Every finding on record at Trinity Elms

Based on record review and staff interviews, the facility failed to provide care in a safe manner. On 5/21/26 around 6:00AM Resident #1, who was ordered to utilize a mechanical sit to stand assist lift for transfer with the assistance of 2 staff, was being transferred from bed to chair by Nursing Aide (NA) #1, without assistance, via a stand pivot sit transfer. Resident #1 became weak when being transferred and the NA lowered Resident #1 to the floor. After Resident #1 was lowered to the floor, NA #1 had NA #2 assist her with picking Resident #1 up off of the floor and moved the resident to the bed. Then NA #1 and NA #2 transferred Resident #1 from the bed to the chair using another stand pivot sit transfer. On 5/25/26 Resident #1 reported pain in her right knee. Resident #1 had a portable x-ray completed which revealed a supracondylar fracture in the distal femur (a break in the thigh bone just above the knee joint). Resident #1 was transferred out to hospital for further evaluation on 5/25/26. The deficient practice occurred for 1of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling and unsteadiness on feet, congestive heart failure, chronic kidney disease, and type II diabetes.Review of Resident #1's care plan revealed a focus area of high risk for falls related to deconditioning. Interventions included after standing resident, give time to ensure she is not dizzy from changing positions. The care plan further indicated a focus for resident's current functional performance, with an intervention for sit to stand lift created on 3/3/26.Review of Resident #1's physician orders revealed an order written on 3/3/26 at 6:18PM by the Nurse Practitioner (NP) for 2 assist transfers with mechanical sit to stand lift. Review of Resident #1's physical therapy discharge summary note dated 4/1/26 revealed Resident #1 demonstrated safe transfers with the use of the sit to stand assist lift.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment and was dependent on staff for transfers.A telephone interview was conducted with Nurse Aide (NA) #1 on 7/30/26 at 1:40PM. She indicated the morning of 5/21/26 at around 6:00AM she attempted to transfer Resident #1 out of bed to her wheelchair via pivot sit transfer. NA #1 further indicated Resident #1 became weak and she eased Resident #1 to the floor. NA #1 indicated that Resident #1 gave no indication that she was in pain. NA #1 asked NA #2 to help get Resident #1 off the floor and back in bed. NA #1 stated once Resident #1 was placed in bed, she and NA #2 did a 2 person stand pivot sit transfer and transferred the resident into her wheelchair NA #1 also stated she was not aware Resident #1 required a sit to stand lift during transfers at that time.An interview was conducted with NA #2 on 7/31/26 at 2:45PM. NA #2 stated on 5/21/26 NA #1 asked her to assist with getting Resident #1 off the floor. NA #2 asked NA # 1, was she aware that Resident #1 was a 2 person transfer with sit to stand lift? NA #2 indicated that NA #1 did not provide an answer to the question. NA #2 indicated she and NA #1 got Resident #1 off the floor and placed her in bed.A follow up interview was conducted on 7/31/26 at 3:10PM with NA #2. NA #2 worked on 5/25/26 during first shift and was assigned to Resident #1, stated she could not recall if resident #1 was out of bed when her shift started. NA #2 indicated she attempted to get the resident out of bed for toileting using the sit to stand lift with another staff member between 9:00AM to 12:00PM on 5/25/26. NA #2 stated when she attempted to stand Resident #1 up, the resident cried out in pain. NA #2 stated Resident #1's right foot was turned inward while she was standing. NA #2 stated she put Resident #1 in her wheelchair at that time. NA #2 stated she reported to Nurse #1 that Resident #1 was complaining of pain.A telephone interview was conducted with Nurse #1 on 7/31/26 at 11:44AM. Nurse #1 indicated on 5/25/26 Resident #1 was up in her wheelchair sitting in her room. Nurse #1 indicated that Resident #1 was grabbing her right knee and reported pain. Nurse #1 could not recall the exact time. Nurse #1 further indicated she contacted the provider requesting an X ray of Resident #1's right leg.A review of Resident #1's orders revealed an order written by the Nurse Practitioner (NP) on 5/25/26 at 5:30PM for a portable X ray of the right knee. A telephone interview was conducted on 7/30/26 at 4:35PM with Nurse #2. Nurse #2 explained she worked on 5/25/26 during the second shift and had Resident #1 on her assignment. Nurse #2 indicated after she received report from Nurse #1 that Resident #1 was complaining of right leg pain, she attempted to assess Resident #1. Nurse #2 stated Resident #1 was visiting with her son on the front porch and chose not to disturb the resident and her son at that time. Nurse #2 indicated when Resident #1's visit with her son was over; she assessed Resident #1. Nurse #2 stated Resident #1 was up in her wheelchair sitting in her room. Nurse #2 indicated Resident was protecting right leg. Nurse #2 asked NA #4 to put Resident #1 in bed. Nurse #2 stated once Resident #1 was in bed she observed a dark discoloration under Resident #1's right thigh.An interview was conducted on 7/31/26 at 3:51PM with NA #4. NA #4 indicated on 5/25/26, Nurse #2 asked her to put resident #1 in bed. NA #4 along with another staff member stand pivot transferred Resident #1 into bed. NA #4 could not recall the staff member that assisted her at that time. NA #4 indicated Resident #1 was not transferred with the sit to stand lift because Resident #1 could not place her right leg on the lift. She further indicated Resident #1 was in pain.A telephone interview was conducted on 7/30/26 at 3:23PM with Resident #1's family member that visited with her on the evening of 5/25/26. The family member stated Resident #1 did not complain of pain during the visit.A review of Resident #1's X ray results dated 5/25/26 revealed a supracondylar fracture in the right distal femur (fracture in the right upper leg bone just about the knee joint).A review of Resident #1's orders revealed an order written by the NP on 5/25/26 at 8:5PM to send Resident #1 to the emergency department for evaluation and treatment.A review of the hospital's health care progress note dated 5/27/26 revealed Resident #1 was admitted to the hospital with a right distal femur fracture. The note further indicated that Resident #1's treatment included non-operative orthopedic care.An interview was conducted with the former Director of Nursing (DON) on 8/7/26 at 12:13 PM. The DON indicated her expectation for staff would be for them to transfer residents according to their physician order.A telephone interview was conducted on 8/7/26 at 8:38AM with the Administrator. The administrator indicated she would expect staff to follow transfers according to the residents chart. The facility provided the following Corrective Action Plan:1. Address how corrective action will be accomplished for those residents affected by the deficient practice:The investigation completed on 5/25/26 determined that on 5/21/26, Nurse Aide (NA) #1 transferred Resident #1 as a one-person assist despite the resident having a transfer status of a sit-to-stand transfer with the assistance from two staff members. During the improper transfer, NA #1 lowered Resident #1 to the floor but did not notify Nurse #2. NA #1 lowered the bed, obtained assistance from NA #2, and returned Resident #1 to bed. On 5/25/26, Resident #1 was transferred to the Emergency Department for evaluation and treatment of the acute right distal femur fracture. Resident #1's responsible party and physician were notified. On 5/25/26, Nurse #1 completed a risk management for the event on 5/21/26, which included a Post Fall Assessment (User Defined Assessment) UDA and Fall Risk Assessment (User Defined Assessment) UDA. These assessments review the factors contributing to the incident, such as medical and environmental, and also the residents condition after the incident has occurred.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 5/26/26, a 100% audit of resident transfer statuses in the Point Click Care (PCC) system was completed by the Minimum Data Set (MDS) nurses with the Therapy Program Manager. This audit was to ensure accuracy of transfer statuses on the Kardex, and that transfer status instructions match current resident capabilities. That process included: the Therapy Manager gave the transfer status to MDS who placed it on the care plan which was reflected into the Kardex for the nursing teammates to reference. On 5/27/26, the Unit Managers or designee completed interviews with interviewable residents to identify any unreported falls or transfer-related concerns within the past 30 days. No issues identified. On 5/27/26, Unit Managers reviewed skin assessments completed after 5/21/26 on non-interviewable residents to identify any potential injuries that may indicate unreported incidents. Any non-interviewable resident who did not receive a skin assessment between 5/21/26 and 5/25/26 received a skin assessment by 5/27/26. No issues identified. On 5/27/26, Unit Manager reviewed skin assessments completed after 5/21/26 on non-interviewable residents to identify any potential injuries that may indicate unreported incidents. Any non-interviewable resident who did not receive a skin assessment between 5/21/26 and 5/25/26 received a skin assessment by 5/27/26. No issues identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 5/25/26, a meeting was scheduled for NA #1. The meeting was held on 5/28/26 with NA #1, who received supervisory intervention and corrective action regarding the failure to utilize the correct transfer status as stated in the medical record Point Click Care system. This meeting was conducted by the Director of Nursing (DON), Assistant DON and Administrator. On 5/25/26, NA #2 was in-serviced on utilizing the correct transfer status by the Staff Development Coordinator and Director of Nursing. The in-service included a return demonstration of locating the transfer status in the Kardex section of Point Click Care charting system. by the Staff Development Coordinator and Director of Nursing. On 5/25/26, the Director of Nursing (DON) or designee in-serviced Nursing Assistants (NAs), Licensed Nurses, and Medication Aides (MAs) on: Following transfer status. Education was completed prior to staff members' next working shifts. On 5/26/26, the DON or designee conducted return demonstrations with NAs on how to locate and verify transfer status in PCC for each resident prior to providing transfer assistance. On 5/25/26, the Staff Development Coordinator implemented a new training document for new hire orientation that includes education regarding how to identify a fall, and the process for immediate reporting and documentation of incidents. This document is reviewed with Nursing Assistants, Medication Aides and Nurses.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 5/25/26 the DON decided to monitor transfers. The Unit Manager or designee will conduct audits of teammates utilizing transfer equipment with direct observation of teammates performing transfers to ensure transfer status is being followed as documented in PCC and the medical record. The audit will be completed at the following frequency: five resident lifts by teammates per week for four weeks, then bi-weekly for one quarter. The audit will include the resident, lift type, sling type, the shift and teammates that were monitored. The audit will include teammates on all shifts and weekend. The Quality Assurance and Performance Improvement (QAPI) committee will monitor quarterly on an ongoing basis until substantial compliance of the set-forth protocol is achieved.Date of alleged compliance: 5/28/26The corrective action plan for Accidents and Transfer Safety was validated on 08/11/2026. Education for nursing staff related to resident transfer status, transfer safety, fall prevention, fall reporting, and post-fall procedures was reviewed. Interviews were conducted with nursing assistants, licensed nurses, the Staff Development Coordinator, Minimum Data Set (MDS) Nurse, and Director of Nursing (DON) regarding the facility's corrective actions.Nursing assistants interviewed reported that residents' current transfer statuses are reviewed in the electronic health record (EHR), including the Kardex, prior to providing transfer assistance. Nursing assistants reported that residents requiring two-person assistance are not transferred by one staff member and that another staff member is obtained before completing the transfer.The Staff Development Coordinator reported that education related to falls and transfer safety is provided during new-hire orientation and through ongoing in-services and competency validation. Training included identification of residents' transfer status, one-person and two-person assistance, fall reporting, and safe transfer practices.The DON reported that staff compliance with residents' documented transfer statuses is monitored through direct-observation audits. The DON reported that residents with different transfer statuses are randomly selected for monitoring and that no noncompliance with residents' documented transfer requirements had been identified. The DON also reported there had been no identified unreported or delayed-reported falls since the compliance date.Observation was conducted of a resident requiring two-person assistance with transfers. Staff were observed providing the resident with the level of transfer assistance identified in the resident's current transfer status and utilizing the appropriate transfer equipment. The transfer was completed safely and in accordance with the resident's documented transfer requirements. No concerns were identified during the observation.Audit records and staff training records were reviewed and reflected completion of the facility's corrective actions. No concerns were identified during review of the audit or training records.The compliance date of 05/28/2026 was validated.

