Every finding on record at The Greens at Hendersonville

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of weight loss for 2 of 4 residents whose MDS assessments were reviewed (Resident #8 and Resident #4). Findings included: 1. Resident #8 was admitted to the facility 06/22/23 with a diagnosis including malnutrition. Review of Resident #8's active physician orders revealed a diet order dated 10/03/23 for a regular diet with fortified foods. Further review revealed there were no physician orders for a weight-loss regimen. A list of Resident #8's weights were as follows: 08/07/25 199 pounds 09/17/25 198.5 pounds 10/16/25 196.4 pounds 11/15/15 157.2 pounds 12/12/25 158 pounds A review of a Registered Dietitian (RD) note dated 12/02/25 indicated Resident #8 consumed between 1% and 75% of meals, received fortified foods (foods enhanced with additional vitamins and minerals), and required increased protein intake to support wound healing. The RD also documented concerns regarding the accuracy of the recorded weight on 11/15/25. A review of Resident #8's nutrition care plan, last updated on 12/06/25, indicated the resident had an actual or potential nutritional concern associated with adult failure to thrive (characterized by unintentional weight loss, decreased appetite, and poor nutrition), dementia, and gastroesophageal reflux disease (GERD). The care plan interventions included monitoring for dysphagia (difficulty swallowing), observing for signs of malnutrition such as muscle wasting or significant weight loss, and ensuring the prescribed diet was provided as ordered. The quarterly MDS assessment dated [DATE] reflected that Resident #8 had weight loss and was on a physician-prescribed weight loss regimen. During a telephone interview on 01/14/26 at 10:21 AM, the Registered Dietitian (RD) reported that the Dietary Technician assisted with completing residents' quarterly MDS assessments and was trained to complete Section K, which addresses weight gain and weight loss. The RD confirmed that the Dietary Technician coded Section K for Resident #8's quarterly MDS assessment dated [DATE]. The RD further stated that Resident #8's care plan did not indicate any desire for weight loss, nor was the resident prescribed weight loss medication. Therefore, the RD was unsure why the MDS was coded as reflecting a physician-prescribed weight loss regimen. The Dietary Technician was not available for interview during the investigation. During an interview on 01/16/26 at 10:54 AM, the MDS Nurse stated that she did not complete Section K of Resident #8's quarterly MDS assessment and was unsure why the Dietary Technician coded the resident's weight loss as physician prescribed. During an interview on 01/16/26 at 11:24 AM, the Administrator stated that MDS assessments should be coded accurately. He further explained that he would expect the Dietary Technician to inform the Registered Dietitian (RD) if Resident #8's weight loss was coded as a physician-prescribed weight loss regimen, and then both should have notified the MDS Nurse for clarification. 2. Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included dementia, chronic kidney disease and diabetes. A physician's order dated 05/09/25 revealed Resident #4 was to receive torsemide (diuretic) 10 milligrams (mg) once daily for diuretic (used to increase urine production to remove excess salt and water from the body). Resident #4's weights were documented as follows: -07/14/25 136 pounds (lbs.) -08/07/25 136 lbs. -09/17/25 137 lbs. -10/16/25 140 lbs. -11/28/25 124 lbs. -12/08/25 117 lbs. Review of Resident #4's active physician orders revealed a diet order dated 11/14/25 for a regular diet with mechanical soft texture and regular consistency. Further review revealed there were no physician orders for a weight-loss regimen. Review of Resident #4's December 2025 Medication Administration Record revealed torsemide 10 mg daily was initialed by nursing staff as administered per physician orders. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had no swallowing disorder, weighed 117 lbs. and received diuretic medication. The MDS further noted Resident #4 had a significant weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was on a physician-prescribed weight-loss regimen. A Dietary Technician progress note dated 12/08/25 revealed Resident #4 had a significant weight loss trend at 1, 3, 6 months and weight changes/fluid shift were likely related to diuretic treatment (torsemide), chronic kidney disease and history of bilateral lower extremities edema. The Dietary Technician recommended continuing to monitor. The Dietary Technician was unable to be interviewed. During an interview on 01/16/26 at 10:55 AM, the MDS Nurse stated she was not sure why the Dietary Technician coded Resident #4's weight loss as physician-prescribed. The MDS Nurse explained for a resident taking diuretic medication, the only time she would code weight loss on the MDS assessment as physician-prescribed was if the medication was intentionally being used for weight loss. During a phone interview on 01/14/26 at 10:11 AM, the Registered Dietician (RD) revealed the Dietary Technician assisted with assessing residents quarterly and had been trained to complete MDS assessments. The RD stated the Dietary Technician likely got the concept that diuretic medication use was considered a weight loss regimen since Resident #4 was losing weight due to a physician-prescribed medication. The RD explained even when diuretic medication was prescribed for fluid buildup it could cause weight loss. The RD stated she would not have coded diuretic medication use a physician-prescribed weight loss regimen on the MDS assessment without verifying the medication was prescribed with the intention for planned weight loss. During an interview on 01/16/26 at 11:24 AM, the Administrator stated he would expect for MDS assessments to be coded accurately. The Administrator stated he would expect for the Dietary Technician to notify the RD that Resident #4's weight loss was coded as a physician-prescribed weight loss regimen and then they should have notified the MDS Nurse for her to clarify.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents previously determined to have a Level I status for a PASRR after a new serious mental disorder was identified for 3 of 3 residents reviewed for PASRR (Resident #99, Resident #12, Resident #101).The findings included: 1. Review of Resident #99's medical record revealed a PASRR Determination Notification letter dated 11/08/13 which reported Resident #99 had a Level I PASRR determination with no expiration date, and no further PASRR screening is required unless a significant change occurs with the individual's status which suggested a diagnosis of mental illness. Resident #99 was admitted to the facility on [DATE]. Review of Resident #99's medical record revealed her current active diagnoses included dementia, generalized anxiety disorder (diagnosed on [DATE]), delusional disorder (diagnosed on [DATE]), and hallucinations (diagnosed on [DATE]). Review of the provider note dated 1/02/26 revealed Resident #99 was followed by psychiatry for anxiety and listed active diagnoses of delusional disorder and hallucinations. Review of the medical record revealed no evidence a request was submitted for a Level II PASRR evaluation. An interview conducted on 1/14/26 at 11:03 AM with the Social Worker (SW) revealed she was aware that a Level II PASRR evaluation submission should be completed for residents with a mental health diagnosis upon their admission, when they received a new mental health diagnosis, or had a significant change in status. She stated she did not have a reason as to why Resident #99 did not have a request for a Level II PASRR evaluation completed. After reviewing Resident #99's mental health diagnoses, the SW stated a Level II PASRR evaluation should have been requested. During an interview on 1/16/26 at 11:47 AM with the Administrator, he indicated that the SW was responsible for submitting a request for a Level II PASRR evaluation. He stated due to Resident #99's new mental health diagnoses on 10/23/24 a request for a Level II PASRR evaluation should have been submitted. 2. A PASRR Determination Notification letter dated 03/22/24 revealed Resident #12 had a Level I PASRR with no expiration date that indicated no further PASRR screening is required unless a significant change occurs with the individual's status which suggested a diagnosis of mental illness or if present, suggests a change in treatment needs for those conditions. Resident #12 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis and anxiety disorder. A Hospice Registered Nurse (RN) progress note dated 11/14/24 revealed facility staff reported Resident #12 had shown increased agitation and aggression the past week. The Hospice RN notified the attending hospice provider and received orders to initiate olanzapine (antipsychotic) 5 milligrams (mg) twice a day. Review of Resident #12's list of cumulative diagnoses revealed a new mental health diagnosis of delusional disorder was added on 11/20/24. The facility was unable to provide documentation that a request was submitted for a Level II PASRR evaluation for Resident #12 following the new mental health diagnosis of delusional disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Her active diagnoses included anxiety disorder and psychotic disorder (other than schizophrenia). She received antipsychotic, antidepressant and anticonvulsant medications during the MDS assessment period. A Nurse Practitioner (NP) progress note dated 12/22/25 revealed Resident #12 had diagnoses of delusional disorder, unspecified psychosis and anxiety disorder. Resident #12 received olanzapine 2.5 milligrams (mg) once daily and quetiapine (antipsychotic) 50 mg twice daily for unspecified psychosis. The NP noted Resident #12 had no acute psychiatric symptoms and her mental status appeared stable related to delusional disorders with the plan to continue current management. During an interview on 01/15/26 at 11:03 AM, the Social Worker (SW) revealed she was the person responsible for submitting requests for a Level II PASRR evaluation. The SW stated she was aware that Level II PASRR evaluations should be completed for residents with a mental health diagnosis upon their admission, when they received a new mental health diagnosis, or had a significant change in status. The SW stated the MDS Nurse notified her of significant changes but currently there was no process in place to notify her when a resident received a new mental health diagnosis. She explained in September 2025, the Corporate Consultant gave her a list of residents with mental health diagnoses for her to submit requests for Level II PASRR evaluations. She stated she was currently working down the list but it was taking some time due to all of her other job responsibilities. The SW verified Resident #12 was on the list to request a Level II PASRR but one had not been submitted until 01/14/26. The SW verified a Level II PASRR evaluation should have been requested following Resident #12's new mental health diagnosis of delusional disorder on 11/20/24. During an interview on 01/16/26 at 11:47 AM, the Administrator confirmed the SW was the person responsible for submitting a request for a Level II PASRR evaluation. He verified that due to Resident #12's new mental health diagnoses of delusional disorder on 11/20/24 a request for a Level II PASRR evaluation should have been submitted. The Administrator explained in September 2025, they had identified an issue with PASRR, the SW was given a list of residents with mental health diagnoses to submit requests for a Level II PASRR evaluation and she was currently making progress. The Administrator stated the SW had a lot of irons on her plate and he planned to work with her to see what job responsibilities could be reassigned to other staff to help with her work load so she could continue working on getting the necessary referrals for PASRR evaluations submitted. 3. Review of Resident # 101's medical record revealed a PASRR Level I was completed on 11/05/2016 prior to admission with a recommendation to resubmit paperwork for a PASARR Level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #101 was admitted to the facility on [DATE]. Review of the Psychiatric Nurse Practitioner's 08/27/2025 progress note revealed Resident #101 was taking Escitalopram (an antidepressant) 5mg daily (after gradual dose reduction) and Lorazepam (antianxiety) 0.5mg twice daily. A diagnosis of bipolar disorder was added at this time with no new orders added. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was coded for mental health diagnoses including anxiety disorder, depression, and bipolar disorder. Review of the medical record revealed there was no documented evidence that a request was submitted for a Level II PASRR evaluation. During an interview on 01/16/2026 at 11:11 AM the MDS Nurse communicated a new mental health diagnosis would come from psychiatric progress notes. The MDS Nurse stated if the MDS Nurse enters a new mental health diagnosis they should notify the Social Worker. The MDS Nurse stated the current process was to email the Social Worker of a new mental health diagnosis. During an interview on 01/15/2026 at 11:03 AM with the Social Worker, she stated when a resident has a new mental health diagnosis, she would be the person responsible for requesting a Level II PASRR evaluation. The Social Worker revealed the MDS Nurse would inform her of a significant change. The Social Worker stated there was no system in place to notify her of new mental health diagnosis, that she was only notified of significant changes. During an interview with the Administrator on 01/16/2026 at 11:47 AM, he stated that anytime psychiatry communicated a diagnosis change the Social Worker should be informed. The Administrator stated it was the Social Worker's responsibility to submit requests for PASRR evaluations and the Social Worker attends morning meetings where all new orders and new diagnoses were discussed.

Based on record review, photographic evidence review, and staff, Law Enforcement Officer, Wound Nurse Practitioner, and Medical Doctor interviews, the facility failed to protect a vulnerable resident's right to be free from physical restraints when Resident #1 was found with socks placed on each hand and held in place by rubber bands wrapped around each wrist for 1 of 3 residents reviewed for restraints (Resident #1). On 01/27/25 at approximately 12:00 AM, Resident #1 was observed with socks covering each hand that were secured with rubber bands wrapped around each wrist, effectively forming tourniquets (device often used in emergency situations to apply pressure to a limb or extremity to stop blood flow) on her wrists, but not in a controlled manner. Her hands appeared larger than normal through the socks and the rubber bands had to be cut in order to remove the socks from Resident #1's hands. Resident #1's right hand was edematous (abnormally swollen due to an accumulation of fluid in the bodies tissues) and bright red in appearance. There were several blisters on the top of the hand, a large fluid filled blister in the palm of the hand with some drainage and a red ligature (visible indentation left on the skin) mark around the right wrist. Resident #1 was evaluated by the Wound NP on 01/27/25 who noted the blister on the palm of Resident #1's right hand measured 17 centimeters (cm) by 20 cm by 0 cm and ordered wound treatment to be applied daily. The reasonable person concept was applied to this deficiency as a reasonable person would not expect to have socks placed on their hands preventing them from freely moving their fingers or using their hands and would experience pain from rubber bands wrapped tightly around their wrists to hold the socks in place. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and multiple sclerosis (a chronic disease that affects the central nervous system). The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severe impairment in cognition. She required total staff assistance for all self-care tasks, mobility and transfers. She had no impairment in her upper or lower extremities and displayed no behaviors or rejection of care. The MDS noted Resident #1 weighed 97 pounds, had no unhealed pressure ulcers or other skin conditions, received hospice care, and used no restraints. A care plan last revised on 11/14/24 revealed Resident #1 had a behavior problem of coprophagy (eating feces). Interventions included for staff to intervene as necessary, divert attention, monitor and provide hygiene care as needed. The care plan did not include any intervention to apply socks and/or rubber bands to her hands. Review of the physician orders for Resident #1 revealed no order for restraints or the application of socks or rubber binding to her hands and/or wrists. A Situation, Background, Assessment and Response (SBAR) summary note written by Nurse #1 on 01/27/25 at 12:30 AM revealed in part, Resident #1 had socks on both hands for protection from scratching and digging. The socks were removed to assess the skin and Resident #1's hands were swollen with serum (clear, watery liquid) blisters to the right hand. The on-call provider and Director of Nursing (DON) were notified. A telephone interview was conducted with Nurse #1 on 01/29/25 at 1:48 PM. Nurse #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. Nurse #1 recalled around 12:30 AM, Nurse Aide (NA) #1 came to let her know that Resident #1 was found with socks on her hands, rubber bands around her wrists and her hands were swollen. Nurse #1 stated she immediately went to assess Resident #1, NA #1 had already removed the sock and rubber bands off Resident #1's right hand and Nurse #1 stated she cut the sock and rubber bands off Resident #1's left hand. Nurse #1 recalled Resident #1's right hand was swollen, blistered and red and her left hand was swollen but not blistered. Nurse #1 notified the DON, called the on-call provider and while waiting for a return phone call from the on-call provider, she went ahead and provided treatment to Resident #1's right hand. Nurse #1 stated she looked through Resident #1's medical records and did not see any physician orders for socks to be placed on her hands and there was no intervention in her care plan either. Nurse #1 explained Resident #1 would play in her feces on occasion and she could only assume that was why someone had placed the socks and rubber bands on her hands; however, that was not an intervention the facility typically used. She did not know who applied the socks or rubber bands on Resident #1's hands or how long they had been in place. Nurse #1 stated during her assessment, Resident #1 did not display signs or symptoms of pain as she had just received her scheduled morphine (pain medication) earlier that evening. Nurse #1 stated no one had mentioned anything to her about the socks and rubber bands observed on Resident #1's hands until it was brought to her attention by NA #1. A telephone interview was conducted with Nurse Aide (NA) #1 on 01/29/25 at 1:21 PM. NA #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. NA #1 recalled she was doing her initial incontinence rounds when she first went in to check on Resident #1 around 12:00 AM. When she went into Resident #1's room and pulled back the covers she observed socks on both of Resident #1's hands that were being held in place by rubber bands. NA #1 stated she thought the rubber bands had been wrapped around Resident #1's wrists at least twice. She stated she could tell Resident #1's hands were swollen even with the socks on because her hands were pressed tightly against the socks and looked much bigger than they should have been. She explained Resident #1's hands were so large, she was not able to pull the socks or rubber bands off and had to cut them in order to remove them from Resident #1's hands. NA #1 stated she started with the right hand and once the sock was removed, she immediately noticed Resident #1's right hand was very swollen, the skin of her hand and wrist was bright red in appearance and there were red marks around her wrist where the rubber bands had been that started to bruise. Resident #1 also had several blisters on top of the right hand and a large blister covering the palm of her right hand that were leaking. NA #1 stated she immediately informed Nurse #1 and when Nurse #1 came to the room to assess Resident #1 she instructed NA #1 to cut the rubber bands and sock off the left hand. NA #1 recalled Resident #1's left hand was also swollen but less red in appearance with no blisters that she recalled and there were red marks around Resident #1's left wrist where the rubber bands had been. NA #1 was not sure who put the socks and rubber bands on Resident #1's hands but recalled staff mentioning in the past that Resident #1 messed with her feces; however, NA #1 had never witnessed Resident #1 display that type of behavior. NA #1 stated if Resident #1 had messed in her feces when she provided her care, she would have just cleaned her up and would never have placed socks and/or rubber bands on her hands to deter the behavior because it would be considered a restraint. A Wound Nurse Practitioner (NP) progress note dated 01/27/25 revealed in part, Resident #1 was seen for a new skin and wound consult. The Wound NP noted facility staff reported Resident #1 had a new blister on the right hand that was caused by socks being secured on her hands. The Wound NP's assessment revealed Resident #1 had a new nonthermal (raised, fluid-filled pocket on the skin that is not caused by heat or burns) blister on the right hand with partial thickness (forms on the skin between the top and middle layer of skin) and measured 17 cm by 20 cm by 0 cm. The periwound (area of skin surrounding the blister) was noted as fragile with erythema (redness of the skin) and edema (swelling). The Wound NP provided recommendations for wound treatment, to notify the Wound NP or provider when the blisters ruptured and become an open wound and to not place/secure socks or any dressing/covering tightly on Resident #1's hand or anywhere on the extremities that could restrict blood flow. A telephone interview was conducted with the Wound NP on 01/30/25 at 3:31 PM. The Wound NP stated when he evaluated Resident #1 on 01/27/25, she had multiple fluid-filled blisters on the dorsal (part of the hand where the knuckles are located) side of the hand and a large blister on the palm of her hand. He stated from what the blisters looked like when he evaluated Resident #1, the damage from the blisters seemed superficial and he left the blisters intact to let them heal naturally. The Wound NP stated the binding used on Resident #1's wrists to keep the socks on her hands was what caused the blisters and swelling. A Medical Doctor (MD) progress note dated 01/27/25 read in part, Resident #1 was seen to evaluate blisters on her right hand. The MD noted socks were placed on both hands, secured with rubber bands, to prevent Resident #1 from scratching certain parts of her body which sometimes gathered fecal matter and the right rubber band was much tighter than the left and it was unclear exactly how long the rubber bands had been on Resident #1's wrists. When the socks were removed, there was an extensive amount of blisters noted to the right hand. The MD assessment revealed Resident #1's right hand had large, raised blisters on the [NAME] (palm) surface and dorsal surface that did not look indurated (hardening and thickening of the skin) and there was no black eschar (dead tissue) or skin discoloration. Resident #1 had good distal vascularity (blood flow in the extremities) and was moving all fingers without difficulty. There was some non-pitting edema noted around the wrist area and the rubber band mark just below the wrist was barely noticeable. The MD cleaned the blisters with alcohol, used a sterile needle to puncture the blisters and clear serous (watery) fluid drained from the blisters. A topical antibiotic cream and gauze dressing was applied to Resident #1's right hand. Resident #1's left hand had a small blister measuring one (1) cm along the thenar eminence (area of the palm at the base of the thumb) with no discoloration or induration noted. Resident #1 was able to move all the fingers of the left hand without difficulty and had good distal vascularity. The blister was drained using a sterile needle and dressing applied. During an interview on 01/29/25 at 4:20 PM and follow-up telephone interview on 01/29/25 at 5:33 PM, the MD stated when he assessed Resident #1 on 01/27/25 she had fluid-filled blisters on the top of the right hand and a large blister on the palm of the right hand that appeared superficial with no black eschar or signs of infection. When he cleansed and punctured the blisters there was no tinge of blood in the serous fluid drainage. He stated Resident #1 had good range of motion in her fingers, good capillary refill (clinical test that assesses the speed of blood flow through the capillaries) and no arterial compromise (condition that occurs when blood flow to an area of body is reduced or blocked) when he checked her wrist pulse. The MD stated when he evaluated Resident #1 again on 01/28/25, she had no blister reformation or skin infection and she still had a very good pulse and was moving her fingers. He stated it was going to take some time but her injuries were improving. He explained the rubber bands placed on Resident #1's wrist did not decrease blood flow as circulation was there but the rubber bands did decrease the venous flow (movement of blood from the hand back to the heart) which backed up into the lymphatic flow (extra fluid that drains from cells and tissues in the body that isn't reabsorbed into the capillaries) causing the blisters. The MD expressed it was difficult to determine how long the socks and rubber bands had been in place on Resident #1's hands and wrists; however, without the binding (referring to the rubber bands) around Resident #1's wrists, there would have been no blisters. During an interview on 01/29/25 at 11:50 AM, the investigating Law Enforcement Officer revealed in addition to law enforcement he also had an extensive medical background that included Medical Examiner and forensic pathology. The Law Enforcement Officer stated he observed Resident #1's hands on 01/27/25 and 01/28/25 and took photos of the injuries. The Law Enforcement Officer stated when he observed Resident #1's hands on 01/27/25, her right hand was wrapped in a gauze dressing. Her right hand was almost degloved (type of traumatic injury that involves the skin and soft tissue being torn away from the muscle and connective tissue underneath) and there were red ligature marks on both the right and left wrists. In addition, Resident #1 had a raised blister on the palm of the right hand that he estimated to contain 50 cc (cubic centimeters) of fluid. On 01/28/25, when he observed Resident #1's right hand again with the gauze dressing removed, the MD had already decompressed the blisters. Her right hand and wrist were red and swollen from the wrist to the fingers which he felt was suggestive of cellulitis (bacterial infection of the skin) and there were long strands of skin hanging off the palm. There were no blisters or significant swelling on her left hand but she did have a red ligature mark around her wrist. The Law Enforcement Officer stated he was informed by the facility that rubber bands had been placed around her wrists to hold the socks in place on her hands. The Law Enforcement Officer stated he was currently conducting an investigation. Photographs taken of Resident #1's hands and wrists received via email correspondence dated 01/28/25 from the investigating Law Enforcement Officer were reviewed. In the first three photographs taken on 01/27/25, Resident #1's hand was covered in a gauze dressing and when the dressing was pulled back, the index finger was outside of the dressing and appeared swollen. The middle and ring fingers were bent inside the gauze dressing and you could partially visualize a raised fluid-filled blister starting at the base of the middle and ring fingers leading down the top of the hand. When the dressing was moved to visualize the wrist, the skin was red with a blister and indentation mark on the inside of the wrist where the rubber bands had been. The remaining pictures taken on 01/28/25, revealed the skin on Resident #1's right hand was red from the wrist to the fingers and there was peeling skin on the top and palm. Her left hand and palm had minimal redness with no blisters and a red mark on the wrist. During a follow-up interview on 01/29/25 at 4:09 PM, the investigating Law Enforcement Officer stated he spoke with NA #1. NA #1 sent him photographs she took on 01/27/25 of the socks and rubber bands on Resident #1's hands and wrists. He stated the pictures clearly showed Resident #1's wrists had two rubber bands bound tightly around her wrists. Photographs of Resident #1's hands and wrists that were taken by NA #1 on 01/27/25 and received via email correspondence on 01/29/25 from the investigating Law Enforcement Officer were reviewed. There were three photographs in total. In the first photograph, both of Resident #1's hands were covered in grayish/tan gripper socks. The left hand was more prominent in the photograph and showed two rubber bands, approximately 1/8 of an inch in width, wrapped around the wrist twice and her hand above the wrist appeared 2 to 3 times its normal size in the sock. Her chin was resting on the right hand and the rubber bands were not visible but you could visualize how large her hand appeared in the sock. In the second photograph, the sock and rubber bands had been removed from the right hand and her palm was facing upward. There were red ligature marks on the lower part of the inside of her wrist. The skin on her wrist, hand and fingers were visibly swollen and bright red in appearance. There was a large, raised fluid-filled blister from the edge of the palm to the bend of her fingers that covered the width of the palm. The sock was still on her left hand and you could visualize a rubber band, approximately 1/8 of an inch in width, bound twice around her wrist. In the third photograph, was a left sided view of Resident #1's right hand that was facing upward and tilted slightly. There was a purple colored, bruised area on the outer wrist along the red ligature mark. The skin from the wrist to the fingers were bright red and swollen 2 to 3 times its normal size, resembling a lobster claw. Just underneath the outer edge of the top of the hand were two raised fluid-filled blisters at the base of the hand and a fluid-filled blister at the bend of the ringer finger to the knuckle. A telephone interview was conducted with Nurse #2 on 01/29/25 at 4:59 PM. Nurse #2 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on Friday 01/24/25 during the hours of 7:00 AM to 3:00 PM. Nurse #2 did not recall noticing socks or rubber bands on Resident #1's hands or wrists. A telephone interview was conducted with NA #2 on 01/29/25 at 12:10 PM. NA #2 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on Friday 01/24/25, Saturday 01/25/25 and Sunday 01/26/25 during the hours of 7:00 AM to 3:00 PM. NA #2 stated she could not honestly recall noticing if Resident #1 had socks or rubber bands on her hands or wrists on 01/24/25 but she did notice the socks on Resident #1's hands when she started her shifts on 01/25/25 and 01/26/25. She explained the socks were placed neatly around Resident #1's hands and she left them on her hands thinking they had been put there by the previous shift as an intervention to keep her from messing in her feces. When asked what she meant by the socks being neatly placed on Resident #1's hands, she stated the socks were pulled down to the tips of the fingers and covered her hand but did not recall them appearing to be tight. NA #2 stated she did not recall noticing any rubber bands around Resident #1's wrists holding the socks in place and felt she would have seen them if they had been there. NA #1 expressed that it was possible the rubber bands could have been folded up in the socks and she just didn't notice. A telephone interview was conducted with NA #3 on 01/30/25 at 2:42 PM. NA #3 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on Friday 01/24/25 to Saturday 01/25/25 during the hours of 4:30 PM (she arrived late to work) to 7:00 AM and again on Sunday 01/26/25 during the hours of 3:00 PM to 11:00 PM. NA #3 recalled on 1/24/25 she was assigned to the left side of 500 Hall (side where Resident #1 resided) and NA #4 was assigned to right side of 500 Hall. NA #3 recalled on 01/24/25 Resident #1 was observed eating her feces after an incontinence episode. She could not remember the exact time but stated at one point during the shift, NA #4 had assisted her with cleaning up Resident #1. NA #3 recalled Resident #1 had socks on her hands that were removed and after care was provided, NA #4 placed new socks back on Resident #1's hands. At that point, NA #3 stated she went to assist Resident #1's roommate while NA #4 left the room. When NA #4 returned, she noticed he had rubber bands in his hands and he went around the privacy curtain to Resident #1. NA #3 stated she did not see NA #4 place the rubber bands around Resident #1's wrists but knew that he had because the rubber bands were on Resident #1's wrists when she checked on her again later in the shift. NA #3 explained she thought that was strange when NA #4 put the socks on Resident #1's hands but he told her that's just what they do and she just assumed that was facility protocol to try and keep Resident #1 from messing in her feces. NA #3 stated she knew that the use of the socks and/or rubber bands on Resident #1's hands were considered a restraint and she didn't question NA #4 further because he was sort of training her and seemed to know the residents well. NA #3 stated she honestly did not think the socks or rubber bands would harm Resident #1 and didn't think much about it the remainder of the shift because it was a busy night. NA #3 recalled when she started her shift on 01/26/25, Resident #1 still had the same socks on both her hands along with the rubber bands around her wrists that were put on 01/24/25 by NA #4. NA #3 could not recall how the socks looked when she started her shift on 01/26/25 or how Resident #1's hands and wrists appeared with the socks in place. NA #3 explained she really wasn't paying attention to how Resident #1's hands presented on 01/26/25 because most of the shift Resident #1 was sleeping on her hands or her hands were under the cover and she couldn't say for sure whether Resident #1's hands appeared larger than normal or swollen. NA #3 restated she knew for a fact that the socks and rubber bands were placed on Resident #1's hands by NA #4 01/24/25 and indicated everyone who worked with Resident #1 since that date would have seen the socks and rubber bands but they all dropped the ball, herself included. A telephone interview was conducted with NA #4 on 01/31/25 at 1:59 PM. NA #4 revealed he was employed by a staffing agency and verified he worked on Friday 01/24/25 during the hours of 3:00 PM to 11:00 PM on Resident #1's hall with NA #3. He explained NA #3 was assigned to provide care to the residents on the left side of 500 Hall where Resident #1 resided and he was assigned to provide care to the residents on the right side of the hall. NA #4 stated it was sometime after supper between 7:00 PM and 8:00 PM when he went to assist NA #3 with cleaning up Resident #1 after she had an incontinence episode. NA #4 recalled when he and NA #3 went into Resident #1's room he noticed that she was eating her feces and she had feces all over her body, mouth and inside of her mouth. NA #4 stated he did not notice Resident #1 with any socks or rubber bands on her hands or wrists when he used facility wipes to clean her hands, fingers and nails and he did not put any socks or rubber bands on her hands when he was done. NA #4 stated after cleaning Resident #1's hands, he assisted NA #3 with giving Resident #1 a bed bath, changed the bed linens and then he left the room. He stated he did not go back in Resident #1's room the remainder of the shift. NA #4 stated he knew people were aware that Resident #1 would eat her feces on occasion because when he started at the facility approximately a year ago, he had noticed her with socks on her hands and when he asked staff about it they told him the socks were placed on her hands to keep her from messing in her feces and/or eating her feces. When NA #4 was asked who had told him that information, he could not recall the names and stated they were agency staff. NA #4 explained anytime he had an assigned residents that would dig in their briefs, he just cleaned them up, usually gave them a shower or bed bath, and never put socks or rubber bands on their hands. NA #4 restated he did not observe or place any socks and rubber bands on Resident #1's hands and wrists when he assisted NA #3 on 01/24/25 and was not sure who did. During a follow-up telephone interview on 02/05/25 at 3:01 PM, the investigating Law Enforcement Officer stated he had received a text message from NA #3 that she had sent to NA #4 prior to the Law Enforcement Officer's interview with NA #3 on 01/30/25. A summarization of the text message revealed NA #3 informed NA #4 that everyone thought she had placed the rubber bands and socks on Resident #1's hands and she would not take the fall for him over something he did. A telephone interview was conducted with Nurse #3 on 01/30/25 at 3:04 PM. Nurse #3 revealed she was employed by the facility and verified she was assigned to provide care to Resident #1 on Saturday 01/25/25 and Sunday 01/26/25 during the hours of 7:00 AM to 7:00 PM. Nurse #3 stated on 01/25/25, Resident #1 was in bed most of the day covered with a blanket and she didn't recall noticing Resident #1's hands. On 01/26/25, Nurse #3 stated she saw the socks on both of Resident #1's hands but did not see any rubber bands. She stated she did not remove the socks from Resident #1's hands to observe the skin and explained the socks did not seem tight or swollen and there was no redness to her arms that she recalled. Nurse #3 stated she didn't question why the socks were placed on Resident #1's hands because she knew that Resident #1 would play in and eat her feces and no one had brought any concerns regarding the socks to her attention. A telephone interview was conducted with NA #5 on 01/30/25 at 10:08 AM. NA #5 revealed she was employed by the facility and verified she worked on Saturday 01/25/25 during the hours of 7:00 AM to 3:00 PM on Resident #1's hall with NA #2. She explained NA #2 was assigned to provide care to the residents on the left side of 500 Hall where Resident #1 resided and she was assigned to provide care to the residents on the right side of the hall. NA #5 recalled sometime right after lunch, NA #2 asked her to pull Resident #1 up in bed and when she did, she noticed Resident #1 had socks on each hand with one rubber band around each wrist that was holding the socks in place. NA #5 stated she did not notice anything unusual about how her hands looked with the socks on nor did she recall noticing any signs of swelling or redness on the visible skin. NA #5 expressed she did not question why Resident #1 had socks and rubber bands on her hands, did not remove them and just assumed the socks were put on for a reason. A telephone interview was conducted with NA #6 on 01/30/25 at 11:32 AM. NA #6 revealed she was employed by a staffing agency and verified she was assigned to provide care to Resident #1 on Saturday 01/25/25 to Sunday 01/26/25 during the hours of 3:00 PM to 7:00 AM. NA #6 recalled when she started her shift on 01/25/25, Resident #1 had had socks on her hands with one (1) rubber band wrapped around each wrist holding the socks in place. She explained the rubber bands were slid over the wrist, not wrapped twice or tight, and described it like someone who would put a hair tie on their wrist loosely in case they wanted to pull their hair up. NA #6 stated usually the nurses were the only ones that had rubber bands and she just assumed the nurses had put the socks and rubber bands on Resident #1's hands and wrists for a particular reason and didn't ask anyone about it. NA #6 stated she assumed it was standard protocol because she was told that Resident #1 liked to dig in her bottom and play with/eat her fecal matter. NA #6 revealed she also worked on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM and had gone into the room with NA #1 to check on Resident #1. NA #6 recalled there were rubber bands wrapped around Resident #1's wrist multiple times to hold the socks in place and even with the socks on her hands, you could see that Resident #1's hands were huge. NA #6 stated NA #1 had to cut the rubber bands off of Resident #1's wrist and she had blisters on her hands that had leaked through the socks onto the bed linens. NA #6 stated NA #1 immediately informed Nurse #1 who came and assessed Resident #1. NA #6 restated she did not question or ask why Resident #1 had socks and rubber bands on her hands and wrists on 01/25/25 and was not sure who put them on Resident #1's hands. Unsuccessful telephone attempts were made on 01/29/25 at 1:12 PM and 01/31/25 at 10:18 PM for an interview with Nurse #4 who was employed by a staffing agency and was assigned to provide Resident #1's care on Saturday 01/25/25 during the hours of 7:00 PM to 7:00 AM. During interviews on 01/29/25 at 3:42 PM and 01/30/25 at 9:40 AM, the Director of Nursing (DON) revealed she received a call from Nurse #1 on 01/27/25 around 1:15 AM informing her that she (Nurse #1) had observed socks on both of Resident #1's hands with rubber bands placed tightly around her wrists, both hands were swollen and the right hand had blisters. The DON recalled when she arrived at the facility around 1:35 AM, Nurse #1 had already provided wound care and bandaged Resident #1's hand. When the DON removed the bandages from Resident #1's hand, both hands were pink and swollen and the right hand had several blisters on the top part of the hand and one large blister covering the palm of the right hand. The DON stated during the assessment, she did not notice any indentation from the rubber bands on Resident #1's wrists due to all the swelling and Resident #1 did not display any signs or symptoms of discomfort or pain. The DON stated she called the Administrator to inform him of the incident and then started an investigation. She stated Resident #1 was evaluated by the MD 01/27/25, he started Resident #1 on an antibiotic prophylactically (treatment taken to prevent or protect against infection) and provided orders for wound treatment twice a day. The DON recalled the MD stating based on the extent of Resident #1's injuries, the rubber bands had been on her wrists for less than 7 hours and if they had been in place any longer, there would have been more cell death. She stated when she spoke with Resident #1's Responsible Party (RP) on 01/27/25 to inform the RP of what had occurred, the RP reported being aware that socks were being put on Resident #1's hands because she played with her feces and was ok with them being used. She explained to Resident #1's RP that type of intervention was not something the facility would use as it was considered a restraint. The DON verified socks placed on the hands and secured with rubber bands was never an appropriate intervention to use on any resident and facility hired and agency staff were informed during orientation that restraints were not something the facility used. During an interview on 01/30/25 at 4:44 PM, the Administrator recalled he woke up around 5:30 AM on 01/27/25 and noticed he had missed a call from the DON. He called the DON and she informed him of the incident involving Resident #1. When asked what he was told by the DON, he stated at that point she was describing the aftermath, basically the extent of Resident #1's injuries. The Administrator stated when he arrived at the facility and observed Resident #1's hands, she still had a good deal of swelling in the right hand and the right hand was red and blistered. Resident #1's left hand was a little less red and swollen with no blisters. The Administrator stated when they started their investigation, they initially thought the rubber bands were placed on Resident #1's wrists on Sunday 01/26/25 during second shift (3:00 PM to 11:00 PM); however, they were learning new details about when the rubber bands were actually placed on her wrists. He stated staff had been trained there was a zero tolerance for abuse and neglect that included the use of restraints. He indicated they were still in the process of conducting an investigation and had not yet been able to narrow it down to a specific individual or how long the socks and rubber bands had been in place on Resident #1's hands. The Administrator, DON and Regional Director of Operations were notified of Immediate Jeopardy on 01/29/25 at 6:00 PM. The facility provided the following Credible Allegation of Immediate Jeopardy removal: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: On 1/27/2025, Resident #1 was observed with a sock on each hand. A binding had been placed around each wrist to hold the socks in place. The facility failed to comply with its abuse and restraint policies and did not protect a resident with severe cognitive impairment from abuse through the use o [TRUNCATED]

