Every finding on record at Westwood Hills Nursing and Rehabilitation Center

Based on record review, observations, and interviews with residents, facility staff, the Nurse Practitioner, and Psychiatric Provider, the facility failed to protect the resident's right to be free from resident-to-resident abuse for 1 of 3 residents reviewed for abuse (Resident #2) on 4/30/26. Resident #2 sustained a left hip fracture and a left olecranon (elbow) fracture. The findings included: Resident #3 was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, dementia, and anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired and required substantial assistance for toileting, dressing and showers. Resident #1 was admitted to the facility on [DATE]. Diagnosis included a fall with traumatic brain injury (TBI), Paranoid Schizophrenia and dementia. Review of annual MDS dated [DATE] revealed Resident #1 was severely cognitively impaired, independent for mobility, required moderate assistance with toileting and bathing. Resident #1 was coded for wandering and behaviors. Review of the Facility Reported Incident dated 4/17/26 revealed that Resident #1 and Resident #3 were at the nurse's station when Resident #3 told Resident #1 to shut up and Resident #1 pushed Resident #3 down. Facility staff intervened and separated the two residents. Resident #3 was assessed by the nurse and was found to have no injuries, and he did not have any complaints of pain at the time of the altercation. Resident #1 was put on 1:1 supervision (a staff member stays with the resident 24 hours a day, 7 days a week) for the rest of the shift and was assessed by the Psychiatric Provider within hours of the altercation. His trazodone (a medication used for depression) was restarted at 50 milligrams three times a day as needed for anxiety. According to the report the Psychiatric Provider determined that it would be okay to remove the 1:1 supervision and put Resident #1 on every 30 minute checks for aggression. An interview was conducted with the Psychiatric Provider on 5/26/26 at 4:00 PM. She reported that Resident #3 had exhibited behaviors in the past of wandering and increased anxiousness with wanting to leave. She reported he was usually easily redirected and his as needed anxiety medications were effective. She reported she did not recall any aggressive behavior from Resident #3. The Psychiatric Provider reported that Resident #1 had a history of verbal aggression toward staff and residents and was impulsive in behavior. The Psychiatric Provider reported that she was aware of the incident that occurred on 4/17/26. She stated that during this incident, Resident #1 became physically aggressive with Resident #3, pushing Resident #3 to the floor after Resident #3 told Resident #1 to shut up. After this incident the Psychiatric Provider reported that she restarted Resident #1's Trazodone. She reported that the facility put him on 1:1 supervision for the remainder of the shift after this incident and she recommended that the 1:1 supervision be discontinued and he be moved to every 30 minute checks. She reported at this time, she felt this was in the best interest of Resident #1 as well as the other residents because Resident #1's trazodone was effective and because of his diagnosis of paranoid schizophrenia, having someone following him could make his symptoms and outburst worseAn interview was conducted with the NP on 5/26/26 at 2:58 PM. The NP stated that Resident #1 could be aggressive both verbally and physically aggressive. She reported she was aware of the incident that occurred between Resident #1 and Resident #3. She revealed that Resident #1 had been placed on 1:1 supervision after the incident with Resident #3 for a short time. She stated that when Resident #1 was on 1:1 supervision he was more easily agitated. She reported that Resident #3 did not have any injuries from the incident on 4/17/26.An interview was conducted with the Director of Nursing (DON) on 5/26/26 at 3:02 PM. She reported that on 4/17/26 Resident #1 and Resident #3 were at the nurse's station. Resident #3 told Resident #1 to shut up and Resident #1 pushed Resident #3 down. The DON stated Resident #3 did not have any injuries from the fall and Resident #1 was placed on 1:1 supervision for the remainder of the shift and then put on every 30-minute checks per direction of the Psychiatric Provider. She reported that the Psychiatric Provider also restarted his Trazodone and it was effective.An interview was conducted with the Administrator on 5/26/26 at 4:15 PM. He reported he was made aware of the incident on 4/17/26 between Resident #1 and Resident #3. He stated an investigation was conducted and no abuse was found. Prior to this incident neither resident had been physically aggressive with anyone in the facility. Resident #2 was admitted to the facility on [DATE]. Diagnosis included right hip fracture, dementia and alcohol abuse. Review of the quarterly MDS dated [DATE] showed Resident #2 was severely cognitively impaired, was coded for wandering and behaviors. He was independent with mobility and required moderate assistance with bathing. Review of the Facility Reported Incident dated 4/30/26 revealed Resident #1 and Resident #2 were at the nurse's station. Resident #1 was yelling at the nursing staff about his remote control being broken. Resident #2 told him to stop yelling at the girls and Resident #1 hit Resident #2 in the left side of the face, knocking him to the ground. The incident was witnessed by Nurse #1. According to the investigation, Nurse #1 was walking down the hall when she heard Resident #2 and Resident #1 verbally attacking one another, she turned around to see Resident #1 hit Resident #2 in the face. She returned to the nurse's station to intervene. The report indicated that Resident #1 immediately returned to his room and Resident #2 was assessed by Nurse #1 and was assisted to a chair by Nurse #1 and Nurse Aide (NA) #1. At the time of the incident Resident #2 complained of burning in his right hip. There were not any abnormalities of his upper or lower extremities noted at the time of the incident. The report noted that the Resident #2 sat at the nurse's station eating snacks and drinking a soda for a good portion of the evening after the incident. The report indicated that Resident #2 was put on 1:1 supervision during this time because staff felt like he was the perpetrator. The investigation revealed that on 5/1/26 around 7:45 am Nurse #2 reported Resident #2 was complaining of pain in his hips, and her assessment revealed that he had a swollen left elbow and his left leg was rotated outwards and was shorter than the right. Nurse #2 notified the NP, who was in the facility at the time. The NP assessed the resident as well and gave orders to give him Norco (an opioid prescription pain reliever) and send him to the emergency room (ER) for evaluation. Review of 5/1/26 hospital records revealed a left olecranon fracture which required a posterior slab splint (a rigid device used to immobilize the elbow) to be placed. This procedure was noted to be done at bedside with no complaints from Resident #2. Hospital records also revealed a left hip fracture, which required total hip arthroplasty (a surgical procedure where a damaged hip joint is removed and replaced with an artificial prosthetic implant). Hospital records reported that Resident #2 tolerated the surgery well with minimal complaints of pain and was discharged back to the facility in good condition. An interview with the Psychiatric Provider was conducted on 5/26/26. She reported that she was aware of the incident between Resident #1 and Resident #2. She stated that Resident #2 had a long history of being rude towards staff, which had caused problems with his care and the facility had made a lot of medications changes to help with his anxiety and outbursts. She stated that Resident #2 gave no warning signs before his outburst and therefore as needed medications could be difficult to manage with him. The Psychiatric Provider reported Resident #2's outburst and aggression had been verbal in nature, and mostly towards staff but occasionally he had said some things that were inflammatory towards other residents. She reported she did not recall any physical aggression towards staff or other residents from Resident #2. She reported that Resident #1 had a history of verbal aggression toward staff and residents and was impulsive in behavior. The Psychiatric Provider reported she had done a telehealth visit with Resident #1 the day after this incident and he could not remember anything that had happened. She reported that the facility had initially put Resident #2 on 1:1 supervision but due to this being the second physical aggression incident towards a resident for Resident #1 they put him on 1:1 supervision for his safety as well as the safety of the other residents. The Psychiatric Provider reported she agreed with the 1:1 supervision at this time for the safety of Resident #1 and the other residents. She reported she was monitoring Resident #1 closely for any increased anxiety and/or behaviors due to the 1:1 supervision.An interview with Nurse #1 was conducted on 5/26/26 at 7:30PM. Nurse #1 reported she was working on 4/30/26 when the incident occurred between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 were at the nurse's station. Nurse #1 revealed Resident #1 was at the nurse's station to report his remote control was broken again, even though staff had shown him several times that it was working. Nurse #1 reported she was called down the hall to assist with another resident. She stated when she walked away from the nurse's station, Resident #1 and Resident #2 were both just standing at the nurse's station and were not arguing. Nurse #1 stated that she got about three quarters of the way down the hall and heard Resident #2 raise his voice, although she could not understand what he said. Nurse #1 reported she turned around and saw Resident #1 punch Resident #2 in the left jaw and Resident #2 fell to the floor. Nurse #1 stated she immediately went to Resident #2 and assessed him. She reported that Resident #1 walked off to his room. Nurse #1 reported that Resident #2 didn't remember that he had been hit and reported that his right hip was burning. She stated this was not a new complaint of pain for him. Nurse #1 stated that she did not note any external rotation of either leg, no swelling in either legs or arms at the time of her assessment. She stated that after her assessment she felt it was safe to move him to a chair. She reported she gave his ordered Tylenol and called the medical provider on call to report the incident. The provider ordered a right hip x-ray. Nurse #1 stated she also put Resident #2 on 1:1 supervision because she felt he was more the aggressor than Resident #1. Nurse #1 reported that after the incident Resident #2 stayed at the nurse's station eating snacks. Nurse #1 stated that NA #1 laid him down, upon his request, sometime between 3:30 AM and 5:00 AM. Nurse #1 reported she was not made aware of any concerns when Resident #2 was laid down, and no distress was noted on her shift. Nurse #1 stated she checked on Resident #2 again around 6:30 AM before her shift ended and he was sleeping on his left side.An interview was conducted with the Director of Nursing (DON) on 5/26/26 at 3:02 PM. She reported that she was called around 8:45 PM on 4/30/26 by Nurse #1 who reported the Resident-to-Resident altercation between Resident #1 and Resident #2. The DON reported that when she arrived at the facility on 4/30/26 at around 9:45 PM, Resident #2 was sitting at the nurse's station in a Broda chair (a recliner type chair) eating a snack. She reported that Nurse #1 had assessed both residents and only some puffiness was noted on Resident #2's left cheek and Resident #1 had no injuries and no complaints of pain. The DON stated that during her assessment Resident #1 was in his room, watching TV and had no complaints of pain and did not remember what had occurred. The DON reported she assessed Resident #2 and did not note any injuries at the time of her assessment, he was also not complaining of pain. The DON reported that staff had placed Resident #2 on 1:1 supervision, as they felt he was the aggressor during this incident. However, after the investigation the facility with the guidance of the Psychiatric Provider determined that Resident #1 would be put on 1:1 supervision since this was his second incident of physical aggression towards a resident. The DON stated that Resident #1 and Resident #2 had not had any problems with one another in the past.An interview was conducted with the Administrator on 5/26/26 at 4:15 PM. He reported he was made aware of the incident on 4/30/26 between Resident #1 and Resident #2. He reported that an investigation was conducted and no abuse was found. He stated that Resident #1 had been aggressive in the past but had been doing well on his current medication regimen and the staff felt he was settling into a routine at the facility. The Administrator reported he felt like this incident was unexpected due to the improvement in Resident #1's recent behaviors.Facility provided the below corrective action plan on 5/27/26:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is [AGE] years old, with diagnoses of Traumatic subdural hemorrhage, Paranoid Schizophrenia, Epilepsy, Unspecified dementia severe with other behavioral disturbances, and resided on the dementia unit.Resident #2 is [AGE] years old, with diagnoses of Dementia, Psychotic disturbance, Chronic pain, Anxiety, History of alcoholism and resided on the dementia unit.On 04/30/2026 approximately 8:30 pm, Resident #1 and Resident #2 were observed by Nurse #1 standing at the nursing station having a conversation. No behaviors or signs of agitation were noted at that time. Nurse #1 stepped away from the nurse's station desk and had walked about 45 feet when she heard bickering. Nurse #1 reported Resident #2 could be heard talking loudly. It was unclear what the residents were saying. When Nurse #1 turned around, she observed Resident #1 hit Resident #2 on the left side of his cheek. Resident #2 lost his balance falling backwards onto the floor. Nurse #1 and nursing assistant #1 intervened immediately by separating residents. Resident #1 returned to his room. Resident #2 was taken to the dining room and placed 1:1 observation.On 4/30/26, Resident #1 and Resident #2 were immediately assessed during the 3-11 shift after the incident. Resident #1 had no injuries or reports of pain noted. Resident #2 complained of a burning sensation in his right hip and puffiness noted on the left side of his cheek below his eye. The nurse notified the provider after becoming aware of the burning sensation in the resident's right hip. A new order was received for an X-ray of the right hip. On 4/30/26, at approximately 8:30 pm, Nurse #1 notified the provider and the Director of Nursing of the incident. Nurse #1 attempted to notify Resident #1 and Resident #2 representative but was unsuccessful. On 4/30/26, skin checks and pain assessments were completed by the nurse on both residents at which time the puffiness around Resident #2's eye had resolved.During the remainder of the 3-11 shift and 11-7 shift, per staff interviews including the 1:1 sitter, staff noted no changes in condition during care.On 5/1/26 at approximately 7:15 am, during care, Resident #2 complained of pain to bilateral hips and left elbow. Nurse #2 assessed Resident #2 and observed left elbow was edematous from the left upper arm extending to the left lower arm and a dark blue circular discoloration noted on the left elbow. The left leg was noted to be shorter than the right leg with slight external rotation. Resident #2 was wincing with movement. The supervisor and medical provider were immediately notified by Nurse #2. Pain medication was administered. The medical provider was on site at the facility and assessed Resident #2 with new orders received to send to the emergency room for further evaluation.On 5/1/26, a telehealth visit by psychiatric services was completed for Resident #1. Trazodone as needed was restarted.On 5/1/26, Resident #2 was found to have a closed left olecranon fracture and left femoral neck fracture per hospital records with surgical repair. On 5/1/26, Resident #1 was placed on 1:1 observation and continues to remain on 1:1 observation.On 5/6/26, Resident #2 returned to the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 4/30/2026, 100% skin checks were initiated on all residents residing in the dementia unit. The skin checks were conducted by the Director of Nursing, the Quality Assurance nurse, and the assigned hall nurse for signs and symptoms of abuse. No concerns were identified during this audit. The skin checks were completed by 5/1/26. On 5/1/26, 100% skin checks were expanded and initiated on all residents residing in the remaining facility, with a brief interview for mental status (BIMS) of 12 and below. The skin checks were conducted by the Director of Nursing, the Quality Assurance nurse, and the assigned hall nurse for signs and symptoms of abuse. No concerns were identified during this audit. The skin checks were completed by 5/6/26. On 5/1/2026, the Director of Nursing audited 100% of all residents' progress notes and behavior alerts in the Point of Care electronic medical record to identify behaviors that occurred in the last 14 days to ensure interventions were in place and documented in the care plan. The audit was completed on 5/1/2026. No concerns were identified during the audit. On 5/1/2026, the Director of Nursing, Assistant Director of Nursing, and Nurse Managers initiated interviews with all staff to identify residents with behaviors. The purpose of the audit was to ensure (1) the behaviors were reflected in the residents' progress notes, (2) the medical provider and resident representative were notified of the behaviors, (3) interventions were in place, including a psychiatric consult as appropriate, and (4) behaviors were care planned. The interviews were completed by 5/1/2026. Any staff who were not interviewed by 5/1/26 were interviewed prior to their next scheduled shift. There were no concerns identified during the interviews. On 5/1/2026, safe surveys were completed by the Social Worker and Assistant Director of Nursing with alert and oriented residents throughout the facility, with a brief interview for mental status of 13 and higher regarding abuse. During the interview, education was provided to the residents on the abuse definitions, resident rights, what to do in an abusive situation, and how to report abuse. On 5/1/2026, the Director of Nursing reviewed incident reports related to resident-to-resident altercations for the past 30 days to identify patterns and trends. There were no other patterns and trends identified during the audit.3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 5/1/26, the Administrator made the decision to post a laminated behavioral intervention guide at the nursing station to help nurses implement appropriate non-pharmacological interventions before behaviors escalate to resident-to-resident abuse. On 5/1/26, an in-service was initiated by the Director of Nursing with all nurses regarding the laminated behavioral intervention guide including the location. On 5/1/26, an in-service was initiated by the Director of Nursing with all staff regarding managing residents with behaviors, reporting behaviors, and prevention of resident-to-resident abuse. The in-service emphasized staff are to report any new or worsening behaviors to the nurse immediately. The nurses were educated to evaluate the resident and ensure interventions are immediately implemented to deescalate the behaviors. The inservice included for nursing staff to immediately document behaviors in the electronic medical record behavior alert system. The in-service was completed by 5/1/2026. After 5/1/2026, any staff who had not worked or completed the in-service completed the in-service prior to working their next scheduled shift. The Assistant Director of Nursing monitored staff's completion. The Assistant Director of Nursing was notified of this responsibility by the Director of Nursing on 5/1/26.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Starting on 5/4/26, 100% of all newly documented residents' progress notes and behavior alerts (electronic medical record documentation utilized by Nursing Assistants and Nurses to document behavior observed during their shift) will be reviewed by the Director of Nursing, Assistant Director of Nursing, and Nurse Managers during the morning and afternoon Monday through Friday interdisciplinary team meeting utilizing the Behavior Audit tool. The purpose of this review is to ensure all behaviors are addressed, including notifying the medical providers and resident representatives, and any new interventions are care planned and updated on the resident care guide to prevent resident to resident altercations. The audit will be completed weekly for 4 weeks then monthly for 1 month and documented on the behavioral audit tool. The Director of Nursing and Administrator will immediately address any areas of opportunity identified. The Administrator or Director of Nursing will review and initial the audits weekly for 4 weeks then monthly for 1 month to ensure all areas of opportunity are addressed appropriately. The Administrator or Director of Nursing will present the findings of the Audit Tool to the Quality Assurance and Performance Improvement Committee monthly for 2 months. The Quality Assurance and Performance Improvement Committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. 5. Date corrective actions completed: 5/06/26 The facility's corrective action plan was validated on 5/27/26 by the following: Interviews with all facility staff revealed they had received education on abuse as well as reporting abuse and neglect where they went through different scenarios of what would be abuse and what would be neglect, if abuse or neglect had been suspected or reported they do not leave residents alone, make sure they are safe, and use resident's call light or yell if needed to get assistance from other staff. Observation of Resident #1 sitting on his bed inside of his room with his one-to-one staff sitting in the room with him. Resident #1's one-to-one staff were able to verbalize the education they had received regarding abuse and neglect, reporting of abuse and neglect, one-to-one supervision protocols. Resident #1 was also observed ambulating down the hallway with his one-to-one staff walking behind him or to the side of him with no issued noted. They were educated about Resident-to-Resident abuse and discussed if they ever observed themselves or it was reported to them how they should proceed and again making sure both residents were safe. Review of staff assignment sheets for shift also revealed the name of the staff person who was assigned to any resident for one-on-one. Reviewed the audit and monitoring tools with no issues noted. Interviews with the Administrator and the DON revealed they provided the same education to all the facility staff, those training sessions were held both in person and via telephone, and all of the staff were able to demonstrate their understanding of the education they had received.

