Every finding on record at The Shannon Gray Rehabilitation & Recovery Center

Based on observations and staff interviews, the facility failed to remove expired medications stored in 1 of 3 medication rooms and 1 of 6 medication carts reviewed for medication storage (Over the Counter (OTC) Medication Storage Room and Medication Cart for 800 hall).The findings included:a. An observation of the Over the Counter Medication Storage Room was conducted on 6/24/2026 at 9:33 AM in the presence of the Supply Coordinator. The observation revealed the following expired medications:-Two bottles of vitamin D-3 10 micrograms (mcg) film-coated tablets (a dietary supplement medication) with an expiration date of 9/2025. Both bottles were opened and observed without labels indicating their opening dates. One bottle contained 65 tablets, and the second bottle contained 34 tablets. The Supply Coordinator confirmed the expiration date by reading aloud the date printed on the bottles and confirmed the bottles were opened and undated.-One tube of triple antibiotic ointment, 0.5 ounce, with an expiration date of 10/2025. The Supply Coordinator confirmed the expiration date by reading aloud the date printed on the box. An interview with the Supply Coordinator was conducted on 6/24/2026 at 9:42 AM. She stated a staff member must have returned the opened Vitamin D bottles to the Over the Counter medication storage room without her knowledge. The Supply Coordinator indicated staff should give her expired over the counter medications so she could properly dispose of them and not place them on the shelf. She explained she typically checked the Over the Counter medication storage room one to two times per week for expired medications and stated the last time she checked the storage room was on 6/17/2026.b. An observation of the medication cart for the 800 hall was conducted on 6/24/2026 at 11:21 AM in the presence of Nurse #2. The observation revealed the following expired medications:-Twenty (20) hydrocodone/acetaminophen 5 milligrams (mg)/325 mg tablets (narcotic pain medication) with an expiration date of 6/1/2026. Nurse #2 confirmed the expiration date by reading aloud the date printed on the medication card. -Two (2) ondansetron 4 mg tablets (medication used to prevent or treat nausea and vomiting) with an expiration date of 5/27/2026. Nurse #2 confirmed the expiration date by reading aloud the date printed on the medication card.-Fifteen (15) benzonatate 200 mg capsules (medication used to help stop coughing) with an expiration date of 3/7/2026. Nurse #2 confirmed the expiration date by reading aloud the date printed on the medication card.-Twenty-nine (29) mycophenolate 500 mg tablets (medication that weakens the immune system to help prevent the body from rejecting a transplanted organ) with an expiration date of 4/24/2026. Nurse #2 confirmed the expiration date by reading aloud the date printed on the medication card.-Five (5) prednisone 20 mg tablets (medication that reduces inflammation and suppresses the immune system) with an expiration date of 3/31/2026. Nurse #2 confirmed the expiration date by reading aloud the date printed on the medication card. An interview with Nurse #2 was conducted on 6/24/2026 at 11:21 AM. She stated medication carts should be checked for expired medications on an ongoing basis. Nurse #2 revealed she last checked her medication cart approximately two weeks earlier but was informed someone from pharmacy checked the cart on 6/19/2026. Nurse #2 indicated she likely overlooked the medications in the bottom drawer because they were as-needed (PRN) medications. She stated narcotic medications would be sent back to the pharmacy for proper disposal. An interview with the Director of Nursing (DON) was conducted on 6/25/2026 at 11:15 AM. The DON stated staff were educated and instructed to check their medication carts for expired medications prior to use. The DON stated expired medications should not remain in the medication carts but believed many of the expired medications identified were as needed medications that they were overlooked. The DON stated physician orders for medications that were unused for 60 to 90 days should be reassessed to determine whether the medication was still needed by the residents. The DON further stated she was unsure why the two opened bottles of Vitamin D were placed in the medication storage room because they should not have been stored there.

Based on record review, staff and resident interviews, the facility failed to provide a resident with dignity and respect when Nurse Aide (NA) #1 confronted Resident #77 about reporting her and making false accusations to management. Resident #77 stated this made her feel fearful and treated unfairly. The facility also failed to provide dignity and respect to Resident #35 when NA #2 spoke smack and not very nice to the resident. Resident #35 stated this made him feel frustrated. This occurred for 2 of 4 residents reviewed for dignity (Resident #77 and Resident #35). The findings included:Resident #77 was admitted to the facility on [DATE] with diagnoses of lumbar spina bifida without hydrocephalus (a birth defect where the bones in the lower back do not fully close leaving a gap without fluid on the brain). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact and required partial/moderate assistance with bathing and was dependent on toileting. There were no behaviors documented on the MDS. Resident #77 was interviewed on 06/23/2026 at 2:20pm. Resident #77 explained that NA #1 had previously (Resident #77 was unable to provide a time frame) confronted her about speaking with the Unit Coordinator about NA #1 not spending time with her and speaking harshly. Resident #77 stated NA #1 told her she was making false accusations and did not appreciate her talking to the Unit Coordinator. Resident #77 stated she didn't want people to be mean to her and stated it was not fair. Resident #77 stated she felt fearful and was treated unfairly. NA #1 was interviewed on 06/24/2026 at 9:39am. NA #1 stated Resident #77 would tell her other staff were rude or speaking harshly to her. The NA indicated she told Resident #77 to speak with upper management. NA #1 stated Resident #77 had made false accusations against her such as saying she had scratched the resident but was unable to provide a time frame of when this occurred. NA #1 explained after Resident #77 spoke with upper management; she went back to Resident #77 and confronted her. NA #1 was unable to say when this occurred. NA #1 stated she wanted to clarify what the problem was and let Resident #77 know she didn't appreciate being reported. An interview with Nurse #1 occurred on 06/24/2026 at 11:21am. Nurse #1 confirmed she had been routinely assigned to Resident #77 during the 7:00am to 3:00pm shift. Nurse #1 stated she didn't know anyone who spoke harshly to Resident #77. Nurse #1 stated Resident #77 had not told her about any incidents with NA #1. Unit Coordinator #1 was interviewed on 06/24/2026 at 11:47am and revealed Resident #77 had come to her with concerns regarding NA #1 (Unit Coordinator #1 could not provide a time frame). Unit Coordinator #1 stated Resident #77 reported NA #1 just wanted to change her and was not taking time with her and was speaking harshly. Unit Coordinator #1 stated she felt NA #1 was direct but not harsh. Unit Coordinator #1 indicated she explained to Resident #77 that NA #1 had a lot of other residents to care for and gave the same amount of time to each resident but if a resident needed more time, then more time would be provided. Unit Coordinator #1 further stated she spoke with NA #1 regarding Resident #77's concerns related to not spending enough time with her and being harsh. The Unit Coordinator stated NA #1 voiced being shocked that Resident #77 had expressed these concerns. Unit Coordinator #1 recalled she spoke with NA #1 but did not have any written notes and did not recall when the meeting occurred. Unit Coordinator #1 indicated she did not feel the event warranted a formal written document and she did not provide any formal instructions to NA #1. Unit Manager #1 stated she hope that staff would not confront Residents with concerns brought to management related to staff. She also stated she did not report the conversation with NA #1 to the Director of Nursing (DON) or Administrator, and she was unaware NA #1 had returned to Resident #77 to confront her on the discussion of the meeting. An interview was conducted with the DON and Administrator on 06/24/2026 at 12:44pm. Both the Administrator and DON indicated they were not aware of Resident #77's encounter with NA #1 until the interview. The DON stated the perspective of the resident was the reality. The Administrator explained that staff were trained on the abuse policy, which included intimidation, yearly. He also stated he needed to speak further with Resident #77. The DON stated after meeting with NA #1, she noted NA # 1 had a lack of knowledge, experience and cultural awareness related to resident care and NA #1 needed further training and education. The Administrator stated NA #1 should not have spoken to Resident #77 about her meeting with Unit Coordinator #1. The Administrator stated if the Unit Coordinator had known about the conflict, he would have expected to be notified. The DON stated Unit Coordinator #1 had told her that during her meeting with NA #1 the Unit Coordinator informed NA #1 not to approach Resident #77 about their conversation. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses of stroke. The quarterly MDS dated [DATE] revealed Resident #35 was cognitively intact and had no rejection of care. Resident #35 was interviewed on 06/22/2026 at 12:51pm. Resident #35 explained that NA #2 was talking smack (verbally mocking, criticizing, or belittling someone) and not very nice. Resident #35 was unable to provide specific details as to what NA #2 said. Resident #35 stated NA #2 had never said a nice word to him, and he had never reported the situation. NA #2 was interviewed via phone call on 06/24/2026 at 3:55pm. NA #2 said she worked 3rd shift (11:00pm to 7:00am) and was familiar with Resident #35. NA #2 stated most residents thought she was a man when she spoke and that her voice carried, and she was told she had a stern voice. NA #2 stated she told Resident #35 she was there to help him to help himself. NA #2 stated that when Resident #35 got upset with her checking on him, she told him, If you could use the bathroom I wouldn't have to keep coming in here. NA #2 also stated she felt the resident needed to be encouraged to do things on his own and that's why he got upset with her. Interview with Nurse #1 occurred on 06/24/2026 at 11:21am. Nurse #1 stated she had not been assigned to Resident #35 often but was assigned to him today (06/24/2026). Nurse #1 stated she never heard anyone not speaking kindly to Resident #35 and the resident had never reported anyone not speaking nicely to him. NA# 1 was interviewed on 06/24/2026 at 9:39am. NA #1 stated she hadn't heard anyone not speaking kindly to Resident #35. A follow up interview occurred with Resident #35 on 06/25/2026 at 9:08am and Resident #35 stated NA #2 didn't upset him when she made the comment that he needed to get up and use the bathroom. Resident #35 indicated he understood what NA #2 was telling him about using the bathroom, but stated NA #2 communicated the message in a rough manner. Resident #35 also stated NA #2 may have meant to say it to hurt him, but it didn't hurt him. Resident #35 stated he and NA #2 had never gotten along from day one and NA #2 had never expressed a kind word to Resident #35. The Resident discussed trying not to bite back at NA #2, but she kept poking at me. Resident #35 expressed feeling frustrated at times when NA #2 did not convey any kind words to him. The Director of Nursing (DON) and Administrator were interviewed on 06/24/2026 at 12:44pm. The DON indicated she was not aware of Resident #35's encounter with NA #2. She stated the perspective of the resident was reality. The Administrator stated staff were trained in intimidation and stated he needed to speak further with Resident #35.

