Every finding on record at Willow Valley Center for Nursing and Rehabilitatio

Based on record reviews, and interviews with facility staff, pharmacy staff, and hospice staff, the facility failed to protect a resident's right to be free from misappropriation of a narcotic medication, Hydrocodone-Acetaminophen, prescribed for pain management. This was for 2 of 2 residents reviewed for medication misappropriation (Resident #2 and Resident #3).The findings included:1. Resident #3 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and had been receiving hospice services from Hospice Provider #1 since 4/4/2025.An interview with an Assistant Director of Hospice Care Provider #1, conducted on 2/19/2026 at 1:20 PM, revealed the following information. An after-hours triage call on 9/24/2025 reported that Resident #3 was experiencing left hip pain without an as-needed pain medication order. An after-hours nurse was dispatched to the facility on 9/24/2025 to assess Resident #3, and an order was sent to the pharmacy for Hydrocodone-Acetaminophen. (Hydrocodone-Acetaminophen is a narcotic medication.) A hospice nurse obtained a container of Hydrocodone-Acetaminophen from the local pharmacy and delivered it to the facility that evening. The Assistant Director stated that he did not have access to the payment records that would verify the quantity dispensed.Resident #3 had a physician's order initiated on 9/24/2025 Hydrocodone-Acetaminophen 5-325 milligrams (mg) to be administered as one tablet by mouth every 4 hours as needed for pain.An interview conducted with Pharmacist #2 from the local pharmacy on 2/20/2026 at 9:26 AM confirmed the local pharmacy dispensed 30 tablets of Hydrocodone-Acetaminophen for Resident #3, and the prescription was picked up on 9/24/2025 at 8:03 PM.The Director of Nursing (DON) reported on 2/17/2026 at 1:17 PM that the facility could not locate the medication monitoring/control record for Resident #3's Hydrocodone-Acetaminophen received from the local pharmacy on 9/24/2025.Documentation in a nursing progress note dated 9/25/2025 at 4:36 PM written by Unit Manager #1 revealed that Resident #3 was complaining of left hip pain. A hospice nurse assessed the resident, and a new order for Hydrocodone-Acetaminophen was initiated to be administered every 4 hours as needed.Documentation on Medication Administration Record (MAR) for September 2025 revealed Resident #3 was administered one tablet of Hydrocodone-Acetaminophen 5-325 mg on 9/25/2025, 9/26/2025, and 9/27/2025. According to the documentation, Resident #3 would have had 27 tablets remaining in the medication container from the local pharmacy.An interview was conducted with the facility's Pharmacy General Manager via telephone on 2/18/2026 at 10:46 AM. The General Manager stated that the pharmacy received an order to dispense 84 tablets of Hydrocodone-Acetaminophen 5-325 mg for Resident #3. The General Manager explained that 30 tablets of Hydrocodone-Acetaminophen 5-325 mg were delivered to the facility from the pharmacy for Resident #3 on 9/30/2025 at 7:53 PM and signed for by Nurse #1.The DON reported on 2/17/2026 at 1:17 PM that the facility was unable to locate the medication monitoring/control record for Resident #3's Hydrocodone-Acetaminophen 5-325 mg that was delivered on 9/30/2025.Documentation on Resident #3's October 2025 MAR revealed she was administered one dose of Hydrocodone-Acetaminophen on 10/2/2025 at 4:39 AM by Nurse #1.An interview was conducted with Pharmacist #1 from the facility pharmacy via the telephone on 2/17/2026 at 2:16 PM. Pharmacist #1 confirmed a prescription for Hydrocodone-Acetaminophen was received on 10/3/2025 and 13 tablets were delivered to the facility on [DATE] at 3:06 AM for Resident #3. Pharmacist #1 stated that the pharmacy did not have any record of notification from the facility of any missing or diverted medications for Resident #3.Documentation on the October 2025 MAR revealed Resident #3 received a dose of Hydrocodone-Acetaminophen on 10/8/2025 at 5:41 PM. There were no other documented administrations of Hydrocodone-Acetaminophen to Resident # 3 in October 2025.The DON provided the following nursing assignment information on 2/17/2026 at 1:17 PM. Nurse #1 was assigned the medication cart on 10/1/2025 at 11:00 PM to 10/2/2025 at 7:00 AM. Medication Aide (Med Aide) #1 assumed responsibility of the medication cart from 10/2/2025 at 7:00 AM until 3:00 PM. Med Aide #2 assumed responsibility of the medication cart from 10/2/2025 at 3:00 PM until 11:00 PM. Nurse #1 reassigned the medication cart from 10/2/2025 at 11:00 PM until 10/3/2205 at 7:00 AM, at which time she reconciled the narcotics on the medication cart with Med Aide #1, transferring responsibility to Med Aide #1.Med Aide #2 was interviewed on 2/17/2026 at 1:59 PM. She stated that, because the incident involving the missing medication occurred several months earlier, she was unable to recall which resident was involved or the exact date of the occurrence. She recalled being interviewed at the time of the incident and reported that when she assumed responsibility for the medication cart, there were no discrepancies in the narcotic count. Med Aide #2 further recalled that the missing medication involved a medication container from an outside pharmacy and that when she completed the narcotic count with a nurse (Nurse #1), that medication container was present on the cart.An attempt was made to contact Nurse #1 on 2/17/2026 at 4:56 PM via the telephone; however, current contact information was not available, as her phone number was no longer active.Med Aide #1 was interviewed on 2/17/2026 at 1:40 PM and confirmed she worked the 7:00 AM to 3:00 PM shift on 10/2/2025 and 10/3/2025. Med Aide #1 stated that when she assumed the medication cart from Nurse #1 on 10/2/2025 at 7:00 AM, she observed 25 tablets in the local-pharmacy container and 30 tablets on a medication card of Hydrocodone-Acetaminophen for Resident #3. Med Aide #1 reported that during the narcotic count with Nurse #1 on 10/3/2025 at 7:00 AM, the Hydrocodone-Acetaminophen for Resident #3 was missing. Initially Med Aide #1 assumed the pain medication for Resident #3 had been discontinued and did not question Nurse #1. Med Aide #1 confirmed the narcotic count she conducted with Nurse #1 at 7:00 AM on 10/3/2025 appeared correct, in that the number of narcotic medications in the drawer on the medication cart matched the number of narcotics on the medication monitoring/control record for each resident. Med Aide #1 revealed that later in her shift on 10/3/2025, she noted that the prescription for Hydrocodone-Acetaminophen for Resident #3 had not been discontinued. Med Aide #1 indicated she then immediately notified the supervising nurse and the DON of the missing medication.On 2/17/2026 at 1:17 PM the DON provided a written statement with the details of an investigation of missing Hydrocodone-Acetaminophen for an unnamed resident. The written statement provided the following information: The Administrator and the DON were notified of missing narcotic medication on a medication cart on 10/2/2025. Med Aide #1 reported the medication missing and the narcotic medication was not on the cart at the beginning of her shift when she reconciled the narcotic medication count with Nurse #1. Med Aide #1 recalled a medication container but did not question Nurse #1 about the medication's absence during the narcotic medication count at the change of shift. The medication carts were checked to ensure the medication was not misplaced. A hospice nurse, who was already in the facility, was made aware of the misplaced medication and a new prescription was obtained and dispensed by the pharmacy. The DON interviewed Nurse #1, who recalled putting the narcotic medication in the drawer, but did not recall anything else. Med Aide #2 was interviewed and remembered counting off with Nurse #1. The DON contacted the pharmacy and confirmed Nurse #1 signed for the narcotic medication. Based on interviews, diversion was not suspected but the medication was misplaced and then immediately replaced. Hospice was aware and was conducting its own investigation.On 2/17/2026 at 1:17 PM the DON was interviewed. The DON did not recall which resident was affected by the missing narcotic medication, but she believed it may have been Resident #2. The DON explained that she was notified during a clinical meeting on 10/3/2025 by Med Aide #1 that narcotic medication was missing from the medication cart. The DON clarified she was notified of the missing narcotic medication on 10/3/2025 and not on 10/2/2025 as previously indicated in her written statement.An interview was conducted with Unit Manager #1 on 2/18/2026 at 11:51 PM. Unit Manager #1 stated that on 10/3/2025 Med Aide #1 interrupted the morning clinical meeting at approximately 10:00 AM to inform the DON of a concern for missing Hydrocodone-Acetaminophen on the medication cart. The Unit Manager revealed that she and the DON checked the medication carts to see if the narcotic medication was misplaced. The Unit Manager stated that the narcotic medication was all accounted for on 10/3/2025 and no other discrepancies were found except for Resident #3's medication.The DON was interviewed on 2/17/2026 at 11:53 AM and stated that a hospice nurse informed her that hospice had their own process they needed to follow when narcotic medication went missing in a facility. The DON recalled the hospice nurse, whose name she could not remember, stating that the medication of hospice residents belonged to hospice, and hospice would conduct their own investigation and report findings to the appropriate authorities. The DON further explained that if the missing medication belonged to hospice, then it was not considered misappropriation of a resident's medication. The DON and the facility Administrator were interviewed on 2/18/2026 at 8:46 AM. The Administrator stated that facility investigated the missing Hydrocodone-Acetaminophen on 10/3/2025; however, all the documentation related to the investigation was lost or misplaced. The DON stated she contacted Nurse #1 on 10/3/2025 and informed her of her suspension and requested a written statement regarding the missing medication. The DON revealed Nurse #1 arrived for her previously scheduled shift at 11:00 PM on 10/3/2025 and was instructed again that she was suspended and needed to come into the facility in the morning to submit a statement. The DON explained Nurse #1 did not return to the facility for several days to submit a statement. The DON indicated when Nurse #1was interviewed, she had no recollection of what happened to the missing Hydrocodone-Acetaminophen or where she may have put the missing narcotic. The DON said that Nurse #1 had her employment terminated due to a lack of stewardship of the narcotics. The Administrator stated that situation did not appear to involve diversion of narcotics and was unclear. The Administrator recalled a hospice nurse informing her that the missing medication belonged to hospice and that hospice would conduct its own investigation and report findings to the authorities.An interview was conducted over the telephone with the Director of Patient Care Services, an Assistant Director, and Hospice Nurse #1 from Hospice Provider #1 on 2/17/2026 at 4:37 PM. Hospice Nurse #1 stated she was contacted by the facility on 10/3/2026, regarding a diversion of Resident #3's Hydrocodone-Acetaminophen, which included 30 tablets on a medication card and an unknown quantity in a medication container from a local pharmacy. Hospice Nurse #1 reported she notified her supervisor and obtained an additional order for Hydrocodone-Acetaminophen for Resident #3 from the hospice nurse practitioner at 12:35 PM on 10/3/2025. Hospice Nurse #1 stated the additional order was sent to the facility pharmacy for dispensing and delivery of the additional medication.The Director of Patient Care Services, the Assistant Director, and Hospice Nurse #1 all confirmed the medication Hydrocodone-Acetaminophen belonged to Resident #3 and not Hospice Provider #1.2. Resident #2 was admitted to the facility on [DATE] with a diagnosis of cerebrovascular disease and was receiving hospice care services from Hospice Provider #2 since 2/24/2025.Resident #2 had a physician's order initiated on 9/25/2025 for Hydrocodone-Acetaminophen 5-325 milligrams (mg) to be administered as one tablet by mouth every 8 hours for pain.An interview was conducted with Pharmacist #1, from the facility pharmacy, via the telephone on 2/17/2026 at 4:00 PM. Pharmacist #1 stated that 43 tablets of Hydrocodone-Acetaminophen were dispensed for Resident #2 and delivered on 9/26/2025 at 2:43 AM. The delivery included 30 tablets on a medication card and 13 tablets on another medication card. Nurse #1 signed for the medication upon delivery. Pharmacist #1 explained that the quantity provided should have lasted until 11/4/2025, if administered as ordered.The Director of Nursing (DON) reported on 2/17/2026 at 1:17 PM that the facility could not locate the medication monitoring/control record for Resident #2's Hydrocodone-Acetaminophen card of 30 tablets received on 9/26/2025. However, the DON provided the medication monitoring/control record for the 13-tablet card received on 9/26/2025, which indicated Resident #2 ran out of Hydrocodone-Acetaminophen on 10/5/2025, with the last dose administered at 2:00 AM. Documentation on the October 2025 Medication Administration Record (MAR) for Resident #2 revealed he received his Hydrocodone-Acetaminophen on a scheduled basis at 2:00 AM, 10:00 AM, and 6:00 PM daily. Medication Aide (Med Aide) #2 documented that Resident #2 did not receive his pain medication on 10/6/2025 at 6:00 PM and to refer to the nursing notes. The October 2025 MAR did not indicate Resident #2 missed any other scheduled doses of Hydrocodone-Acetaminophen.Documentation in the Medication Administration notes for Resident #2 dated 10/6/2025 at 5:07 PM written by Med Aide #2 revealed, Hydrocodone-Acetaminophen oral tablet 5-325 mg give 1 tablet by mouth every 8 hours for pain awaiting pharmacy per nurse.Med Aide #2 was interviewed on 2/17/2026 at 1:59 PM. Med Aide #2 stated she did not recall the circumstances under which Resident #2 did not have his scheduled Hydrocodone-Acetaminophen dose on 10/6/2025, but she likely notified the supervising nurse so that Hospice could be notified. Med Aide #2 stated she did not recall who the supervising nurse was on 10/6/2025.Hospice Nurse #2 was interviewed via the telephone on 2/18/2026 at 12:46 PM and provided the following information. Hospice Nurse #2 saw Resident #2 twice a week since he had been admitted to hospice services with Hospice Provider #2. On 10/6/2025 an after-hours call was received by Hospice Provider #2 that Resident #2 had run out of Hydrocodone-Acetaminophen. Hospice Nurse #2 stated she was responsible for ensuring Resident #2 had his pain medication and ordering more refills if needed. After reviewing the current medication orders and pharmacy dispensing information, she determined Resident #2 should not have run out of Hydrocodone-Acetaminophen until 11/4/2025. Hospice Nurse #2 stated she called the facility and was told Resident #2 ran out of Hydrocodone-Acetaminophen on 10/5/2025. Hospice Nurse #2 then called her manager and the facility pharmacy to confirm the dates and quantities of medication. Hospice Nurse #2 documented a medication error had occurred for Resident #2 because he should have had sufficient Hydrocodone-Acetaminophen to last until 11/4/2025. Hospice Nurse #2 contacted the Assistant Director of Nursing for the facility and was told that an active investigation for diversion of narcotics was underway. Hospice Nurse #2 visited the facility on 10/7/2025 and she spoke with Unit Manager #1, who showed her the Medication Monitoring/Control record book confirming that Resident #2 did not have any Hydrocodone-Acetaminophen left on the medication cart. Hospice Nurse #2 stated she spoke with the facility Administrator, who told her the facility has an open investigation into drug diversion, and they had a nurse who was suspected. The Administrator stated Hospice Nurse #2 would receive additional information after the facility completed their investigation; however, Hospice Nurse #2 reported she was never provided with further details. Hospice Nurse #2 stated she ordered more Hydrocodone-Acetaminophen for Resident #2 but could not recall the details of when it was received by the facility. Hospice Nurse #2 confirmed that medications provided through hospice belong to Resident #2, not Hospice Provider #2.The General Manager of the facility's pharmacy was interviewed via the telephone on 2/18/2026 at 10:46 PM. The General Manager stated that 90 tablets of Hydrocodone-Acetaminophen were delivered to the facility for Resident #2 on 10/7/2025 at 2:33 AM. The General Manager stated that the facility had a valid prescription for Resident #2 to obtain the ordered Hydrocodone-Acetaminophen from the automated medication dispensing cabinet when he ran out on 10/5/2025.Med Aide #1 was interviewed on 2/17/2026 at 1:40 PM. Med Aide #1 stated that she notified the Director of Nursing on 10/3/2025 of missing Hydrocodone-Acetaminophen that belonged to another resident, and that she learned several days later that Resident #2 was missing Hydrocodone-Acetaminophen from the same medication cart.Unit Manager #1 was interviewed on 2/18/2026 at 11:51 AM. Unit Manager #1 stated that Hospice Nurse #2 determined that Resident #2's Hydrocodone-Acetaminophen was missing and notified the DON. Hospice Nurse #2 determined that Resident #2 should have had more medication than what was present, and that he had a whole card of 30 tablets missing from the medication cart.The DON and the facility Administrator were simultaneously interviewed on 2/18/2026 at 8:46 AM. The Administrator stated that facility had investigated the missing Hydrocodone-Acetaminophen that began on 10/3/2025, but all the documentation of the investigation were lost or misplaced. The DON stated she called Nurse #1 and informed her she was suspended on 10/3/2025, and that she needed to obtain a statement from her regarding the missing Hydrocodone-Acetaminophen. The DON revealed Nurse #1 arrived for her previously scheduled shift at 11:00 PM on 10/3/2025 and was instructed again that she was suspended and needed to come into the facility in the morning to submit a statement. The DON explained Nurse #1 did not come to the facility for several days to write a statement. The DON indicated Nurse #1 was interviewed, and she had no recollection of what happened to the missing Hydrocodone-Acetaminophen or where she may have put the missing narcotic. The DON said that Nurse #1 had her employment terminated due to a lack of stewardship of the narcotics. The Administrator stated the situation did not appear to involve diversion and was unclear. The Administrator recalled a hospice nurse stating the missing medication belonged to hospice and that hospice would conduct its own investigation and report to the proper authorities. The DON stated that the facility was informed by a hospice nurse that Resident #2 was missing 30 tablets of Hydrocodone-Acetaminophen, and she thought it was connected to the missing Hydrocodone-Acetaminophen reported on 10/3/2025. The DON confirmed she did not have any evidence of an investigation into Resident #2's missing Hydrocodone-Acetaminophen, but suspected Nurse #1 misplaced Resident #2's medication.An attempt was made to contact Nurse #1 on 2/17/2026 at 4:56 PM via the telephone; however, current contact information was not available, as her phone number was no longer active.

Based on record review, and interviews with staff, hospice staff, and pharmacy staff, the facility failed to implement their abuse policy regarding the investigation and reporting of an allegation of misappropriation of the narcotic medication Hydrocodone-Acetaminophen for 2 of 2 residents reviewed for misappropriation of medication (Resident #2 and Resident #3).The findings included:Record review of the facility abuse, neglect, and exploitation policy, dated as implemented on 12/1/2022, showed that during the investigation of abuse, to include misappropriation of resident property, the facility was required to exercise caution in handling of evidence that could be used in a criminal investigation, focus the investigation on determining if misappropriation occurred, and provide complete and thorough documentation of the investigation. The same policy, under reporting/response section, indicated that the facility would report all alleged violations to the state agency, adult protective services, and law enforcement when applicable within the required 24-hour timeframe if the allegation did not involve serious bodily injury. Additionally, the policy stated that the facility would report to the licensing authority any knowledge it had of actions by a court of law which would indicate an employee was unfit for service.1. Resident #3 had a physician's order initiated on 9/24/2025 Hydrocodone-Acetaminophen 5-325 milligrams (mg) to be administered as one tablet by mouth every 4 hours as needed for pain.An interview conducted with a Pharmacist (Pharmacist #2) from the local pharmacy on 2/20/2026 at 9:26 AM confirmed the local pharmacy dispensed 30 tablets of Hydrocodone-Acetaminophen for Resident #3, and the prescription was picked up on 9/24/2025 at 8:03 PM.Documentation in a nursing progress note dated 9/25/2025 at 4:36 PM, written by Unit Manager #1, revealed that Resident #3 was complaining of left hip pain. A hospice nurse assessed the resident, and a new order for Hydrocodone-Acetaminophen was initiated to be administered every 4 hours as needed.An interview was conducted with the facility's Pharmacy General Manager over the phone on 2/18/2026 at 10:46 AM. The General Manager stated that the pharmacy received an order to dispense 84 tablets of Hydrocodone-Acetaminophen 5-325 mg for Resident #3. The General Manager explained that 30 tablets of Hydrocodone-Acetaminophen 5-325 mg were delivered to the facility from the pharmacy for Resident #3 on 9/30/2025 at 7:53 PM and signed for by Nurse #1.Medication Aide (Med Aide) #1 was interviewed on 2/17/2026 at 1:40 PM. Med Aide #1 reported that during the narcotic count with Nurse #1 on 10/3/2025 at 7:00 AM, the Hydrocodone-Acetaminophen for Resident #3 was missing. Initially, Med Aide #1 assumed the pain medication for Resident #3 had been discontinued and did not question Nurse #1. Later in her shift on 10/3/2025, Med Aide #1 noted that the prescription for Hydrocodone-Acetaminophen for Resident #3 had not been discontinued and immediately notified the supervising nurse and the Director of Nursing (DON) of the missing medication.On 2/17/2026 at 1:17 PM the Director of Nursing (DON) provided a written statement with the details of an investigation of missing narcotic medication for an unnamed resident that went missing in October 2025. The written statement provided the following information: The Administrator and the DON were notified of missing narcotic medication on a medication cart on 10/2/2025. Med Aide #1 reported the medication missing and the narcotic medication was not on the cart at the beginning of her shift when she reconciled the narcotic medication count with Nurse #1. Med Aide #1 recalled a medication container but did not question Nurse #1 about the medication's absence during the narcotic medication count at the change of shift. The medication carts were checked to ensure the medication was not misplaced. A hospice nurse, who was already in the facility, was made aware of the misplaced medication and a new prescription was obtained and dispensed by the pharmacy. The DON interviewed Nurse #1, who recalled putting the narcotic medication in the drawer, but did not recall anything else. Med Aide #2 was interviewed and remembered counting off with Nurse #1. The DON contacted the pharmacy and confirmed Nurse #1 signed for the narcotic medication. Based on interviews, diversion was not suspected but the medication was misplaced and then immediately replaced. Hospice was aware and was conducting their own investigation.On 2/17/2026 at 1:17 PM the DON was interviewed after she provided the written documentation of the facility's investigation into the misappropriation of medication. The DON did not recall which resident was affected by the missing narcotic medication, but she thought it was Resident #2. The DON confirmed that the facility was unable to locate the medication monitoring/control record for Resident #3's Hydrocodone-Acetaminophen 5-325 mg that was delivered on 9/24/2025 or 9/30/2025. The DON explained she reviewed the nursing schedule from 10/1/2025 to 10/3/2025 and determined the only staff members with the responsibility of the medication cart were Nurse #1, Med Aide #2, and Med Aide #1. The DON stated Nurse #1 was assigned the medication cart on 10/1/2025 at 11:00 PM to 10/2/2025 at 7:00 AM. Med Aide #1 took over the responsibility of the medication cart on 10/2/2025 at 7:00 AM until 3:00 PM. Med Aide #2 took over the responsibility of the medication cart on 10/2/2025 at 3:00 PM until 11:00 PM. Nurse #1 was again assigned the medication cart on 10/2/2025 at 11:00 PM until 7:00 AM on 10/3/2025 when she reconciled the medication cart with Med Aide #1. The DON explained that she was notified during a clinical meeting on 10/3/2025 by Med Aide #1 that narcotic medication was missing on the cart. The DON confirmed notification occurred on 10/3/2025 and not on 10/2/2025 as her written statement suggested. The DON stated she immediately checked all medication carts and verified that medication monitoring/control records matched the controlled medication counts. The DON confirmed no discrepancies were found except for Resident #3's medication. The DON explained that she interviewed both Med Aide #1 and Med Aide #2 on 10/3/2025. The DON stated the Med Aides both remembered the medication container with Hydrocodone-Acetaminophen from the outside pharmacy being on the medication cart prior to the 11:00 PM to 7:00 AM ending on 10/3/2025. The DON stated she also interviewed Nurse #1 who did not recall where the narcotic medication was or how it went missing. The DON described Nurse #1's response as unprofessional; Nurse #1 was suspended and ultimately terminated.An interview was conducted with Unit Manager #1 on 2/18/2026 at 11:51 PM. Unit Manager #1 stated that on 10/3/2025, Med Aide #1 interrupted the morning clinical meeting at approximately 10:00 AM to inform the DON of a concern for missing Hydrocodone-Acetaminophen on the medication cart. The Unit Manager reported that she and the DON checked the medication carts to see if the narcotic medication for Resident #3 was misplaced. The Unit Manager stated that they checked the medication carts by comparing the medication monitoring/control record for each resident's-controlled medication to the amount of medication in the drawer. The Unit Manager confirmed that all the narcotic medication was all accounted for on 10/3/2025, and no other discrepancies were found except for Resident #3's Hydrocodone-Acetaminophen.The DON was interviewed on 2/17/2026 at 11:53 AM and stated that hospice nurse informed her that hospice had their own process for addressing missing narcotic medication in a facility. The DON recalled that the hospice nurse, whose name she could not remember, indicated the medication of a hospice resident, belonged to hospice, and hospice would conduct its own investigation and report to the appropriate authorities. The DON further explained that, based on this information, if the missing medication belonged to hospice, then it was not considered misappropriation from a resident. The DON and the facility Administrator were simultaneously interviewed on 2/18/2026 at 8:46 AM. The Administrator stated that facility investigated the missing Hydrocodone-Acetaminophen on 10/3/2025, but all the documentation of the investigation was lost or misplaced. The DON stated she called Nurse #1 on 10/3/2025 to inform her of her suspension and the need to provide a written statement regarding the missing medication. The DON reported Nurse #1 arrived for her previously scheduled shift at 11:00 PM on 10/3/2025, was reminded of her suspension, and was instructed to return in the morning to complete the statement. The DON explained Nurse #1 did not return for several days to provide the statement. The DON indicated when Nurse #1was interviewed, she had no recollection of what happened to the missing Hydrocodone-Acetaminophen or where she may have put the missing narcotic. The DON confirmed that Nurse #1 had responsibility for medication carts on other floors and hallways during her employment. The DON reported that Nurse #1 had her employment terminated due to a lack of stewardship of the narcotics. The Administrator stated that the situation did not seem like a diversion of narcotics and it didn't make sense. The Administrator explained the event was treated as a human resources issue rather than a case of medication diversion. The Administrator recalled a hospice nurse telling her that the missing medication belonged to hospice and not to the resident, and that hospice would conduct its own investigation and report to the authorities. The Administrator confirmed the facility did not report the misappropriation to the state agency, the local authorities, adult protective services, or a licensing agency. An interview was conducted over the telephone with the Director of Patient Care Services, an Assistant Director, and Hospice Nurse #1 from Hospice Provider #1 on 2/17/2026 at 4:37 PM. Hospice Nurse #1 revealed she was contacted on 10/3/2026 by the facility that Resident #3's Hydrocodone-Acetaminophen to include 30 tablets on a medication card and an unknown amount in a medication container from an outside pharmacy had been diverted from the facility. Hospice Nurse #1 stated she would have no way of investigating the diversion of medication in a facility due to a lack of knowledge of nursing staffing information. The Director of Patient Care Services added that Hospice Provider #1 nurses are not the ones to administer the narcotic medication and are not the ones with the responsibility of investigation or reporting of diversion in a facility. All three interviewees confirmed that the medication Hydrocodone-Acetaminophen belonged to Resident #3, not Hospice Provider #1.The facility Administrator was interviewed on 2/18/2026 at 1:15 PM. The Administrator stated that when she became aware of the allegation of misappropriation, she believed the payer source of the medication determined whether misappropriation from a resident had occurred. She explained that since hospice was the payer source for Resident #3's medication, she understood the diversion to affect hospice rather than the resident. Based on this understanding, the Administrator believed the misappropriation was not reportable and assumed hospice would conduct its own investigation and reporting. The Administrator noted that Nurse #1 had been in employment of the facility for 5 months at the time of the incident and had previously struggled with recalling information in an unrelated circumstance. The Administrator added that the facility had been moving office locations and the investigation of the missing Hydrocodone-Acetaminophen in October 2025 for Resident #3 was lost. Without documentation of the investigation, the Administrator declined to speculate what had occurred or what further actions the facility took.2. Resident #2 had a physician's order initiated on 9/25/2025 for Hydrocodone-Acetaminophen 5-325 milligrams (mg) to be administered as one tablet by mouth every 8 hours for pain.An interview was conducted with a Pharmacist #1 from the facility pharmacy via the telephone on 2/17/2026 at 4:00 PM. Pharmacist #1 stated the pharmacy dispensed 43 tablets of Hydrocodone-Acetaminophen for Resident #2, which were delivered on 9/26/2025 at 2:43 AM, 30 tablets on a medication card and 13 tablets on another medication card. The medication for Resident #2, delivered to the facility on 9/26/2025, was signed for by Nurse #1. Pharmacist #1 explained that the 43 tablets was enough medication to last until 11/4/2025, if administered as ordered.Documentation on the October 2025 Medication Administration Record (MAR) for Resident #2 revealed indicated that Hydrocodone-Acetaminophen was administered on a scheduled basis at 2:00 AM, 10:00 AM, and 6:00 PM daily. On 10/6/2025 at 6:00 PM, Medication Aide (Med Aide) #2 documented that Resident #2 did not receive his pain medication and noted to refer to the nursing notes.Documentation in the Medication Administration notes for Resident #2 dated 10/6/2025 at 5:07 PM written by Med Aide #2 revealed, Hydrocodone-Acetaminophen oral tablet 5-325 mg give 1 tablet by mouth every 8 hours for pain awaiting pharmacy per nurse.Hospice Nurse #2 was interviewed via the telephone on 2/18/2026 at 12:46 PM and provided the following information. On 10/6/2025 an after-hours call was received by Hospice Provider #2 that Resident #2 had ran out of Hydrocodone-Acetaminophen. Resident #2 should not have run out of Hydrocodone-Acetaminophen until 11/4/2025. Hospice Nurse #2 called the Assistant Director of Nursing for the facility and was informed of an active investigation into diversion of narcotics was underway. Hospice Nurse #2 stated she spoke with the facility Administrator, who told her the facility has an open investigation into drug diversion, and they had a nurse who was suspected. The Administrator indicated Hospice Nurse #2 would receive additional information after the investigation concluded; however, Hospice Nurse #2 reported no further information was provided. Hospice Nurse #2 clarified Hospice Provider #2 did not own the medication and that the medication supplied through hospice belonged to Resident #2. Hospice Nurse #2 further explained that her role was limited to assessing symptom management for Resident #2 and that she did not have access to the information necessary to investigate narcotic diversion within a facility.An interview was conducted with the Senior Patient Care Manager for Hospice Provider #2 on 2/17/2026 at 2:27 PM. The Senior Patient Care Manager stated that the narcotic medication for Resident #2 did not belong to Hospice Provider #2. She explained that a hospice nurse from Hospice Provider #2 would check the amount of narcotic medication on the medication cart during each visit to verify administration and ensure medication orders were appropriate. The Senior Patient Care Manager reported that on 10/6/2025, she was informed by Hospice Nurse #2 that 30 tablets of Hydrocodone-Acetaminophen for Resident #2 had been diverted from the facility. She clarified Hospice Provider #2 was responsible for ensuring Resident #2's medication was reordered to prevent pain but did not have the responsibility for investigating or reporting narcotic diversion within the facility.During an interview, the Director of Nursing (DON) reported on 2/17/2026 at 1:17 PM that the facility could not locate the medication monitoring/control record for Resident #2's Hydrocodone-Acetaminophen card of 30 tablets received on 9/26/2025. However, the DON provided the medication monitoring/control record for the 13-tablet card received on the same date, which indicated Resident #2 ran out of Hydrocodone-Acetaminophen on 10/5/2025, with the last dose administered at 2:00 AM. The DON explained that she had initiated a diversion investigation on 10/3/2025. The DON stated she reviewed the nursing schedule from 10/1/2025 to 10/3/2025 and determined the only staff members with the responsibility of the medication cart were Nurse #1, Med Aide #2, and Med Aide #1. The DON stated she immediately went to all the medication carts throughout the facility and verified that the medication monitoring/control records for the residents on controlled medication matched the amount of controlled medication in the medication carts. The DON confirmed no discrepancies were found on any of the carts on 10/3/2025. The DON stated she also interviewed the staff with the responsibility of the nursing medication cart with the missing narcotic medication. Nurse #1, during her interview did not recall where the narcotic medication was or how it went missing. The DON indicated Nurse #1's response to the inquiry was unprofessional; Nurse #1 was suspended and then ultimately terminated from her employment with the facility.Unit Manager #1 was interviewed on 2/18/2026 at 11:51 AM. Unit Manager #1 stated that Hospice Nurse #2 determined that Resident #2's Hydrocodone-Acetaminophen was missing and notified the DON. Hospice Nurse #2 determined on 10/6/2025 that Resident #2 should have had more medication than what was present, and that he had a whole card of 30 tablets missing from the medication cart. Unit Manager #1 confirmed that she assisted the DON on 10/3/2025 in comparing the Medication Monitoring/Control Records for each resident on her unit receiving controlled medication and comparing it to the amount of controlled medication in the drawer. Unit Manager #1 stated that neither the Medication Monitoring/Control Record for the 30 tablets of Hydrocodone Acetaminophen nor the medication card was on the medication cart for Resident #2; therefore, the medication count appeared correct when it was checked on 10/3/2025.The DON and the facility Administrator were interviewed together on 2/18/2026 at 8:46 AM. The Administrator stated that facility did investigate the missing Hydrocodone-Acetaminophen beginning on 10/3/2025, but all the documentation of the investigation were lost or misplaced. The DON reported that she called Nurse #1 on 10/3/2025 to inform her of her suspension and the need to provide a written statement regarding the missing medication. The DON stated that Nurse #1 arrived for her previously scheduled shift at 11:00 PM on 10/3/2025, was reminded of her suspension, and was instructed to return in the morning to complete the statement. The DON explained that Nurse #1 did not return for several days to provide the statement. When interviewed by the DON, Nurse #1 stated she had no recollection of what happened to the missing Hydrocodone-Acetaminophen or where it might have been placed. The DON confirmed that Nurse #1's employment was terminated due to lack of stewardship of narcotics. The Administrator stated that it did not seem like a diversion of narcotics and it didn't make sense. The Administrator explained the event was treated as a human resources issue rather than a case of medication diversion. The Administrator remembered a hospice nurse telling her that the missing medication belonged to hospice and not to the resident. The Administrator recalled a hospice nurse informing her that the missing medication belonged to hospice and not to the resident, and that hospice would conduct its own investigation and report to the authorities. The DON stated that the facility was informed by a hospice nurse that Resident #2 was missing 30 tablets of Hydrocodone-Acetaminophen, and she believed this was connected to the missing Hydrocodone-Acetaminophen reported on 10/3/2025. The DON confirmed she had no documentation of an investigation into Resident #2's missing Hydrocodone-Acetaminophen, but she suspected Nurse #1 misplaced it.The facility Administrator was interviewed on 2/18/2026 at 1:15 PM and the following information was provided. The Administrator stated that when she became aware of the allegation of misappropriation, she believed the payer source of the medication determined whether misappropriation from a resident had occurred. She explained that since hospice was the payer source for Resident #2's medication, she understood the diversion to affect hospice rather than the resident. Based on this understanding, the Administrator believed the misappropriation was not reportable and assumed hospice would conduct its own investigation and reporting. The Administrator noted that Nurse #1 had been employed at the facility for five months at the time of the incident and had previously struggled with recalling information in an unrelated circumstance. She added that the facility was in the process of relocating offices, and documentation of the investigation into the missing Hydrocodone-Acetaminophen in October 2025 was lost. Without documentation, the Administrator declined to speculate on what occurred or what further actions were taken by the facility.