Based on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to ensure there was effective communication and assessments related to a resident's fall, which delayed medical evaluation and treatment. An X-ray of the right lower extremity completed on 5/25/26 revealed a supracondylar fracture in the distal femur (a break in the thigh bone just above the knee joint). The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling and unsteadiness on feet, congestive heart failure, chronic kidney disease, and type II diabetes.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment and was dependent on staff for transfers.Review of Resident #1's care plan completed on 3/5/26 revealed a focus area of high risk for falls related to deconditioning. Interventions included after standing resident, give time to ensure she is not dizzy from changing positions. Review of Resident #1's physician orders revealed an order written on 3/3/26 for 2 assist transfers with mechanical sit to stand lift, order written on 5/5/26 for tramadol (medication to treat moderately severe pain) 0.5 milligrams (mg) by mouth three times a day for pain, and an order written on 1/4/26 Acetaminophen 500 mg by mouth three times a day for pain. A telephone interview was conducted with Nurse Aide #1 on 7/30/26 at 1:40PM. She indicated the morning of 5/21/26 at around 6:00AM she attempted to transfer Resident #1 out of bed to her wheelchair without using a sit to stand lift. Nurse Aide #1 further indicated Resident #1 became weak and she eased Resident #1 to the floor. Nurse Aide #1 asked Nurse Aide #2 to help get Resident #1 off the floor and back in bed before Resident #1 was assessed by a nurse. Nurse Aide #1 stated once Resident #1 was placed in bed, she and Nurse Aide #2 transferred the resident into her wheelchair. Nurse Aide #1 stated she did not make the nurse aware that Resident #1 had fallen. Nurse Aide #1 also stated she was not aware that Resident #1 required a sit to stand lift during transfers at that time. An interview was conducted with Nurse Aide #2 on 7/31/26 at 2:45PM. Nurse Aide #2 stated Nurse Aide #1 asked her to assist with getting Resident #1 off the floor. Nurse Aide #2 asked Nurse Aide # 1, was she aware that Resident #1 was a 2 person transfer with sit to stand lift. Nurse Aide #2 indicated she and Nurse Aide #1 got Resident #1 off the floor and placed her in bed before being assessed by a nurse. Nurse Aide #2 further indicated she instructed Nurse Aide #1 to report the fall to the nurse. Nurse Aide #2 stated she did not make the nurse aware that the resident had fallen.Review of a progress note written on 5/21/26 at 3:09PM by the Licensed Clinical Social Worker (LCSW) revealed Resident #1 complained of significant pain in her feet and leg during her visit. The LCSW indicated that Resident #1 attributed the pain to a fall that occurred that morning when she was getting up. The LCSW further indicated that Resident #1 reported a staff member was in the room at the time of the fall. The LCSW indicated that Resident #1 was taken to her nurse to address the pain she was experiencing.A telephone interview was conducted on 7/30/26 at 12:10PM with the LCSW. The LCSW indicated she saw Resident #1 between 1:30PM and 2:00PM on 5/21/26. During that time in the presence of a staff member, Resident #1 reported significant pain in her right leg. The LCSW further indicated that she reported Resident #1's leg pain to nursing staff. The LSCW was unable to recall the name of the nursing staff she reported the information to. The LCSW indicated she left before nursing staff had completed the assessment of Resident #1.A review of a Perfect Serve (process used in healthcare settings to prioritize patients' treatment electronically to help prevent unnecessary emergency department visits) Note dated 5/21/26 at 2:32PM written by Nurse #1 indicated an X ray request for Resident #1. Nurse #1 indicated that Resident #1 had complained of right knee pain. Nurse #1 further indicated that the area was tender to touch and there was no bruising or swelling noted during the assessment. On 5/21/26 Nurse Practitioner (NP) #1 asked Nurse #1 did Resident #1 report any trauma. On 5/21/26 at 2:26PM Nurse #1 responded to NP #1. Nurse #1 reported Resident #1indicated she hit her leg that morning during transfer. Resident #1 did not know what she had hit her leg on. An interview was conducted on 7/30/26 at 10:38AM with Nurse #1. Nurse #1 stated on 5/21/26 Medication Aide #1 came to her and reported Resident #1 was complaining of right knee pain. Nurse #1 stated during her assessment she did not observe any swelling or bruising to Resident #1's right leg. Nurse #1 asked Resident #1 what happened to her right leg. Resident #1 responded, by saying she hit her leg that morning during transfer. Nurse #1 indicated that she requested an X ray for Resident #1 through Perfect Serve. Nurse #1 further indicated that the Nurse Practitioner held the X ray and recommended monitoring Resident # 1. Nurse #1 indicated that the NP stated she would assess Resident #1 on 5/22/26.Review of a Perfect Serve note dated 5/21/26 at 3:55PM written by Nurse #2 revealed a 2nd request for an Xray for Resident #1. The note indicated that the 2nd request for an X-ray for Resident #1 was denied at 4:07PM by the NP.A telephone interview was conducted on 7/30/26 at 4:35PM with Nurse #2. Nurse #2 indicated she received report from Nurse #1 regarding Resident #1 complaining of right leg pain. Nurse #2 indicated she took over the communication through Perfect Serve with the NP and made a second request for an X ray on 5/21/26 at 3:55PM. The request for an X ray was denied by the NP on 5/21/26 at 4:07PM.An interview was conducted on 7/30/26 at 11:13AM with the NP. The NP stated that on the 21st she received a message that Resident #1 was complaining of right knee pain. The NP indicated she instructed Nurse #1 to monitor, and she would assess Resident #1 on 5/22/26. The NP further indicated that she did not believe there was a need for an X ray at that time because there was no report of a fall. She indicated that a report of an injury would prompt her to assess the resident before ordering an X ray. The NP indicated she attempted to assess Resident #1 on 5/22/26 but could not locate the resident. The NP indicated that she received report from nursing staff that Resident #1 had no further complaints of pain. The NP could not recall who she received report from. The NP indicated had she been made aware that Resident #1 had fallen she would have ordered an X ray.A telephone interview was conducted on 8/4/26 at 12:4PM with Nurse Aide #3. Nurse Aide #3 was assigned to Resident #1 on 5/23/26 from 7:00AM to 11:00PM. Nurse Aide #3 stated when she entered Resident #1's room, Resident #1 was in bed. Nurse Aide #3 indicated when she attempted to get Resident #1 out of bed the resident complained of pain and would cry. Nurse Aide #3 further indicated that Resident #1's right knee looked swollen. Nurse Aide #3 indicated she made Medication Aide #2 aware that she was not going to be able to get Resident #1 out of bed because of complaints of pain. Nurse Aide #3 stated after Resident #1 was assessed by Medication Aide #2 she was not aware of the care provided by nursing staff. Nurse Aide #3 indicated she did not attempt to get Resident #1 out of bed for the rest of the shift. Nurse Aide #3 further indicated all the care she provided Resident #1 was provided while Resident #1 was in bed. Nurse #3 further when she rolled Resident #1 on her right side for incontinence care the resident would cry and complain of pain. Nurse Aide #3 was also assigned to Resident #1 on 5/24/26 from 7:00AM to 7:00PM. Nurse Aide #3 indicated on 5/24/26 during her shift, she did not attempt to get Resident #1 out of bed. Nurse Aide #3 further indicated when she performed incontinence care and rolled Resident #1 on her right side, Resident #1 would complain of pain. Nurse Aide #3 stated she did not report to nursing staff on 5/24/26 that Resident #1was still complaining of pain. Nurse #1 stated she assumed nursing staff knew that Resident #1 was still in pain because she had made them aware on 5/23/26.A telephone interview was conducted on 8/4/26 at 1:44PM with Medication Aide #3. Medication Aide #3 stated she was not made aware on 5/23/26 that Resident #1 was complaining of right leg pain.A follow up telephone interview was conducted 7/31/26 at 3:44PM with Nurse Aide #1. Nurse Aide #1 stated she was assigned to Resident #1 on 5/24/26 from 11:00PM to 7:00AM on 5/25/26. Nurse Aide #1 stated she did not get Resident #1 up out of bed during that time. Nurse Aide #1 indicated she provided care while Resident #1 was in bed during the shift. Nurse Aide #1 stated that she did not get Resident #1 up the morning of 5/25/26. Nurse #1 stated she got Resident #1 dressed and left her lying in bed.A follow up interview was conducted on 7/31/26 at 3:10PM with Nurse Aide #2. Nurse Aide #2 stated she could not recall if resident #1 was out of bed when her shift started. Nurse Aide #2 indicated she attempted to get the resident out of bed for toileting using the sit to stand lift with another staff member between 9:00AM to 12noon on 5/25/26. Nurse Aide #2 stated when she attempted to stand Resident #1 up, the resident cried out in pain. Nurse Aide #2 stated that Resident #1's right foot was turned inward while she was standing. Nurse Aide #2 stated she put Resident #1 in her wheelchair at that time. Nurse Aide #2 stated she reported to Nurse #1 Resident #1 was in pain.A follow-up telephone interview was conducted with Nurse #1 on 7/31/26 at 11:44AM. Nurse #1 stated on 5/25/26 Resident #1 was still complaining of pain to the right leg. Nurse #1 indicated she contacted the provider through Perfect Serve requesting an X ray for Resident #1. Nurse #1 stated no one reported to her that Resident #1 was in pain. She further indicated the X ray occurred on 2nd shift.Review of a Perfect Serve Note dated 5/25/26 at 5:27 PM written by Nurse #1 revealed a third request for X ray for Resident #1 for continued complaints of pain to the right leg.A telephone interview was conducted on 7/30/26 at 4:35PM with Nurse #2. Nurse #2 indicated after she received report from Nurse #1 that Resident #1 was complaining of right leg pain, she attempted to assess Resident #1. Nurse #2 stated Resident #1 was visiting with her son on the front porch. Nurse #2 indicated when Resident #1's visit was over; she assessed Resident #1. Nurse #2 indicated that Resident #1 was guarding her leg during the assessment, she noted discoloration under Resident #1's right thigh. Nurse #2 further indicated that Resident #1's vital signs were not at her baseline. A telephone interview was conducted on 7/30/26 at 3:23PM with Resident #1's son that visited with her the evening of 5/25/26. The son stated Resident #1 did not complain of pain during the visit.A review of Resident #1's orders revealed an order written by the NP on 5/25/26 at 5:30PM for Knee RT 2V (right two view X ray).A review of Resident #1's X ray results dated 5/25/26 revealed a supracondylar fracture in the right distal femur (a break in the thigh bone just above the knee joint).A review of Resident #1's orders revealed an order written by the NP on 5/25/26 at 8:5PM to send Resident #1 to the emergency department for evaluation and treatment.A review of Resident #1's Notice Transfer/Discharge form dated 5/25/26 revealed Resident #1 was discharged from the facility on 5/25/26.A review of the hospital's health care progress note dated 5/27/26 revealed Resident #1 was admitted to the hospital with a right distal femur fracture. The note further indicated that Resident #1's treatment included non-operative orthopedic care. The morning of 5/27/26 Resident #1 was deemed medically ready for discharge from the hospital.An interview was conducted with the facility's Medical Director on 7/31/26 at 9:31AM. The Medical Director indicated she would have wanted staff to share the information about Resident #1 falling. She indicated if that information had been provided, most likely an X-ray would have been ordered sooner.A telephone interview was conducted on 8/7/26 at 8:38AM with the Administrator. The Administrator indicated she would expect her staff to report a fall immediately to nursing. She further indicated she would expect staff to follow transfers according to the residents chart. The facility provided a corrective action plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:On 5/21/26, Resident #1 reported to the licensed clinical social worker (LCSW) that she had fallen on the morning of 5/21/26 when Nursing Assistant (NA) #1 assisted her during a transfer and was now experiencing right knee pain. The LCSW relayed this information to Med Aide #1, who then reported it to Nurse #1. Upon assessment by Nurse #1, Resident #1 complained of right knee pain and stated that she had bumped her leg during a transfer. Nurse #1 contacted the Nurse Practitioner (NP) on 5/21/26 to report the complaint of right knee pain and requested an x-ray. Nurse #3 then contacted the Nurse Practitioner after her assessment (there was no bruising and right knee looked similar to left knee) and requested an x-ray; however, the Nurse Practitioner (NP) directed staff to monitor the knee and administer pain medication rather than obtain imaging. The NP indicated she would evaluate the resident tomorrow. Resident #1 received medication for pain management from 5/21/26 through 5/25/26. Due to resident complaint of pain again on 5/25/26, Nurse #1 notified the Nurse Practitioner again on 5/25/26, and an x-ray was ordered, revealing an acute right distal femur fracture. Resident #1 was transferred to the emergency department for evaluation and treatment on 5/25/26, and the provider and resident representative were notified of the findings. The investigation completed on 5/25/26 determined that NA #1 transferred Resident #1 as a one-person assist despite the resident requiring a sit-to-stand transfer with assistance from two teammates. During the improper transfer, NA #1 lowered Resident #1 to the floor but did not notify Nurse #2. NA #1 lowered the bed, obtained assistance from NA #2, and returned Resident #1 to bed. Because Nurse #2 was not informed of the incident on 5/21/26, the provider and responsible representative were not notified, and the required follow-up actions, including a risk management, post-fall assessment, and fall risk assessment, were not completed at the time of the fall. The actions (risk management, notifications, post-fall assessment and fall risk assessment) were completed by the nurse #1 on 5/25/26. On 5/22/26, the Nurse Practitioner visited the facility, however, Nurse Practitioner states, Resident #1 was unavailable for evaluation at the time of the attempted visit. On 5/25/26, Resident #1 was transferred to the Emergency Department for evaluation and treatment of the acute right distal femur fracture. Resident #1's responsible party and physician were notified. On 5/25/26, Nurse #1 completed a risk management for the event on 5/21/26, which included a Post Fall Assessment (User Defined Assessment) UDA and Fall Risk Assessment (User Defined Assessment) UDA. These assessments review the factors contributing to the incident such as medical and environmental and also the resident condition after the incident has occurred.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 5/27/26, the Unit Managers or designee completed interviews with interviewable residents to identify any unreported falls or transfer-related concerns within the past 30 days. No issues identified. On 5/27/26, the Unit Managers reviewed skin assessments completed after 5/21/26 on non-interviewable residents to identify any potential injuries that may indicate unreported incidents. Any non-interviewable resident who did not receive a skin assessment between 5/21/26 and 5/25/26 received a skin assessment by the Unit Manager on 5/27/26. No issues were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 5/25/26, a meeting was scheduled for NA #1. The meeting was held on 5/28/25 with NA #1, who received supervisory intervention and corrective action regarding the failure to report the incident, which occurred on 5/21/26. This meeting was conducted by the Director of Nursing (DON), Assistant DON and Administrator. On 5/25/26, The Staff Development Coordinator and DON in-serviced NA # 2 on the following: reporting falls timely, report immediately so that nurse can assess prior to moving resident, and falls will be reported at the time of incident. On 5/25/26, the Director of Nursing (DON) or designee in-serviced all Nursing Assistants (NAs), Licensed Nurses, and Medication Aides (MAs) on: reporting all falls, including assisted falls; and proper Risk Management completion to include completion of incident reports, and User Defined Assessments (UDAs). Education was completed prior to staff members' next working shifts. On 5/25/26 the DON initiated the procedure for the NP to do an in-person check out prior to leaving the facility on each day she visits. The NP will do an in-person meeting with a member of the nurse administration team to ensure any acute resident needs are addressed. The Nurse Administration team will obtain this information through use of Point Click Care risk management items, 24-hour report, morning clinical meetings, huddles with teammates on the hall or resident and family requests. The Director of Nursing informed the Nurse Practitioner, the Assistant DON and unit managers of this process. On 5/25/26, the Staff Development Coordinator implemented a new training document for new hire orientation that includes education regarding: confirming transfer status with Point Click Care Kardex, gait belt use, ensure rooms are free from clutter, remove foot pedals during transfers, mechanical lift pad sizing and utilizing two teammates for lift transfers, do not move a resident after a fall until nurse does assessment for injury, neuro check protocol, how to identify a fall, and the process for immediate reporting and documentation of incidents. This document is reviewed with Nursing Assistants, Medication Aides and Nurses. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The DON or designee decided on 5/25/26 to conduct an audit of Assessments completed after a fall to include all falls in the risk management in Point Click Care charting system. The audit will monitor fall risk assessment and post fall User Defined Assessments (UDAs). The audit will be completed at the following frequency: five residents per week for four weeks, then bi-weekly for one quarter or as there are falls to monitor. The DON will report results to Quality Assurance Performance Committee (QAPI). Beginning 5/25/26, the DON notified the wound nurse or designee to complete a weekly review of skin checks completed by licensed nurses to monitor for any areas that would indicate injury occurred. (If there is any suspected issue, the Nursing Administration team will investigate.) The results will be reported to the QAPI committee for 2 quarters. Beginning 5/25/26, MDS (Minimum Data Set) coordinator or designee will review PRN (as needed) pain medication use, indication and frequency, and report to interdisciplinary team weekly in clinical review meeting, to monitor for pain that could indicate an injury. (Nursing Administration would investigate any suspect issue.) The MDS coordinator will report any findings to QAPI committee for 2 quarters. Beginning 5/25/26, the Administrator decided to initiate an audit of Nurse Practitioner documentation to verify that timely in-person assessments were completed for residents following falls as indicted in the risk management of Point Click Care charting system. If there are concerns with the Nurse Practitioner, Administrator will report to the NP supervisor at the contracted company and discuss with Medical Director. The audit will include three resident records per week for two weeks, then bi-weekly for one month, then monthly for one quarter. The results will be reported to QAPI committee. Beginning 5/25/26, Staff Development Coordinator or designee will offer a monthly in-service to teammates to include nurse aides, medication aides and nurses on the importance of timely reporting of falls, falls prevention, notifications, transfers to prevent falls, or falls documentation. This will be done for 4 months and reported to QAPI committee. Beginning 5/25/26, the DON informed the Nurse administration team and the Nurse Practitioner that nursing administration will continue an open line of communication with provider and will continue to do daily checkouts when provider is in the facility. This process will be ongoing and will be utilized even if a new provider is assigned to the facility. The DON will report any issues with the process to QAPI committee for 2 quarters. The Quality Assurance and Performance Improvement (QAPI) committee will monitor quarterly on an ongoing basis until substantial compliance of the set-forth protocol is achieved.Date of Compliance: 5/28/2026The corrective action plan was validated on 08/11/2026. Education for nursing staff related to fall reporting, post-fall procedures, and incident reporting was reviewed. Interviews were conducted with nursing assistants, licensed nurses, the Staff Development Coordinator, Minimum Data Set (MDS) Nurse, and Director of Nursing (DON), and the Nurse Practitioner (NP) regarding the facility's procedures for identifying and reporting falls, assessing residents following falls, and identifying potential unreported injuries.Nursing assistants interviewed reported Nursing Assistants also reported that when a resident is safely lowered to the floor, the event is considered a fall and must be immediately reported to the nurse. Staff reported that residents are not moved from the floor prior to nursing assessment due to the potential for injury.Licensed nurses interviewed described the facility's post-fall process, which included resident assessment, vital signs, neurological monitoring as indicated, evaluation for injury and pain, provider and responsible-party notification, post-fall documentation, and continued monitoring. Licensed nurses also reported that unexplained pain, bruising, or other injuries are assessed and reported for additional evaluation when indicated.The MDS Nurse reported that resident pain and as-needed (PRN) pain-medication use are reviewed to identify changes or increased pain requiring additional evaluation. PRN pain-medication use is reviewed to identify changes in the frequency of administration or increased reports of pain that could indicate a change in condition, injury, or potentially unreported incident. The MDS Nurse reported that pain, falls, interventions, and other changes in resident condition are also discussed during weekly clinical review meetings.The NP reported that nursing administration maintains open communication with her regarding residents who experience falls and require provider follow-up. The NP reported that when present in the facility, communication occurs with nursing administration regarding resident concerns and changes in condition, including falls. The NP reported that prior to leaving the facility, she checks out with the DON or a Unit Manager to discuss residents assessed during the visit, changes in condition, falls, identified concerns, recommendations, new or changed orders, and any residents requiring additional follow-up. The NP reported that residents are assessed in person following falls when clinically indicated and that findings from the assessment are documented in the resident's EHR. The NP reported that this communication process is ongoing to ensure identified concerns are addressed and appropriate follow-up is completed. No concerns were identified during the interview with the NP.Audit records and staff training records were reviewed. The records reflected completion of the facility's corrective actions and were consistent with the facility's stated monitoring and education processes. No concerns were identified during the review of the audit or training records.The compliance date of 05/28/2026 was validated.