Based on observation, staff and Physician interviews, and record review, the facility failed to implement their infection control policy and procedure, when a Nurse Aide (NA) failed to perform hand hygiene after the completion of catheter care for Resident #36 who was on Enhanced Barrier Precautions (EBP) for an indwelling catheter. This deficiency occurred for 1 of 4 staff members reviewed for infection control practices (NA #4). The findings included:A review of the facility's policy and procedure titled Infection Control in Long Term Care (LTC) Policy dated April 2026 read in part:Use a piece of personal protective equipment one-time-then throw it away.Change gloves when they are soiled, and when moving from a contaminated to clean area of the body.A review of facility's Infection Prevention and Control Program (IPCP) dated April 2024 read in part: The hand hygiene procedures were to be followed by staff involved in direct resident contactReview of the Hand Hygiene Policy (no date), staff were required to execute hand hygiene when the following tasks are performed:After handling items potentially contaminated with blood, body fluids, secretions, or excretionsBefore and after removing glovesAn observation of urinary catheter care by Nurse Aide #4 for Resident #36 was made on 06/24/2026 at 8:52 AM. While Resident #36 was lying in a flat position NA #4 was observed performing indwelling catheter care. NA #4 gathered a wash basin, warm water, and washcloths. NA #4 was wearing gloves to both hands and a gown. NA #4 held and stabilized the indwelling urinary catheter tubing at the point where it exited the perineal (genital) area with her left hand while cleaning the exposed catheter line with her right hand using a washcloth, soap and water. When catheter care was completed, NA #4 assisted Resident #36 to turn on her right side and re-attached her brief. NA #4 positioned Resident #36 for comfort, pulled her linens up, fluffed and repositioned her pillow and placed her pillow behind her head. NA #4 re-adjusted the bed. NA #4 did not remove her gloves and perform hand hygiene after performing urinary catheter care before touching Resident #36 or Resident #36's personal items. NA #4 then picked up the wash basin and washcloths and went to the bathroom to empty the basin. NA #4 removed her gloves while in the bathroom and performed hand hygiene before leaving Resident #36's room. In an interview with NA #4 06/24/2026 at 9:15 AM she verbalized that she should have changed her gloves after catheter care before touching the resident. NA #4 was unsure of her last urinary catheter care training. NA #4 stated her last education training was in a group setting, although she could not remember when. NA #4 stated she recently received a handout related to catheter care. An interview on 06/25/2026 at 12:43 PM with Unit Coordinator #2 who also served as a backup as an infection preventionist nurse, revealed that proper indwelling catheter care procedure included removal of contaminated gloves immediately after completing catheter care and before touching Resident #36 or Resident #36's personal items. Unit Coordinator #2 stated NA #4 should have removed her gloves, performed hand hygiene then put on clean gloves. She stated the nurse aide should have removed her dirty gloves after providing catheter care. She stated Indwelling Catheter Care Education training was completed upon hire and in yearly checkoffs.In an interview with the Director of Nursing (DON) on 06/26/2026 at 10:30 AM it was revealed the situation did not constitute uncleanliness. She stated that it was not inappropriate for the nurse aide to touch or engage with Resident #36 without performing hand hygiene after catheter care. The DON also stated that it was acceptable for the nurse aide to touch Resident #36's personal items without removing her gloves or performing hand hygiene after completing catheter care.In an interview on 06/25/2026 at 4:10 PM the Physician stated that touching Resident #36's personal belongings or pillow after performing indwelling catheter care without first removing contaminated gloves was not consistent with appropriate infection control standards. The Physician continued to state that the risk of harm was considered low, and NA #4 should have removed their gloves and applied new clean gloves before touching the resident or the residents' personal items.

Based on review of Resident Council meeting minutes, resident and staff interviews, the facility failed to implement an effective process to resolve and communicate the facility's efforts to address repeated concerns by residents related to lack of weekend housekeeping and unlabeled/missing clothing items, for 2 of 5 months of Resident Council meetings (May 2026 and June 2026).The findings included:The Resident Council meeting minutes were reviewed for May 2026. Under the heading Housekeeping/Laundry, the minutes noted residents' concerns of needing more frequent housekeeping visits on the weekend and multiple unlabeled/missing clothing items.The Resident Council meeting minutes were reviewed for June 2026. Under the heading Housekeeping/Laundry, the minutes had no follow up notated. The minutes noted residents' concerns of needing more housekeeping on the weekend for trash removal and multiple unlabeled/missing clothing items.Resident Council was held on 06/24/2026 at 2:00pm. During the Resident Council meeting, the Residents voiced concern that their grievances were not being addressed (Resident #20, #6, #26, #32, #39, #42, #10, #55, #77, #87, #94, #95). The Resident Council President stated housekeeping and laundry have been a continued concern for the past two months without any resolution.An interview occurred with the Resident Council President on 06/25/2026 at 12:35pm. The Resident Council President discussed not seeing housekeeping on the weekends. She also stated when the facility provided laundry services Resident clothes were not being returned. The Resident Council President stated Residents would have to obtain clothes from the donation area.An interview with the Activities Director occurred on 06/25/2026 at 11:32am. The Activities Director discussed grievances within the Resident Council meeting. She stated that her process for grievances voiced during Resident Council was, she would ask a staff member to join the meeting to handle the grievance immediately or she would verbally inform the Administrator, Director of Nursing (DON), or the Social Worker about Resident Council grievances. The Activities Director stated she did not follow up on the grievances but expected the Administrator, DON, or Social Worker to follow up and inform her of the outcome so she could follow up during the next Resident Council.During an interview with the DON on 06/26/2026 at 10:57am, the DON stated she was unaware that there was a process for grievances related to Resident Council.The Administrator was interviewed on 06/26/2026 at 10:33am. The Administrator discussed Residents being able to voice individual concerns at any time. The Administrator was unable to explain how grievances from Resident Council were being addressed.

Based on facility record review, hospital emergency department record review, and Resident, Responsible Party, staff, and Medical Director Interviews, the facility failed to ensure a resident received the medications ordered for her by the physician at discharge from the facility. At the time of discharge on [DATE] medications belonging to another resident were inadvertently provided to Resident #1. On 10/21/25 the Responsible Party looked at the medication packaging and realized the medications were prescribed for another resident and she was taken to the Emergency Department (ED) for evaluation. The ED Provider Note stated Resident #1 had no complaints, but the RP stated she was shaky over the last few days. The ED Provide Note further stated Resident #1 looked good clinically with normal laboratory results and the results of the electrocardiogram completed that day were at her baseline. No treatment or interventions were provided and the ED provider indicated he did not see any evidence of a major medication reaction. Resident #1 was deemed safe for discharge home on [DATE]. The deficient practice occurred for 1 of 3 residents reviewed for discharge from the facility (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with rib fractures due to a fall.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact.During an interview by phone with Nurse #2 on 10/30/2025 at 12:25 pm she stated when she came into the facility for her 7:00 pm shift on 10/17/2025 Resident #1's RP came into the facility and took her to the car without notifying the nurse. Nurse #2 stated Nurse #1 asked the RP to come back into the facility so that she could explain the medications and give him Resident #1's medications. She stated she went over the list of medications with the RP and after explaining the medications he signed the medication list. Nurse #2 stated Nurse #1 gave the bag of medications to the RP and gave him one card of narcotic pain medication that was ordered for Resident #1 that she and Nurse #1 had just counted. Nurse #1 was interviewed by phone on 10/30/2025 at 12:21 pm and she stated Resident #1's Responsible Party (RP) came into the facility on [DATE] during the shift change at 7:00 pm and took Resident #1 to the car without telling anyone that they were leaving. Nurse #1 stated Nurse #2 saw the RP leaving with Resident #1 alerted her and she ran out to the parking lot and asked the RP to allow her to go over Resident #1's discharge instructions before he left. Nurse #1 stated the RP came back into the building but was very agitated and was rushing her when she was giving him the medications and the instructions for Resident #1's medications. Nurse #1 stated she did not know how another resident's medications were put into Resident #1's discharge bag. Nurse #1 stated Nurse #2 who was coming in for the 7:00 pm shift counted Resident #1's narcotic pain medication with her and they both signed them out before giving them to the Responsible Party. Nurse #1 stated she was certain Resident #1 received her own narcotic pain medication.During a phone interview with the Responsible Party (RP) on 10/30/2025 at 12:53 pm he stated Resident #1 was sent home with another resident's medications and he had given her the wrong medications for four days before he realized the medication cards had another resident's name. The RP also stated he was given a list of Resident #1's medications and instructions for how to give them but he looked at the medication cards when he gave Resident #1 the medications and did not look at the medication instructions he was given by the facility. The RP stated he called emergency services on the fourth day when she became confused and had jerking motions in her arms, and he realized the medications he gave her belonged to another resident.On 10/31/2025 at 11:06 am Resident #1 was interviewed by phone and stated she did not remember going to the emergency room on [DATE]. She stated her Responsible Party administered her medications to her after she was discharged from the facility and she did not look at the packages containing the medications.Review of the Emergency Department Provider Notes dated 10/21/2025 at 2:51 PM indicated Resident #1 was brought to the emergency department and was seen and evaluated for the chief complaint of a medication problem. It was noted the resident had recently discharged (10/17/21) from a local skilled nursing facility and her Responsible Party (RP) had been giving her the medications provided by the facility. After a few days the RP began to get suspicious because it seemed she was taking a lot more medications than she had previously. When the RP looked medication packaging, he noticed another resident's name on some of the packaging and called poison control and came to the hospital. The Emergency Department Provider Note stated Resident #1 had no complaints, but the RP stated she was shaky over the last few days. The Emergency Department Provide Note further stated Resident #1 looked good clinically with normal laboratory results and the results of the electrocardiogram completed that day were at her baseline. No treatments or interventions were provided and the ED Provider indicated he did not see any evidence of a major medication reaction. Resident #1 was deemed safe for discharge home on [DATE] at 6:57 PM.An interview was conducted with the facility's Medical Director on 10/30/2025 at 1:56 pm and she stated she cared for Resident #1 during her stay at the facility. The Medical Director stated she reviewed Resident #1's medications and the medications that were inadvertently sent home with her, that belonged to another resident, when she was discharged from the facility. The Medical Director stated the Emergency Department made them aware Resident went home with another resident's medications on 10/21/2025. She stated she reviewed Resident #1's medication list and reviewed the medications the hospital listed were sent home with her that belonged to another resident. The Medical Director further indicated she reviewed the laboratory results, electrocardiogram, and assessments done in the Emergency Department. The Medical Director stated Resident #1 was not harmed and her laboratory and electrocardiogram results did not indicate she had received the medications that were inadvertently sent home with her.The Director of Nursing (DON) was interviewed on 10/30/2025 at 10:55 am and stated Resident #1 discharged from the facility on 10/17/2025. She stated the discharging nurse, Nurse #1, had given Resident #1's RP medications that belonged to another resident. The DON stated the RP had rushed Nurse #1 and she had accidentally picked up the wrong medications. The DON stated the hospital notified the facility on 10/21/2025 of the wrong medications being sent home with Resident #1 and the facility immediately put a plan of correction in place.During an interview with the Administrator on 10/30/2025 at 10:55 am he stated the facility was notified by the hospital on [DATE] that Resident #1 was discharged home with another resident's medication and was at the Emergency Department for evaluation. The Administrator stated they tried to call the RP, but he did not return their call. The Administrator stated they immediately began a plan of correction to ensure no other residents had been discharged with the wrong medications.The facility provided the following corrective action plan with a compliance date of 10/23/2025:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. At the time of discharge on [DATE] medications belonging to another resident were inadvertently provided to Resident #1's Responsible Party (RP) which potentially could have been given to Resident #1 by the Responsible Party. A printed list of Resident #1's medications with instructions was reviewed with and signed by the responsible party when Resident #1 was discharged from the facility. On 10/21/25 Resident #1 was assessed by medical staff, including the physician (MD), in the Emergency Department (ED) at a local hospital. Per the hospital notes, no complications were identified by the MD related to the resident receiving incorrect medications at home. The hospital notes indicated the Responsible Party gave Resident #1 medications that belonged to another resident. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. To identify other residents who had the potential to be affected, the facility clinical nursing team, under the supervision of the Director of Nursing (DON), audited all resident discharges to home that occurred in the 2 weeks prior to the discharge in question on 10/17/2025. This audit included phone calls to the discharged resident or RP of the discharged resident to determine if there were issues with incorrect medications being sent home with the resident. There was no medication issues discovered from this audit which was completed by the DON on 10/23/2025. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. To ensure that deficient practice will not recur, the facility DON and Unit Coordinators (UC) initiated an in-person and telephonic in-service on 10/22/2025 with 100% of current facility nurses, including any agency nurses who work a shift. The telephonic in-service consists of text communication to the nurse from the facility DON, with a visual image of the in-service included. The nurse is required to respond back to the DON that they read and understand the in-service. The DON was responsible for ensuring and recording responses. This in-service training specifies that 2 nurses will be required to sign off on the medication review of any resident who discharges home with medication(s). The training for this newly implemented process will allow the facility to double-check that correct medications are sent home with the resident or the RP of the resident. Any nurse(s) who were not available on 10/22/2025 for this in-service training on medications provided to residents discharging home, will be trained on their next scheduled shift and before they can participate in discharging residents home with medications. The DON is responsible for tracking who requires the in-service and ensuring that no one works before they receive the in-service. Any nurse(s) who are hired (or new agency nurses) after the initiation of this in-service on 10/22/2025 will be trained as part of the orientation process and prior to being allowed to discharge residents home with medications. The DON is responsible for training new staff and tracking compliance. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. The facility will monitor its performance to make sure solutions are sustained in the area of discharging residents' home with the correct medications. The monitoring component will be completed by the DON and UCs, for any resident who discharges home with medications. The DON and UCs will use a QA form, the Medication Prep at Discharge Audit Form, to provide evidence of auditing and if the medication portion of the discharge was performed correctly. Monitoring will take place weekly for four weeks, bi-monthly for four weeks then once monthly for two months. The QA form allows the nurse to verify, via signature, that the right medications are being sent home with the discharging resident and that two licensed nurses verified and signed acknowledgement that only that resident's medications are included. If a resident discharges home with incorrect medications, it will be addressed at the time of the discovery by the DON or UCs who will report directly to the Facility Administrator (NHA) and Medical Director. The facility created a QA team consisting of DON, Administrator and UCs. The initial meeting was held on 10/22/2025 and will be held weekly x 4 weeks, bi-monthly x 4 weeks and then monthly x 1 quarter to ensure compliance. Any discharge(s) since the previous meeting will be reviewed at that time for compliance. The team will also review ongoing in-servicing of new nurses. The DON will be responsible for taking the results of the QA form audits and the team meetings to the Executive Quarterly QA Meeting. The next Executive Quarterly QA meeting is scheduled for 11/6/2025. The facility alleges compliance with this corrective action plan as of 10/24/2025.On 10/30/2025 the facility provided a corrective action plan which included review of Resident #1's emergency department record which stated Resident #1 presented to the emergency department because she received the wrong medications when discharged from the facility. The emergency department record also stated Resident #1 suffered no major medicine reactions, her labs were normal, her electrocardiogram showed no changes, and she was safe to discharge back home from the emergency room. The facility also provided Resident #1's Transfer/Discharge Report dated 10/17/2025 and signed by the RP, which included a medication list that stated how and when the medications should be administered. The facility provided a list of residents that were discharged within the prior two weeks, and each resident or their RP was interviewed to ensure the correct medication was sent home with each resident by the Director of Nursing on 10/23/2025. The facility provided in-service education regarding the discharge process for nurses and specified 2 nurses will be required to sign off on the medication review of any resident who discharges home with medication(s). The in-service education was also included in the facility's orientation process for nurse. A sample of nursing staff were interviewed regarding the in-service education and were able to verbalize understanding of the process for discharge medications. The facility provided documentation of audits beginning 10/24/2025 of discharged resident's medications that occurred after the initial audit of previous residents that were discharged . The facility also provided a copy of the minutes from a Quality Assurance Performance Improvement meeting held 10/22/2025 to discuss and review the plan of correction and any residents that have been discharged . The facility's corrective action plan completion date of 10/24/25 was validated.