Based on record review, photographic evidence review and staff interviews, the facility failed to implement their abuse policy and procedure when nursing staff failed to identify and immediately report the use of a physical restraint for a resident with no medical symptoms along with no assessment for the need for a physical restraint. Staff reported observing socks placed on Resident #1's hands held in place by rubber bands wrapped around each wrist on 01/24/25 without immediately reporting to the Administrator. On 01/27/25 at approximately 12:00 AM, Resident #1 was observed with socks covering each hand that were secured with rubber bands wrapped around each wrist, effectively forming tourniquets (device often used in emergency situations to apply pressure to a limb or extremity to stop blood flow) on her wrists, but not in a controlled manner. Her hands appeared larger than normal through the socks and the rubber bands had to be cut in order to remove the socks from Resident #1's hands. Resident #1's right hand was edematous (abnormally swollen due to an accumulation of fluid in the bodies tissues) and bright red in appearance. There were several blisters on the top of the hand, a large fluid filled blister in the palm of the hand with some drainage and a red ligature (visible indentation left on the skin) mark around the right wrist. Resident #1 was evaluated by the Wound NP on 01/27/25 who noted the blister on the palm of Resident #1's right hand measured 17 centimeters (cm) by 20 cm by 0 cm and ordered wound treatment to be applied daily. This was for 1 of 3 residents reviewed for abuse and restraints (Resident #1). Findings included: The facility's policy titled, Abuse and Neglect Protocol dated 06/13/21, revealed a policy statement that read in part, Our residents have the right to be free from abuse, neglect, misappropriation, exploitation, corporal punishment, physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms, and involuntary seclusion. All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The policy interpretation and implementation section revealed in part, that any staff member or person affiliated with this facility who witnessed or believed a resident had been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report the mistreatment or offense to the Administrator or Director of Nursing Services. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and multiple sclerosis (a chronic disease that affects the nervous system). A telephone interview was conducted with Nurse Aide (NA) #2 on 01/29/25 at 12:10 PM. NA #2 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on 01/24/25, 01/25/25 and 01/26/25 during the hours of 7:00 AM to 3:00 PM. NA #2 stated she could not honestly recall noticing if Resident #1 had socks or rubber bands on her hands or wrists on 01/24/25; however, she did notice the socks but no rubber bands on Resident #1's hands when she started her shifts on 01/25/25 and 01/26/25. She explained she left the socks on Resident #1's hands thinking they had been put there by the previous shift as an intervention to keep her from messing in her feces. NA #2 verified she did not ask anyone why Resident #1 had socks on her hands nor did she report it to anyone. She stated if she had known the socks should not have been on Resident #1's hands she would have told someone. NA #2 confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Nurse Supervisor, DON or Administrator. A telephone interview was conducted with NA #3 on 01/30/25 at 2:42 PM. NA #3 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on 01/24/25 to 01/25/25 during the hours of 4:30 PM (she arrived late to work) to 7:00 AM and again on 01/26/25 during the hours of 3:00 PM to 11:00 PM. NA #3 recalled on 1/24/25 Resident #1 had an incontinence episode and NA #4 had assisted her with cleaning up Resident #1. NA #3 stated Resident #1 had socks on her hands that were removed and after care was provided, NA #4 placed new socks back on Resident #1's hands. At that point, NA #3 stated she went to assist Resident #1's roommate while NA #4 left the room. When NA #4 returned, she noticed he had rubber bands in his hands and he went around the privacy curtain to Resident #1. NA #3 stated she did not see NA #4 place the rubber bands around Resident #1's wrists but knew that he had because the rubber bands were on Resident #1's wrists when she checked on her again later in the shift. NA #3 explained that when NA #4 put the socks on Resident #1's hands, she thought that was strange but NA #4 told her that's just what they do and she just assumed that was facility protocol to try and keep Resident #1 from messing in her feces. NA #3 confirmed she had received inservice training on abuse and restraints and was instructed to immediately report any concerns to administration. She stated she knew that the use of the socks and rubber bands on Resident #1's hands were considered a restraint and she didn't report it to anyone or question NA #4 further because he was sort of training her and seemed to know the residents well. NA #3 recalled when she started her shift on 01/26/25, Resident #1 still had the same socks on both her hands along with the rubber bands around her wrists that were put on 01/24/25 by NA #4. NA #3 could not recall how the socks looked when she started her shift on 01/26/25 or how Resident #1's hands and wrists appeared with the socks in place. NA #3 restated she knew for a fact that the socks and rubber bands were placed on Resident #1's hands by NA #4 on 01/24/25 and everyone who worked with Resident #1 since that date would have seen the socks and rubber bands but they all dropped the ball, herself included. A telephone interview was conducted with NA #5 on 01/30/25 at 10:08 AM. NA #5 revealed she was employed by the facility and verified she worked on 01/25/25 during the hours of 7:00 AM to 3:00 PM on Resident #1's hall with NA #2. NA #5 recalled on 01/25/25 sometime right after lunch, NA #2 asked her to pull Resident #1 up in bed and when she did, she noticed Resident #1 had socks on each hand with one rubber band around each wrist that was holding the socks in place. NA #5 stated she did not notice anything unusual about how her hands looked with the socks on nor did she recall noticing any signs of swelling or redness on the visible skin. NA #5 expressed she did not question why Resident #1 had socks and rubber bands on her hands or report it to anyone. She stated she did not remove them and just assumed the socks were put on for a reason. NA #2 confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Administrator. A telephone interview was conducted with NA #6 on 01/30/25 at 11:32 AM. NA #6 revealed she was employed by a staffing agency and verified she was assigned to provide care to Resident #1 on 01/25/25 to 01/26/25 during the hours of 3:00 PM to 7:00 AM. NA #6 recalled when she started her shift on 01/25/25, Resident #1 had had socks on her hands with one (1) rubber band wrapped around each wrist holding the socks in place. She explained the rubber bands were slid over the wrist, not wrapped twice or tight, and described it like someone who would put a hair tie on their wrist loosely in case they wanted to pull their hair up. NA #6 stated usually the nurses were the only ones that had rubber bands and she just assumed the nurses had put the socks and rubber bands on Resident #1's hands and wrists for a particular reason and didn't ask anyone about it. NA #6 stated she assumed it was standard protocol because she was told that Resident #1 liked to dig in her bottom and play with/eat her fecal matter but realizes she should have told someone. She confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Administrator. NA #6 restated she did not ask anyone why Resident #1 had socks and rubber bands on her hands and wrists on 01/25/25 nor did she report it to anyone. A telephone interview was conducted with Nurse #3 on 01/30/25 at 3:04 PM. Nurse #3 revealed she was employed by the facility and verified she was assigned to provide care to Resident #1 on 01/25/25 and 01/26/25 during the hours of 7:00 AM to 7:00 PM. Nurse #3 stated on 01/26/25 she saw socks on both of Resident #1's hands but did not see any rubber bands. She stated she did not remove the socks from Resident #1's hands to observe the skin and explained the socks did not seem tight or swollen and there was no redness to her arms that she recalled. Nurse #3 stated she didn't question why the socks were placed on Resident #1's hands or report it to anyone because she knew that Resident #1 would play in and eat her feces and no one had brought any concerns regarding the socks to her attention. Nurse #3 confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Administrator. A telephone interview was conducted with Nurse Aide (NA) #1 on 01/29/25 at 1:21 PM. NA #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. NA #1 recalled she was doing her initial incontinence rounds when she first went in to check on Resident #1 around 12:00 AM. When she went into Resident #1's room and pulled back the covers she observed socks on both of Resident #1's hands that were being held in place by rubber bands. NA #1 stated she thought the rubber bands had been wrapped around Resident #1's wrists at least twice. She stated she could tell Resident #1's hands were swollen even with the socks on because her hands were pressed tightly against the socks and looked much bigger than they should have been. She explained Resident #1's hands were so large, she was not able to pull the socks or rubber bands off and had to cut them in order to remove them from Resident #1's hands. NA #1 stated she started with the right hand and once the sock was removed, she immediately noticed Resident #1's right hand was very swollen, the skin of her hand and wrist was bright red in appearance and there were red marks around her wrist where the rubber bands had been that started to bruise. Resident #1 also had several blisters on top of the right hand and a large blister covering the palm of her right hand that were leaking. NA #1 stated she immediately informed Nurse #1 and when Nurse #1 came to the room to assess Resident #1 she instructed NA #1 to cut the rubber bands and sock off the left hand. NA #1 recalled Resident #1's left hand was also swollen but less red in appearance with no blisters that she recalled and there were red marks around Resident #1's left wrist where the rubber bands had been. NA #1 was not sure who put the socks and rubber bands on Resident #1's hands but recalled staff mentioning in the past that Resident #1 messed with her feces; however, NA #1 had never witnessed Resident #1 display that type of behavior. NA #1 stated if Resident #1 had messed in her feces when she provided her care, she would have just cleaned her up and would never have placed socks and/or rubber bands on her hands to deter the behavior because it would be considered a restraint. A telephone interview was conducted with Nurse #1 on 01/29/25 at 1:48 PM. Nurse #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. Nurse #1 recalled around 12:30 AM, Nurse Aide (NA) #1 came to let her know that Resident #1 was found with socks on her hands, rubber bands around her wrists and her hands were swollen. Nurse #1 stated she immediately went to assess Resident #1, NA #1 had already removed the sock and rubber bands off Resident #1's right hand and Nurse #1 stated she cut the sock and rubber bands off Resident #1's left hand. Nurse #1 recalled Resident #1's right hand was swollen, blistered and red and her left hand was swollen but not blistered. Nurse #1 notified the DON, called the on-call provider and while waiting for a return phone call from the on-call provider, she went ahead and provided treatment to Resident #1's right hand. Nurse #1 stated she looked through Resident #1's medical records and did not see any physician orders for socks to be placed on her hands and there was no intervention in her care plan either. Nurse #1 explained Resident #1 would play in her feces on occasion and she could only assume that was why someone had placed the socks and rubber bands on her hands; however, that was not an intervention the facility typically used. Nurse #1 stated no one had mentioned anything to her about the socks and rubber bands observed on Resident #1's hands until it was brought to her attention by NA #1. During interviews on 01/29/25 at 3:42 PM and 01/30/25 at 9:40 AM, the Director of Nursing (DON) revealed she received a call from Nurse #1 on 01/27/25 around 1:15 AM informing her that she (Nurse #1) had observed socks on both of Resident #1's hands with rubber bands placed tightly around her wrists, both hands were swollen and the right hand had blisters. The DON stated she went to the facility, called the Administrator to inform him of the incident and then started an investigation. The DON stated socks placed on the hands and secured with rubber bands was considered a restraint and never an appropriate intervention to use on any resident. She explained facility hired and agency staff were informed during orientation that restraints were not something the facility used and they should immediately report to her or another member of Administration anytime restraints were observed in use. During an interview on 01/30/25 at 4:44 PM, the Administrator recalled he woke up around 5:30 AM on 01/27/25 and noticed he had missed a call from the DON. He called the DON and she informed him of the incident involving Resident #1. When asked what he was told by the DON, he stated at that point she was describing the aftermath, basically the extent of Resident #1's injuries. The Administrator stated when they started their investigation, they initially thought the rubber bands were placed on Resident #1's wrists on 01/26/25 during second shift (3:00 PM to 11:00 PM); however, they were learning new details about when the rubber bands were actually placed on her wrists. He stated all staff had been trained that there was a zero tolerance for abuse and neglect that included the use of restraints. He further stated it was his expectation for staff was to immediately report any suspicion of abuse which would include the use of restraints and explained if staff had questions or concerns about something unusual they had observed, then they were to report their concerns to him or the DON. Review of the initial allegation report submitted by the facility to the Division of Health Service Regulation (DHSR) revealed an allegation type of resident abuse and noted Resident #1 was found with socks on her hands and a soft binding to hold the socks in place. The socks were immediately removed, all other facility residents were checked for similar interventions with no other concerns identified, staff education was initiated, and an investigation was underway. It was noted the facility was made aware of the incident on 01/27/25 at 1:15 AM, the initial report was submitted to DHSR via fax transmission on 01/27/25 at 2:43 AM and law enforcement was notified. The initial report was completed and signed by the Director of Nursing (DON). Photographs taken of Resident #1's hands and wrists received via email correspondence dated 01/28/25 from the investigating Law Enforcement Officer were reviewed. In the first three photographs taken on 01/27/25, Resident #1's hand was covered in a gauze dressing and when the dressing was pulled back, the index finger was outside of the dressing and appeared swollen. The middle and ring fingers were bent inside the gauze dressing and you could partially visualize a raised fluid-filled blister starting at the base of the middle and ring fingers leading down the top of the hand. When the dressing was moved to visualize the wrist, the skin was red with a blister and indentation mark on the inside of the wrist where the rubber bands had been. The remaining pictures taken on 01/28/25, revealed the skin on Resident #1's right hand was red from the wrist to the fingers and there was peeling skin on the top and palm. Her left hand and palm had minimal redness with no blisters and a red mark on the wrist. Photographs of Resident #1's hands and wrists that were taken by NA #1 on 01/27/25 and received via email correspondence on 01/29/25 from the investigating Law Enforcement Officer were reviewed. There were three photographs in total. In the first photograph, both of Resident #1's hands were covered in grayish/tan gripper socks. The left hand was more prominent in the photograph and showed two rubber bands, approximately 1/8 of an inch in width, wrapped around the wrist twice and her hand above the wrist appeared 2 to 3 times its normal size in the sock. Her chin was resting on the right hand and the rubber bands were not visible but you could visualize how large her hand appeared in the sock. In the second photograph, the sock and rubber bands had been removed from the right hand and her palm was facing upward. There were red ligature marks on the lower part of the inside of her wrist. The skin on her wrist, hand and fingers were visibly swollen and bright red in appearance. There was a large, raised fluid-filled blister from the edge of the palm to the bend of her fingers that covered the width of the palm. The sock was still on her left hand and you could visualize a rubber band, approximately 1/8 of an inch in width, bound twice around her wrist. In the third photograph, was a left sided view of Resident #1's right hand that was facing upward and tilted slightly. There was a purple colored, bruised area on the outer wrist along the red ligature mark. The skin from the wrist to the fingers were bright red and swollen 2 to 3 times its normal size, resembling a lobster claw. Just underneath the outer edge of the top of the hand were two raised fluid-filled blisters at the base of the hand and a fluid-filled blister at the bend of the ringer finger to the knuckle. The Administrator was notified of Immediate Jeopardy on 01/29/25 at 6:00 PM. The facility provided the following corrective action plan: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: On 1/27/2025, resident #1 was observed with a sock on both hands and rubber bindings had been placed around each wrist to hold the socks in place. This intervention caused swelling, redness, and a 17 x 20-centimeter blister on resident #1's right hand and redness and swelling on the left hand. The facility failed to comply with the abuse policy when 7 staff members were aware of the socks and/or rubber bindings and failed to report this form of restraint to facility administration. Because of the failure to report, the facility did not protect a resident with severe cognitive impairment from abuse through unnecessary restraints. On 01/27/2025, seven staff members who admitted to knowledge of the socks and/or rubber bindings being on resident #1's hands and failing to report, were suspended pending investigation by the Director of Nursing (DON). Staff interviews attest that staff members began seeing the socks and/or rubber binding beginning on 1/19/25. On 01/27/2025, 1:1 education was provided verbally by DON to staff who reported knowledge of socks and/or rubber binding on resident #1's hands regarding abuse policy, restraint policy and the requirement to report suspected or actual abuse to the administrator or DON. On 01/27/2025, immediately following identification of concerns, DON initiated investigation. Investigation is ongoing by Administrator, DON, and Assistant Director of Nursing (ADON) and Unit Managers. All perpetrators who were aware of the use of socks and/or bindings on resident #1's hands, failed to report, and failed to remove the coverings and/or bindings are being terminated. How will the facility identify other residents having the potential to be affected by the same deficient practice: In an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 1/27/25, the abuse and reporting policy was reviewed by the administrator to ensure no changes were needed. In attendance at this meeting were the DON, ADON, and Unit Managers. It was determined that no changes were needed. On 1/27/2025, the DON completed interviews with all residents having a Brief Interview for Mental Status (BIMS) of 10 or greater to ensure that they had not experienced any abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility. On 1/27/2025, the DON completed skin assessment with all residents having a BIMS of 9 or less to ensure there was no visual indication of abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility. On 1/27/2025, DON and Administrator completed interviews with all staff working over the last 5 days. These staff members were interviewed to determine if they were aware of any other incidents of using interventions that restrict movement or abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility. On 1/27/2025, the Administrator reviewed all grievances and facility reported incidents for the last 30 days to ensure that there were no examples of a failure to report incidents as required by facility abuse and reporting policy. There were no new findings. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On 1/27/2025, the DON/Designee conducted all staff education in person and/or by telephone on the facility abuse and restraint-free policy to include a zero-tolerance for any type of resident abuse or failure to report an incident or suspected incident of abuse. Education also included that all residents have the right to be free from harm, including unnecessary or excessive physical restraint, including applying socks and bindings to hands to hinder manifestations of behaviors or for resident safety. Education focused not only on the requirement to report any unusual devices that could restrict movement, but to have open communication with the Administrator, DON, ADON, and Unit Managers about the resident population, asking questions or inquiring about any treatment or intervention that is new, uncommon, or suspected as possible abuse or a restraint. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities on 1/27/2025. On 01/27/2025, DON or designee educated all staff in person and/or by telephone to proper notification and appropriate intervention for unsafe or other unusual behaviors. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities on 1/27/2025. How will the facility monitor its corrective actions to ensure that the deficient practice will not recur: On 1/27/2025, during an ad hoc QAPI meeting, a root cause analysis was completed, and the root cause was identified as the need for additional staff education on the requirement to report unusual behavior or concerns about any intervention that restricts movement when visualized, as well as the requirement to report any incident or suspected incident of abuse immediately to the Administrator or DON. The decision was made to complete the following audits to maintain compliance with the plan of correction: DON/designee will interview 5 staff members weekly (on alternating shifts) for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present. DON/designee will review the 24-hour report (that includes Sbars) 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present. DON/designee will make a walking round 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present. The facility administrator will review findings of audits to identify patterns or trends and will present audits to QAPI for 2 months, adjusting the plan as needed to maintain compliance. IJ removal date is 1/28/25. The facility alleges compliance with this corrective action plan as of 1/28/25. A validation of the facility's corrective action plan for Immediate Jeopardy removal was completed on 01/31/25. Staff interviews revealed they had received inservice education on the facility's abuse policy and use of restraints policy which included the definition of physical restraints. Staff verbalized they were instructed that socks and rubber bands placed on a resident's hands should never be used as an intervention, was considered a restraint and to report any concerns to the Administrator immediately. Review of the attendance sign-in sheets revealed staff inservice education was completed on 01/27/25. Skin assessments were conducted on all cognitively impaired residents with no concerns identified. Alert and oriented residents were interviewed who all reported no concerns with restraints. An audit was conducted on 01/27/25 of all residents with no other restraints identified. All facility staff were interviewed on 01/27/25 and the employees who reported observing the socks and/or rubber bands on Resident #1 but did not remove them or inform anyone were suspended. Monitoring tools initiated on 01/27/25 through 01/31/25 were reviewed and completed as outlined in the facility's credible allegation with no concerns noted as identified. The Immediate Jeopardy removal date of 01/28/25 was validated.

