NA #2 obtained his vital signs. Nurse #1 stated Resident #1's oxygen saturation was 78% at that time. Nurse #1 stated the resident pointed to his ribs and not his heart when he asked him where his pain was but his family was insistent that he be sent to the ER. Nurse #1 stated he went to the nurse's desk to call the on-call provider for order's and start the transfer paperwork and thought he told NA #2 to put oxygen on Resident #1 per facility standing orders due to his oxygen saturation being 78% when the vital signs were checked but did not think about raising the head of the bed. Nurse #1 stated he called the FNP, DON and the EMS and started the paperwork for the transfer and he did not go back and assess Resident #1 due to trying to get the paperwork completed and did not go with the EMS to his room when they arrived because he wasn't finished with the paperwork. An interview conducted with the Director of Nursing revealed Nurse #1 called her on [DATE] and informed her he was sending Resident #1 to the ER per his family's request. She stated she was not informed Resident #1's oxygen saturation was 78%. She stated all nurses were trained on standing orders and there was a copy of the standing orders on every medication administration book and her expectation was for all nurses to follow the facility standing orders and raise the resident's head of bed and apply oxygen to get the oxygen saturation back to 90%. She further stated Nurse #1 should have followed the facility standing orders and administered oxygen and raised the head of the bed for Resident #1. An interview conducted on [DATE] 3:16 PM with Resident #1's family member revealed she was with Resident #1 all day on [DATE] because he asked her to stay with him. She stated he complained of chest pain and the FNP saw him that day and ordered lab work and a chest x-ray to be done. The family member reported Resident #1 started having difficulty breathing that evening and she checked his oxygen saturation with her own machine and showed it to NA #2 who checked it with the facility machine. She stated NA #2's oxygen saturation reading was 78% around 6:00 PM and she reported it to Nurse #1. Resident #1's family member stated Nurse #1 did not assess Resident #1 but he did come to the door of his room and ask her if she wanted him sent to the ER. She further stated she asked staff to give Resident #1 oxygen due to his shortness of breath and difficulty breathing but no one ever did until the EMS arrived around 6:30 PM and they provided oxygen for him. An interview conducted on [DATE] 3:07 PM NA #2 revealed Resident #1's family member called her to his room on [DATE] around 6:00 PM and showed her the oxygen saturation reading she got on her own private machine and it was 75%. NA #2 stated she checked Resident #1's oxygen saturation with the facility machine and got a reading of 78% and immediately informed Nurse #1. She stated Nurse #1 assessed Resident #1 and she took oxygen into the room for him to put on Resident #1. She stated she didn't see Nurse #1 put the oxygen on Resident #1 and she didn't return to the room after she took the oxygen to the room. She further stated Resident #1 was lying flat in bed and he was having difficulty breathing. An interview conducted on [DATE] at 9:00 AM with the facility Physician revealed it was his expectation for a resident who was short of breath and had an oxygen saturation of 78% to have oxygen applied and the head of the bed raised per facility standing orders. He further stated the on-call provider should be called immediately. On [DATE] at 4:45 PM the Administrator and the DON were notified of Immediate Jeopardy. On [DATE] at 2:44 PM the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: (1) Plan for correcting specific area of concern identified, include the process that led to the concern: It was observed that on [DATE] that LPN #1 failed to ensure the delivery of quality care and to prevent Resident #1 from experiencing neglect. The process breakdown that lead to the concern was as follows: 5.28.18 (11:37pm) LPN #1 documented agitation and verbal aggression as well as [MEDICAL CONDITION]. [MEDICATION NAME] IM given. 5.29.18 Patient seen by Nurse Practitioner related to increased agitation, [MEDICAL CONDITION], and flank pain. No documented fever, dyspnea, cough. Order for chest x-ray, urinalysis, CMP, and left rib x-ray given by nurse practitioner. Respiratory assessment by nurse practitioner shows poor compliance and diminished without wheezes, rales, or rhonchi. New orders for [MEDICATION NAME] as requested for pain. 5.29.18 (6:19pm) LPN #1 documented change of condition assessment related to shortness of breath, oxygen saturation of 78% on room air. Orders noted to send to emergency room . 