Based on record review, observation and interviews of the staff and wound care physician, the facility failed to follow their infection control policy for hand hygiene and glove use when the Wound Care Nurse did not perform hygiene and don new gloves after the dirty portion of the pressure ulcer dressing change and before beginning the clean portion of the dressing change (Resident #53). This deficient practice occurred for 1 of 2 staff observed for infection control practices. Findings included: The infection control policy last updated on 10/22/24 documented, in part, 1. Hand hygiene d. Wash hands after removing gloves. 2. Gloves e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. On 04/02/25 at 10:35 am an observation of Resident #53's pressure ulcer wound care to her right buttock by the wound care nurse was done. The wound care nurse washed her hands and donned gloves. She placed all her supplies on a clean surface next to the resident's bed. The wound care nurse removed the wound dressing. The right buttock stage 3 pressure ulcer was approximately 2 centimeters (cm) around and 1 cm deep with a small amount of serous (light red) drainage present and there were no signs or symptoms of infection. She cleansed the pressure ulcer with normal saline and applied skin prep around the pressure ulcer. The wound care nurse used the same gloves and had not performed hand hygiene before she placed the silver alginate (medicated gauze) into the ulcer wound bed and then placed the dressing over the wound. There was no use of hand sanitizer or change of gloves in-between removing the dirty dressing, cleansing the wound and placement of the treatment and dressing. The wound care nurse was interviewed. The wound care nurse stated she only changed gloves during wound care when the resident had more than one wound. She would change gloves between each wound. If there was only one wound, she would use the same gloves. The wound care nurse commented she wore the same gloves and had not stopped for hand hygiene and re-glove in between the dirty dressing and placing the treatment and clean dressing because Resident #53 had one wound. On 04/02/25 at 12:09 pm an interview was conducted with the wound care physician. The wound care physician stated he remembered Resident #53. The wound care physician stated that the expected use of infection control during wound care would have been to use hand hygiene and don gloves and remove the old/soiled dressing and cleanse as required and then use hand hygiene and change to clean gloves before having placed the treatment and a clean dressing. This would be the same for each wound a resident would have. On 4/1/25 at 4:40 pm an interview was conducted with the Administrator. The deficient practice by the wound care nurse when she failed to perform hand hygiene and change gloves after she removed the dirty pressure ulcer dressing, cleansed the wound and then placed the treatment calcium alginate and sterile dressing was discussed. The Administrator stated he thought that use of the same gloves was appropriate when there was only one wound on the resident. The facility owner was requested to attend the interview. The owner stated if the old dressing was not soiled and there was only 1 wound, it was not necessary to change gloves in-between removing the dirty dressing and cleansing and then placing the treatment and clean dressing. The owner stated the wound care nurse was certified/trained and he thought this process was what she learned. The owner stated he would provide information from SPICE (Statewide Program for Infection Control and Epidemiology) to corroborate the use of the same gloves for dirty dressing/cleanse and clean dressing and would get back to me tomorrow (4/2/25). On 4/2/25 at 10:15 am an interview was conducted with the Administrator. He stated the facility had nothing to add from SPICE or any other information regarding infection control and the use of hand hygiene and gloves during wound care. Hand hygiene and change of gloves would need to be performed during wound care. On 04/03/25 at 11:28 am an interview was conducted with the Director of Nursing (DON). The DON stated the wound care nurse was confused that not changing dirty gloves before starting the clean process for wound care was not part of the SPICE recommendations. The DON informed the wound care nurse that hand hygiene and changing gloves was required during wound care after removing the soiled dressing and cleaning and then handling clean treatment and dressing for each wound.

Based on staff interviews and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of active diagnoses and urinary catheter for 2 of 20 residents reviewed for MDS accuracy (Residents #39 and #100). The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder. A record review indicated Resident #39 had an active diagnosis of Post-Traumatic Stress Disorder (PTSD) since 8/8/23. The annual Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #39 had an active diagnosis of PTSD in the Psychiatric/Mood Disorder section An interview was conducted on 4/3/25 at 10:25 AM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that she did not code an active diagnosis of PTSD in the Psychiatric/Mood Disorder section of Resident #39's annual MDS assessment dated [DATE]. An interview was conducted on 03/06/25 at 10:50 AM with the Administrator. He stated she expected the MDS assessments to be coded accurately. 41579 2. Resident #100 was admitted to the facility on [DATE] with diagnoses which included urinary retention. Resident #100's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #100 was cognitively intact and was frequently incontinent with bladder and was not coded to have an indwelling urinary catheter. A review of Resident #100's care plan 10/30/24 revealed Resident #100 had an indwelling urinary catheter. On 04/02/25 at 3:11 PM an interview was conducted with Nurse #1, and she indicated she was assigned to Resident #100 while he was in the facility. Nurse #1 reported Resident #100 had an indwelling catheter for urinary retention. An interview was conducted on 04/03/25 at 11:33 AM with the Minimum Data Set (MDS) Nurse #1. The MDS Nurse #1 indicated the indwelling catheter should have been coded on the MDS. She stated, I did care plan it. An interview was conducted on 04/03/25 at 1:20 PM with the Administrator and he indicated it was his expectation the MDS assessments to be coded accurately.

