Every finding on record at The Carrolton of Williamston

Based on record review, and interviews with resident, staff, the facility's contracted x-ray staff members, Physician, Physician Assistant (PA), and family member, for a resident who suffered from chronic pain the facility 1) failed to ensure the physician was notified when the resident's pain changed in conjunction with the resident reporting trauma to her leg 2) failed to contact the physician prior to entering orders for additional x-rays recommended by an x-ray technician and 3) failed to communicate with the physician when all ordered x-ray views could not be completed due to the resident's pain. This was for one (Resident # 1) of three residents reviewed for notification to physician.The findings included:Resident # 1 was admitted to the facility on [DATE]. Review of Resident # 1's hospital Discharge summary, dated [DATE], revealed Resident # 1 had been hospitalized for diffuse right leg pain, chronic deep vein thrombosis of the popliteal vein of the right lower extremity, acute deep vein thrombosis of right femoral vein, and tibial artery stenosis (narrowing of the arteries in the leg which can lead to pain). The hospital discharge summary also noted Resident # 1 had sustained a fall while hospitalized and complained of hip pain afterwards, but x-rays showed no fracture at that time. Additionally Resident # 1 had diagnoses which included congestive heart failure, peripheral artery disease, cognitive communication deficit, coronary artery disease, diabetes, mild dementia, prior stroke, prior open reduction and internal fixation of a right tibia fracture in 2023, and history of previous deep vein thrombosis in 2022.Resident # 1's quarterly MDS (Minimum Data Set) assessment, dated 4/9/26, coded the resident as cognitively intact and as experiencing pain which occasionally interfered with her daily activities.Resident # 1's orders included the following pain medications:Acetaminophen 1000 (mg) milligrams every eight hours on a scheduled basis, ordered 5/27/26. On the MAR (Medication Administration Record) this was scheduled at 6:00 AM, 2:00 PM, and 10:00 PM)Gabapentin 300 mg twice per day (started 3/17/26) and an additional order for Gabapentin 300 mg (2 capsules) at bedtime (started 3/16/26)Tramadol 50 mg every six hours as needed for pain (started 5/27/26)Menthol topical analgesic gel 5% apply to left knee and hip topically in the morning for discomfort (started 6/6/26)During an interview on 7/10/26 at 12:22 PM with Nurse # 1, Nurse # 1 reported she walked in the room to find the family using a sliding board to transfer the resident on the date of 6/24/26, and the transfer was not being done correctly. Nurse # 1 further reported she intervened to ensure the resident's safety, and the resident did not complain of pain.Review of Resident # 1's electronic record revealed no narrative nursing notes for the date of 6/25/26 (Thursday). Nurse Aide (NA) # 1 was interviewed on 7/8/26 at 4:18 PM and reported the following information. NA # 2 had requested for her to help get Resident # 1 back in bed on 6/25/26 (Thursday) during the 3:00-11:00 PM shift. They lifted her under her arms and by her pants. She had made no noise and did not express pain. She did not hit her leg or fall.NA # 2 was interviewed on 7/9/26 at 4:29 PM and reported the following information. She cared for Resident # 1 on the 3:00-11:00 PM shift on 6/25/26 (Thursday). The resident wanted to go to bed because her leg was hurting. She obtained assistance from NA # 1. They lifted Resident # 1 back to bed by lifting her under her arms and by her pants. They did not let Resident # 1 fall, and she did not hit her knee. The pain she was having was not new.Resident # 1 was interviewed on 7/8/26 at 11:37 AM and again on 7/9/26 at 9:00 AM and reported the following information. She could not recall the specific date but there was one day when two girls were putting her back to bed. She asked them to use the sliding board, and they said they did not have time to mess with that. They lifted her under the arms and dropped her. When she fell, she jumped and hit her knee on the iron part of the bedframe underneath the bed. It hurt right away and she yelled, Oh, my knee-Oh my knee, because the pain was so bad.NA # 3 was interviewed on 7/9/26 at 3:50 PM and reported the following information. On 6/25/25 (Thursday) she was the lead Nurse Aide who helped other Nurse Aides. Around 7:00 PM, Resident # 1 heard her (NA # 3's) voice in the hall and called her into the room. Resident # 1 told her that her leg was hurt when she was being put back to bed that evening. She told Nurse # 2 about the resident's complaint. Nurse # 2 said he would get some cream for the resident's leg.Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information. He had reported to work at 7:00 PM on 6/25/26 (Thursday) but was not assigned to Resident # 1 at the time. Nurse # 3 was Resident # 1's nurse at the time. He recalled someone saying that Resident # 1 had pain in her leg and he got some Biofreeze and gave it to the Medication Aide to put on Resident # 1's leg.Medication Aide # 1 (MA) # 1, who had cared for Resident # 1 on 6/25/26 (Thursday) from 3:00 PM to 11:00 PM, was interviewed on 7/9/26 at 9:35 PM and again on 7/10/26 at 10:10 AM and reported Resident # 1 was having right knee pain and she applied Biofreeze and gave the resident her regularly scheduled pain medication. MA # 1 reported the resident rested after that.Review of Resident # 1's electronic record revealed no narrative nursing notes for the date of 6/26/26 (Friday). NA # 4, who cared for Resident # 1 on the shift which began at 11:00 PM on 6/25/26 (Thursday) and ended at 7:00 AM on 6/26/26 (Friday), was interviewed on 7/8/26 at 4:26 PM. NA # 4 reported the following information. She routinely cared for Resident # 1 and was very familiar with her. The resident could normally help turn herself without any problem and she moved her legs independently in bed. On her (NA 4's) shift, Resident # 1 could not turn because her right thigh was hurting, and the resident reported she had been dropped. The inability to help turn was a change for the resident. She had told Nurse # 2. Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information. He had been assigned to care for Resident # 2 on the 11:00 PM shift which began on 6/25/26 and ended at 7:00 AM on 6/26/26 (Friday). He recalled a Nurse Aide (did not specify which Nurse Aide) telling him that Resident # 1 had knee pain but did not recall the Nurse Aide telling him at the beginning of the shift. She chronically had pain. She additionally had dementia and would see children in the room who were not there, and therefore her confusion would make it difficult to know what was going on with her. Her knee did not look swollen or warm. He gave her the PRN Tramadol Friday (6/26/26) before leaving. He also thought he mentioned to PA (Physician Assistant) # 1 before he left duty that morning about the resident's pain, but then there was another resident around that same time who needed attention and he was unsure what the PA did about it.Review of Resident # 1's June 2026 MAR revealed Nurse # 2 administered Tramadol 50 mg at 5:50 AM on 6/26/26 for a pain level of 10 on a scale of 1 to 10. Nurse # 2 also documented the Tramadol was effective.PA # 1 was interviewed on 7/9/26 at 1:28 PM and reported the following information. She had been in the facility on 6/26/26 (Friday) morning, and no staff member had reported to her that the resident had a difference in her pain or that she had alleged she was dropped. If this had been reported to her, she would have physically assessed the resident while she was at the facility.NA # 6 was interviewed on 7/9/26 at 11:54 AM and reported the following information. She had cared for Resident # 1 on the 7:00 AM to 3:00 PM shift on 6/26/26 (Friday). Resident # 1 was in pain when her right leg was touched. Resident # 1 would grab her thigh and say, It hurts. It hurts when incontinent care was being provided. She had cared for her the previous day, and this was a big change for the resident.Nurse # 4, who had cared for Resident # 1 from 7:00 AM to 3:00 PM on 6/26/26 (Friday), was interviewed on 7/8/26 at 4:55 PM and reported the following information. He did not recall anyone communicating to him about Resident # 1 having a problem on his shift in order that he be able to communicate with the Physician or Physician Assistant.NA # 7, who had cared for Resident # 1 on the 3:00 PM shift to 11:00 PM shift on 6/26/26 (Friday), was interviewed on 7/10/26 at 12:00 PM and reported the following information. When she tried to turn Resident # 1 she would scream in pain. She had told Nurse # 2 and Nurse # 3.MA # 2, who was assigned to care for Resident # 1 from 3:00 PM to 11:00 PM on 6/26/26 (Friday), was interviewed on 7/10/26 at 11:02 AM and reported the following information. The resident reported her right side hurt bad when moved. She gave Resident # 1 her scheduled acetaminophen and she did not recall Resident # 1 complaining of pain after the acetaminophen.Nurse # 3, who was assigned to care for Resident # 1 on the 3:00-11:00 PM shift on 6/2626 (Friday), was interviewed on 7/8/26 at 4:10 PM and reported the following information. She did not recall Resident # 1 having any different pain when she cared for her or being asked to look at her leg. Therefore, she had not contacted the physician about any change in the resident.NA # 4, who cared for Resident # 1 on the shift which began at 11:00 PM on 6/26/26 (Friday) and ended at 7:00 AM on 6/27/26 (Saturday), was interviewed on 7/8/26 at 4:26 PM. NA # 4 reported when she attempted to turn Resident # 1, she was in pain.Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information about the shift which began on 11:00 PM on 6/26/26 (Friday) and ended at 7:00 AM on 6/27/27 (Saturday). That night he did not recall the resident having pain and she slept through the night.On 6/27/26 (Saturday) at 8:25 AM Nurse # 5 documented on Resident # 1's June 2026 MAR that she administered 50 mg of Tramadol per PRN order for a pain level of 7. The nurse also documented the pain medication was effective.Review of Resident # 1's narrative nursing notes on the date 6/27/26 (Saturday) revealed that on 6/27/26 at 10:03 AM Nurse # 5 documented Resident # 1 complained of leg pain and that PRN tramadol was given. The nurse further documented that the resident reported the doctor already knew about it.On 6/27/26 at 3:21 PM Nurse # 5 documented that an x-ray had been ordered and that PA # 1 would assess on Monday.Nurse # 5, who had cared for Resident # 1 from 7:00 AM to 3:00 PM on 6/27/26 (Saturday), was interviewed on 7/8/26 at 7:36 PM and reported the following information. Nurse # 2 had reported in shift change report to her that Resident # 1 had been hurting, and he had spoken to the resident's daughter and had mentioned it to PA # 1. He was trying to get Biofreeze for the resident. She (Nurse # 5) did not know when Nurse # 2 had mentioned it to PA # 1 or what PA # 1 had done about the problem. At the first of the 6/27/26 dayshift, Resident # 1 looked like she was about to cry, and said they had been rough putting her to bed on Thursday (6/25/26). She administered Tramadol to the resident per the PRN order in addition to her scheduled pain medications. She knew Resident # 1 had arthritis and her knee did not look as swollen. She was concerned that the resident had been hurting since Thursday. She did not work at the facility full time but wondered if the resident needed an x-ray. She asked Nurse # 4 (who was working that day on another unit) and routinely worked at the facility if he could help by getting in touch with the physician. The unit on which she (Nurse # 5) was working was very busy. Nurse # 4 said he had not heard anything about the knee pain. She told the resident to stay in bed that day. She did not hear Resident # 1 [NAME] out in pain that day. The pain medication seemed to help, but then at the end of the shift Resident # 1wanted to go to the hospital. She did not know what Nurse # 4 had done about calling the doctor as she had asked. She (Nurse # 5) therefore talked to the DON (Director of Nursing) and let her know that the resident would sleep and then complain of pain when she awakened. The DON then took care of it and she (Nurse # 5) left at the end of her shift.NA # 6 was interviewed on 7/9/26 at 11:54 AM and reported the following information about the shift of 7:00 AM to 3:00 PM on 6/27/27 (Saturday). Resident # 1's leg was warm to the touch and she would scream with turning. She had told Nurse # 5 who was assigned to care for Resident # 1.On 6/27/26 (Saturday) at 3:59 PM MA # 3 documented that he administered Tramadol 50 mg per the resident's PRN order for a pain level of 7. There was an E by the administration on the record noting the pain medication was effective.On 6/27/26 (Saturday) at 5:00 PM, the DON (Director of Nursing) entered the following information in a nursing note. Resident # 1 continued to complain of right knee pain and PA # 1 was notified and ordered an x-ray and ultrasound due to increased pain and swelling. The resident had both a history of arthritis and deep vein thrombosis but stated that her knee was hit on the mattress during transfer from chair to bed. Resident # 1's family member was present at the bedside and was okay with having the x-ray and ultrasound done at the facility. The oncoming nurse was notified. The DON was interviewed on 7/8/26 at 3:06 PM and reported the following information. No one had mentioned any problems to her prior to Saturday (6/27/26). On the evening of 6/27/26 she was at the facility and a Nurse Aide mentioned to her about the resident's pain. The resident's right knee was swollen but it was swollen at baseline. The resident indicated she had increased pain and that she had been having more pain since she had been transferred with a two person assist since around the date of 6/25/26 (Thursday). She did not indicate she had fallen when the DON had talked to her and only indicated she had more pain during the transfer. She (the DON) called and got orders for x-rays and an ultrasound.Review of Resident # 1's orders revealed on 6/27/26 at 3:45 PM a stat order was entered for a two-view x-ray of Resident # 1's right knee. On 6/27/26 at 3:43 PM a two-view x-ray of the resident's left knee was entered into the computer. On 6/27/26 at 4:00 PM a stat ultrasound order was entered into the record. All three of these orders were entered into Resident # 1's electronic record by the DON. On 6/27/26 at 5:30 PM Nurse # 6 entered additional x-ray orders into the computer. These were for a tibia/fibula x-ray to both knees for pain and swelling due to DVT (deep vein thrombosis). This was entered at 5:30 PM. Additionally an x-ray order for one view of the right femur was entered by Nurse # 6 at 6:00 PM due to pain, swelling, and decreased movement of right leg.On 6/27/26 at 5:35 PM Nurse # 6 entered a nursing note with the following information. The mobile x-ray technician had arrived, and the x-ray staff stated that a tibia/fibula Xray should also be done because a plain knee would not show a DVT (deep vein thrombosis). The ultrasound could not be done until Monday (6/29/26).Review of x-ray reports revealed the report date for Resident # 1's x-rays was dated 6/27/26 at 7:41 PM. According to the x-ray report only one view of the resident's right knee was done. The report read, Only a rotated lateral view was obtained. No obvious fracture is seen as best can be determined on a single view exam. No bony lesions are seen. Joints appear aligned. Diffuse osteopenia is demonstrated. Soft tissues are unremarkable. The radiologist further added, Repeat exam is recommended with standard views. The two view x-ray of the left knee and left tibia/fibula were negative. The radiologist also noted that only a single view of the femur and right tibia/fibula had been completed, no fracture was identified, and repeat exam with standard views was recommended.There was no documentation in the resident's record that the physician was contacted when the x-ray report came back showing only one view of the right knee was completed and recommendations had been made for further testing.PA # 1 was interviewed on 7/9/26 at 1:28 PM and reported the following information. The first she was told about Resident # having increased pain in her right knee was on 6/27/26 (Saturday). The staff had called once that evening, and she was informed there had been no trauma but the resident was having pain. The ultrasound and knee x-rays were ordered at that time. No one called her back to discuss further orders or to let her know that only one view had been completed of the resident's right knee. She had not given orders for additional x-rays to be done later in the evening on 6/27/26. PA # 1 also checked the record and verified that the facility had not contacted any other on-call provider other than her on 6/27/26.MA # 3, who had cared for Resident # 1 on the 3:00 PM to 11:00 PM shift on 6/27/26 (Saturday), was interviewed on 7/9/26 at 12:38 PM and reported the following information. Resident # 1 reported that on Thursday (6/25/26) two people did not use the sliding board and they picked her up and pivoted her to bed. She was telling them to wait-wait-my leg but they did it anyway. He gave her PRN Tramadol on the evening shift of 6/27/26. When incontinent care was provided, she would scream but if she was still then she would not hurt bad-bad. The Tramadol helped.NA # 8, who had cared for Resident # 1 from 3:00 PM on 6/27/26 (Saturday) until 7:00 AM on 6/28/26 (Sunday) was interviewed on 7/10/26 at 9:05 AM and reported the following information. Two x-ray technicians came and she could hear Resident # 1 scream when they were in the room. After that during the evening shift, Resident # 1 would not allow her to touch and care for her because she did not want to be turned.Nurse # 6, who had cared for Resident # 1 from 3:00 PM to 11:00 PM on 6/27/26 (Saturday) was interviewed on 7/9/26 at 10:43 AM and reported the following information. Resident # 1's leg did not have warmth or more swelling than usual when she checked on the resident. She also had pulses. The resident reported that pain medication took the pain away. When she talked to Resident # 1, Resident # 1 indicated her pain was her usual pain. Her scheduled pain medications seemed to help, and she would lie in one position with her leg spread out. She tried talking to the resident about the pain and asked her if she fell. Resident # 1 did not say when the incident had happened but Resident # 1 reported that at some point staff were putting her back in bed and she slipped but did not totally hit the floor. She (Nurse # 6) learned that the ultrasound could not be done when the X-ray technician came, and that ultrasounds were only conducted on Mondays through Friday. The x-ray technician indicated there was some sort of protocol that if an ultrasound was unable to be done, then more x-rays could be done. The x-ray technician told her which orders to enter for that. They were for a tibia and fibula x-ray and a right femur x-ray. She did not call the doctor before entering orders, but as she recalled she told the DON. Nurse # 6 was interviewed regarding why the x-ray technician only did one view of Resident # 1's right knee. Nurse # 6 responded initially that she thought the technician might have needed a special slide but then after giving it more thought replied she was unsure.The x-ray technician, who had performed the x-ray tests, was interviewed via phone on 7/10/26 at 12:44 PM along with the X-ray company's Director of Operations and X-ray supervisor. The facility Administrator and Clinical Nurse Consultant also listened into the phone interview. The X-ray technician reported the following information. Only one view of Resident # 1's right knee was done on 6/27/26 because the resident was having pain. The resident's nurse was in and out of the room, and she (the x-ray technician) had informed the nurse why the second view could not be completed. The x-ray for the femur was added on because the resident was also complaining of hip pain, but she (the x-ray technician) did not know what the facility's protocols were for obtaining orders and if the physician was contacted when new orders were added. The nurse had also asked her if they did ultrasounds on the weekend and she had told her she did not know. The X-ray company's Director of Operations reported the following information. The x-ray orders for the right and left knees came in on 6/27/26 at 4:20 PM. Additional orders for the tibia/fibula and femur were added on at 6:02 PM. AT 6:02 PM their records showed only one view of the right knee was uploaded for the radiologist to read. The x-ray report, which showed the results and that only one view had been completed, was available in Resident # 1's facility electronic medical record on 6/27/26 at 7:40 PM.On 6/27/26 (Saturday) at 11:51 PM Nurse # 2 documented on Resident # 1's June 2026 MAR that he administered Tramadol 50 mg at 11:51 PM for a pain level of 10. There was an E by the administration date noting the pain medication was effective. On 6/28/26 (Sunday) at 5:36 AM Nurse # 2 documented at 5:36 AM that he administered Tramadol 50 mg for a pain level of 10. There was an E by the administration date noting the pain medication was effective.During the interview on 7/10/26 at 9:05 AM with NA # 8, who had cared for Resident # 1 from 3:00 PM on 6/27/26 (Saturday) until 7:00 AM on 6/28/26 (Sunday), NA # 8 reported the following information. Nurse # 2 helped her turn Resident # 1 during the night shift part of her two consecutive shifts so they could get Resident # 1 clean. The resident would yell and say, Oh my leg, my leg-wait-wait. Nurse # 2 had helped support her leg so care could be provided. NA # 8 thought that either Nurse # 6 (the evening shift nurse) or Nurse # 2 (the night shift nurse) had said that Resident # 1 would go out to the hospital in the morning. She did not know why the Nurse thought that.Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information. He had been assigned to care for Resident # 2 on the 11:00 PM shift which began on 6/27/26 (Saturday) and ended at 7:00 AM on 6/2826 (Sunday). The resident's x-ray report came back showing no fracture and he indicated therefore he had not called the physician. He medicated the resident for pain during the night.On 6/28/26 at 8:45 AM Nurse # 4 entered the following nursing note into Resident # 1's electronic record. Resident complains of right knee pain this morning, mild swelling noted, daughter wants resident sent to ED (Emergency Department), daughter informed resident had negative Xray done in house yesterday and was negative, also have ultrasound scheduled for Tomm (tomorrow), she still wants to send resident to ED , Ems called at this time.Resident # 1's family member was interviewed on 7/8/26 at 12:01 PM and reported the following information. She had talked to a head manager on 6/27/26 (Saturday) about the resident's pain. Resident # 1 had already been experiencing pain prior to 6/27/27. The head manager said that maybe arthritis had settled in her knee and they could do x-rays at the facility without the resident bumping around in the rescue squad van to the hospital. On 6/28/26 (Sunday) she talked to the nurse who was assigned to Resident # 1 because Resident # 1 was still having pain. She told the nurse that she wanted Resident # 1 to go to the hospital because the resident was still having pain. The nurse told her there was no reason to go because the x-ray showed no fracture. She in turn told him that the resident had previous surgery on the right leg and she was worried something had happened to the screws and rod which was not seen on the facility's x-ray. They debated back and forth about it until the nurse finally said, fine. The resident was sent to the hospital because of her insistence and not because the staff called the physician on 6/28/26.Nurse # 4, who had cared for Resident # 1 beginning at 7:00 AM on 6/28/26 (Sunday), was interviewed on 7/8/26 at 4:55 PM and reported the following information. The resident's x-rays had returned showing no fracture. The family arrived on 6/28/26 and wanted her sent to the hospital, and therefore they sent the resident to the hospital.During the interview with PA # 1 on 7/9/26 at 1:28 PM, PA # 1 validated no one had called her on the morning of 6/28/26 prior to the resident going to the hospital. The first time she was notified was when the staff called her to tell her that the resident had been at the hospital and was returning. On 6/29/26 (Monday) she (PA # 1) saw Resident # 1 and Resident # 1 reported to her that when staff had been placing her to bed they did not want to mess with the sliding board. They picked her up and when they did her leg slipped, twisted, and she fell. She did not think her bottom hit the floor, but she hit her knee.Review of hospital ED records, dated 6/28/26, revealed Resident # 1 reported to the ED physician that last Monday she fell out of her chair when staff had been trying to get her up and dropped her. While at the ED, three views of the right knee were obtained which revealed an acute oblique minimally displaced fracture of the distal metaphysis of the right femur (a break in the thigh bone just above the knee joint). The resident was diagnosed with a displaced comminuted fracture (broken in three of more pieces) of the shaft of the right femur (leg bone). The ED physician noted Resident # 1 was non- ambulatory at her baseline. She was placed in a right leg immobilizer, instructed to follow up with an orthopedic physician, and discharged from the ED back to the facility without hospital admission.On 7/1/26 an orthopedic physician documented Resident # 1 was seen at his office and noted that she was non-ambulatory. Therefore, surgery would not be attempted at that time.Resident # 1's physician, who served as the facility's medical director, was interviewed on 7/10/26 at 1:12 PM and reported the following information. Resident # 1 was not a reliable historian in accounting for things that had happened to her. She would persistently bring up things that had happened a long time ago. She also had osteopenia and had already sustained a fall while in the hospital before being admitted to the facility. There was a chance there was a hairline fracture that was never identified with the hospital fall and due to her osteopenia the crack worsened. Due to her osteopenia, the fracture could have happened even if no crack had pre-existed. The staff at the facility were very good at calling for help if a resident fell to the floor and he did not think that happened. He felt the fracture was of pathological nature due to the resident's condition of her bones and could have happened with routine care. PA # 1 should have been notified on 6/26/26 when she was at the facility so the resident could have been assessed. The PA or on call provider should also have been notified when the staff were aware that all the x-rays views could not be completed as ordered because of the resident's pain. He did not think the resident had been harmed in any way from the delay in notifying the physician and identifying the fracture. She was already receiving pain medication before the fracture was identified. Tramadol was a good pain medication that would have helped with the fracture pain. There was really no difference in her treatment with the identification of the fracture.The Administrator was interviewed on 7/9/26 at 8:25 AM and again on 7/9/26 at 3:25 PM and reported the following information. It never came up to the administrative staff that Resident # 1 had alleged she had fallen to anyone until they saw it in the 6/28/26 hospital ED record and further talked to staff after she returned. According to staff, the resident had never fallen as she had alleged. They had identified that the staff were not using the correct mode of transfer with the resident, and they had completed a plan of correction that dealt with ensuring residents were transferred correctly. While investigating how the resident had fallen, they did identify that there had been a lack of effective communication between their staff but they had not completed a complete plan of correction that entailed audits and an auditing plan to address notification to physician.