Based on observations, record reviews, and resident representative, staff, Nurse Practitioner, and physician interviews, the facility failed to implement effective systems to effectively communicate and collaborate regarding the resident's care. The deficient practice affected 1 of 5 residents reviewed for accidents (Resident #33).The findings included:Resident #33 was admitted to the facility on [DATE]. Her diagnoses included hypertension, non-Alzheimer's Dementia, adult failure to thrive, muscle weakness (generalized), other abnormalities of gait and mobility, and history of falling. A review of the significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was moderately cognitively impaired with no behaviors present. Resident #33 exhibited verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others. There was no impairment in functional limitations in range of motion (ROM). Resident #33 used a wheelchair as a mobility device. She was dependent in toileting hygiene, shower/baths, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. She was partial to moderate assist with personal hygiene. Resident #33 was on antidepressant medication. Review of the care plan dated 1/5/26 revealed a focus that Resident #33 was at moderate risk for falls related to gait/balance problems. The goal stated Resident #33 would be free of major injury through the review date. Interventions included a 1/4 wing tip mattress, be sure the Resident #33's call light was within reach and encourage Resident #33 to use it for assistance as needed. Resident #33 needed prompt response to all requests for assistance. An interview with the Scheduler on 3/5/26 at 11:01 AM indicated she made rounds on each hall every day to see how things were going with staffing (such as if there were any call-outs, any staffing concerns, etc.), The Scheduler stated on 1/28/26, sometime around 3:30p, she was making her rounds on the hall and as she was walking, she looked in Resident #33's room and resident was already on the floor sitting on her bottom. She asked resident if she was OK. Resident asked her to help her get up. The Scheduler left resident's room to get the nurse (Nurse #7) and medication (Med) aide (Med Aide #2). When the 3 of them arrived back to Resident #33's room, the resident's vital signs were taken, and an assessment was done prior to assisting resident back into her wheelchair. After that, the nurse took resident to the nurses' station. After getting the resident back into her wheelchair, the Scheduler left the unit to continue her rounds on another unit. On 3/5/26 at 10:27 AM, during a telephone interview with Medication Aide (MA) #2, she reported on 1/28/26, she was doing a medication pass. She stated Resident #33 had a behavior where she yelled out. MA #2 stated the Scheduler was walking on the unit and went to see what was going on with Resident #33. The Scheduler found Resident #33 on the floor. The Scheduler got the MA #2 and the nurse (Nurse #7). When asked what happened, Resident #33 stated she got onto the floor by herself. They got her up off the floor, and MA #2 stated she went back to doing her medication pass. MA #2 stated she was not sure what happened after that. MA #2 stated Resident #33 did not have any complaints of pain when they got her up. She stated she did not remember if Resident #33 complained of pain while on her shift and she did not recall if anything was given for pain. On 3/5/26 at 10:39 AM, a telephone interview was conducted with Nurse #7. She stated she had just gotten to work on the 1/28/26 evening shift and had received the report from the previous nurse when the Scheduler advised her of Resident #33's fall. She was unsure of what events took place prior to the fall. Nurse #7 stated she, the Medication Aide, and the Scheduler went into resident's room to find Resident #33 sitting on the floor in front of her wheelchair. Nurse #7 stated she assessed the resident, checked her range of motion, and asked if she was having any pain. Resident #33 said no. The resident had a cushion on her wheelchair and Nurse #7 wondered if it made Resident #33 slide out but the Scheduler told her the resident got onto the floor by herself. Nurse #7 stated she perceived that the Scheduler witnessed Resident #33 getting onto the floor based on their conversation.Record review revealed there was no documentation that an updated Post Fall Evaluation and a Fall Risk Evaluation were completed following Resident #33's fall on 1/28/26. Nurse #7 stated once Resident #33 was back into her wheelchair, she was then taken to the nurse station with Nurse #7. She stated the resident stayed with her for about 10-15 minutes before she wheeled herself to the dining area. Resident ate outside of her room that day at the dining table. Nurse #7 stated resident ate fine. Nurse #7 stated she worked from 3p-7p on 1/28/26 on the memory care unit, then she was moved to a different hall. However, during the time Nurse #7 worked on the hall, resident did not report any pain. Nurse #7 stated Resident #33 usually yelled out when she was in pain, shouting mama mama. Nurse #7 stated during the time she worked with resident, she did not have any issues with her. Regarding falls, Nurse #7 stated when she was trained, for a witnessed fall, you do a full assessment. Nurse #7 stated she was under the impression resident's fall was witnessed because she thought the Scheduler saw it. Because of this, and in addition to the resident not reporting any pain, the Fall Risk/Post Fall Evaluations were not done. However, she did assess and monitor resident after the fall. A telephone interview was conducted with Resident #33's representative (RR) on 3/2/26 at 1:33 PM. On 1/30/26, Resident #33 complained of knee pain, and that she went to the nurse's station to advise the nurse of the pain. The RR stated the nurse (exact nurse unknown) said she asked Resident #33 if she wanted something for pain, and the resident said no. They also asked the resident if she wanted an x-ray, and the resident said no. However, the RR stated an x-ray was ordered but it was not done until after midnight on 2/4/26 (which would have been on 2/5/26). The RR stated they received the x-ray results, and a CT scan was ordered and completed that showed a trauma break. A review of the January Medication Administration Record (MAR) revealed Resident #33 started complaining of right knee pain on 1/30/26 at a level 4 out of 10 (0 - 10 pain scale with 10 being the worst possible pain) on evening shift. Resident was given Acetaminophen Oral Tablet 500 milligrams (MG). Review of the Health Status Note dated 1/30/26 entered by Nurse #11 indicated Nurse #11 notified the Nurse Practitioner (NP) of Resident #33's complaint of pain in her knee and that it was slightly swollen. An x-ray was ordered by NP #2. The resident's family visited and was also notified of the complaint of the right knee pain. Record review revealed on 1/30/26, an x-ray of the right knee was ordered by the Nurse Practitioner (NP) #2 based on Resident #33's complaints of knee pain. There was no evidence of documentation for the x-ray results completed on 1/30/26. Information regarding this x-ray was requested during the survey. However, the information was not provided by the facility. The only x-ray results provided by the facility during the survey were from 2/5/26. On 3/19/26, the facility provided a copy of the 1/30/26 x-ray results which showed there was evidence of a total knee replacement with intact femoral and tibial components. There was no radiographic evidence of acute fracture or dislocation, and no radiographic evidence of loosening or particle disease. There was a mild degree of osteopenia. A record review of the Practitioner note dated 1/31/26 written by Physician Assistant (PA-C) #1 indicated Resident #33's representative (RR) called with concern that resident had right knee pain and swelling, and she was unable to bend her knee. The RR wanted to know if an x-ray was ordered as she requested. The note stated PA-C #1 returned a call to the RR. She advised the RR that the provider had been notified, and an x-ray was ordered but had not yet been done due to weather. Review of the Practitioner note dated 2/4/26 written by Nurse Practitioner (NP) #2 revealed an order was placed for a right hip/pelvis x-ray, will evaluate once resulted. The NP note stated Resident #33 was alert and in no acute distress. She resided on the memory care unit and was unable to fully communicate her needs to staff. She appeared uncomfortable and was unable to sit still and tried to reposition herself frequently. She complained of pain and some limited range of motion (ROM) to the right (R) leg. The note stated staff reported no known injury. History and review of systems (ROS) were limited due to dementia and poor historian. The practitioner note indicated nursing staff had concerns for increasing behaviors and hollering out frequently. They noted resident was difficult to redirect and console. They noted Resident #33 could often become extremely agitated. She was recently tapered off Zoloft at family request. Resident was utilizing Ativan as needed (PRN) which was helping. A record review of the Practitioner Note dated 2/5/26 written by Nurse Practitioner (NP) #2 indicated right (R) hip x-ray results note. Hip joints arthritic changes. Osteopenia of the bones. Limited study. If clinical suspicion for fracture persists, recommended CT for further evaluation. Results discussed with Resident #33 representative (RR). Resident still seemed to be in significant amount of pain. Will Continue Tramadol 25mg to help with pain at this time. The RR was given options to send out to the Emergency Department (ED) for CT scan or could schedule CT scan outpatient in a couple days. The RR chose to set up outpatient CT scan. Resident #33 was sent out for a computed tomography (CT) scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) on 2/9/26. The results showed Resident #33 had multiple serious breaks in the right hip and pelvis, as well as additional fractures in the front part of the right pelvic bones, and flattening of the superior lateral right femoral head. A review of the February Medication Administration Record (MAR) showed Resident #33 continued to have reports of pain (location not specified on some of the dates). Pain was reported on 2/1/26 (pain level a 3 on evening shift and a 6 on night shift), 2/2/26 (pain level a 4 on day shift), 2/4/26 (pain level a 7 on evening shift, right lower extremity, thigh/knee pain), 2/5/26 (pain level a 5 on day shift), 2/6/26 (pain level a 5 on evening shift), 2/7/26 (pain level a 3 on night shift), 2/8/26 (pain level a 6 on night shift), and 2/9/26 (pain level a 5 on day shift and a 6 on evening shift). Resident #33 was given Acetaminophen 500mg on 2/3/26 and 2/4/26. She was given Tramadol HCL 25mg for pain on 2/4/26, 2/6/26, and 2/9/26. She was also given Hydrocodone-Acetaminophen Tablet 5-325mg on 2/9/26. On 3/5/26 at 10:12 AM, a telephone interview was conducted with Nurse Practitioner (NP) #2. She stated she was never officially notified of Resident #33's fall on 1/28/26. She stated she ordered an x-ray on 1/30/26 due to resident's complaints of pain, not because of the 1/28/26 fall. When the x-ray was ordered on 1/30/26, the NP stated she was not notified that the x-ray had not been completed until after the fact. The NP visited the facility on Wednesdays. When she visited the facility on 2/4/26, she was notified the x-ray was not completed due to the inclement weather. The NP stated typically, the facility would call her when a resident fell. The NP stated she felt there was a slight delay in when the fall occurred and when it was reported. She was unaware of any injury at that time. When they received the x-ray results from 2/4/26, the NP spoke with the resident's family to discuss the results and recommendations. The resident's family was given the opportunity to send resident to the emergency room for a CT scan. The fall incident was still unknown at that time. The resident's family was also unaware of the fall at the time. The NP stated when she was at the facility on 1/28/26, she was not made aware of the fall. She remembered asking if there had been a known injury and no one knew anything at that time. On 2/2/26, the resident's family sent a text to the NP regarding concerns about resident's hip based on the way resident was sitting in the chair. The NP stated she and the resident's family became aware of the fall after the fact. An additional telephone interview with Nurse Practitioner (NP) #2 on 3/5/26 at 12:01 PM revealed the Director of Nursing (DON) was the person who initially notified her about resident's fall. After receiving the CT scan results of resident's fracture, the facility started their own internal investigation of Resident #33's injury and what caused it after a nurse admitted the incident. The NP #2 stated she found out about the fall on 2/11/26 when she had a meeting with the DON and Administrator to discuss what happened and what was going on. Another interview on 3/13/26 at 10:49 AM was conducted with Nurse Practitioner (NP) #2. She confirmed she was Resident #33's primary provider and she saw her the most (although the Medical Director would see resident as well). Regarding the x-ray, NP #2 stated the facility had an outside company that did portable x-rays. NP #2 stated if she had known about the fall, and it was an emergent situation, then she would have sent Resident #33 out to have the x-rays done. NP #2 stated with the knee x-ray, it was not an emergency at the time, and there was no known injury. Plus Resident #33 had arthritis, so she was OK with having the x-ray on the next available date. NP #2 stated she was made aware that the x-ray was not done on 1/30/26 when she visited the facility on 2/4/26 and asked about the results. She stated if the situation was non emergent, then it was fine to wait to have x-rays completed. However, if they had expected injury, she would have sent Resident #33 to the Emergency Room. NP #2 stated the x-ray in the facility did not show anything, it just recommended a CT scan. NP #2 revealed if she had known about the fall on 1/28/26, she possibly would have ordered a different x-ray. It would have still been determined by what Resident #33 was complaining of at the time. However, she cannot say for sure if they would have immediately gotten a hip x-ray. NP #2 then stated if a different x-ray was ordered, it possibly would have been an x-ray of the whole right leg (pelvis, knee, etc.), but again, it would be based on what staff had reported to her (such as the fall and complaints of pain). NP#2 stated she did not physically see Resident #33 on 1/30/26 but was going by what Resident #33's family member had reported to her about Resident #33 grabbing at her knee. Therefore, on 1/30/26, NP #2 ordered an x-ray of the right knee. On 2/4/26, when NP #2 visited the facility, she observed Resident #33 sitting at the nurse's station. NP #2 stated Resident #33 was really fidgety, irritable, and looked uncomfortable. Resident #33 appeared to not put any weight on her right side. NP #2 stated she completed a problem assessment where she physically touched Resident #33's leg, knee, hip, back, etc. NP #2 stated because she felt, based on her assessment and observations, Resident #33's pain was related more to the hip than her knee. Therefore, she ordered an x-ray of the right hip and pelvis. NP #2 stated Resident #33 was not able to verbalize pain but had signs of being uncomfortable and irritable. NP #2 stated irritability was not common for Resident #33. When she asked Resident #33 if she had pain, Resident #33 could say yes, yes, yes, but could not define where she was hurting. Regarding the timeframe between receiving the x-ray results and ordering the CT scan, NP #2 stated if she had known about Resident #33's fall on 1/28/26, she would have leaned towards sending Resident #33 to the hospital based on the complaints of pain and the injury, and that the x-ray results did not pick up the fractures. However, NP#2 stated she would had ultimately given Resident #33's family the options and let them decide on whether to send Resident #33 to the hospital for the CT scan or to the outpatient facility. Because NP#2 was unaware of the fall on 1/28/26, and sending residents to the emergency room is more stressful on them and it causes confusion, she felt sending Resident #33 to an outpatient facility for the CT scan at their next available date (following the x-ray) was the best option for her. An interview with the Medical Director on 3/4/26 at 10:35 AM revealed when a resident had a fall, they expected to receive a call. If it was after hours, staff would call the triage team. The providers would then visit the facility to see the resident. If residents complained of pain, they would order an x-ray. The Medical Director stated when she saw Resident #33 during her facility visit on 2/11/26, she did not appear to be in pain, nor was she complaining of pain but was agitated. The Medical Director stated her 2/11/26 visit was the first visit she had with resident after the 1/28/26 fall. Review of the hospital records revealed Resident #33 was admitted on [DATE] after a fall at the nursing facility. She had a serious break in the right hip socket and was experiencing severe pain and difficulty moving. A review of the medical record revealed a late entry Post Fall Note written by the Assistant Director of Nursing (ADON). The note was created on 2/12/26 for effective date of 1/28/26. The note indicated, nurse was notified by staff member that Resident #33 was noted to be on the floor in Resident #33's room. Nurse immediately went to assess and assist Resident #33 with staff member and medication (med) aide. Upon entering the room, Resident #33 was noted to be sitting on the floor on buttocks, positioned in front of wheelchair near entry hallway of the room. Resident #33 was assessed prior to any movement or assistance. Resident #33 was assessed prior to any movement. Resident #33 was alert and able to move all extremities or limitation beyond baseline. No apparent injuries noted at time of assessment. Wheelchair seat cushion was noted to be present on Resident #33's wheelchair. During assessment, nurse stated, 'I wonder if that made her slip out of her chair.' Staff member replied, 'She got down here by herself.' Resident #33 was assisted back into wheelchair by nurse and staff member, with med aide standing behind wheelchair for safety. Resident #33 tolerated intervention well with no indications of pain noted based on PAINAD scale. Resident #33's sneakers were placed on feet. Resident #33 was transported to nursing station for close observation. PAINAD is The Pain Assessment in Advanced Dementia (PAINAD) scale that is a validated, observational tool used to evaluate pain in patients with advanced dementia or severe cognitive impairment who cannot verbally communicate their pain. On 3/3/26 at 5:01 PM, an interview was conducted with the Assistant Director of Nursing (ADON) and the Unit Manager. The ADON and Unit Manager stated Resident #33 had a fall on 1/28/26 which resulted in her hip fracture. The Unit Manager stated the fall on 1/28/26 was unwitnessed on the evening shift. The Nurse Aide (NA) notified Nurse #7. The Nurse assessed Resident #33 prior to any movement. The Unit Manager stated there were no injuries at the time of assessment. The Unit Manager stated according to the records, Resident #33 denied pain. Her vital signs were taken, and they continued to monitor her. The ADON stated on 1/30/26, Resident #33 complained of right knee pain, her leg was swollen. The ADON read in the records that the Nurse Practitioner (NP) was notified (date not provided) and assessed Resident #33. Pain medication was ordered. Upon further reading of the medical records, the Unit Manager reported the following. On 1/31/26, x-rays could not be completed due to the snow. She stated pain medications were given to Resident #33 which were effective in pain management. The family requested the facility to wait on sending Resident #33 out at that time due to the snow. However, when the pain migrated to Resident #33's hip, the family then decided to further investigate as the hip pain was new for Resident #33. The Unit Manager continued reviewing the records and stated there was no fall between Resident #33 complaint of right knee pain and the hip. An x-ray of the knee was done on 2/5/26 and was fine. It showed Resident #33 needed a computed tomography (CT) scan. The Unit Manager further stated the CT scan was scheduled as outpatient on 2/9/26 and it was shown Resident #33 to have a broken hip. The ADON stated nurses should notify the provider, family, and management of a fall immediately after a fall or soon after. An interview with the DON on 3/5/26 at 9:30 AM revealed Resident #33's fall on 1/28/26 did not trigger the Fall Risk or the Post Fall Evaluations as the nurse [nurse #7] who assisted the resident post fall recorded the incident as an injury and not a fall in their electronic medical record (EMR) system. The DON stated the incident type of injury did not trigger their User-Defined Assessment (UDA) (fall assessments/evaluations). The DON also stated daily pain assessments were completed for Resident #33. They addressed the pain. If pain interventions were not effective, they would notify the provider. However, the DON stated when residents experienced a fall, staff were to complete an assessment, communicate with the family, provider, and management. An additional interview was completed on 3/5/26 at 4:07 PM with the Director of Nursing (DON) revealed when a resident had a fall, whoever found them had to ensure the resident was in a safe position. The nurse would do the assessment and UDA (Fall Risk and Post Risk evaluations). They would check vital signs. If the resident was in a safe secure place, staff were to notify the provider and the family. They would determine if the resident needed to go to the Emergency Room. If so, prior to going, staff would confirm with the provider and family. The DON stated once a resident was stable, whether the resident was at the facility or outside of the facility, staff would still complete the required assessments/evaluations. They would follow doctor orders and the protocol based on the situation. The DON stated Resident #33 had a CT scan on 2/9/26 and they received the results on 2/11/26. After looking at the results and resident's documented falls, they started looking at everything and started digging into what happened that resulted in the fractures. As soon as they found out about the actual fall, they notified the NP. The DON stated they figured out which nurse worked on 1/28/26 when the resident fell. However, the DON stated in the event of a fall, staff were expected to assess the resident. If a resident needed to be sent out, orders were obtained. They provided pain management as needed. The DON stated staff must notify the provider, family, and the DON of all falls. She stated they asked the nurses to do a mini investigation as to what happened (what resulted in the fall), including what the resident was doing at the time of the fall. Then staff would implement interventions. Following the fall and mini investigation, the entire management team would follow up and continue their investigation of the incident. They would ensure the proper interventions were in place. During a telephone interview on 3/13/26 at 1:18 PM, the Director of Nursing (DON) described the facility's x ray ordering and scheduling process. She stated that providers either entered imaging orders directly into the electronic medical record or instructed staff to enter them. Staff then confirmed the order and sent it to scheduling. The facility used an outside company for portable imaging. Once the company received the order, they would notify the facility of the scheduled date and time. Regarding Resident #33, the DON stated the facility had contacted the diagnostic company about the 1/30/26 ordered x ray and were initially told no technician was available, and later that the company could not come due to inclement weather. She reported this occurred over two days and acknowledged that follow up communication may not have been documented. The DON stated they followed up again while waiting for a return call. She stated the on call provider was notified on 1/31/26 about the delay, though there was not any evidence of documentation that showed the nursing staff contacting the on-all provider. The DON stated the note could have been documented in their provider on call book or it was not documented at all. She also stated the family had been informed of the weather related delay by the on-call Nurse Practitioner. The DON stated the x ray was reordered on 2/4/26 and results were received on 2/5/26 recommending a CT scan. The CT scan was completed on 2/9/26. The DON emphasized that if imaging was delayed, the facility expected staff to notify the provider, who would then determine whether new orders or alternative steps were needed. An interview on 3/5/26 at 4:33 PM was held with the Administrator. She stated following a fall, the nurses assessed the resident. They were to notify the family, the provider, and nurse supervisor. They were to chart/document what happened and provide care. The Administrator stated she would expect her staff to follow the process. The facility implemented the following Corrective Action Plan.On 01/28/2026, Resident #1 was observed on the floor at approximately 3:20 pm. Nurse #7 observed Resident #1 on the floor but did not notify the provider or the resident representative. Nurse #7 evaluated Resident #1 for pain and injury at the time of the 01/28/2026 incident. No pain or injuries were found, and the resident's vital signs were stable. However, Nurse #7 did not complete required documentation in PointClickCare, which would include the fall risk and post fall evaluation which triggers management to investigate, nor did she include the fall in the shift report.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.According to interviews conducted by the director of nursing with nurse #7 on 2/10/2026, Nurse #7 evaluated Resident #1 for pain and injury at the time of the 01/28/2026 incident. No pain or injuries were found, and the resident's vital signs were stable. Nurse #7 brought Resident #1 to sit with her in the nursing station to continue to monitor her with no signs or symptoms of pain after the fall. However, Nurse #7 did not complete required documentation in PointClickCare, which would include the fall risk and post fall evaluation which triggers management to investigate, nor did she include the fall in the shift report.On 1/29/2026, the resident complained of pain in her right knee. Multiple x-rays were performed on 1/30/26 and 2/5/26, but no injuries were identified. During this time Resident #1 was having pain management done by facility as ordered by the nurse practitioner. On 2/9/2026, the resident underwent a computed tomography (CT) scan of the right hip and pelvis due to ongoing pain and subsequently returned to the facility. The CT scan showed multiple pelvic fractures and flattening of the femoral head.On 2/11/2026, the director of nursing educated Nurse #7 on what constitutes a fall and incident and what steps to follow when a fall occurs, including resident assessment and documentation to include the incident report with both the fall risk and the post fall evaluation, and notification of the resident's provider and responsible party.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.Any resident has the potential to be affected. The following audit was conducted to evaluate residents who had the potential to be affected:The director of nursing audited all falls from 12/1/2025 to 2/13/2026 to ensure that all documentation was complete, including incident reports, assessments, fall risk and post fall evaluations and notifications. This was completed on 2/13/2026.The director of nursing and the staff development coordinator interviewed all nurses to ask about any falls or incidents that may have occurred but were not reported. This was completed on 2/13/2026. No issues identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.Education regarding What constitutes a fall and incident using Lutheran Services Carolinas' policy titled, Fall Risk Reduction and Management was started on 2/11/2026 by the staff development coordinator and completed by 2/13/2026 for all certified nursing assistants, nurses and medication aides. Nurses, medication aides and certified nursing assistants who did not receive training by this date received it prior to their next working shift. The staff development coordinator was responsible for ensuring this education was provided before the next working shift. The education included a review of:What constitutes a fallThe requirement to report a fall and incident to the resident's responsible party, physician, and director of nursing or the administrative nurse.Requirement to complete documentation in PointClickCare regarding falls assessment, which would include the fall risk and post fall evaluations. On 2/11/2026, the staff development coordinator added additional material to new hire orientation to include the following:The staff development coordinator now provides a hard copy of the policy titled, Fall Risk Reduction and Management which specifically reviews how to identify a fall and what to do when one occurs. Previously, the staff development coordinator facilitated training on falls and incidents but did not provide new teammates with a copy of the policy.A competency training document for risk management reporting in PointClickCare (electronic medical record system) was added to new hire orientation. Training for PointClickCare was previously a line item on the orientation checklist but the competency training information is now on its own document. This document includes specific training on the fall risk and post fall evaluations that will trigger management to investigate incidents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Effective 02/11/2026, the director of nursing began reviewing all falls and incidents during the clinical meeting with the Interdisciplinary team in the morning meetings to ensure all documentation and notification was complete. Any incomplete documentation will be corrected, and the director of nursing will ensure correction occurs. This will continue as an ongoing new process for the facility. Effective 2/13/2026, the director of nursing began interviewing staff for ongoing understanding of the fall management policy. Teammates were interviewed as to whether they had seen any resident on the floor and whether or not this was reported and whether they were aware of any falls that had not been reported and documented in PointClickCare. The plan was then revised on 02/25/26 to include interviewing teammates about what constitutes a fall per the policy and the steps to follow when a fall occurs including completion of a fall risk assessment which would then trigger management to investigate further. The director of nursing will complete three interviews per week for four weeks and then five interviews per month for three months.Any issues found during the auditing process will be reported by the director of nursing during the Quality Assurance Performance Improvement meeting. Changes will be made immediately, if needed.Include dates when corrective action will be completed.Compliance Date: February 14, 2026 The Corrective Action Plan was validated on 3/6/26 by reviewing the education that was provided to staff regarding falls and who must be notified. The following documents were also reviewed: annual skills check for nurses, education on completing an incident report in PointClickCare (PCC), orientation and competency checklist on completing assessments in PCC, the orientation checklist for new hires on

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan in the areas of communication and behaviors for 1 of 18 residents whose care plans were reviewed (Resident #90). Findings Included:Resident # 90 was admitted to the facility on [DATE].A review of Resident #90's behavior monitoring and interventions report revealed on 11/2/25 Resident #90 demonstrated behaviors of grabbing others, hitting others, physical aggression toward others, and agitation. On 11/3/25 Resident #90 demonstrated behaviors of hitting others, physical aggression toward others, agitation, anxiousness, and exit seeking behavior.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #90 had adequate hearing with the use of hearing aids, was usually understood, usually understood others and had no behaviors.A review of Resident #90's Care Area Assessment (CCA) summary revealed it was completed on 11/5/25 by the previous Social Work Assistant. Further review revealed the area of communication was a triggered care area. It was indicated in the CAA summary that communication would be addressed in the care plan.A review of Resident #90's care plan dated 10/20/25 with a revision date of 11/13/25 revealed no care plan had been developed or interventions included in the areas of communication or behaviors.A telephone interview was conducted on 3/4/26 at10:53 AM with the previous Social Work Assistant. She indicated that she did complete Resident #90's communication CAA summary and confirmed that Resident #90 should have had a communication care plan and stated she did not know why one had not been developed. The previous Social Work Assistant indicated that she did not review the behavioral monitoring and intervention report that was in the electronic medical record. The previous Social Work Assistant explained she had based her answers on Resident #90's behavior during the assessment, and she did not show any behaviors at that time. She further revealed that she did not know she needed to review the electronic medical record for documentation of behaviors.An interview was conducted with the Director of Nursing (DON) on 3/4/26 at 11:08 AM. She indicated that Resident #90 should have had communication and behavior care plans and was not sure why they had not been completed.

