Every finding on record at Tower Nursing and Rehabilitation Center

Based on record review, resident, Resident Representative (RR), and staff interviews, the facility failed to ensure a written grievance decision included all required components and to provide a written grievance summary for 7 of 7 resident reviewed for grievances (Resident #11, Resident #2, Resident #41, Resident #43, Resident #50, Resident #28 and Resident #85). The findings included: Review of the facility policy dated 07/01/2018 titled Resident Grievance Policy indicated the Administrator was responsible for overseeing, directing and investigating grievances in a prompt manner; reviewing the results of the grievance investigations for conclusion; initiating corrective measure or actions; and ensuring the resident or resident representative is notified timely of the results of the investigation, of corrective measures taken, and this notification will be documented. 1. Resident # 11 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #11's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. A grievance dated 07/02/25 filed by the Endocrinology Nurse Practitioner included a note from the Endocrinology appointment that indicated Resident #11 reported she didn't get her medications in time. The form did not include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the concerns, any corrective action taken by the facility as a result of the grievance, or a date the written grievance decision was issued. There was no documentation on the grievance form that a written response was issued to the resident or resident representative and there was no signature of the facility's grievance officer. A grievance dated 8/30/25 filed by Resident #11 indicated an issue with resident's room being cold at night. The form did not include the date the written grievance decision was issued and there was no documentation that indicated a written response was provided to the resident. The document was signed by the previous Administrator, Administrator #1, who was the grievance officer on 8/30/25. A grievance dated 9/5/25 filed by Resident #11 indicated an issue with the staff that transferred Resident #11 to the toilet. The form did not include who filed the grievance, the date the written grievance decision was issued and there was no documentation that indicated a written response was provided to the resident. The document was signed by Administrator #1 who was the grievance officer on 9/8/25. A grievance dated 9/15/25 filed by Resident #11 indicated an issue with the resident's room being cold and the resident's maneuvering of their wheelchair to the toilet. The form did not include the date the written grievance decision was issued and there was no documentation that indicated a written response was provided to the resident. The document was signed by Administrator #1 who was the grievance officer on 9/15/25. A grievance dated 10/31/25 filed by Resident #11 indicated Resident #11 had concerns with food, care and wanted to discharge. The form did not include the date the written grievance decision was issued and there was no documentation that indicated a written response was provided to the resident. The document was signed by the current Administrator, Administrator #2, who was the grievance officer on 10/31/25. An interview was conducted with Resident #11 on 7/17/26 at 11:40 AM. The resident reported submitting multiple grievances to the facility's administrative staff. Resident #11 recalled that she had reported concerns to the Social Worker, the Director of Nursing, and Administrator. Resident #11 stated she had not been asked whether she wanted a written grievance summary and had not received any written grievance summaries. An interview was conducted with Administrator #1 on 7/17/26 at 1:41 PM. Administrator #1 stated she worked at the facility from July 2025 to September 2025. She revealed she was responsible for overseeing the grievance process by making sure grievances were investigated and resolved. Administrator #1 confirmed that Resident #11 did not receive written summaries for any grievances filed. She acknowledged she was unaware that the person filing a grievance must receive written summaries of grievance findings even if the issues were resolved verbally. Administrator #1 stated staff had communicated resolutions through phone calls or in person conversations, with no written documentation provided. Administrator #1 stated the grievance form was supposed to be filled out completely and reviewed by the grievance officer. She reported that all grievances for Resident #11 were investigated, resolved, and the resolution was verbally communicated to the resident. An interview was conducted with Administrator #2 on 7/20/26 at 9:29 AM. Administrator #2 confirmed she was the grievance officer and responsible for overseeing the grievance process. She indicated she was not fully aware that complainants and those filing a grievance on the residents' behalf must receive a written summary of the grievance findings. Administrator #2 confirmed that she had only given the written summary of grievance findings to the complainant if the person requested the documentation. Administrator #2 stated the grievance resolutions had been communicated through phone calls or in person conversations by the staff responsible for the grievance. Administrator #2 confirmed that all grievances had been resolved but no written documentation had been provided. 2a. Resident # 2 was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment. A grievance dated 1/9/26 indicated the Resident Representative for Resident #2 wanted the resident to be seen by an outside dentist and to have the facility nurse practitioner call him. The form did not include the findings of the investigation, the date the written grievance decision was issued, and there was no documentation that indicated a written response was provided to the resident. The document was signed by Administrator #2, who was the grievance officer on 1/12/26. An attempt to reach Resident #2's Resident Representative by phone was unsuccessful. 2b. Resident #41 was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #41's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. A grievance dated 3/9/26 filed by Resident #41 indicated the resident voiced concern that his roommate was playing music loudly interrupting his sleep at night. The form did not include the date the written grievance decision was issued and there was no documentation that indicated a written response was provided to the resident. The document was signed by Administrator #2, who was the grievance officer on 3/10/26. An interview was conducted with Resident #41 on 7/17/26 at 11:30 AM. Resident #41 reported he had submitted a grievance and reported the concern to the Director of Nursing. Resident #41 stated he had not been asked whether he wanted a written grievance summary and had not received any written grievance summary. 2c. Resident #43 was admitted to the facility on [DATE] and was readmitted [DATE].Resident #43's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment. A grievance dated 5/21/26 filed by Resident #43's Resident Representative revealed the resident's phone and charger were not in the room after a room change. The form did not include the date the written grievance decision was issued and there was no documentation that indicated a written response was provided to the resident or representative. The document was signed by Administrator #2, who was the grievance officer on 5/22/26. An attempt to reach Resident #43's Resident Representative by phone was unsuccessful. 2d. Resident #50 was admitted to the facility on [DATE]. Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. A grievance dated 6/30/26 filed by Resident #50's Resident Representative indicated Resident #50 had not received a shower despite asking for one. There was no documentation on the grievance form that a written response was issued to the resident or resident representative and there was no signature of the facility's grievance officer. An interview was conducted with Resident #50 on 7/17/26 at 11:55 AM. Resident #50 stated her family member had submitted a grievance on her behalf about showers. Resident #50 stated she had not been asked whether she wanted a written grievance summary and had not received any written grievance summary. 2e. Resident 85 was admitted to the facility on [DATE]. She was discharged to the community on 7/9/26. Resident #85's Minimum Data Set (MDS) dated [DATE] indicated she had moderate cognitive impairment. A grievance dated 6/18/26 filed by Resident #85's Responsible Party noted concerns related to Resident #85 not changed into nightclothes for bed, medications and assistance with meals. The form did not include the date the written grievance decision was issued and there was no documentation on the grievance form that a written response was issued to Resident #85 or her Responsible Party. The grievance form was signed by Administrator #2. A grievance dated 6/22/26 filed by Resident #85's responsible party stated there were concerns about Resident #85 being put to bed in the same clothes she had worn all day. The form did not include the date the written grievance decision was issued and there was no documentation on the grievance form that a written response was issued to Resident #85 or her responsible party. The grievance form was signed by Administrator #2. A telephone interview was conducted 7/17/26 at 9:30 AM with Resident #85's Responsible Party who stated she was not asked whether she wanted a written grievance summary and had not received a written grievance summary. She stated the Director of Nursing spoke with her about the grievances and stated the facility would ensure that Resident #85 changed her clothing prior to going to bed, answered her medication questions, and that Resident #85 received assistance with meals. The Responsible Party reported that Resident #85 was discharged shortly after the 6/22/26 grievance was filed (7/9/26). 2f. Resident #28 was admitted to the facility on [DATE]. A grievance dated 4/30/25 indicated concerns regarding a medication pass issue and a missed appointment. The form did not indicate who made the grievance, the employee receiving grievance, or the date the written grievance decision was issued. There was no documentation on the grievance form that written response was issued to Resident #28. The grievance was signed by Administrator #3. Resident #28's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. An interview was conducted with Resident #28 who stated she had not been asked whether she wanted a written grievance summary and had not received a written grievance summary. Resident #28 stated she remembered filing the grievance but could not recall if anyone spoke with her about grievance resolution. She indicated the grievance was resolved. A phone interview was conducted with a former Administrator, Administrator #3, on 7/17/26 at 10:28 AM who stated he worked at the facility from March 2025 until July 2025. He reported he did not recall the circumstances of the grievance filed on behalf of Resident #28. An interview was conducted with the current Social Worker, Social Worker #1, on 7/16/26 at 1:50 PM. Social Worker #1 stated he was responsible for logging the grievances in the grievance logbook and distributing the grievance to the department head responsible for grievance concerns. Social Worker #1 stated the person receiving the grievance was responsible for filling in the resident's name, date received, who the concern/grievance was made by, the name of the employee receiving concern/grievance, and the nature of the concern/grievance. Social Worker #1 stated the grievance was then given to him, he assigned the grievance to the department head, added the date the grievance was assigned to the form and logged the grievance in the grievance logbook. Social Worker #1 stated he then notified the Administrator that the grievance had been filed and logged. An interview was conducted with the previous Social Worker, Social Worker #2, on 7/20/26 at 9:21 AM. Social Worker #2 stated she had worked at the facility from January 2026 to March 2026. She reported that it was her responsibility to log the grievances in the grievance logbook when she received them. Social Worker #2 stated that once the grievance was assigned to the department head and distributed, it was the department head's responsibility to fill in the steps taken, findings, and actions taken/to be taken section of the grievance form. Social Worker #2 stated the department head would bring the grievance back to her once the issue had been addressed. Social Worker #2 stated she then took the grievance form to the Administrator for them the follow up on the concern/grievance resolution. An interview was conducted with Administrator #2 on 7/20/26 at 9:29 AM. Administrator #2 confirmed she was the grievance officer and responsible for overseeing the grievance process. Administrator #2 stated she was not fully aware that complainants and those filing a grievance on the residents' behalf must receive a written summary of the grievance findings. She confirmed that she had only given the written summary of grievance findings to the complainant if the person requested the documentation. She stated the grievance resolutions had been communicated through phone calls or in person conversations by the staff responsible for the grievance. Administrator #2 confirmed that all grievances had been resolved but no written documentation had been provided. An interview was conducted with the [NAME] President of Operations on 7/17/26 at 3:00 PM. The [NAME] President (VP) of Operations stated staff were expected to follow the facility's grievance policy ensuring the complainant was informed of the grievance summary and conclusion.

Based on record review, resident, Resident Representative (RR) and staff interviews, the facility failed to provide written information about advance directives and/or an opportunity to formulate advance directives, and to obtain advance directives and maintain the advance directives in the medical record for 11 of 30 residents reviewed for advance directives (Residents #1, #2, #4, #18, #41, #50, #54, #55, #81, #83 and #100).a. Resident #83 was admitted to the facility on [DATE] with diagnosis that included diabetes, kidney disease and hypertension.Resident #83 had a Full Code physician order dated 5/22/26.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was cognitively intact.An interview completed with Resident #83 on 7/15/26 at 12:28 PM. Resident #83 stated that he does not recall receiving written education regarding Advance Directives.There was no documentation in the record for education regarding formulation of Advance directives and/or an opportunity to formulate Advance directives was offered.b. Resident #81 was admitted to the facility on [DATE] with diagnosis that included rhabdomyolysis and dysphagia.Resident #81 had a Full Code Physician order dated 6/20/26.An admission MDS assessment dated [DATE] revealed Resident #81 was cognitively intact.During an interview completed with Resident #81 on 7/15/26 at 1:23 PM. He stated that he does not recall receiving written education regarding advance directives.There was no documentation in the record for education regarding formulation of Advance directives and/or an opportunity to formulate Advance directives was offered.c. Resident #1 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and diabetes. Resident #1 had a Do Not Resuscitate physician order dated 6/5/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. Attempts to contact the Resident Representative (RR) were unsuccessful. d. Resident #2 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and diabetes. Resident #2 had a Full Code physician order dated 1/9/26.A quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. Attempts to contact the Resident Representative (RR) were unsuccessful. e. Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, heart disease, and congestive heart failure. Resident #4 had a Full Code physician order dated 12/31/24. A quarterly MDS assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview completed with the RR on 7/16/26 at 3:35 PM revealed they were unaware if advanced directive education had been provided by the facility.f. Resident #18 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease and atrial fibrillation. Resident #18 had a Do Not Resuscitate Physician order dated 5/8/26. A quarterly MDS assessment dated [DATE] revealed Resident #18 was cognitively intact. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview completed on 7/16/26 at 10:20 AM with Resident #18 revealed Resident #18 did not recall receiving written education regarding the formulation of an advance directive.g. Resident #41 was admitted to the facility on [DATE] with diagnoses that included heart disease and high blood pressure. Resident #41 had a Full Code physician order dated 5/15/25. A quarterly MDS assessment dated [DATE] revealed Resident #41 was cognitively intact. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview completed on 7/15/26 at 9:35 AM with Resident #41 revealed Resident #41 did not recall receiving written education regarding the formulation of an advance directive.h. Resident #50 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic respiratory failure, and heart disease. A quarterly MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 had a Full Code physician order dated 6/16/26. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview completed on 7/17/26 at 11:00 AM with Resident #50 revealed Resident #50 did not recall receiving written education regarding the formulation of an advance directive.i. Resident #54 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and diabetes. Resident #54 had a Full Code physician order dated 2/25/25. A quarterly MDS assessment dated [DATE] revealed Resident #54 was cognitively intact. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview completed on 7/16/26 at 2:34 PM with Resident #54 revealed Resident #54 did not recall receiving written education regarding the formulation of an advance directive.j. Resident #55 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and high blood pressure. Resident #55 had a Full Code physician order dated 5/20/25. An annual MDS assessment dated [DATE] revealed Resident #55 was severely cognitively impaired. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. Attempts to contact the RR were unsuccessful.k. Resident #100 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and heart disease. An admission MDS dated [DATE] revealed Resident #100 was cognitively intact. Resident #100 had a Full Code Physician order dated 7/3/26. An interview completed with Resident #100 on 7/16/26 at 2:00 PM did not recall receiving written education regarding advance directive. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview was completed on 7/15/26 at 10:55 AM with the Director of Nursing (DON). The DON revealed the facility only discussed the resident's code status with the resident and/or their responsible party.An interview was completed on 7/15/26 at 12:52 PM with the Regional [NAME] President of Operations. He revealed the facility recently had turnover in the Social Worker role that resulted the failure to ensure there was education provided to residents or their representatives regarding advance directive education.Attempts to contact the facility's previous Social Worker were unsuccessful.

Based on observation, record reviews, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #1 placed linen on the floor. The deficient practice occurred for 1 of 3 staff observed for infection control practices. (Nurse Aide #1).The findings included: The facility's Infection Prevention and Control Program (IPCP) policy last updated 4/2023 indicated that the facility was responsible for establishing and maintaining an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections.The facility's Linen Handling Policy which is part of the Infection Prevention and Control Program (IPCP) policy read in part The risk of actual disease transmission from soiled linen with pathogenic microorganisms is insignificant if it is handled, transported, and laundered in a way that avoids transfer of microorganisms. Soiled linen should be bagged or placed in containers at the location where used. Wet and or soiled lines should be placed and transported in leak proof bags.During a continuous observation on 07/15/2026 at 9:34 AM, Nurse Aide (NA) #1 was observed to place the linen that consisted of sheets, a pillowcase, a shirt and a pair of pants on the floor prior to exiting a resident's room. NA#1 exited room [ROOM NUMBER] and proceeded up the hallway to retrieve a couple of trash can liners from a chair that was sitting outside of room [ROOM NUMBER] in the hallway. NA #1 returned to the resident's room and picked up the dirty laundry and placed it into the liner. NA #1 tied the liner, removed her gloves and performed hand hygiene before taking the liner to the soiled linen bin. During an interview with NA #1 on 07/15/2026 at 9:40 AM, she stated she had assisted the resident with changing his clothing and stripped his bed. NA #1 stated that she had placed the linen on the floor by the door because she did not have a clear trash can liner to place the linen in. NA #1 stated she had been trained to not put linen on the floor. NA #1 stated she was trying to get the soiled linen and dirty clothing out of the resident's room. An interview was conducted with the Director of Nursing on 7/17/26 at 2:48 PM. The DON stated it was her expectation that NA#1 follow the Infection Control Policies and Procedures. The DON verified that NA #1 had received the infection prevention education and that nursing staff receive the education during orientation, yearly, and as needed. The DON stated that NA #1 should not have placed the linen on the floor. An interview with the [NAME] President of Operations on 7/17/26 at 3:01 PM revealed he expected NA #1 would have not placed the linen on the floor.