Based on record review and staff, Wound Care Physician, and lab vendor interviews, the facility failed to notify the Wound Care Physician of a positive wound culture lab result when it was reported to the facility which delayed initiating antibiotics for 3 days. This deficient practice affected 1 of 2 sampled residents (Resident #53). Findings included: Resident #53 was admitted to the facility on [DATE] with the diagnosis of dementia. The annual Minimum Data Set, dated dated dated [DATE] for Resident #53 documented she had an intact cognition, a diagnosis of one stage 3 pressure ulcer, and the pressure ulcer stage 3 was reported not present on admission or reentry. The resident was frequently incontinent of bladder and always incontinent of bowel. The care plan dated 3/20/25 for Resident #53 had interventions for pressure reduction, nutrition supplementation for wound healing, and pressure ulcer wound care. The resident was at risk of developing pressure ulcers. Resident #53 had a Wound Care Physician progress note dated 2/10/25 which documented the progress of her pressure ulcer wound. The wound was not progressing and suspected to be infected. A deep swab technique was performed on the stage 3 pressure wound of the right buttock completed on 2/10/25 and order provided for culture. Resident #53's physician ordered a wound culture for stage 3 right buttock pressure ulcer on 2/10/25 that was initiated by the Wound Care Nurse. Resident #53's pressure ulcer wound culture lab result dated 2/14/25 documented the specimen was picked up on 2/11/25 and the final result was completed on 2/14/25. The report was sent to the facility directly into the resident's electronic medical record (EMR) on 2/14/25 and was positive for bacteria organism proteus mirabilis. The culture report had printing dates of 2/14/25 and 2/17/25 on the copy in Resident #53's EMR. On 4/3/25 at 12:44 pm an interview was conducted with Nurse #2. Nurse #2 stated she was assigned to Resident #53 on day shift on 2/14/25. She was not aware of the lab result reported on 2/14/25 for Resident #53. She stated the process for lab results was a paper copy of the lab was provided to staff at the nurses' station by the Director of Nursing (DON). The result would then be reported to the ordering provider. Nurse #2 stated she was not aware that the lab was directly reported into the resident's individual EMR. The EMR type had changed on 12/2024, and the process had changed from paper to directly placed into the EMR. The lab could be reviewed in the lab portal if it was known a lab result had been reported. Nurse #2 stated she was not informed that the resident had a lab result received on 2/14/25 and there was no EMR notification. On 4/2/25 at 10:33 am an observation was done of Resident #53's final lab culture report dated 2/14/25 with Nurse #2. The report had two dates for being printed, 2/14/25 and 2/17/25 on the form. Nurse #2 commented that the report was printed from the internet vendor site showing the two dates and then scanned into the resident's EMR on 2/17/25. On 4/2/25 at 10:33 am an interview was conducted with the Wound Care Nurse. The Wound Care Nurse stated she was absent on Friday, 2/14/25 and returned on Monday 2/17/25. The wound culture result was reported to the Wound Care Physician on 2/17/25 when he was at the facility to see the residents, and the physician ordered antibiotics. The Wound Care Nurse stated she expected the nurse assigned Resident #53 on 2/14/25 to address the lab results reported that day. The Wound Care Nurse was aware the result was posted to the Resident #53's EMR, but thought the result was printed and provided to the staff nurse assigned on 2/14/25. The Wound Care Nurse stated printing a copy of lab results and providing it to assigned nursing staff was the process. The Wound Care Nurse stated she printed her own lab results and thought nursing staff printed their resident assignment lab result(s). The Wound Care Nurse was absent on 2/14/25 and she printed her own copy on 2/17/25. Resident #53's Wound Care Physician progress note dated 2/17/25 documented the wound was exacerbated due to infection, there was a moderate amount of serous drainage (light red liquid), and 100% of granulation tissue. A deep swab technique of stage 3 pressure wound of the right buttock demonstrates proteus mirabilis on 2/10/25. The wound care order remained unchanged, and the antibiotic Invanz 1 gram for 10 days was ordered. Resident #53 had an order dated 2/17/25 for Ivanz (antibiotic) 1 gram intramuscular for 10 days. On 04/02/25 at 10:46 am an interview was conducted with the lab vendor. She stated the wound culture for Resident #53 was posted in the resident's EMR when the final report was completed 2/14/25 at 9:48 am. All labs for facilities that use the connected EMR were automatically posted to their EMR including on the weekends. The labs were placed in the residents' EMR electronically. If the lab was critical the facility was called as well. Resident #53's would culture result was not considered critical. She further stated that this facility was connected directly to the lab to receive reports into the residents' EMR. On 4/2/25 at 11:10 am the DON reviewed Resident #53's wound culture result and was interviewed. The DON stated she was not aware the lab would come directly to the EMR but was expecting a fax. There was no notification in the EMR that a lab result was posted. The DON stated she kept a written logbook of all labs to follow, and Resident #53's wound culture was not recorded in her logbook (the DON opened her logbook and reviewed). The DON stated she kept track of all labs in her book and if known she would have addressed the lab. The DON commented that this EMR type was new to the facility as of 12/2024. A review of the lab culture result revealed it was a final report on 2/14/25 at 9:48 am and was printed at the facility on 2/14/25 and 2/17/25 and scanned into the Resident #53's EMR. The DON further stated she was keeping a logbook of submitted labs and printing a copy of the result from the vendor site instead of accessing the result from the residents' EMR. On 4/2/25 at 12:09 pm an interview was conducted with the Wound Care Physician. The Wound Care Physician stated he completed a wound culture swab of Resident #53's right buttock pressure ulcer on 2/10/25 and he was not informed of the culture report until 2/17/25. The Wound Care Physician indicated the wound culture result should have been reported to me on 2/14/25 when it was received, and he would have ordered the antibiotic on 2/14/25. He commented that the Wound Care Nurse was usually prompt in reporting culture results. The Wound Care Physician further commented that he was available 24/7 by phone, especially for wound culture reports. The delayed start of the antibiotic had not caused the resident harm, and her wound was now improving.

2. Resident #81 was admitted to the facility on [DATE] and had an re-entry of 03/12/25. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was moderately cognitively impaired. The discharge MDS assessment dated [DATE] revealed Resident #81 was discharged to the hospital on [DATE] and was readmitted on [DATE]. The nursing progress note dated 03/08/25 revealed Resident #81 was transferred to the hospital. An interview conducted with Resident #81's Resident Representative (RR) on 04/02/25 at 1:35 PM revealed he had not received any type of notice regarding discharge or transfers since Resident #81 was discharged to the hospital on [DATE]. A telephone interview was conducted on 4/2/25 at 1:07 PM with the Ombudsman who revealed she had not received written notification of hospital transfers since November of 2024. An interview was conducted on 4/2/25 at 2:45 PM with the Administrator. He stated the facility has had administrative staff changes and he determined that notices of transfers had not been sent to the resident and resident representative or the Ombudsman since November of 2024. He further indicated that the notice of transfer for Resident #81 should have been provided to the resident representative and to the Ombudsman as required. Based on record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman, the residents and/or the resident representatives in writing of a resident transfer for 2 of 3 residents reviewed for hospitalization (Resident #88 and Resident #81). The findings included: 1. Resident #88 was initially admitted to the facility on [DATE] and a reentry date of 1/29/25. The nursing progress note dated 1/28/2025 at 2:30 PM revealed Resident #88 was transferred to the hospital for evaluation. Resident #88 was discharged from the facility on 1/28/25 and returned to the facility on 1/29/25. A telephone interview was conducted on 4/2/25 at 1:07 PM with the Ombudsman who revealed she had not received written notification of hospital transfers since November of 2024. Multiple attempts were made to interview the responsbile party however attempts were not successful. An interview was conducted on 4/2/25 at 2:45 PM with the Administrator. He stated the facility has had administrative staff changes and he determined that notices of transfers had not been sent to the resident and resident representative or the Ombudsman since November of 2024. He further indicated that the notice of transfer for Resident #88 should have been provided to the resident representative and to the Ombudsman as required.

Based on observation, record review and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide (NA) #1 and NA #2 failed to remove their masks before exiting a COVID-19 isolation room for 2 of 7 residents reviewed for infection control. (Resident #10 and Resident #24) Findings included: Record review of the Facility Infection Prevention and Control Program Policy last revised 7/13/23 revealed the program outlines strategies designed to reduce the risk of transmission of infectious agents among healthcare workers, residents, and visitors. The policy further stated transmission-based precautions will be utilized in addition to Standard Precautions when the route of transmission is not completely interrupted using Standard Precautions along. The policy indicated that the three categories of transmission-based precautions were contact, droplet (including enhanced) and airborne and appropriate use of personal protective equipment was required. Review of isolation signage placed on the doorway of residents on droplet contact precautions revised 1/20/22 indicated a mask had to be worn when entering the room and removed immediately before leaving room. a. Resident #10 was newly diagnosed with COVID-19 infection as of 1/5/24. An observation was made at 12:32 pm on 1/10/24. NA #1 was observed wearing a mask and taking a lunch meal tray for Resident #10. Prior to entering Resident #10's room, NA #1 was observed donning additional personal protective equipment (PPE), the gown and gloves, as Resident #10 was on special droplet contact precautions on isolation. The PPE available at the entrance of Resident #10's room included gowns, gloves, masks, and face shields. NA #1 was observed exiting Resident #10's room with no gown, no gloves in place, but continued out of the room wearing the mask. NA #1 was not observed discarding her mask or donning a new mask after exiting Resident #10's room but proceeded to pass a lunch meal tray for another resident, who was not on isolation precautions, wearing the same mask. An interview was conducted with NA #1 at 2:41 pm on 1/10/24. NA #1 indicated she donned her face mask upon arrival at the facility to start her scheduled shift starting at 7:00 am on 1/10/24. NA #1 explained she kept the same mask for the entire shift scheduled (7:00 am to 3:00 pm) and would remove the mask when exiting the facility for the day. NA #1 indicated Resident #10 was placed on special droplet contact precautions in an isolation room because of COVID-19 infection. NA #1 indicated she doffed the gloves and gown in Resident #10's bathroom and washed her hands prior to exiting the room. NA #1 indicated she did not change her mask after passing lunch meal tray to Resident #10 because she did not have a mask on her person. b. Resident #24 was newly diagnosed with COVID-19 infection as of 1/5/24. An observation was made at 12:45 pm on 1/10/24. Nurse Aide (NA) #2 was observed wearing three face masks and taking a lunch meal tray to Resident #24. Prior to entering Resident #24's room, NA #2 was observed donning additional PPE, the gown and gloves, as resident was on special droplet contact precautions in an isolation room. The PPE available at the entrance of Resident #24's room included gowns, gloves, masks, and face shields. NA #2 was observed exiting Resident #24's room with no gown and no gloves in place but was still wearing the three masks. NA #2 was not observed removing the three masks or donning a new mask after exiting Resident #24's room but proceeded to pass a lunch meal tray for another resident, who was not on isolation precautions. An interview was conducted with NA #2 at 3:18 pm on 1/10/24. NA #2 indicated she donned her masks upon arrival at the facility to start her scheduled shift starting at 7:00 am on 1/10/24. NA #2 indicated she kept the same masks on for the entire shift scheduled (7:00 am to 3:00 pm) and would remove the masks when exiting the facility for the day. NA #2 indicated she had donned three masks because she did not want to get infected with COVID-19 infection. NA #2 indicated Resident #24 was on special droplet contact precautions in an isolation room because of COVID-19 infection. NA #2 indicated she doffed the gloves and gown in Resident #24's bathroom and washed her hands prior to exiting the room. NA #2 indicated she did not change her masks after passing lunch meal tray to Resident #24 because she did not think she needed to. An interview was conducted with Nurse #1 on 1/10/24 at 3:00 pm. Nurse #1 indicated Resident #10 and Resident #24 were under her care, and each were on special droplet contact precautions requiring isolation for diagnosis of COVID-19 infection. Nurse #1 indicated she donned her mask upon arrival at the facility to start her scheduled shift starting at 7:00 am on 1/10/24 and would doff her mask when exiting the facility after ending her shift at 7:00 pm. Nurse #1 indicated she wears the same mask during the entire shift whether she enters and exits isolation rooms or not. On 1/10/24 at 3:40 pm the surveyor informed the Director of Nursing (DON) and Administrator that staff were observed not changing masks after leaving isolation precautions rooms. On 1/10/24 at 3:40 pm, an interview was conducted with the DON, who was the facility's Infection Preventionist. The DON indicated staff were to remove all contaminated PPE while in an isolation room for any resident on transmission-based precautions, dispose of them in the barrel placed in the resident's bathroom, and wash hands before they could exit the isolation room. DON indicated that upon exiting the isolation precaution room, staff would don a new mask. On 1/10/24 at 3:40 pm the Administrator indicated staff had been educated on Infection control policies and procedures on an ongoing and weekly basis and as needed. Indicated staff should remove all contaminated PPE before they exit the isolation room for residents on transmission-based precautions, wash their hands and put on a new mask.