Based on record review, photographic evidence review and staff interviews, the facility failed to submit an initial report to the State Agency that included details that accurately reflected the cause and extent of a resident's injuries for 1 of 3 residents reviewed for abuse and restraints (Resident #1). Findings included: Review of the initial allegation report submitted by the facility to the Division of Health Service Regulation (DHSR) revealed an allegation type of resident abuse. The allegation details noted Resident #1 was found with socks on her hands and a soft binding to hold the socks in place. Resident #1 was sleeping and did not appear to have any mental anguish. The socks were immediately removed, all other facility residents were checked for similar interventions with no other concerns identified, staff education was initiated, and an investigation was underway. The details of physical or mental injury/harm revealed none was apparent at this time. It was noted the facility was made aware of the incident on 01/27/25 at 1:15 AM, the initial report was submitted to DHSR via fax transmission on 01/27/25 at 2:43 AM and law enforcement was notified on 01/27/25 at 2:34 AM. The initial allegation report was completed and signed by the Director of Nursing (DON). Photographs of Resident #1's hands and wrists that were taken by Nurse Aide #1 on 01/27/25 and received via email correspondence on 01/29/25 from the investigating Law Enforcement Officer were reviewed. There were three photographs in total. In the first photograph, both of Resident #1's hands were covered in grayish/tan gripper socks. The left hand was more prominent in the photograph and showed two rubber bands, approximately 1/8 of an inch in width, wrapped around the wrist twice and her hand above the wrist appeared 2 to 3 times its normal size in the sock. Her chin was resting on the right hand and the rubber bands were not visible but you could visualize how large her hand appeared in the sock. In the second photograph, the sock and rubber bands had been removed from the right hand and her palm was facing upward. There were red ligature marks on the lower part of the inside of her wrist. The skin on her wrist, hand and fingers were visibly swollen and bright red in appearance. There was a large, raised fluid-filled blister from the edge of the palm to the bend of her fingers that covered the width of the palm. The sock was still on her left hand and you could visualize a rubber band, approximately 1/8 of an inch in width, bound twice around her wrist. In the third photograph, was a left sided view of Resident #1's right hand that was facing upward and tilted slightly. There was a purple colored, bruised area on the outer wrist along the red ligature mark. The skin from the wrist to the fingers were bright red and swollen 2 to 3 times its normal size, resembling a lobster claw. Just underneath the outer edge of the top of the hand were two raised fluid-filled blisters at the base of the hand and a fluid-filled blister at the bend of the ringer finger to the knuckle. During an interview on 01/29/25 at 3:42 PM, the DON revealed she received a call from Nurse #1 on 01/27/25 around 1:15 AM informing her that she (Nurse #1) had observed socks on both of Resident #1's hands with rubber bands placed tightly around her wrists, both hands were swollen and the right hand had blisters. The DON explained when she arrived at the facility at approximately 1:35 AM, Resident #1's hands were covered in a dressing after receiving treatment from Nurse #1 and she (Resident #1) didn't have the bandages removed until after the Law Enforcement officer arrived at the facility and they observed Resident #1's hands together. The DON stated she called the Administrator to inform him of the incident and then started an investigation which included submitting an initial report to the State Agency. During an interview on 01/30/25 at 1:45 PM with the Regional Director of Operations and Administrator present, the DON was asked why the initial report indicated there was no apparent harm to Resident #1 and her only response was that when she completed and submitted the initial report, she hadn't yet observed Resident #1's hands or knew the extent of the actual injuries, just what was initially reported by Nurse #1. The DON expressed her main focus when completing the initial report was to get it submitted to the State Agency within two hours. During a joint interview on 01/30/25 at 1:45 PM with the Administrator and DON present, the Regional Director of Operations expressed the DON was trying to ensure the initial report was submitted on time and included the information initially reported to her by Nurse #1. The Regional Director of Operations stated the extent of the injuries was documented in their investigation and would be included in the 5-day investigation report.

Based on observations and staff interviews the facility failed to store a staff member's opened drink bottle separate from residents' stored food in 1 of 3 kitchen refrigerators. The facility failed to maintain and clean 1 of 1 milk cooler, 1 of 2 ice machines, and 1 of 1 floor kitchen drains, and 1 of 1 baking sheet storage rack. The facility failed to date an opened nutritional supplement in 1 of 1 nourishment refrigerators. This practice had the potential to affect one-hundred and five (105) residents who resided at the facility. Findings Included 1. On [DATE] at 9:13 AM an observation of the reach-in milk cooler was found with an opened soda bottle laying on top of stored milk cartons. The morning cook stated on [DATE] at 9:15 AM the opened soda bottle belonged to kitchen staff, and she was unsure which staff it belonged to. She stated the drink bottle should not be kept in the cooler. 2. On [DATE] at 9:13 AM an observation of the reach-in milk cooler revealed the bottom of the milk cooler contained baking sheets which were covered with parchment paper. Multiple areas of parchment paper on each baking sheet contained dried white substance with a fuzzy greenish to brownish substance. 3. An observation of the inside of the kitchen ice maker on [DATE] at 9:17 AM found the white plastic ice shield to be unclean. The bottom of the plastic shield was directly touching the ice in the machine and the plastic shield contained an orange/pink substance that spanned the length of the ice shield. On [DATE] a follow-up kitchen observation was made with the District Dietary Manager. The ice machine plastic shield remained unchanged at 11:38 AM on [DATE]. 4. At 11:40 AM on [DATE] the in-floor drain cover for the two-compartment sink was observed to contain a thick layer of slimy white and pinkish/red colored substance covering a large portion of the drain cover. 5. At 12:33 PM on [DATE], the observation found the storage rack for ready-to-use baking sheets to contain a thick buildup of yellow and waxy to touch substance directly under the baking sheets. The District Dietary Manager stated on [DATE] at 3:34 PM she had been the temporary Dietary Manager for the kitchen since the end of [DATE]. She stated the previous Dietary Manager did not use a cleaning sheet for the kitchen staff to sign off what had been cleaned and she had started a daily cleaning sheet with assignments for kitchen staff. The District Dietary Manager said kitchen staff should not store personal food items in resident areas, the kitchen staff have their own refrigerator for personal items. She said the ice machine was cleaned monthly by the maintenance department and maintenance would clean it in between when notified. Additionally, the District Dietary Manager stated the reach-in milk cooler would be cleaned monthly or when needed. The clean storage racks, the floor drains and reach in cooler were not on a cleaning list and were assigned to be cleaned on weekends and should have been cleaned. 6. The nourishment room refrigerator was observed on [DATE] at 4:02 PM with the District Dietary Manager. The refrigerator door contained one small carton of nutritional supplement that was opened without an open date on it. The District Dietary Manager stated during the observation that the nutritional supplement was placed by a nurse without an open date after the refrigerator had been checked for opened and expired items earlier that day. The Maintenance Director was interviewed on [DATE] at 3:20 PM. He stated he cleaned the ice machine in the kitchen and nourishment room once monthly regularly and when needed. He stated he was not aware the kitchen ice machine needed to be cleaned, normally a kitchen staff would let him know or place it on the maintenance log. The Administrator stated on [DATE] at 3:30 PM dirty areas of the kitchen should be cleaned regularly and when dirty. She said the items in the nourishment room refrigerator should be dated when opened and disposed of when it expired.

Based on record review and staff, Consultant Pharmacist and Nurse Practitioner (NP) interviews the facility failed to follow up on a consultant pharmacist recommended Gradual Dose Reduction attempt (GDR) for a resident. This was for 1 of 5 residents reviewed for unnecessary medications (Resident #13). Findings Included: Resident #13 was admitted on [DATE] with diagnosis that included dementia and diabetes mellitus. A review of Resident #13's quarterly Minimal Dat Set (MDS) dated [DATE] coded her with severe cognitive impairment. She required supervision for eating and toileting, used a wheelchair for mobility and frequently incontinent of bowel and bladder. She was coded as receiving an antidepressant during the 7-day look back period. A review of the pharmacy recommendations dated 7/24/24 for Resident #13 indicated a Gradual Dose Reduction attempt (GDR) was recommended by the Consultant Pharmacist. The Nurse Practitioner (NP) agreed to the GDR for Trazadone 50 mg to Trazadone 25 mg once daily at hours of sleep (HS) and was signed on 9/10/24. The pharmacy recommendations for October 2024, recommended a GDR for Trazadone 50 mg to Trazadone 25 mg once daily at HS. The NP agreed to the GDR and signed the order on 10/19/24. A review of Resident #13's physician orders for September 2024 found that no order for Trazadone 25 mg had been entered on 9/10/24 or after that date. A review of Resident #13's physician orders for October 2024 found that Trazadone 50 mg was discontinued on 10/21/24. A physician's orders for Trazadone 25 mg once daily at HS was entered on 10/21/24. A review of Resident #13's Medication Administration Record (MAR) for September 2024 found that the resident received Trazadone 50 mg once daily during HS every day after the signed order on 9/10/24. A review of Resident #13's October 2024 MAR found the resident received Trazadone 50 mg daily during HS every day until 10/21/24. The MAR indicated that Trazadone 25 mg daily during HS was received by the resident beginning on 10/21/24. The Consultant Pharmacist was interviewed via phone on 11/1/24 at 9:50 AM. She stated she recommended GDR for Resident #13 in her pharmacy review conducted on 7/24/24. The Consultant Pharmacist stated a facility has 30 days to respond to her recommendations. In her September pharmacy review for Resident #13, the GDR for Trazadone had not been attempted, and the GDR recommendation was given to the facility again. The Consultant Pharmacist indicated she was unaware why the recommendation signed on 9/10/24 was not completed for Resident #13. She stated her monthly pharmacy recommendations are given to the Director of Nursing who provides them to the providers. The NP was interviewed via phone on 11/1/24 at 10:16 AM. The NP stated she had been a provider at the facility beginning in early September 2024. She stated there were multiple pharmacy recommendations provided to her from the DON when she began working at the facility. The NP indicated she was not aware the order for the GDR was not entered for Resident #13 after it had been signed on 9/10/24. The NP stated the October 2024 pharmacy review asked for a GDR for the medication again, and again agreed to the GDR of Trazadone on 10/19/24. The NP stated her orders for the GDR should have been entered by the unit manager or DON. The Unit Manager was interviewed on 11/1/24 at 3:43 PM. She stated the providers did give her the pharmacy recommendations after they had been signed by the provider. The Unit Manager said it was her responsibility to ensure all pharmacy recommendations and orders had been entered into resident charts. The Unit Manager stated she always signed and dated each pharmacy recommendation after it was entered into each resident's chart. The pharmacy recommendation for Resident #13 signed by the Nurse Practitioner on 9/10/24 for a gradual dose reduction attempt of Trazadone 50 mg reduced to 25 mg by mouth at hours of sleep (HS) was reviewed by the Unit Manager and was not signed by her to indicate the order had been entered. The Unit Manager stated she overlooked the pharmacy recommendation, and did not enter the order for the GDR. The Director of Nursing (DON) was interviewed on 11/1/24 at 2:25 PM. She stated the facility had changed providers in September 2024 and there had been some confusion on which pharmacy recommendations the previous providers agreed with at that time. The signed order for GDR should have been entered into Resident #13's chart when it was signed by the NP on 9/10/24. The Administrator was interviewed on 11/1/24 at 3:33 PM. She stated the Unit Manager overlooked the order for the GDR and the order should have been entered for Resident #13.

Based on observations, record review and interviews with staff the facility failed to provide a dependent and tall resident with a bed extender for (1 of 1) resident reviewed for accommodation of needs (Resident #256). Findings included: Resident #256 was admitted to the facility on [DATE]. Resident #256 was admitted with diagnosis that included right side paralysis and healing from left fibula fracture. A review of his medical record revealed his height was 72 inches tall. The admission Minimal Data Set (MDS) dated [DATE] coded Resident #256 as cognitively intact. The MDS coded Resident #256 as needing maximum 2-person assistance with transfers, and dependent with bed mobility. Resident #256 was care planned for activities of daily living (ADL) self-care performance deficit and required staff assistance to complete ADL tasks daily (10/17/24). Interventions included the resident's usual performance is to roll left to right, sitting to lying, and lying to sitting (dependent). An in-room observation was conducted in Resident #256's room on 10/29/24 at 10:50 AM. Resident #256 was observed laying in his bed with the head of the bed elevated. His body was positioned diagonally with his head and upper body on the resident's upper right corner of the bed and both his feet pressed against the left side of his bed's foot board. Further in room observation on 10/31/24 at 2:12 PM found Resident #256's feet pressed against the bed foot board. Resident #256 stated in an interview on 10/29/24 at 10:53 AM that he was too long for his bed and his feet were pushed against the foot board when he elevated the top of his bed. He stated it was hard for him to reposition up in his bed to keep his feet from touching the foot board. Additionally, he stated he was able to shift his body diagonally in his bed and it was more comfortable for him and his feet would not be pressed against the foot board. Resident#256 stated a few days after he had moved into his room, he told a staff he was too long for his bed, and he had not been placed in a longer bed and his feet had been pressed against the foot board since he was admitted . He was unable to recall who he had told he was too long for his bed. Resident #256 stated he was paralyzed on his right side of the body and could not reposition easily to prevent his feet from touching the foot board. The Physical Therapist (PT) was interviewed on 10/31/24 at 9:13 AM. The PT stated Resident #256 was receiving PT to work on safety awareness to operate in his home. His goals included to do stand and pivot transfers. Resident #256 had halo bed rails placed on his bed to help with repositioning in bed on 10/17/24. The PT stated Resident #256's body did shimmy down his bed when the head of bed is elevating causing his feet to touch the foot board. The PT said the maintenance department would install bed extenders on beds and he was unaware if maintenance had been notified about the bed extender. Resident #256's Occupational Therapist Assistant (COTA) was interviewed on 10/31/24 at 9:44 AM. She stated Resident #256 was working on strengthening his core and balance for upper body strength so he could pull himself up in bed. She stated Resident #256 would benefit from an extended bed to keep his feet from touching the footboard. The COTA said Resident #256 had made comments to her that he felt really long in his bed, and she had seen his feet touching the foot board. She said Resident #256 did slide down in his bed when the head of the bed was elevated, and she would help the resident slide his body back to the top of the bed. Resident #256's assigned Nursing Assistant (NA) #1 was interviewed on 10/31/24 at 11:56 AM. She stated she had been assigned to Resident #256 when she worked from 7:00 AM to 7:00 PM. NA #1 stated she had seen that his feet would be pushed against his bed's foot board in the morning when she went into his room to check on him after starting her shift at 7:00 AM. NA #1stated Resident #256 had not complained to her about his feet touching the foot board. Resident #256 had told her he shifted his body diagonally in the bed to give his feet more room without touching the foot board. NA #1 said she would help reposition the resident in bed to make him more comfortable by sliding him up to the top of his bed. NA #1 stated she did not know a bed extender could be used to lengthen Resident #256's bed and had not told the nurse about Resident #256's feet touching the foot board. The Maintenance Director was interviewed on 10/31/24 at 1:58 PM and stated he did install bed extenders on two beds and had not been notified Resident #256 needed a bed extender. He stated the nurses would normally let him know if a resident needed an extended bed and that he did have extenders available in the facility. The Director of Nursing (DON) was interviewed on 11/1/24 at 2:25 PM. She stated Resident #256 was tall and did need a bed extender to prevent his feet from pressing against his foot board. The DON stated the resident's assigned NAs and Nurses needed to notify the Maintenance Director for a bed extender when identified. The Administrator was interviewed on 11/1/24 at 3:33 PM. She stated Resident #256's need for a bed extender should have been reported so it could have been addressed.

Based on observations, record review and staff interviews, the facility failed to ensure the armrest of Resident #75's wheelchair remained in good repair for 1 of 3 wheelchairs observed for safe, clean and homelike environment. Findings included: Resident #75 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #75 had severe cognitive impairment. During an observation on 10/29/24 at 12:28 PM Resident #75 was sitting up in his wheelchair in his room eating lunch. On the left side of Resident #75's wheelchair, the padded armrest was being held in place to the armrest frame by 4 rows of purple tape that were wrapped around the bar of the armrest frame and top of the padded armrest. The material of the padded armrest was not cracked, broken or frayed. Subsequent observations conducted on 10/30/24 at 8:55 AM and 10/31/24 at 1:45PM revealed the condition of the armrest on Resident #75's wheelchair remained unchanged. During an interview on 10/31/24 at 1:49 PM, Nurse Aide (NA) #4 revealed Resident #75 usually sat up in his wheelchair when eating his meals. NA #4 stated when she noticed a wheelchair needing repair, she notified the Unit Manager or Nurse Supervisor who then notified the Maintenance Director. NA #4 confirmed the left armrest on Resident #75's wheelchair had purple tape wrapped around the wheelchair frame holding it into place. NA #4 stated she had not previously noticed the condition of the armrest on Resident #75's wheelchair and had not notified anyone that it needed repair. An observation of Resident #75's wheelchair and subsequent interview was conducted with the Maintenance Director on 10/31/24 at 1:57 PM. The Maintenance Director explained he replaced armrests on wheelchairs when informed by staff that repairs were needed but stated he had not been notified that the armrest on Resident #75's wheelchair needed to be replaced. The Maintenance Director confirmed the left armrest of Resident #75's wheelchair had 4 rows of purple tape wrapped around the wheelchair frame holding it into place and stated it was something that he should have been made aware of for repair to be made. During an interview on 10/31/24 at 2:15 PM, the Nurse Supervisor revealed staff usually let her know when repairs were needed and she informed the Maintenance Director. The Nurse Supervisor stated no one had mentioned anything to her regarding the armrest on Resident #75's wheelchair needing repaired. During an interview on 11/01/24 at 2:41 PM, the Director of Nursing (DON) stated staff should have notified the Maintenance Director when Resident #75's wheelchair armrest was noticed needing repair. During an interview on 11/01/24 at 3:42 PM, the Administrator stated she would have expected for staff to have notified the Maintenance Director that the armrest of Resident #75's wheelchair needed repair so that it could have been fixed sooner.

Based on record review, observations, and interviews with the staff the facility failed to ensure the air mattress settings matched the resident's current weight for 2 of 3 residents reviewed for pressure ulcers (Resident #41 and #37). The findings included: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses including age-related physical debility and Parkinson's disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #41 needed supervision/touching assistance to roll in bed and move from a sitting to lying position with no unhealed pressure ulcers or other skin conditions. The MDS noted a pressure reducing device was used for the bed. The care plan revised on 09/23/24 revealed Resident #41 was admitted to the facility with an unstageable pressure ulcer on the right buttocks that previously resolved but reopened on 09/23/24. Interventions included to monitor air mattress settings to ensure they were set to the resident's weight. The current physician orders included the use of an air mattress with directions to monitor the settings every shift and set to the resident's weight started on 09/23/24. A review of Resident #41's Medication Administration Record (MAR) for October 2024 included the physician order for an air mattress with directions to check the settings and set at the resident's weight. The checks were scheduled every shift from 7:00 AM through 7:00 PM and 7:00 PM through 7:00 AM and initialed by the nurses to indicate they checked the air mattress and the weight setting was correct from 10/01/24 through 10/31/24. A review of Resident #41's most current weight documented on 10/17/24 was 148.4 pounds. An observation on 10/31/24 at 10:28 AM revealed Resident #41 resting in the bed on the air mattress. The air mattress setting for weight was set at approximately 182 pounds. During an observation and interview on 11/01/24 at 11:32 AM Nurse #2 confirmed she was the assigned nurse for Resident #41 on 10/31/24 from 7:00 AM through 7:00 PM. Nurse #2 observed the air mattress weight setting was approximately 182 pounds and revealed when she initialed the MAR she checked the air mattress pump to ensure it was functioning. Nurse #2 stated she did not check the weight settings on the air mattress to ensure it was correct based on the weight of Resident #41 and she did not change the weight settings on the air mattress. An interview was conducted on 11/01/24 at 11:33 AM with the Director of Nursing (DON). The DON stated the nurses should visually check the weight setting on the air mattress to ensure it was correct based on the resident's current weight. The DON adjusted the weight setting to Resident #41's current weight of 148.4 pounds. 2. Resident #37 was admitted to the facility on [DATE]. Resident #37's diagnoses included dementia and malnutrition. A review of the current physician orders included the use of an air mattress with directions to ensure the setting matched Resident 37's current weight started on 06/19/24. The care plan revised on 08/05/24 identified Resident #37 as having the potential for developing a pressure ulcer related to needing assistance with bed mobility and refusal to wear and at times removed heel protector boots. Interventions included the use of an air mattress and ensure settings matched the current weight of the resident. Resident #37's quarterly MDS assessment dated [DATE] indicated there were no unhealed pressure ulcers or other skin issues and a pressure reducing device was used for the bed. A review of Resident #37's most current weight documented on 10/18/24 was 95.5 pounds. A review of Resident #37's MAR for October 2024 included the physician order with directions to check the air mattress to ensure the setting matched the resident's current weight. The checks were scheduled every shift from 7:00 AM through 7:00 PM and 7:00 PM through 7:00 AM and initialed by the nurses to indicate they checked the air mattress and the weight setting was correct from 10/01/24 through 10/31/24. The weekly skin assessment date 10/28/24 revealed Resident #37 had no new skin abnormalities. Observations on 10/29/24 at 3:02 PM and 10/30/24 at 3:51 PM revealed Resident #37 resting in bed on the air mattress. The weight setting on the air mattress was set at approximately 252 pounds. During an interview and observation on 11/01/24 at 11:18 AM Nurse #1 confirmed she was the assigned nurse for Resident #37 on 10/29/24 and 10/30/24 from 7:00 AM through 7:00 PM. Nurse #1 observed the weight setting on the air mattress was approximately 252 pounds and stated that was incorrect and she knew Resident #37 did not weigh that much. An interview and observation was conducted on 11/01/24 at 11:23 AM with the Director of Nursing (DON) in the presence of Nurse #1. The DON observed the weight setting on the air mattress was approximately 252 pounds and stated Resident #37's current weight was 95 pounds. It was shared with the DON the weight setting was observed at 252 pounds on 10/29/24 and 10/30/24 and had not changed. The DON stated when the nurses initialed the MAR they should visually check the weight setting on the air mattress and ensure it was correct based on the resident's current weight. The DON changed the weight setting on the air mattress to match Resident #37's current weight. An interview conducted on 11/01/24 at 3:45 PM with the Administrator revealed when the nurses initialed the MAR for air mattress settings it was expected they visually checked the setting to ensure it was correct based on the resident's current weight.

Based on observations, record review, and interviews with staff, the facility failed to follow their infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with an indwelling catheter (Resident #75). This failure occurred for 2 of 2 nursing staff observed for infection control practices (Nurse Aide #2 and Nurse Aide #3). Findings included: Review of the facility's Enhanced Barrier Precautions (EBP) policy and procedures dated 04/24/24 read in part, EBP are used as an infection prevention and control intervention to reduce the spread of multidrug- resistant organisms (abbreviated as MDRO and refers to a type of bacteria that are resistant to one or more classes of antibiotics) to residents. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact care activities requiring the use of gown and gloves for EBP include transferring, changing briefs or assisting with toileting and medical device care or use such as urinary catheter. The policy noted EBP should be used until the discontinuation of the indwelling medical device that placed the resident at higher risk. A physician's order dated 05/06/24 revealed in part Resident #75 was on EBP due to an indwelling urinary catheter and history of methicillin-resistant staphylococcus aureus (abbreviated as MRSA and refers to a type of bacteria resistant to several antibiotics). a. During an observation on 10/29/24 at 11:58 AM, Resident #75 was observed lying on a low bed stating he needed to use the bathroom. EBP signage was posted on the door of Resident #75's room instructing staff to wear a gown and gloves for high-contact resident care activities that included transferring, providing hygiene, changing briefs or assisting with toileting. A cart containing Personal Protective Equipment (PPE) that included gowns, gloves and masks was positioned just outside the door. Nurse Aide (NA) #2 and NA #3 were observed sanitizing their hands and donning gloves prior to entering Resident #75's room and closing the door. At 11:59 AM, when opening the door to Resident #75's room, NA #2 and NA #3 were observed holding on to Resident #75's hands/arms and physically assisting him up out of bed and into his wheelchair. Neither NA #2 nor NA #3 had donned a gown prior to assisting Resident #75 with transferring. During an interview on 10/29/24 at 12:02 AM, NA #3 exited Resident #75's room and walked to the linen cart located in the hall to gather supplies. NA #3 voiced knowledge of EBP but stated she had not noticed the EBP sign posted on Resident #75's door. NA #3 confirmed she had assisted NA #2 with transferring Resident #75 up out of bed and did not don a gown as instructed on the EBP signage prior to preforming high-contact resident care. NA #3 stated she was only trying to help and should have donned a gown in addition to gloves. b. During an observation and interview on 10/29/24 at 12:04 PM, upon knocking on and opening the door of Resident #75's room, Resident #75 was in the bathroom and NA #2 was observed standing by the bathroom door unfolding a brief. NA #2 was not wearing a gown. NA #2 looked into the bathroom and told Resident #75 she would be right back and then walked toward the bedroom door. NA #2 confirmed the EBP signage was posted on Resident #75's door and stated that she was unaware Resident #75 was still on EBP. NA #2 stated Resident #75 was on the toilet and she was assisting him with care. NA #2 verified she did not don a gown prior to assisting Resident #75 up out of bed and to the bathroom. NA #2 expressed she always wore gloves when providing high-contact resident care activities and should have also donned a gown according to the EBP signage. During an interview on 11/01/24 at 9:33 AM, the Director of Nursing (DON)/Infection Preventionist confirmed Resident #75 was on EBP due to having an indwelling urinary catheter. The DON explained if nursing staff were only providing verbal cueing to residents on EBP, then a gown was not necessary. However, if staff were actually touching the resident and/or providing physical assistance during high-contact resident care, they were expected to don the appropriate PPE. During an interview on 11/0124 at 3:42 PM, the Administrator stated staff had received education related to EBP and the posted signage was pretty clear as to what nursing staff were required to do. The Administrator stated both NA #2 and NA #3 should have followed the EBP instructions regarding PPE use when providing Resident #75's care.

Based on record review and staff and Physician interviews the facility failed to provide incontinence care in a safe manner for 1 of 3 residents reviewed for accidents (Resident #3). Findings included: Resident #3 was admitted to the facility 07/01/09 with diagnoses including stroke, hemiplegia (paralysis of one side of the body), repeated falls, and aphasia (a language disorder that affects a person's ability to communicate). Review of Resident #3's Physician orders revealed an order dated 05/03/22 for clopidogrel (an anti-platelet medication) 75 milligrams (mg) once a day for cerebral infarction (stroke) due to unspecified occlusion of cerebral (brain) artery. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired, required partial to moderate assistance with rolling from side to side in bed, had impaired range of motion on one side of his upper and lower extremities, and was always incontinent of bowel and bladder. A telephone interview with Nurse Aide (NA) #1 on 06/19/24 at 3:10 PM revealed she was caring for Resident #3 when he fell out of bed the morning of 03/27/24. She stated she provided incontinence care for Resident #3 and was changing his bottom sheet when he fell out of bed. NA #1 explained she used the bed pad to turn Resident #3 away from her so she could place the clean bed sheet underneath him and he was using his unaffected arm to hold onto a dresser beside his bed. NA #1 stated Resident #3 let go of the dresser and fell face first onto the floor. She stated Resident #3 hit his head on the dresser as he fell and began bleeding from his head. NA #1 stated she immediately notified Resident #3's nurse of his fall and the nurse assessed him right away. She stated after Resident #3's nurse assessed him; she and the nurse assisted him back to bed. NA #3 stated she had only been employed at the facility for a couple of months at the time of Resident #3's fall and she had been trained by other NAs that he only required one person assist for incontinence care and linen changes. She stated she had been trained by facility staff to roll him away from her when providing care, even with no side rails or another staff member present to assist with care. A nurse's note written by Nurse #3 and dated 03/27/24 at 5:34 AM is as follows: During rounds resident was turned and repositioned for care and fell out of the bed with 'certified nursing assistant' (CNA) present. Resident has a bruise on the left side of his head above the eyebrow, skin tear on the left knee, left elbow, second and third knuckle on the right hand. No present complaints of pain, no signs indicating resident is in discomfort. Resident was observed on his back when this writer entered the room. Vitals collected. Lacerations cleaned and dressed. Nurse #3 was unavailable for interview during the survey. Hospital records dated 03/27/24 documented Resident #3 was seen in the Emergency Department (ED) for a fall, facial laceration, and contusion of face at 10:21 AM. The note documented Resident #3 had bruising around his left eye, a laceration above his left eyebrow, and a skin tear to the left elbow and knee. A CT scan (detailed x-ray) dated 3/27/24 documented Resident #3 had no cervical spine (neck) fractures (broken bones), no facial fractures, and no intracranial (inside the skull) abnormality, but had a left forehead hematoma (bruise) with laceration. The note documented Resident #3's facial laceration did not require sutures (stitches) and was closed with tissue adhesive. The note documented Resident #3 was stable and was discharged back to the facility on [DATE] at 2:43 PM. An interview with the Director of Nursing (DON) on 06/20/24 at 3:38 PM revealed all falls were discussed in the morning meeting. She stated Resident #3's fall on 03/27/24 was discussed in the morning meeting and Physical Therapy (PT) was going to evaluate him, his mattress was changed to a bolster mattress (a mattress with built-in bolsters that define the edges of the bed and helps prevent falls), and a halo bed rail (small, round upper handrail to aid with bed mobility) was added to his bed. The DON stated residents with hemiplegia should be turned toward staff when providing care and she educated NA #3 with that information via telephone. In a follow-up telephone interview with NA #3 on 06/19/24 she confirmed she received education on 03/27/24 by the DON to turn Resident #3 toward her in the future when providing his care due to hemiplegia. A telephone interview with Physician #1 on 06/20/24 at 10:32 AM revealed he was asked to assess Resident #3 after his fall the morning of 03/27/24. Physician #1 stated that he gave orders to send Resident #3 to the hospital for evaluation because when he assessed Resident #3, he was moaning, and he felt the laceration above his eyebrow required more than adhesive tape strips to allow the wound to heal. He stated he did not feel the delay between the time Resident #3 fell and the time he was sent to the hospital on 03/27/24 caused Resident #3 any harm. An interview with the Administrator on 06/21/24 at 10:31 AM revealed she felt Resident #3 had not been eating well prior to his fall and that probably caused him to be weaker and his fall was just an unforeseen accident.