Based on record reviews and interviews with resident, staff, Pharmacy Manager and the Medical Director, the facility failed to implement effective systems to safeguard a resident's controlled medication from misappropriation (30 tablets of oxycodone 15 milligrams) for 1 of 1 resident reviewed for misappropriation of property (Resident #22).The findings included:Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome.Review of Resident #22's physician orders dated 10/30/24 revealed an order for oxycodone15 mg by mouth every six hours for pain.Review of Resident #22's Medication Administration Record for 08/2025 revealed he was given oxycodone 15 mg by mouth every six hours as ordered.Review of a pharmacy packing slip revealed Resident #22's oxycodone 15 mg /120 tablets were delivered to the facility on [DATE] and were counted in by Nurse #3 and Nurse #4. The packing slip indicated the count was correct.Review of Resident #22's quarterly Minimum Data Set assessment dated [DATE] indicated the Resident was cognitively intact and received routine pain medication.An interview was conducted with Resident #22 on 11/16/25 at 1:15 PM. The Resident explained that he was in chronic pain all the time and received routine pain medication to help control his pain. He stated that the facility provided his pain medication and he had never run out of pain medication.Review of an Occurrence Investigation Report Summary dated 09/12/25 revealed Resident #22 was ordered oxycodone 15 mg by mouth every six hours. The facility received the Resident's medication from the pharmacy on 08/19/25 of 4 cards of 30 tablets each card for a total of 120 tablets. The order was verified and signed in by two licensed nurses per protocol. The medication was not started until 08/21/25 due to the Resident already having some oxycodone 15 mg tablets on the cart from a previous order. On 09/11/25 the nurse notified the Director of Nursing (DON) that Resident #22 only had two tablets of oxycodone 15 mg left so the DON contacted the pharmacy and was informed that Resident #22 should have enough oxycodone tablets to get through the following week because they sent 120 tablets of oxycodone for the Resident on 08/18/25. The DON immediately reviewed the previous packaging slip and verified that 120 tablets had been verified and signed in by nursing staff on 08/19/25. The DON verified Resident #22's Medication Administration Record that the Resident had not missed any doses and verified one card in the cart labeled #4 of 4 with 2 tablets remaining in the card. The declining count sheet for the oxycodone matched with 2 tablets remaining. The DON then pulled all Resident #22's declining count sheets for the oxycodone that was received on 08/19/25 and discovered that the declining count sheet for card #3 of 4 was missing. The DON pulled the Shift Change Controlled Substance Count Check Form (a count sheet utilized between shifts to indicate the controlled medication cards and declining count sheets match and were correct) for the 100-hall medication cart from July to present and discovered that the sheet from dates 08/16/25 through 08/22/25 was also missing. The DON pulled the packing slip for the previous order of oxycodone for Resident #22 which was 07/17/25 to verify the number of tablets received and signed in and the count was correct. There were no concerns identified.Review of a Pharmacy memo to the facility dated 09/12/25 indicated that the facility was charged for 60 tablets of oxycodone 15 mgs each for Resident #22.Review of a Drug Enforcement Administration form dated 09/14/25 revealed the facility reported the loss or theft of 30, 15 mg oxycodone hydrochloride tablets.Review of the Investigation Report dated and faxed to the Health Care Personnel Registry on 09/18/25 revealed that on 09/12/25 at 9:00 AM the facility became aware of 30, 15 mg oxycodone tablets were missing for Resident #22. The Report indicated that the local police were notified of the missing narcotics on 09/12/25 at 6:30 PM and the Department of Social Services was notified on 09/12/25 as well. The Report continued to explain that the investigation could not confirm a person took the medication therefore, drug diversion could not be confirmed. Also, it was not known whether the pill pack was thrown in the trash mistaken for an empty card. The allegation was not substantiated for drug diversion.Review of Resident #22's Controlled Substance Count Records (declining count sheet) revealed the following: declining count sheet #1 was initiated on 08/21/25 with 30 tablets and exhausted to 0 tablets on 08/28/25. Declining count sheet #2 was initiated on 08/28/25 with 30 tablets and exhausted to 0 tablets on 09/04/25 and declining count sheet #4 was initiated on 09/05/25 with 30 tablets and exhausted to 2 tablets on 09/11/25. There was no record of declining count sheet #3.Review of the Shift Change Controlled Substance Count Check Form for 100 hall revealed the Shift Change Count Sheet for the dates of 08/16/25 through 08/22/25 was missing.An interview was conducted with the Director of Nursing (DON) on 11/17/25 at 2:15 PM. The DON explained that she was notified on the afternoon of 09/11/25 by Nurse #1 that Resident #22 only had 2 oxycodone 15 mg tablets left in the medication card and when Nurse #1 called the pharmacy to request more oxycodone to be sent, the pharmacy informed Nurse #1 that they had sent 120 tablets to the facility on [DATE] and that amount should be enough for at least another week or so. The DON continued to explain that she and Nurse #2 started an investigation into the missing oxycodone. The investigation found that the last supply of Resident #22's oxycodone was delivered to the facility on [DATE] and the count was verified by Nurse #3 and Nurse #4 on 08/19/25. The DON reported that the current medication card that was being used was card #4 so they located the declining count sheets for cards #1 and #2 but could not find card #3's declining count sheet. The DON continued to explain that she was able to locate the Shift Change Controlled Substance Count Check Forms for the time duration when all the declining count sheets were being utilized except for the count sheet for 08/16/25 through 08/22/25. The DON reported that she drug tested all the nurses that worked on the 100-hall medication cart during that time frame and all the drug tests were negative. The DON continued to explain that she interviewed Nurse #3 and Nurse #4 to verbally verify they conducted the correct count when the medication was delivered from the pharmacy on 08/19/25. When the DON was asked if she interviewed Nurse #4 about why he initiated medication card #4 instead of #3 on 09/05/25 the DON remarked the nurses often do not go by the sequence of order when initiating the medication cards. The DON explained that she called the pharmacy and had them send more oxycodone at the facility's expense. The DON stated Resident #22 did not miss a dose of his medication because they were able to obtain more medication before his supply was exhausted. The DON reported that after all the investigation into the missing oxycodone, she could not determine what happened to the medication. She stated that she wanted to believe that the medication card was accidentally thrown away but that would not answer how the declining count sheet and the shift change sheet went missing as well. She stated she did not want to think that someone would have taken the medication but that appeared to be the only reasonable answer. She stated she hoped the new systems they had in place would prevent diversion or misappropriation from happening again.An interview was conducted with Nurse #4 on 11/18/25 at 2:15 PM and 7:34 PM. The Nurse explained that Resident #22 went to the pain clinic for pain control management and prescribed the Resident's oxycodone. Nurse #1 asked him to monitor how much oxycodone Resident #22 had on hand to ensure there was enough to last until his next appointment. On 09/11/25 Nurse #4 noticed that the Resident only had 2 oxycodone left and his next appointment at the pain clinic was scheduled for 09/22/25 so Nurse #4 notified Nurse #1 about the situation. Nurse #4 continued to explain that later the DON interviewed him about whether he and Nurse #3 verified and signed in the correct count of Resident #22's oxycodone on 08/19/25 and whether it was delivered in 4 cards of 30 tablets in each card and if he verified the count with Nurse #3. The Nurse stated that the DON questioned him about where medication card #3 was because they could not locate the declining count sheet for card #3. The DON also questioned Nurse #4 about why he initiated medication card #4. The Nurse continued to explain that he informed the DON that he and Nurse #3 verified the correct count of Resident #22's oxycodone of 120 tablets and that it was delivered in 4 medication cards. He assured her that the count was correct. He also informed the DON that he initiated medication card #4 on 09/04/25 because it was the only card left in the cart with Resident #22's oxycodone. He stated that at the time he initiated the card he did not notice that card #3 was not there, he just started the card that remained in the medication cart.On 11/17/25 at 3:45 PM during an interview with Nurse #1 she explained that Nurse #4 informed her on 09/11/25 that he did not think Resident #22 had enough oxycodone 15 mg tablets to get Resident #22 to his next pain clinic appointment on 09/22/25. Nurse #1 stated she called the pharmacy on 09/11/25 to send more medication, and she was informed that they had delivered enough oxycodone tablets to do the Resident for at least another week or so. She then notified the DON of what the pharmacy told her and the facility started an investigation into why Resident #22 did not have more oxycodone on hand.An interview was conducted with Nurse #3 on 11/18/25 at 7:39 PM who explained that she was the supervisor on 08/19/25 and remembered that she counted in Resident #22's oxycodone 120 tablets in 4 cards of 30 tablets each with Nurse #4. She stated that it was the last time she saw the medication cards because she did not work as a hall nurse.An interview was conducted with Nurse #2 on 11/17/25 at 4:10 PM. The Nurse explained that she collected the declining count sheets and shift change sheets about once or twice a week and filed them in her office. When she searched for the declining count sheet for Resident #22's oxycodone card #3 and the shift change sheet that pertained to that card she could not find it in her files. They were missing.On 11/18/25 at 6:50 PM an interview was conducted with Nurse #5 who explained that he was employed on an as needed (PRN) basis and did not have a set schedule. He continued to explain that he vaguely remembered working on 09/04/25 and dispensing the last dose of Resident #22's oxycodone and that he did not remember how many cards of oxycodone were left in the medication cart. Nurse #5 stated that Nurse #4 who came on after him would have initiated the new card of oxycodone. The Nurse stated that the count on the shift change sheet was correct because if it had not been correct then they would have had to notify the supervisor and that did not happen.On 11/18/25 at 8:30 AM during an interview with the Medical Director, he explained that he was made aware of the missing oxycodone and the facility could not determine what happened to them. He stated the facility had initiated interventions to hopefully prevent diversion or misappropriation from happening again.On 11/19/25 at 9:40 AM an interview was conducted with the Pharmacy Manager who explained that on 09/10/25 the pharmacy received a prescription from the pain clinic for Resident #22's oxycodone hydrochloride 15 mg tablets and 60 tablets were delivered to the facility on [DATE]. The Pharmacy Manager stated that the supply of Resident #22's oxycodone was previously delivered to the facility on [DATE] which was a total of 120 tablets of oxycodone hydrochloride 15 mg tablets that were packaged in four cards of 30 tablets in each card.The facility provided the following action plan with the completion date of 09/16/25. How will corrective action be accomplished for those residents found to have been affected by the deficient practice?On 9/12/25 an investigation by the Director of Nursing (DON) revealed 30 Oxycodone 15mg tablets were missing from the medication cart on Blue Hall for Resident #22. An investigation was initiated immediately. Resident #22 is a [AGE] year-old male with a BIMS of 15. At the time of the reported incident, the resident had an order for scheduled Oxycodone 15 mg every 6 hours. The facility received the resident's medication (Oxycodone 15 mg; 120 tablets/4 cards of 30 tabs each) from the pharmacy on 8/19/25. The pharmacy packing slip date showed the medication was prepared by the pharmacy on 8/19/25 and received in the facility on 8/19/25. On 8/19/25, at the time the facility received the medications, the order was verified, and the medications were signed into the facility by 2 licensed nurses as correct. The first card of 30 tablets was not started until 8/21/25 due to having some medication left in the cart from the previous order. On 9/11/25, the nurse notified the DON that Resident #22 had 2 tablets of Oxycodone 15mg remaining in the cart and needed a refill. The DON then contacted pharmacy and was informed that the resident should have enough medication remaining in the cart throughout the next week. The DON immediately reviewed the previous packing slip and verified 120 tabs had been delivered by the pharmacy and verified that 1 card from that delivery remained in cart labeled 4 of 4 with 2 tablets left on the card. The corresponding count sheet was verified as correct with the card. The DON reviewed all count sheets for Oxycodone 15mg that were received with this order. The DON then discovered that count sheet 3 of 3 and card 3 of 3 were missing from the cart. Upon further investigation, the DON discovered the corresponding shift change sign in sheet for 8/16/25-8/22/25 was also missing from the cart. The DON also reviewed the previous supply delivered of Oxycodone 15mg for this resident received on 7/17/25 and noted no concerns. On 09/11/25 the Director of Nursing and licensed nurses on the unit assisted to look for missing medication, declining count sheet, and the shift-to-shift report sheets in medication room, shred bins, and trash. All other medication carts were checked for the missing medication at this time as well. After the final search for the narcotic medication, corresponding count sheet, and shift to shift change sheets were exhausted the facility determined that the medication was indeed missing. The concern was reported on 9/12/25 to the Department of Health and Human [NAME] and the Medical Provider and the resident was notified as he is his own responsible party (RP) on 9/12/25. On 9/12/25, Resident #22 was assessed for pain by the licensed nurse. No concerns were identified. The Director of Nursing contacted the pharmacy to have the resident's Oxycodone 15mg replaced. The pharmacy replaced the medication on 9/11/25 at no cost to the resident. Facility received 60 tablets on 9/11/25 to refill the resident's current prescription. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 9/12/25 the following actions were taken to prevent concerns for other residents in the facility. -On 9/12/2025 the Director of Nursing (DON) completed an audit of the last 30 days of ordered narcotic medications to ensure the medications were in the medication cart, administered, or returned to pharmacy per protocol. The Director of Nursing initiated an investigation into any identified areas of concern. No concerns were identified.-On 9/12/2025 the DON/Quality Assurance nurse completed an audit of 100% of all residents' Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication cart to ensure there were no discrepancies in the count of the medications. No concerns identified during this audit.-On 9/12/2025, the DON/QA nurse inspected the narcotic blister pill packages for any tampering of medications. No concerns for tampering identified during this audit.-On 9/12/2025 the licensed staff nurses-initiated assessment of all residents for pain. If pain reported the DON was to address and initiate non-pharmacological interventions, pain medication, and/or physician notification for any identified areas of concern during the audit. The audit was completed by 9/13/2025. No complaints of pain were expressed during this audit.-On 9/12/2025 the administrative nurses completed interviews with all alert and oriented residents regarding (1) Do you have any concerns with medication administration to include pain medication? A concern form was to be completed for any identified area of concern. No concerns identified during these interviews.-On 9/12/2025 the administrative nursing staff completed interviews with all licensed nurses and medication aides regarding (1) Do you have any concerns with misappropriation to include medications that have not been reported and addressed (Yes or No)? This will be completed 9/15/25. Any concerns identified were to be addressed immediately by the administrator and DON. No concerns identified during these interviews.-On 9/12/2025 the Payroll Clerk completed an audit of all nurses and medication aides' license verification and Health Care Personnel Registry checks which is verification of valid certification, and no abuse reported on the registry. All areas of concern were to be addressed during the audit. This audit was completed 9/15/25. All licenses and certifications were valid with no concerns identified during this audit.-On 9/12/2025 the DON/QA Nurse reviewed packing slips for the past 30 days to ensure all narcotic medications were checked in appropriately and accounted for. This audit was completed 9/15/2025. No concerns identified during this audit.-On 9/12/25 drug screens were initiated for all licensed nurses who worked Blue hall cart during the timeframe identified in the investigation, 8/15/25-8/23/25. The screenings with results were completed by 9/15/25. No positive screens identified during this audit. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 9/12/25 the administrative nursing staff initiated in-service education with 100% of all licensed nurses and medication aides regarding Controlled substance diversion to include the definition, implications, process for 2 licensed nurses to verify medications and count sheets as correct as they are delivered to the facility and ensure the narcotics are placed on the appropriate cart, and the process for returning narcotic medications to the pharmacy. The process for returning narcotic medications to the pharmacy is as follows: return to pharmacy form is filled out with the narcotic medication and number of medications remaining by the licensed nurse, the form is faxed to the pharmacy and placed in the numbered bag with medications by the licensed nurse and sealed, sealed bag is placed on the medication cart in the narcotic lock box, and the driver brings the fax received with information confirming the correct narcotic medication. The medication and form are taken by the pharmacy in the sealed bag, and the shift-to-shift change form is updated by the licensed nurse to verify new count of medications and sheets in the cart. The nurses were also educated on how to appropriately count the narcotics that are on each cart to include: verifying the prescription number and well as that the narcotic count sheet matches the number on the narcotic blister card, ex: 1 of 4, 2 of 4, 3 of 4 and 4 of 4 and verify all is correct. All in-services will be completed on 9/15/25. After 9/15/25 any licensed nurse or medication aides who have not received the training will complete upon their next scheduled shift by the Staff Development Coordinator. Beginning 9/13/25 the Registered (QI) Quality Assurance Nurse began picking up the completed Narcotic declining count sheets and shift to shift change sheets 2x/weekly for each cart to ensure all declining count sheets and shift to shift count sheets are correct and accounted for. The QI nurse reviews for any concerns and reports to DON as appropriate. The DON reviews and addresses any concerns identified. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:Beginning 9/15/25, a 100% audit of all ordered narcotic medications will be reviewed by the Director of Nursing and the Assistant Director of Nursing weekly x4 weeks and compared to the Controlled Substance Count Sheets, medication administration record, and/or return of drug slips to ensure the narcotic medications are being administered or have been returned to the pharmacy. The Director of Nursing/Assistant Director of Nursing verifies that all narcotic medications, shift to shift change sheets, and declining count sheets are present in the cart and that no other concerns were identified using the Controlled Substance Audit tool. All areas of concern were to be addressed during the audit including any re-education of the licensed nurses and medication aides. The Director of Nursing/Assistant Director of Nursing will review and initial audits weekly for 4 weeks, then monthly for 1 month to ensure all areas of concern were addressed appropriately.On 9/13/25, the Director of Nursing/Assistant Director of Nursing began reviewing the order listing report daily to ensure all narcotic medications are in the medication cart/narcotic lock box and discontinued narcotic medications are taken off the medication cart/narcotic lock box. Any concerns identified are investigated by the DON immediately.The Administrator or Director of Nursing will present the findings of the audit tools to the Quality Assurance Performance Improvement Committee monthly for 2 months. The Quality Assurance Performance Improvement Committee will meet monthly for 2 months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. The QAPI meetings were held on 9/22/25 and 10/21/25. Date of Compliance: 9/16/25 Validation of the corrective action plan was completed on 11/19/25.The corrective action plan was validated by reviewing education provided to staff, reviewing the interviews with staff and residents, and reviewing the monitoring plan put in place. Residents interviewed during the survey denied untreated pain. Controlled medication declining count sheets and shift change sheets were validated at 100% correct. Evidence that action plan was presented in monthly Quality Assurance on 09/22/25 and 10/21/25. The correction action plan completion date of 09/16/25 was validated.

Based on observations and staff interviews, the facility failed to remove 63 expired nutritional shakes from their dry storage area which resulted in 3 of the expired nutritional shakes making it to the service line and prepared for service to residents.The findings included:An observation made of the facility's dry storage area on 11/16/25 at 9:50 AM revealed 48 mixed berry flavored nutritional supplement shakes with an expiration date of 08/01/25 and 18 vanilla flavored nutritional shakes, with an expiration date of 06/20/25, sitting in the dry storage room on the top shelf.A follow-up observation of the kitchen, completed on 11/18/25 at 12:21 PM revealed the 48 mixed berry nutritional supplements with an expiration date of 08/01/25 to still be on the shelf in the dry storage area. However, there were only 15 vanilla flavored nutritional supplements with an expiration date of 06/20/25 in the dry storage area.An observation of the tray service line on 11/18/25 at 12:25 revealed 3 vanilla flavored nutritional shakes with an expiration date of 06/20/25 to be in an ice bin on the service line, ready to be served. The surveyor intervened and removed the expired nutritional shakes from the service line to prevent them from being served to residents.A brief interview with the Assistant Dietary Manager on 11/18/25 at 12:27 PM revealed she believed she had checked all of the nutritional shakes earlier that week but stated she must have missed a few and that the expiration dates should have been checked when she pulled them from the back to place them on the service line. She also indicated that food items were checked as new food stock arrived at the facility.An interview with the Dietary Manager on 11/19/25 at 9:54 AM revealed the facility must have ordered too many nutritional shakes and not enough residents in the facility were drinking them. He also stated the facility's process for ensuring that expired food was removed from stock included checking the food items twice a week, usually when the new food stock comes into the facility. He reported the kitchen storage areas were small and the facility typically ordered enough food to fix the meals scheduled until the next food order arrived. He reported he expected his staff to remove expired food items as they expired and indicated there was no reason for the nutritional shakes to have been overlooked for so long. The Dietary Manager stated the responsibility ultimately belonged to himself to ensure that there were no expired food items in the kitchen.An interview with the Administrator on 11/19/25 at 1:24 PM revealed he did not have many residents in the facility that used nutritional shakes but there was no reason why so many expired nutritional shakes were still in the dry storage area. He also indicated the no expired food items should make it to the service line.

Based on record reviews, facility policy, Center for Disease Control guidance, Statewide Program for Infection Control and Epidemiology (SPICE) representative, local health department, and staff interviews the facility failed to identify the need for and implement broad based testing during a Covid-19 outbreak when the interventions implemented failed to halt transmission of Covid-19 which spread to 2 of 5 hallways (100 and 200) and affected 11 residents on the 100 hall and 1 resident on the 200 hall (Resident #97). The findings included: Guidance from the Center for Disease Control (CDC) website updated 03/18/24 read in part, Responding to a newly identified SARS-CoV-2 infected health care personnel or resident: the approach to an outbreak investigation could involve either contract tracing or a broad-based approach; however a broad based (e.g., unit, floor, or other specific area (s) of the facility) approach is preferred if all potential contracts cannot be identified or managed with contract tracing or if contact tracing fails to halt transmission. If no additional cases are identified during contract tracing or the broad-based testing, no further testing is indicated. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit (s) or facility wide every 3-7 days until there are no new cases for 14 days. Review of a facility policy titled, Infection Control Manual Appendix A: Covid 19 Infection Prevention & Control Program Guidelines last revised on 09/25/23 read in part, facilities have the option to perform outbreak testing through two approaches, contract tracing or broad-based testing. Contract tracing is the recommended method as it more definitively identifies the source and provides best quality of life; although the Administrator, Director of Nursing, and Medical Director reserve the right to utilize broad based approach. If no additional cases are identified after completion of initial serial contact tracing or the broad-based testing, no further testing is indicated. If additional cases continue to be identified and facility assesses ongoing uncontrolled transmission, strong consideration should be given to shifting to the broad-based approach if not already being performed and implement additional precautions as indicated for residents in affected areas of the facility. As a part of the broad-based approach, testing should continue on affected unit(s) or facility wide every 3-7 days until there are no new cases for 14 days. Review of a list of residents that resided on the 100 hall of the facility revealed that Resident #11, #14, #20, #39, #54, #60, #64, #65, #75, 80, and #104 all actively had COVID-19 or had recently recovered from COVID-19. Review of the facility's COVID-19 Outbreak testing log revealed that on 07/31/24 a newly hired Activity Employee #1 tested positive for COVID-19. The log listed the residents and staff that Activity employee #1 had close contact with which included Activity Employee #2 and #3 and Resident #22, 95, and 102. The log revealed that through frequent testing Activity Employee #1, #2, and #3 all tested positive for COVID-19. Resident #22, #95, and #102 through testing tested negative for COVID-19. Further review of the Outbreak testing log revealed that through contact tracing testing Resident #11 and #65 tested positive for COVID-19 on 08/07/24, Resident #14, and #80 tested positive on 08/09/24, Resident #64 and #104 tested positive on 08/10/24, Resident #26 and #54 tested positive on 08/12/24, Resident #60 and #75 tested positive on 08/14/24, and Resident #39 tested positive on 08/15/24. Review of a list of residents that resided on the 200-hall revealed none of the residents had or recently had Covid-19 including Resident #97. Resident #97 was readmitted to the facility on [DATE] and was sent to the emergency room (ER) on 08/19/24. He resided on the 200-hall in the facility. Review of Resident #97's ER record dated 08/19/24 read in part, SARS-CoV-2 Nucleic Acid Test was performed on 08/19/24 at 10:34 AM and was detected (positive Covid-19 test). The report further read; patient states he feels fine and people at his care facility are sick with COVID and he had some mild nasal congestion and cough with some clear sputum however that resolved. Initial blood pressure was 93/59, he was given IV fluids and increase his blood pressure to low normal and slightly tachycardic with no hypoxia on room air and a fever of 101.2 however that was prior to his blood transfusion. The Infection Preventionist (IP) and the Director of Nursing (DON) were interviewed on 08/20/24 at 1:55 PM. The DON explained that the facility's recent Covid-19 outbreak started on 07/31/24 when Activity Employee #1 tested positive for Covid-19. She explained that they obtained a list of residents and staff that were in close contact with Activity Employee #1 and began testing those individuals every other day for 3 tests. The DON stated that during that time they began to get calls from family members reporting that the family member had Covid-19 and had recently visited a resident in the facility. With each call that they received they added that resident to the list of residents to be tested . So, all the residents that were added to the contact tracing list were tested every other day for a series of 3 tests. While those test were being performed, they continued to have residents and staff that were testing positive for Covid-19. The IP stated that on 07/31/24 when Activity Employee #1 tested positive for Covid-19 the facility initiated and required all staff to wear a surgical mask at all times when in the facility except when caring for a Covid-19 positive resident then the staff were instructed to wear a N95 respirator. She stated that they placed surgical masks at the reception desk if visitors wanted to wear a mask as well while visiting. The IP stated that the Covid-19 positive residents and staff resided and worked on the 100 hall and the 700 hall which was the assisted living hall within the facility so because it was contained to one hall, they did not perform broad based testing or test all residents and staff in the facility. The IP stated she had reported the outbreak to the local health department Nurse on 07/31/24 and again on 08/02/24 and she had no additional recommendations for the facility. The DON explained that the same staff that worked on the 100 hall also worked on the assisted living hall within in the facility. In addition, Resident #11 and #65 who resided on 100 hall would go and visit some of their friends that resided on the assisted living hall, so they were unsure if the Covid-19 was being spread by staff or residents, but they continued to test their growing list of contract trace residents and continued to require the staff to wear mask while working in the facility. The DON stated that they also added any symptomatic residents or staff to the list for testing as well. A phone interview was conducted with the representative from SPICE on 08/21/24 at 11:49AM who stated that the CDC guidance regarding outbreak testing was pretty clear. It stated that if contract tracing testing could not identify all individuals who had potentially been exposed or if the contract trace testing and interventions failed to halt transmission of Covid-19 then the facility should strongly consider switching to broad-based testing. The local health department Nurse was interviewed via phone on 08/21/24 at 2:25 PM. She confirmed that she had been notified of the outbreak and she had opened the outbreak case paperwork on 08/02/24. She stated she had been made aware that the outbreak had been contained to one hall and one set of staff and she stated she had instructed them to ensure staff were wearing masks and washing their hands. The Nurse stated that if the Covid-19 outbreak spread to another unit then there may be additional recommendations and of course if a resident was symptomatic, they would recommend the facility test that resident. She added that if she saw the outbreak moving to another unit or other areas of the facility, she would recommend broad based testing. The local health department Nurse was not aware of Resident #97 who resided on the 200 hall and was transferred to the local ER and tested positive for Covid-19 the same day and was also not aware the outbreak affected the residents on the assisted living hall within the facility. A follow up interview was conducted with the local health department Nurse via phone on 08/21/24 at 3:55 PM. She stated that she had spoken to the DON and her health director at the local health department and because Resident #97 was still at the hospital there was nothing, that the staff could do about that, and they continued to support the facilities contract tracing testing at this time and had no additional or new recommendations. She again stated she had been kept informed of the outbreak and had no other recommendations at this time. A follow up interview was conducted with the DON and the Administrator on 08/21/24 at 4:21 PM. The DON stated that they had not considered broad based testing because the outbreak seems like it is fizzing out. If the local health department Nurse would have recommended it, we would have done it. The DON stated that Resident #97 has had no symptoms and that was why he was not tested in the facility. She stated that when they tested the residents' that remained on the contact tracing list on Sunday 08/18/24 everyone that was tested was negative. The Administrator stated that they could not mandate the visitors to wear a mask but did have them available to wear if they wanted to and stated that Resident #97 could have gotten Covid-19 in the ambulance ride on the way to the hospital and had also had an outside appointment on 08/02/24. The DON added that Resident #97 was in a private room and no staff had close contact for more than 15 minutes, so no residents or staff were added to the list for testing. The DON also added that the testing of the contact tracing was completed, and they would only be testing those residents that were symptomatic.

Based on record review and staff interviews the facility failed to ensure a residents (Resident #92) code status election was accurate throughout the medical record for 1 of 1 residents reviewed for advance directives. The findings included: Resident #92 was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #92 was severely cognitively impaired. A care plan last revised on 07/16/24 read: End of Life/Advance Directive and contained the following interventions Cardio-pulmonary resuscitation/Full Code. A physician order dated 08/12/24 read: Do Not Resuscitate (DNR). Nurse #1 was interviewed on 08/21/24 at 9:17 AM. She stated that code status election was done upon admission with the resident and family and then discussed at each care plan meeting. If the resident or family wished to change the advance directive then she would get help from the Unit Manager (UM) at getting the new forms completed, obtaining the physician order, and updating the care plan. She stated that when she completed the quarterly care plan review, she always made sure the care plan matched what the residents/family wishes were. Nurse #1 stated that if a resident changed their code status and once the order was signed off and paperwork completed then the care plan would be updated. UM was interviewed on 08/21/24 at 3:33 PM. The UM stated that she had taken the order for Resident #92 to be a DNR on 08/12/24 and forgot to update the care plan. She stated that she must have gotten busy because normally she would update the care plan when she took the order from the provider. The Director of Nursing (DON) was interviewed on 08/21/24 at 4:14 PM. She stated that Resident #92 recently changed his code status and there was several nurses that updated care plans. Generally, when the UM put the order in the system, she would update the care plan or let Nurse #1 know that the care plan needed to be updated but Resident #92 fell through the crack. The DON added that they also reviewed all new orders in the daily morning meeting but again Resident #92 fell through the crack.