Based on record reviews and staff interviews, the facility failed to notify the resident and resident's representative (RR) in writing of the reason for the transfer/discharge to the hospital and send a copy of the notice to the Ombudsman. The facility also failed to notify the resident and/or Resident's Representative of the facility policy for bed hold for 4 of 7 residents reviewed for hospitalization (Resident #11, Resident #43, Resident #54, and Resident #55). The findings included:1. Resident #11 was admitted to the facility on [DATE].a. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 6/20/25 revealed Resident #11 was sent out to the hospital at 4:33 PM with elevated blood glucose and generalized weakness. The nursing progress note dated 6/22/25 revealed Resident #11 was readmitted to the facility at 5:45 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 6/20/25.b. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 6/26/25 revealed Resident #11 was sent out to the hospital at 6:55 PM with elevated blood glucose.The nursing progress note dated 7/1/25 revealed Resident #11 was readmitted to the facility at 2:26 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 6/26/25.c. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 8/25/25 revealed Resident #11 was sent out to the hospital at 12:35 AM with altered mental status and generalized weakness.The nursing progress note dated 8/27/25 revealed Resident #11 was readmitted to the facility at 3:22 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 8/25/25.d. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 12/22/25 revealed Resident #11 was sent out to the hospital at 12:31 PM for loss of consciousness and unresponsiveness.The nursing progress note dated 12/24/25 revealed Resident #11 was readmitted to the facility at 1:00 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 12/22/25.e. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 1/4/26 revealed Resident #11 was sent out to the hospital at 10:48 AM for decreased blood pressure and decreased oxygen saturation.The nursing progress note dated 1/7/26 revealed Resident #11 was readmitted to the facility at 5:25 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 1/7/26.f. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 2/5/26 revealed Resident #11 was sent out to the hospital at 2:26 PM for unresponsiveness.The nursing progress note dated 2/7/26 revealed Resident #11 was readmitted to the facility at 3:13 PM in stable condition. The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 2/5/26.g. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 2/18/26 revealed Resident #11 was sent out to the hospital at 1:22 PM for elevated blood glucose and lethargy.The nursing progress note dated 2/20/26 revealed Resident #11 was readmitted to the facility at 6:50 PM in stable condition. The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #11's hospital transfer dated 2/18/26.Multiple attempts to contact Resident #11's RR were unsuccessful.During an interview with the current Social Worker on 5/19/26 at 10:18 AM, he stated he had started working at the facility in March of 2026. The Social Worker stated he began sending out written notification of discharge/ transfer to hospital to the Resident Representative (RR) and Ombudsman when he began working in March. He further stated the bed hold policy was sent to the RR when residents were transferred to the hospital. The Social Worker stated he was unable to locate written discharge/ transfer to hospital notification and reported that information to his director. An interview was conducted with the [NAME] President of Operations on 7/16/2026 at 3:06 PM. The VP of Operations stated he had been made aware that the written notification of transfer/discharge to hospital to resident and resident representative, Ombudsman notification and bed hold policy notification had not been sent out by the previous social worker. The VP of Operations stated the Social Worker was responsible for these tasks and he was unable to locate any documentation from the previous Social Worker. The VP of Operations stated the previous Social Worker was responsible for the notices being cited.2. Resident #43 was admitted to the facility on [DATE].The nursing progress note dated 1/21/26 revealed Resident #43 was sent out to the hospital at 4:35 PM due to a change in mental status and elevated blood pressure. The nursing progress note dated 1/28/26 revealed Resident #11 was readmitted to the facility at 6:22 PM in stable condition. The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #43's hospital transfer dated 1/21/26.Attempts to contact Resident #43's RR were unsuccessful.During an interview with the current Social Worker on 5/19/26 at 10:18 AM, he stated he had started working at the facility in March of 2026. The Social Worker stated he began sending out written notification of discharge/ transfer to hospital to the Resident Representative (RR) and Ombudsman when he began working in March. He further stated the bed hold policy was sent to the RR when residents were transferred to the hospital. The Social Worker stated he was unable to locate written discharge/ transfer to hospital notification and reported that information to his director. An interview was conducted with the [NAME] President of Operations on 7/16/2026 at 3:06 PM. The VP of Operations stated he had been made aware that the written notification of transfer/discharge to hospital to resident and resident representative, Ombudsman notification and bed hold policy notification had not been sent out by the previous social worker. The VP of Operations stated the Social Worker was responsible for these tasks and he was unable to locate any documentation from the previous Social Worker. The VP of Operations stated the previous Social Worker was responsible for the notices being cited.3. Resident #54 was admitted to the facility on [DATE].The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 1/3/26 revealed Resident #54 was sent out to the hospital at 6:19 AM due to scrotal cellulitis that was warm and tender to touch with pain at rest.The nursing progress note dated 1/6/26 revealed Resident #54 was readmitted to the facility on [DATE] at 6:43 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #54's hospital transfer dated 1/3/26.During an interview with the current Social Worker on 5/19/26 at 10:18 AM, he stated he had started working at the facility in March of 2026. The Social Worker stated he began sending out written notification of discharge/ transfer to hospital to the Resident Representative (RR) and Ombudsman when he began working in March. He further stated the bed hold policy was sent to the RR when residents were transferred to the hospital. The Social Worker stated he was unable to locate written discharge/ transfer to hospital notification and reported that information to his director. An interview was conducted with the [NAME] President of Operations on 7/16/2026 at 3:06 PM. The VP of Operations stated he had been made aware that the written notification of transfer/discharge to hospital to resident and resident representative, Ombudsman notification and bed hold policy notification had not been sent out by the previous social worker. The VP of Operations stated the Social Worker was responsible for these tasks and he was unable to locate any documentation from the previous Social Worker. The VP of Operations stated the previous Social Worker was responsible for the notices being cited. 4. Resident #55 was admitted to the facility on [DATE].a. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 5/14/25 revealed Resident #55 was sent out to the hospital for further evaluation.The nursing progress note dated 5/19/25 revealed Resident #55 was readmitted to the facility on [DATE] at 5:48 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #55's hospital transfer dated 5/14/25.b. The Situation, Background, Assessment and Recommendation (SBAR) Summary for Provider dated 8/29/25 revealed Resident #55 was sent out to the hospital for further evaluation.The nursing progress note dated 9/1/25 revealed Resident #55 was readmitted to the facility on [DATE] at 6:43 PM in stable condition.The facility was unable to provide documentation of written notification of hospital transfer to the Resident Representative or the Ombudsman, and the facility was unable to provide documentation of notification of the bed hold policy for Resident #55's hospital transfer dated 8/29/25.Multiple attempts to contact Resident #55's RR by phone were unsuccessful.During an interview with the current Social Worker on 5/19/26 at 10:18 AM, he stated he had started working at the facility in March of 2026. The Social Worker stated he began sending out written notification of discharge/ transfer to hospital to the Resident Representative (RR) and Ombudsman when he began working in March. He further stated the bed hold policy was sent to the RR when residents were transferred to the hospital. The Social Worker stated he was unable to locate written discharge/ transfer to hospital notification and reported that information to his director. An interview was conducted with the [NAME] President of Operations on 7/16/2026 at 3:06 PM. The VP of Operations stated he had been made aware that the written notification of transfer/discharge to hospital to resident and resident representative, Ombudsman notification and bed hold policy notification had not been sent out by the previous social worker. The VP of Operations stated the Social Worker was responsible for these tasks and he was unable to locate any documentation from the previous Social Worker. The VP of Operations stated the previous Social Worker was responsible for the notices being cited. The facility submitted a plan of correction dated 3/9/26 that was not accepted due to not having the required components for the identified deficient practice. The missing components included identification of findings that led to the deficient practice, did not address all areas identified in the deficient practice, no identification of other residents having the potential to be affected by deficient practice, no designee for providing education, no information regarding audits being reported to Quality Assurance and Performance Improvement Committee (QAPI), and no date of compliance.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to utilize an Automatic External Defibrillator (AED) during the provision of Cardiopulmonary Resuscitation (CPR) when an AED was available and Nurse #1 became aware that Resident #11, who was a full code, did not have a pulse and was not breathing, and failed to maintain documentation of current, valid CPR certification for Nurse #1 on file. This deficient practice occurred for 1 of 3 residents (Resident #11) reviewed for CPR, and 1 of 8 staff (Nurse #1) whose CPR certifications were reviewed.Findings included:The facility's policy titled Cardiopulmonary Resuscitation dated 8/2012 revealed in part This facility provides the HeartSaver level of CPR as defined by the American Heart Association. Cardiopulmonary resuscitation will be initiated immediately on residents following a cardiopulmonary arrest, unless the resident has a 'Do Not Resuscitate' (DNR) order issued by the physician, or obvious signs of clinical death (including but not limited to: rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer.The American Heart Association (AHA) revealed in part the HeartSaver Courses included training in the lifesaving skills of first aid, CPR, and AED use. The facility's policy titled AED Procedure dated 4/2013 revealed in part Authorization to use AEDS: Any licensed nurse who has completed the required training in the use of AED may deploy the AED in emergency situations where a crash cart is required. Staff will continue to maintain certification in CPR and the AED will be used in tandem with CPR. Procedure: In the event of discovering an unresponsive individual or witnessing the rapid decline of any resident/individual to an unresponsive state, staff will activate the procedure for Code Blue by overhead paging Code Blue and the location of the unresponsive resident/individual three times and activating EMS [Emergency Medical Services} by calling 911. All available staff will immediately deploy the crash cart [an emergency cart containing essential equipment for use during CPR] and AED to the announced location in response to the Code Blue announcement.Resident #11 was admitted to the facility on [DATE] with a diagnosis of chronic atrial fibrillation (irregular heartbeat).A physician's order for Resident #11 dated [DATE] revealed CPR full code.Resident #11's care plan revealed a care guide section dated as initiated on [DATE] with an intervention of advance directives full code.Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She did not receive anticoagulant medication.A nursing progress note dated [DATE] at 6:11 AM written by Nurse #1 revealed at 5:30 AM Resident #11 was found unresponsive on morning rounds. A Code Blue was called, and CPR was initiated and continued until EMS arrived.The Wake County EMS system patient care record for Resident #11 dated [DATE] revealed the call was received at 5:38 AM. Wake County EMS system Unit DC1 arrived on the scene at 5:43 AM. Upon arrival, Unit DC 1 found Resident #11 already under the care of the Wake County EMS Unit EMS 84 and the [NAME] Fire Department who reported that facility staff had found Resident #11 in cardiac arrest and had moved Resident #11 onto the floor for CPR. Wake County Unit EMS 84 had the monitor in AED mode and no shock was advised. Resident #11 remained in asystole (the total cessation of electrical and mechanical heart activity) despite advanced life support measures. Resident #11 expired in the field. The time of her death was pronounced as 6:33 AM. On [DATE] at 8:45 AM a telephone interview with Nurse #1 indicated she recalled Resident #11. She reported she assumed care of Resident #11 on [DATE] at 7:00 PM and cared for her until the time of her death on [DATE]. She stated Resident #11 had been her usual self and did not complain of anything during her care and rounds that shift. Nurse #1 reported she checked on Resident #11 on [DATE] at around 2:30 AM, lightly tapped Resident #11's shoulder and Resident #11 had opened her eyes and spoken to her at that time. Nurse #11 went on to say sometime after 5:00 AM on [DATE], when she checked on Resident #11, she realized that although Resident #11 was still warm, Resident #11 was not responding, not breathing and had no pulse. She reported Code Blue was paged overhead, 911 called, and the crash cart was brought to Resident #11's room immediately. She stated Nurse #2 got to Resident #11's room within seconds, they pulled Resident #11 off the bed and onto the floor, and Nurse #2 performed chest compressions while she provided ventilations with the Ambu bag (an Ambu bag is a manual resuscitator bag used to deliver ventilations and oxygen to a person who is not breathing during CPR) which was hooked up to15 liters of oxygen. Nurse #1 reported although an AED had been available on the wall above the crash cart, everything happened so fast that she didn't think to bring it. She went on to say EMS arrived very quickly and took over. Nurse #1 indicated while she did recall instruction on AED use during her CPR certification training, but she was not aware the AED was something she had to use. She stated she and Nurse #2 just concentrated on doing CPR until EMS arrived. On [DATE] at 12:42 PM a telephone interview with Nurse #2 indicated he recalled Resident #11. He stated on [DATE] he heard the overhead page for Code Blue. He reported he immediately ran to Resident #11's room. He went on to say he and Nurse #1 pulled Resident #11 off her bed and onto the floor, and he provided chest compressions while Nurse #1 provided mechanical ventilations until EMS arrived. Nurse #2 stated EMS arrived very quickly. He reported that while he did recall the crash cart being in Resident #11's room, he did not recall there being an AED. Nurse #2 indicated he had participated in other Code Blues in the facility but the last one he could recall was a couple of years ago. He stated he did not recall ever using an AED during a Code Blue. He reported he just concentrated on CPR until EMS arrived.A review of Nurse #2's AHA 2020 BLS (Basic Life Support) Provider certificate provided by the facility on [DATE] revealed a course date of [DATE] with a recommended renewal date of 2/2027.On [DATE] at 1:38 PM an observation of the AED located on the wall of the 100 Hall above the crash cart was conducted with the Central Supply Clerk. The Central Supply Clerk removed the AED from the wall and powered the AED device on. The AED was observed to power on and begin audible instruction to connect the pads to the patient. An interview with the Central Supply Clerk at that time revealed he was responsible for checking the AED monthly and for ordering additional defibrillator pads when necessary.In a telephone interview on [DATE] at 2:36 PM Nurse #3 stated she was working on [DATE] from 7:00 PM until [DATE] at 7:00 AM. She reported when she heard the overhead page for Code Blue for Resident #11 that morning, she was in another resident's room providing care. She stated that when she got to Resident #11's room, CPR was already being provided, she confirmed EMS had been called, and she returned to caring for her residents. She indicated her CPR certification was current on [DATE]. Nurse #3 reported she had participated in Code Blues at the facility before, but it had been at least 2 years ago. She stated the facility had an AED available. She reported that when a resident experienced cardiopulmonary arrest, the procedure was to call the Code Blue, call EMS, and bring the crash cart and the AED which was located on the wall above the crash cart. She indicated the resident should be placed on the floor for CPR, and one person did compressions while another person provided ventilation with the AMBU bag hooked up to 15 liters of oxygen until EMS arrived. Nurse #3 stated that the AED should be applied to the resident, and then you would just listen to the AED for instructions on whether or not a shock was advised.A review of Nurse #3's AHA BLS (Basic Life Support) Provider certificate provided by the facility on [DATE] revealed an issue date of [DATE] with a recommended renewal date of 11/2026.On [DATE] at 3:20 PM a telephone interview with Director of Nursing (DON) #2 indicated she was the interim DON at the facility on [DATE] when Resident #11 experienced her cardiopulmonary arrest. She reported she worked as a mobile DON in multiple states. She stated she was not sure what the regulations were in North Carolina related to the use of an AED. DON #2 indicated her expectation would be that if a resident experienced a cardiopulmonary arrest, staff would immediately call the Code Blue, call EMS, bring the crash cart to the scene, and begin CPR. She reported that if the facility had an AED available, this should be brought with the crash cart. DON #2 stated the AED should be applied to the resident. She reported not all residents would be candidates for a shock. She indicated staff would just follow the instructions the AED gave to determine if a shock was beneficial. She reported that if the AED instructed a shock was advised, and this was delivered it could assist the resident to regain a heartbeat. On [DATE] at 4:22 PM a telephone interview with the Medical Director indicated he was familiar with Resident #11. He stated when Resident #11 was admitted to the facility, her medical condition was very complicated. He reported Resident #11 had a history of bleeding and was severely anemic (lack of healthy red blood cells reducing oxygen transport to organs). He indicated because of this bleeding, the blood thinning medication used to prevent blood clots from Resident #11's atrial fibrillation could not be given. The Medical Director stated Resident #11 refused all blood transfusions to treat her severe anemia because of her religious beliefs. He reported Resident #11's cardiopulmonary arrest on [DATE] was a rapid sequence of events. He stated staff initiated immediate and high quality CPR. He indicated EMS arrived on scene quickly. He reported he did not feel that the use of an AED by Nurse #1 and Nurse #2 on [DATE] would have changed the outcome for Resident #11. On [DATE] at 10:48 AM an interview with the Administrator indicated that the facility had an AED available for use on [DATE]. She reported because it could have taken additional time to bring the AED, she felt it was appropriate for Nurse #1 and Nurse #2 to just concentrate providing CPR until EMS arrived. She indicated the facility did not currently have a copy of Nurse #1's CPR certification on file but were attempting to obtain this.

Based on observations, record review, and staff interviews, the facility failed to adhere to enhanced barrier precautions (EBP) during catheter care for Resident #4 who had an indwelling urinary catheter. This deficient practice occurred with 1 of 4 staff members observed for infection control practices (Nurse Aide #1).Findings included:The facility's EBP police dated 4/2023 revealed in part: Enhanced Barrier Precautions (EBP) are used in conjunction with Standard Precautions to reduce the risk of MDRO (multi drug resistant organism) transmission during high-contact resident care activities. Includes the use of both gowns and gloves. EBP are meant to be in place for the duration of the resident's stay or the discontinuation of an indwelling medical device. Enhanced Barrier Precautions apply to residents with any of the following: Presence of an indwelling medical devices with or without the presence of an MDRO infection or colonization. Examples of indwelling medical devices: Indwelling Catheters.On 3/4/26 at 11:05 AM a continuous observation of indwelling urinary catheter care was conducted for Resident #4 with Nurse Aide (NA) #1. A sign was observed posted on the entry door to Resident #4's room which read in part Stop, Enhanced Barrier Precautions Everyone must: clean hands before entering and after leaving the room. All HealthCare Personnel must: Wear gloves and gown for the following High Contact Resident Care Activities: Device care or use: urinary catheter. Personal Protective Equipment (PPE) including gowns and gloves were observed at the entrance to Resident #4's room in the hall. NA #1 was observed to perform hand hygiene and enter Resident #4's room. She was not wearing a gown. She was observed to explain the procedure to Resident #4. She set up her supplies, including washcloths, towels, warm water, and soap. NA #1 was observed to perform hand hygiene and apply gloves. She assisted Resident #4 with positioning, opened his incontinence brief, and at 11:15 AM as she was preparing to use a washcloth moistened with soap and water to clean Resident #4's urinary catheter which was inserted into his penis, she was asked to stop, make Resident #4 safe, and step out into the hallway. On 3/4/26 at 11:16 AM NA #1 was interviewed after she had stepped out into the hallway. NA #1 reported she had performed urinary catheter care for Resident #4 in the past. She stated she knew Resident #4 was on EBP and indicated she had received education on EBP. She stated EBP included the use of gowns and gloves when providing catheter care to a resident. NA #1 went on to say EBP was used to protect residents from germs and prevent the spread of infections. She stated she had always followed EBP and wore a gown and gloves when she performed catheter care for Resident #4, but this time she had been nervous and had forgotten to.The facility's Infection Preventionist (IP) was not available for interview during the survey.On 3/4/26 at 11:45 AM an interview with the Director of Nursing (DON) indicated she was not the facility's IP. She stated NA #1 should have worn a gown and gloves when performing urinary catheter care for Resident #4 to prevent the spread of germs which could cause infections. She reported NA #1 was usually very good with observing EPB precautions.On 3/5/26 at 10:48 AM an interview with the Administrator indicated NA #1 should have followed EPB precautions which included the use of a gown and gloves when providing indwelling urinary catheter care to Resident #4 to prevent the spread of infections.

Based on observations, record review, resident and staff interviews, the facility failed to ensure a medical record was accurate regarding medication administration and wound treatment. This was for 2 of 20 sampled residents whose medical records were reviewed (Resident #29 and Resident #7). Findings included: 1. Resident #29 was readmitted to the facility on [DATE] with a diagnosis of hypotension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #29 was cognitively intact. The physician orders for Resident #29 revealed an order dated 11/21/24 for Midodrine HCl Oral Tablet 10 milligrams (mg) 1 tablet by mouth three times a day (8:00 AM, 12:00 PM, and 5:00 PM) for hypotension, take blood pressure (BP) in a sitting position, and hold if the systolic blood pressure (the top number in a BP reading that measures the pressure in the arteries when the heart beats) is greater than 120. A Pharmacist's Report to Nursing dated 2/24/25 revealed that the Midodrine medication was documented as administered to Resident #29 on the following dates per the February 2025 medication administration record (MAR) even though the systolic BP was greater than 120: - 2/1/25: 138/70 (8:00 AM), 145/82 (12:00 PM) - 2/2/25: 128/78 (8:00 AM), 145/84 (12:00 PM), 133/80 (5:00 PM) - 2/7/25: 179/95 (8:00 AM), 171/92 (12:00 PM), 165/80 (5:00 PM) - 2/8/25: 127/78 (8:00 AM), 145/86 (12:00 PM) - 2/9/25: 141/65 (8:00 AM) - 2/12/25: 145/77 (8:00 AM), 139/87 (12:00 PM) - 2/15/25: 145/83 (8:00 AM) - 2/19/25: 124/72 (8:00 AM) - 2/20/25: 155/73 (8:00 AM) - 2/21/25: 170/70 (8:00 AM), 127/76 (5:00 PM) - 2/22/25: 126/74 (8:00 AM), 132/76 (12:00 PM) - 2/23/25: 126/76 (8:00 AM), 126/76 (12:00 PM) The February 2025 MAR revealed the following nurses were responsible for the documentation that Midodrine was administered to Resident #29 even though the systolic BP was greater than 120: - 2/1/25: Nurse #5 - 2/2/25: Nurse #6 - 2/7/25: Nurse #8 (8:00 AM and 12:00 PM), Nurse #6 (5:00 PM) - 2/8/25: Nurse #6 - 2/9/25: Nurse #9 - 2/12/25: Nurse #6 - 2/15/25: Nurse #5 - 2/19/25: Nurse #2 - 2/20/25: Nurse #2 - 2/21/25: Nurse #6 - 2/22/25: Nurse#2 - 2/23/25: Nurse #2 - 2/27/25: 126/76 (8:00 AM), 126/76 (12:00 PM), 126/76 (5:00 PM) The March 2025 MAR revealed the following BP values and nurses who documented they administered Midodrine to Resident #29 even though the systolic BP was greater than 120: - 3/2/25: 131/85 at 5:00 PM by Nurse #6 - 3/4/25: 138/84 (8:00 AM) and 162/87 (12:00 PM) both by Nurse #10 - 3/6/25: 123/79 at 8:00 AM by Nurse #6 - 3/7/25: 163/89 (8:00 AM), 163/89 (12:00 PM), 192/98 (5:00 PM) all by Nurse #8 - 3/8/25: 140/88 at 8:00 AM by Nurse #11 - 3/9/25: 126/74 (8:00 AM) and 126/74 (12:00 PM) both by Nurse #3 An interview was conducted with Resident #29 on 3/20/25 at 12:31 PM. She was able to describe the appearance of the Midodrine tablet and indicated she would not have taken Midodrine if anyone attempted to give it to her with a systolic BP higher than 120. Nurse #6 was interviewed via telephone on 3/20/25 at 11:59 AM. She revealed that if a medication order states to hold if systolic BP was greater than 120, she would not administer the medication. Nurse #6 stated that Resident #29's BP was taken right before Midodrine was scheduled to be given. For the dates that she documented Midodrine was given, even though Resident #29's systolic BP was greater than 120, she did not administer the medication. She stated that she made the wrong choice of coding on the February and March MARs in error. Nurse #6 indicated that instead of coding Midodrine as given, she should have chosen 5, which meant Hold/See Nurses Notes. She stated she needed to pay more attention and read the MAR more closely. An interview was conducted with Nurse #5 on 3/20/25 at 12:10 PM. She revealed that if an order with parameters for Midodrine was initiated, then the medication should be held if the systolic BP was greater than 120. Nurse #5 stated that for all entries on the MARs that indicated it was given even though Resident #29's systolic BP was higher than 120, they were entered in error. She should have chosen the action as 5 for Hold/See Nurses Notes. Nurse #5 stated that Resident #29 was alert and oriented and very familiar with her own medication regimen. Nurse #2 was interviewed on 3/20/25 at 12:35 PM. She revealed that if an order stated to hold Midodrine if systolic BP was greater than 120, she would hold the medication and not administer it. Nurse #2 indicated that in the MAR there was an option where the BP value could be entered and an opportunity to choose if the medication was held. Nurse #2 indicated that the Midodrine was not given to Resident #29 when her systolic BP was greater than 120. She stated that the electronic medical record (EMR) was new to her, and the reason why administered was chosen instead of hold was due to clerical errors. She indicated that Resident #29 was aware of her medication orders and any parameters. An interview was conducted via telephone with Nurse #9 on 3/20/25 at 12:48 PM. She revealed that she did not administer the Midodrine on 2/9/25 at 8:00 AM. It must have been a clerical error. Nurse #9 indicated that Resident #29 was alert and oriented, very involved in her care, and would not accept the medication if her systolic BP was more than 120. During a telephone interview with Nurse #10 on 3/20/25 at 12:54 PM, she revealed that the Midodrine medication was held on 3/4/25. She indicated she must not have coded the MAR correctly. Multiple attempts were made to contact Nurse #3, Nurse #8, and Nurse #11 during the investigation, but they did not return the phone calls. The Director of Nursing (DON) was interviewed on 3/20/25 at 1:14 PM. She revealed that all nurses should not have chosen the code in the MAR that indicated Midodrine was administered for Resident #29 when it was not given. They should have chosen the correct code of 5 - Hold/See Nurses Note. During an interview with the Administrator on 3/20/25 at 1:16 PM, he revealed that all nurses should have chosen hold rather than administered when Midodrine was not given in February and March 2025. 45045 2. Resident #7 was admitted to the facility on [DATE]. Resident #7 had diagnoses which included a pressure ulcer of sacral region stage 3. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment and was coded for a stage 3 pressure ulcer. Resident #7 had a physician order dated 1/28/25 to validate wound vac (negative pressure wound therapy) function and setting every shift for monitoring. Observations of Resident #7 were conducted on 3/19/25 at 8:30 am and 9:30 am with the wound vac machine was noted to be in the off position and the drainage canister was empty. A wound care observation was conducted on 3/19/25 at 10:20 am with the Wound Treatment Nurse. Upon initiation of the treatment, Resident #7's wound vac was noted to connected to the wound vac dressing, the machine was in the off position, and the drainage canister was empty. The Wound Treatment Nurse removed the wound vac therapy and changed the treatment to a wet to dry dressing due to appearance of the wound bed. Review of Resident #7's Medication Administration Record (MAR) for 3/19/25 through 3/20/25 revealed the following: 3/19/25 7:00 am to 3:00 pm shift- the wound vac was validated as functioning with proper settings by Nurse #2. 3/19/25 3:00 pm to 11:00 pm shift- the wound vac was validated as functioning with proper settings by Nurse #2. 3/19/25 11:00 pm to 7:00 am shift- the wound vac was validated as functioning with proper settings by Nurse #1. 3/20/25 7:00 am to 3:00 pm shift- the wound vac was validated as functioning with proper settings by Nurse #6. An attempt to interview Nurse #1 on 3/20/25 at 10:39 am was unsuccessful. An attempt to interview the Wound Treatment Nurse on 3/20/25 at 10:42 am was unsuccessful. An interview was conducted on 3/20/25 at 10:48 am with Nurse #2 who revealed she was not notified by the Wound Treatment Nurse on 3/19/25 that Resident #7's wound vac was removed. Nurse #2 stated she did not really look at the wound vac because the Wound Treatment Nurse took care of the wound. Nurse #2 stated she did not recall if she checked if Resident #7's wound vac was functioning and at the correct setting before she documented it was for the 7:00 am-3:00 pm and 3:00 pm-11:00 pm shifts on 3/19/25. An interview and observation with Nurse #6 was conducted on 3/20/25 at 10:51 am. Nurse #6 stated she did not perform wound treatments at the facility but confirmed Resident #7 no longer had the wound vac therapy in place. Nurse #6 stated the Wound Treatment Nurse had just completed Resident #7's wound treatment and she did not report that the wound vac therapy was removed and the order was still in the computer. Nurse #6 was unable to state why she documented Resident #7's wound vac therapy to be functioning with correct settings without confirming it was in place. During an interview on 3/20/25 at 11:02 am the Director of Nursing (DON) revealed the nurses were responsible for checking the wound vac prior to documenting it was functioning. She stated the nurses should not have documented the wound vac therapy was functioning when it was no longer in place. The DON stated the Wound Treatment Nurse should have discontinued or placed the wound vac therapy orders on hold so the staff would know what treatment was being performed.