Based on record review and interviews with the Medical Doctor, Family Member, and staff the facility failed to initiate medical services for treatment of an acute change in the level of consciousness (LOC) when a resident (Resident #1) appeared lethargic and difficult to arouse. Neurological checks showed Resident #1 was drowsy at 8:30 AM with confused conversation and remained at the facility until emergency medical services was called at 5:47 PM resulting in a delay of treatment. Resident #1 was admitted to the hospital 3/31/2024 secondary to drowsiness and altered mentation. She remained in the hospital from 3/31/24 through 4/10/24 and received treatment for acute metabolic encephalopathy, acute on chronic hypoxemic respiratory failure with hypoxia, possible aspiration pneumonia, and pulmonary hypertension. This was for 1 of 3 residents reviewed to ensure the facility was free of medication errors. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, and anxiety disorder. The quarterly Minimum Data Set, dated dated dated [DATE] assessed Resident #1's cognition was severely impaired, and she was not taking opioid medications during the lookback period. The care plan last revised on 2/25/24 identified the risk of acute or chronic pain related to peripheral vascular disease, neuropathy, and falls. Interventions included administer analgesia per Medical Doctor (MD) orders and monitor for side effects of pain medication and report to the nurse complaints of pain or request for treatment. Review of the physician orders revealed no opioid medications were prescribed for Resident #1 while she was a resident at the facility. Review of the Medication Administration Record (MAR) for Resident #1 revealed the nurses initialed the following medications were administered on 3/31/24: -Levothyroxine 125 micrograms (mcg) for hypothyroidism (decreased thyroid hormones) at 6:30 AM. -Lidocaine 4% external patch for pain at 8:00 AM. -Diltiazem 240 milligrams (mg) for cardiovascular at 8:00 AM. -Pregabalin 75 mg for anxiety at 8:00 AM. -Torsemide 10 mg for edema (accumulation of fluid in body tissue) at 8:00 AM. -Albuterol sulfate 2.5 mg/3 milliliter nebulization treatment for wheezing at 8:00 AM. -Diclofenac Sodium gel 1% for neck pain at 8:00 AM. -Acetaminophen extra strength 1000 mg for pain at 8:00 AM. -Saline nasal gel for nosebleed at 9:00 AM. -Fluticasone-Umeclidin-valiant 200-62.5-25 mcg for COPD at 9:00 AM. -Clonazepam 0.5 mg for anxiety at 9:00 AM (drug class benzodiazepine not identified as positive on the hospital urine drug screen on 3/31/24). Review of a nurse progress note dated 3/31/24 at 4:59 AM revealed Unit Manager #1 documented the situation-background-assessment-recommendation (SBAR) to evaluate Resident #1 for fall on 3/30/24. Unit Manager #1 documented no changes were observed in Resident #1's mental status. During an interview on 4/11/24 at 9:47 AM Unit Manager #1 revealed right before she documented the SBAR on 3/31/24 at 4:59 AM she checked Resident #1 who was asleep in the recliner chair wearing a bilevel positive airway pressure (BiPap) (a non-invasive ventilation machine that helps with breathing and sleep apnea) and was not in distress. Unit Manager #1 explained the SBAR was a scheduled assessment for a follow-up from a previous fall on 3/30/24 used to identify any type of latent injury or change of condition and routine protocol after a resident fell . Unit Manager #1 revealed she did not administer any medications or take vital signs when she did the SBAR evaluation. Review of Resident #1's neuro checks that included vital signs and documented by Nurse #1 on 3/31/24 revealed the following: - 7:00 AM blood pressure 96/58, pulse 80, respiratory rate 18, and temperature 98.1 and the LOC alert, eyes opened to speech, and verbal responses were oriented. - 7:30 AM blood pressure 107/63, pulse 78, respiratory rate 17, temperature 97.5, LOC was drowsy, eyes opened to speech, and verbal responses were oriented. - 8:00 AM blood pressure 113/75, pulse 85, respiratory rate 18, temperature 97.3, LOC was drowsy, eyes opened to speech, and verbal responses were oriented. - 8:30 AM blood pressure 110/81, pulse 72, respiratory rate 17, temperature 97.5, LOC drowsy, eyes opened to speech, and verbal responses were now confused. - 9:30 AM Nurse #1 documented asleep with no other information provided. - 10:30 AM Nurse #1 documented asleep with no other information provided. - 11:30 AM Nurse #1 documented asleep with no other information provided. - 12:30 PM Nurse #1 documented asleep with no other information provided. Review of Resident #1's electronic medical record labeled vital signs revealed on 3/31/24 at 10:18 AM the resident's blood pressure was 96/58 and at 11:40 AM the blood glucose was 123 and oxygen level was 94% and was documented by Nurse #1. The next neuro check recorded by Nurse #1 on 3/31/23 at 4:30 PM included vital signs with a blood pressure reading of 132/85, pulse 73, respirations 16, and temperature 97.3. Nurse #1 documented Resident #1's LOC remained drowsy, eyes now opened to pain, and verbal responses continued as confused conversation. Review of the progress note written on 3/31/24 at 6:31 PM by Nurse #1 read in part, Resident #1 took the morning medications, had eaten small amount of breakfast, was sitting in the chair, and was sleepy. Resident #1 did not eat lunch, was lethargic, could not speak loudly but could follow some commands. The vital signs and blood sugar were taken, and Resident #1 was sent to the hospital. During an interview on 4/9/24 at 1:14 PM Nurse #1 revealed on 3/31/24 she was responsible for the care and completed the neuro checks for Resident #1 who appeared sleepy with each one. During the morning medication pass Nurse #1 stated she had to wake Resident #1 who was sleeping in the recliner chair, and they had short a conversation and made eye contact and the resident said she was sleepy. She described during their conversation Resident #1 did not slur her speech and it appeared she was just sleepy. It was sometime after lunch when Nurse Aide (NA) #1 made her aware Resident #1 did not eat and was still sleeping. She stated Resident #1's vital signs were normal and when she tried to wake the resident her eyes did open but she would go right back to sleep. She asked Nurse #2 sometime after lunch to check Resident #1 as she was not very familiar with the resident. Nurse #2 checked Resident #1's vital signs and they were normal, and Resident #1 was transferred to her wheelchair and placed at the nurse station so the nursing staff could keep an eye on her. Nurse #1 stated when Resident #1's LOC did not change, she reported it to Unit Manager #2 right before emergency medical services (EMS) was called and Resident #1 was transferred to hospital. Nurse #1 confirmed she did not administer the scheduled dose of clonazepam at 2:00 PM to Resident #1 because she was sleeping. An interview was conducted with the NA #1 on 4/10/24 at 3:19 PM. NA #1 revealed he was responsible for assisting Resident #1 with care on 3/30/24 and 3/31/24 and it was the first time he was the assigned NA for the resident and he was not very familiar with her. On 3/30/24 NA #1 stated he observed Resident #1 was active and doing everything herself and used the walker to take herself to the bathroom. On 3/31/24 NA #1 revealed his shift started at 7:00 AM and Resident #1 was awake and when he picked up the breakfast tray Resident #1 had not eaten or drank what was served. He asked Resident #1 if she needed help with eating and she shook her head to indicate no but did not say anything. After breakfast NA #1 stated he observed Resident #1 in the recliner chair with the television on and it was after lunch when he reported to Nurse #1, she did not eat breakfast or lunch. Nurse #1 took vital signs and asked another nurse to check Resident #1 and a second set of vital signs were taken. After the vital signs were taken NA #1 stated he assisted with transferring Resident #1 to the wheelchair, and she was placed at the nurse station for the nurses to watch. An interview was conducted on 4/10/24 at 2:15 PM with Nurse #2. Nurse #2 stated on 3/31/24 sometime after lunch Nurse #1 asked her to check Resident #1 because the resident was sleepy. Nurse #2 stated Resident #1 was sleeping in the recliner chair and when she called her name her eyes opened, and she looked at the nurse and said her son and daughters' names then closed her eyes and went back to sleep. Nurse #2 stated that was not Resident #1's baseline to be sleepy after lunchtime, but Nurse #1 said the vital signs were normal. Nurse #2 stated she, and NA #1 transferred Resident #1 to the wheelchair, and she took the resident to Unit Manager #2. She asked Unit Manager #2 to watch Resident #1 because she was sleepy. Nurse #2 stated normally Resident #1 was a one person assist with transfer, but that day needed two persons. Nurse #2 revealed Resident #1 does have times she was sleepy but on 3/31/24 kept closing her eyes and would not stay awake when talking with her. Review of the nurse's progress dated 3/31/24 at 6:22 PM revealed Unit Manager #2 documented an SBAR evaluation that included Resident #1's vital signs at 5:45 PM and the blood pressure was 153/54, pulse 75, respiratory rate 18 breaths per minute, blood glucose 121, oxygen level 91%, and temperature 98.1. The SBAR was an evaluation of Resident #1 for a change of condition due to altered mental status. The note read in part, appeared very sleepy after lunch, refused to eat lunch, and continued to be lethargic till supper time. Was easy to arouse using verbal and tactile stimuli. Complained of shortness of breath and received a bronchodilator inhaled medication but was slow to respond. The physician was notified and recommended to send Resident #1 to the emergency room for further evaluation. An interview was conducted with Unit Manager #2 on 4/11/24 at 12:16 PM. Unit Manager #2 revealed she saw Resident #1 sitting in the wheelchair at the nurses' station on 3/31/24 sometime after lunch and it appeared she was taking a nap and resting and stated no one communicated Resident #1 had been lethargic with decrease LOC or asked her to monitor or check Resident #1 at that time. She revealed it was sometime after 5:00 PM when Nurse #1 told her Resident #1 was very sleepy and asked her to check Resident #1. Unit Manager #2 stated she went directly to the room of Resident #1 and the resident's vital signs and a blood sugar had already been taken and none were abnormal. She described her assessment of Resident #1 who answered questions correctly using clear speech and followed commands and to her Resident #1 appeared sleepy with a low voice tone and was difficult to hear. Unit Manager #2 stated she called the MD right after her assessment and received an order to send Resident #1 to the emergency room . Unit Manager #2 revealed on 3/31/24 she was the person the nurses report to, and no one reported they had administered the wrong medication. She revealed she had worked on 3/30/24 from 7:00 AM through 7:00 PM and Resident #1 was visiting with a family member, and they were talking and eating and there were no concerns. Review of the EMS report revealed on 3/31/24 at 5:47 PM EMS was called and on the scene at 5:57 PM. The EMS narrative revealed nursing home staff reported Resident #1 had not spoken since 12:30 PM and appeared extremely lethargic. The EMS neurological assessment indicated Resident #1 was alert to verbal stimuli, aphasic (loss of speech) with constricted pupils and an intravenous catheter for saline fluids was placed. Review of the hospital records revealed on 3/31/24 Resident #1's evalution described she was slightly hypertensive, disoriented and weak but moving all extremities and nontoxic appearing. The Physician noted Resident #1 was well known to hospitalist service and had a complex medical history including chronic respiratory failure on home oxygen, chronic diastolic congestive heart failure, chronic kidney disease and diabetes mellitus with long-term insulin use. She had a thorough evaluation in the emergency department (ED) for altered mental status including head CT which was normal. Vitals signs in the ED included: BP 160/70, Pulse 87, Temperature 98.1 F and Respirations 20. Resident #1 was admitted for drowsiness and altered mentation. The urine drug screen was positive for opiates and negative for benzodiazepines. It was noted in the hospital records Resident #1 was administered Clonazepam (benzodiazepine) earlier that day. Resident #1 was positive for opiates with no documented administration of opioid medication in the resident's MAR. The hospital suspected an overdose and administered naloxone (an opioid reversal agent-opioid antagonist) and Resident #1 did awaken for a few minutes and then dozed off again. She was given a second dose of naloxone and had severe vomiting. Resident #1 was treated with antibiotics from 4/1/24 through 4/4/24 for possible aspiration pneumonia. A swallow study was obtained on 4/4/24 for concern of aspiration and identified minimal aspiration was present and recommended thickened liquids. Mild respiratory depression was noted with a rate of 10 breaths per minute and Resident #1 required 6 liters of oxygen before weaned back to a baseline oxygen use of 3 liters. Creatinine (lab used to check kidney function) was high 2.06 (normal 0.5 - 0.8) and the sodium level was high 146 (normal 136- 145) and Resident #1 was treated with intravenous fluids for acute kidney failure with history of stage 3 kidney disease. A chest x-ray on 4/4/24 identified congestion and edema related to a history of pulmonary hypertension that was treated with furosemide (a medication used to remove excess fluid from the body). Resident #1 remained in the hospital until discharged in stable condition on 4/10/24. An interview was conducted with the Family Member who visited Resident #1 on 3/30/24. The Family Member revealed he came to facility around 4:00 PM and visited with Resident #1 for approximately 1 to 2 hours and she did not appear sleepy and did not doze off and they had a normal conversation with each other. The Family Member revealed on 3/31/24 sometime between 5:00 PM or 6:00 PM he received a message Resident #1 was sent to the hospital and when he first saw her, she was mumbling non-legible words and it appeared to him she was in a coma like state. He was told the hospital found some type of opioid in her system and observed them administer naloxone and after the first dose was given Resident #1 woke up right away and started talking and forming legible words. That lasted approximately 2 to 3 minutes then Resident #1's condition went back to the same as it was. She was given a second dose of naloxone and had projectile vomiting and was in the hospital from 3/31/24 through 4/10/24. During an interview on 4/16/24 at 5:32 PM the Director of Nursing (DON) stated based on her interviews with the nurses and NA staff Resident #1 ate a little bit of breakfast and took her morning medications and it was sometime around lunch time when Nurse #2 indicated she had informed Unit Manager #2 that Resident #1 appeared to have decreased LOC. It was shared with the DON that Unit Manager #2 stated she did not receive report about Resident #1 until sometime after 5:00 PM. The DON stated it appeared Nurse #2 did not emphasize or provide enough information to Unit Manager #2 about what was going on with Resident #1's decreased LOC nor did she ask her to assess the resident. The DON stated the nurses monitored Resident #1 and did the neurological checks and it was noted there were no abnormal vital signs and no difficulty with breathing and the nurses based their decision not to call the MD on that information. The DON stated the nurses were aware Resident #1 did not always wear her BiPap at night and would appear sleepy the next day. She stated the nurses should have notified the MD for further guidance when Resident #1 was first noted to have a decreased LOC and not wait as long as they did. The DON was aware Resident #1 received 2 doses of naloxone at the hospital for a suspected opioid overdose and revealed the facility had naloxone available for use when a resident was suspected to have an opioid overdose, but no one suspected that as the cause of lethargy or decreased LOC because Resident #1 had no physician's orders for any type of opioid medication. The DON stated the nurses were educated to notify the MD right away when a resident had a change of condition or decreased LOC due to there were many unknown factors including a possible medication error that could cause a resident to have a change of condition or decrease in LOC. An interview was conducted on 4/9/245 at 9:45 AM with the MD. The MD revealed he was surprised the hospital's urine drug screen was positive for opiates since Resident #1 did not have an order for any type of opioid medication and this was why the facility requested a second test to rule out false positive. He did not understand why the drug screen was negative for the clonazepam that was ordered to be administered daily and was given on 3/30/24 and 3/31/24. He stated clonazepam remained in the body's system for at least 24 hours after being taken and he would have expected it to be identified in the urine drug screen on 3/31/24. The MD stated he had no other information about how the Resident #1's urine drug screen was positive for opiates but understood why the hospital suspected the resident received the wrong medication. The MD described Resident #1's baseline if having a good day, she was able to communicate her medical needs and have a conversation with him. During a follow-up interview on 4/12/24 at 3:26 PM the MD stated when Resident #1 presented with changes in her LOC observed by the nurses, he would expect the nurse to notify the MD right away to determine if resident needed to be sent to the hospital and the sooner the better. The MD stated he did not know what condition Resident #1 was in when she arrived at the hospital or what her vital signs were and cannot say the delay in treatment caused Resident #1 harm. The MD stated he was aware Resident #1 was lethargic and the urine tested positive for opiates and two doses of naloxone were administered for suspected opioid overdose. During an interview on 4/22/24 at 8:28 AM the Police Detective revealed the blood and urine samples law enforcement obtained from Resident #1 while in the hospital to rule out the possibility of a false positive or contaminated sample were sent to the state lab, but no results had been received at this time. The Police Detective revealed he would notify the State Agency (surveyor) as soon as possible once those results were received.

Based on record review and interviews with the Medical Doctor and staff the facility failed to notify the physician of a change in the resident's level of consciousness that resulted in delay in the treatment of a possible opioid overdose for 1 of 1 resident reviewed for notification (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, and anxiety disorder. The quarterly Minimum Data Set, dated dated dated [DATE] assessed Resident #1's cognition was severely impaired. Review of neuro checks documented by Nurse #1 on 3/31/24 revealed at 7:00 AM Resident #1's level of consciousness (LOC) was alert and her eyes opened to speech and verbal responses were oriented. At 8:30 AM her LOC was drowsy, and her eyes opened to speech, but the verbal responses were now confused. From 9:30 AM through 12:30 PM Resident #1 was asleep with no other information provided on those neuro checks. The next neuro check at 4:30 PM revealed Resident #1's LOC remained drowsy, but her eyes now opened to pain, and verbal responses continued as confused conversation. Further review of Resident #1's medical record revealed there was no documentation that the physician was notified of the resident's change in level of consciousness from 9:30 AM through 4:30 PM. During an interview on 4/9/24 at 1:14 PM Nurse #1 revealed on 3/31/24 she was responsible for the care and completed the neuro checks for Resident #1 who appeared sleepy with each one. It was sometime after lunch when Nurse Aide (NA) #1 made her aware Resident #1 did not eat and was still sleeping. She stated Resident #1's vital signs were normal and when she tried to wake the resident her eyes did open but she would go right back to sleep. She asked Nurse #2 sometime after lunch to check Resident #1 as she was not very familiar with the resident. Resident #1 was transferred to her wheelchair and placed at the nurse station so the nursing staff could keep an eye on her. Nurse #1 stated when Resident #1's LOC did not change, she reported it to Unit Manager #2 right before emergency medical services (EMS) was called (5:47 PM) and Resident #1 was transferred to hospital. An interview was conducted on 4/10/24 at 2:15 PM with Nurse #2. Nurse #2 stated on 3/31/24 sometime after lunch Nurse #1 asked her to check Resident #1 because the resident was sleepy. Nurse #2 stated it was not Resident #1's baseline to be sleepy after lunchtime, but Nurse #1 said the vital signs were normal. Nurse #2 stated that she, and NA #1 transferred Resident #1 to the wheelchair, and she took the resident to Unit Manager #2 and asked her to watch Resident #1 because she was sleepy. Nurse #2 revealed Resident #1 does have times she was sleepy but on 3/31/24 kept closing her eyes and would not stay awake when talking with her. Review of Unit Manager #2's progress note dated 3/31/24 at 6:22 PM revealed Resident #1's was assessed for a change of condition due to altered mental status and appeared very sleepy and continued to be lethargic till supper time. Unit Manager #2 notified the Medical Doctor who recommended Resident #1 be sent to the emergency room for further evaluation. An interview was conducted with Unit Manager #2 on 4/11/24 at 12:16 PM. Unit Manager #2 revealed she saw Resident #1 sitting in the wheelchair at the nurses' station on 3/31/24 sometime after lunch and it appeared she was taking a nap and resting. She stated no one ask she check Resident #1 for decreased LOC at that time. She revealed it was sometime after 5:00 PM when Nurse #1 reported Resident #1 was very sleepy. She assessed Resident #1 who appeared sleepy and called the MD and received an order to send Resident #1 to the emergency room . Review of the EMS report revealed on 3/31/24 at 5:47 PM EMS was called and on the scene at 5:57 PM. The EMS narrative revealed nursing home staff reported Resident #1 had not spoken since 12:30 PM and appeared extremely lethargic. EMS assessed Resident #1 was alert to verbal stimuli, aphasic (loss of speech) with constricted pupils. During an interview on 4/16/24 at 5:32 PM the Director of Nursing (DON) stated it appeared Nurse #2 did not emphasize or provide enough information to Unit Manager #2 about what was going on with Resident #1. The DON stated the nurses monitored Resident #1 neurological checks and noted there were no abnormal vital signs and no difficulty with breathing and based their decision not to call the MD on that information. She stated the nurses should have notified the MD for further guidance when Resident #1 was first noted to have a decreased LOC and not wait as long as they did. An interview on 4/12/24 at 3:26 PM the MD stated when Resident #1 presented with changes in her LOC observed by the nurses, he would expect the nurse to notify the MD right away to determine if resident needed to be sent to the hospital and the sooner the better. He stated he did not know what condition Resident #1 was in when she arrived at the hospital or what her vital signs were and cannot say the delay in treatment caused Resident #1 harm.

Based on record review and interviews with the Police Detective and staff the facility failed to submit an initial report to the state agency no later than 2 hours after receiving an allegation of neglect that resulted in hospitalization for a suspected opioid overdose for a resident who was not prescribed opioids. This deficient practice was for 1 of 3 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. The discharge Minimum Data Set, dated dated dated [DATE] indicated Resident #1 was discharged to the hospital and expected to return to the facility. The resident was not taking opioid medications during the lookback period. Review of the hospital records revealed on 3/31/24 Resident #1 was admitted for drowsiness, altered mentation, and appeared disoriented and weak. A urine drug screen revealed Resident #1 was positive for opiates and the hospital suspected an overdose and administered two doses of naloxone (an opioid reversal agent-opioid antagonist). Review of the facility's initial investigation to the state agency revealed the date and time the facility became aware of the neglect allegation was 4/3/24 at 11:45 AM. During an interview on 4/11/24 at 11:30 AM the Police Detective stated he contacted the facility on 4/2/24 and served a subpoena to obtain the medical records of Resident #1. The Police Detective revealed an allegation of neglect was made against the facility related to a medication. The Police Detective revealed he was in a hurry and did not speak with the Administrator on 4/2/24 and gave the subpoena to the person at the front desk and left. An interview was conducted on 4/11/24 at 5:11 PM with the Administrator. The Administrator revealed it was sometime after 4:30 PM on 4/2/24 when she was notified the facility was served subpoena requesting the medical records of Resident #1. She explained the subpoena included the reason was for either potential or possible negligence. She no longer had the subpoena for review but stated she was told a second Police Detective would be back in morning on 4/3/24 to explain the details. On 4/3/24 at approximately 11:45 AM the Police Detective reported the family alleged neglect related to a medication and at that time she called the Department of Social Services and sent the initial report to the state agency and began the investigation. The Administrator revealed she was aware Resident #1 was treated at the hospital for suspected opiate overdose and was not currently prescribed any type of opioid medication and she considered that as a possible medication error not a report of abuse or neglect.

Based on record review and staff interviews the facility failed to verify or check the competency and skills of an agency nurse prior to providing care and services to residents for 1 of 2 staff reviewed for competency (Nurse #3). Findings included: Review of the employee file for Nurse #3 revealed the facility verified an active and unencumbered license to practice in the state. The file did not contain verification that skills or competencies were checked to ensure Nurse #3 was competent to provide care and services to residents prior to her assignment on 3/30/24. During an interview on 4/10/24 at 3:54 PM Nurse #3 confirmed she worked for a nurse staffing agency. Nurse #3 revealed on 3/30/24 she worked the night shift from 6:45 PM through 7:15 AM on 3/31/24 and it was her first shift at the facility. An interview was conducted on 4/11/24 at 5:11 PM with the Director of Nursing (DON) and Administrator. The DON stated the facility used several staffing agencies but the competencies skills for Nurse #3 was not verified by the facility prior to her assignment on 3/30/24. She explained it was an emergency, a holiday, and last-minute attempt to cover the shift. The DON stated the Unit Manager and Administrator were at the facility during the shift on 3/30/24 and available to assist and answer any questions Nurse #3 needed help with. The Administrator revealed the facility recently lost the Scheduler whose task included setting up employee files for every agency staff in a facility position. This was the process used in the past the facility had implemented in which the Scheduler would set up agency staff files to include skill competencies check off, but the facility had lost several Schedulers. The Administrator stated moving forward the newly hired Scheduler would be tasked with setting up employee records for agency staff, but their training was not completed. The Administrator revealed it was in their contract with the staffing agencies that prior to sending staff to the facility their skills were checked to ensure they were competent to provide care and services to residents. The Administrator confirmed they did not verify with the staffing agency they had checked the competency and skills of Nurse #3 before she worked the shift on 3/30/24 and stated the agency kept the skills competency check off. A follow-up interview with Nurse #3 was attempted on 4/12/24 at 1:52 PM with no response.

Based on record review, observations, and staff interviews the facility failed to obtain active physician orders for medications observed at the bedside for 1 of 1 resident reviewed for self-administration of medications (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus and chronic pulmonary disease. The significant change Minimum Data Set assessment dated [DATE] revealed Resident #3 had minimally impaired cognition and needed extensive assistance for activities of daily living. The care plan revised on 08/28/23 revealed Resident #3 was at risk for adverse reactions related to polypharmacy and included interventions to review medications with the Medical Doctor and/or Consulting Pharmacist for duplicate medications or prescriptions, proper dosing, timing and frequency of administration, adverse reactions, and supporting diagnosis. Review of the document, Self-Medication assessment dated [DATE] revealed Resident #3 was able to administer oral medications, creams, and inhalers with supervision and cueing. An observation and interview were conducted on 10/16/23 at 10:00 AM with Resident #3. Placed on the overbed table were two 4-ounce tubes of 40 % zinc oxide cream, a bottle of fluticasone nasal spray (a steroid medication), and a bottle of nystatin powder (an antifungal medication). Resident #3 revealed the nasal spray was used once a day, the nystatin powder was applied underneath each breast when getting dressed and the zinc cream was applied after incontinence episodes. Review of the physician orders revealed no active orders for the administration or use of fluticasone, nystatin powder, and zinc oxide. An interview was conducted on 10/16/23 at 10:39 AM with Nurse #1 who confirmed she was assigned to administer medications to Resident #3. Nurse #1 revealed she was not aware Resident #3 was assessed to self-administer medications and kept zinc cream, nystatin powder, and fluticasone nasal spray in the room on the overbed table. Nurse #1 stated a physician order was needed for medications to be administered and after reviewing the orders revealed Resident #3 had no current orders in place for zinc oxide, nystatin powder, and fluticasone and removed them from the room. During an interview on 10/16/23 at 6:43 PM the Director of Nursing (DON) stated an active physician's order would need to be in place for administering zinc oxide, nystatin powder, and fluticasone nasal spray. During an interview on 10/16/23 at 7:00 PM the Administrator stated for Resident #3 to have zinc oxide, nystatin powder, and fluticasone nasal spray administered there would need to be active physician orders.