Based on staff interviews and record reviews, the facility failed to accurately document the administration of Hydrocodone Acetaminophen, a narcotic medication, on the medication administration record for 1 of 2 residents reviewed for accurate narcotic documentation (Resident #2).The findings included:Resident #2 had a physician's order dated 9/25/2025 for Hydrocodone Acetaminophen 5 325 mg to be administered as 1 tablet every 8 hours for pain, scheduled for 2:00 AM, 10:00 AM, and 6:00 PM.A telephone interview was conducted with Pharmacist #1 on 2/17/2026 at 4:00 PM. Pharmacist #1 reported that the pharmacy dispensed 43 tablets of Hydrocodone Acetaminophen for Resident #2, delivered to the facility on 9/26/2025 at 2:43 AM. The supply consisted of one 30 tablet medication card and one 13 tablet medication card. Nurse #1 signed for the delivery. Pharmacist #1 stated that 43 tablets would have been sufficient to last until 11/4/2025 if administered as ordered.The Director of Nursing (DON) reported on 2/17/2026 at 1:17 PM that the facility was unable to locate the medication monitoring/control record for the 30 tablet card received on 9/26/2025. The DON did provide the monitoring/control record for the 13 tablet card, which showed that Resident #2 ran out of Hydrocodone Acetaminophen on 10/5/2025, with the last documented dose removed from the medication cart at 2:00 AM.Documentation on the medication monitoring/control record for the 13 tablet card for Hydrocodone-Acetaminophen indicated that Nurse #1 removed the first dose at an unclear date in 2025 at 8:00 PM, an unscheduled administration time for Resident #2.Documentation on the September 2025 Medication Administration Record (MAR) indicated that Nurse #1 administered Hydrocodone Acetaminophen to Resident #2 on 9/26/2025 at 2:00 AM. No additional doses administered by Nurse #1 were documented on the September 2025 MAR.The medication monitoring/control record for the 13 tablet card of Hydrocodone-Acetaminophen further indicated that Nurse #1 documented removing doses from the cart on 10/2/2025 at 8:00 PM and again at 060, an unclear military time entry. Both entries reflected unscheduled administration times. There was no documentation on the record of medication being removed for Resident #2 at the scheduled administration time of 2:00 AM on 10/2/2025 by Nurse #1. Documentation on the October 2025 MAR indicated that Nurse #1 administered Hydrocodone-Acetaminophen to Resident #2 on 10/2/2025 at 2:00 AM. An attempt was made to contact Nurse #1 on 2/17/2026 at 4:56 PM via telephone; however, current contact information was unavailable, as her phone number was no longer active.During an interview on 2/17/2026 at 1:17 PM, the DON stated she observed that Nurse #1 documented removing tablets from the 13 tablet medication card at unscheduled times that were not reflected on the MAR. The DON reported that she questioned Nurse #1 about these discrepancies during an investigation into possible misappropriation of Resident #2's Hydrocodone Acetaminophen. According to the DON, Nurse #1 could not recall whether the medication had been administered or explain the discrepancies in the documentation. The DON acknowledged that the documentation on the medication monitoring/control record should match the documentation on the MAR for a clear accounting of the narcotic medication.

Based on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a blood glucose meter (glucometer) assigned to Resident #11 and used a glucometer that was assigned to another resident, Resident #141, to check Resident #11's blood glucose level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #11's blood glucose level and would have had no way to know if another staff member had previously disinfected the glucometer assigned to another resident. Glucometers can become contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer has the high likelihood of exposing residents to the spread of bloodborne pathogens. There were no residents with documented blood borne pathogens in the facility at the time of the observation. The deficient practice occurred for 1 of 2 staff members observed for glucometer use (Nurse #1). Immediate Jeopardy began on 8/28/2025 when Nurse #1 was observed performing a blood glucose level check on Resident #11 using Resident #141's assigned glucometer without disinfecting the glucometer per the glucometer manufacturer's instructions and the disinfectant wipes manufacturer's recommendations before or after using the glucometer on Resident #11. Immediate Jeopardy was removed on 8/29/2025 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems was in place and employee education was completed. The findings included: The facility's policy that was implemented on 12/1/2022 and reviewed on 1/1/2025 indicated glucometers would be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant after each use and according to manufacturer's instructions regardless of whether they were intended for a single resident or multiple use. A review of the manufacturer's instructions for the glucometer used when Resident #11's blood glucose level was checked on 8/28/2025 at 9:42 am indicated the glucometer should be cleaned of any dirt, blood, or other bodily fluids from the exterior of the glucometer before performing the disinfecting procedure. The instructions further stated that the glucometer should be cleaned with two disposable, germicidal wipes after each use, one wipe to clean the glucometer and the second to disinfect the glucometer. The manufacturer's instructions for the disposable germicidal wipes used by the facility stated a glucometer should be wiped with a pre-moistened wipe on the surface of the glucometer remaining visibly wet for 2-minutes, additional wipes should be used to maintain wetness for the entire 2-minutes and then allow the surface to air dry after every blood glucose level check. Resident #11 was admitted to the facility on [DATE] with a cumulative list of diagnoses that included diabetes. Resident #141 was admitted to the facility on [DATE] with a cumulative list of diagnoses that included diabetes. Resident #141 did not have a diagnosis of a communicable disease. On 8/28/2025 at 9:42 am an observation and interview were conducted with Nurse #1 during a medication administration observation. During the observation Nurse #1 was observed to look through her medication cart and then removed a glucometer from the medication cart that was in a plastic bag and carried it into the resident's room without cleaning or disinfecting the glucometer. The name on the glucometer was not visible while Nurse #1 obtained Resident #11's blood glucose level. During the observation Nurse #1 checked Resident #11's blood glucose level and then placed the glucometer and storage bag on the table in front of the resident after sticking her finger and the name on the storage bag and glucometer were for another resident, Resident #141. Upon exiting Resident #11's room Nurse #1 stated she could not find Resident #11's glucometer in the medication cart and used Resident #141's glucometer which she stated was new and had not been used before, since the resident had just moved to unit from another unit. Review of the history for Resident #141's glucometer showed several previous blood glucose levels recorded. Nurse #1 placed Resident #141's glucometer on the medication cart and stated she would replace Resident #141's glucometer and obtain a new glucometer for Resident #11. Nurse #1 stated there were glucometers in the facility's supply room and she should have called down to get a replacement glucometer for Resident #11 but was anxious because of the observation. Nurse #1 stated she had been educated regarding how to clean the glucometer and stated they should be cleaned with disinfectant wipes after each time they were used. Nurse #1 opened the medication cart and identified the germicidal wipes used to clean the glucometer. She stated the glucometer should be cleaned with one wipe and then another wipe was to be used to disinfect the glucometer by wetting the surface for 2 minutes and then allowing the glucometer to air dry. Nurse #1 gave the Resident #141's glucometer to the Unit Manager and the Unit Manager stated she would dispose of the glucometer and obtain a new glucometer for Resident #141 and a new glucometer for Resident #11. An interview was conducted with the Administrator on 8/28/2025 at 10:39 am in the presence of the Chief of Nursing Operations (a corporate representative. The Director of Nursing was not available at the time. The Administrator and Chief of Nursing Operations were made aware Nurse #1 had used another resident's, Resident #141's, glucometer to check Resident #11's blood glucose level without cleaning and disinfecting the glucometer prior to use on Resident #11. The Administrator stated each resident in the facility had their own personal glucometer, and there were glucometers in the facility's central supply and the medication rooms on each floor to be assigned to any resident whose glucometer was not working or could not be found. The Administrator stated Nurse #1 should have notified the Unit Manager she was not able to find Resident #11's glucometer and a new glucometer should have been assigned to the resident. The Medical Director was interviewed by phone on 8/28/2025 at 1:41 pm and he stated he did not believe there was any harm, or risk, to Resident #11 when the staff used Resident #141's glucometer without cleaning it because there was no blood-to-blood contact. The Medical Director further stated Nurse #1 should have followed the facility's policy and cleaned the glucometer using the manufacturer's instructions for the disinfectant wipes. On 8/29/2025 at 8:37 am the Director of Nursing, who was certified as an Infection Preventionist, was interviewed, and she stated Nurse #1 should have immediately stopped what she was doing when she could not find Resident #11's glucometer in the medication cart and obtained a new glucometer from the Medication Room or the Supply Room. The Director of Nursing stated the facility felt it was best practice for residents who required a blood glucose level to have their own glucometer, and the glucometer should be labeled with the resident's name, room number, and the glucometer should be stored in a plastic bag in the medication cart. The Director of Nursing stated even though the facility had personal glucometers for each resident, Nurse #1 should have cleaned and disinfected the glucometer per the facility's protocol. The Director of Nursing stated Nurse #1 should have used one disinfectant wipe to clean the glucometer, another disinfectant wipe to disinfect the glucometer per the manufacturer's instructions and then allowed the glucometer to air dry before and after using the glucometer. The facility's Infection Preventionist was not available during the survey. The Administrator was made aware of the immediate jeopardy on 8/28/25 at 2:47 PM. The facility implemented the following plan for Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; [NAME] 8/28/2025 at 11:00 a.m., Nurse #1 prepared to conduct a fingerstick blood glucose check on Resident #11. The Nurse was unable to locate a glucometer labeled for Resident #11. The Nurse removed a glucometer from the medication cart which had been designated and labeled for Resident #141. The Nurse did not cleanse or disinfect the glucometer designated for Resident #141, according to the glucometer's manufacturer's instructions and germicidal wipe manufacturer's instructions, prior to conducting the fingerstick blood glucose check on Resident #11. The nurse proceeded to conduct the fingerstick blood glucose check on Resident #11 utilizing the glucometer designated for Resident #141, which had not been cleaned or disinfected. Upon completion of the fingerstick blood glucose check on Resident #11 the nurse failed to cleanse and disinfect the glucometer designated for Resident #141 according to the glucometer's manufacturer's instructions and germicidal wipe manufacturer's instructions.All residents that required blood glucose monitoring through the use of a glucometer were identified as having suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance on the 8/28/2025. Through review of the census all residents who required blood glucose monitoring through the use of a glucometer were added to the potentially affected resident list. The facility had 61 residents who received blood glucose checks with a glucometer as of 8/28/2025. During the interview with Nurse #1 she denied using glucometer designated for a different resident on any resident other than when she used Resident #141's glucometer for Resident #11. The facility interviewed current nurses and current med aides and they denied using a glucometer labeled for another resident on a different resident. Residents that were alert and oriented, as determined by a Brief Interview for Mental Status (BIMS) score of 12 and higher, were interviewed and denied observing a glucometer used for checking their finger stick blood glucose with another resident's name.On 8/28/2025 at 11:48 a.m. the Assistant Director of Nursing (ADON) in-serviced Nurse #1 on the manufacturer's recommendations for the disinfectant wipes, and the glucometer's manufacturer's instructions for cleaning and disinfecting glucometers. The ADON then observed a return demonstration of cleaning and disinfecting the glucometer per manufacturer's instructions. Nurse #1 was educated by the ADON on potential consequences of not properly cleaning and disinfecting glucometers which included the potential to infect the resident with bloodborne pathogens. The education included the manufacturer's instructions for the glucometer and the germicidal wipe instructions to clean and then disinfect with two minutes of wet contact time as written in the germicidal wipe manufacturer's instructions.On 8/28/2025 the Unit Manager removed the glucometer of Resident #141 from the cart and discarded it. Resident #11's glucometer was not located. A new glucometer was placed and labeled in the resident's room for Resident #11 and Resident #141. Resident #11 was notified by the Unit Manager on 8/28/25 of the incident. Resident #11 had no questions or concerns. Resident #11 was her own responsible party and has a BIMS (Brief Interview for Mental Status) of 15 indicating no impairment in cognition. The BIMs was most recently assessed on 7/23/25. Labs for screening blood borne pathogens were offered to Resident #11 and she refused. 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 8/28/2025 at 11:14 a.m., The Medical Director was notified of the incident by the Director of Nursing. The clinical team discussed education and systems to put into place to prevent future staff competency issues related to infection control of blood glucose monitoring. These systems included education provided by the Director of Nursing and Assistant Director of Nursing started on 8/28/25 to nurses, and medication aides in the facility. Education provided included the manufacturer's recommendations for the disinfectant wipes, and the glucometer's manufacturer's instructions for cleaning, disinfecting glucometers, and system to keep resident glucometer in resident's room labeled. The Director of Nursing, Assistant Director of Nursing, and Unit Managers audited residents that require glucometers and placed them in the resident room labeled with the resident's name. For staff not in the facility the Director of Nursing and Assistant Director of Nursing began making calls to provide education. The education will be monitored by the Assistant Director of Nursing and Director of Nursing and will be included in orientation to newly hired nurses and medication aides. Training will be completed with oncoming staff prior to starting their assignments. On 8/28/2025 at 11:48 a.m. the Assistant Director of Nursing (ADON) in-serviced Nurse #1 on the manufacturer's recommendations for the disinfectant wipes, and the glucometer's manufacturer's instructions for cleaning and disinfecting glucometers. The ADON then observed a return demonstration of cleaning and disinfecting the glucometer per manufacturer's instructions. Nurse #1 was educated by the ADON on potential consequences of not properly cleaning and disinfecting glucometers. The education included the manufacturer's instructions for the glucometer and the germicidal wipe instructions to clean and then disinfect with two minutes of wet contact time as written in the germicidal wipe manufacturer's instructions.On 8/28/2025 at 2:10 p.m. the clinical team reviewed the manufacturer's recommendations for glucose cleansing and disinfecting. The manual under section B read; Testing confirmed the following wipes will not damage the functionality or performance of the meter, this included suggested manufacturer germicidal disposable wipes. The germicidal disposable wipes directions for use read: To disinfect nonporous surfaces use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface of the glucometer. Allow the surface of the glucometer to remain wet for two minutes. Let the glucometer air dry. The Assistant Director of Nursing then began in-servicing nurses and medication aides working on 8/28/2025. The Assistant Director of Nursing then began in-servicing nurses and medication aides not currently working at the facility via the telephone. Nursing staff and medication aides were instructed to see the Director of Nursing (DON) and/or Assistant Director of Nursing before their next shift for a return demonstration of blood glucose monitoring cleansing and disinfection process. The Assistant Director of Nursing will educate newly hired nurses and medication aides regarding cleaning and disinfection of glucometers per manufacturer's instructions during orientation and before receiving an assignment. On 8/28/2024, the Assistant Director of Nursing was notified by Nurse Consultant #1 of his responsibility to conduct education with nurses and medications aides regarding each resident's personal glucometer for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed. The Assistant Director of Nursing will be responsible for keeping up with the newly hired staff. In the event a nurse or med aide cannot locate a resident's glucometer, education was provided to retrieve a new glucometer from Central Supply. The glucometer will be labeled using a permanent marker with first initial and last name. The Unit Manager will be made aware the glucometer was placed/replaced. On 8/28/2025 the Director of Nursing, Assistant Director of Nursing and Unit Manager, assessed, cleansed, and disinfected all glucometers according to the manufacturer recommendations for glucometer disinfection and per the directions for the germicidal disposable wipes. On 8/28/2025, an audit was conducted by the Unit Managers to verify each resident who required fingerstick blood glucose monitoring had a designated glucometer on the medication carts, and that the designated glucometer was bagged and labeled. The audit revealed 100% of residents who required glucose monitoring had individualized glucometers available including Resident #11 and Resident #141, The Administrator notified [NAME] County Department of Health of the incident on 8/28/2025. The Health Department staff member was not available, but a message was left requesting a return call. The glucometer policy was placed on every medication cart by the Assistant Director of Nursing on 8/28/25 and read: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, germicidal disposable wipe (bactericidal, tuberculocidal, and virucidal). 3. Perform Hand Hygiene. 3. Explain the procedure to the resident. 4. Provide privacy. 5. [NAME] gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) wipes from germicidal (bactericidal, tuberculocidal, and virucidal) disposable wipe container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the germicidal (bactericidal, tuberculocidal, and virucidal) wipe, according to the glucometer manufacturer's instructions. Follow the germicidal wipe directions for the dry time. Allow the glucometer to air dry. 11. Discard germicidal (bactericidal/tuberculocidal/virucidal) wipes in waste receptacle.12. Perform hand hygiene. On 8/28/2025 the Director of Nursing, Assistant Director of Nursing, Unit Managers, Administrator and Nurse Consultant made the decision to move the glucometers off the medication carts and into each resident's room and will be stored in a pencil box/pouch. Education was provided by the Unit Managers to the nurses and the Medication Aides (MA) working on 8/28/2025 regarding the location of the glucometers in the rooms and this education will be provided to nursing and MA staff prior to working the next shift, by the Unit Managers. Any nurse or medication aide found to be sharing glucometers will be subject to disciplinary action. IJ removal date 8/29/2025Date of Removal of Immediate Jeopardy: 8/29/2025The facility's credible allegation of immediate jeopardy removal was validated on 8/29/2025. A review was conducted of the facility's education for glucometer disinfection with the nursing staff and the education was completed on 8/29/2025. The nursing staff were able to verbalize the education and training provided regarding disinfection of glucometers assigned to the residents before and after use. An observation was conducted on 8/29/2025 when a nurse performed a blood glucose check and there were no issues observed, the assigned glucometer was used on the correct resident, and the assigned nurse disinfected the glucometer before and after use. During the observation, disinfectant wipes were observed in the medication cart. A sample of residents were observed of the residents' personal glucometers in their room and stored in a container with each resident's name and room number on the glucometer and the container. An observation was also made to ensure the facility had replacement glucometers in stock. The immediate jeopardy removal date of 8/29/2025 was validated.

Based on observations and staff interviews, the facility failed to keep food preparation areas, floors and food service equipment clean, free from debris and/or dried spills during two kitchen observations. The facility failed to clean the ceiling vents located over the food preparation and food service areas. These practices had the potential to affect food served to residents. The findings included:During a kitchen tour on 8/25/25 at 10:32 AM, the following observations were made with the Dietary Manager:a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. b. The 4-plate warmers had 4 rows of clean plates stored inside the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around.c. The 6-compartment steam table had floating food particles in standing water, the lids of the steam table had large volumes of dried food and greasy build up around edges.d. The fryer had dried brown/yellow liquid matter encrusted on edges inside and outside and the fryer also had a heavy grease and food build-up inside and outside. Food products were observed behind the fryer and on the floor that included paper products, dried meats and vegetables.e. The floor area under the stoves, oven, preparation tables, steam tables were sticky with old food debris when walking across the floor. f. All 10 meal carts with dry food products stored in them had dried liquids, food crumbs and particles inside. The outside of all 10 carts also had dried liquids running down the fronts/sides of the cart.g. The 3 ceiling vents had large volumes of black dust/debris blowing over the steam table, clean dry dishware storage racks, food service and preparation surfaces.h. The microwave had large amounts of dried food and liquid products on the inside and outside.An interview was conducted on 8/25/25 at 10:30 AM with the Dietary Manager (DM) who stated the dietary staff were required to wipe down kitchen equipment after each meal and deep clean weekly in accordance with the kitchen cleaning checklist. The DM stated she was responsible for ensuring the kitchen staff kept the equipment clean and orderly. The DM acknowledged the identified kitchen equipment and ceiling vents had not been cleaned in accordance with the checklist. An interview was conducted on 08/25/25 at 12:24 PM with the Maintenance Assistant who stated that he was unaware of the cleaning process for the kitchen vents or the grease container because he was recently hired. A follow-up observation and interview were conducted on 8/27/25 at 11:27 AM with the Dietary Manager (DM) and Regional Director of Dietary Services who observed the meals were placed in the dirty meal carts and delivered to the main dining rooms and on the halls of 4 floors. The ceiling fans had not been cleaned from the initial tour on 8/25/25. Staff was observed preparing meals with dust particles were blowing overtop of the food prep table and steam table. The steam tables continue to have food particles in water. An interview was conducted on 8/27/25 at 11:27 AM with the Regional Director of Dietary Services who stated the DM and Assistant Dietary Manager (ADM) was responsible for ensuring the kitchen equipment and floors were cleaned in accordance with the kitchen cleaning checklist. The Regional Director of Dietary Services acknowledged the vents needed to be cleaned and stated the dietary staff and maintenance staff were responsible for ensuring the vents were cleaned. An interview was conducted on 8/27/25 at 2:00 PM with the Regional Consultant for Maintenance and Environmental Services. He stated he was unable to confirm when the vents in the kitchen were last cleaned.

Based on observations and staff interviews, the facility failed to ensure the garbage and refuse was disposed of and keep 4 of 4 dumpsters and 1 of 1 grease interceptor container, and surrounding dumpster area clean and free from debris. This practice had the potential to attract pests and rodents. The findings included:During an initial tour observation on 8/25/25 at 10:00 AM, 4 dumpsters and 1 grease interceptor container located near a wooded area at the back of the facility. The dumpsters had several bags of garbage and refuse overflowing from the tops. In addition, there were loose paper products, boxes, food products, mattresses, furniture, old pallets, clothing, and a blanket outside of the dumpster containers littering the ground and surrounding areas. The grease interceptor container was leaking grease on the ground along with the trash onto the parking lot. A follow-up observation and interview were conducted on 8/25/25 at 10:15 AM with the Dietary Manager revealed the trash bags filled with garbage left on the ground had been removed, however the surrounding area had not been thoroughly cleaned evidenced by the remaining paper and food products and grease was still on the ground around the sides and backs of the dumpsters. The Dietary Manager stated the dietary and housekeeping staff were responsible for cleaning the dumpsters daily.An observation and interview were conducted on 8/25/25 at 11:40 AM with the Administrator who acknowledged the condition of the dumpster area and the overflowing grease interceptor container. She stated the dumpster area has been in this condition for some time and stated housekeeping, dietary and maintenance staff were responsible for ensuring the dumpster and surrounding area cleaned and maintained daily.An interview was conducted on 8/25/25 at 3:20 PM with the Regional Consultant for Maintenance and Environmental Services who stated the housekeeping, dietary and maintenance were responsible for ensuring the dumpster area was cleaned daily. He further stated he was unaware of when grease interceptor container had been cleaned. He stated it should have been cleaned monthly.An interview was conducted on 8/27/25 at 11:00 AM with the Dietary Manager (DM) and Regional Director of Dietary Services who both stated the maintenance staff were also responsible to ensure the grease receptor was cleaned daily and free of any long-standing grease or debris. The Regional Director of Dietary Service acknowledged the grease interceptor had not been cleaned consistently for several months.

Based on record review and staff interviews, the facility failed to notify the North Carolina Medicaid Uniform Screening Tool (NC MUST), that is the State Mental Health or Intellectual Disability Authority, when a significant change in condition was identified for a resident with a mental disorder and failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation for PASRR Level II for 2 of 3 residents reviewed for significant change in condition (Resident #10 and Resident # 204). The findings included: 1. The resident's electronic medical record (EMR) included information from the North Carolina Medicaid Uniform Screening Tool (NC MUST). This record revealed Resident #10 was evaluated and found to have a PASRR Level I determination with a start date of 10/28/18. The PASRR Level I evaluation assessed the resident for the appropriateness of nursing facility placement and no further PASRR screening was required unless a significant change occurred with the individual's status which suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. The Level I designation specified there was no end date and no limitation unless the resident had a change in condition. Resident #10 was admitted to the facility on [DATE]. His cumulative diagnoses included a diagnosis of schizoaffective disorder, bipolar type and post-traumatic stress disorder. Resident #10's electronic medical record revealed a hospital psychiatric care coordination note dated 7/11/24 which revealed a problem list and noted a diagnosis of other schizophrenia on 8/11/22 and a diagnosis of post-traumatic stress disorder dated 6/7/19. Physician order dated 3/19/25 revealed a new order for .5 milligrams of Ativan three times a day for anxiety. This medication was discontinued on 7/22/25. Physician order dated 7/23/25 revealed an order for quetiapine fumarate 200 milligrams to be administered at bedtime for bipolar disorder. A psychiatric quarterly treatment plan and progress note dated 7/25/25 indicated Resident #10 has had a decline in mental status and anxiety symptoms had worsened since her previous treatment plan. An interview was conducted on 8/28/25 at 9:27 AM with the Director of Social Services and she indicated she did not realize Resident #10 had diagnosis of schizoaffective disorder and post-traumatic stress disorder added to the diagnosis list after the initial level I PASRR screening had been completed. She further revealed that she and the social work assistants were not aware that Resident #10 and a decline in mental status and anxiety symptoms and therefore did not initiate a Level II PASRR screening. The Director of Social Services also indicated that a Level II PASRR screening should have been initiated for Resident #10 due to having a serious mental illness and a noted decline in mental status, anxiety symptoms and changes in treatment. An interview was conducted with the Director of Nursing on 8/28/2025 at 9:41 AM. She indicated that due to Resident #10 having a diagnosis of a serious mental illness with a change in behaviors and treatments he should have been screened for a level II PASRR. 2. The review of the PASRR Level 1 determination dated 8/3/23 for Resident #204, read in part: “No further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. Resident #204 was originally admitted to the facility on [DATE] with diagnoses which included moderate dementia with mood disturbance, and anxiety. Review of the quarterly Minimum Data Set, dated [DATE] indicated Resident #204 was moderately, cognitively impaired with the diagnoses of depression, mood disorder, and anxiety. The clinical record revealed Resident #204's diagnoses was updated on 11/4/24 to include bipolar disorder. A review of the Psychiatric Progress Note dated 8/1/25 revealed Resident #204's past medical history included the diagnosis of bipolar disorder for which he was ordered and received Seroquel (an antipsychotic medication) for mood disorder. Review of the facility's records indicated Resident #204 was not referred to the state-designated authority for a Level II PASRR evaluation post his bipolar disorder diagnosis. During an interview on 8/29/25 at 9:49 a.m. the facility's Director of Social Services revealed she began working at the facility in January 2025. She indicated she was not aware Resident #204 had a diagnosis of bipolar disorder added to her list of diagnoses after the initial level 1 PASRR. The Director of Social Services acknowledged a Level II PASRR screening request should have been submitted to the state's mental health authority when Resident #204's mental status changed resulting in the diagnosis of bipolar disorder.

Based on observations, record review, and staff interviews, the facility failed to ensure residents were provided clean footwear for 1 of 5 residents dependent on staff for Activities of Daily Living (ADL) care (Resident #4). Findings Included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included Dementia and enlarged prostate gland with an indwelling catheter. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed as severely cognitively impaired with no behaviors or rejection of care. Resident #4 was assessed as requiring substantial / maximum assistance for toileting hygiene and partial / moderate assistance personal hygiene. The care plan dated 7/3/25 revealed Resident #4 was care planned for ADL self-care deficit related to Dementia. The goal indicated Resident #4 will maintain current level of function through the review date. Interventions included provide sponge bath when a full bath or shower cannot be tolerated and make sure shoes are comfortable and not slippery. During an observation on 8/25/25 at 11:20am, Resident #4 was observed walking from his bedroom towards writer. Resident approached writer wearing yellow socks with purple stripes. Both socks were saturated with a liquid substance. Resident #4 wore plaid pajama pants that were saturated with a liquid substance down the back of his right pants leg. Visible wet footprints were coming from the resident's room door. At the foot of the residents' bed on the floor a small wet area was observed with multiple wet footprints surrounding the area. During an observation on 8/26/25 at 9:30am, Resident #4 was observed lying in bed on his left side wearing a hospital gown and yellow socks with two purple stripes with light brown stains on the bottom of both socks. During an observation on 8/26/25 at 11:25am, Resident #4 was observed lying in bed on his back with his legs crossed at the feet wearing yellow socks with two purple stripes with light brown stains on the bottom of both socks. During an observation on 8/27/25 at 8:40am, Resident #4 was observed wearing gray sweatpants with gray nonskid footies. During an interview on 8/27/25 at 9:10am, Nursing Assistant (NA) #1, indicated she was assigned to the resident. NA #1 further indicated she applied the yellow socks with purple stripes on Resident #4 the morning of 8/25/25. She stated she was not assigned to the resident on 8/26/25. NA #1 also indicated she removed the same yellow socks with purple strips she applied to the resident the morning of 8/25/25 the morning of 8/27/25. During an interview on 8/27/24 at 9:20am, Medication Aide (MA) #1, indicated Resident #4 normally lets staff groom him. She indicated the resident wore a leg bag because of his catheter. During an interview on 8/27/25 at 9:40am, the Unit Manager #1 indicated Resident #4 would mess with his leg bag sometimes. She indicated frequent checks were implemented to ensure Resident #4 was not disconnecting his leg bag from the catheter. Unit Manager #1 stated she was not aware the resident wore the same yellow socks with purple stripes from 8/25/25 through 8/27/25. She stated NA #2 told her she changed the residents' socks on 8/26/25. During an interview on 8/27/25 at 10:00am, NA #2 indicated she put gray socks on Resident #4 on 8/26/25. She stated she could not remember what socks he had on prior to her getting him dressed after lunch. She indicated she put the soiled clothing in a bag and placed it in the soil linen room. During an interview on 8/29/25 at 10:17am, the Assistant Director of Nursing (ADON) indicated staff were instructed to replace the resident's socks as needed. The ADON indicated he did not know why Resident #4 would have the same socks on for multiple days in a row. The ADON stated he would follow up with the unit manager and reinforce the importance of proper footwear to the unit staff.

Based on record review, and staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council and communicate the facility's efforts to address grievances voiced during Resident Council meetings for 2 of 2 consecutive months: June 2025, and July 2025.The findings included:a. A review of the Resident Council minutes completed by the Activities Director dated 6/24/25 revealed the following grievances were expressed: housekeeping does not take out their trash, nursing assistants take their time putting the residents to bed, 3rd shift nurses are sleeping in the day room and not answering call bells, laundry was not being sent up in a timely manner. A review of the grievances for the month of June 2025 revealed no Resident Council grievances were submitted. b. A review of the Resident Council minutes completed by the Activities Director dated 7/23/25 revealed the following grievances were expressed: second shift does not help residents into bed timely, television time in the day room is not being shared with residents and missing personal items. There was no documented discussion or resolution of the previous month's grievances. A review of the grievances for the month of July 2025 revealed no grievances were submitted. A Resident Council meeting was held on 8/27/25 at 11:00 AM with Residents #30, #83, #90 #161, # 189, 217. During the meeting, Resident #90, the resident council president, expressed that the Resident Council had voiced several grievances in the past two months which had not been fully addressed, and the staff have not communicated the facility's efforts in addressing their grievances. An interview with the Activities Director on 8/28/25 at 10:57 AM revealed that he was not aware that he needed to document resident council grievances or to communicate the facility's efforts in addressing the grievances.An interview with the Administrator on 8/29/25 at 12:45 PM revealed that Resident Council grievances should have been documented and the follow up to those grievances should have been provided to the Resident Council members at the next meeting.

Based on record reviews, responsible party and staff interviews, the facility failed to provide written conclusions and resolutions of grievances reported by the Responsible Party (RP) for 1 of 1 resident (Resident #225) reviewed for grievances.Findings included: The review of the facility's policy on Resident and Family Grievances with a copyright date of 2024 read in part: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The procedure of the policy included: In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s).iv. A statement as to whether the grievance was confirmed or not confirmed.v. Any corrective action taken or to be taken by the facility as a result of the grievance.vi. The date the written decision was issued. Resident #225 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: end-stage renal disease and diabetes mellitus. The most recent Minimum Data Set assessment dated [DATE] indicated Resident #225 was moderately, cognitively impaired. Review of the facility's grievances revealed two grievances (7/8/24 and 1/13/25) reported to the facility's Social Services department by Resident #225's RP. On 7/8/24 the resident's RP reported concerns about the cleanliness of Resident #225's room and concerns about the resident's wound treatment. The investigation and resolution revealed staff from the nursing department spoke with the RP regarding the resident's dressing change and frequency; and the environmental services' supervisor informed the RP the resident's room was deep cleaned. The RP also reported a grievance to the Social Services department on 1/13/25 concerning Resident #225's unclean bathroom. The findings of the investigation by the Environmental Services department and the resolution of the cleaning of the bathtub and floor and the refilled soap dispenser were verbally reported to the RP by the Environmental Services Manager. Each of these grievance forms documented the investigation results and resolution steps were verbally communicated to the RP but no written documentation of the investigations' conclusions and resolutions was sent to the RP as follow-up. During a telephone interview on 8/28/25 at 8:56 a.m., Resident #225's RP indicated the facility frequently did not communicate with him when he had concerns about the resident's care. He had filed grievances with Social Services, but the facility did not follow-up with him. During an interview on 8/29/25 at 1:05 p.m., the facility's Director of Social Services revealed she began working at the facility in January 2025. She stated after reviewing the notebook of copies of Grievance Response Letters maintained by the previous Director of Social Services, the letters sent to the complainants were discontinued after October 2024. She stated that she was not made aware of the federal requirement of notifying a complainant in writing of the conclusion and resolution of his/her reported grievance.

