Every finding on record at The Greens at Cabarrus

Based on record review, and Nurse Practitioner (NP) and staff interviews, the facility failed to write an order to resume warfarin (an anticoagulant medication used to thin blood after a stroke) after laboratory results were received which resulted in a resident missing 3 consecutive doses of warfarin. This was for 1 of 4 residents reviewed for professional standards (Resident #1).The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke, left-sided hemiplegia (paralysis on one side of the body) and heart disease. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 was cognitively intact. The MDS documented Resident #1 was taking anticoagulant medications. A care plan dated 10/30/25 addressed Resident #1's use of anticoagulant medication with interventions including administering the anticoagulant medications as ordered and observe for adverse reactions including bruising, blood in the urine or stool, or changes in vital signs. Review of the facility warfarin protocol (no date) signed by the facility physician revealed laboratory blood draws for Protime/International Normalized Ratio (PT/INR) (blood work to test blood clotting time in response to the medication warfarin), revealed that residents taking warfarin were to have PT/INR lab draws on Monday and Thursday of every week and orders were as follows depending on results: - INR results less than 2.0: increase the daily dose of warfarin by 0.5 mg and recheck the PT/INR on the next scheduled date- INR results 2.0-3.0: no dose change, recheck the PT/INR next scheduled day- INR results 3.01-3.50: decrease the dose by 0.5 mg, recheck PT/INR next scheduled day- INR results 3.51-4.0: hold warfarin for 1 day, decrease the dose by 0.5 mg, recheck PT/INR the next scheduled day- INR results 4.01-6.0: hold warfarin for 2 days, decrease the dose by 1 mg, recheck the PT/INR the next scheduled day- INR results 6.01-7: hold warfarin, recheck the PT/INR next scheduled day, and notify the physician/NP immediately if active bleeding present- INR results more than 7.01: hold warfarin, give Vitamin K (a vitamin that promotes blood clotting) 5 mg intramuscularly immediately, notify the physician/NP if active bleeding present and repeat the INR the next day. Review of the physician orders for Resident #1 revealed an order dated 11/7/25 for warfarin 11.5 milligrams (mg) to be administered daily at 8:00 PM. Review of the medication administration record for Resident #1 revealed he received warfarin 11.5 mg daily at 8:00 PM from 11/7/25 until 11/10/25. PT/INR lab results for Resident #1 dated 11/10/25 were 1.18. Further review of the physician orders for Resident #1 revealed the order for warfarin 11.5 mg to be administered daily was discontinued on 11/11/25.Review of the physician orders revealed no order had been written to resume warfarin for Resident #1 after it was discontinued on 11/11/25. Review of the medication administration record revealed no doses of warfarin were administered to Resident #1 from 11/11/25 to 11/13/25. Unit Manager #1 (a nurse) was interviewed on 11/14/25 at 12:12 PM. Unit Manager #1 explained she was responsible for reviewing all PT/INR results, adjusting the medication doses, and notifying the physician/NP if necessary. Unit Manager #1 reported she received the PT/INR results for Resident #1 on 11/11/25 and she used the warfarin protocol to increase his dose to 12 mg. Unit Manager #1 explained she believed she wrote a physician order to increase his dose to 12 mg, but upon reviewing the physician orders, reported she had not written the order. Unit Manager #1 explained Resident #1 should have received 12 mg of warfarin on 11/11/25, 11/12/25, and 11/13/25. The Unit Manager #1 reported the lab was unable to obtain the blood sample for the PT/INR on 11/13/25 and she had written an order to have an immediate PT/INR lab drawn 11/14/25. A follow-up interview was conducted with Unit Manager #1 on 11/14/25 at 1:00 PM and she reported Resident #1's PT/INR results was 2.8 and he would resume warfarin 12 mg at 8:00 PM on 11/14/25. The NP was interviewed on 11/14/25 at 12:48 PM and she reported Resident #1 had been difficult to get to a therapeutic PT/INR level which would be 2.0-3.0, and he required frequent warfarin dosage adjustments. The NP reported the lab results were sent to the facility, and the Unit Managers used the physician approved warfarin protocol to adjust the warfarin dose. The NP explained that missing the 3 doses of warfarin did not harm Resident #1. The NP reported when she was notified of the missed warfarin, she checked on Resident #1 and he was fine. The NP concluded that she expected the staff to follow the warfarin protocol for all residents receiving warfarin. The Director of Nursing (DON) was interviewed on 11/14/25 at 2:48 PM. The DON reported on 11/14/25 Unit Manager #1 was reviewing the PT/INR results from 11/13/25 and noticed that the PT/INR for Resident #1 was not obtained. The DON explained the facility ordered for an immediate PT/INR lab draw and notified the NP of the missed medication. The DON reported Unit Manager #1 reported she thought she put in the new warfarin order, but it was not in the system. The DON reported she expected the changed warfarin orders to be entered into the system according to the warfarin protocol. The Administrator was interviewed on 11/14/25 at 3:45 PM and she reported she expected the policy and procedures to be followed to prevent medication errors.

Based on record review, resident representative, staff, dialysis staff, and manager of the transport company interviews, the facility failed to send a lift pad with the resident causing the resident to miss their dialysis appointment for 1 of 3 resident reviewed for dialysis (Resident #32). Findings included:Resident #32 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, diabetes, and dependence on renal dialysis.Review of Resident #32's initial nursing assessment dated [DATE] revealed Resident #34 was alert and oriented and required extensive assistance with one person staff for transfers.Review of Resident #32's Kardex (quick reference tool that summarizes essential patient information for nurses) dated 07/18/25 revealed the resident was supposed to have a lift pad under her on dialysis days Monday, Wednesday, and Fridays and was a lift transfer on dialysis days only. Review of Resident #32's physician orders dated 07/18/25 revealed the resident was ordered to have a lift pad under her on dialysis days Monday, Wednesday, and Friday.Observation and interview conducted with Resident #32 and Resident Representative (RR) on 07/21/25 at 2:40 PM revealed both the resident and RR were upset and frustrated due to the resident missing her dialysis appointment 07/21/25. The RR further revealed the facility failed to send Resident #32 with a lift pad which the dialysis center must have to transfer Resident #32 to receive her treatment. The RR stated Resident #32 would have to be sent out to the hospital to receive her dialysis treatment because the dialysis center was unable to schedule her back in. The RR and Resident #32 indicated this has happened multiple times and was an ongoing issue when she was a prior resident.A phone interview conducted with Resident #32's Dialysis Nurse #1 on 07/23/25 at 8:30 AM revealed she had cared for Resident #32 for a couple years at the dialysis center. Dialysis Nurse #1 indicated on 07/21/25 Resident #32 arrived at the dialysis center without a lift pad. Dialysis Nurse #1 stated she contacted the transporter that brought the resident, and they went back to the facility to retrieve the pad and brought it back to the dialysis center. The transporter returned and placed the lift pad on the back of Residents #32's wheelchair and failed to notify the dialysis employees. Dialysis Nurse #1 revealed by the time the pad arrived Resident #32 had missed majority of her sitting time and was unable to receive her treatment. It was further revealed the dialysis center expected for residents to have the lift pad under the resident when they arrived. Dialysis Nurse #1 indicated this had also happened on 03/24/25 and 05/19/25 when Resident #32 was a resident at the facility previously.A phone interview conducted with the manager of the transport company on 07/23/25 at 2:50 PM revealed a driver took Resident #32 to her dialysis appointment on 07/21/25 without a lift pad. The transporter drove back to the facility and retrieved the lift pad and once the driver arrived at the dialysis center the dialysis staff refused to transfer the resident onto the pad. The manager of the transport company indicated nursing staff from the facility needed to place the lift pad under the resident before arriving at the dialysis center. Resident #32 was unable to receive her dialysis treatment and was sent back to the facility. The interview further revealed the facility had sent Resident #32 without her lift pad to dialysis appointments before.An interview was conducted with Nurse Aide (NA) #1on 07/24/25 at 10:20 AM revealed she had assisted Resident #32 with getting ready for her dialysis appointment on 07/21/25. NA #1 indicated 7/21/25 was the first time she had cared for Resident #32 and was not aware she required a lift pad for her appointment and failed to put it under the resident on this date. NA #1 indicated Resident #32 was a sit-to-stand one person assist for transfers and was not aware she was a total lift at her dialysis appointment.An interview conducted with the Director of Nursing (DON) on 07/23/25 at 11:30 AM revealed she was aware Resident #32 went to her dialysis appointment on 7/21/25 and the lift pad was not sent. the DON indicated nursing staff was responsible for ensuring the resident's lift pad was under her when she went out to the appointment. The DON stated Resident #32 was unable to be re-scheduled at the dialysis center and was sent out to the hospital to receive her dialysis treatment. The DON revealed Resident #32 was not a total lift for transfers in the facility but was at dialysis appointments. The DON stated she expected nursing staff to get the residents to all appointments with all needed accessories.

Based on observation, record review and staff, Wound Nurse Practitioner (WNP), Nurse Practitioner (NP), and Physician interviews, the facility failed to prevent resident's gangrenous right foot ulcer from contracting a maggot infestation. The maggots were discovered on 7/10/23 by Nursing Aide #1 (NA#1) during the early morning rounds. The Nurse Practitioner was notified and saw a whitish worm-like movement in resident's right foot ulcer that resulted in Resident #1 being transported to the emergency room (ER) for evaluation and treatment. The surgeon removed the visible maggots crawling in and out on his right foot ulcer in the ER and ordered an antibiotic as prophylaxis for possible necrotizing fasciitis (an aggressive skin and soft tissue infection that causes dying of the muscle and tissues). On 7/11/23 the Physician and the Treatment Nurse removed 63 additional maggots. A reasonable person could have feelings of anger, distress, fear and/or anxiety knowing maggots were in their wound. This was for 1 of 3 residents (Resident #1) reviewed for ulcers (skin conditions). Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of critical limb ischemia (inadequate blood supply to body part) of both lower extremities, and Peripheral Vascular Disease (PVD). The Minimum Data Set (MDS) on 7/13/23 coded Resident #1 with severely impaired cognition. Resident #1 could communicate his needs to staff. He was coded to require extensive assistance with bed mobility, transfer, dressing, personal hygiene, and toilet use. Impaired Range of Motion (ROM) of the right lower extremity. Review of the vascular consult record on 4/28/23 revealed the resident developed a 2nd toe ulcer on the right foot and was diagnosed with critical right lower extremity ischemia with dry gangrene (a condition where a loss of body supply causes body tissues to die). The Vascular Surgeon suggested amputation and was discussed with the resident and family. The resident and his family member refused the amputation and wanted to treat it conservatively. The Vascular Surgeon ordered to clean the wound daily and paint with half strength povidone-iodine (an antiseptic). Record review of the physician treatment order dated 6/20/23 revealed to apply povidone-iodine generously and leave open to air every day to the right 2nd toe/foot. The Treatment Administration Record (TAR) for 7/1/23 through 7/20/23 reflected the physician order and was signed daily as completed by a nurse. Interview with Nurse #1 on 7/20/23 at 1:49 PM revealed that she did the treatment of the right foot ulcer on 7/9/23 and no maggots were observed. An SBAR (Situation Background Assessment Recommendation) note dated 7/10/23 at 8:21 AM completed by the Nurse Unit Manager revealed the ulcer on the top of Resident #1's right foot was noted with maggots and larvae. Nursing Aide #1 (NA#1) was interviewed on 7/20/23 at 10:27 AM and stated on 7/10/23 at 6:00 AM she saw some whitish movement in the resident's right foot during early morning care rounds. She immediately called Nurse#1 in the hall and reported the observation of the maggots. The NA also stated that the resident was bed bound and didn't get out to the chair or bed. She stated she had never seen flies in the room and the resident was always covered with a blanket. Interview with Nurse #1 on 7/20/23 at 10:40 AM revealed she was called by NA #1 to the Resident #1's room the morning of 7/10/23. She stated she saw a white worm-like substance in the resident's right foot ulcer indicative of maggots. She called the Nurse Unit Manager into the room. She stated she had never seen fly activity in Resident #1's room. Interview with the Nurse Unit Manager on 7/20/23 at 10:30 AM revealed Nurse #1 called her into Resident #1's room on morning of 7/10/23 and showed the resident's right foot wound and she saw whitish maggots in the residents' foot. She notified the Wound NP and Treatment Nurse right after she saw the maggots. Nurse Unit Manager stated she didn't see any fly activity in Resident #1's room. Interview with the Wound NP on 7/20/23 at 8:01 AM revealed she was called into the Resident #1's room early in the morning of 7/10/23 to check his right foot ulcer and she noticed maggots in the wound. She said the Treatment Nurse was in with her, and she let the Treatment Nurse notify Hospice. She recommended sending Resident #1 to hospital ER for evaluation. She said there were lots of maggots in the wound and needed immediate attention. She stated the ulcer had a small wet opening that probably attracted flies to lay eggs and became maggots. The Wound NP stated there were no visible flies when she was in the resident's room. Interview with the Treatment Nurse on 7/20/23 at 8:12 AM revealed during the early morning rounds with the Wound NP on 7/10/23, they were called in the Resident #1's room. She stated they saw several moving maggots in the right foot ulcer, and she called the Hospice Nurse about the maggots and expressed the recommendation of Wound NP to send the resident to hospital ER. The Treatment Nurse stated that they informed the family member about the ulcer with maggots and the immediate transport of resident to the hospital ER. Emergency Management Services (EMS) was contacted and transported the resident to the hospital. Review of the hospital records dated 7/10/23 revealed that Resident #1 arrived at 9:05 AM and was evaluated in the hospital ER. During the ER visit, they consulted general surgery to evaluate the right foot ulcer. The report from the surgeon revealed the visible maggots crawling in and out the right foot ulcer were removed, and an antibiotic treatment was ordered as prophylaxis for possible necrotizing fasciitis (an aggressive skin and soft tissue infection that causes dying of the muscle and tissues). A wound treatment instruction was ordered to irrigate with Sodium Hypochlorite Solution and pack with povidone-iodine-soaked gauze twice daily and resident was sent back to the facility on [DATE]. Record review of the treatment orders transcribed on 7/10/23 revealed to irrigate the right foot ulcer with Sodium Hypochlorite Solution (skin disinfectant) and pack with povidone-iodine-soaked gauze twice daily. The Physician was interviewed by phone on 7/20/23 at 11:59 AM and stated that Resident #1 had PVD and there was no blood flow in his right foot. The resident developed gangrene on the right foot that started from the 2nd right toe. The foot lost blood supply and turned all toes on the right foot to black and wet gangrene was observed. He stated the wet gangrene had a foul odor like decaying meat and would attract flies. The Physician stated that the resident refused to amputate his foot and wanted to keep his body parts. He stated that the treatment with povidone-iodine-soaked gauze was implemented to maintain the ulcer. He said they consulted the vascular specialist and the Vascular Surgeon recommended amputation, but the resident refused the amputation. The Physician stated that when he visited the resident on 7/11/23, he ordered to soak the right foot ulcer with hydrogen peroxide, and they got a lot of maggots out. Interview with the Treatment Nurse on 7/20/23 at 8:12 AM revealed she was with the Physician on 7/11/23 when they soaked the resident's right foot ulcer with hydrogen-peroxide. She said there were 63 maggots removed and then she dressed the wound with gauze. She stated that she did the same treatment on 7/12/23 and she removed 2 more maggots. And on 7/13/23, she said there were no more maggots from the ulcer. Observation of Resident #1's right foot ulcer with the Treatment Nurse was done on 7/20/23 at 8:17 AM. The Treatment Nurse pulled back the sheet and a disposable bed pad was observed covering the right foot. The Treatment Nurse uncovered the right foot and revealed all toes were black and had necrotic (dead tissue). Some areas showed crusty black skin and there was some wetness on top of his right foot with no signs of infection. Several observations of Resident #1's room on 7/20/23 at 8:17 AM and 1:51 PM were made the day of the investigation and there was no fly activity observed in his room. Observations on 7/20/23 at 2:24 PM different halls, common areas of the facility, and other residents' rooms showed no fly activity. Several observations on 7/20/23 revealed the front door of the facility continuously had visitors and residents who were coming in and out to the patio in the front of the building. All residents sitting on a wheelchair going out the front door took longer to close while wheeling out. The door in the front entrance did not have a fly fan (a fan above the door to supply high velocity of air stream to keep insects from entering the building). There was no fly activity observed in the lobby. Interview with the Nurse Practitioner on 7/20/23 at 12:14 PM revealed at the beginning Resident #1's right foot ulcer was dry and then it became moist. She stated she smelled a rotten odor during her visit to Resident #1 from the previous weeks since June 2023. She said that one fly can lay 150 eggs and she was not surprised with the wound the resident could attract flies because of the rotten odor. She stated that it was an acute onset, and she believed the maggots were present no more than 24 hours. Interview with Nurse #2 on 7/20/23 at 11:35 AM revealed she had seen some flies on her hall (100), but they were not so much of an issue. Interview with the Maintenance Director on 7/20/23 revealed there were two main doors used to enter the facility. One in the hallway close to the kitchen in the back and one in the front. He stated the back door had a fly fan and the front door didn't have a fly fan. The Maintenance Director indicated he had not observed any fly activity in the facility and there was not a problem with flies. Review of the monthly pest control visit logs from March 2023 to July 2023 showed there were ants identified in April and May 2023. The ants were treated and no further reports of ants after. Fly activity was not identified as a problem during any of the visits. Interview with the Director of Nursing (DON) on 7/20/23 at 12:36 PM revealed the nurses and unit manager made her aware of the maggots on resident's right foot ulcer in the morning of 7/10/23 before the resident was sent out. She stated the room that Resident #1 resided in was warm all the time as the resident wanted it that way. She said they moved the resident into another room to make it cooler because a warm room could make the odor worse. The DON indicated the facility did not have a problem with flies. The DON stated that there was sporadic fly in the building. An interview with the Administrator and the Regional Nurse Consultant on 7/20/23 at 10:59 AM revealed that they don't know what happened with Resident #1 because they don't have any problems with flies. The Administrator stated that they acted quickly to send the resident to the hospital ER for treatment. She stated that the front door was the only entry for flies to get into the building when the visitors and residents were going in and out to the front patio. The Administrator was notified of the immediate jeopardy on 7/20/23 at 5:01 PM. The Administrator provided the following corrective action plan with a compliance date of 7/13/23. Corrective Action for Resident that was identified with wounds on 7/10/23. Nursing identified maggots and immediately reported to Wound Nurse who notified Wound Nurse Practitioner. Resident sent to ER for treatment and removal of maggots on 7/10/23. Resident returned with new treatment orders of Dakins/Sodium Hypochlorite to right foot topically and to apply betadine wrap for protective covering, every day and evening shift. On 7/11/23 the Medical Director removed numerous maggots. On 7/12/23 Wound Nurse removed 2 more and continued daily monitoring for any maggots and Wound Nurse Practitioner continued weekly monitoring of appropriate treatments. Facility worked with resident on his preference for a room change which promoted an improved temperature and a private room, residents room was changed 7/12/23. Any resident with open wound, gangrenous wound, tube feeding, stoma's and ostomies are at risk of being affected. An audit performed of these residents showed there were no other affected residents. Audit completed by Director of Nursing and nursing supervisors 7/11/23. On 7/11/23 The Administrator provided fly swatters to front receptionist, nurses stations and department managers. The Administrator provided the Activities Director with fly swatters to hand out to alert and oriented residents. The side door closer to dumpster has a blow back system to prevent flies/pests entering. Residents that enjoy going outside in the front area are being provided with increased assistance getting in/out of the door to avoid the door being open too long and adjusting timing of door as needed. On 7/11/23 the Wound Nurse informed the receptionist to assist residents going in and out of the front door to minimize the time the door is open and prevent flies from entering. The administrator, HR Coordinator and receptionist check on residents daily that are outside for hydration and discuss reminders regarding doors being opened for long periods can result in flies in the facility. The facility provides a full-time day and evening receptionist and a weekend receptionist from 8am-8pm. Wound Nurse and charge nurse monitor dressings daily for wounds, tube feedings, stoma's/ostomies to assure no issues with maggots and if there is an open wound or drainage that may attract flies, review/revise treatment to prevent/protect from flies. There have been no concerns noted with wounds and maggots since 7/12/23. Pest control is in the building monthly and for the past six months have not identified flies as being an issue nor any recommendations. Director of Nursing educated Wound Nurse on 7/11/23 to increase monitoring of any resident with wounds that are open to air or gangrenous and treatment changes as needed to prevent any maggot infestation. Wound Nurse will continue to work closely with charge nurses for monitoring wounds and any concerns with maggots. Wound Nurse and Charge Nurses dispose of dirty wound dressings in a double bag immediately after the dressing change to prevent flies and/or maggots. The double bag is then taken to the soiled utility room. This has been an ongoing practice at the facility. The Director of Nursing and Nursing Supervisors held a nursing staff meeting on 7/12/23 to update on importance of fly prevention and nurses' observation of wounds for any signs of maggots. Nurses and Nursing Assistants attended the meeting. The Director of Nursing and Nursing Supervisors verbally called any nursing staff not on the schedule to communicate highlights of the meeting which included awareness of flies and maggots. In addition, there is an education/communication binder at the nurse's station to promote continuous communication and education. The Director of Nursing and nursing supervisors document and update binder with in-services and communication for the nurses and nursing assistants to read. On 7/12/23- The Administrator and HR Coordinator placed visual reminders regarding being aware and mindful of flies in the facility. The visual reminders are located on the Bee Kind Board, by the time clock, in the breakroom and in the Administrator's office located by the refreshment area provided by the Administrator for all staff and families who visit almost daily. For ongoing prevention, on 7/11/23 Administrator and Director of Nursing reviewed deep clean schedule with Environmental Director and discussed any high-risk rooms. High Risk would include residents that are tube fed with a potential for leakage on the poles. Discussed that the leakage could attract flies. Environmental Director to ensure poles are cleaned daily. The facility has an ongoing program called (Caring Angels). The Department Heads and Managers are assigned a group of rooms with the goal of visiting them weekly on a regular basis. The Residents Caring Angel is posted on the resident's bulletin board in their room so that they know who the Angel is and their contact information. On 7/11/23 the Administrator advised the department managers/Angels to communicate to their residents the importance of prevention of flies. Communication included the following tips: Report spills to staff immediately, request for tray pickup timely, maintain personal food items in closed containers, encourage good hygiene, visual reminders were posted in resident's rooms. Facility reviewed concerns regarding residents with maggots during morning meeting on 7/11/23 as an AD HOC QAPI to monitor any resident with open wounds and potential for maggots. The Director of Nursing, Nurse Supervisors and Wound Nurse are monitoring Residents with wounds, that are tube fed, stomas and ostomies for any signs of drainage and maggots. Monitoring is 5 days a week for four weeks and then three days a week for four weeks. Findings will be reviewed at QAPI on 7/25/23 for any revisions or updates. On 7/25/23, the facility's credible allegation for immediate jeopardy was validated. Resident #1 was observed to be in a private room and wound was free of any maggots. During the tour of the facility residents were observed to be assisted in and out of the front door, and fly swatters were present through- out the facility. The in-services included information on managing an unexpected case of maggots, notification of administration for any changes to wound areas that are left open to air, increased monitoring of open wound areas, as well as fly prevention. Staff interviews confirmed education was received for fly prevention and daily monitoring of wounds, ostomies, and tube feed sites for the presence of maggots. The facility provided evidence of daily Quality Assurance auditing of all residents with wounds, ostomies, and tube feed for the presence of maggots beginning 7/10/23 and ongoing. The facility's corrective action plan was validated as 7/13/23.