Based on record review, and resident, staff and Medical Director interviews, the facility failed to honor a resident with a diagnosis of type I diabetes the choice to use an insulin pump (small, wearable device that delivers doses of insulin at specific times and are an alternative to multiple daily injections) as preferred for 1 of 1 resident (Resident #29) reviewed for choices. Findings included: Resident #29 was readmitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #29 was cognitively intact and was independent or required supervision with most activities of daily living (ADL). Resident #29's care plan dated 10/13/23 revealed Resident #29 had diabetes mellitus and the potential for complications of hyper/hypoglycemia such diabetic ketoacidosis (DKA). The care plan was revised on 12/30/24 to include that Resident #29 had a potential for fluid volume deficit due to a history of dehydration requiring intravenous fluids, nausea and vomiting, acute kidney injury, and diabetic ketoacidosis due to hyperglycemia. Review of physician orders for Resident #29 revealed that she received the following insulin orders: - 2/25/25: Insulin Lispro Injection Solution 100 unit/milliliter (mL) Inject as per sliding scale: if 200 - 250 = 2 unit; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 500 = 10 units if 400 and over give 10 units and call the physician, subcutaneously four times a day for diabetes - 2/26/25: Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/mL Inject 20 units subcutaneously one time a day for diabetes Review of a Medical Director Encounter note dated 2/25/25 revealed that Resident #29 had a follow up endocrinology appointment today, and the use of an insulin pump with the hope of restarting would be readdressed. Review of an Endocrine Follow-up visit dated 2/26/25 revealed that the consultation was requested by the Medical Director. She had been in and out of hospitals over the past few months due to her Parkinson's and blood pressure. Resident #29 was not allowed to use an insulin pump at the nursing facility. However, she had been hospitalized twice in the past year for DKA, and the blood sugars were not controlled. The plan was to start Resident #29 on continuous glucose monitor, since she will be moving to an independent facility. Review of an Medical Director Encounter note dated 2/28/25 revealed that Resident #29 went to the endocrinologist on 2/26/25 for a follow up. Resident #29 requested the use of an insulin pump. The endocrinologist office ordered one for her and would provide her with proper training. An interview was conducted with Resident #29 on 03/17/25 11:57 AM. She revealed that she had an insulin pump prior to admission, but the facility would not allow her to use it due to policy. Resident #29 stated that she was a very brittle diabetic, and her endocrinologist had spoken to facility staff about the use of an insulin pump. All the supplies could be sent to her directly, and she would use the pump on her own. The Medical Director was interviewed on 3/18/25 at 1:49 PM. She revealed that Resident #29 used to be on an insulin pump, so when she went into DKA in the hospital or when she was admitted to the facility, the insulin pump was replaced with short-/long-acting insulin for better blood sugar control. The Medical Director recently referred Resident #29 to endocrinology to prepare her for a planned discharge. Resident #29 was seen on 2/26/25 and was last seen by the endocrinologist over a year ago. The Medical Director stated that the facility had a continuous glucose monitor (a wearable device by the user that tracks blood sugar every few minutes 24 hours per day) in the building, but Resident #29 was not using it yet because she was waiting for the insulin pump to arrive. The endocrinologist office ordered the insulin pump, and Resident #29 required reeducation on its use. The Medical Director stated she had not yet received permission from corporate for Resident #29 to use the insulin pump. She further stated that she was aware Resident #29 wanted an insulin pump for the last 6 months. If Resident #29 received an insulin pump education and received it from the endocrinologist, then she would be safe to administer the insulin pump. An interview was conducted with the Regional [NAME] President on 3/18/25 at 2:21 PM. He stated that the facility did not have a policy on insulin administration, and if there was not a policy related to an insulin pump, then that meant the facility did not allow that specific medical device. The Regional [NAME] President indicated he was under the impression that an insulin pump was brought up by Resident #29 due to her planned discharge. However, Resident #29 did not approve of the facility where she was to be transferred. Now that she remained in the facility, the insulin pump conversation was on pause. During a follow-up interview with Resident #29 on 3/18/25 at 2:42 PM, she revealed that she administered the insulin pump on her own for 5 years prior to admission and received multiple education opportunities. Currently, she was waiting for an independent handicap apartment to be discharged from the facility. Resident #29 stated that she discussed the insulin pump with the Medical Director many times, and she recommended that it was a medical necessity. Resident #29 stated that nursing staff did not know how to respond with insulin to her brittle blood sugar readings. She did refuse certain insulin dosages at times to prevent hypoglycemia. During a follow-up interview with the Medical Director on 3/19/25 at 2:08 PM, she stated that the insulin pump for Resident #29 was a preference, and not a medical necessity. The Regional Assistant [NAME] President (AVP) of Health Services was interviewed on 3/19/25 at 8:33 AM. She revealed that she was contacted by the Director of Nursing (DON) 2 weeks ago about how to get an insulin pump for Resident #29 because the endocrinologist was going to order a pump and continuous glucose monitor upon discharge. The Regional AVP of Health Services stated that she was unsure how to attain these medical devices, provide education to the resident and staff, and which vendor source to use. Home health was supposed to provide Resident #29 with education about the insulin pump when she admitted to another facility. She indicated that a resident could obtain an insulin pump if they were admitted with one, since they already had a carrier for the device. The company's pharmacy did not provide insulin pumps. If Resident #29 requested an insulin pump 6 months ago, the facility would have made efforts to fulfill this medical device request. If facility staff spoke directly to pharmacy, then this request would be denied without further investigation. The Regional AVP of Health Services said she performed more investigation since contacted by the DON, and she found that if the resident was not admitted with an insulin pump but expressed great interest to acquire one, the facility would accommodate the request as best as possible. During an interview with the DON on 3/19/25 at 2:44 PM, she revealed that the first time she heard about Resident #29 wanting an insulin pump was several weeks ago. Resident #29 had an appointment with the Endocrinologist on 2/26/25. The DON contacted the endocrinology office to speak with the provider, which took a couple of days for a return phone call. The provider told the DON that Resident #29 could use the insulin pump upon discharge from the facility. The DON told the provider that she needed to speak with the Medical Director on the use of this medical device. The provider stated that Resident #29 needed to come back to the office to receive the authorization and education on the insulin pump, and it would be a few weeks before she would receive the supplies in the mail. The DON stated she spoke with the Medical Director, who was aware of the entire situation and was working on getting Resident #29 the insulin pump. The DON then left it with the Medical Director because she was already working on the request. The DON indicated that if there was not a problem with implementing the insulin pump, and the facility approved, then Resident #29 should be able to use that preferred medical device. The Administrator was interviewed on 3/19/25 at 3:18 PM. He revealed that Resident #29's preference for an insulin pump should have been fulfilled in a timely manner.

Based on record review, staff interviews, and resident interviews, the facility failed to honor a resident's right to participate in the planning process of the person-centered plan of care for 1 of 4 residents reviewed for care planning (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE]. Review of the care plan meeting note dated 4/30/24 revealed a care plan meeting was conducted with Resident #34 and their Responsible Party (RP). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #34 was cognitively intact. A review of Resident #34's electronic medical record revealed no further documentation that a care plan meeting had been held or that Resident #34 had been invited to participate in a care plan meeting in the time between the 4/30/24 care plan meeting through 3/17/25. During an interview on 3/17/25 at 12:47 pm Resident #34 reported she was unable to remember the last time the facility invited her to attend a care plan meeting. Resident #34 stated she would be interested in attending a care plan meeting to review her medications and other concerns but it had not been offered. An interview was conducted with the Social Worker on 3/18/25 at 2:05 pm. The Social Worker revealed she started working at the facility in August of 2024 and she had not had a care plan meeting for Resident #34. The Social Worker stated long-term care residents were to have a care plan meeting every 3 months or more often if requested. The Social Worker stated she had been trying to keep track of the process of scheduling care plan meetings but she stated she was not provided with an actual list of resident care plan meetings that were due. The MDS Nurse was interviewed on 3/18/25 at 2:37 pm who revealed it was not her normal practice to provide the Social Worker with a list of residents who required a care plan meeting based on the MDS assessments. The MDS Nurse stated a resident care plan would be automatically updated when she opened them and each department would have to review and sign off on their sections. She stated she did not participate in the care plan meeting. The MDS Nurse stated that once all the departments have completed their sections of the care plan, she would complete the nursing portions and sign off that the care plan had been reviewed. The MDS Nurse stated she did not confirm that the Social Worker scheduled and held a care plan meeting for Resident #34 before she completed the care plan review. An interview was conducted with the Administrator on 3/20/25 at 1:44 pm who revealed the MDS Nurse should have provided the Social Worker with a list of residents that needed to have a care plan meeting scheduled when the quarterly care plans were reviewed.

Based on record review, and resident and staff interviews, the facility failed to provide a written grievance decision to a resident for 1 of 1 resident reviewed for grievances (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 was cognitively intact. Review of the Facility Concern/Grievance Form dated 1/20/25 revealed Resident #24 had reported concerns to the Social Worker regarding staff language in hall and not getting along with a roommate and possible room change. The grievance was assigned to the Director of Nursing (DON) on 1/20/25 with an expected return due date of 1/23/25. The actions taken section, which was completed by the DON, noted that she spoke with Resident #24 related to reported concerns and that she met with staff members related to customer service, mindfulness of environment, and professionalism. The DON further noted the Social Worker was aware of Resident #24's request for a room change. The Facility Concern/Grievance Form noted it was to be returned to the Administrator after the investigation was completed. The grievance resolution section was not completed and the grievance was not signed by the facility's grievance officer. Review of Resident #24's progress notes dated 1/20/25 through 3/18/25 revealed no documentation regarding the discussion of the room change requested on the 1/20/25 grievance form. An interview was conducted with Resident #24 on 3/18/25 at 12:37 pm who reported she had talked to someone a few months ago about a room change because the roommate kept her awake at night and that the staff language in the hall was not appropriate. Resident #24 stated she did not know what the outcome of her reported concern was because she was still in the same room and the staff were still loud in the hallways. During an interview on 3/18/25 at 3:43 pm with the Social Worker she revealed that when Resident #24 reported the grievance she talked about a possible room change but did not recall her requesting the room to be changed at the time the grievance was reported. The Social Worker stated the DON did not tell her that Resident #24 wanted to change her room after the DON met with Resident #24. She stated the grievance form was to be returned to the grievance officer once the DON completed the investigation for Resident #24's concerns. The Social Worker stated the previous Administrator was the grievance officer at the time Resident #24's Facility Concern/Grievance Form was received and was responsible to provide the written grievance resolution to Resident #24. An interview was conducted with the DON on 3/19/25 at 2:11 pm who revealed she did not follow up with the Social Worker about the room change request after meeting with Resident #24 because she thought the Social Worker was aware. The DON stated she met with staff when Resident #24's concerns were reported but she did not follow up with Resident #24 to discuss steps taken towards the resolution of the concerns or if the concerns were resolved. The DON stated she believed she returned Resident #24's grievance to the Social Worker. The DON stated she did not recall seeing the form was to be returned to the Administrator once she completed her portion. A telephone interview was conducted on 3/19/25 at 2:30 pm with the previous Administrator who revealed she was the facility grievance officer at the time of Resident #24's concern. She stated she was responsible for providing the written resolution of grievance to the residents once the concern was fully investigated. She reported at the time she had left the facility in March 2025, the DON still had not returned several grievance forms and Resident #24's grievance could have been one that was outstanding. The previous Administrator stated she would have reviewed the grievance investigation when it was completed and the resolution would have been completed. She stated if Resident #24 confirmed to the DON that she wanted a room change it would have been discussed and implemented. The previous Administrator stated she did not recall Resident #24's grievance being brought to her to complete the resolution or address the requested room change.

Based on observation, record review, and resident, staff, and Responsible Party interviews, the facility failed to ensure that a resident with reported hearing difficulties was evaluated for treatment and services to maintain his hearing ability for 1 of 1 resident reviewed for vision and hearing (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses which included unspecified sensorineural hearing loss (hearing loss caused by damage to the inner ear or nerve from the ear to the brain with treatment that included hearing aids). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #14 had severe cognitive impairment and was coded for moderate hearing difficulty and was not coded for the use of hearing aids. The care plan last reviewed on 3/05/25 revealed Resident #14 had a care plan in place for auditory alteration characterized by decreased hearing in the left and right ears related to aging process. Interventions included getting the resident's attention before speaking and moving the resident to a low-noise place or remove as much background noise before speaking with the resident. Review of Resident #14's electronic health record revealed no audiology consultations (healthcare professionals that identify, assess, and manage hearing issues) were scheduled or completed regarding Resident #14's hearing difficulties. An interview and observation were conducted on 3/17/25 at 10:50 am with Resident #14. Resident #14 reported he was very hard of hearing and this surveyor needed to speak louder if he was to hear what was being said. This surveyor had to move about 2 inches from Resident #14's left ear for Resident #14 to hear the questions. Resident #14 stated he found it hard to listen to his television so he just looked at the screen without the volume up. Resident #14 stated he did not remember anyone asking him about his hearing or getting him tested for hearing aids but stated he would like to have them. During an interview on 3/17/25 at 11:00 am Nurse Aide (NA) #1 revealed he knew Resident #14 well and was assigned to his care at times. NA #1 stated Resident #14 was very hard of hearing. NA #1 stated he did not recall Resident #14 ever having hearing aids he just knew he needed to talk very loud for the resident to hear him. A telephone interview was conducted with Resident #14's Responsible Party (RP) on 3/17/25 at 2:27 pm. The RP stated she was aware of Resident #14's hearing loss but did not know if he had any previous hearing tests or hearing aids prior to admission to the facility. An interview was conducted on 3/18/25 at 2:42 pm with the MDS Nurse who revealed she completed Resident #14's MDS assessment and coded him for hearing impairment. She stated if she felt the hearing loss was chronic or their baseline hearing she would not normally discuss it with the interdisciplinary team. The MDS Nurse stated the facility had the availability to have an audiology consult conducted in the facility and the Social Worker would be responsible for the scheduling. The MDS Nurse stated she made sure Resident #14 had a care plan in place for hearing loss but she did not discuss the need for an audiology consult with the Social Worker because she felt it was chronic and his baseline. During an interview with the Social Worker on 3/18/25 at 3:38 pm she revealed she had been employed at the facility for approximately six months, and she was not aware Resident #14 was hard of hearing. The Social Worker stated she was not notified by the MDS Nurse that Resident #14 had hearing impairment so she did not schedule him for an audiology consult at the facility. The Social Worker stated she was unable to locate any documentation that Resident #14 had been seen by the audiology provider and she stated she would have scheduled the consultation had she been notified of the need. An interview was conducted on 3/20/25 at 1:38 pm with the Administrator who revealed the MDS Nurse should have provided the hearing impairment findings for Resident #14 to the Social Worker so the audiology consult could have been completed to determine if there was a need for hearing aids or other treatment options.

Based on record review, observation, and staff and Pharmacist interviews, the facility failed to remove expired medications stored for use in the medication storage room [ROOM NUMBER] of 1 medication storage room observed. The findings included: During an observation on 3/19/25 at 7:52 am of the medication storage room with the Director of Nursing (DON) the following was observed: Twenty-two (22) lidocaine 4% pain relief patches with an expiration date of 2/25/25. The expired lidocaine 4% pain relief patches were located in a bin on the counter in the medication storage room with multiple bags of unexpired lidocaine 4% pain relief patches. The expiration date was confirmed by the DON. A telephone interview was conducted with the Pharmacist on 3/20/25 at 10:08 am who revealed the facility was able to return expired medications to the pharmacy every day. She stated the facility would have to put the expired medications in the pharmacy tote when they were ready to be returned and would be picked up when the daily delivery was made. An interview was conducted on 3/19/25 at 2:13 pm with the DON who stated the facility did not have anyone who was assigned or responsible to make sure expired medications were removed from the medication storage room. The DON stated she did not notice that the pain patches were expired, but she stated it was possible that the pain patches were supposed to be sent back to the pharmacy. The DON stated medications were able to be returned to the pharmacy a few times a week but they may have missed sending the pain patches back. During an interview with the Administrator on 3/20/25 at 1:49 pm he revealed the Director of Nursing and the nursing team were responsible for ensuring expired medications were removed from the medication room.