Based on record review and staff interviews the facility failed to ensure 1 of 1 residents, Resident #73, reviewed for care planning was given an opportunity for the resident or resident representative to participate in development and revision of their care plan. Findings included: Resident #73 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was severely cognitively impaired. Review of the Care Plan Team Meeting Sign-in sheets for Resident #73 revealed her last Care Plan Team Meeting was 1/20/2022. During an interview with the Family Member on 8/29/2022 at 2:01 pm she stated she had not been invited to a care plan meeting since 1/2022. An interview was conducted with the Social Worker on 8/31/2022 at 11:12 am and she stated she had missed scheduling the past two quarterly Care Plan Team Meetings with Resident #73 and her Family Member. The Social Worker stated when the calendar for the Minimum Data Set (MDS) assessments changed it changed the Care Plan schedule and caused her to miss sending out the Care Plan Team Meeting invitations. The Administrator was interviewed on 9/1/2022 at 1:34 pm and stated the Social Worker should have followed the rules and regulations regarding scheduling of Resident #73's Care Plan Team Meetings.

Based on record review, observations, staff, and physician interviews the facility failed to ensure 1 of 3 residents (Resident #92), reviewed for discharge from the facility, was not provided monitoring after she experienced a low oxygen saturation, received a narcotic analgesic, and antianxiety medication. Furthermore the facility failed to have a licensed nurse assess a resident after a fall before moving her in the [CONDITION(S)] center parking lot. This was evident of 1 of 3 (Resident #1) residents who were reviewed for accidents. Findings included: 1. Resident #92 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #92 was cognitively intact. On 8/31/2022 at 3:02 pm an interview we conducted by phone with Nurse Aide #1, and she stated she was assigned to Resident #92 on the morning of 6/11/2022. She stated the resident was a little confused and while she was assisting her to the bathroom, she passed out in the bathroom. Nurse Aide #1 stated Resident #92's eyes went back in her head, her speech was slurred, and she was not making sense. Nurse Aide #1 stated she called Nurse Aide #2 in to assist her with putting Resident #92 back to bed. She explained after they put her back to bed, raised her legs, she began to come around, she called Nurse #1 into the room, and told her Resident #92 had an episode of unresponsiveness. Nurse Aide #1 stated Nurse #1 put oxygen on Resident #92 and assessed her. Review of Resident #92's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic medical record revealed Nurse #1 had documented an oxygen saturation of 92% on 6/11/2022 at 9:21 pm. There were no other oxygen saturation levels documented for 6/11/2022. A Progress Note dated 6/11/2022 at 10:44 am by Nurse #1 stated she was notified by Nurse Aide #1 that Resident #92 was not feeling well and upon assessment Resident #92's oxygen saturation was 62 to 65%, a normal oxygen saturation level is 95 to 100%. Nurse #1's Progress Note further stated Resident #92 was alert and oriented, and complaining of gas pain, and was medicated with a narcotic pain medication for pain and an antihistamine for nausea. The Progress Note stated Resident #92's oxygen saturation level was rechecked, after she was placed on oxygen, and was 90 to 92% and Resident #92 stated she was feeling better; and monitoring was put into place. A telephone interview was conducted with Nurse #1 on 8/31/2022 at 12:52 pm and she stated she was administering medications on her assignment when Nurse Aide #1 notified her Resident #92 needed pain medication and she went to assess Resident #92 and she checked her vital signs. Nurse #1 stated Resident #92's oxygen saturation was 62 to 65% when she checked her vitals and she put oxygen on Resident #92, and she assisted Nurse Aide #1 with getting Resident #92 into the bed. Nurse #1 stated Nurse Aide #1 did not tell her Resident #92 had an unresponsive episode and Resident #92's oxygen saturation went back up to 92% within a few minutes of starting the oxygen. Nurse #1 stated she did not notify the Physician or Nurse Practitioner of Resident #92's oxygen saturation and did not recheck Resident #92's oxygen saturation after it had increased to 92% when she assessed her. During an interview with the Administrator on 9/1/2022 at 1:24 pm he stated he felt the nursing staff had handled Resident #92's care appropriately but had failed to document that she had monitored Resident #92 after the episode of decreased oxygen saturation and unresponsiveness. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed as being cognitively intact and required extensive assistance with one-person physical assist with bed mobility, transfer, walk in corridor, dressing, toilet use and bathing. Further review of the MDS revealed Resident #1 had no history of falls before admission to the facility. A review of Resident #1's care plan dated 10/18/21 revealed Resident was able to ambulate in room with a rollator independently, however, gait was somewhat unsteady. Intervention included Resident was encouraged to ask for assistance with transfers and ambulation. Review of incident report was done and indicated Resident #1 had a fall at the [CONDITION(S)] center and returned. No documentation of Resident being assessed by a nurse at the [CONDITION(S)] center. An interview was conducted with family member on 08/31/22 at 11:00 am. Family member indicated that Resident #1 had a fall after her [CONDITION(S)] treatment in October 2021. Family member indicated Resident was not assessed after the fall at the [CONDITION(S)] center. During an interview with Transportation staff member on 08/31/22 at 12:45pm, it was indicated he had written a statement in October 2021 after the incident with Resident #1. He indicated Resident #1 had fell on her hands and knees and he assisted her back to the wheelchair because resident was persistent about getting back in the wheelchair and stated to him, she did not need help getting up. He also indicated he did not seek help from the [CONDITION(S)] center and transported Resident #1 back to the facility and informed the nurse and the nursing aide at the facility. Attempted to contact the Nurse Aide who was assigned to Resident #1 on 10/22/21 and was unsuccessful. Attempted to contact the Nurse who completed the incident report on 10/22/21 and was unsuccessful. During a second interview with family member on 08/31/22 at 4:40 pm, it was indicated, she was informed by Resident #1 she had a fall at the [CONDITION(S)] center and that staff had not assessed her after the fall. Family member indicated she visited the facility that afternoon and she informed the Nurse on duty, and at that was when the Nurse assessed her mother. An interview was conducted with Resident #1 on 09/01/22 at 10:00 am and it was indicated she had not informed the Transportation staff member that she did not need help after the fall. She indicated the Transportation staff member assisted her back into the wheelchair and took her back to the facility and dropped her off in her room. Resident #1 indicated the Nurse did not assess her until her family member came to the facility and informed the Nurse of the fall. During an interview on 09/01/22 at 10:40 am the Director of Nursing stated it was her expectation that staff would call the facility immediately and report an incident. She indicated staff were not to move a resident after a fall until a Nurse assessed the resident. During an interview on 09/01/22 at 11:05 am with the Administrator, it was indicated he expected employees to follow the rules and regulations of the State of North Carolina and the Board of Nursing. Findings included: 2. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed as being cognitively intact and required extensive assistance with one-person physical assist with bed mobility, transfer, walk in corridor, dressing, toilet use and bathing. Further review of the MDS revealed Resident #1 had no history of falls before admission to the facility. During an interview with Transportation staff member on 08/31/22 at 12:45pm, it was indicated he had written a statement in October 2021 after the incident with Resident #1. He indicated Resident #1 had fell on her hands and knees and he assisted her back to the wheelchair because resident was persistent about getting back in the wheelchair and stated to him, she did not need help getting up. He also indicated he did not seek help from the [CONDITION(S)] center and transported Resident #1 back to the facility and informed the nurse and the nursing aide at the facility. An interview was conducted with Resident #1 on 09/01/22 at 10:00 am and it was indicated she had not informed the Transportation staff member that she did not need help after the fall. She indicated the Transportation staff member assisted her back into the wheelchair and took her back to the facility and dropped her off in her room. Resident #1 indicated the Nurse did not assess her until her family member came to the facility and informed the Nurse of the fall. During an interview on 09/01/22 at 10:40 am the Director of Nursing stated it was her expectation that staff would call the facility immediately and report an incident. She indicated staff were not to move a resident after a fall until a Nurse assessed the resident.

Based on record review and staff, Nurse Practitioner, and Physician interviews the facility failed to ensure the Nurse reported a change in condition to the Physician for 1 of 3 residents, Resident #92, reviewed for hospitalization when the resident had an episode of unresponsiveness and a low oxygen saturation. Findings included: Resident #92 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #92 was cognitively intact. On 8/31/2022 at 3:02 pm an interview we conducted by phone with Nurse Aide #1, and she stated she was assigned to Resident #92 on the morning of 6/11/2022. She stated the resident was a little confused and while she was assisting her to the bathroom, she passed out in the bathroom. Nurse Aide #1 stated Resident #92's eyes went back in her head, her speech was slurred, and she was not making sense. Nurse Aide #1 stated she called Nurse Aide #2 in to assist her with putting Resident #92 back to bed. She explained after they put her back to bed, raised her legs, she began to come around, she called Nurse #1 into the room, and told her Resident #92 had an episode of unresponsiveness. Nurse Aide #1 stated Nurse #1 put oxygen on Resident #92 and assessed her. A Progress Note dated 6/11/2022 at 10:44 am by Nurse #1 stated she was notified by Nurse Aide #1 that Resident #92 was not feeling well and upon assessment Resident #92's oxygen saturation was 62 to 65%, a normal oxygen saturation level is 95 to 100%. Nurse #1's Progress Note further stated Resident #92 was medicated with a narcotic pain medication for pain and an antihistamine for nausea. The Progress Note stated Resident #92's oxygen saturation level was rechecked and was 90 to 92% and Resident #92 stated she was feeling better. A telephone interview was conducted with Nurse #1 on 8/31/2022 at 12:52 pm and she stated she was administering medications on her assignment when Nurse Aide #1 notified her Resident #92 needed pain medication and she went to assess Resident #92 and she checked her vital signs. Nurse #1 stated Resident #92's oxygen saturation was 62 to 65% when she checked her vitals and she put oxygen on Resident #92, and she assisted Nurse Aide #1 with getting Resident #92 into the bed. Nurse #1 stated Nurse Aide #1 did not tell her Resident #92 had an unresponsive episode and Resident #92's oxygen saturation went back up to 92% within a few minutes of starting the oxygen. Nurse #1 stated she did not notify the Physician or the Nurse Practitioner of Resident #92's oxygen saturation being 62 to 65%. A phone interview was conducted with the Physician on 9/1/2022 at 10:44 am and he stated Resident #92 came to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician stated Nurse #1 had not reported Resident #92's oxygen saturation had dropped to 62 to 65% and had required oxygen to bring her oxygen saturation up to 92%. The Physician stated since Resident #92's oxygen saturation returned to normal with the oxygen he did not feel the Nurse #1 should have notified him. A telephone interview was conducted with Nurse Practitioner #1 on 9/2/2022 at 6:36 pm and she was not called when Resident #92 had the episode of decreased oxygen saturation. Nurse Practitioner #1 stated she was not present in the building when Resident #92 had the decreased oxygen saturation, but the oxygen saturation had come up to within normal limits after Resident #92 received oxygen per the standing orders. Nurse Practitioner #1 stated she did not know if she would have ordered anything differently since she was not present when Resident #92's oxygen saturation was low. During an interview with the Administrator on 9/1/2022 at 1:24 pm he stated he felt the nursing staff had handled Resident #92's care appropriately but had not reported the change in condition to the Nurse Practitioner or Physician. The Administrator stated he was not a clinician and was not sure if Nurse #1 should have notified the Nurse Practitioner or Physician of the decreased oxygen saturation since she had administered oxygen and the oxygen saturation had returned to normal.