Based on observations, record review and staff interviews, the facility failed to keep nutritional supplements cold that required refrigeration in accordance with the manufacturer's instructions for 2 of 2 supplements on 1 of 2 medication carts (300 hall). The facility also failed to date a multiple use medication bottle when opened or check the medication expiration date for 1 of 10 medication bottles on 1 of 2 medication carts (400 hall). In addition, the facility failed to date insulin pens when opened for 5 of 8 insulin pens on 2 of 2 medication carts (300 and 400 hall). Findings included: The medication cart for the 400 hall was checked with Nurse #2 on [DATE] at 3:05 PM. The following opened and undated medications were noted on the medication cart: -A 30-ounce bottle of a multiple patient use protein supplement used to promote wound healing was noted to be opened, without an open date and to have expired [DATE]. Manufacturer instructions were to date the bottle when opened and discard 3 months after opening. The bottle was verified with Nurse #2 as being half empty. -Glargine insulin pen100units (u)/milliliter (ml) with no opened date -Glargine insulin pen100u/ml with no opened date -Lispro insulin pen100u/ml with no opened date -Humalog insulin pen100u/ml with no opened date. 2. The Medication Cart for the 300 hall was checked with the Unit Manager (UM) on [DATE] at 2:55 PM. The following was identified: a. A cooler on top of the cart was noted to have a thawed ice pack that was warm, and contained 2 room temperature supplements. The temperature was verified by the UM. She noted the supplements were used for medications for residents. The supplements included: -an opened half empty 8-ounce bottle of chocolate nutritional shake with tape on top that indicated the bottle was opened on [DATE]. Manufacturer instructions on the bottle noted the medication was to be refrigerated and used within 48 hours after opened. -an unopened thawed sugar free vanilla 4-ounce. Manufacturer recommendations were to thaw under refrigeration at 40 degrees or below, then keep refrigerated and use within 14 days of thawing. No date was on the carton when the supplement was thawed. b. An opened Levemir Insulin pen 100 unit/ml with no opened date. c. Assure blood glucose test strip bottle- 50 count with approximately 30 strips left as verified by the UM that was undated when opened. The manufacturer instructions noted glucose test strips would expire 90 days from when the bottle was opened. Review of the manufacturer guidelines for Glargine, Lispro and Humalog insulin revealed the medication should only be used for 28 days upon opening. An interview was done with the UM on [DATE] at 2:58 PM. The Unit Manager said the nutritional supplement cartons were to be kept frozen and refrigerated when thawed. She noted the nurses were supposed to obtain fresh coolers and ice packs each shift, to keep the supplements cold. The Unit Manager stated the bottle of blood glucose test strips should have been dated when opened and the strips were used with all resident meters. An interview with Nurse #2 was conducted on [DATE] at 3:05 PM. She stated the multi-dose medication bottle and insulin pens should have been dated when opened. The nurse noted the multi-dose medication bottle was facility stock and should have been checked for the expiration date when administering medications and not used if expired. An interview was conducted on [DATE] at 4:14 PM with the Director of Nursing (DON). She was informed of the findings regarding medication storage which included opened insulin pens that were not dated on two medication carts, expired medication on a cart and nutritional supplements in coolers on top of medication cart that were at room temperature. The DON stated the staff should have checked the medication carts. She noted multi-dose medication including the insulin pens should be dated when opened, and medication expiration dates should be checked prior to being administered. The DON said night shift checked the medication carts and the pharmacy liaison. The Administrator was interviewed on [DATE] at 2:05 PM regarding medication storage. She stated the staff should ensure supplements were kept within the appropriate temperature range per manufacturer guidelines. The Administrator noted she would expect the staff to follow the policy regarding expiration date checks and manufacturer recommendations. The expired medication was to be discarded and the medication should be dated when opened.

Based on observation, record review and staff interview the facility failed to store a tube feeding syringe with the plunger separated from the plunger for 1 of 2 residents (Resident #60) reviewed for enteral feeding management, which created a potential for bacterial growth. Findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses of seizure disorder and heart disease. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 was severely cognitively impaired and she received enteral feedings for nutrition. During an observation of Resident #60 on 2/7/2023 at 4:43 pm she was in bed with enteral feeding being administered by an enteral feeding pump. The enteral feeding pump stand had an enteral feeding syringe hanging in a plastic bag. The enteral feeding syringe was stored with the plunger in the syringe and there was clear fluid in the tip of the plunger. During an observation and interview with Nurse #1 at 2/7/2023 at 6:01 pm Resident #60 continued to have an enteral feeding syringe with clear fluid in the tip of the plunger and the syringe continued to be in a clear plastic bag hanging from the enteral feed pump. Nurse #1 stated she gave Resident #60 her medication through her gastrostomy tube at 5:30 pm and the plunger was in the syringe when she gave the medication, and she left the plunger in the syringe after giving the medication. Nurse #1 stated she was not aware she should allow the syringe to dry and store the plunger out of the syringe so that liquid would not be trapped and cause a risk for bacteria growth. Nurse #1 stated she was an agency nurse and had not received education from the facility regarding how to store the syringe. An interview was conducted with the Assistant Director of Nursing (ADON) on 2/7/2023 at 6:04 pm and she stated the plunger and syringe for enteral feedings should be allowed to air dry and then stored separately in the storage bag. On 2/8/2023 at 4:14 pm an interview was conducted with the Director of Nursing (DON) and she stated the staff are trained to rinse the enteral feeding syringe after use and place it on a barrier to dry and when the syringe and plunger are dry they should store syringe with the plunger separate. The DON stated the agency nurses are given the same education as the nurses that work for the facility and Nurse #1 received the education. The DON stated Nurse #1 should have followed the facility's procedure.

Based on record review and staff interviews and observations, the facility's Quality Assurance and Performance committee (QAPI) failed to maintain implemented procedures and monitor the interventions put into place during a recertification survey dated 5/13/2021 (F693) and on the current recertification/ complaint survey on 2/9/2023. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. Findings included: This tag is cross referenced to: F693 - Based on observation, record review and staff interview the facility failed to store a tube feeding syringe with the plunger separated from the barrel for 1 of 2 residents (Resident #60) reviewed for enteral feeding management, which created a potential for bacterial growth. During the recertification survey of 5/13/2021,the facility failed to store a tube feeding syringe barrel and syringe plunger separately after use and rinsing which created the potential for bacterial growth. An interview was conducted with the Administrator on 2/9/2023 at 2:45 PM. The Administrator stated she had not been aware that syringes used for tube feeding medication administration were stored incorrectly. The Administrator stated she believed the audit process for the storage of tube feeding syringes after use and storage had been resolved by the previous Administrator.

Based on record review and staff, Family Member and Physician interviews, the facility failed to provide care in a safe manner for 2 of 3 residents, Resident #1 and Resident #2. Resident #1 sustained a left femur fracture due to a fall during transfer. Resident #2 fell from the bed while being turned on an air mattress for incontinence care. Findings included: 1. Resident #1 admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], spinal stenosis, and [CONDITION(S)]. She discharged to the hospital on 12/17/2021 with a left leg fracture due to fall. Review of Resident #1's hospital record revealed an x-ray completed 12/17/2021 which stated Resident #1's left leg had mild [CONDITION(S)] and a fracture of the femur just above the knee. An annual Minimum Data Set assessment dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance of two staff members for transfers. Resident #1's Care Plan which was dated 10/21/2020 and updated on 1/10/2022 stated resident #1 required extensive assistance by staff to move between surfaces. A Nurse Aide Kardex Report which stated Resident #1 required a 1-2 staff (depending on her functional status) to move between surfaces. During an interview with Resident #1 on 2/15/2022 at 2:50 pm she stated she remembered the fall she had in December 2021 when she broke her left femur. Resident #1 stated the staff usually used two people when they transferred her but when Nurse Aide #1 took her to the shower room in her wheelchair and transferred her to the shower chair from her wheelchair without assistance. She stated after her shower Nurse Aide #1 stated she was going to transfer her back to her wheelchair. Resident #1 stated she told Nurse Aide #1 she should get help to transfer her since she usually had two people and the floor was wet and she did not have shoes on. Resident #1 stated Nurse Aide #1 stated she could handle it. Resident #1 stated Nurse Aide #1 was in front of her and was trying to move her from the shower chair to the wheelchair but her feet slid from under her and her leg went under her in a strange position. Resident #1 stated she knew her leg was fractured because it was in a strange position and she was in so much pain. Resident #1 stated she did not remember any popping noise before she slid to the floor. Resident #1 stated Nurse Aide #1 called for help and the Nurse assessed her and called emergency services. A Nurse's Progress Note written by Nurse #1 dated 12/17/2021 at 8:43 pm stated Resident #1 was getting showered by Nurse Aide #1 when she lost her balance and fell with her leg bent backwards. The note further stated Nurse Aide #1 had reported she heard a pop when the resident fell . Nurse #1 also wrote she called emergency services and notified the Physician of the fall. An interview was conducted with Nurse #1 on 2/16/2022 at 2:10 pm and she stated she was working as the Unit Manager when Resident #1 fell on [DATE] in the shower room. Nurse #1 stated Nurse Aide #1 had called out for assistance because Resident #1 fell and she and Nurse #2 went to assess Resident #1. Nurse #1 stated when she got to the shower room Resident #1's leg was bent behind her and she was lying on the floor. Nurse #1 stated she told the staff not to move her and she went to call emergency services and the Physician. Nurse #1 stated after Resident #1 left for the hospital Nurse Aide #1 told her when she pivoted Resident #1 she heard a pop and that is when she fell to the floor. Nurse #1 stated Nurse Aide #1 told her she thought Resident required only one person to transfer her. On 2/16/2022 at 1:57 pm an interview was conducted with Nurse Aide #1 and she stated she was assigned to Resident #1 when she fell in the shower room on 12/17/2021. Nurse Aide #1 stated she took Resident #1 to the shower room in her wheelchair and transferred her to the shower bench in the bathroom. Nurse Aide #1 stated she gave Resident #1 a shower and dried her off and put a towel under her feet. Nurse Aide #1 stated Resident #1 did ask her if she should get someone to help with the transfer but she told her she thought she could transfer her without help. Nurse Aide #1 stated she helped Resident #1 to stand up and when she pivoted her to the wheelchair she heard a loud pop and she lowered her to the floor. Nurse Aide #1 stated Resident #1's left leg was turned in a little. Nurse Aide #1 stated she had not transferred Resident #1 before but she thought staff used one person to transfer. Nurse Aide #1 stated the electronic Nurse Aide Kardex stated Resident #1 needed 1 or 2 person assisted transfer. During an interview with Nurse #2 on 2/16/2022 at 2:28 pm she stated she was assigned to Resident #1 on 12/17/2021 when she fell in the shower room. Nurse #2 stated Nurse Aide #1 called out and said Resident #1 fell . Nurse #2 stated when she entered the shower room Resident #1 was on the floor and her leg was arranged in a way that you could tell it was injured. Nurse #2 stated Resident #1 stated she had fallen when being transferred from the shower chair to the wheelchair. Nurse #2 stated Nurse #1 asked Nurse Aide #1 if she had transferred Resident #1 without another staff member. Nurse #2 stated Nurse Aide #1 stated she thought Resident #1 was a 1 person assist for transfers. Nurse #2 stated Resident #1 did not have shoes or nonskid socks on and there was not a towel under her feet and the floor was wet. Physical Therapist #1 was interviewed on 2/16/2022 at 3:03 pm and stated she worked with Resident #1 before she fell on [DATE]. Physical Therapist #1 stated she had not transferred Resident #1 to and from her wheelchair by pivoting her and had transferred her by sliding her from the bed to the chair and from the chair to the bed. Physical Therapist #1 stated she had not done any education with the nursing staff regarding how Resident #1 should be transferred. During an interview with Nurse Aide #2 on 2/16/2022 at 3:25 pm she stated she had cared for Resident #1 before she fell on [DATE] and she had transferred her from the bed to the chair and from the chair to a shower chair with a stand and pivot with two staff members. A telephone interview was conducted 2/18/2022 at 1:58 pm with the previous Director of Nursing and she stated she interviewed Nurse Aide #1 after Resident #1 fell on [DATE]. The previous Director of Nursing stated Nurse Aide #1 told her she heard a pop when she was transferring Resident #1 from the shower chair to the wheelchair and lowered her to the floor. The previous Director of Nursing stated she did not remember if Resident #2 required two staff members for transfers but if Resident #1 told Nurse Aide #1 she should get assistance to transfer, Nurse Aide #1 should have ensured the Resident #1 felt safe and asked another staff member to assist her. The Physician was interviewed on 2/18/2022 at 2:52 pm and stated he was told Nurse Aide #1 heard a pop before she was lowered to the floor and the resident had a history of [CONDITION(S)] and [CONDITION(S)] which would have made her bones weak. The Physician stated the fracture was probably pathologic from her body weight and being pivoted during the transfer. The Physician stated he was not aware of how Resident #1 should have been transferred but being transferred without pivoting or with a mechanical lift may have made a difference in whether she sustained a fracture. An interview was conducted with the Administrator on 2/18/2022 at 3:23 pm and he stated he interviewed Nurse Aide #1 when Resident #1 fell in the shower on 12/17/2021 and sustained a fracture. The Administrator stated Nurse Aide #1 stated she heard a pop when she was pivoting Resident #1 and lowered her to the floor. The Administrator stated Resident #1 was a 1 to 2 persona assist for transfers depending on her level of fatigue. The Administrator stated the Nurse Aide Kardex is generated from the Care Plan, which was based on the Nurse's assessment. The Administrator stated he was not aware Resident #1 asked Nurse Aide #1 to have someone help with the transfer when she was transferred from the shower chair to the wheelchair on 12/17/2021. The Administrator stated Nurse Aide #1 should have requested assistance from another staff member when Resident #1 asked her to get assistance. . 2. Resident #2 admitted to the facility on [DATE] with diagnoses of brain damage, [CONDITION(S)], and a persistent vegetative state. A review of Resident #2's most recent quarterly Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired and required total assistance for bed mobility and transfers. Resident #2's Care Plan dated 1/14/2022 was reviewed and stated 1 to 2 staff members should assist with turning and repositioning in the bed. A Nurse's Progress Note dated 12/21/2021 at 11:32 am written by Nurse #4 stated Resident #2 fell from the bed to the bedside mat while turning during incontinence care was being provided and he was assessed by Nurse #4 and no injuries were found. Attempts were made to reach Nurse #4 by phone without success. During an observation of Resident #2 on 2/15/2022 at 9:35 am he did not move independently in the bed. Resident #2 was on an air mattress. During an observation on 2/15/2022 at 10:15 am of Nurse #8 changing Resident #8's dressing to his gastrostomy tube site Resident #2 did not move his arms, legs or head. During an observation on 2/15/2022 at 10:15 am Nurse Aide #1 gave Resident #2 a bed bath with the assistance of Nurse Aide #2. Resident #2 did not assist when he was turned and did not support himself with his arms or legs. After Nurse Aide #1 completed Resident #2's bed bath they placed him on a mechanical lift and positioned him in a reclining wheeled chair. During an interview with Nurse Aide #1 on 2/16/2022 at 2:01 pm she stated she was providing incontinence care and had turned Resident #2 to his left side when he began to jerk and she could not stop him from falling off the opposite side of the bed. Nurse Aide #1 stated Resident #2 had an air mattress on his bed. During an interview on 2/18/2022 at 1:54 pm with the previous Director of Nursing (DON) she stated she was the DON when Resident #2 fell on [DATE]. The previous DON stated since Resident #2 was total care there should have been two staff members when he was turned for incontinence care in the bed. During an interview with the Administrator on 2/18/2022 at 3:23 pm he stated he expected the Nurse Aides to follow the Nurse Aide Kardex, which is generated from the Care Plan, which was based on the Nurse's assessment. He stated Resident #2's Kardex stated there should be 1 or 2 staff to assist and the staff should make a decision on whether 1 or 2 staff members were needed depending on the resident's level of functioning when they provide care. The Administrator did not answer when asked if Nurse Aides should be responsible for assessing whether Resident #2 needed 1 or 2 staff assistance with bed mobility. The Administrator also stated the facility had made a decision that all residents that are on air mattresses would require a 2 person assist with bed mobility in the future.