5.29.18 (6:35pm) LPN #1 completed transfer form. Oxygen was not documented as an intervention at this time. Per the transfer form to the hospital - - O2: 78%, Res: 28, Pulse: 113, B/P: ,[DATE]. Pain eval conducted; rated as 4 of 10. Known d/x of [MEDICAL CONDITION] and [MEDICAL CONDITION] Statements from EMS surrounding this event revealed that no staff member was present in room with Resident #1 and head of bed not elevated at time EMS arrived and that oxygen was not being administered 5.30.18 (01:22pm) LPN #1 documented nurses note related to change of condition and orders to send to hospital. Attending physician notified and sister aware and in room. Resident left facility at 6:45pm. At, 11:00pm facility was notified that resident was admitted to the hospital related to pneumonia (1) Plan for correcting specific area of concern identified, include the process that led to the concern: It was observed that on [DATE] that LPN #1 failed to ensure the delivery of quality care and to prevent Resident #1 from experiencing neglect. The process breakdown that lead to the concern was as follows: 5.28.18 (11:37pm) LPN #1 documented agitation and verbal aggression as well as [MEDICAL CONDITION]. [MEDICATION NAME] IM given. 5.29.18 Patient seen by Nurse Practitioner related to increased agitation, [MEDICAL CONDITION], and flank pain. No documented fever, dyspnea, cough. Order for chest x-ray, urinalysis, CMP, and left rib x-ray given by nurse practitioner. Respiratory assessment by nurse practitioner shows poor compliance and diminished without wheezes, rales, or rhonchi. New orders for [MEDICATION NAME] as requested for pain. 5.29.18 (6:19pm) LPN #1 documented change of condition assessment related to shortness of breath, oxygen saturation of 78% on room air. Orders noted to send to emergency room . 5.29.18 (6:35pm) LPN #1 completed transfer form. Oxygen was not documented as an intervention at this time. Per the transfer form to the hospital - - O2: 78%, Res: 28, Pulse: 113, B/P: ,[DATE]. Pain eval conducted; rated as 4 of 10. Known d/x of [MEDICAL CONDITION] and [MEDICAL CONDITION] Statements from EMS surrounding this event revealed that no staff member was present in room with Resident #1 and head of bed not elevated at time EMS arrived and that oxygen was not being administered 5.30.18 (01:22pm) LPN #1 documented nurses note related to change of condition and orders to send to hospital. Attending physician notified and sister aware and in room. Resident left facility at 6:45pm. At, 11:00pm facility was notified that resident was admitted to the hospital related to pneumonia. 6.28.18 (08:00) NC Department of Health and Human Services arrive to facility to investigate complaint of event on [DATE]. Facility was cited with F600 for neglect. Upon review of the aforementioned event, there is evidence that LPN #1 did not follow facility procedures when addressing Resident #1's change of condition including implementation of interventions for low oxygen saturation levels (78%) and shortness of breath, which subsequently resulted in neglect, defined by CMS as Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (See 42 CFR Part 488.301.). Interview with LPN #1 states that nurse had instructed CNA #1 to get oxygen while he was completing documentation to send Resident #1 to hospital. Per LPN #1, he believed that Resident #1 was sitting on edge of bed, and thus could not raise the head of bed. LPN #1 also believe that CNA #1 was applying O2 to resident. Interview with LPN #1 revealed that he understood that setting up O2 was out of CNA scope of practice, but was trying to save time in light of Resident #1's change of condition. Resident #1's O2 saturation rate was 78% which justified supplemental oxygen and monitoring until baseline O2 saturation rate is achieved The plan to correct this identified concern includes the completion of a thorough investigation surrounding the event on [DATE], completion of a Root Cause Analysis to identify the variables that led to the process failure, house-wide education and in-service training to appropriate staff on areas for opportunity to include topics of abuse, neglect, abuse reporting, resident rights, Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plans. The facility will also implement monitoring measures and random audits spread over the course of the next 90 days to ensure compliance and efficacy of this plan. Lastly, all audit results will be shared with the facility Quality Assurance Performance Improvement team and the