Based on record review, and interviews with resident, staff, the facility's contracted x-ray staff members, Physician, Physician Assistant (PA), and family member, for a resident who suffered from chronic pain the facility 1) failed to ensure staff communicated effectively amongst themselves and with the provider about a difference in the resident's pain and alleged trauma the resident reported to some staff members and 2) failed to recognize when the resident's x-ray report returned negative that all views had not been completed as ordered which therefore made the x-ray limited in identifying problems. This was for one (Resident # 1) of three residents reviewed for professional standards of practice.The findings included:Resident # 1 was admitted to the facility on [DATE]. Review of Resident # 1's hospital Discharge summary, dated [DATE], revealed Resident # 1 had been hospitalized for diffuse right leg pain, chronic deep vein thrombosis of the popliteal vein of the right lower extremity, acute deep vein thrombosis of right femoral vein, and tibial artery stenosis (narrowing of the arteries in the leg which can lead to pain). The hospital discharge summary also noted Resident # 1 had sustained a fall while hospitalized and complained of hip pain afterwards, but x-rays showed no fracture at that time. Additionally Resident # 1 had diagnoses which included congestive heart failure, peripheral artery disease, cognitive communication deficit, coronary artery disease, diabetes, mild dementia, prior stroke, prior open reduction and internal fixation of a right tibia fracture in 2023, and history of previous deep vein thrombosis in 2022.Resident # 1's quarterly MDS (Minimum Data Set) assessment, dated 4/9/26, coded the resident as cognitively intact and as experiencing pain which occasionally interfered with her daily activities.Resident # 1's orders included the following pain medications:Acetaminophen 1000 milligrams every eight hours on a scheduled basis; ordered 5/27/26. On the MAR (Medication Administration Record) this was scheduled at 6:00 AM, 2:00 PM, and 10:00 PM.Gabapentin 300 mg twice per day (started 3/17/26) and an additional order for Gabapentin 300 mg (2 capsules) at bedtime (started 3/16/26)Tramadol 50 mg every six hours as needed for pain (started 5/27/26)Menthol topical analgesic gel 5% apply to left knee and hip topically in the morning for discomfort (started 6/6/26)Review of Resident # 1's care plan, revised on 7/2/26, revealed the following information. Resident # 1 experienced chronic pain. Staff were directed to monitor and document the effectiveness of the resident's pain medication. The care plan also included that Resident # 1 needed assistance with transfers. On 3/16/26 two interventions were added to the care plan. One included to transfer Resident # 1 with a mechanical lift and the second included that Resident # 1 was able to transfer with moderate assistance. The current care plan of 7/2/26 only included a mechanical lift transfer. The care plan also noted Resident # 1 had a behavioral problem of talking to a baby that was nonexistent.During an interview with the facility's care plan nurse on 7/9/26 at 9:56 AM, the care plan nurse reported therapy had worked with Resident # 1 when she first was admitted with a two person assist and a sliding board but she had not made sufficient progress for nursing staff to use those two modes of transfer. Upon discontinuation of therapy, staff were supposed to use a mechanical lift for the resident.During an interview with OTA (Occupational Therapist Aide) #1 on 7/8/26 at 2:40 PM and again on 7/10/26 at 10:05 AM OTA # 1 reported the following information. Resident # 1 had been placed back on occupational therapy's caseload at the current time and she (OTA # 1) had been working with Resident # 1 with sliding board transfer training, but Resident # 1 required a lot of assistance with that. Staff were not instructed to use the sliding board with Resident # 1.During an interview on 7/10/26 at 12:22 PM with Nurse # 1, Nurse # 1 reported the following information. On the date of 6/24/26 (Wednesday) she had walked in the room and found Resident # 1's family members pulling Resident # 1 across a sliding board from a wheelchair to the bed. Resident # 1 was not participating, and the sliding board was not placed correctly. Resident # 1's right leg appeared to be bent and out of place. She and another staff member intervened and lifted Resident # 1 back in bed for safety. Once in bed, Resident # 1 appeared fine, laughed and reported she was okay. Nurse # 1 instructed the family that they were not to use the sliding board for Resident # 1.Review of Resident # 1's electronic record revealed no narrative nursing notes for the date of 6/25/26 (Thursday). Nurse Aide (NA) # 1 was interviewed on 7/8/26 at 4:18 PM and reported the following information. NA # 2 had requested for her to help get Resident # 1 back in bed on 6/25/26 (Thursday) during the 3:00-11:00 PM shift. They lifted her under her arms and by her pants. She had made no noise and did not express pain. She did not hit her leg or fall.NA # 2 was interviewed on 7/9/26 at 4:29 PM and reported the following information. She cared for Resident # 1 on the 3:00-11:00 PM shift on 6/25/26 (Thursday). The resident wanted to go to bed because her leg was hurting. She obtained assistance from NA # 1. They lifted Resident # 1 back to bed by lifting her under her arms and by her pants. They did not let Resident # 1 fall, and she did not hit her knee. The pain she was having was not new.Resident # 1 was interviewed on 7/8/26 at 11:37 AM and again on 7/9/26 at 9:00 AM and reported the following information. She could not recall the specific date but there was one day when two girls were putting her back to bed. She asked them to use the sliding board, and they said they did not have time to mess with that. They lifted her under the arms and dropped her. When she fell, she jumped and hit her knee on the iron part of the bedframe underneath the bed. It hurt right away and she yelled, Oh, my knee-Oh my knee, because the pain was so bad.NA # 3 was interviewed on 7/9/26 at 3:50 PM and reported the following information. On 6/25/25 (Thursday) she was the lead Nurse Aide who helped other Nurse Aides. Around 7:00 PM, Resident # 1 heard her (NA # 3's) voice in the hall and called her into the room. Resident # 1 told her that her leg was hurt when she was being put back to bed that evening. She told Nurse # 2 about the resident's complaint. Nurse # 2 said he would get some cream for the resident's leg.Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information. He had reported to work at 7:00 PM on 6/25/26 (Thursday) but was not assigned to Resident # 1 at the time. Nurse # 3 was Resident # 1's nurse at the time. He recalled someone saying that Resident # 1 had pain in her leg and he got some Biofreeze and gave it to the Medication Aide to put on Resident # 1's leg.Medication Aide # 1 (MA) # 1, who had cared for Resident # 1 on 6/25/26 (Thursday) from 3:00 PM to 11:00 PM, was interviewed on 7/9/26 at 9:35 PM and again on 7/10/26 at 10:10 AM and reported the following information. She thought it was NA # 3 who had gone to Nurse # 2 and told him that Resident #1's leg was hurting. Nurse # 2 gave her some Biofreeze to put on the resident's leg. It was Resident # 1's right leg that was hurting. She (MA # 1) lifted Resident # 1's right leg slightly up off the bed and rubbed the Biofreeze under her knee. (MA # 1 demonstrated the degree to which she lifted the leg and it was approximately two inches). Resident # 1 reported the application felt good to her knee. She (MA # 1) also gave Resident # 1 her regularly scheduled bedtime gabapentin and Acetaminophen and she rested after that.Nurse # 3, who was assigned to care for Resident # 1 on the 3:00-11:00 PM shift on 6/25/26 (Thursday), was interviewed on 7/8/26 at 4:10 PM and reported the following information. She did not recall Resident # 1 having any different pain when she cared for her or being asked to look at her leg.Review of Resident # 1's electronic record revealed no narrative nursing notes for the date of 6/26/26 (Friday). NA # 4, who cared for Resident # 1 on the shift which began at 11:00 PM on 6/25/26 (Thursday) and ended at 7:00 AM on 6/26/26 (Friday), was interviewed on 7/8/26 at 4:26 PM. NA # 4 reported the following information. She routinely cared for Resident # 1 and was very familiar with her. The resident could normally help turn herself without any problem and she moved her legs independently in bed. On her (NA 4's) shift, Resident # 1 could not turn because she was hurting. Resident # 1 would run her hand up and down her right thigh and say that was where her leg hurt. Not being able to turn because of pain was a change for Resident # 1. She (NA # 4) asked Resident # 1 what happened and Resident # 1 reported she had fallen. She (NA # 4) asked Resident # 1 how and Resident # 1 reported two girls tried to put her in bed and told her they did not have time to mess with the sliding board. She (NA # 4) had to obtain assistance from NA # 5 that night to help turn Resident # 1 and that was not normal. She provided incontinent care three times during her shift that night and the last two times, she barely lifted each buttock and slid the brief under her because the resident could not turn without having pain. She had told Nurse # 2, and she asked NA # 5 to also tell Nurse # 2 so he would be sure to check the resident.Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information. He had been assigned to care for Resident # 1 on the 11:00 PM shift which began on 6/25/26 and ended at 7:00 AM on 6/26/26 (Friday). He recalled a Nurse Aide (did not specify which Nurse Aide) telling him that Resident # 1 had knee pain. She chronically had pain. She additionally had dementia and would see children in the room who were not there, and therefore her confusion would make it difficult to know what was going on with her. Her knee did not look swollen or warm. He gave her the PRN (as needed) Tramadol Friday (6/26/26) before leaving. He also thought he mentioned to PA (Physician Assistant) # 1 before he left duty that morning about the resident's pain, but then there was another resident around that same time who needed attention and he was unsure what the PA did about it.Review of Resident # 1's June 2026 MAR revealed Nurse # 2 administered Tramadol 50 mg at 5:50 AM on 6/26/26 for a pain level of 10 on a scale of 1 to 10. Nurse # 2 also documented the Tramadol was effective.NA # 6 was interviewed on 7/9/26 at 11:54 AM and reported the following information. She had cared for Resident # 1 on the 7:00 AM to 3:00 PM shift on 6/26/26 (Friday). Resident # 1 was okay if she was not touched but she (NA # 6) had a hard time providing incontinent care because Resident # 1 was in pain when her right leg was touched. Resident # 1 would grab her thigh and say, It hurts. It hurts. This was a big change from when she (NA # 6) had cared for Resident # 1 on the previous dayshift of 6/25/26 (Thursday). On 6/25/26 Resident # 1 had been chipper and had no complaints of pain. She (NA # 6) did not get Resident # 1 out of bed on 6/26/26 (Friday) because of the pain. She (NA # 6) talked to Nurse # 4 and let him know the resident was hurting. She asked Resident # 1 what had happened and initially Resident # 1 said she did not know. Then later Resident # 1 said two girls put her back in bed but did not say what happened when they did so.Nurse # 4, who had cared for Resident # 1 from 7:00 AM to 3:00 PM on 6/26/26 (Friday), was interviewed on 7/8/26 at 4:55 PM and reported the following information. He did not recall anyone communicating to him about Resident # 1 having a problem on his shift.NA # 7, who had cared for Resident # 1 on the 3:00 PM shift to 11:00 PM shift on 6/26/26 (Friday), was interviewed on 7/10/26 at 12:00 PM and reported the following information. Resident # 1 was okay at the beginning of the shift and ate her dinner. After dinner, she (NA # 7) tried to turn Resident # 1 and she screamed in pain. She (NA # 7) talked to MA # 2 who was assigned to care for Resident # 1. Both Nurse 2 and Nurse # 3 were at the nursing desk that night and she and MA # 2 told both of them. Nurse # 3 went to check and assess Resident # 1. She (NA # 7) continued making rounds and never saw Resident # 1 again after that.MA # 2, who was assigned to care for Resident # 1 from 3:00 PM to 11:00 PM on 6/26/26 (Friday), was interviewed on 7/10/26 at 11:02 AM and reported the following information. She had helped NA # 7 provide incontinent care for Resident # 1 that evening. The resident reported her right side hurt bad when moved. It was a little worse than her normal pain. When she got still, the resident was okay. She did notify Nurse # 3 that evening. Her leg did not look different when they changed the resident, and the resident did not report anything that happened. She gave Resident # 1 her scheduled acetaminophen and she did not recall Resident # 1 complaining of pain after the acetaminophen. The resident just did not want to be moved.Nurse # 3, who was assigned to care for Resident # 1 on the 3:00-11:00 PM shift on 6/2626 (Friday), was interviewed on 7/8/26 at 4:10 PM and reported the following information. She did not recall Resident # 1 having any different pain when she cared for her or being asked to look at her leg.NA # 4, who cared for Resident # 1 on the shift which began at 11:00 PM on 6/26/26 (Friday) and ended at 7:00 AM on 6/27/26 (Saturday), was interviewed on 7/8/26 at 4:26 PM. NA # 4 reported the following information. The resident's pain was the same as when she had cared for her the previous night shift. When she attempted to turn Resident # 1, she was in pain. She did not talk to Nurse # 2 again because she had already told him the night before that the resident's pain was different and he was aware.Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information about the shift which began on 11:00 PM on 6/26/26 (Friday) and ended at 7:00 AM on 6/27/27 (Saturday). That night he did not recall the resident having pain and she slept through the night.On 6/27/26 (Saturday) at 8:25 AM Nurse # 5 documented on Resident # 1's June 2026 MAR that she administered 50 mg of Tramadol per PRN order for a pain level of 7. The nurse also documented the pain medication was effective.Review of Resident # 1's narrative nursing notes on the date 6/27/26 (Saturday) revealed that on 6/27/26 at 10:03 AM Nurse # 5 documented Resident # 1 complained of leg pain and that PRN tramadol was given. The nurse further documented that the resident reported the doctor already knew about it.On 6/27/26 at 3:21 PM Nurse # 5 documented that an x-ray had been ordered and that PA # 1 would assess on Monday.Nurse # 5, who had cared for Resident # 1 from 7:00 AM to 3:00 PM on 6/27/26 (Saturday), was interviewed on 7/8/26 at 7:36 PM and reported the following information. Nurse # 2 had reported in shift change report to her that Resident # 1 had been hurting, and he had spoken to the resident's daughter and had mentioned it to PA # 1. He was trying to get Biofreeze for the resident. She (Nurse # 5) did not know when Nurse # 2 had mentioned it to PA # 1 or what PA # 1 had done about the problem. At the first of the 6/27/26 dayshift, Resident # 1 looked like she was about to cry, and said they had been rough putting her to bed on Thursday (6/25/26). She administered Tramadol to the resident per the PRN order in addition to her scheduled pain medications. She knew Resident # 1 had arthritis and her knee did not look as swollen. She was concerned that the resident had been hurting since Thursday. She did not work at the facility full time but wondered if the resident needed an x-ray. She asked Nurse # 4 (who was working that day on another unit) and routinely worked at the facility if he could help by getting in touch with the physician. The unit on which she (Nurse # 5) was working was very busy. Nurse # 4 said he had not heard anything about the knee pain. She told the resident to stay in bed that day. She did not hear Resident # 1 [NAME] out in pain that day. The pain medication seemed to help, but then at the end of the shift Resident # 1wanted to go to the hospital. She did not know what Nurse # 4 had done about calling the doctor as she had asked. She (Nurse # 5) therefore talked to the DON (Director of Nursing) and let her know that the resident would sleep and then complain of pain when she awakened. The DON then took care of it and she (Nurse # 5) left at the end of her shift.NA # 6 was interviewed on 7/9/26 at 11:54 AM and reported the following information about the shift of 7:00 AM to 3:00 PM on 6/27/27 (Saturday). Resident # 1's leg was warm to the touch on her (NA # 6's) shift and it was hard to turn her because of pain. She (NA # 6) had to get help to turn her. She would scream with turning. She had told Nurse # 5 who was assigned to care for Resident # 1.On 6/27/26 (Saturday) at 3:59 PM MA # 3 documented that he administered Tramadol 50 mg per the resident's PRN order for a pain level of 7. There was an E by the administration on the record noting the pain medication was effective.On 6/27/26 (Saturday) at 5:00 PM, the DON (Director of Nursing) entered the following information in a nursing note. Resident # 1 continued to complain of right knee pain and PA # 1 was notified and ordered an x-ray and ultrasound due to increased pain and swelling. The resident had both a history of arthritis and deep vein thrombosis but stated that her knee was hit on the mattress during transfer from chair to bed. Resident # 1's family member was present at the bedside and was okay with having the x-ray and ultrasound done at the facility. The oncoming nurse was notified. The DON was interviewed on 7/8/26 at 3:06 PM and reported the following information. No one had mentioned any problems to her prior to Saturday (6/27/26). On the evening of 6/27/26 she was at the facility and a Nurse Aide mentioned to her about the resident's pain. The resident's right knee was swollen but it was swollen at baseline. The resident indicated she had increased pain and that she had been having more pain since she had been transferred with a two person assist since around the date of 6/25/26 (Thursday). She did not indicate she had fallen when the DON had talked to her and only indicated she had more pain during the transfer. She (the DON) called and got orders for x-rays and an ultrasound.Review of Resident # 1's orders revealed on 6/27/26 at 3:45 PM a stat order was entered for a two-view x-ray of Resident # 1's right knee. On 6/27/26 at 3:43 PM a two-view x-ray of the resident's left knee was entered into the resident's record. On 6/27/26 at 4:00 PM a stat ultrasound order was entered into the record. All three of these orders were entered into Resident # 1's electronic record by the DON. On 6/27/26 at 5:30 PM Nurse # 6 entered additional x-ray orders into the record. These were for a tibia/fibula x-ray to both knees for pain and swelling due to DVT (deep vein thrombosis). This was entered at 5:30 PM. Additionally an x-ray order for one view of the right femur was entered by Nurse # 6 at 6:00 PM due to pain, swelling, and decreased movement of right leg.On 6/27/26 at 5:35 PM Nurse # 6 entered a nursing note with the following information. The mobile x-ray technician had arrived, and the x-ray staff stated that a tibia-fibula Xray should also be done because a plain knee would not show a DVT (deep vein thrombosis). The ultrasound could not be done until Monday (6/29/26).Review of x-ray reports revealed the report date for Resident # 1's x-rays was dated 6/27/26 at 7:41 PM. According to the x-ray report only one view of the resident's right knee was done. The report read, Only a rotated lateral view was obtained. No obvious fracture is seen as best can be determined on a single view exam. No bony lesions are seen. Joints appear aligned. Diffuse osteopenia is demonstrated. Soft tissues are unremarkable. The radiologist further added, Repeat exam is recommended with standard views. The two view x-ray of the left knee and left tibia/fibula were negative. The radiologist also noted that only a single view of the femur and right tibia/fibula had been completed, no fracture was identified, and repeat exam with standard views was recommended.PA # 1 was interviewed on 7/9/26 at 1:28 PM and reported the following information. The first she was told about Resident # 1 having increased pain in her right knee was on 6/27/26 (Saturday). The staff had called once that evening, and she was informed there had been no trauma but the resident was having pain. The ultrasound and knee x-rays were ordered at that time. No one called her back to discuss further orders or to let her know that only one view had been completed of the resident's right knee. The standard x-ray typically includes two or three views, and the staff should have verified with the technician why the two-view could not have been completed.MA # 3, who had cared for Resident # 1 on the 3:00 PM to 11:00 PM shift on 6/27/26 (Saturday), was interviewed on 7/9/26 at 12:38 PM and reported the following information. Resident # 1 reported that on Thursday (6/25/26) two people did not use the sliding board and they picked her up and pivoted her to bed. She was telling them to wait-wait-my leg but they did it anyway. He gave her PRN Tramadol on the evening shift of 6/27/26. When incontinent care was provided, she would scream but if she was still then she would not hurt bad-bad. The Tramadol helped. Resident # 1's family member had arrived and wanted her sent to the hospital. The DON talked to them and the resident had an x-ray ordered at the facility to be done.NA # 8, who had cared for Resident # 1 from 3:00 PM on 6/27/26 (Saturday) until 7:00 AM on 6/28/26 (Sunday) was interviewed on 7/10/26 at 9:05 AM and reported the following information. At the beginning of the evening shift, Resident # 1 was not in need of incontinent care and did not need to be turned. Two x-ray technicians came and she could hear Resident # 1 scream when they were in the room. After that Resident # 1 would not allow her to touch and care for her because she did not want to be turned. She knew one of the x-ray technicians had talked to Nurse # 6 while the technicians had been there.Nurse # 6, who had cared for Resident # 1 from 3:00 PM to 11:00 PM on 6/27/26 (Saturday) was interviewed on 7/9/26 at 10:43 AM and reported the following information. Resident # 1's leg did not have warmth or more swelling than usual when she checked on the resident. She also had pulses. The resident reported that pain medication took the pain away and therefore she (Nurse # 6) did not think it was a blood clot. When she talked to Resident # 1, Resident # 1 indicated her pain was her usual pain. Her scheduled pain medications seemed to help, and she would lie in one position with her leg spread out. She tried talking to the resident about the pain and asked her if she fell. Resident # 1 did not say when the incident had happened but Resident # 1 reported that at some point staff were putting her back in bed and she slipped but did not totally hit the floor. When describing the incident, Resident # 1 pointed to the other bed in the room which did not make sense. The DON obtained orders for the x-rays and an ultrasound on the evening shift. When the x-ray technician arrived she (Nurse # 6) learned that the ultrasound could not be done, and that ultrasounds were only conducted on Mondays through Friday. The x-ray technician indicated there was some sort of protocol that if an ultrasound was unable to be done, then more x-rays could be done. The x-ray technician told her which orders to enter for that. They were for a tibia and fibula x-ray and a right femur x-ray. She did not call the doctor before entering orders, but as she recalled she told the DON. Nurse # 6 was interviewed regarding why the x-ray technician only did one view of Resident # 1's right knee. Nurse # 6 responded initially that she thought the technician might have needed a special slide but then after giving it more though replied she was unsure.The x-ray technician, who had performed the x-ray tests, was interviewed via phone on 7/10/26 at 12:44 PM along with the X-ray company's Director of Operations and X-ray supervisor. The facility Administrator and Clinical Nurse Consultant also listened into the phone interview. The X-ray technician reported the following information. Only one view of Resident # 1's right knee was done on 6/27/26 because the resident was having pain. Resident # 1 would say, Don't move me. Don't move me. The resident's nurse was in and out of the room, and she (the x-ray technician) had informed the nurse why the second view could not be completed. The x-ray for the femur was added on because the resident was also complaining of hip pain, but she (the x-ray technician) did not know what the facility's protocols were for obtaining orders and if the physician was contacted when new orders were added. The nurse had also asked her if they did ultrasounds on the weekend and she had told her she did not know. The X-ray company's Director of Operations reported the following information. The x-ray orders for the right and left knees came in on 6/27/26 at 4:20 PM. Additional orders for the tibia/fibula and femur were added on at 6:02 PM. AT 6:02 PM their records showed only one view of the right knee was uploaded for the radiologist to read. The x-ray report, which showed the results and that only one view had been completed, was available in Resident # 1's facility electronic medical record system on 6/27/26 at 7:40 PM.On 6/27/26 (Saturday) at 11:51 PM Nurse # 2 documented on Resident # 1's June 2026 MAR that he administered Tramadol 50 mg at 11:51 PM for a pain level of 10. There was an E by the administration date noting the pain medication was effective. On 6/28/26 (Sunday) at 5:36 AM Nurse # 2 documented at 5:36 AM that he administered Tramadol 50 mg for a pain level of 10. There was an E by the administration date noting the pain medication was effective.During the interview on 7/10/26 at 9:05 AM with NA # 8, who had cared for Resident # 1 from 3:00 PM on 6/27/26 (Saturday) until 7:00 AM on 6/28/26 (Sunday), NA # 8 reported the following information. Nurse # 2 helped turn Resident # 1 during the night shift part of her two consecutive shifts so they could get Resident # 1 clean. The resident would yell and say, Oh my leg, my leg-wait-wait. She (NA # 8) did not think that people understood how much pain Resident # 1 had until they were helping the resident turn. Nurse # 2 had helped support her leg so care could be provided. NA # 8 thought that either Nurse # 6 (the evening shift nurse) or Nurse # 2 (the night shift nurse) had said that Resident # 1 would go out to the hospital in the morning. Nurse # 2 was interviewed on 7/8/26 at 11:16 PM and again on 7/9/26 at 7:10 AM and reported the following information. He had been assigned to care for Resident # 2 on the 11:00 PM shift which began on 6/27/26 (Saturday) and ended at 7:00 AM on 6/2826 (Sunday). The resident's x-ray report came back showing no fracture. He medicated the resident for pain during the night. Although the x-ray was negative, he did recall one morning while he was working with her, that she hollered when she would roll over while he was assigned to her. He did not recall which day.On 6/28/26 at 8:45 AM Nurse # 4 entered the following nursing note into Resident # 1's electronic record. Resident complains of right knee pain this morning, mild swelling noted, daughter wants resident sent to ED (Emergency Department), daughter informed resident had negative Xray done in house yesterday and was negative, also have ultrasound scheduled for Tomm (tomorrow), she still wants to send resident to ED , Ems called at this time.Resident # 1's family member was interviewed on 7/8/26 at 12:01 PM and reported the following information. She had talked to a head manager on 6/27/26 (Saturday) about the resident's pain. Resident # 1 had already been experiencing pain prior to 6/27/27. The head manager said that maybe arthritis had settled in her knee and they could do x-rays at the facility without the resident bumping around in the rescue squad van to the hospital. On 6/28/26 (Sunday) she talked to the nurse who was assigned to Resident # 1 because Resident # 1 was still having pain. She told the nurse that she wanted Resident # 1 to go to the hospital because the resident was still having pain. The nurse told her there was no reason to go because the x-ray showed no fracture. She in turn told him that the resident had previous surgery on the right leg and she was worried something had happened to the screws and rod which was not seen on the report. They debated back and forth about it until the nurse finally said, fine.Nurse # 4, who had cared for Resident # 1 beginning at 7:00 AM on 6/28/26 (Sunday), was interviewed on 7/8/26 at 4:55 PM and reported the following information. On 6/28/26, the resident's x-rays had returned showing no fracture. The family arrived and wanted her sent to the hospital, and therefore they sent the resident to the hospital.Review of hospital ED (Emergency Department) records, dated 6/28/26, revealed Resident # 1 reported to the ED physician that last Monday she fell out of her chair when staff had been trying to get her up and dropped her. While at the ED, three views of the right knee were obtained which revealed an acute oblique minimally displaced fracture of the distal metaphysis of the right femur (a break in the thigh bone just above the knee joint). The resident was diagnosed with a displaced comminuted fracture (broken in three of more pieces) of the shaft of the right femur (leg bone). The ED physician noted Resident # 1 was non- ambulatory at her baseline. She was placed in a right leg immobilizer, instructed to follow up with an orthopedic physician, and discharged from the ED back to the facility without hospital admission.On 7/1/26 an orthopedic physician documented Resident # 1 was seen at his office and noted that she was non-ambulatory. Therefore, surgery would not be attempted at that time.Resident # 1's physician, who served as the facility's medical director, was interviewed on 7/10/26 at 1:12 PM and reported the following information. Resident # 1 was not a reliable historian in accounting for things that had happened to her. She would persistently bring up things that had happened a long time ago. She also had osteopenia and had already sustained a fall while in the hospital before being admitted to the facility. There was a chance there was a hairline fracture that was never identified with the hospital fall and due to her osteopenia the crack worsened. Due to her osteopenia, the fracture could have happened even if no crack had pre-existed. The staff at the facility were very good to call for help if a resident fell to the floor and he did not think that happened. He felt the fracture was of pathological nature due to the resident's condition of her bones and could have happened with routine care. He also did not think the resident had been harmed in any way from the delay in identifying the fracture. She was already receiving pain medication before the fracture was identified. Tramadol was a good pain medication that would have helped with the fracture pain. There was really no difference in her treatment with the identification of the fracture.The Administrator was interviewed on 7/9/26 at 8:25 AM and again on 7/9/26 at 3:25 PM and reported the following information. It never came up to the administrative staff that Resident # 1 had alleged she had fallen to anyone until they saw it in the 6/28/26 hospital ED record and further talked to staff after she returned. According to staff, the resident had never fallen as she had alleged. They had identified that the staff were not using the correct mode of transfer with the resident, and they had completed a plan of correction that dealt with ensuring residents were transferred correctly. While investigating how the resident had fallen, they did identify that there had been a lack of effective communication between their staff but they had not completed a complete plan of correction that ent