Based on observations, record reviews, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when the Wound Treatment Nurse failed to apply personal protective equipment (PPE) during wound care for residents on Enhanced Barrier Precautions (EBP). This deficient practice was for for 1 of 1 staff member observed for wound care (Wound Treatment Nurse). The findings included: The facility's Infection Prevention and Control Program (IPCP) policy last updated 4/2023 indicated that the facility was responsible for establishing and maintaining an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections. The policy further noted that the objectives of the IPCP included ensuring proper utilization of standard precautions and or when needed, transmission-based precautions which should be the least restrictive possible for a resident under the given circumstances. The facility's Enhanced Barrier Precautions (EBP) policy last revised 7/26/22 revealed EBP was to be utilized for all residents who had a wound (skin opening that required a dressing). The policy further noted that personal protective equipment (PPE) for EBP was necessary when performing high-contact care activities which included wound care and required staff to wear gloves and gown when the wound care was provided. a. Resident #7 had signage posted on the door that alerted staff that the resident was on EBP. The signage noted that providers and staff must wear gloves and gowns for the following high-contact resident care activities which included wound care. A 3-drawer bin was observed in the hall stocked with PPE, which included disposable gowns. A continuous observation of wound care was conducted on 3/19/25 at 10:20 am through 10:45 am for Resident #7. The Wound Treatment Nurse was observed to perform hand hygiene and don clean gloves and began to perform wound care for Resident #7. The Wound Treatment Nurse performed Resident #7's stage 3 sacral pressure ulcer treatment without a gown in place. During an interview on 3/29/25 at 11:38 am the Wound Treatment Nurse confirmed Resident #7 was on EBP for her wounds and she was required to wear a gown during the wound care. The Wound Treatment Nurse stated she normally wore a gown when she performed wound care but she must have forgotten to put on a gown when she performed Resident #7's wound treatment. An interview was conducted with the Director of Nursing (DON) on 3/19/25 at 2:35 pm who revealed the facility did not have an Infection Preventionist but she stated she had worked with the previous Unit Manager to provide education to staff regarding EBP and use of PPE. The DON stated the Wound Treatment Nurse was required to wear a gown when she performed wound care for Resident #7. During an interview on 3/20/25 at 1:40 pm with the Administrator he revealed the Wound Treatment Nurse should have followed the guidelines for EBP when she performed wound care. b. Resident #22 had signage posted on the door that alerted staff that the resident was on EBP. The signage noted that providers and staff must wear gloves and gowns for the following high-contact resident care activities which included wound care. A 3-drawer bin was observed in the hall stocked with PPE, which included disposable gowns. A continuous observation was conducted on 3/19/25 at 11:07 am through 11:37 am for Resident #22's wound care treatment. The Wound Treatment Nurse was observed to perform hand hygiene and don clean gloves and began wound care for Resident #22. The Wound Treatment Nurse completed Resident #22's stage 3 pressure ulcer and venous stasis ulcer (wound on the leg or ankle caused by abnormal or damage to veins) treatments to the lower extremities without a gown in place. During an interview on 3/29/25 at 11:38 am the Wound Treatment Nurse confirmed Resident #22 was on EBP for his wounds and she was required to wear a gown during the wound care. The Wound Treatment Nurse stated she normally wore a gown when she performed wound care but she must have forgotten to put on a gown when she performed Resident #22's wound treatments. An interview was conducted with the Director of Nursing (DON) on 3/19/25 at 2:35 pm who revealed the facility did not have an Infection Preventionist but she stated she had worked with the previous Unit Manager to provide education to staff regarding EBP and use of PPE. The DON stated the Wound Treatment Nurse was required to wear a gown when she performed wound care for Resident #22. During an interview on 3/20/25 at 1:40 pm with the Administrator he revealed the Wound Treatment Nurse should have followed the guidelines for EBP when she performed wound care.

Based on observations, record review, staff interviews, and Medical Director interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 8/27/21 recertification and complaint investigation survey and the 10/15/22 recertification and complaint investigation survey. This was for 5 recited deficiencies on the current recertification and complaint investigation survey of 2/08/24 in the areas of Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plan (F656), Pharmacy Services/Procedures/Pharmacist/Records (F755), Free from Unnecessary Psychotropic Medications (F758), and Label/Store Drugs & Biologics (F761). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of Pre-Admission Screening and Resident Review (PASRR) for 2 of 19 sampled residents whose MDS were reviewed (Resident #56 and Resident #23). During the 8/27/21 recertification and complaint investigation survey the facility failed to accurately code the Minimum Data Set (MDS) assessment. During the 10/15/22 recertification and complaint investigation survey the facility failed to accurately code the smoking status of a resident on a Minimum Data Set (MDS) assessment. An interview was conducted on 2/08/24 at 10:30 am with the Administrator who revealed the facility monitored each section of the MDS assessments for accuracy, but the PASRR information was a slight oversight on the part of the facility. F656: Based on observations, record review, staff interviews, and Responsible Party (RP) interview, the facility failed to develop a person-centered care plan for 1 of 1residents reviewed for activities (Resident #5). During the 10/15/22 recertification and complaint investigation survey the facility failed to develop and implement an individualized person-center care plan. An interview was conducted on 2/08/24 at 10:30 am with the Administrator who revealed the care plans were reviewed and updated by the interdisciplinary team (IDT). The Administrator was unable to state how the care plan was missed. F755: Based on observation, record review and staff interviews, the facility failed to maintain an accurate count of a controlled antianxiety medication for 1 of 4 residents observed for controlled substance administration (Resident #56). During the 10/15/22 recertification and complaint investigation survey the facility failed to establish a secured and effective system to contain and record control drugs to be returned to the pharmacy for a discharge resident. During an interview on 2/08/24 at 10:30 am the Administrator stated the facility had completed audits of the medication carts, but she was unable to state how the oversight occurred. F758: Based on record review, staff interviews, and Medical Director interview, the facility failed to stop an antidepressant medication prescribed for 30 days which resulted in the resident receiving the medication over the prescribed 30 days for 1 of 5 residents reviewed for unnecessary medications (Resident #5). During the 8/27/21 recertification and complaint investigation survey the facility failed to obtain a stop date for an as needed (prn) antipsychotic medication. During the 10/15/22 recertification and complaint investigation survey the facility failed to implement a 14-day stop date for an as needed psychotropic medication. An interview was conducted with the Administrator on 2/08/24 at 10:30 am who revealed the normal process was for the IDT team to discuss and review all orders and pharmacy recommendations. The IDT team had completed audits to ensure the identified areas were completed but this was somehow missed during their review. F761: Based on record review, observations, and staff interviews, the facility failed to refrigerate medications according to manufacturer's recommendations for 1 of 1 medication refrigerators located in the Medication room. During the 8/27/21 recertification and complaint investigation survey the facility failed to label an open vial of insulin on one of three medication carts reviewed, and the facility failed to affix the locked narcotic box to the refrigerator in one of one medication rooms reviewed. During the 10/15/22 recertification and complaint investigation survey the facility failed to date two opened medications for 1 of 2 medication carts used for medication administration and failed to store medication in a locked cabinet. An interview was conducted on 2/08/24 at 10:30 am with the Administrator who revealed the facility had diligently checked medication rooms and carts daily and she was unable to state how the oversight occurred.

Based on record review, staff interviews, and Medical Director interview, the facility failed to stop an antidepressant medication prescribed for 30 days which resulted in the resident receiving the medication over the prescribed 30 days for 1 of 5 residents reviewed for unnecessary medications (Resident #5). The findings included: Resident #5's hospital discharge summary dated 10/05/23 revealed an order for trazodone (an antidepressant medication) 50 milligram (mg) tablet take 0.5 tablet (25 mg) by mouth nightly for 30 days. Resident #5 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety, and schizoaffective disorder. An active physician order dated 10/06/23 for olanzapine (an antipsychotic medication) 5 mg tablet, give 4 tablets at bedtime for schizoaffective disorder. An active physician order dated 10/06/23 for escitalopram (an antidepressant medication) 5 mg daily for depression. An active physician order dated 10/06/23 for trazodone oral tablet 50 mg. Give 1/2 tablet by mouth one time a day for depression; give 25 mg by mouth nightly for depression. The physician order did not have a stop date. A telephone interview was conducted on 2/07/24 at 10:24 am with Nurse #1 who entered the trazodone order for Resident #5. Nurse #1 was unable to state why the trazodone order did not include the stop date from the hospital discharge summary for Resident #5. Record review of Resident #5's Consultant Pharmacist's Medication Regimen Review (MMR) dated 10/24/23 revealed the Consultant Pharmacist reported the trazodone was written incorrectly without a stop date. Please correct/clarify. Record review of Resident #5's Consultant Pharmacist's Recommendation dated 1/26/24 revealed a gradual dose reduction (GDR) was recommended for the trazodone order because Resident #5 had been using the medication since 10/06/23. The electronic medication administration records (MARs) were reviewed and revealed the trazodone 25 mg was administered to Resident #5 every night from 10/06/23 through 2/06/24. During an interview on 2/07/24 at 11:43 am with the Director of Nursing (DON), she revealed the new admission medications were reviewed in the morning clinical meeting but that did not include matching the hospital discharge orders to the entered orders for accuracy. The DON was unable to state how the stop date for Resident #5's trazodone was missed for so long. The previous Unit Manager was unavailable for a telephone interview on 2/07/24. A telephone interview was conducted on 2/08/24 at 9:02 am with the Medical Director who revealed Resident #5 required the trazodone when she was admitted to the facility because the change of environment was a difficult adjustment and the trazodone helped to calm her. The Medical Director stated she reviewed the hospital discharge summary orders before she signed the facility orders to ensure they were entered accurately, but she stated she missed that the order did not have the stop date. The Medical Director stated she did not receive the Consultant Pharmacist recommendation from the facility regarding the incorrect transcription with no stop date for Resident #5's trazodone order. The Medical Director reported she completed a gradual dose reduction (GDR) recommendation from the Consultant Pharmacist Recommendation on 2/07/24 for Resident #5's trazodone.

Based on record review, observations, and staff interviews, the facility failed to refrigerate medications according to manufacturer's recommendations for 1 of 1 medication refrigerators located in the Medication room. Findings included: The manufacturer's recommendations for Insulin glargine, insulin degludec and Humulin R recommended that insulin be stored in a refrigerator at approximately 36 to 46 [degrees Fahrenheit] to avoid freezing. On 2/07/24 at 1:45 PM the Medication Room was observed with Nurse #4. The medication top-freezer refrigerator was observed with a secured lock on the refrigerator section. Inside the top-freezer was a white plastic basket containing: 1- Insulin glargine 10 milliliters (ml) multidose vial unopened 2- Insulin glargine 3 ml injection pens 2- Insulin deglu[DATE] ml injection pens 2- Insulin dulaglutide 0.5 ml injection pens 3- Humulin R 10 ml multidose vials unopened On 2/07/24 at 1:47 PM Nurse #4 stated the insulins should not have been placed into the freezer. Nurse #4 explained the refrigerator was kept locked due to controlled substances which required refrigeration. She further explained the hall nurses each had a key to the Medication Room but only the 100-Hall nurse had the key to the medication refrigerator. On 2/07/24 at 2:38 PM an interview with the Director of Nursing (DON) was conducted. She stated she stated she was unsure who would place insulin into the freezer and not the refrigerator. She explained insulin should not be frozen and would expect the nurses to store the insulin as directed. On 2/08/24 at 8:57 AM an interview with the Administrator was conducted. She stated insulin should be stored at the proper temperature.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of Pre-Admission Screening and Resident Review (PASRR) for 2 of 19 sampled residents whose MDS were reviewed (Resident #56 and Resident #23). The findings included: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder and anxiety. Review of the Pre-Admission Screening and Resident Review (PASRR) Level II Determination Notification dated 3/14/23 revealed Resident #56 was appropriate for nursing home placement. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #56 was not coded to reflect his PASRR Level II status. An interview was conducted with the MDS Nurse on 2/07/24 at 10:40 am who confirmed Resident #56 had a PASRR Level II. The MDS Nurse stated she was not sure how she missed the PASRR Level II information for Resident #56 when she completed his annual assessment. An interview was conducted on 2/07/24 at 2:38 pm with the Administrator who revealed the MDS Nurse was responsible to ensure Resident #56's MDS assessments were coded correctly. 2. Review of the Pre-Admission Screening and Resident Review (PASRR) Level II Determination Notification dated 9/13/21 revealed Resident #23 was appropriate for nursing home placement. Resident #23 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and personality/behavioral disorder. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #23 was not coded to reflect his PASRR Level II status. During an interview on 2/07/24 at 2:06 pm the MDS Nurse revealed Resident #23's electronic medical record was not updated with the PASRR Level II information at the time the MDS assessment was completed. The MDS Nurse stated whoever received the PASRR Level II Determination Notification was responsible to update the electronic medical record with the information. An interview was conducted on 2/07/24 at 2:13 pm with the Admission Director who revealed she was responsible to ensure Resident #23's PASRR Level II status was updated in the electronic medical record when he was admitted to the facility. She stated she must have seen the PASRR Level I information on the medical record from a previous admission and just assumed it was the correct information. The Admission Director stated she completed an audit at a later date and realized she did not have the correct PASRR information listed for Resident #23, so she updated the medical record with the PASRR Level II information. An interview with the Administrator was conducted on 2/07/24 at 2:38 pm. The Administrator stated the PASRR Level II information for Resident #23 should have been updated by the Admission Director, so the information was available so the MDS Nurse could accurately complete the assessment.

Based on observations, record review, staff interviews, and Responsible Party (RP) interview, the facility failed to develop a person-centered care plan for 1 of 1residents reviewed for activities (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses which included stroke and major depressive disorder. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Resident #5 reported the following activity preferences were very important: books, magazines, and newspapers to read, listen to music, participate in group activities, participate in religious services, and to be outdoors for fresh air when weather was good. Resident #5's care plan initiated on 10/16/23 and last updated on 2/05/24 revealed she had a care plan in place for daily preferences and activity preferences related to daily care. A care plan goal was in place for Resident #5's daily and activity preferences to be provided through the next review. The care plan had no interventions noted at the time of initial review on 2/05/24. An observation on 2/05/24 at 10:05 am revealed Resident #5 was alone in her room, sitting in her wheelchair with a single coloring sheet and colored pencils. A telephone interview was conducted on 2/05/24 at 11:47 am with Resident #5's Responsible Party (RP) who revealed she had discussed with the facility during an interview the activities that Resident #5 enjoyed which included music, coloring, attending church services, and group activities. Resident #5's RP stated when she visited Resident #5, she was most often alone in her room with coloring sheets. An interview was conducted on 2/06/24 at 1:11 pm with the Activity Assistant who revealed the MDS Nurse was responsible to create Resident #5's care plan because she was not able to create care plans. The Activity Assistant stated Resident #5 did participate in group activities for church services and movies at times, but often she delivered coloring pages to her room because she knows Resident #5 enjoyed coloring. An interview was conducted on 2/07/24 at 12:09 pm with Nurse Aide (NA) #1 who revealed he provided care to Resident #5 during the 7:00 am-3:00 pm shift. NA #1 stated he was unsure of what activities Resident #5 enjoyed participating in, but he stated if he knew he would take her to the scheduled activity of her choice. An interview was conducted on 2/07/24 at 1:35 pm with Nurse #2 who he did not know if there was an activity that he could offer for Resident #5 when she was in her room alone. During an interview on 2/07/24 at 1:54 pm with the MDS Nurse she revealed she was responsible for completing the care plan for Resident #5, but she was unable to state why there were no interventions for the activity care plan. The MDS Nurse stated she noticed there were no interventions listed for Resident #5's activity care plan, so she added color with color pencils and coloring pages on 2/05/24. The MDS Nurse stated she did not review the MDS admission assessment for the activity preferences to create a person-centered care plan for Resident #5, but stated she recalled Resident #5 enjoyed coloring in the past. An interview was conducted with the Administrator on 2/07/24 at 2:47 pm who revealed the MDS Nurse was responsible for Resident #5's activity care plan. The Administrator stated Resident #5's care plan interventions should have been added when the care plan was created.

Based on observation, record review and staff interviews, the facility failed to maintain an accurate count of a controlled antianxiety medication for 1 of 4 residents observed for controlled substance administration (Resident #56). Findings included: Review of Resident #56's February 2024 Medication Administration Record (MAR) revealed he received alprazolam 1 milligram (mg) at 8:00 AM, 12:00 PM and 4:00 PM daily. A medication administration observation was conducted on 2/07/24 at 8:20 AM with Nurse #2. The nurse verified Resident #56's medications, opened the locked narcotic box and retrieved Resident #56's alprazolam 1 mg tablets. The individual tablets were in a blister pack with each tablet numbered. Upon removal from the box, the blister pack showed there were 19 tablets. Nurse #1 removed one tablet and showed there were 18 tablets remaining in the blister pack. At the time of the observation a review of Resident #56's Controlled Substance Count Record for alprazolam 1 mg was completed with Nurse #2. There was a line for each tablet's administration documentation which included the quantity, date, time, amount given, amount left, and a space for the nurse's signature. The previous notation indicated there had been 20 tablets remaining in the blister pack. Nurse #2 was observed writing on the next line of the Controlled Substance Count Record that there had been quantity 19 tablets, and the amount left was 18 tablets. The Shift-Change Controlled Substance Count Check form was noted as signed as completed on 2/06/24 at 7:00 PM and again on 2/07/24 at 7:00 AM, both counts had been conducted by Nurse #2 and Nurse #3. On 2/07/24 at 8:21 AM Nurse #2 was asked about the Controlled Substance Count Record discrepancy indicating there were 20 tablets remaining on the previous line, and after removing 1 tablet there were now 18 left. He explained when he and Nurse #3 counted the controlled substances on 2/06/24 at 7:00 PM and again on 2/07/24 at 7:00 AM the count was correct. He then took the blister pack and the Controlled Substance Count Record to the Director of Nursing (DON). A phone interview with Nurse #3 was conducted on 2/07/24 at 7:17 PM. Nurse #3 stated she had counted the controlled medications twice with Nurse #2 when she was starting her shift on 2/06/24 at 7:00 PM and again on 2/07/24 when she was ending her shift. She explained they looked at both the blister pack card and the Controlled Substance Count Record for each medication to make sure the numbers were correct. She explained she could only think that she did not pay close attention and thought the count had been correct. Nurse #3 stated she could not explain how that medication had been miscounted twice. On 2/07/24 at 8:30 AM the DON reviewed the Controlled Substance Count Record and Resident #56's MAR. She noted the 2/06/24 at 4:00 PM scheduled dose had been signed on the MAR by Nurse #2 but not the Controlled Substance Count Record. She stated she was unsure how the controlled medications could have been counted twice as correct when they were not. On 2/07/24 at 2:38 PM the DON stated it was their process for the on-coming and off-going nurses to count both the controlled substance blister pack cards and sign-off sheets to make sure the numbers match with both nurses looking at and verifying the medications as correct. She explained she would expect controlled substances to be signed out when they were administered.

Based on record review, staff interviews, Consultant Pharmacist interview, and Medical Director interview, the facility failed to address recommendations made by the Consultant Pharmacist based on the monthly Medication Regimen Review (MRR) for 1 of 5 residents reviewed for unnecessary medications (Resident #5). The findings included: The hospital discharge summary dated 10/05/23 revealed Resident #5 was discharged with an order for trazodone (an antidepressant medication) 50 milligram (mg) tablet take 0.5 tablet (25 mg) by mouth nightly for 30 days. Resident #5 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and anxiety. An active physician order entered by Nurse #1 and dated 10/06/23 for trazodone oral tablet 50 mg. Give 1/2 tablet by mouth one time a day for depression; give 25 mg by mouth nightly for depression. The physician order did not have a stop date. A telephone interview was conducted on 2/07/24 at 10:24 am with Nurse #1 who revealed she did not recall entering the trazodone order for Resident #5, but she thought all medication orders were checked by nursing management after admission and would have expected the error to be corrected if needed. Nurse #1was unable to state why the trazodone order was not transcribed correctly for Resident #5. Record review of Resident #5's Consultant Pharmacist's Medication Regimen Review (MMR) dated 10/24/23 revealed the Consultant Pharmacist reported the trazodone was transcribed incorrectly without a stop date. Please correct/clarify. Record review of Resident #5's electronic medication administration records (MAR) revealed Resident #5 received the trazodone medication nightly from 10/06/23 through 2/06/24. An interview was conducted on 2/07/24 at 11:43 am with the Director of Nursing (DON) who revealed the previous Unit Manager was responsible for the Consultant Pharmacist recommendations for Resident #5 to be reviewed and addressed as needed. The DON stated she did not request the MMRs to be returned to her when completed, and she did not check with the previous Unit Manager to ensure the Consultant Pharmacist MMR was addressed. The DON stated she was not aware that the MMR was not addressed prior to this date. The DON stated new admission medication reviews were completed in the morning clinical meeting but that did not include matching the hospital discharge orders to the entered orders for accuracy in transcription. The DON was unable to state how the Consultant Pharmacist recommendation for Resident #5's trazodone was missed for so long. The previous Unit Manager was unavailable for a telephone interview on 2/07/24. A telephone interview was conducted on 2/08/24 at 9:02 am with the Medical Director who revealed she normally reviewed the hospital discharge orders when she confirmed and signed the orders entered by the facility, but she was unable to state how she missed the trazodone order discrepancy from the discharge summary. The Medical Director stated she was not concerned that Resident #5 continued with the trazodone medication, but she stated she did not receive the Consultant Pharmacist recommendation from the facility to review for Resident #5's trazodone medication. An interview was conducted with the Administrator on 2/07/24 at 2:42 pm who confirmed she received an email from the Consultant Pharmacist regarding the Medication Regimen Reviews for the facility, but she stated the DON was responsible for the Consultant Pharmacist recommendations. The Administrator was unable to state how the MMR for Resident #5's trazodone order was missed. A telephone interview was conducted on 2/08/24 at 9:09 am with the Consultant Pharmacist who revealed the normal process for the Medication Regimen Review was to send the report via email to the DON and the Administrator of the facility as well as to send a copy in the pharmacy delivery tote to be reviewed and addressed as needed. The Consultant Pharmacist stated they would try to review the previous MMR during the next visit to see if recommendations were acted upon by the facility.