Based on record review, observations, and interviews with staff, the facility failed to maintain personal hygiene for a resident dependent on staff to clean and trim fingernails for 1 of 3 residents reviewed for activities of daily living (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident, dementia, and Parkinson's disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 cognition was minimally impaired and extensive assistance was needed for bathing and personal hygiene. The MDS indicated there were no rejection of care behaviors during the lookback period. The care plan in place for activities of daily living revised on 03/07/23 revealed a deficit in Resident #2's ability to perform self-care. Interventions included provide extensive to total assistance with personal hygiene and bathing. Review of the document, Skin Monitoring: Comprehensive Nurse Aide (NA) Shower Review revealed on 10/14/23 Resident #2 received a bed bath and was signed by NA #2. The document did not include information fingernail care was provided as part of the bed bath. During an observation and interview on 10/16/23 at 11:09 AM, Resident #2 revealed staff did provide nail care but could not recall when it was last done. Resident #2 showed the fingernails on the right and left hand were long. The right thumb and index fingernails and the left pinky, index, and ring fingernails extended approximately 1.5 to 2 centimeters (cm) past the tips of the fingers. The right thumb and index fingernails appeared dirty with a thick build-up of debris underneath the nails that was black in color. An observation on 10/16/23 at 12:25 PM revealed Resident #2 had been served the lunch meal and was eating the food using silverware. There was no change in the appearance of the fingernails. During an interview on 10/16/23 at 1:14 PM the Unit Manager revealed she kept the Skin Monitoring: Comprehensive Nurse Aide (NA) Shower Review completed by NA staff and reviewed those to ensure bathing was provided as scheduled. She revealed on 10/14/23 NA #2 signed the document for Resident #2 to indicate a bed bath was provided and there was no documentation care was refused during the bath. An observation and interview were conducted on 10/16/23 at 1:31 PM with NA #2. NA #2 confirmed she provided Resident #2 with a bed bath on 10/14/23. NA #2 observed Resident #2's fingernails were long, and the right thumb and index nails were dirty with a thick build-up of black colored debris underneath the nails. NA #2 stated she cleaned Resident #2's fingernails on 10/14/23 and was included as part of the bath but didn't recall if she had cut the nails stating at times Resident #2 would refuse nail care. NA #2 revealed when she did cut resident fingernails, she clipped the nails straight across close to top of the nail to prevent cutting the tip of the finger. NA #2 asked Resident #2 if the fingernails could be clipped and cleaned and he agreed to the care. During an interview on 10/16/23 at 2:46 PM, NA #3 confirmed she was assigned to provide personal hygiene care for Resident #3 on 10/16/23. NA #3 revealed she did notice Resident #2's fingernails were long and appeared dirty but did not offer to clean or cut the fingernails because she got busy. NA #2 revealed fingernails were supposed to be cut on bath days and it was not Resident #2's scheduled bath day and she did not serve Resident #2's meal tray and did not offer clean the fingernails prior to the lunch meal. During an interview on 10/16/23 at 6:26 PM the DON revealed Resident #2 was dependent on nursing for personal hygiene including fingernail care. The DON stated education was provided to the nurses and NA staff, the shower sheets were given to the nurse who follow up with the resident to ensure bathing was completed and the resident appeared clean including fingernails were cut and clean. The DON revealed the process failed when the nurse did not follow up to ensure nail care was done on 10/14/23 and when Resident #2's fingernails were observed to have a build-up of thick black debris, she would expect hand hygiene and/or nail care was provided to remove debris before the Resident #2 was served a meal tray. During an interview on 10/16/23 at 7:00 PM the Administrator revealed she expected NA staff provide hand hygiene prior to meal service and fingernails should be cut and cleaned if Resident #2 was accepting of the care. The Administrator revealed if a resident refused, she expected the NA staff to report this to the nurse and nurse would follow up with the resident and report to the Unit Manager.

Based on record review, observations, and staff interviews, the facility failed to serve fortified foods as directed by the physician's diet order for 2 of 3 sampled residents (Resident #1 and #2). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and dementia. An active diet order dated 09/10/23 for Resident #1 read in part, mechanical soft texture and fortified foods. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. He was independent with eating receiving setup help only with meals, received a therapeutic diet and weighed 130 pounds with no significant weight loss or gain during the MDS assessment period. During an observation on 10/16/23 at 12:40 PM, Resident #1 was observed sitting up in bed eating his lunch. Resident #1 received a serving of chicken pot pie, mixed vegetables and sliced peaches. The meal card on his lunch tray revealed a diet order for fortified foods and he was to receive fortified creamed soup. There was no soup observed on his meal tray. During an observation and interview on 10/16/23 at 12:50 PM the Administrator confirmed Resident #1 did not receive the fortified cream soup with his lunch as ordered by the physician and should have. The Administrator stated she would check with the kitchen and get the fortified soup for Resident #1. During an interview on 10/16/23 at 1:53 PM the District Dietary Manager revealed for the lunch meal on 10/16/23, residents with diet orders for fortified foods received either mashed potatoes fortified with powdered milk or fortified creamed soup. The District Dietary Manager stated Resident #1 should have received fortified creamed soup with his lunch meal and was not sure why it was overlooked. She explained the dietary aide at the end of the tray line was responsible for ensuring fortified soup was added to the meal tray when indicated on residents' meal tray cards and before the meal trays left the kitchen. During an interview on 10/16/23 at 2:18 PM, Nurse Aide (NA) #1 confirmed she delivered Resident #1 his lunch meal and there was no fortified soup served on his meal tray. NA #1 stated it had just slipped her mind to look at the meal tray card and didn't realize he should have received fortified soup with his lunch. During an interview on 10/16/23 at 7:03 PM, the Administrator stated she was not sure where the process broke down during meal service that led to Resident #1 not receiving the fortified soup as indicated on his meal tray card. The Administrator stated she expected for residents to receive fortified foods as instructed on the physician's diet order. 37538 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident, dementia, and Parkinson's disease. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had minimally impaired cognition and required supervision with setup for eating. The active physician's diet order dated 10/11/22 revealed Resident #2 receive a regular diet and fortified foods for all meals. An observation and interview were conducted on 10/16/23 at 11:50 AM of the lunch meal tray line with the Dietary Manager. The Dietary Manager revealed she recently started her position approximately one month ago. She revealed the fortified foods for the lunch meal on 10/16/23 included cream of chicken soup and mashed potatoes and showed those were available. During an observation on 10/16/23 at 12:25 PM Resident #2 was sitting upright in bed eating the lunch meal. The lunch meal consisted of chicken pot pie, mixed vegetables, a biscuit, and a bowl of fruit. The diet card on the plate read in part regular diet with no instructions fortified foods were provided at all meals. An observation and interview were conducted on 10/16/23 at 12:40 PM of the lunch meal served to Resident #2 with the Administrator. The Administrator confirmed there were no fortified foods served to Resident #2 and the diet card did not include instructions to provide with all meals. The Administrator stated if a physician's diet order was in place for Resident #2 to have fortified foods it should be served on the plate. An interview was conducted on 10/16/23 at 1:54 PM with the District Dietary Manager. The District Dietary Manager revealed a paper copy of the diet order was needed before it was entered into the meal tracker system. She stated diet orders were not entered without a paper copy of the order and was unsure the correct order was provided that include instructions to serve Resident #2 fortified foods with all meals. An interview was conducted on 10/16/23 at 7:00 PM with the Administrator. The Administrator revealed diet orders were recently audited to verify the order in the medical record matched the meal tracker and she was unsure were the breakdown in communication occurred or why fortified foods with all meals was changed and not included in the meal tracker per the current diet order instructions for Resident #2.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 12/09/21 and the recertification survey completed on 08/04/23. This was for one repeat deficiency in the area of therapeutic diet prescribed by a physician originally cited on 12/09/21 during a recertification and complaint investigation survey, 08/04/23 during a recertification survey, and subsequently recited on 10/16/23 during the revisit and complaint investigation survey. In addition, there were two repeat deficiencies in the areas of professional standards and activities of daily living provided to dependent residents originally cited on 08/04/23 during a recertification survey and subsequently recited on 10/16/23 during the revisit and complaint investigation survey. The continued failure of the facility during three federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F658: Based on record review, observations, and staff interviews the facility failed to obtain active physician orders for medications observed at the bedside for 1 of 1 resident reviewed for self-administration of medications (Resident #3). During the recertification survey of 08/04/23, the facility failed to obtain a physician's order prior to administering a medication. F677: Based on record review, observations, and interviews with staff, the facility failed to maintain personal hygiene for a resident dependent on staff to clean and trim fingernails (Resident #2) for 1 of 3 residents reviewed for activities of daily living. During the recertification survey of 08/04/23, the facility failed to maintain residents' personal hygiene by not cleaning and trimming fingernails and not trimming toenails. F808: Based on record review, observations, and staff interviews, the facility failed to serve fortified foods as directed by the physician's diet order for 2 of 3 sampled residents (Resident #1 and #2). During the recertification and complaint investigation survey of 12/09/21, the facility failed to provide therapeutic diets as ordered by the Physician for 3 residents. During the recertification survey of 08/04/23, the facility failed to serve fortified foods as directed by the physician's diet order. During an interview on 10/16/23 at 7:03 PM, the Administrator revealed it was hard for her to pinpoint where the breakdown occurred regarding the repeat concerns as they were not the result of the same caring angel who made daily rounds, same resident hall or same staff. The Administrator stated she felt the processes they put into place to address the concerns identified during the recertification survey of August 2023 were working overall as the repeat concerns identified during the revisit survey were far less and not widespread. The Administrator explained they would continue monitoring the processes previously put into place to address the areas of concern as well as review and discuss during QAPI meetings in an effort to achieve and maintain compliance going forward.

Based on record review and staff, Responsible Party, Nurse Practitioner and facility Medical Director (MD) interviews, the facility failed to protect a resident from injuries of unknown origin for 1 of 3 residents reviewed for abuse (Resident #1). On the evening of 08/09/22, Resident #1 was observed guarding her right hip and displaying pain during care. On the morning of 08/10/22, Resident #1 hollered out in pain when care was attempted, was sent out to the hospital for evaluation due to increase lethargy, and subsequently admitted for further treatment when diagnosed with the following fractures: 1) an acute (symptoms that are severe and sudden in onset) intertrochanteric fracture (type of hip fracture between the bony points of the top of the bone where the muscles of the thigh and hip attach) of the right proximal (top of the bone, closer to the center of the body) femur (thigh bone) with approximately one shaft width lateral (to the side of, or away from, the middle of the body) displacement (bone snapped in two or more parts and moved so that the two ends are not lined up straight), 3 centimeters (cm) displacement and valgus (occurs when the broken bones are turned outward away from the midline of the body to an abnormal degree) impaction (occurs when the broken ends of the bone are jammed together by the force of the injury), 2) an acute comminuted (the bone has broken into three or more pieces and in most cases, the number of bone fragments corresponds with the amount of force needed to break the bone) fracture of the left proximal femur with subtrochanteric and intertrochanteric components, at least 7 cm proximal displacement with varus (occurs when the broken bones are turned toward the center of the body) angulation (when the two ends of the broken bone are at an angle to each other), and 3) acute nondisplaced fractures (when the bone breaks or cracks but retains its proper alignment) of the left inferior and superior pubic rami (group of bones that make up part of the pelvis) extending into the pubic body that required surgical repair. Immediate Jeopardy began on 08/10/22 when Resident #1 was admitted to the hospital and found to have sustained multiple fractures. Immediate Jeopardy was removed on 11/19/22 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with severe impairment in cognition. Resident #1 required extensive staff assistance with bed mobility, transfers and toileting and limited staff assistance with walking and locomotion off the unit using a wheelchair for mobility. The MDS further noted she had no impairment of the upper or lower extremities and had no falls since admission. Resident #1's Activities of Daily Living (ADL) care plan, initiated on 08/10/22, revealed she had a self-care performance deficit related to disease process and requiring staff assistance to complete daily ADL tasks. Interventions included: extensive assistance of 1-2 staff members with bed mobility, toileting, and transfers. An incident/accident report dated 08/03/22 and completed by the Unit Supervisor noted in part, Resident #1 was observed knocking over a bedside table and sitting down on the floor from her wheelchair. Resident #1 was assessed by the Unit Supervisor with no injuries identified or signs/symptoms of pain. An incident/accident report dated 08/04/22 and completed by the Unit Supervisor noted in part, Resident #1 was seated in her wheelchair out in the hallway, lurched (make an abrupt unsteady, uncontrolled movement) out of the wheelchair and landed on her knees on the floor. Resident #1 was assessed by the Unit Supervisor with no injuries identified or signs/symptoms of pain. An incident/accident report dated 08/05/22 and completed by the Unit Supervisor noted in part, Resident #1 was seated in her wheelchair out in the hallway and launched herself out of the wheelchair landing on her bottom on the floor. Resident #1 was assessed by the Unit Supervisor with no injuries identified or signs/symptoms of pain. During an interview on 11/10/22 at 2:04 PM, the Occupational Therapy (OT) Assistant revealed he often picked up extra shifts working as a hall Nurse Aide (NA) and was assigned to provide Resident #1's care on 08/05/22 and 08/06/22. The OT Assistant explained Resident #1 was unable to ambulate on her own and required extensive staff assistance with ADL tasks. In addition, he stated Resident #1 would try to stand up unassisted by grabbing onto the handrail while out in the hall, unsteady when attempting to stand and wasn't good with verbal commands. He added nursing staff liked for Resident #1 to be up in her wheelchair during the day so that they could keep her out in the hall in visual sight because if left in bed, she had the tendency to flop around which he described as moving her legs around and not lying still. The OT Assistant recalled on 08/05/22 Resident #1 was at her normal baseline and he got her up and ready for the day without incident. He could not recall the exact time but stated while he was in another resident's room providing care, she fell out of her wheelchair out in the hallway and when he came out of the resident's room, staff were already assisting her up off the floor, but he could not recall who the staff members were. On 08/06/22, the OT Assistant stated he had noticed Resident #1 wasn't feeling well, so he left her in the bed and told the hall nurse she wasn't acting her normal self. He stated Resident #1 remained in bed the duration of his shift and when he provided her care, she did not cry out in pain or display any facial grimaces of discomfort when turned and repositioned nor did he notice any bruising, deformity or other injuries when care was provided. The OT Assistant stated he didn't feel Resident #1 was a good candidate for OT services because she couldn't retain cues or follow verbal commands. The OT Assistant stated other than 08/05/22, Resident #1 had not fallen when he was assigned to provide her care. During an interview on 11/14/22 at 5:09 PM, the Rehab Manager revealed Resident #1 was discharged from Physical Therapy (PT) and OT services on 08/08/22. The Rehab Manager stated on 08/08/22 Resident #1 received lower extremity exercises focusing on range of motion, flexibility and strengthening. The Rehab Manager added Resident #1 needed 50% verbal cueing along with manual resistance to get her to move a little more and she displayed no pain that was addressed during the therapy sessions. She added if Resident #1 had any signs of fracture on 08/08/22 the PT and/or OT therapists would have noticed when doing her lower extremity exercises and no one knew of Resident #1 having any abnormal injuries. The Rehab Manager explained Resident #1 had times when she would be very volatile with extreme movements and then other times, she would be completely docile. She added Resident #1 needed substantial to maximum assistance to transfer from the bed to wheelchair, her participation with therapy sessions would be up and down as she could retain information at times but not consistently, and basically stayed at baseline, not really advancing in therapy goals. A MD progress note dated 08/08/22 revealed in part, Resident #1 was seen at the request of family due to concerns of altered mental status, lethargy, confusion, and poor appetite .she was resting in bed in no obvious distress although she would not keep her eyes open for the family, she's more confused and not acting herself. Concerned she may have a Urinary Tract Infection ([CONDITION(S)]) or some other acute issue. The physical exam noted Resident #1 had no joint deformity or swelling, generalized weakness and her skin was warm and dry with very poor skin turgor (ability of the skin to change shape and return to normal). There was no bruising of the extremities noted. As part of the plan, the MD ordered a Urine Culture and Sensitivity (test that checks for bacteria in the urine that could cause an infection). A Nurse Practitioner (NP) progress noted dated 08/09/22 revealed in part, Resident #1 was seen to evaluate current diet orders due to nursing concerns she was on a regular texture diet and had no teeth or dentures. The physical exam noted Resident #1 had no lower extremity [CONDITION(S)] (swelling). As part of the plan, the NP ordered a Speech Therapy consult. During a telephone interview on 11/16/22 at 8:51 AM, Resident #1's Responsible Party (RP) recalled she had been at the facility the evening of 08/09/22 visiting with Resident #1 and was concerned she wasn't acting right and appeared to be in pain. The RP asked Resident #1's nurse if her behavior was normal and the nurse stated it was. The RP added the nurse stated she would continue to monitor her throughout the night and notify her of any changes. The RP stated sometime that evening (08/09/22), she received a call from the nurse who stated she had noticed Resident #1 guarding her hip and displaying pain during care. The RP asked the nurse if she needed to be sent out to the hospital for evaluation and the nurse stated she would have the physician evaluate the next morning and obtain an x-ray. The RP stated on the morning of 08/10/22 when she arrived at the facility, Resident #1 still wasn't acting normal and appeared to be in pain so she requested the facility staff to send her to the hospital for evaluation. During telephone interviews on 11/14/22 at 9:20 AM and 3:24 PM, Nurse #4 confirmed she worked 08/06/22 to 08/09/22 during the hours of 7:00 AM to 7:00 PM and was assigned to provide Resident #1's care. Nurse #4 recalled Resident #1 had remained in bed the entire weekend and did not have any falls during her shifts. Nurse #4 explained Resident #1 moaned at baseline but did not voice complaints of pain or display any non-verbal indicators of pain. Nurse #4 did not recall observing or being notified from NA staff of any bruising or deformity noticed on Resident #1's lower extremities. Nurse #4 confirmed NA #1 assisted while she inserted a catheter to obtain a urine sample from Resident #1 on 08/09/22. Nurse #4 explained they assisted Resident #1 onto her back and NA #1 held Resident #1's legs open slightly by the knees while she inserted the catheter. Nurse #4 stated during the process, she was focused on getting the urine sample and did not recall noticing any deformities or bruising to Resident #1's pelvic/hip region. Nurse #4 stated Resident #1 didn't try to resist and only cried out when the catheter was inserted but did not attempt to move in an effort to resist or try to push them away with her hands. After the urine sample was collected, Nurse #4 stated she assisted NA #1 with cleaning Resident #1 and placing her in a clean brief. Nurse #4 stated she was never told during shift report on 08/06/22 that Resident #1 had fallen on 08/03/22, 08/04/22 or 08/05/22 and didn't learn of her falls until a week later when asked to fill out some paperwork for the former DON. During a telephone interview on 11/15/22 at 1:15 PM, NA #1 confirmed she worked on 08/09/22 during the hours of 7:00 AM to 7:00 PM and was assigned to provide Resident #1's care. NA #1 explained it was the first time she had provided care to Resident #1 and recalled she had remained in bed the entire shift and did not fall. NA #1 could not recall the exact time but at one point during the shift she assisted Nurse #4 with obtaining a urine sample from Resident #1. She explained when they went into Resident #1's room, she was in bed lying on her side, they turned her over on her back, and each held her legs open by placing their hands on her inner thighs. NA #1 stated Resident #1 did not complain of any pain or try to push their hands away in an attempt to get them to stop and only hollered out when Nurse #4 inserted the catheter. After the urine sample was collected, NA #1 stated she and Nurse #4 cleaned Resident #1, placed her in a clean brief, and repositioned her back onto her side in bed. NA #1 stated Resident #1 did not display any signs of discomfort or distress the remainder of the shift. NA #1 did not recall noticing if Resident #1 had any deformity, bruising or redness when they were collecting the urine sample and stated she didn't really pay attention as she was focused on assisting Nurse #4. A nurse progress note written by Nurse #3 dated 08/10/22 at 5:41 AM read in part, Resident #1 holding right hip, grimacing while resting in bed. When ADL/incontinent care was provided, Resident #1 guards right hip/leg, holds right hip, yells out in pain. Note in physician book requesting evaluation and x-ray. During a telephone interview on 11/10/22 at 12:42 PM, NA #2 confirmed she worked on 08/09/22 during the hours of 7:00 PM to 7:00 AM and was assigned to Resident #1's hall; however, she did not specifically recall Resident #1 or care that was provided during her shift. NA #2 did state no residents had fallen during her shift on 08/09/22 and if they had, she would have reported it to the hall Nurse. During an initial telephone interview on 11/10/22 at 3:56 PM and follow-up telephone interviews on 11/15/22 at 12:00 PM and 11/16/22 at 3:56 PM, Nurse #3 confirmed she worked on 08/09/22 during the hours of 7:00 PM to 7:00 AM and was assigned to provide Resident #1's care. Nurse #3 recalled Resident #1 had poor safety awareness, at times she would sit up on the side of her bed and staff would have to help her turn around to lie back down. Nurse #3 added once in bed, Resident #1 might move her arms around a little but not in an aggressive kind of way or attempting to get up out of bed. Nurse #3 explained she kept her medication cart out in the hall outside Resident #1's door so that she could keep an eye on her and another resident across the hall and Resident #1 did not fall during the shift on 08/09/22. Nurse #3 explained staff typically went in pairs to provide Resident #1's care not because she was combative or resistive but more for safety due to her flailing her arms a lot during care, which was her baseline behavior. She stated sometime between 8:30 PM and 9:00 PM she assisted the NA (could not recall the name of the staff member) with providing incontinence care to Resident #1 and when she assisted the NA with turning Resident #1 onto her side, she noticed Resident #1 appearing to guard her hip by reaching over and placing her hand to her right hip but she did not wince or display any signs of acute pain. Nurse #3 recalled thinking is that new referring to Resident #1's behavior and stated as they provided her care, she did not notice deformity, bruising or anything else that appeared acute and Resident #1 did not display any non-verbal indicators of pain. After they had finished providing Resident #1's care, Nurse #3 stated she was repositioned back onto her right side, bed was placed in a low position and she slept fairly well the remainder of the shift. Nurse #3 added on that particular night, Resident #1 wouldn't open her eyes when spoken to but she would verbally respond to simple questions. Nurse #3 stated she spoke with Resident #1's RP that evening (08/09/22) about her condition and recalled asking the RP if it was typical behavior for Resident #1 to guard her hip and keep her eyes closed when talking to her. She remembered the RP asking if Resident #1 needed to go out to the hospital and explained she would monitor Resident #1 closely the remainder of the night and notify the physician to examine Resident #1 and order an x-ray as they usually tried to treat in house before sending residents out to the hospital. When asked about the nurse progress note she wrote on 08/10/22, Nurse #3 stated she used the wrong wording to describe Resident #1's pain the evening of 08/09/22 and explained Resident #1 was not really yelling, just moaning. Nurse #3 added at the time, she did not think Resident #1 had any acute issues that needed immediate attention so she did not call the on-call doctor, just put a note in the physician communication book and reported to the Unit Supervisor the next morning during shift report. During a telephone interview on 11/10/22 at 11:03 AM, NA #3 confirmed she worked on 08/10/22 during the hours of 7:00 AM to 3:00 PM and was assigned to provide Resident #1's care. NA #3 stated it was the first time she had provided care to Resident #1 and recalled she had remained in bed that morning until she was sent out to the hospital and did not fall. NA #3 stated she fed Resident #1 her breakfast, changed and repositioned her in bed and she never cried out or displayed any signs of pain or distress. NA #3 added when care was provided, she did not notice Resident #1 having any deformities, bruising, shortening of the legs and if she had noticed anything abnormal, she would have reported it to the hall nurse. During an interview on 11/10/22 at 2:42 PM, the Unit Supervisor recalled Resident #1 was a massive fall risk and impulsive so staff would keep her in visual sight whenever she was up out of bed in her wheelchair. The Unit Supervisor stated she was the hall nurse assigned to Resident #1's hall on 08/03/22, 08/04/22 and 08/05/22 when she had fallen from her wheelchair. On 08/03/22, the Unit Supervisor stated she was in another resident's room when notified by the Treatment Nurse that Resident #1 had lifted herself up out of the wheelchair and sat down on the floor. The Unit Supervisor stated when she immediately assessed Resident #1, she had no injuries nor displayed any signs of pain. On 08/04/22, the Unit Supervisor stated she was standing at her medication cart when she observed Resident #1 literally launch herself up out the wheelchair which she described as Resident #1 putting her hands on the armrests of the wheelchair and pushing herself forward, landing on her knees on the floor. The Unit Supervisor stated Resident #1 had been in close proximity to her medication cart; however, she couldn't reach Resident #1 fast enough to prevent the fall. She stated Resident #1 was immediately assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/05/22, the Unit Supervisor stated she witnessed Resident #1 impulsively go forward out of her wheelchair landing on her bottom on the floor. She stated Resident #1 was immediately assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The Unit Supervisor stated she didn't work again until 08/10/22 and was unaware of Resident #1 having any other falls. The Unit Supervisor recalled on the morning of 08/10/22, she was assigned to provide Resident #1's care and during shift report, Nurse #3 did not report Resident #1 having a fall or any other incident but did state Resident #1 was guarding her hip and suggested they get orders for an x-ray. The Unit Supervisor stated when she went into Resident #1's room the morning of 08/10/22, she was lying in bed, with the bed in a low position, and would not open her eyes but would respond when spoken to. The Unit Supervisor stated when she assessed Resident #1 she did not notice any bruising or other abnormalities, however, she did holler out in pain when she assisted NA #3 with turning her over to be changed. She stated Resident #1's legs were drawn up and when they tried to straighten her legs, she cried out in pain, so they stopped and she obtained orders for an x-ray. She stated Resident #1 did not fall during her shift the morning of 08/10/22 and was sent out to the hospital for evaluation due to increased lethargy. The Unit Supervisor stated due to poor safety awareness, Resident #1's bed was kept in a low position and while it was possible Resident #1 could have physically pulled herself up back into the bed, given her mentation she would have more likely just crawled or sat on the floor. The x-ray report of Resident #1's right femur and hip that was completed at the facility on 08/10/22 revealed in part, acute transverse displaced comminuted intertrochanteric fracture femur is noted. No other acute fracture or dislocation. Chronic fracture deformity at right inferior pubic ramus is noted .mineralization is decreased. A telephone interview was conducted on 11/18/22 at 10:16 AM with the X-Ray Representative of the company who performed Resident #1's x-ray at the facility on 08/10/22. The X-ray Representative explained the Radiologist who read Resident #1's x-ray was not able to give a medical opinion on how a fracture could have occurred. She stated the facility had reached out to request a second opinion and when the x-ray was read by second Radiologist, they had agreed with the original findings noted on the x-ray results. The Hospital Transfer Form dated 08/10/22 and completed by the Unit Supervisor revealed Resident #1 was sent to the hospital on 08/10/22 at 11:30 AM for evaluation of lethargy (condition marked by drowsiness and an unusual lack of energy and mental alertness). The Emergency Medical Services (EMS) report dated 08/10/22 noted upon arrival at the skilled nursing facility, Resident #1 was lying in bed with family and facility staff at bedside. The EMS report read in part, patient had her eyes closed, mumbling incoherently and was positioned oddly in bed with legs turned to the right side. Patient grimaces in pain at any attempt to straighten her extremities and is extremely tender to right hip palpation. Patient left in position of comfort, lifted via sheet and transferred to EMS stretcher. Patient remained stable, appeared comfortable and did not require any further intervention. Patient arrived at the Emergency Department (ED) where care was transferred to ED staff with report given. During a telephone interview on 11/10/22 at 12:25 PM, the EMS Responder recalled when they arrived at the facility on 08/10/22, Resident #1 was lying on the bed in an awkward position with her knees bent and turned to the right side. The EMS Responder could not recall if facility staff reported Resident #1 had fallen that day or within the past few days but stated typically when a hip injury was suspected, they would splint with a pillow placed between the legs; however, Resident #1 would not allow them to do so due to pain so they kept her in position of comfort. The EMS Responder stated with the way Resident #1 was laying, he could not tell if her leg was rotated, deformed or shorter than the other and based on the information provided by facility staff, he just assumed she had a hip fracture and focused on keeping her comfortable during transport to the hospital. The ED physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient slipped off the front of her chair today and is thought to have right-sided hip fracture per outside facility. Unclear from physical exam. Patient unable to contribute to history. Further review revealed an addendum that read in part, patient was admitted for severe [CONDITION(S)] (high concentration of sodium in the blood) and altered mental status, x-rays of her hips and pelvis were pending. The x-rays show bilateral hip fractures and pubic rami fractures. Orthopedic Surgeon will consult on patient in the hospital. Their severity is concerning and this has been noted by the Orthopedic Surgeon as well. There was no notation of any bruising. The hospital radiology report dated 08/10/22 at 3:26 PM revealed Resident #1 had the following fractures: 1) acute intertrochanteric fracture of the right proximal femur with approximately one shaft width lateral displacement, 3 cm proximal displacement and valgus impaction, 2) acute comminuted fracture of the left proximal femur with likely subtrochanteric and introchanteric components, at least 7 cm proximal displacement with varus angulation, and 3) acute nondisplaced fractures of the left inferior and superior pubic rami extending into the pubic body. Telephone attempt on 11/16/22 at 12:56 PM for interview with the Hospital Radiologist was unsuccessful. The hospital history and physical dated 08/10/22 at 4:59 PM read in part, Resident #1 was admitted to the hospital for evaluation of increased lethargy, [CONDITION(S)] and right hip fracture that was identified via x-ray at the skilled nursing facility .she was found on the ground and sent to the emergency room for further evaluation. She was found to have bilateral hip fractures, pelvic fracture and [CONDITION(S)]. The physical exam noted Resident #1's hips are deformed and shortened. There was no notation of any bruising. The Orthopedic Surgeon consultation progress note dated 08/10/22 for Resident #1 read in part, admitted for management of altered mental status, recent [CONDITION(S)], and new onset of hip discomfort. The records are not completely available and the history was pieced together through combination discussion with the Hospitalist and family .she has been noted by the family to have a deformity of both lower extremities for at least a few days. Today apparently, she was felt to have had a ground level fall. This was not witnessed. She was transferred to the ED where she was diagnosed with bilateral hip fractures and [CONDITION(S)]. Physical Examination: she is lying in the bed with the left lower extremity markedly internally rotated at the hip with the foot lying laterally. She has prominence (projection or protrusion) laterally of her femur, almost tenting (skin maintains a triangular or tentlike appearance when gently pinched) the gluteus maximus. Her right leg has slightly less prominent deformity but there is definite shortening of each extremity .she is grossly neurovascular intact (relating to or involving both nerves and blood vessels) with a bout of skin changes, but again, her exam was limited by her ability to cooperate. Recommendations: when medically cleared, we will proceed with open reduction and internal fixation of each hip .she has these significantly shortened and comminuted fractures that appear much older and much more complex than a simple ground level fall would indicate. During a telephone interview on 11/16/22 at 11:19 PM, the Orthopedic Surgeon declined to have his medical opinion included as part of the investigation regarding Resident #1's fractures. During a telephone interview on 11/14/22 at 11:05 AM, the former Director of Nursing (DON) recalled on the morning of 08/10/22, Nurse #3 reported Resident #1 was complaining of hip pain with movement during care the evening of 08/09/22 and an x-ray was obtained on 08/10/22 of her right hip. The former DON stated when she assessed Resident #1 the morning of 08/10/22, Resident #1 was lying on the right side with her knees bent and was not moaning or showing any signs of discomfort. She recalled Resident #1 would not let staff stretch her legs out and she did not try to roll Resident #1 onto her back but did look at her right hip and groin area and did not notice any redness, swelling or deformity. The former DON stated she spoke with Resident #1's RP who insisted they send Resident #1 out to the hospital and orders were obtained. She added prior to Resident #1's transport to the hospital, the x-ray had been completed and the results were forwarded to the hospital when received. The former DON stated she was not notified of Resident #1 falling on 08/09/22 or 08/10/22 prior to her transport to the hospital. The former DON stated the facility's Medical Director (MD) reviewed Resident #1's medical record but could not remember exactly what was determined to be the root cause related to Resident #1's fractures. During an interview on 11/15/22 at 11:44 AM, the Administrator revealed they had found out about the extent of Resident #1's fractures indirectly when the Admissions Director contacted the hospital for an update on her status. He stated they reached out to the hospital for more information and even requested Resident #1's hospital medical records but never received a response. The Administrator explained since the hospital would not provide any additional information related to Resident #1, their investigation of her injury was based on the x-ray obtained at the facility that showed a right hip fracture and interviews with staff who provided her care and no one reported any knowledge of Resident #1 having fallen after 08/05/22. In addition, the Administrator stated the MD reviewed Resident #1's medical record and based on her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he wasn't clinical and the MD reviewed Resident #1's medical record in attempt to try and figure out how she sustained the fracture. During a telephone interview on 11/14/22 at 12:10 PM, the Nurse Practitioner (NP) confirmed Resident #1 was seen by her on 08/09/22 due to poor appetite and concerns from nursing staff that she wasn't eating because she didn't have any dentures or teeth. The NP stated during her exam, Resident #1 was not complaining of or displaying non-verbal indicators of pain, such a guarding a particular area, nor did she observe any deformity or bruising that would have caused her to look into the acute issues further. The NP stated as part of her exams, she always observed a resident's lower legs to see if there was any [CONDITION(S)] which would indicate possible heart failure and Resident #1 had none. The NP stated she did not examine Resident #1's hip area and did not recall Resident #1's legs appearing shorter than the other during the examination. The NP stated Resident #1 was very tiny and frail and given her condition, she was prone to fractures. The NP was not aware Resident #1's hospital x-ray identified bilateral hip and pelvic fractures and explained they could have been caused due to her bone density being so poor but it was difficult to say for sure what could have caused her to sustain those types of fractures. During an interview on 11/14/22 at 2:05 PM, the facility MD stated he reviewed Resident #1's medical record as part of the facility's investigation but did not have access to her hospital medical records at the time. The MD stated during her stay at the facility, Resident #1 was able to participate with therapy, had no acute pain and would not have sustained the type of fractures indicated on the hospital x-ray due to a fall from the bed or wheelchair. Instead, he stated those types of injuries as indicated on the hospital radiology report would likely be sustained from a trauma related injury such as a motor vehicle accident, [MEDICATION(S)] force hitting the bone or a fall from a significant height and even then, the chances of bilateral hip fractures would be unlikely and would not have occurred from a single fall. He stated when he examined Resident #1 on 08/08/22, she did not display any significant pain or indicators of a fracture. He added with her fractures identified at the hospital, she would not have been without severe pain or been able to continue participating with therapy. He further stated he did not think it was possible the fractures could have occurred when she fell out of the wheelchair on 08/04/22 or 08/05/22 and not display any pain until 08/10/22. The MD added if she had an unwitnessed fall on 08/09/22 or 08/10/22, Resident #1 would not have been able to pull herself back up off the floor and into bed. The MD stated with her injuries, he would have expected her to have significant pain, bruising and/or hematoma and if there had been that type of evidence, it was not something he, facility staff or EMS would have missed. The MD stated he did not f [TRUNCATED]