Based on record review, family, staff, and Nurse Practitioner interviews the facility failed to prescribe an antibiotic that would effectively treat a urinary tract infection (Resident #29) for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #29 was severely cognitively impaired and was frequently incontinent of bowel and bladder. A urinalysis laboratory report dated 08/17/24 indicated that Resident #29 was positive for greater than 100,000 bacteria and the culture report attached indicated that it was resistant to Ciprofloxacin (Cipro is an antibiotic). The report was signed by the Nurse Practitioner. Resident #29's family member was interviewed on 08/18/24 at 11:55 AM. The family member stated that Resident #29 had recently had 2 falls and the staff thought she may have a urinary tract infection and the medical provider over the weekend was going to order a test to determine if she did or did not have a urinary tract infection. A physician order dated 08/19/24 read, Cipro 500 milligrams (mg) by mouth twice a day for urinary tract infection proteus for five days. Review of the Medication Administration Record (MAR) dated August 2024 revealed that Resident #29 had received the Cipro one time on 08/19/24 and twice on 08/20/24. The Unit Manager (UM) was interviewed on 08/21/24 at 8:42 AM. The UM stated that generally lab reports were automatically uploaded into the system from the lab company and the medical providers would go in and review them and then write any orders that were needed. The UM stated if she saw a lab report that had not been addressed, she would say something to the provider and have them review and address it. The UM stated that if the providers were in the facility she generally did not review the lab reports because she assumed the providers would take care of them. However, if she was aware the provider was off or not going to be in the facility then she would review them and call anything urgent to the on-call provider. The Nurse Practitioner (NP) was interviewed on 08/21/24 at 8:50 AM. The NP stated she had reviewed Resident #29's urinalysis and started her on antibiotic because the urinalysis revealed she did have a urinary tract infection, and she was symptomatic. The NP was asked to review the culture again and draw her attention to the Cipro that indicated it was resistant to the bacteria that Resident #29 had, the NP stated, that was faux pas (error or mistake) on me and I will have to change it right now because the Cipro will not help her. The Director of Nursing (DON) was interviewed on 08/21/24 at 4:17 PM. The DON stated that the NP had reported to her that she had prescribed the wrong antibiotic. She stated the NP had already switched Resident #29 to the correct antibiotic. The DON stated that infection preventionist checked the urinalysis reports to ensure that the correct antibiotic had been ordered and she was very meticulous and would have probably caught the error in another day or two.

Based on record review and staff interviews, the facility failed to protect Resident #87 from physical abuse from Nurse Aide (NA #1). NA #1 grabbed Resident #87's wrists when the resident became combative during incontinent care and Resident #87 hit NA #1. Resident #87 was cognitively impaired and resided on the dementia care unit. Resident #87 had three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #87). Immediate Jeopardy began on 03/08/23 when Resident #87 was physically abused by NA #1. The immediate jeopardy was removed on 07/15/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with agitation and anxiety disorder. Resident #87's admission Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no psychosis, rejection of care, or instances of wandering. Resident #87 was coded as having other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal or vocal symptoms like screaming or disruptive sounds) as occurring 1-3 days during the lookback period. Resident #87 required extensive assistance with 1 person assist for toilet use, personal hygiene, and bathing. Resident #87's care plan updated on 01/23/23 revealed no care plan area for aggressive or combative behaviors. Resident #87 was care planned for wandering and putting objects in his mouth. A skin assessment dated [DATE] indicated that Resident #87 had a skin tear to his left forefinger that was cleaned and dressed. No other skin issues were noted on the assessment. The assessment was completed by Nurse #2. An interview via telephone was attempted with Nurse #2 on 07/14/23 but was unsuccessful. Resident #87's progress notes revealed the following note dated 03/08/23 at 8:21 PM written by Nurse #1, Heard certified nurse aide (NA #1) call for help. This writer walked into resident's room to see [NA #1] holding [Resident 87's] arms. Resident [#87] was kicking legs and yelling. [NA #1] reported [Resident #87] was conversant and was willing to let [NA #1] change brief. When he turned [Resident #87] toward him, [Resident #87] hit him in the nose with his fist. [NA #1] held arms to try to calm [Resident #87]. [Resident #87] started to calm and [NA#1] stepped away from [Resident #87]. Skin tears noted to bilateral arms with bruising to bilateral arms. Skin tears cleaned and dressed per protocol. An interview with NA #1 via phone on 07/11/23 at 12:43 PM revealed he remembered the incident and stated he was in Resident #87's room providing incontinence care with Resident #87 rolled onto his right side, suddenly, Resident #87 became combative and rolled back onto his back and NA #1's arms. NA #1 stated one of his arms was stuck between Resident #87's legs and his other arm was underneath Resident #87's back. NA #1 stated he had worked with Resident #87 before and had never had him become aggressive or combative with him while he provided care. He reported Resident #87 hit and struck him in the head and nose. NA #1 reported once he was able to get his arms loose, he held Resident #87's arms and began hollering for help from Nurse #1. NA #1 stated when Nurse #1 arrived at the room, she assisted him in getting Resident #87 calmed down and he let go of Resident #87's arms. NA #1 stated he observed skin tears on Resident #87's arms and stated he could not tell if the skin tears were from where he held Resident #87's arms or from where Resident #87 hit him. NA #1 stated he had received dementia and abuse training and reported he knew he should back away from aggressive or combative residents and reapproach them later. He also reported he finished his shift and stated he was not suspended after the incident. A skin assessment completed on 03/08/23 at 8:31 PM by Nurse #1 and reviewed on 03/09/23 by the Wound Nurse revealed Resident #87 was treated for a skin tear to his left wrist, a skin tear to his right elbow, and a skin tear to his right arm. An interview with Nurse #1 via phone on 07/11/23 at 2:47 PM revealed she remembered the incident with NA #1 and Resident #87 on 03/08/23, and stated NA #1 had called out for help while he was in Resident #87's room. She stated when she entered the room, NA #1 was standing by Resident #87's bed and was holding Resident #87 by his wrists. She reported NA #1 told her Resident #87 had become combative during incontinence care and had hit him in the nose and he held Resident #87's arms to prevent Resident #87 from hitting him. Nurse #1 stated she observed Resident #87 lying on his back with his arms extended towards the ceiling with NA #1 holding onto his both wrists. She stated she noted multiple skin tears to both of Resident #87's arms and she provided first aid. Nurse #1 described the skin tears as about the size of a half dollar and were located on both of Resident #87's forearms or wrists. Nurse #1 stated she reported the incident to the Wound Nurse because of the injuries, and she also informed the Unit Manager and the Quality Assurance Nurse who came and assessed Resident #87. Nurse #1 stated when she informed the Unit Manager and the Quality Assurance Nurse, she was confident she let them know that she had seen NA #1's hands grasping Resident #87's wrists. Nurse #1 reported she had received training regarding combative residents and that staff were expected to remove themselves from combative residents and reapproach them later. An interview with the Wound Nurse on 07/11/23 at 12:14 PM revealed she viewed and treated Resident #87's wounds after the incident with NA #1. She reported Resident #87 had significant bruising to his lower arms and multiple skin tears. She stated she believed the skin tears were to Resident #87's lower arms and were large. She stated Resident #87's bruising to his lower arms was observed to be approximately the size of a tennis ball on both of Resident #87's arms. The Wound Nurse reported she cleaned the wounds with normal saline and covered them with 2 inches by 2 inches foam dressings. She reported the wound dressings would have been changed every 3 days until healed but stated she could not remember how long she treated the wounds. Review of physician orders revealed the following: 03/09/23- clean large skin tear to left lower forearm/wrist area with normal saline, apply xeroform (foam dressing) and a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean skin tear to right lower forearm/wrist with normal saline, apply xeroform and cover with a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean second skin tear to left lower forearm/wrist with normal saline, apply xeroform and a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean pea sized skin tear to right elbow with normal saline, apply xeroform and cover with clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean large skin tear to right elbow with normal saline, apply xeroform and cover with clear dressing every Tuesday, Thursday, and Saturday. During an interview with the Unit Manager on 07/11/23 at 3:10 PM, she reported she was informed of the incident but was unsure if it was the day the incident occurred or the day after. She reported it was her understanding that Resident #87 had become combative during care and NA #1 had attempted to prevent Resident #87 from hitting him. Unit Manager reported she did not recall being informed that NA #1 had held Resident #87 by his arms or wrists but stated she was aware that there were multiple skin tears that required treatment following the incident. She reported staff had received training regarding combative or aggressive residents and that staff were expected to step away from the resident and reapproach at a later time. An interview with the Quality Assurance Nurse on 07/11/23 at 3:42 PM revealed Nurse #1 had approached her to come look at Resident #87's arms. She stated she was told that NA #1 had provided Resident #87 with incontinent care and during the care, Resident #87 had become combative and hit NA #1 in the nose. She stated NA #1 told her when he was hit in the nose, he reactively grabbed Resident #87's wrists to keep Resident #87 from hitting him again and resulted in multiple skin tears to Resident #87's lower forearms or wrists. She reported she questioned NA #1 why he grabbed Resident #87 and was told it was reactionary. The Quality Assurance Nurse reported NA #1 told her he released Resident #87's wrists when he began to calm down. She reported she observed the wounds to Resident #87 and that the skin tears seemed fresh. She also reported staff were educated to remove themselves from combative residents and to reapproach them later. An interview with the Director of Nursing (DON) on 07/11/23 at 3:16 PM revealed she was aware of an incident regarding NA #1 and Resident #87. She stated when she was informed of the incident, she began an investigation and when she spoke with NA #1 he reported he had gone into Resident #87's room to provide care and during that time, Resident #87 became combative and begun to swing and kick at NA #1. The DON stated she was not told that NA #1 had grabbed Resident #87's wrists. She did report that Resident #87 suffered multiple skin tears to his bilateral arms during the incident. The DON reported she did not believe the actions of NA #1 were abusive in nature and stated she had worked with NA #1 for a long time and was insistent that he did not willfully injure Resident #87. She stated she felt the incident was a reaction to having been hit in the nose. She stated she did not see how NA #1 could have done anything different and stated that the staff on the locked dementia unit were beat up by Resident #87 daily. The Director of Nursing stated NA #1 had received abuse and combative resident training and it was expected that he back away and reapproach later but insisted he did not have another option with his arm being trapped. An interview with the Administrator on 07/11/23 at 4:39 PM revealed it was his understanding that NA #1 had gone into Resident #87's room to provide incontinence care and Resident #87 had become combative, hitting NA #1 in the nose. He stated he did not believe the actions of NA #1 was abusive as he did not believe they were willful. The Administrator stated he firmly believed there was no intent to hurt Resident #87 when NA #1 held Resident #87's arms during the incident. The Administrator and DON were notified of the Immediate Jeopardy on 07/12/23 at 12:18 PM. The facility provided the following corrective action plan: Resident #87 was having his brief changed, and CNA #1 turned him over. CNA #1 reports that Resident #87 suddenly started mumbling and hit CNA #1 hard in the nose. One of the CNAs' #1 arms was caught between resident #87 legs as he scissored his legs; the other arm was up under resident #87. CNA #1 knew he needed to back away but couldn't. He stated, I buried my head in his chest to keep him from hitting my face again. CNA #1 reported that he did not know if the skin tears had happened when the resident hit him. CNA #1 stated he was yelling for the nurse to help. He said, The resident was wild, he finally could back off when holding resident #87 wrist for a moment and pulling his other hand out from under resident #87 after the nurse came in the room. The nurse reports she heard CNA #1 call for help, she walked into the room and saw CNA #1 hold onto Resident #87 arms, CNA #1 let go of Resident #87 arms and placed them on the bed, and CNA #1 was able to back away. The resident was kicking his legs and yelling. CNA #1 told the nurse that resident #87 was talking and was willing to let CNA #1 change his brief, and when he turned the resident back towards him, he hit him in the nose with his fist. CNA #1 stated he took hold of his arms to try and calm the resident so that he could back away. The nurse reports skin tears were noted on bilateral arms and right elbow. She could not determine how the skin tears happened, so she cleaned the areas and applied a dressing. The Quality Assurance (QA) nurse was asked to see the resident after the incident related to resident #87 skin tears; she explained that resident #87 was being cooperative when all of a sudden, he became combative with CNA #1, the CNA #1 had his hand on the resident's arms. The QA nurse observed resident #87 out of his room, walking around in another resident's room and then in the dining room. The QA nurse saw the bandages on Resident #87 and saw that he was not displaying any signs or symptoms of mental anguish. The facility reviewed the incident during Interdisciplinary Team Meeting (IDT) on 3/9/2023 and updated the person-centered care plan to include 2 staff members to ensure staff and resident safety during care with Resident #87. Having 2 staff members present when providing care for (1 staff member will provide the care) Resident #87 will ensure safety by assisting with the ability to remove themselves more quickly, and/or 1 staff member will be able to get assistance from the licensed staff if a resident becomes combative during care. Staff are instructed to provide care per Resident #87's Care Plan and to remove themselves from the room if the resident becomes combative. Inservice education on managing behaviors with dementia unit staff and CNA#1 was completed on 3/9/2023. On 5/30/23, Skin assessments were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned nurse with a BIMS of 12 or below with no negative findings. On 5/30/23, Safe Surveys were completed for alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above by licensed staff. The Director of Nursing noted no areas of concern upon her review On 3/9/23, an in-service was proactively scheduled and completed using the electronic learning system for CNA #1 on Dementia Residents with Behaviors. The in-service emphasizes while providing care to residents with Dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. Dementia unit staff, including nurses, CNA, agency staff, and contract staff, received an in-service regarding, needing a 2-person assist for Resident #87, to have a staff member present (not assisting with care) during care that could assist if the resident becomes combative, getting assistance from the licensed nurse or assisting the other staff member in safely exiting the resident's room, in addition to Relias training for Caring for Dementia Residents with Behaviors, Combative Residents. Staff are instructed to provide care per Resident #87's per the care guide, which is on the electronic documentation tablet the CNAs use for charting, and to remove themselves from the room if the resident becomes combative. Inservice education on managing behaviors with dementia unit staff and CNA#1 was completed on 3/9/2023. The referenced in-service education was completed only with Dementia unit staff. However, 100% Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff in-service education related to Abuse and Dementia care was completed on 5/30/2023. On 5/30/23, An in-service was conducted by the Quality Assurance Nurse, with 100% of the Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse, Neglect, Misappropriation and providing great customer service. The in-service included the definition and prevention of Abuse, Neglect, and Misappropriation. It also emphasized that while providing care to residents with dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. In-services were completed by 5/31/23. The RN Quality Assurance Nurse and the RN Staff Development Coordinator monitored staff completion of the in-service; if a staff member did not attend the initial in-service, they were required to complete the in-service before their next scheduled shift. On 5/30/23, a Performance Improvement Plan was developed for abuse and was reviewed and approved by the Quality Assurance Performance Improvement team (QAPI). Administrative staff, who include the Administrator, Director of Nursing, and Department Managers, will speak to 3 staff members per week x 4 weeks and ask questions about residents' behaviors and staff burnout. During the questionnaires, the Team members will provide additional education on resident behaviors and staff burnout as needed and bring any concerns back to the Interdisciplinary Team for interventions. As part of the facility's daily QA meeting, care rounds were completed by Departments managers and licensed staff to ensure ADL care was provided and to monitor behaviors in the Dementia Unit and staff-to-resident interactions. Any findings were addressed immediately and brought to the morning QA meeting. The Unit Manager and Staff Development Coordinator observe care weekly in the Dementia unit to monitor staff competencies in the care and treatment of residents. Concerns are discussed in the daily QA meeting. Daily QA meeting minutes are documented 5x weekly. The Administrator reported the results of these monitoring tools to the Quality Assurance Committee, and any issues will result in a revision to the performance improvement plan. The facility has no tolerance for abuse, and protecting resident rights is of utmost importance to the facility. The Administrator and Director of Nursing are committed to providing excellent care, protecting residents from abuse, and maintaining the resident's rights at all times. Date of Corrective Action Completion 5/31/23. The state survey agency returned to the facility on [DATE] to validate the corrective action plan. The corrective action plan could not be validated as the facility failed to have sufficient evidence of care that was to be observed weekly on the dementia care unit to ensure staff were competent in the care and treatment of residents. The facility was asked to provide a credible allegation of IJ removal on 07/20/23. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 3/8/23, Resident #87 was having his brief changed, and Certified Nursing Assistant (CNA #1) turned him over. CNA #1 reports that Resident #87 suddenly started mumbling and hit CNA #1 hard in the nose. One of CNAs' #1 arms was caught between resident #87 legs as he scissored his legs; the other arm was up under Resident #87. CNA #1 knew he needed to back away but couldn't. He stated, I buried my head in his chest to keep him from hitting my face again. CNA #1 reported that he did not know if the skin tears had happened when the resident hit him. CNA #1 stated he was yelling for the nurse to help. He said, The resident was wild, he finally could back off when holding resident #87 wrist for a moment and pulling his other hand out from under resident #87 after the nurse came in the room. The nurse reports she heard CNA #1 call for help, she walked into the room and saw CNA #1 hold onto Resident #87 arms, CNA #1 let go of Resident #87 arms and placed them on the bed, and CNA #1 was able to back away. The resident was kicking his legs and yelling. CNA #1 told the nurse that resident #87 was talking and was willing to let CNA #1 change his brief, and when he turned the resident back towards him, he hit him in the nose with his fist. CNA #1 stated he took hold of his arms to try and calm the resident so that he could back away. The nurse reports skin tears were noted on bilateral arms and right elbow. She could not determine how the skin tears happened, so she cleaned the areas and applied a dressing. The Quality Assurance (QA) nurse was asked to see the resident after the incident related to resident #87 skin tears; she explained that resident #87 was being cooperative when all of a sudden, he became combative with CNA #1, the CNA #1 had his hand on the resident's arms. The QA nurse observed resident #87 out of his room, walking around in another resident's room and then in the dining room. The QA nurse saw the bandages on Resident #87 and saw that he was not displaying any signs or symptoms of mental anguish. On 3/9/23, the facility reviewed the incident during Interdisciplinary Team Meeting (IDT) and updated the person-centered care plan to include 2 staff members to ensure staff and resident safety during care with Resident #87. Having 2 staff members present when providing care for (1 staff member will provide the care) Resident #87 will ensure safety by assisting with the ability to remove themselves more quickly, and/or 1 staff member will be able to get assistance from the licensed staff if a resident becomes combative during care. Staff are instructed to provide care per Resident #87's Care Plan and to remove themselves from the room if the resident becomes combative. On 5/30/23, Skin assessments were completed on all non-alert and oriented residents including Resident # 87 for signs or symptoms of abuse by the assigned nurse with a BIMS of 12 or below with no negative findings. On 5/30/23, Safe Surveys were completed for alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above by licensed staff. The Director of Nursing noted no areas of concern upon her review. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring and when the action will be complete. On 3/9/23, an in-service was proactively scheduled by the Quality Assurance Nurse and completed using the electronic learning system for CNA #1 on Dementia Residents with Behaviors. The in-service emphasizes while providing care to residents with Dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. On 3/9/23, The Quality Assurance Nurse conducted an inservice with Dementia unit staff, including nurses, CNAs, and contract staff, regarding needing a 2-person assist for Resident #87. One staff member will provide care, and the other staff will be available if the resident becomes combative to get assistance from the licensed nurse or to assist the other staff member in safely exiting the resident's room. In addition, Relias training was completed on Caring for Dementia Residents with Behaviors. The inservice was completed on 3/9/23. Inservice education on managing behaviors with dementia unit staff and CNA#1 was completed on 3/9/2023 by the Quality Assurance Nurse. The referenced in-service education was completed only with Dementia unit staff. However, 100% Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff in-service education related to Abuse and Dementia care was completed on 5/30/2023 by the Quality Assurance Nurse. On 5/30/23, an in-service was conducted by the Quality Assurance Nurse, with 100% of the Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse, Neglect, Misappropriation and providing great customer service. The in-service included the definition and prevention of Abuse, Neglect, and Misappropriation. It also emphasized that while providing care to residents with dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. In-services were completed by 5/31/23. The RN Quality Assurance Nurse and the RN Staff Development Coordinator monitored staff completion of the in-service; if a staff member did not attend the initial in-service, they were required to complete the in-service before their next scheduled shift. On 7/14/23, an inservice was conducted by the Assistant Director of Nursing on abuse with Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff to include removing the staff member immediately, notification of the Administrator and Director of Nursing, and abuse will not be tolerated. The inservices was completed on 7/14/23. After 7/14/23, any staff who has not worked and received the education will complete on their next scheduled shift. The Assistant Director of Nursing and Staff Development Coordinator will monitor staff completion of the in-service; if a staff member did not attend the initial in-service, they are required to complete the in-service before their next scheduled shift. Date of immediate jeopardy removal: 7/15/23 While onsite on 07/20/23 the IJ removal plan was validated. Resident #87's care plan was noted to have been updated on 03/09/23 to include the need for two staff members for all care provided. NA #1's education that occurred on 03/09/23 on providing care to dementia residents was reviewed. Education that was provided to all staff across all departments was reviewed along with staff sign in sheets to confirm receipt of abuse and neglect training that occurred on 05/30/23 was reviewed. Skin assessment of all residents that were not alert and oriented in the facility were done between 05/02/23 and 05/30/23 with no other significant findings noted. Alert and oriented residents were asked three questions on a safe survey regarding any other potential abuse situations with no pertinent findings. The facility's resident council was also educated on abuse and neglect and how to report any abuse during the meeting held on 05/24/23 with ten residents in attendance. Staff interviews across the nursing, activities, housekeeping, and administrative departments confirmed that they had received education regarding abuse and neglect on 05/30/23 and again on 07/14/23. The facility's IJ removal date of 07/15/23 was validated.