Based on observation and staff interviews the facility failed to (1) maintain walls and faucets in good repair for 4 of 9 resident rooms (Rooms 206, 208, 210 and 212) and the facility failed to (2) maintain a clean living environment for 1 of 9 resident rooms (Room 206) observed for environment. Findings included: 1.Observation of hall 200 revealed staff failed to maintain resident walls and water faucet in good repair for the following rooms: a. Room 206 was observed on 6-29-21 at 10:50am. The observation revealed an approximately 1 inch by 2-inch mark on the wall where the paint had been stripped off and the dry wall was showing. A second observation was conducted on 7-1-21 at 3:24pm with the Maintenance Assistant and the Building Manager. The observation revealed an approximately 1 inch by 2-inch mark on the wall where the paint had been stripped off and the dry wall was showing. An interview with the Maintenance Assistant occurred on 7-1-21 at 3:25pm. The Maintenance Assistant stated he had begun patching the walls but stated he was the maintenance person for the building right now and had not been able to examine every resident room. b. An observation of room 208 occurred on 6-29-21 at 10:53am. Room 208 was observed to have wall damage in several spots under the television revealing dry wall. Observation of the room's bathroom revealed a steady stream of water coming out of the faucet even though the faucet handles had been turned off. The second observation of room 208 occurred on 7-1-21 at 3:26pm with the Maintenance Assistant and the Building Manager. The observation revealed wall damage in several spots under the television revealing dry wall and a steady stream of water coming out of the faucet even though the faucet handles had been turned off. An interview with the Maintenance Assistant occurred on 7-1-21 at 3:27pm. The Maintenance Assistant stated he had work orders placed at the nursing stations and that staff were to fill out the work order sheet when they saw something that needed repaired. He also stated he had checked the work orders at each nursing station throughout the day. The Maintenance Assistant stated he had not been made aware of the faucet not working properly. c. Room 210 was observed on 6-29-21 at 10:55am. The observation revealed an approximately 0.5 inch by 0.5-inch hole in the rooms ceiling. A second observation in room 210 occurred on 7-1-21 at 3:28pm with the Maintenance Assistant and the Building Manager. The observation revealed an approximately 0.5 inch by 0.5-inch hole in the rooms ceiling. An interview with the Maintenance Assistant occurred on 7-1-21 at 3:29pm. The Maintenance Assistant stated he was not aware of the issue but would have the hole repaired. d. During an observation of room 212 on 6-29-21 at 11:05am, the observation revealed the bathroom in room 212 had approximately 5 areas in a rectangle shape on the wall where the paint had peeled off and the dry wall was exposed. A second observation was made on 7-1-21 at 3:30pm with the Maintenance Assistant and the Building Manager. The second observation revealed the bathroom in room 212 had approximately 5 areas in a rectangle shape on the wall where the paint had peeled off and the dry wall was exposed. During an interview with the Maintenance Assistant on 7-1-21 at 3:32pm, the Maintenance Assistant stated the wall appeared to have had something removed and the paint was removed with the object. He stated he was unaware of the issue but would have it fixed. 2. Observation of hall 200 revealed staff failed to maintain a clean-living environment for the following room. a. An observation of room 206 occurred on 6-29-21 at 10:50am. The observation revealed 13 brown spots on the resident's ceiling above her bed and the vent in her bathroom ceiling contained dust. A second observation was conducted on 7-1-21 at 3:24pm with the Maintenance Assistant and the Building Manager. The observation revealed 13 brown spots on the resident's ceiling above her bed and the vent in her bathroom ceiling contained dust. The Building Manager was interviewed on 7-1-21 at 3:25pm. The Building Manager discussed the spots on the ceiling appeared to be from a soda exploding and should have been cleaned by housekeeping. He also discussed having a check list for the housekeepers when they are cleaning a resident room to ensure all areas are cleaned and inspected. The Building Manager stated the bathroom vents are on the check list to be inspected daily. The Administrator was interviewed on 7-1-21 at 3:35pm. The Administrator discussed staffing issues in maintenance and housekeeping and expressed his positivity that the issues mentioned would be corrected.

Based on observation, record review, review of enhanced droplet/contact precautions policy, preparing for COVID-19 in nursing homes policy and What to do when COVID-19 gets into your long term care facility policy, staff interview and physician interview, the facility failed to implement their policies and procedures when 1 of 3 staff members (nursing assistant (NA) #1) who worked with residents who were on enhanced droplet/contact precautions, was observed not wearing PPE including; gloves or gown and not performing hand hygiene when entering and exiting the residents room. These failures occurred during the COVID19 pandemic. Findings included: The document titled What to do when COVID-19 gets into your long term care facility dated 3-26-20 was reviewed and revealed in part; consider having health care providers wear all recommended PPE to include gown, gloves, eye protection and face mask for the care of all residents regardless of presence of symptoms. The document titled preparing for COVID-19 in nursing homes dated 3-28-20 revealed in part under the sub-heading create a plan for managing new admissions and readmissions whose COVID-19 status is unknown; Health care providers should wear face mask, eye protection, gloves and a gown when caring for these residents. Review of the facility's enhanced droplet/contact precautions policy and procedure dated August 2020 revealed in part; Hand hygiene shall be performed before and after any direct contact with a patient or patient equipment, before contact with the next patient and before leaving the patient room. A face mask shall be worn when providing care to a patient, gloves should be worn before entering a patient room and removed before leaving the patient room, gowns are worn before entering the patient room and removed before leaving the patient room. During an interview with the Administrator on 9-29-20 at 10:38am, the Administrator discussed the facility not having any positive cases of COVID19. He stated the facility did have a quarantine unit for new admissions and residents returning from the hospital on hall 400. He further explained each resident on hall 400 were on enhanced droplet/contact precautions. Observation of the quarantine hall occurred on 9-29-20 at 1:30pm. The observation revealed 13 residents were present and located in separate rooms. Each room was observed to have an enhanced droplet/contact precaution sign posted on the door frame. There were isolation carts located outside of each resident room that contained gowns, gloves and goggles/face shield. Hand sanitizing dispensers were also observed spaced out between the resident rooms. NA #1 was observed on 9-29-20 between 1:35pm and 1:45pm. NA #1 was noted to be feeding Resident #4 on the quarantine hall without donning a gown or gloves. The NA was observed leaving Resident #4's room without performing hand hygiene and returned the resident's lunch tray to the food cart, then, walked into Resident #5's room without performing hand hygiene, touched items on the resident food tray without gloves, walked out of the resident room without performing hand hygiene and brought the residents food tray to the food cart then proceeded into Resident #6's room without performing hand hygiene, touched items on the residents food tray without gloves, walked out of the residents room without performing hand hygiene and brought the resident's lunch tray to the food cart. An interview with NA #1 occurred on 9-29-20 at 2:13pm. NA #1 stated she had received education on hand hygiene, enhanced droplet/contact precautions and the use of proper PPE. She confirmed she had not performed hand hygiene before or after contact with a resident. The NA said, I just forgot to sanitize my hands between each room, but I should have. She also confirmed she had not been wearing a gown or gloves while feeding a resident and she stated she did not know she needed to wear a gown and gloves when she was feeding a resident. The NA acknowledged the residents she was in contact with were on enhanced droplet/contact precautions. During an interview with the Administrator on 9-29-20 at 2:26pm, the Administrator stated all staff had been educated on the use of PPE, enhanced droplet/contact precautions and infection control. He further discussed the facility would provide further education. The Infection Control Preventionist (ICP) was interviewed on 9-29-20 at 3:16pm. The ICP stated NA #1 was a new employee and had received training in orientation related to infection control, enhanced droplet/contact precautions, hand hygiene and COVID19. She discussed the quarantine unit being a 14-day isolation unit for new admissions or residents returning from the hospital. She further discussed the expectation on the quarantine unit was for staff to wear full PPE every time they enter a resident room. The ICP explained she provided education to the staff weekly regarding different topics of infection control measures, hand hygiene, enhanced droplet/contact precautions and COVID19. The facility physician was interviewed on 9-30-20 at 9:49am by telephone. The physician stated the facility had discussed the issue of the NA not using PPE and proper hand hygiene. He discussed he did not know what happened because staff was educated weekly but felt the situation was concerning. He further commented that there was a chance of cross contamination if one of the quarantine residents would become positive.

Based on observations, record review, staff interviews and review of the facility's Hand Hygiene policy and procedure, the facility failed to perform hand hygiene after exiting 2 of 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) and after resident contact. These failures occurred during a COVID-19 pandemic. The findings included: A review was conducted of the facility policy titled, Hand Hygiene, reviewed on 3/11/20. The policy specified that hands should be washed for at least 20 seconds using soap and water under the following conditions: before and after having direct contact with a resident. The policy also stated hand sanitizers may be used when soap and water not readily available. On 4/29/20 at 9:35 AM, an observation was made of Nurse Aide (NA) #1 entering room [ROOM NUMBER] without gloves and exiting the room with a breakfast tray. NA #1 was observed to place the breakfast tray in the dining area and then enter room [ROOM NUMBER] without washing or sanitizing her hands. NA #1 exited room [ROOM NUMBER] carrying two more breakfast trays and placed them in the dining room. NA #1 was than observed comforting a resident in the hallway by placing her right hand on the resident's right shoulder than pushing the wheelchair forward a short distance without washing or sanitizing her hands and without wearing gloves. On 4/29/20 at 9:40 AM, an interview was conducted with NA#1. She stated she sanitized her hands every chance she got. She stated she washed or sanitized her hands after providing care to the residents when she removed her gloves. NA #1 stated she usually did sanitize her hands when picking up trays, but she didn't that time. On 4/29/20 at 9:42 AM, an observation was conducted of the 800 hall nurses station. A large approximately gallon jug of hand sanitizer over half full was observed on top of the desk. On 4/29/20 at approximately 12:30 PM, an interview was conducted with the Director of Nursing. She revealed hand hygiene should be conducted after contact with residents. On 4/30/20 at 2:45 PM, an interview was conducted with the Infection Control Nurse. She stated extensive education regarding infection control and prevention had been ongoing and they were encouraging staff to wash their hands instead of using hand sanitizer. Hand washing education had been completed with staff demonstration and was being monitored.