Based on record review, observations and interviews with resident, staff and the Medical Director (MD), the facility failed to transfer a dependent resident using the mechanical lift which resulted in an acute left femoral neck fracture for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2). The findings included: Resident #2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #2 as being cognitively intact and requiring extensive assistance of two staff for transfers. The MDS further revealed Resident #2 had physical limitation due to right above knee amputation (AKA) and impaired vision. The Care Area Assessment (CAA) for Activities of Daily Living (ADL) associated with the 03/22/19 MDS indicated that Resident #2 required extensive assistance with bed mobility, transfer, and toileting. Resident #2 was a Spanish-speaking resident who required an interpreter to communicate all needs. Review of the care plan for ADL that was initiated on 06/14/18 and last revised on 04/01/19 revealed that Resident #2 had a self-care performance deficit related to right AKA, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The goal was that Resident #2 would improve current level of function in ADL through the next review date. Interventions included encouraging active participation in tasks, providing cueing with tasks as needed, and transferring with a mechanical lift with 2-person assist. Review of the care plan for falls that was initiated on 06/14/18 and last revised on 04/02/19 revealed Resident #2 was at risk for falls related to balance problems during transition, right AKA, and impaired vision. The goal was that Resident #2 would be free of falls through the next review date. Interventions included anticipating and meeting Resident #2's needs, ensuring call light was within reach and encouraging Resident #2 to use it for assistance as needed, and following facility fall protocol. A falls risk assessment completed on 12/13/18 revealed Resident #2 had high risk for fall due to right AKA and impaired vision. A transfer evaluation dated 12/13/18 indicated that Resident #2 required caregivers to perform 100% of the transferring task with the use of the mechanical Lift. A Situation Background Assessment Recommendation (SBAR) communication form reviewed for Resident #2 and dated 03/10/19 noted: Resident stated he felt his leg crack in the left upper groin during the 2-person transfer from chair to bed. Hoyer Lift was not used. Resident complained of severe pain after the transfer. Interpreter used for communication for 4 times. Resident complained of pain localized to the left groin only. Review of progress notes documented by Nurse #1 revealed that the physician was notified on 03/10/19 at 7:10 PM when Resident #2 complained of severe pain at his left groin areas after being transferred from wheelchair to the bed. Resident #2's responsible party (RP) was notified and present at 7:20 PM. Review of physician order [REDACTED].#2. Review of progress notes documented by the Director of Nursing (DON) revealed the facility received X-ray results on 03/11/19 at 9:52 AM which indicated Resident #2 was confirmed with an acute left femoral neck fracture. Emergency Medical Services (EMS) was called on the same day at 10:05 AM and Resident #2 was transported via stretcher by EMS to the hospital at 10:30 AM. Resident #2 was re-admitted to the facility on [DATE]. Review of incident report dated 03/11/19 revealed Resident #2 was being transferred from wheelchair to the bed on 03/10/19 by 2 nurse aides without using the mechanical lift, resulting in left femoral neck fracture. The investigation conducted by the facility was unable to determine if the fracture was caused by improper lifting or repositioning of Resident #2's leg in bed due to severe [MEDICAL CONDITION]. During an interview conducted on 04/08/19 at 4:49 PM via translator over the phone, Resident #2 stated on 03/10/19 at around 7:00 PM, 2 nurse aides (NAs) transferred him from the wheelchair to the bed without using the mechanical lift. According to Resident #2, the male NA lifted him up with both arms underneath Resident #2's shoulder while the female NA lifted the leg by lifting his pant instead of putting both of her arms underneath the leg. During the transfer, Resident #2's left leg was stuck against the bed. He heard a cracking sound and felt extreme pain at his left groin when he landed on the bed. Resident #2 added that he suffered a broken hip and was hospitalized for [REDACTED]. During a phone interview conducted on 04/08/19 at 5:48 PM, Nurse #1 stated on 03/10/19 around 7:00 PM NA #1 and NA #2 transferred Resident #2 from the wheelchair to the bed without using the mechanical lift. During the transfer, Resident #2's left leg was unsupported and pressed against the bed, causing the crack. Resident #2 complained of pain at his left groin areas after the transfer. Nurse #1 assessed Resident #2 immediately, notified the physician and RP right after the incident. Then she requested the X-ray per physician order. Nurse #1 educated both NAs of the proper way to transfer Resident #2 with the mechanical lift. During a phone interview conducted on 04/08/19 at 6:13 PM, NA #1 stated about one month ago around 7:00 PM Resident #2 requested repeatedly to be transferred from the wheelchair to the bed. NA #1 indicated that he was aware of the requirement to transfer Resident #2 by using the mechanical lift with 2-person assist but recalled the lift was around the corner and there was no lift pad underneath Resident #2 on the wheelchair. Since Resident #2 was not heavy and it was late, he decided to transfer him with the help of NA #2 without using the mechanical lift. NA #1 explained during the transfer, he lifted Resident #2 up with both arms underneath the shoulder and NA #2 grasped Resident #2's pants instead of putting her arms underneath the left leg. NA #1 denied hearing any cracking sound when Resident #2 landed on the bed. However, he did state Resident #2 complained of left leg pain after the transfer. NA #1 informed the nurse of the resident's pain immediately. Multiple attempts to interview NA #2 via phone were unsuccessful. She was unavailable to answer the calls and did not call back. During an interview conducted on 04/09/19 at 9:35 AM, the DON stated it was her expectation for all the staff to transfer residents as ordered in the care plan and follow manufacturer's directions during the transfer. The DON stated the corrective actions were started right after the incident on 3/11/19. During a phone interview conducted on 04/09/19 at 10:27 AM, the physician stated that Resident #2 was diagnosed with [REDACTED]. He stated that Resident #2's bones were so fragile that a rough landing onto the bed could have caused the fracture of his hip. It was his expectation for all the nursing staff to follow the order during transfers. During an interview conducted on 04/09/19 at 1:38 PM, the Administrator stated that it was her expectation for all the nursing staff to follow the care plan as ordered and manufacturer's directions for a safe and appropriate transfer. The facility's corrective actions implemented after the incident to prevent a reoccurrence included the following: 1. Resident #2 was assessed by Nurse #1 right after the incident on 03/10/19 and his Responsible Party (RP) and the physician were contacted immediately. Order obtained for in-house X-ray and as needed pain medication in addition to scheduled pain medication. The NAs involved in this incident were re-educated and their knowledge of Resident #2's plan of care was verified on 03/10/19. Resident #2 was sent to the hospital for evaluation and treatment when the X-ray confirmed Resident #2 with acute left femoral neck fracture on 03/11/19. 2. On 03/11/19, NA's care guides for all residents were reviewed and updated with transfer status. On the same day, return demonstration of Mechanical Lift education began by Assistant DON or designee to ensure 100% education for all nursing staff. No employees would be allowed to begin an assigned shift without having return demonstration in place. From 03/11/19 through 03/14/19, all residents' transfer evaluations were audited by the MDS coordinator for accuracy. 3. Quality improvement monitoring was initiated on 03/13/19 after all training was completed to randomly observe transfer utilizing the Mechanical Lift daily for 14 days, 5 days per week for 4 weeks, and then 3 days per week for 6 weeks. 4. The results of the monitoring would be reported at the monthly Quality Assurance and Performance Improvement (QAPI) meeting until such time as substantial compliance had been achieved. The QAPI committee recommended quarterly oversight by the District Director Clinical Services to maintain compliance when completing clinical systems review. Ad Hoc QAPI meeting was held on 03/12/19 with the DON and the Administrator in attendance. The root cause statement dated 03/12/19 in this incident was: The NAs opted to make a decision of the transfer status of a resident. The facility's corrective actions were verified on 04/08/19 through 04/09/19 by record review, observations and interview with residents and staff. The medical record of Resident #2 was reviewed. He was assessed by Nurse #1 immediately on 03/10/19. The Physician and RP were informed of the incident. Resident #2 was immediately sent to the hospital for evaluation and treatment when X-ray confirmed acute left femoral neck fracture. The DON investigated the incident. The 24-hour and 5-day reports were sent to the State Agency in timely manner. The NAs involved in the 03/10/19 incident were re-educated and their knowledge of Resident #2's plan of care was verified. In-service records were reviewed with training started on 03/11/19 and ongoing (as new staff reported for duty). All staff signed attendance sheets with in-services addressing Mechanical Lift education during transfer. A return demonstration of the Mechanical Lift was required by all the staff. All newly hired employees, nursing staff and agency staff working since 03/11/19 had received training and a system was in place to ensure all new facility staff and agency staff were properly trained and able to demonstrate return demonstration on use of all lifts. During the investigation, observations of staff transferring dependent residents utilizing the Mechanical Lift were made. Interviews were conducted with dependent residents regarding assistance provided by the staff when utilizing Mechanical Lifts for transfers. No issues were identified with observations or interviews. During the investigation, nurses and NAs (both facility and agency staff) were interviewed and verified that they received in-service on transferring residents with Mechanical Lifts with emphasis on unsafe acts or practices. Nursing staff reported that they had to demonstrate the use of the Mechanical Lift before they were allowed to start their assigned shifts. NAs stated that they had to review the care guides before every shift to identify any changes with transfer requirements for residents that they were assigned to care for. The monitoring tools were reviewed and they included random checks for residents and staff from all shifts and in the time frame indicated. The monitoring was started on 03/13/19 and was ongoing at the time of the investigation. Review of the monitoring information revealed that no concerns were noted.

Based on observations, record review, staff interviews, and resident interviews, the facility failed to keep 2 of 2 sampled residents who smoked and utilized oxygen therapy from smoking with their oxygen tanks connected to the back of their wheelchairs (Residents #2 and #4). Resident #2 sustained 2nd degree burns to his face and hand when his oxygen tubing ignited as he was smoking with his oxygen cannula in place and oxygen running. The facility failed to immediately implement an effective intervention to extinguish the fire and left the resident unattended. Resident #4 was observed smoking under staff supervision with her oxygen tank on the back of her wheelchair but turned to the off position. Immediate Jeopardy began on 12/06/16 when Resident #2 went outside with his oxygen tank running, the nasal cannula in his nares, and lit a cigarette which resulted in him catching himself on fire resulting in second degree facial and hand burns and staff did not effectively attempt to extinguish the fire and left the resident unattended. Immediate jeopardy was removed on 12/21/16 at 3:26 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of 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 supervision to prevent accidents. The findings included: The facility's Safe Smoking / Tobacco Use Policy, revised November 2016, included: *Warning: Smoking is NOT permitted while oxygen is in use. and *staff members maintain all smoking materials as appropriate and distribute smoking materials to residents at smoking times. The facility's Oxygen Storage and Assembly policy revised June 2007 included Do not smoke or allow others to smoke within 10 feet while oxygen is in use. 1. Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. A Safe Smoking Evaluation dated 10/05/16 and completed by Minimum Data Set (MDS) Nurse #1 assessed Resident #2 as able to communicate that smoking materials were for personal use only, that smoking materials were for use only in the designated smoking area, and that the resident was able to physically hold the smoking device while smoking. Upon observations it was noted that he could light and smoke a cigarette while demonstrating safe technique for putting out the matches, lights and disposing of ash and that he remained alert during the course of smoking. The evaluation determined Resident #2 was a safe smoker and no supervision was required while smoking. Under the notes section was instructed not to use O2 (oxygen) when out smoking and voiced understanding. During an interview with the Minimum Data Set (MDS) Nurse #1 conducted on 12/20/16 at 9:35 AM revealed that she watched Resident #2 smoke during his smoking assessment in October 2016. She stated she assessed him while smoking in his wheelchair with the oxygen tank located on the back of his wheelchair. She further stated that she made sure the oxygen tank was turned off but could not recall if he turned it off or if she just made sure it was turned off. MDS Nurse #2, present at this interview, and MDS Nurse #1 both stated they had observed Resident #2 smoking in the designated smoking area while in his wheelchair with the oxygen tank located on the back of the wheelchair. Both MDS Nurse #1 and MDS Nurse #2 stated they did not question the safety of smoking with an oxygen tank in the same area as this practice was normal for the facility. Resident #2's quarterly MDS dated [DATE] coded him with intact cognition, having no mood issues or behavior issues, and required supervision with bed mobility, transfers, walking, locomotion, dressing, eating and hygiene. He was coded as having impaired vision, unable to read newspaper/book print, and having no functional limitations to his upper and lower extremities. He was coded as receiving oxygen therapy. Review of the Situation, Background, Assessment, Recommendation (SBAR) report dated 12/06/16 revealed Resident #2 was outside smoking and his oxygen tubing caught fire. His hair was singed and his nose had black singed areas. This report also indicated he stated he thought his oxygen was off. The Incident/Accident Investigation Follow-up dated 12/06/16 revealed Resident #2 was out smoking with his oxygen on and set fire to his hair and face. Resident #2 was sent to the emergency room . The new intervention listed to prevent reoccurrence was for supervised smoking. Review of the hospital history and physical dated 12/06/16 revealed Resident #2 was assessed with [REDACTED]. He was noted to have second degree burns to his bilateral nares and left hand. Resident #2 was admitted to the intensive care unit for steroid intravenous therapy and close monitoring. The hospital discharge summary dated 12/08/16 included the discharge [DIAGNOSES REDACTED].>*principal problem was burn any degree involving 10-19% of body surface; *active problems included partial thickness burn of face; 2nd degree burn of left hand; COPD exacerbation; chronic respiratory failure, chronic anemia, and tobacco abuse. Resident #2 was readmitted to the facility 12/08/16 with physician orders [REDACTED]. Observations on 12/19/16 at 10:01 AM the smoking area was observed and noted to have a fire extinguisher, fire blanket, and 3 bright signs stating smoking area no oxygen. Nurse Aide (NA) #1 was interviewed on 12/19/16 at 12:22 PM. She stated she had seen Resident #2 smoke previous to the accident. She stated Resident #2 would turn his oxygen tank off before he went outside but generally smoked with the oxygen tank located on the back of his wheelchair. She stated she was never instructed that the oxygen tank should not be kept on the back of the wheelchair while he smoked. She stated she had concerns about the tank being present during smoking but no one told her otherwise. She stated she clocked out the night of 12/06/16 to go on break in the staff smoking area. She passed Resident #2 who was sitting in the alcove outside of the facility's exit leading to the smoking areas. She could not recall if he had oxygen in place or not. She proceeded to the staff smoking area and then heard a popping and crackling sound. She turned around and saw he had flames in front of his face. She stated he was flailing his arms and she could not get close to turn off the oxygen. He was situated in front of the door and she could not get inside the building so she ran to the front entrance of the building while at the same time she called 911. She stated she thought about using the fire blanket but was afraid that when she placed the blanket over his head, the running oxygen would gather under the blanket and fuel the fire causing more damage and possibly causing the oxygen to explode. When she entered the facility and got help, she and Nurse #1 and Nurse #2, found him in his room with his breathing treatment in place. Upon follow up interview via a phone call on 12/20/16 at 2:09 PM, NA #1 stated that she had been an emergency medical technician (EMT) 6 to [AGE] years ago. She stated that she was trained in the use of a fire blanket but knew it could either benefit someone or make it worse. She stated that she could not get close to him due to the flames and could not reach the oxygen tank to turn it off. She stated due to the fire, she felt the situation was unsafe for him and for her. She did not want to use the fire extinguisher because of his breathing problems and was afraid the fire blanket would create a pocket for the oxygen to build up and feed the fire. She left him in order to get help as he was blocking the door to reenter the facility and called 911 while going to get help. She stated she made the decisions she did based on her EMT training. On 12/19/16 at 2:32 PM, Resident #2 was observed propelling himself down the hall in the wheelchair with oxygen running at 3 liters per minute. No signs were located on the back of his wheelchair to alert people that oxygen was located on the wheelchair. He agreed to be interviewed at this time and proceeded to leave his wheelchair and oxygen in the hall as he walked into his room. Resident #2 was observed with slight pinkness on his cheeks where oxygen tubing would rest, his nares were shiny with what he stated was antibiotic ointment and his left hand had a scab about quarter size between the base of his thumb and base of his forefinger, which he stated was from the fire. Resident #2 stated he had been watching television in the activity room when he decided to go outside to smoke. At that time he was permitted to keep his own lighter and cigarettes. He stated the wind was blowing so he stayed close to the door of the building, not in the designated smoking area of the gazebo area and lit his cigarette. He stated he had forgotten his oxygen tubing was on his face and the oxygen was running at this time. He stated when he went to take another puff on the cigarette and flames flashed up. Resident #2 stated he burned his cannula, eyebrows, nose and hand as he yanked the nasal cannula off his face. He then stated the fire just went out. He further stated a staff member was outside and she got scared and ran around the building to get help. Once the flames were out, he went back inside the building to his room and applied his nebulizer treatment. Resident #2 stated he didn't realize he was hurt until staff and the emergency medical services (EMS) arrived. Resident #2 stated that he had always gone outside with his oxygen on the back of his wheelchair. He stated he always remembered to remove the cannula and place it away from the flames/cigarette. Resident #2 stated the tank would still be running sometimes but the cannula would be away from the cigarette. Resident #2 stated he was never told that he could not have his tank with him when he went outside to smoke. On 12/19/16 at 3:19 PM an interview with housekeeper #1 revealed she had seen Resident #2 smoke outside and he would have turned his oxygen tank off. She further stated he would keep the oxygen tank on the back of his wheelchair while he smoked after removing the nasal cannula and hanging it on the oxygen tank. On 12/19/16 at 3:24 PM Resident #10, assessed on the MDS dated [DATE] as cognitively intact, stated that when he had been outside smoking, Resident #2 had come out smoking with his oxygen tank on the back of the wheelchair. He stated that most of the times, Resident #2 turned the tank off. At times, he and other residents expressed concern to Resident #2 about the dangers of smoking with oxygen. Staff would be in their smoking area, about 20 feet away and visible between the two areas. He never told anyone of his concerns. The Nurse #1 stated on 12/19/16 at 4:21 PM that she had seen Resident #2 smoke but did not recall him smoking with oxygen in place. She stated she responded to NA #1 and another staff running in the building looking for Resident #2 saying he was on fire. Nurse #1 stated she located him in his room with soot on his face, near his eyebrows and had singed hair. NA #1 had already called 911. Interview with the Director of Nursing (DON) on 12/19/16 at 5:50 PM revealed she had not observed the residents smoke since coming to this facility a few months ago. Interview with the Staff Development Coordinator on 12/20/16 at 9:26 AM revealed that prior to Resident #2's smoking accident, she included training about the designated smoking area and the need to remove all oxygen prior to residents smoking in her orientation of new employees. On 12/20/16 at 10:03 AM, the Administrator stated she was unaware that residents were smoking with their oxygen tanks in the smoking area until 12/06/16. Resident #5, assessed per the MDS dated [DATE] as being cognitively intact, stated on 12/20/16 at 10:21 AM that she had seen Resident #2 smoking with the oxygen tank on the back of his wheelchair. She stated staff were aware of this behavior and explained she witnessed staff on occasion reminding Resident #2 to make sure his oxygen tank was turned off. Interview with the Maintenance Supervisor on 12/20/16 at 3:30 PM revealed that he trained all new employees prior to Resident #2's accident on the location of fire alarms, fire extinguishers and fire blanket. He stated there had been 2 paper signs located in plastic sleeves at the gazebo area stating this was a smoking area and no oxygen was allowed. These paper signs had been replaced since the accident with larger, brighter, sturdier ones. Nurse #2 was interviewed on 12/20/16 at 4:47 PM. Nurse #2 stated that per her own observations, Resident #2 smoked with the oxygen tank on the back of his wheelchair but had the tank turned off. Nurse #2 responded to NA #1 alerting staff she had seen him on fire. Nurse #2 stated she found him back in his room giving himself a breathing treatment she had left ready for him. She further stated that she had warned him about the tank being on the back of the wheelchair while he was smoking and he assured her staff the tank was turned off. She stated his upper lip and under his nose was blackened and the oxygen tubing had melted on his cheek. Nurse #2 stated she saw him smoke when she also smoked and he usually turned the oxygen tank off, wrapped up the nasal cannula and tubing and sat on it while he smoked. 2. Resident #4 was admitted to the facility on [DATE] with chronic obstructive pulmonary disease and dementia. Resident #4's safe smoking assessment dated [DATE] stated she needed constant supervision with smoking. Physician orders [REDACTED]. The most recent Minimum (MDS) data set [DATE] coded Resident #4 with moderately impaired cognition, adequate vision, requiring supervision for most activities of daily living skills. She was coded as using oxygen. Interview with the Director of Nursing (DON) on 12/19/16 at 5:50 PM revealed she had not observed the residents smoke since coming to this facility a few months ago. Interview with the Staff Development Coordinator on 12/20/16 at 9:26 AM revealed that prior to 12/06/16 she included training about the designated smoking area and the need to remove all oxygen prior to residents smoking in her orientation of new employees. Interview with the MDS Nurses #1 and #2 on 12/20/16 at 9:35 AM, revealed they assessed residents for smoking safety by watching them smoke outside in the designated area. Both stated that each had observed Resident #4 since the assessment in the smoking area with the oxygen tank on the back of her wheelchair, explaining again it was permitted. On 12/20/16 at 10:03 AM, the Administrator stated she was unaware that residents were smoking with their oxygen tanks in the smoking area until 12/06/16. On 12/20/16 at 10:19 AM, Resident #4 was observed in the smoking area, wearing an apron being directly supervised by agency staff #1. She was in her wheelchair but had no oxygen tank or tubing with her. During this observation, Resident #4 appeared confused when she asked staff what she was doing and the agency staff who was monitoring her explained she was outside smoking. Observations revealed bright colored 'smoking area no oxygen' signs in front of the gazebo and inside the gazebo. Interview with NA #2 on 12/20/16 at 10:15 AM revealed NA #2 supervised Resident #4 when smoking. She stated that the oxygen tank was usually on the back of her wheelchair during smoking as she was never instructed to remove the tank prior to taking her to smoke. NA #2 made sure the oxygen tank was turned off prior to lighting her cigarette. She further stated Resident #4 always kept her cigarettes in her coat pocket but did not have a lighter. NA #2 stated that all cigarettes and lighters were now kept locked up and anyone assessed as an unsafe smoker does not have access to the smoking materials. Interview with the Maintenance Supervisor on 12/20/16 at 3:30 PM revealed that prior to 12/06/16 he trained all new employees on the location of fire alarms, fire extinguishers and fire blanket. He stated there had been 2 paper signs located in plastic sleeves at the gazebo area stating this was a smoking area and no oxygen was allowed. These paper signs had been replaced since 12/06/16 with larger, brighter, sturdier ones. The Administrator and DON were informed of Immediate Jeopardy on 12/20/16 at 1:43 PM. On 12/21/16 at 12:58 PM, the facility provided the following Credible Allegation of Compliance: 1. On 12/6/16 at approximately 8:30pm Resident #2 was observed sitting outside the 400 Hall Door near the Resident and Staff smoking area by NA #1 who was exiting the facility, she did not notice if Resident #2 was smoking. NA #1 walked past Resident #2 to the staff smoking area less than 10 feet away, as she turned to sit down at the picnic table she noticed flames at Resident #2's face and hands. NA#1 immediately noticed that Resident #2 had an oxygen tank on his wheelchair and a cannula in his nares, she attempted to turn off the oxygen at the regulator but Resident #2 was flailing his arms and had positioned himself with the back of the wheelchair against the door and she was unable to reach the regulator. She was also unable to re-enter the facility for help because the wheelchair was blocking the door. NA #1 was reluctant to cover the resident with the Fire Blanket for fear of trapping more oxygen and worsening the flames. NA #1 then ran around the left corner of the facility and called 911 on her cell phone as she was running to the front door of the facility for help. As she entered the facility she notified the Charge Nurse #1 and the Supervisor #1. Charge Nurse #1 immediately ran to the 400 Hall Door and Resident #2 was no longer located there, he had extinguished the flames and returned to his Resident Room # 207. As the Charge Nurse #1 entered the Resident Room #207 she noticed Resident #2 had applied his nebulizer mask and started a nebulizer treatment, he stated I am fine, just need to finish my breathing treatment. Charge Nurse #1 and Supervisor #1 immediately removed the mask and began to assess Resident #2 for injuries. Observations included black soot to the lower half of his face and singed hair on the left side of his head and surrounding his face. The Fire Department and the Emergency Medical Services arrived and immediately transported Resident #2 to the emergency room , where he was admitted in stable condition to the ICU for observation of burns to the nasal area and respiratory monitoring. On 12/6/16 Supervisor #1 notified Resident #2's responsible party, the On Call Physician, the Facility Medical Director, the Facility Administrator and the Facility Director of Nursing. Facility Administration including the Administrator and Director of Nursing developed an immediate and interim plan to ensure safe smoking that included assigning an attendant to the Resident Smoking Area to ensure all Residents attempting to smoke were provided supervision, 12 residents were identified as current smokers and were re-assessed to determine status for oxygen use and to designate supervised or unsupervised smoking status. A meeting was conducted on 12/7/16 at 1pm with the Administrator and Director of Nursing and the District Support team to complete a full investigation into the events occurring on 12/6/16 involving Resident #2 and a Root Cause Analysis and further development of a permanent plan to ensure safe resident smoking. Resident #2 is alert and oriented with a Brief Interview for Mental Status score of 15 last assessed 9/2/16 with no recent changes in condition or mental status. His last Smoking assessment was completed on 10/5/16 at which time he was deemed safe smoker. On 10/5/16 the nurse educated Resident #2 to remove his oxygen prior to smoking and he verbalized understanding. Resident #2 was care planned as a safe smoker and able to remove his own oxygen prior to smoking. On 12/20/16 Resident #4, who uses oxygen on an as needed basis, was reviewed by the Director of Nursing. Resident #4's assessment and care plan were validated as a supervised smoker, smoking was observed and oxygen tank removed from wheelchair prior to entering the designated smoking area. On 12/20/16 NA #1 received one on one education by the Director of Nursing to include the facility's policy regarding Fire Management, Fire Extinguisher usage, the use of a Fire Blanket to extinguish a personal fire, turning off any Oxygen in use during a fire, and to supervise and attend to a resident during an emergency situation by not leaving the resident until further assistance has arrived. 2. Current Residents who smoke have the potential to be affected by this practice. By 12/7/16 the Director of Nursing and Nurse Managers completed new Smoking Assessments for current residents who smoke to determine the need for supervised smoking and to evaluate the resident's use of Oxygen. Each Resident's care plan was updated with individualized interventions based on the assessment to include: A. The need for Supervision while smoking B. The storage of smoking materials C. The use of smoking aprons D. The management of oxygen while smoking By 12/8/16 the Administrator and Director of Nursing conducted 2 meetings with 12 current residents who smoke to review and discuss the following: A. The Facility Policy for Resident's Safe Smoking B. The Difference between Supervised and Unsupervised Smokers C. The storage of smoking materials D. The schedule for supervised smoking and allowing resident input in scheduling E. Designated smoking area and available safety equipment- fire blanket, fire extinguisher and acceptable ashtrays and receptacles. Family and visitors interested in assisting residents to smoke will see the Nurse for direction prior to smoking and will be allowed in designated smoking areas. F. Smoking attendant and use of umbrellas during inclement weather to travel to the designated smoking area. G. Use of smoking aprons H. Oxygen is not allowed in the Designated Smoking Area 3. Measures put in place to ensure the alleged deficient practice does not recur include: On 12/8/16 a plan was developed to included educating Facility Staff, current Residents who smoke, and Residents' Families on re-implementation of the Facility Policy for Safe Smoking, new requirements for storage of smoking materials, how Residents are assessed to determine needs for supervision during smoking, the facility schedule for supervised smoking, no Oxygen allowed in the designated smoking areas, no smoking allowed outside of the designated area. As part of this plan a smoking attendant was assigned to monitor the designated smoking area and another attendant to monitor non-designated areas on 12/7/16. These smoking attendants will assist Residents to the designated smoking area and monitor for use of smoking aprons and no oxygen use. These attendants will also monitor non-designated areas to ensure there is no smoking in these areas. Any issues with compliance will be reported to the Administrator or Director of Nursing. Education was completed as follows: 1. By 12/8/16 the Director of Nursing and Assistant Director of Nursing educated the Facility staff on regarding the Facility Policy for Safe Smoking to include the following: A. Assessment and Care Planning of current resident who smoke on admission and quarterly and as needed with changes. Designating resident as Supervised and Unsupervised smokers. B. Receiving and Storing resident's smoking materials. C. Location of Designated Smoking Areas for Residents and Staff. Directing visitors who want to assist a resident to smoke. D. Smoking schedules and Supervision of smokers in designated smoking areas and the use of smoking aprons. Location and use of safety equipment in this area including the fire blanket, the fire extinguisher and ashtrays and receptacles. E. There is no Oxygen allowed in the designated smoking area. Additional education was provided on 12/20/16 to all facility staff by the Administrator, Director of Nursing, Area Staff Development Director and Nurse Managers to include: -the Facility policy for Fire Management - Fire Extinguisher usage to include the Pull, Aim, Squeeze and Sweep method for effective fire extinguishing -use of a Fire Blanket to cover and smother flames to manage a personal fire -discontinuing any Oxygen in use and removing the tank as soon as possible during a fire -Supervise and attend to a Resident during an emergency situation by not leaving the resident until further assistance has arrived No staff shall work after 12/20/16 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 in resident care areas after 12/20/16. 2. By 12/8/16 the Administrator and Director of Nursing conducted 2 meetings with 12 current residents who smoke and their families to review and discuss the following: A. The Facility Policy for Resident's Safe Smoking B. The Difference between Supervised and Unsupervised Smokers C. The storage of smoking materials D. The schedule for supervised smoking and allowing resident input in scheduling E. Designated smoking area and available safety equipment- fire blanket, fire extinguisher and acceptable ashtrays and receptacles. Family and visitors interested in assisting residents to smoke will see the Nurse for direction prior to smoking and will be allowed in designated smoking areas. F. Smoking attendant and use of umbrellas during inclement weather to travel to the designated smoking area. G. Use of smoking aprons H. Oxygen is not allowed in the Designated Smoking Area New Residents who smoke and are admitted after 12/8/16 will receive this education when the Smoking Assessment is completed and Care Plan developed. The Facility's new Admission packet has been updated to include this information and education. Immediate jeopardy was removed on 12/21/16 at 3:26 PM when interviews with residents, nursing staff, administrative staff and non-nursing staff confirmed they had receiving in-service training on the facility's policy to remove all oxygen tanks and tubing prior to going into the designated smoking area, the new storage system for smoking materials, the available smoking equipment including smoking aprons, ashtrays, fire extinguisher and fire blankets, the returned demonstration of how to use a smoking blanket and what actions to take when a resident was found on fire.