Based on observation, record review, and interviews with resident, staff, the facility's contracted x-ray staff members, Physician, Physician Assistant, and family member, for a resident who had not made sufficient progress in therapy to stand and pivot or use a sliding board, the facility failed to ensure she was transferred by staff by a mechanical lift as outlined in the resident's care plan. This was for one (Resident # 1) of three residents reviewed for accidents.The findings included:Resident # 1 was admitted to the facility on [DATE]. Review of Resident # 1's hospital Discharge summary, dated [DATE], revealed Resident # 1 had been hospitalized for diffuse right leg pain, chronic deep vein thrombosis of the popliteal vein of the right lower extremity, acute deep vein thrombosis of right femoral vein, and tibial artery stenosis (narrowing of the arteries in the leg which can lead to pain). The hospital discharge summary also noted Resident # 1 had sustained a fall while hospitalized and complained of hip pain afterwards, but x-rays showed no fracture at that time. Additionally Resident # 1 had diagnoses which included congestive heart failure, peripheral artery disease, cognitive communication deficit, coronary artery disease, diabetes, mild dementia, prior stroke, prior open reduction and internal fixation of a right tibia fracture in 2023, and history of previous deep vein thrombosis in 2022.Resident # 1's quarterly MDS (Minimum Data Set) assessment, dated 4/9/26, coded the resident as cognitively intact and as experiencing pain which occasionally interfered with her daily activities. She was coded as needing partial to moderate assistance with transfers during the assessment period.Review of Resident # 1's current care plan, revised on 7/2/26, revealed the following information. Resident # 1 was to transfer with a mechanical lift. This had been originally added to the care plan on 3/16/26 and remained when the care plan was revised on 4/8/26 and on 7/2/26. Review of previous interventions on the care plan revealed that on 3/16/26 there was also an intervention added that included Resident # 1 was to be transferred with moderate assistance. This was no longer a part of the active care plan. The care plan also noted Resident # 1 had a behavioral problem of talking to a baby that was nonexistent and experienced chronic pain.Review of therapy notes revealed Resident # 1 received physical therapy from 3/16/26 until 4/24/26. At time of physical therapy discharge, the resident's mobility total score was a 3 with a score of 12 being the highest which would indicate the highest mobility on the scale. The discharging therapist also noted sliding board training had been given to Resident # 1 and at time of discharge she still required moderate to maximum assistance to use the sliding board.During an interview with the facility's care plan nurse on 7/9/26 at 9:56 AM, the care plan nurse reported therapy had worked with Resident # 1 when she first was admitted with a two person assist and a sliding board, but the resident did not make sufficient progress with those two transfer modes in order that they be used by nursing staff. Upon discontinuation of therapy, nursing staff were supposed to use a mechanical lift for the resident. This had been conveyed from therapy staff to her as the care plan nurse.During an interview with OTA (Occupational Therapist Aide) #1 on 7/8/26 at 2:40 PM and again on 7/10/26 at 10:05 AM OTA # 1 reported the following information. Resident # 1 had been placed back on occupation therapy's caseload and was currently receiving occupational therapy once again. She (OTA # 1) had been working with Resident # 1 with sliding board transfer training again, but Resident # 1 required a lot of assistance with that. Nursing staff were not instructed to use the sliding board with Resident # 1.Review of orders revealed Resident # 1 regularly received Acetaminophen and gabapentin on a scheduled basis. She additionally had orders for PRN (as needed) Tramadol. These orders had been in effect prior to 6/24/26. According to Resident # 1's Medication Administration Record, Resident # 1 received PRN Tramadol five times from 6/26/26 to the morning of 6/28/26; with notations the pain medication was effective. She was also documented as receiving her scheduled gabapentin and acetaminophen as ordered on all days between 6/25/26 and 6/28/26.During an interview on 7/10/26 at 12:22 PM with Nurse # 1, Nurse # 1 reported the following information. On the date of 6/24/26 (Wednesday) she had walked in the room and found Resident # 1's family members pulling Resident # 1 across a sliding board from a wheelchair to the bed. Resident # 1 was not participating, and the sliding board was not placed correctly. Resident # 1's right leg appeared to be bent and out of place. She and another staff member intervened and lifted Resident # 1 back in bed for safety. She was concerned that the family was using the sliding board and asked the resident to press down with her left foot onto her (Nurse # 1's) foot to see if she had any strength to even be a candidate for using the sliding board. Resident # 1 could not press down with her left leg at all onto the nurse's foot. Once in bed, Resident # 1 appeared fine, laughed and reported she was okay. Nurse # 1 instructed the family that they were not to use the sliding board for Resident # 1.Review of Resident # 1's electronic record revealed no narrative nursing notes for the date of 6/25/26 (Thursday). Nurse Aide (NA) # 1 was interviewed on 7/8/26 at 4:18 PM and reported the following information. NA # 2 had requested for her to help get Resident # 1 back in bed on 6/25/26 (Thursday) during the 3:00-11:00 PM shift. They lifted her under her arms and by her pants. She had made no noise and did not express pain. She did not hit her leg or fall.NA # 2 was interviewed on 7/9/26 at 4:29 PM and reported the following information. She cared for Resident # 1 on the 3:00-11:00 PM shift on 6/25/26 (Thursday). That was the first time she had transferred Resident # 1, and she had not referenced the care plan before transferring the resident. The resident wanted to go to bed because her leg was hurting. She obtained assistance from NA # 1. They lifted Resident # 1 back by bed by lifting her under her arms and by her pants. They did not let Resident # 1 fall, and she did not hit her knee. The pain she was having was not new.Resident # 1 was interviewed on 7/8/26 at 11:37 AM and again on 7/9/26 at 9:00 AM and reported the following information. She could not recall the specific date but there was one day when two girls were putting her back to bed. She asked them to use the sliding board, and they said they did not have time to mess with that. They lifted her under the arms and dropped her. When she fell, she jumped and hit her knee on the iron part of the bedframe underneath the bed. It hurt right away and she yelled, Oh, my knee-Oh my knee, because the pain was so bad.On 6/27/26 (Saturday) at 5:00 PM, the DON (Director of Nursing) entered the following information in a nursing note. Resident # 1 continued to complain of right knee pain and PA # 1 was notified and ordered an x-ray and ultrasound due to increased pain and swelling. The resident had both a history of arthritis and deep vein thrombosis but stated that her knee was hit on the mattress during transfer from chair to bed. Resident # 1's family member was present at the bedside and was okay with having the x-ray and ultrasound done at the facility. The oncoming nurse was notified. The DON was interviewed on 7/8/26 at 3:06 PM and reported the following information. No one had mentioned any problems to her prior to Saturday (6/27/26). On the evening of 6/27/26 she was at the facility and a Nurse Aide mentioned to her about the resident's pain. The resident's right knee was swollen but it was swollen at baseline. The resident indicated she had increased pain and that she had been having more pain since she had been transferred with a two person assist since around the date of 6/25/26 (Thursday). She did not indicate she had fallen when the DON had talked to her and only indicated she had more pain during the transfer. She (the DON) called and got orders for x-rays and an ultrasound.Review of x-ray reports revealed the report date for Resident # 1's x-rays was dated 6/27/26 at 7:41 PM. According to the x-ray report only one view of the resident's right knee was done. The report read, Only a rotated lateral view was obtained. No obvious fracture is seen as best can be determined on a single view exam. No bony lesions are seen. Joints appear aligned. Diffuse osteopenia is demonstrated. Soft tissues are unremarkable. The radiologist further added, Repeat exam is recommended with standard views. The two view x-ray of the left knee and left tibia/fibula were negative. The radiologist also noted that only a single view of the femur and right tibia/fibula had been completed, no fracture was identified, and repeat exam with standard views was recommended.MA # 3, who had cared for Resident # 1 on the 3:00 PM to 11:00 PM shift on 6/27/26 (Saturday), was interviewed on 7/9/26 at 12:38 PM and reported the following information. Resident # 1 reported that on Thursday (6/25/26) two people did not use the sliding board and they picked her up and pivoted her to bed. She was telling them to wait-wait-my leg but they did it anyway. He gave her PRN Tramadol on the evening shift of 6/27/26. The Tramadol helped. Since he had cared for Resident # 1, he had seen the mechanical lift used to transfer the resident only one time. The Nurse Aides would generally take off the wheelchair arm, place the wheelchair next to the bed, and stand and pivot the resident. At one time there had been a sliding board in the resident's room and he had seen some of the Nurse Aides use that also. It had not been in her room on the date of 6/27/26.On 6/28/26 at 8:45 AM Nurse # 4 entered the following nursing note into Resident # 1's electronic record. Resident complains of right knee pain this morning, mild swelling noted, daughter wants resident sent to ED (Emergency Department), daughter informed resident had negative X-ray done in house yesterday and was negative, also have ultrasound scheduled for Tomm (tomorrow), she still wants to send resident to ED , Ems called at this time.Review of hospital ED records, dated 6/28/26, revealed Resident # 1 reported to the ED physician that last Monday she fell out of her chair when staff had been trying to get her up and dropped her. While at the ED, three views of the right knee were obtained which revealed an acute oblique minimally displaced fracture of the distal metaphysis of the right femur (a break in the thigh bone just above the knee joint). The resident was diagnosed with a displaced comminuted fracture (broken in three of more pieces) of the shaft of the right femur (leg bone). The ED physician noted Resident # 1 was non- ambulatory at her baseline. She was placed in a right leg immobilizer, instructed to follow up with an orthopedic physician, and discharged from the ED back to the facility without hospital admission.On 7/1/26 an orthopedic physician documented Resident # 1 was seen at his office and noted that she was non-ambulatory. Therefore, surgery would not be attempted at that time.Resident # 1's physician, who served as the facility's medical director, was interviewed on 7/10/26 at 1:12 PM and reported the following information. Resident # 1 was not a reliable historian in accounting for things that had happened to her. She would perseverate over things. She also had osteopenia and had already sustained a fall while in the hospital before being admitted to the facility. There was a chance there was a hairline fracture that was never identified with the hospital fall and due to her osteopenia the crack worsened. Due to her osteopenia, the fracture could have happened even if no crack had pre-existed. The staff at the facility were very good to call for help if a resident fell to the floor and he did not think that happened. He felt the fracture was of pathological nature due to the resident's condition of her bones and could have happened with routine care. He also did not think the resident had been harmed in any way from the delay in identifying the fracture. She was already receiving pain medication before the fracture was identified. Tramadol was a good pain medication that would have helped with the fracture pain. There was really no difference in her treatment with the identification of the fracture.The Administrator was interviewed on 7/9/26 at 8:25 AM and again on 7/9/26 at 3:25 PM and reported the following information. It never came up to the administrative staff that Resident # 1 had alleged she had fallen to anyone until they saw it in the 6/28/26 hospital ED record and further talked to staff after she returned although the resident had indicated to the DON on 6/27/26 that the pain started during a transfer around the time of 6/25/26. According to staff, the resident had never fallen as she had alleged. When the resident returned from the hospital and they saw she alleged that she had fallen, they completed a complete plan of correction. They were unable to corroborate that the resident had fallen. They had identified that the staff were not using the correct mode of transfer with the resident. They also identified that the resident's care plan had two modes of transfer. Both the mechanical lift was listed, and the moderate assistance transfer had been on the care plan when they investigated the incident. They had removed the moderate assistance transfer direction on the care plan. They had completed a plan of correction that dealt with ensuring residents were transferred correctly. The Administrator presented the following plan of correction.Immediate action(s) taken for the resident(s) found to have been affected include:On 6/25/26 CNAs (certified nurse aides) 1 and CNA 2 provided a transfer to resident #1, using 2 person assist method. During the days of 6/26/26 through 6/27/26, the resident began expressing increased pain above her normal baseline. The MD / NP ordered interventions to address the pain and diagnose the root cause. Immediate interventions included multiple x-rays (with no negative findings) after which, she was sent for an emergency room visit on 6/28/26. During the ER visit, the resident had another x-ray, and was diagnosed to have a comminuted fracture of the right femur. Consultation with the physician confirmed that a comminuted fracture is a pathological fracture of crumbling nature thereby ruling out the transfer method as the source for root cause. Review of her medical record revealed that Resident #1, was identified to have a care plan that did not reflect the correct method of transfer on 6/28/26. The care plan indicated a transfer method of moderate assist on the comprehensive care plan and mechanical lift on the individual care service plan. Interviews with the Rehab Director (Rehabilitation Director) and the nursing aides that work with the resident revealed that the resident was initially moderate assist with 2 person assist but was transitioned to a mechanical lift transfer.2. Identification of other residents having the potential to be affected was accomplished by:All residents (100%) with transfers have the potential to be negatively impacted by inconsistent care plan directions for transfer instructions. An audit of 100% of the facility's current care plans was conducted by the DON / designee to ensure accuracy related to mode of transfers. This audit was completed 7/2/26. Problems identified include no transfer directions and 3 with inconsistencies. Any discrepancies that were identified were corrected on that date. The facility administrator, Director of Nursing, and Unit Manager met via phone with Carrolton Facility Management (Chief Operating Officer and Chief Nursing Officer) on 6/27/26 and 6/28/26 to discuss the situation and plans for corrective action regarding the transfer (from 6/25/26). On 6/29/27 the Administrator held an ad-hoc QAPI meeting to discuss the incident, plan of correction and monitoring that will be used to monitor effectiveness. A corrective plan was implemented on that date. Actions taken/systems put into place to reduce the risk of future occurrence include:All nursing staff members were in serviced between 6/28/26 and 7/2/26. Staff members were not allowed to work until they had completed education. Education topics included:Safe transfers and effective communication Reviewing and following the care plan prior to attempting transfer and calling the nurse if there are any questions about transfer status.If the resident asks you to stop or wait- follow the resident's instructions.Nurses were educated about assessing residents for any changes, including increased pain.All incident / accident reports for the last 90 days were reviewed to identify if care plan errors were the cause of the incident with no negative findings. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur:All incident / accident reports will be monitored daily by the Director of Nursing daily to identify root cause and intervention. Nursing staff members will be educated immediately the DON or designee, if problems are identified. Any week-end incidents are reviewed during the Monday Morning clinical meeting to ensure follow up. All incident / accident reports will be monitored daily by the Administrator to ensure that they are complete, accurate, and appropriate follow-up and intervention. Additional education will be provided to the DON if problems are identified. The Director of Nursing and Unit Manager will monitor five (5) transfers a week for four (4) weeks beginning the week of 7/6/26 to ensure that transfers are completed safely and in accordance with the resident's care plan. All incidents will be reviewed by the QAPI committee for tracking and trending to ensure that interventions were implemented appropriately until the committee determines that consistent, substantial compliance has been achieved. Corrective action completion date: July 3, 2026 The facility's corrective action plan was validated by the following:Beginning on 7/8/26 a tour of the facility was conducted during which multiple interviews were conducted with residents. Other than Resident # 1, no other resident had complaints of improper transfers or safety concerns. On 7/9/26 at 3:45 PM two Nurse Aides were observed as they transferred a dependent resident from bed to wheelchair. The Nurse Aides were observed to transfer the resident safely and by the correct intervention noted on the resident's active care plan. During the survey, multiple nursing staff were interviewed and validated that they had attended inservice training as per the facility's plan of correction. Staff were able to report topics that were covered. A review of Resident # 1's current care plan revealed the care plan had only one mode of transfer and that was for a mechanical lift transfer. The facility presented audits as outlined in their plan of correction. The facility's completion date for their corrective action plan was validated to be 7/3/26.

Based on record review and interviews with resident and staff the facility failed to ensure the accurate documentation and administration of a controlled medication in sufficient detail to enable an accurate reconciliation. This was for one (Resident # 4) of three sampled residents whose controlled drug records were reviewed.The findings included:Record review revealed Resident # 4 was admitted to the facility on [DATE]. One of Resident # 4's diagnoses included chronic pain syndrome.Resident # 4's quarterly MDS (Minimum Data Set) assessment, dated 5/20/26, coded the resident as cognitively intact.Review of Resident # 4's medication orders and Medication Administration Record (MAR) revealed the following orders:Fentanyl transdermal patch 72 hour 50 micrograms/hour every three days (started 2/14/26)Morphine Sulfate Extended Release 15 mg (milligrams) every 12 hours (started 2/13/26); The Morphine was scheduled on the MAR to be given at 9:00 AM and 9:00 PM. Nurses were to sign a pain level score with each administration of Morphine at 9:00 AM and 9:00 PM on the MAR.Percocet 10-325 milligrams one tablet every eight hours PRN (as needed) for pain/discomfort (started 3/13/26)A reconciliation review of Resident # 4's Percocet Controlled Substance Declining Sheet with Resident # 4's MAR revealed the following information. (A Controlled Substance Declining Sheet reflects when a nurse signs out controlled substances from a resident's supply from double locked storage in order to administer the controlled medication).On 6/2/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/2/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/2/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 0 when he administered the resident's scheduled Morphine (which was the same time Nurse # 4 removed the Percocet without signing the Percocet was administered.) On 6/3/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/3/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/3/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 0 when he administered the resident's scheduled Morphine (which was the same time Nurse # 4 removed the Percocet without signing the Percocet was administered.) On 6/10/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/10/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/10/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 0 when he administered the resident's scheduled Morphine (which was the same time Nurse # 4 removed the Percocet without signing the Percocet was administered.) On 6/13/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/13/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/13/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 0 when he administered the resident's scheduled Morphine (which was the same time Nurse # 4 removed the Percocet without signing the Percocet was administered.) On 6/14/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/14/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/14/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 0 when he administered the resident's scheduled Morphine (which was the same time Nurse # 4 removed the Percocet without signing the Percocet was administered.) On 6/16/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/16/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/16/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 7 when he administered the resident's scheduled Morphine at 9:00 AM. On 6/17/26 at 9:00 AM Nurse # 4 signed he removed one dose of Resident # 4's Percocet from controlled storage.On 6/17/26 there was no documentation on Resident # 4's MAR the Percocet was administered at any time that day.On 6/17/26 at 9:00 AM Nurse # 4 documented Resident # 4's pain level was a 0 when he administered the resident's scheduled Morphine (which was the same time Nurse # 4 removed the Percocet without signing the Percocet was administered.) Nurse # 4 was interviewed on 7/9/26 at 3:00 PM and Resident # 4's MAR and Percocet Controlled Substance Declining Sheet were reviewed with Nurse # 4. Nurse # 4 reported the following information. He had administered the Percocet to Resident # 4 every time he had signed out for the Percocet. He (Nurse # 4) was aware that Resident # 4 hurt, and he would say he was in pain. He would give him the Percocet in addition to the scheduled Morphine. Nurse # 4 was further interviewed regarding why the record noted the resident's pain level was a 0 at some of the times that the Percocet was removed. Nurse # 4 reported there was a button on the MAR that you could press to bring forward the last pain level score and at times he would do that rather than put the actual pain level. On 7/9/26 at 3:18 PM the Unit Manger was accompanied to Resident # 4's room and Resident # 4 was interviewed regarding whether he had been requesting and receiving Percocet. The resident reported he had not been requesting Percocet, and he only wanted his scheduled pain medications because he was concerned about addiction. Interview with the Corporate Nurse Clinical Consultant on 7/10/26 at 10:30 AM revealed the following information. Prior to 7/9/26 the facility had not been aware of any controlled substance records that could not be reconciled with administration of controlled substances. Following the interview with Resident # 4 on 7/9/26, who had reported he had not requested the Percocet, Nurse # 4 was drug tested and was negative. Therefore, the facility did not suspect diversion. Nurse # 4 was counseled on the accounting for controlled substances. The Clinical Nurse Consultant reported that Resident # 4's Controlled Substance Declining Sheet should be able to be reconciled to match the administration of the Percocet on Resident # 4's MAR and that the resident's documented pain level should coincide to support the use of the removal and administration of the Percocet. The Administrator was interviewed on 7/10/26 at 3:31 PM and reported that although Resident # 4 was assessed to be cognitively intact on his Minimum Data Set Assessment and had reported he had not requested the Percocet, that Resident # 4 did have periods of confusion.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set Assessment (MDS) for dialysis services for 1 of 5 residents reviewed for accuracy of assessments (Resident #2).The findings included: Resident #2 was readmitted to the facility on [DATE] with diagnoses including end-stage renal disease requiring dialysis.Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had end-stage renal disease but did not reflect that dialysis services were being provided. During an interview with the MDS nurse on 1/7/26 at 9:14 am, she stated the former MDS nurse should have indicated Resident #2 was receiving dialysis services and acknowledged the error. She confirmed that the MDS assessment was inaccurate and that the MDS should have been coded correctly by the former MDS nurse. An attempt was made to interview the former MDS nurse by telephone on 1/7/26 at 11:57 am with no return call. During an interview with the Administrator on 1/7/26 at 1:00 pm, he stated the expectation was for all MDS assessments to be accurately coded.

Based on record review and staff interviews, the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis for 1 of 1 resident reviewed for dialysis (Resident #2).The findings included: A review of the hospital Discharge summary dated [DATE] revealed that Resident #2 was hospitalized on [DATE] due to shortness of breath and progressive renal failure. A permacath (a soft flexible tube used for long-term dialysis access) was placed for the initiation of dialysis, and dialysis was initiated on 8/19/25. Subsequent treatments were scheduled on Tuesday, Thursday, and Saturday outpatient dialysis schedule.Resident #2 was readmitted to the facility on [DATE] with diagnoses including end-stage renal disease requiring dialysis.Upon readmission to the facility on 8/26/25, the physician's orders did not include dialysis services.The resident's care plan, updated on 8/27/25, documented the need for dialysis related to renal failure with interventions which included checking and changing dressing daily at the access site, monitoring the access site daily and as needed for signs of infection, redness, swelling, warmth or drainage and encourage resident to go for the scheduled dialysis appointments three times a week.Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident as having end-stage renal disease. Resident #2 was not coded for receiving dialysis services.During an interview on 1/6/26 at 11:36 am, Nurse #2 stated Resident #2 was at dialysis and would return to facility between 12:15 pm and 12:30 pm. The Director of Nursing (DON) was interviewed on 1/6/26 at 2:20 pm and reported she was unaware that the dialysis order was missing and acknowledged staff likely failed to enter the order upon Resident #2's readmission.In an interview on 1/7/26 at 1:00 pm, the Administrator stated the dialysis order should have been entered into the computer system when the resident returned from the hospital.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #38 and Resident #54). The findings included: 1. Resident #38 was admitted to the facility on [DATE]. He was readmitted to Medicare Part A skilled services on 3/11/25. Resident #38's Medicare Part A skilled services ended on 3/28/25. He remained in the facility. Record review revealed there was no documentation Resident #38 or his responsible party were issued a SNF-ABN. During an interview with the facility social worker on 7/2/25 at 3:40 PM she stated it was her job to issue the SNF-ABN. She further stated there was an error in processing and Resident #38 did not receive the correct notification. An interview was conducted with the Administrator on 7/2/25 at 6:01 PM who indicated Resident #38 should have received the SNF-ABN as required by Federal guidelines. 2. Resident #54 was admitted to the facility on [DATE]. She was admitted to Medicare Part A skilled services on 4/17/25. Resident #54's Medicare Part A skilled services ended on 6/13/25. She remained in the facility. Record review revealed there was no documentation Resident #54 or her responsible party were issued a SNF-ABN. During an interview with the facility social worker on 7/2/25 at 3:40 PM she stated she was responsible for issuing the SNF-ABN. She further stated there was an error in processing and Resident #54 did not receive the correct notification. An interview was conducted with the Administrator on 7/2/25 at 6:01 PM who indicated Resident #54 should have received the SNF-ABN as required by Federal guidelines.