Medical Director no less than monthly for review. All negative audit results will be immediately brought before the QAPI team and Medical Director for immediate review and remedy. (2) The procedure for implementing the acceptable plan of correction for the specific deficiency cited: On [DATE], the Director of Nursing immediately suspended LPN #1 pending investigation regarding neglect and failure to provide quality of care. If investigation is substantiated, facility will follow policy of terminating LPN #1's employment and reporting event to required agencies and licensing boards, as appropriate. On [DATE], the Director of Nursing, Staff Development Coordinator, MDS nurse, and Assistant Director of Nursing created a timeline of events surrounding the [DATE] occurrence in order to successfully conduct a Root Cause Analysis of the process failure. Process failure was determined after reviewing timeline by DON and Administrator on [DATE]. The failed process identified was that LPN #1 did not follow facility O2 protocols when he observed resident with 78% O2 saturation rate. At the time a low saturation rate was observed, LPN #1 should have placed resident on supplemental Oxygen, elevated head of bed, and remained with resident until resident could reach a baseline O2 saturation rate, which LPN #1 failed to do. On [DATE], the Director of Nursing conducted 100% chart audit of other residents discharged from facility (either due to death or hospitalization ) within the last 90 days to review for vital sign monitoring, change of condition, and following of standing orders. Area for opportunity was self-identified in 1 of 15 residents with no negative outcomes noted as a result. However, these audit findings were added to ongoing Quality Assurance / Performance Improvement plan and discussed with IDT / Medical Director on [DATE]. On [DATE], the facility's Staff Development Coordinator gathered the facility's policies and procedures regarding abuse, neglect, abuse reporting, and resident rights and began 100% in-servicing of all staff on this topic with post - test administered. Starting on [DATE], no staff is permitted to work until education is received and post -test completed. Staff education to be completed by [DATE] on abuse, neglect, abuse reporting, and resident rights. All staff who have not completed in-person / over the phone education and post-tests will be mailed a copy of each via USPS Certified Mail and will not be permitted to work until this education and post-test is completed. Compliance will be ensured and tracked by each employee's respective department manager. This training included: 1. Resident Rights - specific focus on §483.12 that The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms 2. Abuse - As defined by the Centers for Medicare and Medicaid Services, Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 3. Procedure - If an employee suspects or witnesses abuse, they are to immediately protect the resident from abuse. Staff must intervene to assure the safety of the resident and other residents. The alleged perpetrator must be removed from the facility, and cannot be left unattended, to avoid any further contact with residents. The staff member will immediately report the incident or suspicions to their supervisor, Director of Nursing, or Administrator. Appropriate agencies will be notified by the Administrator within two hours of any suspected abuse, neglect, mistreatment or exploitation. On [DATE], the facility's Staff Development Coordinator gathered the facility's policies and procedures regarding Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plan. SDC, MDS, DON, and ADON began 100% in-service education of all clinical staff (LPN, RN, CNA, contract therapy) on this topic with post - test administered. Starting on [DATE], no clinical staff is permitted to work until education is received and post -test completed. Staff education to be completed by [DATE] regarding Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plan. All staff who have not completed in-person / over the phone education and post-tests will be mailed a copy of each via USPS Certified Mail and will not be permitted to work until this education and post-test is completed. Compliance will be ensured and tracked by each employee's respective department manager. This training included: 1. MD Orders / Standing Orders - Educated on process including explanation that there are hard copies orders for all residents in the narcotics book. When a nurse needs to implement a Standing order, facility requires nurse to place that order in the computer (EMR), and complete an E-Interact change of condition form along with that order, and to also document communication in the MD communication book. The expectation is that MD orders will be followed at all times. 