Based on observations, record reviews, staff and resident interviews the facility failed to remove Nurse Aide (NA) #1 from a resident care assignment after Nurse #1 witnessed the NA holding both of Resident #87's wrists to prevent the resident from hitting him when the resident became combative during care. In addition, the facility failed to identify, thoroughly investigate, and to report abuse to the state agency, Adult Protective Services, and local law enforcement for 1 of 3 residents (Resident #87) reviewed for abuse. Immediate Jeopardy began on 03/08/23 when the facility allowed NA #1 to continue working a resident care assignment after Nurse #1 observed NA #1 physically abuse Resident #87. The immediate jeopardy was removed on 07/15/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included A review of the facility's policy titled Abuse, Neglect, or Misappropriation of Resident Property Policy revised 03/10/17 revealed: Allegations of abuse, neglect, exploitation, or misappropriation of resident property and injuries of unknown origin will be investigated by the facility. The Administrator is responsible to direct the investigation process and to ensure that appropriate agencies are notified, as directed. The policy also dictated that the Administrator was responsible for ensuring incidents were reported to the appropriate local, state, and federal agencies, including the Nurse Aide Registry. The policy also stated that employees accused of being directly involved in allegations of abuse, neglect, exploitation, or misappropriation of property will be suspended immediately from duty pending the outcome of the investigation. Resident #87 was admitted to the facility on [DATE]. Resident #87's progress notes revealed the following note dated 03/08/23 at 8:21 PM written by Nurse #1, Heard certified nurse aide [NA #1] call for help. This writer walked into resident's room to see [NA #1] holding [Resident #87's] arms. Resident [#87] was kicking legs and yelling. [NA #1] reported [Resident #87] was conversant and was willing to let [NA #1] change brief. When he turned [Resident #87] toward him, [Resident #87] hit him in the nose with his fist. [NA #1] held arms to try to calm [Resident #87]. [Resident #87] started to calm and [NA #1] stepped away from [Resident #87]. Skin tears noted to bilateral arms with bruising to bilateral arms. Skin tears cleaned and dressed per protocol. An interview with NA #1 via phone on 07/11/23 at 12:43 PM revealed he was currently employed at the facility and remembered the 03/08/23 incident with Resident #87. NA #1 stated he was in Resident #87's room providing incontinence care shortly after his shift started at 3:00 PM. He reported the resident was rolled onto his right side when he (Resident #87) suddenly became combative and rolled onto his back and onto NA #1's arms. NA #1 stated one of his arms was stuck between Resident #87's legs and his other arm was underneath Resident #87's back. He reported Resident #87 hit and struck him in the head and nose. NA #1 reported once he was able to get his arms loose, he held Resident #87's arms and began hollering for help from Nurse #1. NA #1 stated when Nurse #1 arrived at the room, she assisted him in getting Resident #87 calmed down and he let go of Resident #87's arms. He reported he finished his shift providing resident care and stated he was not suspended after the incident. NA #1 reported he was not full time and his hours varied but he had worked at the facility for over [AGE] years. An interview with Nurse #1 via phone on 07/11/23 at 2:47 PM revealed she remembered the incident with NA #1 and Resident #87 on 03/08/23, and stated NA #1 had called out for help while he was in Resident #87's room. She stated when she entered the room, NA #1 was standing by Resident #87's bed and was holding Resident #87 by his wrists. She reported NA #1 told her Resident #87 had become combative during incontinence care and had hit him in the nose and he held Resident #87's arms to prevent Resident #87 from hitting him. Nurse #1 stated she observed Resident #87 lying on his back with his arms extended towards the ceiling with NA #1 holding onto his both wrists. She stated she noted multiple skin tears to both of Resident #87's arms and she provided first aid. Nurse #1 described the skin tears as about the size of a half dollar and were located on both of Resident #87's forearms or wrists. Nurse #1 stated she reported the incident to the Wound Nurse because of the injuries, and she also informed the Unit Manager and the Quality Assurance Nurse of what she observed. She stated they (Unit Manager and Quality Assurance Nurse) both came and assessed Resident #87. Nurse #1 stated when she informed the Unit Manager and the Quality Assurance Nurse, she was confident she let them know that she had seen NA #1's hands grasping Resident #87's wrists. Nurse #1 reported she could not remember if NA #1 was suspended or allowed to finish his shift after the altercation with Resident #87 on 03/08/23. An interview with the Quality Assurance Nurse on 07/11/23 at 3:42 PM revealed on 03/08/23 Nurse #1 had approached her to come look at Resident #87's arms. She stated she was told that NA #1 had provided Resident #87 with incontinent care and during the care, Resident #87 had become combative and hit NA #1 in the nose. She stated NA #1 told her when he was hit in the nose, he reactively grabbed Resident #87's wrists to keep Resident #87 from hitting him again and resulted in multiple skin tears to Resident #87's lower forearms or wrists. She stated she reported the incident to the Administrator since he was still at the facility at the time of the incident. She indicated she did not believe the actions of NA #1 were abusive in nature and that they were reflexive. An interview with the Director of Nursing (DON) on 07/11/23 at 3:16 PM revealed she was aware of an incident regarding NA #1 and Resident #87 that occurred on 03/08/23. She stated when she was informed of the incident by the Administrator on 03/08/23, she began an investigation. She indicated when she spoke with NA #1 he reported he had gone into Resident #87's room to provide care and during that time, Resident #87 became combative and began to swing and kick at NA #1. The DON stated she was not told that NA #1 had grabbed Resident #87's wrists. She reported that Resident #87 suffered multiple skin tears to his bilateral arms during the incident. The DON reported she did not believe the actions of NA #1 were abusive in nature and stated she had worked with NA #1 for a long time and was insistent that he did not willfully injure Resident #87. She stated she felt the incident was a reaction to having been hit in the nose. The Director of Nursing also reported due to her not believing the actions of NA #1 were abusive in nature, he was not suspended and was allowed to finish his shift. She also stated a 24 hour and 5 working day report was not completed and sent to the state agency. She indicated her investigation consisted of speaking with NA #1 and Nurse #1. During an interview with the Administrator on 07/11/23 at 4:39 PM, he reported he was made aware of the incident that occurred on 03/08/23 between Resident #87 and NA #1 shortly after it occurred. He stated he did not believe the actions of NA #1 were abusive in nature as there was no willful intent to cause injury to Resident #87. He stated he firmly believed that NA #1 had no intention to harm Resident #87 and that because of his belief, no 24 hour or 5 working day report was completed. He stated the police department was not called, nor was the information provided to the local department of social services. The Administrator verified that NA #1 was not suspended and was allowed to finish his shift on 03/08/23. The Administrator and DON were notified of the Immediate Jeopardy on 07/12/23 at 12:18 PM. The facility provided the following corrective action plan: 1. Resident #87 was having his brief changed, and CNA #1 turned him over. CNA #1 reports resident #87 suddenly started mumbling and hit CNA #1 hard in the nose. One of the CNAs' #1 arms was caught between resident #87 legs as he scissored his legs; the other arm was up under resident #87. CNA #1 knew he needed to back away but couldn't. He stated, I buried my head in his chest to keep him from hitting my face again. CNA #1 reported he did not know if the skin tears had happened when the resident hit him. CNA #1 stated he was yelling for the nurse to come help. He said, The resident was wild, he finally could back off when holding resident #87 wrist for a moment and pulling his other hand out from under resident #87 after the nurse came in the room. The nurse reports she heard CNA #1 call for help, she walked into the room and saw CNA #1 hold onto resident #87 arms, CNA #1 let go of resident #87 arms and placed them on the bed and CNA #1 was able to back away. The resident was kicking his legs and yelling. CNA #1 told the nurse that resident #87 was talking and was willing to let CNA #1 change his brief, and when he turned the resident back towards him, he hit him in the nose with his fist. CNA #1 stated he took hold of his arms to try and calm the resident so that he could back away. The nurse reports skin tears were noted on bilateral arms and right elbow. She could not determine how the skin tears happened, so she cleaned the areas and applied a dressing. The Quality Assurance (QA) nurse was asked to see the resident after the incident related to resident #87 skin tears; she explained resident #87 was being cooperative when all of a sudden, he became combative with CNA #1, the CNA #1 had his hand on the resident's arms. The QA nurse observed resident #87 out of his room, walking around in another resident's room and then in the Dining Room. The QA nurse saw the bandages on Resident #87 and saw he was not displaying any signs or symptoms of mental anguish. QA nurse notified the Administrator on 3/8/23. CNA #1 did not provide care to Resident #87 after the incident occurred on 3/8/2023 until he was re-educated on 3/9/2023. However, he did continue to work and care for other residents CNA #1 was educated through Relias related to caring for dementia residents with behaviors; the licensed nurse and another CNA provided the care for the remainder of the shift on 3/8/2023, to resident #87. All other residents were not assessed, and law enforcement was not notified. 2. On 5/30/23, Skin assessments were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned nurse with a BIMS of 12 or below with no negative findings. On 5/30/23, Safe Surveys were completed for alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above by licensed staff. The Director of Nursing noted no areas of concern upon her review 3. On 3/9/23, an in-service was proactively scheduled and completed using the electronic learning system for CNA #1 on caring for dementia residents with behaviors. The in-service emphasizes while providing care to residents with dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. On 3/9/2023, Dementia unit staff, including nurses, CNA, agency staff, and contract staff, received an in-service related to the need for a 2-person assist for Resident #87 for the purpose of having a staff member present (not assisting with care) during care that could assist if the resident becomes combative in getting assistance from the licensed nurse or assisting the other staff member in safely exiting the resident's room for the protection of the resident in addition to Relias training for caring for dementia residents with behaviors. On 5/30/23, An in-service was conducted by the Quality Assurance Nurse, with 100% staff to include, administrative staff (Administrator, Director of Nursing and Department managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse, Neglect, Misappropriation, to include; identification of abuse, protection of residents including suspending the identified staff immediately and removing from facility and assessing other residents for signs of abuse, reporting of Abuse to Administrator timely, external reporting to law enforcement, Adult Protective Services and Healthcare Personnel Registry the in-service also emphasized while providing care to residents with dementia they are to approach in a calm, quite manner, explain all procedures they are going to do and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse The in-service included the definition and prevention of Abuse, Neglect, and Misappropriation. In-services were completed by 5/31/23. The RN Quality Assurance Nurse and the RN Staff Development Coordinator monitored for in-service completion; if a staff member did not attend the initial in-service, they were required to complete the in-service before their next scheduled shift. 4. On 5/30/23, a Performance Improvement Plan was developed for Abuse/Late Reporting and was reviewed and approved by the Quality Assurance Performance Improvement team (QAPI). The Administrator and the Director of Nursing will immediately review any allegations of abuse that are verbally and written reported based on progress notes review or through the resident concerns process, and ensure that resident protection by removing the accused staff member from the facility, assessing other residents for signs of abuse, reporting requirements including law enforcement, Adult Protection Services, Healthcare Personnel Registry to meet the F607 requirements utilizing the Abuse Action Checklist. As part of the facility's daily QA meeting, care rounds were completed by Departments managers and licensed staff to ensure ADL care was provided, to monitor behaviors for the Dementia Unit, and appropriate staff and resident interactions. Any findings were addressed immediately and brought to the morning QA meeting. The Unit Manager and Staff Development Coordinator observe care weekly in the dementia unit to monitor staff competencies in the care and treatment of residents. Concerns are discussed in the daily QA meeting. Daily QA meeting minutes are documented 5x weekly. The Nurse Consultant is contacted about incidents and allegations of abuse and will review all reportable incidents electronically in the medical record and through verbal communication by the Administrator and DON to ensure compliance with F 607. The Administrator reported the results of these monitoring tools to the Quality Assurance Committee, and any issues will result in a revision to the performance improvement plan. 5. Date of Corrective Action Completion 5/31/23. The state survey agency returned to the facility on [DATE] to validate the corrective action plan. The corrective action plan could not be validated as the facility failed to have sufficient evidence of care that was to be observed weekly on the dementia care unit to ensure staff were competent in the care and treatment of residents. The facility was asked to provide a credible allegation of IJ removal on 07/20/23. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 3/8/23, Resident #87 was having his brief changed, and Certified Nursing Assistant (CNA #1) turned him over. CNA #1 reports Resident #87 suddenly started mumbling and hit CNA #1 hard in the nose. One of CNAs' #1 arms was caught between Resident #87 legs as he scissored his legs; the other arm was up under resident #87. CNA #1 knew he needed to back away but couldn't. He stated, I buried my head in his chest to keep him from hitting my face again. CNA #1 reported he did not know if the skin tears had happened when the resident hit him. CNA #1 stated he was yelling for the nurse to come help. He said, The resident was wild, he finally could back off when holding resident #87 wrist for a moment and pulling his other hand out from under resident #87 after the nurse came in the room. The nurse reports she heard CNA #1 call for help, she walked into the room and saw CNA #1 hold onto resident #87 arms, CNA #1 let go of Resident #87 arms and placed them on the bed and CNA #1 was able to back away. The resident was kicking his legs and yelling. CNA #1 told the nurse that resident #87 was talking and was willing to let CNA #1 change his brief, and when he turned the resident back towards him, he hit him in the nose with his fist. CNA #1 stated he took hold of his arms to try and calm the resident so that he could back away. The nurse reports skin tears were noted on bilateral arms and right elbow. She could not determine how the skin tears happened, so she cleaned the areas and applied a dressing. The Quality Assurance (QA) nurse was asked to see the resident after the incident related to resident #87 skin tears; she explained resident #87 was being cooperative when all of a sudden, he became combative with CNA #1, the CNA #1 had his hand on the resident's arms. The QA nurse observed resident #87 out of his room, walking around in another resident's room and then in the Dining Room. The QA nurse saw the bandages on Resident #87 and saw he was not displaying any signs or symptoms of mental anguish. QA nurse notified the Administrator on 3/8/23. CNA #1 did not provide care to Resident #87 after the incident occurred on 3/8/2023 until he was re-educated on 3/9/2023. However, he did continue to work and care for other residents. CNA #1 was educated through Relias related to caring for dementia residents with behaviors; the licensed nurse and another CNA provided the care for the remainder of the shift on 3/8/2023, to resident #87. All other residents were not assessed, APS was not notified, a report was not sent to the state agency and law enforcement was not notified on the day of the incident due to the incident note being identified as abuse. On 3/8/23, an investigation was initiated by the Quality Assurance Nurse and an incident report was completed related to the incident for the skin tears and bruise but it was not identified as abuse during the investigation. On 5/30/23, Skin assessments including resident # 87 were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned nurse with a BIMS of 12 or below with no negative findings. On 5/30/23, Safe Surveys were completed by the Social Worker and Admission's Coordinator for alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above. The Director of Nursing noted no areas of concern upon her review. On 7/12/23, the Administrator suspended CNA #1 pending investigation. On 7/13/23, the Administrator reported the allegation to the Healthcare Personnel Registry, Adult Protective Services and Law Enforcement. On 7/14/23, skin assessments including resident # 87 were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned License Practical Nurse (LPN) or Registered Nurse (RN) charge nurses with a BIMS of 12 or below with no negative findings to ensure no resident is currently at risk for abuse. There were no identified areas of concern during the audit. On 7/14/23, Safe Surveys were completed by the Social Worker for all alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above to ensure no residents are currently at risk for abuse. There was no identified area of concern during the audits. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring and when the action will be complete. On 3/9/23, an in-service was proactively scheduled by the Quality Assurance Nurse and completed using the electronic learning system for CNA #1 on caring for dementia residents with behaviors. The in-service emphasizes while providing care to residents with dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. On 3/9/23, The Quality Assurance Nurse conducted an inservice with Dementia unit staff, including nurses, CNAs, and contract staff, regarding needing a 2-person assist for Resident #87. One staff member will provide care, and the other staff will be available if the resident becomes combative to get assistance from the licensed nurse or to assist the other staff member in safely exiting the resident's room. In addition, Relias training was completed on Caring for Dementia Residents with Behaviors. The inservice was completed on 3/9/23. On 5/30/23, An in-service was conducted by the Quality Assurance Nurse, with 100% staff to include, administrative staff (Administrator, Director of Nursing and Department managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse, Neglect, Misappropriation, to include; identification of abuse, protection of residents including suspending the identified staff immediately and removing from facility and assessing other residents for signs of abuse, reporting of Abuse to Administrator timely, external reporting to law enforcement, Adult Protective Services and Healthcare Personnel Registry. The in-service also emphasized while providing care to residents with dementia they are to approach in a calm, quite manner, explain all procedures they are going to do and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. The education was completed by 5/31/23. The RN Quality Assurance Nurse and the RN Staff Development Coordinator monitored for in-service completion; if a staff member did not attend the initial in-service, they were required to complete the in-service before their next scheduled shift. On 7/14/23, an inservice was conducted by the Assistant Director of Nursing on abuse with Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff to include removing the staff member immediately, notification of the Administrator and Director of Nursing, and abuse will not be tolerated. The inservices was completed on 7/14/23. After 7/14/23, any staff who has not worked and received the education will complete on their next scheduled shift. The Assistant Director of Nursing and Staff Development Coordinator will monitor staff completion of the in-service; if a staff member did not attend the initial in-service, they are required to complete the in-service before their next scheduled shift. Date of immediate jeopardy removal: 7/15/23 While onsite on 07/20/23 the IJ removal plan was validated. Resident #87's care plan was noted to have been updated on 03/09/23 to include the need for two staff members for all care provided. NA #1's education that occurred on 03/09/23 on providing care to dementia residents was reviewed. Education that was provided to all staff across all departments was reviewed along with staff sign in sheets to confirm receipt of abuse and neglect training that occurred on 05/30/23 was reviewed. Skin assessment of all residents that were not alert and oriented in the facility were done between 05/02/23 and 05/30/23 with no other significant findings noted. Alert and oriented residents were asked three questions on a safe survey regarding any other potential abuse situations with no pertinent findings. The facility's resident council was also educated on abuse and neglect and how to report any abuse during the meeting held on 05/24/23 with ten residents in attendance. Staff interviews across the nursing, activities, housekeeping, and administrative departments confirmed that they had received education regarding abuse and neglect on 05/30/23 and again on 07/14/23. The education included protection of residents by suspending the identified staff immediately and removing from facility. The facility's IJ removal date of 07/15/23 was validated.

Based on record review and staff interviews, the facility failed to protect Resident #87 from physical restraint from Nurse Aide (NA #1). NA #1 grabbed Resident #87's wrists when the resident became combative during incontinent care and Resident #87 hit NA #1. Resident #87 was cognitively impaired and resided on the dementia care unit. Resident #87 had three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #87). The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with agitation and anxiety disorder. Resident #87's admission Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no psychosis, rejection of care, or instances of wandering. Resident #87 was coded as having other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal or vocal symptoms like screaming or disruptive sounds) as occurring 1-3 days during the lookback period. Resident #87 required extensive assistance with 1 person assist for toilet use, personal hygiene, and bathing. Resident #87's care plan updated on 01/23/23 revealed no care plan area for aggressive or combative behaviors. Resident #87 was care planned for wandering and putting objects in his mouth. A skin assessment dated [DATE] indicated that Resident #87 had a skin tear to his left forefinger that was cleaned and dressed. No other skin issues were noted on the assessment. The assessment was completed by Nurse #2. An interview via telephone was attempted with Nurse #2 on 07/14/23 but was unsuccessful. Resident #87's progress notes revealed the following note dated 03/08/23 at 8:21 PM written by Nurse #1, Heard certified nurse aide (NA #1) call for help. This writer walked into resident's room to see [NA #1] holding [Resident 87's] arms. Resident [#87] was kicking legs and yelling. [NA #1] reported [Resident #87] was conversant and was willing to let [NA #1] change brief. When he turned [Resident #87] toward him, [Resident #87] hit him in the nose with his fist. [NA #1] held arms to try to calm [Resident #87]. [Resident #87] started to calm and [NA#1] stepped away from [Resident #87]. Skin tears noted to bilateral arms with bruising to bilateral arms. Skin tears cleaned and dressed per protocol. An interview with NA #1 via phone on 07/11/23 at 12:43 PM revealed he remembered the incident and stated he was in Resident #87's room providing incontinence care with Resident #87 rolled onto his right side, suddenly, Resident #87 became combative and rolled back onto his back and NA #1's arms. NA #1 stated one of his arms was stuck between Resident #87's legs and his other arm was underneath Resident #87's back. NA #1 stated he had worked with Resident #87 before and had never had him become aggressive or combative with him while he provided care. He reported Resident #87 hit and struck him in the head and nose. NA #1 reported once he was able to get his arms loose, he held Resident #87's arms and began hollering for help from Nurse #1. NA #1 stated when Nurse #1 arrived at the room, she assisted him in getting Resident #87 calmed down and he let go of Resident #87's arms. NA #1 stated he observed skin tears on Resident #87's arms and stated he could not tell if the skin tears were from where he held Resident #87's arms or from where Resident #87 hit him. NA #1 stated he had received dementia and abuse training and reported he knew he should back away from aggressive or combative residents and reapproach them later. He also reported he finished his shift and stated he was not suspended after the incident. A skin assessment completed on 03/08/23 at 8:31 PM by Nurse #1 and reviewed on 03/09/23 by the Wound Nurse revealed Resident #87 was treated for a skin tear to his left wrist, a skin tear to his right elbow, and a skin tear to his right arm. An interview with Nurse #1 via phone on 07/11/23 at 2:47 PM revealed she remembered the incident with NA #1 and Resident #87 on 03/08/23, and stated NA #1 had called out for help while he was in Resident #87's room. She stated when she entered the room, NA #1 was standing by Resident #87's bed and was holding Resident #87 by his wrists. She reported NA #1 told her Resident #87 had become combative during incontinence care and had hit him in the nose and he held Resident #87's arms to prevent Resident #87 from hitting him. Nurse #1 stated she observed Resident #87 lying on his back with his arms extended towards the ceiling with NA #1 holding onto his both wrists. She stated she noted multiple skin tears to both of Resident #87's arms and she provided first aid. Nurse #1 described the skin tears as about the size of a half dollar and were located on both of Resident #87's forearms or wrists. Nurse #1 stated she reported the incident to the Wound Nurse because of the injuries, and she also informed the Unit Manager and the Quality Assurance Nurse who came and assessed Resident #87. Nurse #1 stated when she informed the Unit Manager and the Quality Assurance Nurse, she was confident she let them know that she had seen NA #1's hands grasping Resident #87's wrists. Nurse #1 reported she had received training regarding combative residents and that staff were expected to remove themselves from combative residents and reapproach them later. An interview with the Wound Nurse on 07/11/23 at 12:14 PM revealed she viewed and treated Resident #87's wounds after the incident with NA #1. She reported Resident #87 had significant bruising to his lower arms and multiple skin tears. She stated she believed the skin tears were to Resident #87's lower arms and were large. She stated Resident #87's bruising to his lower arms was observed to be approximately the size of a tennis ball on both of Resident #87's arms. The Wound Nurse reported she cleaned the wounds with normal saline and covered them with 2 inches by 2 inches foam dressings. She reported the wound dressings would have been changed every 3 days until healed but stated she could not remember how long she treated the wounds. Review of physician orders revealed the following: 03/09/23- clean large skin tear to left lower forearm/wrist area with normal saline, apply xeroform (foam dressing) and a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean skin tear to right lower forearm/wrist with normal saline, apply xeroform and cover with a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean second skin tear to left lower forearm/wrist with normal saline, apply xeroform and a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean pea sized skin tear to right elbow with normal saline, apply xeroform and cover with clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean large skin tear to right elbow with normal saline, apply xeroform and cover with clear dressing every Tuesday, Thursday, and Saturday. During an interview with the Unit Manager on 07/11/23 at 3:10 PM, she reported she was informed of the incident but was unsure if it was the day the incident occurred or the day after. She reported it was her understanding that Resident #87 had become combative during care and NA #1 had attempted to prevent Resident #87 from hitting him. Unit Manager reported she did not recall being informed that NA #1 had held Resident #87 by his arms or wrists but stated she was aware that there were multiple skin tears that required treatment following the incident. She reported staff had received training regarding combative or aggressive residents and that staff were expected to step away from the resident and reapproach at a later time. An interview with the Quality Assurance Nurse on 07/11/23 at 3:42 PM revealed Nurse #1 had approached her to come look at Resident #87's arms. She stated she was told that NA #1 had provided Resident #87 with incontinent care and during the care, Resident #87 had become combative and hit NA #1 in the nose. She stated NA #1 told her when he was hit in the nose, he reactively grabbed Resident #87's wrists to keep Resident #87 from hitting him again and resulted in multiple skin tears to Resident #87's lower forearms or wrists. She reported she questioned NA #1 why he grabbed Resident #87 and was told it was reactionary. The Quality Assurance Nurse reported NA #1 told her he released Resident #87's wrists when he began to calm down. She reported she observed the wounds to Resident #87 and that the skin tears seemed fresh. She also reported staff were educated to remove themselves from combative residents and to reapproach them later. An interview with the Director of Nursing (DON) on 07/11/23 at 3:16 PM revealed she was aware of an incident regarding NA #1 and Resident #87. She stated when she was informed of the incident, she began an investigation and when she spoke with NA #1 he reported he had gone into Resident #87's room to provide care and during that time, Resident #87 became combative and begun to swing and kick at NA #1. The DON stated she was not told that NA #1 had grabbed Resident #87's wrists. She did report that Resident #87 suffered multiple skin tears to his bilateral arms during the incident. The DON reported she did not believe the actions of NA #1 were abusive in nature and stated she had worked with NA #1 for a long time and was insistent that he did not willfully injure Resident #87. She stated she felt the incident was a reaction to having been hit in the nose. She stated she did not see how NA #1 could have done anything different and stated that the staff on the locked dementia unit were beat up by Resident #87 daily. The Director of Nursing stated NA #1 had received abuse and combative resident training and it was expected that he back away and reapproach later but insisted he did not have another option with his arm being trapped. An interview with the Administrator on 07/11/23 at 4:39 PM revealed it was his understanding that NA #1 had gone into Resident #87's room to provide incontinence care and Resident #87 had become combative, hitting NA #1 in the nose. He stated he did not believe the actions of NA #1 was abusive as he did not believe they were willful. The Administrator stated he firmly believed there was no intent to hurt Resident #87 when NA #1 held Resident #87's arms during the incident.