Based on record review, observations, resident interview and staff interviews, the facility failed to provide maintenance services to a resident room that was observed with damaged sheetrock on the wall to the left side of the bed, a dresser with visible damage and a broken track for the bottom drawer and a bathroom cabinet with doors that did not latch and the pressboard in the bottom of the cabinet was observed sunken inward and covered with a dirty white thin board with dry white paper towel lying flat to the surface observed in the right back corner with dry black material covering over half of the paper towel for 1 of 1 resident reviewed for homelike environment on 1 of 6 halls in the facility (Resident #92). The findings included: A review of the census revealed Resident #92 was moved into room [ROOM NUMBER] on 1/1/2025. Resident #92's quarterly Minimum Data Set assessment dated [DATE] indicated Resident #92 was cognitively intact. A review of undated maintenance logs recorded a work order #2554 that stated the walls needed repair and paint in Resident #92's room. Work order #2557 dated 1/6/2025 recorded that the baseboard behind the bed needed repair and work order #2558 dated 1/6/2025 recorded that the bathroom floor fixtures and the toilet needed repaired in Resident #92's room. On 6/30/2025 at 11:17 am, the right side of Resident #92's bed was observed pushed up against the wall. There was torn sheetrock on the wall approximately 8 inches above the right side rail and the torn sheetrock on the wall continued below the right side rail. There was also torn sheetrock observed in the corner of the wall behind the head of the bed. The left side of Resident #92's dresser was observed with dry cracked and buckled wood four inches from the floor. On 6/30/2025 at 11:17 am in an interview with Resident #92, she stated when she moved into the room the walls were torn and staff at the facility were aware of the torn sheetrock on the walls. Resident #92 stated the male staff member who brought the resident's bed into the room the day she moved into the room stated at that time they would need to fix the wall. On 7/1/2025 at 8:41 am, two wooden cabinet doors were observed open approximately 2 inches in the bathroom of Resident 92's room. The two wooden cabinet doors would not close or latch and there were dry white specks observed on the two wooden cabinet doors in the bathroom. There was a sunken inward dry pressboard observed inside the wooden cabinet in the bathroom that had been covered with a dirty white thin board. There was a dry white paper towel lying flat to the surface in the right back corner of the cabinet with dry black material covering half of the dry paper towel. On 7/1/2025 at 8:45 am, the bottom drawer of Resident #92's wooden dresser was observed unsteady and off track. The wooden drawer (measuring approximately 24 inches in length and 6 inches in height) continued to move forward when opening the dresser drawer and human physical strength was used to prevent the heavy wooden drawer from falling to the floor. On 7/1/2025 at 8:45 am in an interview with Resident #92, she stated she was unable to remember who she voiced her concerns about the wooden dresser and bathroom cabinet. Resident #92 stated the staff was aware because she had dropped the dresser drawer on her foot ( x-ray revealed no fracture) and the staff could see the walls and bathroom cabinet when in Resident #92's room. On 7/2/2025 at 6:30 pm in an interview with Resident #92, she stated she washed herself daily in the attached bathroom. On 7/2/2025 at 3:07 pm in an interview with Nurse #4, she stated the bottom drawer of the wooden dresser did not work correctly and the bathroom cabinet was damaged with swelling of the wood. Nurse #4 stated the damaged walls occurred prior to Resident #92 moving into the room and the maintenance department had been informed of the needed repairs. Nurse #4 was unable to recall when the maintenance department was informed of the needed repairs in Resident #92's room but stated it was after Resident #92 moved into the room. On 7/3/2025 at 9:12 am in an interview with the Maintenance Assistant, he stated resident rooms were checked weekly for repairs and he was not aware of the repairs needed in Resident #92's room [ROOM NUMBER]/2/2025. He stated he did not recall the wall in Resident #92's room being scratched up when Resident #92 was moved into the room. On 7/3/2025 at 8:57am, the Maintenance Director was observed pulling the bottom drawer from the wooden dresser that continued to move forward and nearly came out of the wooden dresser on to the floor. On 7/3/2025 at 8:57 am in an interview with Maintenance Director, he explained the torn sheetrock in Resident #92's room came from a previous resident rising the bed up and down with the bed positioned close to the wall. He explained when Resident #92 was moved into the room, it was a quick move and didn't have time to make the repairs to the wall. He stated the bottom of the wooden dresser was caved in and the dresser drawer was not on track to stop the dresser drawer from continuing to be pulled forward and out of the wooden dresser. He explained that water damage to the wooden dresser occurred due to toileting running at some point in time. He explained that the staff reported damage or needed repairs resident rooms through a communication system. The Maintenance Director explained he was not aware of the damaged dresser and bathroom cabinet in Resident #92's room until he was informed by staff on 7/2/25. He explained that the maintenance department had been completing resident room remodeling that started in another part of the facility, and they had not gotten to Resident #92's room to make needed repairs. He stated while remodeling, the maintenance department would attend to needed repairs when there were resident complaints. The Maintenance Director further stated the bathroom cabinet in Resident #92's room was not useable. On 7/1/2025 at 5:31 pm in an interview with the Interim Director of Nursing (DON), she stated when Resident #92 pulled the dresser drawer completely out on 1/5/2025 and it fell on her foot. The dresser drawer was not broken and she was able to be put back into the wooden dresser and replaced on the track. The interim DON explained that the physician was notified, and an x-ray was performed that showed there was no fracture. She stated Resident #92 had bruising to the foot. In a follow up interview on 7/3/2025 at 1:04pm, the Interim DON stated it was the top drawer that Resident #92 pulled out and dropped on her foot on 1/5/2025. On 7/3/2025 at 1:10 pm in an interview with the Administrator, she stated the facility had been conducting some remodeling and six months was too long to wait for repairs to the walls, dresser and bathroom cabinet in Resident #92's room. She stated the facility's goal was to maintain a homelike environment in the residents' rooms.

Based on record review, observations, resident interview and staff interviews, the facility failed to place a resident's call light device within reach to allow for the resident to request assistance as needed for 1 of 2 residents reviewed for accommodation of needs (Resident #90). Findings included: Resident #90 was admitted to the facility on [DATE] with diagnoses including stroke and aphasia (difficulty speaking). The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #90 was severely cognitively impaired with no range of motion impairments to upper and lower extremities and was dependent on staff to provide assistance with all activities of daily living and mobility. The pain assessment in the MDS assessment indicated Resident #92 was not receiving a pain medication regimen or as needed pain medications and was not experiencing pain. On 6/30/2025 at 3:30pm, the beige colored string exiting from the call light wall device on the left side of the bed was observed lying on top of the light fixture in Resident #90's room above Resident #90's head of the bed. Resident #90 was observed repeatedly moving her left hand off the side of the bed and lying her hand on her chest and pointing to her right cheek area, where a tear was observed running down the right side of her face from the outer right eye. During the interview with Resident #90 on 6/30/2025 at 3:30 pm, Resident #90 was asked if she could use the call light device to call for help if the call light device was in her reach. Resident #90 moved her head up and down to answer yes and moved her mouth to answer in a low soft voice yes. Resident #90 also moved her head up and down to answer yes and moved her mouth to answer in a low soft voice yes when asked if she was experiencing pain. In an interview with Nurse #4 on 6/30/2025 at 3:40 pm, she stated Resident #90 couldn't pull the string connected to the call light wall device or push a button-control call light device to call for help. Nurse #4 was informed Resident #90 was pointing to the tear running down her face and indicating she was in pain when asked and pointing to her cheek area. Nurse #4 was observed walking toward Resident #90's room. On 6/30/2025 at 4:25 pm, Resident #90 was observed lying in the bed. There was a dark brown string observed attached to the beige colored string exiting from the call light wall device on the left side of the bed and the brown string was observed lying across Resident #90's waist. Resident #90 was observed gripping the brown string and picking up the brown string that was lying across the waist without difficulty. In a follow up interview with Nurse #4 on 7/2/2025 at 2:58 pm, she stated on 6/30/2025 Resident #90 complained she was uncomfortable in the position she was lying in and was repositioned up in the bed and the head of the bed was elevated. She stated upon entering the resident's room, the string to the call light wall device was positioned up on the light fixture out of Resident #90's reach. Nurse #4 stated she did not know why the string to the call light device was up on the light fixture out of Resident #90's reach on 6/30/2025 and had recommended Resident #90's call light device be changed to a flat call light device that she could better operate with her hands. In an interview with the Interim Director of Nursing on 7/1/2025 at 5:47pm , she stated Resident #90 could pull the string to activate the call light device. She stated Resident #90's call light device was to be within her reach at all times.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of behaviors for 1 of 26 residents whose MDS assessments were reviewed (Resident #167). Findings included: Resident #167 was admitted to the facility on [DATE] with diagnoses that included dementia. A progress note dated 9/13/24 revealed Resident #167 had behaviors including spitting and urinating on the floor. These behaviors were not directed towards others. A progress note dated 9/15/24 revealed Resident #167 refused to have a nursing assessment completed including blood pressure taken. He placed his sheet over his head and refused to answer any questions. A progress note dated 9/17/24 indicated Resident #167 adjusted his brief and voided on the floor. Resident #167's admission Minimum Data Set (MDS) assessment dated [DATE] was coded for having verbal behaviors directed toward others for 1-3 days during the 7-day lookback period. There were no other behavioral symptoms or rejection of care coded. On 7/2/25 at 3:44 PM during an interview with MDS Coordinator #1, she stated the 9/17/24 MDS for Resident #167 should have been coded for having rejection of care and other behaviors. She stated it was a coding error. An interview was conducted with the Administrator on 7/2/25 at 6:01 PM. She stated Resident #167's MDS assessment dated [DATE] should have accurately reflected behaviors present during the 7-day lookback period.

Based on manufacturer directions, observations and staff interviews, the facility failed to remove 3 multi-dose insulin injector pens that were expired in 2 of 5 medication carts ([NAME] medication cart and Split medication cart), remove expired medication in 1 of 5 medication carts (Split medication cart), and remove 1 opened and expired vial of Pneumococcal vaccine in 1 of 1 medication storage room refrigerator reviewed for medication storage and labeling. The findings included: a. The manufacturer's directions for lispro insulin injector pen stated it should be discarded 28 days after opening. An observation of the [NAME] medication cart on 7/3/25 at 9:23 am revealed one Lispro insulin injector pen that was open and dated 5/20/25. Interview with Nurse # 5 during the medication cart observation on 7/3/25 at 9:23 am and stated the insulin pen should have been removed after 28 days. b. An observation of the Split medication cart on 7/3/25 at 9:30 am revealed two Lispro insulin injector pens that were opened and dated 6/2/25 and a opened bottle of docusate sodium liquid (a medication primarily used as a stool softener) with the expiration date of 1/31/25. Interview with Nurse #5 during the medication cart observation on 7/3/25 at 9:30 am stated the insulins pen should have been removed after 28 days and the docusate sodium liquid should have been removed in January 2025. c. An observation of the medication storage room on 7/3/25 at 9:35 am revealed an opened vial of Pneumococcal vaccine in a plastic bag with an expiration date of 8/12/24 and no open date on the vial or plastic bag. Interview with the interim Director of Nursing (DON) during the medication storage room observation on 7/3/25 at 9:35 am, stated the vial should have been dated when opened and removed when the vial expired. The interim DON did not know when the vial had been opened. The interim DON further stated herself and the nursing staff were responsible for regularly checking the medication carts for expired medications and the medication storage room refrigerators for expired medications and/or vaccines. During an interview with the Administrator on 7/3/25 at 1:50 pm, she stated the nursing staff were responsible for dating the insulin pen injectors when opened and discarding them after 28 days. The Administrator further stated the nursing staff were responsible for checking and removing expired medications from the medication carts. The Administrator indicated all nursing staff were responsible for checking the medication storage room regularly and removing expired medications and vaccines from the refrigerators. The Administrator added that no residents had received the pneumococcal vaccine in the last 6 months.

Based on record review, observation, and staff interview the facility failed to follow their infection control policy and procedures for enhanced barrier precautions for one (Nurse #5) of three nursing staff members observed for infection control procedures. Findings included: Review of the facility policy on enhanced barrier precautions, dated as implemented on 11/1/2024, revealed the following information. The facility will have the discretion on how to communicate to staff which residents require to use of enhanced barrier precautions (EBP), as long as staff are aware of which residents require to use of EBP prior to providing high-contact care activities. Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 1. Resident #6 was readmitted to the facility on [DATE] with diagnoses of Stage 4 pressure ulcer and presence of a tracheostomy tube. Observation on initial tour on 11/6/2024 at 10:22 AM revealed Resident #6 did not have an enhanced barrier precaution sign on her door and did not have any personal protective equipment (PPE) on or near her door. Upon entering the room after knocking to request permission, Nurse #5 responded and stated she had just finished up providing wound care for Resident #6. Two additional staff members were in the room with Nurse #5. It was observed there was no PPE in the room of Resident #6. An interview was conducted with Nurse #5 on 11/7/2024 at 9:49 AM. Nurse #5 acknowledged on the previous day, 11/6/2024, when she performed wound care for Resident #6, she and the two staff members assisting her did not wear gowns when performing wound care. Nurse #5 stated that when Resident #6 was first admitted there was an Enhanced Barrier Precautions sign and PPE on her door, but for some reason when her room was deep cleaned the sign was removed and not put back up. Nurse #5 stated she knew she needed to wear a gown when performing wound care for a chronic stage 4 pressure ulcer, but she had forgotten due to a lack of the sign. An interview with the Director of Nursing (DON) was conducted on 11/7/2024 at 11:42 AM. The DON confirmed Nurse #5 should have worn a gown while she was providing wound care for Resident #6 on 11/6/2024. The DON confirmed an enhanced barrier precaution sign should have been on the door along with PPE supplies on the door so staff could wear a gown while performing resident care activities to include wound care, bathing, changing linens, and personal hygiene. The DON did not know when or why the sign was removed from the door of Resident #6. The DON explained the staff was trained in the requirements to wear gowns as enhanced barrier precautions for residents with wounds and the PPE was available on every hall. The DON further explained the nursing staff needed to be retrained on when enhanced barrier precautions were needed. An interview was conducted with the Administrator on 11/7/2024 at 3:05 PM. The Administrator stated the facility policy was to have enhanced barrier precaution signs on the door of residents who require wound care and staff need to wear gowns when performing wound care and personal care for those residents. The Administrator stated someone removed the enhanced barrier precaution signs on the door of Resident #6 when her room was deep cleaned when she went to the hospital and the sign was not replaced. The Administrator indicated additional training was needed for the staff on enhanced barrier precautions. 2. Resident #8 had diagnoses of stage 4 pressure ulcer and Type 2 diabetes. An observation of the door of Resident #8 on 11/7/2024 at 8:41 AM revealed a sign posted entitled, Enhanced Barrier Precautions. The sign stated in part, All Healthcare Personnel must: Wear gloves and gown for the following High-Contact Resident Car Activities: One of the activities on the sign for which gloves and a gown were to be worn was for wound care: any skin opening requiring a dressing. There were no visible gowns or gloves available in the hallway or on the door of Resident #8 Nurse #5, the wound care nurse, was observed approaching the room of Resident #8 on 11/7/2024 at 8:43 AM and prepared her supplies to perform wound care to include multiple pairs of gloves. Nurse #5 entered the room of Resident #8 and performed wound care without donning a gown. Nurse #5 was interviewed directly after completion of the wound care for Resident #8 on 11/7/2024 at 8:52 AM. Nurse #5 acknowledged she did not wear a gown while she was performing wound care for Resident #8 as directed to do so on the enhanced barrier precaution sign on her door. Nurse #10, who was standing at her medication cart directly across the hallway, reminded Nurse #5 in that moment that a gown and gloves must be worn while caring for residents with wound care requiring a dressing, a central line, urinary catheter, feeding tube, and/or a tracheostomy. Nurse #5 said she was aware of the need for a gown while providing wound care, but she forgotten to do so. An interview with the Director of Nursing was conducted on 11/7/2024 at 11:42 AM. The Director of Nursing confirmed Nurse #5 should have worn a gown while she was providing wound care for Resident #8.

Based on record review and staff interview the facility failed to treat a resident in a dignified manner for one (Resident #4) of three residents reviewed for dignity. Findings included: Resident #4 had a diagnosis of Alzheimer's disease and resided on a locked dementia unit in the facility. Documentation on the most recent quarterly Minimum Data Set assessment dated [DATE] coded Resident #4 as severely cognitively impaired with no moods or behaviors. An interview was conducted with Medication Aide (Med Aide) #3 on 11/7/2024 at 9:56 AM. Med Aide #3 stated on 9/28/2024 he was in the hallway after the evening meal with a view visible into the day room of the dementia unit. Med Aide #3 stated Resident #4 was standing up and he witnessed Nurse Aide (NA) #1 grab the shirt of Resident #4 and push Resident #4 into the chair telling her to sit down. Med Aide #3 stated NA #1 pushed Resident #4 harder than necessary making the chair hit the wall. Med Aide #3 revealed he heard Resident #4 state, I'm telling and NA #1 responded, Go ahead. Med Aide #3 confirmed he went to the Nurse to report what he witnessed on behalf of Resident #4. NA #1 did not respond to requests for an interview. The facility Administrator was interviewed on 11/6/2024 at 2:03 PM. The Administrator stated she was notified immediately of what Med Aide #3 witnessed on the dementia unit on 9/28/2024. The Administrator stated she interviewed NA #1 about what had occurred. The Administrator revealed she was told by NA #1, she forcibly put Resident #4 into the chair because she was going to get up and bother other residents. The Administrator stated she felt like NA #1 was admitting to treating Resident #4 disrespectfully and NA #1 could not have known what Resident #4 was going to do as she routinely just walked around the unit not bothering anyone. The facility provided the following corrective action plan with a completion date of 10/4/2024: The immediate actions taken for the resident found to have been affected: Resident #4, a resident in the dementia unit, was treated disrespectfully on 9/28/2024 by NA #1. Med Aide #3 observed NA #1, grab a resident by her shirt, forcing her into the day room and pushing her into her chair hard. Med Aide #3 immediately told the nurse what he observed. Resident #3 was assessed by the nurse and there were no visible signs of injury per the nursing assessment. Resident #4 was assessed by the nurse for pain and for emotional distress. Resident #4 did not display any signs or symptoms of discomfort, anxiety, or being upset. The nurse immediately notified the Charge Nurse who called the Director of Nursing and Administrator. NA #1 was immediately suspended and escorted from the facility due to her disrespectful behavior with the resident. An abuse investigation was immediately begun, and the incident was reported to the state agency. The nurse notified the physician and the family member of Resident #4. Identification of other residents having the potential to be affected: The facility determined the behavior of NA #1 was inappropriate and resulted in failure to treat Resident #4 with dignity and respect. All residents are at risk for a negative impact if they are not treated with dignity and respect. Actions taken/systems put into place to reduce the risk of future occurrences: Resident interviews were initiated on 9/28/2024 and 100% of cognitively intact residents in the facility were interviewed by the Social Worker. No additional issues with inappropriate undignified behavior, abuse, or neglect were identified. The Nursing Staff initiated skin assessments on 9/28/2024 and 100% of all cognitively impaired residents, to include the residents on the dementia unit, were assessed. There were no issues identified. Education was initiated by the Director of Nursing on 9/28/2024 for all nursing staff members. The subject of the education was treating residents with dignity, prevention of abuse and neglect, resident protection, and reporting. How the corrective actions will be monitored to ensure deficient practice will not reoccur: Daily rounds were initiated on 9/28/2024 by the senior management team for 10 % of the resident population to ensure that residents are treated with dignity and respect always. In the event there are areas of concern identified; immediate action will be taken to protect the residents. Daily rounding results will be reviewed in the monthly Quality Assurance Performance Improvement committee meetings to identify on-going issues and opportunities for improvement. The corrective action plan completion date was 10/4/2024. The facility's corrective action plan was verified on 11/07/2024 by the following: Interviews and record review verified Resident #4 was assessed for pain, injury, or emotional distress on 9/28/2024. Record review revealed all cognitively impaired residents were assessed for injury while cognitively intact residents were interviewed for any mistreatment including incidents involving dignity issues. Interviews with nursing staff revealed they were educated on treating residents with dignity and reporting violations of resident mistreatment. Record reviews and interviews confirmed daily rounds by the senior management team were being completed to ensure residents were treated with dignity. The compliance date of 10/4/2024 was validated.

Based on record review, staff interviews, and wound care physician interview the facility failed to accurately document a resident's admission skin assessment, initiate treatment for a pressure ulcer, complete a weekly assessment, and administer treatments as ordered according to the care plan for one (Resident #6) of three residents reviewed for pressure sore care. Findings included: Resident #6 was originally admitted to the facility on [DATE] and discharged back to the hospital on 10/6/2024. Resident #6 had multiple diagnoses some of which included type 2 diabetes mellitus, severe quadriparesis/neuropathy, coronary artery disease, congestive heart failure, tracheostomy status, percutaneous gastrostomy tube, cerebral vascular accident, dysphagia, and pressure sore injury to sacrum and left buttock. Documentation on the hospital discharge summary for Resident #6 dated 9/24/2024 included physician orders for a sacral pressure injury, left medial buttock tissue loss as well as left knee pressure injury. The wound care physician orders included in part the following: sacrum and left buttock: start Santyl ointment with [gauze dressing] to wound bed, Cleanse with normal saline during each dressing change, apply Santyl nickel thick to entire wound base, followed by moist dressing within wound margins, cover with [foam] sacral border dressing upside down, change daily and [as needed] drainage/soilage. Santyl ointment is a prescription medication that removes dead tissue from wounds so they can start to heal. Documentation on the care plan dated as initiated on 9/25/2024 revealed Resident #6 had a focus area for a Stage 4 pressure ulcer on her sacrum relative to deconditioning, immobility, and activity intolerance. Some of the interventions listed on the care plan were to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing at least every week and as needed, measure length, depth where possible, assess and document status of wound perimeter, wound bed, and healing progress, report improvements and declines to the medical doctor, and refer to wound specialist. Documentation on the nursing admission screening dated 9/25/2024 revealed Resident #6 was assessed by Nurse #2 as having, unstageable to sacrum, red open area to right buttock, trach (tracheostomy) stoma, PEG (percutaneous gastrostomy) tube incision intact. There were no measurements of length, width, or depth of the wounds. There was no description of the perimeter of the wounds or the wound bed. Documentation on a skin observation tool dated 9/25/2024 revealed Resident #6 was assessed by Nurse #2 with, unstageable wound to sacrum, open area to right buttock, bruises to abdomen, PEG tube sit, [and] trach stoma to neck. There were no measurements of length, width, or depth of the wounds. There was no description of the perimeter of the wounds or the wound bed. Documentation on a weekly observation tool initiated by Nurse #2 dated 9/25/2024 was blank and did not include any information regarding the wounds of Resident #6. Documentation in an Admission nursing note written by Nurse #2 revealed Resident #6 had an Unstageable wound noted to sacrum, dressing in place. Open area noted right buttock, dressing in place. An interview with Nurse #2 was conducted on 11/7/2024 at 12:54 PM. Nurse #2 stated she asked the Director of Nursing (DON) to help her assess the wounds on Resident #6 upon admission. Nurse #2 stated she observed the wound on the sacrum of Resident #6 to be a small, light brown wound covered in necrotic tissue and the area on the right buttock to be a small, reddened area. Nurse #2 recalled that both wounds had bandages. An interview was conducted with the DON on 9/25/2024 at 11:42 AM. The DON stated she observed the sacral pressure area on admission along with Nurse #2 on 9/25/2024. The DON explained on admission the sacral wound was about the size of a lemon slice, with adherent brown necrotic tissue that was dry with no drainage. The DON said the wound on the right buttock was a very small red open stage 3 pressure area. The DON explained the facility did not know Resident #6 had wounds prior to her coming to the facility and an air mattress was obtained for her on 9/26/2024. There were no physician orders for a wound care treatment for the right buttock initiated on 9/25/2024. There was no documentation on the treatment administration record (TAR) of wound care for the right buttock wound from 9/26/2024 to 10/2/2024. Documentation in the physician orders dated as initiated on 9/26/2024 and discontinued on 10/02/2024 revealed Resident #6 was to have 250 units/gram of Santyl external ointment (Collagenase) applied to her sacral area topically every day shift for wound care. Documentation on the treatment September administration record (TAR) revealed the treatment record was blank on 9/26/2024 for the wound care order for the sacral wound of Resident #6. Review of the daily nursing schedule for 9/26/2024 revealed Nurse #7 was assigned to perform treatments for the hallway which Resident #6 resided. Nurse #7 was interviewed on 11/7/2024 at 12:27 PM. Nurse #7 revealed he did not recall if he provided a wound care treatment to the sacral area of Resident #6 on 9/26/2024 and he did not recall what the wound looked like when Resident #6 was first admitted . Documentation on an initial wound evaluation and management summary dated 10/1/2024 written by the facility consultant wound care physician revealed the sacral and right buttock wounds of Resident #6 were assessed and the following information was provided. The wound care physician documented the Stage 4 sacral wound to be 7 centimeters (cm) in length, 8 cm in width, and 1.5 cm in depth with heavy serous exudate and 100% necrotic tissue. The sacral wound was debrided, and the nonviable tissue was removed. The dressing treatment plan was for Dakin's solution to be applied twice daily for 30 days, packed with Kling dressing soaked in 1/4 strength Dakin's solution twice a day, covered with a superabsorbent gelling fiber with silicone foam border dressing. The wound care physician documented the Stage 3 pressure wound on the right buttock of Resident #6 to be 2 cm in length, 1.5 cm in width, and 0.2 cm in depth with light serous exudate and 100 % slough. The wound care physician surgically removed the nonviable tissue on the Stage 3 pressure wound on the right buttock. The dressing treatment plan for the stage 3 pressure wound on the right buttock was for Alginate calcium silver with a gauze island border dressing applied once daily. The Admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #6 as having one Stage 3 present on admission and one stage 4 present of admission. The assessment also coded Resident #6 as having a pressure reducing devise for the bed, nutrition/hydration interventions, pressure injury/ulcer care, and application of nonsurgical dressings. Resident #6 was also coded as requiring substantial or total dependence for assistance with mobility. There was no weekly observation tool in the electronic medical record of Resident #6 dated 10/2/2024. Documentation on a physician's orders revealed Resident #6 had an order initiated on 10/2/2024 for the sacrum wound to be cleansed with quarter strength Dakin's solution then pack with Dakin's moistened Kling twice a day, every day shift and night shift. Documentation on physician orders revealed Resident #6 had an order initiated on 10/3/2024 for the right buttock to be cleaned with normal saline or wound cleaner, calcium alginate with silver applied, and a border gauze dressing to be completed every day. Documentation on the October TAR revealed Resident #6 did not receive wound care as ordered for the daily right buttock treatment or the twice daily treatment for the sacrum on 10/4/2024 and 10/5/2024. Review of the daily nursing schedule for 10/4/2024 revealed Nurse #7 on the 7:00 AM to 3:00 PM shift and Nurse #5 on the 3:00 PM to 11:00 PM shift was assigned to provide wound care treatments for the hallway which Resident #6 resided. Review of the daily nursing schedule for 10/5/2024 revealed Nurse #7 on the 7:00 AM to 3:00 PM shift and Nurse #9 on the 3:00 PM to 11:00 PM shift was assigned to provide wound care treatments for the hallway which Resident #6 resided. Nurse #7 was interviewed on 11/7/2024 at 12:50 PM. Nurse #7 stated if he did not check off the treatment as being completed for Resident #6 then he would have passed it off to the next nurse shift nurse. Nurse #7 could not recall what the wound looked like on 10/4/2024 and 10/5/2024 but he recalled when he provided wound care treatments to Resident #6 on the morning of 10/6/2024, the wound had a lot of necrotic tissue and smelled very bad. Nurse #5 was interviewed on 11/7/2024 at 1:07 PM. Nurse #5 stated she did not recall doing wound care for Resident #6 on 10/4/2024 and did not recall Nurse #7 telling her the wound care treatments were not completed on the morning shift on 10/4/2024. Nurse #5 explained she had just returned from an absence from the facility, and she was working as a hall nurse on 10/4/2024. Nurse #5 further explained she was the wound care nurse at the facility, and she would have completed the treatments for Resident #6 if she had been asked by Nurse #7 to do so. Nurse # 9 was interviewed on 11/7/2024 at 1:43 PM. Nurse #9 stated she did not recall if she was asked by Nurse #7 to complete the wound care treatments for Resident #6 on 10/5/2024. Nurse #9 explained she was the MDS nurse who was helping out on the floor on 10/5/2024 but, she could not recall if she did wound care treatments for Resident #6 on that day. An interview was conducted with the DON on 9/25/2024 at 11:42 AM. The DON stated the nurses were responsible for doing wound treatments on their assigned halls and all treatment orders should have been completed for Resident #6. The DON acknowledged the sacral wound of Resident #6 did deteriorate very quickly. An interview was conducted with the facility Administrator on 11/7/2024 at 3:05 PM. The Administrator stated it was not best practice to not do treatments and not document treatments. An interview was conducted on 11/7/2024 at 2:01 PM with the facility wound care consultant physician who completed the initial wound evaluation for Resident #6 on 10/1/2024. The wound care physician provided the following information. A deep tissue injury wound can deteriorate very quicky. The stage 4 pressure sore on the sacral area of Resident #4 could have had an unknown depth with damage that was previously done.