Based on record review, staff interview, Physician Assistant interview, Physician interview, and hospice staff interviews the facility failed to communicate effectively to ensure comprehensive assessment and care were provided to address bruising to Resident #2's right hip and thigh that was first identified on 5/21/23 by Nursing Assistant (NA) #1 and Nurse #3 two days following a fall (5/19/23). The facility continued to transfer the resident via stand pivot method with weight being placed on the right leg and on 5/30/23 NA #3 noted the resident's right leg was in an awkward position and he straightened it. The resident was admitted to the hospital on 5/31/23 with a comminuted and angulated hip fracture (a comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other) and significant bruising from the right hip to thigh. This was for one (Resident # 2) of seven residents reviewed for care following falls and injuries. The findings included: Resident #2 was admitted to the facility on [DATE]. The resident's diagnoses, in part, included supranuclear palsy (a progressive neurogenerative disease), stroke, polyneuropathy, dementia, aphasia (the loss of ability to comprehend and express speech due to brain damage), and ataxia (poor muscle control causing problems with balance and walking). Resident #2's significant change Minimum Data Set assessment, dated 3/7/23, coded the resident as moderately cognitively impaired and as needing extensive assistance with transfers and hygiene needs. She was not assessed to be ambulatory. The resident also was assessed to have a history of falls with major injury on the assessment. The resident was not on an anticoagulant. Resident #2's care plan, updated on 5/19/23, noted the resident had a history of falls with fracture. The care plan included multiple interventions which included but were not limited to keeping a fall mat by the resident's bed and encouraging her to be out of her room. On 5/19/23 at 7:24 PM Nurse #1 noted the following in Resident #2's record within a nursing note. The resident had been observed on the floor, was assessed for injuries with no apparent injuries found. Range of motion was performed on all extremities. A voice mail was left for the physician. Review of Nurse #1's statement, which was in the facility's investigative file, indicated she assessed Resident #2 following the 5/19/23 fall and the resident was able to move all her extremities without pain. She had removed the resident's clothes, examined her skin, and found no bruising on 5/19/23. Nurse #1 was interviewed on 6/29/23 at 2:30 PM and reported the following. Resident #2 had been at the nursing station when she fell on [DATE]. No one had seen the resident fall, and she was called to assess the resident and found no signs of injury. The resident was transferred to the bed after the fall by pivoting her, and the resident transferred without any problems. She removed her clothes and did not find any bruises or injury. Following the date of 5/19/23 no one had mentioned to her that Resident #2 had a bruise on the days on which she cared for her. During an interview on 6/27/23 at 3:00 PM the Administrator and Corporate Nurse Consultant were interviewed and reported there was an investigative file for Resident #2 related to a bruise which was first observed on 5/21/23 and assessed by Nurse #3. The facility presented an investigative file which included staff member's statements. NA #1 was interviewed on 6/29/23 at 6:55 AM and reported the following. She had worked a double shift beginning on 5/20/23 on second shift and lasting until 5/21/23 at the end of third shift. The resident had no bruising during her check up until 6:00 AM. At that time, she saw a discolored, round reddish area on the right side of her leg. The resident did not complain of pain. She told Nurse #3. Review of Nurse #3's statement, which was in the facility's investigative file, revealed on 5/21/23 the resident's NA (NA #1) had told him about the bruise. He assessed the bruise, found it to be dark red on her right thigh, and larger than his hand. Nurse #3 was interviewed on 6/27/23 at 4:50 PM and reported the following. It was close to the end of the shift when NA #1 reported a bruise on Resident #2's right thigh on 5/21/23. He assessed it, found it to be on the anterior part of her thigh and to be a large bruise. He thought it was related to her fall on 5/19/23. It was the first time he had seen it. Resident #2 was moving her legs and did not seem to be in pain. He took her vital signs to make sure it was not related to a bleeding problem and felt it should be something that should be monitored but did not tell the physician. The resident's vital signs were stable. The resident could not answer any questions related to the bruise. The facility's investigational summary indicated the following information for 5/22/23: - NA #6 observed a dark purple bruise to Resident's right hip during care and reported it to the nurse. He provided her incontinent care and transferred the resident via stand pivot. Resident #2 did now show signs of pain and her legs were straight. NA #6 was interviewed on 6/28/23 at 1:53 PM and reported the following. The resident seemed to bear weight on 5/22/23 when he transferred her. He did recall that he had talked to a nurse about the bruise. According to the staffing schedule, NA #1 cared for Resident #2 again on 5/22/23 and 5/23/23. During the interview with NA # 1 on 6/29/23 at 6:55 AM NA # 1 reported during the times she cared for her, the resident liked to stretch out her leg and did not keep her leg in an awkward position. NA # 2 did not recall working with Resident # 2 following 5/23/23. On 5/23/23 at 6:49 AM Nurse #2 noted in a nursing note that Resident #2 had a bruise to right hip/thigh. There was no notation of further assessment or that the physician was updated. On 5/23/23 Resident #2 was seen by her physician who noted the following. Patient noted to have a change in mental status. Patient is awake and alert and sitting up in wheelchair however appears glazed and withdrawn. Patient is less talkative and not reaching for things. She was unable to fully participate with OT [occupational therapy]. No acutes signs of pain to her arms and legs on passive range of motion. The physician further noted that she would order labs for the resident. The facility's investigational summary indicated the following information for 5/24/23: - The resident was observed by the Physician Assistant (PA) at nursing station. Resident appeared lethargic and was leaning to the side. Resident was looking at PA but did not talk as she normally did. - NA #7 noted at 11:00 PM resident was observed in bed awake with bruising noted to her right hip. She was unable to remember the color but remembered it was significant. There were no signs of pain. The bruise was reported to a nurse. On 5/24/23 at 12:23 PM the Administrator made a notation in the progress notes that she had spoken to Resident #2's responsible party and he was interested in pursuing hospice services for Resident #2. On 5/25/23 at 6:33 PM the Administrator made a notation in the record in the progress notes that Resident #2 had been admitted to hospice services for cerebrovascular disease. On 5/26/23 at 6:52 AM Nurse #2 made a notation within a nursing note that Resident #2 had a right thigh/hip bruise. There was no notation of further assessment or that the physician was updated. The facility's investigational summary indicated the following information for 5/26/23. NA #6 observed bruise that was light purple with yellow on the front and darker purple towards the side. The bruise was similar in size as noted by NA on 5/22/23. Bruising again was reported to the nurse. During an interview with NA #6 on 6/28/23 at 1:53 PM he indicated he cared for Resident #2 on 5/26/23 and on that day she had a fever, and he was concerned about the bruise as well. Therefore, he did not get her up on 5/26/23. Her leg was straight, and he took care to push a brief up under her rather than turning her completely from side to side. The facility's investigational summary indicated the following information for 5/27/23 indicated NA #8 observed the bruise to Resident #2's right leg. Resident did not get out of the bed and was not eating like usual self. Resident #2's roommate informed NA # 8 that the resident had fallen. She indicated Resident #2's right leg seemed more bent and the left leg was straight. NA # 8 asked the resident if she was in pain and the resident did not respond. She indicated the resident did not move around in bed as usual. NA #8 had not reported the bruising or other changes due to being told the resident had fallen previously. On 5/27/23 an admission Hospice Nurse electronically signed an admission assessment for Resident #2 for a start of service date on 5/25/23. The Hospice Nurse noted the following. The resident was lethargic. Not oriented to person place, time, or situation. Aphasic. Makes eye contact at times but mostly stares into the distance. Right at the end of the visit she let out an audible, unintelligible sound. The Hospice Nurse further documented, Patient's right thigh, anterior and lateral are coved in black and blue bruises. The lateral portion of thigh/hip swelling about 1/3 the size of her left thigh. No interventions. No pain, anxiety or shortness of breath on exam. The Hospice Nurse noted the resident should be non-weight bearing on the hospice care plan. The Hospice Nurse, who had signed the admission hospice assessment on 5/27/23 was interviewed on 6/29/23 at 2:45 PM and reported the following. During her admission assessment, Resident #2 was in bed. Resident #2's right hip was swollen and 1/3 size larger than her left hip. She had a black and blue bruise which was on her hip, anterior thigh, and lateral thigh. She was not exhibiting pain or anxiety. She had reviewed the record and saw that Resident #2 had been seen by her facility physician with no further work up by the physician. She interpreted that to be that there was to be none since the resident was hospice. She had talked to Nurse #4 while in the facility. The facility's investigational summary indicated the following information for 5/28/23, 5/29/23, and 5/30/23: - 5/28/23: The NA noted a bruise on Resident #2's right thigh that was purple with yellowish colors. She did not report the bruise as she thought if most like came from a fall. - 5/29/23: An NA indicated a bruise was noted on Resident #2's right leg from her hip to her knee. Her right leg was bent with her knee towards the left side of the bed. There were no complaints of pain. - 5/30/23: At approximately 8:00 AM, NA #3 noted the resident's right leg was turned and bent with dark purple bruising from her hip to her thigh. NA #3 indicated he reported to the nurse who responded that the resident had fallen previously, and it probably took a while for the bruising to come up. NA #3 slowly straightened Resident #2's leg and then proceeded to provide bathing, incontinent care, and dressing. He then transferred Resident #2 via stand pivot transfer. The resident was noted to favor the right leg and she was leaning more to the left. Once seated in the wheelchair, NA #3 noted her right leg did not seem as if it was turned like it was before. There were no signs or symptoms of pain. - 5/30/23: At approximately 11:30 AM the Hospice NA took the resident to her room to lay her down. She positioned the chair next to the bed and then picked the resident up to move her to the bed. The Hospice NA indicated Resident #2 was able to bear some weight but stated she basically lifted the resident. The resident did not show any signs or symptoms of pain when transferred. Once in bed the Hospice NA noticed Resident #2's right leg was turned in and bent and her left leg was straight. She indicated she asked facility about Resident #2's leg and was informed by staff that she had fallen several days ago. Review of the facility's investigative file revealed NA #3 had been assigned to care for Resident #2 on the 7:00 AM to 3:00 PM shift on 5/30/23. The following information appeared in NA #3's statement. When he was bathing and dressing the resident, her right leg was turned and bent. There was dark purple bruising from her hip to her thigh. He told Resident #2's nurse who in turn told him Resident #2 had fallen and it probably took a while for the bruising to come up. He then slowly straightened Resident #2's leg and proceeded with care. When he transferred her to the chair, she seemed to be favoring her right leg and leaning more to her left. He took her to the nursing station to sit and later that morning noticed she was leaning forward in her wheelchair. The hospice NA came and placed her in the bed. NA #3 was interviewed on 6/28/23 at 2:35 PM and reported the following. When he first cared for her on the morning of 5/30/23, her right leg seemed to be in an awkward position when compared to the left. He took precautions and straightened it. It did not seem to cause her pain. When he pivoted her to the wheelchair, she seemed to put more weight on her left leg than her right leg. After she was in the wheelchair, he noticed she was leaning forward and that was the first day he had noted her to do that. Later a hospice NA came and put her in bed. He had talked to the nurse on the hall about her leg being in an awkward position, and he felt sure the nurse had checked her. Review of the facility's investigative file revealed a statement from the Hospice NA who had cared for Resident #2 on 5/30/23. The statement read, On 5/30/23 I got to the facility around 10:30 AM. [Resident #2] was sitting at the nurse's station bent over with her eyes open. I asked [NA #2] about her care and whether she always leaned like that. She told me that [Resident #2] was a pivot transfer and that she did not always lean like that. The hospice nurse was also at the nurse's station at this time and did not say anything about her care. I asked if I should leave her there or lay her down. I took her to the room to lay her down. I positioned her chair next to the bed and then picked her up to move her to the bed. (Resident #2) was able to bear some weight, but I basically lifted her. [Resident #2] did not show any signs and symptoms of pain when I transferred her. I then held her and lifted her legs into the bed while turning her. I noticed her right leg was turned in and bent and her left leg was straight. I went and got [NA#3] to help pull her up in bed. When we got her pants off, I saw a bruise on her right leg from her hip to her knee. I asked [NA # 3] about her leg and he told me that she had fallen several days ago. The Hospice NA was interviewed on 6/28/23 at 12:12 PM and reported the following. When she arrived, she found Resident #2 in her wheelchair, and she was leaning forward so that her head was facing downward. When she transferred Resident #2 on 5/30/23 she (the NA) did about 80% of the work. The resident did not bear all her weight. When she got Resident #2 back in bed, she noticed her leg was bent. It was bent so that the knee was inward, and the bottom of her leg was outward. The bruise covered her hip and most of her upper thigh. She did not tell the facility nurse or the Hospice Nurse because NA #3 already knew about it. The facility's investigational summary indicated the following information for 5/31/23: - At approximately 11:00 AM the NA reported to the hall nurse that Resident #2 had a change in condition. While providing care it was noted by NA that Resident #2 had bruising to her right hip and thigh and signs of pain to right hip. The nurse assessed the resident. The nurse observed purple bruising to the right hip and right thigh. Bruising showed signs of fading. Resident #2 was noted with facial grimacing and furrowing of eyebrows indicating pain. This nurse noted internal rotation of right hip. The PA was in the facility and was notified by the nurse to assess the resident. - The PA noted Resident #2 had progressive decline which included change in mental status, increased lethargy, and overall withdrawal. She was less engaged, not verbally responding to questions and had decreased oral intake. She was noted with moderate soft tissue swelling with significant bruising noted lateral aspect right thigh. The right leg was in an angulated position. Attempted to gently straighten leg and Resident #2 demonstrated discomfort by wincing. When questioned about pain there was no verbal response. On 5/31/23 the Physician Assistant saw Resident #2 and noted the following. Patient with significant swelling and bruising right hip history of fall on 5/19/23. She is wheelchair dependent, non-ambulatory patient seen lying in bed with right leg angulation highly suspicious for right hip fracture, stat x-ray of right hip was ordered however due to time delay in obtaining imaging decision was made to transfer to (hospital) for further evaluation. The Physician Assistant (PA) was interviewed on 6/28/23 at 1:20 PM and reported the following. She was at the facility every Wednesday and the physician was at the facility every Tuesday and Friday. She had not been told of a bruise before 5/31/23. When she had been in the facility on the previous Wednesday (5/24/23), Resident #2 just looked tired. The physician had seen her the previous day on 5/23/23 and they thought something metabolic might be occurring. Labs had been ordered. She was declining and placed on hospice that week. On Wednesday (5/31/23) she was in route to the facility when she received a call that the resident's hip looked awkward. She ordered an x-ray while in route. When she arrived, she assessed Resident #2 and found that while at rest, Resident #2 appeared comfortable. With range of motion, she winced. The hip appeared angulated. The exact time the x-ray was to be completed could not be estimated, and therefore she talked to hospice and the decision to send her to the hospital was made. She knew Resident #2 had fallen on 5/19/23 and no injury had been identified on that date, but felt something might have happened on 5/19/23 that progressed with time. A review of hospital records for the date of 5/31/23 included a digital photograph of Resident #2's hip and thigh which had become part of her hospital medical record. Review of the medical record photograph revealed the right hip was a yellowish color and the anterior thigh down to the knee was predominantly a dark purplish color. The hospital physician noted Resident #2 had significant bruising in multiple stages of healing and internal rotation of right hip. An x-ray was completed showing a comminuted and severely angulated fracture of the right hip. (A comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other). Hospice services were continued for the resident, and she did not undergo surgery. According to the facility's schedules, following the time Resident #2's bruise had been found on 5/21/23, Nurse #2 had cared for Resident #2 on 5/21/23, 5/22/23. 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, and 5/30/23. Nurse #2 was interviewed on 6/28/23 at 6:44 AM and reported the following. She recalled another nurse telling her about the bruise and that the resident had fallen before it was found. She did not talk to the physician about the bruise because she thought a facility manager already knew about the bruise. She never saw that Resident #2's leg was deformed. The resident never appeared in pain when she cared for her, and her legs appeared symmetrical. When she had looked at the bruise, there was never any indication the resident's leg was fractured. Review of Nurse #1's statement revealed the following. She worked with Resident #2 on 5/22/23, 5/28/23, and 5/29/23. Nurse #1 was interviewed on 6/29/23 at 2:30 PM and reported no one had mentioned to her that Resident #2 had a bruise on the days on which she cared for her (5/22/23, 5/28/23, 5/29/23). According to schedule sheets, NA #2 had cared for Resident #2 on 5/20/23, 5/23/23, 5/25/23 and 5/29/23 on the 7:00 AM to 3:00 PM shift. NA #2 was interviewed on 6/28/23 at 10:45 AM and reported the following. She thought it was around the time she was assigned to care for Resident #2 on 5/23/23 that the resident had a big, dark, blue bruise. It covered most of the top of her thigh. She asked another NA about the bruise, and they told her Resident #2 had fallen. She did not talk to a nurse about it. Resident #2 moved her leg okay, and she could stand and pivot the same as she usually did. She did not seem to be in pain, and the bruise was the only thing that seemed different about her. According to schedule sheets, Nurse #4 had cared for Resident #2 on 5/25/23, 5/26/23, 5/30/23, and 5/31/23. A review of the facility's investigative file revealed a statement from Nurse #4 which noted the following information. A hospice nurse had not talked to her about Resident #2's bruise. She had never been told in report about a bruise or a fall. She had read in the resident's record about a fall. On 5/30/23 an NA told her Resident #2 had a bruise and she told him it was probably due to the fall. She did not assess the bruise that day. On 5/31/23 two NAs came to her and reported Resident #2's hip looked swollen and as if it was out of socket. She reported this to the physician and the Director of Nursing. Nurse #4 was interviewed on 6/27/23 at 4:00 PM and again on 6/29/23 at 1:45 PM. Nurse #4 reported the following. The only way she knew about the fall was because she had read the resident's record. When the NA told her on 5/30/23 she did not recall him saying anything about the resident's leg being bent. If he had done so, she would have told the Director of Nursing (DON) right away. It had also not been reported to her that Resident #2 was leaning in her wheelchair before they laid her back down on 5/30/23. She had been busy and not seen that herself. On 5/31/23 she was called into the room by a NA and Resident #2's hip looked like it was out of place. She immediately let the DON know and the Physician Assistant came in to look at her. She did not seem to be in a lot of pain. Interview with the Director of Nursing on 6/30/23 at 12:46 PM revealed none of her staff had reported Resident #2's bruise to her before the morning of 5/31/23. Resident #2's physician was interviewed on 6/29/23 at 4:00 PM and reported the following. Typically, Resident #2 could transfer with assistance, but she was non-ambulatory. She had some unusual spontaneous movements due to her neurological disease, but her legs were normally straight. On Tuesday (5/23/23) she had seen Resident #2 because therapy had said she was not acting like herself. The resident was very out of it and was not reaching for things. She saw her at the nursing station. She was able to move her wheelchair. She (the physician) was aware Resident #2 had fallen and checked her range of motion. The resident did not wince with range of motion. She had not been told anything about a bruise. If she had been notified of this, then she would have taken Resident #2 back to her room, laid her down, and examined the bruise. On 5/23/23 Resident #2 was not hospice yet, and she probably would have ordered an x-ray on that day also. Since she was not acting herself, she decided to order labs. Later, the resident became hospice because she had a long history of progressively declining. On 5/26/23 (the Friday she was routinely in the facility) she did not see Resident #2. The plan at that point was not to be aggressive with the resident's care. She had not been told anything about the bruise before 5/31/23. She had never known that hospice had recommended she be non-weight bearing. They did not get paperwork from hospice until after Resident #2 was discharged from the facility. Interview with the Administrator on 6/30/23 at 11:40 AM revealed the facility received nothing from hospice related to their concern about Resident #2's hip or the hospice nurse's admission assessment until after Resident #2 was discharged from them. On 6/30/23 at 1:30 PM the facility Administrator was informed of immediate jeopardy. The Administrator presented a corrective action plan. - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 is alert to self. A Brief Interview for Mental Status (BIMS) score could not be obtained due to cognition. Diagnoses include but not limited to Progressive Supranuclear Ophthalmoplegia (unable to move eyes at will in all directions), history of Cerebral Infarction (stroke) affecting right side, Glaucoma (increased pressure behind the eyes), Convulsions (seizures), aphasia (difficulty communicating), Dysphagia (difficulty swallowing), Major Depressive Disorder, Dementia with behaviors, Abnormalities of gait and mobility (difficulty walking), history of repeated falls, Nontraumatic subarachnoid hemorrhage (bleeding on the brain not caused by injury), polyneuropathy (muscle and nerve pain), ataxia, (impaired balance), Fibromyalgia (muscle pain), displaced simple history of fracture of bone between hip and knee, history of fracture of nasal bones, Age-related Osteoporosis (weakening of bones) and Osteopenia (softening of the bones), Adult Failure to Thrive. On 5/19/23 at 1:20 pm, staff observed the resident on the floor. The nurse assessed the resident for injuries, and the resident could move all extremities with no apparent pain. After the resident was transferred to the chair, the nurse completed a head-to-toe assessment with no bruising noted. The nurse attempted to notify the on-call physician and left a voicemail. The nurse notified the resident representative of the fall. On 5/21/23 at 6:00 am, the Nursing Assistant (NA) observed a large bruise on the top inner thigh and notified the nurse. The nurse assessed the resident and noted a dark red bruise on the right thigh, larger than a hand. The physician was not notified of the newly identified bruise. On 5/23/23, the resident was seen by the physician for a change in mentation. The provider notes the resident was observed sitting up in a wheelchair by the nursing station with (1) No acute injuries noted from the fall on 5/19/23, (2) No signs of pain or discomfort, (3) No wincing on exam of arms, and legs (4) Resident manipulated wheelchair backward using both feet without complaints of pain (5) Cooperative, Frail, in no apparent distress, sitting up in a wheelchair, awake and alert, not speaking, appears withdrawn. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urine/urine culture were ordered. On 5/25/23 the provider started an antibiotic for a possible urinary tract infection (UTI). On 5/25/23 at 6:33 pm, the resident was admitted to hospice services with a visit by the hospice nurse. From 5/21/23-5/30/23, multiple facility staff observed bruising to the resident's right thigh. Staff had not reported the bruising to the physician. However, the resident exhibited no complaints of pain or swelling during care nor stand and pivot transfers. On 5/31/23 at approximately 11:00 am, the NA reported to the hall nurse that the resident had bruising to the right hip and thigh and signs of pain to the right hip while providing care. The nurse assessed the resident and observed fading purple bruising to the right hip and thigh with internal rotation. The resident was noted with facial grimacing and furrowing of eyebrows indicating pain. The nurse notified the provider. The provider assessed the resident and ordered a STAT (immediately) x-ray. On 5/31/23 at 2:45 pm, the resident was transferred to the hospital by emergency services due to the length of time to obtain an in-house x-ray. The resident was admitted to the hospital with a diagnosis of a right femur fracture. The Administrator initiated an investigation for injury of unknown origin to include notification of police, Adult Protective Services (APS), and state reporting per facility protocol. - Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 5/31/23, the Unit Manager completed a 100% skin audit of residents to identify all residents with signs and symptoms of a fracture, new bruising, pain, and/or deformity of extremities. There were no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers completed an audit of all residents to determine if the resident was experiencing a change in condition, with no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers reviewed progress notes for the past 14 days to determine if a resident exhibited a change in condition, including signs/symptoms of a fracture, pain, or bruising, and ensure the practitioner was notified timely. The Director of Nursing will address all areas of concern identified during the audit, including the physician's notification for further instruction. The audit was completed by 6/8/23. On 6/6/23, the Administrator, Medical Director and Director of Nursing reviewed with the Hospice Director all residents currently receiving hospice services to identify any concerns or changes in condition that had not been previously addressed. No additional concerns were identified. - Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/6/23, the Administrator, Medical Director and Director of Nursing met with Hospice Director regarding communication and timely reporting of resident acute changes. Beginning 6/7/23, all Hospice personnel will exit with the Unit Manager, Director of Nursing and/or Administrator following each visit to the facility to provide an update for any concerns or resident changes in condition. On 6/2/23, An in-service was initiated by the administrative nurses to include the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC), and Unit Managers with all nurses regarding (1) Notification of Changes with emphasis on (a) a prompt complete assessment of a resident's slight or subtle changes with physician notification will ensure adequate management of the resident's acute illness or exacerbation of a chronic illness. (b) notification of physician with any change in resident condition to include but not limited to new bruising, pain, and deformity of extremity after a fall with documentation in the electronic record (2) Signs and Symptoms of a Fracture with emphasis on signs and symptoms of a fracture to include but not limited bruising, swelling over a bone or pain, assessment of the resident, and immediate notification of the physician with documentation in the electronic record. In-services will be completed by 6/8/23. After 6/8/23, any nurse who has not worked or received the in-service will receive it prior to the next scheduled work shift. All newly hired nurses will be in-service during orientation regarding Notification of Changes, and Signs and Symptoms of a fracture. - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Monitoring actions began on 5/31/23. 15 residents' charts, including charts of residents with recent falls, new or worsening bruising and residents receiving hospice services will be reviewed by the Unit Managers weekly x 4 weeks, then monthly x 1 month utilizing the Notification Audit Tool. This audit is to ensure the physician was notified of changes in condition and changes related to new bruising, pain, and deformity of extremities for further recommendations and to ensure the coordination of care with hospice services. The Unit Managers will address all