2. Interventions for respiratory distress / low O2 levels - facility processes include: Staff member is to be present if resident is noted to be in distress and have a low O2 saturation, Nurse will request that another staff member go and retrieve O2 concentrator or tank with tubing. Staff will follow protocol for administering Oxygen, and how to observe oxygen saturation by using Pulse Ox per protocol. Nurses will delegate to other staff to stay with resident once resident is stable. After resident is stable the nurse is to call MD for orders. Nurse will place all orders into the computer including orders implemented from Standing orders (ex: oxygen placement and settings. Refer to Order/care plan guide for items to include in orders). Nurse will then start completing the required paper work to transfer out if order received. Paperwork includes E-interact Change of Condition, and transfer form. If in an emergent situation arises and the nurse does not feel that the resident is stable, nurse will instruct another staff member to call 911 and help gather the required paperwork. 3. Change of Condition / MD Notification / Resident Assessment- With any change of condition, vital signs need to be obtained appropriately, and frequently, vital signs should be taken at time of incident. If any abnormal VS, vitals need to be obtained at a minimum of every 4 hours until VS stable per baseline. Oxygen - the resident should not be left alone until O2 is at an acceptable level (at acceptable baseline), continue to monitor. Blood pressure- if you have an abnormal blood pressure for the resident, you are to notify the MD immediately and obtain orders, continue to monitor. Pulse- if you have an abnormal pulse for the resident, you are to notify the MD immediately and obtain orders, continue to monitor. Respirations- encourage resident to purse lip breath. In through their nose out through their mouth. Slow, deep and steady. Temperature- Administer medications per standing orders, notify MD, and continue to monitor. 4. Updating / Following of Care Plan - It is the expectation of the facility that nursing staff will follow and / or update each resident's specific plan of care. On [DATE], the Staff Development Coordinator, Director of Nursing, MDS Nurse, and ADON began 100% in-service education with nursing staff that the on-call nurse is to be notified immediately with any and all resident changes in condition. On [DATE], the Administrator / RVP reported the [DATE] event to the NC Department of Health and Human Services via Fax. The Administrator will proceed with required subsequent reporting protocol (5-day report, etc.) as required. On [DATE], the Administrator / RVP began neglect investigation by having DON, ADON, SDC, MDS and Regional Nurse complete 100% interviews with interviewable residents (BIMS>8) to ensure they are free from abuse and neglect. No negative findings were noted during these interviews. On [DATE], the DON, ADON, SDC, MDS and Regional Nurse also completed 100% observation and skin assessments of non-interviewable residents (BIMS<8) to ensure there are no signs or symptoms of fear, neglect, or abuse. No negative findings were noted during these observations and skin assessments. (3) The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and / or in compliance with regulatory requirements: Starting on [DATE], each unit's 24-hour report and available push reports will be reviewed daily (M-F) in clinical meeting to validate identified at-risk residents' vitals are within normal limits, care plans are followed, code statuses honored, and appropriate O2 protocol is being followed as appropriate. On [DATE], the Regional Nurse Consultant developed a monitoring flow sheet to check and validate at-risk residents as identified by the 24-hour report or available push report. This flow sheet includes assessment of abnormal vitals, honoring of code status and care plans, and oxygen protocol being followed as indicated. Starting [DATE], this flow sheet will be populated and reviewed daily (M-F) in morning clinical meeting to review and track at-risk residents over the previous 24 hours (72 hours if weekend). Starting on [DATE], the DON, ADON, SDC, MDS, Regional Nurse, or designated nurse manager will conduct (3) random audits of patient charts to review vitals, code status changes, incident reports, orders, change of condition and required notifications therein, as well as care plans 5x weekly for 4 weeks, then 