Based on observations, record review, resident interview, staff interviews and a Physician interview, the facility failed to provide sufficient nursing staff to ensure a resident was administered morning scheduled medications in the allotted time frame for 1 of 1 resident reviewed for significant medications (Resident #211). Resident #211 not receiving her scheduled morning medications in the allotted time frame caused Resident #211 to remain in bed for fear of falling due to feeling dizzy. Findings included: This tag is cross reference to: F760: Based on record review, observation, resident interview, staff interviews and a Physician interview, the facility failed to administer significant medications of a resident's medication regimen in the scheduled time frame that caused the resident to remain in bed for fear of falling due to feeling dizzy for 1 of 1 resident reviewed for administration of significant medications (Resident #211). In an interview with the Director of Nursing (DON) on 3/13/2024 at 11:15 a.m., she explained on 3/13/2024 due to the call out of a scheduled medication aide, NA (Medication Aide) #7 was assigned both the sparks unit and skills unit medication cart. She explained usually one nurse/medication aide was assigned the sparks unit and skills unit medication carts since the skills unit fluctuated in the number of residents and the level of care on the unit. She stated Nurse #6 was assigned to the cover the sparks unit and skills unit for nursing tasks, and it would have been best if she (DON) had assigned Nurse #6 to one of the medication carts so the administration of medications were administered in the scheduled time frame for Resident #211. The Director of Nursing reported attendance issues among the nursing staff and the issue of not having enough staff for the five medications carts had caused a delay in scheduled medications administered in the allotted time frame. She stated as the DON she had been assigned a medication cart to administered medications due to not having enough staff, and the facility was slowly hiring nurses and nurse aides. In an interview with the Administrator on 3/13/2024 at 4:36 p.m., she stated Resident #211 should have received her medications one hour before or after the scheduled time and explained the reason Resident #211 received her medications late was because a medication aide called out on 3/12/2024. She explained due to the residents on the sparks unit having fewer medications, one nurse/medication aide was assigned the sparks unit and skills unit medications cart when there were limited nurses/medications aides in the facility. She stated retaining enough nurses/medications aides for the five medication carts in the facility was a challenge. She stated nursing staff worked overtime to help cover staff needs and the facility made every effort to ensure residents received their scheduled medications in a timely manner. She also stated she continued to work in recruiting new nursing staff.

Based on record review, observation, resident interview, staff interviews and a Physician interview, the facility failed to administer significant medications of a resident's medication regimen in the scheduled time frame that caused the resident to remain in bed for fear of falling due to feeling dizzy for 1 of 1 resident reviewed for administration of significant medications (Resident #211). Findings included: Resident #211 was admitted to the facility on [DATE] with diagnoses including hypertension, atrial fibrillation, epilepsy (seizures), anxiety and pain. Resident #211's care plan dated 2/29/2024 included a focus for hypertension and atrial fibrillation, and interventions included giving antihypertensive medications as physician ordered and monitoring for side effects. Resident #211's care plan also included the use of anti-anxiety and seizure medications. Interventions included administering the medications as ordered by the physician, monitoring for side effects and effectiveness of the medications and seizure precautions. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #211 was cognitively intact and received anti-anxiety medications, opioids (pain relief medications) and antiplatelets (medications that prevent the blood to clot). A review of physician's orders indicated Resident #211 was ordered the following significant medications in her medication regimen on 2/29/2024: * Metoprolol Tartrate oral tablet 25 milligrams (mg) two tablets by mouth two times a day for hypertension. * Lorazepam oral tablet 0.5 mg one tablet by mouth two times a day for anxiety. * Lisinopril oral tablet 20 mg one tablet by mouth one time a day for hypertension. * Levetiracetam oral tablet 500 mg one tablet by mouth two times a day for seizure. * Dronedarone HCl oral tablet 400mg one tablet by mouth two times a day for heart failure. * Aspirin Enteric Coated Tablet Delayed Release 81mg one tablet by mouth two times a day for coronary artery disease/atrial fibrillation. A review of Resident #211's March Medication Administration Record (MAR) reported Metoprolol Tartrate, Lorazepam, Lisinopril, Dronedarone HCL and Aspirin were scheduled for administration at 8:30 a.m. daily and given. A review of Resident #211's medication audit report from 3/1/2024 to 3/12/2024 reported Resident #211 received her scheduled 8:30 a.m. medications after the one-hour time frame for administration on the following dates: * On 3/2/2024, Nurse #1 recorded medications were administered at 10:55 a.m. * On 3/3/2024, NA (Medications Aide) #7 recorded medications were recorded administered between 10:13am and 10:19 a.m. * On 3/4/2024. Nurse #3 recorded medications were administered at 11:06 a.m. * On 3/8/2024, NA (Medications Aide) #7 recorded medications were administered between 10:56 a.m. and 11:00 a.m. * On 3/12/2024, NA (Medications Aide) #7 recorded medications were administered between 10:57 a.m. and 11:02 a.m. A review of Resident #211's blood pressure readings indicated a slight elevation on 3/3/2024 at 4:46 a.m. with a reading of 140/86, 3/3/2024 at 3:21 a.m. with a reading of 138/85, and on 3/11/2024 at 1:01 a.m. 142/74. On 3/10/2024 at 10:34 a.m. in an interview with Resident #211, she said the nursing staff usually administered her medications between 8:00 am and 9:00 a.m., and there was one day since admission she received her scheduled morning medications at 11:00 a.m. She explained the morning she received her morning medications at 11:00 a.m., she was feeling dizzy by the time her medications were administered. She said she spoke to the nurse about receiving her morning medications earlier in the morning. She was unable to recall the date when her medications were given at 11:00 a.m. and the name of the nurse she had spoken with about receiving her medications earlier in the morning. On 3/12/2024 at 8:21 a.m. in a follow up interview with Resident #211, she explained she didn't take her medications at home late in the morning and would experience dizziness, trembling and jitters when her medications were administered later in the morning around 11:00 a.m. She stated the dizziness, trembling and jitters disappeared after receiving her morning medications. On 3/12/2024 at 9:27 a.m. NA (medications Aide) #7 was observed exiting the sparks unit with a medications cart and moving to the skills unit medication cart to begin the scheduled morning medications. In an interview with NA (medications Aide) #7 on 3/12/2024 at 9:27 a.m., she explained she was assigned both medications carts for the sparks unit and the skills unit, and Nurse #6 and the Director of Nursing (DON) knew she was assigned both medications carts. She said had the keys to both medication carts since reporting to work at 7:00 a.m., and no one had been to get the keys for the skills medication cart to start the scheduled morning medications for the residents. She stated medications were to be administered one hour before or after the scheduled time, and due to starting the skills hall medication administration at this time, she would not be able to administered the residents' their scheduled morning medications on time. On 3/12/2024 at 11:05 a.m., NA (medications Aide) #7 was observed in Resident #211 room and the skills unit medication cart outside the Resident #211 door. NA (medications Aide) #7 stated she had just administered Resident #211 her scheduled morning medications. In an interview with Resident #211 on 3/12/2024 at 11:08 a.m., she stated she had asked three times for her scheduled morning medications and had just received her medications. She stated that due to feeling dizzy she had stayed in the bed so she wouldn't fall. Resident #211 denied needing to get out of bed while waiting to receive her medications and stated the dizziness would go away now that she had been administered her scheduled morning meds. In an interview with Nurse #4 on 3/13/2024 at 2:44 p.m., he stated he couldn't recall why the medications were given after the scheduled time frame on 3/2/2024 to Resident #211. He explained usually there was one nurse or medication aide assigned to both the sparks unit medication cart and the skills unit medication cart, and it was not unusual for residents' medications to be administered medications after the scheduled time frame. He further stated on 3/2/2024 he did not inform the physician Resident #211's mediations were administered after the scheduled time frame and was not a usual practice. Attempts to interview Nurse #3 were unsuccessful. In an interview with Nurse #6 on 3/13/2024 at 2:35 p.m., she stated as unit manager she notified the physician when medications were administered after the scheduled time frame and called the physician on 3/12/2024. She stated she was not aware on 3/2/2024, 3/3/2024, 3/4/2024 and 3/8/2024 Resident #211 received her medications after the scheduled time frame. She explained on 3/12/2024 NA (Medication Aide) #7 was assigned the medication cart for the sparks and skills unit because there were only four nurses/medication aides scheduled and there were five medication carts in the facility. She stated she did not work the medication cart often, and the Director of Nursing (DON) made the decision when the unit manager worked a medication cart if not enough staff. She said on 3/12/2024, the DON made decision for her to not work a medication cart. In an interview with the Director of Nursing (DON) on 3/13/2024 at 11:15 a.m., she explained scheduled medications were to be administered one hour before or after the scheduled time, and Resident #211 receiving her scheduled morning medications after 11:00 a.m. was not acceptable. The DON explained usually with one medication aide and a nurse covering the hall, residents' medications were administered in the scheduled allotted time frame. She explained on 3/13/2024 due to a scheduled medication aide calling out, NA (Medication Aide) #7 was assigned both the sparks unit and skills unit medication cart. She stated Nurse #6 was assigned to the cover sparks unit and skills unit for nursing tasks and it would had been best if she had been assigned one of the medication carts for administration of medications in the scheduled time frame for Resident #211. In a phone interview with Physician #1 on 3/13/2024 at 1:54 p.m., he stated Resident #211's scheduled morning medications should be administered in the allotted time frame. He explained the nursing staff informed him on 3/12/2024 there was a delay in administering Resident #211's medications and noted the reason was due to staffing. He stated Resident #211 receiving her scheduled morning medications two hours after the allotted scheduled time frame was not acceptable and should not cause any harm. He explained that Resident #211 not receiving the Metoprolol Tartrate (a medication for high blood pressure) medication timely could have caused some slight dizziness. Physician #1 said he was not notified of Resident #211 not receiving her morning scheduled medications in the allotted time frame on 3/2/2024, 3/3/2024, 3/4/2024 and 3/8/2024, and the facility needed to improve in administering scheduled medications in a timely manner. In an interview with the Administrator on 3/13/2024 at 4:27 p.m., she explained that due to residents' complaints of receiving medications late, the nursing staff received an in-service in administering medications in a timely manner one to two months ago. She stated Resident #211 should have received her medications one hour before or after the scheduled time.

Based on record reviews and staff interviews, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week, to designate a director of nursing (DON) who worked on a full-time basis, and to have the DON only serve as a charge nurse when the average daily census was 60 residents or less for 23 of 39 days reviewed for staffing. Findings included: The nursing staff schedule and staff posting was reviewed from 2/1/24 through 3/10/24. The daily staff sheet indicated a Registered Nurse (RN) was not scheduled for at least eight consecutive hours a day on 2/3/24. Review of staff timecard dated 2/3/24 showed there was not an RN on duty at the facility that day. Review of the staffs' timecards dated 2/10/24 showed one RN worked. The RN was scheduled for the day shift 7:00 A.M. to 3:00 P.M. The timecard showed the RN worked from 7:49 A.M. to 3:29 P.M. for a total of 7 hours and 40 minutes. Review of the DON time punches for the week of 2/15/24 through 2/21/24 showed the DON worked 29.36 hours in the DON role. - 2/15/24, Thursday: DON hours logged 9:30 A.M. to 3:00 P.M., RN hours logged 3:01 P.M. to 12:08 A.M./ total DON hours 5.30, total RN hours 9.07 - 2/16/24, Friday: RN hours logged 3:19 P.M. to 11:37 P.M./ total RN hours 8.18 - 2/17/24, Saturday: RN hours logged 2:15 P.M. to 9:57 P.M./ total RN hours 7.42 - 2/19/24, Monday: DON hours logged 9:01 A.M. to 3:05 P.M./ total DON hours 6.04 - 2/20/24, Tuesday: DON hours logged 7:06 A.M. to 4:50 P.M./ total DON hours 9.44 - 2/21/24, Wednesday: DON hours logged 8:32 A.M. to 5:30 P.M./ total DON hours 8.58 Review of the DON time punches showed the week of 2/22/24 through 2/28/24 the DON worked 30.47 hours in the DON role. - 2/22/24, Thursday: DON hours logged 8:29 A.M. to 3:00 P.M.; RN hours logged 3:01 P.M. to 11:25 P.M./ total DON hours 6.32, total RN hours 8.24 - 2/23/24, Friday: DON hours logged 12:11 P.M. to 3:00 P.M./ total DON hours 2.49 - 2/24/24, Saturday: RN hours logged 3:01 A.M. to 10:42 A.M. and 3:23 P.M. to 11:20 P.M./ total RN hours 7.41 and 7.57 - 2/26/24, Monday: DON hours logged 8:48 A.M. to 5:10 P.M./ total DON hours 8.22 - 2/27/24, Tuesday: DON hours logged 9:30 A.M. to 4:52 P.M./ total DON hours 7.22 - 2/28/24, Wednesday: DON hours logged 8:37 A.M. to 3:00 P.M., RN hours logged 3:01 P.M. to 11:25 P.M. / total DON hours 6.23, total RN hours 8.24 Review of the DON time punches for the week of 2/29/24 through 3/6/24 showed the DON worked 37.02 hours in the DON role. - 2/29/24, Thursday: DON hours logged 9:44 A.M. to 5:27 P.M./ total DON hours 7.43 - 3/2/24, Saturday: DON hours logged 3:14 P.M. to 8:57 P.M. / total DON hours 5.43 - 3/3/24, Sunday: DON hours logged 3:08 P.M. to 12:07 A.M./ total DON hours 8.59 - 3/6/24, Wednesday: DON hours logged 4:55 P.M. to 8:52 P.M./ total DON hours 15.57 During the week of 2/29/24 through 3/6/24 the DON was on the schedule with a resident assigned on 3/2/24 during the shift from 3:00 P.M. -11:00 P.M. and 3/3/24 during the shift from 3:00 P.M. - 11:00 P.M. The facility had a census greater than 60 residents. An interview was conducted on 3/13/24 at 12:30 P.M. with Scheduler #2 who stated she was aware an RN was to be scheduled for 8 consecutive hours each day. She indicated the facility no longer had agency staff working at the building and she was not always able to find a RN available to work. The Scheduler explained when she was unable to find the RN coverage, she filled the schedule with other licensed nurses to meet resident needs. During the interview, Scheduler #2 explained the Administrator and the Director of Nursing were aware of the lack of RN coverage because they reviewed the schedule weekly when it was created. An interview was conducted on 3/13/24 at 4:54 P.M. with the Director of Nursing (DON) who stated when the schedule was completed, she reviewed it to ensure the schedule had enough staff to meet resident needs. The DON indicated she was unaware of the requirement that the facility needed a RN for eight consecutive hours a day. The DON explained the facility only had one RN other than herself, and they had been unsuccessful at hiring additional RNs. The DON explained the facility does not work with agency staff at this time. During the interview, the DON indicated when staff called out, she tried to find coverage and when she was unable to find any coverage, she worked on the medication cart to meet resident needs. She further explained she had also been assigned the medication cart, typically on the evening 3:00 P.M. to 11:00 P.M. shift, when no one else was available. The DON stated she tried to complete her responsibilities as DON any time she had a free minute, no matter if she was working in the DON role or as a nurse on the medication cart. The DON indicated when she was assigned to a medication cart with a resident assignment, she had gotten pulled away by staff to handle DON responsibilities. During the interview, the DON indicated the facility census had been approximately 102 since she started in January 2024. An interview was conducted on 3/13/24 at 1:08 P.M. with the Administrator who stated she was aware of the requirement a RN worked eight consecutive hours in a day and to her knowledge the facility had a RN scheduled to meet these needs. The Administrator stated she was not aware a RN had not worked a scheduled shift until the shift had already passed. The Administrator indicated she had a limited number of RNs employed at her facility and this made it difficult to cover the RN hour requirements. During the interview, the Administrator stated the facility had one RN hired full time, one RN hired part time, and the DON assisted on the floor as needed. The Administrator explained the facility did not have any agency staff working at this time and there were no waivers in place. The Administrator stated she was aware the DON was unable to serve as a charge nurse if the facility census was greater than 60 and she stated the DON was picking up the 3:00 P.M. to 11:00 P.M shift after her DON responsibilities were completed. During the interview, the Administrator further indicated if she had been made aware the DON responsibilities were not being completed, she would pull staff from a sister facility to provide assistance.

Based on record review, North Carolina Board of Nursing Registry, observations, resident interviews, staff interviews and a Physician interview, the facility failed to provide effective leadership and oversight to ensure the Director of Nursing (DON) implemented her responsiblities in these areas: sufficiently staffing the facility to administer medications in a timely manner, having a registered nurse work eight consecutive hours daily and a DON who worked full time and only serves as a charge nurse when census was less than 60 residents, monitoring and tracking expiration of nursing licenses (Nurse #3) and nurse aide certifications (NA #9, NA # 4, NA #1, and NA #8), completing yearly performance evaluations for nurse aides (NA #4, NA #7, NA #6 and NA #5) and providing and monitoring 12 hours of annual training for nurse aides ( NA #4, NA #7, NA #6 and NA #5). This deficient practice had the potential to affect 105 of 105 facility residents. Findings included: This tag is cross reference to: F725: Based on observations, record review, resident interview, staff interviews and a Physician interview, the facility failed to provide sufficient nursing staff to ensure a resident was administered morning scheduled medications in the allotted time frame for 1 of 1 resident reviewed for significant medications (Resident #211). Resident #211 not receiving her scheduled morning medications in the allotted time frame caused Resident #211 to remain in bed for fear of falling due to feeling dizzy. F727: Based on record reviews and staff interviews, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week, to designate a director of nursing (DON) who worked on a full-time basis, and to have the DON only serve as a charge nurse when the average daily census was 60 residents or less for 23 of 39 days reviewed for staffing. F729: Based on observation, record review and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure 5 of 47 nurse aides employed at the facility remained listed on the NC Nurse Aide Registry with an active Nurse Aide I certification (NA #6, NA #9, NA #4, NA #1,and NA #8). F730: Based on staff interviews and record reviews, the facility failed to complete a performance review every 12 months for 4 of 5 nursing assistants (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (NA #4, NA #7, NA #6, and NA #5). F839: Based on observations, record review, North Carolina Board of Nursing (NCBON) verification registry and staff interviews, the facility failed to ensure Nurse #3, who was observed providing resident care at the facility, maintained a current and active professional nursing licenses with the NCBON for 1 of 12 nurses reviewed. F947: Based on record review and staff interviews, the facility failed to ensure at least 12 hours of annual training to include dementia and areas of weakness as determined in the nursing aides' performance reviews were completed for 4 Nursing Assistants (NA #4, NA #7, NA #6, and NA #5) of 5 reviewed for staffing. In an interview with the Administrator on 3/13/2024 at 6:00 p.m., she explained in June 2023 the corporate office made the decision not to use agency nursing staff in the facility, and due to the location of the facility in the non-healthcare community, she was finding it hard to recruit nurses to the facility. She explained the Director of Nursing had only had a few days with another sister facility's Director of Nursing (DON) since her employment date 1/8/2023 and the facility could not locate the DON's competency worksheets since her employment. She explained that due to her (the Administrator) nursing background, she helped to ensure resident care was provided and assisted with Minimum Data Set (MDS) assessments as needed. She stated she needed a staff development position in the facility to minimize workload of the DON and herself, and there had been an increase the nursing pay scale in attempt to attract nurses to the facility.

Based on observation and staff interviews, the facility failed to ensure bathrooms (room [ROOM NUMBER], #60, #61, #65, #67/69, #70) on the locked unit were free of fecal matter or black/brown matter on various surfaces for 6 of 10 bathrooms reviewed for clean and homelike living environment. The findings included: On 3/10/24, a Sunday, at 1:02 PM, an observation of the bathroom between rooms [ROOM NUMBERS], rooms on the locked unit, revealed the inner and outer parts of the toilet had multiple areas of dried black matter. room [ROOM NUMBER] was occupied by 2 residents, and room [ROOM NUMBER] was occupied by 1 resident. The residents of these rooms were able to use the bathroom on their own or with supervision assistance by staff. On 3/10/24 at 1:03 PM, an observation of the bathroom in room [ROOM NUMBER], a room on the locked unit, revealed brown matter on multiple areas of the toilet. room [ROOM NUMBER] was occupied by 1 resident. The resident of this room was able to use the bathroom on her own. On 3/10/24 at 1:04 PM, an observation of the bathroom in room [ROOM NUMBER] revealed multiple areas of a dried brown matter along the inner rim of the toilet. room [ROOM NUMBER] was occupied by 2 residents. The residents were able to use the bathroom on their own or with supervision assistance by staff. During a continuous observation and interview with the Environmental Services Manager (ESM) on 3/10/24 from 1:05 PM until 1:16 PM, she revealed that every resident room and bathroom were cleaned daily and deep cleaned monthly. Deep cleaning consisted of moving furniture to clean behind and below surfaces, clean the floors and the walls of the bathrooms, and in addition to mopping and sweeping, the floor was also polished. She stated there should have been 4 housekeepers scheduled each day for the whole facility, but on 3/9/24 and 3/10/24 only 2 housekeepers were in the building. An observation of room [ROOM NUMBER], on the locked unit, revealed multiple areas of brown matter on the inside of the toilet bowl and on the outer rim. ESM confirmed the observation and identified the brown matter as feces. Observation of room [ROOM NUMBER]on the locked unit, revealed a dried, light brown matter on the toilet cover that the ESM was able to wipe off. The ESM stated she would have a housekeeper clean the locked unit after lunch meal, and it should take them about 2 hours to clean. On 3/11/24 at 8:07 AM, an observation was made in the bathroom between rooms [ROOM NUMBERS] and brown matter was smeared all over the toilet paper roll sitting on the handlebar next to toilet. On 3/11/24 at 8:10 AM, an observation was made in the bathroom of room [ROOM NUMBER]. [NAME] matter was all over the commode cover, on the toilet seat, and on the floor. On 3/11/24 at 10:09 AM, an observation was made of the bathroom in room [ROOM NUMBER]. The brown matter on the toilet and commode was cleaned slightly, but a brown residue remained on the toilet seat and inside the toilet bowl. An interview was conducted with the Administrator on 3/13/24 at 8:11 AM. She revealed the locked unit should be cleaned daily and as needed. The Administrator indicated she had not heard of any complaints about resident bathrooms. She further stated Housekeeping was short staffed often and cleaned the locked unit at some point on the same day. She stated that fecal matter on the toilets would need to be cleaned as soon as possible.