Based on record review, review of manufacturer's instructions, and staff interviews, the facility failed to ensure securement was according to manufacturer's recommendations to provide a safe van transport. Resident #50 slid out of a reclined high back wheelchair into a seated position on the floor of the van with his legs extended in front of him and the seatbelt was above his head. Resident #50 alerted the transportation driver he had fallen. The transportation driver stopped the van in the center turning lane of a well-traveled road in the afternoon with the hazard lights on and lifted the Resident back into the high back wheelchair in a bear hug motion. The transportation driver proceeded to take Resident #50 to his appointment, failing to report the incident to the facility. Resident #50 was not assessed for injuries from the incident until later in the day; Resident #50 complained of a bruise to the right under arm, a left forearm bruise, and right ankle pain. This was for 1 of 11 residents reviewed for supervision to prevent accidents. This incident had the high likelihood of serious harm, injury or death. Findings included: Review of 4-point wheelchair securement system's use and care manual not dated found on the manufacture's website included the following information: ensure shoulder and lap belts are adjusted as firmly as possible, but consistent with user comfort. Resident #50 was admitted to the facility on [DATE] with cumulative diagnoses that included stroke and peripheral vascular disease (PVD). Review of physician orders revealed that 50 milligrams (mg) of Tramadol HCl powder every 6 hours as needed for pain was ordered on 2/3/23. Review of physician orders revealed that 650 mg of Tylenol three times daily as needed for pain was ordered on 2/7/23. Resident #50's admission Minimum Data Set (MDS) dated [DATE] indicated he was moderately cognitively impaired. Resident #50 required the assistance of two staff members with transfers and was unable to walk. He had a wheelchair for mobility. Review of an incident report dated 3/2/23 and completed by the Unit Manager revealed that on 3/2/23 the transportation driver stated Resident #50 slid out of the wheelchair on the transportation van during transport to an outside appointment. The report indicated a complete body assessment was performed on Resident #50 with no injuries noted, and he was provided pain medicine. A skin inspection dated 3/2/23 was reviewed and revealed Resident #50 included, in part, the following new skin conditions: a bruise to the right under arm, a left forearm bruise, and right ankle pain. Nurse's progress note written by the Unit Manager dated 3/2/23 at 3:27 PM showed Resident #50 complained of right leg pain. The Medical Director (MD) was notified and ordered immediate x-rays. As needed pain medication was provided to Resident #50. Review of Resident #50's Medication Administration Records (MAR) for March 2023 showed he received Tylenol 650 milligrams (mg) ordered for severe pain on 3/2/23 at 8:00 PM for a pain level of 3 on a 0-10 pain scale where 0 is no pain and 10 is the highest pain level. Resident #50 also received tramadol on 3/2/23 for a pain level of 2 on a 0-10 pain scale. On 3/3/23, Resident #50 received Tylenol at 8:00 AM for a pain level of 3 and received tramadol on 3/3/23 for a pain level of 4. Nurse's progress note written by the Unit Manager dated 3/2/23 at 5:30 PM revealed the mobile x-ray company was contacted. Nurse's progress note written by the Unit Manager dated 3/2/23 at 5:46 PM showed Resident #50 refused to go to the emergency room (ER) for evaluation. An interview was conducted with the Unit Manager on 7/5/23 at 11:47 AM. She revealed Resident #50 went out for a scheduled appointment on 3/2/23, and when he returned to the facility, he told another staff member (name unknown) that he had slid out of his wheelchair in the van. The Unit Manager stated she then notified the Administrator and performed a skin assessment with no visible injuries. She notified the MD as well who had requested for him to be sent to hospital, but he refused. Resident #50 denied any pain or discomfort and appeared nervous after the incident. Physician order dated 3/2/23 showed x-rays were ordered for the left/right hips, left thigh, right/left knees, and left/right lower legs. Review of the x-ray results for the pelvis (both hips) dated 3/2/23 showed Resident #50 had no acute fractures or dislocation. Review of the x-ray results for the right/left knees, left thigh, and right/left lower legs dated 3/3/23 showed Resident #50 had no acute fractures or dislocation. MD note dated 3/3/23 showed Resident #50 was evaluated by the MD after he slid out from the wheelchair while on the transportation van. Resident #50 had complained of left knee pain and was offered to go to the hospital, but he declined. X-rays were ordered and performed in the facility. The note indicated Resident #50 had a small bruise noted on the right side of his forehead and bruising to his leg (no indication of which side). An interview was attempted with the MD, but she was unavailable during the investigation. Review of an investigation summary report created by the Administrator dated 3/3/23 showed at 1:05 PM Resident #50's high back wheelchair was in a reclined position at approximately a 45-degree angle. The shoulder strap did not fit snug to the resident due to the wheelchair being reclined, and the transportation driver did not sit Resident #50 upright in the wheelchair. During transport at 1:30 PM, the transportation driver heard Resident #50 say I'm down. At 1:31 PM, the transportation driver stopped the van in the middle lane of a busy road and applied the hazard lights. Resident #50 was at the base of the footrests with his back against the front of the wheelchair and his legs extended out in front. The transportation driver lifted him back into his wheelchair and continued to the appointment destination. At 2:45 PM, the transportation driver returned to the facility, returned Resident #50 to his room, and did not notify anyone of the incident on the van. At 3:00 PM, the Administrator, previous Director of Nursing (DON), and the Unit Manager met with the resident and his family to discuss the appointment. Resident #50 told them he slid out of his wheelchair on the van during transport. He was assessed for injuries with none noted. The Administrator called the transportation driver immediately to return to the facility. A reenactment of the incident was performed to show exactly what had occurred. There were not any other witnesses. At 3:30 PM, the Administrator ceased all future transportation appointments for the day and utilized an outside transportation company for any further travel. At 4:30 PM, the transportation driver returned to the facility, was provided education on reporting of incidents, and was suspended pending the investigation. A witness statement given by the transportation driver on 3/2/23 showed that Resident #50 was in a reclined position during transport and remained in a reclined position during transport. A witness statement given by Nurse Aide (NA) #4 read on 3/2/23 at 11:30 AM Resident #50 was adjusted in a high back wheelchair to a slightly reclined position. At approximately 12:00 PM, he was picked up for transport. Resident #50 was discharged from the facility on 3/28/23 and unable to be reached for an interview. The transportation driver's witness statement dated 3/2/23 read: I was transporting Resident #50 to his medical appointment. He was in a high back wheelchair in a reclined position. The wheelchair remained in a reclined position during transport. The seatbelt was secured around Resident #50's waist with straps beneath the arm rest. Resident #50 reported the seat belt position was comfortable. He was secured at the base of the wheelchair. During transport, Resident #50 yelled out I'm down. I looked in the rear-view mirror. At that time, I was getting off highway 440. I stopped the van in the middle lane - hazards were applied. I went to the back of the van to see what was going on. Resident #50 was noted to have slid out of his wheelchair: his back was against the wheelchair and his bottom rested on the footrests. Both legs were extended out in front of his body. Resident #50 did not report he was in pain. I pulled him back up into the wheelchair. Once back in the wheelchair, I proceeded to take Resident #50 to his appointment, which was rescheduled. I returned him to the facility with still no reports of pain. The transportation driver could not be reached for an interview because a contact phone number was not available, and he no longer worked at the facility. An interview was conducted with NA #4 on 3/2/23 at 4:07 PM. She revealed that if Resident #50 sat up straight in the high back wheelchair, then he would slide out of the chair. On 3/2/23, NA #4 indicated that Resident #50 was just slightly reclined, not even halfway in his wheelchair prior to transport. An interview was conducted with Nurse #5 on 7/5/23 at 12:53 PM, who was assigned to Resident #50 on 3/2/23 from 7:00 AM - 7:00 PM; however, she could not recall the details of Resident #50 or the events on 3/2/23. An interview was conducted on 7/5/23 at 11:50 A.M. with the Nurse Consultant. During the interview, the Nurse Consultant indicated that although the investigation summary noted Resident #50 was reclined at a 45-degree angle during transport, he was in fact reclined only slightly (15 degrees at the most). An interview was conducted on 7/5/23 at 4:33 PM. During the interview, the Administrator indicated the transportation driver could have secured Resident #50 more safely and should have reported the incident to management immediately. Resident #50 told her on 3/2/23 that he had a seat belt on and slid from the wheelchair to the footrest of the wheelchair. No injuries were noted, and immediate x-rays were performed immediately following the incident with no injuries noted. Resident #50 declined to go to the hospital for evaluation. He told the Administrator that the transportation driver stopped the van and assisted the resident back into the wheelchair then continued to the scheduled appointment. On 7/5/2023 at 4:15 P.M., the facility's Administrator was informed of the immediate jeopardy. The facility provided the following corrective action plan with a completion date of 3/8/22: Resident #50 is alert and oriented with a Brief Interview of Mental Status (BIM) of 10. Diagnosis include Diabetes, hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (inflammation of the lungs that reduces air flow) , Ischemic Cardiomyopathy ( enlarged heart), history of heart attack, Anemia, Cerebral Infarction (stroke), Coronary Artery Disease (blockage of major blood vessels), Hyperlipidemia (high levels of lipids/fat in the blood), Peripheral Artery Disease (narrowing blood vessels that reduces blood flow), deep vein thrombosis (blood clot), Hemiplegia (paralysis) and hemiparesis (partial weakness) affecting left side, and Aneurysm (ruptured blood vessel). Per the driver's report, on 3/2/2023, at approximately 11:00 am, the transportation driver arrived at the facility to transport resident to a medical appointment. The transportation driver lowered and secured the wheelchair ramp onto the ground. The transportation driver entered the facility and assisted Resident #50 by high back wheelchair onto the van wheelchair lift. The high back wheelchair was in a reclined position. The driver backed the wheelchair and resident onto the lift and into the van. The transportation driver secured the wheelchair/resident in the van by locking the brakes and placing/tightening the back-floor straps around the frame of the wheelchair on the back right and sides. The transportation driver then secured the front floor straps around the front frame of the wheelchair and tightened the straps. The transportation driver then placed the seat belt with the shoulder strap hooked to the lap belt through the arms of the wheelchair and fastened it around the resident waist. The shoulder strap did not fit snugly to the resident due to the wheelchair being reclined. The transportation driver did not sit the resident upright in the chair. At approximately 1:30 pm, the transportation driver heard the resident yell, I'm down. At 1:31 pm, the transportation driver stopped the van in the center turning lane of a well-traveled roadway with his hazard lights on. Upon entering the back of the van, the resident was positioned at the base of the footrests, with the resident's back against the front of the wheelchair, the resident's bottom was positioned on the leg rests, and the resident legs were extended in front of the resident. The seatbelt was positioned at the top of the resident's head. The transportation driver unbuckled the seatbelt and placed the resident back in the wheelchair. The resident denied pain or injury and was transported to the appointment. On 3/2/23, during a discussion with the resident, resident representative, Administrator, and Registered Nurse (RN) Unit Manager, Resident #50 reported he slid out of a wheelchair while being transported in the van. The Administrator immediately initiated an investigation. The Director of Nursing (DON) and Unit Manager assessed the resident with no identified concerns. The resident declined to go to the emergency room for further evaluation. The Medical Director was notified of the incident on the van. On 3/2/23, the van driver was suspended by the Administrator pending investigation. On 3/2/23, at approximately 3:30pm, the facility Administrator stopped all resident wheelchair transport utilizing the facility's van. An alternate contracted van transport company was utilized until education and return demonstration could be completed with the facility van transport driver. On 3/2/23 a root cause analysis was completed to identify root cause for van driver not securing a snug fit of the shoulder strap per manufacturer guidelines and why he did not immediately report to the facility and call Emergency Management Services. The transportation driver was trained on securing a resident during transport, as well as what to do if resident had fall on van. Training was performed 12/3/21, which included stopping van, putting hazard lights on, not moving the resident, notifying Emergency Medical Services (EMS) and the facility. Resident #50 utilized a mechanical lift for transfers with the assistance of one. Resident #50 had therapy assessment completed on 2/3/23 that indicated resident was appropriate to transfer into upright wheelchair. On 3/2/23, the Social Worker (SW) initiated resident questionnaires with all alert and oriented residents regarding medical transport to include: Do you have any concerns related to medical transport? If yes, please explain. There were no additional concerns identified. On 3/2/23, The DON and Unit Manager completed an audit of all incident reports for the past 30 days. This audit was to identify any other incidents during medical transport. There were no additional identified areas of concern. On 3/2/23, the van including straps was inspected by the Maintenance Assistant with no identified concerns. - Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring. On 3/2/23, the Administrator completed an in-service with the van driver regarding prompt notification to the facility regarding van incidents, procedure for van incidents, proper positioning of resident on van, and securing residents on van. The transportation driver was the only driver employed by the facility at the time of the event. The sister facility transportation driver is responsible for training newly hired facility van drivers to include return demonstration. On 3/7/23, a sister facility transportation driver completed training with return demonstration with the facility's van transport driver, Unit Manager, Housekeeping Supervisor, and the Maintenance Assistant on how to properly secure a resident during medical transport. The manufacturer's video was utilized for reviewing the appropriate technique of securing resident for medical transport. This in-service also included emphasis on (1) never position the lap belt over the abdominal area, over the wheelchair armrests, through the wheelchair arm rests or with the belt assembly twisted and (2) ensuring wheelchairs are not reclined during transport. - The procedure for monitoring the plan of correction. Monitoring actions began on 3/2/23. The Director of Nursing, Unit Managers, and/or Administrator will complete an audit of 5 facility wheelchair medical transports weekly x 4 weeks to ensure resident is secured properly and safely in the van prior to transport. The Administrator and/or DON will address all concerns identified during the audit to include but not limited to immediately stopping all medical transport for any concerns identified. The Social Worker will complete 5 resident questionnaires weekly x 4 weeks utilizing the Resident Questionnaire Van Transport. This questionnaire is to identify any concerns related to van transport. The Administrator and/or DON will address all concerns identified during the questionnaires to include but not limited to immediately stopping all medical transport for any concerns identified. The Administrator will present the findings of the Resident Questionnaires Van Transport and Medical Transport Audits to the Quality Assurance Committee on 3/7/23 and monthly x 1 month. The Quality Assurance Committee will review the Resident Questionnaires Van Transport and Medical Transport Audits monthly x 1 months to determine trends and/or issues that may require further interventions put into place and to determine the need for further and/or frequency of monitoring. The Administrator and DON were responsible for the implementation of corrective actions to include all 100% audits, in-services and monitoring related to the plan of correction. Date of corrective action completion: 3/8/23. The facility's credible allegation of Immediate Jeopardy removal was validated on 7/5/23 and the corrective action plan was verified as completed on 3/8/23. The validation was evidenced by staff interviews, record reviews, and review of competency training logs. The interventions included verified training for the previous transportation driver with a certificate of completion for safe transport, continuous audit of the transportation driver's performance with weekly performance checklists, initial and continuous questionnaires for alert and oriented residents related to their transportation experience, and audits of incident reports within 30 days of the incident on 3/2/23.