Based on observations, and resident and staff interviews, the facility failed to maintain walls, floors, baseboards in good condition, and rooms free from debris in 9 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Room#327, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on 6 of 8 resident halls. In addition, the facility failed to maintain floors 3 of 8 halls and a ceiling in 1 of 4 common areas in good condition. The findings included: a. room [ROOM NUMBER] was observed on 06/23/25 at 9:46AM. The entrance to the room had dry black and brown raised material on the floor that scraped up with pressure from a shoe. The bathroom floor had visible dirt built up observed. A plastic wrapper and temperature probe were observed on the floor under the bed. During a walk around with the Regional Maintenance Director, Environmental Services (EVS) Director, and the acting Maintenance Director on 06/23/25 at 2:40pm, room [ROOM NUMBER] was observed to have the same issues. The EVS Director discussed not being aware of the black and brown raised material or the built-up dirt on the bathroom floor. He explained he did not believe housekeeping had been in the room to clean yet and stated the housekeeping department was short staffed. The EVS Director discussed needing 2 housekeepers per floor and explained right now there was only one housekeeper for the second floor. b. room [ROOM NUMBER] was observed on 06/23/25 at 9:51 AM. Heavy buildup of dirt and brown material was noted in all corners and along the baseboards of the bathroom. In the shared bathroom, there was a dark brown stain around the entire toilet base; the seal around the toilet base was absent. [NAME] material was seen on the wall on and above the commode grab bar. The bathroom wall behind the door had visible splatters of brown & orange matter. Dried green stains were seen around the toilet base bolt. A panel of the privacy curtain between the beds was pulled from the ceiling track and was laying on the floor with brown matter on it. Baseboards in all corners of the room were noted to have brown stains and dirt buildup. On 06/23/25 at 2:44 PM, room [ROOM NUMBER] was observed with the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS. The EVS Director stated that housekeeping had completed cleaning of the room. The EVS Director shared his department was experiencing staffing problems. The Regional Maintenance Director/Environmental Services (EVS) Director stated the facility was working on increasing the number of housekeepers and floor technicians. The EVS Director stated he was unaware of the issues and that housekeeping staff were responsible for ensuring the room was clean, which would include wiping down walls/baseboards when there was visible dirt. He also discussed not being aware of the privacy curtain being on the floor. The EVS Director explained if a privacy curtain fell and/or was dirty, the housekeeper was responsible for letting him know so he could remove the curtain and place it in the laundry. The acting Maintenance Director stated he was unaware of the seal around the base of the toilet missing. He also discussed the lack of maintenance staff but explained a maintenance assistant was to start in a week. c. room [ROOM NUMBER] was observed on 06/23/25 at 9:56 AM. The trash can had no liner in place and the bottom of trash can was heavily soiled with a dried brown, orange, and black substance. On 06/23/25 at 2:42 PM, room [ROOM NUMBER] was observed with was observed with the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS. The EVS Director stated that housekeeping had completed the cleaning of the room at the time of the observation. A trash can liner was in place, but the bottom of the trash can remained heavily soiled with brown, orange, and black substances. The EVS Director stated that housekeepers should clean trash cans before replacing the liner. The assigned housekeeper for room [ROOM NUMBER] on 06/23/25 was not available for interview. d. room [ROOM NUMBER] was observed on 06/23/25 at10:20 AM. The wall behind the room entry door had 2 holes near the baseboard. Hole #1 measured 6 inches x 3 inches. Hole #2 measured 6 inches x 6 inches and was packed with gauze pads. An approximately 6-inch section of baseboard was observed pulled away from the wall behind bed A. There was a heavy buildup of brown material in all corners of the room. The left entry wall of the bathroom had an approximately 3-inch section of baseboard pulling away from the wall. Above the displaced baseboard was a hole that measured 3 inches x 3 inches (These were measured by the Acting Maintenance Director during group observation rounds in the afternoon.) [NAME] dried matter was noted on the toilet seat. The toilet base seal was absent with heavy brown staining around the base and heavy buildup of dirt in corners behind the toilet. The wall tile behind the toilet was heavily splattered with dried brown and black matter. The wall by the commode grab bar was splattered with brown material. There was no trash can liners in place for the 2 trash cans and the bottom of both were covered with dried dark brown material with brown splatters to walls of both trash cans. On 06/23/25 at 2:49 PM, the holes in the wall behind the entry door and the left wall of the bathroom in room [ROOM NUMBER] were measured by the Acting Maintenance Director. He removed the gauze pads from hole # 1 and stated that he had no idea why someone put that gauze there. The acting Maintenance Director stated he was unaware of the holes in the wall/baseboards and explained there was a Maintenance Assistant starting next week and that he planned on having the Assistant work on fixing the walls which would include any loose baseboards. The EVS Director stated that the room had been cleaned earlier that day. The brown dried matter on the toilet seat, the absent toilet base seal with heavy brown staining around the base, the heavy buildup of dirt in corners behind the toilet were observed by the group. The wall tile behind the toilet and the wall by the commode grab bar remained splattered with dried brown and black matter. The Regional Maintenance/EVS Director asked the facility's EVS Director if housekeepers cleaned walls as part of their routine cleaning. He replied, if they see something then yes, they should clean it. Trash can liners were in place for both trash cans but the bottom of both were covered with dark brown material and brown splatters were observed on the walls of both trash cans. The Regional Maintenance/EVS Director shared with the EVS Director that trashcans should be cleaned before replacing liners. The assigned housekeeper for room [ROOM NUMBER] on 06/23/25 was not available for interview. e. room [ROOM NUMBER] was observed on 06/23/25 at 10:25 AM. Several patches of dried brown matter were noted on the floor between the beds. The entire room floor was sticky and heavy dirt built up was observed in all corners of the room as well as around the air conditioning unit and baseboards. There were dried dark brown raised splatters visible on the wall behind bed B. In the shared bathroom, the wall tiles behind the toilet and the shower curtain were splattered with dried brown matter. On 06/23/25 at 2:44 PM the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS observed in room [ROOM NUMBER] several patches of brown, dried matter on the floor between the beds, heavy dirt build up on the floor around the air conditioning unit and baseboards, and dried dark brown, raised splatters on the wall behind bed B. In the shared bathroom, the wall tiles behind the toilet and the shower curtain remained splattered with dried brown matter. The EVS Director did not know if the room had been cleaned yet and he was unaware of the condition of the room. He again discussed the lack of housekeeping staff and stated there was only one housekeeper for the third floor. The EVS Director explained if the housekeeper had already cleaned the room he would have expected the housekeeper to clean the walls, air-conditioning unit, and remove the shower curtain for cleaning. The Regional Director discussed the room needing to be re-cleaned to the facility standards. f. room [ROOM NUMBER] was observed on 06/23/25 at 10:02 AM. It was noted that a one-foot section of the baseboard to the left of the air conditioning unit had pulled away from the wall. Black and brown stains were present on the exposed wall behind the baseboard that had pulled away from the wall. The ceiling above the air conditioning unit had a crumbling and peeling area with two baseball sized round, brown stains observed. A panel of the privacy curtain between the beds was pulled from the ceiling track and it was laying on the floor. The ceiling above the toilet had 2 round brown rings. There was no trash can liner in the trash can and the bottom of the trash can was heavily soiled dark brown matter, and brown splatters were observed to walls of trash can. One broken floor tile was noted on the floor near bed B. On the wall between the beds and approximately at the level of the headboards exposed electrical wires were observed in a square open area that was large enough for a hand to reach the wires located between two call light wall mounts between bed A and bed B. On 06/23/25 at 2:49 PM observations were made in room [ROOM NUMBER] along with the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS. noted the displaced baseboards, the stains on the ceiling in the room and bathroom, the broken floor tile, and the privacy curtain panel laying on the floor. There was no trash can liner in the trash can and the bottom of the trash can was heavily soiled dark brown matter, and brown splatters were observed to walls of trash can. The exposed electrical wires located in a junction box between the two call light wall mounts between bed A and bed B were observed by the Acting Maintenance Director and the Regional Maintenance/EVS Director. The Acting Maintenance Director stated he was not aware of the exposed electrical wires, and broken floor tiles. He stated he was aware of the ceiling tiles and discussed the on-going issue of the pipe leaking. The EVS Director stated he was not aware of the trash can condition or the privacy curtain laying on the floor. The EVS Director confirmed the housekeeper had already cleaned the room today and should have informed him of the privacy curtain as well as cleaned the trash can. g. room [ROOM NUMBER] was observed on 06/23/25 at 10:10 AM. An approximately one-foot corner section of baseboard between bed A and the bathroom was observed to be pulled away from wall with an exposed nail visible. The entire room floor had visible scuff marks embedded in the flooring. Above bed A, a baseball sized round brown ring was observed on the ceiling. There was no trash can liners in place in 3 of the 3 trash cans and the bottoms of each had dried thick brown matter with brown splatters to walls of the trash cans. In the shared bathroom, a square cut was seen in the ceiling above the toilet with plumbing pipes visible. A steady flow of water from the ceiling hole was observed and heard. A large gray raised commode seat covered the toilet with a large white bucket on top to collect water and the bucket appeared to be half full. Water was noted on the floor of the entire bathroom extending to the threshold of the bathroom. Several dirty and water saturated towels were on the floor in front of the toilet. A musty smell was noted on entering the bathroom. A resident from room [ROOM NUMBER] (Resident #11) was interviewed on 06/23/25 at 10:30 AM. When asked how long the bathroom had been leaking water from the ceiling she said on and off for 2 months. She stated, they fix it and it leaks again. When asked how long this instance, she stated around 2 days. Resident #11 stated due to this leak she must use her wheelchair to go to the unit's shower room to use the commode, even at night due to the current leak which was inconvenient. She stated that the facility had not told her when this leak would be fixed. Review of Resident #11's MDS completed on 06/19/25 revealed that the resident was cognitively intact. An interview was held with the Maintenance Assistant on 06/23/25 at 3:24 PM. He stated he was on call on 06/20/25 when a staff member called him directly on his phone at 10:45 AM and again at 4:02 PM to report that there was flooding from the ceiling in the bathroom of room [ROOM NUMBER]. He stated he did not come in when he received the calls but told the staff to turn the faucets off in room [ROOM NUMBER], directly above room [ROOM NUMBER]. He explained that he was aware of the problem as the previous maintenance tech had worked on it. He stated he had ordered the parts to fix the leak a week or two ago but had not received the parts. He explained they typically took 4 to 10 days to ship. He stated that he had not checked the status of the order on 06/23/25. He shared that he had not put a formal work order in the system as of 06/23/25 at 3:24 PM but had communicated the issue verbally in a face-to-face report with the Acting Maintenance Director when he arrived at the facility that morning. 06/23/25 at 1:11 PM, the EVS Director was observed exiting the bathroom in room [ROOM NUMBER] with a mop and mop bucket. Observation of the bathroom revealed no water on the bathroom floor but several dirty and water saturated towels remained on the floor in front of the toilet. No water heard or seen from the open ceiling area above the toilet. When interviewed, the EVS Director stated that due to callouts in his department, he was assigned to room [ROOM NUMBER]. He explained he had just mopped the water up off the bathroom floor. When asked about the dirty wet towels on the floor the EVS Director stated, they were left there when someone was trying to clean up the water. The EVS Director left the room leaving the dirty wet towels on the bathroom floor. On 06/23/25 at 3:05 PM room [ROOM NUMBER] was observed along with the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS. The EVS Director stated that the floor had been cleaned but scuff marks were visible in the flooring. The EVS Director stated that the floor and room had been cleaned. He stated he was aware of the issue and was working with the chemical representative to evaluate floor cleaning solution concentrations to address it. There was trash can liners in place in all the trash cans but the bottoms of each had dried thick brown matter with brown splatters to walls of the trash cans. The group observed the square cut in the bathroom ceiling. No dripping water was noted or heard. The Acting Maintenance Director stated that the Maintenance Assistant had instructed the staff to turn off the water and not use the faucets in the room directly above room [ROOM NUMBER]. A large gray raised commode seat covered the toilet with a large white bucket on top to collect water. The bucket was empty. Several dirty and water saturated towels were on the floor in front of the toilet. A musty smell was noted on entering the bathroom. The Acting Director of Maintenance stated he would ask the Maintenance Assistant to share the status of the leak and the timeline for fixing it. The EVS Director stated above he was assigned the room. h. room [ROOM NUMBER] was observed on 06/23/25 at 10:15 AM. Shoe impressions and dirt were observed in the floor wax on the entire room floor. Raised, brown material observed on the left and right walls of the bathroom door. The ceiling above the toilet had an area with paint flaking and a round, brown stain approximately the size of a dinner plate present. There was no trash can liners in place for 2 of 2 trashcans and the bottoms of both cans were heavily soiled with dried dark brown and red matter with brown splatter to the walls of the trash cans. The assigned housekeeper for room [ROOM NUMBER] on 06/23/25 was not available for interview. On 06/23/25 at 3:10 PM room [ROOM NUMBER] was observed with the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS. Shoe impressions were present in the floor wax on the entire room floor. The EVS Director stated that the floor and room had been cleaned. He stated he was aware of the issue and was working with the chemical representative to evaluate floor cleaning solution concentrations to address it. Trash can liners were in place for both trashcans, but the bottoms of both cans remained heavily soiled with dried dark brown and red matter with brown splatter to the walls of the trashcans. The Regional Maintenance Director/Environmental Services (EVS) Director and the Acting Maintenance Director noted the ceiling stains and stated the building plumbing was older and leaks were an ongoing issue that was being addressed. i. room [ROOM NUMBER] was observed on 06/23/25 at 10:52 AM. The floor was noted to be sticky throughout the entire room. The shared closet area on right when entering the room had a hole just above the floor measuring 9 inches x 9 inches. (Measured by the Acting Maintenance Director during group observation rounds in the afternoon.) The closet shelf was broken and had pulled partially away from the wall of the closet. Under bed B by the headboard were a dinnerplate sized area of gray crumbles, which felt like plastic. In the bathroom a heavy buildup of brown/black material was observed in all corners and brown splatters on the walls behind the toilet and around the commode grab bars. The representatives of Resident #14 in room [ROOM NUMBER] were interviewed on 06/23/25 at 10:52 AM. They stated housekeeping did not clean her room daily. They stated that the gray plastic crumbles and dirt under Resident #14's bed had been there several days. 06/23/25 at 3:15 PM, in room [ROOM NUMBER]. The Acting Maintenance Director measured the hole in the shared closet and noted the broken closet shelf. The EVS Director, acting Maintenance Director, and Regional Maintenance/EVS Director observed under bed B by the headboard were a dinnerplate sized area of gray crumbles, which felt like plastic. In the bathroom a heavy buildup of brown/black material was observed in all corners and brown splatters on the walls behind the toilet and around the commode grab bars. The Acting Maintenance Director was unaware of the maintenance issues in room [ROOM NUMBER]. The Director of EVS stated that the room had been cleaned that day. He discussed not being aware of the issues in the room but would have expected the housekeeper to sweep under bed B and clean all surfaces in the bathroom that had visible dirt. j. On 06/23/25 at 09:30 AM and 2:30 PM the second-floor dayroom ceiling directly above air conditioning unit had two large, circular, brown rings. k. On 06/23/25 at 09:35 AM and 2:30 PM the second-floor metal threshold plates bolted to the floor on both hallways had heavy dirt buildup. l. On 06/23/25 at 10:45 AM and 2:43 PM the third-floor metal threshold plates bolted to the floor on the hallway had heavy dirt buildup. m. On 06/23/25 at 10:50 AM and 3:30 PM the fourth-floor metal threshold plates bolted to the floor on the hallway had heavy dirt buildup. On 06/23/25 at 3:25 PM, following the group walking rounds, a group interview was conducted with the Regional Maintenance Director/Environmental Services (EVS) Director, the Acting Maintenance Director, and the Director of EVS. The Acting Maintenance Director stated he was aware of the wall damage to the bathroom ceiling in room [ROOM NUMBER] and the bathroom wall holes but not to entry room walls in room [ROOM NUMBER] and room [ROOM NUMBER]. The Acting Maintenance Director stated that he spent a lot of his time trying to fix walls in the facility when it was brought to his attention. He stated he had been told of the pipe leak in room [ROOM NUMBER] by the Maintenance Assistant in the AM of 06/23/25 but he had not observed it himself before the group walking rounds. He offered to bring the Maintenance Assistant in to share the progress of repairs for room [ROOM NUMBER]. The Acting Maintenance Director stated that he was unaware of the baseboard issues in rooms of Rooms #311, #400, and #522 and the exposed electrical wires in room of room [ROOM NUMBER]. The Acting Maintenance Director stated that the expectations for staff were to report missing or loose baseboards, wall damage, leaks, or any other damage/issues through the electronic tracking system. The Regional Maintenance Director/Environmental Services (EVS) Director stated that he, the Acting Maintenance Director, and the Director of EVS all received immediate notification of issues on their phone app of work order system once staff entered a work order request. The Regional Maintenance/EVS Director and the Acting Maintenance Director stated they had not received notification of the issues in room [ROOM NUMBER] on their phone. On 06/23/25 at 3:35 PM. during the group interview, the Director of EVS stated that he was unaware of the floor, wall, and room cleanliness concerns for room [ROOM NUMBER], #228, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] and the dirt on the metal thresholds on the hallways of the second, third and fourth floors. The Director of EVS explained that the assigned housekeeper should wipe down any high touch areas, dust, clean the bathroom, empty trashcans, and sweep/mop the floor of each resident room daily. He stated that he and a floor technician were responsible for carpet cleaning and buffing and cleaning corners of rooms and bathrooms throughout the facility. The Director of EVS stated if the housekeeper saw spillage or dirt on the walls/doors they were responsible for cleaning the area. He shared that he was responsible for training the EVS staff in how to clean rooms and floors. The Director of EVS stated the rooms observed were not cleaned to expectations. The Director of EVS stated that he did routine rounds to look for issues several times a week. On 06/23/25 at 3:35 PM. The Maintenance Assistant explained he and the Acting Maintenance Director relied heavily on housekeeping and nursing assistants to complete work orders in the computerized tracking system. The Maintenance Assistant stated he was unaware of the holes in any of the walls other than the ceiling in room [ROOM NUMBER] because no one had entered the issue into the computerized system. He explained that anyone can enter an issue into the computerized system which then sends an alert to his phone. The Maintenance Assistant stated once an issue had been fixed, he logged into the computerized system and marked the issue as completed. The Maintenance Assistant stated that he did not do routine rounds to look for issues. The Administrator was interviewed on 06/23/25 at 3:50 PM. She stated it was her expectation that staff report missing or loose baseboards, items in disrepair in resident rooms, and water leaks in resident rooms. She stated that this could be done through the electronic tracking system or directly to the Maintenance Assistant. She was aware of ceiling stains and the water leak in room [ROOM NUMBER] but had not observed the room herself. The Administrator stated she was not aware of any of the floor and wall issues in room [ROOM NUMBER] and #522, and the exposed electrical wires in room of room [ROOM NUMBER] but the facility was in the process of hiring additional environmental services staff and hoped to have an additional full-time maintenance staff soon.

Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter drainage bag from touching the floor to reduce the risk of infection for 1 of 1 resident reviewed for urinary catheter (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE]. His related diagnoses included overactive bladder and neuromuscular dysfunction of bladder. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was moderately cognitively impaired with no behaviors. He was documented on the MDS as having an indwelling urinary catheter. Resident #6 had a care plan dated 03/11/25 for a suprapubic catheter due to neurogenic bladder (bladder doesn't empty or store urine properly due to nerve damage or dysfunction). The care plan interventions included positioning the catheter bag and tubing below the level of the bladder and away from entrance room door, checking for tubing kinks each shift. Record review revealed Resident #6 had a urinary tract infection (UTI) on 4/17/25. On 06/23/25 at 10:00 am Resident #6 was observed in his room in bed. He had an indwelling suprapubic urinary catheter connected to a bedside urine drainage bag. The bedside drainage bag was observed positioned below bladder level but unsecured and laying directly on the floor. The urine bag appeared to be half full. A follow up observation was conducted on 06/23/25 at 2:20 pm of Resident #6's suprapubic urinary catheter drainage system. The bedside drainage bag was observed positioned below bladder level but on the floor. The urine drainage bag appeared to be full. An interview and observation were conducted with Nurse Aide (NA) #1 on 06/23/25 at 2:20 pm who confirmed that she was assigned to Resident #6 on 06/23/25. NA #1 stated catheter care consisted of putting the drainage bag below the level of the bladder, not putting the bag on the bed, and securing it to the bedframe to keep it off the floor. NA #1 was accompanied to Resident #6's room and she confirmed Resident #6's urine drainage bag was lying on the floor. NA #1 attempted to hang the urine drainage bag back onto the bed frame but stated the hook for the bag was not able to be attached onto the bed frame. She stated that the nurse had been notified at beginning of shift when NA #1 observed in on the floor and determined it could not be attached to the bed frame. She stated that she would go now to obtain a privacy bag that would allow the urinary drainage bag to be attached to Resident #6's bed frame. When asked why she did not obtain a privacy bag earlier she stated, I didn't think about it. An interview was conducted with Nurse #1 on 06/23/25 at 2:25 pm. Nurse #1 stated she was the assigned nurse for Resident #6. Nurse #1 indicated she was told by the assigned NA the hook for Resident #6's urinary drainage bag would not attach to the bed frame and so the urine drainage bag was on the floor when she assumed the assignment that morning at 7:15 am. Nurse #1 confirmed she was aware the drainage bag had been on the floor all day and stated she meant to change the drainage bag to a drainage bag that would be able to attach to Resident #6's bed frame but had not had the time. An interview was conducted with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 06/24/25 at 4:10 pm. The IP/SDC stated urinary catheter drainage bags, and the drainage valve should be kept off the floor because of germs and to prevent contamination. The IP/SDC shared that urinary catheter bags should be hung on the side of the bed below the level of the bladder when a resident was in bed and the drainage valve should be secured. She stated that staff were provided with this training during the new hire process and during the facility's annual competency training. An interview was conducted with the Director of Nursing (DON) on 06/24/25 at 8:45 am. The DON stated that urinary catheter drainage bags should not be on the floor for infection control reasons. She stated the urinary drainage bag should be hung on the bed frame and positioned below the level of the bladder but should not be touching the floor. An interview was conducted with the Administrator on 06/24/25 at 8:45 am. The Administrator reported that urinary catheter drainage bags should not be on the floor for infection control reasons. She stated the urinary drainage bag should be hung on the bed frame and positioned below the level of the bladder but should not be touching the floor. The Administrator stated she did not know why staff had not fixed or changed out resident #6's drainage bag when they were aware of the issue.

Based on record review and staff interviews, the facility failed to safely assist a resident with incontinence care causing injury to 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 received care by Nurse Aide (NA) #1 and fell from her bed to the floor and sustained a closed fracture of the right hip. The findings included: Resident #1 was admitted on [DATE] with diagnoses which included dementia, malnutrition, and osteoporosis. Review of Resident #1's significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired and required extensive assistance with two people assist for bed mobility. The MDS further revealed Resident #1 was not coded for any upper or lower extremity impairment. Review of Resident #1's vital sign's dated 9/10/24 revealed Resident #1 weighed 97.3 pounds (lbs.). Review of Resident #1's care plan revised on 09/18/24 revealed the resident had an activities of daily living (ADL) self-care performance deficit due to dementia. Resident #1 required extensive to total assistance with ADLs. Interventions included Resident #1 required staff participation to reposition and turn in bed and was a two person assist for ADLs. Resident #1's care guide (undated) revealed the resident required staff participation to reposition and turn in bed and was a two person assist for ADLs. A progress note dated 09/29/24 completed by Nurse #1 revealed Nurse Aide (NA) #1 had provided care and Resident #1 rolled off the bed onto the floor. The note further revealed Resident #1 was assessed and had a small skin tear to the left shoulder. According to the note, as needed pain medication was administered, responsible party was notified, on call provider was notified, and the hospice nurse was also notified and indicated they would assess the resident to determine if Resident #1 needed to seek emergency care. A progress note dated 09/29/24 completed by Nurse #2 revealed Resident #1 was positive for a right femur fracture and was ordered to send the resident to the emergency room . Resident #1's order dated 09/29/24 revealed to start morphine sulfate concentrate 10 mg (milligram) every 6 hours for pain for 24 hours and hold if blood pressure is lower than 85. Review of hospital admission note dated 09/29/24 revealed Resident #1 was admitted to the hospital for a fall at the facility and obtained a closed fracture of the right hip. It was decided Resident #1 to receive orthopedic care management and not receive surgery. Resident #1 was discharged from the hospital and was discharged to another facility on 09/30/24. A phone interview conducted with NA #1 on 10/16/24 at 3:15 PM revealed she consistently cared for Resident #1 and was normally a one person assist for bed mobility due to being so small. NA #1 further revealed it was around 6:00 AM and she was giving incontinence care to Resident #1 alone and had the resident sit up in bed. NA #1 indicated the resident was sitting up in bed but it was wet, so she decided to do a linen change and while removing a sheet the Resident rolled over to her side and fell off the bed to the left and landed on her right side. NA #1 stated it happened so fast that she was unable to catch her. NA #1 revealed she immediately yelled for staff and Nurse #1 entered the room and assessed the Resident. NA #1 stated Nurse #1 and she assisted Resident #1 back into bed. NA #1 indicated Resident #1 did not make facial expression or noises that she was in pain. NA #1 revealed once the Resident was in bed it was shift change and she left around 7:00 AM. It was further revealed to NA #1 by the Director of Nursing (DON) going forward that Resident #1 needed a second person for bed mobility assistance. A phone interview conducted with Nurse #1 on 10/16/24 at 1:50 PM revealed on 09/29/24 at the end of 3rd shift she heard NA#1 yell out for assistance. Nurse #1 further revealed she went to Resident #1's room and found the resident laying on her right side on the left side of the bed. Nurse #1 indicated she assessed Resident #1 and found a small skin tear towards her right back shoulder with no other injuries. Nurse #1 indicated Resident #1 complained of pain in her feet but did not show any other signs of pain when assessed. Nurse #1 stated they transferred Resident #1 back into bed with a bed sheet and notified the hospice on call. Nurse #1 revealed she believed Resident #1 was a one person assist due to being so small. Nurse #1 stated NA #1 disclosed to her that she was giving incontinence care, and the resident fell off the bed when the NA turned her to dry her. Nurse #1 revealed she updated Nurse #2 at shift change and left her shift with the hospice staff coming to assess the resident. An interview conducted with Nurse #2 on 10/16/24 at 12:10 PM revealed she worked first shift 09/29/24 at 7:00 AM and Nurse #2 disclosed Resident #1 had a fall from her bed and that hospice was on the way to assess the resident as well. Nurse #2 further revealed when hospice arrived Resident #1 had experienced pain in her right hip, and it was ordered for Resident #1 to have a x-ray completed. Nurse #2 stated a mobile x-ray was obtained and results showed a possible right femur fracture. Nurse #2 stated she notified the family and hospice and sent Resident #1 to the emergency room (ER). A phone interview conducted with Hospice Director of Patient Services on 10/16/24 at 2:20 PM revealed on 09/29/24 hospice staff received a call Resident #1 had fallen from her bed and went out to the facility around 8:40 AM. It was further revealed hospice nurse assessed Resident #1 and observed bruising on right hip and was very tender to the touch. The Hospice Director of Patient Services stated orders were obtained for mobile x-rays to be completed which resulted in a right femur fracture. It was revealed Resident #1 was admitted to hospice on 09/04/24. A phone interview conducted with the Nurse Practitioner (NP) on 10/17/24 at 9:40 AM revealed Resident #1's health had declined mentally and physically. The NP further revealed Resident #1 was small and recalled her being a one person assist. The NP stated after the incident on 09/29/24 the facility spoke to her about the incident. The NP revealed Resident #1 had osteoporosis and was fragile due to decline of health. An interview conducted with the DON dated 10/17/24 at 10:20 AM the DON stated Resident #1 was not alert and oriented and laid on an air mattress. The DON further revealed she expected staff to follow resident care guides and keep residents safe when giving care. The DON indicated in-service was completed the next day with nursing staff. An interview conducted with the Administrator on 10/17/24 at 11:00 AM the Administrator revealed Resident #1 was coded and documented to be a two person assist and she expected for nursing staff to follow that. The administrator provided the following Corrective Action Plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 9/28/2024 Resident #1 rolled off of the bed and on to the floor while Certified Nursing Assistant (CNA) #1 was turning the resident on her side to provide care. Resident #1 was assessed by the nurse and had a small skin tear to the left shoulder. Nurse administered pain medication, responsible party was notified, on call provider was notified, and the hospice nurse was also notified and indicated they would assess to determine if Resident #1 needed to seek emergency care. Mobile x-ray of Resident #1 right hip and pelvis were obtained at the facility revealing an intertrochanteric fracture of the right femur. Resident #1 was sent to the emergency department for further evaluation and treatment of an intertrochanteric fracture of the right femur. Hospital x-rays confirmed right femur fracture. Resident discharged to a hospice house from hospital on 09/30/2024. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Residents care planned for maximum assistance of 2 people with activities of daily living (ADL) have been identified as having the potential to be affected by the deficient practice. The Director of Nursing (DON) and Unit Managers completed an audit of current residents with a care plan of maximum assistance of 2 people with ADLs, and 35 residents were identified to have the potential to be affected by the deficient practice by requiring maximum assistance of 2 people with ADLs. An audit was conducted 10/01/2024 to verify by observation that residents were provided the correct assistance with ADL care and bed mobility. No other residents were found to be affected as ADL care was provided by maximum assistance of 2 people for the 35 residents identified. Residents were interviewed while observations were completed, and none had concerns regarding with ADL care or assistance. DON, Assistant Director of Nursing (ADON), and Unit Managers will complete an assessment of residents upon admission, quarterly, and any change in condition will be re-assessed for any change required during ADL care assistance. Assessment will ensure if any changes are identified, care plan will be updated and referral to therapy if necessary. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Root cause analysis revealed Resident #1 was care planned for maximum assistance of 2 people however CNA #1 was providing care alone. Education was completed on 9/29/2024 with CNA #1 and on 10/01/2024 with current CNA staff by the Staff Development Coordinator (SDC). Certified Nursing Assistants (CNA) were educated on ADL care and bed mobility for residents that require maximum assistance of 2 people for safety. CNAs and newly hired CNAs or agency CNAs that did not receive the education will receive education prior to his/her next scheduled shift. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Quality assurance performance improvement (QAPI) committee met on 09/30/2024 and reviewed residents with ADL care that require maximum assistance and bed mobility. Plan for improvement was accepted by the committee. Results of audits and education will be presented by DON or ADON at QAPI committee for three months. Observational rounds during ADL care and ADL care plans were reviewed by administrative nurses to identify the amount of assistance required for residents on 10/01/2024. Administrative nurses will audit through observation 10 residents per week for twelve weeks to verify that ADL and bed mobility with maximum assist residents is completed correctly. The facility was in compliance effective 10/02/2024. An onsite validation of the facility's Corrective Action Plan was complated on 11/22/24. A review of the Bed Mobility Audit dated 10/1/24 revealed the audt was completed and there were no concerns. Reviewed education dated 10/1/24: Nursing Assistants (NAs) were to check the residents Kardex prior to providing care to ensure the correct amount of assistance is being provided. If a resident was care planned for maximum assistance of 2 people then 2 people must be present while providing Activity of Daily Living (ADL) care/bed mobility. Reviewed Inservice sign-in sheets with staff signage with dates of 9/30/24 & 10/1/24 and NAs were found to be trained. Reviewed bed mobility audit sheets dated 10/4/24, 10/8/24, 10/15/24, 10/25/24, 11/1/24, 11/4/24, 11/11/24, and 11/19/24. No concerns were identified. Resident #1 discharged to hospital on 9/29/24. Reviewed falls for 2 residents and no concerns were identified. Staff interviewed and they were able to verbalize education training provided in reference to providing care to ensure the correct amount of assistance needed for ADL care/ bed mobility. The facility was validated as being back into compliance as of 10/2/24.