Based on observations, record review, resident interviews, and staff interviews, the administration failed to oversee and enforce the facility's smoking policy and procedures to ensure 2 of 2 sampled residents (Residents #2 and #4) who smoked and utilized oxygen did not smoke with oxygen tanks on their wheelchairs and that staff were educated and followed the smoking policy. In addition, the administration failed to provide leadership in ensuring staff was adequately prepared to react in an emergency situation when one resident (Resident #2) caught fire while smoking with oxygen running resulting in 2nd [MEDICAL CONDITION] his face and hand. Immediate jeopardy began on 12/06/16 when Resident #2 went outside with his oxygen tank running, the nasal cannula in his nares, away from the designated smoking area and lit a cigarette which resulted in him catching himself on fire resulting in second degree facial and hand burns. Nurse Aide #1 who was in a nearby area at the time of the incident, failed to effectively intervene when she saw Resident #2 on fire. She left the resident on fire outside blocking the facility door as she ran around the building to the front door while calling 911 in order to obtain additional staff assistance. Immediate jeopardy was removed on 12/21/16 at 3:26 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of 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 supervision, oxygen storage and use, smoking material storage and staff preparedness to extinguish a resident who is on fire. The findings included: 1. Cross Refer to F323: Based on observations, record review, staff interviews, and resident interviews, the facility failed to keep 2 of 2 sampled residents who smoked and utilized oxygen therapy from smoking with their oxygen tanks connected to the back of their wheelchairs (Residents #2 and #4). Resident #2 sustained 2nd [MEDICAL CONDITION] his face and hand when his oxygen tubing ignited as he was smoking with his oxygen cannula in place and oxygen running. The facility failed to immediately implement an effective intervention to extinguish the fire and left the resident unattended. Resident #4 was observed smoking under staff supervision with her oxygen tank on the back of her wheelchair but turned to the off position. 2. Cross Refer to F518: Based on record reviews, policy review, staff interviews and resident interviews, the facility failed to provide effective staff training on fire prevention and fire emergency measures which resulted in second [MEDICAL CONDITION] 1 of 2 oxygen dependent residents who smoked, Resident #2, who was found on fire while smoking with his oxygen flowing. The facility Administrator and Director of Nursing were informed of Immediate Jeopardy on 12/20/16 at 1:43 PM. The facility provided a credible allegation of compliance on 12/21/16 at 1:51 PM as follows: 1. On 12/6/16 at approximately 8:30pm Resident #2 was observed sitting outside the 400 Hall Door near the Resident and Staff smoking area by NA #1 who was exiting the facility, she did not notice if Resident #2 was smoking. NA #1 walked past Resident #2 to the staff smoking area less than 10 feet away, as she turned to sit down at the picnic table she noticed flames at Resident #2's face and hands. NA #1 immediately noticed that Resident #1 had an oxygen tank on his wheelchair and a cannula in his nares, she attempted to turn off the Oxygen at the regulator but Resident #2 was flailing his arms and had positioned himself with the back of the wheelchair against the door and she was unable to reach the regulator. She was also unable to re-enter the facility for help because the wheelchair was blocking the door. NA#1 was reluctant to cover the resident with the Fire Blanket for fear of trapping more oxygen and worsening the flames. NA#1 then ran around the left corner of the facility and called 911 on her cell phone as she was running to the front door of the facility for help. As she entered the facility she notified the Charge Nurse #1 and the Supervisor #1. Charge Nurse# 1 immediately ran to the 400 Hall Door and Resident #2 was no longer located there, he had extinguished the flames and returned to his Resident room [ROOM NUMBER]. As the Charge Nurse #1 entered the Resident room [ROOM NUMBER] she noticed Resident #2 had applied his nebulizer mask and started a nebulizer treatment, he stated I am fine, just need to finish my breathing treatment. Charge Nurse #1 and Supervisor #1 immediately removed the mask and began to assess Resident #2 for injuries. Observations included black soot to the lower half of his face and singed hair on the left side of his head and surrounding his face. The Fire Department and the Emergency Medical Services arrived and immediately transported Resident #2 to the emergency room , where he was admitted in stable condition to the ICU for observation [MEDICAL CONDITION] the nasal area and respiratory monitoring. On 12/6/16 Supervisor #1 notified Resident #2's responsible party, the On Call Physician, the Facility Medical Director, the Facility Administrator and the Facility Director of Nursing. Facility Administration including the Administrator and Director of Nursing developed an immediate and interim plan to ensure safe smoking that included assigning an attendant to the Resident Smoking Area to ensure all Residents attempting to smoke were provided supervision, 12 residents were identified as current smokers and were re-assessed to determine status for oxygen use and to designate supervised or unsupervised smoking status. A meeting was conducted on 12/7/16 at 1pm with the Administrator and Director of Nursing and the District Support team to complete a full investigation into the events occurring on 12/6/16 involving Resident #2 and a Root Cause Analysis and further development of a permanent plan to ensure safe resident smoking. Resident #2 is alert and oriented with a BIMS score of 15 last assessed 9/2/16 with no recent changes in condition or mental status. His last Smoking assessment was completed on 10/5/16 at which time he was deemed safe smoker. On 10/5/16 the nurse educated Resident #2 to remove his oxygen prior to smoking and he verbalized understanding. Resident #2 was care planned as a safe smoker and able to remove his own oxygen prior to smoking. On 12/20/16 Resident #4, who uses oxygen on an as needed basis, was reviewed by the Director of Nursing. Resident #4 ' s assessment and care plan were validated as a supervised smoker, smoking was observed and oxygen tank removed from wheelchair prior to entering the designated smoking area. On 12/20/16 NA #1 received one on one education by the Director of Nursing to include the facility ' s policy regarding Fire Management, Fire Extinguisher usage, the use of a Fire Blanket to extinguish a personal fire, turning off any Oxygen in use during a fire, and to supervise and attend to a resident during an emergency situation by not leaving the resident until further assistance has arrived. 2. Current Residents who smoke have the potential to be affected by this practice. By 12/7/16 the Director of Nursing and Nurse Managers completed new Smoking Assessments for current residents who smoke to determine the need for supervised smoking and to evaluate the resident's use of oxygen. Each Resident's careplan was updated with individualized interventions based on the assessment to include: A. The need for Supervision while smoking B. The storage of smoking materials C. The use of smoking aprons D. The management of oxygen while smoking By 12/8/16 the Administrator and Director of Nursing conducted 2 meetings with 12 current residents who smoke and their families to review and discuss the following: A. The Facility Policy for Resident's Safe Smoking B. The Difference between Supervised and Unsupervised Smokers C. The storage of smoking materials D. The schedule for supervised smoking and allowing resident input in scheduling E. Designated smoking area and available safety equipment- fire blanket, fire extinguisher and acceptable ashtrays and receptacles. Family and visitors interested in assisting residents to smoke will see the Nurse for direction prior to smoking and will be allowed in designated smoking areas. F. Smoking attendant and use of umbrellas during inclement weather to travel to the designated smoking area. G. Use of smoking aprons H. Oxygen is not allowed in the Designated Smoking Area New Residents who smoke and are admitted after 12/8/16 will receive this education when the Smoking Assessment is completed and Care Plan developed. The Facility's new Admission packet has been updated to include this information and education. 3. Measures put in place to ensure the alleged deficient practice does not recur include: On 12/7/16 the Administrator, Director of Nursing, District Director of Operation and District Director of Clinical Services held a meeting with the Interdisciplinary Team to conduct a Root Cause Analysis regarding Resident non-compliance with the Facility's policy for Safe Smoking, safety for Residents who smoke and use Oxygen, and Residents identified smoking in areas not designated for smoking. The Team reviewed the current policy, discussed the current method for assessing Residents, observed designated smoking area for environmental needs and improvements, addressed Oxygen storage prior to entering the designated smoking area, identified an opportunity with effective storage for resident's smoking materials and recommended a need for monitoring both designated and non-designated areas to ensure compliance. Based on the results of this Root Cause Analysis a plan was developed to included Facility specific policy and procedures to ensure safe smoking by Residents. A plan was developed by the Interdisciplinary team including the Administrator, Director of Nursing and Facility Department Heads to include Facility specific policy and procedures to ensure safe smoking by Residents. These policies were implemented by educating current Facility Staff, current Residents who smoke, and Residents' Families on the Facility Policy for Safe Smoking. New requirements for storage of smoking materials, how Residents are assessed to determine needs for supervision during smoking, the facility schedule for supervised smoking, no Oxygen allowed in the designated smoking areas, no smoking allowed outside of the designated area, and fire safety were included in this education. As part of this plan a smoking attendant was assigned to monitor the designated smoking area and another attendant to monitor non-designated areas on 12/7/16. These smoking attendants will assist Residents to the designated smoking area and monitor for use of smoking aprons and no oxygen use. These attendants will also monitor non-designated areas to ensure there is no smoking in these areas. Any issues with compliance will be reported to the Administrator or Director of Nursing. Education was completed as follows: 1. By 12/8/16 the Director of Nursing and Assistant Director of Nursing educated the Facility staff including Administration, Nursing, Therapy, Housekeeping and Dietary regarding the Facility Policy for Safe Smoking to include the following: A. Assessment and Care Planning of current resident who smoke on admission and quarterly and as needed with changes. Designating resident as Supervised and Unsupervised smokers. B. Receiving and Storing resident ' s smoking materials C. Location of Designated Smoking Areas for Residents and Staff. Directing visitors who want to assist a resident to smoke. D. Smoking schedules and Supervision of smokers in designated smoking areas and the use of smoking aprons. Location and use of safety equipment in this area including the fire blanket, the fire extinguisher and ashtrays and receptacles. E. There is no Oxygen allowed in the designated smoking area An educational plan was developed by the Interdisciplinary Team consisting of the Administrator, Director of Nursing, Social Services, Director of Rehab, Director of Housekeeping and Director of Dietary Services on 12/20/16 to include Facility specific policy and procedures for Fire Management and Smoking that address Oxygen is prohibited in designated smoking areas. On 12/20/16 this Fire Safety educational plan was reviewed and further developed by the Administrator, Director of Nursing and the Area Staff Development Director with assistance from the District Field Support Team. This review included involvement with the local Fire Marshall who reviewed and accepted this plan. Additional education was provided on 12/20/16 to all facility staff including Administration, Nursing, Therapy, Housekeeping and Dietary by the Administrator, Director of Nursing, Area Staff Development Director and Nurse Managers to include: A. -The Facility policy and procedures for Fire Management, Smoking and that Oxygen is not prohibited in designated smoking areas. B. -Fire Extinguisher usage to include the Pull, Aim, Squeeze and Sweep method for effective fire extinguishing as outlined in the facility policy for Fire Management. C. -Use of a Fire Blanket to cover and smother flames to manage a personal fire as outlined in the facility policy for Fire Management. D. -Discontinuing any Oxygen in use and removing the tank as soon as possible during a fire as outlined by the facility policy for Fire Management. E. -Supervise and attend to a Resident during an emergency situation by not leaving the resident until further assistance has arrived. The Administrator and Director of Nursing will oversee this updated educational plan for completion and effectiveness during orientation and annual training based on observations and ongoing participation in training sessions. Monthly observation of education and return demonstration by staff during educational sessions will be observed and completed by the Administrator and Director of Nursing to validate the effectiveness of education for 6 months. Fire Drills will be conducted monthly by the Maintenance Director with oversight from the Administrator and Director of Nursing to further validate compliance. Ongoing education will include additional Fire Safety training for current facility staff provided by the local Fire Marshall to be completed by January 15, 2017. This education will include: -General Fire Safety with a video presentation -When and How to correctly use a Fire Extinguisher -When and How to correctly use a fire Blanket -Oxygen precautions with regards to Fire Safety This training is scheduled on the following dates: -January 4, 2017 at 7am -January 5, 2017 at 2:30pm -January 11, 2017 at 10am -January 12, 2017 at 3:30pm The Administrator and Director of Nursing will have no tolerance for noncompliance with the Facility Safe Smoking policies and Fire Safety. No staff shall work after 12/20/16 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 in resident care areas after 12/20/16. Ongoing Fire Safety training will be held annually for all facility staff and more frequently if an opportunity with compliance is identified. Immediate jeopardy was removed on 12/21/16 at 3:26 PM when interviews with residents, nursing staff, administrative staff and non-nursing staff confirmed they had receiving in-service training on the facility's policy to remove all oxygen tanks and tubing prior to going into the designated smoking area, the new storage system for smoking materials, the available smoking equipment including smoking aprons, ashtrays, fire extinguisher and fire blankets, the returned demonstration of how to use a smoking blanket and what actions to take when a resident was found on fire. Interview with the 24/7 staff monitors and observations revealed all smoking materials were maintained in a secured location and verified by staff, all oxygen tanks were removed prior to going to the smoking area and supervision with necessary equipment was provided to all unsafe smokers. Interview with the administration revealed they observe the smoking area regularly to ensure that oxygen is maintained away from the smoking area in the designated area before residents enter the smoking area and oversee the education of staff related to emergency preparedness. Administration put into place ongoing fire drill schedule and secured additional training from the local fire marshall.