Based on record review, staff interview, Physician Assistant interview, Physician interview, and hospice staff interview the facility failed to notify the physician of bruising to Resident #2's right hip and thigh that was identified on 5/21/23 by Nursing Assistant (NA) #1 and Nurse #3 two days following a fall (5/19/23). The bruising continued through 5/31/23 and was accompanied by swelling. On 5/31/23 the resident also showed signs of pain. On 5/31/23 the resident was admitted to the hospital with a comminuted and angulated hip fracture (a comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other) and significant bruising from the right hip to thigh hip fracture. This was for one (Resident # 2) of seven residents reviewed for physician notification following falls with injury. The findings included: Resident # 2 was admitted to the facility on [DATE]. Resident # 2's significant change Minimum Data Set assessment, dated 3/7/23, coded the resident as moderately cognitively impaired. On 5/19/23 at 7:24 PM Nurse #1 noted the following in Resident # 2's record. The resident had been observed on the floor, was assessed for injuries with no apparent injuries found. Range of motion was performed on all extremities. A voice mail was left for the physician. Nurse #1 was interviewed on 6/29/23 at 2:30 PM and reported the following. Resident #2 had been at the nursing station when she fell on [DATE]. No one had seen the resident fall, and she was called to assess the resident and found no signs of injury. The resident was transferred to the bed after the fall by pivoting her, and the resident transferred without any problems. She removed her clothes and did not find any bruises or injury. Following the date of 5/19/23 no one had mentioned to her that Resident #2 had a bruise on the days on which she cared for her. NA #1 was interviewed on 6/29/23 at 6:55 AM and reported the following. She had worked a double shift beginning on 5/20/23 on second shift and lasting until 5/21/23 at the end of third shift. The resident had no bruising during her check up until 6:00 AM. At that time, she saw a discolored, round reddish area on the right side of her leg. The resident did not complain of pain. She told Nurse #3. On 6/27/23 at 3:00 PM the Administrator and Corporate Nurse Consultant were interviewed and reported Resident # 2's bruise was first observed on 5/21/23 and assessed by Nurse #3. The facility presented an investigative file for Resident # 2's bruise and fracture, which included staff member's statements. Review of Nurse #3's statement, which was in the facility's investigative file, revealed on 5/21/23 the resident's NA (NA #1) had told him about the bruise. He assessed the bruise, found it to be dark red on her right thigh, and larger than his hand. Nurse #3 was interviewed on 6/27/23 at 4:50 PM and reported the following. It was close to the end of the shift when NA #1 reported a bruise on Resident #2's right thigh on 5/21/23. He assessed it, found it to be on the anterior part of her thigh and to be a large bruise. He thought it was related to her fall on 5/19/23. It was the first time he had seen it. Resident #2 was moving her legs and did not seem to be in pain. He took her vital signs to make sure it was not related to a bleeding problem and felt it should be something that should be monitored but did not tell the physician. The resident's vital signs were stable. The resident could not answer any questions related to the bruise. The facility's investigational summary indicated the following information for 5/22/23: - NA #6 observed a dark purple bruise to Resident's right hip during care and reported it to the nurse. He provided her incontinent care and transferred the resident via stand pivot. Resident #2 did now show signs of pain and her legs were straight. NA #6 was interviewed on 6/28/23 at 1:53 PM and reported the following. The resident seemed to bear weight on 5/22/23 when he transferred her. NA #6 recalled he talked to a nurse about the bruise. On 5/23/23 at 6:49 AM Nurse #2 noted in a nursing note that Resident #2 had a bruise to right hip/thigh. There was no notation of further assessment or that the physician was updated. On 5/23/23 Resident #2 was seen by her physician who noted the following. Patient noted to have a change in mental status. Patient is awake and alert and sitting up in wheelchair however appears glazed and withdrawn. Patient is less talkative and not reaching for things. She was unable to fully participate with OT [occupational therapy]. No acutes signs of pain to her arms and legs on passive range of motion. The physician further noted that she would order labs for the resident. The physician made no notation that she had been informed of a bruise to the resident's hip/thigh. The facility's investigational summary indicated the following information for 5/24/23 and 5/26/23: - 5/24/23: The resident was observed by the Physician Assistant (PA) at nursing station. Resident appeared lethargic and was leaning to the side. Resident was looking at PA but did not talk as she normally did. - 5/24/23: NA #7 noted at 11:00 PM resident was observed in bed awake with bruising noted to her right hip. She was unable to remember the color but remembered it was significant. There were no signs of pain. The bruise was reported to a nurse. - 5/26/23 indicated NA #6 observed bruise that was light purple with yellow on the front and darker purple towards the side. The bruise was similar in size as noted by NA on 5/22/23. Bruising again was reported to the nurse. On 5/26/23 at 6:52 AM Nurse #2 made a notation that Resident # 2 had a right thigh/hip bruise. There was no notation that the physician was updated. On 5/27/23 an admission Hospice Nurse electronically signed an admission assessment for Resident #2 for a start of service date on 5/25/23. The hospice nurse noted the following. Patient's right thigh, anterior and lateral are covered in black and blue bruises. The lateral portion of thigh/hip swelling about 1/3 the size of her left thigh. No interventions. No pain, anxiety or shortness of breath on exam. The hospice nurse noted the resident should be non-weight bearing on the hospice care plan. The facility's investigational summary indicated the following information for 5/28/23, 5/29/23, and 5/30/23: - 5/28/23: The NA noted a bruise on Resident #2's right thigh that was purple with yellowish colors. She did not report the bruise as she thought if most like came from a fall. - 5/29/23: An NA indicated a bruise was noted on Resident #2's right leg from her hip to her knee. Her right leg was bent with her knee towards the left side of the bed. There were no complaints of pain. - 5/30/23: At approximately 8:00 AM, NA #3 noted the resident's right leg was turned and bent with dark purple bruising from her hip to her thigh. NA #3 indicated he reported to the nurse who responded that the resident had fallen previously, and it probably took a while for the bruising to come up. NA #3 slowly straightened Resident #2's leg and then proceeded to provide bathing, incontinent care, and dressing. He then transferred Resident #2 via stand pivot transfer. The resident was noted to favor the right leg and she was leaning more to the left. Once seated in the wheelchair, NA #3 noted her right leg did not seem as if it was turned like it was before. There were no signs or symptoms of pain. - 5/30/23: At approximately 11:30 AM the Hospice NA took the resident to her room to lay her down. She positioned the chair next to the bed and then picked the resident up to move her to the bed. The Hospice NA indicated Resident #2 was able to bear some weight but stated she basically lifted the resident. The resident did not show any signs or symptoms of pain when transferred. Once in bed the Hospice NA noticed Resident #2's right leg was turned in and bent and her left leg was straight. She indicated she asked facility about Resident #2's leg and was informed by staff that she had fallen several days ago. NA #3 was interviewed on 6/28/23 at 2:35 PM and reported the following. When he first cared for her on the morning of 5/30/23, her right leg seemed to be in an awkward position when compared to the left. He took precautions and straightened it. It did not seem to cause her pain. When he pivoted her to the wheelchair, she seemed to put more weight on her left leg than her right leg. After she was in the wheelchair, he noticed she was leaning forward and that was the first day he had noted her to do that. Later a hospice NA came and put her in bed. He had talked to the nurse on the hall about her leg being bent. The Hospice NA was interviewed on 6/28/23 at 12:12 PM and reported the following. When she arrived, she found Resident #2 in her wheelchair, and she was leaning forward so that her head was facing downward. When she transferred Resident #2 on 5/30/23 she (the NA) did about 80% of the work. The resident did not bear all her weight. When she got Resident #2 back in bed, she noticed her leg was bent. It was bent so that the knee was inward, and the bottom of her leg was outward. The bruise covered her hip and most of her upper thigh. She did not tell the facility nurse or the Hospice Nurse because NA #3 already knew about it. The facility's investigational summary indicated the following information for 5/31/23: - At approximately 11:00 AM the NA reported to the hall nurse that Resident #2 had a change in condition. While providing care it was noted NA that Resident #2 had bruising to her right hip and thigh and signs of pain to right hip. The nurse assessed the resident. The nurse observed purple bruising to the right hip and right thigh. Bruising showed signs of fading. Resident #2 was noted with facial grimacing and furrowing of eyebrows indicating pain. This nurse noted internal rotation of right hip. The PA was in the facility and was notified by the nurse to assess the resident. - The PA noted Resident #2 had progressive decline which included change in mental status, increased lethargy, and overall withdrawal. She was less engaged, not verbally responding to questions and had decreased oral intake. She was noted with moderate soft tissue swelling with significant bruising noted lateral aspect right thigh. The right leg was in an angulated position. Attempted to gently straighten leg and Resident #2 demonstrated discomfort by wincing. When questioned about pain there was no verbal response. On 5/31/23 the Physician Assistant saw Resident #2 and noted the following. Patient with significant swelling and bruising right hip history of fall on 5/19/23. She is wheelchair dependent, non-ambulatory patient seen lying in bed with right leg angulation highly suspicious for right hip fracture, stat x-ray of right hip was ordered however due to time delay in obtaining imaging decision was made to transfer to (hospital) for further evaluation. A review of hospital records for the date of 5/31/23 included a digital photograph of Resident # 2's hip and thigh which had become part of her hospital medical record. Review of the medical record photograph revealed the right hip was a yellowish color and the anterior thigh down to the knee was predominantly a dark purplish color. The hospital physician noted Resident # 2 had significant bruising in multiple stages of healing and internal rotation of right hip. An x-ray was completed showing a comminuted and severely angulated fracture of the right hip. (A comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other). Hospice services were continued for the resident, and she did not undergo surgery. According to the facility's schedules, following the time Resident #2's bruise had been found on 5/21/23, Nurse #2 had cared for Resident #2 on 5/21/23, 5/22/23. 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, and 5/30/23. Nurse #2 was interviewed on 6/28/23 at 6:44 AM and reported the following. She recalled another nurse telling her about the bruise and that the resident had fallen before it was found. She did not talk to the physician about the bruise because she thought a facility manager already knew about the bruise. She never saw that Resident #2's leg was deformed. The resident never appeared in pain when she cared for her, and her legs appeared symmetrical. When she had looked at the bruise, there was never any indication the resident's leg was fractured. According to the schedule sheets, Nurse #4 had cared for Resident #2 on 5/25/23, 5/26/23, 5/30/23, an 5/31/23. Nurse #4 was interviewed on 6/27/23 at 4:00 PM and again on 6/29/23 at 1:45 PM. Nurse #4 reported the following. The only way she knew about Resident #2's fall was because she had read the resident's record. When the NA told her on 5/30/23 she did not recall him saying anything about the resident's leg being bent. If he had done so, she would have told the Director of Nursing (DON) right away. It had also not been reported to her that Resident #2 was leaning in her wheelchair before they laid her back down on 5/30/23. She had been busy and not seen that herself. On 5/31/23 she was called into the room by a NA and Resident #2's hip looked like it was out of place. She immediately let the DON know and the Physician Assistant came in to look at her. It was validated with Nurse # 4that she had not spoken to the Physician or the Physician Assistant prior to 5/31/23 about the bruise or the leg being bent. The Physician Assistant (PA) was interviewed on 6/28/23 at 1:20 PM and reported the following. She is at the facility every Wednesday and the physician is at the facility every Tuesday and Friday. She had not been told of a bruise before 5/31/23. When she had been in the facility on the previous Wednesday (5/24/23, Resident # 2 just looked tired. The physician had seen her the previous day on 5/23/23 and they thought something metabolic might be occurring. Labs had been ordered. She was declining and placed on hospice that week. On Wednesday (5/31/23) she was in route to the facility when she received a call that her hip looked awkward. She ordered an x-ray while in route. When she arrived, she assessed Resident # 2 and found that while at rest, Resident # 2 appeared comfortable. With range of motion, she winced. The hip appeared angulated. The exact time the x-ray was to be completed could not be estimated, and therefore she talked to hospice and the decision to send her to the hospital was made. She knew Resident # 2 had fallen on 5/19/23 and no injury had been identified on that date, but felt something might have happened on 5/19/23 that progressed with time. Resident # 2's physician was interviewed on 6/29/23 at 4:00 PM and reported the following. On Tuesday (5/23/23) she had seen Resident # 2 because therapy had said she was not acting like herself. The resident was very out of it and was not reaching for things. She saw her at the nursing station. She was able to move her wheelchair. She (the physician) was aware Resident # 2 had fallen and checked her range of motion. The resident did not wince with range of motion. She had not been told anything about a bruise. If she had been notified of this, then she would have taken Resident # 2 back to her room, laid her down, and examined the bruise. On 5/23/23 Resident # 2 was not hospice yet, and she probably would have ordered an x-ray on that day also. Since she was not acting herself, she decided to order labs. Later, the resident became hospice because she had a long history of progressively declining. On 5/26/23 she did not see Resident # 2. The plan at that point was not to be aggressive with the resident's care. She had not been told anything about the bruise before 5/31/23. She had never known that hospice had recommended she be non-weight bearing. They did not get paperwork from hospice until after Resident # 2 was discharged from the facility. On 6/30/23 at 1:30 PM the facility Administrator was informed of immediate jeopardy. The Administrator presented a corrective action plan. - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 is alert to self. A Brief Interview for Mental Status (BIMS) score could not be obtained due to cognition. Diagnoses include but not limited to Progressive Supranuclear Ophthalmoplegia (unable to move eyes at will in all directions), history of Cerebral Infarction (stroke) affecting right side, Glaucoma (increased pressure behind the eyes), Convulsions (seizures), aphasia (difficulty communicating), Dysphagia (difficulty swallowing), Major Depressive Disorder, Dementia with behaviors, Abnormalities of gait and mobility (difficulty walking), history of repeated falls, Nontraumatic subarachnoid hemorrhage (bleeding on the brain not caused by injury), polyneuropathy (muscle and nerve pain), ataxia, (impaired balance), Fibromyalgia (muscle pain), displaced simple history of fracture of bone between hip and knee, history of fracture of nasal bones, Age-related Osteoporosis (weakening of bones) and Osteopenia (softening of the bones), Adult Failure to Thrive. On 5/19/23 at 1:20 pm, staff observed the resident on the floor. The nurse assessed the resident for injuries, and the resident could move all extremities with no apparent pain. After the resident was transferred to the chair, the nurse completed a head-to-toe assessment with no bruising noted. The nurse attempted to notify the on-call physician and left a voicemail. The nurse notified the resident representative of the fall. On 5/21/23 at 6:00 am, the Nursing Assistant (NA) observed a large bruise on the top inner thigh and notified the nurse. The nurse assessed the resident and noted a dark red bruise on the right thigh, larger than a hand. The physician was not notified of the newly identified bruise. On 5/23/23, the resident was seen by the physician for a change in mentation. The provider notes the resident was observed sitting up in a wheelchair by the nursing station with (1) No acute injuries noted from the fall on 5/19/23, (2) No signs of pain or discomfort, (3) No wincing on exam of arms, and legs (4) Resident manipulated wheelchair backward using both feet without complaints of pain (5) Cooperative, Frail, in no apparent distress, sitting up in a wheelchair, awake and alert, not speaking, appears withdrawn. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urine/urine culture were ordered. On 5/25/23 the provider started an antibiotic for a possible urinary tract infection (UTI). On 5/25/23 at 6:33 pm, the resident was admitted to hospice services with a visit by the hospice nurse. From 5/21/23-5/30/23, multiple facility staff observed bruising to the resident's right thigh. Staff had not reported the bruising to the physician. However, the resident exhibited no complaints of pain or swelling during care nor stand and pivot transfers. On 5/31/23 at approximately 11:00 am, the NA reported to the hall nurse that the resident had bruising to the right hip and thigh and signs of pain to the right hip while providing care. The nurse assessed the resident and observed fading purple bruising to the right hip and thigh with internal rotation. The resident was noted with facial grimacing and furrowing of eyebrows indicating pain. The nurse notified the provider. The provider assessed the resident and ordered a STAT (immediately) x-ray. On 5/31/23 at 2:45 pm, the resident was transferred to the hospital by emergency services due to the length of time to obtain an in-house x-ray. The resident was admitted to the hospital with a diagnosis of a right femur fracture. The Administrator initiated an investigation for injury of unknown origin to include notification of police, Adult Protective Services (APS), and state reporting per facility protocol. -Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 5/31/23, the Unit Manager completed a 100% skin audit of residents to identify all residents with signs and symptoms of a fracture, new bruising, pain, and/or deformity of extremities. There were no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers completed an audit of all residents to determine if the resident was experiencing a change in condition, with no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers reviewed progress notes for the past 14 days to determine if a resident exhibited a change in condition, including signs/symptoms of a fracture, pain, or bruising, and ensure the practitioner was notified timely. The Director of Nursing will address all areas of concern identified during the audit, including the physician's notification for further instruction. The audit was completed by 6/8/23. - Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/2/23, An in-service was initiated by the administrative nurses to include the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC), and Unit Managers with all nurses regarding (1) Notification of Changes with emphasis on (a) a prompt complete assessment of a resident's slight or subtle changes with physician notification will ensure adequate management of the resident's acute illness or exacerbation of a chronic illness. (b) notification of physician with any change in resident condition to include but not limited to new bruising, pain, and deformity of extremity after a fall with documentation in the electronic record (2) Signs and Symptoms of a Fracture with emphasis on signs and symptoms of a fracture to include but not limited bruising, swelling over a bone or pain, assessment of the resident, and immediate notification of the physician with documentation in the electronic record. In-services will be completed by 6/8/23. After 6/8/23, any nurse who has not worked or received the in-service will receive it prior to the next scheduled work shift. All newly hired nurses will be in-service during orientation regarding Notification of Changes, and Signs and Symptoms of a fracture. - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Monitoring actions began on 5/31/23. 15 residents' charts, including charts of residents with recent falls, new or worsening bruising and residents receiving hospice services will be reviewed by the Unit Managers weekly x 4 weeks, then monthly x 1 month utilizing the Notification Audit Tool. This audit is to ensure the physician was notified of changes in condition and changes related to new bruising, pain, and deformity of extremities for further recommendations and to ensure the coordination of care with hospice services. The Unit Managers will address all areas of concern identified during the audit, including assessment of the resident, notification of the physician of changes, and staff re-training. The DON will review the Notification Audit Tool weekly x 4 weeks then monthly x 1 month to ensure all areas of concern are addressed. The DON will present the findings of the Notification Audit Tool to the Quality Assurance Performance Improvement (QAPI) committee, including but not limited to the Administrator, Director of Nursing, Maintenance Director, Dietary Manager, Activities Director, Social Worker, Therapy Director, and MDS Director and Medical Director monthly for 2 months. The QAPI Committee will meet monthly for 2 months to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. Date of corrective action completion: 6/9/23 The facility's corrective action plan was validated by the following. On 6/27/23 and beginning at 9:05 AM a tour of all facility halls was made. Multiple residents were interviewed at this time. The residents did not report any medical problems that had not been brought to the physician's attention and addressed. Multiple residents, who had sustained falls, were placed on a sample. There was documentation the physician had been notified of any injuries related to falls sustained by other sampled residents. The facility presented documentation they had completed their audits and inservices as noted in their corrective action plan. Multiple staff members were interviewed during the survey dates and validated they had attending inservice training as outlined in the facility's corrective action plan. On 6/30/23 the facility's correction date of 6/9/23 was validated.