3x weekly for 4 weeks, then weekly for 4 weeks to monitor delivery of quality care and to ensure resident is free from neglect. Any noted issues from audits will be discussed with the IDT and QA committee and addressed immediately. Starting on [DATE], the DON, ADON, SDC, MDS, Regional Nurse, Manager on Duty, or designated nurse will conduct random abuse post-tests with (3) staff each shift daily x 2 weeks, then (3) staff each shift 2x per week x 4 weeks, then (3) staff each shift 1x per week x 4weeks with score of 100% to ensure staff are well informed of facility abuse / neglect policies and protocols. Any noted issues from post-tests will be discussed with IDT and QA committee and addressed immediately. Starting on [DATE], the DON, ADON, SDC, MDS, Regional Nurse, Manager on Duty, or designated nurse manager with conduct (3) random resident interviews with residents with BIMS > 8 and (3) random resident skin assessments / observations for residents with BIMS < 8 daily x 2 weeks, then 3x per week x 4 weeks, then weekly x 4 weeks to ensure residents are free from abuse and neglect. Any noted issues from interviews / skin assessments will be discussed with IDT and QA committee and addressed immediately. Starting [DATE], the Inter Disciplinary Team and Medical Director will attend QAPI meeting to review the efficacy of the aforementioned plan weekly x 4 weeks, then bi-weekly x 1 month, and then monthly thereafter to ensure continued compliance with the requirements of participation. The IDT includes the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admissions Coordinator, Staff Development Coordinator, Housekeeping Director, Maintenance Director, MDS Nurse, Dietary Director, Medical Director, and Pharmacist. (4) The title of the person responsible for implementing the acceptable plan of correction: The individual responsible for implementing the credible plan of correction is the Administrator. Immediate Jeopardy was removed on [DATE] when the facility demonstrated that staff had been trained on the topics of abuse, neglect, resident rights, Physician Orders, Standing Orders, Interventions for respiratory distress, protocol for low Oxygen levels, change of condition, physician notification, resident assessments, and updating / following care plan. a. 6.28.18 (08:00) NC Department of Health and Human Services arrive to facility to investigate complaint of event on [DATE]. Facility was cited with F600 for neglect. Upon review of the aforementioned event, there is evidence that LPN #1 did not follow facility procedures when addressing Resident #1's change of condition including implementation of interventions for low oxygen saturation levels (78%) and shortness of breath, which subsequently resulted in neglect, defined by CMS as Failure to provide goods and services necessary to avoid phys (TRUNCATED)

Based on record review and interviews the facility failed to assess transfer needs and failed to provide instruction to direct care staff to prevent resident injury during a transfer for one (1) of four (4) sampled residents. (Resident #19). The findings are: 1. Resident #19 was admitted to the facility 04/04/07 with [DIAGNOSES REDACTED]. The latest Minimum Data Set ((MDS) dated [DATE] assessed the resident with no problems with memory or cognition and total dependence on staff assistance for all care. The MDS indicated no transfers, ambulation, or locomotion on or off the unit occurred during the assessment period. A care plan dated 01/07/11 identified Resident #19 at risk for falls related to a history of falls, morbid obesity, immobility, and bleeding. Goals contained in the care plan included resident will be free from injury and will have no signs and symptoms of bleeding threw the next 90 days. Interventions listed for Nursing Service included instruct on and provide safety measures with transfers and personal care to avoid injury to skin. Interventions for nursing assistants were lock wheels on wheelchair prior to transfers. No instructions for nursing assistants regarding method for transfers or how many persons were required for transfers were noted. A review of a nurse progress note dated 01/19/11 at 5:25 p.m. and signed by Licensed Nurse #1 stated "at 1000 (10:00 a.m.) this morning, CNAs (nursing assistants) were assisting the resident in the sit-to-stand lift, to the shower chair - resident was leaning to the left, in the lift and was not attempting to help stand - the CNAs felt like she was going to fall, so they assisted her to sit on the floor - when they sat her on the floor, she bent her left knee slightly". The note continues after the resident was