Based on record review and staff interviews the facility failed to allow 1 of 1 resident, Resident #3, to return to the facility after he waited for placement for 80 days in the hospital and was discharged to another skilled nursing facility. Findings included: Resident #3 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He discharged to the hospital on 10/22/2021 with behaviors. During an interview with Resident #3's interim Guardian on 2/15/2022 at 12:52 pm she stated the facility refused to allow Resident #3 to readmit to the facility because he had refused to take the COVID vaccine. The interim Guardian stated she was not sure if the facility had agreed to allow Resident #3 to return to the facility later because his Guardian returned and resumed his case. During an interview on 2/15/2022 at 1:42 pm with the Administrator he stated Resident #3 discharged to the hospital due to severe behaviors. The Administrator stated Resident #3 was hitting staff and he was afraid Resident #3 would harm staff or himself. During an interview with the Guardian on 2/15/2022 at 4:57 pm she stated she called the Administrator several times, but he did not return her calls, but did return her emails. The Guardian sent a copy of the email communication with the Administrator: 12/29/2021 - The Guardian emailed the Administrator and asked if the facility would consider allowing Resident #3 to return to the facility and explained Resident #3 had not displayed any behaviors in several weeks. The Guardian's email further stated she felt Resident #3's behaviors were a result of a urinary tract infection treated in the hospital. 12/29/2021- The Administrator emailed the Guardian and stated the facility would admit him as soon as possible but they had COVID cases and were working towards mitigating the spread. 1/14/2021- The Guardian emailed the Administrator and inquired into the COVID status of the building and whether Resident #3 would be allowed to return. 1/14/2021- The Administrator emailed the Guardian and stated he had waitlisted Resident #3 for admission to the next appropriate long term care bed. During a second interview with the Administrator on 2/18/2022 at 3:23 pm he stated when Resident #3 was ready to return to the facility they did not have an appropriate bed for him. The Administrator stated they had Medicare certified beds available but did not have a Medicaid certified bed available and he was not sure if Resident #3's behaviors would be considered a skilled service under Medicare guidelines. The Administrator stated they had not readmitted Resident #3 to the facility.

Based on record review, legal guardian and staff interviews the facility failed to provide a resident's legal guardian written information regarding a bed hold prior to transfer to the hospital for 1 of 1 resident, Resident #3, reviewed for discharge to the hospital. Findings included: Resident #3 admitted to the facility on [DATE]. He discharged to the hospital on 10/22/2021 due to behaviors. Resident #3's Minimum Data Set Quarterly assessment dated [DATE] revealed he was moderately impaired cognitively and did not have plans to discharge to the community. On 2/15/2022 at 3:12 pm an interview was conducted with Nurse #6 and she stated she discharged Resident #3 to the hospital on 10/22/2021. Nurse #6 stated she called both the guardians listed on Resident #6's record and the and left a message asking if they wanted to hold Resident #3's bed when he went to the hospital but they did not call her back. Nurse #6 stated Resident #3 would not have understood what a bed hold was in his condition when he was discharged to the hospital. During a phone interview with Resident #3's legal Guardian on 2/15/2022 at 4:57 pm she stated she had not received a voicemail, email or written notification regarding a bed hold for Resident #3 before or after he was discharged from the facility to the hospital on 10/22/2021. The Guardian stated she had been on leave from her office during his discharge but had checked her emails, voicemails and mail daily. The Admissions Coordinator was interviewed on 2/16/2022 at 10:27 am and she stated Resident #3 was a long term resident of the facility and was hospitalized for behaviors on 10/22/2021. She further stated the Business Office Manager would have been responsible for sending a bed hold policy to Resident #3's guardian, but the facility may not have had a Business Office Manager when Resident #3 was sent to the hospital. On 2/17/2022 at 1:43 pm an interview was conducted with the Business Office Manager (BOM) and she stated she was employed with the facility on 11/8/2021. The BOM further stated Resident #3 was discharged to the hospital on 10/22/2021 and she reached out to the Admission's Coordinator regarding the plan for Resident #3 after discharge when she came to the facility and was told he would not be returning to the facility. During an interview with the Administrator on 2/18/2022 at 3:23 pm he stated Nurse #6 left a message for the Guardian when Resident #3 discharged to the hospital on 10/22/2021 and she did not return the call. The Administrator stated Resident #3 was a ward of the state and he did not know if the state would pay for a bed hold and a written notice of bed hold was not sent to the Guardian.

Based on observations, resident, staff and nurse practitioner interviews and record review, the facility failed to prevent a resident from falling off the bed during care for 1 of 3 residents, Resident #60, reviewed for supervision to prevent accidents. Resident #60 was turned to her side, rolled off the bed sustaining pain and bruising to her elbow and shoulder. Findings included: Resident #60 admitted to the facility on [DATE] and her diagnoses included [CONDITION(S)] and [CONDITION(S)]. A Care Plan revised on 3/27/2021 stated Resident #60 required extensive to total assistance of one staff member for incontinence care and extensive assistance of one staff member to turn and reposition in bed due to impaired mobility and obesity. The Care Plan further stated Resident #60 was at risk for falls due to deconditioning, immobility, and incontinence. Review of Resident #60's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact; required extensive assistance of one person for turning in bed; and had not had any falls since the previous assessment. A Nurses Note by Nurse #1 written 5/2/2021 at 5:13 pm stated Resident #60 fell from the bed to the floor when Nurse Aide #1 was changing the resident's bed pads. The note further stated Resident #60 had hit the floor with her right shoulder and was complaining of right shoulder and elbow pain; and Nurse Practitioner #1 was notified. A Physician's Order dated 5/2/2021 at 4:13 pm written by the Nurse Practitioner for [MEDICATION(S)] Patch 5% apply to right shoulder topically every 24 hours was written due to the injury and pain Resident #60 had due to the fall on 5/2/2021. A review of the Medication Administration Record for 5/2021 revealed Resident #60 had complained of pain after the fall on 5/2/2021: A review of the Medication Administration Record for 5/2021 revealed Resident #60 was administered [MEDICATION(S)]/Acetaminophen 10/325 milligrams one tablet at 12:41 am, 9:14 am and 5:24 pm on 5/3/2021 for pain relief. Resident #60 had rated her pain at 6 on a scale of 1 to 10 at 12:41 am; 5 on a scale of 1 to 10 at 9:14 am; and 4 on a scale of 1 to 10 at 5:24 pm. Resident #60 was also administered a [MEDICATION(S)] Patch 5% to her right shoulder at 9:22 am on 5/3/2021 for pain relief, she rated her pain at a 3 on a scale of 1 to 10. On 5/4/2021 at 5:10 am and 3:52 pm Resident #60 was administered [MEDICATION(S)]/Acetaminophen 10/325 milligrams one tablet and a [MEDICATION(S)] Patch 5% was placed on Resident #60's right shoulder for pain per the Medication Administration Record for 5/2021 at 9:08 am. According to the Medication Administration Record Resident #60 rated her pain at 5 at 5:10 am, 5 at 9:08 am, and there was no rating recorded for 3:52 pm. On 5/5/2021 Resident #60 was administered [MEDICATION(S)]/Acetaminophen 10/325 milligrams one tablet at 5:15 am and 8:15 pm. Resident #60 had rated her pain at 5 on a scale of 1 to 10 with both doses. Further review of the Medication Administration Record revealed Resident #60 received [MEDICATION(S)]/Acetaminophen 10/325 milligrams one tablet at 7:30 pm on 5/9/2021 after rating her pain at 4 on a scale of 1 to 10. On 5/10/2021 at 9:11 am Resident #60 was administered [MEDICATION(S)]/Acetaminophen 10/325 milligrams one tablet after rating her pain at 5 on a scale of 1 to 10. During an observation of Resident #60 on 5/10/2021 at 11:07 am a bruise was noted to her right elbow. The bruise extended from the middle of Resident #60's upper arm to below her elbow on her right posterior arm. Resident #60 stated Nurse Aide #1 was providing incontinence care and turned her to her side and she fell from the bed and hit her elbow. Resident #60 stated the fall occurred a week ago and she still had a lot of pain in her right shoulder and elbow. Resident #60 further stated the Nurse Practitioner had ordered an x-ray on the day she fell and another x-ray on 5/10/2021 and the nurse had told her there was not a fracture. Nurse #2 was interviewed on 5/12/2021 at 9:33 am. She stated she had not worked when Resident #60 fell on [DATE] but she had cared for her since the fall. Nurse #2 stated Resident #60 had complained of pain to her right shoulder and elbow since the fall and the Nurse Practitioner had changed her pain medication and ordered a follow up x-ray since she continued to have pain. Nurse #2 stated she was not aware of Resident #60 having falls before 5/2/2021. An interview was conducted with Nurse #1 on 5/12/2021 at 4:38 pm. Nurse #1 stated Resident #60 was assigned to him on 5/2/201 when she fell from the bed. Nurse #1 stated Nurse Aide #1 was providing incontinence care for Resident #60 and was turning her on her side when she slipped from the bed and fell to the floor. Nurse #1 stated the Nurse Practitioner who was in the facility at the time of the fall was notified and she evaluated Resident #60 before she was moved back to the bed. Nurse #1 further stated Resident #60 is alert and oriented and told him how the fall occurred. On 5/13/2021 at 10:02 am an interview was conducted with Nurse Aide #1 who is no longer employed with the facility. Nurse Aide #1 stated she had provided care for Resident #60 several times before she fell on [DATE] and was not aware she should have two staff members to turn her until after Resident #60 fell from the bed. Nurse Aide #1 stated several staff had told her after the fall on 5/2/201 that Resident #60 required two staff members for turning in the bed. Nurse Aide #1 stated she had never seen a care plan or Nurse Aide Care Instructions for Resident #60 that told you how many staff were required to turn her in the bed. Nurse Aide #1 stated she was turning Resident #60 to her side to provide incontinence care when she slipped from the bed and she could not catch her. Nurse Aide #1 stated she could have asked someone to help her turn Resident #60 if she had known she should have had two staff to assist. During an interview with Nurse Aide #2 on 5/13/2021 at 10:26 am she stated she had cared for Resident #60 several times before she fell on [DATE]. Nurse Aide #2 stated she usually got another Nurse Aide to help her because she felt Resident #60 needed two staff members. The Interim Director of Nursing was interviewed on 5/13/2021 at 10:42 am and stated Resident #60 required extensive assistance of one staff member for turning in the bed. The Interim Director of Nursing stated after Resident #60's fall on 5/2/2021 the staff were in-serviced on turning and repositioning residents and the staff were educated they should ask for assistance any time they felt they could not handle a resident during bed mobility or any other assistance they provided. The Interim Director of Nursing stated Nurse Aide #1 should have asked for help when turning Resident #60 but the Care Plan had stated she only needed assistance of one staff member. The Interim Director of Nursing stated Nurse Aide #1 was small and she felt she would have a hard attempting to turn Resident #60. The Nurse Practitioner was interviewed on 5/13/2021 at 2:02 pm and stated she assessed Resident #60 after her fall on 5/2/2021 and Resident #60 told her she fell from the bed and landed on her right side. The Nurse Practitioner stated Resident #60 had complained of right shoulder and elbow pain. The Nurse Practitioner stated she obtained an x-ray of Resident #60's right shoulder and elbow which did not show a fracture or dislocation. The Nurse Practitioner stated she saw Resident #60 again on 5/9/2021 because she continued to complain of pain in the right shoulder and elbow and she order another x-ray. On 5/13/2021 at 4:36 pm an interview was conducted with the Administrator and he stated although Resident #60 had not required two staff members to turn her before the fall but he wanted the staff to ask for assistance before turning and repositioning any resident they felt required another staff member to provide care rather than have a resident fall. Validation of Past Non-compliance: The [NAME] Center Health and Rehabilitation Cabarrus submitted a Plan of Correction with a compliance date of 5/3/2021: Nurse #1 was interviewed on 5/12/2021 at 4:38 pm and stated Resident #60 was assessed for injury, pain medication was provided immediately after the fall for right shoulder pain, and an x-ray was ordered of the right shoulder. Nurse #1 further stated the Nurse Practitioner assessed Resident #60 immediately after the accident. Nurse Aide #1 was educated on turning and repositioning and requesting assistance on 5/2/2021. This was validated by review of the in-service attendance form dated 5/2/2021 and an interview with Nurse Aide #1 on 5/13/2021 at 10:02 am. On 5/3/2021 the Director of Nursing and Staff Development Coordinator re-educated staff regarding turning and repositioning, resident Kardek and Care Plan, and asking for assistance. This was validated through record review of the in-service attendance form dated 5/3/2021. The Director of Nursing completed a Fall Risk Assessment for all current residents for accuracy and validation of interventions which was dated 5/3/2021. Review of the Turning/Repositioning/Bed Mobility and Kardex/Care Plan Review Audits revealed the Director of Nursing had audited 3 Nurse Aides weekly since 5/3/2021. The Plan of Correction dated 5/3/2021 stated the Director of Nursing would report the results of the audits during the Quality Assurance Meetings monthly for three months. Compliance was achieved on 5/3/2021. Validation included interviews with Nurse #1, Nurse Aide #1, and review of in-service education and auditing tool provided by the facility.

Based on record review, observation, staff, physician and Nurse practitioner interview, the facility failed to prevent significant medication errors for 1 of 6 residents observed for medication administration (Resident #130). Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #3 was observed preparing [MEDICATION(S)] for injection for Resident #130 on 5/12/2021 at 8:54 AM. Nurse #3 removed two insulin syringes from the medication cart and withdrew [MEDICATION(S)] into both syringes. Nurse #3 was stopped as she went into the room and questioned if using insulin syringes was a standard of practice for the administration of [MEDICATION(S)]. Nurse #3 reported she did not know what type of syringe to use for the [MEDICATION(S)] injection because she did not have a small enough needle in the cart. Nurse #3 asked Nurse #6 to get her a syringe to administer the [MEDICATION(S)] with because she didn ' t know what syringe to use. Nurse #6 obtained a TB syringe and Nurse #3 prepared [MEDICATION(S)] 5,000 units 1 ml and administered to Resident #130. The syringe that Nurse #3 used was observed as a 50-unit insulin syringe and was labeled as ½ ml in volume. Nurse #3 was interviewed on 5/12/2021 at 11:22 AM. Nurse #3 reported she knew [MEDICATION(S)] had to be administered with a small needle and because she could not find a small needle in her cart, she thought that using the small needle on the insulin syringe would be fine. Nurse #3 reported she thought it was odd she was going to have to use 2 insulin syringes to administer one dose of medication, but she did not know which syringe to use. The DON and the District Director of Clinical Services (DCS) were interviewed on 5/12/2021 at 5:03 PM. The DCS and DON reported it was not a nursing standard to use an insulin syringe for the administration of [MEDICATION(S)] and Nurse #3 should not have attempted to use the insulin syringe. The facility physician (MD) was interviewed on 5/13/2021 at 3:41 PM. The MD reported that insulin syringes were not used for [MEDICATION(S)] administration because there was a difference between units and milliliters. The MD reported because the syringes were ½ milliliters by volume, Resident #130 would have most likely received the correct dosage of [MEDICATION(S)], but typically insulin syringes were used for only insulin.

Based on record review, observations, staff, physician and nurse practitioner interviews, the facility failed to ensure the medication error rate was less than 5% as evidenced by 5 medication errors out of 25 opportunities for a medication error rate of 20% (Resident #16, Resident #130, and Resident #15). Findings included: 1. A medication pass was observed on 5/11/2021 at 4:16 PM. Nurse #2 prepared Resident #16 ' s medications and administered [MEDICATION(S)] 20 milligrams (mg) to Resident #16. Nurse #2 did not check Resident #16 ' s blood pressure. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 was interviewed on 5/12/2021 at 10:51 AM. Nurse #2 reported she was not aware she should have checked Resident #16 ' s blood pressure prior to administering the [MEDICATION(S)]. Nurse #2 read the order and reported she had never read the entire order and she had not checked Resident #16 ' s blood pressure. Nurse #2 reported the order had not been entered to trigger a pop-up box to document the blood pressure, and because there was not a reminder/pop-up box, she did not check Resident 16 ' s blood pressure. The Director of Nursing (DON) was interviewed on 5/12/2021 at 5:03 PM. The DON reported she did not know why Nurse #2 would have missed checking Resident #16 ' s blood pressure. 2. Resident #130 was admitted to the facility 5/11/2021. a. Nurse #3 was observed administering [MEDICATION(S)] 10 ml to Resident #130 by mouth on 5/12/2021 at 8:54 AM. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nurse #3 at 5/12/2021 at 11:22 AM. Nurse #3 reported after she had administered the [MEDICATION(S)], she noticed the order read to administer the medication by the PEG-tube. Nurse #3 reported she needed to get a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was interviewed on 5/12/2021 at 5:03 PM. The DON did not know why Nurse #3 would have administered the [MEDICATION(S)] by mouth instead of by PEG-tube. b. Nurse #3 was observed administering [MEDICATION(S)] 2.5 ml to Resident #130 by mouth on 5/12/2021 at 8:54 AM. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #3 was interviewed on 5/12/2021 at 11:22 AM. Nurse #3 reported she had not noticed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was interviewed on 5/12/2021 at 5:03 PM. The DON did not know why Nurse #3 would have administered the [MEDICATION(S)] by mouth instead of by PEG-tube. c. Nurse #3 was observed preparing [MEDICATION(S)] (a blood thinning medication) for injection for Resident #130 on 5/12/2021 at 8:54 AM. Nurse #3 removed two insulin syringes from the medication cart and withdrew [MEDICATION(S)] into both syringes. Nurse #3 was stopped as she went into the room and questioned if using insulin syringes was a standard of practice for the administration of [MEDICATION(S)]. Nurse #3 reported she did not know what type of syringe to use for the [MEDICATION(S)] injection because she did not have a small enough needle in the cart. Nurse #3 asked Nurse #6 to get her a syringe to administer the [MEDICATION(S)] with because she didn ' t know what syringe to use. Nurse #6 obtained a TB syringe and Nurse #3 prepared [MEDICATION(S)] 5,000 units 1 ml and administered to Resident #130. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An insulin syringe used observed and it was a 50-unit syringe and was labeled as ½ ml in volume. Nurse #3 was interviewed on 5/12/2021 at 11:22 AM. Nurse #3 reported she knew [MEDICATION(S)] had to be administered with a small needle and because she could not find a small needle in her cart, she thought that using the small needle on the insulin syringe would be fine. Nurse #3 reported she thought it was odd she was going to have to use 2 insulin syringes to administer one dose of medication, but she did not know which syringe to use. The DON and the District Director of Clinical Services (DCS) were interviewed on 5/12/2021 at 5:03 PM. The DCS and DON reported it was not a nursing standard to use an insulin syringe for the administration of [MEDICATION(S)] and Nurse #3 should not have attempted to use the insulin syringe. The facility physician (MD) was interviewed on 5/13/2021 at 3:41 PM. The MD reported that insulin syringes were not used for [MEDICATION(S)] administration because there was a difference between units and milliliters. The MD reported because the syringes were ½ milliliters by volume, Resident #130 would have most likely received the correct dosage of [MEDICATION(S)], but typically insulin syringes were used for only insulin. 3. Nurse #6 was observed administering [MEDICATION(S)] 0.5 mg 1 tablet to Resident #15 on 5/12/2021 at 10:13 AM. Nurse #6 administered a full tablet of [MEDICATION(S)] to Resident #15. Resident #15 medication orders were reviewed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tablet orally twice daily was ordered on 12/21/2021. The narcotic count sheet for Resident #15 ' s [MEDICATION(S)] was reviewed. The sheet noted that Resident #15 received 1 full tablet of [MEDICATION(S)] on 5/12/2021. A nurse practitioner note dated 12/21/2021 indicated a gradual dose reduction would be attempted for Resident #15 with [MEDICATION(S)] and she planned to halve the dose from 0.5 mg to 0.25 mg to see how Resident #15 tolerated the lower dose. Nurse #6 was interviewed on 5/12/2021 at 11:38 AM. Nurse #6 checked the order for Resident #15 and reported she was confused by the way the order was written, and because all other nursing staff had administered a full tablet of [MEDICATION(S)] 0.5 mg, she did not think to double check the dosage. The Director of Nursing (DON) and the District Director of Clinical Services (DCS) were interviewed on 5/12/2021 at 5:03 PM. The DON reported the order for [MEDICATION(S)] for Resident #15 had been transcribed incorrectly and this led to nurses incorrectly administering the medications.