Based on observation, record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications (Resident #85), discharge (Resident #101) and restraints (Resident #27) for 3 of 21 residents reviewed for MDS accuracy. The findings included: 1. Resident #85 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction. A review of Resident #85's physician orders dated 05/26/23 revealed an order for Zoloft (antidepressant) 50 milligrams (mg) by mouth once a day for anxiety. A review of Resident #85's Medication Administration Record for 06/2023 revealed the Resident received the Zoloft 50 mg by mouth at 5:00 PM every day of the month. A review of Resident #85's Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was not coded as receiving an antidepressant in the look back period. An interview was conducted with the Minimum Data Set (MDS) Nurse #1 on 07/11/23 at 2:50 PM who explained that she was helping part time at the facility while the new MDS Nurse #2 was on vacation. MDS Nurse #1 continued to explain that MDS Nurse #2 was still learning, and the Resident should have been coded as receiving an antidepressant on the MDS assessment dated [DATE]. An interview was conducted with the Assistant Director of Nursing (ADON) and the Administrator on 07/11/23 at 3:03 PM. The ADON explained that she used to be the MDS Nurse before she became the ADON. The ADON explained that when completing the MDS a medication should be coded as the classification of the medication therefore Resident #85's MDS should have been coded as receiving an antidepressant since he was prescribed Zoloft which is an antidepressant. On 07/12/23 at 9:39 AM an interview was conducted with the Minimum Data Set (MDS) Consultant who explained that the current MDS Nurse had only been with the facility for about 5 weeks and was still learning the MDS process. The Consultant continued to explain that she normally reviewed the new MDS Nurse's work but was out the previous week and was unable to review it before she transmitted the MDS' to the state but felt confident that she would have caught the error. The Consultant confirmed that Resident 85's MDS dated [DATE] should have been coded as receiving an antidepressant since the Resident received an antidepressant during the lookback period. 2. Resident #101 was admitted to the facility on [DATE] for a closed fracture of left femur. A review of Resident #101's progress note dated 06/16/23 at 10:10 AM revealed the Resident was discharged home via private vehicle with family. A review of Resident #101's Minimum Data Set, dated dated dated [DATE] revealed the discharge status was to acute hospital. An interview was conducted with MDS Nurse #1 on 07/11/23 at 2:50 PM who explained that she was helping part time at the facility while the new MDS Nurse #2 was on vacation. The MDS Nurse #1 continued to explain that MDS Nurse #2 was still learning, and the Resident should have been coded for a discharge to the community on the Resident's 06/16/23 discharge MDS. An interview was conducted with the Assistant Director of Nursing (ADON) and the Administrator on 07/11/23 at 3:03 PM. The ADON explained that she used to be the MDS Nurse before she became the ADON. The ADON indicated Resident #101's MDS should have been coded for a discharge to the community on the 06/16/23 MDS. On 07/12/23 at 9:39 AM an interview was conducted with the Minimum Data Set (MDS) Consultant who explained that the current MDS Nurse had only been with the facility for about 5 weeks and was still learning the MDS process. The Consultant continued to explain that she normally reviewed the new MDS Nurse's work but was out the previous week and was unable to review it before she transmitted the MDS' to the state but felt confident that she would have caught the error. The Consultant confirmed that Resident 101's MDS dated [DATE] should have been coded as discharge to community since the Resident went home. 38515 Resident #27 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a stroke. A review of Resident #27's care plan reviewed on 05/20/23 revealed a care plan for the use of a half side rail on the right side of Resident #27's bed. This side rail was used to aide in Resident #27's independence with transfers and to assist with bed mobility. A review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. She required limited assistance with bed mobility and transfers. She was coded as utilizing a bed rail daily as a physical restraint. During an interview with the Assistant Director of Nursing (ADON) on 07/12/23 at 1:22 PM she reported she was serving in the capacity as the MDS nurse at the time Resident #27's 05/26/23 MDS assessment was completed. She stated Resident #27 did not utilize and had never utilized a physical restraint and the coding of a bed rail used daily as a restraint was an oversight and was coded in error. She reported Resident #27 did have a bed rail attached to the bed that did not restrict Resident #27's mobility. During an interview with the Administrator on 07/12/23 at 2:06 PM, he reported Resident #27 did not utilize any physical restraints. He reported Resident #27 had a bed rail attached to the bed to serve as mobility assistance and insisted that it did not restrict Resident #27's movements in any way. The Administrator indicated the coding of a bed rail as a restraint on Resident #27's MDS assessment was an error.

Based on observations, record review, and staff interviews the facility failed to remove expired medications from 2 of 5 medications carts reviewed for medication storage (Yellow Hall and Orange Hall). The findings included: 1a. An observation of Yellow Hall medication cart was conducted on 07/09/23 at 2:15 PM along with Medication Aide (MA) #1. The observation revealed an open bottle of Calcium 250 milligrams (mg) with Vitamin D3 that expired on 06/23 that was on the medication cart and available for use. The observation further revealed an open bottle of Atropine 1% (used to dry secretions) that expired 02/23 on the medication cart available for use. An interview was conducted with MA #1 on 07/09/23 2:21 PM and revealed that she generally worked on the Blue Hall Medication cart and the Yellow Hall medication cart was not her normal medication cart to work. She stated that she was here about two to three weeks ago and the pharmacy had gone through the Blue Hall medication cart, but she was not sure that they had gone through the Yellow Hall medication cart. She added that MA #2 had just gone through the medication cart the other day and did not catch those expired medications. MA #1 stated that she had not gone through the medication cart because MA #2 had just gone through the medication cart and she thought it was fine. MA #2 was interviewed on 07/09/23 at 2:29 PM who confirmed that she had just gone through the Yellow Hall medication cart the other day, she believed it was Friday and did not catch the expired medications. She stated that they should have been pulled off the cart and discarded and she had no idea where the expired medication came from. 1b. An observation of Orange Hall medication cart was made on 07/09/23 at 2:36 PM along with MA #2. The observation revealed an open bottle of Calcium 250 mg with Vitamin D3 that expired 06/23. An interview was conducted with MA #2 on 07/09/23 at 2:44 PM who confirmed that she had just gone through the Orange Hall medication cart one day last week and did not see the expired medication, she stated that she had no idea where the medication came from. She stated she had checked the supply of those same calcium tablets and none of them were expired so she could not explain where the expired medication had come from. She stated the medication should be removed from the medication cart and discarded. An interview with the Director of Nursing (DON) was conducted on 07/09/23 at 3:55 PM who stated that MA #2 went through the medication carts and rooms weekly and she had just gone through the carts and did not find those medications. She stated that they were very attentive to the medication rooms and carts and that if a medication expired within the month or next month it was removed from the medication cart and discarded or returned to the pharmacy. She added that MA #2 reordered the stock medication when they got less than ten bottles and if they ran out sooner, they would just go to the local pharmacy and get what they needed. The DON could not explain where the expired medication came from.

Based on observations, record review, and staff interviews, the administration, and governing body failed to ensure the facility followed their abuse policies and procedures when a corporate nurse consultant stated the facility did not need to complete a 24 hour or 5 working day report to the state agency after a nurse aide grabbed a resident (Resident #87) by the wrists during incontinence care resulting in three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with agitation and anxiety disorder. Resident #87's admission Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no psychosis, rejection of care, or instances of wandering. Resident #87 was coded as having other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal or vocal symptoms like screaming or disruptive sounds) as occurring 1-3 days during the lookback period. Resident #87 required extensive assistance with 1 person assist for toilet use, personal hygiene, and bathing. Resident #87's progress notes revealed the following note dated 03/08/23 at 8:21 PM written by Nurse #1, Heard certified nurse aide (NA #1) call for help. This writer walked into resident's room to see [NA #1] holding [Resident 87's] arms. Resident [87] was kicking legs and yelling. [NA #1] reported [Resident #87] was conversant and was willing to let [NA #1] change brief. When he turned [Resident #87] toward him, [Resident #87] hit him in the nose with his fist. [NA #1] held arms to try to calm [Resident #87]. [Resident #87] started to calm and [NA#1] stepped away from [Resident #87]. Skin tears noted to bilateral arms with bruising to bilateral arms. Skin tears cleaned and dressed per protocol. An interview with the Administrator on 07/11/23 at 4:39 PM revealed he spoke with his Corporate Nurse Consultant about the incident after it happened during the clinical morning meeting and was told it did not need to be reported to the state agency as she did not believe there was any intent by NA #1 to harm Resident #87. The Administrator stated he had this conversation with her and agreed with her that the actions by NA #1 were not abusive in nature and therefore did not complete a 24 hour or 5 working day report to the state agency. An interview with Corporate Nurse Consultant on 07/11/23 at 5:28 PM, she reported she recalled being informed of the incident between Resident #87 and NA #1 on 03/08/23 during the clinical meeting on 03/09/23. She reported after speaking with the Director of Nursing, the Administrator, and NA #1 she felt it was not abusive in nature and that it was not an event that needed to be reported to the state agency.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey that occurred on 12/16/21. This failure was for 1 deficiency originally cited in the area of Resident Assessment (F641). The repeat deficiency during two surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F641: Based on observation, record reviews, and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications (Resident #85), discharge (Resident #101), and restraints (Resident #27) for 3 of 21 residents reviewed for MDS accuracy. During the recertification survey on 12/16/21 the facility failed to accurately code the Minimum Data Set assessment to reflect a resident received dialysis therapy, this was evident for 1 of 1 resident reviewed for dialysis. During an interview with the Administrator on 07/11/23 at 3:42 PM, he reported the quality assurance (QA) team met monthly and included all the department heads, dietary, maintenance, business office staff, and the medical director. He reported they reviewed their complaints system for repetitive concerns and reviewed any other issues the QA committee was following. The Administrator reported the facility had been using an MDS consultant to complete MDS assessments and reported she must have clicked wrong buttons on the MDS assessments that were coded incorrectly.

Based on record review and staff and physician interviews the facility failed to follow a physician order to stop a tube feeding after 16 hours per the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused Resident #64 to vomit, have bilateral adventitious (abnormal) lung sounds and was in visible distress with an oxygen saturation level of 81% and necessitated an emergent transfer to the emergency room (ER) to be assessed for aspiration. The Findings Included: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #64's electronic physician orders revealed an order dated 11/08/21 for [MEDICATION(S)] (type of parental nutrition) 1.5, infuse at 75 milliliters per hour for a continuous 16 hours. Additional review of Resident #64's physician orders revealed an order dated 11/11/21 that read in the morning disconnect tube feeding at 6:00 AM. A review of Resident #64's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #64 to be severely impaired for daily decision making. She was coded as requiring total assistance with eating and was coded as having a feeding tube while admitted to the facility, receiving 51% or more of her total calories via feeding tube. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #2 indicating the tube feeding had been stopped at 6:00 AM on 11/13/21. Attempted phone call with Nurse #2 was completed on 12/14/21 at 4:20 PM with no answer. A voicemail was unable to be left due to the mailbox being full. A review of a nursing progress note written by Nurse #1 on 11/13/21 at 2:02 PM read called to room by hall nurse [Nurse #3] to assess [Resident #64]. Resident [#64] observed sitting up at 45 degrees, seeming to be having difficulty breathing. Bilateral rhonchi and crackles noted. Emesis observed on [Resident # 64's] chest and clothing. Heart rate at 130 [beats per minute], oxygen saturation at 81% on nasal cannula at 2 liters per minute. Resident [#64] visibly distressed. Orders received to transfer to emergency department for evaluation and treatment as indicated, first responders requested with emergent transfer. During an interview with Nurse #1 on 12/14/21 at 3:18 PM, she reported she was familiar with Resident #64 and verified she was working as the weekend supervisor on 11/13/21. She stated she was contacted by the hall nurse, Nurse #3, on 11/13/21 due to Resident #64 having respiratory distress. She stated Resident #64 was supposed to be on a 16-hour continuous tube feeding and believed that the night nurse, Nurse #2, had forgotten to disconnect the tube feeding resulting in Resident #64 receiving more feeding than what was ordered. Nurse #1 reported when she went to the room to assess Resident #64, she was receiving oxygen via nasal cannula, so she suctioned her, checked Resident #64's airway, and then called the on-call physician for further orders. She reported Resident #64 was sent out to the emergency department for evaluation and treatment. An interview with Nurse #3 via telephone call on 12/15/21 at 11:27 AM revealed she remembered Resident #64 and was assigned to her on 11/13/21 from 7:00 AM to 3:00 PM on 11/13/21. She reported it was the first time she had worked with Resident #64 as she was an agency nurse and new to the facility. Nurse #3 stated there were no concerns throughout the shift and she checked the placement of Resident #64's feeding tube to see if there was any residual feeding when she provided her morning medications around 9:00 AM. Nurse #3 reported she did not believe Resident #64 had any scheduled medications to be given at lunch time and received most of her medications in the morning. Nurse #3 stated when she went in to restart Resident #64's feeding, she noticed Resident #64 looked different and was breathing fast. Nurse #3 immediately went to Nurse #1 because she did not know what Resident #64's baseline was and was aware Nurse #1 would. Nurse #3 stated she and Nurse #1 went to Resident #64's room and Nurse #1 assessed resident, checked her airway, and turned off the feeding tube. Nurse #3 stated the head of the bed was elevated and there was a trace amount of regurgitation on Resident #64's clothing and was the color of feeding tube fluid. Nurse #3 reported she provided ordered tube flushes during the day at the scheduled times and reported there were no noted issues or distress prior to 2:00 PM when she went into the room to restart the tube feeding. Review of an Emergency Department (ED) Provider Note dated 11/13/21 at 2:48 PM read, in part, 69- year- old female presents to the emergency department via emergency medical services (EMS) from [local nursing facility] for aspiration. EMS reports initial oxygen saturation levels (SpO2) in the 70's. SpO2 rose to 89% on 15 liters via non-rebreather. EMS states the patient's skin appeared mottled upon their arrival. Patient arrives with MOST (medical orders for scope of treatment) form and Do Not Resuscitate for comfort measures only. The progress note continued, stating Resident #64 was noted with a fever while at the emergency department with respiratory distress due to a history of recent aspiration, likely pneumonia. According to the note, resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment included treating the fever with Tylenol and air hunger addressed with some [intravenous] IV [MEDICATION(S)]. According to the note, no chest x-ray was taken, and resident was stable to discharge back to the facility without admission to the hospital after a few hours with no new orders. A nurse's note dated 11/13/21 at 6:27 PM indicated Resident #64 had returned to the facility from the emergency department via EMS. The ED Nurse had reported the Resident's temperature was 103.5. The nurse noted Resident #64's oxygen was titrated up to 4 liters/minute and she appeared calm and comfortable. A review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician noted Resident #64 had some respiratory distress and was transferred to the hospital recently. Due to her being comfort measures only she was treated symptomatically with [MEDICATION(S)] and she returned to the facility. The physician documented the Resident did not appear to be in any distress but remained a high risk for decompensation. A Registered Dietitian (RD) progress note dated 11/17/21 indicated Resident #64 was recently hospitalized for aspiration, which was likely due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD noted Resident #64 had been tolerating the tube feeding regimen that week with no signs or symptoms of intolerance or distress. An interview with Nurse Aide #1 on 12/14/21 at 5:33 PM, she verified she was working on Resident #64's hall on 11/13/21 but was not assigned to the Resident. She reported she remembered towards the end of the shift, Resident #64 had to be sent out to the hospital due to aspirating and vomiting. She stated she remembered the head of the bed was elevated and does not remember Resident #64 being in any distress during her shift before being asked to clean her up for transportation to the emergency department. Attempts to contact the Nurse Aide assigned to Resident #64 on 11/13/21 for the 7:00 AM to 3:00 PM shift during the investigation were not successful. An interview with the Director of Nursing on 12/14/21 at 4:53 PM revealed she was aware of the incident regarding Resident #64's feeding tube not being stopped on 3rd shift by Nurse #2. She reported the incident was processed and investigated as a medication error. She verified Resident #64's feeding tube should have been disconnected at 6:00AM on 11/13/21 by Nurse #2 and it was not. She stated when she spoke to Nurse #2 during the investigation, Nurse #2 reported she assumed the feeding tube was continuous for 24 hours at a time and she did not verify the order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing reported once Nurse #2 signed off on the MAR, Nurse #3 would not have received any notification regarding the feeding until 2:00 PM when she would have received a notification to start another 16-hour feeding. She reported at 2:00 PM, when Nurse #3 received that notification, she immediately reported it to Nurse #1 who went and assessed Resident #64, found her in distress and sent her to the emergency room for evaluation and treatment. During a follow up interview with the DON on 12/15/21 at 3:56 PM she reported when she questioned Nurse #2 during her investigation, she stated Nurse #2 indicated it was just oversight. She reported she had tried to reach back out to Nurse #2 but had not received a return call. The DON reported Nurse #2 should not have signed off on a physician order as done if it had not been completed. She stated orders should be signed off on as they are completed, not before. During an interview with the Medical Director on 12/15/21 at 9:27 AM he reported he was notified of the incident regarding Resident #64's tube feeding being left running for an additional 8 hours. He stated he believed she was sent out to the emergency room after aspirating and was sent back. He reported he assessed the resident a few days later and did not note any concerns or injury to Resident #64 related to tube feeding being left running for longer than it was supposed to. The facility provided the following Corrective Action Plan with a completion date of 12/07/21: Identify those recipients who have suffered, a serious adverse outcome as a result of the noncompliance Resident #64 is alert but very confused, she is rarely/never understood, Minimum Data Set Brief Interview for Mental Status score was unable to be performed, she has no ability to make cognitive decisions. Resident has long and short-term memory loss. Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has tube feeding via gastrostomy tube [MEDICATION(S)] 1.5 at 75 ml/hour for 16 hours. Tube feeding is stopped at 6:00 am and restarted at 2:00 pm per Medical Director orders. On 11/13/21, Nurse #2, the nurse working 11pm to 7am did not turn off resident's tube feeding at 6:00 am, Nurse #2 signed off she had turned it off. Nurse #3 working the 7am to 3pm shift contacted the Nurse #1, the RN weekend supervisor midafternoon and made her aware Resident #64 tube feeding was on a continuous feeding when the order was for 16 hours. Nurse #1 reported, Nurse #3 told her Nurse #2 did not stop the tube feeding at 6:00am. Nurse #3 assessed the resident and found she was on O2 at 2 liters via nasal cannula, her airway and lung sounds were checked and due to the resident being in respiratory distress Nurse #3 contacted the on-call physician, and the resident's resident representative. The decision was made to send resident #64 to the emergency room for evaluation and treatment. The resident was seen in the emergency room , she was given IV [MEDICATION(S)] for respiratory distress and Tylenol for fever. The emergency room doctor called and spoke with resident representative and the decision was made to send resident back to the facility due to DNR with comfort measures. The resident returned to the facility with the following Clinical Impressions from the emergency room , they were: Fever in adult, Respiratory distress, DNR (do not resuscitate) Nurse #3 noted the resident was calm and in no acute distress. The resident was seen by the Medical Director on 11/16/21 status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The Corporate Registered Dietitian saw the resident on 11/17/21 with no new orders, the RN nurse consultant for Medicare Replacement extender saw the resident on 12/2/21 with no new orders or recommendations. Resident has had no further issues with her tube feeding and no further respiratory distress. The root cause discussed and identified by the Quality Assurance Performance Improvement (QAPI) team, was Nurse #2 signed the order to turn the tube feeding off at 6:00 am on 11/13/21 but did not go to the resident room and turn the feeding off. Nurse #3 gave the resident her medication and flushes as ordered through the shift. At 2:00pm when Nurse #3 went to turn the tube feeding on she found the feeding had not been turned off at 6:00am. Identify those recipients who are or are likely to suffer, a serious adverse outcome as a result of the noncompliance All residents receiving feedings via a gastrostomy tube that are not continuous 24-hour feeding are at risk for receiving their tube feeding for longer than the Medical Director ordered length of time. There are no other residents currently residing in the facility with a tube feeding. All residents admitted to the facility that have non-continuous tube feeding will have an order to turn the tube feeding off at the specified time and another order to verify the tube feeding was turned off. The order will be on the Medication Administrative Record with written instructions of time to start the tube feeding and time to stop the tube feeding. The order will have a large capitalized note stating DISCONNECT TUBE FEEDING AT (TIME ORDERED) and another order to CONFIRM ENTERAL TUBE FEEDING IS TURN OFF The Corporate Registered Dietitian, will review all current and new admissions tube feeding orders and make recommendations as appropriate for resident tube feeding formula and rate at which the tube feeding is running. All new admissions are reviewed daily through the interdisciplinary team meeting (IDT) conducted daily for quality assurance, any negative findings are corrected immediately, and additional training will begin. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete ¢ The Director of Nursing (DON) was notified on 11/13/21 by Nurse #1 immediately upon finding the resident #64 in distress and Nurse #1 was sending the resident to the emergency room . ¢ The Director of Nursing (DON) on 11/13/21, instructed Nurse #1 the RN supervisor to begin in-servicing on Continuous enteral feeding vs Timed Enteral feedings, to include ensuring the order is carried out as written and proper point of care documentation to sign the completed order after the task or medication is given with Nurse #3 and all nursing currently working. ¢ On 11/13/21, the spoke with Nurse #2, took her statement and in-serviced her Continuous enteral feeding vs Timed Enteral feedings, to include ensuring the order is carried out as written and proper point of care documentation to sign the completed order after the task or medication is given. ¢ 11/14/21 The QAPI Adverse Event PIP (Performance Improvement Plan) initiated and the formal monitoring tool was initiated by the DON. ¢ Monitoring began on 11/14/21 by the Unit Manager and RN supervisor to visually inspect that Resident #64's tube feeding was indeed discontinued at 6:00am. If there were any negative findings, it was to be corrected immediately and the DON was made aware for additional training per Monitoring Tool. The Tube Feeding audit will be conducted daily x 1week, weekly x 4 weeks and monthly x 1 month. ¢ The DON/Assistant Director of Nursing (ADON) on 11/15/21 began in-servicing all nurses on staff and nurses from the agency. All nurses were educated by 11/15/21. All new hires, PRN or new agency nurses are tracked by the DON and educated on tube feedings during their orientation or their return to work. ¢ 11/15/21 Interdisciplinary quality team reviewed the event, (IDT) in the interdisciplinary team meeting. Meeting is held as part of QAPI 5 days a week. Minutes from 11/13/21 and 11/14/21 done by RN supervisor Nurse #1. In-servicing was continued by the DON/ADON/Staff Development Coordinator (SDC) to ensure all nurses were in-serviced. It was determined by the interdisciplinary quality team the QAPI Adverse Event Audit and the Tube Feeding monitoring tool to verify the tube feeding was turned off, to check for negative findings or additional training needed and the name of the auditor would begin immediately. The audit will be conducted daily x 1week, weekly x 4 weeks and monthly x 1 month ¢ 11/16/21 QAPI Quarterly meeting was held, the Medical Director was in attendance and this QAPI Adverse Event was discussed. He agreed with the improvement plan, in-services and monitoring tools. ¢ 12/4/21 the DON and ADON in review of resident event during Interdisciplinary quality team meeting it was decided for further prevention of a re-occurrence of tube feeding not being turned off would write a large capitalized note on the turn off order at 6:30am order DISCONNECT TUBE FEEDING AT 6:00am and to add an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . CONFIRM ENTERAL TUBE FEEDING IS TURN OFF The DON will be responsible to ensure that the order is completed on all residents that have a timed tube feeding. All new orders for current and new admissions are reviewed at a minimum of 5 days a week to ensure accuracy in the interdisciplinary quality team meeting and directed by the DON. ¢ The DON will report the results of audits at the monthly QAPI meetings for 3 months. Additional audits will be completed if determined necessary by the QAPI team. The facility alleged compliance on 12/07/21. The Corrective Action Plan was validated on 12/22/21 and concluded the facility implemented an acceptable corrective action plan on 12/07/21. The facility provided training to all nursing staff, amended the physician orders to trigger a verification a timed enteral feed had been stopped, and initiated monitoring tools to ensure the new policies and procedures were followed. The Corrective Action Plan was reviewed during QAPI meeting held on 11/15/21. The weekly monitoring logs for residents with feeding tubes were reviewed for the month of December 2021 with no concerns identified. Review of the nursing staff in-service sheets on feeding tubes revealed the nursing staff had initialed as receiving the in-services training. Interviews conducted with nursing staff from first, second, and third shifts revealed they had received the in-service trainings on feeding tube policies and procedures as stated by the facility.

Based on observations, record reviews and interviews the facility failed to provide a dignified dining experience by standing over residents while providing feeding assistance for 2 of 3 residents reviewed for dignity (Resident #67 and Resident #66). The findings include: 1. Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 sometimes understood others and sometimes made self-understood and had long and short term memory problems. The MDS also indicated the Resident required extensive assistance with eating. On 12/13/21 from 12:35 PM to 12:44 PM a continuous observation was made of Nurse Aide (NA) #1 standing at Resident #67's bedside while feeding the Resident her lunch. The Resident's head of bed was in an upright position and the NA stood above the Resident's eye level during the dining experience. There was a chair in the room that was available for the NA to use. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set (MDS) 11/17/21 revealed Resident #66's cognition was severely impaired, and she required extensive assistance with eating. On 12/13/21 from 12:45 PM to 1:01 PM a continuous observation was made of NA #1 standing at Resident #66's bedside while feeding the Resident her lunch. The Resident's head of bed was in an upright position and the NA stood above the Resident's eye level during the dining experience. There was a chair in the room that was available for the NA to use. An interview was conducted with Nurse Aide #1 on 12/13/21 at 3:02 PM. The NA explained that when she fed on the hall, she always stood by the residents' bedside but when she fed in the dining room she always sat in a chair because it was important to sit at eye level with the residents. The NA stated she did not like to sit down and feed the residents because she had a bad back. During an interview with Unit Manager (UM) #1 on 12/15/21 at 12:12 PM she explained that the staff should sit down and feed the residents because it could be intimidating to the resident for someone to hover over them and risk them not eating at all. The UM stated the facility was their home and the residents should be made to feel comfortable. An interview was conducted with the Director of Nursing (DON) on 12/15/21 at 2:52 PM. The DON explained that nurse aides were taught in class to sit at the residents' side and feed them at eye level in order to provide a dignified dining experience. During an interview with the Administrator on 12/16/21 at 12:01 PM she explained that her expectation was for the nurse aides to be seated at eye level in order to give the residents their undivided attention.