assisted back to bed, she complained of left knee pain. Additional note review revealed the attending physician was notified and ordered an x-ray of the left knee. A review of a Radiology report dated 01/19/11 revealed Resident #19 sustained a fracture involving the left upper leg above the knee with mild displacement. Continued medical record review revealed Resident #19 was admitted to an acute care facility on 01/21/11. Further medical record review revealed the resident required surgical repair of the lower femur which was done 01/26/11. An interview was conducted with Nursing Assistants (NA) #1 and #2 on 02/10/11 at 2:43 p.m. NA #1 stated on the morning of 01/19/11, she and NA #3 utilized the sit-to-stand lift to attempt to transfer Resident #19 from her bed to a wheel chair for transport to the shower room. NA #1 added all attempts were unsuccessful because the resident was unable to hold on to the lift. NA #1 stated they offered Resident #19 the mechanical lift that uses a sling and the resident refused. NA #1 said Resident #19 insisted on going to the shower room for a shower, so she and NA #3 solicited the assistance of NA#2 and NA #6. NA #1 and #2 explained a gait belt was placed around Resident #19's waist. An NA was positioned on each side and in front of the resident. The fourth NA was holding the wheelchair in place. NA #2 stated when they assisted the resident into a standing position, her legs gave way. The three NAs lowered Resident #19 to the floor. An interview with LN #1 on 02/10/11 at 3:08 p.m. and continued at 3:37 p.m. revealed the NAs attempted to use the sit-to-stand lift. She stated the sit-to-stand lift was usually successful in transferring this resident but this morning, she wasn't able to support her own weight. An interview with NA #3 on 02/11/11 at 8:38 a.m. revealed she and NA #1 attempted to transfer Resident #19 from her bed to a wheel chair utilizing the sit-to-stand lift. She stated three attempts were unsuccessful; the resident's arms were not strong enough to hold onto the lift. NA #3 stated it was their decision to solicit two more NAs to attempt a stand and pivot transfer using a gait belt. She added this decision was made without consulting a Licensed Nurse. NA #3 described two NAs stood on each side of the resident, one in front, and one held the wheel chair. When the resident could not stand with assistance, they lowered her to the floor. An interview with the Physical Therapy Director (PTD) on 02/11/11 at 9:22 a.m. revealed Resident #19 was evaluated 09/15/10. She stated the resident was totally non ambulatory and the strength in her legs was fair. She continued the sit-to-stand lift was utilized for this resident at this time and seemed to work well. The PTD added the resident received two (2) physical therapy sessions for leg strengthening before being admitted to the hospital on [DATE]. Approximately three (3) weeks after Resident #19 returned to the facility on [DATE], she was re-evaluated by physical therapy. Resident #19 declined further therapy due to weakness. The PTD stated if consulted, the physical therapist would evaluate a resident and make a recommendation for a lift to be utilized for transfers. An interview with the Director of Nurses (DON) was conducted on 02/11/11 at 10:22 a.m. The DON stated she expected the facility NAs to practice safe lifting and transfer techniques. She added she does not expect the NAs to decide which lift/technique to use on their own; they should consult a Licensed Nurse.

Based on record review and staff interviews the facility repositioned a resident's leg prior to assessment after the resident experienced a fall for one (1) of four (4) sampled residents. (Resident #19) The findings are: 1. Resident #19 was admitted to the facility 04/04/07 with [DIAGNOSES REDACTED]. The latest Minimum Data Set ((MDS) dated [DATE] assessed the resident with memory and cognition intact and total dependence on staff assistance for all care. The MDS indicated no transfers, ambulation, or locomotion on or off the unit occurred during the assessment period. A care plan dated 01/07/11 identified Resident #19 at risk for falls related to a history of falls, [MEDICAL CONDITION], immobility, and bleeding. Goals contained in the care plan included resident will be free from injury for the next 90 days. Interventions for nursing assistants were lock wheels on wheelchair prior to transfers. A review of a nurse progress note dated 01/19/11 at 5:25 p.m. and signed by Licensed Nurse #1 stated "at 1000 (10:00 a.m.) this morning, CNAs (nursing assistants) were assisting the resident in the sit-to-stand lift, to the shower