Based on record review, staff interviews, nurse practitioner (NP) and physician interviews the facility neglected to identify a positive x-ray result for a mildly displaced [MEDICAL CONDITION] femoral neck which resulted in a 3-day delay in the resident receiving treatment for [REDACTED].#6). The resident described his pain level as incapacitating in his right upper thigh to the physical therapist (PT) on 9/4/19 and experienced a decline in mobility due to pain. Resident #6 was transferred to the hospital on [DATE] for complaints of severe hip pain and was found to have a [MEDICAL CONDITION] which required surgical repair. Findings Included: Resident #6 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #6 revealed he had 2 or more falls, required staff assistance to stabilize balance, required extensive one -person assistance with bed mobility, transfers and toilet use and his cognition was intact. A care plan with an onset date of 7/25/19 identified Resident #6 had pain. Interventions included to provide pain medication before pain became severe, Nurse to obtain pain management orders as necessary and nursing to monitor daily for pain. A nursing note dated 9/1/19 at 6:40 am for Resident #6, written by Nurse #3, stated he was found on the floor at 5:45 am in a sitting position around the bathroom door. The resident had taken off his brief which was laying on his bed and was dry. The resident had voided on the floor while walking to the bathroom and consequently slid to the floor. He denied hitting his head and no injury sustained. He was assisted to his wheelchair and transferred to his bed for patient care. Floor mats were in place. The resident was resting without any complaints of pain voiced. Vital signs taken and within normal limits and his family would be notified of the incident later in the morning. A nursing note dated 9/1/19 at 6:15 pm for Resident #6 stated no complaints of pain or injuries noted from the fall. There were no additional nursing note entries until 9/4/19. An interview on 9/17/19 at 3:18 pm with Nursing Assistant (NA) #2 revealed she worked with Resident #6 on second shift both before and after his fall on 9/1/19. She stated prior to his fall he could get up on his own and walk. She explained the resident wasn ' t supposed to walk on his own because he had fallen multiple times, but he was confused, and he would still do this. NA #2 stated after the fall on 9/1/19 the resident was in a lot of pain and he couldn ' t move around like he normally did. She added when she provided care, he was having pain which she reported to the nurse. NA #2 stated she was not sure if the nurse did anything about the pain. A nursing note dated 9/1/19 at 7:34 am for Resident #6, written by Nurse #1, stated the resident ' s family was notified of the fall and were reassured that he was stable at that time. The staff would continue to monitor for any acute changes to his condition. An incident report dated 9/1/19 at 5:45 am for Resident #6, completed by Nurse #3, revealed he was found on the floor in a sitting position. The resident stated he had used his walker to go to the bathroom. First aide provided included checking his range of motion (ROM) and vital signs which were normal. Pain scale was documented as a zero. A 24-hour follow-up identified mobility, mental status and vital signs were within normal limits. An intervention dated 9/1/19 to schedule toileting at 5:30 am. An intervention dated 9/2/19 for Speech Therapy (ST) screen and placed on caseload for cognition and safety. An intervention dated 9/3/19 for Physical Therapy (PT) to screen and on 9/4/19 placed on PT caseload. An interview on 9/17/19 at 2:03 pm with NA #1 revealed she provided care for Resident #6. She stated on 9/4/19 the resident told her he had fallen, and he thought his leg was broken. She explained when she tried to move him, or he tried to move himself he complained of pain. NA #1 added she felt like he was in a lot of pain, which was not normal for the resident. She stated she reported this to the nurse who told her they were going to get x-rays on him. NA#1 explained the resident could typically move himself around in bed, could sit up on his own, get out of bed on his own and could walk sometimes. She added she knew something was wrong because he couldn ' t move without being in pain. A PT plan of care dated 9/4/19 for Resident #6 stated he was seen for evaluation and treatment due to a decline in function secondary to a recent fall. The resident complained of pain to his right lower extremity, had difficulty with transfers and bed mobility, was unable to walk and presented with weakness. The resident reported pain scale rating of incapacitating pain for right thigh area. Unable to assess muscle strength and to safely transfer due to pain in right lower extremity. An x-ray was requested. A nursing note dated 9/4/19 at 8:40 am for Resident #6, written by Nurse #1, stated the resident had complaints of pain to right hip and knee. He had a fall on 9/1/19. Nurse Practitioner (NP) notified of change in condition and an x-ray of right hip and knee was ordered. The x-ray results for Resident #6 dated 9/4/19 revealed the right knee showed [MEDICAL CONDITION] and postoperative changes with no acute fracture or dislocation. Results for the right hip revealed mildly displaced [MEDICAL CONDITION] femoral neck with an associated mild Varus type deformity indeterminant in dating. The x-ray results were electronically signed by the physician of the x-ray company. An interview on 9/17/19 at 11:35 am with a representative from the x-ray company that performed the x-ray dated 9/4/19 for Resident #6 revealed the results were faxed to the facility on [DATE] at 8:05 pm. She added there was confirmation that the fax was received. A nursing note, written by Nurse #1, dated 9/5/19 at 10:20 am for Resident #6 stated results of the right hip and knee x-rays were negative and residents responsible party was notified. A phone interview on 9/17/19 at 11:40 am with Nurse #1 revealed she was a nurse for Resident #6. She stated on 9/5/19 she was approached by the PT about x-ray results for the resident. She explained she was not aware the resident had fallen or had pending x-ray results because she had just returned to work. Nurse #1 stated she spoke to Unit Coordinator #2 who told her the x-ray results were back and they were negative. She stated later that morning another nurse manager asked her to notify Resident #6 ' s family that his x-rays were negative. She added she contacted the family and documented this in the nurse ' s notes. Nurse #1 stated she never saw the x-ray results. She explained on 9/5/19 and 9/6/19 Resident #6 did stay in bed, which was not usual for him and she did administer Tylenol for pain. She added on 9/7/19 she was assisting a NA with his care and she noticed he was in severe pain with movement. Nurse #1 stated she notified the on-call NP who instructed her to send him to the hospital. An interview on 9/17/19 at 12:07 pm with Unit Coordinator #2 revealed she was aware of Resident #6 ' s fall on 9/1/19 and that he had an x-ray completed on 9/4/19. She stated the nurse who received the results of the x-ray were responsible for notifying the residents medical provider. She explained if the results were positive the on-call medical provider would have been called and if they were negative, they would be placed in the medical providers box. Unit Coordinator #2 stated she never saw the x-ray results for Resident #6. She added the Director of Nursing (DON) contacted her on 9/7/19 and asked her if she had seen the x-ray results and she said no. A PT note dated 9/5/19 for Resident #6, written by PT #1, stated per nursing the resident was negative for fractures to right lower extremity. The resident continued to complain of pain to his right thigh area. Applied bio-freeze and resident stated that made it feel better. Provided gentle ROM exercises to decrease tightness of bilateral lower extremities. Assisted the Nursing Assistant (NA) with bed mobility and instructed the NA with hand placement during hygiene due to residents increase pain during turning and when pressure applied to right thigh area. A PT note, written by PT #2, dated 9/6/19 for Resident #6 stated the resident was in bed upon arrival and noted with increased fatigue. The resident was instructed in supine bilateral therapeutic exercise with active ROM to left lower extremity and passive ROM to right lower extremity secondary to pain. A phone interview on 9/17/19 at 2:20 pm with the PT #1 revealed she had evaluated Resident #6 on 9/4/19 after he sustained a fall on 9/1/19. She stated the resident was in bed during the evaluation. She explained normally the resident could sit up on his own and would pop right up, but during the evaluation he was not able to sit on the edge of the bed and he had facial grimacing upon movement. The PT added the resident complained of pain and she felt like something was wrong because that was not normal for the resident. She explained she notified the resident ' s nurse and recommended an x-ray of his right leg. She stated on 9/5/19 she inquired about the results of the x-ray and Nurse #1 told her it was negative. She added she also read a nurses note that stated the x-ray was negative. The PT explained Resident #6 did receive therapy on 9/5/19 and 9/6/19 that included ROM and bed mobility exercise. She added he received bio-freeze on 9/5/19 and ice packs on 9/6/19 to the right leg during his therapy which seemed to help the pain. The (MONTH) 2019 Medication Administration Record [REDACTED]. The record identified from 9/1/19 through 9/7/19 the resident received 1000 mg of Tylenol twice on 9/6/19 (no times identified) related to pain in right hip and leg. The record did not identify any other pain medications ordered or administered from 9/1/19 through 9/7/19. A pain scale with a start date of 6/18/19 identified a pain level of 6 on 9/1/19 on the night shift, a 4 on the day and night shift on 9/6/19 and a 4 on the day shift for 9/7/19. The numeric pain scale identified 0 as no pain, 1 to 3 as mild pain, 4 to 6 as moderate pain and 7 to 10 as severe pain. A nursing note, written by Nurse #1, on 9/7/19 at 2:27 pm for Resident #6 stated the resident complained of severe right hip pain with movement. The on-call NP was notified, and a new order obtained to send the resident out to the emergency room for further evaluation. The hospital record dated 9/7/19 for Resident #6 revealed the patient had sustained a fall a week ago at the nursing home and the initial x-ray at the nursing home were negative. The patient continued to have right hip pain but was able to ambulate and due to increased hip pain a second x-ray was done on 9/7/19 which showed mildly displaced right femoral neck fracture with mild medial angulation. The patient had right hip hemiarthroplasty (a surgical procedure that involved replacing half of the hip joint) done on 9/8/19. During an interview with the NP for Resident #6 on 9/17/19 at 11:10 am she stated she was usually in the facility on Tuesdays and Thursdays. She stated Resident #6 had a fall on Sunday, 9/1/19 and she did not work on weekends, so the on-call provider would have been notified of the fall. The NP explained she was notified on 9/4/19 by a facility nurse that Resident #6 was complaining of pain in his right lower extremity and she ordered an x-ray. She explained if the results of the x-ray were faxed in after 5:00 PM, the on-call provider would have been notified of the results. The NP stated when she came into the building on 9/5/19 she was not given any x-ray results. She added she had checked her box that was located on the unit but there were no x-ray results present for Resident #6. The NP stated she did not examine Resident #6 on 9/5/19 but stated she did see him on the unit in his wheel chair self-propelling. She stated Resident #6 did not have any grimacing and there were no symptoms that stood out that would alert her to do a full evaluation and assessment on him. When asked if the initials on the x-ray results dated 9/4/19 were hers, she stated they were, but she had noted the results a couple of days ago, and that she didn ' t usually date lab or x-ray results when she read them. The NP stated she did not see the x-ray result prior to the resident leaving to go to the hospital on [DATE]. When asked to read Resident #6 ' s x-ray result from 9/4/19 she stated if she had seen and read the x-ray results, she would have determined the resident had a fracture to his right lower extremity and sent him to the hospital for an evaluation. When asked if the resident was cognitively intact, she stated that due to his comorbidities he had some better days cognitively than others and had intermittent confusion. A phone interview on 9/17/19 at 4:16 pm with the Physician for Resident #6 revealed he was aware the resident had a fall on 9/1/19. He stated it was his understanding the resident displayed a change in his status and an x-ray was obtained. The Physician explained he believed there was some miscommunication regarding the x-ray results and the facility may have misread the results of the knee x-ray which was negative and missed the right hip results which were positive for a fracture. He added he wasn ' t sure that was what occurred or where the breakdown came from. He stated he did expect that a resident who had a positive x-ray result for a fracture would be sent right out to the hospital for further evaluation. An interview on 9/17/19 at 5:33 pm with the Administrator revealed it was his expectation residents received adequate care and services. He stated that would include reading x-ray results correctly, notifying the residents medical provider and receive the appropriate treatment for [REDACTED]. The quality assurance (QA) plan dated 9/9/19 was provided by the facility Chief Operating Officer and revealed: In response to a review of the resident ' s chart / records and employee interviews, the facility created a new QA team (The x-ray monitoring and communication team) and an internal plan of correction / allegation of compliance to ensure best practice moving forward. The current QA team created, reviewed and implemented the internal plan items as part of a series of meetings on 9/9/19. We believed our plan of correction / allegation of compliance will be effective on 9/9/19. Actions included: The resident in question was discharged to the hospital for follow-up on 9/7/19. The facility Director of Nursing (DON) notified the residents family via a phone call on 9/7/19 that she was aware the resident had been discharged to the hospital and she would investigate further and follow-up again with the family on 9/9/19. A f/u phone call was attempted on 9/9/19. An audit by the DON and facility Unit Coordinators (UC ' s) of all residents with x-ray orders since 9/1/19 forward was completed on 9/9/19. The audit confirmed these residents had results provided to the facility and the results were followed up and communicated to the MD (Medical Doctor) or RP (Responsible Party) accordingly. The facility logged the x-ray audit results on a newly created internal QA x-ray tracking and communication form. This QA form will continue to be utilized by the administrative nursing team (DON and UC ' s) to track x-ray results (including to and focused on post fall x-ray results as well) moving forward. The facility initiated a 100% in-service for nurses specific to follow-up expectations of x-ray results. The facility has now added an additional step to x-ray result reviews so that a second nurse is required to verify the x-ray results at the time they are received at the facility. This in-service was created by the QA team members and implemented by the DON. Any nurse who could not be in-serviced on 9/9/19 will be in-serviced before their next scheduled shift., including telephonically. Nurses who were not in-serviced on or before 9/10/19 will be in-serviced upon their return to work. The facility will also provide this same in-service to any newly hired nurses moving forward (as part of orientation). To monitor if x-ray results are received and followed up accordingly, the administrative nurses will monitor and then document on the QA tool to ensure: · The facility has x-ray results completed, received and followed up accordingly, including communication to the RP and MD. Any results not verified by the following day will be a priority follow-up the following day by the administrative nursing team. · A second nurse has reviewed the x-ray results prior to contacting the MD or RO to ensure follow-up is in fact appropriate. The x-ray monitoring and communication QA team will continue to meet and will expand in size for their next scheduled weekly meeting on 9/18/19. Additional attendees for the 2nd scheduled meeting will include unit coordinators who will remain active in compliance monitoring. This QA team will meet independent of the current facility weekly QA meetings for a least one month from the inception to ensure the plan of correction / allegation of compliance is being followed. The DON or Administrator will be responsible for brining the weekly x-ray audits / tracking to the weekly meetings. Once compliance has been achieved and sustained, the QA team in question will continue to meet and discuss / review ongoing compliance efforts during the weekly QA meetings through at least the next annual survey process. Note: The DON will also bring QA monitoring results and report to the Executive Quarterly QA Committee. The next quarterly meeting is scheduled for (MONTH) 23, 2019. The facility alleges full compliance with this plan of correction / allegation of compliance as of 9/9/19. The facility QA plan was verified on 9/17/19. The in-service record identified 30 nurses received the training either in person or by phone. A sample of nurses interviewed confirmed they had been trained on the new x-ray process. The x-ray tracking and communication QA tool was reviewed and had been completed for x-rays obtained from 9/4/19 through 9/8/19. The facility ' s date of full compliance of 9/9/19 was verified.