Based on record review, observations, staff interviews and interviews with Wound Care Physician Assistant (PA), the facility failed to (1) perform wound care to a pressure ulcer per physician's order (Resident #19), (2) set the alternating pressure air mattress at the correct setting based on the resident's weight (Resident #104), and (3) change the treatment for a pressure ulcer when ordered by the Wound Care PA (Resident #77) for 3 of 4 residents reviewed for pressure ulcers. The findings included: 1. Resident #19 was admitted to the facility on [DATE], and diagnoses included dementia and right hip fracture. Resident #19's care plan dated 1/14/2024 included a focus for a right heel suspected deep tissue injury (SDTI). Interventions included administration of treatments as ordered by the physician and monitor effectiveness of treatments. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was moderately cognitively impaired and was receiving treatments for a pressure ulcer. Wound Care PA notes reported an odorless slough adherence to the right heel pressure ulcer, tenderness and mild redness to the skin around the wound on 2/21/2024. Visible necrotic tissue was debrided, and Resident #19 was stated on Doxycycline, an antibiotic, for seven days. On 3/6/2024, the Wound Care PA documented improvement of Resident #19's right heel pressure ulcer measuring 1.05 x 1.5 x 0.7 x 0.3 centimeters with 90% pink granulated tissue and 10% yellow tissue and moderate amounts of serosanguineous drainage. Physician orders dated 2/29/2024 included an order to cleanse the right heel with wound cleaner, to apply collagen particles before applying calcium silver alginate and a foam heel dressing and to secure the dressing with kerlix (a wrap to hold primary and secondary dressings in place) every other day for wound healing. A review of the March 2024 Treatment Administration Record (TAR) for Resident #19 indicated Nurse #3 recorded providing treatment of the right heel pressure ulcer on 3/11/2024. During observation of wound care to Resident #19's right heel pressure ulcer on 3/12/2024 at 10:05 a.m., the old foam dressing to the right heel was observed dated 3/9/2024 with NA #6 initials. On 3/12/2024 at 10:12 a.m. in an interview with the Director of Nursing (the nurse who provided Resident #19's wound care on 3/12/202), she stated Nurse #3 had documented on 3/11/2024 changing the pressure ulcer dressing to the right heel on Resident #19's TAR and stated obviously based on the date and NA #6 initials (who was a NA II that had been trained to help with stage I and Stage II pressure ulcer dressings) on the right heel dressing it was not changed. The Director of Nursing explained due to the absence of the Wound Nurse, she had informed Nurse #3 on 3/11/2024 she was responsible for Resident #19's wound care, and Nurse #3 assured her she had performed Resident #19's wound care. Attempts to interview Nurse #3 were unsuccessful. On 3/13/2024 at 8:30 a.m. in an interview with the Wound Care Nurse and the Wound Care PA, they stated Resident #19's right heel pressure ulcer was treated with antibiotics in February due to increased pain and inflammation to the area. They stated Resident #19's right heel pressure ulcer had improved and was slowing decreasing in size. They stated in the absence of the wound nurse, the nursing staff were responsible for changing Resident #19's right heel pressure ulcer dressing every other day as ordered. 43222 2. Resident #104 was admitted to the facility on [DATE] with diagnoses that included a stage 3 pressure ulcer of other site, diabetes, and hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #104 as moderately cognitively impaired and required supervision or touching assistance with rolling left to right in bed. The MDS indicated a stage 3 pressure ulcer was present on admission and a pressure reducing device was used for the bed. The care plan revised on 1/24/24 identified Resident #104 had a stage 3 pressure ulcer to her sacrum on admission. Interventions included: administer treatments as ordered and monitor for effectiveness, educate the resident/family/caregivers as to causes of skin breakdown, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of the documented weights for Resident #104 revealed on 3/4/24 the resident weighed 140.6 pounds (lbs.). Observations on 3/10/24 at 11:56 AM and 3/12/24 at 8:18 AM revealed Resident #104 was in bed with an alternating pressure air mattress in place that was functioning. The air mattress settings were locked, and the weight set at 350 lbs. During both observations, Resident #104 complained that the air mattress was lumpy and caused pain to the sacral pressure ulcer site. The Wound Care Nurse was interviewed on 3/13/24 at 8:38 AM. She revealed that Resident #104's air mattress setting was supposed to be at 120 lbs. During her rounds, the Wound Care Nurse indicated that she would double check the air mattress settings for all residents with wounds. She stated Resident #104 never complained that the air mattress caused her pain in the sacral area. During an interview with the Wound Care Physician Assistant on 3/13/24 at 8:45 AM, she revealed that Resident #104's air mattress should have been set at the appropriate setting. During rounds, she and the Wound Care Nurse would correct the settings if not accurate. An observation and interview were conducted on 3/13/24 at 9:00 AM with Nurse #1. Nurse #1 observed Resident #104 in bed with the alternating pressure air mattress functioning and the settings locked and the weight at 350 lbs. Nurse #1 stated Resident #104 did not weigh 350 lbs. and that maintenance usually set up the air mattresses in resident rooms. Nurse #1 then adjusted the weight setting to 150 lbs., which was closest to Resident #104's weight value. An interview was conducted with the Maintenance Director on 3/13/24 at 9:10 AM. He stated the air mattresses were calibrated by the resident's weight. He indicated that he did not adjust the settings on the air mattresses, he only installed them when needed. The Maintenance Director revealed the Wound Care Nurse adjusted the correct settings. The Director of Nursing (DON) was interviewed on 3/13/24 at 9:41 AM. She revealed according to the manufacturer, the resident's weight determines the setting. The Wound Care Nurse was responsible for setting the weight on Resident #104's air mattress. The DON indicated that the Wound Care Nurse just came back to the facility after being away for 3-4 days. She stated that she was not aware of Resident #104's complaint related to the firmness of the air mattress. The DON revealed that she did not know why Resident #104's air mattress was set to 350 lbs. She stated she had discussed with the Maintenance Director last week about the air mattress control settings and witnessed him turn the weight all the up in a resident's room. She notified him that was incorrect. The Maintenance Director told her that was what he was told to do. The air mattress was supposed to pressure reducing. The DON stated that if it was on the wrong setting, the pressure ulcer could worsen or a new pressure ulcer could develop on the bony prominence. During an interview with the Administrator on 3/13/24 at 9:58 AM, she revealed that maintenance puts the air mattresses in the rooms. The Wound Care Nurse researched the resident's weight and adjusted the settings for the air mattress. The Administrator stated she was not sure why Resident #104's air mattress was set to 350 lbs. The Wound Care Nurse checked the air mattress settings when providing wound care. She indicated that she was not aware Resident #104 complained the air mattress was too lumpy and caused her pain. 50234 3. Resident #77 was admitted to the facility on [DATE] with diagnoses including history of prostate cancer, Chronic Obstructive Pulmonary Disorder (COPD), and a sacral pressure sore. Resident #77 Minimum Data Set, dated dated dated [DATE] revealed Resident #77 had short- and long-term memory and severely impaired decision making. Resident #77 was totally dependent on staff for all Activities of Daily Living. Resident #77 was at risk of pressure ulcers and had 1 unstageable pressure ulcer which was present on admission. Resident #77's care plan updated 3/3/24 revealed he had a Stage 4 pressure ulcer on his sacrum with osteomyelitis. The treatment listed on the care plan was Silver Alginate and a foam dressing. Interventions included to administer treatments as ordered and monitor for effectiveness. Record review of Resident #77's physician's orders revealed a wound treatment order dated 1/21/24 to clean the unstageable pressure ulcer with normal saline/wound cleanser. Apply calcium silver alginate and cover with a foam dressing every day shift for wound healing. Record review of Resident #77's wound consultant Progress Notes Report dated 3/6/24 revealed the treatment order was Change to Dakin's 0.5% wet to moist gauze covered with super absorbent dressing - change daily. An interview was conducted on 3/13/24 at 8:33 AM with the Wound Care Nurse and the Wound Care Physician Assistant. The Wound Care Nurse stated when the Wound Care Physician Assistant changed the treatment orders, the Wound Care Nurse usually wrote the wound care order change. If the Wound Care Nurse was not available, the nurse on the hall had the responsibility to change any wound care order from a provider in her absence. Observation on 3/13/24 at 9:20 AM of Resident #77's wound dressing change by the Wound Care Nurse. Resident #77's wound bed was beefy red with a small amount of slough in the center. Resident #77's wound had copious amounts of drainage. There was no odor. The Wound Care Physician Assistant measured the wound in centimeters 6.6 x3.8 tunneling was 15cm at 3 o'clock, 7cm at 12 o'clock and 0.9 cm at 9 o'clock. During the interview the wound was scraped by the Wound Care Physician Assistant, who described removing the slough to encourage tissue growth. The wound was dressed in Calcium Alginate and a foam silicone dressing. In an interview with the Wound Care Physician Assistant on 3/13/24 at 9:30 AM, she changed the treatment order on 3/6/24 to Dakin's 0.5% wet to moist gauze covered with a super absorbent dressing the be changed daily. However, because the wound was draining and had not progressed, she would change the order back to calcium silver alginate and with a foam dressing. The Wound Care Nurse indicated that the staff had not changed the order from the wound visit on 3/6/24 while the Wound Care Nurse was on leave. Review of the Treatment Administration Record for March 2024 revealed Resident #77 received the calcium silver alginate and foam dressing treatment every day shift from 3/6/24 through 3/11/24. Record review revealed that on 3/6/24 that Nurse #5 was the assigned nurse and responsible for the dressing change. In an interview 3/13/24 at 11:08 AM with Nurse #5 indicated that she changed the dressing order on 3/6/24 but did not recall who worked with the Wound Care Physician Assistant that day. She did not know how the wound care orders were communicated to the facility from the Wound Care Physician Assistant. She stated that if she made rounds with the Wound Care Physician Assistant, she would have known there was a change. She stated that she did not know who was responsible for putting the wound care orders into the medical record system, that the Wound Care Nurse always changed those. In an interview on 3/13/24 at 11:15 AM, the Wound Care Physician Assistant indicated on 3/6/24, NA #6 made rounds with her. She said that the wound care notes were sent to the facility. In an interview with Nurse #6 on 3/13/24 at 11:47 am, she stated she was also the unit manager. She said she was responsible for confirming the physician orders and the Wound Care Nurse updated the wound care orders. The Wound Care Physician Assistant sent the order change by email to the Director of Nurses (DON). The DON would update the orders or would delegate the order updates to Nurse #6 or the floor nurse. Nurse #6 indicated that on 3/6/24, the Wound Care Nurse was not on duty, and she was not aware of any change to any wound treatments. Interview on 3/13/14 at 1:48PM with the DON revealed that the wound care nurse was responsible for changing wound orders made by the Wound Care Physician Assistant. She indicated she did not know how the wound care nurse obtained the order changes. She stated she was provided the wound care consultant treatment notes via email for all residents treated. Review of the reports with the DON revealed that the documents included the order changes in bold print. When asked if the bold printed text was considered an order, the DON said Yes. She stated she should have had someone change the orders.

Based on record review, staff interview, physician assistant interview, and physician interview the facility failed to provide care in a safe manner resulting in a hematoma and a left ankle fracture for one (Resident #1) of three residents reviewed for accidental falls. Findings included: Resident #1 had cumulative diagnoses some of which included epilepsy (seizure disorder), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) affecting right non-dominate side, and cerebral infarction. Resident #1 had a current physician's order initiated on 10/19/2022 for 500 milligrams of Keppra to be administered as one tablet two times a day for a seizure disorder. Documentation on the medication administration record revealed Resident #1 received the seizure medication as ordered for the month of January 2023. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, was coded as requiring extensive assistance of one for bed mobility and total dependence on one for bathing. Resident #1 was also coded as having range of motion impairment on one side of upper and lower extremities with incontinence of both bowel and bladder. Documentation on the care plan dated 12/9/2022 had a focus area for a resident care guide. Some of the interventions listed were, aide of 1 or 2 people and no side rails. Documentation in a late entry health status note written by Nurse #1 dated 1/25/2023 at 5:21 AM stated, Staff was washing up resident, when she turned him over to change his bedding he fell on the floor. 911 was called and resident was taken to the hospital for evaluation. Family and [Medical Doctor] aware. Nurse #1 was interviewed on 2/16/2023 at 12:39 PM. Nurse #1 described the following events and actions taken on 1/25/2023 when Resident #1 fell out the bed. Nurse #1 stated that at approximately 4:40 AM NA #1 came running down the hall calling her to come quick because Resident #1 fell out of the bed. Nurse #1 ran down the hall to the room of Resident #1 to find him on the floor next to the bed face down. Nurse #1 explained she asked Resident #1 if he was okay. Resident #1 was talking but was complaining of being in pain. Nurse #1 stated she immediately went to get more help and found two more nurses to assist her because Resident #1 was a large person and therefore a lot of help was needed. Nurse #1 explained that every time Resident #1 was touched he complained of pain and complained of leg pain. Nurse #1 did not think it was a good idea to move Resident #1 because of his complaints of pain. Nurse #1 asked one of the other nurses in the room to go call 911. Nurse #1 stated she tried to get the vital signs for Resident #1 but was only able to get his temperature because he was laying face down. Nurse #1 stated her concern was that Resident #1 might have broken something and more damage could have occurred if he was moved. Nurse #1 revealed that EMS (emergency medical services) arrived quickly and requested the use of a mechanical hydraulic lift pad and mechanical hydraulic lift to move Resident #1 to the stretcher. Nurse #1 revealed with the assistance of the facility nurses, the EMS staff were able to get Resident #1 on the stretcher to take him to the hospital. Nurse #1 stated that as soon as Resident #1 was leaving with EMS, she called the on-call physician assistant and the responsible party for Resident #1. Nurse Aide (NA) #1 was interviewed on 2/16/2023 at 1:34 PM. NA #1 explained the following events and actions taken on 1/25/2023 when Resident #1 fell out of bed. NA #1 revealed she was very familiar with Resident #1 and had bathed him on her own many times. NA #1 stated she was giving Resident #1 a bath, had completed the bath, and had started to change the sheets. NA #1 stated Resident #1 was positioned on his left side and he had his left hand hanging on to the head of the bed. NA #1 revealed she went to the foot of the bed to get the pad on correctly and fit the sheet around the mattress when Resident #1 rolled out of the bed onto the floor, and she could not catch him. NA #1 explained Resident #1 was a big man who, just tipped over before I could get around the bed to catch him. NA #1 further explained Resident #1 tried to grab the nightstand next to his bed, but he just fell right on his face on the floor. NA #1 said she ran to get the nurse at the end of the hall. NA #1 explained she helped to clean up Resident #1 and stayed with him and the nurses until EMS arrived. Documentation in an emergency department note dated 1/25/2023 revealed the emergency department performed a left knee x-ray, CT (computed Tomography) scan of the cervical spine, and a CT scan of the head of Resident #1. Degenerative changes were noted on the left knee x-ray, degenerative changes on the CT of the cervical spine, and old cerebral infarcts noted on the head CT scan. The discharge assessment in the emergency room stated, Patient awake, alert and oriented x 3. No cognitive and/or functional deficits noted. Patient verbalized understanding of disposition instructions. Patient awake and alert. Documentation in a health status note dated 1/25/2023 at 9:05 AM written by Nurse #2 stated, Assessed resident upon return room from [hospital]. Resident appeared shaken from fall. Visibly shaken, shoulders vibrating. Placed on list for visit from provider today. denies pain at this time. bed in low position, call bell in reach. Nurse #2 was interviewed on 2/16/2023 at 3:21 PM and revealed she was the unit manager. Nurse #2 stated she went to assess Resident #1 as soon as he came back from the hospital on 1/25/2023. Nurse #2 stated Resident #1 was not complaining of pain when he returned to the facility but appeared visibly shaken and trembling. Nurse #2 stated she made sure the physician saw Resident #1 after he returned from the hospital on 1/25/2023. Documentation in a physician progress note dated 1/25/2023 stated in part under the plan portion of the note, Reassured him that he is not going to die. He checked out ok at the ER. Will order Ativan 0.5 mg (milligrams) [twice a day] for chronic anxiety and tremor .Apparently, he fell hard and hit his head and was shaken from the fall. Resident #1 had a physician's order initiated on 1/26/2023 for 0.5 milligrams of Ativan to be administered as one tablet by mouth two times a day for anxiety. Documentation on the Medication Administration Record for January 2023 revealed Resident #1 received Ativan as ordered beginning on 1/26/2023. An interview was conducted with NA #5 on 2/17/2023 at 10:30 AM. NA #5 confirmed she was very familiar with Resident #1 working on the 7:00 AM to 3:00 PM shift on the hallway he resided. NA #5 confirmed she was assigned to care for Resident #1 on 1/27/2023 and 1/28/2023. NA #5 stated that in the days after his fall Resident #1 did not complain of acute pain to her and his legs were not swollen or appear injured. NA #5 stated after the fall on 1/25/2023, Resident #1 stopped feeding himself and he seemed, out of it. NA #5 stated that at the time of the interview Resident #1 was doing a little better in that he was again able to feed himself, but he was not back 100% verbally. Documentation on a health status note dated 1/29/2023 at 11:20 AM written by Nurse #6 stated, Resident unresponsive during medication administration, Nurse alert, to find resident breathing heavily eyes rolling episode lasted 2 minutes. [Nurse Practitioner name] informed order send to ER (emergency room ) for evaluation follow up for previous fall injury to head right side. Seizure activity. [Resident representative] informed [name]. Documentation on an emergency room notes from the hospital dated 1/29/2023 revealed Resident #1 arrived in the emergency room at 11:44 AM. The documentation under the exam portion revealed Resident #1 was complaining of leg pain and assessed as having pain and swelling in his left lower leg, left ankle, left foot, with increased tenderness to internal rotation of the left lower leg. The exam portion also revealed Resident #1 was assessed as having right lower ankle and foot swelling and edema. X-rays of the pelvis, left tibia and fibula, left foot, and left ankle were taken in the emergency room . Resident #1 was discharged back to the facility on [DATE] with a diagnosis of nondisplaced facture of lateral malleolus of left fibula (ankle fracture just above the ankle joint) and a fracture of lower end of left tibia (shin bone fracture near the ankle). Nurse #6 was interviewed on 2/17/2023 at 9:45 AM. Nurse #6 explained she was the nurse who was on the hallway assigned to care for Resident #1 when he returned from the hospital on 1/25/2023, working the 7:00 AM to 7:00 PM shift. Nurse #6 revealed Resident #1 was not his normal self in that he was quiet and shaking with nervousness. Nurse #6 stated Resident #1 did not complain of pain, but he had a huge protruding lump on the right side of his head. Nurse #6 explained she performed an assessment of Resident #1 when he returned on 1/25/2023 from the ER and did not note any pain or swelling to his legs at that time. Nurse #6 stated she did not receive any reports from the nurse aides of any pain or swelling in the legs of Resident #1 in the days after the fall. Nurse #6 revealed that on 1/29/2023 Resident #1 did take his medications at around 9:00 AM but he did not seem like himself. Nurse #6 stated she checked on Resident #1 again on 1/29/2023 at around 11:00 AM and his eyes were rolled back in his head, shaking, and not responding to questions. Nurse #1 said she knew Resident #1 had a diagnosis of a seizure disorder and she had concern perhaps something was missed when he was sent to the hospital for assessment after the fall on 1/25/2023. Nurse #1 revealed Resident #1 had not had any seizure activity in the last few years since she had been coming to the facility as an agency nurse. Nurse #1 stated she contacted the Nurse Practitioner, and an order was received to send Resident #1 to the ER. Nurse #1 revealed Resident #1 was returned to the facility from the emergency department on 1/29/2023 with his left foot wrapped and a diagnosis of fractures of the left tibia and fibula. Nurse #1 also revealed that at that time it was noted Resident #1 had a swollen right leg. Documentation on an orthopedic consultation dated 1/31/2023 revealed Resident #1 had a fracture of the left lower tibia and fibula and a right sided tibia/fibula fracture of 6 to 8 weeks of age with minimal healing. Documentation on a physician's progress note for Resident #1 dated 2/1/2023 stated, He had a fall on 1/25/23 and went to ER. He had a hematoma on right forehead, no other findings noted, no changes made. He was then sent back to theER on [DATE] due to seizure like activity and recent fall. He was [diagnosed ] with left Tibia/Fibula fracture, splinted, and sent back to the facility for [follow up] with [Orthopedics]. Staff reported [right lower extremity] pain as well and hospital reported that they did not x-ray the right lower extremity. X-ray showed fracture and he was sent toER on [DATE] and diagnosed with distal femur fracture (right) and put in knee immobilizer. He has oxycodone 5 [milligrams] [every] 6 hours [as needed] for pain. An interview was conducted with the Director of Nursing (DON) on 2/16/2023 at 12:21 PM. After an investigation into the fall of Resident #1 a discussion was held in the morning meeting discussing the fall the next day (1/26/2023). The DON stated the facility ordered a bariatric bed for Resident #1 and put upper side rails on his bed so he could grab onto them during care. The DON also stated education materials were distributed to all the nursing staff on 1/26/2023 letting everyone know Resident #1 required 2 people for the provision of activities of daily living and repositioning as well as to let nursing administration know if a bed was too small or side rails were needed. The DON confirmed the care plan was updated at that time to reflect 2 people were needed for the provision of care for Resident #1 and the use of side rails for mobility. An interview was conducted with the facility Administrator on 2/17/2023 at 11:30 AM who indicated the cause of the fall for Resident #1 was poor positioning of the resident during care. The Administrator elaborated and stated that although Resident #1 was a large man, the bed he was in prior to the fall was big enough for him and he did not need side rails. The Administrator reiterated that if Resident #1 had been positioned correctly he would not have fallen. The Administrator stated NA #1 was retrained in positioning of residents and a four-point plan was being initiated to make sure all staff are trained in positioning of residents to prevent further occurrence of this type of accident. An interview was conducted with the facility physician assistant (PA #1) on 2/23/2023 at 2:40 PM. PA #1 stated on 1/25/2023 the hospital took a CT (computerized tomography) scan of the head of Resident #1 and reported to the facility there were no abnormalities such as a brain bleed. PA #1 further explained the stress of the fall and the fracture put Resident #1 at continued risk for break through seizure activity despite being on medication for seizures. PA #1 stated she was not sure if the seizure-like activity Resident #1 had was an actual seizure on 1/29/2023 because she was not there to witness it. PA #1 elaborated to say the hospital did not report to the facility on [DATE] Resident #1 had a seizure and there was no treatment or medication changes made as a result of the seizure-like activity on 1/29/2023. An interview was conducted with the physician (MD #1) for Resident #1 on 2/27/2023 at 11:26 AM. MD #1 stated Resident #1 was on medication for seizures and he had not known him to have any seizure activity while he was a resident in the facility. MD #1 revealed he doubted Resident #1 had a seizure on 1/29/2023. MD #1 further revealed Resident #1 was a very debilitated resident who was hard to assess. MD #1 stated Resident #1 would have been in a postictal state for a period if he had a seizure and there was not enough of a description in the nursing notes to prove he had a seizure. (A postictal state is a period that begins when a seizure subsides and ends when a patient returns to baseline. It typically lasts between 5 and 30 minutes.)