Based on record review, observation, resident, and staff interviews the facility failed to protect a resident's dignity (a) when the resident was left with 3 briefs on that were soiled and saturated with urine during the breakfast meal and (b) left to urinate in a brief after she had told a Nursing Assistant (NA) #10 she had to urinate. The resident voiced feeling dirty angry and neglected. This occurred for 1 of 1 resident (Resident #209) reviewed for incontinence care. Findings included: 1 (a) Resident #209 was admitted to the facility on [DATE] with multiple diagnoses that included enterocolitis (inflammation in the intestines) and diabetes. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #209 was cognitively intact and required substantial to max assistance with toileting. The MDS documented Resident #209 with adequate vision and no issues with communicating. The MDS also documented Resident #209 was frequently incontinent of urine and always incontinent of bowel. Resident #209's care plan dated 5-23-24 revealed the resident had an activities of daily living (ADL) deficit due to enterocolitis and diabetes. The goal for Resident #209 was to improve the current level of ADL function. The interventions were one staff assist for personal hygiene and toileting. Resident #209 also had an intervention for two staff to assist the resident with transfers. Resident #209 was interviewed on 6-10-24 at 11:25am. Resident #209 was observed to be tearful and stated she was angry because she had been laying in a soiled and urine saturated brief since 8:15am. The resident explained she had put her call light on at 8:15am (stated she knew it was 8:15am because she looked at the clock on the wall) and asked NA #8 to be changed. She stated NA #8 told her she had to wait because the breakfast trays were arriving on the unit. Resident #209 said she told NA #8 again when she delivered her tray that she needed changed and stated NA #8 told her she would get changed after breakfast. Resident #209 said It is not right that I had to eat in this dirty brief and expressed this made her feel neglected and dirty. She stated she still had not been changed. The resident was observed to put her call light back on for assistance. Observation of incontinence care occurred on 6-10-24 at 11:33am with NA #4. During the observation, Resident #209 was observed to have 3 briefs and another brief was laid flat under her. When asked if she requested 3 briefs, Resident #209 stated no, the aide (NA #9) told me I had to have them on because I was a heavy wetter. It was observed that Resident #209's bowel movement and urine had seeped through all 3 briefs, the draw sheet, the cotton pad, and the fitted sheet. There were areas on the draw sheet, cotton pad, and fitted sheet that had dark yellow rings and on Resident #209's skin there were areas where her bowel movement had dried to her skin. The resident's skin was intact with no redness. NA #4 was interviewed on 6-10-24 at 11:44am. The NA explained she had come into work late, so she had not completed initial rounds on her assigned residents. She confirmed Resident #209 was assigned to her. NA #4 stated NA #8 had not informed her when she arrived that Resident #209 needed to be changed. When discussing the condition of Resident #209, NA #4 discussed that it was not normal practice to see 3 briefs on a resident and that due to the drying of urine and dried feces, NA #4 said she did not think the resident had been changed since the night before. NA #4 explained staff could change residents even when trays were being delivered and did not know why Resident #209 had not received incontinence care. During an interview with NA #8 on 6-10-24 at 11:50am, NA #8 explained the NA assigned to Resident #209 had come to work late so initial rounds were not completed on the resident. She stated at 8:15am, Resident #209 had put her call light on but said the resident never informed her she needed to be changed. When asked, NA #8 could not state what activity she provided the resident or what the resident wanted at 8:15am when she answered her call light. She also stated when she provided Resident #209 with her breakfast tray, the resident never told her she needed to be changed. A telephone interview occurred with NA #9 on 6-12-24 at 7:30am. The NA confirmed she had been assigned to Resident #209 on 6-9-24 during the 11:00pm to 7:00am shift. NA #9 explained she had usually changed Resident #209 every hour because she urinates a lot. She stated she had last changed Resident #209 between 6:00am and 6:30am on 6-10-24. NA #9 discussed Resident #209 asking for 2 briefs, but the NA stated she placed one brief on the resident and laid another one down flat under the resident. NA #9 stated she had not placed 3 briefs on the resident. A follow up interview occurred with Resident #209 on 6-12-24 at 10:33am. Resident #209 again stated she had not asked for extra briefs to be placed on her. She explained that NA #9 had told her she had to have 3 briefs on because she was a heavy wetter. (b) Observation and interview occurred with Resident #209 on 6-12-24 at 10:33am. The resident was observed wiggling in her bed. When questioned, Resident #209 stated she had to urinate. She explained she had put her call light on and when Nursing Assistant (NA) #10 arrived she had told the NA she had to urinate. Resident #209 explained NA #10 adjusted her brief and told her If you get the fitted sheet wet you will have to lay on just the mattress because we don't have any other fitted sheets. The resident said she has been holding her urine because she does not want to get her sheets wet. Resident #209 voiced feeling angry and neglected having to go to the bathroom in her brief when she could use a bed pan. When asked, Resident #209 stated she did not know why she was not taken to the bathroom or provided a bed pan. This surveyor left Resident #209's room and requested the unit manager come to the resident's room. Interview with the unit manager occurred on 6-12-24 at 10:37am. This surveyor explained Resident #209's situation and the unit manager questioned why NA #10 did not provide a bed pan. The unit manager was observed going to Resident #209's room where Resident #209 explained the situation. The unit manager provided Resident #209 a bed pan. The unit manager stated any resident who was able to use a bed pan should be provided a bed pan and that it was not dignified to expect a resident to urinate in a brief when they are able to use the restroom or bed pan. During an interview with NA #10 on 6-12-24 at 10:41am, the NA confirmed she had answered Resident #209's call light. She explained the resident had informed her she needed to urinate, and that the resident had asked her to adjust her brief. NA #10 stated she adjusted the resident's brief and walked out. NA #10 discussed not thinking about giving the resident a bed pan, because she was wearing a brief, and the resident did not specifically ask for a bed pan or to go to the bathroom. The Director of Nursing was interviewed on 6-12-24 at 2:37pm. The DON discussed staff receiving yearly training on incontinence care, dignity, and resident rights. She stated staff were able to provide incontinence care if the meal trays were on the unit but that she would expect them to wash their hands prior to passing the trays. The DON discussed Resident #209 and stated no resident should have to eat their meal in a soiled and wet brief. She also stated it was not the facilities policy to apply more than one brief to a resident. The DON explained if the resident requested more than one brief, the resident would be care planned for more than one brief. She stated since Resident #209 was cognitive enough to know when she needed to use the restroom, she would have expected NA #10 to offer Resident #209 to go to the bathroom or a bed pan. The Administrator was interviewed on 6-12-24 at 4:32pm. The Administrator discussed it not being appropriate for a resident to have on more than one brief but also said she felt this may have been a one-time occurrence. She stated if Resident #209 urinated frequently, then she would expect the resident to be care planned for more frequent visits. The Administrator also discussed if a resident was aware enough to say they needed to use the bathroom, then NA #10 should have offered this to Resident #209 instead of expecting the resident to use the bathroom in a brief.

Based on observation, record review, staff, and resident interviews, the facility failed to protect a resident's right to be free from neglect when Resident #209 was (a) left with 3 briefs on that were soiled and saturated with urine during the breakfast meal and (b) left to urinate in a brief after she had told a Nursing Assistant (NA) #10 she had to urinate. The resident voiced feeling dirty angry and neglected. This occurred for 1 of 1 resident (Resident #209) reviewed for neglect. Findings included: This tag is cross referenced to: F550: Based on record review, observation, resident, and staff interviews the facility failed to protect a resident's dignity (a) when the resident was left with 3 briefs on that were soiled and saturated with urine during the breakfast meal and (b) left to urinate in a brief after she had told a Nursing Assistant (NA) #10 she had to urinate. The resident voiced feeling dirty angry and neglected. This occurred for 1 of 1 resident (Resident #209) reviewed for incontinence care. The Administrator was interviewed on 6-12-24 at 4:32pm. The Administrator stated NA #8 had answered Resident #209's call light at 8:15am but had not changed the resident but said if Resident #209 needed incontinence care provided at that time NA #8 should have provided the care.

Based on observations, record reviews, and staff interviews, the facility failed to ensure the sanitizing solution (chlorine) was maintained at the required concentration of 50 ppm (parts per million) during the final rinse cycle according to manufacturer's instructions in the low temperature dish machine; failed to maintain the food service equipment clean, free from debris and in good working condition; failed to ensure leftover food items stored for use in the walk-in cooler and walk-in freezer were sealed, dated and labeled; and failed to ensure facial hair was covered by dietary staff during food preparation. These practices had the potential for cross-contamination of food served to residents. Findings included: 1a. During the initial tour of the kitchen on 6/10/24 at 10:40 a.m., the operation of the low temperature dishwasher of the soiled breakfast dishware by dietary staff was observed. The sanitizing solution (chlorine) for the low temperature dishwasher did not register on the chlorine testing strips provided by the dietary staff. After retesting the concentration of the chlorine solution in the dishwasher with the same results, this surveyor informed the DM (Dietary Manager) the observed dishware would have to be rewashed and sanitized: 1-rack of plates, 3-racks of lid covers, 2-racks of meal trays, and 1-rack of silverware. During an interview on 6/10/24 at 10:45 a.m., the DM revealed that earlier that morning she tested the chlorine sanitizer in the dishwasher, and it read 50 ppm. The DM directed the 2-dietary staff to discontinue using the dishwasher and transfer the dishware to the three compartment sink to be rewashed and sanitized. 1b. During an observation of the kitchen on 6/12/24 at 1:15 p.m., there were no doors attached to the door hinges of 4 of the 10 meal delivery carts. On 6/12/24 at 2:05 p.m., the DM revealed the doors to 4 of the 10 meal delivery carts had been in disrepair for approximately three months. 2a. On 6/10/24 at 10:46 a.m., during the initial tour, the floor of the kitchen had food particles scattered throughout and the floor area near the stove was slippery with grease. The lower wall behind the stove and convection ovens was also littered with dark grease spots. There was black grease and dried food crumbs on the inside and outside of the two convection ovens and the deep fryer. The inside of the two plate-warmers contained food debris and bread slices. Also, next to a food preparation table a stand-alone fan with dry, gray lint covering the protective grid while in use. 2b. A follow up visit to the kitchen on 6/12/24 at 2:05 p.m. revealed the lint covered standing fan was in operation while directed at the preparation table where dietary staff was preparing sandwiches. The two plate-warmers contained food debris and plastic gloves in the bottom and clean plates. The filter on the outside of the ice machine contained thick gray lint. During an interview on 6/12/24 at 4:56 p.m., the DM stated dietary did not have a cleaning policy but had a sanitation inspection policy checklist. The checklist the DM presented for review did not document the dietary staff assigned to any of the cleaning tasks. She revealed the dietary department did not maintain the completed sanitation checklists. 3. During the initial tour of the kitchen on 6/10/24 at 10:45 a.m., there was 1-unsealed and not dated box of rice on the shelf beneath the food preparation table. An observation of the walk-in cooler revealed 1-opened box with an opened bag of pork loin that was not dated; 1-resealed plastic bag of boiled eggs that was not dated, on the floor beneath the shelf; and 1-opened container of pasteurized liquid egg that was not dated. The walk-in freezer consisted of 10-plastic bags of unidentifiable frozen items, not dated or labeled (8-resealed and 2-not sealed). 4. During a kitchen observation on 6/12/24 at 1:15 p.m., 2 of 5 dietary staff were observed with exposed/uncovered facial hair ranging from 1/2 inch to 1 inch in length. The two staff were noted to perform various food service tasks including meal production and service without hair coverings over their facial hair.

Based on observations and staff interviews the facility failed to maintain clean and sanitary floors and walls (bathroom of rooms #321 and #509), maintain clean and sanitary shower curtains (rooms #503, #509, #512, and #525), maintain clean and sanitary privacy curtains (rooms #302, #321, #503, #504, and #506), ensure the toilet was clean and in good repair (room [ROOM NUMBER]), maintain doors and walls in good repair (rooms #424, #517, #525, and #528), maintain privacy curtain ceiling tracks in good repair (rooms #504 and #506), maintain bathtubs/showers clean and in good repair (rooms #506, #507, #516, #517, and #525), maintain furniture in good repair (rooms #409, #513), and maintain the ceiling and polyvinyl chloride pipe (PVC) in good repair (room [ROOM NUMBER]) for 4 of 4 halls (200 hall, 300 hall, 400 hall, and 500 hall ) reviewed for safe, clean, and homelike environment. The findings included: 1. (a). Observations of room [ROOM NUMBER] on 06/10/24 at 11:45 AM and 06/11/24 at 10:00 AM revealed dried brown matter scattered across the bottom of the shower curtain. The observation further revealed the bracket from which the polyvinyl chloride pipe (PVC) hung was dislodged from the ceiling. (b). Observations of room [ROOM NUMBER] on 06/10/24 at 11:50 AM and 06/11/24 at 10:05 AM revealed stained privacy curtains hung loosely off the eyelet hooks on the left side of 504 A bed and the left side of 504 B bed due to not being properly attached to the ceiling tracks. (c). Observations of room [ROOM NUMBER] on 06/10/24 at 12:00 PM and 06/12/24 at 11:18AM revealed hundreds of small pieces of shredded purple confetti paper and a sticky residue under the bed of 321 B. Stained privacy curtains hung on the left side in the bed of 321 A bed and the left side in the bed of 321 B bed. (d). Observations of room [ROOM NUMBER] on 06/10/24 at 12:17 PM and 06/11/24 at 10:07 AM revealed stained privacy curtains privacy curtains on the left side, by the door, of 506 A bed and the left side of 506 B bed due to not being properly attached to the eyelet hooks in the ceiling tracks. The privacy curtain rod for 506 B bed was dislodged from the drywall. Observation of the shared bathroom revealed the tiles around bathtub faucet had been removed and the plumbing pipes inside of the wall were exposed. (e). Observations of room [ROOM NUMBER] on 06/10/24 at 12:19 PM and 06/11/24 at 10:17 AM revealed the shower head was broken off from the shower fitting and was lying in the tub. (f). Observations of room [ROOM NUMBER] on 06/10/24 at 12:49 PM and 06/11/24 at 9:39 AM revealed a stained privacy curtain on the window side of the room was not attached well and the bracket was loose from wall. The privacy curtain near resident's bed was soiled with brown stains along the bottom and sides of the curtain. There were brown splatters and streaks on the wall behind the toilet in the bathroom and on the shower curtain. (g). Observations of room [ROOM NUMBER] on 06/10/24 at 1:18 PM and 06/11/24 at 10:24 AM revealed a stained shower curtain and dried smears of brown matter in the bathtub. There was a specimen collection container in the bathtub with dark amber matter in bottom. During the room observation on 06/10/24 the Resident's family member stated the brown matter on the wall, privacy curtain, shower curtain, and behind the toilet were from an episode of diarrhea the resident had experienced two weeks ago. She stated she had not expected there to still be feces on the wall when she arrived on 06/10/24. (h). Observations of room [ROOM NUMBER] on 06/12/24 at 8:46 AM and 06/12/24 at 4:00 PM revealed the vinyl wood grain veneer had peeled off the 3-drawer dressers on both resident's dressers. The middle drawer of 409 A's 3-drawer nightstand was missing and the bottom drawer of the nightstand had all the vinyl wood grain covering peeled off (exposing a plain yellow under surface). An interview was conducted with Housekeeper #2 on 06/11/24 at 10:07 AM while he cleaned room [ROOM NUMBER]. He stated the 500 hall was his assigned area for cleaning. He stated he swept and mopped each room daily. He further stated he disinfected the bathroom sink, toilet and bathtub in every resident room on the 500 hall daily. He said he had just completed his housekeeping duties for all rooms from 501through 514. When asked if he had swept, mopped, and disinfected the bedrooms and bathrooms for rooms 501through 514 he stated yes, completely. An interview and walking round were conducted with the Environmental Services Director and the Regional Director of Dietary and Environmental Services on 06/11/24 at 4:55 PM. Observations included the floors and walls of the bathrooms in rooms #321 and #509, the shower curtains in rooms #503, #509, #512, and #525, the privacy curtains in rooms #302, #321, #503, #504, and #506, the toilet in room [ROOM NUMBER], and the bathtubs/showers in rooms #506, #507, #516, #517, and #525. The Environmental Services Director stated routine cleaning of resident rooms included disinfecting all flat surfaces, sweeping and mopping the floor and bathroom floor, cleaning the bathroom sink, toilet, shower, and removing the trash. The Environmental Services Director stated all resident rooms were to be cleaned daily and as needed if the rooms needed further attention. The Environmental Services Director stated he expected bathrooms and resident rooms to be clean. He stated nursing staff were responsible for cleaning up any body fluids on the floor (blood, vomit, urine, and feces) and then environmental services staff disinfect the area after it has been cleaned. The Environmental Services Director and the Regional Director of Dietary and Environmental Services stated in-services on cleaning up body fluids on the floor will start immediately. They stated the stained shower curtains were being replaced. On 06/11/24 at 5:05 PM an interview was conducted with Nurse #1and she stated if a resident had diarrhea and it got on the floor, walls, or curtains the nursing staff cleaned visibly soiled areas and then housekeeping cleaned the rest. She stated this pertained to all other body fluids as well. An interview and walking round were conducted with the Maintenance Director on 06/12/24 at 2:11 PM. During observations of the rooms on the 500 hall he stated he was not aware of the condition of the rooms including the toilet in room [ROOM NUMBER], the doors and walls in rooms #424, #517, #525, and #528, the privacy curtain ceiling tracks in rooms #504 and #506, the bathtubs/showers in rooms #506, #507, #516, #517, and #525, the furniture in rooms #409, #513, and the ceiling and polyvinyl chloride pipe (PVC) in room [ROOM NUMBER]. He stated any staff could and should put in a work order through the computer-based maintenance reporting program. He stated when a member of staff observed broken equipment or furniture in disrepair it should be reported through a work order. He stated information would be placed at the nursing station to remind staff to enter work orders promptly. He stated the furniture in disrepair would be replaced. He stated he and his assistant made weekly rounds to prioritize repairs. He stated repairs that impacted resident safety were completed first. On 06/14/24 at 2:00 PM an interview was conducted with the Administrator, and she stated she was trying to get all needed repairs and cleaning up to date. She stated she had removed a lot of the broken furniture and prioritized replacements. She stated there were more needed repairs. She said staff should enter needed repairs in the computer-based maintenance reporting program but if it is an item that could impact resident safety it would need to be removed immediately. 38920 2. Initial tour and subsequent follow up tours of hall 300 revealed the following. (a) room [ROOM NUMBER] was observed on 6-10-24 at 9:57am. The floor was noted to be dirty with brown and orange particles and pieces of paper. On 6-11-24 at 8:32am, room [ROOM NUMBER] still had brown and orange particles as well as paper on the floor. Housekeeper #1 was interviewed on 6-11-24 at 8:34am. The housekeeper confirmed hall 300 was her assignment and explained she was not working yesterday (6-10-24). She explained when she was not working, management should assign another person to clean the hall. The housekeeper stated there were housekeeping staff on the weekends and should be emptying trash, cleaning the tables, sweeping, mopping and cleaning the bathrooms as she stated she completed each day. Observation of room [ROOM NUMBER] occurred on 6-11-24 at 8:38am directly after housekeeper #1 finished cleaning the room. The room was observed to still have brown and orange particles as well as paper on the floor. Housekeeper #1 observed room [ROOM NUMBER] with surveyor on 6-11-24 at 8:42am. The housekeeper stated, what did not come up needs to be scrapped and I do not have a scrapper. When showed the debris was not stuck to the floor, housekeeper #1 had no response. A fourth observation of room [ROOM NUMBER] occurred on 6-12-24 at 1:24pm with the Environmental Service Manager and the Maintenance Director. The room continued to have debris (brown/orange particles, paper) under the over the bed table, around the trash can, next to/under the bed, and in the corners. The Environmental Service Manager was interviewed on 6-12-24 at 1:25pm. The Environmental Service Manager stated the housekeepers are responsible for sweeping and mopping the floors. He explained his assistant conducted room to room morning rounds and if there were issues, he would speak to the housekeeper assigned to that room. When discussing the issues found, the Environmental Service Manager stated he did not believe his assistant was performing the rounds as he was supposed to. (b) During an initial observation of room [ROOM NUMBER], the room was observed to have an orange substance down the front of the heat/air unit, the floor had a yellow/orange substance that was sticky by the bathroom door, and there was debris on the floor that included food particles, paper, medicine cups, and dust. Another observation of room [ROOM NUMBER] occurred on 6-12-24 at 1:27pm with the Environmental Service Manager and the Maintenance Director. The room had orange substance down the front of the heat/air unit, the floor had a yellow/orange substance by the bathroom door, and there was debris on the floor that included food particles, paper, medicine cups, and dust. The Environmental Service Manager was interviewed on 6-12-24 at 1:28pm. The Environmental Service Manager stated the housekeepers are responsible for cleaning the front of the air/vent units. He stated he did not know why this had not been cleaned. (c) room [ROOM NUMBER] was observed on 6-10-24 at 10:42am. The privacy curtains in the room were observed to have 4 areas of a brown substance smeared on the curtain. On 6-12-24 at 1:30pm, a second observation was made of room [ROOM NUMBER] with the Environmental Service Manager and the Maintenance Director. The privacy curtains were observed to have 4 areas of a brown substance smeared on the curtain. The Environmental Service Manager was interviewed on 6-12-24 at 1:31pm. The Environmental Service Manager explained that HK was supposed to check the curtains for cleanliness and tell him if they needed to be cleaned. He also stated if staff saw the curtains were dirty, they could inform housekeeping so they could get them clean. The Environmental Service Manager stated he did not know why this was not completed. (d) An initial observation of room [ROOM NUMBER] occurred on 6-10-24 at 1:11pm. The room was observed to have paper, food particles, and an orange substance on the floor and a brown substance caked on the side rails of the resident's bed. A second observation of room [ROOM NUMBER] occurred on 6-11-24 at 11:09am. The room was observed to have been swept and mopped as the floor was still wet. However, the brown substance remained caked on the resident's side rails. During a third observation of room [ROOM NUMBER] occurred on 6-11-24 at 2:59pm. The observation revealed the caked on brown substance on the resident's side rails were still present. A fourth observation of room [ROOM NUMBER] occurred on 6-12-24 at 1:33pm with the Environmental Service Manager and the Maintenance Director. The observation revealed the caked on brown substance on the resident's side rails were still present. The Environmental Service Manager was interviewed on 6-12-24 at 1:34pm. The Environmental Service Manager explained that housekeeping would not clean up urine or feces. He explained nursing staff would perform the initial cleaning of the feces and then housekeeping would follow by disinfecting the area. The Environmental Service Manager stated he did not know if the brown substance was feces so housekeeping should have wiped down the resident's side rails. (d) room [ROOM NUMBER] was observed on 6-10-24 at 12:36pm. The observation revealed metal showing where the plaster and paint had been stripped away, the floor had a yellow/clear substance on the floor that was sticky, and there was a hole approximately 1 inch by 1 inch in the middle of the bathroom door. A follow up observation of room [ROOM NUMBER] occurred on 6-12-24 at 1:36pm with the Environmental Service Manager and the Maintenance Director. The observation revealed the yellow/clear substance had been cleaned however the metal was still showing where the plaster and paint had been stripped away and there was a hole approximately 1 inch by 1 inch in the middle of the bathroom door. The Environmental Service Manager was interviewed on 6-12-24 at 1:37pm. The Maintenance Director discussed having one person assigned to plaster and paint but said he did not know if he was aware of the issues in room [ROOM NUMBER]. (e) During a resident interview and observation of room [ROOM NUMBER] on 6-10-24 at 10:13am, the resident stated he was able to use the bedside commode but on Saturday (6-8-24) he stated he had a bowel movement on the floor by the bedside commode. Upon observing the room, the bowel movement was present under/behind the bedside commode. The resident stated staff were aware because he told them but said he could not remember who he told. Another observation of room [ROOM NUMBER] on 6-11-24 at 8:16 revealed there was still feces on the resident's floor under/behind the bedside commode. NA #18 was interviewed on 6-11-24 at 8:20am. The NA confirmed she had worked the weekend with the resident but stated she was not aware he had a bowel movement on the floor. A third observation on 6-11-24 at 11:00am, after the housekeeper was seen cleaning the resident's room, revealed remanence of feces under/behind the bedside commode. A fourth observation of room [ROOM NUMBER] occurred on 6-12-24 at 1:39pm with the Environmental Service Manager and the Maintenance Director. The observation revealed a brown/orange area where the feces had been under/behind the resident's bedside commode as well as red/orange debris under his bed and food particles on the floor. The Environmental Service Manager was interviewed on 6-12-24 at 1:40pm. The Environmental Service Manager discussed starting training with the housekeeping staff on how to properly clean a resident's room. He stated the training started yesterday (6-11-24) but that the housekeeper for hall 300 was not present. (f) room [ROOM NUMBER] was observed on 6-10-24 at 11:02am. The room was observed to have an approximately 2 foot wide by 2.5-foot-long area of a yellow dry sticky substance at the head of the bed. There were also brown and orange substances on the resident's wall next to her bed. A follow up observation of room [ROOM NUMBER] occurred on 6-12-24 at 1:41pm with the Environmental Service Manager and the Maintenance Director. The follow up observation revealed remanence of the yellow substance and the brown and orange substances on the resident's wall next to her bed remained present. The Environmental Service Manager and the Assistant Administrator were interviewed on 6-12-24 at 1:43pm. The Environmental Service Manager discussed that housekeeping was supposed to be checking the walls for any spills or dirt and cleaning any area that contained an issue. The Environmental Service Manager stated he had not been aware of the issues discussed during the observations. The Assistant Administrator stated she believed there was a disconnect between what the facility felt was clean and what the Environmental assistant believed to be clean. The Director of Nursing (DON) was interviewed on 6-12-24 at 3:04pm. The DON stated she could not speak to the environment but stated the Environmental Service Manager was new to the building. The DON also stated the nursing staff were aware they were responsible for cleaning any urine or feces first then contacting housekeeping to disinfect. She stated she did not know why feces had stayed on the resident's floor for days. The Administrator was interviewed on 6-12-24 at 5:09pm. The Administrator discussed housekeeping staff needing to identify those residents who require more frequent cleaning and develop a cleaning schedule. She also discussed that there were assigned staff to perform ambassador rounds each morning in the resident rooms and stated if the ambassador was not catching the issues, then staff or housekeeping should. The Administrator explained If a staff member (ambassador, nursing, maintenance) saw any issues, she would expect them to report the issue to the proper staff so the issue can be resolved. 20906 3.a. Observation was conducted on 6/11/24 at 12:42 PM, room [ROOM NUMBER] there were several pieces of tile missing from the back wall in the bathtub. b. Observation was conducted on 6/11/24 at 12:47 PM, room [ROOM NUMBER] there was no drain faucet in the bathtub. c. Observation was conducted on 6/11/24 at 12:48 PM, room [ROOM NUMBER], the closet doors and drawers were broken apart. The floor was very sticky, heavily stained and a very strong urine odor was present. There was stained dried liquids and old food under resident beds and around dresser and closet area. An interview was conducted on 6/12/24 at 2:27pm, the Maintenance Director stated work orders are put into the maintenance work order program which generated a work list. He further stated he did not have a complete list of repairs that needed to be done throughout the facility. The assigned maintenance staff for each of the floors were responsible for doing rounds and completing the needed repairs in resident rooms such as shower heads, tiles in bathrooms should be reported to maintenance the work order system. He indicated he did not have a system in place to monitor the repairs. 42007 4. An observation was conducted on 6/11/24 at 12:30 PM, room [ROOM NUMBER] showed 5 feet of baseboard trim lying on the floor and not attached to the drywall. The inside of the bathroom door had deep, large scrapes dug into the bottom quarter of the door exposing rough wood door grain. There were also deep, large gouges into the wall just inside of the bathroom on the right-hand side exposing the drywall. Further inspection of the bathroom revealed the faucet in the bathtub was running. The faucet handles were in the off position. During an interview with the resident in bed A, whose quarterly Minimum Data Set assessment dated [DATE] had him as cognitively intact, on 6/11/24 at 12:40 PM, he stated that maintenance had fixed the trim on the baseboard several weeks ago, but it didn't stay that way for long before it fell off again. He also stated that the bathtub faucet had been running for several days. He stated that he mentioned it to several aides, but nothing had been done to fix it. An interview and observation were conducted with the Administrator on 6/11/24 at 1:24 pm in room [ROOM NUMBER]. She stated that she was unaware of the issues in that room and was also unaware that the resident in bed A had attempted to bring it to the attention of staff multiple times. She stated that she would see to it that maintenance was made aware of the issues immediately. An interview was conducted on 6/13/24 at 3:34pm, the Maintenance Director stated the nursing staff would enter needed repairs into the computerized system that would notify him and his staff. He stated they would print out the work repair requests and assign the tasks to maintenance staff assigned to each floor who were supposed to be doing weekly rounds for all areas including resident rooms. He stated he was not aware of the issues in room [ROOM NUMBER] and was also not aware that the bathtub faucet was running. He stated that the system currently in place was for maintenance workers to check their assigned floor for any issues.

Based on record reviews and staff interviews the facility failed to submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination 3 of 4 residents (Resident #37, Resident #102 and Resident #103) reviewed for PASRR. Resident #37, Resident #103 and Resident #102 received a new mental health diagnosis following admission. The findings included: 1. Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included traumatic brain injury (TBI), dementia with agitation and major depressive disorder. Upon re-admission, Resident #37 had a Level I PASRR number. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. The MDS further revealed the resident had no behaviors during the look back period. Nursing note dated 10/19/23 and authored by Nurse # 11 revealed Resident #37 had increased agitation. Further review of the nursing note revealed Situation, Background and Assessment (SBAR) for providers. The situation stated a change in condition were behavioral symptoms to include agitation and psychosis. Nursing progress note dated 11/8/23 and authored by Nurse #2 revealed Resident #37 was having behaviors of hallucination and being aggressive because of the hallucinations. The note continued with orders to refer the resident to psychiatry, give 1 time dose of Haldol (an anti-psychotic medication) 1 milligram (mg) and lab work to include complete blood count (CBC), comprehensive metabolic panel (CMP). Physician order dated 11/8/23 stated Haloperidol tablet 1mg. Give 1 tablet by mouth one time only for mood/aggressive behaviors until 11/8/23. Behavior note dated 2/19/24 and authored by Nurse #6 revealed Resident #37 was noted being aggressive with a visitor. Physician order dated 2/19/24 revealed Haloperidol lactate injection solution 5mg/ml (milliliter). Inject 2.5mg intramuscularly (IM) one time only for agitation and aggressiveness for 1 day. Care Plan dated 3/4/24 revealed Resident #37 had the potential to be verbally aggressive (resident hit/punching others) related to dementia, ineffective coping skills, mental/emotional illness, poor impulse control and resident had a history of Post Traumatic Stress Disorder (PTSD). The goals included Resident #37 would demonstrate effective coping skills and Resident #37 would verbalize understanding of need to control verbally abusive behavior. The interventions included psychiatric/psychogeriatric consult as indicated and when the resident became agitated intervene before agitation escalates; bide away from source distress, engage calmly in conversation; if response is aggressive staff to walk calmly away and approach later. Behavior note dated 3/3/24 and authored by Nurse #9 revealed the Resident #37 made inappropriate sexual remarks to the Medication Aide and verbalized delusional thoughts regarding implants in his ear and being ambushed by a family member. Quarterly MDS assessment dated [DATE] indicated Resident #37 was cognitively intact, had no behaviors during the look back period and had a diagnosis that included Post Traumatic Stress Disorder. Behavior note dated 5/24/24 and authored by Nurse #10 revealed Resident #37 went into two resident rooms and demanded the residents turn their tv's off. Resident #37 was educated that he could not go into other residents' rooms. The note continued with Resident #37 began swinging his cane in the hallway towards the resident in one of the rooms. Resident #37 was informed he could not use his cane to hit another person or swing it toward anyone in the facility. Resident #37 then called the nurse a racial slur and began swinging his cane towards the nurse. The nurse was able to get the cane and escorted Resident #37 back to his room. The Assistant Director of Nursing (ADON) was made aware. Nursing note dated 5/28/24 and authored by Nurse #2 started the nurse had spoken with Resident #37's family about his verbal and physical aggression towards staff and resident. A new order was received for Ativan 3 times a day (TID). Patient centered care follow note dated 5/28/24 revealed Resident #37 was seen for an acute visit due to nursing staff complaint of agitation. Resident #37 stated he had been feeling more agitated lately. There were no new recommendations identified on the follow up note. Review of SBAR Summary for providers dated 6/2/24 and authored by Nurse #4 indicated a change in condition that was identified as behavioral symptoms to include agitation and psychosis. The note continued with nursing observations, evaluation and recommendations were Resident #37 was observed being verbally aggressive with staff. Charged staff member resulting in loss of balance and fall without injury. Resident continued verbally aggression shortly after occurrence. The on-call Nurse Practitioner (NP) indicated to send resident to emergency room (ER) for evaluation. The recommendations stated send Resident #37 to ER for evaluation following combative/aggressive behavior. Review of Resident #37's medical record revealed a new application for PASRR had not been completed after the resident was diagnosed with PTSD and demonstrated a change in behaviors. Interview with the Social Worker on 6/13/24 at 11:00 am revealed she was responsible for submitting information to North Carolina Medicaid Uniform Screening Tool (NC MUST-an online platform used to complete PASRR applications) when a resident experienced a change in condition regarding behaviors that may be associated with mental illness. She further indicated she had a number of residents during her audit that were in need of being screened or re-screened. She indicated she was aware of an increase in behaviors with Resident #37 and indicated with his change in condition he would need to be screened to determine if there would be a change in his PASRR I status. In a continued interview with the Social Worker on 6/13/24 at 11:20 am indicated Resident #37 was not identified during her audit and had not had a request for screening by PASRR. She further stated she must have missed him during her audit. Interview with the Director of Nursing (DON) on 6/13/24 at 3:18 pm revealed the Social Woker was responsible for notifying NC MUST of residents that had a change in condition to establish a new PASRR level. 27111 2. Review of Resident #102's medical record revealed documentation of a Level I PASRR determination dated 6/22/18 prior to his admission on 11/8/21. His admission diagnoses included dysphagia and hypertension. A diagnosis of schizoaffective disorder was added on 11/1/23. Further record review did not indicate a referral for a Level II PASRR review had been made. An interview with the Social Worker on 6/13/24 at 2:01PM revealed that she was not aware of Resident #102 had a change of diagnosis. An interview with the Administrator on 6/14/24 at 10:40 AM revealed a new diagnosis of paranoid schizophrenia or schizoaffective disorder should be triggered for a new PASRR evaluation. She indicated that she had started an audit to make sure that the PASRR was getting done by the Social Worker. She stated maybe the audit was not as effective as she thought since one of the residents was missed by the audit. 3. Review of Resident #103's medical record revealed documentation of a Level I PASRR determination dated 7/21/17 prior to his admission on 12/17/21. His admission diagnoses included anxiety, depression, respiratory failure and diabetes mellitus. A diagnosis of paranoid schizophrenia was added on 8/1/23. Further record review did not indicate a referral for a Level II PASARR review had been made. An interview with the Social Worker on 6/13/24 at 2:01PM revealed that Resident #103 had the new diagnosis of paranoid schizophrenia and corporate had directed her to refer for a new PASRR. She revealed that the new diagnosis was on 8/1/23 and it should have already been referred. She indicated that she had the stack of referrals on her desk, she was the only person with the PASRR logon, and she was behind. An interview with the Administrator on 6/14/24 at 10:40 AM revealed a new diagnosis of paranoid schizophrenia or schizoaffective disorder should be triggered for a new PASRR evaluation. She indicated that she had started an audit to make sure that the PASRR was getting done by the Social Worker. She stated maybe the audit was not as effective as she thought since one of the residents was missed by the audit.