chair - resident was leaning to the left, in the lift and was not attempting to help stand - the CNAs felt like she was going to fall, so they assisted her to sit on the floor - when they sat her on the floor, she bent her left knee slightly". The note continues after the resident was assisted back to bed, she complained of left knee pain. Additional note review revealed the attending physician was notified an ordered an x-ray of the left knee. A review of a Radiology report dated 01/19/11 revealed Resident #19 sustained a fracture involving the left upper leg above the knee with mild displacement. Continued medical record review revealed Resident #19 was admitted to an acute care facility on 01/21/11. Further medical record review revealed the resident required surgical repair of the lower femur which was done 01/26/11. An interview was conducted with Nursing Assistants (NA) #1 and #2 on 02/10/11 at 2:43 p.m. NA #1 stated on the morning of 01/19/11, she and NA #3 utilized the sit-to-stand lift to attempt to transfer Resident #19 from her bed to a wheel chair for transport to the shower room. NA #1 added all attempts were unsuccessful. She said Resident #19 was unable to hold on to the lift. NA #1 stated they offered Resident #19 the mechanical lift that uses a sling and the resident refused. NA #1 reported Resident #19 insisted on going to the shower room for a shower, so she and NA #3 solicited the assistance of NA#2 and NA #6. NA #1 and #2 explained a gait belt was placed around Resident #19's waist. An NA was positioned on each side and in front of the resident. The fourth NA was holding the wheelchair in place. NA #2 stated when they assisted the resident into a standing position, her legs gave way. The three NAs lowered Resident #19 to the floor. NA #1 stated her left leg was bent and under her right leg. The resident repeatedly asked the NA to straighten her leg. NA #1 stated she straightened the leg just as LN #1 walked into the room. An interview with NA #3 on 02/11/11 at 8:38 a.m. revealed the attempt to transfer Resident #19 from her bed to a wheelchair utilizing the gait belt and four person assist was unsuccessful. She added the resident was lowered to the floor. Resident #19's left leg was bent under her right leg. She stated NA #1 straightened out the leg as she went to get a Licensed Nurse. At 8:54 a.m. on 02/11/11, NA #1 stated she did not recall being instructed not to move a resident who had fallen before they were assessed by a nurse. She repeated LN #1 was walking into the room when she straightened Resident #19's leg. NA #1 added the nurse had not assessed the resident before she repositioned the resident's leg. An interview with the Director of Nurses (DON) and the Corporate Nursing Consultant was conducted on 02/11/11 at 10:22 a.m. The DON stated she expected the facility NAs to practice safe lifting and transfer techniques. Following this interview, the Corporate Nursing Consultant provided an undated facility document containing Nursing Assistant Orientation information. He referenced the first bullet under Nursing Assistant strategies to implement when a fall occurs. The first bullet stated "DO NOT move the resident until an assessment had been completed by a licensed nurse".

Based on record review and staff interviews, the facility failed to develop a plan of care guiding direct care staff in safe transfers resulting in resident injury for one (1) of ten (10) sampled residents. (Resident #19). The findings are: Resident #19 was admitted to the facility 04/04/07 with [DIAGNOSES REDACTED]. The latest Minimum Data Set ((MDS) dated [DATE] assessed the resident with memory and cognition intact and total dependence on staff assistance for all care. The MDS indicated no transfers, ambulation, or locomotion on or off the unit occurred during the assessment period. A care plan dated 01/07/11 identified Resident #19 at risk for falls related to a history of falls, [MEDICAL CONDITION], and immobility. Goals contained in the care plan stated resident will be free from injury for the next 90 days. Interventions listed for fall prevention included lock wheel chair prior to transfers and assist bars on bed to aid in self-positioning and transfers. Disciplines targeted for these interventions included nursing and nursing assistants. The care plan also identified the resident as at risk for bleeding regarding the use of anticoagulant therapy with goals of no signs and symptoms of bleeding over the next 90 days. Interventions for this risk included instruct on and provide safety measures with transfers and personal care. Nursing was the discipline targeted by this