Based on record review, resident representative and staff interviews, the facility failed to develop a baseline care plan that addressed the resident's immediate needs related to fall prevention and pain management for 1 of 12 residents reviewed for baseline care plans (Resident #3).The findings included:Review of the FL2 (a North Carolina Medicaid form that documents a patient's medical condition and needs for long term care facilities) completed 12/18/25 revealed Resident #3 had a diagnosis of chronic neck pain, chronic pain syndrome, and mild dementia. A review of Resident #3's hospital discharge summary indicated his Resident Representative (RR) reported Resident #3 had experienced a cognitive and functional decline slowly over the past serval months and the week prior to hospitalization Resident #3 was not able to ambulate as easily with his walker and had increased confusion. The discharge summary also indicated Resident #3 was discharged on 12/22/25 with diagnoses of chronic pain syndrome, chronic neck pain, and mild dementia. A review of the hospital history and physical revealed a provider progress note dated 12/16/25 that indicated Resident #3 presented with generalized weakness, acute renal failure likely related to dehydration, that likely resulted from his balance disorder and severe major neurocognitive disorder. In addition, the progress note indicated an active problem of debility, other reduced mobility, and impaired mobility due to medical condition present on admission.Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, and mild dementia with other behavioral disturbance. Review of Resident #3's fall risk evaluation completed on admission to the facility on [DATE] indicated Resident #3 was considered at high risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #3's physician order dated 12/22/25 to administer acetaminophen extended released 650 milligrams (mg) by mouth every eight hours as needed for pain. Review of Resident #3's physician order dated 12/23/25 to apply lidocaine (a topical anesthetic used to provide temporary localized pain relief) 4 % patch to the lower back topically every morning for pain. Apply morning and remove it at bedtime. Review of the baseline care plan dated 12/23/25 completed by the Minimum Data Set (MDS) Nurse #1 revealed no goal or interventions for Resident #3's diagnosis of chronic pain syndrome and did not include a plan that addressed Resident #3's immediate need related to fall risk prevention. An interview with MDS Nurse #1 on 3/9/26 at 9:35 AM, indicated that the baseline care plan was completed within 48 hours of admission that included transfer status, therapy, and dietary and covered all disciplines. She further indicated that she felt Resident #3's baseline care plan met the minimum requirements for basic safety. An interview was conducted with Resident #3's Resident Representative on 3/5/26 at 10:14 AM. She indicated Resident #3 had a history of chronic pain and required pain medication to keep him comfortable. She explained that his pain continued after admission to the facility. The Resident Representative also expressed that she felt Resident #3 was at a high risk for falls due to his physical and mental condition. She stated she would have wanted staff to be aware of Resident #3's chronic pain and fall risk. An interview was conducted with the Director of Nursing (DON) on 3/5/26 at 10:48 AM. She indicated that the baseline care plan should include the minimum healthcare information necessary to meet a resident's needs. She further indicated that Resident #3's baseline care plan should have included information related to being at high risk for falls so that the staff would be aware of that risk and know what interventions were needed. The DON indicated she did not know why this was not included in the baseline care plan. A follow-up telephone interview was conducted with the DON on 3/13/26 at 11:41 AM. The DON indicated that Resident #3's baseline care plan should have also included information related to pain and she did not know why this had not been included. An interview was conducted with the Administrator on 3/04/2026 at 12:12 PM. She indicated that the baseline care plan should include the minimum healthcare information for a resident upon admission.

Based on record review and staff interviews, the facility failed to code a Minimum Data Set (MDS) assessment in the areas of intravenous (IV) midline access (specialized vascular access device designed for patients requiring IV therapy for a moderate length of time), and IV antibiotic medication use (Resident #99) and insulin medication use (Resident #95) and behaviors (Resident #90) for 3 of 18 residents whose MDS assessments were reviewed.The findings included: 1. Resident #99 was admitted on [DATE] with a diagnosis of pneumonia (a severe, rapidly progressing lung infection) and meningitis (an inflammation of the brain lining and spinal cord) requiring IV access and IV antibiotic medications. Record review of the admission summary dated [DATE] at 3:35 PM by Nurse #4 for Resident #99 indicated he arrived at the facility with an IV access in his right antecubital fossa (the inner bend of the right elbow) and was to continue receiving IV antibiotic medication. Review of physician orders dated 12/10/2025 at 6:21 PM revealed an order for ceftriaxone sodium (an antibiotic) IV solution 2 grams to be given every 12 hours for meningitis for 13 days. An additional physician order dated 12/11/2025 at 10:01 AM indicated to flush the right arm IV access and then clamping off. Review of the Medication Administration Record (MAR) for December 2025 indicated antibiotic medication was administered intravenously (IV) on 12/10/2025, 12/11/2025, and 12/12/2025. The MAR further revealed orders for saline flush to the IV access every shift. Review of Nurse Practitioner progress note dated 12/11/2025 indicated Resident #99 was receiving IV antibiotic medications and had peripheral IV access in place in the right arm. The IV antibiotic medication was to continue through the midline catheter (a long peripheral venous access inserted into an upper arm vein). The discharge return not anticipated assessment dated [DATE] did not indicate Resident #99 had midline IV access or had received IV antibiotics upon admission, while a resident or at discharge from the facility. An interview conducted with the MDS Nurse on 3/3/2026 at 11:41 AM. The MDS Nurse indicated she completed the MDS for Resident #99. After reviewing the MDS dated [DATE] she stated the IV access and use of IV antibiotic medication was not marked for Resident #99 and this was an error. An interview conducted with the Director of Nursing (DON) 3/3/2026 at 2:31 PM revealed she was a part of an interdisciplinary team that worked together to comb though the resident's medical record to capture the full picture of the resident's overall condition. She further revealed coding correctly was the expectation with the MDS assessments. An interview conducted with the Administrator 3/5/2026 at 10:53 AM revealed she expected all MDS to be coded accurately. 2. Resident #95 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus with hyperglycemia (high blood glucose). Review of physician orders dated 1/25/26 revealed an order for Tirzepatide (a medication to improve blood sugar control) 0.5 milliliters subcutaneously on Sunday for diabetes mellitus type 2. A review of Resident #95's Medication Administration Record (MAR) from 1/23/26 to 1/29/26 revealed she was administered an injection of Tirzepatide 0.5 milliliters subcutaneously on 1/25/26. The MAR did not indicate Resident #95 had received an injection of insulin. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was coded for one insulin injection. An interview was conducted with MDS Nurse #1 on 3/9/26 at 3:45 PM. She indicated she had coded one insulin injection on Resident #95's admission MDS because she thought Tirzepatide was considered insulin. MDS Nurse #1 further revealed that after a review she realized Tirzepatide was not insulin and that she had coded this incorrectly. An interview conducted with the Administrator 3/5/2026 at 10:53 AM revealed she expected all MDS to be coded accurately. 3. Resident #90 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. Review of the Behavior Monitoring and Intervention Report for the month of November 2025 revealed Resident #90 demonstrated behaviors of grabbing others, hitting, physical aggression and agitation on 11/2/25. The report also indicated that behaviors of hitting others, physical aggression toward others, agitation, anxiousness, and exit seeking behavior occurred on 11/3/25. Review of a progress note authored by Nurse #10 dated 11/3/25 indicated Resident #90 has been yelling since this morning when gotten up by the nursing assistants and later threw her Med Pass (a nutritional supplement). Review of a progress noted authored by the Administrator dated 11/4/25 indicated Resident #90 demonstrated mood/behavior indicators of yelling, angry, throwing med, hitting, grabbing, agitated, anxious, restless, refusing care, and wandering on the unit. The admission Minimum Data Set with an Assessment Reference Date (ARD, the last day of the look-back period) of 11/5/25 revealed Resident #90 was severely cognitively impaired, received antianxiety medication and had no behaviors. A telephone interview was conducted with the previous Social Work Assistant on 3/4/26 at 10:43 AM. The Social Work Assistant indicated she was aware that Resident #90 had exhibited combative and resistive behaviors however during the admission MDS assessment period she did not observe these behaviors and therefore did not code them on the MDS. The previous Social Work Assistant further explained that she was not aware that she needed to review the electronic medical record for documented behaviors and was not aware that any behaviors had been documented. An interview was conducted with Administrator on 3/3/26 at 2:04 PM. The Administrator indicated she documented the progress note on 11/4/25 regarding Resident #90's behaviors and that these behaviors were discussed in their weekly meetings with administrative staff. She further revealed that due to Resident #90's behaviors and cognitive impairment she was transferred to the memory care unit on 11/10/25. The Administrator indicated that the Social Work Assistant should have coded Resident #90's behaviors on the admission MDS assessment and did not know why the social worker did not code the MDS correctly.

Based on record reviews, resident representative, staff, Medical Director and Nurse Practitioner (NP) interviews, when the facility notified the nurse practitioner (NP) and responsible party (RP) of knee pain on 1/30/26, the facility failed to inform the NP and RP the resident had fallen on 1/28/26. This affected medical diagnostics and treatment. The deficient practice affected 1 of 5 residents reviewed for accidents (Resident #33). The findings included:Resident #33 was admitted to the facility on [DATE] with diagnoses of non-Alzheimer's dementia, adult failure to thrive, history of falling, and hypertension. On 3/5/26 at 10:39 AM, a telephone interview was conducted with Nurse #7. She stated she had just gotten to work for her 3p-7p shift on 1/28/26 and had received the report from the previous first shift Nurse (Nurse #7 did not provide the Nurse's name but according to the nursing daily assignment sheet, the previous shift nurse was Nurse #5) when the Scheduler advised her of Resident #33's fall. She was unsure of what events took place prior to the fall. Nurse #7 stated she, the Medication Aide, and the Scheduler went into Resident #33's room to find Resident #33 sitting on the floor in front of her wheelchair. Nurse #7 stated she assessed Resident #33, checked her range of motion, and asked if she was having any pain. Resident #33 said no. Nurse #7 stated she was under the impression Resident #33's fall was witnessed because she thought the Scheduler saw it. Nurse #7 stated she did not notify the provider, the family, or the Director of Nursing (DON) on 1/28/26 of the fall. A review of the January Medication Administration Record (MAR) revealed Resident #33 started complaining of right knee pain on 1/30/26 at a level 4 out of 10 (0 - 10 pain scale with 10 being the worst possible pain) on evening shift. Resident was given Acetaminophen Oral Tablet 500 milligrams (MG). Review of the Health Status Note dated 1/30/26 entered by Nurse #11 indicated Nurse #11 notified the Nurse Practitioner (NP) of Resident #33's complaint of pain in her knee and that it was slightly swollen. An x-ray was ordered by NP #2. The resident's family visited and was also notified of the complaint of the right knee pain. A review of the February Medication Administration Record (MAR) showed Resident #33 continued to have reports of pain (location not specified on some of the dates). Pain was reported on 2/1/26 (pain level a 3 on evening shift and a 6 on night shift), 2/2/26 (pain level a 4 on day shift), 2/4/26 (pain level a 7 on evening shift, right lower extremity, thigh/knee pain), 2/5/26 (pain level a 5 on day shift), 2/6/26 (pain level a 5 on evening shift), 2/7/26 (pain level a 3 on night shift), 2/8/26 (pain level a 6 on night shift), and 2/9/26 (pain level a 5 on day shift and a 6 on evening shift). Resident #33 was given Acetaminophen 500mg on 2/3/26 and 2/4/26. She was given Tramadol HCL 25mg for pain on 2/4/26, 2/6/26, and 2/9/26. She was also given Hydrocodone-Acetaminophen Tablet 5-325mg on 2/9/26. Resident #33 was sent out for a computed tomography (CT) scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) on 2/9/26. The results showed Resident #33 had multiple serious breaks in the right hip and pelvis, as well as additional fractures in the front part of the right pelvic bones, and flattening of the superior lateral right femoral head. On 3/3/26 at 5:01 PM, an interview was conducted with the Assistant Director of Nursing (ADON) and the Unit Manager. The ADON and Unit Manager stated Resident #33 had a fall on 1/28/26 which resulted in her hip fracture. The Unit Manager stated the fall on 1/28/26 was unwitnessed on the evening shift. The Nurse Aide (NA) notified Nurse #7. The Nurse assessed Resident #33 prior to any movement. The Unit Manager stated there were no injuries at the time of assessment. The Unit Manager stated according to the records, Resident #33 denied pain. Her vital signs were taken, and they continued to monitor her. The Unit Manager stated, while they were reviewing the medical record, Resident #33's family was notified of the fall but a specific date was not provided during this interview. The ADON stated on 1/30/26, Resident #33 complained of right knee pain, her leg was swollen. The ADON read in the records that the Nurse Practitioner (NP) was notified (date not provided) and assessed Resident #33. Pain medication was ordered. Upon further reading of the medical records, the Unit Manager reported the following. On 1/31/26, x-rays could not be completed due to the snow. The family requested the facility to wait on sending Resident #33 out at that time due to the snow. However, when the pain migrated to Resident #33's hip, the family then decided to further investigate as the hip pain was new for Resident #33. An x-ray of the knee was done on 2/5/26 and was fine. It showed Resident #33 needed a computed tomography (CT) scan. The Unit Manager further stated the CT scan was scheduled as outpatient on 2/9/26 and it was shown Resident #33 to have a broken hip. The ADON stated nurses should notify the provider, family, and management of a fall immediately after a fall or soon after. On 3/5/26 at 10:12 AM, a telephone interview was conducted with Nurse Practitioner (NP) #2. She stated she was never officially notified of Resident #33's fall on 1/28/26. She did not receive a call notifying her of Resident #33's fall on 1/28/26. NP #2 stated she ordered an x-ray due to Resident #33's complaints of pain on 1/30/26. NP #2 stated she was not notified that the x-ray had not been completed until after the fact. NP #2 visited the facility on Wednesdays. When she visited the facility on 2/4/26, she was notified the x-ray was not completed due to the snow. NP #2 stated typically, the facility would call her when a resident fell. NP #2 stated she felt there was a slight delay in when the fall occurred and when it was reported. She was unaware of any injury at that time. When they received the x-ray results from 2/4/26, NP #2 spoke with Resident #33's family to discuss the results and recommendations. Resident #33's family was given the opportunity to send Resident #33 to the emergency room for a CT scan. The fall incident was still unknown at that time. Resident #33's family was also unaware of the fall at the time. NP #2 stated when she was at the facility on 1/28/26, she was not made aware of the fall. She remembered asking if there had been a known injury and no one knew anything at that time. On 2/2/26, Resident #33 's family member sent a text to NP #2 regarding concerns about Resident #33's hip based on the way Resident #33 was sitting in the chair. NP #2 stated she and Resident #33's family member became aware of the fall after the fact. An additional telephone interview with Nurse Practitioner (NP) #2 on 3/5/26 at 12:01 PM revealed the Director of Nursing (DON) was the person who initially notified her about Resident #33's fall on 2/11/26. After receiving the CT scan results of Resident #33's fracture, the facility started their own internal investigation of Resident #33's injury and what caused it after a nurse admitted the incident. On 3/5/26 at 12:09 PM, a telephone interview was completed with Resident #33's representative (RR). The RR stated she was not notified of Resident #33's fall on 1/28/26. The first time she was ever made aware of the fall was in February after Resident #33's CT scan when she discussed the results with NP #2. The RR was not able to provide an exact date of the notification. Review of the hospital records revealed Resident #33 was admitted on [DATE] for a displaced transverse-posterior fracture of the right acetabulum (socket of the hipbone) and severe pain with functional decline after experiencing a fall at her nursing facility. An interview with the Medical Director on 3/4/26 at 10:35 AM revealed when a resident had a fall, they expected to receive a call. If it was after hours, staff would call the triage team. The providers would then visit the facility to see the residents. If residents complained of pain, they would order an x-ray. The Medical Director became aware of the 1/28/26 fall on 2/11/26 through record review in preparation of her visit with Resident #33. An interview with the DON on 3/5/26 at 9:30 AM revealed Resident #33's fall on 1/28/26 did not trigger the Fall Risk or the Fall Post Evaluations as the Nurse who assisted Resident #33 post fall recorded the incident as an injury and not a fall in their electronic medical records system. The DON stated the incident type of injury did not trigger their User-Defined Assessment (UDA) (fall assessments/evaluations). However, the DON stated when residents experienced a fall, staff were to complete an assessment, and communicate with the family, provider, and management immediately after a fall. An interview on 3/5/26 at 4:33 PM was held with the Administrator. She stated following a fall, the nurses assessed the resident. They were to notify the family, the provider, and nurse supervisor. They were to chart/document what happened and provide care. The Administrator stated she would expect her staff to follow the process. The facility implemented the following Corrective Action Plan.On 01/28/2026, Resident #1 was observed on the floor at approximately 3:20 pm. Nurse #7 observed Resident #1 on the floor but did not notify the provider or the resident representative. The provider and the resident representative were still not notified that the resident was noted on the floor on 1/28/2026 when they were notified of the pain beginning two days later.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.Based on interviews with Nurse #7, Resident #1 was assessed for pain and injury by Nurse #7 at the time of the incident on 01/28/2026. No pain or injury was observed or noted by Nurse #7.On 1/30/2026, the electronic medical record reflects that Resident #1 reported pain to her right knee. Resident #1's daughter and the nurse practitioner were notified of the pain on this date; however, they were not notified that the resident had been observed on the floor two days prior. On 1/30/2026, the nurse practitioner ordered an x-ray. X-rays were obtained on the following dates: 1/30/26 and 2/5/26. No injuries noted on either of the x-rays. Resident #1's pain was being addressed and managed by the facility, and Resident #1 continued to be active and attempting self-transfers and walking. The second x-ray noted if pain persisted that a computerized tomography (CT) scan should be considered. The resident went for a computerized tomography scan on 2/9/26 at an outpatient clinic, the results showed fractures in several locations in Resident #1's pelvis and flattening of the femoral head due to impaction fracture. Nurse #7 was educated on the requirement to notify the provider and the resident representative of any incident including falls (whether observed or not) by the director of nursing on 2/10/2026. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.Any resident could be affected. The following audit was conducted to evaluate residents who had the potential to be affected:The director of nursing conducted a 100% audit of all reported falls from 12/1/25 through 02/13/26 in the electronic medical record to check compliance for appropriate notification. No issues identified that hadn't already been addressed. Completed on 2/13/2026. The director of nursing and the staff development coordinator interviewed all nurses to ask if they were aware of any potential fall or incident that may have occurred but was not reported. This was completed on 2/13/26. No issues identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.Education regarding Notification of Falls and Incidents was started on 2/11/2026 by the staff development coordinator and completed by 2/13/2026 for all nurses, certified nursing assistants and medication aides. Nurses, certified nursing aides, and medication aides who did not receive training by this date received it prior to their next working shift; the staff development coordinator was responsible for ensuring no one worked after 2/13/2026 without being trained. On 2/11/2026, the staff development coordinator added additional material to new hire orientation to include the following:The staff development coordinator now provides a hard copy of the policy related to Falls and Incidents and specifically reviews how to identify a fall and what to do when one occurs. Previously, the staff development coordinator facilitated training on falls and incidents but did not provide new teammates with a copy of the policy.A competency training document for risk management reporting in PointClickCare (electronic medical record system) was added to new hire orientation. Training for PointClickCare was previously a line item on the orientation checklist but the competency training information is now on its own document.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Effective 2/11/26, the director of nursing will audit the electronic medical record for appropriate notification to the provider and responsible party regarding falls at the following frequency:Five falls per week for five weeksTen falls per month for three monthsEffective 2/13/26, the director of nursing will interview staff for ongoing understanding of proper identification of a fall as well as reporting a fall to ensure proper documentation is captured in the record. The audit will be completed at the following frequency:Three interviews per week for five weeksTen interviews per month for three months Any issues found during the auditing process will be reported by the director of nursing during the Quality Assurance Performance Improvement meeting. Changes will be made immediately, if needed.Include dates when corrective action will be completed.Compliance Date: February 14, 2026 The Corrective Action Plan was validated on 3/6/26 by reviewing the education that was provided to staff regarding falls and who must be notified. The following documents were also reviewed: annual skills check for nurses, education on completing an incident report in PointClickCare (PCC), orientation and competency checklist on completing assessments in PCC, the orientation checklist for new hires on falls, audit of staff on proper fall identification and reporting, and the policies of What Constitutes a Fall and Fall Risk Reduction and Management. The compliance date of 2/14/26 was validated.