Based on staff interview and record review the facility failed to protect residents when NA #1 and NA #2 were not removed from resident care assignments after an allegation of abuse with Resident #222. NA #1 and NA #2 continued to provide resident care. This had the high likelihood to put other residents at high risk for abuse and harm. The facility also failed to conduct a thorough investigation. Immediate jeopardy began on 3/25/22 when the facility allowed NA #1 and NA #2 to continue working after Resident #222 stated, That bitch broke my leg and She was yanking on it. The immediate jeopardy was removed on 10/15/22 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure monitoring systems are put into place and are effective to complete employee in-service training. Findings Included: Resident #222 was admitted to the facility on [DATE]. Her diagnoses included dementia. The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #222 had severe cognitive impairment. She required extensive assistance with bed mobility and transfers occurred once or twice. Total assistance was needed for toilet use and supervision for eating. The MDS indicated Resident #222 had no rejection of care. Record review revealed the following nurses note by the Director of Nursing (DON) #2 on 3/25/22 at 8:35 PM: Approximately 12:46 PM Nurse #5 came to my office stating that the resident leg is swollen, and it was not like that this morning on her assessment. I went to the resident's room and the resident bed was noted to be pulled out of the wall at the foot of the bed. The therapy director was standing on the right side of the bed against the wall. Occupational Therapy and the charge nurse were standing on the left side of the bed. The resident was laying on her back with her right foot partially off the bed. The resident left leg was on the bed. The resident left thigh appeared swollen and warm to touch. No discoloration, bruising or redness noted. Her skin color to her right thigh was in normal limits with the rest of her body. The resident was attempting to move her leg. I informed the resident several times while in the room not to move her leg, we needed to send her to the emergency room for evaluation. While in the room the resident did not appear to be in pain, she was answering questions but was becoming agitated when asked about her leg. She stated, You see my leg don't you. I asked her what happened to her leg, and she stated she did not know what happened to her leg, but something was wrong with it. I asked her did anyone hurt her, and she stated, no. Resident was left with nurse so I could notify the MD and receive an order for transport to emergency department. Physician notified and stated ok to send to emergency department. A second note by the DON #1 dated 3/28/22 at 3:25 PM read as follows: Correction the resident's right thigh appeared swollen. Her left leg was within normal limits. Record review revealed on 3/31/22 the facility sent their investigation report on Resident #222 for an injury of unknown cause to the state survey agency. The report indicated Adult Protective Services and law enforcement were notified of the incident. The facility reported incident was unsubstantiated for injury of unknown cause. The summary of the facility investigation read as follows: Resident #222 was unable to tell what occurred when asked. Resident #222 reported that she was up walking around cleaning. Resident #222 was unable to walk around without assistance and had not been cleaning. Resident #222 did not report any abuse per Administrator interview in the presence of 2 Emergency Medical Services personnel. Resident #222 replied, No when asked if anyone hurt or harmed her. Nurse #5 was interviewed on 10/14/22 at 11:00 AM. She stated she was the nurse caring for Resident #222 on 3/25/22. Nurse #5 reported she left for lunch and when she came back, she could hear Resident #222 saying go get the nurse so she went to her room. Nurse #5 stated she entered Resident #222's room and noticed her right leg laterally rotated towards the right. She stated she evaluated patient leg/femur and it was swollen and hot to the touch. Resident #222 yelled out in pain and stated, This bitch broke my leg and she was yanking on it. Nurse #5 stated NA #1 was in Resident #222's room and that's who she was talking about. Nurse #5 stated she left the room to go get the DON #1 to come to the room. She reported she went to the nurses' station to get the paperwork ready for Resident #222 to be sent to the hospital. On 10/14/22 at 2:54 PM an interview was conducted with the Administrator, and she stated when she found out what had occurred the ambulance was still outside with Resident #222 in the back. She stated she ran outside and spoke with Resident #222. The Administrator reported she asked Resident #222 if anyone hurt her, touched her, or harmed her and she responded no. An interview was conducted with NA#1 on 10/14/22 04:21 PM. She stated after the incident with Resident #222 she went back to work and provided care for other residents in the facility. Attempts made to contact NA#2 were unsuccessful. An interview was conducted with the Administrator on 10/14/22 at 4:12 PM, and she stated she interviewed Resident #222 while she was in the ambulance about to leave for the hospital on 3/25/22. She stated Resident #222 reported to her no one hurt her, touched, or harmed her. She had no concerns regarding abuse based on what Resident #222 reported to her. She stated an investigation was not conducted regarding abuse, but an investigation was completed regarding an injury of unknown cause. The Administrator stated she did not believe abuse based on what Resident #222 had stated. The Administrator reported NA#1 and NA#2 were not sent home after the incident and they continued to provide care to other residents in the facility for the remainder of their 8-hour shift. The Administrator stated had abuse been a concern, NA#1 and NA#2 would have been escorted out of the building and an abuse investigation would have been conducted. The facility was notified of the immediate jeopardy on 10/14/22 at 3:57 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident is alert to self with confusion. Brief Interview for Mental Status (BIMS) is 4. Diagnoses include Dementia without behavioral, Cellulitis of left lower limb, Hypertension, Anemia, disturbance, Glaucoma, Pressure ulcer of left heel Unstageable, Chronic kidney disease, Urinary tract infection, Uterovaginal prolapse, Bacteremia and osteoarthritis. The resident was able to make her needs known. On 03/25/22 at, 12:15 pm nursing assistant (NA) #1 entered resident room to provide incontinent care. Resident # 222 was agitated and declined care. On 03/25/22 at 12:20 pm, NA #2 heard resident yell ouch. NA #1 came out and asked NA #2 for assistance with incontinent care. NA#1 and NA #2 returned to the resident room to provide care. The bed was positioned slightly away from the wall. Resident was lying on right side with brief off and legs positioned slightly off the bed on the right side. NA #2 adjusted the bed slightly further away from the wall and positioned self at head of resident bed to assist with care. The resident was agitated, failing arms and yelling. Resident hit NA #2 in the chest when failing arms so NA#2 held the resident 's hands while NA#1 provided incontinent care. After the incontinent care provided, NA #1 and NA #2 rolled resident back to supine (lying face upward) position using draw sheet. Left leg landed onto the bed in an anatomically correct position. The right leg was rotated to the right from the knee downward and positioned slightly off to the right side of the bed. NA #2 noticed swelling and abnormal position of leg. NA #1 and NA #2 stopped care. NA #2 left room to notify the nurse. On 3/25/22 at 12:45pm, Nurse #1 entered resident room and noted right leg laterally rotated towards the right. The nurse evaluated patient leg/femur noted to be swollen and hot to the touch. Patient yelled out in pain. The resident stated, this bitch broke my leg. At no time during the conversation with the nurse did the resident identify a specific individual or specific event. On 3/25/22 at approximately 12:46 pm, the Director of Nursing (DON) notified of potential injury to Resident # 222. DON entered resident room and observed resident right leg externally rotated and swollen. DON assessed resident with no bruising or abrasions noted. Resident stated, nothing happened, and no one has hurt me, I don't know what is wrong with it and attempted to move right leg from side to side. On 3/25/22 at 12:46 pm, the DON notified the physician of potential injury to Resident # 222 with new order to transfer to the emergency room for evaluation and treatment. On 3/25/22 at approximately 12:46 pm, Emergency Medical Services (EMS) notified to transport Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22, the assigned nurse informed the resident representative (RR) of pain and swelling of Resident # 222's right thigh and that resident was being sent to the emergency room (ER) for evaluation. On 03/25/22 at 12:48 pm, the Administrator notified of potential injury to Resident # 222. On 3/25/22 at approximately 1:00 pm, EMS transported Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22 the Administrator completed and faxed the Initial Report to the Health Care Personnel Investigation Unit related injury of unknown origin. On 3/31/22, the Administrator completed and faxed the Investigation Report to the Health Care Personnel Investigation Unit related injury of unknown origin. The nursing assistant (NA) #1 and nursing assistant #2 were not removed from the floor following the incident. However, NA #1 and NA #2 did not return to work after their shift, pending the investigation There were no other allegations of injury of unknown origin or allegations of abuse in the past 30 days that identified an employee. On 3/28/22, the Interdisciplinary team reviewed concerns and acute changes from 3/25/22 to 3/27/22 including allegations of abuse and injury of unknown origin with no concerns identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4/22/22, a mandatory in-service was completed with the attendance of the Administrator, and Director of Nursing regarding reportable allegations including possible abuse, and notification to the Regional [NAME] President and Facility Consultant to always ensure the involved resident and all other residents are safe and protected first, removing the alleged perpetrator, placing the perpetrator in a non-resident care area, if the perpetrator is another resident supervise the resident until details of the incident can be determined and appropriate interventions initiated, assessment of the resident and reporting within a 2 hour time frame. On 6/16/22, a town hall meeting was held by the Administrator with nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse to include removing identified staff immediately to protect the resident and reporting abuse. On 10/14/22, an in-service was initiated by the Administrator with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse and what to do when residents display aggressive behaviors. The in-service included the definition of physical abuse and the consequences if found guilty of abuse. In-services to be completed by 10/14/22. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. Date of Corrective Action Completion 10/15/22 On 10/15/22 the credible allegation of immediate jeopardy removal was validated by onsite verification. Record review indicated an in-service was completed on 10/14/22 with 100% staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse, definition of abuse, and consequences of abuse of found guilty. A review of the in-service sign-in sheets as well as staff interviews conducted on 10/15/22 verified education was provided on abuse. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. The facility's immediate jeopardy removal date of 10/15/22 was verified.

Based on record review, staff interviews and physician interview the facility failed to protect a resident's right to be free from abuse. Staff provided care on a cognitively impaired resident who was resisting and flailing her arms and legs. The resident's arm was held down while care was provided, and staff continued to provide care even when they knew it was a struggle. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was for 1 of 1 resident reviewed for abuse (Resident #222). Immediate Jeopardy began on 3/25/22 when NA #1 (Nursing Assistant) and NA #2 provided care to Resident #222 when the resident was resistant, and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place are effective and to complete employee in-service training. Findings Included: A review of Resident #222's closed record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #222 had severe cognitive impairment. She required extensive assistance with bed mobility and total assistance with toilet use. The MDS indicated Resident #222 did not have behaviors. Resident #222 was care planned on 2/17/22 for problematic manner in which resident acts characterized by inappropriate behavior; resistive to treatment/care related to: argumentative, aggressive, combative to staff during care. The goal included will receive care within resident's choices and preferences through next review. Interventions included the following: o Allow for flexibility in ADL routine to accommodate resident's mood. o Document care being resisted per facility protocol and notify physician of patterns in behavior. o Elicit family input for best approaches to resident o If resident refuses care, re-attempt at another time. o Provide non-care related conversation proactively before attempting ADL Record review revealed the following nurses note by the former Director of Nursing on 3/25/22 at 8:35 PM: Approximately 12:46 PM Nurse #5 came to my office stating that the resident leg is swollen, and it was not like that this morning on her assessment. I went to the resident's room and the resident bed was noted to be pulled out of the wall at the foot of the bed. The therapy director was standing on the right side of the bed against the wall. Occupational Therapy and the charge nurse were standing on the left side of the bed. The resident was laying on her back with her right foot partially off the bed. The resident left leg was on the bed. The resident left thigh appeared swollen and warm to touch. No discoloration, bruising or redness noted. Her skin color to her right thigh was in normal limits with the rest of her body. The resident was attempting to move her leg. I informed the patient several times while in the room not to move her leg, we needed to send her to the emergency room for evaluation. While in the room the resident did not appear to be in pain, she was answering questions but was becoming agitated when asked about her leg. She stated, you see my leg don't you. I asked her what happened to her leg, and she stated she did not know what happened to her leg, but something was wrong with it. I asked her did anyone hurt her, and she stated, no. Resident was left with nurse so I could notify the MD and receive an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A second note by the former DON dated 3/28/22 at 3:25 PM read as follows: Correction the resident's right thigh appeared swollen. Her left leg was within normal limits. A telephone interview was conducted with NA#1 on 10/14/22 at 9:12 AM. She stated she went to provide incontinence care to Resident #222 on 3/25/22. She stated Resident #222 was resistant and was flailing both her arms and legs. She stated she stopped and went into the hall and asked someone to come help her. NA #1 stated the whole thing was a struggle. She stated NA#2 came in the room to assist and her and NA#2 tried to be careful and keep Resident #222 safe. She stated NA#2 adjusted the bed away from the wall and positioned herself at the head of the bed. NA#1 stated NA#2 held one of Resident #222's arm to keep her from moving and hurting herself while she continued to give care. NA#1 stated even though Resident #222 was combative, they still tried to give care. She reported there was a lot of fighting and resisting and Resident #222 was moving both her arms and her legs. NA#1 stated when they rolled Resident #222 over on her back was when she noticed a deformity in her leg, and she went to get a nurse. NA#1 stated NA#2 and well as herself were from an agency and did not work for the facility. Attempts made to contact NA#2 were unsuccessful. Nurse #5 was interviewed on 10/14/22 at 11:00 AM. She stated she was the nurse caring for Resident #222 on 3/25/22. Nurse #5 reported she left for lunch and when she came back, she could hear Resident #222 saying go get the nurse so she went to her room. Nurse #5 stated she entered Resident #222's room and noticed her right leg laterally rotated towards the right. She stated she evaluated patient leg/femur and it was swollen and hot to the touch. Resident #222 yelled out in pain and stated, this [OBSCENITY] broke my leg and she was yanking on it. Nurse #5 stated NA#1 was in Resident #222's room and that's who she was talking about. Nurse #5 stated she left the room to go get the former DON to come to the room. She reported she went to the nurses' station to get the paperwork ready for Resident #222 to be sent to the hospital. On 10/14/22 at 10:15 AM a telephone interview was conducted with Therapist #1. She stated she was in a nearby room and could hear Resident #222 loudly calling for help. She stated she went into the room and saw NA#1 and NA#2 and noticed Resident #222's leg was displaced. She stated she heard the NA's say they were providing care and the resident was agitated. Therapist #1 stated she was holding Resident 222's hand trying to comfort her. She stated she didn't hear Resident #222 say what happened to her leg. An interview was conducted with the Rehab Director on 10/14/22 at 10:05 AM and she stated Therapist #1 texted her and said she needed her in Resident #222's room. The Rehab Director stated Therapist #1 heard Resident #222 screaming and went into her room. The Rehab Director stated she saw the right upper leg was deformed and she got Nurse #1 and the former DON. She stated Resident #222 allowed her to hold her hand to try and comfort her before she left the room. The Rehab Director stated Resident #222 did not say what had happened to her leg. Nurse #1 was interviewed on 10/14/22 at 10:00 AM and he reported he went into Resident #222's room and looked at her leg and went to get the former DON. He stated she came to the room and took over and he left. On 10/13/22 at 5:05 PM a telephone interview was conducted with the former Director of Nursing (DON). She stated what she remembered about the incident involving Resident #222 was NA #1 went in to give Resident #222 a bath and she was combative. She stated she was told by NA#1 Resident #222 was flailing her arms and legs. She stated NA#1 stopped care and went into the hall and got help. NA#2 went into the room to assist with the bath. The former DON reported she was told when Resident #222 was rolled on her back they noticed her leg had a deformity and they went to get Nurse #1 and after he looked at Resident #222's leg he went and got and her. She stated when she entered Resident #222's room she observed Resident #222's right leg externally rotated and swollen. She stated she assessed Resident #222 with no bruising or abrasions. The former DON stated she didn't know if Resident #222 was still combative when NA#2 went into the room. The discharge summary from a local hospital for Resident #222 was reviewed. Resident #222 was admitted to the hospital on 3/25/22. A computerized tomography (CT) scan was completed on 3/25/22 and revealed Resident #222 had a stable displaced acute distal femoral (upper leg) fracture. On 3/26/22 she had open treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge summary indicated Resident #222 received physical and occupational therapy and was weight bearing as tolerated. On 10/14/22 at 11:18 AM and interview was conducted with Resident 222's Physician. She stated Resident #222 had advanced dementia and she could be pleasant but on exam, proving care, and providing incontinent care Resident #222 could get combative waving arms about and legs. The Physician stated she went to Resident #222's room and saw the deformity. She reported Resident #222 was hollering in pain. On 10/14/22 at 2:54 PM an Interview was conducted with the Administrator, and she stated when she found out what had occurred the ambulance was still outside with Resident #222 in the back. She stated she ran outside and spoke with Resident #222. The Administrator reported she asked Resident #222 if anyone hurt her, touched her, or harmed her and she responded no. The administrator stated she never had any concerns for abuse based on what Resident #222 reported. The facility was notified of the Immediate Jeopardy on 10/14/22 at 2:24 PM. The facility provided the following credible allegation for abuse. Credible Allegation-F 600 Abuse Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident is alert to self with confusion. Brief Interview for Mental Status (BIMS) is 4. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was able to make her needs known. On 03/25/22 at, 12:15 pm nursing assistant (NA) #1 entered resident room to provide incontinent care. Resident # 222 was agitated and declined care. On 03/25/22 at 12:20pm, NA #2 heard resident yell ouch. NA #1 came out and asked NA #2 for assistance with incontinent care. NA#1 and NA #2 returned to the resident room to provide care. The bed was positioned slightly away from the wall. Resident was lying on right side with brief off and legs positioned slightly off the bed on the right side. NA #2 adjusted the bed slightly further away from the wall and positioned self at head of resident bed to assist with care. At no time during the conversation with the nurse did the resident identify a specific individual or specific event. On 3/25/22 at approximately 12:46 pm, the Director of Nursing (DON) notified of potential injury to Resident # 222. DON entered resident room and observed resident right leg externally rotated and swollen. DON assessed resident with no bruising or abrasions noted. Resident stated, nothing happened, and no one has hurt me, I don't know what is wrong with it and attempted to move right leg from side to side. On 3/25/22 at 12:46 pm, the DON notified the physician of potential injury to Resident # 222 with new order to transfer to the emergency room for evaluation and treatment. On 3/25/22 at approximately 12:46 pm, Emergency Medical Services (EMS) notified to transport Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22, the assigned nurse informed the resident representative (RR) of pain and swelling of Resident # 222's right thigh and that resident was being sent to the emergency room (ER) for evaluation. On 03/25/22 at 12:48 pm, the Administrator notified of potential injury to Resident # 222. On 3/25/22 at approximately 1:00 pm, EMS transported Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22 the Administrator completed and faxed the Initial Report to the Health Care Personnel Investigation Unit related injury of unknown origin. On 3/31/22, the Administrator completed and faxed the Investigation Report to the Health Care Personnel Investigation Unit related injury of unknown origin. On 03/25/22, the DON initiated an audit of all residents not able to report for signs and symptoms of a fracture including bruising, pain, swelling, skin tears. Audit was completed on 03/25/22 with no additional concerns identified. On 03/25/22 the Register Nurse (RN) Supervisor interviewed all alert and oriented residents regarding: Have you sustained any injury that has not been reported to staff? The assigned nurse will address all concerns identified during the questionnaires. Questionnaires were completed on 03/28/22 with no additional concerns identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 03/28/22, the DON initiated Staff Quiz with all therapy staff, nurses and nursing assistants to include agency regarding Combative /Aggressive Residents. This quiz is to validate staff knowledge on combative/aggressive residents to include reporting combative/ aggressive behaviors and leaving resident in a safe manner when combative/ aggressive and attempting care when calm. Quizzes will be completed by 3/28/22. After 3/28/22, After 3/28/22, the Receptionist will mail quiz to any therapy staff, nurse or nursing assistant who has not worked or who has not received the quiz with instructions to complete, sign and return to the DON prior to next scheduled shift. On 4/22/22, a mandatory in-service was completed with the attendance of the Administrator, and Director of Nursing regarding reportable allegations including to always ensure the involved resident and all other residents are safe and protected first, removing the alleged perpetrator, placing the perpetrator in a non-resident care area, if the perpetrator is another resident supervise the resident until details of the incident can be determined and appropriate interventions initiated, assessment of the resident and reporting within a 2 hour time frame. On 6/16/22, a town hall meeting was held by the Administrator with nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance and admission staff regarding Abuse to include removing identified staff immediately to protect the resident and reporting abuse. On 03/28/22 the DON initiated in-service with all therapy staff, nurses and nursing assistants to include agency in regards to (1) Combative Residents with emphasis on making sure resident is safe and leave resident to calm down then re-approach for care, (2) Turning and Positioning with care with emphasis on technique for turning and positioning, (3) Signs and Symptoms of a fracture with emphasis on identifying signs/symptoms of a fracture and immediately reporting symptoms to nursing (4) Safe Handling with emphasis on checking care guide prior to providing care to ensure safety of the resident and (5) Pain with emphasis on immediately reporting pain with care to the nurse for pain management. In-services will be completed by 3/28/22. After 3/28/22, the Receptionist will mail in-services to any therapy staff, nurse or nursing assistant who has not worked or who has not received the in-service with instructions to read, sign and return to the DON prior to next scheduled shift. All newly hired therapy staff, nurse or nursing assistant to include agency will be in-serviced during orientation regarding Combative Residents, Turning and Positioning, Signs and Symptoms of a Fracture, Safe Handling and Pain. On 10/14/22, an in-service was initiated by the Administrator with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse. The in-service included the definition of physical abuse and the consequences if found guilty of abuse. In-services to be completed by 10/14/22. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. Date of credible allegation of immediate jeopardy removal was competed on 10/15/22. On 10/15/22 the credible allegation of immediate jeopardy removal was validated by onsite verification. Record review indicated an in-service was completed on 10/14/22 with 100% staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse, definition of abuse, and consequences of abuse of found guilty. A review of the in-service sign-in sheets as well as staff interviews conducted on 10/15/22 verified education was provided on abuse. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. The facility's immediate jeopardy removal date of 10/15/22 was verified.