Based on record reviews, policy review, staff interviews and resident interviews, the facility failed to provide effective staff training on fire prevention and fire emergency measures which resulted in second [MEDICAL CONDITION] 1 of 2 oxygen dependent residents who smoked, Resident #2, who was found on fire while smoking with his oxygen flowing. Immediate Jeopardy began on 12/06/16 when Resident #2 went outside with his oxygen tank running, the nasal cannula in his nares, away from the designated smoking area and lit a cigarette which resulted in him catching himself on fire resulting in second degree facial and hand burns. Nurse Aide #1 who was in a nearby area at the time of the incident, failed to attempt to put out the flames via the use a fire extinguisher or fire blanket which were nearby. She left the resident on fire outside blocking the facility door as she attempted to obtain assistance by entering another facility door. Immediate jeopardy was removed on 12/21/16 at 3:26 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of 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 staff being prepared to extinguish a resident who is on fire. The findings included: The facility's Fire policy for emergency preparedness revised June 2012 included the Emergency Directions under Fire Response-upon discovering fire or smoke: 1. Remove the residents from immediate danger. 2. Call aloud Code Red and the location of the fire. 3. Begin R.A.C.E. program = Rescue, Alarm, Confine and Extinguish/Evacuate. The facility's Safe Smoking / Tobacco Use Policy, revised November 2016, included Warning: Smoking is NOT permitted while oxygen is in use. Neither this policy nor the Fire policy revised June 2012 indicated the distance oxygen should be from any ignition source. The facility's Oxygen Storage and Assembly policy revised June 2007 included Do not smoke or allow others to smoke within 10 feet while oxygen is in use. Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. A Safe Smoking Evaluation dated 10/05/16 and completed by Minimum Data Set (MDS) Nurse #1 assessed Resident #2 as a safe smoker and no supervision was required while smoking. Under the notes section was instructed not to use O2 (oxygen) when out smoking and voiced understanding. During an interview with the Minimum Data Set (MDS) Nurse #1 conducted on 12/20/16 at 9:35 AM revealed that she watched Resident #2 smoke during his smoking assessment in October 2016. She stated she assessed him in his wheelchair with the oxygen tank on the back of his wheelchair. She further stated that she made sure the oxygen tank was turned off but could not recall if he turned it off or if she just made sure it was turned off. MDS #1 stated that at the time of this assessment, oxygen was permitted to be with the resident in the smoking area as long as the tank was turned off. MDS Nurse #2, present at this interview, and MDS Nurse #1 both stated they had observed Resident #2 in the designated smoking area smoking with the oxygen tank on the back of his wheelchair and stated that prior to 12/06/16, they understood that oxygen was permitted in the smoking area as long as the oxygen tank was turned off. Resident #2's quarterly MDS dated [DATE] coded him with intact cognition, having no mood issues or behavior issues, and required supervision with bed mobility, transfers, walking, locomotion, dressing, eating and hygiene. He had impaired vision, able to see large print not newspaper print and had no functional limitations of his upper and lower extremities. He was coded as receiving oxygen therapy. Review of the Situation, Background, Assessment, Recommendation (SBAR) report dated 12/06/16 revealed Resident #2 was outside smoking and his oxygen tubing caught fire. His hair was singed and his nose had black singed areas. This report also indicated he stated he thought his oxygen was off. The Incident/Accident Investigation Follow-up dated 12/06/16 revealed Resident #2 was out smoking with his oxygen on and set fire to his hair and face. Resident was sent to the emergency room . The new intervention listed to prevent reoccurrence was for supervised smoking. Review of the hospital history and physical dated 12/06/16 revealed Resident #2 was assessed with [REDACTED]. He was noted to have second [MEDICAL CONDITION] his bilateral nares and left hand. Resident #2 was admitted to the intensive care unit for intravenous steroids and close monitoring. Resident #2 was readmitted to the facility 12/08/16 with physician orders [REDACTED]. Nurse Aide (NA) #1 was interviewed on 12/19/16 at 12:22 PM. She stated she had seen Resident #2 smoke previous to the accident. She stated Resident #2 would turn his oxygen tank off before he went outside but generally smoked with the oxygen tank located on the back of his wheelchair. She stated she was never instructed that the oxygen tank should not be kept on the back of the wheelchair while he smoked. She stated she clocked out the night of 12/06/16 to go on break in the staff smoking area. She passed Resident #2 who was sitting in his wheelchair in the alcove just outside of the facility's exit leading to the smoking areas. She could not recall if he had oxygen in place or not. She proceeded to the staff smoking area and then heard a popping and crackling sound. She turned around and saw he had flames in front of his face. She stated he was flailing his arms and she could not get close enough to turn off the oxygen tank. He was sitting backed up, blocking the door to the facility and she could not get inside the building. She stated she ran to the front entrance of the building to obtain help at the same time calling 911 on her cell phone. She stated she thought about using the fire blanket but was afraid that when she placed the blanket over Resident #2's head, the running oxygen would build up under the blanket and fuel the fire causing more damage and possibly causing the oxygen to explode. Upon follow up interview via a phone call on 12/20/16 at 2:09 PM, NA #1 stated that she had been an emergency medical technician (EMT) 6 to [AGE] years ago. She stated that she was trained in the use of a fire blanket but knew it could either benefit someone or make it worse. She stated that she could not get close to him due to the flames and could not reach the oxygen tank to turn it off. She stated due to the fire, she felt the situation was unsafe for him and for her. She did not want to use the fire extinguisher because of his breathing problems and was afraid the fire blanket would create a pocket for the oxygen to build up and feed the fire. She left him in order to get help as he was blocking the door to reenter the facility and called 911 while going to get help. She stated she made the decisions she did based on her EMT training. On 12/19/16 at 2:32 PM, Resident #2 was interviewed. Resident #2 was observed with slight pinkness on his cheeks where oxygen tubing would rest, his nares were shiny with what he stated was antibiotic ointment and his left hand had a scab about quarter size between the base of his thumb and base of his forefinger, which he stated was from the fire. Resident #2 stated he had been watching television in the activity room when he decided to go outside to smoke. At that time he was permitted to keep his own lighter and cigarettes. He stated the wind was blowing so he stayed close to the door of the building, not in the designated smoking area of the gazebo area and lit his cigarette. He stated he had forgotten his oxygen tubing was on his face and the oxygen was running at this time. He stated when he went to take another puff on the cigarette and flames flashed up. Resident #2 stated he burned his cannula, eyebrows, nose and hand as he yanked the nasal cannula off his face. He then stated the fire just went out. He further stated a staff member was outside and she got scared and ran around the building to get help. Once the flames were out, he went back inside the building to his room and applied his nebulizer treatment. Resident #2 stated he didn't realize he was hurt until staff and the emergency medical services (EMS) arrived. On 12/19/16 at 5:50 PM, the Director of Nursing (DON) stated that if a resident was on fire, she would expect staff to try to smother the fire with a fire blanket as long as there was no chance of blowing oneself up. She stated it depended on the location of the resident and where the fire was on the body. She stated each situation would be individualized and she would expect some form of rescue and or making the resident safe as possible. The DON further stated that when she listened to NA #1's explanation as to why she did not use the fire blanket and left Resident #2, it made logical sense to her and indicated NA #1 was thinking through the situation. She stated she supported the actions of NA #1 as the aide felt unsafe and wanted to get help immediately for Resident #2. Interview with the Staff Development Coordinator (SDC) on 12/20/16 at 9:26 AM revealed that she trained all new employees about the designated smoking area and the need to remove all oxygen prior to residents smoking. She conducted fire training upon orientation which included a video staff watched. She stated that she reviewed how to use the fire extinguisher and talked about how there were no smoking products permitted in an unsecured location. She stated that smoking assessments were completed on admission, routinely and as needed for changes in condition. The SDC also stated that the Maintenance Supervisor also reviewed fire safety with employees. Review of the 12 minute video included in orientation revealed staff were to know the facility's smoking policy, the need to report noncompliance to a supervisor and training in RACE. The video showed how to use a fire extinguisher. The video did not show how to use a fire blanket or what to do if a resident was on fire, just what to do if a resident room or building was on fire. On 12/20/16 at 1:43 PM the Administrator stated that if a resident was on fire, she expected staff to do the best they could and assist the best they could. She stated that she was not sure if a fire extinguisher should be used on a person and the fire blanket could be used depending on the size of the fire. The Administrator stated that NA #1 calling 911 was extremely important and that she felt the nurse aide did what she could in that situation. The administrator supported the NA in her decision to leave the resident to get help and call 911. A phone interview with the local fire marshal on 12/20/16 at 3:04 PM revealed that his first choice would have been to use a fire blanket to smother the fire. He further stated that the likelihood of oxygen gathering in a pocket under the blanket creating a possible explosion would be unlikely and mostly control the fire. Phone interview with the Battalion Chief of the responding emergency response team conducted on 12/20/16 at 3:14 PM revealed that using a blanket over the resident with oxygen flowing would have smothered the fire. Interview with the Maintenance Supervisor on 12/20/16 at 3:30 PM revealed that he trained all new employees on the location of fire alarms, fire extinguishers and fire blanket. He stated there had been 2 paper signs located in plastic sleeves at the gazebo area stating this was a smoking area and no oxygen was allowed. He stated he did not review with employees how to use a fire blanket. Nurse #2 was interviewed on 12/20/16 at 4:47 PM. Nurse #2 stated she responded to NA #1 alerting staff she had seen him on fire. Nurse #1 stated they found him back in his room giving himself a breathing treatment she had left ready for him. She stated his upper lip and under his nose was blackened and the oxygen tubing had melted on his cheek. The Administrator and Director of Nursing were informed of immediate jeopardy on 12/20/16 at 4:37 PM. The facility provided an acceptable allegation of compliance on 12/21/16 at 1:51 PM as follows: 1. On 12/6/16 at approximately 8:30pm Resident #2 was observed sitting outside the 400 Hall Door near the Resident and Staff smoking area by NA #1 who was exiting the facility, she did not notice if Resident #2 was smoking. NA #1 walked past Resident #2 to the staff smoking area less than 10 feet away, as she turned to sit down at the picnic table she noticed flames at Resident #2's face and hands. NA #1 immediately noticed that Resident #2 had an oxygen tank on his wheelchair and a cannula in his nares, she attempted to turn off the Oxygen at the regulator but Resident #2 was flailing his arms and had positioned himself with the back of the wheelchair against the door and she was unable to reach the regulator. She was also unable to re-enter the facility for help because the wheelchair was blocking the door. NA #1 was reluctant to cover the resident with the Fire Blanket for fear of trapping more oxygen and worsening the flames. NA #1 then ran around the left corner of the facility and called 911 on her cell phone as she was running to the front door of the facility for help. As she entered the facility she notified the Charge Nurse #1 and the Supervisor #1. Charge Nurse #1 immediately ran to the 400 Hall Door and Resident #2 was no longer located there, he had extinguished the flames and returned to his Resident Room # 207. As the Charge Nurse #1 entered the Resident room [ROOM NUMBER] she noticed Resident #2 had applied his nebulizer mask and started a nebulizer treatment, he stated I am fine, just need to finish my breathing treatment. Charge Nurse #1 and Supervisor #1 immediately removed the mask and began to assess Resident #2 for injuries. Observations included black soot to the lower half of his face and singed hair on the left side of his head and surrounding his face. The Fire Department and the Emergency Medical Services arrived and immediately transported Resident #2 to the emergency room , where he was admitted in stable condition to the ICU for observation [MEDICAL CONDITION] the nasal area and respiratory monitoring. On 12/6/16 Supervisor #1 notified Resident #2's responsible party, the On Call Physician, the Facility Medical Director, the Facility Administrator and the Facility Director of Nursing. On 12/20/16 NA #1 received one on one education by the Director of Nursing to include the facility's policy regarding Fire Management, Fire Extinguisher usage, the use of a Fire Blanket to extinguish a personal fire, turning off any Oxygen in use during a fire, and to supervise and attend to a resident during an emergency situation by not leaving the resident until further assistance has arrived. 2. Current residents have the potential to be affected by this same alleged deficient practice. By 12/8/16 the Director of Nursing and Assistant Director of Nursing educated all Facility staff including Administration, Nursing, Therapy, Housekeeping and Dietary regarding the Facility Policy for Safe Smoking to include the following: - Location and use of safety equipment in this area including the fire blanket, the fire extinguisher and ashtrays and receptacles. On 12/20/16 an updated educational plan was developed by the Interdisciplinary Team consisting of the Administrator, Director of Nursing, Social Services, Director of Rehab, Director of Housekeeping and Director of Dietary Services on to include Facility specific policy and procedures for Fire Management and Smoking that address Oxygen is prohibited in designated smoking areas. On 12/20/16 this Fire Safety educational plan was reviewed and further developed by the Administrator, Director of Nursing and the Area Staff Development Director with assistance from the District Field Support Team. This review included involvement with the local Fire Marshall who reviewed and accepted this plan. On 12/20/16 all facility staff including Administration, Nursing, Therapy, Housekeeping and Dietary by the Administrator, Director of Nursing, Area Staff Development Director and Nurse Managers received this updated education to include: -The Facility policy and procedures for Fire Management, Smoking and that Oxygen is not prohibited in designated smoking areas. -Fire Extinguisher usage to include the Pull, Aim, Squeeze and Sweep method for effective fire extinguishing as outlined in the facility policy for Fire Management. -Use of a Fire Blanket to cover and smother flames to manage a personal fire as outlined in the facility policy for Fire Management. -Discontinuing any Oxygen in use and removing the tank as soon as possible during a fire as outlined by the facility policy for Fire Management. -Supervise and attend to a Resident during an emergency situation by not leaving the resident until further assistance has arrived. The Administrator and Director of Nursing will oversee the ongoing implementation of this updated educational plan for completion and effectiveness during orientation and annual training based on observations and ongoing participation in training sessions. Monthly observation of education and return demonstration by staff during educational sessions will be observed and completed by the Administrator and Director of Nursing to validate the effectiveness of education for 6 months. Fire Drills will be conducted monthly by the Maintenance Director with oversight from the Administrator and Director of Nursing to further validate compliance. Ongoing education will include additional Fire Safety training for all facility staff provided by the local Fire Marshall to be completed by January 15, 2017. This education will include: -General Fire Safety with a video presentation -When and How to correctly use a Fire Extinguisher -When and How to correctly use a fire Blanket -Oxygen precautions with regards to Fire Safety This training is scheduled on the following dates: -January 4, 2017 at 7am -January 5, 2017 at 2:30pm -January 11, 2017 at 10am -January 12, 2017 at 3:30pm The Administrator and Director of Nursing will have no tolerance for noncompliance with the Facility Safe Smoking policies and Fire Safety. No staff shall work after 12/20/16 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 in resident care areas after 12/20/16. Ongoing Fire Safety training will be held annually for all facility staff and more frequently if an opportunity with compliance is identified. Immediate jeopardy was removed on 12/21/16 at 3:26 PM when interviews with nursing staff, administrative staff, and non-nursing staff confirmed they had received training on the facility's procedure to correctly use a fire extinguisher, correctly use a fire blanket, discontinue oxygen if in use and stay with a resident involved until help arrived. Verification of staff training was reviewed, appropriate signage was observed in the designated area, 24 hour monitoring of the smoking are, storage for oxygen tanks outside the smoking area and storage of smoking materials was observed in place.

Based on observations, record reviews, resident and family interviews, and staff and physician interviews the facility failed to administer pain medication to a resident who had a [MEDICAL CONDITION] causing the resident to have unrelenting pain for 1 of 3 sampled residents reviewed for pain management. The facility also failed to follow a physician's orders [REDACTED].#197 and #158). The findings included: 1) Resident #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. A review of a document titled Controlled Medication Utilization Record dated 07/29/16 through 08/03/16 with an affixed pharmacy label which read in part [MEDICATION NAME] 5 mg take 1 tablet every 4 hours as needed for mild pain and take 2 tablets by mouth every 4 hours as needed for moderate to severe pain. The document indicated Resident #197 was administered her last dose of [MEDICATION NAME] 10 mg (2 tablets) on 08/03/16 at 9:31 AM with the remaining amount of medication available as 0 zero. A review of the electronic Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. There was no indication on the MAR indicated [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #197 was cognitively intact and required limited assistance for toileting and was independent with all other activities of daily living (ADL). Further review of the MDS under Section J titled Pain Assessment coded Resident #197's pain as almost constantly with a pain rating of 8 out of 10 on a scale of 1 to 10, with 1 being little to no pain and 10 being the worst pain. A review of a nurse's note dated 08/03/16 at 9:28 AM indicated Resident #197 had been administered [MEDICATION NAME] 10 mg. Further review of the nurse's notes indicated on 08/03/16 at 2:14 PM the pain medication administered at 9:28 AM was effective. Resident #197 had no [MEDICATION NAME] noted as being administered for pain from 08/03/16 at 9:28 AM until 08/04/16 at 1:30 AM (approximately 16 hours between doses) or until 08/04/16 at 6:20 AM (approximately 21 hours between doses). Further review revealed another document titled Controlled Medication Utilization Record dated 08/04/16 through 08/05/16 with an affixed pharmacy label which read in part [MEDICATION NAME] 5 mg-take 1 tablet every 4 hours as needed for mild pain and take 2 tablets by mouth every 4 hours as needed for moderate to severe pain. The document indicated a quantity of 30 tablets was received from the pharmacy on 08/04/16 and that Resident #197 was administered [MEDICATION NAME] 10 mg (2 tablets) on 08/04/16 at 1:30 AM and on 08/04/16 at 6:20 AM. A nurse's note dated 08/04/16 at 6:20 AM indicated Resident #197 had been administered [MEDICATION NAME] 10 mg. The nurse' note further indicated Resident #197 was again administered [MEDICATION NAME] 10 mg on 08/04/16 at 10:03 AM. The nurse's note dated 08/04/16 at 3:07 PM indicated the pain medication administered at 10:03 AM was effective. Resident #197 was observed on 08/04/16 at 11:07 PM to be in a wheelchair on the side walk at the front of the facility. Resident #197 stated the facility was out of my pain medication and I went all day yesterday (08/03/16) without any. Resident #197 was observed to have a [MEDICAL CONDITION] (BKA) with staples noted and no dressing over the stump. The resident further stated they let me suffer all day with pain and did not give me anything. On 08/04/16 at 11:25 PM, an interview was conducted with Nurse #7. She stated she was unaware of Resident #197 not having pain medication on 08/03/16. Nurse #7 further stated medications were delivered to the facility each night between 12:00 AM and 5:00 AM Monday through Saturday by an out of town night-time pharmacy. Nurse #7 also stated they used a local pharmacy for back-up should a medication be needed before the night delivery of medications was made. She revealed the facility also had a Pyxis machine which was used primarily for newly admitted residents or when medications had not yet been delivered from the night-time pharmacy. Nurse #7 went on to say the Pyxis was not stocked with [MEDICATION NAME] and was stocked with a limited amount of medications which consisted of antibiotics, Tylenol, and insulins. On 08/04/16 at 11:35 PM, an interview was conducted with Nurse #8. She stated she was unaware of Resident #197 not having pain medication on 08/03/16. Nurse #8 further stated she signed for the medications which were delivered by the night-time pharmacy on 08/04/16 at around 2:00 AM and the [MEDICATION NAME] medication for Resident #197 was included in the delivery. On 08/05/16 at 10:45 AM, an interview was conducted with Medication Aide (MA) #1. MA #1 confirmed she was the MA on 08/03/16 from 3:00 PM until 11:00 PM on the hall were Resident #197 resided. MA #1 stated she was not aware that Resident #197 was out of her pain medication, [MEDICATION NAME] until the resident came to her around 4:00 PM and requested the pain medication. MA #1 stated Resident #197 had reported her pain at an 8 on a scale of 1 to 10. MA #1 further stated she immediately advised her nurse supervisor, Nurse #9, that Resident #197 needed her [MEDICATION NAME] and would there be any way of getting the medication for her from the back-up pharmacy or from the Pyxis. MA #1 revealed as a medication aide she was not allowed to take medication from the Pyxis or to call the pharmacy to order a medication and that she was to advise her nurse supervisor, which was what she had done. MA #1 further stated she had apologized to Resident #197 on the evening of 08/03/16 around 6:00 PM for being out of the pain medication and that she had advised the nurse supervisor. MA #1 further stated at that time Resident #197 appeared to be in great pain and was upset in regards the pain medication not being available. On 08/05/16 at 10:55 AM, Resident #197's pharmacy bubble pack card for [MEDICATION NAME] was observed and MA #1 verified the date of 08/03/16 for which the pharmacy filled and dispensed the medication. MA #1 stated the medication was delivered to the facility by the night-time pharmacy on 08/04/16 at around 2:00 AM. On 08/05/16 at 3:50 PM, an interview was conducted with Nurse #6. She stated she was responsible for ordering of the narcotic medications for the facility. Nurse #6 indicated she had to obtain a hard copy prescription from the physician, faxed the prescription to the pharmacy, and the hard copy prescription would be placed in a bin for the night-time pharmacy to pick up when the medications were delivered to the facility. Nurse #6 stated she had obtained a hard copy prescription for the narcotic [MEDICATION NAME] for Resident #197 on 08/03/16 around 4:30 PM after she had finished her shift from 7:00 AM until 3:00 PM on another hall. Nurse #6 further stated she had not had an opportunity or the time to have obtained a hard copy prescription from the nurse practitioner (NP) until the 2nd shift nurse had relieved her. Nurse #6 confirmed she faxed the hard copy prescription for Resident #197's pain medication, [MEDICATION NAME], to the pharmacy around 5:30 PM and had not marked the prescription as a stat order. Nurse #6 stated she could have called the local pharmacy to have obtained a one-time stat dose of the [MEDICATION NAME] but did not do so because she was unaware that Resident #197 was completely out of the pain medication. On 08/05/16 at 4:10 PM, an interview was conducted with the NP. The NP stated she was at the facility all day on 08/03/16 and was advised sometime around 5:00 PM by Nurse #6 that she needed a hard copy prescription written for [MEDICATION NAME] for Resident #197. The NP further stated she was not made aware at any time on 08/03/16 that Resident #197 was completely without her pain medication. The NP stated she would have expected the nursing staff to have informed her sooner in order for the resident to have not been without her pain medication. On 08/05/16 at 5:00 PM, a telephone interview was conducted with the pharmacist. She confirmed that the pharmacy had received a faxed copy of the hard copy prescription for [MEDICATION NAME] for Resident #197 on 08/03/16 at around 6:00 PM and that it was not a stat order. The pharmacist also confirmed 60 tablets of the [MEDICATION NAME] for Resident #197 was delivered to the facility on [DATE] around 2:00 AM. The pharmacist stated should the prescription have indicated stat the pharmacy would have delivered the medication in approximately 1 hour from obtaining the faxed copy of the prescription. On 08/05/16 at 5:30 PM, an interview was conducted with the Director of Nursing (DON). She stated she would have expected the nursing staff to have better communicated to ensure that Resident #197's pain medication was in the facility and ready to be administered at her request. The DON further stated she was aware of some problems with ordering of residents medications and that was one of the many things she would be fixing. On 08/05/16 at 7:15 PM, a telephone interview was conducted with the 2nd shift nurse, Nurse #9. Nurse #9 confirmed he was responsible for the residents on halls 200 and 500 on 08/03/16 from 3:00 PM until 11:00 PM. Nurse #9 stated he was made aware by MA #1 of Resident #197's pain medication, [MEDICATION NAME] was not available. Nurse #9 further stated he was told by Nurse #6 that the order was called into the pharmacy as a stat order and it was after Resident #197 came to him cursing, upset, and appeared to be in great pain that he started looking into why the medication was not available. Nurse #9 indicated he called the pharmacy around 9:00 PM, which was the first time he had an opportunity to call, and was advised by the pharmacy that the medication was not ordered stat and that it would be delivered to the facility later that night. Nurse #9 stated the medication was not available in the Pyxis and he apologized to Resident #197 and made her aware of the situation in regards to her pain medication. 2. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #158 was cognitively intact and required extensive assistance for bed mobility, transfers, dressing, personal hygiene, toileting and bathing. She was coded as receiving Hospice services. There was no care plan for the left foot vascular wound. Review of the Nurse Practitioner's (NP) note dated 07/05/16 revealed Resident #158 had left foot [MEDICAL CONDITION]/discoloration. Will treat with conservative measures and elevation and pain management. The NP note dated 07/12/16 revealed Resident #158's left foot with [MEDICAL CONDITION] and discoloration - hematoma? Stable. Review of the physician order's revealed the following; · 07/07/16 left foot wound - cleanse with normal saline, pat dry, apply xeroform, a non-adherent medicated wound dressing, to wound bed, cover with an absorbent pad and wrap with a gauze bandage roll. An observation made on 08/04/16 at 2:45 PM revealed Resident #158's left foot elevated on a pillow with a piece of xeroform dressing hanging loosely from her toes. Resident #158's foot was black from the top of the foot to her toes, there was a dried reddish, brownish substance on her pillow case her foot was elevated on and on the sheets. An observation made on 08/05/16 at 4:12 PM revealed Resident #158's left foot to be lying on the bed, not elevated on pillows, the pillows were in the floor by the bedside, a piece of xeroform dressing continued to hang loosely over her toes. There was a dried reddish, brownish substance on her fitted sheet and top sheet from the waist level down and she had the same dried substance on her right foot and toes. An interview conducted on 08/04/16 at 2:45 PM with Resident #158's family member revealed he visited her every day and most days when he came in the dressing was not on her left foot. He stated he had asked the nurse aides (NAs) and nurses over and over to make sure the dressing stayed on Resident #158's foot. An interview conducted on 08/04/16 at 4:00 PM with the Certified Medication Aide (CMA) revealed she was aware Resident #158's dressing on her left was off but it was the nurse's job to do the dressing changes. She stated she told the NA to let the nurse know the dressing needed to be changed. The CMA further stated Resident #158's dressing came off often and wouldn't be redressed until the nurse got time to do it. An interview and observation of Resident #158's left foot and dressing change of the left foot wound was conducted on 08/04/16 at 4:30 PM with the Corporate Nurse, the Director of Nursing (DON) and Nurse #2. They agreed there was no dressing on Resident #158's left foot except a piece of xeroform hanging loosely over her toes and there was a dried reddish, brownish substance on the sheets and her other foot. Nurse #5 performed the dressing change on the left foot. The Corporate Nurse stated it was unacceptable the left foot was not treated as ordered and the nurse should have been notified and changed the dressings. She further stated the bed linens should have been changed and Resident #158's right foot should have been washed. An interview conducted on 08/04/16 at 4:20 PM with Nurse #4 revealed it was her job to do dressing changes for the entire building on 08/04/16 but she also worked the medication cart on the 100 hall and stated she had not had time to change Resident #158's dressings. She stated no one had informed her the dressings were off. An interview conducted on 08/05/16 at 8:34 AM with the NP revealed she was asked to see Resident #158 on 07/05/16 for left foot [MEDICAL CONDITION] and discoloration. She stated when she assessed the left foot it was red, [MEDICAL CONDITION] and had what appeared to be a blister on the top of her foot. The NP stated Resident #158 had a fall on 07/03/16 and hit her foot when she fell and due to being chronically anticoagulated was the cause of the redness and [MEDICAL CONDITION]. She stated she ordered treatment for [REDACTED]. The NP stated the wound had progressed to a vascular ulcer and the treatment was the same. The NP stated it was her expectation all treatments be done as ordered. An interview conducted on 08/05/16 at 3:15 PM with NA #3 revealed she provided care for Resident #158 on 08/04/16 day shift. NA #3 stated Resident #158 would kick her dressing off of her left foot because she moved around in the bed. She stated she would let the nurse know but she had been very busy on 08/04/16 and may not have told the nurse the dressing was off. She further stated the dressing to the left foot would be off for most of the shift on days the nurse was too busy to put it back on. An interview conducted on 08/05/16 at 3:50 PM with the DON revealed it was her expectation for treatments to be done as ordered. She stated if the dressing came off the nurse should be notified immediately and the dressing be redone. An interview conducted on 08/05/16 at 4:15 PM with the facility Physician revealed it was his expectation for treatments to be done as ordered and dressings to stay in place. He stated it was important to the healing process for the medicated dressings to be done and worn as ordered.

Based on record reviews and staff interviews the facility failed to provide supervision for a resident who fell from bed and fractured his right hip for 1 of 3 sampled residents for accidents. (Resident #192). The findings included: Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #192 was discharged from the facility to the hospital on [DATE] and did not return to the facility. A review of a discharge Minimum Data Set ((MDS) dated [DATE] indicated Resident #192 had no short term memory impairment and he was independent in cognitive skills for daily decision making. The MDS also indicated Resident #192 required extensive assistance with transfers and required supervision while walking in his room and he had a nephrostomy tube (a tube placed through the abdomen for drainage of urine) and he was occasionally incontinent of bowel. A review of an interim plan of care dated [DATE] indicated potential and actual falls due to a history of falls, decreased safety awareness and weakness. The goals indicated Resident #192 would be free of fall related injury through next review and interventions included in part for pressure pad alarm, call light within reach and a bed alarm. A review of a facility document titled Fall Risk Evaluation dated [DATE] revealed Resident #192 had a total risk score of 14 (a score of 10 or greater represented high risk for falls). A review of a facility document titled Fall Risk Evaluation dated [DATE] revealed a total risk score of 18 and indicated predisposing disease of weakness and a history of falls. A review of a facility document titled Situation, Background, Assessment and Request (SBAR) communication form and progress note dated [DATE] indicated Resident #192 had a fall on [DATE]. The section labeled Background indicated Resident #192 had a urinary tract infection, kidney failure and anemia. A section labeled Request included nurse's notes and revealed Resident #192 was lying on the floor and when asked why he was in the floor he stated he was going to the bathroom and fell . The notes indicated in part Resident #192 was able to move all extremities without any difficulty, had no complaints of pain and he was lifted back to bed and his back and buttocks were assessed after he was in bed and no redness or broken areas of skin were noted. A review of an incident and accident report dated [DATE] indicated the date of incident was [DATE] at 4:30 AM and the location was in the resident's room. The report indicated the resident's description of the incident when he was found lying beside his bed revealed he was going to the bathroom and fell . A section labeled equipment involved was checked as no and a section labeled resident outcome was checked as no apparent injury. A section labeled description of incident and accident indicated a primary assessment was completed when he was in bed and he was turned on his side for the nurse to do the assessment. A review of a physician's progress notes dated [DATE] but did not have a time documented revealed in part Resident #192 had a fall on [DATE] in the early morning. The notes indicated Resident #192 stated he was attempting to get to the bathroom and fell and thought he landed on his back but denied hitting his head. The notes further indicated Resident #192 was complaining of right hip and groin pain and he was alert and oriented to time, place and person and was lying in bed guarding his right hip. The notes revealed Resident #192 was frail and had general wasting of his body and his right lower extremity was shortened and was externally rotated (turned outward) and he complained of pain with palpation of his right femur (thigh bone). The notes further revealed x-rays were ordered and to continue neurological checks and fall precautions. A review of an x-ray report dated [DATE] indicated the right hip showed an acute, slightly angulated intertrochanteric (the upper part of the thigh bone) fracture and osteopenia (reduced bone mass of lesser severity than osteoporosis) was present and there were degenerative changes. A review of a physician's orders [REDACTED].#192 to the emergency room for acute right intertrochanteric fracture. A review of a Resident Transfer Form dated [DATE] with no time documented indicated to transfer Resident #192 to the hospital and the reason for transfer was right femur fracture. No time of transfer was documented. A review of a Nursing Daily Skilled Summary dated [DATE] at 2:00 PM revealed in part Resident #192's right hip was found to be positive for fracture by x-ray at 11:45 AM and he was sent out to the hospital for evaluation. During an interview on [DATE] at 2:53 PM with Resident #192's roommate who was cognitively intact for daily decision making he explained he remembered the night Resident #192 rolled out of bed onto the floor. He stated prior to the fall a Nurse Aide (NA) was in the room around 11:00 PM on [DATE] and provided care to Resident #192. He further stated no staff came back into the room after that until Resident #192 rolled out of bed and hit the over bed table and it bumped into his bed and he looked and saw Resident #192 on the floor. He explained he pushed the call light but nobody came to the room so he sent a text on his phone to a family member to call the nurse's station to tell them to check on Resident #192. He confirmed he sent the text message at 4:28 AM and a nurse came in the room at 4:36 AM. He explained the nurse called for assistance and another nurse and 2 Nurse Aides (NAs) came into the room and picked Resident #192 up off the floor and put him in the bed. He stated he asked Resident #192 what had happened and he said he needed to go to the bathroom and fell . During a phone interview on [DATE] at 3:50 PM with a family member of Resident #192 she stated Resident #192 had hip surgery after he went to the hospital and was discharged to another facility but had recently expired because he never recovered and could not walk. She further stated the roommate had reported to her that NAs had not checked on Resident #192 during the night and he had to text his family to call the nurses station because they did not answer the call light. During an interview on [DATE] at 10:23 AM with Certified Medication Aide #2 she explained she arrived at the facility at 3:00 AM on [DATE]. She explained at night there was 1 Nurse Aide on the hall where Resident #192 lived to provide care to residents. She stated NAs were supposed to do rounds and check on residents every 2 hours or more often as needed. She further stated she did not go into Resident #192's room on [DATE]. During an interview on [DATE] at 10:43 AM with Nurse #4 who identified herself as a Unit Manager of the unit where Resident #129 lived explained when she arrived at the facility in the morning on [DATE] after Resident #192's fall Nurse #5 who was assigned to Resident #192's care on the night shift stated he was found on the floor in his room around 4:30 AM. She stated Nurse #5 also reported she had assessed Resident #192 and she didn't think he was injured. During an interview [DATE] at 11:16 AM with a Nurse Practitioner she explained she saw Resident #192 on [DATE] during the morning after his fall. She stated she got to the facility around 8:00 AM and the nurses told her he had fallen and she went to his room. She stated Resident #192 was alert with clear speech and he told her he was trying to go to the bathroom. She explained when she examined him he was very guarded with his right leg and it was shortened and externally rotated. She stated Resident #192 was complaining of right hip and groin pain and she thought he had fractured his hip or leg so she ordered x-rays to be done immediately in the facility and the results showed a right hip fracture. She further stated she then wrote orders to send him to the hospital During an interview on [DATE] at 12:21 PM with Nurse #2 he explained he was the day shift nurse on [DATE] after Resident #192 had a fall and received report from Nurse #5. He stated Nurse #5 reported to him that Resident #192 had fallen and was found on the floor in his room around 4:30 AM. He explained she said she checked for range of motion in Resident #192's legs, his pain level and said he appeared to be alright. He stated he saw Resident #192 later that morning and he complained of pain and he gave him pain medication. He further stated he was not sure if Resident #192 was a fall risk and did not recall fall prevention interventions. During an interview on [DATE] at 2:22 PM with Nurse #5 who was assigned to care for Resident #192 during the night shift on [DATE], she stated she was going down the hall to take a resident a snack around 4:30 AM and then she looked in on Resident #192 and he was lying in the floor next to his bed. She stated she had not been in Resident #192's room since the beginning of her shift at 11:00 PM. She further stated she assessed Resident #192 while he was in the floor and she didn't see any obvious injury so she called for NAs to help her put him back in bed. She explained NAs were supposed to do rounds and check on resident's every 2 hours or more often as needed but no one had checked on Resident #192 after 11:00 PM that she was aware of. During an interview on [DATE] at 3:28 PM with the Area Staff Development Manager she explained she was the former Director of Nursing (DON) in the facility when Resident #192 fell on [DATE]. She stated when she got to the facility staff told her Resident #192 had fallen. She stated she started an investigation but did not interview Resident #192 because he was sent to the hospital. She stated she got a statement from the NA who was assigned to Resident #192 during the night shift and was told she assisted Resident #192 with care at 11:15 PM and did not go back in his room after that. She confirmed the NA no longer worked at the facility and attempts to contact her by phone were unsuccessful. She stated it was her expectation that staff should make rounds and check on residents every 2 hours or more often as needed.