Based on record review, observation, family member interview, and staff interviews, the facility limited visitation to the lobby or front entrance and failed to allow private, unsupervised, visits for one of one resident reviewed for visitation (Resident #39). Findings included: Resident #39 was admitted to the facility on [DATE]. The resident was residing in a private room at the time of the recertification. The Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 4/6/21 indicated Resident #39 was in a persistent vegetative state with no discernable consciousness. Review of Resident #39's care plan, updated on 4/22/21 revealed a focus area which documented the resident's family was very supportive and involved. The focus area provided further information the resident's family visits the resident often through video conferencing. There were two goal areas listed in the care plan which included Resident #39 will receive one on one weekly visits for sensory and video conferencing with the resident's family and to continue outdoors in-person visits as tolerated and able. The second goal was, due to COVID-19 restrictions, he receives one on one weekly visits for sensory as tolerated, no outside vendors, nor guest, openly permitted indoors. Scheduled restricted in-person visitation only during this time. Further review of the care plan revealed a focus area documenting the resident had restricted visitation secondary to COVID-19 precautions. The goal was for the resident to maintain psychosocial well-being during the restricted visitation period. The listed intervention was to provide an alternative method of communicating with family and friends. An undated document from the facility identified as a corporate supplied Tool kit for resident visitation was reviewed. There was a page titled, In-Room Visitation. On that page it documented facilities could allow in room visitation under specific circumstances (end of life, resident is bed bound, equipment necessary for the resident's health cannot be easily moved). The document provided further information regarding there must be sufficient space to social distance and staff was to be available to stay with the resident during the visit to ensure safety and infection control practices were followed. Additionally, it was documented staff must be present during the visit to assure social distancing and appropriate infection control processes. A phone interview was conducted on 5/11/21 at 9:29 AM with a family member of Resident #39. The family member stated she was not allowed to visit the resident in his room. She further stated the facility mandated all visits to occur in the front lobby of the facility at the entrance. She said she would like to be able to go to the resident's room and visit with him in private. During an interview conducted on 5/11/21 at 2:08 PM with Nurse #8 she stated the family of Resident #39 came to the facility on ce a week or so to visit with the resident. She explained visitors, such as family members were not allowed in the general part of the facility. She said if a family member wanted to visit with a resident, it would have to be at the front of the facility either in the lobby or just outside the lobby at the front entrance. On 5/11/21 at 3:11 PM an observation of the lobby at the front entrance of the building revealed two separate groups of residents and family members visiting outside of the front entrance and no resident and family members visiting inside at the lobby. The receptionist was at the desk in the lobby and was able to observe the visitation. An interview was conducted on 5/11/21 at 3:53 PM with the receptionist. He stated all visitation for residents was allowed in the lobby and outside at the front entrance. Unit Manager #1 stated during an interview conducted on 5/11/21 at 3:59 PM Resident #39 had met with his family outside. She explained all visitors were screened at the front entrance and all visitations took place up front, at the lobby, at the front entrance. An interview was conducted with the Social Worker (SW) on 5/11/21 at 4:03 PM. She said all family visits with residents must be scheduled, the visits are limited to once per week, and are limited to 30 minutes. However, she explained, if the family would like more visits or more time, it was open to them, because the weather was getting nicer, and it allowed them to have additional visitation areas outside of just inside the lobby, where they could only have two visitations at a time. The SW further stated they had not received a new tool kit from corporate regarding in room visits so they could not proceed with in room visits at this time. She said they had to await guidance from corporate regarding visitation for residents past the front entrance. She said the facility was awaiting the new tool kit which would explain how visitation was going to be conducted. She said there had been families who had asked about visiting residents in the facility, but until the new tool kit was received they could not allow any visitation beyond the front lobby and outside at the front entrance. The SW stated there was no date as to when corporate would release the new took kit. The SW added she felt visitation was based on the county positivity rate and how corporate was addressing visitation. During an interview conducted on 5/13/21 at 3:36 with the Administrator and the Regional Clinical Consultant (RCC), the RCC stated Resident #39 was in a private room and should be allowed to have visits in his room. The administrator stated family visits with residents were being conducted outside at the front entrance, in the front lobby, and the guidance was to limit the visitations to 30 minutes. The administrator explained the facility had received a new tool kit from corporate and it was going to open things up regarding family visitation. The administrator said, however, the facility was not able to put the new tool kit into place regarding family visits into place due to the recertification. The administrator stated each facility in the company had to await directives from corporate on how to proceed with certain matters, and visitation was one of those matters.

Based on observations, staff interviews, and record review the facility failed to provide an on-going activity program which met the individual interests and needs to enhance the quality of life for one of one resident reviewed for activities (Resident #30). The findings included: Resident #30 was admitted to the facility on [DATE]. The resident ' s cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an undated Activities profile sheet of Resident #30 it was documented the resident preferred independent time, one-on-one visits are offered as tolerated, watching television, relaxing in room/common areas, supportive family, music, and it was noted the resident had cognitive, communication impairments, needed assistance and redirecting. The Minimum Data Set (MDS) significant change comprehensive assessment with an Assessment Reference Date (ARD) of 10/10/20 indicated Resident #30 had severe cognitive loss. A resident interview was conducted for Daily and Activity Preferences and revealed it was very important to her: to listen to music, do things with groups of people, do her favorite activities, and to participate in religious services or practices. Review of Resident #30 ' s care plan, which had been most recently updated on 4/14/21 revealed a focus area which documented the resident actively observed group activities, bingo, music, movies, pretty nails, and social events. The focus area also documented the resident was alert with confusion, she knew herself, and her family, but was confused to time, place, and placement. The resident was documented as enjoying watching television, would benefit from group activity participation, and being around other residents to increase social function. The goals listed were for the resident to participate in one-on-one weekly visits for activities, however due to COVID 19 restrictions the resident was offered one-on-one weekly visits as well as leisure material as tolerated. The resident could participate in small group activities, no outside vendors, nor guests openly permitted indoors. Scheduled in-person visitations only during this time. An intervention listed was the resident needed one-on-one bedside/in room visits and activities if unable to attend out of room events. Review of Resident #30 ' s individual participation record for the month of April 2021 revealed the resident was documented as having participated in television/radio/music and talking to herself on 4/1/21, on 4/14/21 and 4/23/21 it was documented the resident had participated in live music outdoors, and on 4/19/21 it was documented the resident had participated in an ice cream truck event which was also outdoors. There was no documentation of any other activity participation for Resident #30 including one-on-one activity. An Activities note dated 4/2/21 and timed 6:29 PM by the Activities Director (AD) documented Resident #30 remained alert to her surroundings with episodes of confusion. The resident was able to communicate some needs verbally. Due to COVID 19 the resident was offered one-on-one weekly visits and leisure materials as tolerated, small group activities were offered, however no outside vendors nor guest openly permitted indoors at this time. There was no individual participation record for Activities for the month of May 2021 available for review for Resident #30. During multiple observations were conducted on 5/10/21, which started at 12:25 PM and ended at 4:08 PM, Resident #30 was seen out in the hallway near her room. During these observations she was observed to be sitting in her wheelchair, appeared distressed, anxious, and she was calling out for your help to staff who were passing her. Multiple observations were conducted on 5/11/21 and 5/12/21 of Resident #30. Although the resident was not observed to have been as distressed, anxious, or requesting attention, she was observed to be out in the hallway, often sitting by the nurse ' s cart. Through none of the observations was the resident provided one-on-one activity time by the activity staff or other facility staff. The resident was not observed to have participated in any group activities. An interview was conducted with the Activities Director (AD) on 5/13/21 at 9:35 AM. The AD stated they started back doing activities in the facility on 3/10/21. The AD explained Resident #30 participated or would watch small group activities, and she enjoyed music. She said they have been doing outside activities such as music and they had an ice cream truck. She said Resident #30 goes about as she pleases, will go to different areas in the facility, and enjoys talking. She said the resident ' s cognitive loss is significant enough that she was unable to do an activity like BINGO and she did better in small group activities or one-on-one. She stated the resident did have times when she would become anxious and when she would become anxious, she would try to calm her down by doing things like combing her hair, and spending time with her, which helped to settle and calm her down. The AD stated Resident #30 needed one-one-one activity. The AD stated she did not have any documentation of one-on-one visitation or activity thus far for the month of May and did not have any documentation for the month of April. The AD was observed to have had one-on-one documentation for other residents for the requested time period. The AD was unable to identify what days or how often she had one-on-one activity time with Resident #30. During an interview conducted on 5/13/21 at 3:36 PM with the Administrator and the Regional Clinical Consultant (RCC), the RCC stated the expectation was for there to be appropriate activities for the residents. The Administrator stated the Nursing Assistants on the hall do interact with Resident #30 to help ease her anxiety.

Based on observations and staff interviews the facility failed to maintain infection control when 1 of 4 nurses (Nurse #4) was observed administering medications and failed to perform hand hygiene between residents (Resident #7, Resident #3, and Resident #13). Findings included: Nurse #4 was observed preparing medications for Resident #7 on 5/12/2021 at 4:21 PM. Nurse #4 was observed applying gloves to her hands and entering Resident #7 ' s room, administering oral medications and obtained a blood glucose level on Resident #7. Nurse #4 returned to her medication cart and removed her gloves. Nurse #4 did not perform hand hygiene. Nurse #4 prepared medication for Resident #3 on 5/12/2021 at 4:29 PM. Nurse #4 administered the medication to Resident #3 and returned to her medication cart. Nurse #4 did not perform hand hygiene. Nurse #4 returned to her medication cart and prepared medication for Resident #13 on 5/12/2021 at 4:31 PM. Nurse #4 administered medication to Resident #13 and returned to her medication cart. Nurse #4 did not perform hand hygiene. Nurse #4 was interviewed on 5/12/2021 at 4:35 PM. Nurse #4 reported she was not aware she had not performed hand hygiene after administering medication to each of the 3 residents. Nurse #4 reported she should have used alcohol-based hand sanitizer (ABHS) after each resident and medication administration. The Director of Nursing (DON) and District Director of Clinical Services were interviewed on 5/12/2021 at 5:03 PM. The DON reported Nurse #4 should have used ABHS or washed her hands in a sink with soap and water after each medication administration. The DON reported the nursing staff had been provided with education regarding hand hygiene and infection control measures. The DON reported she expected all nurses to maintain infection control measures during medication administration.

Based on record review and staff interviews, the facility failed to maintain a system of disposition of controlled substances for 1 of 6 residents reviewed for medication administration (Resident #15). Findings included: A physician order for Resident #15 dated 12/21/2020 ordered [MEDICATION(S)] 0.25 milligrams (mg) orally twice per day. The order was transcribed as [MEDICATION(S)] 0.5 mg ½ tablet orally twice per day. The controlled medication utilization record for Resident #15 ' s [MEDICATION(S)] revealed 0.5 mg tablets had been dispensed. The administration of [MEDICATION(S)] on 5/8/2021 documented ½ tablet had been administered to Resident #15. One nurse ' s signature was noted on 5/8/2020 to indicate that ½ tablet had been administered to Resident #15. No waste amount of the medication was documented, and no witness signature was documented. The administration of [MEDICATION(S)] on 5/11/2021 documented ½ tablet had been administered to Resident #15. One nurse ' s signature was noted on 5/11/2020 to indicate that ½ tablet had been administered to Resident #15. No waste amount of the medication was documented, and no witness signature was documented. Unit manager (UM) #1 was interviewed on 5/12/2021 at 2:15 PM. UM #1 stated that two nurses should sign on any wasted narcotic. UM #1 reported if ½ tablet of [MEDICATION(S)] was administered on 5/8/2021 and 5/11/2021, the tablet had been split and one half of the tablet had been discarded (wasted). UM #1 reported she did not know why the nurses did not have a witness to the discarded half of [MEDICATION(S)]. The Director of Nursing (DON) and the District Director of Clinical Services (DCS) were interviewed on 5/12/2021 at 5:03 PM. The DCS reported that all narcotic waste should be performed by one nurse and witnessed by another nurse. The DCS reported the controlled medication utilization record should have signed by two nurses to show the disposition of the wasted [MEDICATION(S)]. The DON reported she did not know why the [MEDICATION(S)] had not been witnessed by a second nurse for 5/8/2020 or 5/11/2020.

Based on record review, observations, and staff interviews, the facility failed to check agency nurse competencies for 1 of 1 agency nurses observed for medication administration (Nurse #3). Findings included: Nurse #3 was observed preparing [MEDICATION(S)] for injection for Resident #130 on 5/12/2021 at 8:54 AM. Nurse #3 removed two insulin syringes from the medication cart and withdrew [MEDICATION(S)] into both syringes. The syringe that Nurse #3 used was observed as a 50-unit insulin syringe and was labeled as ½ milliliter (ml) in volume. A syringe used for [MEDICATION(S)] administration would be labeled in volume of greater than 1 ml. Nurse #3 was stopped as she went into the room and questioned if using insulin syringes was a standard of practice for the administration of [MEDICATION(S)]. Nurse #3 reported she did not know what type of syringe to use for the [MEDICATION(S)] injection because she did not have a small enough needle in the cart. Nurse #3 asked Nurse #6 to get her a syringe to administer the [MEDICATION(S)] with because she didn ' t know what syringe to use. Nurse #3 was interviewed on 5/12/2021 at 11:22 AM. Nurse #3 reported 5/12/2021 was her first day working for the facility as an agency nurse. Nurse #3 reported she had received a packet of papers and she signed that she received the papers. Nurse #3 reported she had not read all the papers given to her and no nurse checked medication competency with her. Unit manager (UM) #2 was interviewed on 5/12/2021 at 2:15 PM. UM #1 reported she provided a packet of information for Nurse #3. UM #2 reported she and Nurse #3 signed the checklist, but UM #2 did not check Nurse #3 ' s competency with medication administration or any other tasks. The DON and the District Director of Clinical Services (DCS) were interviewed on 5/12/2021 at 5:03 PM. The DCS and DON reported the UM provided information to the agency nurses but did not perform competency checks for agency nurses. The DON and DCS reported they were not aware competencies needed to be checked for agency staff.

Based on observation, record review and staff interviews, the facility failed to separate the tube feeding syringe components stored for use, which creates the potential for bacterial growth, for one of one resident reviewed for tube feeding (Resident #39). Findings included: Resident #39 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 4/6/21 indicated Resident #39 was in a persistent vegetative state with no discernable consciousness. The resident was coded as having a feeding tube, receiving 51% or more of his total calories via tube feeding, and more than 501 cubic centimeters of fluid via tube feeding. An observation conducted on 5/10/21 at 12:25 PM revealed a clear plastic bag hanging on an intravenous (IV) pole at resident #39 ' s bedside. Inside the clear plastic bag, a 2-ounce syringe was observed with the plunger fully depressed into the barrel of the 2-ounce syringe. Visible droplets of clear moisture were observed in the tip of the syringe. An interview was conducted with Nurse #4 on 5/13/21 at 2:37 PM in conjunction of an observation of Resident #39 ' s tube feeding pole. The nurse stated she had been assigned to Resident #39 during the day shift (from approximately 7:00 AM to 3:00 PM). The nurse stated she did store the plunger, inside the barrel of the syringe, in the bag hanging on the IV pole. The nurse stated after she had finished utilizing the syringe she rinsed with syringe with water, inserted the plunger in the barrel of the syringe, and then placed the 2-ounce syringe into the plastic bag with the plunger depressed into the barrel of the syringe. The nurse said that was how she stored the syringe, with the plunger inside of the barrel of the syringe. She further stated she did not separate the plunger from the barrel when she would place the syringe in the plastic bag for storage. The 2-ounce syringe was observed with the plunger fully depressed into the barrel of the 2-ounce syringe and stored in a plastic bag. Visible droplets of moisture were observed in the tip of the syringe. The nurse stated she had returned the syringe to the plastic bag earlier after she had administered the resident his medication via the feeding tube and flushed the feeding tube. During an observation which was conducted in conjunction with an interview on 5/13/21 at 2:43 PM the Regional Clinical Consultant (RCC) stated the plunger should be stored removed from the barrel of the syringe in the plastic bag to minimize bacterial growth. The RCC made the statement after she observed the plunger in the barrel of the syringe with moisture in the tip in the room of Resident #39. During an interview conducted on 5/13/21 at 3:36 PM with the Administrator and the Regional Clinical Consultant (RCC), the RCC stated the expectation was for the plunger to be stored removed from the barrel of a syringe. The Administrator stated it was his expectation for the tube feeding syringe to be stored properly.

Based on observation, record review, and staff interviews, the facility failed to determine a resident ' s ability to self-administer medications for one of one resident observed to have medications in his room (Resident #22). Findings Included: Resident #22 was admitted on [DATE] the resident ' s cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 2/26/21 indicated Resident #22 had moderate cognitive impairment. Review of Resident #22 ' s care plan, which had been most recently updated on 4/28/21 revealed a focus area which documented the resident had impaired cognitive function or impaired thought process related cognitive communication deficit and altered mental dysfunction. The review revealed no focus area for medication self-administration. Review of Resident #22 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May MAR for Resident #22 did not reveal an orde for instantr oral pain relief, nor an order medicated anti-itch lotion. Review of Resident #22 ' s Treatment Administration Record for the month of May up till 5/10/21 revealed no order for instant oral pain relief, nor an order medicated anti-itch lotion. An observation conducted of Resident #22 was conducted in conjunction with an interview with the resident on 5/10/21 at 1:24 PM. The resident was observed to have had a tube of [MEDICATION(S)] Cream 0.1% (with a prescription label on it for Resident #22), a small glass bottle of instant oral pain relief, and 2 yellow bottles of medicated anti-itch lotion. The resident stated he kept the items at his bedside because he had a sore tooth and he used the cream on his legs. An interview was conducted on 5/11/21 at 2:37 PM with Nursing Assistant (NA) #3 who was assigned to Resident #22 and she stated she was not aware of any medications which were supposed to be left at the bedside of Resident #22. She further stated she had not observed any medications at the bedside of Resident #22. An interview was conducted on 5/11/21 at 2:41 PM with Nurse #6, who was the treatment nurse. She stated she only provided a wound treatment to the resident ' s foot and she did not provide antifungal cream application for Resident #22. During an interview conducted on 5/13/21 at 3:36 PM with the Administrator and the Regional Clinical Consultant (RCC), the RCC stated residents were allowed to self-administer medications if they were screened and deemed appropriate to self-administer medications. She further stated the medications would have to be properly secured and the resident would be care planned for medications self-administration. She stated Resident #22 was not approved to self-administer medications and the observed medications should not have been at his bedside. The Administrator stated Resident #22 should not have had those medications as he was not evaluated for medication self-administration.

Based on staff interview and record review, the facility failed to post accurate staffing information as compared to the Staff Schedule/ Assignment Sheets for 5 days of the 5 days reviewed. Findings included: The Daily Staffing Form for 5/1/21 revealed the posted staffing for first shift (7:00 AM to 3:00 PM) had 5 Nursing Assistants (NAs) for a total of 37.5 hours. Further review revealed the second shift (3:00 PM to 11:00 PM) had 4 NAs for a total of 30 hours and 2 Registered Nurses (RNs) for a total of 16 hours. The third shift (11:00 PM to 7:00 AM) had 2 NAs for 15 hours. The facility nursing schedule for 5/1/21 revealed for first shift there were 5 NAs for 37.5 hours. Further review revealed for second shift there were 6 NAs for 45 hours and 3 RNs for 20.5 hours (one RN worked an abbreviated shift). The third shift had 3 NAs for 22.5 hours. The Daily Staffing Form for 5/2/21 revealed the posted staffing for first shift had 6 NAs for a total of 45 hours. The facility nursing schedule for 5/2/21 revealed for first shift there were 5 NAs for 37.5 hours. The Daily Staffing Form for 5/3/21 revealed the posted staffing for first shift had 7 NAs for a total of 52.5 hours. Further review revealed the second shift had 5 NAs for a total of 37.5 hours. The third shift had 5 NAs for 37.5 hours and two LPNs for 16 hours. The facility nursing schedule for 5/3/21 revealed for first shift there were 6 NAs for 45 hours. Further review revealed for second shift there were 7 NAs for 52.5. The third shift had 4 NAs for 30 hours, 1 LPN for 8 hours, and 1 RN for 8 hours. The Daily Staffing Form for 5/4/21 revealed the posted staffing for first shift had 6 NAs for a total of 45 hours. Further review revealed the second shift had 8 NAs for a total of 60 hours. The third shift had 5 NAs for 37.5 hours. The facility nursing schedule for 5/4/21 revealed for first shift there were 7 NAs for 52.5 hours. Further review revealed for second shift there were 6 NAs for 45. The third shift had 4 NAs for 30 hours. The Daily Staffing Form for 5/5/21 revealed the posted staffing for first shift had 8 NAs for a total of 60 hours. Further review revealed the third shift had 5 NAs for 37.5 hours. The facility nursing schedule for 5/5/21 revealed for first shift there were 7 NAs for 52.5 hours. Further review revealed the third shift had 3 NAs for 22.5 hours. An interview was conducted in conjunction with a record review on 5/12/21 at 2:46 PM with the scheduler. She said she made changes to the posted staffing sheets, such as call outs, no call no shows, when she came to the facility in the mornings based on what had happened the day before. She explained she would correct the staffing sheet for Monday on Tuesday, and she would correct the staffing sheets for Friday, Saturday, and Sunday, when she came in on Monday. She said there was no one assigned, such as the charge nurse to update the staffing sheets throughout the day. The posted staffing sheets were reviewed with the nursing schedule from 5/1/21 through 5/5/21 and she stated she had made all of the changes on the posted staffing sheets the following day and then she had entered the changes into a software staffing management program in her computer. During an interview conducted on 5/13/21 at 3:36 PM with the Administrator he stated he expected for the posted staffing sheets to updated throughout the day.