Based on interviews with the staff, Nurse Practitioner (NP), and Medical Doctor (MD), and Emergency Medical Services (EMS), hospital, and facility record reviews, the facility failed to correctly identify a resident when the medications ordered for one resident were inadvertently administered to another resident. This occurred for 1 of 3 resident (Resident #1) whose medications were reviewed. The findings included: Resident #1 was admitted to the facility on [DATE] with cumulative diagnoses which included a history of hypertensive heart disease with heart failure, atrial fibrillation (a type of heart arrythmia), and dementia with behaviors. A review of the resident's electronic medical record (EMR) indicated her 4/15/25 admission physician's orders included the following: --17 micrograms (mcg) per actuation ipratropium (an oral inhalation medication used to treat asthma and/or chronic obstructive pulmonary disease) to be inhaled as two puffs orally every 6 hours as needed for shortness of breath; --6.25 milligrams (mg) carvedilol (an antihypertensive medication used to treat high blood pressure and/or atrial fibrillation) to be given as one tablet by mouth twice daily; --125 mcg (5000 units) cholecalciferol (a Vitamin D supplement) to be given as one capsule by mouth one time a day; --40 mg citalopram (an antidepressant medication) to be given as one tablet by mouth one time a day; --5 mg apixaban (an oral anticoagulant) to be given as one tablet by mouth two times a day; --600 mg guaifenesin (an expectorant used to thin mucous secretions) extended release (ER) to be given as one tablet by mouth every 12 hours as needed for congestion; --20 mg pantoprazole (a medication used to treat acid reflux) to be given as one tablet by mouth one time a day; and, --100 mg quetiapine (an antipsychotic medication) to be given as one tablet by mouth at bedtime. An order was also received on 4/15/25 to check the resident's vital signs every day and evening shift. The resident's 4/22/25 admission Minimum Data Set (MDS) reported Resident #1 had severely impaired cognition. Resident #1's EMR included her vital sign results from 4/15/25 through 4/23/25. This review revealed Resident #1's blood pressure (BP) and pulse (P) readings were variable. The low and high readings for her BP and pulse from 4/15/25 - 4/23/25 included the following: --On 4/16/25 at 9:46 AM, her BP was documented to be 147/84 (a high BP reading for this resident); --On 4/16/25 at 9:46 AM, her pulse was documented to be 61 beats per minute (lowest pulse reading); --On 4/18/25 at 9:54 AM, the resident's pulse was documented to be 81 beats per minute (highest pulse reading); --On 4/21/25 at 3:40 PM, the resident's BP was documented to be 105/64 (a low BP reading for this resident). A Medication (Med) Error Report dated 4/24/25 at 10:50 AM documented that a medication error was reported to have occurred on 4/24/25 at 10:00 AM by Medication Aide (Med Aide) #1. The Medication Error Report indicated this med error involved the wrong medication, administration procedure not followed, and the wrong resident. Medications mistakenly administered to Resident #1 included the following: --1 tablet of 10 mg amlodipine (an antihypertensive medication); --1 tablet of 81 mg aspirin; --1 tablet of 5 mg benazepril (an antihypertensive medication); --1 tablet of 10 mg buspirone (an antianxiety medication); --1 tablet of 20 mg citalopram (an antidepressant); --1 tablet of 5 mg oxybutynin XL (an extended release formulation of a medication used to treat overactive bladder); --2 tablets of 100 mg docusate (a stool softener); --1 spray in each nostril of 50 mcg fluticasone nasal spray (a steroid used to treat inflammation due to allergies); --1 tablet of 40 mg pantoprazole (a medication used to treat acid reflux); --1 tablet of 0.5 mg risperidone (an antipsychotic medication); --1 tablet of 100 mg trimethoprim (an antibiotic); --1 drop of 0.4-0.3% Systane eye drops (a lubricant eye drop) instilled into each eye; --1 tablet of 10 mg hydralazine (an antihypertensive medication). The Med Error Report noted the resident's NP was notified of the error on 4/24/25 at 10:55 AM and the MD was notified on 4/24/25 at 11:00 AM. The provider spoke with the resident's Responsible Party (RP) and ordered the resident to be sent to the Emergency Department (ED). An initial interview was conducted on 4/29/25 at 2:10 PM with Med Aide #1 in the presence of the facility's Director of Nursing (DON). Med Aide #1 was identified as the staff member who mistakenly administered another resident's medications to Resident #1 on 4/24/25. The Medication Aide reported she administered Resident #1's morning medications to her around 8:20 AM. At that time, the resident was not wearing her glasses or holding a stuffed animal. During the morning medication pass, she noticed a therapist had come to the hall to get Resident #2 for a therapy session, so she initially skipped over giving Resident #2 her morning medications. A while later (around 10:00 AM), she saw Resident #1 sitting in the TV room. She thought Resident #1 was Resident #2 because she looked quite different (she was now wearing her glasses and holding a stuffed animal). Med Aide #1 stated when she approached Resident #1, she addressed her by Resident #2's name, and Resident #1 responded. She then administered Resident #2's morning medications to Resident #1. Med Aide #1 reported that about one hour or so later, she realized she had made an error and reported it to the nurse (Nurse #1). Resident #1's EMR included a Health Status Note dated 4/24/25 at 11:57 AM and authored by Nurse #1. Nurse #1 was the hall nurse assigned to care for Resident #1 on the first shift of 4/24/25. The note read, Resident was given the wrong medications this am [morning], NP notified and advised for resident to be sent out to be evaluated, POA [Power of Attorney] notified and came to the building. BP 110/68, resident is alert no signs of pain or distress at this time. EMT [Emergency Medical Technicians] were called and are taking resident to [name of hospital]. A telephone interview was conducted on 4/29/25 at 2:26 PM with Nurse #1. When asked, Nurse #1 recalled what transpired the morning of 4/24/25. She reported that Med Aide #1 came and told her that she thought she accidentally gave Resident #1 someone else's medications. The nurse told the med aide to check Resident #1's blood pressure a couple of times to be sure she was doing okay while she herself informed the facility's Director of Nursing (DON), NP (who happened to be in-house), and resident's RP of the incident. She stated the DON and NP joined her as they came to check on Resident #1 and talk with the resident's family member (who came to the facility). When asked if the resident had a change in condition, Nurse #1 stated she did not. Nurse #1 recalled her first BP was a little low (99/63), but when her BP was taken again it was 110/68. However, she reported the decision was made to send the resident out for evaluation as a precautionary measure. Meanwhile, staff stayed with the resident at the nursing station until Emergency Medical Services (EMS) arrived. An NP Encounter Note dated 4/24/25 reported the resident was seen on this date per staff request due to a medication error. The notes read, in part: Staff nurse reports that resident was given her scheduled am [morning] medication and was also administered another resident's am [morning] medication . She reported the resident was sitting up in a wheelchair and described her as, alert and oriented at her baseline. She is in no acute distress. She denies pain, dizziness, headache, light-headedness. She is speaking in full sentences. No apparent adverse reactions. Staff nurse reports BP of 99/63. The NP's plan of care noted, .She was stable, at her baseline, in no acute distress. BP 110/68 prior to transfer . An interview was conducted on 4/29/25 at 12:02 PM with the NP. During the interview, the NP recalled she initially saw Resident #1 as a new admission on 4/21/25. On 4/24/25, the nurse notified her that the resident accidentally received her own morning medications plus those intended for another resident. The NP stated she reviewed the additional medications given to the resident and was primarily concerned about a potential drop in her blood pressure. The NP also noted that since Resident #1 was accidentally given another antipsychotic med, she wanted to have her monitored for potential drowsiness. She reported that although the decision was made to send Resident #1 out to the hospital for further evaluation, her BP was 110/68 prior to leaving the facility and the resident was very stable. The NP added, Absolutely she's had no reactions. The EMS Report related to the transportation of Resident #1 from the facility to the hospital ED on 4/24/25 was reviewed. The Incident Times listed indicated the call was received from the facility on 4/24/25 at 11:50 AM with EMS on scene at 12:00 PM and departing the scene at 12:13 PM. The resident's vital signs were noted at 12:21 PM to include a BP of 118/58 and pulse of 59 bpm. EMS arrived at the hospital ED at 12:25 PM. A narrative of the EMS Report read in part, No interventions were rendered at this time. The pt [patient] was monitored in route to the facility of family's choice. Care was transferred to the ED RN [Registered Nurse]. The hospital ED records were received and reviewed. An ED Provider Note dated 4/24/25 at 12:55 PM noted the resident was alert and at baseline. Vital signs taken at 12:36 PM included BP 113/54 and at 12:40 PM her pulse was 59. The provider noted he reviewed the meds given incorrectly and noted There are couple antihypertensives and some medicine that can cause sedation. Discussed with family will give IV [intravenous] fluid bolus and monitor overnight. An ED Extended Stay Discharge Note dated 4/25/25 at 9:04 AM read, in part: There were all single dose meds and none were especially worrisome. She remained stable overnight. This morning she is asymptomatic and her family feels that she is at her baseline. Her vitals remained normal overnight and she has been stable during the 20 hour ED visit. Resident #1 was discharged back to the facility on [DATE]. An interview was conducted on 4/29/25 at 2:41 PM with the facility's Medical Director, who was also Resident #1's Medical Doctor (MD). During the interview, the MD reported she was made aware of the 4/24/25 medication error involving Resident #1. When asked, the MD reported the main concern with this situation was about the extra BP medications the resident received. She stated she agreed with the NP in recommending the resident be sent out to the hospital. The MD reported sending her out was more precautionary than anything else. The resident wasn't dizzy, light-headed, or showing any concerning signs or symptoms prior to leaving the facility and she was at her baseline. Upon inquiry, the MD stated she was told the resident did receive fluids in the ED. She added that Resident #1 did not experience any adverse drug effects. An interview was conducted on 4/30/25 at 8:55 AM with the facility's DON. During the interview, the DON was asked what her expectations were for the nursing staff when conducting medication administration. She responded by saying, That they follow their administration guidelines related to the 6 rights [referring to the right person, right medication, right dose, right time, right route, and right documentation].

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours, licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 4 2024 July 1-September 30). Findings included: Review of the PBJ for Fiscal Year Quarter 4 2024 (July 1- September 30) revealed there were no Registered Nurse (RN) hours for 9/1/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/11/24,9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/18/24, 9/19/24 9/23/24, 9/24/24 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24. The PBJ report also noted the facility failed to have licensed nursing coverage 24 hours per day for 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24. Review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for 9/1/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/11/24,9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/18/24, 9/19/24 9/23/24, 9/24/24 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24 were reviewed and revealed there were RN hours for Quarter 4 of the fiscal year 2024. The Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24 were reviewed and revealed there were 24-hour per day licensed nursing coverage for Quarter 4 of the fiscal year 2024. An interview was conducted on 1/16/25 at 9:37 AM with the Human Resources Payroll Manager who revealed she was responsible for entering all nursing hours into the payroll system. The Human Resources Payroll Manager stated she recalled that she received notice on 10/10/24 that PBJ data file she submitted for September of 2024 was rejected. She further revealed that she was able to make the corrections and resubmitted the file on 11/14/24 and it was accepted. During an interview on 1/16/25 at 10:31 AM with the Administrator she revealed the PBJ data was submitted based on the information entered by the Human Resources Manager. The Administrator stated the facility had RN hours and licensed nursing staff as required but there must have been an error when the data was reported. She further revealed that the error was corrected as of 11/14/24. The facility implemented the following Corrective Action Plan with a completion date of 11/15/24. On 10/10/24 Validation for PBJ report with an error code. The error was noted and corrected prior to midnight of 11/15/24 deadline. An accepted validation report was received on 11/14/24. On 11/14/24, a monthly PBJ report audit was initiated by the Human Resources Payroll Manager and the Administrator for the previous months July 2024 and August 2024 to determine if any errors occurred . The audit revealed no errors for July 2024 and August 2024. Education on PBJ reporting accuracy was provided to the Human Resources Payroll Manager by the Administrator on 11/14/24. The Administrator will audit monthly PBJ Validation Reports for the months of October 2024-January 2025 to confirm that the reports were accepted without error. The results of the audits will be discussed during the QAPI monthly meetings for the next two quarters and reevaluated for resolution. The facility's alleged compliance date was 11/15/24. The Corrective Action Plan was validated on 1/17/25 and concluded the facility had implemented an acceptable corrective action plan on 11/15/24. An Interview was conducted with the Human Resource Payroll Manager revealed she received education on PBJ reporting accuracy on 11/14/24. The audits conducted on 11/14/24 revealed no errors for the months of July 2024 and August 2024. The audits conducted for October 2024 through December 2024 revealed errors for October 2024 and November 2024 which were all corrected and accepted. A review of the Quality Assurance and Performance Improvement (QAPI) minutes on 11/15/24 revealed the PBJ validation audits were discussed. The correction date of 11/15/24 was validated.

Based on staff interviews and record reviews the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper medical record for 1 of 1 resident reviewed for advance directive (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE]. Resident #48's electronic medical record (EMR) revealed a physician's order dated 12/12/24 that read full code. Review of Resident #48's paper medical record located at the nurse's station revealed Resident #48 had a signed Do Not Resuscitate (DNR) form dated 12/16/24. Resident #48's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was moderately cognitively impaired. Resident #48's EMR showed a communication banner on the top of Resident #48's opened EMR and her code status read full code. An interview was conducted with Nurse #1 on 1/15/25 at 9:01 AM. During the interview, Nurse #1 indicated if there was an emergency she needed to know code status she would check the hard chart (paper medical record) first. Nurse #1 indicated that if there was a discrepancy between the hard chart and EMR she would check with the Director of Nursing (DON). Nurse #1 verified discrepancy that Resident #48's paper medical record indicated a DNR and her EMR read full code. An interview was conducted on 1/15/25 at 9:07 AM with the DON and revealed if an emergency were to happen, staff should check the hard chart located in the binder at the nurse's station to see if there is a DNR. The interview further revealed it was her expectation that the EMR and paper medical record match. An interview was conducted on 1/16/25 at 3:16 PM with the Administrator and it was revealed it was her expectation that the paper medical record and EMR should match.

Based on observations, record review, and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 3 of 3 residents (Residents #57, #69, and #48) reviewed for respiratory care. The findings included: a. Resident #57 was admitted to the facility on [DATE] with pneumonia due to hemophilus influenzae (bacteria in the upper respiratory tract). A review of Resident #57's physician orders revealed an order dated 12/10/24 for oxygen to be administered continuously via nasal cannula at 1 Liter/minute. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #57 was coded for receiving oxygen. An observation on 1/15/25 at 10:52 AM revealed Resident #57 was sitting in her wheelchair by her door with oxygen being administered via portable oxygen tank via nasal cannula at 1 L/minute. There was no cautionary or safety signage posted at the entrance to Resident #57's room to indicate oxygen was in use. An observation of Resident #57 conducted on 1/16/25 at 8:56 AM revealed she was sitting in a wheelchair in her room with oxygen being administered via nasal cannula at 1 L/minute. There was no cautionary or safety signage posted at the entrance to Resident #57's room to indicate oxygen was in use. b. Resident #69 was admitted to the facility on [DATE] with acute respiratory failure with hypoxia. A review of Resident #69's physician orders revealed an order dated 12/23/24 for oxygen that may titrate up to 2 Liters/minute continuously via nasal cannula to maintain oxygen saturation of greater than 90%. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #69 was coded for receiving oxygen. An observation on 1/13/25 at 11:15 AM revealed Resident #69 was sitting in his wheelchair in his room with oxygen being administered via nasal canula at 1.5 L/minute. There was no safety signage posted at the entrance to Resident #69's room to indicate oxygen was in use. An observation on 1/15/25 at 2:29 PM revealed that Resident #69 was sitting in his wheelchair in his room with oxygen being administered via nasal canula at 2 L/minute. There was no safety signage posted at the entrance to Resident 69's room to indicate oxygen was in use. c. Resident #48 was admitted to the facility on [DATE] with pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. A review of Resident #48's physician orders revealed an order dated 12/13/24 for 2 L/minute of oxygen continuously via nasal cannula. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #48 was coded for receiving oxygen. An observation on 1/13/25 at 10:44 AM revealed Resident #48 was sitting in her wheelchair in her room with oxygen being administered via nasal cannula at 2 L/minute. There was no safety signage posted at the entrance to Resident #48's room to indicate oxygen was in use. An observation on 1/15/25 at 2:16 PM revealed Resident #48 was sitting in her wheelchair in her room with oxygen being administered via nasal canula at 2 L/minute. There was no safety signage posted at the entrance to Resident #48's room to indicated oxygen was in use. An interview with the Director of Nursing (DON) was conducted on 1/16/25 at 10:15 AM. She indicated that it was her expectation that the required oxygen signage be posted for residents who received oxygen. An interview was conducted with the Administrator on 1/16/24 at 3:19 PM. Interview further revealed that it was her expectation that the facility had the required oxygen signage posted for residents who received oxygen.

Based on record review, observations, and interviews with resident and staff, the facility failed to secure medications observed at bedside for 1 of 1 resident reviewed for medication storage (Resident #77). The findings included: Resident #77 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hypertension, hyperlipidemia, anxiety, pleural effusion, and polyneuropathy. A review of the electronic medical record revealed an assessment to self-administer medications which was completed on 9/13/24. The assessment indicated that Resident #77 required assistance to administer oral medications and therefore was not approved to self-administer medications or to keep medications at bedside. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #77 was cognitively intact. On 1/13/25 at 10:38 AM, an observation was made of medications spread out in a line on Resident #77's overbed table. Resident #77 stated that the medications had been sitting there since this morning. Resident #77 further explained that it was normal for the nurse to leave the medications sitting on the overbed table and the plan was to take the medications when Resident #77 was ready to take them. An interview was conducted with Nurse #1 on 1/13/25 at 10:44 AM. She verified she was the nurse that left Resident #77's morning medications on the overbed table for her to take. She also indicated that she thought Resident #77 had been assessed to be safe to self-administer her medications. A review of Resident #77's January 2024 medication administration record revealed the medications left on Resident #77's over the bed table included the following: Gabapentin 100 milligrams (mg), Labetalol 100 mg 1 tablet, Clopidogrel 75 mg 1 tablet , Zetia 10 mg 1 tablet, Lasix, Isosorbide 60 mg 1 tablet, Cozaar 100 mg 1 tablet, Multivitamin 1 tablet, Zoloft 50mg 1 tablet. The Director of Nursing (DON) was interviewed on 1/13/25 at 11:38 AM. The DON indicated Resident #77's medications should not have been left at bedside.