Based on staff and consultant pharmacist interviews and record reviews, the facility failed to act on recommendations made by the consultant pharmacist and retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record for 1 of 7 residents whose medications were reviewed (Resident #97). The findings included: Resident #97 was admitted to the facility on [DATE]. Her cumulative diagnoses included an adjustment disorder with anxiety. A review of the resident's electronic medical record (EMR) revealed the following medication orders were received for diazepam (an antianxiety medication). Diazepam is a psychotropic medication and a controlled substance medication. --A physician's order was received on 11/10/23 for 5 milligram (mg) diazepam to be given as one tablet by mouth every 8 hours as needed (PRN) for anxiety. The order was discontinued on 12/6/23. --On 12/12/23, 5 mg diazepam was ordered to be given by mouth every 8 hours PRN for anxiety and/or muscle relaxant. This order was discontinued on 12/19/23. --A physician's order was received on 12/19/23 for 5 milligram (mg) diazepam (an antianxiety medication) to be given as one-half tablet (2.5 mg) by mouth scheduled twice daily for anxiety. --On 2/23/24, an order was received for 10 mg diazepam to be given as one tablet by mouth every 8 hours as needed for crying and/or anxiety. There was no end date or rationale documented for this PRN diazepam order to be extended beyond 14 days. --The order for the 2.5 mg of scheduled diazepam given twice daily was discontinued on 3/22/24 and another order was received on 3/22/24 for 5 mg of diazepam to be given as one tablet by mouth scheduled twice a day for anxiety. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. Resident #97 was reported to have intact cognition with no behaviors nor rejection of care. The Medication section of the MDS revealed Resident #97 received an antianxiety medication during the 7-day look back period. Resident #97's EMR indicated the physician's orders for both the scheduled diazepam (ordered on 3/22/24) and the PRN diazepam (ordered on 2/23/24) continued as active orders up through the date of the review on 6/12/24. A review of Resident #97's Medication Administration Records (MARs) revealed eight (8) doses of PRN diazepam were administered to the resident from 2/23/24 through the date of the review (6/12/24). The last dose of PRN diazepam was documented as having been administered on 6/7/24. The resident's EMR also included Pharmacist Reviews / Visit Progress Notes completed by the consultant pharmacist each month from August 2023 to May 2024 on the following dates: 8/31/23; 9/30/23 10/30/23; 11/29/23; 12/30/23; 1/30/24; 2/29/14; 3/30/24; 4/30/24; and 5/31/24. Each of these monthly notes read: MRR [Medication Regimen Review] completed: Medical Record Reviewed including: orders, available labs, progress notes. See consultant pharmacist report for consult on any noted irregularities and/or recommendations. A request was made for the facility to provide the consultant pharmacist reports with the noted irregularities and/or recommendations made for Resident #97 from August 2023 up to the date of the review (6/12/24). The facility provided two pharmacist reports (Consultant Pharmacist Medication Regimen Reviews) for Resident #97. Only one report (dated 2/29/24) was related to the PRN diazepam ordered for Resident #97. The Consultant Pharmacist Medication Regimen Review dated 2/29/24 noted the pharmacist made a recommendation to Psychiatry which read, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for the PRN order. This recommendation was signed by a Nurse Practitioner (NP) on 3/21/24 with a response that read: Continue current dose of diazepam 10 mg q 8 hrs (every eight hours) PRN for anxiety. Neither the duration of the order nor the clinical rationale for continuation of the PRN diazepam were addressed in the provider's response. The NP who responded to the pharmacist's 2/29/24 recommendation related to PRN diazepam use for Resident #97 was not available for an interview and no longer worked at the facility. A telephone interview was conducted on 6/13/24 at 3:23 PM with the facility's consultant pharmacist. During the interview, the pharmacist confirmed she had made multiple recommendations to address the use of Resident #97's PRN diazepam over the last several months. The pharmacist was also informed of a concern regarding the facility's failure to retain the pharmacist's Consult Reports and/or provider responses. She stated that all the pharmacist's recommendations (without the physician's responses) were available for review within the facility via a connection with the pharmacy's software. The pharmacist reported she typically encouraged each of her facilities to give one copy of the pharmacy recommendations to the provider while they kept a second copy in a binder. After the provider returned a signed response for the recommendation, one copy should be scanned into the resident's permanent medical record with another copy replacing the unsigned recommendation in the binder. On 6/14/24 at 9:14 AM, additional documentation was provided by the consultant pharmacist for review. The documents included three (3) Consultant Pharmacist Medication Regimen Reviews with recommendations related to Resident #97's PRN diazepam. These three Consultant Pharmacist Medication Regimen Reviews had not been previously provided by the facility. Neither the resident's EMR nor the facility provided documentation to show Resident #97's physician reviewed or responded to the following Consultant Pharmacist Medication Regimen Reviews: --On 11/30/23, the pharmacist made a physician recommendation which noted, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for the PRN order. --On 1/31/24, a recommendation was made to Psychiatry which read, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for the PRN order. --On 5/31/24, a recommendation was again made to Psychiatry which read, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for the PRN order. An interview was conducted on 6/14/24 at 12:50 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she was aware that orders for PRN psychotropic medications required a stop date. The DON also stated that she was now aware that additional documentation was required to continue PRN psychotropic medications (other than antipsychotic meds) for an extended duration.

Based on observations, interviews with staff, and record reviews, the facility failed to: 1) Label medications (meds) with the minimum information required, including the name of the resident, on 1 of 5 medication (med) carts observed (300 Short Med Cart); 2) Discard expired medications and/or meds without a legible expiration date on 4 of 5 medication carts observed (300 Short Med Cart, 300 Long Med Cart, 200 Long Med Cart, and 200 Short Med Cart); 3) Discard opened single-dose vials (SDV) after their initial use on 2 of 5 medication carts observed (300 Short Med Cart and 300 Long Med Cart); 4) Store medications in accordance with the manufacturer's storage instructions on 2 of 5 medication carts observed (300 Long Med Cart and 200 Long Med Cart). The findings included: 1. An observation was conducted on 6/11/24 at 4:00 PM of the 300 Short Med Cart in the presence of Nurse #9. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use insulin glargine prefilled pens should be stored at room temperature of less than 86 Fahrenheit (oF) and used within 28 days. One (1) opened insulin glargine pen was observed to be stored on the medication cart. The pen was not labeled with a resident's name or the date it had been opened. When asked, Nurse #9 examined the insulin pen and confirmed it was not labeled with a resident's name or date it was opened. The nurse stated the pen would need to be discarded. b. According to the product manufacturer, in-use insulin lispro prefilled pens should be stored at room temperature of less than 86 oF and used within 28 days. One (1) opened insulin lispro prefilled pen was observed to have an illegible name written in a blue marker on the pen. Initially, Nurse #9 stated she thought the insulin pen belonged to Resident #84. However, the pen was stored inside a plastic bag labeled with Resident #103's name. The pen was not labeled as to when it had been opened or put on the medication cart. Upon further inquiry, the nurse stated the pen would need to be discarded. c. According to the product manufacturer, in-use insulin aspart prefilled pens should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days. One (1) opened insulin aspart prefilled pen with Resident #185's name hand-written on the pen was stored on the med cart. The pen was also labeled with a handwritten (but illegible) date as to when it had been opened. An interview was conducted with Nurse #9 at the time of the observation. When the nurse was asked whether she could read the date the pen had been opened, she reported she could not. d. The Center for Disease Control and Prevention (CDC) Injection Safety Guidelines include information on when single-dose vials (SDVs) should be discarded. The Guidelines state, Vials that are labeled as single-dose or single-use should be used for only a single patient as part of a single case, procedure, injection . Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient. One (1) opened 1 milliliter (ml) vial of 1000 micrograms (mcg) / ml of cyanocobalamin (Vitamin B12) for injection was observed stored on the med cart. The vial was labeled as a single dose vial (SDV). At the time of the observation, Nurse #9 was asked what her thoughts were about the opened SDV being stored on the med cart. The nurse responded by stating she would typically discard a SDV after it had been opened. An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired. With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications. 2. An observation was conducted on 6/11/24 at 11:38 AM of the 300 Long Medication (Med) Cart in the presence of Nurse #5. The observation revealed the following medications were stored on the med cart: a. According to the product manufacturer, in-use insulin lispro prefilled pens should be stored at room temperature of less than 86 degrees Fahrenheit (oF) and used within 28 days. An opened insulin lispro pen dispensed for Resident #1 was stored on the medication cart. An illegible date was written on a yellow auxiliary sticker placed on the pen to indicate when the pen was opened. No expiration date was noted on the sticker. The yellow auxiliary sticker read, Discard after 28 days. The mini sticker on the pen included a date as to when the pen was dispensed from the pharmacy, but that date was also illegible. At the time of the observation, Nurse #5 was asked what her thoughts were about the dates on the insulin pen. The nurse stated she could not read them. b. According to the product manufacturer, in-use insulin aspart prefilled pens should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days. One (1) opened insulin aspart pen dispensed for Resident #209 on 5/13/24 was stored on the med cart. The yellow auxiliary sticker placed on the pen by the pharmacy had two blanks (one blank was for the Date Opened and one for the Date Expired). Neither date was filled out. The auxiliary sticker read, Discard after 28 days. Upon review, it was determined 29 days had elapsed since the insulin pen had been dispensed from the pharmacy. c. According to the manufacturer, in-use insulin glargine prefilled pens should be stored at room temperature (less than 86 oF) and used within 28 days. One (1) opened insulin glargine pen dispensed from the pharmacy on 5/9/24 for Resident #190 was stored on the med cart. A yellow pharmacy auxiliary sticker placed on the pen had one date written on the Date Expired line which read, 6/9. Upon inquiry, Nurse #5 stated that most staff usually wrote the opened date on the insulin pens. However, she added that they probably should also write the shortened expiration date on the auxiliary sticker so there would be no confusion. The nurse confirmed it could not be determined for certain whether the insulin pen was past its expiration date. d. The Center for Disease Control and Prevention (CDC) Injection Safety Guidelines include information on when single-dose vials (SDVs) should be discarded. The Guidelines state, Vials that are labeled as single-dose or single-use should be used for only a single patient as part of a single case, procedure, injection . Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient. 1) Two (2) opened 10 milliliter (ml) single-dose vials (SDV) of sterile water for injection was stored on the med cart. The vial of sterile water for injection was labeled for single use only. 2) One (1) opened 5 ml SDV of 1% lidocaine for injection was stored on the med cart. The vial of lidocaine was labeled for single use only. At the time of the observation, Nurse #5 was asked what her thoughts were about the opened SDV being stored on the med cart. The nurse reported the vials needed to be discarded. e. According to the product manufacturer, an unopened Humalog KwikPen should be stored under refrigeration between 36 oF and 46 oF until the expiration date or at room temperature (less than 86 oF) and used within 28 days. One (1) unopened Humalog Kwikpen dispensed from the pharmacy on 6/10/24 for Resident #159 was stored on the med cart. No date was written on the pen as to when it had been put on the med cart. When Nurse #5 was asked, she reported the unopened pen should have been stored in the med room refrigerator until it needed to be opened. An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications. 3. An observation was conducted on 6/11/24 at 3:30 PM of the 200 Long Med Cart in the presence of Nurse #6. The observation revealed the following medications were stored on the med cart: a. The manufacturer's storage instructions printed on the box of 0.5 milligrams (mg) / 2 milliliters (ml) budesonide inhalation suspension read, in part: .Store unopened ampules in the foil envelope placed upright in the carton .Once the foil envelope is opened, use the ampules within two weeks. 1) One (1) manufacturer's box of 0.5 mg/ 2 ml budesonide inhalation suspension ampules dispensed from the pharmacy on 4/23/24 for Resident #415 was stored on the med cart. The box contained one opened envelope with 4 ampules stored inside. The opened envelope was not dated as to when it was opened. 2) One (1) manufacturer's box of 0.5 mg/ 2 ml budesonide inhalation suspension ampules dispensed on 4/30/24 for Resident #197 was stored on the med cart. The box contained one opened envelope with 2 ampules stored inside and one ampule placed outside of the foil envelope and lying on the bottom of the box. The opened envelope was not dated as to when it was opened. 3) One (1) manufacturer's box of 0.5 mg/ 2 ml budesonide inhalation suspension ampules dispensed on 5/11/24 for Resident #150 was stored on the med cart. The box contained 3 unopened pouches and one opened pouch with 1 ampule stored inside. The opened pouch was not dated as to when it was opened. b. The manufacturer's storage instructions printed on the box of 0.25 mg / 2 ml budesonide inhalation suspension read, in part: .Store unopened ampules in the foil envelope placed upright in the carton .Once the foil envelope is opened, use the ampules within two weeks. One (1) manufacturer's box of 0.25 mg/ 2 ml budesonide inhalation suspension ampules dispensed from the pharmacy on 4/23/24 for Resident #415 was stored on the med cart. The box contained three unopened envelopes and one opened envelope with 1 ampule stored inside. The opened envelope was not dated as to when it was opened. c. The manufacturer's storage instructions printed on the box of 0.5 mg / 3 mg ipratropium / albuterol inhalation solution read in capital letters: Store in pouch until time of use. One (1) manufacturer's box of 0.5 mg / 3 mg ipratropium / albuterol inhalation solution dispensed from the pharmacy on 4/25/24 for Resident #143 was stored on the med cart. Two vials were stored in the manufacturer's box (not inside of a pouch). No pouch was in the box. An interview was conducted with Nurse #6 at the time of the medication cart observation. During the interview, the nurse acknowledged the envelopes (or pouches) containing inhalation solution or suspension ampules needed to be dated when opened. An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications. 4. An observation was conducted on 6/11/24 at 3:05 PM of the 200 Short Med Cart in the presence of Nurse #8. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use Fiasp insulin prefilled pens should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days. One (1) opened Fiasp insulin pen dispensed from the pharmacy on 4/29/24 for Resident #78 was dated to indicate it was opened on 5/5/24. Upon review, it was determined 37 days had elapsed since the insulin pen had been opened and it was kept past its shortened expiration date. During an interview conducted with Nurse #8, the nurse was asked what her thoughts were with regards to this insulin pen. She confirmed the insulin pen was expired. b. According to the manufacturer, in-use Lantus insulin vials should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days. One (1) opened Lantus insulin vial dispensed from the pharmacy on 4/18/24 for Resident #177 was stored on the med cart. A yellow pharmacy auxiliary sticker placed on the vial containing the insulin had two blanks (one blank for the Date Opened and one for the Date Expired). Neither of the dates were filled out. The auxiliary sticker also read, Discard after 28 days. When Nurse #8 was asked how she would know whether the insulin vial had been kept past its shortened expiration date, she stated, I wouldn't. An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications.

Based on record review, staff, and Nurse Practitioner (NP) interviews the facility failed to immediately notify the physician of Resident #250's unwitnessed fall that occurred on [DATE] at 1:00 p.m. The on-call physician was not notified of the fall until [DATE] at 6:50 p.m. when it was discovered the resident had an altered mental status. The facility also failed to immediately notify the physician when the ordered intervention of STAT (immediate) laboratory work and normal saline (mixture of sodium chloride and water used to treat dehydration) were not able to be completed STAT. Additionally, the facility failed to notify the physician of Resident #250's tube feeding that was found leaking on the floor and in the bed. These failures resulted in a delay in the physician's initial assessment and initiation of treatment. Resident #250 was discovered unresponsive in her bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. This occurred in 1 of 2 residents reviewed for notification of change. Immediate Jeopardy began on [DATE] when Resident #250 had an unwitnessed fall from the bed that occurred at 1:00 p.m. and Charge Nurse #1 failed to immediately notify the physician. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (actual harm that is not immediate jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee training. The findings included: Resident #250 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #250 had severe cognitive impairment and had not had a fall since the prior assessment. The Resident had a feeding tube and received greater than 51% of meals and greater than 501 cubic centimeters (cc) of fluids by this route. A review was conducted of an incident report for Resident #250, completed by Nurse # 6, dated [DATE], and revealed the Resident had an unwitnessed fall from the bed. She was discovered on the floor by staff. She was free of injury. The physician was notified. An interview was conducted with Charge Nurse #1 on [DATE] at 3:37 p.m. and revealed on [DATE] Resident #250 had a second unwitnessed fall and was discovered lying on the floor at 1:00 p.m. She assessed the Resident and she had no injuries. She then conducted a neurological assessment, and the Resident was verbally responsive. She then assisted the Resident back to the bed. She did not notify a physician of the fall at that time, and she was unsure why because a provider was available in the facility on that Friday at 1:00 p.m. Later in the shift, a nursing assistant, name unknown, informed her that the Resident was not responding like usual. Charge Nurse #1 was not able to specify an approximate time. She went to assess the Resident and discovered she had an altered mental status. The Resident was responding to questions with a yes or no reply only and was lethargic (drowsy, sluggish, and difficult to arouse). Charge Nurse #1 notified the on-call physician of the change in mental status and the fall that occurred at 1:00 p.m. She was not able to specify an approximate time for the on-call physician notification. This was the first time a physician was notified of the fall. The On-call Physician conducted a visit via video conference at 6:50 PM and felt the Resident might be dehydrated. He ordered STAT (immediate) intravenous (IV) fluids of Normal Saline (NS) at 100 milliliters/hour (ml/hr.) for 72 hours, STAT laboratory work that included a complete blood count (CBC), complete metabolic panel (CMP), and a urinalysis (UA) with a culture and sensitivity (C&S). She then stated she had been unsuccessful at starting an IV for the Resident and called the on-call Physician back to request the fluids be delivered by hypodermoclysis (a method of administering fluids subcutaneously under the skin). The physician agreed and adjusted the administration route as requested and the dosage was changed to 60 ml/hr. She added she had been unable to start the hypodermoclysis fluids because she needed to order the supplies from the pharmacy, and they did not arrive on her shift. She revealed she had not notified the on-call physician that the supplies for the fluids were unavailable and would be delayed. She added she had thought the on-call physician would know the facility did not have the supplies. She conducted an in an out urine catheterization and did not receive enough urine to complete the urine lab orders. She added she had not notified the on-call physician that she was unable to collect the urine. She stated she reported to the following shift nurse to try to collect more urine. A review of the On-Call Physician video visit summary, dated [DATE] at 6:50 p.m., documented the resident had a fall out of the bed earlier in the day, and the staff were requesting the Resident be evaluated due to an altered mental status. The Resident presented with lethargy, increased confusion, nonverbal, and not engaging. The Resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The assessment plan noted recent repeated falls and altered mental status (a change from a resident's base line alertness and cognition). Recommendations included to continue the facility post fall protocol, conduct a STAT CBC, CMP, UA with C&S, and NS at 100 ml/hr. x 72 hours. A review of the On-Call Physician summary dated [DATE] at 8:35 p.m., documented Charge Nurse #1 requested to administer the IV fluids via hypodermoclysis. The order was adjusted to 60 ml/hr. NS via hypodermoclysis. Nurse reported the UA C&S and laboratory work was pending and an additional video conference was not needed. An interview was conducted with Nurse Aide #1 (NA) on [DATE] at 5:25 p.m. and she revealed she had been assigned as the care giver to Resident #250 frequently. About a month prior to [DATE]/,d+[DATE] and [DATE]/,d+[DATE], she had reported to the Unit Manager (UM) the Resident's gastrostomy (G-tube) was leaking. She stated the leaking and the flap to close the tube had not closed. She was informed by the UM a piece of tape had been placed over the closure area. She stated the concerns with the leaking tube feeding continued for the month and she had tried to inform the previous administrator by going to his office and requesting to speak with him regarding Resident #250 but he shooed her away without listening and was ignored. She continued to provide reports regarding the leaking tube feeding to the UM. She added the Resident could move a little but did not usually fall out of the bed from movement. The two falls ([DATE] and [DATE]), close together, were new for the Resident. A review of the facility progress notes for Charge Nurse #2, the 11:00 p.m. - 7:00 a.m. hall nurse for Resident #250, documented: 1) [DATE] at 3:48 a.m. she attempted to collect a UA C&S from Resident #250 and a small amount returned from the in and out urine catheterization. 2) [DATE] at 4:09 a.m. Resident #250 was started on NS via hypodermoclysis running at 60 ml/hr. Attempted the UA C&S earlier with no results due to a small amount of urine. This nurse will continue to monitor. An interview was conducted with Charge Nurse #2 on [DATE] at 9:31 a.m. and she revealed the Pharmacy delivery sometimes comes as late as 2:00 a.m. She added on the night of [DATE] through [DATE] Resident #250 looked dehydrated during her assessment and did not respond to her name. She had not reported to the physician about the time of the pharmacy delivery because she was not aware it had not been previously reported. A review of the electronic medical record revealed Resident #250 was discovered unresponsive in her bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. A review of the death certificate for Resident #250 listed the cause of death as a Cerebral Vascular Accident. An interview was conducted with the Medical Director on [DATE] at 12:25 p.m. and he revealed he was not allowed to list some conditions as the cause of death on a death certificate but if he was able, he would have listed fluid volume depletion disorder as the cause of death for Resident #250. An interview was conducted with Nurse Practitioner (NP) #1 on [DATE] at 10:17 a.m. and she revealed she had a routine visit with Resident #250 on the morning of [DATE] prior to 1:00 p.m. The Resident had responded to questions during the visit. The NP stated this was routine visit. The On-Call physician for the medical group, had been notified on [DATE] at 6:50 p.m. that the Resident had an unwitnessed fall from the bed at 1:00 p.m. When she arrived at the facility on [DATE] she read the On-Call physician documentation from the 6:50 p.m. video visit and went to visit the Resident. Upon arrival in the room, the Resident had NS 60 ml/hr running via hypodermoclysis. The STAT laboratory work was not available in the electronic medical record. She called the laboratory provider and requested the results. She was informed there was pending laboratory blood work for Resident #250, but they had not been informed it was a STAT lab. The NP added she had not been notified of an error in the ordering of the STAT laboratory blood work. She revealed the failure to notify a Physician of the fall on [DATE] at 1:00 p.m. and the STAT laboratory work delayed the treatment and workup. She added, if she had received the critical laboratory results, at the expected time, around noon on [DATE], she would have recommended treatment at a higher level of care. The Administrator and Corporate Consultant were notified of the immediate jeopardy on [DATE] at 6:15 p.m. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] resident #250 had a second unwitnessed fall from the bed at 1:00 p.m. that would have required medical attention. The charge nurse did not notify the medical provider regarding this fall from the bed. Approximately 6:40pm resident #250 had a change of condition. The charge nurse sent the medical director a message and called the on-call provider. The on-call provider called back and did a tele-health visit with the resident at 6:50 p.m. The nurse practitioner asked the charge nurse to perform a skin turgor on the resident and he then stated the resident seemed to be mildly dehydrated. The nurse practitioner provided stat orders on [DATE] for intravenous fluids normal saline at 100 milliliters per hour and urine for culture and sensitivity. The charge nurse attempted to gain IV access and failed twice. The charge nurse called the on-call provided approximately 8:15 p.m. The nurse practitioner gave a new order to change the IV fluids to be administered through a hypodermoclysis and change the rate to 60 milliliters per hour. Charge nurse #1 noted there were no hypodermoclysis kits in the facility. She called the pharmacy and requested the kits to be delivered on the next delivery. The kits were delivered on [DATE] at 3:05 a.m. and the IV fluids were started immediately by a different charge nurse. The charge nurse obtained the urine and she stated that she was unable to obtain enough urine to for the lab to be able to run the culture and sensitivity test. Charge nurse #1 failed to notify the physician of the second unwitnessed fall, the unavailability of the hypodermoclysis, and that she was unable to obtain enough urine for the culture and sensitivity. The charge nurse #1 also failed to notify the medical provider she failed to obtain stat labs. The nurses failed to notify the medical provider regarding the tube feeding that was found leaking on the floor and in the bed. Resident #250 was discovered unresponsive on [DATE] at approximately 8:45 p.m. and was pronounced deceased at 10:09 p.m. On [DATE] the Director of Nursing, unit managers, and MDS nurses reviewed current residents who have fallen during [DATE] through [DATE] to validate that a medical physician had been notified of the fall. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. On [DATE] the Director of Nursing, unit managers, and MDS nurses reviewed notes during [DATE] through [DATE] for any change in conditions and new orders for stat labs of the current residents and validate that a medical physician was notified of the change in condition and that the stat labs were drawn. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. On [DATE] the Registered Dietitian reviewed residents' medication administration record to ensure residents were receiving the correct amount of tube feeding. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. On [DATE] the Director of Nursing, unit managers, and MDS nurses assessed the current residents for a change in condition. The assessment included a change in mental status, abnormal pain, a decrease in range of motion, and dehydration and will notify a medical physician immediately if a change in condition is noted. 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 [DATE] the Director of Nursing and Unit Managers educated Licensed Nurses regarding the requirement of notifying the medical provider following an incident, such as a fall, or change of condition and when they are unable to obtain a stat lab. The Director of Nursing and unit managers educated nurse aides and medication aides on when a change in condition is noted in the resident, they are to notify the Charge nurse immediately. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE] the Director of Nursing and unit managers educated licensed nurses when a resident is found to not receive the required amount of tube feeding the licensed nurses will inform medical provided immediately. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE], the Director of Nursing and unit managers educated the nurse aides on if a resident has fallen or if a change in condition is noted they are to notify the licensed nurses immediately. If the nurse aides assume the licensed nurses have not assessed the resident or made an attempt to call the medical physician, they will call the Director of Nursing and Administrator. The nurse aides were informed where the Administrator and the Director of Nursing numbers are posted, which is behind each nurse's station. On [DATE], the Director of Nursing called the staff that were scheduled in the facility on [DATE] for the hours of 7:00 a.m. until 3:00 p.m. to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. The education will include a pretest and posttest. Education will be completed by [DATE]. On [DATE] the Regional Nurse Consultant educated the Director of Nursing and unit managers on informing the Registered Dietitian when a resident is noted to have not received the required amount of tube feeding. Education completed on [DATE]. On [DATE] the Regional Director of Clinical Services educated the Director of Nursing, all unit managers, MDS nurse, and the Administrator regarding the clinical morning meeting process to include a review of residents with falls, stat labs, and change of condition, to validate completion and documentation notification of the MD and responsible party by reviewing progress notes, incident reports, medical provider notes, and orders. This education was completed on [DATE]. Effective [DATE] the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Date of alleged immediate jeopardy removal is [DATE]. On [DATE] the facility's credible allegation for Immediate Jeopardy removal was validated. The validation was evidenced by record review of in-services given to staff and audits completed by staff management. Validation was also evidenced by interview of staff members from various departments. The facility's education was reviewed and included documentation of completion, per the facility's immediate jeopardy removal plan. The facility's audits were also reviewed. There was documentation that audits had been completed. Staff members from various departments were interviewed and reported that they had attended in-service training on notification of changes. The staff attendance was verified on the attendance logs. Staff members were able to report specific details of the training they had received that included notifying the medical providers following an incident, such as a fall, and if they were unable to complete a STAT order/lab. The Administrative team reported the education provided regarding notification of the medical team when a change of condition occurred. The immediate jeopardy was removed on [DATE].