Based on record review, staff, nurse practitioner, physician interviews, and [MEDICAL TREATMENT] staff interviews, the facility failed to obtain a physician ' s order to treat a resident with a high blood glucose level for 1 of 7 residents reviewed for diabetic management (Resident #1). Resident #1 experienced sustained high blood glucose levels which resulted in a hospitalization for diabetic ketoacidosis (a serious complication of diabetes). Immediate jeopardy began on 8/14/2018 when Nurse #1 failed to obtain a physician order to treat a resident ' s high blood glucose which was elevated above 450 milligrams per deciliter (mg/dl) and administered insulin without a physician order. The Immediate Jeopardy was removed on 8/23/2018 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to notifying physician of resident changes. Findings included: A review of the facility policy titled Physician Services with a revision date of (MONTH) (YEAR) revealed an on-call physician service was available for times when the attending physician is not generally available, for example after 6:00 PM and on the weekends before noon. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed Resident #1 received [MEDICAL TREATMENT] treatment three times per week on Tuesday, Thursday and Saturday. A review of the care plans for Resident #1 revealed a care plan in place dated 1/11/2018 and revision date of 2/28/2018 that addressed her [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #1 to be cognitively intact without behaviors or rejection of care. The medical chart was reviewed, and physician orders dated 8/3/2018 revealed an order to check Resident #1 ' s blood glucose level before meals, at bedtime and as needed. A physician order dated 8/9/2018 for [MEDICATION NAME] insulin, inject subcutaneously before meals and at bedtime per sliding scale: blood glucose results 0-60 notify nurse practitioner (NP) or physician (MD); 201-250 mg/dl, inject 2 units of [MEDICATION NAME] insulin; 251-300 mg/dl, inject 4 units of [MEDICATION NAME] insulin; 301-350 mg/dl, inject 6 units of [MEDICATION NAME] insulin; 351-400 mg/dl, inject 8 units of [MEDICATION NAME] insulin; 401-450 mg/dl; inject 10 units of [MEDICATION NAME]and recheck blood glucose, if remained above 400 mg/dl call NP/MD, if greater than 451 mg/dl, notify NP/MD. A physician order dated 8/9/2018 specified blood glucose to be checked at 3:00 AM daily due to unstable blood glucose levels. There were no orders to administer insulin at that time. There was no stop date on the order. The nursing notes were reviewed, and a note dated 8/13/2018 written by Nurse #1 noted a blood glucose result of 533 mg/dl at 3:00 AM. The note documented contacting the on-call physician (MD #2) and the order of 20 units of [MEDICATION NAME]to be administered and the blood glucose to be monitored. The nurse documented at 6:07 AM the blood glucose had been rechecked at 6:00 AM with a High result. Nurse #1 documented she administered 20 units of [MEDICATION NAME] insulin. Nurse #1 documented no sign/symptoms of diabetic distress observed. There was no physician contact documented and no physician order documented in the medical record for the documented blood glucose level of High at 6:00 AM 8/13/2018. A note written by MD #2 on 8/13/2018 at 3:50 AM documented a one-time order had been given to administer 20 units of [MEDICATION NAME]and to monitor the blood glucose for Resident #1. There was no further documentation by MD #2 in the patient progress notes after 8/13/2018. A note dated 8/14/2018 at 6:07 AM written by Nurse #1 documented a blood glucose result of High and the administration of 20 units of [MEDICATION NAME]by sliding scale at that time. Nurse #1 documented NAD (no apparent distress) in her note. The medical record contained no information that the physician was notified of Resident #1 ' s blood glucose of High or a physician order had been obtained. A nursing note dated 8/15/2018 at 3:19 AM written by Nurse #1 documented a blood glucose reading of High at 3:00 AM. Nurse #1 documented the administration of 20 units of [MEDICATION NAME]per sliding scale and that Resident #1 had NAD noted. The medical record contained no information that the physician had been notified on 8/15/2018 of Resident #1 ' s blood glucose level of High or a physician order had been obtained. A nursing note dated 8/15/2018 at 6:36 AM written by Nurse #1 documented a blood glucose of 508 mg/dl at 6:00 AM. The nurse administered 20 units of [MEDICATION NAME]per sliding scale and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/15/2018 of Resident #1 ' s blood glucose level of 508 mg/dl or a physician order had been obtained. A nursing note dated 8/16/2018 at 6:36 AM written by Nurse #1 documented a blood sugar result of 485 mg/dl at 6:30 AM, the administration of 20 units of [MEDICATION NAME]and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/16/2018 of Resident #1 ' s blood glucose level of 485 mg/dl or a physician order had been obtained. Nurse #1 wrote a note dated 8/18/2018 at 3:16 AM that documented a blood glucose result of 454 mg/dl at 3:00 AM, the administration of 20 units of [MEDICATION NAME]and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/18/2018 at 3:16 AM of Resident #1 ' s blood glucose level of 454 mg/dl or a physician order had been obtained. A nursing note dated 8/18/2018 at 6:52 AM written by Nurse #1 revealed a blood glucose result of 531 mg/dl at 6:30 AM. Nurse #1 documented the administration of 20 units of [MEDICATION NAME]and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/18/2018 at 6:52 AM of Resident #1 ' s blood glucose level of 531 mg/dl or a physician order had been obtained. A nursing note written by Nurse #2 dated 8/18/2018 at 3:00 PM documented the blood glucose result of 450 mg/dl at 10:30 AM. Nurse #2 documented administration of 20 units of [MEDICATION NAME]via sliding scale orders dated 8/9/2018 and communication of the blood glucose results to the [MEDICAL TREATMENT] treatment center. The medical record contained no information that the physician had been notified on 8/18/2018 by Nurse #2 for Resident #1 ' s blood glucose result of 450 mg/dl. The MD sliding scale for insulin coverage specified the resident was to have 10 units of [MEDICATION NAME]with a blood glucose level of 450 mg/dl. A review of the hospital records revealed Resident #1 was admitted to the hospital for recurrent diabetic ketoacidosis (DKA) on 8/18/2018 and received intravenous fluids and intravenous insulin to reduce her blood glucose level. The admission note for the hospitalization dated 8/18/2018 revealed the resident was admitted with abdominal pain, chest discomfort and shortness of breath. Blood glucose level at 5:12 PM was 520 and at 6:58 PM was 581 mg/dl. She was admitted to the Intensive Care Unit for continual monitoring and treatment of [REDACTED]. Resident #1 was discharged back to the facility on [DATE]. The resident ' s primary physician (MD #1) was interviewed on 8/21/2018 at 8:57 AM. MD #1 reported Resident #1 was non-compliant and had unstable blood glucose control. An interview was conducted with NP #1 on 8/21/2018 at 2:26 PM. She reviewed the order for sliding scale insulin dated 8/9/2018 and stated that the physician or nurse practitioner should have been notified of the blood glucose results that were over 450 on 8/14/2018, 8/15/2018, 8/16/2018. She further reported it was her expectation that orders were followed for diabetics due to the potential for complications related to elevated blood glucose levels. Resident #1 was interviewed on 8/22/2018 at 9:09 AM. She reported she was not certain why she had a recent hospitalization . Nurse #1 was interviewed on 8/22/2018 at 9:19 AM via phone call. Nurse #1 reported she had been assigned to Resident #1 on 8/13/2018, 8/14/2018, 8/15/2018, 8/16/2018 and 8/18/2018 on the third shift (11:00 PM to 7:00 AM). Nurse #1 reported she checked Resident #1 ' s blood glucose at 3:00 AM every night she worked because Residents #1 ' s blood glucose was unstable and sometimes she would have very low blood glucose levels or very high blood glucose levels. Nurse #1 reported that a High reading usually indicated a blood glucose over 500 mg/dl. Nurse #1 reported she had called the on-call physician service on 8/13/2018 at 3:25 AM and was asked by the on-call physician (MD #2) about Resident #1 ' s sliding scale. Nurse #1 reported she conveyed the amount of insulin to be administered to Resident #1 for blood glucose over 400 mg/dl and MD #2 instructed her to give 20 units of insulin. Nurse #1 went on to explain she thought that because MD #2 had ordered insulin according to the sliding scale, she had not written a physician order. Nurse #2 went on explain that she felt MD #2 had told her to use the sliding scale insulin protocol for blood glucose results in the future. Nurse #1 concluded by reporting she had not written a physician order to use the sliding scale insulin protocol for the 3:00 AM blood glucose checks and she had used the facility sliding scale insulin protocol to administer 20 units of insulin when Resident #1 ' s blood glucose was above 450 mg/dl during her shift because she did not want to bother the on-call physician. An interview via phone call was conducted with MD #2 and MD #3 on 8/22/2018 at 11:28 AM. MD #2 reported she was the physician on-call the night of 8/13/2018 and she had given the order to cover the blood glucose result of 533 with 20 units of [MEDICATION NAME] insulin. MD #2 went on to explain she had asked Nurse #1 to read the sliding scale to determine the amount of insulin to administer to Resident #1. MD #2 went on to explain she had not given an order to use the sliding scale insulin orders for future 3:00 AM blood glucose checks and her expectation was staff would call for orders for blood glucose results obtained at 3:00 AM. MD #3 added the on-call service was contracted by the facility was to be used for off-hour physician contact for any issues, and he reported it was his expectation that nursing staff would call the on-call agency to provide care for residents during physician off-hours. Nurse #2 was interviewed on 8/22/2018 at 12:00 PM. Nurse #2 reported she worked day shift (7:00 AM to 3:00 PM) on 8/18/2018 and had received report from Nurse #1 at the beginning of her shift. Nurse #2 reported she had checked the blood glucose two hours after the 6:30 AM blood glucose at 8:30 AM and it was 450. Nurse #2 administered insulin as ordered on the sliding scale orders dated 8/9/2018. Nurse #2 went on to explain the orders on for sliding scale insulin on 8/9/2018 ordered for a physician to be called if the blood glucose was more than 450, so she had administered the ordered insulin and had not called a physician. Nurse #2 concluded by reporting Resident #1 had complained of back pain, and she administered Tylenol prior to Resident #1 leaving for [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] center nurse ([MEDICAL TREATMENT] Nurse #1) was interviewed via phone call on 8/22/2018 at 12:54 PM. She reported she was very familiar with Resident #1 and had been assigned to her to provide [MEDICAL TREATMENT] treatment on 8/18/2018. [MEDICAL TREATMENT] Nurse #1 reported that Resident #1 told her she did not feel well and wanted to go to the hospital upon her arrival at the [MEDICAL TREATMENT] center on 8/18/2018. The nurse went to describe the [MEDICAL CONDITION] (swelling) Resident #1 had in her face, her low blood pressure, pain in her abdomen and blood glucose of 464. [MEDICAL TREATMENT] Nurse #1 contacted the [MEDICAL TREATMENT] center NP and reported Resident #1 ' s symptoms. The [MEDICAL TREATMENT] center NP ordered for [MEDICAL TREATMENT] Nurse #1 to attempt to provide the [MEDICAL TREATMENT] treatment to Resident #1 and to send to the emergency room for evaluation after treatment. The Director of Nursing (DON) was interviewed on 8/21/2018 at 3:39 PM and she reported it was her expectation that nursing would contact a physician for all patient issues, including abnormal blood glucose results. The DON was interviewed again on 8/23/2018 at 12:15 PM and she further stated she did not know why Nurse #1 would have administered insulin without an order or why Nurse #1 had not contacted the on-call physician service for the elevated blood glucose levels of Resident #1. The DON reported Nurse #1 had been suspended until a medication retraining could be completed with her. The Administrator, Director of Nursing, and Area Staff Development Manager were notified of Immediate Jeopardy on 8/22/2018 at 3:10 PM and they provided the following credible allegation of Immediate Jeopardy removal: Brian Center Health and Retirement Cabarrus respectfully submits this allegation of compliance to lift the allegation of immediate jeopardy identified on (MONTH) 14, (YEAR) for F684 Resident #1 has had physician orders related to diabetic management as follows: On 8/3/18 reads as follow: Check fasting blood sugar one-time a day at 3 am. [MEDICATION NAME] 10 unit before meals, and per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401 - 450 = 18 units; 451+ = 20 units, after meals and at bedtime A new order dated 8/9/18 read as follows: [MEDICATION NAME] 6 unit subcutaneously before each meals AND Inject as per sliding scale: if 0 - 60 Notify NP/MD; 61 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units & recheck FSBS in 2 hours; if FSBS still > 400, notify NP/MD; 451+ Notify NP/MD, subcutaneously before meals and at bedtime. August 18, (YEAR) at approximately 3:13 am Nurse #1 obtained FBS of 454 and administered 20 units of [MEDICATION NAME]based on previous instruction from physician, however she did not notify the physician of the results or receive any new orders. Nurse # 1 rechecked FBs at 6:45 am of 531 and administered 20 units of [MEDICATION NAME]. Nurse # 4 obtained FBS at 9:30 am of 450 and administered 10 units of [MEDICATION NAME] sliding scale and 6 units of scheduled 70/30 per order (8-9-18). Nurse #4 reported to [MEDICAL TREATMENT] the fasting blood sugar of 450 at 9:30 am and insulin coverage per [MEDICAL TREATMENT] communication form. On (MONTH) 18, (YEAR) approximately 10:30 am resident transported to [MEDICAL TREATMENT] Center by wheelchair. Nurse # 4 reports per progress note dated 8-18-18 resident alert and oriented but complained of lower back pain. Tylenol was administrated per resident request. Nurse # 4 received call from resident #1 husband at approximately 2 pm to inform the facility that [MEDICAL TREATMENT] was transferring resident to the hospital. Nurse # 4 called [MEDICAL TREATMENT] to determine if resident was transferred to the hospital. The [MEDICAL TREATMENT] center informed facility resident was transferred to the hospital due to pain on left side and resident request to be transferred to the hospital. Resident #1 was admitted to the hospital with [REDACTED]. Nurse # 1 was suspended on 8/23/18. A Root Cause analysis was conducted by the Interdisciplinary Team (IDT) which included the Administrator NHA), the Director of Nursing (DON), the Nurse Manager, and the District Director of Clinical Services on 8/23/18 and it was determined that Nurse #1 did not have physician orders for resident #1 to administrator [MEDICATION NAME] Insulin 20 units on (MONTH) 18, (YEAR). Nurse #1 failed to notify the attending physician on 18, (YEAR) per the physician order. The root cause analysis identified that Nurse #1 failed to review Resident #1 physician ' s orders prior to administration of [MEDICATION NAME]20 units. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; 1. All residents who have physician orders to perform fasting blood sugar and /or insulin administration have a potential to be affected by this alleged deficient practice. On 8/23/18 the Director of Nursing and Nurse Managers conducted an audit of residents identified with orders for insulin and/or obtaining fasting blood sugars for the last 30 days to validate FBS and insulin administration was completed according to the current physician ' s orders. The twenty-four-hour reports and physician orders were reviewed by the Director of Nursing and Nurse Managers to ensure residents that have a change in condition during the last 30 days had been identified and appropriate action had been taken. The resident ' s medical records were then reviewed by the Director of Nursing and Nurse Managers to validate there is Nursing documentation present supporting the completion of a nursing assessment following of a significant change in condition and notification to the Physician following the significant change. The Nurse Managers completed notification to the Physician for any opportunities identified a result of this review. On (MONTH) 13, (YEAR) at approximately 3:00 am Nurse 1 obtained fasting blood sugar (FBS) reading of HIGH for Resident #1. Nurse #1 contacted on-call physician services and order was received to administrated [MEDICATION NAME] 20 units insulin (subcutaneously). At approximately 6:00 am on (MONTH) 13, (YEAR) Nurse #1 rechecked the resident fasting blood sugar (FBS)with reading of High. Nurse #1 administrated 20 units of [MEDICATION NAME](subcutaneously). On (MONTH) 15, (YEAR) at approximately 3:00 am Nurse #1 obtained fasting blood sugar reading of HIGH on Resident #1. (MONTH) 15, (YEAR) at approximately 6:00 am Nurse #1 obtained fasting blood sugar of 508. Nurse #1 administrated 20 units of [MEDICATION NAME] (subcutaneously). On 8/23/18 The Director of Nursing and Nurse Managers re-educated current Licensed Nurses regarding the facility policy for Changes in Resident Condition, with a focus on assessment following HIGH blood sugar or blood sugar that is outside physician order parameter. The re- education of current Licensed Nurses also included the 5 steps regarding medication administration, to include validation of resident physician orders prior to administration of insulin or performing of fasting blood sugars. Twenty-two of facilities licensed nurses received the in-service as of 8/23/18. No staff shall work after 8/23/18 before receiving this education. This education has been added to the Facility Orientation program for all new hires and agency staff to be completed prior to beginning work after 8/23/18. The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; On 8/24/18 a new process will be initiated during the morning clinical meeting 5 times per week for 12 weeks. This will include a review, by the Director of Nursing and Nurse Managers, of residents identified with physician orders for fasting blood sugars and/or insulin to validate the following process was completed as implemented. The attending physician was notified of fasting blood sugar outside physician order parameters and/or change condition. The physician orders for fasting blood sugars and/or insulin are being followed. Residents receiving insulin and/or fasting blood sugars had current physician orders. The Director of Nursing will report the results of this monitoring during the monthly QAPI (Quality Improvement Performance Improvement) meeting and the committee will make recommendations as needed. 2. Facility Administrator is responsible for implementing this acceptable plan of correction The facility ' s credible allegation was verified on 8/23/2018 at 7:15 PM. The in-service records were reviewed, and 22 nurses received in-service on fingerstick blood glucose, notifying the physician and the 5 rights of medication administration. The charts of 7 residents with the [DIAGNOSES REDACTED]. Ten out of 22 nurses were interviewed, and all could state the 5 rights of medication administration (right drug, right dose, right time, right route, right documentation) and all could verbalize the steps to notifying a physician for a blood sugar out of parameters or for a change of status. All nurses could state the correct form to complete when notifying a physician of an elevated blood glucose or change in status (Situation Background, Assessment Response – SBAR form).