Based on record review, observations, interviews with staff, Dermatologist, and Medical Director, the facility staff failed to notify medical provider of a change in condition for a nonverbal resident with a diagnosis of diabetes when new skin wounds were observed on 7/22/24. The Medical Director was notified on 7/23/24 and Resident #1 was sent to the Emergency Department (ED) on 07/23/24 and was diagnosed with deep partial thickness burns to the anterior (front) and medial thighs bilaterally as well as the mons pubis (fatty tissue that covers the pubic bone). Resident #1 was hospitalized from 07/23/24 to 07/25/24, had an indwelling catheter inserted to help with wound healing, had daily wound care treatment with Silvadene cream (a topical antibiotic used in partial thickness and full thickness burns to prevent infection) and was administered oxycodone (opioid pain medication used to treat severe pain) for pain. This deficient practice occurred for 1 of 3 resident reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE], with diagnosis that included lumbar degenerative disc disease, fibromyalgia, foot drop, right hand contracture, diabetes, heart failure, chronic kidney disease, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was severely cognitively impaired and rarely/never made self-understood and sometimes understood others (responds adequately to simple, direct communication only). Incident report dated 07/22/24 at 10:00 PM, completed by Nurse #1 was reviewed. The report revealed, on 07/22/24 at 10:00 PM Nurse Aide (NA) #1 notified Nurse #1 that Resident #1 had skin tears to both thighs noted during resident's scheduled shower. NA #1 stated that Resident #1 was scratching inner thighs during shower. NA #1 attempted to prevent Resident #1 from scratching; however, each opportunity that arose (while NA #1 bathed other parts of body/obtained wash cloth towel, etc.) Resident #1 continued to scratch at both thigh areas and in between legs. NA #1 stated that once the skin broke, it could be visually seen that the skin was 'rolling up' causing the exposed areas. Nurse #1 went into resident's room and assessed Resident #1 skin. Both Left and Right upper thighs had redness and thin layer of skin off thigh areas at time of assessment- rectangular in shape. There was small square shape reddened area in the middle of the mons pubic area. Resident #1 was still attempting to scratch when nurse was assessing areas of injury. Resident #1 was encouraged to not scratch and given one of her teddy bears to hold as a possible deterrent from scratching. Resident #1 shows no signs of discomfort not pain; no verbal responses to pain nor facial grimaces displayed. Area was cleaned with saline and covered with dressing in an attempt to prevent infection and also to prevent further scratching by resident. Note made in PEC (Physician Elder Care) book concerning this incident. The incident report further indicated the Physician (Medical Director) was notified on 07/23/24 at 7:18 AM and family member was notified on 07/23/24 at 1:19 AM. An interview was conducted with Nurse #1 on 08/06/24 at 8:11 AM. Nurse #1 indicated she worked a 4-hour shift (7:00 PM to 11:00 PM) on 07/22/23. Nurse #1 confirmed that she relieved Nurse #3 who had just worked a 12-hour day shift (7:00 AM to 7:00 PM). Nurse #1 stated that during report from Nurse #3, no skin alterations were reported in reference to Resident #1. Nurse #1 revealed that on 07/22/24 at about 9:00 PM, NA #1 notified her of a change in Resident #1 skin after completing giving Resident #1 a shower. Nurse #1 indicated that NA #1 stated that Resident's #1 skin started peeling off during shower. Nurse #1 explained she went to Resident #1's room to complete an assessment immediately upon notification. Nurse #1 confirmed that Resident #1 was non-verbal and did not have any non-verbal signs of pain noted. Nurse #1 revealed that the top layer of skin on both Resident #1's upper thigh were gone, and the top of her mons pubis was red. Nurse #1 indicated that the middle of Resident #1 mons pubis had skin peeled off and some of her pubic hair had fallen out. Nurse #1 explained that she cleaned the wounds with normal saline and dressed both thighs with ABD pads to protect the area from infection. Nurse #1 indicated at the end of her shift (11:00 PM) she passed on the information to the oncoming Nurse #2 during shift report. Nurse #1 indicated that she did not notify the medical provider of a change in Resident #1's condition because she did not have time to. Nurse #1 stated that she communicated with Nurse #2 during shift change at 11:00 PM, who confirmed that she (Nurse #2) would notify medical provider. An interview was conducted with Nurse #2 on 08/06/24 at 8:38 AM. Nurse #2 confirmed that she worked an 8-hour shift (11:00 PM to 7:00 AM) on 07/22/24 and she relieved Nurse #1. Nurse #1 reported to Nurse #2, that Resident #1 had an incident where she was rubbing her thighs in the shower according to NA #1. Nurse #1 told her Resident #1 had ABD pads to her bilateral upper thighs and the areas were red but not inflamed. Nurse #2 explained that she went with NA #3 at about 11:30 PM to assess Resident #1. Nurse #2 confirmed Resident #1's pubic area had red patchy areas, and pubic hair had fallen out. Nurse #2 indicated that Resident #1 did not have any nonverbal signs of pain. Nurse #2 stated that she did not do anything else for Resident #1 throughout her shift. Nurse #2 indicated that by morning (7:00 AM) on 07/23/24, the areas on Resident #1's genitalia and bilateral upper thighs was more reddened and irritated. Nurse #2 confirmed that at the end of her shift on 07/23/24 at 07:00 she reported Resident #1's wounds to Wound Nurse and Nurse #3. Nurse #2 indicated on 07/23/24 at about 7:30 AM she assessed Resident #1 with the Wound Nurse and Nurse #3, after which she left as her shift had ended. Nurse #2 indicated that she did not notify Medical Provider because she had instructed Nurse #1 to notify Medical Provider and Family when Nurse #1 was completing the incident report. Progress note that was completed on 07/23/24 at 7:52 AM by Nurse #3 was reviewed. The documentation indicated that Prior nurse reports of red area to groin, pubic area, and blister noted to inside of left dorsal/lateral thigh. Nurses enter room noting skin peeling, beefy red, in bi lat (bilateral) groin areas, front of upper thigh, fluid filled blister to dorsal/lateral left thigh. Wound nurse notified and assessed resident with new order to send to hospital for further evaluation. An interview was conducted with Nurse #3 on 08/05/24 at 4:01pm. Nurse #3 confirmed that she returned to work on 07/23/24 to start her shift at 7:00 AM and during report, Nurse #3 revealed that Nurse #2 reported Resident #1's skin had peeled completely off in between her thighs and groin area. Nurse #3 recalled Nurse #2 told her Resident #1 had received a shower from NA #1 at 8:00 PM on 07/22/24 and during that shower, the skin peeled off. Nurse #3 confirmed she observed Resident #1's skin with the Wound Nurse present on 07/23/24 at about 8:00 AM and the skin had completely peeled off her bilateral anterior thighs and she had a redness to the pubic area with patchy areas of peeled skin and pubic hair coming out. There was also a blister to the back/posterior left thigh. Nurse # 3 stated that the bilateral upper thighs and pubic area skin looked bad (very red and raw). Nurse #3 indicated that Wound Nurse notified ADON via phone about Resident #1 wounds while in Resident #1's room. Nurse #3 indicated that ADON was on the phone with Wound Nurse and ADON notified provider. Nurse #3 recalled the ADON communicated by phone the provider had been notified and Resident #1 had orders to be transferred to the emergency room . An interview was conducted with Wound Nurse on 08/06/24 at 12:03 PM. The Wound Nurse confirmed that Resident #1 did not have any wounds or skin alterations prior to being discharged to hospital on 07/23/24. The Wound Nurse stated on 07/23/24 she was notified by Nurse #3 to come urgently to Resident #1's room. The Wound Nurse stated that she assessed Resident #1 in the presence of Nurse #3 and Resident #1's brief was open to air to avoid it from touching the wounds on her bilateral thighs, groin and pubic area. Wound Nurse explained the skin on Resident #1's bilateral thighs was peeled, raw and red approximately the same size (both wounds were approximately the same shape and size) from the inner thighs to the medial lateral side (from the inside of the thighs to the middle of the thighs) of the upper thigh. The Wound Nurse noted Resident #1's pubic area had patchy areas of missing skin and hair, and the dorsal (upper side) side of the left leg had an intact blister about 2 inches wide. Wound Nurse indicated that there was a little bit of drainage to bilateral upper thighs and pubic areas wounds. The Wound Nurse indicated that Resident #1 was nonverbal and did not have any nonverbal signs of pain during the assessment. Wound Nurse revealed that she notified ADON on 07/23/24 via phone about Resident #1 wounds while in Resident #1's room. Wound Nurse stated that ADON notified provider, while on the phone with her. Wound Nurse further explained that ADON communicated by phone that the provider had been notified and Resident #1 had orders to be transferred to the emergency room . An interview was conducted with the Assistant Director of Nursing (ADON) on 08/06/24 at 12:19 PM. The ADON indicated that she received a call on 07/23/24 at 7:15 AM from the Wound Nurse stating something had happened to Resident #1 and things were not adding up. ADON indicated that Wound Nurse described the areas were on Resident #1's bilateral upper thighs and had quite a large area of skin peeled off and raw tissue exposed, pubic area had patches of skin peeled off and pubic hair fallen off and the back of her thigh had an intact blister. The ADON noted after the Wound Nurse communicated with her on 07/23/24 at about 7:30am, she notified the provider of Resident #1 new wounds, per the description she obtained from Wound Nurse. ADON indicated that she notified MD and MD indicated to send resident to ED. ADON indicated that she instructed the Wound Nurse to send Resident #1 out to ED. Progress note that was completed on 07/23/24 at 9:00 AM by Nurse #3 was reviewed. The documentation indicated that EMS was notified at 08:00 AM. The note further revealed that EMS transferred resident onto stretch and departed the facility at 8:35 AM. ED provider notes dated 07/23/24 indicated that Resident #1 presented with deep partial thickness burns to the anterior and medial thighs bilaterally as well as the mons pubis. ED provider notes included Resident #1 vital signs on 07/23/24 at 9:07 AM to be a body temperature of 100.2 ?, blood pressure of 147/84, pulse rate of 82 beats per minute and respirations of 16 breaths per minutes. It was noted Resident #1 came from nursing home today with burns to her thighs. Supposedly she had a shower last night at the nursing home and now she has burns. Resident #1 is nonverbal and as such unable to offer any history. The ED provider notes further indicated that Resident #1 had severe contractures (shortening of muscles, tendons, skin and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to bilateral lower extremities, knee extension and hips. ED notes indicated that Resident #1 had right upper extremity flexion contracture. ED notes indicated that Resident #1 only moved left upper extremity spontaneously-grossly 3/5 (medical muscle strength assessment that indicated Resident #1 could move her left arm on her own without assistance, but the strength would be rated as 3 out of 5, indicating moderate weakness. A score of 5 would represent normal strength.) Interview with Medical Director conducted on 08/06/24 at 1:56 PM. MD indicated that she received a call on 07/23/24 at 7:30 AM from Assistant Director of Nursing (ADON). The MD indicated that ADON indicated that Resident #1 had an area to the groin and bilateral thighs, and it looked like a burn. MD indicated she gave orders for Resident #1 to be sent out. MD indicated that the description given was that the area was inflamed, extensive to the bilateral thighs and groin, blister to the back/posterior right thigh. MD further indicated based on the severity and how the skin injury happened quickly, and this was new for Resident #1, the facility should have contacted MD upon change of condition. A Dermatology consultation report dated 08/07/24 was reviewed and indicated that skin lesions to bilateral upper thighs appeared consistent with thermal injury (skin injuries caused by excessive heat), as they were evenly and broadly denuded (removal of skins surface layers) with rounded edges and spare with folds. The report further indicated that no bullae (fluid-filled sacs or lesions that appear when fluid is trapped under a thin layer of skin), or inflammation was noted and there was evidence of re-epithelialization (wound healing) and repigmentation regaining normal skin color) in a follicular (densely packed follicles of varying size lined by a single later of epithelium) pattern. The report also indicated that the skin lesions were not consistent with autoimmune blistering disorder, contact dermatitis, infection, self-excoriation, or a medication reaction like fixed bullous drug eruption or Stevens-Johnson Syndrome (SJS) (a rare and serious disorder that affects skin, mucous membrane, genitals and eyes. It causes flu like symptoms along with painful rash that spreads and blisters) and Toxic Epidermal Necrolysis (TEN) (severe form of SJS, diagnosed when more than 30% of the skin surface is affected and the moist linings of the body). The report noted a second dermatologist reviewed the clinical images for Resident #1 and agreed with thermal burns from something hot sitting on Resident #1's lap. Recommendations from the report included to use Mepilex Ag dressings (dressing that absorbs drainage and inactivates wound pathogens) to be changed every three days and to discontinue treatment once the skin was completely re-epithelialized. An interview with the Dermatologist who examined Resident #1 on 08/07/24 was conducted on 08/19/24 at 12:15 PM. The Dermatologist indicated that she examined Resident #1 on 08/07/24 and that Resident #1 was accompanied to the dermatologist office by her daughter and a non-administrative nurse from the facility. The Dermatologist stated that she spoke to the Administrator and a nurse manager over the phone on 08/07/24 and the Administrator indicated that she wanted Dermatologist to examine the wounds that had just have been found one day on Resident #1. The Dermatologist shared that she had already reviewed the resident's hospital records the day prior to her coming into the dermatology office. The Dermatologist indicated that facility never shared with her any incident had occurred and the facility Administrator indicated via phone on 08/07/24 just found the wounds one day. The Dermatologist stated that Administrator was very vague, and Dermatologist did not dwell on asking more details from Administrator. The Dermatologist stated she examined Resident #1, and her assessment was that Resident #1 sustained a thermal burn. She was sure that Resident #1 had a thermal burn, and her injuries were not associated with any other cause. The Dermatologist also stated that some burns were not painful at all, but in this case because this were second degree burns, they were painful. Dermatologist further explained that often deeper and more in-depth wounds like a third-degree burn, one would not feel pain because the nerves are burned away. The Dermatologist added that it would have been best for the facility to have notified the medical provider when the injuries occurred, because the skin was denuded, and this increased the risk of infection and due to her being high risk due to diabetes. The Dermatologist further stated that anytime skin was denuded like Resident #1's skin, there is a risk for high infection. She also indicated that burns have a higher risk of infection and that was why the hospital used the Silvadene cream to treat it. The Dermatologist confirmed Resident #1's injuries were not caused by any scratches but could have been caused by hot water or could also have been caused by a washcloth that was wet and hot, that sat on Resident #1 lap. The Dermatologist further stated that it looked like Resident #1 could have been covered with a washcloth on that area at some point. The Dermatologist continued to explain that the burns spared the skin folds, so it was possible that her legs were clamped together, which is why water did not run between them. Or it was something more solid that was placed on her. Dermatologist indicated she would expect that the Resident #1 wound have scars and that there would be change to the color and texture of the skin on the areas. The Administrator was notified of the immediate jeopardy on 08/06/24 at 4:39 PM. The facility provided the following corrective action plan for IJ removal. How corrective action will be accomplished for those residents found to have been affected: On 7-22-24, Nurse #1 was called by Nurse Aide #1 to assess Resident #1 after a shower. Nurse Aide #1 reported that Resident #1 was in the shower room on a shower gurney, receiving a shower using the handheld showerhead when wounds on thighs were noted. Nurse #1 came to assess Resident #1, Resident #1 had new wounds on bilateral thighs and mons pubis which were treated per physician's group wound protocol by Nurse #1. Nurse #1 described the wounds as, bilateral upper anterior thighs near groin area are altered. Appearing pink in color with rectangular shaped areas that appeared to have top layer of skin absent. Resident #1 had no signs of pain per Nurse #1. Resident's family was notified on 7-22-24 by Nurse #1. On 7-22-24 Nurse #1 placed resident #1 on Physician follow up list to be seen in the morning of 7-23-24 per physician wound protocol. The standing orders for skin care guidelines from the physicians' group states: For stasis and traumatic wounds, the skin care guidelines provide treatment options and state the patient should be placed on problem list for follow-up by clinician on their next visit. On 7-23-24, Nurse #3 called wound nurse to look at the wound, wound nurse called assistant director of nursing, assistant director of nursing called resident #1's medical director to notify the medical director of Resident #1's skin condition. The medical director gave orders to send Resident #1 to the hospital for further evaluation to determine the etiology of the skin condition and the appropriate treatment. How corrective action will be accomplished for those residents having potential to be affected: On 7-23-24, the facility administrator, director of nursing and assistant director of nursing reviewed incident reports for the past 30 days to ensure the physician was contacted for any incidents involving skin per policy. Physicians were properly notified per policy and physician guidelines for all incidents reviewed. What measures will be put into place or systemic changes made to ensure that the practice will not occur. On 7-23-24, education was conducted by the assistant director of nursing and the staff development coordinator for nursing staff on reporting to physicians and standing facility protocols, per facility policies. The education stated that a physician should be notified when there is a significant injury or change in condition, per policy. The education was completed for all nursing staff on 7-31-24. On 7-23-24, education was provided to all nursing staff, licensed nurses and nursing assistants, by staff development coordinator and assistant director of nursing on the shower protocol. The shower protocol education contained a bullet stating report immediately to nurse and administrative nurse for any possible signs of any type of injury or any type of skin changes. The education was completed for all nursing staff by 7-31-24. Beginning 7-23-24, a QAPI is in place that the administrator or director of nursing will audit all skin and wound incident reports five days per week to ensure the physician was contacted appropriately and timely for one month, then will audit incident reports weekly for one month, then will audit monthly for one quarter. The incident reports are internal documents used for reporting certain incidents and are used for quality assurance. The reports that will be reviewed contain information about any new skin conditions such as wounds, pressure ulcers, skin tears, bruises, etc. These reports are only completed by nurses, and nurses are responsible for notifying the physician as required by the facility and physician protocols. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The PoC is integrated into the quality assurance system of the facility. A Quality Assurance Performance Improvement plan was initiated on 7/23/2024. The findings of the audits will be reported by the administrator to the Quality Assurance Committee at each quarterly meeting for one year. Alleged date of IJ removal: 08/01/24 Validation of the immediate jeopardy removal plan was conducted in the facility on 08/20/24. The facility's initial plan audit was verified and signature sheet for education reviewed with no concerns. Facility nurses were interviewed and were aware of the pain management protocol, how and when to assess pain, and how to appropriately respond to a resident's request or nonverbal signs of pain. Facility medication aides, nurse aides, dietary staff, housekeeping staff and rehabilitation staff were also aware of the pain protocol and how to observe for nonverbal signs of pain and how to respond to resident's request or nonverbal signs of pain. The facility's immediate jeopardy removal date of 08/01/24 was validated.