Based on record review and staff interview the facility failed to accurately code the Minimum Data Set in the area of [CONDITION(S)] for 1 of 1 resident that received [CONDITION(S)] services (Resident #88). The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of [CONDITION(S)] communication sheets dated 11/19/21 and 11/21/21 indicated that Resident #88 had received [CONDITION(S)] and no acute issues were noted. The communication sheet contained Resident #88's vital signs and weight and the staff signature from the local [CONDITION(S)] center. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #88 was cognitively intact for daily decision making and required limited assistance with activities of daily living. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #88 had not received [CONDITION(S)] during the assessment reference period. The MDS was completed by former MDS Nurse #1. MDS Nurse #1 was interviewed via phone on 12/15/21 at 3:04 PM. MDS Nurse #1 confirmed that she used to work at the facility from August 2021 to December 2021. She recalled Resident #88 and stated that she regularly received [CONDITION(S)] and would refuse from time to time but never more than one treatment at a time. MDS Nurse #1 stated that the lack of coding on the quarterly MDS dated [DATE] to reflect [CONDITION(S)] was an oversight on her part and the facility should process a correction due to transcription error. The Administrator was interviewed on 12/16/21 at 11:31 AM. The Administrator stated MDS Nurse #1 made a mistake when coding the quarterly MDS dated [DATE] probably because we had not had any residents that received [CONDITION(S)] for a while and was just an oversight on her part. The Director of Nursing (DON) was interviewed on 12/16/21 at 2:07 PM. The DON stated that she expected the MDS to be coded accurately and updated accordingly.

Based on observations, record reviews and staff and Resident interviews the facility failed to implement the care plan intervention for oxygen humidification for 1 of 1 Resident reviewed for choices (Resident #5). The finding included: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #5's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's care plan initiated 07/01/21 and revised 07/19/21 revealed a potential for ineffective breathing pattern related to [CONDITION(S)] with interventions of administering oxygen at four liters and to attach water for humidification per the Resident's request. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was cognitively intact and required oxygen therapy. On 12/13/21 at 11:54 AM an observation was made of Resident #5 in bed sleeping with continuous oxygen via nasal cannula administered at four liters per minute. The water bottle attached to the oxygen system for humidification was empty. On 12/13/21 at 4:04 PM a second observation made of Resident #5's water bottle while the Resident was sleeping. The water bottle remained empty. During an interview with Nurse #1 on 12/13/21 at 4:14 PM the Nurse accompanied the Surveyor to Resident #5's room (who was still sleeping) and observed the water bottle remained empty. The Nurse explained that every nurse who entered the room should monitor for the need to replace the water bottle. On 12/15/21 10:11 AM an interview was conducted with Medication Aide (MA) #1 who confirmed that she worked with Resident #5 on 12/13/21 and explained that she glanced at the Resident's water bottle on the oxygen system and meant to inform the nurse of the need to replace it but she forgot. The MA indicated that the medication aides and nurse aides could only monitor the humidification bottles for water but that only the nurses could replace the humidification bottles on the oxygen systems. An interview was conducted with the Director of Nursing (DON) on 12/15/21 at 3:00 PM who explained that all staff should be checking the water bottles when they enter the room and they could inform the nurse of the need to replace it. The DON stated the humidification should be maintained as requested on Resident #5's care plan. A review of Resident #5's Care Guide dated 12/16/21 indicated oxygen with humidification per the Resident's request. During an interview with the Minimum Data Set (MDS) Nurse #2 on 12/16/21 at 11:55 AM she explained that if an intervention was important enough to be included on the Resident #5's care plan then it was her expectation for the staff to implement the intervention. During an interview with the Administrator on 12/16/21 at 11:58 AM she stated if Resident #5 requested humidification for the oxygen system to be applied then the humidification should be maintained, and the care plan should be followed.

Based on record review, staff, and Medical Doctor interview the facility failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #88). The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #88 was cognitively intact for daily decision making and required limited assistance with activities of daily living. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #88 had not received [CONDITION(S)] during the assessment reference period. Review of a care plan revised on 11/29/21 read in part, Resident #88 has [CONDITION(S)] and is at risk for complications due to hemodialysis. The interventions included [CONDITION(S)] on Monday, Wednesday, and Friday, communicate with [CONDITION(S)] center as indicated, assess resident upon return from [CONDITION(S)], do not draw blood or take blood pressure in arm with access site (left arm), maintain dressing as ordered, monitor access site for bleeding and/or signs of infection, monitor vital signs, and monitor for changes in level of consciousness, skin turgor, oral mucosa, or heart/lung sounds. Review of Resident #88 active order summary printed on 12/16/21 revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Charge Nurse from the local [CONDITION(S)] center was interviewed on 12/21/21 at 9:37 AM. The Charge Nurse stated that when Resident #88 left [CONDITION(S)] she would have a pressure dressing over her access site, and it was required to be removed 4-6 hours after treatment by the facility staff she also stated that the staff at the facility should be assessing the access site to make sure it does not close and that would include listening to the bruit (the swooshing sound of [CONDITION(S)] fistula) with a stethoscope and feeling for a thrill (a vibration felt over the fistula). The Charge Nurse indicated that these instructions generally were included in the resident's orders at the facility where they live. MDS Nurse #2 was interviewed on 12/15/21 at 2:38 PM and reported that Resident #88 did regularly receive [CONDITION(S)] and could not explain why there was not a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Nurse #2 stated that the staff should be monitoring Resident #88's access site at least daily to ensure no bleeding or signs of infection. MDS Nurse #1 was interviewed on 12/15/21 at 3:12 PM and stated she worked at the facility from August 2021 to December 2021 and knew that Resident #88 regularly received [CONDITION(S)]. She further explained that Resident #88 was the only [CONDITION(S)] resident and she had not been at the facility long enough to know about her [CONDITION(S)] order. MDS Nurse #1 stated that she recalled an order to remove a pressure dressing after [CONDITION(S)] but stated she did not recall seeing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She added that Resident #88 was alert and oriented and would let someone know if something was going on with it. Unit Manager #1 was interviewed on 12/16/21 at 10:10 AM and confirmed that there should be a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that Resident #88 had received [CONDITION(S)] since her admission in June 2021. UM #1 also confirmed that she was responsible for entering most of the orders in the facility and was just an oversight on her part. She further state that the facility staff really did not do much with Resident #88's [CONDITION(S)] access site except they should definitely be monitoring for infection and bleeding. The Administrator was interviewed on 12/16/21 at 11:31 AM. The Administrator confirmed that UM #1 entered most of the orders at the facility and it was just an oversight on her part. She stated that the facility had not had a [CONDITION(S)] resident in a long time, and they reviewed the orders in the morning stand up meeting but just missed ensuring that Resident #88 had a physician order in place for her [CONDITION(S)] and for the care and maintenance of her access site. The Director of Nursing (DON) was interviewed on 12/16/21 at 2:07 PM. The DON stated she absolutely expected Resident #88 to have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. She added the physician order should include the care and monitoring of Resident #88's [CONDITION(S)] access site. The Medical Doctor (MD) was interviewed on 12/21/21 at 10:28 AM. The MD stated that he generally did not write specific orders for [CONDITION(S)] and he assumed the facility staff would just enter the order into the electronic system and he would sign off on it. He stated the important thing was that she was getting to/from [CONDITION(S)] 3 times a week. The MD further stated that the facility staff did not have to do anything to the access site and no monitoring was required because she went to [CONDITION(S)] every other day. He stated that once the facility got her to [CONDITION(S)], and they managed the rest from there.

Based on record review and facility staff interviews, the facility failed to maintain an accurate recording of a tube feeding on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Findings Included: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #64's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #64's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Enteral Feed Order - in the morning Disconnect tube feed at 6 am. Attempted phone call with Nurse #2 was completed on 12/14/21 at 4:20 PM with no answer. A voicemail was unable to be left due to the mailbox being full. An interview with the Director of Nursing on 12/14/21 at 4:53 PM revealed she was aware of the incident regarding Resident #64's tube feeding not being disconnected on 3rd shift on 11/13/21 by Nurse #2. She reported the incident was processed and investigated as a medication error. She stated when she spoke to Nurse #2 during the investigation, Nurse #2 reported she assumed the feeding tube was continuous for 24 hours and she did not verify the order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a follow up interview with the DON on 12/15/21 at 3:56 PM she reported when she questioned Nurse #2 during her investigation, she stated Nurse #2 indicated it was just oversight. She reported she had tried to reach back out to Nurse #2 but had not received a return call. The DON reported Nurse #2 should not have signed off on a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated orders should be signed off on as they are completed, not before.

Based on observations and resident and staff interviews, the facility failed to repair an exterior window screen that obstructed a resident view for 1 of 2 residents and broken window blinds for 1 of 2 windows reviewed (Room 311). The facility failed to clean resident walls and ceilings in 3 of 10 resident rooms (Rooms 311, 506, and 510). The facility failed to remove dead bugs from light fixtures on the 500 hall, light fixtures in 2 of 3 resident rooms and the window sill in 1 of 3 resident rooms (Room #'s 512, 513, 516 and the 500 hall). The facility failed to maintain functional privacy curtains for 8 of 8 residents privacy curtains (Room 514, 511, 505, 506, 508, 507, 510, and 512). The facility failed to clean light fixture and air circulation vents in 3 of 3 resident rooms and the dining room (Room 511, 512, 514 and the dining room.) These observations occurred on 2 of 4 resident halls (300 and 500 Halls) and the dining room. Findings included: Window Screen and blinds: 1 a. An observation on 12/13/21 at 11:34 AM revealed a window screen to have a visible slit in the center (Room 311). An observation on 12/16/21 at 9:07 AM revealed the exterior window screen of an occupied resident room (Room #311) to contain an approximately 18 inch slit and claw type marks on the surface. The screen had been partially pulled up at the bottom which partially obstructed the view from the inside of the resident room. b. An observation on 12/16/21 at 9:27 AM revealed the window blinds to be broken (Room 510). Walls and Ceiling: 2 a. An observation on 12/13/21 at 11:36 AM revealed brown spots on the walls near the bed, closet, and window of room (Room 311). An observation on 12/16/21 at 9:07 AM revealed brown streaks running down the walls next to the sink and bathroom doors along with the wallpaper peeling up near the sink (Room 311). Nickel size spots of a brown substance were visible on the wall next to the foot of the resident's bed and brown spots near the white wall board used as a protective barrier attached to the wall (Room 311). b. An observation on 12/16/21 at 9:16 AM revealed dark brown substances from the doorway to the nightstand on the wall (Room 506). c. An observation on 12/16/21 at 9:27 AM revealed large brown oblong shaped spot on the ceiling measuring 6 x 4 (inches)and another one measuring approximately 16 x 6 on the right side of the light fixture. Another brown spot on the ceiling near the bathroom measuring approximately 8 x 3. The wallpaper was observed to be peeling away from the wall near the bathroom sink (Room 510) Dead Bugs: 3 a. An observation on 12/13/21 at 11:23 AM revealed 2 dead bugs in the window sill below the window blinds (Room 512). An observation on 12/16/21 at 9:30 AM revealed 3 dead bugs in the window sill below the window blinds (Room 512). b. An observation on 12/16/21 at 9:25AM revealed dead bugs in the light fixtures in the hallway (Hallway 500). c. An observation on 12/16/21 at 9:38 AM revealed there were bugs and dirt under the plastic light fixture covering (Room 513). d. An observation on 12/16/21 at 9:40 AM revealed there were bugs and dirt under the plastic light fixture covering (Room 516). Curtains: 4. a. An observation on 12/13/21 at 11:05 AM revealed a curtain with the originally white netting near the top partially bleed to pink over a portion of the curtain and 2 rivets off the runner and detached from the track (Room 514). b. An observation on 12/13/21 at 11:18 AM revealed a privacy curtain with the 3 rivets off the runner and detached from the track on the ceiling causing a portion of the curtain to sag downwardly (Room 511). c. An observation on 12/16/21 at 9:15 AM revealed a curtain with 3-4 rivets off the track and detached from the track causing the curtain to sag. The curtain had three rivets off the track and dirty on the lower ½ of the curtain (Room 505). d. An observation on 12/16/21 at 9:16 AM revealed the curtain with 2 rivets off the track (Room 506) e. An observation on 12/16/21 at 9:18 AM revealed a privacy curtain which was stuck in the track and unable to allow curtain to close greater than an approximately 18-inch area (Room #508) f. An observation on 12/16/21 at 9:20 AM revealed a curtain with 2 rivets off the track (Room #507). g. An observation on 12/16/21 at 9:27 AM revealed large brown areas of visible dirt and sticky substance on the privacy curtain (Room 510). h. An observation on 12/16/21 at 9:30 AM revealed a curtain with 5 rivets off the track (Room 512). Dirty Light Fixtures and Vents: 5 a. An observation on 12/13/21 at 11:18 AM revealed a light fixture that contained debris inside the plastic covering (Room 511). b. An observation on 12/16/21 at 9:22 AM revealed a large light fixture in the dining area with brown stains on the plastic surface and a collection of dead bugs under the plastic covering (Dining Room). c. An observation on 12/16/21 at 9:30 AM revealed the air vent near the bathroom with a ½ thick fuzzy substance covering the vent (Room 512). d. An observation on 12/16/21 at 9:32 AM revealed the air vent near the bathroom with a ½ thick fuzzy substance covering the vent along with dirt and bugs in the light fixtures above the beds (Room 511). e. An observation on 12/16/21 at 9:36 AM revealed the air vent near the bathroom with a ½ thick fuzzy substance covering the vent (Room 514). An interview with Housekeeper # 1 on 12/16/21 at 2:20 PM revealed he was responsible for cleaning resident rooms. He indicated he was responsible to report all damaged surfaces, curtains, and bugs to the supervisor. Housekeeper #1 stated he had not noticed any of the items observed on the unit during his daily cleaning but had been attempting to get the major areas cleaned and had not reported the damages he had been trained to report. An interview with the Housekeeping (EVS) /Maintenance Supervisor on 12/16/21 at 2:35 PM revealed she was recently made responsible for both housekeeping and maintenance departments. She indicated staff had been taught to log concerns into an electronic tracking system, but she had not been granted access since she took over the position. The EVS Supervisor explained someone from corporate came once a month to check on major concerns and they maintained the access to the electronic log. She stated she expected all areas in resident rooms and resident care units to be cleaned and be free from bugs daily, curtains to be maintained on their tracks and in working condition, light fixtures to be cleaned monthly and when debris is visible. An interview with the Administrator on 12/16/21 at 3:52 PM revealed staff had been trained to log request in the electronic tracking system, but she was aware staff had also been taught to place the logs on a paper form if it was urgent. She also expects all resident care areas to be maintained in functional order and surfaces to be cleaned and free from bugs and dirt.