Based on record review, hospital staff, law enforcement, 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 the decision for 1 of 3 residents reviewed for transfer and discharge (Resident #1). This resulted in Resident #1 being found in a ditch approximately six miles from the facility the day after the hospital discharge. Immediate Jeopardy began on 10/28/20 when the facility, after Resident #1 was medically and psychiatrically cleared by the hospital physicians to return to the facility, refused to allow Resident #1 into the facility which resulted in Resident #1 being discovered in a ditch on 10/29/20 approximately six miles from the facility. Immediate Jeopardy was removed on 10/31/20 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. Findings included: Resident #1 was admitted to the facility on [DATE] with a history [MEDICAL CONDITION] and mood disorder. His [DIAGNOSES REDACTED]. Resident #1 transferred to the facility from the hospital after a hospital admission from 5/26/20-6/25/20 due being struck by a car going approximately 50 miles an hour. His injuries included multiple rib fractures, a fracture to his right lower extremity and a fracture to his right upper extremity. The latest Minimum Data Set (MDS) a quarterly MDS dated [DATE] revealed Resident #1 was severely cognitively impaired. His speech was clear, he made himself understood and he understands others. He had verbal behaviors directed towards others but no physical behavioral symptoms. Resident #1 had rejection of care 1-3 days. He was independent with eating, bed mobility, transfers, walking and locomotion on the unit. He required supervision for toileting, needed limited assistance for dressing and required extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. He received antipsychotic and antianxiety medications daily. He had a wander/elopement guard in place daily. The care plan for Resident #1 updated on 7/2/20 indicated Resident #1 had chronic/progressive decline in Intellectual functioning characterized by deficits in memory, judgement, decision making and thought process related to brain deterioration, mental illness, long term memory loss and short term memory loss. On 7/08/20 a focus area of ineffective coping with verbal and physical aggression or agitation and combativeness related to anger, loss of control, unpredictable situations (outbursts due to not being able to go outside when he wants to smoke, laying in the floor in the hallway to sleep was updated. The interventions included allow resident to respond to directions or request (due to dementia more time is required to absorb instructions); document summary of each episode; and monitor and document behavior. A focus area updated on 8/03/20 indicated Resident #1 was resistive to treatment due to cognitive impairment, laying in the floor in the hallway to sleep and refuses to go in the room. A progress note dated 10/21/20 revealed Resident #1 was discharged to the hospital on [DATE] due to agitated and aggressive behavior. Resident #1 hit a staff member and resident #1 was involuntarily committed to the hospital. During an interview with the facility social worker on 10/30/20 at 1:06 PM, she stated when Resident #1 struck a staff member she went to the magistrate's office and filed for an involuntary commitment. She reported that Resident #1 had behaviors since his admission in June, but no efforts had been made to discharge him elsewhere. Review of a hospital note dated 10/28/20 revealed Resident#1 was released from involuntary commitment by a psychiatrist and the physician ordered the resident be sent back to the facility. An interview with law enforcement officer #1(LEO #1) on 10/30/20 at 11:57AM revealed he had been contacted that Resident #1 was at a local hospital and been released from involuntary commitment. LEO #1 stated he took Resident #1 to the magistrate's office to deal with some old warrants. He reported Resident #1 was released with a written promise to appear in court. LEO #1 stated he transported Resident #1 to the facility. He continued that he was advised by someone who identified themselves as the Administrator that Resident #1 was not welcome and had been discharged from the facility. LEO #1 stated when he spoke with Resident #1 the resident informed him he was going to walk to his mother's home. LEO #1 stated he left the resident at the facility. LEO #1 stated approximately ten minutes later he was called to return to the facility. He reported upon arrival to the facility the Administrator stated Resident #1 was still on the premises. He stated he spoke to Resident #1 and agreed to take him to his mother's home. LEO #1 stated when he and Resident #1 were driving by a car wash Resident #1 stated he saw his brother. Resident #1 requested the officer stop the car. LEO #1 stated Resident #1 requested to be left with an individual he identified as his brother. LEO #1 stated he complied. During an interview with law enforcement officer #2 (LEO #2) on 10/30/20 at 11:47 AM he stated he was the responding officer to an emergency call on 10/29/20 at approximately 9:00 AM. He reported Resident #1 was found lying in a ditch approximately 6 miles from Williamston. He reported that Resident #1 appeared fine and was assessed by Emergency Medical Services. LEO #2 stated he contacted the facility and spoke with the Administrator. He reported he was told that Resident #1 had assaulted one of their patients and would not be allowed back at the facility. He stated Resident #1 was transported to a local hospital. An interview was conducted with the Director of Outpatient Nursing Services at the hospital on [DATE] at 1:35 PM, who reported when Resident #1 was ready to be discharged the assigned nurse attempted to contact the facility to give report with no success. She further stated the hospital was never told that Resident #1 could not return to the facility prior to discharge on the 10/28/20. During an interview with the hospital case manager assigned to Resident #1 on 10/30/20 at 1:52 PM, she stated the hospital psychiatrist rescinded the involuntary commitment on Resident #1. She reported she attempted to fax clinical information needed for Resident #1's readmission. The case manager stated the fax never went through. She indicated prior to refaxing the information she was advised by the Emergency Department Director that Resident #1 had been transported to the facility by the local police department. The hospital case manager stated she had spoken with the facility Admissions Director on 10/26/20 about discharge preparations. She stated they had attempted to place him with no success and he appeared to have stabilized. The hospital case manager stated she was advised by the facility Admissions Director that she would need to contact the Administrator and the Director of Nursing to determine if Resident #1 would be allowed to return. The hospital case manager stated she never received any follow-up information from the facility Admissions Director. An interview was conducted with the Admissions Director on 10/30/20 at 2:15 PM who stated she was not aware Resident #1 was being transferred back to the facility. She reported that the Administrator and the Director of Nursing went outside when Resident #1 and the police officer arrived and spoke with the police officer. The Admissions Director stated she contacted the hospital case manager who stated Resident #1 had some outstanding warrants and needed to be transported to the magistrate. The Admissions Director stated she had spoken with the emergency room case manager on 10/26/20 who stated the physician felt Resident #1 had stabilized. The Admissions Director stated she told the emergency room case manager that she did not think the facility would be taking him back but she needed to check with the Administrator and the Director of Nursing. She stated she sent a text message to both the Administrator and Director of Nursing. She reported she spoke with the Director of Nursing first who stated it was her understanding that Resident #1 would not be accepted back to into the facility, but she would need to speak to the Administrator. The Admissions Director stated she spoke with the Administrator who stated Resident #1 would not be returning to facility as they couldn't meet his needs. During an interview with a nurse at the hospital on [DATE] at 2:30 PM he revealed he was Resident #1's assigned nurse the day he was discharged from the hospital. The nurse stated the psychiatrist voided the involuntary commitment paperwork and he arranged for the police department to take Resident #1 to the facility. The hospital nurse stated he attempted to contact the facility multiple times and the one time he got an answer he was placed on hold for thirty minutes The nurse stated hospital staff frequently ask the police department to transport residents who are discharged from the hospital emergency room . He further stated that Resident #1 did not meet the criteria for ambulance transportation. During an interview conducted with the Administrator on 10/30/20 at 2:48 PM she stated she and other staff members were in the dining room having a clinical meeting. They noticed a police car outside with Resident #1 in the back. The Administrator stated she spoke with the Admissions Director to ascertain Resident #1's status. The Admissions Director was on the phone with the assigned hospital case manager and was told Resident #1 was to go to the magistrate to deal with outstanding warrants. She stated she spoke with the officer and explained that the facility was not aware that Resident #1 was returning to the facility. She continued that the police officer told her the hospital had attempted to contact the facility and had faxed the discharge paperwork. The Administrator further stated that the police officer asked for Resident #1's belongings. She reported the police officer was gone when staff returned with Resident #1's belongings. The Administrator reported contact was made with the officer who returned to building to transport Resident #1 away from the building. During an interview on 10/30/20 at 4:20 PM the facility Staff Development Coordinator stated she saw a man dressed in a paper gown in the ditch while she was driving to work at approximately 8:00 AM on 10/29/20. She stated she stopped her vehicle and called 911. The Staff Development Coordinator stated she contacted the facility and advised them she had found Resident #1. The temperatures 10/28-10/29/20 ranged from 67 degrees to 78 degrees with no rainfall according to the Weather Channel website (https://weather.com) referenced 10/30/20 at 4:00 PM A hospital physician progress notes [REDACTED].#1 was brought to the emergency department by emergency medical services for safety and well-being. Resident #1 was in the emergency department for 7 days on involuntary commitment paper from 10/21/20-10/28/20. Patient had a telepsychiatry evaluation and was awaiting placement to a psychiatric facility. In the emergency department he exhibited increased confusion and [MEDICAL CONDITION] at times but was easily redirected. Patient was never noted to be dangerous or a threat to staff. Patient had a telepsychiatry evaluation and the involuntary commitment was discontinued. He was discharged back to the nursing home. Law enforcement came to pick him up and advised he had outstanding warrants. Patient was taken to jail in handcuffs and presented to the magistrate. The magistrate released him. The patient was taken by the law enforcement officer to the nursing home. The nursing home staff refused to accept patient and stated he does not belong here and that he has been discharged . Patient was given his belongings. The law enforcement officer dropped him at an unknown address. Patient walked away from that address and was found sitting in a ditch. He spent all night in the elements sitting out in the ditch. This morning Emergency Medical Service brought him to the emergency department for his well-being and safety. On arrival he voiced no complaints. He has not taken his medications since before discharge from the emergency department. A hospital progress note dated 10/29/20 revealed Resident #1 had not had any food or personal hygiene since his discharge on 10/28/20. Patient was provided food and clean clothes upon admission. An interview with Resident #1 was conducted on 10/30/20 at 6:30 PM. He reported that he went to visit his mother and was resting in the ditch when he was found. He stated he did not remember the events leading up to the decision to visit his mother. An interview with the Admission Director on 10/30/20 at 6:43 PM revealed the facility had beds available on 10/28/20 and 10/29/30. On 10/30/20 at 7:55 PM the Administrator and Director of Nursing were notified of Immediate Jeopardy. On 11/2/20 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. Background facts: Resident # 1 was not permitted to timely return to the facility after the local hospital notified and/or attempted to notify the facility that resident was ready to return to the facility. Resident # 1 had not been officially discharged from the facility. The facility's admissions staff did not follow up with the local hospital after she was initially contacted by the hospital about the resident's return to the facility. In addition to Resident #1, other residents who could have potentially suffered an adverse outcome include any other residents with recent hospital stays or therapeutic leave absences. Both Resident #1 and those other potential residents have been addressed in the steps outlined in item 2, below. 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 On October 30, 2020, Resident #1 was safe and sleeping soundly in his hospital bed at the local hospital. Communication was provided to the Hospital that a bed would be made available to Resident #1 as soon as he was prepared for discharge. He returned to the facility that same evening and was assessed for signs and symptoms of injury and harm. None presented. The resident had no recall of the incident. A private sitter was placed with him for the night and will continue through the weekend. Date completed: October 30, 2020. All residents that have left the facility for hospital care and/or therapeutic leave and who have requested to return from a hospital stay or therapeutic leave during the last 31 days have been reviewed as of October 31, 2020 to ensure that any resident who was ready to return to the facility, and still needed the level of care offered by the facility, was not denied readmission consistent with federal law. No inappropriate denials of readmission to the facility or other problems or issues were identified from this review. Date completed: October 31, 2020. On October 31, 2020 at 3:00 pm a full staff, mandatory meeting for all direct care staff, management staff and admissions staff was conducted the dining room at the facility. Any staff who could not be present for this training will not be allowed to provide care to residents or otherwise resume their normal job roles until they completed the training. Date completed: All staff were trained as of October 31, 2020 with the exception of one nurse who was not scheduled for duty until the week of November 2 and one housekeeper. Training for both of these employees, as noted, will occur before they are allowed to return to work, with the nurse's training scheduled for Monday, November 2, 2020. Training topics includes the following: 1. Status of survey and update on Resident #1 2.Training on appropriate discharge and readmit policy and procedure to ensure full compliance with resident rights consistent with applicable state and federal law, specifically including a resident's right to return from a hospital visit or therapeutic leave if the facility remains able to provide care needed by the resident, once the facility is notified that the resident is ready to return to the facility. 3. If the facility is no longer able to provide the level of care the resident needs based upon a documented assessment, then appropriate discharge notice and planning will be initiated consistent with federal law governing resident discharges. 4. Retraining of facility management and admission staff to ensure they are aware of: a.Residents' rights to return to the facility following a hospitalization or therapeutic leave, if they still need the services offered by the facility, consistent with federal law; b. That all requests for resident readmissions for the next 30 days will be routed to the facility's corporate Compliance Team for review, evaluation, a decision and follow up to ensure compliance. c. That all communications from any hospital regarding a resident's readiness to return will also be routed to the facility's corporate Compliance Team for evaluation and further direction and follow up. d. If, following telephone contact by a discharging hospital, the facility receives no discharge paperwork from the hospital, the facility admission staff will follow up to determine if the resident still plans to return to the facility and, if so, to ensure timely receipt of the hospital discharge paperwork. For the foreseeable future, all returns for readmissions from hospital visits or therapeutic visits will be routed for analysis to the Compliance Team. Decisions regarding readmission will be made by the corporate compliance team to ensure compliance with all applicable federal and state law. Follow up by the Compliance Team will also occur to ensure that all readmission decisions are fully and properly implemented in accordance with applicable law. This process will continue until the Compliance Team is satisfied that all readmission requests are being properly received, responded to and implemented. Date completed: action initiated effective October 31, 2020 and ongoing. The Compliance Team monitoring will continue for a period of 30 days and will continue thereafter on a stepped-down basis, assuming no further incidents are involved, for a period of 60 days thereafter. Immediate Jeopardy was removed on 10/31/20. The credible allegation was verified 11/2/20 at 11:00 AM. Staff were interviewed and confirmed they received training from the Managing Director on regulatory requirements pertaining to resident rights pertaining to discharge and transfers. An observation on 11/2/20 at 9:30 AM revealed Resident #1 in a room watching television with a sitter. Staff stated there had been no behavior problems since his readmission.

Based on observations, staff, Nurse Practitioner, responsible party and police interviews, and record review the facility failed to prevent staff to resident abuse for 1 of 1 residents. Resident #7 was struck by a nurse aide four or five times with a closed fist during care. This physical abuse resulted in Resident #7 experiencing bruising to his left arm. The resident had an x-ray and was found to have no fractures. Immediate Jeopardy began on 11/19/19 when Resident #7 was receiving incontinent care from Nurse Aide (NA) #3 and NA #3 struck Resident #7 four or five times with a closed fist. Immediate jeopardy was removed on 11/21/19 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #7 was admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Resident #7's quarterly minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He was assessed to have adequate hearing, clear speech and was able to make himself understood by others. He was assessed to have no behaviors. He required extensive assistance with bed mobility, dressing and personal hygiene. He was totally dependent on staff for toilet use. Resident #7 was assessed to be incontinent of bowel and bladder. Resident #7's care plan dated 9/17/19 revealed he was care planned for ineffective coping with Agitation/Combativeness. The interventions included for Resident #7 to receive behavior management and psychiatric consults, give medication as prescribed by the physician, give resident item or task to distract, and pharmacy review of medications monthly and/or as needed. He was also care planned for resistance to treatment and care related to cognitive impairment. Resident #7 refused activities of daily living care and medications. The interventions included to allow for flexibility in activities of daily living routine to accommodate resident's mood, document care being resisted per facility protocol and notify physician of patterns in behavior, and if resident refused care, re-attempt at another time. Resident #7's (MONTH) 2019 physician's orders [REDACTED]. During an interview on 11/21/19 at 1:37 PM Resident #7's family member stated Resident #7 had delusions and thought people were out to get him and on 11/20/19 Resident #7 was making delusional statements. The family member stated on 11/20/19 he showed the Facility Nurse Consultant bruises on Resident #7's arm. The family member stated at this point Resident #7 told the Facility Nurse Consultant he had been hit. Facility Nurse Consultant then brought the administrator to the resident's room and Resident #7 then told the Administrator he thought he was hit by Nurse Aide #3 but could not remember what time or the date. The Administrator informed them she would contact the police. The family member specified the police detective arrived and Resident #7 told him a female staff member upset him, and said if you hit me, I'll hit you back twice as hard. The family member stated Resident #7 told the police detective he hit the staff member and in response the staff member hit him four times. The family member said the police detective told him on 11/21/19 Nurse Aide #3 quit last night and the reason she hit Resident #7 was because he called her a b During an interview on 11/22/19 at 7:45 AM the Facility Nurse Consultant stated on 11/20/19 around 10:00 AM the family member of Resident #7 spoke to her about some concerns he had with the facility, and as they were talking Resident #7 suddenly stated and that girl grabbed my arm and hit me. The Facility Nurse Consultant then asked him to repeat what he said, and he stated the same thing. The Facility Nurse Consultant left the room and brought the Administrator to Resident #7's room. She asked Resident #7 to please tell the Administrator what he just told her. Resident #7 then said an aide told him if you hit me, I ' ll hit you. Resident #7 indicated the nurse aide hit him with a fist four times on his left arm. Resident #7 stated about the third time the nurse aide hit him, he hit her back. Resident #7 stated Nurse Aide #3 was the NA that hit him. The Facility Nurse Consultant stated she and the administrator then left the resident's room, called the police, initiated the 24-hour report to the state and then began their investigation. During an interview on 11/21/19 at 3:54 PM the Administrator stated about 10:00 AM on 11/20/19 she was alerted by the Facility Nurse Consultant that she was needed in Resident #7's room. The administrator stated Resident #7 informed her that Nurse Aide #3 came in his room, held his arm and hit him four times on his left arm with her fist. He then indicated there was bruising along his entire left forearm. Resident #7 said, he was being belligerent with Nurse Aide #3 and the nurse aide said to him you hit me and I'm going to hit you back. The Administrator stated the facility initiated the 24-hour report, notified the police and began their investigation. The administrator stated Nurse Aide #3 called her at around 3:45 PM on 11/20/19. Nurse Aide #3 first stated to the administrator at around 2:00 PM to 3:00 PM on 11/19/19 she was going to change Resident #7 and when she started with the care, Resident #7 became aggressive. Nurse Aide #3 stated Resident #7 called her a b and went on to explain the resident required incontinent care. So, she proceeded to get things ready to provide incontinent care for him. Nurse Aide #3 said she put the head of the resident's bed down and Resident #7 started to swing at her. She told Resident #7 don't do that and said, the resident jumped at me like he wanted to hit me. The resident hit Nurse Aide #3 on her left arm and the nurse aide said she proceeded to turn the resident on his left side where she cleaned his backside and rolled the linens which were soiled under the resident to change them. Nurse Aide #3 stated she then rolled him to his right side where the resident again began swinging at her. She finished cleaning the resident and replaced clean linens on the bed, raised the head of the bed and left the room. The nurse aide stated she went and told Nurse #1 that Resident #7 had behaviors. Nurse Aide #3 then stated that either Nurse Aide #4 or the Wound Care Nurse was in the hallway and heard the resident call her a [***] . Nurse Aide #3 reported no issues or behaviors with morning care on 11/19/19. At that time Nurse Aide #3 denied having any other facts about the incident. After prompting by both the Regional Vice President and Administrator, Nurse Aide #3 said there was more to the story. She then stated the resident was calling her all kinds of b es. While she was changing him, he did jump at her like he was going to hit her. Resident #7 seemed more out of it and started hitting her. She stated she then told Resident #7, If you hit me again, I'm gonna hit you back. The resident continued to strike Nurse Aide #3 in the chest area. Nurse Aide #3 then stated, I hit him a few times. Twice on the arm, on his side, and then on his thigh. She stated she did not strike him hard and then she reported to Nurse #1 about the behaviors but did not report that she had struck the resident. The Administrator stated at that point Nurse Aide #3's employment was obviously terminated and a full plan of correction was immediately initiated. During an interview on 11/21/19 at 1:56 PM Resident #7 stated a nurse aide made him angry but could not remember why. He stated he then made a fist with his right hand and the nurse aide told him, hit me and I'll hit you again harder. Resident #7 further stated he then hit the nurse aide and the nurse aide hit him back on the arm. Review of a written statement dated 11/20/19 revealed the following statement was obtained from Nurse Aide #3 by the Administrator. Nurse Aide #3 called the facility as per the Administrator's request at about 3:34 PM on 11/20/19 to discuss the physical abuse allegation that was made against her. The Administrator asked if she had any issues recently with Resident #7. Nurse Aide #3 explained Resident #7 yelled out a lot and he always thought someone was going to cut something off him such as his legs or arms. The nurse aide went on to explain Resident #7 had visual hallucinations. Nurse Aide #3 then stated on 11/19/19 Resident #7 was aggressive and struck her in her chest area. The nurse aide told Resident #7 not to do that and Resident #7 apologized. Nurse Aide #3 stated she worked with Resident #7 on both 11/16/19 and 11/17/19 on 7 AM to 3 PM shift. Nurse Aide #3 stated Resident #7 did not have any behaviors on those shifts. The Administrator asked Nurse Aide #3 if Resident #7 had ever made a statement to her about being struck or hit by someone to which the nurse aide responded no. Nurse Aide #3 was then asked to explain the combative episode on 11/19/19 in greater detail. The nurse aide stated around 2 PM or 3 PM she went to change Resident #7 and he became aggressive and called her a b She put his bed down and Resident #7 started to swing at her. Nurse Aide #3 told Resident #7 not to do that. The resident jumped at her like he wanted to hit her. He hit her on the left arm, and she turned him on his left side and cleaned his back side. Nurse Aide #3 then rolled him to his right side and Resident #7 again began to swing at her. She finished care and placed the bed back in the position it had been prior to care and exited the room. She informed Nurse #1 of his behaviors. She stated Nurse Aide #4 or the Wound Care Nurse were in the hallway and heard the resident call her a [***] . Nurse Aide #3 was then asked if there was anything else that the Administrator needed to be aware of and Nurse Aide #3 denied having any other information. The Regional Vice President then took over the line of questioning and told Nurse Aide #3 the Sheriff's Department had explained to the facility that Nurse Aide #3 had pertinent information on Resident #7. Then Nurse Aide #3, after prompting by the Administrator and Regional Vice President, stated there was more to the story. She then stated Resident #7 was calling her, all kinds of [***] es. While she changed him, he jumped at her like he was going to hit her and he seemed more out of it. Resident #7 began hitting her and she told him, if you hit me again, I'm gonna hit you back. Resident #7 continued to strike Nurse Aide #3 in the chest area. Nurse Aide #3 then told them she hit Resident #7 a few times, twice on the arm, on his side and then on his thigh. She explained that she did not hit him hard. The nurse aide then concluded she told Nurse #1 about the behaviors but did not report that she had struck the resident. During a phone interview on 11/21/19 at 4:18 PM Nurse Aide #3 stated she went in Resident #7's room on 11/19/19 to provide incontinent care between 2:00 PM and 3:00 PM. The aide stated Resident #7 was combative. Resident #7 was soiled and had a bowel movement. Nurse Aide #3 stated she prepped everything she needed for incontinent care and entered his room. Resident #7 swung at her as she was laying him back and she told Resident #7 not to do that. She stated she proceeded to change him and as she was taking his brief off. Resident #7 was still swinging at her and she continued to tell him not to do that. She rotated Resident #7 to his left side, cleaned his backside and put a new brief under him. She stated she then rotated him towards her and he again began swinging at her. Nurse Aide #3 told him it was not nice to swing at people. She stated she then popped him on the upper right side of his left arm around the shoulder area. She stated she hit Resident #7 four or five times. She stated she hit him for every time he hit her. Nurse Aide #3 continued to state they went back and forth a few times and then she turned him on his back to get his brief on. When asked what she meant by she popped the resident, Nurse Aide #3 stated she struck Resident #7 with a closed fist but not very hard. At this point Resident #7 was calling her a b Nurse Aide #3 stated she raised the head of his bed up and left the room. She went to Nurse #1 and informed her Resident #7 was having behaviors. She stated she did not inform Nurse #1 that she hit Resident #7. She stated after that it was time to go home as it was shift change. The nurse aide concluded she did not inform any staff she hit Resident #7 and did not return to work. During an interview on 11/21/19 at 3:16 PM the police detective with the local Police Department stated the police had probable cause through a confession from Nurse Aide #3 that she assaulted Resident #7. The nurse aide admitted to hitting Resident #7 with a closed fist five times which lead the detective to pursue a felony warrant against NA #3 for abusing a patient with injury. A review of a witness statement dated 11/21/19 revealed Nurse #1 stated on 11/19/19 at about 2:50 PM Nurse Aide #3 came to her at the nursing station. Nurse Aide #3 informed her Resident #7 was acting up during care and he did not want her to do his care. Nurse #1 told Nurse Aide #3 she would go to his room and the nurse aide informed her there was no need because she already finished care. Nurse #1 told Nurse Aide #3 from then on to come get her when residents were acting up or refusing care. Nurse Aide #3 stated okay, and Nurse #1 concluded she did not notice any abnormal bruising on Resident #7 and he never reported any abuse on anyone treating him badly. She stated the Director of Nursing had already documented the bruising before she came on shift on 11/21/19. During an interview on 11/21/19 at 6:13 PM Nurse #1 stated on 11/19/19 at 2:50 PM Nurse Aide #3 came to her at the nursing station and stated Resident #7 had been combative during care. She further stated she then offered to go down to the room and assist with his care. The nurse aide stated she had already completed the care. The nurse then educated the nurse aide the next time he was combative to come and get her for assistance. She further stated the nurse aide did not inform her she had struck Resident #7. The nurse aide stated okay and went home. She further stated she did not notice any complaints of pain, bruising, or anything to Resident #7's left side. Nurse #1 stated she had no reason to look for his bruising and did not do skin checks unless something was wrong. She further stated on 11/20/19 her nurse aide did not report any bruising to Resident #7's left side. During an interview on 11/22/19 at 2:11 PM Medication Aide #1 stated she worked with Resident #7 on second shift on 11/19/19. She stated Nurse #1 did not tell her anything specific about Resident #7 when she came on duty on 11/19/19. She further stated she did not notice any unusual or new bruising to Resident #7. She stated the only behaviors she noted that shift with Resident #7 was around 5:00 PM she heard him calling the nurse aide a b . During an interview on 11/22/19 at 11:41 AM Nurse #2 stated she was Resident #7's nurse on 11:00 PM to 7:00 AM shift the night of 11/19/19. She stated Nurse #3 did not report anything unusual about Resident #7 during change of shift report. During observation on 11/21/19 at 6:21 PM Resident #7 was assessed with [REDACTED]. No bruises were noted on his left upper arm or shoulder, no bruises on left chest or abdomen area, no bruises were observed on his left thigh. Resident #7 was noted to have a large bruise on his left lower arm and several smaller bruises on his left lower arm around the elbow area. Some bruising was noted on his left hand. The Director of Nursing had measured bruising and documented the bruise to his left lower arm to be approximately 12 centimeters long by 7 centimeters wide A skin assessment and measurements performed by the Director of Nursing on 11/21/19 revealed Resident #7's left upper forearm had a large bruise 12 centimeters long and 7 centimeters wide. His left upper wrist also had a bruise which measured 3 centimeters long and 3.5 centimeters wide. A small u-shaped scab was documented on the skin where the large bruise was. It was less than 0.3 centimeters in size. The radiology results report for Resident #7 revealed on 11/21/19 an x-ray had been taken of Resident #7's left arm. The findings were elbow arthritis, spurring of the elbow and no fractures or displacement. During another interview on 11/22/19 at 11:17 AM Facility Nurse Consultant #1 stated she informed the Psychiatric Mental Health Nurse Practitioner there were allegations of abuse for Resident #7. She stated she intended for Resident #7 to tell her about the incident. She stated she would have liked to have told her specifically that Resident #7 had been struck by Nurse Aide #3, but the Psychiatric Mental Health Nurse Practitioner had spoken to her on the hallway. She concluded she would ask her to reevaluate the resident. During an interview on 11/22/19 at 11:54 AM the Psychiatric Mental Health Nurse Practitioner stated she reevaluated Resident #7 on 11/22/19. She stated he was somewhat irritable and she introduced herself. Resident #7 stated he did not trust her because she lied to his family member. She asked what she said and Resident #7 stated you know what you said. She asked him again and he stated everyone would all evaporate soon. She stated she asked him to describe what happened when he got hit and Resident #7 stated he could not remember. Resident #7 told her she had all the information. She stated Resident #7 presented to her the same as before and she did not feel he had suffered any psychosocial trauma at that time. She further stated he could be blocking his experience and there was potential for trauma related to the incident. The Administrator was notified of the immediate jeopardy on 11/21/19 at 7:00 PM. On 11/22/18 at 10:43 AM the facility provided the following credible allegation of immediate jeopardy removal. F 600-Abuse · Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance Resident # 7 is alert and oriented to self with a [DIAGNOSES REDACTED]. On 11/20/2019 at approximately 10:00 am, resident # 7 reported to the Facility Nurse Consultant that a Nursing Assistant (NA) # 3 held resident's arm down and punched residents arm four times with a closed fist. On 11/20/2019 at approximately 10:02 am the Facility Nurse Consultant made the Administrator aware of resident # 7's report of abuse. On 11/20/2019 at approximately 10:05 am, the Administrator and the Facility Nurse Consultant re-interviewed resident # 7 regarding the allegation of abuse. On 11/20/2019 the hall nurse completed a head to toe assessment on resident # 7 with no signs and symptoms of abuse observed. On 11/20/2019 at approximately 11:10 am the Administrator notified the police department of resident # 7's allegation of abuse. On 11/20/19 the Resident Representative (RR) of resident # 7 was in resident # 7's room when resident # 7 reported the allegation of abuse. On 11/20/2019 at approximately 11:30 am, the police department arrived onsite to investigate the allegation of abuse. On 11/20/19 the physician was notified of the allegation of abuse. On 11/20/19 a thorough investigation was initiated by the Administrator and Director of Nursing related to the allegation of abuse reported by resident #7. On 11/20/19 the Administrator completed and faxed the initial allegation report to the Health Care Personnel Investigations. Resident # 7 was reassessed by the Director of Nursing on 11/21/19 with a bruise observed to resident's left arm. On 11/21/19, the physician was notified of the bruise by the Director of nursing with an order received to obtain an x-ray. The x-ray results were negative for an injury. After 11/19/2019 NA # 3 never returned back to work. Psych services is scheduled to be at facility on 11/22/2019 to assess resident # 7 for psychosocial follow-up. Resident # 7 has no negative affect noted. On 11/20/19, a 100 % Resident Questionnaires was completed by the Social Worker with all alert and oriented residents in regards to: Do you know what abuse means? Are there any instances that you felt you were abused in any way? Do you know of any residents that have been abused in any way? Do you know who to report abuse to? Do you feel safe here? There were no other allegations of abuse verbalized. On 11/20/2019, 100% skin checks were initiated on all residents to include resident # 7, who are unable to report signs/symptoms of abuse utilizing a resident census by the Unit Managers, Hall nurses and Assistant Director of Nursing. The skin checks will be completed by 11/21/19. · Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring On 11/20/2019, Abuse Quizzes were initiated by the Facility Consultant, Administrator, and DON with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Administrative assistant, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Activities Assistant, Medical Records, Central Supply Clerk, Maintenance Director, Maintenance Assistant, Social Worker (SW), and[NAME] Clerk with questions in regards to (1) who should you report abuse to? (2) When should you report abuse? (3) Give 2 examples of abuse. (4) What is the first thing you do if you see or hear a resident being abused from a staff member, visitor or another resident? (5) Who is the abuse coordinator? (5) If a resident becomes combative or resist care what should you do? The abuse quizzes will be completed by 11/21/19. After 11/21/2019 any remaining staff that has not worked and not received the quizzes will receive it prior to starting the next scheduled shift. On 11/21/2019, the Administrator called the Ombudsman to schedule an in-service in regards to dealing with combative residents and resident abuse. A message was left for the Ombudsman on 11/21/19. The in-service will be posted once scheduled for mandatory attendance by all staff. On 11/21/19 a questionnaire was initiated by the staff facilitator with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Administrative assistant, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Activities Assistant, Medical Records, Central Supply Clerk, Maintenance Director, Maintenance Assistant, Social Worker (SW), and[NAME] Clerk with question in regard to: Do you know of any staff member that has abused a resident that has not been reported and addressed? The questionnaires will be completed by 11/21/19. After 11/21/2019 any remaining staff that has not worked and not received the questionnaire will receive it prior to starting the next scheduled shift. On 11/21/19, a staff scenario was initiated by the staff facilitator with all nurses and nursing assistants regarding dealing with combative residents and prevention of abuse. The purpose of the scenario is to validate staff knowledge and understanding of what to do when a resident is being combative during care. The scenarios will be completed by 11/21/19. After 11/21/2019 any remaining staff that has not worked and not received the scenario will receive it prior to starting the next scheduled shift. On 11/20/2019 an in-service was initiated by the Facility Nurse consultant and staff facilitator with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Administrative assistant, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Activities Assistant, Medical Records, Central Supply Clerk, Maintenance Director, Maintenance Assistant, Social Worker (SW), and[NAME] Clerk regarding dealing with combative residents, abuse, and dementia training. The in-service included verbal, sexual, mental or physical abuse, neglect or mistreatment of [REDACTED]. In-services to be completed by 11/21/2019. After 11/21/19, the receptionist will mail the in-services via certified mail to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the staff facilitator or Director prior to next scheduled work shift. The Administrator and Director of Nursing were responsible for the implementation of corrective actions to include all 100% audits and in-services. · Date of corrective action completion Immediate Jeopardy Removal date will be 11/21/2019. The credible allegation for Immediate Jeopardy removal was validated on 11/22/19 at 3:09 PM, which removed the Immediate Jeopardy on 11/21/19, as evidenced by staff interviews, in-service record reviews, and observation. The in services included information on caring for combative residents, abuse and neglect policies and procedures, types of abuse, and reporting incidents of abuse.