Based on record review, staff, nurse practitioner, physician interviews, and [MEDICAL TREATMENT] staff interviews, the facility failed to notify a physician to report a resident with a high blood glucose level for 1 of 7 residents reviewed for diabetic management (Resident #1). Resident #1 experienced sustained high blood glucose levels which resulted in a hospitalization for diabetic ketoacidosis (a serious complication of diabetes). Immediate jeopardy began on 8/14/2018 when Nurse #1 failed to notify a physician of a blood glucose level which was elevated above 450 milligrams per deciliter (mg/dl) and administered insulin without a physician order. The Immediate Jeopardy was removed on 8/23/2018 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to notifying physician of resident changes. Findings included: A review of the facility policy titled Physician Services with a revision date of (MONTH) (YEAR) revealed an on-call physician service was available for times when the attending physician is not generally available, for example after 6:00 PM and on the weekends before noon. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed Resident #1 received [MEDICAL TREATMENT] treatment three times per week on Tuesday, Thursday and Saturday. A review of the care plans for Resident #1 revealed a care plan in place dated 1/11/2018 and revision date of 2/28/2018 that addressed her [DIAGNOSES REDACTED]. A review of the training attendance log dated 6/22/2018 for the in-service entitled Changes in Condition was signed as attended by Nurse #1 and Nurse #2. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #1 to be cognitively intact without behaviors or rejection of care. The medical chart was reviewed, and physician orders dated 8/3/2018 revealed an order to check Resident #1 ' s blood glucose level before meals, at bedtime and as needed. A physician order dated 8/9/2018 specified blood glucose to be checked at 3:00 AM daily due to unstable blood glucose levels. There were no orders to administer insulin at that time. There was no stop date on the order. A physician order dated 8/9/2018 for [MEDICATION NAME] insulin, inject subcutaneously before meals and at bedtime per sliding scale: blood glucose results 0-60 notify nurse practitioner (NP) or physician (MD); 201-250 mg/dl, inject 2 units of [MEDICATION NAME] insulin; 251-300 mg/dl, inject 4 units of [MEDICATION NAME] insulin; 301-350 mg/dl, inject 6 units of [MEDICATION NAME] insulin; 351-400 mg/dl, inject 8 units of [MEDICATION NAME] insulin; 401-450 mg/dl; inject 10 units of [MEDICATION NAME]and recheck blood glucose, if remained above 400 mg/dl call NP/MD, if greater than 451 mg/dl, notify NP/MD. The nursing notes were reviewed, and a note dated 8/13/2018 written by Nurse #1 noted a blood glucose result of 533 mg/dl at 3:00 AM. The note documented contacting the on-call physician (MD #2) and the order of 20 units of [MEDICATION NAME]to be administered and the blood glucose to be monitored. A note written by MD #2 on 8/13/2018 at 3:50 AM documented a one-time order had been given to administer 20 units of [MEDICATION NAME]and to monitor the blood glucose for Resident #1. The nurse documented at 6:07 AM the blood glucose had been rechecked at 6:00 AM with a High result. Nurse #1 documented she administered 20 units of [MEDICATION NAME] insulin. Nurse #1 documented no sign/symptoms of diabetic distress observed. There was no physician contact documented in the medical record for the documented blood glucose level of High at 6:00 AM 8/13/2018. There was no further documentation by MD #2 in the patient progress notes after 8/13/2018 to indicate the on-call service had been notified of an elevated blood glucose. A note dated 8/14/2018 at 6:07 AM written by Nurse #1 documented a blood glucose result of High and the administration of 20 units of [MEDICATION NAME]by sliding scale at that time. Nurse #1 documented NAD (no apparent distress) in her note. The medical record contained no information that the physician was notified of Resident #1 ' s blood glucose of High. A nursing note dated 8/15/2018 at 3:19 AM written by Nurse #1 documented a blood glucose reading of High at 3:00 AM. Nurse #1 documented the administration of 20 units of [MEDICATION NAME]per sliding scale and that Resident #1 had NAD noted. The medical record contained no information that the physician had been notified on 8/15/2018 of Resident #1 ' s blood glucose level of High. A nursing note dated 8/15/2018 at 6:36 AM written by Nurse #1 documented a blood glucose of 508 mg/dl at 6:00 AM. The nurse administered 20 units of [MEDICATION NAME]per sliding scale and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/15/2018 of Resident #1 ' s blood glucose level of 508 mg/dl. A nursing note dated 8/16/2018 at 6:36 AM written by Nurse #1 documented a blood sugar result of 485 mg/dl at 6:30 AM, the administration of 20 units of [MEDICATION NAME]and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/16/2018 of Resident #1 ' s blood glucose level of 485 mg/dl. Nurse #1 wrote a note dated 8/18/2018 at 3:16 AM that documented a blood glucose result of 454 mg/dl at 3:00 AM, the administration of 20 units of [MEDICATION NAME]and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/18/2018 at 3:16 AM of Resident #1 ' s blood glucose level of 454 mg/dl. A nursing note dated 8/18/2018 at 6:52 AM written by Nurse #1 revealed a blood glucose result of 531 mg/dl at 6:30 AM. Nurse #1 documented the administration of 20 units of [MEDICATION NAME]and Resident #1 had no signs/symptoms of diabetic distress. The medical record contained no information that the physician had been notified on 8/18/2018 at 6:52 AM of Resident #1 ' s blood glucose level of 531 mg/dl. A nursing note written by Nurse #2 dated 8/18/2018 at 3:00 PM documented the blood glucose result of 450 mg/dl at 10:30 AM. Nurse #2 documented administration of 20 units of [MEDICATION NAME]via sliding scale orders dated 8/9/2018 and communication of the blood glucose results to the [MEDICAL TREATMENT] treatment center. The medical record contained no information that the physician had been notified on 8/18/2018 by Nurse #2 for Resident #1 ' s blood glucose result of 450 mg/dl. A review of the hospital records revealed Resident #1 was admitted to the hospital for recurrent diabetic ketoacidosis (DKA) on 8/18/2018 and received intravenous fluids and intravenous insulin to reduce her blood glucose level. The admission note for the hospitalization dated 8/18/2018 revealed the resident was admitted with abdominal pain, chest discomfort and shortness of breath. Blood glucose level at 5:12 PM was 520 and at 6:58 PM was 581 mg/dl. She was admitted to the Intensive Care Unit for continual monitoring and treatment of [REDACTED]. Resident #1 was discharged back to the facility on [DATE]. The resident ' s primary physician (MD #1) was interviewed on 8/21/2018 at 8:57 AM. MD #1 reported Resident #1 was non-compliant and had unstable blood glucose control. He was not aware that the on-call MD had not been notified of elevated blood glucose levels for Resident #1. An interview was conducted with NP #1 on 8/21/2018 at 2:26 PM. She reviewed the order for sliding scale insulin dated 8/9/2018 and stated that the physician or nurse practitioner should have been notified of the blood glucose results that were over 450 on 8/14/2018, 8/15/2018, 8/16/2018 and 8/18/2018. She further reported it was her expectation that MD or NP were notified of elevated blood glucose in a diabetic resident due to the potential for complications related to elevated blood glucose levels. Nurse #1 was interviewed on 8/22/2018 at 9:19 AM via phone call. Nurse #1 reported she had been assigned to Resident #1 on 8/13/2018, 8/14/2018, 8/15/2018, 8/16/2018 and 8/18/2018 on the third shift (11:00 PM to 7:00 AM). Nurse #1 reported she checked Resident #1 ' s blood glucose at 3:00 AM every night she worked because Residents #1 ' s blood glucose was unstable and sometimes she would have very low blood glucose levels or very high blood glucose levels. Nurse #1 reported that a High reading usually indicated a blood glucose over 500 mg/dl. Nurse #1 reported she had called the on-call physician service on 8/13/2018 at 3:25 AM and was asked by the on-call physician (MD #2) about Resident #1 ' s sliding scale. Nurse #1 reported she conveyed the amount of insulin to be administered to Resident #1 for blood glucose over 400 mg/dl and MD #2 instructed her to give 20 units of insulin. Nurse #1 went on to explain she thought that because MD #2 had ordered insulin according to the sliding scale, she had not written a physician order. Nurse #2 reported that she felt MD #2 had told her to use the sliding scale insulin protocol for blood glucose results in the future. Nurse #1 concluded by reporting she had not written a physician order to use the sliding scale insulin protocol for the 3:00 AM blood glucose checks and she had used the facility sliding scale insulin protocol to administer 20 units of insulin when Resident #1 ' s blood glucose was above 450 mg/dl during her shift because she did not want to bother the on-call physician. An interview via phone call was conducted with MD #2 and MD #3 on 8/22/2018 at 11:28 AM. MD #2 reported she was the physician on-call the night of 8/13/2018 and she had given the order to cover the blood glucose result of 533 with 20 units of [MEDICATION NAME] insulin. MD #2 went on to explain she had asked Nurse #1 to read the sliding scale to determine the amount of insulin to administer to Resident #1. MD #2 went on to explain she had not given an order to use the sliding scale insulin orders for future 3:00 AM blood glucose checks and her expectation was staff would call for orders for blood glucose results obtained at 3:00 AM. MD #3 added the on-call service was contracted by the facility was to be used for off-hour physician contact for any issues, and he reported it was his expectation that nursing staff would call the on-call agency to provide care for residents during physician off-hours. Nurse #2 was interviewed on 8/22/2018 at 12:00 PM. Nurse #2 reported she worked day shift (7:00 AM to 3:00 PM) on 8/18/2018 and had received report from Nurse #1 at the beginning of her shift. Nurse #2 reported she had checked the blood glucose two hours after the 6:30 AM blood glucose at 8:30 AM and it was 450. Nurse #2 administered insulin as ordered on the sliding scale orders dated 8/9/2018. Nurse #2 went on to explain the orders for sliding scale insulin on 8/9/2018 ordered for a physician to be called if the blood glucose was more than 450, so she had administered the ordered insulin and had not called a physician. Nurse #2 concluded by reporting Resident #1 had complained of back pain, and she administered Tylenol prior to Resident #1 leaving for [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] center nurse ([MEDICAL TREATMENT] Nurse #1) was interviewed via phone call on 8/22/2018 at 12:54 PM. She reported she was very familiar with Resident #1 and had been assigned to her to provide [MEDICAL TREATMENT] treatment on 8/18/2018. [MEDICAL TREATMENT] Nurse #1 reported that Resident #1 told her she did not feel well and wanted to go to the hospital upon her arrival at the [MEDICAL TREATMENT] center on 8/18/2018. The nurse went to describe the [MEDICAL CONDITION] (swelling) Resident #1 had in her face, her low blood pressure, pain in her abdomen and blood glucose of 464. [MEDICAL TREATMENT] Nurse #1 contacted the [MEDICAL TREATMENT] center NP and reported Resident #1 ' s symptoms. The [MEDICAL TREATMENT] center NP ordered for [MEDICAL TREATMENT] Nurse #1 to attempt to provide the [MEDICAL TREATMENT] treatment to Resident #1 and to send to the emergency room for evaluation after treatment. The Director of Nursing (DON) was interviewed on 8/21/2018 at 3:39 PM and she reported it was her expectation that nursing would contact a physician for all patient issues, including abnormal blood glucose results. The DON was interviewed again on 8/23/2018 at 12:15 PM and she further stated she did not know why Nurse #1 had not contacted the on-call physician service for the elevated blood glucose levels of Resident #1. The DON reported Nurse #1 had been suspended until a medication retraining was completed by her. The Administrator, Director of Nursing, and Area Staff Development Manager were notified of Immediate Jeopardy on 8/22/2018 at 3:10 PM and they provided the following credible allegation of Immediate Jeopardy removal: Brian Center Health and Retirement Cabarrus respectfully submits this allegation of compliance to lift the allegation of immediate jeopardy identified on (MONTH) 14, (YEAR) for F580 Resident #1 has had physician orders related to diabetic management as follows: On 8/3/18 reads as follow: Check fasting blood sugar one-time a day at 3 am. [MEDICATION NAME] 10 unit before meals, and per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401 - 450 = 18 units; 451+ = 20 units, after meals and at bedtime A new order dated 8/9/18 read as follows: [MEDICATION NAME] 6 unit subcutaneously before each meals AND Inject as per sliding scale: if 0 - 60 Notify NP/MD; 61 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units & recheck FSBS in 2 hours; if FSBS still > 400, notify NP/MD; 451+ Notify NP/MD, subcutaneously before meals and at bedtime. August 18, (YEAR) at approximately 3:13 am Nurse #1 obtained FBS of 454 and administered 20 units of [MEDICATION NAME]based on previous instruction from physician, however she did not notify the physician of the results or receive any new orders. Nurse # 1 rechecked FBs at 6:45 am of 531 and administered 20 units of [MEDICATION NAME]. Nurse #1 did not notify the physician of the resident fasting blood sugar of 531. On (MONTH) 18, (YEAR) approximately 10:30 am resident transported to [MEDICAL TREATMENT] Center by wheelchair. Nurse # 4 reports per progress note dated 8-18-18 resident alert and oriented but complained of lower back pain. Tylenol was administrated per resident request. Nurse # 4 received call from Resident #1 ' s husband at approximately 2 pm to inform the facility that [MEDICAL TREATMENT] was transferring resident to the hospital. Nurse # 4 called [MEDICAL TREATMENT] to determine if resident was transferred to the hospital. The [MEDICAL TREATMENT] center informed facility resident was transferred to the hospital due to pain on left side and resident request to be transferred to the hospital. Resident #1 was admitted to the hospital with [REDACTED]. Nurse # 1 was suspended on 8/23/18. A Root Cause analysis was conducted by the Interdisciplinary Team (IDT) which included the Administrator NHA), the Director of Nursing (DON), the Nurse Manager, and the District Director of Clinical Services on 8/23/18 and it was determined that Nurse #1 failed to notify the attending physician on of the high fasting blood sugar per the physician order. The root cause analysis identified that Nurse #1 failed to review Resident #1 physician ' s orders prior to administration of [MEDICATION NAME]20 units. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; 1. All residents who have physician orders to perform fasting blood sugar and /or insulin administration have a potential to be affected by this alleged deficient practice. On 8/23/18 the Director of Nursing and Nurse Managers conducted an audit of residents identified with orders for insulin and/or obtaining fasting blood sugars for the last 30 days to validate that physicians were notified per orders regarding abnormal fasting blood sugars. The twenty-four-hour reports and medical records of residents on insulin and fasting blood sugar checks were reviewed by the Director of Nursing and Nurse Managers to ensure physicians were notified of abnormal fasting blood sugars per physician orders. The Nurse Managers completed notification to the Physician for any opportunities identified as a result of this review. On 8/23/18 The Director of Nursing and Nurse Managers re-educated current Licensed Nurses regarding the facility policy for Changes in Resident Condition, with a focus on physician notification of abnormal fasting blood sugars per physician orders. Twenty-two of the facility ' s licensed nurses received the in-service as of 8/23/18. No staff shall work after 8/23/18 before receiving this education. This education has been added to the Facility Orientation program for all new hires and agency staff to be completed prior to beginning work after 8/23/18. The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; 2. On 8/24/18 a new process will be initiated during the morning clinical meeting 5 times per week for 12 weeks. This will include a review, by the Director of Nursing and Nurse Managers, of residents identified with physician orders for fasting blood sugars to validate that physician were notified of the abnormal blood sugars. -The attending physician was notified of fasting blood sugar outside physician order parameters and/or change condition The physician orders for fasting blood sugars and/or insulin are being followed. Residents receiving insulin and/or fasting blood sugars had current physician orders. The Director of Nursing will report the results of this monitoring during the monthly QAPI (Quality Improvement Performance Improvement) meeting and the committee will make recommendations as needed. 3. The Facility Administrator is responsible for implementing this acceptable plan of correction. The facility ' s credible allegation was verified on 8/23/2018 at 7:15 PM. The in-service records were reviewed, and 22 nurses received in-service on fingerstick blood glucose, notifying the physician and the 5 rights of medication administration. The charts of 7 residents with the [DIAGNOSES REDACTED]. Ten out of 22 nurses were interviewed, and all could state the 5 rights of medication administration (right drug, right dose, right time, right route, right documentation) and all could verbalize the steps to notifying a physician for a blood sugar out of parameters or for a change of status. All nurses could state the correct form to complete when notifying a physician of an elevated blood glucose or change in status (Situation Background, Assessment Response – SBAR form).

Based on observation, record review, staff and physician interviews, the facility failed to alert the resident ' s physician after discovering that 1 of 3 residents (Resident #7) with pressure ulcers, condition worsened. The findings include: Resident #7 was admitted to the facility on [DATE] with the following cumulative Diagnoses: [REDACTED]. On his admission Minimum Data Set (MDS), 6/25/12, he was assessed as having short term memory loss and modified independence with his daily decision making. He showed no resistance to care and needed extensive assistance for transfers and bed mobility. He was continent of bowel and used a catheter. Resident #7 did not have a pressure ulcer at the time of his admission or MDS assessment. The Nursing Admission Assessment to identify pressure sore risks was reviewed. It indicated that on the following dates, 6/18/12, 6/25/12, 7/2/12 and 7/9/12, Resident # 7 received a score of 16 each time, which placed him in the Mild Risk (15-18) category. A review of the care plan dated 6/26/12 revealed Resident # 7 had a potential for pressure ulcers due to decreased activity and impaired mobility, impaired diffuse or localized blood flow. The goal included to ensure that Resident # 7 would have intact skin without signs of skin breakdown through the next review in 90 days. Approaches to be used included: Apply a pressure reduction mattress to the bed, reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinence episode, complete a full body check weekly and document, monitor lab values as ordered and referrals to physical, occupational and speech therapy as well as referral to physician. A review of the "Nursing Daily Skilled Summary" dated 6/30/12 revealed a coccyx was noted to be "excoriated (removal of skin); note new orders." On 7/1/12 at 2:40 pm, a nurse's note (Nurse # 9) on the skilled summary sheet indicated on the coccyx, right inner buttocks noted to be open 2.5cm (centimeters) x 1.5cm wound bed red/purple. Peri wound red/white with small amount of red drainage, no odor noted. The right buttock 1.5cm x 2.0cm, wound bed red/purple. Peri wound red/white with small amount of red drainage. Cleansed coccyx and right buttock with normal saline. Applied excuderm, see new order and continue to monitor. Nurse # 9 indicated in her notes that the responsible party and physician were informed. On 7/5/12, the Weekly Pressure Ulcer Record, completed by the Assistant Director of Nursing, documented that Resident # 7's sacrum measured 2.5cm x 1.5cm, with no depth and no undermining. It had serous exudate (an oozing protein fluid) of a scant amount, with a red wound bed and pink color normal surrounding tissue. She checked that there was pain related to the wound and that there were no new orders for treatment. Under her progress notes, she indicated that she would continue to monitor and use an air mattress as an intervention. Nurse # 6 was present during an observation of Resident # 7's wound care on 7/12/12 at 8:45am. At 9:00 am she shared that she last provided care to Resident # 7 a week ago and at that time his wound was red and superficial, with no yellow or black colors. She expressed that the current treatment wasn't doing any good. She stated that now his largest wound was yellow and black and had increased in size. The surrounding tissue was red. The coccyx measured at 1.9cm x 6.2cm x 0.9cm; the right buttock measured at 1.6cm x 1.9cm and the left buttock measured at 3.0cm x 0.5cm. On 7/12/12, the facility requested that Resident # 7's wound be re-examined by the physician. On 7/12/12 at 11:25 am, Nurse #2 was interviewed. He shared that at the time of discovering a skin breakdown, he would report the incident, to start an investigation. He would proceed with notifying the doctor so that recommendations and new orders could be given. If the pressure ulcer had black tissue, he shared that he would let the doctor know that it was not getting any better and would ask the doctor to see the resident on his next rounds. He would order blood work to check the protein levels. He shared that black tissue usually indicated necrosis (dying tissue) and an ulcer at Stage III. This normally called for debrieding it and changing the treatment orders to a more frequent dressing change, perhaps daily. On 7/12/12 at 11:40 am, Nurse # 3 was interviewed. She stated that she handled concerns relating to the worsening of a pressure ulcer, by contacting the physician so that a referral could be made to the wound clinic. She shared that when she noticed that the tissue has turned black, she would expect a more frequent dressing change; perhaps daily. In an interview with the ADON on 7/12/12 at 6:45 pm, she stated that she felt the sacral wound, previously assessed as a Stage II, should be listed as unstageable. Nurse # 5 was interviewed on 7/12/12 at 7:15 pm. She commented that she changed the dressing on Resident # 7 on 7/11/12 and stated that the area looked okay, as this was the first time that she had observed it and could not make a comparison observation. She stated that was no drainage, odor and that she did not measure the area, since someone else did that. Review of the Nursing Daily Skilled Summary from 7/2/12 to 7/11/12 revealed that the physician was not notified again of the condition of Resident # 7's pressure ulcer until 7/12/12. The physician responded to their request to examine Resident # 7 and visited with him while making rounds on 7/13/12 to re-assess his condition. Review of the MD (medical director's) Communication Board for July, 2012, (who was the assigned physician to Resident # 7), documented that no notes were forwarded to the physician about Resident # 7's skin condition. The last note addressed to the MD occurred on 6/29/12 before the discovery of the pressure ulcer. On 7/13/12 at 11:00 am, the pressure ulcer was again observed with Nurse # 6 and the physician. The nurse and physician felt that the wounds were at stage II as there was no necrosis present, just debris. The physician indicated that if the wound became larger, he would refer Resident # 7 to the wound clinic. Nurse # 6 indicated at 11:15 am that the physician had changed Resident # 7' s blood pressure medication, but the treatment would remain the same for the skin care regimen.