Based on record review, observations, and interviews with staff, Hospital Case Manager, Plumbing Contractor, Dermatologist, and the Medical Director, the facility staff failed to supervise a severely cognitively impaired and nonverbal resident in the shower room. On 7/22/24 Nurse Aide (NA) #1 left Resident #1 unattended and naked on the shower bed with the water running on her body. When NA #1 returned to the shower spa, Resident #1 had a pool of water over her bilateral thighs and genital area. NA #1 took a washcloth to remove the puddle of water and noticed that Resident #1's top layer of skin on her bilateral upper thighs was peeling off. Resident #1 was sent to the Emergency Department (ED) 07/23/24 and was diagnosed with deep partial thickness burns to the anterior (front) and medial thighs bilaterally as well as the mons pubis (fatty tissue that covers the pubic bone). Resident #1 was hospitalized from 07/23/24 to 07/25/24, had an indwelling catheter inserted to help with wound healing, had daily wound care treatment with Silvadene cream (a topical antibiotic used in partial thickness and full thickness burns to prevent infection) and was administered oxycodone (opioid pain medication used to treat severe pain) for pain. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE], with diagnosis that included lumbar degenerative disc disease, fibromyalgia, foot drop, right hand contracture, diabetes, heart failure, chronic kidney disease, and vascular dementia without behavioral disturbance. Review of the physician orders revealed that Resident #1 had an order initiated on 03/16/24. Minerin Creme (skin protectant cream)- Apply to arms, legs, face topically one time a day for dry skin Apply to arms, legs, face and other external areas needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was severely cognitively impaired and rarely/never made self-understood and sometimes understood others (responds adequately to simple, direct communication only). The MDS assessment further indicated Resident #1 had functional limitation in range of motion impairment on one side of her upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides of her lower extremities (hip, knee, ankle, foot). The assessment noted Resident #1 had no unhealed pressure ulcers/injuries, or any other ulcers, wounds or skin problems. The MDS assessment also indicated that Resident #1 was not receiving any opioid medication and did not have an indwelling catheter. Review of Resident #1's care plans last revised on 06/26/24 revealed no care plan for behaviors including scratching herself. The functional performance-long term care resident; unable to care for herself; Needs assistance with all care - care plan indicated that Resident #1 required total assistance of two-person physical assistance with a total lift for transfers. The care plan revealed that Resident #1 had impaired cognitive function and thought processes related to Alzheimer's. The care plan also indicated that staff needed to apply right hand palm protector in the morning and remove in the evening due to Resident #1's right hand contracture. Nurse Aide electronic documentation (Documentation Survey Report) revealed on 07/21/24, Nurse Aide (NA) #5 noted that Resident #1 did not have any behaviors observed. Documentation revealed that for the task monitor skin observation, NA #5 noted that Resident #1 had none of the above (scratched, red area, discoloration, skin tear, open area) observed. An interview was conducted on 08/05/24 at 3:48 PM with NA #5. NA #5 indicated that she provided care to Resident #1 on 07/21/24 during the evening shift (3:00 PM to 11:00 PM). NA #5 indicated that Resident #1 did not have any skin issues. NA #5 stated that Resident #1 did not have any verbal or nonverbal signs or symptoms of pain. Skin only evaluation assessment that was completed on 07/22/23 at 6:33 PM by Nurse #3 was reviewed. The documentation indicated that Resident #1 skin was warm and dry, skin color within normal limits, and turgor was normal. The documentation further indicated Resident #1 had dryness noted to all extremities and treatment was applied per orders. Written statement from NA #1 dated 07/23/24 was reviewed. On Monday 07/22/24 Resident #1 was due for a shower. So, with help the NA student help with cleaning her bowel movement. We cleaned her and ready her for the shower. We put her on a gurney to be transported by stretcher (gurney) to shower room. While in the shower room the student aides had to leave. So I was left with task on going to get the body wash after I had wet Resident #1 body. I hung up the running shower head on the wall. Resident #1 had been digging between her legs. Having washed her before I thought it would be alright to proceed to clean where she had been scratching which was nothing new, she had done it before while being clean. This time I notice her skin began to peel as I washed with a washcloth. I finish cleaning all body part and hair. I lower the temperature to remove the excess bowel movement between her legs and dried her off. Reported to the nurse. An interview with the facility Administrator was conducted on 08/06/23 at 11:18am. The Administrator explained that NA #1 had requested to be taken off the schedule on 07/24/24 and asked to leave facility while at work. Administrator stated that NA #1 had not returned or communicated with the facility since 07/24/24 even after multiple attempts. On 08/08/24 at 11:04 AM, the facility had arranged for NA#1 to come to the facility and the interview was conducted over the phone. The surveyor was continuing the survey remotely due to adverse weather. The surveyor could hear people whispering in the room between questions during the interview with NA #1. NA #1 would pause answering questions during telephone interview and SA could hear whispering in the background, after which NA #1 would change the response to a question he had previously answered. NA #1 indicated that he worked second shift (3:00 PM to 11:00 PM) on 07/22/24. NA #1 stated Resident #1 was not able to bend her knees, and that the only part of Resident #1's body that she could move was her left arm. NA #1 noted Resident #1 was a total care and had a shower scheduled on 07/22/24. NA #1 stated that between 7:30 PM and 8:00 PM he and two NA students went to Resident #1's room to prepare for her shower. While in the room, NA #1 revealed that Resident #1 had a bowel movement and needed to be cleaned prior to transferring Resident #1 onto the shower bed. NA #1 confirmed that when providing perineal care to her genital and rectal area, NA #1 did not observe any scratches, bruises, blisters, skin tears or any skin alterations. NA #1 indicated that together with the two NA students, Resident #1 was wheeled to the spa room. NA #1 noted the two NA students had to leave at 8:00 PM which left him alone in the spa room with Resident #1. NA #1 revealed that Resident #1's head was positioned against the wall that had a mounted handheld showerhead. NA #1 indicated that Resident #1's legs were facing away from the wall that had the mounted handheld showerhead. NA #1 confirmed that he turned on the water for the handheld showerhead and tested the water on his hand. NA #1 revealed that the water felt good to him and did not want to answer if it was hot, but adamantly stated it felt good to me. NA #1 indicated that the water did not have steam. NA #1 stated that after he had rinsed Resident #1 with the water, he realized he did not have soap to use for the shower. NA #1 stated that he placed the handheld showerhead, with water still running, back on the mount on the wall. The stream of the water was directed at Resident #1's body, not at her face. NA #1 indicated that he did not want to use the soap that was mounted in the shower room because it was hand soap. NA #1 confirmed that he then left Resident #1 unattended and walked to the storage room which was down another hall. NA #1 stated that he did not use the call light mounted in the spa room because he was just going to the storage area and back. NA #1 confirmed that he left Resident #1 unattended and naked because she did not move at all, and she was fine. NA #1 indicated he got the soap from the storage room, walked back to the spa room. At first NA #1 stated Resident #1 was left unattended in the shower spa for 30 seconds and later stated it was 10 seconds. NA #1 revealed that when he returned to the spa room, Resident #1 had a pool of water over her bilateral upper thighs and around the genital area. NA #1 confirmed that he noted Resident #1 was grimacing, scratching herself down there and he moved Resident #1's left hand off her genital area because she was scratching. Her fingernails were not long. NA #1 indicated that he tested the water and lowered the temperature of the water because the skin on her genital area started peeling. NA #1 stated that he took a washcloth to remove the puddle of water and noticed that Resident #1's top layer of skin on her bilateral upper thighs was peeling off. NA #1 stated Resident #1 seemed comfortable after he lowered the temperature of the water but could not explain this as he noted the resident was nonverbal. NA #1 indicated he continued to wash Resident #1's entire body with the washcloth including her genital area and upper thighs even though he observed the skin was peeling off. When he was done with the shower, he covered her with a towel and took her back to her room and transferred her into her bed. After that NA #1 went to get Nurse #1 and told her when he was giving Resident #1 a shower her skin was peeling off. NA #1 explained that Nurse #1 came to Resident #1's room, assessed the resident and took a picture of the resident with her phone. An observation was made on 08/06/24 at 1:40 PM of the [NAME] spa room where Resident #1 received her shower on 07/22/24 from NA #1. To get to the storage room you would exit the spa room and go right down the hall, then make a left onto another hallway, walk a couple of steps, and make a left onto a third hallway to get to the storage room. It took the surveyor approximately 45 seconds to walk from the [NAME] spa room to storage room and back to the storage room, without entering the storage room. Nurse Aide electronic documentation revealed that on 07/22/24 at 10:38 PM NA #1 provided shower to Resident #1. Documentation confirmed on 07/22/24 at 10:28 PM, NA #1 noted that Resident #1 did not have any behaviors observed. Documentation revealed that for the task monitor skin observation, on 07/22/23 at 10:38 PM, NA #1 noted that Resident #1 had a skin alteration observed. Incident report dated 07/22/24 at 10:00 PM, completed by Nurse #1 was reviewed. The report revealed, on 07/22/24 at 10:00 PM Nurse Aide (NA) #1 notified Nurse #1 that Resident #1 had skin tears to both thighs noted during resident's scheduled shower. NA #1 stated that Resident #1 was scratching inner thighs during shower. NA #1 attempted to prevent Resident #1 from scratching; however, each opportunity that arose (while NA #1 bathed other parts of body/obtained wash cloth towel, etc.) Resident #1 continued to scratch at both thigh areas and in between legs. NA #1 stated that once the skin broke, it could be visually seen that the skin was 'rolling up' causing the exposed areas. Nurse #1 went into resident's room and assessed Resident #1 skin. Both Left and Right upper thighs had redness and thin layer of skin off thigh areas at time of assessment- rectangular in shape. There was small square shape reddened area in the middle of the mons pubic area. Resident #1 was still attempting to scratch when nurse was assessing areas of injury. Resident #1 was encouraged to not scratch and given one of her teddy bears to hold as a possible deterrent from scratching. Resident #1 shows no signs of discomfort not pain; no verbal responses to pain nor facial grimaces displayed. Area was cleaned with saline and covered with dressing in an attempt to prevent infection and also to prevent further scratching by resident. Nurse Aide electronic documentation revealed that on 07/22/24 at 10:28 PM, NA #3 noted that Resident #1 did not have any behaviors observed. Documentation revealed that for the task monitor skin observation, NA #3 noted that Resident #1 had none of the above (scratched, red area, discoloration, skin tear, open area) observed. Written statement from NA #3 dated 07/23/24 documented while putting Resident #1 back to bed, I did not notice anything. I changed her and her skin was fine. Resident #1 legs and groin area was normal. Multiple attempts were made to reach NA #3 for an interview were unsuccessful. Written statement from Nurse #1 dated 07/23/24 at 1:20 PM revealed, I worked at [facility name] for a as needed (prn)shift (07:00 PM to 11:00 PM) on 07/22/24. During my shift, around 10:00 PM, I was notified by NA #1 of Resident #1 skin injury. Resident #1 was said to have been scratching her thighs intensively while being given a shower. Once notified by NA #1, I went into Resident #1's room and assessed the newly noted skin alterations. At his time Resident #1 thighs, bilaterally, (upper anterior thighs, near groin area) were altered, appearing pink in color, and ironically, both had rectangular shaped areas that appeared to have the top layer of skin absent. Per NA #1 recollection and report to me, while showering he attempted to prevent Resident #1 from scratching her thighs but Resident #1 persistently kept doing so. NA #1 stated that Resident #1 skin was broken from her scratching and Resident #1 skin just rolled/pulled off. When in resident's room completing assessment of the area, Resident #1 was attempting to scratch the thigh area. A teddy bear in her nightstand was given to her in her left hand in at attempt to deter resident from scratching. There was also a pink area in the center of the mons pubis. Resident #1 had no signs or symptoms of pain or discomfort at this time. No moaning, yelling, no facial grimacing. In an attempt to clean and cover the areas, I cleaned both thighs and mons pubis with saline and covered both thighs with dressings. Resident #1 was sitting in shower chair at the time of assessment. Resident was continued to be monitored. (no bleeding nor drainage noted). An interview was conducted with Nurse #1 on 08/06/24 at 8:11 AM. Nurse #1 indicated she worked a 4-hour shift (7:00 PM to 11:00 PM) on 07/22/23. Nurse #1 confirmed that she relieved Nurse #3 who had just worked a 12-hour day shift (7:00 AM to 7:00 PM). Nurse #1 stated that during report from Nurse #3, no skin alterations were reported in reference to Resident #1. Nurse #1 revealed that on 07/22/24 at about 9:00 PM, NA #1 notified her of a change in Resident #1 skin after completing giving Resident #1 a shower. Nurse #1 indicated that NA #1 stated that Resident's #1 skin started peeling off during shower. Nurse #1 explained she went to Resident #1's room to complete an assessment immediately upon notification. Nurse #1 confirmed that Resident #1 was non-verbal and did not have any non-verbal signs of pain noted. Nurse #1 revealed that the top layer of skin on both Resident #1's upper thigh were gone, and the top of her mons pubis was red. Nurse #1 indicated that the middle of Resident #1 mons pubis had skin peeled off and some of her pubic hair had fallen out. Nurse #1 explained that she cleaned the wounds with normal saline and dressed both thighs with ABD pads (large gauze wound dressings) to protect the area from infection. Nurse #1 indicated at the end of her shift (11:00 PM) she passed on the information to the oncoming Nurse #2 during shift report. Written statement from Nurse #2 dated 07/23/24 revealed, I came in on 3rd (11:00 PM to 7:00 AM) shift on 07/22/24 behind Nurse #1. Nurse #1 reported an incident related to Resident #1. Stated that Resident #1 had skin that peeled back on thighs. Nurse #1 asked if she needed to do an incident report, and I said yes and call family and doctor. I went down with NA#2 and NA #6 to check on Resident #1. Resident #1 had dressings on inner thighs. I assessed Resident #1's thighs. They were light pink without signs of infection. New sterile ABD pads added and covered areas. Resident #1 had no signs or symptoms of pain. Nurse #3 put a clean rolled up towel between knees to help. Resident #1 did have some pink, red area to her pubic hair area also. Oncoming Nurse #3 and Wound Nurse notified in the morning. I did call Resident #1 daughter and notify her at around 07:00 AM. Area to inner thighs looks darker and worse than earlier. Wound light pink-no extra skin -no bleeding, uneven edges. No signs or symptoms infection to inner bilateral thighs and no signs or symptoms of pain. Pink/Red area pubic area. This was observed at beginning of my shift. An interview was conducted with Nurse #2 on 08/06/24 at 8:38 AM. Nurse #2 confirmed that she worked an 8-hour shift (11:00 PM to 7:00 AM) on 07/22/24 and she relieved Nurse #1. Nurse #2 stated that Resident #1 was not known to have any wounds or skin alterations prior to 7/22/24. Nurse #2 confirmed that Resident #1 was nonverbal. Nurse #2 stated that Resident #1 did not have a history of scratching, and no one had reported any concerns about any new behaviors. Nurse #1 reported to Nurse #2, that Resident #1 had an incident where she was rubbing her thighs in the shower according to NA #1. Nurse #1 told her Resident #1 had ABD pads to her bilateral upper thighs and the areas were red but not inflamed. Nurse #2 explained that she went with NA #3 at about 11:30 PM to assess Resident #1. Nurse #2 confirmed Resident #1's pubic area had red patchy areas, and pubic hair had fallen out. Nurse #2 indicated that Resident #1 did not have any nonverbal signs of pain. Nurse #2 stated that she did not do anything else for Resident #1 throughout her shift. Nurse #2 indicated that by morning (7:00 AM) on 07/23/24, the areas on Resident #1's genitalia and bilateral upper thighs was more reddened and irritated. Nurse #2 confirmed that at the end of her shift on 07/23/24 at 07:00 she reported Resident #1's wounds to Wound Nurse and Nurse #3. Nurse #2 indicated on 07/23/24 at about 7:30 AM she assessed Resident #1 with the Wound Nurse and Nurse #3, after which she left as her shift had ended. Nurse Aide electronic documentation revealed that on 07/23/24 at 12:44 AM, NA #2 noted that Resident #1 did not have any behaviors observed. Documentation revealed that for the task monitor skin observation, NA #2 noted that Resident #1 had none of the above (scratched, red area, discoloration, skin tear, open area) observed. Written statement from NA #2 dated 07/23/24 revealed, I arrived at work at 11:00 PM, the NA from second shift took me to show me what happened to Resident #1 when he gave a shower earlier. Resident #1 thigh and part of her pubic area was gone. It was pink area in color. I had the Nurse #2 to come and look at it as well. Multiple attempts were made to reach NA #2 for an interview were unsuccessful. Progress note completed on 07/23/24 at 7:52 AM by Nurse #3 was reviewed. The documentation indicated, Prior nurse reports of red area to groin, pubic area, and blister noted to inside of left dorsal/lateral thigh. Nurses enter room noting skin peeling, beefy red, in bilateral groin areas, front of upper thigh, fluid filled blister to dorsal/lateral left thigh. Wound nurse notified and assessed resident with new order to send to hospital for further evaluation. Written statement from Nurse #3 dated 07/23/244 at 7:40 AM stated: this nurse completed skin check between 1315-1330 (1:15 PM and 1:30 PM) with no wound noted to skin. Resident had not yet had shower due to 3-11pm shower. No CNAs reported to this nurse no new areas to skin after skin check completed. A second written statement from Nurse #3 dated 07/28/24 documented: prior to this nurse notifying 911 for transport of Resident #1, I asked Wound Nurse what Resident #1 was being transferred to ED for and how to word injury. I notified 911 for transport to [local hospital] for skin injury to groin and pubic area being treated as abuse investigation. 911 operator asked this nurse if I thought it was abuse or sexual I stated no. When EMS arrives to transport Resident #1, they asked how the injury occurred. I could only give information passed from prior nursing report. That resident was given a shower late the night before the NA that was assisting reported to the 3:00 PM to 11:00 PM nurse Resident #1 was scratching upper thigh area, skin tear reported that nurse treated area with wound spray and completed incident report. An interview was conducted with Nurse #3 on 08/05/24 at 4:01pm. Nurse #3 revealed that she provided care to Resident #1 on 07/21/24, 07/22/24, and 07/23/24. Nurse #3 confirmed that she worked a 12-hour shift (7:00 AM to 7:00 PM) on 07/22/24. Nurse #3 stated that Resident #1 required two-person assistance with providing incontinence care, bathing and showers. Nurse #3 confirmed that Resident #1 could move her left arm and rub or scratch her right arm. Nurse #3 confirmed that Resident #1 had never scratched herself to the point of having any skin alterations. Nurse #3 also indicated that Resident #1 was nonverbal. Nurse #3 explained that on 07/22/24 she assisted NA #3 with providing incontinence care to Resident #1 and Resident #1 did not have any skin alterations. Nurse #3 indicated that Resident #1 had dryness on her face and was ordered skin protectant cream once a day. Nurse #3 confirmed that she returned to work on 07/23/24 to start her shift at 7:00 AM and during report, Nurse #3 revealed that Nurse #2 reported Resident #1's skin had peeled completely off in between her thighs and groin area. Nurse #3 recalled Nurse #2 told her Resident #1 had received a shower from NA #1 at 8:00 PM on 07/22/24 and during that shower, the skin peeled off. Nurse #3 confirmed she observed Resident #1's skin with the Wound Nurse present on 07/23/24 at about 8:00 AM and the skin had completely peeled off her bilateral anterior thighs and she had a redness to the pubic area with patchy areas of peeled skin and pubic hair coming out. There was also a blister to the back/posterior left thigh. Nurse # 3 stated that the bilateral upper thighs and pubic area skin looked bad (very red and raw). Nurse #3 indicated that Wound Nurse notified the Assistant Director of Nursing (ADON) via phone about Resident #1 wounds while in Resident #1's room. Nurse #3 indicated that ADON was on the phone with Wound Nurse and ADON notified provider. Nurse #3 recalled the ADON communicated by phone the provider had been notified and Resident #1 had orders to be transferred to the emergency room . Skin only evaluation assessment that was completed on 07/23/23 at 8:36 AM by Wound nurse was reviewed. The documentation indicated, Resident #1 Skin warm & dry, skin color WNL and turgor is normal. Right palm protector External device removed, and site inspected: Head, neck, and ears intact with scattered dry skin and moles. Trunk inspected and intact with scattered moles. BUE intact with scattered dry skin. Back, buttock, and sacrum intact. Peeled open wounds to bilateral thighs and inner thighs with an intact blister to the left dorsal/lateral thigh. Lower half of bottom extremities intact with scattered moles and dry skin. Slight redness to heels, toes intact. Written statement from Wound nurse dated 07/23/24 was reviewed. The Wound Nurse documented, I was texted by Nurse #3 at 7:05 AM about an urgent assessment needed on Resident #1. I arrived a few minutes later to find nursing staff at bed side with Resident #1 brief open to air with a large raw bilateral wound to the legs and pubic area with an intact blister to the dorsal area of the left leg. ADON notified at 07:11 AM of injuries, zeroform (bacteriostatic wound dressing) and ABD pads applied. A full skin assessment was completed. All skin was intact, old wound area noted on the back of the knee. Resident #1 was clean and dressed at bedside, visibly stable, and management was notified. An interview was conducted with Wound Nurse on 08/06/24 at 12:03 PM. The Wound Nurse confirmed that Resident #1 did not have any wounds or skin alterations prior to being discharged to hospital on 07/23/24. The Wound Nurse stated on 07/23/24 she was notified by Nurse #3 to come urgently to Resident #1's room. The Wound Nurse stated that she assessed Resident #1 in the presence of Nurse #3 and Resident #1's brief was open to air to avoid it from touching the wounds on her bilateral thighs, groin and pubic area. Wound Nurse explained the skin on Resident #1's bilateral thighs was peeled, raw and red approximately the same size (both wounds were approximately the same shape and size) from the inner thighs to the medial lateral side (from the inside of the thighs to the middle of the thighs) of the upper thigh. The Wound Nurse noted Resident #1's pubic area had patchy areas of missing skin and hair, and the dorsal (upper side) side of the left leg had an intact blister about 2 inches wide. Wound Nurse indicated that there was a little bit of drainage to bilateral upper thighs and pubic areas wounds. The Wound Nurse indicated that Resident #1 was nonverbal and did not have any nonverbal signs of pain during the assessment. An interview was conducted with the ADON on 08/06/24 at 12:19 PM. The ADON indicated that she received a call on 07/23/24 at 7:15 AM from the Wound Nurse stating something had happened to Resident #1 and things were not adding up. ADON indicated that Wound Nurse described the areas were on Resident #1's bilateral upper thighs and had quite a large area of skin peeled off and raw tissue exposed, pubic area had patches of skin peeled off and pubic hair fallen off and the back of her thigh had an intact blister. The ADON indicated that at that time they did not have an idea of what was the cause. The ADON stated she got more information that it was in relation to a shower and self-inflicted scratching from an interview she conducted with NA #1. The ADON explained she interviewed NA #1 in the presence of the Administrator and MDS Nurse #1. ADON stated that NA #1 indicated that he took Resident #1 to the spa room to give her a shower on 07/22/24, on a shower bed. NA #1 indicated that he turned on the handheld shower and began to rinse Resident #1 and he did not have any soap and had to leave Resident #1 in the shower room alone and unattended to get soap. NA #1 indicated that when he returned to the spa room, Resident #1 was scratching her genital area. NA #1 reported the skin started to peel off Resident #1's bilateral upper thighs and he continued to wash her with a washcloth. NA #1 indicated after completing shower, he returned Resident #1 to her room and notified Nurse #1. NA #1 indicated to them he wanted to finish showering Resident #1 then notify the nurse. The ADON indicated that she was concerned that NA #1 left Resident #1 alone in the spa room with water running on her skin. ADON indicated that NA#1 knew not to leave a severely impaired resident alone and unattended in the spa room. The ADON noted after the Wound Nurse communicated with her on 07/23/24 at about 7:30am, she notified the provider of Resident #1 new wounds, per the description she obtained from Wound Nurse. Progress note completed by Nurse #3 on 07/23/24 stated: Prior nurse reports of red area to groin, pubic area, and blister noted to inside of left dorsal/lateral thigh. Nurses enter room noting skin peeling, beefy red, in bilateral groin areas, front of upper thigh, fluid filled blister to dorsal/lateral left thigh. Wound nurse notified and assessed resident with new order to send to hospital for further evaluation. Progress note that was completed on 07/23/24 at 9:00 AM by Nurse #3 was reviewed. The documentation indicated that EMS was notified at 08:00 AM. The note further revealed that EMS transferred resident onto stretch and departed the facility at 8:35 AM. ED provider notes dated 07/23/24 indicated that Resident #1 presented with deep partial thickness burns to the anterior and medial thighs bilaterally as well as the mons pubis. ED provider notes included Resident #1 vital signs on 07/23/24 at 9:07 AM to be a body temperature of 100.2 ?, blood pressure of 147/84, pulse rate of 82 beats per minute and respirations of 16 breaths per minutes. It was noted Resident #1 came from nursing home today with burns to her thighs. Supposedly she had a shower last night at the nursing home and now she has burns. Resident #1 is nonverbal and as such unable to offer any history. The ED provider notes further indicated that Resident #1 had severe contractures (shortening of muscles, tendons, skin and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to bilateral lower extremities, knee extension and hips. ED notes indicated that Resident #1 had right upper extremity flexion contracture. ED notes indicated that Resident #1 only moved left upper extremity spontaneously-grossly 3/5 (medical muscle strength assessment that indicated Resident #1 could move her left arm on her own without assistance, but the strength would be rated as 3 out of 5, indicating moderate weakness. A score of 5 would represent normal strength.) ED notes dated 07/23/24 indicated, Resident #1 cleaned up due to voiding. Wound rinsed with water and pat dried. New chux pad (disposable under pads) applied and new gown applied. An emulsion dressing was placed around the burned area and put a PC (permanent catheter-indwelling) on. ED notes dated 07/24/24 stated Resident #1 was repositioned on her right side with pillow support. Call light within reach. After visit summary note dated 07/25/24 indicated the medications administered to Resident #1 while in the hospital on 07/23/24 at 09:50 AM to include Acetaminophen (Tylenol) and silver sulfadiazine topical dressing on bilateral thighs. Hospital wound care notes dated 07/24/24 indicated: Patient seen today for skin/wound consult. Heels clear. Feet overall very dry. Raw reddened burn like areas to suprapubic area and bilateral inner thighs. Right thigh wound is approximately 12 centimeters(cm) x 17 cm x 0.2 cm. Right thigh wound noted to have a thick pale layer of tissue sloughing. Left thigh wound is approximately 11.5 cm x 14 cm x 0.2 cm. Perineum is a combination of open areas and discoloration. Open area is approximately 4.5 cm x 6.5 cm. Black discoloration extending down both labia. Darker discolored skin will likely slough as well. Would hold off on purwick (purwick is a female external catheter for collecting urine) placement at this time due to discolored areas on labia. Discussed concerns with MD (Medical Doctor). Patient is also incontinent of urine at baseline. Appears to be partial thickness burns of thighs. No other burned areas noted on body. Patient keeps legs very tight together. Abdominal fold and breast fold clear. Bilateral upper extremities clear. Back clear. Shinny gray yeasty appearance to bilateral inner buttocks, gluteal crease and peri rectum. Skin currently intact. Patient on pressure redistribution surface. Records discussed with MD and nurse. Hospital Focused Physical Therapy initial evaluation dated 07/24/24 indicated: Patient presents from long term care facility with burns to inner thighs from bath water. Patient also unable to follow commands-did not follow one command this session. Spoke with nursing. Nursing cleared patient to participate in therapy. No pain reported, no grimaces noted. No pain reported, did not observe patient in any discomfort. A statement written by Minimum Data Set (MDS) Nurse #1 dated 07/23/24 revealed: Interview with NA #1. NA #1 stated that around 8:00 PM on Monday evening 7/22/24, he began to get Resident #1 ready for her shower. Resident #1 had a BM and he cleaned her before putting her on the stretcher. 2 student CNAs were present and assisted him with incontinence care prior to placing her on the stretcher. The students then had to leave. He rolled her to the shower room and proceeded to turn on the water and l [TRUNCATED]