Based on record review and staff, Nurse Practitioner (NP) and Medical Director interviews the facility failed to ensure a resident had on-going comprehensive assessments completed after a resident with functional quadriplegia experienced a second unwitnessed fall on [DATE] at 1:00 p.m. and then later that same day had altered mental status due to suspected dehydration. A Physician video visit was conducted on [DATE] at 6:50 p.m. to evaluate the resident due to altered mental status. At that time the physician noted the resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The physician ordered STAT (immediately) laboratory blood work and intravenous (IV) normal saline (mixture of sodium chloride and water used to treat dehydration). The STAT blood work was not collected until the morning of [DATE]. The staff's failure to communicate pertinent information about the resident to each other and lack of comprehensive assessments caused a delay in medical evaluation and medical services which resulted in a serious adverse outcome. The Resident was discovered unresponsive in bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. This occurred for 1 of 1 resident reviewed for quality of care (Resident #250). Immediate Jeopardy began on [DATE] when Resident #250 had an acute change in condition and did not receive necessary care and services. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (actual harm that is not immediate jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee training. The findings include: Resident #250 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia, gastrostomy, and a cerebrovascular disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #250 had severe cognitive impairment and had not had a fall since the prior assessment. She required extensive assistance of two staff members with bed mobility and personal hygiene and total assistance of one staff member for bathing. The Resident had a feeding tube and received greater than 51% of meals and greater than 501 cubic centimeters (cc) of fluids by this route. A review of the Care Plan dated [DATE], for Resident #250, had an identified focused area that read; The Resident had an activities of daily living self-care performance deficit related to confusion, dementia, and limited mobility. The interventions included, provide extensive assistance of staff to turn and reposition in bed, required extensive assistance with personal hygiene, and monitor/document declines in function. An incident report dated [DATE] and completed by Charge Nurse #7, revealed the Resident #250 had an unwitnessed fall from the bed. She was discovered on the floor by staff. She was free of injury. A mental status assessment documented Resident #250 was oriented to person, place, and time. The physician was notified. The Administrator and Corporate Nurse Consultant were requested to provide any neurological exams conducted on [DATE] after the fall and the fall incident report was the only documentation from Resident #250's medical record provided. An interview was conducted with the Corporate Nurse Consultant on [DATE] at 11:09 a.m. and she provided a fall incident report for Resident #250 dated [DATE]. She confirmed this was all the documents from the medical record she had regarding the fall on [DATE]. An interview was conducted with Charge Nurse #7 on [DATE] at 2:39 p.m. and revealed she had been assigned to Resident #250 on [DATE] and [DATE]. When asked if she conducted assessments and provided tube feedings as ordered, she stated she documents what she had completed in the electronic medical record and tube feeding documentation would be on the Medication Administration record (MAR). An interview was conducted with Nurse Practitioner (NP) #1 on [DATE] at 10:17 a.m. and she revealed she had a routine visit with Resident #250 on the morning of [DATE] prior to 1:00 p.m. The Resident had responded to questions during the visit. She had not been informed on [DATE] the family had concerns with leaking from the gastrostomy tube site and had not been informed the family had concerns for dehydration. A review of a grievance report, dated [DATE], filed by the Guardian for Resident #250, revealed the family had concerns the Resident was dehydrated and her diet had been changed. It stated the family had discussed the concern with the Administrator the previous Thursday, [DATE]. The findings of the investigation included a note from the Administrator, that read; I spoke with the family on Tuesday, [DATE], and not on Thursday. Resident showed no signs of dehydration at that time. Her skin turgor (the elasticity or firmness of skin) was good. Her mucous membranes were moist. Family were concerned regarding resident being wet and it not being urine but leakage from her tube feeding. Area being treated by the nurse. The nurse was not identified in the grievance report. An interview was conducted with the Administrator on [DATE] at 10:00 a.m. The grievance report, dated [DATE] for the date of [DATE], was reviewed and indicated the family had requested to meet with her. She met with the family in the Resident's room [DATE]. The family had expressed concerns that the Resident's tube feeding was leaking and causing dehydration. The Administrator stated assessed good skin turgor and moist mucous membranes. She did not assess the gastrostomy tube site. The Resident was wet as evidenced by dampness on her sheet. The Administrator indicated did not lift the sheet to assess if the wetness was from the tube site or urine. She requested the assigned nurse to arrange for the Resident to be provided dry sheets. She was unable to provide the name of the nurse because this was the Administrator's second day at the facility. A review of the nursing progress notes for [DATE] written by Charge Nurse #1 included the following late entries: - 9:04 p.m. A situation, background, assessment, recommendation (SBAR) report was completed for a fall. The report stated: At the time of the evaluation the resident's vital signs were: Blood Pressure: ,d+[DATE] taken on [DATE] at 2:40 p.m. Pulse: 63 taken on [DATE] at 2:40 p.m. Respiratory rate: 16 taken on [DATE] at 2:40 p.m. Temperature: 97.5 taken [DATE] at 2:40 p.m. Pulse oximetry: 96% taken [DATE] at 2:40 p.m. The recommendations provided by the provider were documented to follow the facility fall protocol. The SBAR did not include vital signs for the time of the fall. A post fall blood sugar was not included. - 9:17 p.m. An SBAR was conducted for altered mental status. The vital signs were: Blood Pressure: ,d+[DATE] taken on [DATE] at 8:11 p.m. Pulse: 86 taken on [DATE] at 8:12 p.m. Respiratory Rate: 20 taken on [DATE] at 8:12 p.m. Temperature: 97.7 taken [DATE] at 8:12 p.m. Pulse Oximetry: 90% taken [DATE] at 8:12 p.m. on room air. Findings reported on resident for this change in condition were altered level of consciousness. The Provider recommendations included a Complete Blood Count (CBC) with no differential, Comprehensive Metabolic Panel (CMP) with glomerular filtration rate (GFR), a Urine Analysis (UA) culture and sensitivity (C&S). A late entry progress note written at 9:17 p.m. on [DATE] by Charge Nurse #1 read: Resident rolled out of the bed onto floor, bed was in lowest position. No complaints of pain or discomfort. No injury to note. Vital signs within normal range. Resident alert and able to respond appropriately to staff. On-call made aware of incident. No new orders concerning fall to note. There were no details regarding, 1) what happened to the reported assessments, 2) the specific values for the vital signs, and 3) if the fall was witnessed or if neuro checks were initiated. There was not a fall incident report completed on [DATE] by Charge Nurse #1 for Resident #250's fall. In addition, there were no documented neurological checks located in the medical record. A late entry progress note written at 9:20 p.m. on [DATE], by Charge Nurse #1 read: Resident slightly lethargic, vital signs taken, and resident denies pain. Responding appropriately to staff, telehealth contacted. Video conference call made by on call physician. Determined altered mental status with tenting of skin the Resident had some dehydration. Labs were ordered and telephone order to begin resident on Intravenous (IV) normal saline at 100ml (milliliters)/hour x 72 hours. An attempt to start the IV was unsuccessful. Contacted telehealth on call to start hypodermoclysis (a method of administering fluids or medication under the skin). On call gave a telephone order to start the Normal saline at 60 ml/hour by hypodermoclysis until an IV could be started. There were no details regarding the specific values for the vital signs or if neurological checks were initiated or continued. A review of the On-Call Physician video visit summary, dated [DATE] at 6:50 p.m., documented the resident had a fall out of the bed earlier in the day, and the staff were requesting the Resident be evaluated due to an altered mental status. The Resident presented with lethargy, increased confusion, nonverbal, and not engaging. The Resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The assessment plan noted recent repeated falls and altered mental status (a change from a resident's base line alertness and cognition). Recommendations included to continue the facility post fall protocol, conduct a STAT CBC, CMP, UA with C&S, and Normal Saline (NS) at 100 ml/hr. x 72 hours. A review of the On-Call Physician summary dated [DATE] at 8:35 p.m., documented Charge Nurse #1 requested to administer the IV fluids via hypodermoclysis. The order was adjusted to 60 ml/hr. NS via hypodermoclysis. The Nurse reported the UA C&S and laboratory work was pending and an additional video conference was not needed. The Corporate Nurse Consultant and Administrator provided a copy of the SBAR notes and the telehealth visit for the date of [DATE]. No other neurological assessments and no fall incident report for [DATE], were provided. An interview was conducted with Charge Nurse #1 on [DATE] at 3:37 p.m. and revealed on [DATE] she was the assigned nurse on the 7:00 a.m. - 11:00 p.m. shift. Resident #250 had a second unwitnessed fall and was discovered lying flat on the floor, on the window side of the bed, at 1:00 p.m. She was unable to provide the name of the staff member that discovered the Resident on the floor. She assessed the Resident, and she had no injuries. She was unsure if the Resident had hit her head, so she completed a neurological assessment, and the Resident was verbally responsive then she and another staff member (she did not recall) assisted the Resident back to the bed. She stated she had completed the neurological assessments and documented them on a piece of paper but did not conduct them at the recommended intervals required for an unwitnessed fall, that included every 15 minutes x 4, every 30 minutes x 4, every hour x 4, then every 4 hours x 4. When asked how many assessments she had completed, she stated, a few. She added she did not document an assessment (neurological assessment or vital signs), at the time of the fall, in the electronic medical record because she accidentally shredded the paper and was unable to obtain access to the shred storage box. Charge Nurse #1 added she did not write a progress note to summarize what she had assessed and did not notify a physician of the fall at that time. She was unsure why because a provider was available in the facility on that Friday at 1:00 p.m. Later in the shift, a nursing assistant, name unknown, informed her that the Resident was not responding like usual. Charge Nurse #1 was not able to specify an approximate time. She went to assess the Resident and discovered she had an altered mental status. The Resident was responding to questions with a yes or no reply only and was lethargic (drowsy, sluggish, and difficult to arouse). Charge Nurse #1 notified the on-call physician of the change in mental status and the fall that occurred at 1:00 p.m. She was not able to specify an approximate time for the on-call physician notification. This was the first time a physician was notified of the fall. She stated she created an SBAR that included the information reported to the physician and included the vital signs and neurological assessment conducted. The two SBAR progress notes were created at the end of her shift. Charge Nurse #1 explained the On-call Physician conducted a visit via video conference at 6:50 PM and felt the Resident might be dehydrated. He ordered STAT (immediate) intravenous (IV) fluids of Normal Saline (NS) at 100 milliliters/hour (ml/hr.) for 72 hours, STAT laboratory work that included a complete blood count (CBC), complete metabolic panel (CMP), and a urinalysis (UA) with a culture and sensitivity (C&S). She entered the STAT laboratory order into the computer and wrote the laboratory order on the lab book. She did not call the Laboratory provider to inform them she had STAT blood work ordered. She then stated she had been unsuccessful at starting an IV for the Resident and called the on-call Physician back to request the fluids be delivered by hypodermoclysis (a method of administering fluids subcutaneously under the skin). She added she did not request a second nurse to attempt to start the IV. The physician agreed and adjusted the administration route as requested and the dosage was changed to 60 ml/hr. She added she had been unable to start the hypodermoclysis fluids because she needed to order the supplies from the pharmacy, and they did not arrive on her shift. She revealed she had not notified the on-call physician that the supplies for the fluids were unavailable and would be delayed. Charge Nurse #1 added she had thought the on-call physician would know the facility did not have the supplies. She conducted an in and out urine catheterization and did not receive enough urine to complete the urine lab orders and she had not notified the on-call physician that she was unable to collect the urine. She stated she reported to the following shift, Charge nurse #2, to try to collect more urine and did not report to the nurse another attempt to start the IV was requested by the on-call physician. An interview was conducted with Nurse Aide (NA) #1 on [DATE] at 5:25 p.m. and she revealed she had been assigned as the care giver to Resident #250 frequently. She added the Resident could move a little but did not usually fall out of the bed from movement. She was assigned to Resident #250 on [DATE] and [DATE], day shift. She was assigned to Resident #250 on [DATE], 7:00 a.m. - 11:00 p.m. On [DATE] she was assigned to Resident #250 from 7:00 a.m. - 3:00 p.m. At 3:00 she was pulled to conduct showers. She was unsure what NA took over the assignment. During her shifts, she added the Resident was squirming around more like she was uncomfortable. She stated the Resident was not her normal self on [DATE] and this was reported this to the nurse. She did was not sure of the Nurses name. About a month prior to [DATE] and [DATE], she had reported to the Unit Manager (UM) the Resident's gastrostomy (G-tube) was leaking. She stated the leaking and the flap (the feeding port cover) to close the tube had not closed. She was informed by the UM a piece of tape had been placed over the closure area. She stated the concerns with the leaking tube feeding continued for the month and she had tried to inform the previous Administrator by going to his office and requesting to speak with him regarding Resident #250 but he shooed her away without listening and was ignored. She continued to provide reports regarding the leaking tube feeding to the UM. A review of the facility progress notes for Charge Nurse #2, the 11:00 p.m. - 7:00 a.m. shift hall nurse for Resident #250, documented: 1) [DATE] at 3:48 a.m. she attempted to collect a UA C&S from Resident #250 and a small amount returned from the in and out urine catheterization. 2) [DATE] at 4:09 a.m. Resident #250 was started on NS via hypodermoclysis running at 60 ml/hr. Attempted the UA C&S earlier with no results due to a small amount of urine. This nurse will continue to monitor. An interview was conducted with Charge Nurse #2 on [DATE] at 9:31 a.m. and she revealed she was assigned to Resident #250 on the [DATE] at 11:00 p.m. - [DATE] at 7:00 a.m. shift. She received a report from Charge Nurse #1 that the Resident required Hypodermoclysis at 60 ml/hour to be started when the supplies arrived from Pharmacy. She did not receive a report that the on-call Physician requested the hypodermoclysis be conducted until an IV could be obtained on the Resident. At 3:48 a.m. she received the supplies and started the ordered fluids. She attempted to collect urine and was unable. She reported the Resident appeared to be dehydrated and had labored breathing. Charge Nurse #2 did not notify the on-call physician that she was unable to collect the UA C&S or that the Resident appeared dehydrated, because she had not been told she needed to. She did not conduct scheduled neurological assessments and document them in the electronic medical record. A review of the [DATE] NP #1 progress note documented an unwitnessed fall without injury was reported. The Resident had a new onset of tachycardia and hypotension. Fluids from hypodermoclysis was observed initiated. Orders for a CBC, CMP, UA with C&S were ordered. The laboratory results were not completed at the time of the evaluation. Vital Signs: Blood pressure ,d+[DATE], Pulse 112, temperature 97.9, oxygen saturation 95% on room air. Level of consciousness: Nonverbal, lethargic, makes eye contact when spoken to. Information regarding this encounter were shared with the Unit Manager and Director of Nursing in person. An interview was conducted with Nurse Practitioner (NP) #1 on [DATE] at 10:17 a.m. and she revealed the On-Call physician for the medical group, had been notified on [DATE] at 6:50 p.m. that the Resident had an unwitnessed fall from the bed at 1:00 p.m. When she arrived at the facility on [DATE] she read the On-Call physician documentation from the 6:50 p.m. video visit on [DATE] and went to visit the Resident. Upon arrival in the room, the Resident had NS 60 ml/hr. running via hypodermoclysis. The Resident had vital signs, taken by NP #1, that included a blood pressure of ,d+[DATE] and a pulse of 112. The low blood pressure and the tachycardia could represent dehydration or an infection, therefore she needed to evaluate the laboratory results. The STAT laboratory work was not available in the electronic medical record. She called the laboratory provider and requested the results. She was informed there was pending laboratory blood work for Resident #250, but they had not been informed it was a STAT lab. The NP added she had not been notified of an error in the ordering of the STAT laboratory blood work. She revealed the failure to notify a Physician of the fall on [DATE] until 1:00 p.m. and the laboratory work not being drawn STAT delayed the treatment and workup. She added, if she had received the critical laboratory results, at the expected time, around noon on [DATE], she would have recommended treatment at a higher level of care. She did not receive the laboratory results prior to leaving for the day. The NP provided the following instructions and orders prior to leaving the facility on [DATE]: 1) Midline IV to be placed and once started, begin 0.45% normal saline at 100 ml/hr. x 2 liters. 2) Discontinue the hypodermoclysis once the Midline is obtained. 3) Obtain a chest x-ray. 4) If the chest x-ray or UA results were abnormal or if the [NAME] Blood cells were elevated, please initiate 1-gram Rocephin intramuscular every day for 7 days. 5) If the Oxygen saturation drops below 90% give supplemental oxygen via nasal cannula as needed to keep oxygen saturation above 90%. A progress note was written by Charge Nurse #3 for the date of [DATE] at 12:47 a.m. that read; Resident was alert and oriented x 1. Nurse Practitioner ordered a Midline to be placed for fluids. Laboratory blood work was ordered and blood drawn. Will continue to monitor. A progress note was written by the Unit Manager on [DATE] at 6:39 p.m. that read; This writer notified on-call Nurse Practitioner #2 about the Resident's critical lab values reported from the laboratory provider. The Blood urea nitrogen (BUN) was 157.4 (normal range ,d+[DATE] mg/dl) , Sodium 156 (normal range 135 - 145 mEq/l). The X-rays were ordered per the earlier orders and an IV access provider was contacted to start the midline. Attempts were made to interview NP #2 without success. Review of the critical lab results revealed: BUN at 157.4 mg/dL (normal range ,d+[DATE] mg/dL) Na at 156 mmol/L (normal range of ,d+[DATE]) Creatinine at 6.01 mg/dL (normal range 0XXX,d+[DATE].2 mg/dL) BUN/Creatinine ratio at 26.2 (range of ,d+[DATE]). A progress note was written by Nurse #3 at 10:44 p.m. written by Charge Nurse #3, that read; Resident #250 was discovered unresponsive in her bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. An interview was conducted with Charge Nurse #3 on [DATE] at 11:02 a.m. She revealed she had an assignment change on [DATE] at 3:00 p.m. and was then assigned to Resident #250. This was the first time she was assigned to this resident. She stated she did not get all the information she was supposed to get in report. The Director of Nursing was present during the report. She thought the Resident had transitioned to Hospice services based on her report and that the Resident was experiencing an expected decline. She was not informed of the pending laboratory values and when the critical laboratory value results were received, the Unit Manager had received them and failed to inform her of the status and the family had been in to visit the Resident. She reported she was informed by a staff member and did not recall the name, that the Resident was unresponsive at 8:50- 9:00 p.m. (the progress note stated 9:50) and she went to the telephone to contact the physician and the Guardian. That was when she discovered the Resident was a full code and she began cardiopulmonary resuscitation (CPR). The team contacted 911 and emergency medical services (EMS) arrived around 10:00 p.m. and pronounced the Resident as deceased at 10:09 p.m. The Midline was never placed. An interview was conducted with the Corporate Nurse Consultant on [DATE] at 12:48 p.m. and she reviewed the Laboratory provider results for Resident #250, dated [DATE]. She stated the results should have indicated the term, STAT somewhere on the results. She investigated and discovered the Laboratory order should have been entered into the electronic medical record and then the Nurse was expected to call the laboratory provider to inform them the order was STAT. She was informed this step did not occur because the nurse forgot to call. The death certificate signed by the Physician on [DATE] revealed the immediate cause of death were Cerebrovascular Accident (CVA), Vascular dementia, Lupus, and Dysphagia as late effect of CVA. An interview was conducted with the Medical Director on [DATE] at 12:25 p.m. and he revealed he was not allowed to list some conditions as the cause of death on a death certificate but if he was able, he would have listed fluid volume depletion disorder as the cause of death for Resident #250. He added it was his expectation that neurological assessments be conducted following an unwitnessed fall and documented in the electronic medical record. He stated it was his expectation that STAT laboratory work be conducted as ordered. The Administrator and Corporate consultant were notified of the immediate jeopardy (IJ) on [DATE] at 6:12 p.m. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] resident #250 had an unwitnessed fall approximately 11:07 a.m. The charge nurse stated in her interview that a nurse aide informed her the resident had slid out of the bed. Upon entering the residents' room, the charge nurse noted the resident sitting on the floor with her back up against the nightstand. She asked the resident if she slid out of the bed and the resident shook her head yes. The charge nurse assessed the resident for pain, abnormal range of motion, and obtained her vitals. She stated that this was all within normal limits. The charge nurse assessed the resident for mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness because she was under the impression the fall was witnessed by the nurse aide. The charge nurse stated the lack of documentation was due to her becoming busy and it was a lapse in judgement. There is no supporting documentation regarding the on-going assessments being performed on the resident on [DATE]. On [DATE] resident #250 had an unwitnessed fall approximately 1:00 p.m. The charge nurse stated in her interview that the maintenance assistant discovered the resident on the floor approximately 1:00 p.m. He asked the resident if she was okay, and she gave him a smile. The charge nurse was informed immediately and assessed the residents' range of motion, pain level, and vital signs. The charge nurse stated that the resident was not in pain and the range of motion and vital signs were within normal limits. During the duration of the day the charge nurse increased her rounds on the resident to ensure she did not have a change in condition. During the rounds the charge nurse stated she assessed the residents mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness. The mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness were within normal limits. The charge nurse stated the lack of documentation about the findings of her assessment were due to her throwing the sheet she had documented on in the shredder box and no one had a key to open the box. The charged nurse was asked why there was a lack of documentation in the residents' medical record from the fall and she stated that the day was extremely busy, and time got away from her. On [DATE] approximately 6:40 p.m. resident #250 was found to have a change in her mental status and the charge nurse informed the medical provider immediately. The medical provider called through tele-health and gave the charge nurse stat orders to obtain blood work, and urine for a culture and sensitivity and administer fluids via IV at 100mls per hour. The nurse attempted to start the IV twice and was unsuccessful. The nurse stated that she attempted to locate another nurse on a different unit and was unable to locate the nurse she was looking for. She called the on-call medical provider and received an order to run the fluids via hypodermoclysis and change the rate to 60mls per hour. The charge nurse could not locate a hypodermoclysis kit in the facility. She then called the pharmacy to send some kits on the next run. She stated she failed to call the provider back because she assumed the kits would be delivered before she left the facility. There is supporting documentation on [DATE] at the following times 9:04 p.m., 9:11p.m., 9:17 p.m., and 9:50 p.m. On [DATE] the kits arrived at the facility at approximately 3:00 a.m. The charge nurse that was on duty applied the cylsis kit and started the IV fluids approximately 3:20 a.m. The charge nurse #1 entered the orders for the blood work to be drawn stat in the resident's medical record, however she failed to enter the orders into the lab computer system and failed to call the lab company for the labs to be drawn. She stated the reason is due to her forgetting that she needed to call the lab company to have the labs drawn stat. The blood work was drawn as a routine lab on [DATE] due to the 11:00 p.m. to 7:00 a.m. nurse writing a requisition form at 6:00 a.m. and resulted at 5:28 p.m. per the lab results in the resident's medical record. The nurse practitioner viewed the resident medical recorded and noted the stat labs that were ordered had not resulted. She placed another order in the residents' medical record to obtain stat labs, however the NP was unaware of the labs being drawn that morning. The charge nurses and unit managers failed to call the lab company to follow-up on lab results. The NP called the lab company approximately 3:00 p.m. to follow up on the results and she was informed the labs were not drawn stat. She then asked the lab company to have the labs run stat. The lab work resulted at 5:28 p.m., and the critical labs were called to the facility at 6:28 p.m. to the unit manager. The unit manager attempted to reach out to the provider on-call immediately. The provider called the unit manager back approximately 9:23 p.m. with no new orders. The charge nurse stated the resident was last seen at 8:45 p.m. and the resident was resting. The resident was found to be unresponsive on [DATE] approximately at 8:45 p.m. and resident was pronounced deceased at 10:09 p.m. On [DATE], the Regional Nurse Consultant spoke with the Director of Client Services for the pharmacy regarding the cylsis kits. He stated that the kits are normally not sent to the facility unless it is requested. The Director of Client Services stated that 12 clysis kits will be sent to the facility on [DATE]. On [DATE], the Regional Nurse Consultant educated Central Supply on the ordering process for the cylsis kits, such as filling out the ordering form and faxing the sheet to pharmacy or calling the pharmacy to request to amount that is needed, to ensure 10 kits are in the facility for licensed nurses to access in the medication rooms. On [DATE] the Director of Nursing, unit managers, and MDS nurse reviewed current residents that had fallen on [DATE] through [DATE] to ensure nurse assessed residents for a change in condition by reviewing the progress notes in the residents' medical record. The assessments included range of motion to ensure within normal limits, pain to ensure resident has no abnormal pain, mental status, cognition, strength, coordination, gait and mobility, and level of consciousness to ensure there were no changes to the residents. There were no abnormal findings. On [DATE] the Director of Nursing, unit managers, and MDS nurse reviewed current residents progress notes from the medical providers from [DATE] through [DATE] to ensure orders that were ordered stat were implemented immediately. There were no stat orders that were not implemented immediately. 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 [DATE] the Director of Nursing and Unit Managers educated Licensed Nurses regarding the requirements to complete fall documentation after the resident is assessed. The requirements for the documentation will be when a resident falls the licensed nurse will assess the resident immediately for pain, decrease in range of motion, and vital signs. If the resident has an unwitnessed fall the licensed nurse will assess for mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness which will include vital signs as follows every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 1 hour for 4 hours, and every 4 hours

Based on record review and staff, Registered Dietician (RD), Speech Therapy (SLP), Nurse Practitioner (NP) and Physician interviews, the facility failed to maintain the hydration status for 1 of 2 residents reviewed for tube feedings (Resident # 250). When it was determined the resident was dehydrated, the facility failed to administer ordered fluids immediately, and failed to complete STAT (immediate) laboratory orders to assess the resident and provide information to the physician for needed treatment. The resident had critical laboratory values of Blood Urea Nitrogen (BUN) - 157.4 milligrams per deciliter (mg/dL) (normal range 6 - 20 mg/dL) (test measures the amount of urea nitrogen found in blood), Creatinine at 6.01 mg/dL (normal range 0XXX,d+[DATE].2 mg/dL), and Sodium level (Na) -156 millimoles per liter (mmol/L) (normal range 135 - 145 mEq)(measures the amount of sodium in your blood) (elevated BUN, Creatinine and Sodium can be indicators of dehydration; dangerously high BUN levels indicates kidney damage that should be addressed immediately) on [DATE] at 5:30 pm. The resident was pronounced dead on [DATE] at 10:09 pm. This was for 1 of 2 residents (Resident #250) reviewed for tube feeding. Immediate Jeopardy began on [DATE] when Resident #250 was observed to have signs and symptoms of dehydration and the facility failed to ensure the resident received immediate interventions. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential of more than harm that is not immediate jeopardy) to complete education and to immediately implement effective systems for residents with tube feedings to ensure adequate hydration. Findings included: Resident #250 was readmitted to the facility on [DATE] with diagnoses that included Cerebral Vascular Accident (CVA), lupus, dysphagia, and gastrostomy tube placement. Review of Medical Orders for Scope of Treatment (MOST) form with an effective date of [DATE] revealed checked mark on Attempt Resuscitation with full scope of treatment including antibiotic use and feeding tube for long term if indicated. A lab report for CMP on [DATE] at 10:19 am revealed the results were BUN - 13.2 mg/dL, Na - 141 mmol/L, Creatinine - 0.57 mg/dL (check for normal function of kidney) (normal range 0.5 - 1.20 mg/dL), and BUN/Creatinine ratio - 23.2 (normal range 6 -25). Interview with RD on [DATE] at 8:28 am revealed Resident #250 had been receiving Gastrostomy Tube (GT) feedings since her admission to the facility in 2020. She stated that in [DATE], the resident had order for therapeutic nutrition formula 1.2 continuous tube feeding at 60ml/hr. A physician order on [DATE] revealed pleasure food with aspiration precautions was initiated. The pleasure food tray consisted of a pureed diet and thin liquids. The quarterly Minimum Data Set (MDS) on [DATE] coded Resident #250 with severely impaired cognition. Resident #250 could communicate her needs to staff. She was coded to require extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She was coded to have a feeding tube for nutrition. A physician order for tube feeding on [DATE] revealed Resident #250 would receive a GT feed of therapeutic nutrition formula 1.2 Cal at 60 ml per hour continuous feeding and 125 ml of water flush every 4 hours. The order also included an instruction to allow tube feeding to be turned off for 2 hours per day to prevent the feeling of fullness for the resident. A care plan dated [DATE] revealed a goal to remain free of side effects or complications related to tube feeding, to maintain adequate nutritional and hydration status, and no signs and symptoms of malnutrition or dehydration. The intervention included to monitor aspiration, shortness of breath, tube dysfunction/malfunction, abnormal lab values, and dehydration. Interview with the RD on [DATE] at 9:10 am revealed the resident weighed 131 pounds (lbs.) on [DATE] and needed at least 1,800 ml of fluids per day to maintain her hydration. A telephone interview with SLP on [DATE] at 11:41 am revealed she evaluated Resident #250 on [DATE] for her swallowing and meal consumption. She stated the facility wanted to advance the resident to bolus tube feeding due to clogging issues with her GT. She stated the resident needed one person assistance to eat. She stated during her assessment, the resident ate 100% with her help. She said the resident demonstrated good rehabilitation potential as she followed direction and was an active participant. She further stated that the resident could drink thin liquids. A progress note written by RD on [DATE] revealed that Resident #250 was referred by Director of Nursing (DON) due to recently being seen by SLP with good oral intake of pureed diet with thin liquids. The height of 68 inches with Current Body Weight (CBW) of 131.30 ([DATE]) with a normal Body Mass Index (BMI) of 20.0. Weight history of 1.00% change for 30 days and -0.45% for 90 days. There were no significant weight changes and/or trends present during her assessment. A weekly weight order was to monitor the resident. Resident #250 receives a pleasure tray of a pureed diet with thin liquids consuming about ,d+[DATE]% of some meals. Resident previously reported that she normally doesn't eat anything by mouth. The resident on red tray status related to aspiration precautions. Resident #250 also receives therapeutic nutrition formula 1.2 at 60cc/hr. with 125cc H2O flushes q4hrs. Tube Feed (TF) may be turned off for 2 hours per day to prevent a feeling of fullness. The current TF regimen provides: 1320 mL, 1584 kcals (kilo calorie), 73-gram protein, and 1082 mL free water plus 750 mL from flushes equals to 1832 mL fluid total. The GT is also flushed with 30 ml of water before/after meds, before initiating feeding, or when there is an interruption of feeding to maintain tube patency. Resident tolerated the TF. RD Recommended to add to promote oral intake, to change TF regimen to 8 oz bolus feedings of therapeutic nutrition formula 1.5 TID 1 hour after each meal if consumes less than 50% of corresponding meal to promote oral intake/nutrition support. Always give 8 oz bolus of therapeutic nutrition formula 1.5 every day at 9 pm for additional nutrition support. Interview with RD on [DATE] at 8:29 am revealed that she visited Resident #250 twice a month since 2020 for her dietary evaluation. She stated Resident #250 was stable and had an order for pleasure trays with thin liquids. She stated that the Director of Nursing (DON) spoke to her on changing the continuous tube feeding to bolus for the resident was eating more than 75% of her food. The RD then recommended on [DATE] to give the resident pureed diet meal with thin liquids and changed the tube feeding to bolus of therapeutic nutrition formula 1.5 Cal 8oz 4 times a day with 30 ml of water flushes before and after the bolus. An additional instruction was that bolus will only be given if the resident ate less than 50% of her meal. A physician order that was initiated on [DATE] revealed Resident #250's GT feeding was changed to a bolus of therapeutic nutrition formula 1.5 Cal 8oz 4 times a day with 30 ml of water flush before and after the bolus. An instruction to give bolus 1 hour after every meal if the resident ate less than 50%. A 30 ml of water flushes before and after medication was also included. Interview with Medication Aide #1 (Med Aide) on [DATE] at 2:59 pm revealed she worked with Resident #250 for 2 to 3 weeks before she passed. She stated that the NA's would report how much the resident ate for her meals and if it was less than 50%, they should give the bolus feeding. She stated that the GT leaked feeding several times and she stated that NA #1 also reported the leaking to the Charge Nurse in the hall several times. Review of the staff schedule provided by the Director of Nursing (DON) on [DATE] revealed that NA #1 was scheduled to work with Resident #250 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] in the morning and part of the evening shift. Interview with NA #1 on [DATE] at 5:25 pm revealed she took care of Resident #250 most of the time when she was working on the third floor. She stated that the tube feeding was leaking and draining in the bed that started on [DATE]. She stated that when she checked the resident, the bed sheets would be wet with the tube feeding solution. She stated that the tube leaked due to the top of the GT not closing well and the nurses put tape around the top but would dislodge all the time. She also stated the GT would be clogged and it will keep the feeding pump beeping for hours before a nurse would come and stop the pump from beeping. She stated she told the Charge Nurse #1 of resident's poor meal intake which was less than 50% on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. She stated she reported it to the Unit Manager and even reported it to the previous Administrator about the resident not eating and the GT was leaking. Interview with RD on [DATE] at 8:29 am stated that therapeutic nutrition formula 1.5 Cal 8oz 4 times a day amounted to 724 ml of free water. She stated after looking at the electronic record filled by the NA's, the resident received all tube feeding boluses from [DATE] - 30, 2023 and from [DATE] - 6, 2023. Review of the Medication Administration Record (MAR) and per mouth (PO) Intake form provided by the facility revealed Resident #250 was documented of receiving fluid on the following dates: [DATE] with 2,314 ml of fluid intake [DATE] with 2,264 ml of fluid intake [DATE] with 1.964 ml of fluid intake [DATE] with 1,894 ml of fluid intake [DATE] with 1,964 ml of fluid intake [DATE] with 2,014 ml of fluid intake [DATE] with 1,964 ml of fluid intake [DATE] with 1,964 ml of fluid intake [DATE] with 1,664 ml of fluid intake [DATE] with 2,384 ml of fluid intake. Interview with NA #2 on [DATE] at 11:51 am revealed she had seen the tube feed leaking from the Resident #250's tube. She saw the G-tube removed from resident's stomach one time and was hanging out, and she reported it to the Charge Nurse on the hall. She did not remember what day it happened or who the charge nurse was at that time. Interview with the Housekeeper #1 on [DATE] at 2:56 pm revealed she worked on the short hall on the third floor where Resident #250 resided. She stated that the tube feeding machine pump kept beeping and it could take an hour before nursing staff would come and look. Housekeeper #1 stated she reported the beeping to the Charge Nurse. She stated that the tube feeding leaked brown milky drips on the floor next to Resident #250's bed. She would mop them every day when she worked in the hall. She described the spill on the floor as big as a basketball ball and needed a scraper to remove the dried tube feeding on the floor. She reported the tube feeding leakage to her supervisor and the Charge Nurse on the hall. Interview with the Unit Manager on [DATE] at 2:02 pm revealed a Charge Nurse on the floor once reported Resident #250's feeding tube was leaking a little and she didn't remember when and who reported to her. She stated it was never leaked or clogged when she was working as a charge nurse on the hall. Interview with the Power of Attorney (POA) on [DATE] at 12:40 pm stated the family was visiting the resident twice a week. She stated the family told her they were worried about Resident #250's report from staff that Resident #250 was not eating well and her changed condition. She said the resident used to be alert and communicated her needs to family. She said the family reported the GT leaking to the Charge Nurse. She stated she didn't understand why the resident went downhill from the time they changed the tube feeding order. Interview with the Administrator on [DATE] at 10:13 am revealed the grievance report for [DATE] was received after the death of the resident. She documented on the bottom of the form that she had assessed Resident #250 on [DATE]. The Administrator wrote that Resident #250 showed no signs of dehydration at that time. She wrote the skin turgor was good, observed her with moist mucous membranes. She stated the family was concerned of dehydration and the GT leaking. Record review of printed cellphone text messages provided by the facility on [DATE] at 6:40 pm revealed Charge Nurse #1 contacted the Physician via text messaging. She informed the Physician of Resident #250 was refusing meals, slightly lethargic and thought the resident may be dehydrated. The Physician answered that he was not the primary physician for Resident #250. Record of telehealth document dated [DATE] at 6:50 pm provided by NP#1 revealed that Charge Nurse #1 contacted the on-call Physician via telehealth, and she wanted Resident #250 to get checked out for altered mental status with lethargy and increased confusion. Resident #250 was seen by the on-call Physician through video call with the Charge Nurse and skin tenting (test that can indicate severe dehydration) was seen by the on-call Physician. It was also noted that the resident had multiple falls including earlier that day on [DATE]. The on-call Physician ordered STAT Complete Blood Count (CBC) no differential (the total number of white blood cells), Comprehensive Metabolic Panel (CMP), Serum Osmolality (the concentration of chemicals in your blood for fluid imbalance), Urinalysis with Culture and Sensitivity (UA C&S) (culture looks for bacteria that cause UTI's and sensitivity test can pinpoint the bacteria), and IV of Normal Saline (NS) at 100 ml/hr. for 72 hours. The telehealth video was not recorded according to the facility Administrator when asked for a copy of the encounter. A Situation Background Assessment Recommendation (SBAR) note dated [DATE] at 8:17 pm completed by the Charge Nurse #1 revealed Resident #250 had altered mental status. The Nurse contacted the On-call Physician via telehealth, and she got the order for Intravenous (IV) fluids for Normal Saline (NS) to run for 100ml per hour (ml/hr.) for 72 hours, stat CBC, CMP, and UA C&S. Record review of the telehealth document dated [DATE] at 8:35 pm provided by NP #1 revealed Charge Nurse #1 contacted the on-call Physician asking if they can do hypodermoclysis since she could not get an IV started and on-call Physician advised her to do hypodermoclysis at 60 ml/hr. and to continue all previous orders. Interview with Charge Nurse #1 on [DATE] at 2:40 pm revealed she received an order from the on-call Physician after the Telehealth call [DATE] at 9:17 pm. She stated that Resident #250 was not as responsive as she was before the past two weeks. She stated she was on vacation a week before and came back the week of [DATE]. She stated that the on-call Physician asked her to do skin tenting on the resident's skin and the on-call Physician determined that the resident was dehydrated and ordered the IV of NS for 100ml/hr. Charge Nurse #1 stated she was unsuccessful in her attempts to start an IV and there was no available nurse when she tried to seek help for the IV insertion. She called the on-call Physician again and asked for an order for hypodermoclysis (a method of administering fluids under the skin) instead of IV. She got the order to infuse NS 60ml per hour via hypodermoclysis until the IV could be placed. Charge Nurse #1 revealed that there was no hypodermoclysis kit available in the facility and she called the pharmacy to deliver hypodermoclysis kit in their next delivery. Charge Nurse #1 did not mention the order for urine C&S. A telephone interview with Charge Nurse #2 on [DATE] at 9:31 am revealed she started the hypodermoclysis on [DATE] at 3:57 am. She stated the pharmacy delivered the hypodermoclysis kit around 3 am. She stated that Resident #250 looked dehydrated with very dry lips. She also stated that Resident #250 had labored breathing. She stated that her attempt to collect the urine sample was unsuccessful with an in-and-out catheter because there was small amount urine output, and it was not enough to send to lab. She stated she didn't think of reporting anything to the Physician at that time. Record review of the progress note written on [DATE] at 3:57 am revealed the hypodermoclysis was started by Charge Nurse #2. A note included that the attempt to collect urine sample was unsuccessful due to the small amount of urine. The note also read to continue to monitor the resident. Interview with the NP #1 on [DATE] at 10:17 am revealed she visited Resident #250 in the morning of [DATE] around 10 am. She followed up on the stat laboratory results that were ordered by the on-call Physician and discovered they were not drawn or completed. No one from the facility staff could answer her about the labs. She said if they were ordered stat, they should already have the lab result. NP#1 stated she reordered the stat labs, chest x-ray, and reordered the IV. NP #1 spoke to the lab technician around 11 am -12 pm and stated the lab result should be out around 1 pm. She kept checking the electronic medical record around 1 pm and there was no lab result. NP #1 called the lab again to follow up and learned the lab requisition did not indicate stat. She stated the Lab Tech tracked the blood specimen to complete the testing. NP #1 stated she requested the RD to change the water flushes to 240ml of water for 24 hours for dehydration. Record review of the progress note on [DATE] at 12:47 pm written by Charge Nurse #3 revealed the NP ordered Mid-line catheter (an ,d+[DATE] centimeters catheter inserted in the upper arm with the tip located just below the axilla) for IV fluids. The blood sample was drawn at noon and was sent to the lab for testing. An encounter note dated [DATE] at 2:47 pm by the NP #1 revealed the resident was nonverbal and lethargic. The vital signs taken by the NP #1 revealed the Blood Pressure (BP) - ,d+[DATE]-millimeter mercury (normal range above ,d+[DATE] and less than ,d+[DATE]), and Heart Rate (HR) - 112 beats per minute (normal range 60 -100). The progress notes further revealed that Resident #250 became tachycardic (high HR) and hypotensive (low BP). NP #1 ordered Mid-line IV and to continue hypodermoclysis of Sodium chloride (NaCl) at 60 ml/hr. until IV was placed. Then begin 0.45% NaCl at 100 ml/hr. She added an order for stat chest x-ray and UA with C&S. NP #1 also ordered an increase in water flushes to 240 ml every four hours. NP #1 wrote that she was waiting for the stat CBC and CMP and would change fluids if needed. And then she wrote that for positive results, or elevated WBC, she will initiate treatment with 1gm Ceftriaxone (antibiotic) intramuscularly (IM) daily for 7 days. She added on her instruction that if SpO2 (oxygen saturation level) is less than 90% (normal range is 95% - 100%) to give supplemental oxygen via nasal cannula as needed to keep SpO2 less than 90%. Interview with NP #1 on [DATE] at 11:51 am revealed she didn't know about issues of GT leaking or clogging of Resident #250's GT. Interview with NP #1 at [DATE] on 10:17 am revealed the delay in drawing the labs and obtaining the results delayed the treatment and work up for the resident. NP #1 stated she would have sent the resident to a higher level of care for evaluation which would have provided the best possible outcome. The progress notes on [DATE] at 6:39 pm written by the Unit Manager revealed she notified NP for Resident #250's critical laboratory results with a BUN at 157.4 mg/dL (normal range ,d+[DATE] mg/dL), and Na at 156 mmol/L (normal range of ,d+[DATE]). The other laboratory high results were Creatinine at 6.01 mg/dL (normal range 0XXX,d+[DATE].2 mg/dL), and BUN/Creatinine ratio at 26.2 (range of ,d+[DATE]). There were orders for chest x-ray and Mid-line IV access to be started. The progress note revealed the Unit Manager contacted IV access (a third-party company that inserts Mid-line catheter) to place Mid-line catheter. Progress note written by Charge Nurse #3 on [DATE] at 10:44 pm revealed Resident #250 was found unresponsive at 9:50 pm. The emergency response was initiated immediately and 911 was called to help. Cardio-Pulmonary Resuscitation (CPR) was started. The NP #1 was notified about the resident's status. At 10:09 pm the Emergency Medical Services (EMS) team pronounced Resident #250 deceased and the Power of Attorney (POA) was notified. Interview with Charge Nurse #3 on [DATE] at 11:02 am revealed that she was working with Resident #250 on [DATE] at 7:30 pm and that there was an order from the NP #1 for Mid-line catheter placement. She stated that the Mid-line catheter was never inserted, and she did not know who was supposed to insert the Mid-line catheter. She stated Resident #250 didn't look too good and the family members were in the room with the resident. She stated that the resident was able to shake her head to answer when the family was talking to her. She stated there was so much confusion at that time and it was her first-time taking care of the resident. She said she was not told by the Unit Manager what was happening with the resident. Interview with the Physician on [DATE] at 12:25 pm revealed that the cause of death on the death certificate he signed for Resident #250 was chosen based on the most recent diagnoses. He stated that the state won't allow him to write fall or dehydration. He added he would have chosen Fluid Depletion Disorder based on the electronic medical record information that included critical lab values. The death certificate signed by the Physician on [DATE] revealed the immediate cause of death were Cerebrovascular Accident (CVA), Vascular dementia, Lupus, and Dysphagia as late effect of CVA. The Administrator and the Regional Nurse Consultant were notified of the immediate jeopardy on [DATE] at 6:12 pm. The Administrator provided and implemented the following credible allegation of compliance on [DATE]. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] resident #250 had an order to receive bolus tube feeding of 8 ounces of Osmolite 1.5 for nutrition support one time a day. She also had an order to receive 8 ounces of Osmolite 1.5 for nutrition support after corresponding meal if consumed <50% three times a day. The order includes flushing with 30 cc of water before and after bolus. The resident received the new orders due to her ability to eat a puree diet and drink thin liquids per the speech therapist. The resident received a new order on [DATE] to receive 240ml of water flushes every 4 hours. In interviewing the staff that worked on the unit resident resided on the residents feeding from the tube were found to be leaking on the floor from the tube hanging on the pole or leaking in the bed due to the tube becoming disconnected from the peg. On [DATE] approximately 6:40 p.m. resident #250 was found to have a change in her mental status and the charge nurse informed the medical provider immediately. On [DATE] the medical provider called through tele-health at 6:50 p.m. and gave the charge nurse stat orders to obtain blood work, urine culture and sensitivity, and administer fluids via IV at 100mls per hour. The nurse attempted to start the IV twice and was unsuccessful. She called the on-call medical provider and received an order to run the fluids via hypodermoclysis and change the rate to 60mls per hour. The charge nurse could not locate a hypodermoclysis kit in the facility. She then called the pharmacy to send some kits on the next run. She stated she failed to call the provider back because she assumed the kits would be delivered before she left the facility. On [DATE] the kits arrived at the facility at approximately 3:00 a.m. The charge nurse that was on duty applied the cylsis kit and started the IV fluids approximately 3:20 a.m. On [DATE] charge nurse #1 entered the orders for the blood work to be drawn stat. The charge nurse failed to enter the orders into the lab computer system and failed to call the lab company for the labs to be drawn. She stated the reason is due to a lapse in memory to call the lab company. The charge nurse attempted to obtain urine on the resident. She stated she was unable to obtain enough for the lab company to run the lab. The blood work was drawn on [DATE] at 6:00 a.m. and resulted at 5:28 p.m. The critical lab values of BUN 157.4 mg/dl and sodium level 156mEq/L were called to the unit manager at 6:28 p.m. By this evidence, the resident did not receive an adequate amount of fluid. Upon reviewing the residents' medical record there was a lack of evidence that assessments for dehydration were completed. On [DATE] Registered Dietitian reviewed and assessed current residents that are receiving tube feeding to ensure residents are receiving adequate hydration. The RD assessed the following, estimated energy needs verses what the tube feeding regimes are providing and for any complications or intolerances. The RD reviewed the residents that are receiving continuous feeding via pump to ensure the correct feeding was being administered, rate of the feeding, flushes were entered correctly on the tube feeding pump, and to verify the amount that was administered correlated to the time it was started. The RD verified the residents that are receiving their tube feeding via bolus have the correct tube feeding on each unit. The RD confirmed there are no further residents residing in the facility receiving food intake and supplement tube feeding. There are no residents that reside in the facility that are receiving meals and supplement tube feeding. There was no area of concern. On [DATE], the Director of Nursing was reviewing the medical recorded of resident #250. Upon reviewing the critical labs, the Director of Nursing called the medical director to receive new orders to obtain lab work on current residents that were receiving tube feeding. There were no areas of concern. On [DATE], the Director of Nursing assessed current residents on tube feeding for nutrition and hydration for signs and symptoms of dehydration due to resident #250 not assessed appropriately for dehydration. This is to ensure residents that are receiving tube feeding are being properly hydrated. There were no areas of concern. 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 [DATE], the Director of Nursing and unit managers educated license nurses to ensure residents are receiving the amount of tube feeding, this is also to include water flushes as ordered by the medical physician. Education includes when orders for fluids are received to give stat this is to be done without lapse of time, without delay. The Director of Nursing called the staff that were scheduled in the facility on [DATE] for the hours of 7:00 a.m. until 3:00 p.m. to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE], the Director of Nursing and unit managers educated current staff, to include housekeeping, dietary, maintenance, social workers, and nursing, if they notice the tube feeding leaking feeding pump alarming, or removal of tube, they are to notify the nurse immediately. The Director of Nursing called the following staff, housekeeping, dietary, and nursing, that were scheduled in the facility on [DATE] to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE], the Director of Nursing and unit manages educated the license nurses, medication aides, and nurse aides on the signs and symptoms of dehydration, which are fatigue, dark colored urine and low urine output, dry skin, decrease in skin elasticity, and cracked lips, headaches, light-headedness and dizziness, and low blood pressure. The Director of Nursing called the license nurses, medication aides, and nurse aides that were scheduled in the facility on [DATE] on all shifts throughout the day to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE], the Director of Nursing and unit managers educated the license nurses on dehydration is a serious risk for the long-term tube-fed resident who is not allowed oral intake, has an altered mental status, is unable to communicate, is elderly or fluid-restricted, or has thirst impairment. The Director of Nursing called the staff that were scheduled in the facility on [DATE] on all shifts to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. Effective [DATE] the Administrator will be ultimately responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] On [DATE], the facility's credible allegation for immediate jeopardy was validated. The survey team confirmed the education and training included information on calling the Physician, NP, and On-Call NP immediately after assessing a change of mental status for any residents. Education on implementing orders that are given stat to be done immediately without lapse, to report the inability to follow a physician order (that includes not being able to get stat orders carried out) to be reported to the physician immediately. Education on assessing and documenting residents with change of mental status. Education on signs and symptoms of dehydration. Education of any staff who notices a gastrostomy tube leaking, feeding pump alarming or removal of tube, will notify the nurse immediately. Interview with several facility staff about getting the educations were validated. The team observed a resident on tube feeding and there were no concerns. The facility provided the logs and audits for tube feedings. The facility also implemented the monitoring process for reviewing weekly assessments for each resident with tube feedings and to assess for clinical signs of dehydration weekly. The facility's corrective action plan was validated on [DATE].