Based on staff and Resident Representative interviews and medical record review, the facility failed to notify the Resident Representative of a change in condition and subsequent order for a doppler ultrasound for 1 of 1 resident (Resident #76) reviewed for notification of change in condition. Findings included: Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 had impaired memory and severely impaired daily decision making skills. A review of the medical record revealed Resident #76's representative was a family member. A review of a nurse's note dated 6/2/19 revealed, On Sunday, 6/2/19, patient noted to have swelling to left leg from knee to foot. No indications of pain. Patient assisted to bed and leg elevated. On-call provider notified and gave orders to obtain venous doppler ultrasound of left lower extremity . On 6/3/19 at 1:44 PM an interview was completed with Family Member #1. She stated she was the person who was notified of any change in condition for Resident #76. Family Member #1 said when she visited Resident #76 on the morning of 6/3/19 she observed someone completing an ultrasound of Resident #76's left leg. She stated she immediately went to the nurse's desk and inquired about the test and was told by staff they were unaware of why the test was completed but that Resident #76's leg was swollen over the weekend. Family Member #1 reported that she had not been notified by staff over the weekend that Resident #76's leg was swollen nor that an ultrasound was ordered. Family Member #1 further reported she had told the facility in the past that she wanted to be notified prior to any procedures or tests that were completed for Resident #76. On 6/4/19 at 10:40 AM an interview was completed with Nurse #4. She said she was not the nurse on duty when the doppler ultrasound was ordered. She stated Family Member #1 came to her and inquired about the test that was ordered and Nurse #4 told Family Member #1 she wasn't sure why the doppler ultrasound had been ordered but knew Resident #76 had leg pain. Nurse #4 said facility protocol was that the resident representative was notified prior to any test or procedure. She further stated Family Member #1 had requested in the past that she be notified prior to any tests or procedures. On 6/5/19 at 2:56 PM an interview was completed with Nurse #5. She said she was the nurse on duty when the doppler ultrasound was ordered. She stated on 6/2/19 a nurse aide notified her that Resident #76's left leg was [MEDICAL CONDITION]. Nurse #5 assessed the left leg and said it was swollen, was not hot to the touch and had no redness. Nurse #5 stated she called the on-call provider and received an order for [REDACTED]. Nurse #5 said at the end of her shift she entered the provider's order into the electronic health record but forgot to call and notify Family Member #1 of the ordered doppler ultrasound. I forgot to call the family and I should have. Nurse #5 said not calling the resident representative was not proper procedure. On 6/6/19 at 5:08 PM an interview was completed with the Chief Operating Officer (COO). He stated he expected Family Member #1 to have been notified during the shift of the ordered procedure.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set assessment in the areas of, skin conditions for 1 of 2 residents (Resident #43) and nutrition status for 1 of 4 (Resident #27) residents reviewed for nutrition and pressure ulcers. The findings included: 1. Resident #27 was admitted to the facility on [DATE]. Her diagnoses, in part, included dementia and dysphagia. A review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #27 weighed 191 pounds. A record review revealed a weight of 184 obtained on 3/12/19. An interview with Restorative Aide #1 on 6/5/19 revealed she and the other restorative aide obtain the weights for the facility. She stated she obtains the weights and then puts them into the computer. An interview on 6/5/19 at 2:30 PM with the Minimum Data Set Nurse #2 revealed she enters the weight for the assessment that she finds in the computer. She stated the weight she entered was for (MONTH) 2019. She stated she didn ' t know there was another weight obtained on 3/12/19 of 184 because it wasn ' t in the computer yet. An interview on 6/6/19 at 3:47 PM with the Administrator revealed his expectation was for the Minimum Data Set assessment to be coded accurately. 2. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was at risk for developing pressure ulcers but did not have a current pressure ulcer. The MDS further reflected Resident #43 had one venous or arterial ulcer and was receiving pressure ulcer care. A record review revealed a wound report indicating a deep tissue injury was identified to Resident #43 ' s left heel on 2/5/19. On 3/19/19, the wound report indicated Resident #43 had a Stage 2 pressure ulcer to her left heel. An observation of wound care to Resident #43 ' s left heel wound was completed on 6/3/19 at 10:04 AM. The wound nurse removed the soiled dressing and the left heel wound was observed to have bone exposed with approximately 50% eschar. There was also slough present in approximately 25% of the wound. Purulent drainage was noted in the wound and on the soiled dressing. There was no odor observed. An interview with MDS Nurse #1 was conducted on 6/6/19 at 1:28 PM. She stated she entered no pressure ulcers on Resident #43 ' s quarterly assessment dated [DATE] because Resident #43 went out to the hospital from 3/8/19 – 3/12/19 and was diagnosed with [REDACTED]. An interview was conducted on 6/6/19 at 4:49 PM with the Administrator. He stated his expectation was for MDS assessments to be accurately coded.

Based on observations, record reviews, resident and staff interviews, the facility failed to develop care plans for 1 of 3 sampled residents (Resident #54) reviewed for ADL (activities of daily living) and for 1 of 3 sampled residents (Resident #37) reviewed for dementia care. Findings included: 1. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of the quarterly minimum data (MDS) set dated 4/16/19 indicated Resident #54 was moderately, cognitively impaired; required extensive assistance with bed mobility, transfers, locomotion, personal hygiene, toileting and dressing; required partial assistance with bathing; and had impairment of his bilate,ral lower extremities. Review of the care plan dated 4/30/19 revealed the extent and type of ADL assistance required for Resident #54 for personal hygiene, bathing and dressing were not included in the care plan. During an interview on 6/3/19 at 4:17 p.m., Resident #54 indicated his ADL care included a nursing assistant setting up a washbasin of water and two washcloths then leaving his room for him to wash himself. During an interview on 6/6/19 at 5:48 p.m., MDS Nurse#2 acknowledged there was no ADL care area/problem included in Resident #54's care plan. She asserted that bed mobility, transfers, and assistance with feeding were included in different areas of the care plan; but due to human error, personal hygiene, bathing, and dressing were not included in Resident #54's care plan. 2. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of the significant change minimum data set ((MDS) dated [DATE] indicated Resident #37 was moderately, cognitively impaired and had a neurological [DIAGNOSES REDACTED]. The care plan dated 4/11/19 did not include the care and interventions required for Resident #37's [DIAGNOSES REDACTED]. During an observation on 6/6/19 at 9:07 a.m., Resident #37 was in her room in a wheelchair, feeding herself breakfast of mechanical soft consistency. NA#2 (nurse aide) entered room to assist/encourage the resident, but the resident refused to consume more. During an interview on 6/6/19 at 10:20 p.m., NA#2 revealed Resident #37 had been in declining health for several months. She stated that previously required limited assistance with activities of daily living, but currently required total assistance with care. During an interview on 6/6/19 at 2:17 p.m., MDS Nurse#1 revealed the facility's Social Workers were responsible for completing the cognition section of the MDS. During an interview on 6/6/19 at 2:25 p.m., SW#2 (Social Worker) stated that dementia care was not included in the care plan because there was no documentation in the clinical records indicating Resident #37 had the [DIAGNOSES REDACTED].#2 revealed she did not refer to section I ([DIAGNOSES REDACTED].