Based on observation, record review, resident, staff and physician interviews, the facility failed to put prescribed interventions in place (correct air mattress setting , weekly skin checks and physician consultation) to avoid the development of a pressure ulcers for 1 of 3 (Resident # 7) sampled residents. The findings include: Resident # 7 was admitted to the facility on [DATE] with the following cumulative Diagnoses: [REDACTED]. On his admission Minimum Data Set (MDS), 6/25/12, he was assessed as having short term memory loss and modified independence with his daily decision making. He showed no resistance to care and needed extensive assistance for transfers and bed mobility. He was continent of bowel and used a catheter. Resident #7 did not have a pressure ulcer at the time of his admission or MDS assessment. The Nursing Admission Assessment to identify pressure sore risks was reviewed. It indicated that on the following dates, 6/18/12, 6/25/12, 7/2/12 and 7/9/12, Resident # 7 received a score of 16 each time, which placed him in the Mild Risk (15-18) category. On 6/19/12, orders were placed on the Treatment Administration Record, to provide weekly head to skin assessments, each Tuesday. The Head to Toe Skin Checks form was reviewed. There was one note from Nurse # 9, on 6/19/12 that stated that Resident #7 ' s skin was intact and that there was an absence of bruises, skin tears, abrasions or rashes. All preventative measures were in place. There was no data on the form for the following Tuesdays, (6/26/12, 7/3/12 and 7/10/12) when the weekly assessments were due. The Assistant Director of Nursing was interviewed on 7/12/12 at 3:10 pm. She reviewed the Head to Toe Skin Checks form and acknowledged that it lacked evidence of weekly skin assessments being performed. She stated that she does all the measurements of the pressure ulcers in the facility. She stated that Resident # 7 was last measured by her on 7/5/12 for inner thigh and sacrum wounds and that she had planned to record new measurements today. A review of the care plan dated 6/26/12 revealed Resident # 7 had a potential for pressure ulcers due to decreased activity and impaired mobility, impaired diffuse or localized blood flow. The goal included to ensure that Resident # 7 would have intact skin without signs of skin breakdown through the next review in 90 days. Approaches to be used included: Apply a pressure reduction mattress to the bed, reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinence episode, complete a full body check weekly and document, monitor lab values as ordered and referrals to physical, occupational and speech therapy as well as referral to physician. On 8/1/12 at 3:20 pm, in a phone interview with Nurse # 10, she stated that the pressure relieving air mattress for Resident # 7 was initiated on 6/26/12. A review of the "Nursing Daily Skilled Summary" dated 6/30/12 revealed a coccyx was noted to be "excoriated (removal of skin); note new orders." On 7/1/12 at 2:40 pm, a nurse's note (Nurse # 9) on the skilled summary sheet indicated on the coccyx, right inner buttocks noted to be open 2.5cm (centimeters) x 1.5cm wound bed red/purple. Peri wound red/white with small amount of red drainage, no odor noted. The right buttock 1.5cm x 2.0cm, wound bed red/purple. Peri wound red/white with small amount of red drainage. Cleansed coccyx and right buttock with normal saline. Applied excuderm, see new order and continue to monitor. Nurse # 9 indicated in her notes that the responsible party and physician were informed. On 7/5/12, the Weekly Pressure Ulcer Record, completed by the Assistant Director of Nursing, documented that Resident # 7's sacrum measured 2.5cm x 1.5cm, with no depth and no undermining. It had serous exudate (an oozing protein fluid) of a scant amount, with a red wound bed and pink color normal surrounding tissue. She checked that there was pain related to the wound and that there were no new orders for treatment. Under her progress notes, she indicated that she would continue to monitor and use an air mattress as an intervention. On 7/12/12 at 8:45 am, Resident # 7 was observed in bed, lying on his back with eyes closed on a pressure relieving air mattress that was set to 10 (firmest). Nurse # 6 was present and was preparing to do his wound care treatment. A chart review revealed his weight as of 7/9/12 was 167.8 pounds. The manufacturer's guidelines on the air mattress, recommended an air setting of 5-6 for an individual weighing the same amount as Resident # 7. Nurse # 6 was interviewed on 7/12/12 at 9:00 am. She shared that she last provided care to Resident # 7 a week ago and at that time his wound was red and superficial, with no yellow or black colors. She expressed that the current treatment wasn't doing any good. Now his largest wound was yellow and black and had increased in size. The surrounding tissue was red. The coccyx measured at 1.9cmx 6.2cm x 0.9cm; the right buttock measured at 1.6cm x 1.9cm and the left buttock measured at 3.0cm x 0.5cm. On 7/12/12 at 9:30 am, Resident # 7 was viewed lying in bed, on his back. His pressure relieving mattress was still set at 10. The manufacturer's instruction for using the mattress was located at the end of the bed, above the digital setting for firmness. It read that the setting the mattress at 1, was not firm and 10 was the firmest. The setting 10 should be used for an individual weighing 400 pounds. A piece of tape with the numbers 5-6 was on the resident's footboard, next to the manufacturer's guidelines. Resident # 7 remained out of his room, attending therapy at 11:38 am. Despite his absence, the mattress on his bed remained set at 10. At 1:35pm, Resident # 7 was observed sitting in his wheelchair, on a chair cushion. When asked how his bottom felt, he said, "pain". The mattress to his bed remained set at 10. Interviewed was held with Nurse # 3 on 7/12/12 at 11:40 am. She stated that a pressure relieving mattress can be used for residents with pressure ulcers. The mattress setting to her knowledge can be set by the physician or therapist. Normally she found the recommended setting for the mattress documented on the treatment cart or on the appliance. Nursing staff are also expected to turn and reposition the resident every 1 to 2hrs on the alternate side. An interview was held with Nurse Aide # 7 on 7/12/12 at 11:05 am. She stated that some residents used pressure relieving mattresses that had adjustable firmness. Ordinarily she adjusted the mattress to the firmest position when she performed incontinence care, then softened the mattress when she was done. She did not know the guidelines to set the firmness, stating that she puts the setting back where she found it which was usually halfway in the middle; however, she never based the setting on the resident's weight. On 7/12/12 at 4:00 pm, an observation of Resident # 7 in bed revealed that his mattress setting had been lowered to 6. On 7/12/12 at 5:00 pm, Resident # 7's wound was observed with the (ADON) Assistant Director of Nursing. The measurements she recorded during the observation were: the sacral wound was measured at 4.5cm x 5.0cm and the right inner buttock was 2.0cm x 2.0cm. The sacral wound was pink on the edges, red near the center and some black in the center. The ADON stated that the wound was a stage II. She also indicated that the air pressure on Resident # 7 ' s bed should be set at 5-6; however she was not certain who was responsible for setting the air mattresses. During a follow up interview with the ADON on 7/12/12 at 6:45 pm, she stated that she felt the sacral wound, previously assessed at Stage II, should be listed as unstageable. Review of the Nursing Daily Skilled Summary from 7/2/12 to 7/11/12 revealed that the physician was not notified again of the condition of Resident # 7's pressure ulcer until 7/12/12. On 7/13/12 at 11:00 am, the pressure ulcer was again observed with Nurse # 6 and the physician. The nurse and physician felt that the wounds were at stage II and recommended keeping the skin care treatment orders the same, as there was no necrosis present, just debris. The physician indicated that if the wound became larger, he would refer Resident # 7 to the wound clinic. The DON was interviewed on 7/13/12 at 2:45 pm. She stated that pressure relieving mattresses have a setting to determine firmness, which is based on the resident's weight. She stated that anyone can assess the setting by viewing the guidelines which is listed on the appliance.

Based on record review and staff interviews, the facility failed to provide continuous supervision for 1 of 3 residents (Resident # 1) who was determined high risk for falls; once they became aware that the self released alarming seat belt malfunctioned. The findings include: Resident # 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following cumulative Diagnoses: [REDACTED]. On 4/16/12 an admission's Minimum Data Set (MDS) was performed. It assessed her as having cognitive impairments, needing extensive assistance for transfers as well as limited assistance for ambulating on the unit. She had a known history of falls, resulting in no injuries. The medical chart was reviewed and indicated that Resident #1 had sustained two falls on 4/9/12 and 5/7/12; neither resulting in injuries. Interventions to be used to prevent reoccurrence included: using a chair and bed alarm, placing her in a low bed, keeping her call light within reach, placing a fall mat on the floor next to her bed and keeping her in view of staff when she was up in her wheelchair. On the Fall Risk Evaluations, dated 4/9/12, 4/16/12, 4/23/12 and 4/30/12 she scored a 14, this placed her in the high risk category. On 4/19/12, a doctor's order for a trial self release alarming seat belt was obtained due to decreased safety awareness and continual attempts to get stand independently. The June, 2012 Medication Administration Record reflected that an anti-anxiety medication was also used as needed when she showed anxiety and agitation that could not be redirected. An 6/9/12 Incident/Accident Report documented that at 3:30 pm, Resident # 1 was heard by Nurse # 2, screaming after a loud noise was heard at the nurse ' s station. Staff rushed to the scene and found her lying on her left side in the fetal position. Resident #1 had tried to ambulate unassisted before the incident. Her wheelchair contained a non-functioning self-release seat belt. On 7/12/12 at 10:40 am, Nurse Aide #1 (NA# 1) was interviewed. She stated that she was assigned to Resident # 1 on 6/9/12 from 7:00 am to 7:00 pm. She shared, that morning around 8:30-9:00 am, after breakfast, she went to adjust Resident # 1's seatbelt and noticed that the alarm wasn't working. She stated that it was typical for Resident # 1 to mess with her alarm a lot. Once she discovered that the alarm wasn't working properly she went to tell Nurse # 1, who advised her to keep an eye on Resident # 1. They also brought their concern to the attention of the weekend nurse supervisor, Nurse # 2. NA# 1 commented that she had 11 residents that day, so she took Resident # 1 to the nurse's station after her family members were finished with her visit. She stated that Nurse # 2 was sitting at the nurse's station when she took her down there. On 7/12/12, at 6:15pm, the Administrator presented a typed statement, dated 6/10/12 from NA#1. It read, "On Saturday, June 9th, Resident #1 fell out of her wheelchair. I had been advised by Nurse #1 to keep her in at the nurse's station in high visible area. The chair alarm she had was not working properly. She stood up and nobody could get to her soon enough before she fell ." NA# 2 was interviewed on 7/13/12 at 11:17 am. She stated that she was working on the 300 hall on 6/9/12 when she saw the call light on in Resident # 1's room. She stated that she went in the room, close to lunch time and found Resident #1 in bed, with several family members present. They requested that she assist them with moving Resident # 1 from the bed into her wheelchair, which she did. She noticed that the seatbelt was already unfastened in the wheelchair. When she secured the device to Resident # 1, then re-opened it to make sure it was working, it didn't sound. At the point, she stated that she explained to the family member that she needed to put Resident # 1 back in bed for safety precautions and took the wheelchair to the nurse's station for Nurse # 1 to examine. Nurse # 1 told her to take the wheelchair to the therapy department. The therapist told her that they didn't have an extra seatbelt alarm so she suggested that NA# 2 keep Resident #1 in bed, where an alarm functioned or if they left her up, she would need to be monitored. She commented that monitoring meant that Resident # 1 shouldn't be left by herself and someone would need to sit with her at the nurse's station, at all times. She recalled that the wheelchair's cushion had a working alarm on it. The therapist told NA# 2 that she would write up an order to have the wheelchair self released seat belt alarm evaluated and replaced. At that point, NA# 2 took the chair back to the nurse and informed her of the therapist's direction. Then she explained that she took the chair to NA# 1 who was assigned to Resident # 1 and informed her about the seatbelt alarm not working. On 7/12/12 at 11:30 am, the Rehabilitation Director was interviewed. She stated that the alarms are checked weekly and she accompanied her technician and the admission nurse to check Resident # 1's self released alarming seatbelt on 6/8/12 and it was functioning properly. On 7/12/12 at 11:57 am, the Certified Occupational Therapy Assistant (COTA) was interviewed. She stated that she was on duty, 6/9/12, when NA # 2 came to the therapy department with Resident # 1's wheelchair. The chair had a self release alarming seat belt attached to it. The alarm should go off when the Velcro was unstripped from the belt, but hers didn't. She explained that underneath the fabric belt are wires, which had loosened. The wires were fed into an alarm box. The device was actually mounted underneath the chair. She was trained to reinstall the device but was not aware that an old self release alarming seat belt was in storage in her supervisor's office. The COTA stated that on 6/9/12 she told NA# 2 to keep the current self release alarming seat belt on the resident as a deterrent to stand up, but to keep her in a high traffic area for monitoring or she should put Resident #1 back to bed, where there was an alarm in place. On 7/12/12 at 6:15 pm, the Administrator presented a typed statement from Nurse # 1 dated 6/10/12 that read, " Family into visit Resident # 1. Got Resident #1 out of bed. Checked alarm, noted not working. Also told family member when you get ready to leave please bring Resident to nurse's station so we can monitor her. Family brought resident to nurse's station and left. Told therapy she needed new alarm because hers wasn't working and reported it to oncoming nurse." Nurse # 2 was interviewed on 7/12/12 at 11:13 am. He stated that last month, he worked at the facility as the weekend supervisor. On 6/9/12, he functioned in that role, however, had to go on the floor to pass meds at 3:00 pm for a nurse who called out. He shared that Resident # 1 wore an alarmed seatbelt once she was gotten up from bed and was ordinarily brought to the nurse's station so that staff could keep an eye on her. On 6/9/12, he learned from Nurse #1 that the alarm wasn't working on her seatbelt. They thought that it had some wires short, preventing it from working properly. To his knowledge, the device had stopped working mid-day on 6/9/12. He recalled that someone brought Resident # 1 down to the nurse's station, to be supervised because she had a habit of always trying to get out of her chair. He was sitting at the nurse's station, making phone calls to businesses that may be able to come to the facility to repair her alarm. He stated that his stature is tall enough, that he could see her while he sat at the nurse's station. He mentioned that she was positioned between the 200-300 halls. Nurse # 2 stated that he kept popping up from his seat to check on her, when he realized that she had removed her seat belt and took a few steps down the hall and fell . He shared that Resident #1 gait was not good at all. On 7/12/12, at 6:15 pm, the Administrator provided a typed statement from Nurse # 2, dated 6/9/12 that read, "I was down the hall doing med pass when I noticed Resident #1 trying to stand unassisted while she was at the nurse's station to be monitored. I went down to try and assist Resident # 1 but she had already fallen onto her left side. Resident # 1 was assessed for injuries. Due to Resident # 1's reaction to movement from present position, was sent to hospital for possible fracture." The Administrator was interviewed on 7/12/12 at 4:50 pm. He stated Resident # 1 was a busy individual who stayed confused. She needed interventions from staff, to prevent her from falling. They would keep her in proximity to staff, as well as use a self released seat belt, that sounded when unhooked. On 6/9/12, he was told that family members visiting with Resident # 1 told staff that the alarm was not working on her seatbelt. So staff took her to the nurse's station for monitoring. He stated that staff kept her busy with activities at the station, to keep her occupied. When Nurse # 2 stepped away from the nurse's station, he was told that she stood up and fell . On 7/13/12 at 2:45 pm, the DON was interviewed. Regarding Resident # 1, she felt that staff monitored her the best way they could on 6/9/12 by placing her at the nurse ' s station. She commented that although alarms sound to alert others of a resident ' s intent to stand, supervision was still the best way to prevent an accident and in the case of Resident # 1, she felt the fall was unavoidable, since she was in a high traffic area, yet still managed to get up and fall. The hospital's discharge summary, dated 6/18/12 was reviewed. It revealed that on admission, Resident #1 was found to have a urinary tract infection and left femoral neck fracture (hip) fracture. On 6/12/12, her hip was surgically repaired. On 6/18/12, Resident # 1 was readmitted to the facility, but then transferred to another skilled nursing facility, closer to relatives on 6/29/12.