Based on record review, staff, Medical Director (MD) and Nurse Practitioner (NP) interviews, the facility failed to: 1) immediately inform the physician when Resident #610 had an unwitnessed fall and could not get up as usual and notify the physician of x-ray results upon receipt from the radiology company. Resident #610 was diagnosed with a fractured femur and a spinal injury. 2) notify the physician after a Resident #607, who received anticoagulant medication, fell for two of three residents reviewed for accidents (Residents #610 and #607). Immediate Jeopardy began on 5/2/2022 when the facility failed to inform the physician that Resident #610 had an unwitnessed fall and could not get up on his own, as usual. Immediate jeopardy was removed on 5/21/2022 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to implement corrections for Resident #607 and ensure the monitoring of the systems put into place and to complete facility employee training. The findings included: 1. Resident #610 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual Minimum Data Set (MDS) dated [DATE] documented Resident #610 had severe cognitive impairment. A review of Resident #610's electronic medical record revealed no progress notes documented on the date of 5/2/2022. A signed statement made by NA #1, written on 5/4/2022 and read, on 5/2/2022 NA#1 was passing out 500 hall dinner trays, as I was taking Resident #610 his tray, he was sitting in the floor. She sat the tray down and attempted to help him up but he was waving her off, so she asked another NA, NA #2, to assist her with helping pick him up to eat his food tray. After that, I saw Resident #610 walking on the hall before leaving my shift. A signed statement made by Nurse #3, dated 5/5/2022 read: On May 2, 2022 Nurse #3 was the nurse taking care of Resident #610 from 7a.m. through 11 p.m. Resident #610 took his medication without any complications. He appeared to be at his baseline the entire shift. No issues or any changes in Resident #610 were reported to me throughout the entire shift from 7 a.m. - 11 p.m. An attempt was made to interview the NA #1, NA #2 and Nurse #3 who worked on the evening of 5/2/2022, via telephone, unsuccessfully. An interview was conducted on 5/19/2022 at 2:44 p.m. with Social Worker Assistant #1 via telephone with the Social Worker present. The interview revealed on 5/3/2022 Social Worker Assistant #1 was responsible for transporting Resident #610 to a podiatry visit in another area of the facility. She stated upon arrival in the room, between 10:30 a.m. and 11:00 a.m., she discovered Resident #610 sitting on the side of the bed with his pants not pulled up. She said she requested an NA, name unknown, to assist her to pull up the Resident's pants. She revealed the Resident refused to stand up with their assistance and wanted to only stand on his right leg and not his left leg. He kept his left leg bent and grimaced when they tried to stand him up. She said he appeared to be in a lot of pain. She added at this point, they laid the Resident down and proceeded to provide peri care because it was discovered he was wet and in need of care. When on his back, he pulled both legs up like he was in a fetal position, made a face like a grimace and like he was in pain. She said when the NA and herself pulled his pants down, it was discovered the Resident had a swollen left knee. She then said she went immediately and informed the hall nurse (Nurse #1). She said she was aware to report all new findings to a nurse because she was previously an NA and that was standard practice. Resident #610's progress notes revealed a nursing note dated 5/3/2022 at 2:52 p.m. (documented on 5/4/2022 at 12:57 p.m. as a late entry) written by Nurse #1 that read: baseline activity tolerance is up ad lib and ambulatory without assistance. Resident has not been ambulating this shift. He has been lying in bed. He did sit up and eat his breakfast and lunch on the side of the bed but continued to lay back down after eating. The Nurse Practitioner (NP) was in to assess him, ordered x-rays of the left hip, the left knee and the left foot, a pain-relieving gel for bilateral knees and Tylenol 500 milligrams (mg) 3 x a day for pain for 7 days. A call was placed to radiology company on 5/19/2022 at 10:55 a.m. and an interview was conducted with a staff member. He revealed the results of Resident #610 were faxed to the telephone number (336) [PHONE NUMBER] on 5/3/2022 at 2300 and an email sent to the facility that read, ALERT, in all capital letters across the front. He added that a staff member from radiology company called the facility on 5/4/2022 at 11:52 a.m. and spoke to Nurse #2 to provide a report of the questioned fracture that required an additional x-ray or CT scan. An interview was conducted with the NP on 5/18/2022 at 3:39 p.m. and she revealed she received a verbal report during rounds on 5/3/2022 from the Nurse that Resident #610 appeared to be in pain during the nurses care that day. She added that during her assessment the left knee appeared to have [CONDITION(S)] joint changes, through physical palpitation. She consulted with the MD and informed him of the changes she had observed. She stated the Resident was nonverbal but grimaced, so she provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the x-ray was not ordered as STAT because she was not aware there had been an unwitnessed fall and there was not reason to suspect a fracture. She added that the next day, on 5/4/2022, she was provided the results of the x-ray verbally during rounds and provided an order to transfer the Resident to an acute care hospital for further evaluation and treatment. An interview was conducted with the Medical Director (MD) on 5/18/2022 at 12:58 p.m. and he revealed his expectation for Resident #610 concerning the unwitnessed fall on 5/2/2022 at 5:00 p.m. was for a nurse to be notified at the time of the incident and an assessment conducted with MD notification to follow. He revealed the NP was notified verbally on 5/3/2022 by the day shift nurse during rounds and ordered diagnostic studies that included an x-ray. The MD added that he did not feel there was a concern with the delay in treatment because he needed to be scheduled, upon arrival at the hospital, for surgery. An interview was conducted with the previous DON on 5/18/2022 at 1:31 p.m. and revealed she became aware Resident #610 had a fractured femur on 5/4/2022 when he was being transported to the hospital. She was informed by a unit manager from another unit via electronic communication. She added this was the first time she had been informed anything was going on with Resident #610. She stated the assigned hall nurse, was Nurse #3 and the Nurse provided a statement that she had not been informed the Resident was discovered in the floor and had not conducted an assessment after the evening meal because it was the baseline for Resident #610 to go to bed after dinner. She added it was her expectation that the assigned hall nurse be informed of a fall immediately by any staff member that discovered a fall. This should be conducted prior to moving the resident to allow the nurse to conduct an assessment and then the physician should be notified and the standard practices after a fall should be implemented. She stated it was her expectation that night shift staff check for any updates on all outstanding lab work and x-ray results. She added that not following the facility process of sending all residents who fell to the emergency room for an exam, delayed Resident #610's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #610 was transferred from the facility to the emergency roiagnom on [DATE] at 11:58 a.m. A review of the emergency room Physician notes for the date of service, 5/4/2022 revealed Resident #610 was not in acute distress on examination but was not able to straighten his legs on examination. He was observed to keep his legs bent towards his torso. The Resident was found to have multiple traumatic injuries on imaging. These included a left femoral fracture, a possible ligamentous injury with the cervical spine and a rectus sheath hematoma with a possible active extravasation (an uncommon cause of acute abdominal pain. It was an accumulation of blood in the sheath of the rectus abdominis, secondary to rupture of an epigastric vessel or muscle tear). A review of the hospital discharge summary dated 5/11/2022 documented Resident #610 was admitted to the hospital on 5/4/2022. The trauma team managed the Resident by providing aggressive pain control. Orthopedic trauma was consulted for the left femur fracture and Resident #610 underwent a surgical procedure, on 5/7/2022. The Orthopedic spine team was consulted for the ligamentous injury at the C6-C7 level (cervical disc near the lower part of the neck near the top of the shoulder). The Resident was managed non operatively and fitted with a hard cervical collar. The Administrator was notified of immediate jeopardy on 5/20/2022 at 12:50 p.m. The facility provided a credible allegation of immediate jeopardy removal dated 5/20/2022. An incident report, was completed on 5/4/2022 5:00pm by the Director of Nursing, based on information obtained from facility staff regarding an event occurring on 5/2/22 where Resident #610, who was observed sitting on the floor beside his bed when staff entered his room to deliver the dinner tray. Resident #610 often preferred, to be seated on the floor, however he was unable to stand unassisted per his normal baseline. Two Nursing Assistants assisted with transferring resident #610 to be seated at the bedside for dinner. Both Nursing Assistants indicated Resident #610 did not appear to be in any distress and did not verbalize any complaints when he was assisted to side of bed. This occurrence was not reported to Nurse #1 as this was usual activity for Resident #610. Nurse #1 documented a late entry for Resident #610 on 5/4/2022 at 12:57PM, for the date of 5/3/2022, stating the baseline activity tolerance is up ad lib and ambulatory without assistance, resident has not been ambulating this shift, he is lying in bed, he did sit up and eat breakfast and lunch on the side of the bed but continued to lay back in the bed after eating. On 5/3/2022 the Nurse Practitioner was in to assess the resident at the request of Nurse # 1 related to a new complaint of left leg pain and reduced mobility. The NP ordered bilateral x-rays of the hip, knee, and foot and Tylenol 5mg 3 x a day for pain x 7 days with [MEDICATION(S)] gel to bilateral knees. On 5/3/2022 at 11:58pm the x-ray result conclusion: acute left femoral neck fracture questioned, a possible ligamentous injury with the cervical spine and a rectus sheath hematoma, further recommended repeat x-ray or computerized tomography (CT) scan. On 5/4/2022 at 11:58 am Nurse #2 received the x-ray results from 5/3/222 notified the Nurse Practitioner of the results from 5/3/2022 and received an order to transfer the resident to the Emergency Department for evaluation, transfer was arranged via ambulance. On 5/4/2022 the guardian was notified of the x-rays results and the order received to transfer to the Emergency Department. Resident #610 was admitted to the hospital on 5/4/2022 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/2022 the Nurse managers reviewed residents who have fallen during the last 30 days to validate that the MD had been notified any opportunities identified during this audit will be corrected by the Nurse Managers by 5/20/22. 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 Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers educated Licensed Nurses regarding the requirement to complete and document a post fall nursing assessment to include requirements for notification of the Physician following an incident or change of condition and when receiving ordered lab and x-ray results. The Nurse Managers educated Nursing Assistants on the definition of a fall including a change of plane and to report falls and change in resident condition to the Licensed Nurse immediately. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. Education will be completed by 5/20/22 by the Nurse Managers. The Regional Director of Clinical Services educated the Nurse Management team and the Administrator regarding the clinical morning meeting process to include a review of residents with falls and change of condition, to validate completion and documentation of post fall nursing assessment and including notification of the MD and responsible party. This education was completed on 5/20/22. The Staff Development Coordinator, Regional Director of Clinical Services, and unit managers educated Licensed Nurses regarding the follow up on X-Ray results and obtaining results from the Trident portal. Instructions for reference remain available at the Nurse's station. All licensed nurses have access to the Trident portal. License nurses follow up on the same shift if the X-Ray was obtained on their shift if no results they are to follow-up on the next shift. Abnormal results are to be called immediately to MD once received for further orders. Education complete date 5/20/2022. Effective 5/19/2022 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 5/21/2022 Onsite validation was completed on 5/24/2022 through record review, staff, and resident interviews. Staff were interviewed to validate in-service completion on post fall assessments and physician notification that included obtaining lab results. A review of the Staff Development Coordinators education logs was conducted and compared to the staff log. The facility immediate jeopardy removal was validated to be completed as of 5/21/2022. 2. Resident #607 was admitted to the facility on [DATE]. The resident's cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #607's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #607 did not have intact cognitive skills for daily decision making. The MDS indicated Resident #607 received an anticoagulant medication on 7 out of 7 days during the look back period. A review of Resident #607's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note written by Nurse #8 and dated 2/8/2022 at 8:30 P.M. read in part Resident's lower extremities slid off left side of bed during incontinent care provided by assigned CNA. Large skin tears noted on bilateral lower extremities. Call placed to responsible party to make aware. Message left to call facility ASAP. MD will be notified. Writer cleansed wounds with normal sterile saline, applied [MEDICATION(S)], & wrapped both wounds with Kerlix. Writer will contact Wound Care Dir., in AM. Denied pain. Will continue to monitor, closely. An acute care Physician Note written by the Medical Director and dated 2/9/2022 read in part Call was placed to her responsible party. A message was left to call the facility ASAP. As per the note, MD will be notified (notification was not done to me until this morning). The writer cleaned the wound with normal saline. [MEDICATION(S)] was applied. Also, the wounds were wrapped with Kerlix. As per writer, they will contact the wound care doctor also in the morning. Wound care team assessed the patient on 02/09/2022 afternoon. They have noticed the patient does have skin tears to the right elbow, right knee, right inferior leg, and bilateral shins. Also noted bruising to the forehead which is light in color and bilateral hands and back of the left arm. The patient is chronically on blood thinners also. Treatment orders were initiated, and I was notified of the findings. I did examine the patient personally in the room after that finding with wound care team. The patient has been examined fully with the wound care team in the afternoon of 02/09/2022. At that time, decision was made to send the patient to the local emergency department for their evaluation and management and further definitive treatment. An interview was conducted with Nurse #8 on 5/18/2022 at 11:15 A.M. During the interview Nurse #8 revealed she was asked to go to Resident #607's room to assess her after a fall. During the interview Nurse #8 stated she left the Medical Director a message and he called back right away. An interview was conducted with the Medical Director (MD) on 5/18/2022 at 1:32 P.M. During the interview the MD revealed he was unaware Resident #607 had a fall on 2/8/2022 until he was contacted on 2/9/2022 by the Wound Care Director to assess a bruise on Resident #607's forehead. The MD stated had staff contacted him on 2/8/2022 and stated Resident #607 had a fall and was on an anticoagulant, he would have given orders to send Resident #607 to the emergency room for an evaluation. An interview was conducted with the Administrator on 5/19/2022 at 2:45 P.M. During the interview the Administrator stated when a resident had a fall at the facility, staff should have immediately contacted the medical director with resident medical information and information about the fall.

Based on record review, staff, Nurse Practitioner (NP), Medical Director (MD), and radiology company interviews, the facility failed to assess Resident #610 after he was found on the floor and was unable to get up without assistance, as he normally was able to do. Two nurse aides picked him up from the floor and put him in bed. The nurse was not informed. The next day, Resident #610 was prepared for a transfer by Social Worker Assistant #1 when Resident #610 was found in pain and had a swollen knee. An assessment was initiated, the Nurse Practitioner assessed, ordered x-rays and pain relievers. X-ray results were faxed to the facility late that night but were not seen until close to noon the following day. Resident #610 was diagnosed with a femur fracture, a spinal injury and a rectus sheath hematoma. A rectus sheath hematoma is an accumulation of blood in the sheath of the abdominus muscle. This deficient practice affected one of three residents reviewed for accidents. Immediate Jeopardy began on 5/2/2022 when two staff picked up Resident #610 off the floor without reporting it to the nurse. Immediate jeopardy was removed on 5/21/2022 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimum harm that is not immediate jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee training. The findings included: Resident #610 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) dated [DATE] documented Resident #610 had severe cognitive impairment, was rarely or never understood, and had disorganized thinking continuously present that did not fluctuate during the lookback period. The Resident required minimal assistance of one staff with bed mobility and supervised assistance of one staff with transfers, walking in the corridor and locomotion on the unit. He was assessed to be not steady when walking but able to stabilize without staff assistance. No range of motion impairments were identified. Resident #610 had not had a fall since the prior assessment. The current care plan, initiated 3/8/2021, revealed focused areas that included: Resident #610 had a risk of potential for injury from other residents with dementia, wandering and behaviors. Resident #610 was a wanderer related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #610 was at risk for falls related to confusion, incontinence, and psychoactive drug use. The Resident specific interventions included: 1) Anticipate and meet the Resident's needs. 2) Report to the Medical Director changes in Resident's behavior. 3) Assess for fall risk. 4) Monitor, document, and report as needed any changes and declines in function. Resident #610's electronic medical record revealed no progress notes documented on the date of 5/2/2022. A signed statement made by NA #1, written on 5/4/2022 and read, on 5/2/2022 NA#1 was passing out 500 hall dinner trays, as I was taking Resident #610 his tray, he was sitting in the floor. She sat the tray down and attempted to help him up but he was waving her off, so she asked another NA, NA #2, to assist her with helping pick him up to eat his food tray. After that, I saw Resident #610 walking on the hall before leaving my shift. A signed statement made by Nurse #3, dated 5/5/2022 read: On May 2, 2022 Nurse #3 was the nurse taking care of Resident #610 from 7a.m. through 11 p.m. Resident #610 took all of his medication without any complications. He appeared to be at his baseline the entire shift. No issues or any changes in Resident #610 were reported to me throughout the entire shift from 7 a.m. - 11 p.m. An attempt was made to interview the NA #1, NA #2 and Nurse #3 who worked on the evening of 5/2/2022, via telephone, unsuccessfully. An interview was conducted on 5/19/2022 at 2:44 p.m. with Social Worker Assistant #1 via telephone with the Social Worker present. The interview revealed on 5/3/2022, Social Worker Assistant #1 was responsible for transporting Resident #610 to a podiatry visit in another area of the facility. She stated upon arrival in the room, between 10:30 a.m. and 11:00 a.m., she discovered Resident #610 sitting on the side of the bed with his pants not pulled up. She said she requested an NA, name unknown, to assist her to pull up the Resident's pants. She revealed the Resident refused to stand up with their assistance and wanted to only stand on his right leg and not his left leg. He kept his left leg bent and grimaced when they tried to stand him up. She said he appeared to be in a lot of pain. She added at this point, they laid the Resident down and proceeded to provide peri care because it was discovered he was wet and in need of care. When on his back, he pulled both legs up like he was in a fetal position, made a face like a grimace and like he was in pain. She said when the NA and herself pulled his pants down, it was discovered the Resident had a swollen left knee. She then said she went immediately and informed the hall nurse (Nurse #1). She said she was aware to report all new findings to a nurse because she was previously an NA and that was standard practice. Resident #610's progress notes revealed a nursing note dated 5/3/2022 at 2:52 PM (documented on 5/4/2022 at 12:57 p.m. as a late entry) written by Nurse #1 that read: baseline activity tolerance was up ad lib and ambulatory without assistance. Resident has not been ambulating this shift. He has been lying in bed. He did sit up and eat his breakfast and lunch on the side of the bed but continued to lay back down after eating. The Nurse Practitioner (NP) was in to assess him, ordered x-rays of the left hip, the left knee and the left foot, a pain-relieving gel for bilateral knees and Tylenol 500 milligrams (mg) 3 x a day for pain for 7 days. Resident 610's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was documented as administered on 5/3/2022 2:00 p.m. and 9:00 p.m. and on 5/4/2022 at 9:00 a.m. A review of the pain assessment using a scale of 0 to 10, with 0 being no pain and 10 being the worst pain ever, revealed a documented pain level on 5/3/2022 of 4 out of 10. The NP notes dated 5/3/2022 documented, Resident #610 was seen on 5/3/2022 at the request of Nurse #1 due to signs of pain in the left leg and not ambulating. The Resident's baseline was usually ambulating and today he was not walking around per usual and appears to be in pain per Nurse #1. Resident has dementia and therefore was unable to communicate his needs or cannot describe his pain. Pain was first noticed by Nurse #1 5/3/2022 in the a.m. The assessment revealed left leg pain with movement and bilateral knees with [CONDITION(S)] joint disease changes. Orders for x-rays to the left knee, hip and foot, Tylenol 500 mg 3 x day with a pain-relieving gel to bilateral knees. The x-ray lab result dated 5/3/2022 at 10:58 p.m. revealed a result of a fracture of the left femoral neck with impaction. The conclusion read: Acute left femoral neck fracture questioned, recommended repeat x-ray or computerized tomography (CT) scan. The result had a large ALERT typed across the result. A call was placed to Radiology company on 5/19/2022 at 10:55 a.m. and an interview was conducted with a staff member. He revealed the results of Resident #610 were faxed to the telephone number (336) [PHONE NUMBER] on 5/3/2022 at 11:00 PM and an email sent to the facility that read, ALERT, in all capital letters across the front. He added that a staff member from the radiology company called the facility on 5/4/2022 at 11:52 a.m. and spoke to Nurse #2 to provide a report of the questioned fracture that required an additional x-ray or CT scan. Resident #610's nursing progress notes revealed a note on 5/4/2022 at 11:58 a.m. written by Nurse #2 and read: Received x-ray results from 5/3/2022. Notified the NP of results and new order noted to send to the emergency room for evaluation. 911 was called for transport of the Resident. A call was placed to Resident's guardian and notified of x-ray results and order to transfer. Emergency medical services on site for transport. The NP progress notes for the date of service 5/4/2022 read, seen today at request of staff due to an abnormal left hip x-ray. X-ray revealed a left femoral neck fracture questioned and Resident will need an acute care evaluation in the emergency department. Resident was lying in bed, had been started on Tylenol 500 mg by mouth 3 x day. The Resident grimaces when the left lower extremity was flexed towards the body and repositioned. An interview was conducted with the NP on 5/18/2022 at 3:39 p.m. and she revealed she received a verbal report during rounds on 5/3/2022 from the hall nurse, Nurse #1, on the 500 hall that Resident #610 appeared to be in pain during the nurses care that day. She added that during her assessment the left knee appeared to have [CONDITION(S)] joint changes, through physical palpitation. She consulted with the MD and informed him of the changes she had observed. She stated the Resident was nonverbal but grimaced, so she provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the x-ray was not ordered as STAT because she was not aware there had been an unwitnessed fall and there was not reason to suspect a fracture. She added that the next day, on 5/4/2022, she was provided the results of the x-ray verbally during rounds and provided an order to transfer the Resident to an acute care hospital for further evaluation and treatment. An interview was conducted with the Medical Director (MD) on 5/18/2022 at 12:58 p.m. and he revealed his expectation for Resident #610 concerning the unwitnessed fall on 5/2/2022 at 5:00 PM was for a nurse to be notified at the time of the incident and an assessment conducted with MD notification to follow. He revealed the NP was notified verbally on 5/3/2022 by the day shift nurse during rounds and ordered diagnostic studies that included an x-ray. The MD added that he did not feel there was a concern with the delay in treatment because he needed to be scheduled, upon arrival at the hospital, for surgery. The MD revealed he requested the DON investigate what happened. The facility incident report completed on 5/4/2022, for the date of 5/2/2022 at 5:00 PM, by the Director of Nursing (DON #1) documented per nursing assistant staff, Resident was observed sitting on the floor beside his bed when his dinner tray was brought in the room on 5/2/2022. Sitting on the floor was not an uncommon observation for resident but Resident did not get up out of the floor unassisted per his baseline as he normally would. Nursing assistant indicated another nursing assistant came in the room and assisted with transferring Resident to bedside to eat his dinner. Nursing assistants indicated Resident did not appear to be in any distress when he was assisted to the side of the bed, but this was not reported to the nurse. An interview was conducted with the DON #1 on 5/18/2022 at 1:31 p.m. and revealed she became aware Resident #610 had a fractured femur on 5/4/2022 when he was being transported to the hospital. She was informed by a unit manager from another unit via electronic communication. She added this was the first time she had been informed anything was going on with Resident #610. She stated she came into the facility immediately, investigated and was able to determine an unwitnessed fall occurred on 5/2/2022 that involved two nursing assistants, nursing assistant (NA) #1 and NA #2, two agency staff members. She stated the investigation revealed NA#1 discovered the Resident sitting in the floor beside his bed and went to get NA#2 to assist her to help Resident #610 up to the side of the bed for his evening meal tray. She provided directions of where her file of the statements from NA #1 was located. She stated the assigned hall nurse, was Nurse #3 and the Nurse provided a statement that she had not been informed the Resident was discovered in the floor and had not conducted an assessment after the evening meal because it was the baseline for Resident #610 to go to bed after dinner. She added it was her expectation that the assigned hall nurse be informed of a fall immediately by any staff member that discovered a fall. This should be conducted prior to moving the resident to allow the nurse to conduct an assessment and then the physician should be notified and the standard practices after a fall should be implemented. She stated it was her expectation that night shift staff check for any updates on all outstanding lab work and x-ray results. She added that not following the facility process of sending all residents who fell to the emergency room for an exam, delayed Resident #610's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #610 was transferred from the facility to the emergency roiagnom on [DATE] at 11:58 a.m. The emergency room Physician notes for the date of service, 5/4/2022 revealed Resident #610 was not in acute distress on examination but was not able to straighten his legs on examination. He was observed to keep his legs bent towards his torso. The Resident was found to have multiple traumatic injuries on imaging. These included a left femoral fracture, a possible ligamentous injury with the cervical spine and a rectus sheath hematoma with a possible active extravasation (an uncommon cause of acute abdominal pain. It was an accumulation of blood in the sheath of the rectus abdominis, secondary to rupture of an epigastric vessel or muscle tear). A review of the hospital discharge summary dated 5/11/2022 documented Resident #610 was admitted to the hospital on 5/4/2022. The trauma team managed the Resident by providing aggressive pain control. Orthopedic trauma was consulted for the left femur fracture and Resident #610 underwent a surgical procedure, on 5/7/2022. The Orthopedic spine team was consulted for the ligamentous injury at the C6-C7 (cervical disc near the lower part of the neck near the top of the shoulder) level which was managed non-operatively and fitted with a hard, cervical collar. The Administrator was notified of immediate jeopardy on 5/19/2022 at 4:10 p.m. The facility provided a credible allegation of immediate jeopardy removal dated 5/21/2022. An incident report, was completed on 5/4/2022 5:00pm by the Director of Nursing, based on information obtained from facility staff regarding an event occurring on 5/2/22 where Resident #610, who was observed sitting on the floor beside his bed when staff entered his room to deliver the dinner tray. Resident #610 often preferred, to be seated on the floor, however he was unable to stand unassisted per his normal baseline. Two Nursing Assistants assisted with transferring resident #610 to be seated at the bedside for dinner. Both Nursing Assistants indicated Resident #610 did not appear to be in any distress and did not verbalize any complaints when he was assisted to side of bed. This occurrence was not reported to Nurse #1 as this was usual activity for Resident #610. Nurse #1 documented a late entry for Resident #610 on 5/4/2022 at 12:57PM, for the date of 5/3/2022, stating the baseline activity tolerance is up ad lib and ambulatory without assistance, resident has not been ambulating this shift, he is lying in bed, he did sit up and eat breakfast and lunch on the side of the bed but continued to lay back in the bed after eating. On 5/3/2022 the Nurse Practitioner was in to assess the resident at the request of Nurse # 1 related to a new complaint of left leg pain and reduced mobility. The NP ordered bilateral x-rays of the hip, knee, and foot and Tylenol 5mg 3 x a day for pain x 7 days with [MEDICATION(S)] gel to bilateral knees. On 5/3/2022 at 11:58pm the x-ray result conclusion: acute left femoral neck fracture questioned, a possible ligamentous injury with the cervical spine and a rectus sheath hematoma, further recommended repeat x-ray or computerized tomography (CT) scan. On 5/4/2022 at 11:58 am Nurse #2 received the x-ray results from 5/3/222 notified the Nurse Practitioner of the results from 5/3/2022 and received an order to transfer the resident to the Emergency Department for evaluation, transfer was arranged via ambulance. On 5/4/2022 the guardian was notified of the x-rays results and the order received to transfer to the Emergency Department. Resident #610 was admitted to the hospital on 5/4/2022 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/2022 the Nurse managers reviewed residents who have fallen during the last 30 days to validate documentation of post fall nursing assessment including range of motion and pain assessment, MD and Responsible party notification was completed. Any opportunities identified during this audit will be corrected by the Nurse Managers by 5/20/22. 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 Staff Development Coordinator, Regional Director of Clinical Services, and unit managers educated Licensed Nurses regarding the requirement to complete and document a post fall nursing assessment to include range of motion and pain assessment prior to moving the resident. Education also included requirements for notification of the MD and Responsible Party following an incident. The Nurse Managers educated Nursing Assistants on the definition of a fall including a change of plane and to report falls to the Licensed Nurse immediately, prior to moving the resident. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. Education will be completed by 5/20/22 by the Nurse Managers. The Regional Director of Clinical Services educated the Nurse Management team and the Administrator regarding the clinical morning meeting process to include a review of residents with falls, to validate completion and documentation of post fall nursing assessment including Range of Motion and Pain assessment and notification of the MD and responsible party. This education was completed on 5/20/22. The Staff Development Coordinator, Regional Director of Clinical Services, and unit managers educated Licensed Nurses regarding the follow up on X-Ray results and obtaining results from the Trident portal. Instructions for reference remain available at the Nurse's station. All licensed nurses have access to the Trident portal. License nurses follow up on the same shift if the X-Ray was obtained on their shift if no results they are to follow-up on the next shift. Abnormal results are to be called immediately to MD once received for further orders. Education complete date 5/20/2022 Effective 5/19/2022 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 5/21/2022 Onsite validation was completed on 5/24/2022 through record review, and staff interviews. Staff were interviewed to validate in-service completion on post fall assessments and physician notification that included obtaining lab results. A review of the Staff Development Coordinators education logs was conducted and compared to the staff log. The facility immediate jeopardy removal was validated to be completed as of 5/21/2022.