Based on observations, record review, staff interviews, review of the signage labeled Droplet Precautions and review of the facilities infection control policies, the facility staff failed to don and doff PPE (Personal Protective Equipment) per CDC guidelines for residents under transmission based precautions, failed to display Enhanced Droplet Contact Precautions signage for confirmed and possible COVID-19 exposure resident rooms, and failed to perform hand hygiene before entering or after contact with a resident or objects in a residents room who were under isolation precautions. The facility failed to develop and implement a policy for Enhanced Droplet Contact Precautions for suspected and quarantined residents. These failures in infection control practices occurred during a COVID-19 pandemic and had the potential to affect all residents in the facility through the transmission of COVID-19. A total of 37 residents were confirmed as positive for COVID-19 as of 08/03/20. Immediate Jeopardy began on 07/28/20, when the facility failed to identify residents with potential exposure of COVID-19 by not placing them on Enhanced Droplet Contact Precautions, failed to implement basic infection control practices, and failed to prevent cross over of staff from the quarantine hall to the general population. Immediate Jeopardy was removed on 08/11/20 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. The findings included: According to the facility policy titled Standard and Transmission-Based Precautions dated 03/10/20 indicated in part: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in healthcare facilities and standard precautions are used for the care of all residents. Handwashing should be performed after touching contaminated items whether gloves are worn or not, immediately after gloves are removed, between residents, and when otherwise necessary to avoid transfer of microorganisms to other residents or the environment. Good hygiene is essential and in the absence of an outbreak either soap and water or alcohol-based sanitizer may be utilized. Gloves are to be worn when touching contaminated items. Remove gloves promptly before touching non-contaminated items and environmental surfaces and before going to another resident. It further indicated in part under the heading titled sharps that care is to be taken to prevent injuries when using needles, scalpels, and other sharp objects or devices, when handling sharp instruments after procedures, when cleaning instruments, and when disposing of needles. The policy details contact, droplet and airborne precautions, but does not address the CDC's recommended isolation precaution of Enhanced Droplet Contact Precautions for the COVID-19 pandemic. During the entrance conference on 07/28/20 at 10:45 AM, the Director of Nursing (DON) identified the 600 hall was designated as the New Admission/ Observation quarantine hall. Observations on the 600 hall on 07/28/20 began at 10:52 AM and ended at 2:20 PM and revealed Nurse #1, Nurse #2, Nurse Aide (NA) #1, NA #3, NA#6, and Housekeeper #1 were working on the facility's quarantine unit. The following observations were made: A review of the Droplet Precaution signage displayed in the 600 hall revealed a visual illustration that indicated staff were to wear a mask, perform hand hygiene before and after entering the room, and dietary was not permitted in these care areas. A review of the Contact Precaution signage displayed in the 600 hall revealed a visual illustration that indicated staff were to wear a gown and gloves, perform hand hygiene before and after entering the room, and to use single use equipment or sanitize multi-use equipment between patients. a. An observation on 07/28/20 at 10:56 AM revealed Housekeeper #1 wore a gown as she exited Resident #1's room and carried a mop, a soiled cloth, and a bottle of sanitizing spray. Signage on Resident #1's door indicated Droplet Precautions. Housekeeper #1, with her gloved hands, opened the lid of her cart using a key located on a lanyard around her neck. She placed the spray bottle in the cart, disposed of the used rag, and removed the soiled mop pad from the mop handle. Housekeeper #1 placed the mop pad in a plastic bag attached to the cart and disposed of her gloves. Housekeeper #1 then pushed her cart to Resident #2's room and did not perform hand hygiene. Resident #2's door revealed signage that indicated Droplet Precautions. When she approached Resident #2's room, she donned clean gloves, picked up the bottle of disinfectant and other items from the cart and locked the cart with the key around her neck. She then entered Resident #2's room and closed the door. An interview with Housekeeper #1 on 07/28/20 at 11:38 AM revealed Housekeeper #1 had worn a gown, mask, face shield, and gloves in Resident #1's room to clean. Housekeeper #1 indicated she should have performed hand hygiene when she removed her gloves. Housekeeper #1 acknowledged she touched items on the cart with both dirty gloves and clean hands and that the cart and items should have been sanitized to prevent cross contamination and she should have performed hand hygiene, and donned clean gloves before she entered Resident #2's room. Housekeeper #1 revealed she was educated to don PPE in the front lobby and she wore her gown for the duration of her shift and was not educated to change gowns when she left the 600 hall New Admission/observation quarantine unit and went to other areas in the facility. An interview with the Housekeeping Supervisor on 08/04/20 at 1:51 PM revealed she was the Supervisor for Housekeeper #1. She stated Housekeeper #1 should have placed the items on the outside of the cart while she removed her gloves, performed hand hygiene, and donned clean gloves and wiped off the bottle of sanitizer used in Resident #1's room who was on Droplet Precautions. She stated after she sanitized the bottle, Housekeeper #1 should have removed her gloves and performed hand hygiene again before she proceeded to Resident #2's room. b. An observation on 07/28/20 at 12:23 PM revealed Nurse Aide (NA) #3 entered Resident #8's room which had signage on the door that indicated Droplet Precautions. NA #3 picked up a knife from the room and exited the room with the knife in her bare hand. NA #3 carried the knife to the 600 hall nourishment room and closed the door. NA #3 exited the nourishment room carrying the knife soiled with visual residue in her hand and walked down the hall and she entered a room labeled employees only located behind the nurses' station. NA #3 was not observed to wear gloves when she entered Resident #8's room nor while she held a contaminated knife from inside of Resident #8's room. An interview with NA #3 on 7/31/20 at 10:14 AM revealed she routinely worked the 600 New Admission/observation quarantine hall on day shift. She stated she was required to wear full PPE on that unit which included a gown, mask, and face shield, and gloves and she did not change her gown during her shift. She stated she was unaware that a resident on her unit had signage that indicated Contact Precautions and she would be required to change her PPE when she cared for that resident. She stated she changed gloves between residents but did not think she needed to don gloves when she entered to retrieve an object in Resident #8's room. She acknowledged Resident #8 was on Droplet Precautions and she should have worn gloves when in the room and performed hand hygiene when she exited Resident #8's room. She stated she should not have entered the nourishment room, or the room labeled employees only behind the nurses' station while she held the potentially contaminated knife from Resident #8's room. NA #3 acknowledged those areas should have been sanitized after she touched them because she potentially spread infection to other surfaces. NA #3 indicated she was required to assist on the adjacent 400 hall (general population) and did not change her PPE when she exited the 600 hall. She acknowledged there were no signs on the 400 hall that indicated any resident was on isolation precautions. c. An observation on 07/28/20 at 12:25 PM revealed Nurse #2 entered the room of Resident #9 and she held a medication cup in her bare hand. Resident #9's door indicated Contact Precautions. Nurse #2 administered the cup of medications then exited the room and returned to the medication cart in the hallway. Nurse #2 was not observed to don clean PPE to include a gown, gloves, mask, and face shield when she entered Resident #9's room nor doff her gown and gloves or perform hand hygiene before she returned to the medication cart. Nurse #2 spoke to Nurse #1 at the medication cart, Nurse #1 handed Nurse #2 a cup of medications and Nurse #2 left the medication cart and entered the room of Resident #10 and #11 and did not don clean PPE that included a gown, gloves, mask, and face shield. Signage on Resident #10 and #11's door indicated Droplet Precautions. Nurse #2 administered the cup of medications and exited the room and was not observed to perform hand hygiene when she exited Resident #10 and #11's room. An interview with Nurse #2 on 07/28/20 at 1:15 PM revealed she worked on the 600 hall New Admission/observation quarantine unit. Nurse #2 revealed she was required to wear full PPE when she worked on this unit that included a gown, mask, face shield, and gloves. Nurse #2 stated she thought all residents on that unit were under Droplet Precautions and she had not noticed the Contact Precaution sign before she entered Resident #9's room to administer her medications and failed to perform hand hygiene when she exited. She further revealed because she had not realized Resident #9 was on a different isolation precaution than the other residents on the unit, she had not changed her PPE after she exited Resident #9's room. d. An observation on 07/28/20 at 12:28 PM revealed Nurse #1 entered the room of Resident #12. As she entered the room, she pushed Resident #12's wheelchair out of the way with her bare hands as she approached the bed and answered the call light. Signage on Resident #12's door indicated Droplet Precautions. Nurse #1 was not observed to perform hand hygiene before she left Resident #12's room. An interview on 07/28/20 at 1:05 PM with Nurse #1 revealed Nurse #1 admitted she had not worn gloves in Resident #12's room when she entered and moved the wheelchair out of the way while she approached the bed to see what Resident #12 needed. She stated she went in the room to answer the call light and did not think about Resident #12's Droplet Precautions. Nurse #1 revealed she entered the room and did not don gloves nor wash her hands when she left the room. e. An observation on 07/28/20 at 12:30 PM revealed Nurse Aide #6 enter the room of Resident #9 and carried a lunch meal tray with her bare hands. Signage on Resident #9's room indicated Contact Precautions. NA #6 sat the meal tray down on the overbed table and set the tray up then exited the room. NA #6 was not observed to wear gloves nor perform hand hygiene before she returned to the meal tray cart located in the hallway. At 12:33 PM, NA #6 entered the room of Resident #13 and Resident #14. Signage on the door indicated Droplet Precautions. NA #6 placed the tray on the bedside table of Resident #13 and exited the room. NA #6 was not observed to don gloves nor perform hand hygiene while she delivered a lunch meal tray to Resident #13. An interview with NA #6 on 07/31/20 at 6:54 PM revealed NA #6 worked the 600 hall New Admission/observation quarantine unit on day shift. NA #6 stated she was required to wear full PPE that included a gown, mask, and face shield always and wore gloves when she provided incontinence care. NA #6 indicated she had not change PPE during her shift and was required to wear the same gown for the duration of her shift unless it became visibly soiled. NA #6 stated she was unaware that Resident # 9's door contained signage that indicated Contact Precautions and she had not changed her PPE or perform hand hygiene when she exited the room of Resident #9 after she delivered the meal tray. NA #6 revealed she did not don gloves when she retrieved Resident #13's tray from the meal tray cart and delivered it to Resident #13. NA #6 stated she should have worn gloves and performed hand hygiene when in Resident #13's room that indicated Droplet Precautions. NA #6 indicated she was required to help on the 400 hall, but she was not educated that PPE must be changed between units. She stated she did not recall any signage on the 400 hall to indicate any resident was on isolation precautions. f. An observation on 07/28/20 at 12:35 PM revealed Nurse #2 entered the room of Resident #3 and carried a cup of medications in her bare hand. Signage on the door indicated Droplet Precautions. Nurse #2 was not observed to wear gloves or to perform hand hygiene after contact with Resident #3 during medication administration. Nurse #2 exited the room and approached Nurse #1 at the medication cart, then she obtained a box of tissues from the top of the nurses' station, and re-entered Resident #3's room as she carried the box of tissues and handed the box to Resident #3. Nurse #2 was not observed to perform hand hygiene after she exited Resident #3's room the second time. Resident #3's lab results dated 07/28/20 indicated a positive COVID-19 detected test. An interview with Nurse #2 on 07/28/20 at 1:15 PM revealed Nurse #2 stated she acknowledged Resident #3 was on Droplet Precautions, but she failed to don gloves before she entered the room or perform hand hygiene after she exited the room. She stated she should have performed hand hygiene before she touched items at the nurses' station and donned clean gloves before she returned to Resident #3's room to give her the tissues. g. An observation on 07/28/20 at 12:40 PM revealed Nurse #1 entered the room of Resident #12 and carried a glucometer, test strip, and an alcohol prep pad in her bare hands. Signage on the door indicated Droplet Precautions. She donned gloves and obtained Resident #12's blood sugar. Nurse #1 then exited the room and wore gloves on both hands, placed the glucometer on a tissue on the top of the cart. Nurse #1 then opened the drawer of the cart and obtained a pouch that held a wipe and placed the wipe over the glucometer. She then turned to the laptop on the medication cart and entered the medical record of Resident #12 as she used her right gloved hand. Nurse #1 then opened the drawer of the medication cart and retrieved a bottle of insulin and a syringe and drew the insulin in the syringe and laid the syringe on the top of the cart. She opened the drawer on the right side of the medication cart and dispensed a medication into a cup and placed the cup on top of the cart. Nurse #1 picked up the medication cup and the insulin syringe and re-entered Resident #12's room. She administered the medication and the insulin, removed and discarded her gloves, and exited the room and held the used syringe in her bare hand. She placed the insulin syringe in the sharps box on the medication cart and was observed to continue to type on the laptop. Nurse #1 was not observed to perform hand hygiene before or after contact with Resident #12. An interview on 07/28/20 at 1:05 PM with Nurse #1 revealed she wore gloves while she obtained the blood sugar for Resident #12, but she should have removed the test strip from the glucometer, removed her gloves, and performed hand hygiene before she touched items on the medication cart. Nurse #1 stated she should have pulled the oral medications from the medication cart first, drew up the insulin into the syringe, then applied clean gloves before she re-entered Resident #12's room to administer the medications. She should have removed the glove from one hand, carried the syringe in the gloved hand and discarded it in the sharps container on the cart, then removed her other glove and performed hand hygiene before she touched items on the medication cart such as the laptop. Nurse #1 acknowledged Resident #12 was on Droplet Precautions. h. An observation on 07/28/20 at 12:46 PM revealed Nurse Aide #2 worked the 200 hall carried a meal tray to the 600 hall New Admission/observation quarantine unit with her bare hands. NA #2 wore a gown, a mask, and a face shield when she entered the unit. She carried the meal tray to Resident #3's room, setup the tray, and exited the room. She was not observed to doff the PPE worn in the quarantine unit, perform hand hygiene, and don clean PPE after she left Resident #3's room or before she exited the unit. An interview with NA #2 on 08/05/20 at 4:55 PM revealed NA #2 worked the 200 hall where residents who had been exposed to COVID-19 from a previous roommate resided. NA #2 stated she was instructed to wear full PPE that included a gown, mask, and face shield for the duration of her shift unless they became visibly soiled and gloves were to be worn in all resident rooms. She further elaborated she had not worn gloves to deliver meal trays on her unit and therefore, had not thought she needed to apply gloves when she delivered Resident #3's tray to the 600 hall which was designated as a New Admission/ observation quarantine unit and she had not noticed the signage on Resident #3's door which indicated she was on Droplet Precautions. She stated she setup the meal tray and exited the room to return to her unit. She stated she had not changed her PPE between units when she delivered the meal tray. i. An observation on 07/28/20 at 12:50 PM revealed Nurse #1 entered the room of Resident #8 on the 600 hall New Admission/observation quarantine unit and she held a glucometer, alcohol prep pad, and a test strip in her bare hand. Signage on the door indicated Droplet Precautions. Nurse #1 donned gloves and obtained Resident #8's blood sugar. At 12:52 PM, Nurse #1 then exited the room with her gloved hands and carried the glucometer with the test strip attached and sat it on a tissue on the top of the medication cart. Nurse #1 then opened the drawer of the medication cart and obtained a bottle of insulin and a syringe and drew the insulin into the syringe. She then re-entered Resident #8's room. She carried the syringe and administered the insulin. Nurse #1 removed and discarded her gloves and exited the room and she carried a used syringe in her bare hand. She placed the syringe in the sharps box on the medication cart and began to type on the laptop located on the medication cart. An interview on 07/28/20 at 1:05 PM with Nurse #1 revealed she wore gloves and carried supplies to obtain Resident #8's blood sugar. Nurse #1 stated after she obtained Resident #8's blood sugar, she should have discarded the test strip, removed her gloves, and performed hand hygiene before she touched items on the medication cart. Nurse #1 stated she should have pulled the oral medications first, drew up the insulin into the syringe, then applied clean gloves before she re-entered Resident #8's room to administer the medications. Then she should have removed the glove from one hand, carried the syringe in the gloved hand and discarded it in the sharps container on the cart, then she should have removed her other glove and performed hand hygiene before she touched the items on the medication cart such as the laptop. Nurse #1 acknowledged Resident #8 was on Droplet Precautions. j. An observation on 07/28/20 at 12:56 PM revealed Nurse #1 exited the room of Resident #13 and #14 she carried a glucometer with her gloved hands. Signage on the door indicated Droplet Precautions. She placed the glucometer on a tissue on top of the medication cart, obtained a bottle of alcohol spray from the side of the medication cart, sprayed the glucometer, removed her gloves and discarded them. Nurse #1 then wiped the glucometer with a tissue and her ungloved hands. Nurse #1 was not observed to perform hand hygiene after she exited Resident #13 and #14's room or after she cleaned the glucometer with the alcohol spray. An interview on 07/28/20 at 1:05 PM with Nurse #1 revealed she had removed her gloves before she cleaned the glucometer after she had exited the room of Resident #13 and #14 with signage that indicated Droplet Precautions but she should have worn gloves to clean the glucometer and then performed hand hygiene. She stated she worked on the New admission/observation quarantine unit and full PPE that included a mask, gown, face shield and gloves are always required when in rooms with residents on isolation precautions. She also stated gloves should be changed between residents to include meal delivery. k. An observation on 07/28/20 at 2:20 PM revealed Nurse #1 was on the lower end of 400 hall adjacent to the 600 hall. She had pulled medications for medication administration and she wore a mask, face shield, and a gown in the hallway. An interview with Nurse #1 on 08/04/20 at 3:30 PM revealed when she worked the 600 hall New Admission/observation quarantine unit she was also responsible for medication administration for residents in rooms 406-410 on the adjacent unit. She acknowledged there were no residents on the 400 hall under any form of isolation precautions. Nurse #1 stated she had been instructed to wear the same gown during her entire shift and did not change it unless it was soiled until the date of the survey but did change gloves between patients on the 400 hall. An interview with Nurse #1 on 08/04/20 at 3:30 PM revealed when she worked the 600 hall New Admission/observation quarantine unit she was also responsible for medication administration for residents in rooms 406-410 on the adjacent unit. She acknowledged there were no residents on the 400 hall under any form of transmission based precautions. Nurse #1 stated she had been instructed to wear the same gown during her entire shift and did not change it unless it was soiled until the date of the survey but did change gloves between patients on the 400 hall. An interview with Nurse #4 on 07/31/20 at 1:48 PM revealed Nurse #4 was the nurse on the 600 hall New Admission/observation quarantine unit on the evening shift. Nurse #4 stated he was required to wear full PPE which included a gown, gloves, mask, and a face shield when on duty and he donned the PPE in the front lobby of the facility. Nurse #4 reported he was educated to wear the same gown for the duration of the shift unless it became visibly contaminated. Nurse #4 indicated he thought all the residents on the 600 hall unit were on Droplet Precautions and had not noticed the signage on Resident #9's door that indicated Contact Precautions and had not changed PPE when he cared for Resident #9. Nurse #4 stated the 600 hall nurse was also responsible for medication administration on a portion of the rooms on the end of 400 hall which he recalled were rooms 406-410. Nurse #4 revealed there was no signage on the doors of any residents on the 400 hall that indicated they were on any form of transmission based precautions. He stated he was not educated to change PPE between units when he cared for the residents on the 600 hall quarantine unit and residents on the 400 hall where there had been no known COVID-19 exposures. An interview with the IC Nurse and DON on 07/28/20 at 3:30 PM revealed neither had thought about the potential for cross contamination when staff wore the same PPE between the 600 hall and the 400 hall units. l. An observation on 07/28/20 at 10:59 AM in the 500 hall secured memory care unit revealed 9 residents sitting in the day room and Resident #20 had ambulated and stood in the hallway outside the room. Nurse Aide #1 was observed to wear a gown, mask, and face shield while she pushed the soiled linen/trash receptacles through the double doors to leave the unit. She had not worn gloves as she pushed the cart through the double doors on the memory care secured unit. An interview with Nurse Aide #1 on 08/05/20 at 3:39 PM revealed NA #1 worked the secured memory care unit. She stated she was required to wear full PPE to include gown, mask, and face shield during her entire shift and she did not change gowns unless it becomes soiled. She stated she left the unit for break when she was observed to push the soiled linen/trash receptacle out the double doors of the unit. She further elaborated she should have worn a glove to push the contaminated cart to the laundry room . An interview with Nurse #3 on 07/28/20 at 11:05 AM revealed NA #1 should have worn a glove to push the cart to the laundry room. The following observations were made on the 100/200 halls which were identified by the Director of Nursing and the Infection Control Nurse as potential exposure halls during the entrance conference on 07/28/20. m. Observations of the 100/ 200 hall on 07/28/20 between 11:08 AM and 11:19AM revealed no signage which indicated any form of transmission based precautions to include Enhanced Droplet Contact Precautions on the doors of residents who had potentially been exposed to COVID-19 by their former roommates. An interview with NA #2 on 08/05/20 at 4:55 PM revealed NA #2 worked the 200 hall where residents who had potential exposure to COVID-19 from a previous roommate resided. She stated she was instructed to wear full PPE which included a gown, mask, and face shield for the duration of her shift unless they became visibly soiled and gloves were to be worn in all resident rooms She stated there was no visible signage to indicate Enhanced Droplet Contact Precautions on the doors of the rooms where residents with potential exposures resided to alert her that her PPE should be changed when she exited that room and therefore she did not know which residents were considered exposed and/or potentially contagious. An interview with NA #8 on 8/4/20 at 9:48 AM revealed she works the 200 hall on day shift. NA #8 explained she was required to wear full PPE to include a gown, mask, and face shield always when in the facility. She stated she was educated that gloves are to be worn with resident care and hand hygiene is to be performed before and after gloves are used. She reported she has recently worked both 100 and 200 hall unit on the same shift and she had not been educated to change gowns between the units. She was instructed to wear the same gown the entire shift unless it tore or was soiled. She stated there was no signage on either the 100 or 200 hall units that indicated any residents were on isolation precautions and no signage to indicate any resident on either unit had Enhanced Droplet Contact Precaution signage to alert staff PPE should be changed when they cared for that resident. An interview with NA #4 on 07/31/20 at 12:23 PM revealed NA #4 worked the 100 and 700 hall units in the facility on day shift. NA #4 stated she was required to wear full PPE to include a gown, mask, and face shield the duration of her shift and she wore gloves when she performed incontinence care, and she performed hand hygiene between residents. She indicated she was educated to wear the same gown for the duration of her shift and only change gowns if it became visibly soiled. She revealed there were no signage on the doors on her unit that indicated any resident was on isolation precautions and no signage that indicated Enhanced Droplet Contact Precautions that required her to change PPE when she cared for that resident. She stated she was unaware if any residents on her hall may have been potentially exposed to COVID-19. NA #4 explained she had not worn gloves when she delivered meal trays on her unit. An interview with NA #5 on 07/31/20 at 6:33 PM revealed NA #5 worked 12 hours shifts on the 100 and 700 hall units in the facility on day shift. NA #5 stated she was unaware of any resident on her unit that had signage that indicated any form of isolation precautions and there was no signage that indicated Enhanced Droplet Contact Precautions that would alert her that her PPE should be changed when she cared for a resident on her unit. NA #4 indicated she had been educated to wear her PPE to include gown, mask, and face shield for the duration of her shift unless it became visibly soiled and she donned all PPE in the front lobby of the facility at the start of her shift. She stated she cleans her face shield when she goes on break and at the end of the shift and occasionally must change her gown when it becomes wet with sweat. She stated she had not been educated that she needed to wear gloves when she delivered meal trays on her unit or that she needed to change gowns if she went to other areas of the facility. An interview with NA #9 on 08/04/20 at 10:19 AM revealed NA #9 worked the 100 hall unit on day shift. NA #9 reported she was unaware of any resident on the 100 hall who was on any form of transmission-based precautions and had not seen any signage posted that indicated Enhanced Droplet Contact Precautions on resident doors to indicate PPE should be changed when she cared for the resident on her unit. NA #9 indicated she had been educated to wear full PPE which included a gown, mask, and face shield for the duration of her shift unless it becomes soiled. NA #9 explained she had not been educated to change gowns when she left the unit or went to other areas within the facility. NA #9 further indicated she had not worn gloves when she delivered meal trays on her unit. n. An observation on 07/28/20 at 11:15 AM revealed Housekeeper #2 was mopping the room of Resident #4 and #5 had not worn gloves. Housekeeper #2 wore a gown and a mask. Housekeeper #2 exited the room and removed the mop pad from the mop with her bare hands and placed it in a bag attached to the cart. She then picked up a bottle of cleaner and re-entered the room and began to clean the sink. An interview on 07/28/20 at 11:18 AM revealed Housekeeper #2 was in Resident #3 and #4's room. She was mopping the floor and wore a gown and mask. Housekeeper #2 stated she had not replaced her face shield yet and had not been educated that she needed to wear gloves when she mopped the floor or when she removed the soiled mop pad from the handle. Housekeeper #2 stated she was unaware if any residents on the 200 hall had a potential exposure to COVID-19 but there was no signage on any resident door on the unit that indicated Enhanced Droplet Contact Precautions to show her she needed to take extra precautions in that room or that she should change her PPE when she exited the room. An interview with the Housekeeping Supervisor on 08/04/20 at 1:51 PM revealed she was the Supervisor for Housekeeper #2. She stated Housekeeper #2 had not been educated to wear gloves when she mopped in a resident's room; however, she acknowledged gloves should have been worn to remove the mop pad from the handle. The Housekeeping Supervisor stated Housekeeper #2 may not have known which rooms had potentially exposed residents because there was no signage that indicated any residents on the 200 hall were on isolation precautions and Housekeeper #2 had not been educated to change PPE when in rooms of the potentially exposed residents. An interview with Nurse #8 on 08/04/20 at 5:10 PM revealed Nurse #8 was the day shift supervisor and was responsible to oversee all the halls in the facility. Nurse #8 stated she was aware the first cases of COVID-19 in the facility were residents who had resided on the 100/200 hall units and the roommates of those residents had been relocated to other rooms on these units. Nurse #8 explained she had not recalled any signage on the doors of any resident rooms on 100/200 hall that indicated a resident was on isolation precautions and there were no signs that indicated Enhanced Droplet Contact Precautions that would alert staff that PPE should be changed when they cared for the residents in those rooms. Nurse #8 indicated she wore full PPE which included a gown, mask, and face shield always. Nurse #8 voiced she had been educated to wear her gown (TRUNCATED)

Based on observation, record reviews, and staff interviews the facility failed to accurately assess and prevent the development of a pressure ulcer for one of three sampled residents (Resident # 25). The resident developed a Stage III pressure ulcer after the placement of a long leg immobilizer due to a femur, tibia, and fibular fracture on 06/13/17. The findings included: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. The Minimum Data Set MDS) annual assessment dated [DATE] indicated the resident required extensive assistance by two persons for bed mobility, dressing, and personal hygiene. Resident #25 required only supervision for meals. She was dependent for transfers and always incontinent for bowel and bladder functions. The MDS dated [DATE] indicated Resident #25 had one unstageable pressure ulcer which measured 1.5 centimeters in length, 3/6 centimeters in width, and 00.1 centimeter in depth and had yellow slough tissue in the base of the wound. The MDS assessment also indicated that the resident had a stage unstageable pressure ulcer. Record review for Resident #25, indicated the care plan was updated 06/15/17, with new interventions due to the new [DIAGNOSES REDACTED]. A record review of the Emergency Department (ED) MD note dated 06/13/17 revealed that the resident had sustained a right distal femoral fracture, right proximal tibia and fibular fracture. Resident #25 was determined to not be well enough for surgery and returned to the facility on [DATE] with a full leg immobilizer in place. The ED Provider note also stated that the resident was advised to stay in her knee immobilizer at all times and remain with no weight bearing. A review of a cast observation flow sheet dated 06/21/17 revealed Resident #25 had a leg immobilizer on right leg, and indicated surrounding skin was within normal limits, with [MEDICAL CONDITION] in bilateral lower [MEDICAL CONDITION], and no open wound. The form dated 06/22/17 indicated that Resident #25 had a pressure ulcer to right upper inner thigh above immobilizer. A record review of form entitled Wound Ulcer flowsheet assessment flow sheet was completed by the wound treatment nurse and was dated 06/21/17 with time of 15:48. The form indicated resident with pressure ulcer which measured 1.5 centimeter in length, 3.6 centimeter in width and the wound bed surface was 90% covered with yellow slough. The pressure ulcer was assessed to be a Stage II wound. The Wound Ulcer Flow Sheet also stated MD had been notified on that date of the development of the pressure ulcer. The physician was notified and an order was present on the medical record dated 06/21/17 for wound care to the pressure ulcer on the right upper leg by applying santyl ointment and dry dressing. A record review of Wound Ulcer Flowsheet dated 06/27/17 revealed the resident had a pressure ulcer on the right inner thigh which measure 1.5 centimeters in length, 4.0 centimeters in width, and 0.5 centimeter in depth. The pressure ulcer was assessed to be an unstageable wound. Record review of follow up orthopedic consultation note dated 07/12/17 indicated Resident #25 had an ulcer on right inner thigh related to pressure from immobilizer. At that time the resident was treated with antibiotics and immobilizer changed to a new one that did not rub the area of the wound. On 08/02/17 11:14 AM Wound Treatment Nurse was observed performing wound care for pressure ulcer on right inner thigh of Resident #25. The Treatment Nurse cleaned the wound, applied Santyl debridement ointment, and covered the wound with dry dressing. The immobilizer remained on the leg during the treatment and covered the area from mid-thigh to the heel of right leg. The pressure ulcer on the upper thigh area was pink, without drainage and no signs of infection in the surrounding skin. Resident #25 denied having pain at the wound site but did request medication for knee pain. The medication was given. On 08/02/17 at 11:32 AM and interview was conducted with Nursing Assistant (NA) # 1. The NA stated that the resident had received a bed bath when Resident #25 first had the leg immobilizer in place after the new fractures on 06/13/17. NA #1 also stated that she was to report any change in the resident's skin to the nurse. She stated that she had not been the one who first observed the wound on the resident's thigh. NA # 1 stated that the resident had pillows to position the leg and keep pressure off the metal part of the immobilizer. An interview was conducted with Nursing Assistant (NA) #2 on 08/02/17 at 11:41 AM. NA #2 had stated that the immobilizer was very long and extended from the heel area to the upper thigh, almost into the groin of Resident #25. NA #2 also stated that the skin above the immobilizer was to be observed each time incontinence care was provided for the resident. On 08/02/17 at 2:39 PM an interview was conducted with Nurse #3 who had cared for Resident #25 soon after she returned with the immobilizer on. Nurse #3 stated that the immobilizer had a stiff metal part on located on the upper, inner thigh. Nurse #3 had also stated that skin assessments were to be done daily and that the area of the inner thigh was to be visualized every day. An interview was conducted on 08/02/17 at 4:55 PM with Nursing Assistant (NA) #3 who stated that she had cared for Resident #25. The Nursing Assistant stated that she had provided incontinence care for Resident #25 and assisted in repositioning her several times each day. The NA stated the immobilizer remained in place all the time and it had not interfered with provision of care. An interview was conducted with the Treatment Nurse at 11:55 AM on 08/03/17, who stated that the wound was first assessed on 06/21/17. The Treatment Nurse stated that the wound had developed in an area of the thigh of Resident #25 where a metal piece extended above the fabric of the immobilizer high on the right thigh, nearly into the groin area. The Nurse also stated that the wound area developed in the area where the metal piece of the immobilizer was against the resident's skin. The Nurse also stated that the immobilizer was to be worn continuously by the resident and the nursing staff did not loosen or open the immobilizer because Resident #25 had been diagnosed with [REDACTED]. The treatment nurse stated that the wound should have been documented as an unstageable ulcer on 06/27/17 because of the slough that was present in the wound. The wound treatment nurse stated that she had received education on assessment of wounds and their staging. She also stated that she had not made an addendum or entered corrected information into the record. On 08/03/17 at 12:00 PM an interview was conducted with the Director of Nursing (DON). The DON stated during the interview that it was the expectation that the medical record be accurate. She also stated that the electronic nursing note could not be changed once it was entered into the medical record. An interview was conducted on 08/03/17 at 2:54 PM with the Director of Nursing and the Treatment Nurse. During the interview, it was stated that the MD had instructed that the long leg immobilizer remain on Resident #25 at all times. The DON stated that the immobilizer had a long metal pieces on the inner thigh which extended past the black fabric part of the immobilizer. The DON also stated that it was her expectation that the skin outside of the immobilizers be inspected during personal care and documented daily in the medical record. An interview was conducted on 08/04/17 with Medical Director who stated it was his expectation that the skin assessment be completed frequently due to the potential of pressure from the immobilizer on right leg of Resident #25.