intervention. No indication of lifts or methods recommended for safe transfers was found on the care plan. A review of a nurse progress note dated 01/19/11 at 5:25 p.m. and signed by Licensed Nurse #1 stated "at 1000 (10:00 a.m.) this morning, CNAs (nursing assistants) were assisting the resident in the sit-to-stand lift, to the shower chair - resident was leaning to the left, in the lift and was not attempting to help stand - the CNAs felt like she was going to fall, so they assisted her to sit on the floor - when they sat her on the floor, she bent her left knee slightly". The note continues after the resident was assisted back to bed, she complained of left knee pain. A review of a Radiology report dated 01/19/11 revealed Resident #19 sustained a fracture involving the left upper leg above the knee with mild displacement. Continued medical record review revealed Resident #19 was admitted to an acute care facility on 01/21/11. Further medical record review revealed the resident required surgical repair of the lower femur which was done 01/26/11. An interview was conducted with Nursing Assistants (NA) #1 and #2 on 02/10/11 at 2:43 p.m. NA #1 stated on the morning of 01/19/11, she and NA #3 utilized the sit-to-stand lift to attempt to transfer Resident #19 from her bed to a wheel chair for transport to the shower room. NA #1 added all attempts were unsuccessful. She continued Resident #19 was unable to hold on to the lift. NA #1 stated they offered Resident #19 the mechanical lift that uses a sling and the resident refused. NA #1 continued Resident #19 insisted on going to the shower room for a shower, so she and NA #3 solicited the assistance of NA #2 and NA #6. NA #1 and #2 explained a gait belt was placed around Resident #19's waist. A NA was positioned on each side and in front of the resident. The fourth NA was holding the wheel chair in place. NA #2 stated when they assisted the resident into a standing position, her legs gave way. The three NAs lowered Resident #19 to the floor. An interview with NA #3 on 02/11/11 at 8:38 a.m. revealed she and NA #1 attempted unsuccessfully to transfer Resident #19 from her bed to a wheelchair utilizing the sit-to-stand lift.. NA #3 stated it was their decision to solicit two more NAs to attempt a stand and pivot transfer using a gait belt. She added this decision was made without consulting a Licensed Nurse. An interview with Unit Manager (UM) #1 on 02/11/11 at 9:00 a.m. revealed the nursing assistant's part of a resident's care plan consisted of interventions from the plan of care designated for direct care staff. She stated all interventions utilized by nursing assistants for Resident #19 are on the nursing assistant plan of care. An interview with the Physical Therapy Director (PTD) on 02/11/11 at 9:22 a.m. revealed Resident #19 was evaluated 09/15/10. She stated the resident was totally non ambulatory and the strength in her legs was fair. She continued the sit-to-stand lift was utilized for this resident at this time and seemed to work well. The PTD added the resident received two (2) physical therapy sessions for leg strengthening before being admitted to the hospital on [DATE]. Approximately three (3) weeks after Resident #19 returned to the facility on [DATE], she was re-evaluated by physical therapy. Resident #19 declined further therapy due to weakness. The PTD stated if consulted, the physical therapist would evaluate a resident and make a recommendation for a lift to be utilized for transfers. At 9:30 a.m. on 02/11/11 NA #1 was observed looking at interventions for Resident #19 on the nursing assistant care plan. Continued interview with NA #1 at this time revealed she was unable to find any intervention indicating which method of transfer or lift should be utilized for Resident #19's transfers. She stated after the incident on 01/19/11, she looked at the care plan to see if she had done anything wrong. NA #1 added she was unable to find any intervention regarding transfers for Resident #19 at that time. She stated after the incident, UM #1 verbally instructed the NAs to only use the mechanical lift with a sling for transfers. NA #1 added two (2) weeks prior to this incident, she had successfully utilized stand and pivot method of transfer with three (3) person assist for Resident #19. An interview with the Director of Nurses (DON) on 02/11/11 at 10:22 a.m. revealed she expected staff to practice safe lifting/transfer techniques. She added these techniques should be included on the resident's care plan. The DON continued care plans should be continually updated according to the performance capabilities of the residents.