Based on observation, physician interview, staff interview, resident interview, and record review facility staff failed to apply a knee immobilizer correctly which contributed to the development of pressure ulcers (left lower leg) which were not identified until they presented as unstageable wounds for 1 of 3 sampled residents (Resident #3) with pressure ulcers. The facility also failed to measure and assess a pressure ulcer (left buttock/sacrum) for 13 days after it was identified, and failed to put nutritional interventions in place to help heal this ulcer in a timely manner and provide a consult with the registered dietitian as recommended by the dietary manager for 1 of 3 sampled residents (Resident #3) with pressure ulcers. Findings include: Resident #3 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. a. Labs collected on 06/22/12 documented Resident #3's [MEDICATION NAME] level was within normal limits, 3.7 grams per deciliter (g/dL) with normal being 3.5 - 5.2 g/dL. X-rays taken on 08/30/12 documented Resident #3 had bilateral tibia fractures. A 08/31/12 physician's orders [REDACTED]. The resident's 09/05/12 Significant Change Minimum Data Set (MDS) documented her cognition was moderately impaired, and she required extensive assistance from two staff members for bed mobility. On 09/12/12 "Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure related to: incontinence-bowel and/or bladder, immobility, total assistance needed with turning & positioning" was identified as a problem on the resident's care plan. Interventions to this problem included, "Monitor skin daily during care for any changes. Report any abnormal observations to nurse" and "Notify appropriate personnel of changes in eating/drinking patterns. Interventions also included, "Weekly assessment of wound/ulcer. Notify physician of changes as indicated." A 09/15/12 electronic Resident Progress Note documented, "...Leg immobilizers in place to bilat (bilateral) lower extremities ...Swelling remains of extremities @ (at) knees and below. Pedal pulses present bilat. Resident keeps feet externally rotated. Propped with pillow to prevent rotation. Receives pain medication as prescribed." A 09/19/12 electronic Resident Progress Note documented, "Resident lying in bed, c/o (complains of) pain to Lt (left) leg. Stated leg felt like it was bleeding. Immobilizer loosened on leg. Bruising and swelling @ & (at and) below knee. No bleeding present. Pedal pulse present bilat (bilaterally). Legs positioned for comfort." A 09/20/12 physician's orders [REDACTED].#3 at all times unless the resident was being bathed. A 09/24/12 electronic Wound/Ulcer Flow Sheet documented the presence of two pressure ulcers on Resident #3's left lower leg. The sheet documented the ulcer on the proximal left lower leg measured 2 x 1.5 centimeters (cm), and was identified as unstageable, with the wound bed being 100% necrotic tissue. The sheet documented this pressure ulcer was caused by rubbing from the knee immobilizer. The sheet documented the ulcer on the distal left lower leg measured 2.5 x 2 cm, and was identified as unstageable with the wound bed being 100% necrotic tissue. The sheet documented this ulcer was caused by pressure from the knee immobilizer. A 09/26/12 physician's progress note documented Resident #3 was being seen for evaluation of an abrasion of her left tibial surface. The physical exam portion of the note documented, "Peripheral pulses are equal in all extremities. No significant varicosities or arterial venous malformations are noted." The assessment portion of the note documented, "Abrasion left tibial surface (secondary to slippage of knee immobilizer)." The plan portion of the note documented, "Knee immobilizer has been stabilized to reduce risk of slippage." At 9:12 AM on 09/27/12 treatment/dressing changes were provided to Resident #3's left lower leg by two treatment nurses. The nurses removed bilateral bunny boots and bilateral immobilizers containing hard rods from the resident's feet and legs. A pressure ulcer four to five inches above the resident's left ankle was 75 % yellow slough and 25% pink tissue, approximately 2 x 3 cm. A pressure ulcer near the resident's left ankle presented as 100% yellow slough with pink edges, approximately 2 x 2 cm. After removal of the old dressings, the ulcers were cleaned with wound cleanser and wet-to-dry dressings were applied. At this time Treatment Nurse (TN) #1 stated the pressure ulcers to Resident #3's left lower leg were the result of an improperly applied immobilizer which had rubbed against the resident's leg. She explained when the immobilizers were applied, the resident's knees were not in the center which caused the immobilizers to bunch toward the bottom of the resident's legs. TN #1 reported that since finding the pressure ulcers on Resident #3's left lower leg, the hall nurses were having to check the resident's immobilizers each shift and sign off that they were properly applied. At 9:21 AM on 09/28/12 a telephone conversation was held with nursing assistant (NA) #8, who the facility identified as Resident #3's primary NA on first shift. According to NA #8, when staff tried to turn the resident on her sides she complained about pain to her sacrum and legs. She explained the resident would request to be repositioned on her back once again. The NA stated she provided daily bed baths to Resident #3, and was told by nursing that she could remove the immobilizers before the baths and reapply them after the baths. She reported that she was the staff member who actually removed and reapplied the immobilizers. NA #8 commented the facility provided her with no training on how to apply and remove the immobilizers the best she could. She reported that to the best of her knowledge she did not seem to have any problems taking them off or putting them back on. However, she stated the resident did yell and complain of pain when applying and removing the immobilizers. According to NA #8, because of the signs and symptoms of pain, she placed towels inside Resident #3's immobilizers to make them more comfortable until a nurse advised her that the towels would generate too much heat inside closed environments. The NA reported that she found a brown/black area on Resident #3's lower left leg on either Monday, 09/24/12, or Tuesday, 09/25/12. She commented she reported this wound to the hall nurse as soon as she found it. At 11:32 AM on 09/28/12 Resident #3's primary physician stated the resident's diabetes was poorly controlled, the resident was non-compliant with her diabetic diet, and the resident was non-compliant with turning and repositioning. At 3:00 PM on 09/28/12 TN #2 stated Nurse #1 informed the TNs that Resident #3 had pressure ulcers to her left lower leg. According to TN #2, Nurse #1 showed the TNs that the resident's immobilizer was not applied correctly, and was sliding down the resident's left leg. TN #2 reported that it was agreed going forward that the hall nurses had to check the application of the immobilizers after bed baths to make sure they were on the resident's legs correctly. During a telephone interview at 3:24 PM on 09/28/12 Nurse #1 stated she observed two brown/black areas on Resident #3's left lower leg, one near the ankle and the other on the lower leg. This nurse reported she informed the TNs who stated the areas were 100% hard necrotic tissue. She commented she thought the wounds on the resident's left lower leg were caused by the immobilizer sliding down the leg. Nurse #1 stated she thought the bottom part of the immobilizer was rubbing against the leg. At 3:08 PM on 09/28/12 Resident #3's primary physician stated if the resident had [MEDICAL CONDITION], it was very mild. He explained the resident's previous physician documented a [DIAGNOSES REDACTED]. The physician reported he had checked the pulses in the resident's feet and ankles, and they were very good for a geriatric resident. However, the physician commented the staff needed to be careful in the application of the immobilizers because they could rub places on the resident's feet and lower legs. According to the physician, scabs did not spontaneously appear. Instead, he explained that wounds progressed from a reddened area which yellowed, thickened, and turned into dark scabs. If a resident's nutrition and health were impaired, the physician commented he had seen scabs develop within a week's time. At 3:14 PM on 09/28/12 Resident #3 stated the leg immobilizers were not comfortable, and they rubbed a place on her leg. She reported she complained they were painful, but was given medicine to keep the pain under control. She stated the NAs took the immobilizers off before baths, and reapplied them afterwards. At 3:18 PM on 09/28/12 NA #9 stated she cared for Resident #3. She reported the resident complained the immobilizers were uncomfortable, but would wear them. She commented she had taken off and reapplied the immobilizers when bathing the resident. According to NA #9, no one in the facility trained her how to apply or remove the immobilizers, but she had worked with other residents over the years that had them, so she felt she could apply and remove them without any problems. At 3:32 PM on 09/28/12 the Director of Nursing (DON) stated the facility did not provide any training to direct care staff about how to apply and remove immobilizers. She reported she was informed the wounds on Resident #3's left lower leg were caused by friction from the immobilizer. However, she commented no staff members had reported to her having problems applying or removing Resident #3's immobilizers. According to the DON, typically wound beds were not found as hard eschar or scabs. She explained pressure ulcers usually started as non-blanchable areas that reddened, opened, and sometimes proceeded to deepen. However, the DON reported she had seen cases with nutritionally compromised residents when this progression from red area to scab occurred in less than a week. At 4:30 PM on 10/05/12 NA #10 stated, during a telephone conversation, she cared for Resident #3 on 09/22/12 and 09/23/12 second shift. She reported although she did not bathe the resident herself on these days, the charge nurse did remove the immobilizers during this time. The NA commented she did not remember seeing any bruising or discoloration to the resident's ankles upon removal. According to the NA, Resident #3 complained about the immobilizers being tight, but she was able to get two fingers under them so she reassured the resident they were okay. She stated she did not notice Resident #3's immobilizers sliding down her legs. At 12:18 PM on 10/09/12 NA #11 stated, during a telephone conversation, she cared for Resident #3 on 09/23/12 when she washed the resident's legs and feet. She explained she had to lift the resident's legs a little in order to wash her feet and heels. NA #11 reported there was yellow bruising on both legs between the knees and the feet. However, she commented she did not see any other skin integrity problems associated with her lower extremities. According to NA #11, Resident #3 did complain some about her ankles hurting and being sore. She also reported the resident complained of the immobilizers being hot and wanting them removed. This NA stated the facility did not provide her with any training about how the immobilizers were to be applied or removed and how they should fit. On 10/10/12 the facility faxed copies of Annual Nurse Assistant Skills Checklists for NA #8 (09/20/11), NA #10 08/04/11), and NA #11 (01/30/12) which documented the NAs were checked off for "Braces, Splints, Prosthesis." At 2:47 PM on 10/10/12, during a telephone conversation, the DON stated the Staff Development Coordinator (SDC) who completed the checklists no longer worked in the facility. However, she reported she had observed this SDC completing the checklists. For each skill on the checklist the DON explained the SDC reviewed the policy and procedure related to it. She stated there was no demonstration or return demonstration involved in completing the skills checklists. b. Labs collected on 06/22/12 documented Resident #3's [MEDICATION NAME] level was within normal limits, 3.7 grams per deciliter (g/dL) with normal being 3.5 - 5.2 g/dL. A 08/27/12 physician progress notes [REDACTED]. A 08/29/12 11:34 AM electronic Resident Progress Note documented Resident #3 was found to have an open blister on her left buttock. The note also documented the wound was cleansed and a dressing was applied. A 09/04/12 Report of Consultation from the orthopedist documented, "Also large decub (decubitus) ulcer left (symbol used) buttock." The resident's 09/05/12 Significant Change Minimum Data Set (MDS) documented her cognition was moderately impaired, she required extensive assistance from two staff members for bed mobility, she did not resist care, and she had one stage II pressure ulcer. In a 09/05/12 Dietary Supplemental Assessment the Dietary Manager (DM) documented Resident #3's meal intake had dropped to 1 - 25% in the last 20 days. According to the assessment, the resident had been receiving a Magic Cup every night for snack and 90 cubic centimeters (cc) of Resource 2.0 three times daily with medication pass. The DM documented the resident's nutritional requirement was 1712 calories daily, with actual intake being only 856 calories daily. The DM also documented, "...Will refer to RD (Registered Dietitian) for consult ...." At 4:02 PM on 09/27/12 Nurse #2 reported Resident #3 was started on a Magic Cup nightly on 02/07/12, and the resident had been receiving Resource supplement since at least 2009. Review of electronic Resident Progress Notes revealed Resident #3 had not been assessed by the RD (as of 09/28/12 AM). The first documented assessment of Resident #3's buttock/sacral pressure ulcer was on 09/11/12 when an electronic Wound/Ulcer Flow Sheet documented the resident had a stage II buttock/sacral pressure ulcer measuring 6 x 5.5 centimeters (cm) with no depth provided, no exudate, no tunneling/undermining, no odor, and no pain. A wet-to-dry dressing was applied, and the wound bed was 25% yellow/white slough and 75% granulation tissue. On 09/12/12 "Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure related to: incontinence-bowel and/or bladder, immobility, total assistance needed with turning & positioning" and "Actual skin breakdown. Stage 2 to coccyx" were identified as problems on the resident's care plan. Interventions to these problems included, "Monitor skin daily during care for any changes. Report any abnormal observations to nurse" and "Notify appropriate personnel of changes in eating/drinking patterns." Interventions also included, "Weekly assessment of wound/ulcer. Notify physician of changes as indicated." A 09/12/12 physician's progress note did not document any information about the resident's buttock/sacral pressure ulcer. In fact, it documented, "No [MEDICAL CONDITION], rashes, jaundice or lymphadenopathy are noted." An electronic 09/17/12 Wound/Ulcer Flow Sheet documented Resident #3's buttock/sacral pressure ulcer was a stage III wound which measured 5 x 4 cm with no depth provided, no exudate, no tunneling/undermining, no odor, and no pain. A wet-to-dry dressing was applied, and the wound bed was 100% yellow/white slough. A 09/21/12 physician's progress note did not document any information about the resident's buttock/sacral pressure ulcer. In fact, it documented, "No [MEDICAL CONDITION], rashes, jaundice or lymphadenopathy are noted." An electronic 09/24/12 Wound/Ulcer Flow Sheet documented Resident #3's buttock/sacral pressure ulcer was a stage III wound which measured 4.4 x 4 cm. No other description of the wound was documented. A 09/26/12 physician's orders [REDACTED]. A 09/26/12 physician's progress note addressed the wounds to Resident #3's left lower leg, but did not document any information pertaining to the resident's buttock/sacral pressure ulcer. At 9:12 AM on 09/27/12 the Treatment Nurses (TNs) changed the dressing on Resident #3's buttocks/sacrum. There was yellowish drainage on the old dressing which was removed, and a very strong odor was present when this dressing was removed. The wound presented as unstageable with areas of red tissue, yellow slough, and gray slough. The ulcer measured approximately 4 x 4 cm. At 3:50 PM on 09/27/12 TN #2 stated she had only been working as a TN in this facility for about 3 months, but she thought Resident #3 had a history of [REDACTED]. According to NA #2, the nursing assistants (NAs) were responsible for completing skin checks which were conducted daily as the NAs bathed and showered residents. At 8:37 AM on 09/28/12 the facility's RD stated she was in the facility on 09/21/12, but was not told or notified in writing that she needed to assess Resident #3. However, she commented Resident #3 was on the pressure ulcer list she received before beginning her 09/21/12 assessments. During a telephone conversation at 9:21 AM on 09/28/12 Nursing Assistant (NA) #8, who the facility identified as Resident #3's primary NA on first shift, stated that the resident hollered out and complained of pain during a bed bath sometime between Monday and Thursday following a fall on 08/25/12. When the NA examined the resident, she reported she found the skin had been rubbed off the resident's sacrum. She stated TN #2 placed a [MEDICATION NAME] on the resident's sacrum. 1 to 2 weeks later NA #8 reported the Treatment NA was going to only put cream on the area, and she told the Treatment NA that the resident had open areas to the sacrum. When the Treatment NA and NA #8 observed the area, NA #8 commented the wound was completely yellow. At 9:47 AM on 09/28/12 TN #2 stated Resident #3's primary physician had signed off on the facility's 09/13/12 Quality Improvement (QI) wound list. However, she reported he had not signed off on the facility's 09/20/12 QI wound list although it was completed. She stated the only medical doctor (MD) communication form sent to Resident #3's physician, concerning her buttocks/sacral pressure ulcer was on 08/29/12 when a nurse documented the resident had an open blister on her left buttock. At 10:25 AM on 09/28/12 the facility's RD stated the facility identified the communication between the DM and RD as a problem 45 - 60 days ago, and it was handled internally, but not run through the facility's QI program. She commented the problem was the DM was documenting referrals in the computer, but not relaying them to the RD on paper so RD assessments could be completed. At 11:32 AM on 09/28/12 Resident #3's primary physician stated he thought he had observed and assessed the resident's buttocks/sacral pressure ulcer, but was not absolutely certain. He stated he thought he heard that this wound would get better and then decline. This physician commented the facility often referred residents with pressure sores out to another physician who specialized in wound assessment, but was not sure if this was done for Resident #3. He stated he did not remember the resident's buttock/sacral pressure ulcer starting out as a blister, but thought it was due to refusal of turning and repositioning in the bed. According to Resident #3's physician, wounds with slough did not usually appear spontaneously, but started out as open reddened areas that declined. At 11:48 AM on 09/28/12 the Treatment NA stated usually hall NAs would tell her about skin changes, and she would write them down so she could observe them. However, she reported she could not find any written record which she made of Resident #3's buttocks/sacral area. According to the Treatment NA, she remembered finding skin off the resident's sacrum, and a TN applied a [MEDICATION NAME] to be changed every 7 days. She stated she observed Resident #3's buttocks/sacral pressure ulcer again on 09/11/12 when the dressing was changed to wet-to-dry daily. At that time, the Treatment NA remembered there being odor to the wound, the wound was deeper, and about 25% of the wound was covered with yellow slough. At 12:22 PM on 09/28/12 TN #2 stated, according to the facility's Treatment Administration Record (TAR), Resident #3 had a transparent dressing placed on an open blister on 08/29/12. Then on 08/30/12 and 08/31/12 a [MEDICATION NAME] dressing was placed on the buttocks/sacral pressure ulcer. On 09/04/12 TN #2 reported a [MEDICATION NAME] dressing was placed on the ulcer, and replaced with the same type of dressing on 09/05/12 because of rolling up. According to TN #2, she thought she remembered looking at Resident #3's buttocks/sacral ulcer on 09/04/12, and the wound bed was red with no slough. TN #2 commented she did not document any measurements of descriptions of this ulcer until 09/11/12 when the dressing was changed to a daily wet-to-dry. She commented because of the decline in the buttocks/sacral ulcer and the emergence of wound odor she placed a call to the corporate wound consultant today (09/28/12). At 3:32 PM on 09/28/12 the Director of Nursing (DON) stated it was facility policy to measure and assess pressure ulcers weekly on the electronic Wound/Ulcer Flow Sheets. She reported that Resident #3 had not been referred outside of the facility for wound consults. She commented skin checks were completed by the NAs as they provided daily baths and showers. The DON explained the NAs reported skin integrity problems to the hall nurses who then contacted the TNs.