Based on observation, staff interviews and document review, the facility failed to provide pain management interventions that addressed a resident's pain prior to care and treatment and did not monitor the pain management interventions to assure these were addressing the resident's pain for 1 of 4 residents (Resident #261). The facility also failed to transcribe the doctor's orders to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The findings include: Findings included: 1. Resident # 261 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital 72 Hour MAR (Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 2 mg(milligram)/mL(milliliter) inj (injection) 1 mL syringe, 2 mg per 1 mL Injection IV every 30 minutes as needed for pain - this was given once on 4/21/12 at 8:45 AM. [MEDICATION NAME]-acetominophen 5mg - 325 mg tablet, 1 - 2 tablets every 4 hours as needed for pain. This was given on 4/21/12 at 6:55 PM, and 4/23/12 at 6:15 AM and 10:39 AM. Review of the Pain Evaluation dated 4/24/12 revealed Resident #261 was able to participate in the assessment and indicated that he had frequent pain and that it limited his day-to-day activities. The location of his pain was his L (left) femur and was described as an aching pain. At the time of the assessment Resident #261 rated his pain as 7 on a 0-10 scale (0 for no hurt, 9-10 for hurts worst). For "Worst Pain/Hurting Gets" the resident indicated a pain score of 10 and for "Best Pain/Hurting Gets" he indicated a pain score of 4. The things that relieved his pain were rest, positioning and medication administration. The things that contributed to his pain were: repositioning, exercise/mobility/range of motion, bathing, activities of daily living and rising from chair. Under the heading "Manner of Expressing Pain and Associated Symptoms" the following were checked: verbalization, grimacing and groaning. Review of the Initial Plan of Care dated 4/24/12 revealed the following goal: "(Name of Resident) will have pain alleviated with both pharmacological and non-pharmacological interventions with evidence of pain relief through both verbal and non-verbal indicators such as grimacing, groaning, crying through next review." The interventions checked off were: "observe for signs/symptoms of verbal and non-verbal indicators of pain at each medication pass, and periodically", "provide diversion activities such as positioning, music, television", provide medications as ordered and document effective results of medication administration", and "notify MD (Medical Doctor) of unrelieved pain." Review of the Comprehensive Care Plan for profound hearing loss dated 4/25/12 revealed the following goal: "Resident will be able to make needs known and have needs met x (times) 90 days." The approaches checked were "provide devices to assist with communication (communication board, writing materials, etc)", "face resident and give time for appropriate form of communication", "provide patient [MEDICATION NAME] care, anticipate needs of resident to reduce frustration levels." Review of the Comprehensive Care Plan for Behavioral symptoms of "yells out, curses at staff, hits out during care" dated 4/26/12 revealed the following goal: "(Name of Resident) will have decreased episodes of identified behaviors to no more than 1 times per day, 1 time per week through next review." The approaches checked off were: "use firm gentle voice, identifying self to individual prior to initiating care", "give simple clear directions, repeat as necessary", "ignore verbal outbursts", "check for discomfort, pain, redirect as needed", "notify MD (Medical Doctor) as needed", and "will explain all care prior to providing care." Review of the Comprehensive Care Plan for Pain completed on 5/10/12, revealed the following goal: "(Name of resident) will have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain." The approaches checked off were: Positioning support Relaxation Administer [MEDICATION NAME] as ordered See physician orders Implement pain management flow sheet Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions Notify physician if interventions are not consistently effective Medicate resident for pain prior to treatments and therapy if indicated Review of the physician's orders [REDACTED]. There was no specification with this order to give it prior to care or treatment. There was also an admission order dated 4/24/12 for [MEDICATION NAME] 0.5 mg twice daily before shower and as needed for anxiety. The order was clarified on 4/24/12 to read [MEDICATION NAME] 0.5 mg every 12 hours as needed for anxiety. Review of the Therapy and Progress note Update dated 5/1/12 for 4/25/12 - 5/1/12 revealed, in part, electrical stimulation was being utilized in physical therapy to decrease pain. It also read, in part, "pt (patient) has high anxiety with his left hip pain", "pt easily screams of pain in anticipation of feeling pain from the L leg." Review of the Psychiatric Consultant's note dated 5/3/12 revealed, in part, "since arrival here, the staff report the patient can be resistive at times, agitated at others. They report yesterday for example, they had to do therapy with him in bed and was swinging trying to hit staff. He is very confused on interview." The consultant's recommendation included "Patient is agitated and interfering with his ability to receive PT (Physical Therapy). Will start [MEDICATION NAME] 125 mg bid (twice a day)." Review of the medical record and Controlled Medication Utilization Record from 5/6/12 to 5/10/12 revealed: On 5/6/12 at 12:00 midnight the resident received 1 tablet of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 5/6/12 9 AM nursing note revealed, in part, "Resident yelled loudly during am care." On 5/6/12 at 10 AM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 5/6/12 at 9 PM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 5/7/12 at 8:30 AM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 5/7/12 2:30 PM nursing note revealed, in part, "screams and combative with staff during care." On 5/8/12 at 9 AM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Administration Record was completed and revealed a pre administration pain score of 8 with verbal complaints of pain, positioning and support was indicated as the non-pharmacological intervention used and the post administration pain score was 1 with no non verbal pain indicators. The 5/8/12 2 PM nursing note indicated that the 9 AM dose of [MEDICATION NAME]-[MEDICATION NAME] has some effect. Review of the Therapy and Progress note Update dated 5/8/12 for 5/1/12 - 5/8/12 revealed, in part, electrical stimulation was being utilized in physical therapy to decrease pain. It also read, in part, "Pt has decreased participation in therapy easily gets anxious (without) any movement of his B (bilateral) legs, body or exam B LE's (lower extremities, also has a lot of pain to L hip from his surgery." Review of the PT and OT Progress Status dated 5/8/12 (no time noted) revealed Resident #261 participated in therapy on 5/8/12. The PT note read, in part, "easily screams with anticipation of pain to LLE (left lower extremity) with ther (therapeutic) ex (exercise)." The OT note read, in part, "sitting EOB (edge of bed) max (maximum) bed mob (mobility) patient yelling." On 5/9/12 at 8:50 AM Resident #261 was overheard yelling loudly "don't touch me" "please leave me alone"; he was also overheard moaning from the hallway periodically from 9 AM to 11 AM. On 5/9/12 at 8:50 AM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Administration Record was completed and revealed a pre administration pain score of 7 with verbal complaints of pain, positioning and support was indicated as the non-pharmacological intervention used and the post administration pain score was 1 with no non verbal pain indicators. On 5/9/12 at 11:25 Nurse # 1 entered the room to check his blood sugar. Resident #261 was overheard to yell loudly "please leave me alone", "please, please leave me alone" and "ow ". On 5/9/12 at 12:57 NA # 1 was observed taking the resident's lunch tray into his room. Resident #261 could be overheard from the hall was moaning as he was repositioned by rolling up the head of the bed for lunch. On 5/9/12 at 1:03 PM NA # 1 was observed exiting Resident #261's room with his lunch tray. On interview at this time she stated the resident ate a couple of bites of the pasta and had a few sips sweet tea for lunch and then refused to eat anymore. On 5/9/12 at 1:55 PM the resident was given [MEDICATION NAME] 0.5 mg. The Behavior Monitoring Form - Anti-Anxiety Medications for Resident #261 was not in the Medication Administration book or on his medical record. Review of a blank Behavior Monitoring Form - Anti-Anxiety Medications revealed "Specify each target behavior in the space provided. For each shift, chart the number of episodes." "Identify intervention(s) used, outcome and any possible medication side effects observed." On 5/9/12 at 2:10 PM Resident #261 was overheard from the hallway repeatedly yelling "please leave me alone". The resident was then observed up in his wheelchair dressed in day clothes. On 5/9/12 at 2:30 PM Resident #261 was observed in his wheelchair in the Physical Therapy room. His eyes were closed and he was not actively participating in PT at this time. Interview with Physical Therapist #1 on 5/9/12 at 2:30 PM revealed the resident's progress in Physical Therapy was complicated by the resident being hard of hearing and also by confusion, pain and anticipation of pain. He stated that on some occasions Resident #261 had been able to participate in therapy but on others he would yell out and seem to be in pain but that sometimes he would do it without even being touched. The 5/9/12 2:30 PM nursing note read, in part, "Resident alert (with) confusion - yells out and combative with every touch - spoke slowly to explain patient care to him - he yells out 'Don't touch me'", "up in wheelchair with lift and 3+ assist to therapy - yells at intervals even if arms or other body part touched." The note also indicated that the 8:50 AM dose of pain medication had "some helpfulness" and that the 1:55 PM dose of [MEDICATION NAME] was given with "little help noted." On 5/9/12 at 2:48 PM Resident #261 was observed in his wheelchair in the Physical Therapy room. His eyes were closed and he was not actively participating in PT at this time. On 5/9/12 at 2:50 PM interview with NA #1 revealed Resident #261 yelled out frequently during care and sometimes when just approached but not touched. She indicated that she got him up daily in the afternoon for physical therapy and that the Nurse helped her get him in the wheelchair with the mechanical lift. She said that sometimes an extra person was needed because he would strike out at staff. NA #1 added that Resident #261 did not like being moved at all but that once he was in the wheelchair or back in bed he was fine, as long as he wasn't moved. On 5/9/12 at 3 PM Resident #261 was observed in his wheelchair in the Physical Therapy room. His eyes were closed and he was not actively participating in PT at this time. The 5/9/12 3 PM nursing note read "refused to do therapy." Review of the PT and OT Progress Status dated 5/9/12 (no time noted) revealed Resident #261 went to therapy on 5/9/12. The PT note read, in part, "attempted w/c (wheelchair) to hat (with) slideboard but pt (patient) refusing and screams before he is even touched on any part of his body." On 5/9/12 at 3:55 PM Resident #261 was observed being wheeled back to his room by NA #2. The resident's eyes were closed at this time. NA #2 stated that he had refused to participate in therapy and he was yelling and distressing the other residents. NA #2 then approached the resident to remove his sweatshirt and put on a hospital gown. The moment she approached Resident #261 and touched his arm gently to wake him he yelled "ow". He continued to say "please leave me alone" and "ow" as she removed his sweatshirt and put on the gown. After this NA # 2 went to get NA #3 to help her use the mechanical lift to transfer Resident #261 back to bed. When they started to hook up the lift and when they started to lift him Resident #261 yelled out again "please stop", "please leave me alone" and moaned. Initially he would not let go of the arm of the wheelchair with his right hand so the lift could not proceed. NA #3 was unable to release his hand using gentle force so stopped trying until he relaxed and closed his eyes again. She then held his hand and the lift proceeded. Resident #261 continued to yell out "please stop" during the lift, he also clutched his left leg with his left hand and yelled "ow" louder than before every time his left leg moved slightly. Once in bed, NA # 1 and #2 rolled him onto his right side to perform incontinent care and remove his pants. He was grasping the bed rail and would not let go to be turned onto his left side to continue incontinent care. Resident #261 was repeatedly yelling "please stop", "leave me alone", "ow, ow, ow" and moaning loudly. Nurse # 2 then entered the room and asked the NA's "do you want me to him some pain medication and you can try again later?" NA #2 then said "we need to get this brief on him". Nurse #5 then talked to the resident in a calm, gentle, simple manner loud enough for his to hear and tried to get his cooperation. She also asked him where it hurts. Resident #261 responded "please leave me alone, you don't know how much it hurts." Nurse #5 replied "we're just trying to get this brief on you, then I'll give you some pain medication, ok." Resident #261 continued to yell "please leave me alone" and was holding on tightly to Nurse #5's fingers with his free hand. Nurse #5 wiggled her fingers free after he did not respond to her requests to let got of her hand. Nurse #5 then said "ok, we're going to leave him alone and you can come back and try again later. At that point the Administrator entered the room to see what was going on and suggested that Resident #261 be given pain medication. During this interaction with Resident #261 NA #2 and NA #3 both remained calm and explained what they were trying to do briefly and in simple terms. All staff present left the room at 4:30 PM. On 5/9/12 at 4:33 PM Nurse #5, NA #2, the Administrator and Administrative Nurse #2 entered Resident #261's room. The resident was overheard yelling "please leave me alone." On 5/9/12 at 4:36 PM Resident # 261 was observed with his brief already on and Administrative Nurse #2 was stroking his arm and asked him what hurt. Resident #261 responded "everything". Resident #261 was then positioned and yelled "ow" when his legs were raised slightly to float his heels on a pillow. On 5/9/12 at 4:40 PM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Administration Record was completed and revealed a pre administration pain score of 10 with facial grimacing and rubbing L hip, relaxation was indicated as the non-pharmacological intervention used and the post administration pain score was 0 with no non verbal pain indicators. The 5/9/12 5:45 PM nursing note revealed "during ADL's (Activities of Daily Living) res (resident) yelling "Leave me alone", "Get out". Staff provided relaxation time and res denies discomfort. Staff able to provide ADL care (after) relaxation. Res holding L hip yelling out "I hurt." PRN (as needed) [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) given (with) results pending." On 5/10/12 at 10:15 AM the resident received two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5mg-500 mg. The PRN Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems and was severely impaired in decision making. He also was coded as having moderate hearing impairment and as being usually understood and usually able to understand. The MDS indicated the resident exhibited physical, verbal and other behaviors directed towards others that put the resident and others at risk for physical illness or injury, significantly interfered with the resident's care and with his participation in activities. Resident #261 also rejected care according to the assessment. For bed mobility, dressing, toilet use and personal hygiene the MDS indicated Resident #261 required extensive assistance of 2 people and for locomotion and eating extensive assistance of 1 person. For transfers the assessment indicated the resident was totally dependent and required the assistance of 2 people. He was coded as having one sided limited range of motion of the lower extremity. The MDS indicated the resident received pain medications as needed and non-pharmacological interventions and that he had frequent pain that limited his day to day activities. According to the MDS the resident was unable to score his pain when interviewed. Interview with Nurse #4 on 5/10/12 at 10:20 AM revealed that Resident #261 was known to yell out every time he was moved but he was generally fine once he was up. Nurse #4 also said she had previously observed Resident #261 participating in therapy by peddling the bike pedals without indications of pain. She added that the resident tended to anticipate pain and would yell out when approached even before he was touched. Nurse #5 acknowledged that on 5/9/12 Resident #261 seemed to be yelling more than he had before and really wouldn't let them do anything with him. She said that for pain management she always gave him prn pain medication in the morning, prior to morning care. She also indicated that the resident went to PT/OT in the afternoon. When asked why Resident #261 was still sent to PT despite how much he was yelling on 5/9/12, she stated it was because once he was up in his wheelchair he was generally fine. On 5/10/12 at 12:20 pm interview with the Social Worker revealed that she had a telephone care conference with the resident's Responsible Party (RP) on 5/9/12. She stated that Resident #261 only yells out when he has care and sometimes even when you just knock on the door. She added that his RP was aware of this and said that Resident #261 had always been like that and anxious since being in the war years ago. The Social Worker acknowledged that on 5/9/12 Resident #261 had yelled out more than he had before although she thought he was similar when he was first admitted . On further review of the Medical Record this information from the RP about the resident's behavior/anxiety/pain response prior to admission to the facility was not documented. On 5/10/12 at 1:20 PM during interview with the Physician he indicated that prn [MEDICATION NAME] may not be the most effective approach for a resident with dementia and that scheduled doses prior to care may be more appropriate. He also indicated that [MEDICATION NAME] can make residents with dementia more confused and this may have been the case on 5/9/12 for resident #261. On 5/10/12 at 1:50 PM interview with the Administrator and Director of Nursing (DON) revealed that they had not had an Interdisciplinary Meeting to discuss Resident #261's potential change in condition or pain response. The DON stated that Resident #261 anticipated pain and had anxiety and she did not necessarily think the yelling was pain related. She indicated that and given this, [MEDICATION NAME] prior to care or treatment would not be indicated. When asked if the resident had been assessed to determine if he was in fact experiencing pain, or there was some underlying cause, they both indicated that his dementia and anxiety response made it difficult to assess. The DON stated that the orthopedic doctor had seen the resident and his leg was healing fine and that Resident #261 had been seen by psychiatry and started on new medications. The Administrator did acknowledge that given the extent of the resident's yelling to be left alone on 5/9/12, that Physical Therapy or Occupational Therapy could have attempted to treat him in his room at that time. On 5/10/12 at 2 PM interview with the Administrator revealed that every time prn [MEDICATION NAME] was administered, Nursing staff were to complete the pre and post administration pain assessment on the PRN Pain Medication Administration Record. After reviewing the PRN Pain Medication Administration Records for Resident #261 and comparing the entries against the documentation in the Controlled Medication Utilization Record of [MEDICATION NAME]-[MEDICATION NAME] doses administered, he acknowledged the pain assessment was not consistently completed. On 5/24/12 at 12:59 PM interview with the Responsible Party (RP) revealed that resident #261 had recently moved from the facility back to his Assisted Living Facility on 5/17/12, with hospice care, and passed away on 5/21/12. The RP stated that he had also witnessed the resident's behavior and pain type response to care at the facility and that he believed it was due to the resident's dementia and fear or pain. He stated that prior to the fracture, the resident was ambulatory and combative at times; maybe once every two weeks and also when he frist went to the ALF, but other than that he was happy. He also said that Resident #261 was very hard of hearing and generally read lips to know what someone was saying. The RP added that various medications had been tried for Resident #261's behaviors in the past but he would have reactions to them and nothing really worked. The RP said he had wanted Resident #261 back at the ALF as soon as possible because he had settled down there previously once he got used to the staff. On 5/24/12 at 2:25 PM interview with the Rehabilitation Director revealed Physical Therapy had done Electrical-Stimulation therapy with Resident #261 for pain management with little improvement. She also stated that on 5/10/12 there was a new order for pain medication prior to therapy so from then on the Therapists coordinated therapy times with the nurse so Resident #261 could be pre-medicated. She added that pre-medicating the resident was not that helpful and indicated that he still yelled out even prior to being touched, which she felt had to do with anxiety. The Rehabilitation Director also said that the RP had told them in the 5/9/12 Care Conference that Resident #261 had a [DIAGNOSES REDACTED]. This [DIAGNOSES REDACTED]. 2. Resident # 266 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The MAR for May, 2012 was reviewed. [MEDICATION NAME] was transcribed to the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 05/09/12 at 11:50 AM, Nurse #1 was interviewed. Nurse #1 acknowledged that he transcribed the [MEDICATION NAME] to the MAR indicated [REDACTED]. He should have not written the time of administration (0800 & 1600) because it was a PRN order but he did so it was administered round the clock.

Based on record review and staff and physician interviews, the facility failed to obtain an orthopedic consult in a timely manner which resulted to skin ulceration and stiffness of fingers from the use of the temporary splint for 1 of 3 sampled residents with splints. The findings include: Resident # 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact. Resident #1 was admitted from the hospital with a splint on her left wrist. The care plan dated 01/04/12 was reviewed. There was no care plan that addressed the problem, goal and approaches for the use of the temporary splint. The hospital discharge summary dated 12/19/11 was reviewed. One of the discharge [DIAGNOSES REDACTED]. Under follow up, the notes indicated " the patient will be followed up with her primary care physician (name of the physician) in 2 weeks " . Review of the entire medical records revealed that Resident #1 didn't have a follow up visit with her primary physician. On 04/04/12 at 10:10 AM, interview with Administrative staff #1 was conducted. She stated that the reason why Resident #1 did not go to her primary care physician because most of the time the attending physician managed the resident's care at the facility. The physician's progress notes dated 12/28/11 was reviewed. The notes indicated that Resident #1 had a left wrist splint and plan #1 was " left wrist fracture: continue ortho (orthopedic) f/u (follow up) " . On 04/03/12 at 2:55 PM, the attending physician was interviewed. He stated that he had seen Resident #1 on 12/28/11. He indicated that he was not aware that there was no order from the hospital for orthopedic consult. He added that he had to depend on nursing to inform him of needed consult and if there was swelling on the area where the splint was on. He stated that residents with a splint should be referred to an orthopedic doctor in 1 to 1 ? weeks after the splint was placed. He stated that " we dropped the ball, unfortunately the resident had developed complications. This should not have happened " . Review of the head to toe skin checks dated 12/26/11 and 1/23/12 revealed that the skin was intact. On 04/03/12 at 3:15 PM, Nurse #2 was interviewed. She stated that the upper part of the fingers was covered with the splint. She added that the lower part of the fingers was swollen but there was no open area. The doctor's progress notes dated 01/23/12, 01/30/12, 02/17/12 and 03/13/12 were reviewed. The notes revealed that Resident #1 was seen by the Nurse Practitioner. The notes did not address the use of the splint and the need for orthopedic consult. The Nurse Practitioner was not available for interview. A report of consultation form dated 01/26/12 was reviewed. The form indicated that Resident #1 was seen by the orthopedic doctor. The report revealed that Resident #1 was six weeks status [REDACTED]. The splint was originally placed at the hospital. The resident stated that she had numbness and stiffness. The report also indicated that the splint (neutral, volar splint) was in place extended past PIP joints (middle joints of fingers). An Ace bandage was in place (tight) and digits were [MEDICAL CONDITION]. There was decreased sensation and decreased cap (capillary) refill. The fingers stuck together and skin ulcerations were present. The digits were pulled apart and skin sores and bleeding were present. The radial carpal joint was extremely stiff and the patient was unable to bend the digits. The report further indicated that Resident #1 had a Distal Radius [MEDICAL CONDITION] wrist that was left untreated for [REDACTED]. The recommendations were wound care daily dressing changes, OT (occupational therapy) twice daily hand/wrist motion and follow up in 2 weeks. On 02/09/12, Resident #1 was again seen by the orthopedic doctor. The report indicated that Left Distal Radius fracture with severe stiffness on wrist and fingers secondary to long term splint immobilization and must have formal hand therapy to address the stiffness. On 04/03/12 at 2:20 PM, Administrative staff #1 was interviewed. She stated that Resident #1 was admitted from the hospital with the splint of her left arm from the forearm extended down below the knuckles. She stated that the fingers were exposed and there was swelling noted. She also stated that the left arm was elevated to reduce the swelling and if the swelling increased, the physician was notified. In this case, the swelling was not so bad so the physician was not notified. On 04/03/12 at 2:30 PM, Nurse #1 was interviewed. Nurse #1 stated that he had assessed Resident #1 on admission. The resident had a splint on her left arm up to the middle of her fingers. He indicated that the fingers had no swelling or redness noted. On 04/03/12 at 3:15 PM, Nurse #2 was interviewed. She stated that Resident #1 had a splint on her left arm when admitted . The splint was from her arm to her fingers just below the knuckles. The fingers were exposed and were swollen. She revealed that the OT staff had inquired about the resident's orthopedic appointment. When she checked, there was no orthopedic appointment made for the resident. She then called and made the appointment for 01/26/12. She was not sure of when she called but she indicated it was that Monday 01/23/12. On 04/03/12 at 3:30 PM, therapist #1 was interviewed. She stated that Resident #1 had a splint from her forearm down to her middle fingers. She revealed that there was no therapy done to her wrist/fingers because there was no doctor's order. She stated that the fingers were swollen. She further revealed that the therapist assistant had brought to the attention of nursing the need for orthopedic appointment but she did not remember when. On 04/03/12 at 3:45 PM, the therapist assistant #1 was interviewed. She stated that Resident #1 had a splint on her left wrist. She stated that she was not working on her wrist/fingers because there was no order. She stated that the fingers were swollen. She further revealed that she had informed her manager of the need for orthopedic appointment for the resident and her manager had brought it up on the daily administrative meeting. On 04/03/12 at 4:40 PM, administrative staff #1 was interviewed. She stated that the rehab (rehabilitation) manager had brought it up on the morning meeting on 01/19/12 to look at the orthopedic appointment for Resident #1. The administrative staff stated that she did not know if somebody had followed up on it after the meeting. She further stated that the physician or the orthopedic doctor was only informed if there were changes in the resident's condition like redness or increased swelling on the area where the splint was on. She indicated that swelling and pain were expected for resident with fracture. On 04/05/12 at 10:20 AM, the orthopedic doctor was interviewed. He stated that he saw Resident #1 on 01/26/12. He indicated that the resident had a volar splint which was a temporary splint placed in the emergency room . He revealed that this splint has to stay for 2 weeks at the most and the orthopedic doctor has to see the patient. The splint has to be removed and a cast is placed if needed. He stated that the resident was referred to them (orthopedic clinic) after 6 weeks which was way too long for the splint to stay which resulted to stiffness and skin sores.