Based on staff interviews and record review the facility failed to notify the physician when they couldn't complete a thorough assessment of a resident in pain after falling out of bed and the resident was requesting an ambulance for 1 of 2 sampled residents (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with dementia, cognitive communication deficit, right [MEDICAL CONDITION] (07/06/15) and others. The Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making but had clear speech, was able to make herself understood and usually understood others. The MDS also specified the resident required extensive assistance with activities of daily living, had no presence of pain and had fallen twice without injury. Review of Resident #24's medical record revealed a nurse's entry made by the night shift supervisor dated 07/06/15 at 3:20 AM that read in part, Resident was found on the floor laying on her right side. Resident clutched middle portion of thigh and was reluctant to move right leg. An incident report dated 07/06/15 completed by the night shift supervisor specified Resident #24 was found in the floor clutching her thigh and was reluctant to move her right leg asking call an ambulance, get me an ambulance. The incident report revealed the resident was placed back in bed. The night shift supervisor documented on the incident report that the physician was contacted at 3:20 AM. Further review of the medical record revealed a nurse's entry dated 07/06/15 at 1:20 PM specified the on-call nurse practitioner was notified that Resident #24 was having increased pain to right leg and the leg was drawn up. The resident would yell out when range of motion was performed. The on-call practitioner ordered an x-ray. The radiology report dated 07/06/15 revealed Resident #24 had a [MEDICAL CONDITION] hip. Resident #24 was transported to the Emergency Department on 07/06/15 at 10:30 PM. On 07/06/15 at 4:10 PM Nurse #1 was interviewed and explained that he was orienting to night shift on 07/06/15 and that he normally worked 7 AM to 3 PM (day shift). He added that during the day shift if a resident fell and developed a new onset of pain he would contact the physician. Nurse #1 reported that on 07/06/15 he was notified that Resident #24 fell ; he stated that he responded to the resident and checked her out. He stated that he couldn't see any red marks and felt it was safe to put her back to bed. The nurse stated that he assessed Resident #24 before deciding to transfer her off the floor but was unable to check range of motion due to pain in her right leg. Nurse #1 explained that Resident #24 was in pain and when asked where the pain was located she patted her right hip, she was unable to verbalize a 1 to 10 pain scale but the resident showed facial grimacing and was holding her right side. The nurse stated that the new onset of pain after the fall was a change in the resident's condition and he notified the night shift supervisor. He added that Resident #24 had as needed pain medication which he offered but the resident refused. Nurse #1 stated that he did not notify the physician of Resident #24's complaint of pain or inability to move her leg after the fall because he deferred to the night shift supervisor. Nurse #1 also stated that he did not document his assessment of Resident #24. On 07/31/15 at 9:00 AM the night shift supervisor was interviewed and reported that on 07/06/15 Nurse #1 notified her that Resident #24 fell and complained of pain that did not appear excruciating but had refused pain medication. The night shift supervisor stated Resident #24 was in bed when she assessed the resident. The supervisor reported that Resident #24's legs were the same length and showed no deviation but that Resident #24 was gripping her right knee and didn't want to move the leg. The supervisor reported that other than a skin tear she didn't see any injuries. The night shift supervisor reported that she did not see a need to contact the physician since the resident was refusing pain medication. The night shift supervisor stated that she did not contact the physician and offered no explanation why it was documented on the incident report that the physician was contacted. On 07/31/15 at 9:30 AM the day shift supervisor was interviewed and reported that she was notified on 07/06/15 that Resident #24 had fallen but did not appear injured. She explained that she did not assess the resident until 11 AM when the medication aide reported that Resident #24 was complaining of pain. The day shift supervisor stated that she contacted the on-call nurse practitioner and received orders for an x-ray. The day shift supervisor reported that when a resident fell and complained of pain the physician should be notified then for further direction. On 07/31/15 at 10:55 AM the physician was interviewed on the telephone and reported that he did not expect nurses to contact him immediately after every fall. He explained that he expected nurses to use clinical judgment to determine when to contact the physician. The physician stated that if a fall occurred and there was a new sudden onset of pain not relieved with medication and no obvious injury then the nurse should notify a physician. On 07/31/15 at 2:10 PM the Director of Nursing was interviewed and reported that a significant change in a resident's condition would be a new onset of pain after a fall and the nurse should contact the physician.

Based on staff interviews and record review the facility neglected to seek medical intervention for a resident in pain who requested an ambulance after she fell for 1 of 2 sampled residents (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with dementia, cognitive communication deficit, right [MEDICAL CONDITION] (07/06/15) and others. The Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making but had clear speech, was able to make herself understood and usually understood others. The MDS also specified the resident required extensive assistance with activities of daily living, had no presence of pain and had fallen twice without injury. Review of Resident #24's medical record revealed a nurse's entry made by the night shift supervisor dated 07/06/15 at 3:20 AM that read in part, Resident was found on the floor laying on her right side. Resident clutched middle portion of thigh and was reluctant to move right leg. An incident report dated 07/06/15 completed by the night shift supervisor specified Resident #24 was found in the floor clutching her thigh and was reluctant to move her right leg asking call an ambulance, get me an ambulance. The incident report revealed the resident was placed back in bed. The physician's orders [REDACTED].#24's right hip and right knee due to pain. A second physician order [REDACTED]. Further review of the medical record revealed a nurse's entry dated 07/06/15 at 1:20 PM the specified Resident #24 was having increased pain to right leg and the leg was drawn up. The resident would yell out when range of motion was performed. The on-call nurse practitioner was notified and ordered x-rays. Review of the Medication Administration Record [REDACTED]. The radiology report dated 07/06/15 at 5:39 PM revealed Resident #24 had a [MEDICAL CONDITION] hip. Resident #24 was transported to the Emergency Department on 07/06/15 at 10:30 PM. On 07/30/15 at 4:00 PM nurse aide (NA) #1 was interviewed and reported that she was assigned to care for Resident #24 on 07/06/15. The NA explained that when making rounds she found Resident #24 laying in the floor calling for help and saying she was hurt. The NA added that she went immediately to get Nurse #1. NA #1 reported that Nurse #1 assessed Resident #24 and determined that it was okay to put the resident back to bed. The NA added that the resident complained of pain and appeared in pain but remained in the bed the rest of the shift. NA #1 stated that she checked on Resident #24 around 6:00 AM and Resident #24 appeared to really be hurting, complaining of knee and hip pain. The NA stated that she notified Nurse #1 again of Resident #24's complaint of pain. The NA added that her shift ended. On 07/30/15 at 4:10 PM Nurse #1 was interviewed and explained that he was orienting to night shift on 07/06/15 and that he normally worked 7 AM to 3 PM (day shift). He added that during the day shift if a resident fell and developed a new onset of pain he would contact the physician. Nurse #1 reported that on 07/06/15 he was notified that Resident #24 fell ; he stated that he responded to the resident and checked her out. He stated that he couldn't see any red marks and felt it was safe to put her back to bed. The nurse stated that he assessed Resident #24 before deciding to transfer her off the floor but was unable to check range of motion due to pain in her right leg. Nurse #1 explained that Resident #24 was in pain and when asked where the pain was located she patted her right hip, she was unable to verbalize a 1 to 10 pain scale but the resident showed facial grimacing and was holding her right side. The nurse stated that the new onset of pain after the fall was a change in the resident's condition and he notified the night shift supervisor. He added that Resident #24 had an as needed pain medicine ordered and he offered the resident the pain medication but she refused. Nurse #1 stated that he did not notify the physician of Resident #24's complaint of pain or inability to move her leg after the fall because he deferred to the night shift supervisor. On 07/31/15 at 9:00 AM the night shift supervisor was interviewed and reported that on 07/06/15 she was very busy orienting Nurse #1 to night shift and monitoring three other halls. She explained that Nurse #1 notified her that Resident #24 fell and complained of pain that did not appear excruciating but had refused her PRN (as needed) pain medication. The night shift supervisor stated she assessed the resident and found the resident in bed. The supervisor reported that Resident #24's legs were the same length and showed no deviation but that Resident #24 was gripping her right knee and didn't want to move the leg. The supervisor reported that other than a skin tear she didn't see any injuries. The night shift supervisor reported that she did not see a need to contact the physician since the resident was refusing pain medication. The night shift supervisor reported that at 5 AM the day shift supervisor relieved her of her duties. On 07/31/15 at 11:00 AM NA #3 was interviewed and reported that she worked with NA #2 on 07/06/15 and that she recalled Resident #24 being in pain after the fall. She explained that she didn't provide direct care for Resident #24 that day but was in the room and assisted NA #2. NA #3 stated that Resident #24 was complaining of pain and looked like she was in a lot of pain and kept holding her leg. Attempts were made to contact NA#2 but she was unable to be reached for an interview. On 07/31/15 at 2:10 PM the Director of Nursing was interviewed and reported that a significant change in a resident's condition would be a new onset of pain after a fall and the nurse should contact the physician.

Based on staff interviews and record review the facility failed to seek medical intervention when they couldn't complete a thorough assessment due to pain and the resident requested an ambulance after falling out of bed for 1 of 2 sampled residents (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with dementia, cognitive communication deficit, right [MEDICAL CONDITION] (07/06/15) and others. The Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making but had clear speech, was able to make herself understood and usually understood others. The MDS also specified the resident required extensive assistance with activities of daily living, had no presence of pain and had fallen twice without injury. Review of Resident #24's medical record revealed a nurse's entry made by the night shift supervisor dated 07/06/15 at 3:20 AM that read in part, Resident was found on the floor laying on her right side. Resident clutched middle portion of thigh and was reluctant to move right leg. An incident report dated 07/06/15 completed by the night shift supervisor specified Resident #24 was found in the floor clutching her thigh and was reluctant to move her right leg asking call an ambulance, get me an ambulance. The incident report revealed the resident was placed back in bed. The physician's orders [REDACTED].#24's right hip and right knee due to pain. A second physician order [REDACTED]. Further review of the medical record revealed a nurse's entry dated 07/06/15 at 1:20 PM the specified Resident #24 was having increased pain to right leg and the leg was drawn up. The resident would yell out when range of motion was performed. The on-call nurse practitioner was notified and ordered x-rays. Review of the Medication Administration Record [REDACTED]. The radiology report dated 07/06/15 at 5:39 PM revealed Resident #24 had a [MEDICAL CONDITION] hip. Resident #24 was transported to the Emergency Department on 07/06/15 at 10:30 PM. On 07/30/15 at 4:00 PM nurse aide (NA) #1 was interviewed and reported that she was assigned to care for Resident #24 on 07/06/15. The NA explained that when making rounds she found Resident #24 laying in the floor calling for help and saying she was hurt. The NA added that she went immediately to get Nurse #5. NA #1 reported that Nurse #5 assessed Resident #24 and determined that it was okay to put the resident back to bed. The NA added that the resident complained of pain and appeared in pain but remained in the bed the rest of the shift. NA #1 stated that she checked on Resident #24 around 6:00 AM and Resident #24 appeared to really be hurting, complaining of knee and hip pain. The NA stated that she notified Nurse #5 again of Resident #24's complaint of pain. The NA added that her shift ended. On 07/30/15 at 4:10 PM Nurse #5 was interviewed and explained that he was orienting to night shift on 07/06/15 and that he normally worked 7 AM to 3 PM (day shift). He added that during the day shift if a resident fell and developed a new onset of pain he would contact the physician. Nurse #5 reported that on 07/06/15 he was notified that Resident #24 fell ; he stated that he responded to the resident and checked her out. He stated that he couldn't see any red marks and felt it was safe to put her back to bed. The nurse stated that he assessed Resident #24 before deciding to transfer her off the floor but was unable to check range of motion due to pain in her right leg. Nurse #5 explained that Resident #24 was in pain and when asked where the pain was located she patted her right hip, she was unable to verbalize a 1 to 10 pain scale but the resident showed facial grimacing and was holding her right side. The nurse stated that the new onset of pain after the fall was a change in the resident's condition and he notified the night shift supervisor. He added that Resident #24 had an as needed pain medicine ordered and he offered the resident the pain medication but she refused. Nurse #5 stated that he did not notify the physician of Resident #24's complaint of pain or inability to move her leg after the fall because he deferred to the night shift supervisor. On 07/31/15 at 9:00 AM the night shift supervisor was interviewed and reported that on 07/06/15 she was very busy orienting Nurse #1 to night shift and monitoring three other halls. She explained that Nurse #5 notified her that Resident #24 fell and complained of pain that did not appear excruciating but had refused her PRN (as needed) pain medication. The night shift supervisor stated she assessed the resident and found the resident in bed. The supervisor reported that Resident #24's legs were the same length and showed no deviation but that Resident #24 was gripping her right knee and didn't want to move the leg. The supervisor reported that other than a skin tear she didn't see any injuries. The night shift supervisor reported that she did not see a need to contact the physician since the resident was refusing pain medication. The night shift supervisor reported that at 5 AM the day shift supervisor relieved her of her duties. On 07/31/15 at 9:30 AM the day shift supervisor was interviewed and reported that she was notified on 07/06/15 that Resident #24 had fallen but did not appear injured. She explained that she did not assess the resident until 11 AM when the medication aide reported that Resident #24 was complaining of pain. The day shift supervisor stated that she contacted the on-call nurse practitioner and received orders for an x-ray. Then she added she contacted the on-call nurse practitioner again and received orders to administer pain medication which the resident accepted at 1:20 PM. The day shift supervisor reported that when a resident fell and complained of pain the physician should be notified then for further direction. On 07/31/15 at 9:52 AM the second shift supervisor was interviewed and reported that when she came on duty on 07/06/15 at 3 PM she was notified that Resident #24 had fallen, complained of pain but did not appear to have a fracture. The second shift supervisor added that she was told that Resident #24 had been given pain medication and she was aware that an x-ray had been completed but they were still waiting on the results. She stated that when she made her first rounds between 3:30 - 4:00 PM Resident #24 was asleep in bed. The second shift supervisor explained that around 10:30 PM the nurse aides reported that the resident was crying in pain; she stated that she went to assess the resident, pulled back the covers and saw that the resident's legs were two different lengths and immediately called 9-1-1 and the resident was transported to the Emergency Department. On 07/31/15 at 11:00 AM NA #6 was interviewed and reported that she worked with NA #2 on 07/06/15 and that she recalled Resident #24 being in pain after the fall. She explained that she didn't provide direct care for Resident #24 that day but was in the room and assisted NA #2. NA #6 stated that Resident #24 was complaining of pain and looked like she was in a lot of pain and kept holding her leg. Attempts were made to contact NA#2 but she was unable to be reached for an interview. On 07/31/15 at 2:10 PM the Director of Nursing (DON) was interviewed and reported that a significant change in a resident's condition would be a new onset of pain after a fall and the nurse should contact the physician. The DON reported that it took several hours to obtain x-ray services and results because of the facility's location and depending on the schedule of the mobile x-ray company. She added that if at any time a resident showed signs of distress or obvious injury then she would expect the nurse to obtain orders to send a resident to the Emergency Department for evaluation and not wait on mobile x-ray services.

Based on observations, record review, staff interviews, resident interviews, and physician assistant interview, the facility failed to plan and administer effective pain control medication for 2 of 4 residents reviewed for pressure sores and implement the facility's bowel regime for 1 of 10 residents reviewed for constipation. Resident #22's pain regimen was not clarified and planned to coordinate with therapy and pressure ulcer dressing changes. Resident #20 was not assessed for pain prior to a dressing change and staff failed to stop the procedure when pain occurred. Resident #94's constipation was not addressed per the facility's protocol. The findings included: 1. Resident #22 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. In addition, [MEDICATION NAME] 50mg twice daily was ordered on [DATE] for neuropathic pain and scheduled at 8 AM and 4 PM. On 12/31/12 a telephone order was written for [MEDICATION NAME] cream 3% to be applied to the right heel ulcer twice a day along with a wound consult with a wound care physician for the evaluation and treatment of the right heel ulcer. On 01/03/13 the [MEDICATION NAME] gel was changed to once a day (to coincide with once a day dressing changes). The most recent Minimum Data Set, a significant change dated 02/01/13, coded Resident #22 with severely impaired cognition skills, requiring extensive assistance with most activities of daily living skills, receiving schedule pain medications, having no pain, and having an unstageable deep tissue injury measuring 1.8 cm x 1.7 cm x 0.7 cm. There was no trigger for a care area assessment for pain. A current care plan, initiated 06/06/12, addressed the potential for actual pain related [MEDICAL CONDITION] of the left hand and [MEDICAL CONDITION]. The goal was for no interruption in normal activities due to pain through next review (05/7/13). Interventions included: *acknowledge presence of pain and discomfort and listen to resident's concerns; *administer pain medication as per MD orders and note the effectiveness; *anticipate resident's need for pain relief and respond appropriately; *monitor for signs/symptoms of non-verbal pain such as changes in breathing, grunting, moans, yelling out, mood/behavior changes, sad expression, crying, clenched teeth, grimacing, tenseness, rigidity of body/limbs and report to nurse. Review of the medical record revealed Resident #22 had been being treated by a wound care physician with notes including: *On 02/08/13 the wound care physician's note stated the wound measured 2.0 cm x 2.0 cm with a depth of 0.7 cm. There was minimum granulation tissue and the wound extended down to the tendon and also on probing this to the bone. The area was anesthetized with 5% [MEDICATION NAME] jelly, but the resident "still had a fair amount of pain." The treatment was changed from [MEDICATION NAME] to santyl ointment to try to have some enzymatic debridement as the physician was "not really able to effectively debride this with the pain." The subsequent nursing note dated 02/08/13 stated the wound care physician applied [MEDICATION NAME] for 30 minutes prior to the examination of the heel and trimmed the wound. The resident stated he could not stand that and that it hurt. A new order for santyl was given by the wound care physician. *On 02/12/13 the area was "very tender to any manipulation." The treatment of santyl was continued. Nursing notes dated 02/12/13 revealed the wound care physician removed some yellow slough from the heel wound and the resident verbalized pain when the wound was touched or cleaned. *On 02/19/13 [MEDICATION NAME] jelly was applied and this left on for several minutes. Using forceps the wound was debrided and curetted. The resident "had a fair amount of discomfort" and "given the pain and discomfort, not able to entirely debride this." The area was noted to be improving slightly with the santyl and the pulse lavage provided by physical therapy. On 02/28/13 at 10:02 AM, Resident #22 was observed receiving pulse lavage therapy from the physical therapist aide (PTA). When the PTA removed his right sock, the resident groaned. The PTA proceed to provide the pulse lavage therapy which included using 15 liters per minute of oxygen from a tank and spraying the wound with normal saline and oxygen to help clean and debride the pressure ulcer on his right heel. During the procedure, Resident #22 flinched; stated this one was the sorest he had ever had; stated he had all he could stand; flinched some more; stated it was ok for hurting; and stated it hurt so bad he didn't want to move it. The PTA stated the wound was very sensitive and that most of the time he was able to tolerate the spray but that it was debrided recently and he had more trouble with sensitivity since the debridement. The wound was covered loosely in anticipation the wound nurse would dress it soon. This procedure took approximately 15 minutes. On 02/28/13 at 10:40 AM, the wound nurse #1 and Nurse #2 entered to provide the treatment and dressing to Resident #22's right heel ulcer. When the wound nurse washed the open wound with sterile water, Resident #22 called out "don't mash it" and "you don't know how bad that hurts, I feel like kicking the moon." [MEDICATION NAME] gel was then applied to the wound via a Qtip and santyl was immediately applied to the wound with another Qtip. Skin prep was then applied around the wound and foam covered the wound and was affixed with tape. The resident grimaced and flinched during this procedure. He called out again when his sock was reapplied. On 03/01/13 at 8:42 AM an interview was conducted with the wound care nurse #1. Per the wound care nurse #1, Resident #22's heel wound had been very sensitive causing the physician to order arterial studies and X-rays to rule out osteo[DIAGNOSES REDACTED]. She stated some days were worse than others related to the pain the resident felt during treatment. The depth of the wound made it more sensitive per the nurse. She reviewed the chart and stated he had some routine pain meds ordered. A follow up interview with the PTA on 03/01/13 at 11:04 AM revealed Resident #22's complaints of pain varied. She had been gone for the past 3 weeks and before she left the right heel was not quite as sensitive to the lavage treatment as he was on 02/28/13. PTA stated his sensitivity had increased since the debridement. She stated she discussed the pain with the wound care nurse "a while back" who ordered the [MEDICATION NAME] gel. There was no discussion with the wound care nurse to administer the [MEDICATION NAME] gel or other pain medications before the pulse lavage treatment. Interview with the Director of Nursing (DON) on 03/01/13 at 11:08 AM revealed she thought the [MEDICATION NAME] should work immediately but that it should be administered prior to the pulse lavage treatment. On 03/01/13 at 11:15 AM the Nurse Practioner (NP) who ordered the [MEDICATION NAME] gel was interviewed. She stated that the pain regimen should be coordinated around the pulse lavage and dressing treatment. The NP further stated the [MEDICATION NAME] should be given 30 minutes before the pulse lavage treatment and the [MEDICATION NAME] should be administered 15 - 30 minutes prior to the dressing change. She stated staff had informed her that the pain was under control. A follow up interview with the wound care nurse #1 on 03/01/13 at 11:23 AM revealed she initiated the order for [MEDICATION NAME] gel for Resident #22. She stated she never clarified the [MEDICATION NAME] order to determine if there was any wait time for effectiveness. She further stated she had checked to make sure he had routine pain medications ordered but had not tried to coordinate the time of the routine pain meds with the therapy and dressing changes. She stated she tried to do the dressing change shortly after the pulse lavage treatment but there was no set time and no coordination of pain regimen. She further stated that additional studies had been completed due to the fact Resident #22 was having more pain with the wound care than staff thought he should. Observations on 03/01/13 revealed the pulse lavage was finished at 11:34 AM, the dressing change began at 11:38 AM and Resident #22 received his routine [MEDICATION NAME] at 11:59 AM. 2. Resident #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was not impaired. The MDS also specified the resident experienced frequent pain that made if hard for her to sleep at night and limited her day-to-day activities. The Care Area Assessment (CAA) dated 12/10/12 for pain specified Resident #20 acknowledged presence of pain and discomfort; specified to listen to resident's concerns and administer pain medication as ordered by the medical doctor. The CAA also specified to encourage resident to request pain medication before pain becomes severe and monitor resident for characteristics of pain and non-verbal signs of pain such as moans, yelling out, clenched teeth, grimacing and rigidity of body. Resident #20's care plan for pain dated 11/30/11 specified the resident would have pain relief and included interventions such as: - Acknowledge pain and discomfort. Listen to resident's concerns - Administer pain medications as ordered by the physician - Encourage resident to request pain medication before pain becomes severe Review of Resident #20's medical record revealed physician orders [REDACTED]. - [MEDICATION NAME] 100mg twice a day - [MEDICATION NAME] 5/325mg every 4 hours as needed for pain Further review of Resident #20's Medication Administration Records (MAR) dated 01/13 and 02/13 revealed she requested her as needed pain medication daily because of complaints of pain. On 2/28/13 at 12:40 PM observations were made of the treatment nurse providing wound care to Resident #20. The observations revealed the resident was in bed for the wound care. The resident's right foot was noted to be wrapped with bandages and rested on a covered pillow. The treatment nurse removed the bandages from Resident #20's right foot. Resident #20 replied, "My foot's burning me to death." The treatment nurse proceeded to provide wound care to Resident #20's right heel. Resident #20 reported to the treatment nurse that the treatment hurt. At 12:45 PM Resident #20 grimaced in pain and flinched when her ankle was turned. During this time the treatment nurse was interviewed and stated that she usually checked with the nurse to determine if a resident had received pain medications prior to wound care. She added she had not checked with Resident #20's nurse prior to beginning the treatment. She reported she assumed the resident had already received pain medication. She added that it was the responsibility of the resident to ask for pain medication prior to receiving wound care. Resident #20 spoke and added that pain medication was effective in lessening the pain of the treatment. At 12:51 PM the treatment nurse offered to get Resident #20 pain medication. The treatment nurse continued providing the wound care and had completed the care as the nurse entered the room with Resident #20's as needed pain medication. On 03/01/13 at 10:30 AM the Director of Nursing (DON) was interviewed. The DON reported that she expected the treatment nurse to assess a resident's pain level prior to beginning treatment. She added that she would also expect the treatment nurse to coordinate with the medication nurse to offer a resident pain medication prior to performing a treatment to prevent the resident from experiencing pain during wound care. 3. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS also specified the resident was frequently incontinent of bowel and bladder. Resident #94's care plan dated 10/25/12 for bowel incontinence specified interventions that included: - Record bowel movement, note size and consistency and report any abnormalities to nurse - Evaluate resident's bowel control and pattern Review of Resident #94's medical record revealed a document titled "Standing Orders" signed by the physician on 07/25/12 that read in part: 2) Milk of Magnesia (laxative) as needed for constipation. Notify attending physician if constipation persists. 3) Fleets enema per rectum as needed for constipation not relieved by Milk of Magnesia. Notify attending physician if constipation persists. Resident #94's bowel elimination records were reviewed and revealed the following: a. Starting 01/22/13 and continuing for 4 days no bowel movements were documented. b. Starting 02/14/13 and continuing for 5 days no bowel movements were documented. c. Starting 02/20/13 and continuing for 7 days no bowel movements were documented. A review of nursing notes for Resident #94 for the periods of 01/22/13 through 01/25/13; 02/14/13 through 02/18/13; and 02/20/13 through 02/27/13 revealed no documentation of assessment or treatment for constipation. Further review of Resident #94's medical record revealed he did not receive routine laxatives or medications for constipation and did not receive Milk of Magnesia or a Fleets enema per standing orders. On 03/01/13 at 9:00 AM the Quality Improvement nurse (QI) was interviewed and reported that the facility monitored residents to ensure they experience a bowel movement every 3 days. She added that daily a report was generated from the computer to identify residents who had not had a bowel movement in 3 days. She stated that the report was given to individual nurses to administer medications to relieve constipation. The QI nurse added that she would follow-up the next day to ensure the interventions were effective in relieving a resident's constipation. The QI nurse reviewed Resident #94's bowel elimination record and revealed that she discovered that the periods of constipation had not been reported to the nurse to address. She stated this was an oversight. On 03/01/13 at 10:30 AM the Director of Nursing (DON) was interviewed and stated all residents were expected to be monitored for constipation. She stated there was an oversight that resulted in the nurses not being notified of Resident #94's episodes of constipation.