Based on observations, record review and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication error rate of 7.69% (2 errors out of 26 opportunities) for Resident #60. The findings included: 1a. A medication administration for Resident #60 was observed on 8/23/23 at 10:47 AM, Medication Aide (Med Aide) #4 administered a Metoprolol Succinate ER 12.5 mg tablet, for Atrial Fibrillation (irregular heartbeat) after crushing it with other medications and mixing it in applesauce. Review of physician orders for Resident #60 revealed an order dated 8/12/22 at 2:49 pm for Metoprolol Succinate ER Tablet Extended Release. Give 0.5 tablet of 25 mg tablet by mouth once a day for Atrial Fibrillation (an irregular heartbeat). Review of the August 2023 Medication Administration Record for Resident #60 revealed no orders for crushed medications, and the Metoprolol Succinate Extended Release 24 Hour tablet, half of a 25 mg tablet (12.5 mg) by mouth was administered August 1 through August 23, 2023. Review of the Progress Notes revealed Nurse #5 documented crushing medications for Resident #60 due to difficulty swallowing on 6/25/23 at 9:57 am, on 7/2/23 at 12:21 pm, and on 8/7/23 at 11:58 pm. Review of the 7/27/23 at 1:34 pm Social Services Progress Note revealed Social Worker #1 documented Resident #60 had slurred speech related to Dysphagia, Pharyngoesophageal phase, and could make her needs known and be understood. The monthly Pharmacy Consultant #1's Progress Note on 8/9/23 at 11:38 am revealed that medication changes were reviewed, and that the status of Resident #60 was being monitored. There were no recommendations. The previous month's documentation by Pharmacy Consultant #1 on 7/9/23 at 12:04 pm also revealed the medication changes were reviewed and that the status of Resident #60 was being monitored. There were no recommendations. An interview on 8/23/23 at 3:41 pm with Pharmacy Consultant #1 revealed that Metoprolol Succinate extended release could be cut in half from a 25 mg tablet but should not be crushed because it was intended to be administered once a day and would slowly release throughout the day once swallowed. She continued that the dose of 12.5 mg was a small dose and would not cause harm if crushed. An interview on 8/23/23 at 4:40 pm with Nurse #6 revealed she recalled that Resident #60 started to receive crushed medications the previous month because Resident #60 occasionally choked on her medications and had vomited them up on one occasion. She further revealed Resident #60 would have been able to take the 12.5 mg Metoprolol Succinate tablet without crushing it because it was small enough that she wouldn't have choked on it. On 8/23/23 at 9:00 pm, a new order was in the electronic medical record for Resident #60 for Metoprolol Tartrate Oral Tablet, 6.25 mg by mouth two times a day for Atrial Fibrillation. An interview with the Director of Nursing (DON) on 8/25/23 at 10:22 am revealed that Resident #60 had a decline in June 2023, began to receive crushed medications, and the nurses and med aides were informed about crushing Resident #60's medications through communication at the change of shift reports. The DON continued that there were standing orders from their parent company for crushing medications, and that a standing order for crushing medications was an order that could be implemented, unless contraindicated by the drug manufacturer, and the nurses and med aides would know a standing order had been implemented by documentation in the Progress Notes. She continued that crushing medications could also be temporary, and that Resident #60 had no orders from a physician for crushing medications because a standing order was an order. She revealed that the extended-release Metoprolol Succinate ER tablet should not have been crushed, and that a new order for Metoprolol Tartrate was being added for Resident #6. An interview on 8/25/23 at 11:00 am, Med Aide #4 stated she gave Resident #60 crushed medications because Resident #60 liked them to be crushed. Med Aide #4 recalled that the medication card for Resident #60 from Pharmacy for Metoprolol Succinate had do not crush written on it and crushed it anyway because of discussions at change of shift reports that Resident #60 preferred her medications crushed. She continued that she could not write in the Progress Notes but read in the Progress Notes about crushing medications for Resident #60. She concluded that she confused Metoprolol Succinate (a non-crushable medication) with Metoprolol Tartrate (a crushable medication). 1b. During the medication administration observed to Resident #60 on 8/23/23 at 10:47 AM, Med Aide #4 administered one capful of polyethylene glycol 3350 powder solution sugar free mixed in a medication plastic cup with water. Med Aide #4 set the medication cup of polyethylene glycol in front of Resident #60 on her bed table. Resident #60 began to sip the liquid polyethylene glycol and Med Aide #4 left the room. Review of physician orders for Resident #60 revealed an order dated 9/8/22 at 7:00 am for polyethylene glycol 3350. Give one scoop by mouth one time a day for Constipation. Review of the August 2023 Medication Administration Record for Resident #60 revealed polyethylene glycol 3350, one scoop by mouth one time a day for constipation was administered August 1 through August 23, 2023. An interview on 8/23/23 at 11:21 am with Nurse #6 revealed when she passed medications, she stayed with Resident #60 until she completed her polyethylene glycol mixed with water. On 8/23/23 at 4:34 pm, the medication plastic cup with liquid polyethylene glycol was observed undrunk and sitting in front of Resident #60 on her bed table. An interview with the DON on 8/25/23 at 10:22 am revealed there would be extra training for Med Aide #4, and the nurses would also complete closer oversight of the Med Aides to ensure correct medication pass protocols were followed. An interview on 8/25/23 at 11:11 am with Med Aide #4 revealed that she left the cup of polyethylene glycol mixed in water on the bedside table of Resident #60.

Based on record review and staff and local Department of Social Services (DSS) Adult Protective Services (APS) Supervisor interviews, the facility failed to report an allegation of resident abuse to Adult Protective Services within the required time frame for 1 of 1 resident abuse allegation reviewed (Resident #2). Findings included: Review of the policy titled Abuse investigation and reporting for Senior Services dated 4/19/06 and revised 1/26/23. Which stated: The administrator (or designee) will ensure that a completed DHSR form initial Allegation Report located at: NC DHSR CHCPIS: Provider Information fncdhhs.gov) is submitted to the Health Care Personnel Registry Section of the Division of Health Services Regulations within 2 hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury (see #1). All other allegations will be reported using the same form within 24 hours. Even though the form asked for employee information, it can and should be utilized for any individual against whom an allegation is made. Adult Protective Services must also be notified within the same frames. Resident #2 was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and had no negative behaviors. The Initial Allegation Report dated 7/31/23 revealed an allegation of resident to resident abuse for Resident #2 who was observed by staff with a male resident (Resident #283) in her room with his head on her bare chest. The report was faxed to Health Care Personnel Investigations (HCPI) of the Division of Health Services Regulations (DHSR) on 7/31/23 at 10:36 PM. Review of section I Notification to Other Agencies- Department of Social Services revealed it was left blank. The Investigation Report (5day) was faxed to the HCPI Section of the Division of Health Services Regulations (DHSR) on 8/7/23 3:34 PM. Review of section I Notification to Other Agencies- Department of Social Services indicated APS was notified on 8/7/23. An interview conducted on 8/29/23 at 5:05 PM the Administrator revealed she had a prior agreement with their county DSS/APS to send them the report after the 5- day investigation was completed. An interview conducted on 8/31/23 at 11:19 AM the DSS Adult Protective Services Supervisor revealed that nursing homes were required to follow guidance from DHSR for reporting.

Based on observations and staff interview the facility failed to ensure opened foods were sealed, labeled and dated. This was evident for 1 of 1 kitchen observation. Findings Included: An observation of the kitchen on 3/28/22 at 10:50 am was conducted with the Assistant Food Service Director (AFSD). The following concerns were identified in the walk-in freezer: 1. A partial case of Salisbury steak patties that had been removed from the original packaging were not labeled and dated. 2. A partial case of breaded vegetable rounds were open and exposed to the air. 3. A partial case of pizza crusts were open and exposed to the air. 4. A partial case of French toast were open and exposed to the air. 5. A partial case of pasta sheets were open and exposed to the air. An interview with the AFSD revealed all these items should have been sealed, labeled and dated when opened. An interview on 3/31/22 at 11:15 am with the Administrator revealed she expected foods to be closed, labeled and dated when opened.

Based on observations, record review and staff interview the facility failed to maintain an indwelling urinary catheter bag and a nephrostomy bag off the floor. This was evident for 2 of 3 observations of Resident #25. Findings Included: Resident #25 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly minimum data set (MDS) dated [DATE] for Resident #25 identified he had an indwelling urinary catheter. A care plan dated 11/1/21 for Resident #25 revealed he had a catheter and bilateral nephrostomy tubes. Interventions included for the nurse to take care of his catheter and nephrostomy tubes and the aides to take care of his catheter equipment. An observation on 3/28/22 at 12:26 pm of Resident #25 revealed the resident ' s bed was in a lower position. The indwelling urinary catheter bag and one nephrotomy tube bag were touching the floor. An observation on 3/29/22 at 10:00 am of Resident #25 revealed he was in bed being fed his breakfast and one nephrostomy tube bag was touching the floor. An interview on 3/30/22 at 11:42 pm with Medication Aide (MA) #1 revealed Resident #25 had a urinary catheter and a bag on each side that drained his kidneys. She stated the only thing she did was empty them and report his output to the nurse. MA #1 added the nurse was responsible for the rest of his care for the catheter and nephrostomy tubes. An interview on 3/30/22 at 12:10 pm with Nurse #1 revealed Resident #25 had an indwelling urinary catheter and bilateral nephrostomy tubes. She stated the resident ' s indwelling urinary catheter and nephrostomy tubes should be positioned so they can drain and should not be touching the floor. An interview on 3/31/22 at 11:05am with the Director of Nursing (DON) revealed Resident #25 ' s catheter should have been placed in a basin when the resident ' s bed was in a lower position, so the catheter bag was not touching the floor. She stated Resident #25 ' s nephrostomy tube bag should not have been touching the floor.

Based on staff interviews, resident interviews and record review the facility failed to develop a base line care plan that included minimum healthcare information to provide effective, person centered care for residents with uncontrolled blood sugars or who required [MEDICAL TREATMENT] with fluid restrictions for 2 of 2 residents (Resident #343 and Resident #340) reviewed for base line care plans. Findings included: 1.Resident #343 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 8-1-18 admission physician's orders [REDACTED].#343 was ordered to have fluid restriction of 1500 milliliters daily and attend [MEDICAL TREATMENT] on Tuesday, Thursday and Saturdays. A review of Resident #343's base line care plan dated 8-2-18 revealed a goal that the resident would improve her ability to participate in her activities of daily living (ADL), transfer safely and move around independently. The interventions for that goal were as followed; explain procedures, prompt use of [MEDICATION NAME], check skin, reposition while in bed, transfer with full body lift, assist with incontinence care and assist with ADL care. The second goal listed was for Resident #343 not to have any uncontrolled or abnormal bleeding or bruising. The interventions for that goal were as followed; assess for any abnormal bleeding, report labs to the physician, assess for pain and assess color or temperature changes to the resident's extremities. The resident's base line care plan did not address the resident's fluid restriction or her [MEDICAL TREATMENT] 3 times a week. During an interview with Resident #343 on 8-6-18 at 2:00pm the resident stated when she was admitted , staff was allowing her to drink as much as she wanted and felt that was why her hands were swollen on 8-6-18. The resident also stated the only goal she knew of was for therapy, so she could go back home. An interview with the Minimum Data Set (MDS) manager occurred on 8-8-18 at 2:19pm. The MDS manager stated she reviewed the base line care plans but that the admissions coordinator developed the plan. She also stated the facilities base line care plans only discuss the ADL care the resident will need when they are admitted . The MDS manager also confirmed the resident's base line care plan did not address the resident's fluid restriction or her [MEDICAL TREATMENT]. During an interview with the Administrator on 8-8-18 at 3:30pm she stated she expected base line care plans to reflect the needs of the resident while the full care plan was being developed. 2.Resident #340 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #340's base line care plan dated 8-4-18 revealed a goal that the resident will improve his ability to walk, transfer safely and complete his activities of daily living (ADL) independently. The interventions for that goal were as followed; explain procedures, prompt use of [MEDICATION NAME], assess skin, assist with toileting, assist with ADL care. The resident's base line care plan did not address his diabetes or his [MEDICAL CONDITION]. A review of the physician's history and physical dated 8-6-18 revealed Resident #340 had been hyperglycemic (high blood sugar) since admission. The Medication Administration Record [REDACTED]. During an interview with Resident #340 on 8-8-18 at 11:05am the resident stated the only goals he was aware of were for him to be more independent, so he could go home. An interview with the Minimum Data Set (MDS) manager occurred on 8-8-18 at 2:19pm. The MDS manager stated she reviewed the base line care plans but that the admissions coordinator developed the plan. She also stated the facility's base line care plans only discuss the ADL care the resident will need when they are admitted . The MDS manager also confirmed the resident's base line care plan did not address the resident's diabetes or his [MEDICAL CONDITION]. During an interview with the Administrator on 8-8-18 at 3:30pm she stated she expected base line care plans to reflect the needs of the resident while the full care plan was being developed.

Based on observation, record review and staff interview the facility failed to cleanse Resident #1 buttocks after a urine incontinence. The facility failed to apply protective ointment as directed in 1 of 3 sampled residents dependent on staff for activity of daily living. Findings included: Resident # 1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 1 had impaired short and long-term memory and dependent on staff for toileting, personal hygiene and bathing. The MDS coded Resident #1 as frequently incontinent of urine and always incontinent of bowel. Review of the care plan updated 9/14/17 and 11/15/17 which indicated a problem with incontinence of bowel and bladder. The approaches included pericare when incontinent and apply barrier cream after each incontinent episode and whenever necessary. Review of the physician orders [REDACTED]. · Apply 3-2-1 cream to the scrotum and penis twice a day. · Apply protective ointment to the buttocks every shift Observation of (3) threes Nursing Assistant (NA) #1, NA #2 and NA #3 on 11/15/17 at 4:08 PM during incontinence care was conducted. Resident #1 had experienced a urine incontinent episode. NA #3 cleansed the groin areas, scrotum and the skin fold under his abdomen with perineal wash. These areas were observed to have reddened skin. Then NA #1 and NA #2 repositioned the resident on his left side. A 3-2-1 barrier cream was then applied to the buttocks. It should be noted that the buttocks had not been cleansed. No ointment had been applied to the groin or scrotum. A clean brief was then placed on the resident. An inquiry during an interview on 11/15/17 at 4:51 PM with NA #3 about the performed incontinence care that was observed. NA #3 stated she had not cleansed the skin on Resident #1 ' s buttocks because she was out of washcloths and Resident #1 was not soiled (referring to an incontinence of bowel and visibly seeing urine). Continued interview with NA #3 revealed she was unaware the 3-2-1 crème should have been applied on his penis, groin, scrotum and not the buttocks. An inquiry was made about how she would know the resident ' s care needs and NA #3 stated I cannot answer that about how I know how to care for the resident. Interview on 11/16/17 at 9:58 AM with the Administrator and Director of Nurses (DON) was conducted. The DON stated her expectation was to have the buttocks cleansed as part of incontinence care and to apply the barrier creams as ordered.