Based on observations, record review, staff and resident interview the facility failed to treat residents who required assistance with incontinence care in a dignified manner. Resident #77 expressed feelings of embarrassment because she did not have on a brief, was wet and had no linen on her bed. Resident #53 expressed feelings of embarrassment because the staff used 2 briefs and a towel to manage her incontinence because the facility did not have the correct size brief for her. This was evident for 2 of 8 residents reviewed for dignity. Finding included: 1. Resident #77 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #77's quarterly Minimum Date Set (MDS) dated [DATE] revealed her cognition was intact and she was able to communicate her needs to staff. Resident #77 was occasionally incontinent of bowel and bladder. Review of Resident #77's care plan dated 04/11/22 indicated Resident #77 needed extensive one-person assistance with bed mobility, dressing and personal hygiene. She was totally dependent on staff for toilet use. An observation of Resident #77 on 5/18/22 at 5:30 am revealed she was lying in bed and a strong urine odor was noted. The resident was lying on the right side of the bed, on her back with no bed covering on her body. She had a bath blanket folded in half lying under her torso and a folded sheet under her feet. The resident was not wearing an adult brief. The bath blanket under her torso was saturated with urine dripping onto the floor. There was a puddle of urine on the floor. The resident stated a nursing assistant (NA) changed her top blanket but not the one under her. She stated she was a heavy sleeper and required a brief at night in case she was incontinent and could not make it to the bedside commode. She said the staff told her they were having trouble locating briefs in her size, a 4x, and they would return with one. She said this was at 11:30 p.m. No one returned with a brief and she fell asleep. When she woke up this morning she was drenched, and nobody had been in to change her all night. She said she would have liked to have been helped during the night instead of being left in a wet mess. The resident added she felt very embarrassed about not having a brief for her incontinence and left in such a mess and now someone had to clean the entire floor because she was not provided with the items she needed for her incontinent episodes during the night. An interview conducted on 5/18/22 at 5:52 am with NA#10 revealed she had not performed peri-care or put a clean sheet on Resident #77 ' s bed; she added she had cleaned the floor. NA #10 stated the resident told her she did not need to be changed because she could take herself to the bedside commode. An interview with Resident #77 on 5/18/22 at 5:54 am revealed NA #10 didn ' t clean up the floor and she hadn ' t told the NA on night shift she didn ' t need help. The resident stated NA #10 told her she was going to get linens and brief and never came back. A second observation of Resident #77 on 5/18/22 at 11:00 am revealed she did not have a brief on. Resident #77 state the staff informed her that her size brief was not available. Resident #77 indicated this had been a going problem for a month. Resident #77 did not have any sheets under her during this observation. The resident indicated she was embarrassed about not having a brief on and not having a sheet underneath her. An observation was conducted of the supply room on the 3rd floor on 05/19/22 at 11:25 am and there were no 3 x or 4 x briefs for residents on that hall. An interview with the Administrator on 5/20/22 at 5:20 pm revealed she expected all residents needs to be met and the facility should have the correct size briefs available. 2. Resident #53 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #53's quarterly Minimum Date Set (MDS) dated [DATE] revealed her cognition was intact and was able to make her needs know to staff. Resident #53 was occasionally incontinent of bowel and bladder. Review of Resident #53's care plan dated 04/11/22 indicated she needed extensive one-person assistance with bed mobility, dressing and personal hygiene and was totally dependent for toilet use. Resident #53 was interviewed on 05/17/22 at 11:45am and indicated the facility was short on briefs for her size. She stated the staff had to put two smaller size briefs together for her buttocks and place a towel in front of her for incontinence care. Resident #53 indicated this was embarrassing to her. She added the facility never had enough briefs in her size and this had been going on since she came to the facility in December 2021. Resident #53 indicated that it was a bad feeling for staff to have to use two briefs. During an interview on 05/19/22 at 11:15 am with Nursing Assistant #11 (NA) she indicated she had only been working at the facility for a few months and it had been an ongoing issue with not having size 4x briefs for Resident #53. An observation was conducted of the supply room on the 3rd floor on 05/19/22 at 11:25 am and there were no size 3x or 4x briefs for residents on that hall. An interview with the Administrator on 5/20/22 at 5:20 pm revealed she expected all residents needs to be met and the facility should have the correct size briefs available.

Based on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on [DATE]. This was for 4 deficiencies that were cited in the areas of Resident Rights / Exercise of Rights (F550), Reasonable Accommodation of Needs / Preferences (F558), Provision of activities of daily living (ADLs) for dependent residents (F677) and Food procurement, storage, preparation and service under sanitary conditions (F812) on [DATE] and recited on the current recertification and complaint survey of [DATE]. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on [DATE]. This was evident for 1 deficiency in the area of Maintaining Essential Equipment in Safe Operating Condition (F908) originally cited on the recertification and complaint survey on [DATE] and recited on the current recertification and complaint survey of [DATE]. The duplicate citations during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag is cross referenced to: 1.F550 - Based on observations, record review, staff and resident interview the facility failed to treat residents who required assistance with incontinence care in a dignified manner. Resident #77 expressed feelings of embarrassment because she did not have on a brief, was wet and had no linen on her bed. Resident #53 expressed feelings of embarrassment because the staff used 2 briefs and a towel to manage her incontinence because the facility did not have the correct size brief for her. This was evident for 2 of 8 residents reviewed for dignity. During the recertification and complaint survey [DATE] the facility failed to provide a dignified dining experience by talking on a cell phone while aiding with feeding for 1 of 8 residents (Resident #114) reviewed for dining. An interview with the Administrator on [DATE] at 5:15 pm revealed she was new to the facility and had only been there for 4 weeks. She stated she was not aware of any active QAPI (quality assurance and performance improvement) plans in place at the facility. She added the facility had conducted one QA meeting since she had started, and the committee was determining what areas needed to have a QAPI plan. 2. F558- Based on observations, record reviews, resident and staff interviews, the facility failed to provide the proper size briefs for 2 of 3 residents reviewed for accommodation of needs (Resident #53 and Resident #77). This resulted in the residents expressing they felt bad and embarrassed. During the recertification and complaint survey [DATE] the facility failed to ensure 1 of 35 residents (Resident #118) reviewed for call light accessibility was able to reach their call light. Resident #118 was unable to reach for his call light due to left sided weakness and contracture of the left hand. An interview with the Administrator on [DATE] at 5:15 pm revealed she was new to the facility and had only been there for 4 weeks. She stated she was not aware of any active QAPI (quality assurance and performance improvement) plans in place at the facility. She added the facility had conducted one QA meeting since she had started, and the committee was determining what areas needed to have a QAPI plan. 3.F677 - Based on observations, record review, staff and resident interviews the facility failed to provide incontinence care (Resident #77, Resident #111), failed to provide clean and dry linens (Resident #77, Resident #111, Resident #610), failed to keep dependent residents' fingernails trimmed and clean (Resident #111), failed to shave a male resident (Resident #111) and failed to provide a shower (Resident #50) for 4 of 7 residents reviewed for activities of daily living (ADL) care. During the recertification and complaint survey [DATE] the facility failed to provide a dependent resident with assistance with eating for 2 of 6 residents (Resident #114 and Resident #129) reviewed for activities of daily living. An interview with the Administrator on [DATE] at 5:15 pm revealed she was new to the facility and had only been there for 4 weeks. She stated she was not aware of any active QAPI (quality assurance and performance improvement) plans in place at the facility. She added the facility had conducted one QA meeting since she had started, and the committee was determining what areas needed to have a QAPI plan. 4.F812 - Based on observations, staff interviews and record reviews, the facility failed to: 1) seal, label/date, and/or discard expired food in 1 of 1 walk-in cooler; 2) seal and label/date opened food items in 1 of 1 dry storage rooms; 3) seal and/or label/date opened food items stored in 1 of 1 walk-in freezer; 4) label/date opened food items and/or discard expired food in in 4 of 4 nourishment rooms (200 Hall, 300 Hall, 500 Hall and 400 Hall), keep the ice machines clean and free of gray residue (mold buildup) inside the machine in 2 of 4 nourishment rooms (500 Hall nourishment room and 400 Hall nourishment room), and keep 1 of 4 nourishment room refrigerators maintained with the proper temperature (400 Hall nourishment room); and 5) keep the kitchen vents and fans, floor, and food service equipment clean within the Dietary Department. These practices had the potential to effect food served and distributed to all residents During the recertification and complaint survey [DATE] the facility failed to ensure 7 of 15 dishware were dry before stacked and ready for use. The facility additionally failed to discard 26 of 30 expired milk cartons stored in 1 of 2 refrigeration units. These practices had the potential to affect food served to residents. An interview with the Administrator on [DATE] at 5:15 pm revealed she was new to the facility and had only been there for 4 weeks. She stated she was not aware of any active QAPI (quality assurance and performance improvement) plans in place at the facility. She added the facility had conducted one QA meeting since she had started, and the committee was determining what areas needed to have a QAPI plan. 5.F908 - Based on observations and staff interviews, the facility failed to maintain 1 of 1 food steamer, 1 of 1 upright food warmer, and 2 of 2 lowerator plate warmers in safe operating condition During the recertification and complain survey [DATE] the facility failed to maintain one of one walk-in refrigerator in operating condition. An interview with the Administrator on [DATE] at 5:15 pm revealed she was new to the facility and had only been there for 4 weeks. She stated she was not aware of any active QAPI (quality assurance and performance improvement) plans in place at the facility. She added the facility had conducted one QA meeting since she had started, and the committee was determining what areas needed to have a QAPI plan.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide the proper size briefs for 2 of 3 residents reviewed for accommodation of needs (Resident #53 and Resident #77). This resulted in the residents expressing they felt bad and embarrassed. Finding included: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's quarterly Minimum Date Set (MDS) dated [DATE] indicated that Resident #53 was cognitively intact. Resident #53 needed extensive assistance with toilet use, dressing, transfer, and bed mobility. Resident #53 was occasionally incontinent of bowel and bladder. Resident #53's care plan dated 03/14/22 indicated that Resident #53 required extensive one-person assistance with bed mobility, dressing, toilet use and personal hygiene. A review of the central supply order forms for briefs indicated that from November 2021 to May 2022 the orders revealed only 4 boxes of 3 x to 4 x briefs ordered. Resident #53 was interviewed on 05/17/22 at 11:45 am and indicated the facility was short on briefs for her size. She stated the staff had to put two smaller size brief s together for her buttocks and place a towel in front of her for incontinence care. Resident #53 indicated this was embarrassing to her. Resident #53 indicated that she needed a size 4 x brief. She added the facility never had enough briefs in her size and this had been going on since she came to the facility in December 2021. Resident #53 indicated that it was a bad feeling for staff to have to use two briefs. During an interview on 05/19/22 at 11:15 am with Nursing Assistant #10 (NA) she indicated she had only been working at the facility for a few months and it had been an ongoing issue with not having 4 x briefs for Resident #53. An observation was conducted of the supply room on the 3rd floor on 05/19/22 at 11:25 am and there were no 3 x or 4 x briefs for residents on that hall. The Central Supply staff was not available for interview. An interview with the Administrator on 5/20/22 at 5:20 pm revealed she expected all residents needs to be met and the facility should have to correct size briefs available. 2. Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #77's quarterly Minimum Date Set (MDS) dated [DATE] indicated that Resident #77 was cognitively intact. Resident #77 needed extensive one-person assistance with bed mobility, dressing and personal hygiene and was totally dependent on staff for toilet use. Resident #77 was occasionally incontinent of bowel and bladder. Resident #77's care plan dated 04/11/22 revealed she had a care plan for toilet use and was totally dependent on staff. A review of the central supply order forms for briefs indicated that from November 2021 to May 2022 the orders revealed only 4 boxes of 3 x to 4 x briefs ordered. An observation of Resident #77 and an interview were conducted on 5/18/22 at 5:30 am and revealed she did not have a brief on and there was a puddle of urine under her bed. The resident indicated she was very embarrassed by that. She added the staff informed her that her size brief (4 x) was not available. Resident #77 indicated this had been going on for month. A second observation of Resident #77 on 05/19/22 at 11:00 am and revealed that Resident #77 did not have on a brief. During an interview on 05/19/22 at 11:15 am with Nursing Assistant (NA) #10 she indicated she had only been working at the facility for a few months and it had been an ongoing issue with not having 4 x briefs for Resident #77. An observation was conducted of the supply room on the 3rd floor on 05/19/22 at 11:25 am and there were no 3 x or 4 x briefs for residents on that hall. The Central Supply staff was not available for interview. An interview with the Administrator on 5/20/22 at 5:20 pm revealed she expected all residents needs to be met and the facility should have to correct size briefs available.

Based on observations, record review, staff and resident interviews the facility failed to provide incontinence care (Resident #77, Resident #111), failed to provide clean and dry linens (Resident #77, Resident #111, Resident #610), failed to keep dependent residents' fingernails trimmed and clean (Resident #111), failed to shave a male resident (Resident #111) and failed to provide a shower (Resident #50) for 4 of 7 residents reviewed for activities of daily living (ADL) care. The findings included: 1. Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #77's quarterly Minimum Date Set dated 4/11/2022 revealed Resident #77 had intact cognition. The Resident was able to communicate her needs and had occasional incontinence of bowel and bladder. A review of Resident #77's care plan dated 4/11/2022 indicated that Resident #77 required extensive assistance of one staff member with bed mobility, dressing and personal hygiene. She was totally dependent on staff for toilet use. An observation of Resident #77 was conducted on 5/18/2022 at 5:28 a.m. and revealed a strong odor of urine. The Resident was lying on the right side of the bed, on her back, with no bed covering on her body. She had a bath blanket folded along the length of the blanket, under her torso and bottom. The blanket was dripping a wet substance onto the floor. There was not an incontinence pad. A puddle was observed under half of the bed, extending to the bedside table, the oxygen concentrator and to the wall. The Resident stated she was a heavy sleeper and required a brief at night in case she was incontinent and could not make it to the bedside commode. She said the staff, name unknown, told her they had trouble locating briefs in her size, a 4x, and they would return with one. She added this was at 11:30 p.m. on 4/17/2022 and no one returned. She said she fell asleep and woke up this morning drenched. She stated no one offered her assistance during the night until around 5:00 a.m. She said she would liked to have been offered assistance during the night instead of being left in the wet mess. She added that when the nursing assistant (NA) #9 came in to provide assistance she did not help her to clean up. The Resident then pointed to her peri care area, the private areas of a resident. She stated she felt very embarrassed when there was such a wet mess and someone had to clean the entire floor because she was not provided the items she needed for her episodes during the night. An interview was conducted on 5/18/2022 at 5:42 a.m. with Nurse #7, the hall nurse assigned to Resident #77. Nurse #7 stated she observed urine leaking from bed linens onto the floor with a puddle that was under the bed, under the bedside table and going towards the wall. She added the Resident had no top sheet or blanket. She revealed it was her expectation that when care was provided for a Resident, the Resident should have been provided clean sheets with a bariatric fitted sheet, peri care provided, and a blanket provided to the Resident. She revealed basic housekeeping needed to occur to the floor and the NA was responsible for this service since the housekeeping staff were not on duty yet. Nurse #7 stated she would immediately get a NA to help her provide assistance to the Resident. An interview was conducted with NA#9 on 5/18/2022 at 5:50 a.m. and she stated she had been in around 5:00 a.m. to provide care to Resident #77. She stated peri care was not provided to Resident #77 and a clean sheet underneath the Resident was not provided. She stated she cleaned the floor and did not change the Resident because she said she could take herself to the bedside commode. The Resident spoke up and stated, You did not clean the floor and I did not tell you that I did not need help this morning. You told me you were going to get linens. The NA then stated, well I am an agency NA and this was only my second day. I was going to clean the floor and get clean linens, but this was only my second night. No further comments were made, and she exited the room. 2. Resident #111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #111's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #111 had moderate cognitive impairment. The Resident was able to communicate his needs to staff, was always incontinent of bowel and bladder and required extensive assistance of one staff member for bed mobility, personal hygiene and toileting. A review of Resident #111's current care plan dated 4/22/2022 indicated a focused area that read: Resident #111 has an Activities of Daily living (ADL) self care performance deficit related to performance deficit. The interventions included the Resident requires assistance by staff for toileting, personal hygiene, and to turn and reposition. An interview was conducted on 12:14 p.m. with Resident #111 and he stated he was wet and then held up the sheet and showed a saturated brief. The Resident was observed to have an orange substance on his face and beard. His nails were untrimmed with brown debris in the cuticle and under the nail. The Resident had scooted down the bed with his feet hanging off 6 inches and he stated, I want to get out of the wet diaper. His face was unshaven on the side with a goatee around the mouth. The unshaven area was 0.5 cm long. The sheet around the Resident had a large wet area with a strong urine odor. As the Resident moved around it was possible to observe the back of the brief and it was wet to the top of the brief. When asked if he could press the call light to call for assistance, he stated it was hard to press a call light with his tremors but he made the effort and successfully pressed the call light at 12:21 p.m. On 5/17/2022 at 12:26 p.m. NA#11 entered Resident #111's room to respond to the call light and stated she would be back in a few moments with the necessary items to clean up the Resident. On 5/17/2022 at 12:28 p.m. an observation of ADL care was conducted for Resident #111. NA #11 updated the Resident on what she was going to do. She pulled the privacy curtains, removed the soiled brief. The Resident was observed with a bowel movement and urine. She requested the Resident to roll to his side and an area of wet urine was around the lower area below his incontinence pad and on the incontinence pad. A large area covering the entire section under a draw sheet was wet with dried outer edges of yellow and brown discoloration. The NA stated she had checked on the Resident during rounds at 7:30 a.m. in the morning and he was dry at that time but she stated she did not check under the draw sheet or incontinence pad. She changed the sheets and provided a partial bed bath. She revealed she observed he needed to be shaved and his nails were dirty. She stated after lunch she would provide a shave and be sure his nails were trimmed. She stated it was the responsibilities of the hall nurse and the NA to trim fingernails. 3. Resident #610 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) dated [DATE] documented Resident #610 had severe cognitive impairment and was rarely or never understood. Resident #610 required assistance of one staff with bed mobility, and personal hygiene and total assistance of one staff for toileting. A review of the current care plan initiated 3/8/2021 had a focused area identified for daily living self care performance deficit related to dementia with interventions that included, the Resident requires assistance by staff with personal hygiene, The Resident requires assistance by staff for toileting, and anticipate and meet the Resident's needs. An observation was conducted on 5/18/2022 at 6:00 a.m. of Resident #610 lying in bed. The top sheet had a dried yellow stain and was covering half of the Resident. The bottom sheet had an area of dark yellow dried urine visible coming out from under the draw blanket. The draw blanket had dark areas that were wet and dried in other areas. On the right side of the Resident, a [MEDICATION(S)] wrapper was observed waded up, and a straw wrapper stuck to the Resident's side, on his skin, visible from the door way. The bedside table was not near the bed. The Resident's gown was stuck to his skin and moist. An interview was conducted on 5/18/2022 at 6:02 a.m. with Nurse #6 and he revealed Resident #610 had received personal hygiene care during the morning rounds by the nursing assistant staff. He stated the reason the sheets were soiled was because the staff were waiting for clean linens to arrive to the floor. He lifted the Resident's gown and demonstrated a dry brief but stated he was unaware the Resident was lying on a wet draw sheet. When asked about the trash stuck to the Resident's skin he stated he was unsure how the trash got into the bed with the Resident because he could not walk to get the trash. He stated the [MEDICATION(S)] wrapper must have been left in the bed by accident by the nurse. He stated he would have staff change the sheets as soon as possible and get the Resident a clean gown and wash his skin off. 4. Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact and could communicate her needs to staff. On the interview for daily and activity preferences, the question, how important was it to the Resident to choose between a tub bath, shower, bed bath, or sponge bath, the Resident answered very important. The Resident required total dependence on one staff member for bathing. The current care plan dated 5/15/2021 identified a focused area that read, Resident #50 has an ADL self care performance deficit related to impaired balance and limited mobility with interventions that included, the Resident required assistance by staff with bathing and showering as necessary and check nail length and trim and clean on bath day as necessary. On 5/17/2022 a review of the electronic medical record for the bath history task list revealed documentation that the Resident received a shower on 4/20/2022 at 2:59 and on 5/9/2022 at 1:59 p.m. The Resident was documented to have had a full bed bath on 4/22/2022 at 11:51 a.m., 4/25/2022 at 1:12 p.m. and 5/6/2022 at 2:29 p.m. An interview was conducted on 5/17/2022 at 12:53 p.m. with NA #10 when questioned about shower documentation, she revealed at this time, she was not able to complete showers as scheduled but would complete a bed bath on all of her people. She stated this was due to the staffing ratio on the unit. She revealed with the lay out of the unit, with the halls not able to be visualized from one hall to the next, and with dementia residents wandering into the day room, with three NAs on the total assignment, one would need to watch the day room area, one would be on one of the split hall and one on the other hall. She stated if they leave the hall to go to the shower room, it does not feel safe. She stated this had been expressed to the previous and current administrator. She added she could only complete about two assigned showers a day out of 5 or 6 assigned showers. An interview was conducted on 5/17/2021 at 4:30 p.m. with Resident #50 and she revealed she loved to take a shower. She stated she was able to wash herself and give herself a shower if staff would set everything up. She stated the shower room was kept locked so she had to wait until staff were willing. She revealed she will walk up to the nursing station and request a shower and was usually provided some excuse why the staff cannot give her a shower. She added she usually just washed herself up at the sink and that staff do not assist her with this. She added that she had been to the shower room once in the past month that she could remember and when shown the documentation on the ADL task report she stated, that it was probably about right and then said, isn't that sad. She stated not getting her showers makes her feel lousy and dirty. She went on to say taking a shower makes a person feel better and she was afraid she was now going to die dirty. She added that she had told the staff she preferred a shower over a bed bath or a sink bath and was not offered a shower and was not offered assistance. An observation was observed on 5/17/2022 at 4:33 p.m. of Resident #50 with hair uncombed and greasy. An interview was conducted with NA #12 on 5/18/2022 at 9:13 a.m. and she demonstrated where the shower schedule was for the 500 hall. She stated she was an agency staff member and the shower schedule was demonstrated to her on the first day of orientation to the facility. She added she was aware of how and where to locate what residents receive a shower based on the location of this book and what was written inside. A review of the shower schedule book, on the 500 hall, revealed the A beds for the even rooms were scheduled on Monday, Wednesday and Friday for first shift and the B beds wound be on second shift of the same days. The odd rooms would be on Tuesday, Thursday and Saturday with the A beds on first shift and the B beds on second shift. Based on this, Resident #50 was in an even room in an A bed so she was assigned Monday, Wednesday and Friday for first shift.

Based on record review and staff interview, the facility failed to provide safe care to a dependent resident which resulted in the resident falling out of bed and substaining injuries. One staff repositioned Resident #607, who received anticoagulant medication, too close to the edge of the bed and Resident #607 slid off the bed. The resident was sent to the hospital and diagnosed with a left proximal humerus fracture, a fractured eye socket, and a mild scalp contusion. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #607). Findings included: Resident #607 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included [CONDITION(S)], [CONDITION(S)], presence of a pacemaker, generalized muscle weakness, and lack of coordination. The plan of care for Resident #607 included a focus area for potential risk for falls related to gait/balance problems and incontinence with an initiation and last revision date of 8/30/2021. Interventions included anticipate and meet the resident's needs, educate the resident/family/caregiver about safety reminders and what to do if a fall occurs. The care plan stated Resident #607 had a at risk for abnormal bleeding or hemorrhage due to anticoagulant use related to [MEDICATION(S)] use for [CONDITION(S)] with an initiation and last revision date of 8/30/2021. Interventions included monitor for signs of bleeding, call medical director for signs and symptoms of noted bleeding. Resident #607's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #607 did not have intact cognitive skills for daily decision making. The MDS indicated Resident #607 was assessed as extensive assistance from two staff members with bed mobility and transfers. Resident #607 required total assistance from one staff member with toileting and personal hygiene. The MDS further showed Resident #607 was always incontinent of bladder and bowel. A review of Resident #607's Physician Orders included a medication order started on 1/23/2022 for [MEDICATION(S)] (an anticoagulant medication) 2.5 milligram tablet, given two times a day for [CONDITION(S)]. A post fall review report dated 2/8/2022 completed by Nurse #8 indicated Resident #607 had a witnessed fall on 2/8/2022 at 8:30 P.M. The fall resulted in an injury of large unmeasurable skin tears noted on bilateral lower extremities. The report indicated Resident #607 was in her room in bed prior to the fall and Resident #607 was receiving incontinence care at the time of the fall. A Nursing Progress Note dated 2/8/2022 at 8:30 P.M. completed by Nurse #8 read in part Resident's lower extremities slid off left side of bed during incontinent care provided by assigned NA. NA stated she made an attempt to avoid it, but resident continued to slide off bed. She landed in sitting position. Large skin tears noted on bilateral lower extremities. Writer cleansed wounds with normal sterile saline, applied [MEDICATION(S)] (an ointment antibiotic used to prevent wound infections), & wrapped both wounds with Kerlix(rolled gauze used wrap around body part to cover open wounds). Writer will contact Wound Care Dir., in AM. Denied pain. Will continue to monitor, closely. A telephone interview was attempted with Nurse Aide (NA) #13 on 5/18/2022 at 12:24 P.M. The NA was unable to be reached. NA#13 was assigned Resident #607 at the time of the fall on 2/8/2022. An interview was conducted with NA #14 on 5/20/2022 at 7:26 P.M. During the interview, NA #14 stated she completed rounds on 2/8/22 with NA #13 prior to the end of shift at 11 P.M. NA #14 stated she entered Resident #607's room with NA #13 and found Resident #607 lying in bed on her back. NA #14 stated when Resident #607 was checked, she was clean of incontinence; however, Resident #607 was found with bowel movement on her fitted bed sheet, and the sheet needed to be changed. NA #14 stated she left the room to get a clean fitted sheet and told NA #13 she would be right back. NA #14 stated when she returned to Resident #607's room with the fitted sheet, Resident #607 up on her side. NA #14 stated NA #13 repositioned Resident #607 too far onto her side and Resident #607 fell off the side of the bed away from the door and onto the floor. NA #14 stated when she walked to the side of the bed Resident #607 fell from, the resident was found lying beside the bed with blood on her legs. NA #14 stated she was unsure if Resident #607 hit her head when she fell . NA #14 stated she went to get the nurse, while NA #13 stayed with Resident #607. NA #14 revealed Resident #607's bed had been raised to the high position because there were two staff member present in the room to change the fitted sheet and NA #14 stated the other NA should have waited for her to return to the room before repositioning Resident #607. During the interview NA #14 further stated there was not a fall mat beside the bed and she did not recall the bed having a side rail. NA #14 stated Resident #607 slept through the night and did not voice any concerns of pain. An interview was conducted with Nurse #8 on 5/18/2022 at 11:15 A.M. During the interview, Nurse #8 stated she was not assigned Resident #607 on 2/8/22, but an NA came to her hallway and told her Resident #607 had fallen from her bed. Nurse #8 stated she went to Resident #607's room and found Resident #607 sitting on the floor beside the bed. Nurse #8 indicated the NA told her Resident #607 started to slip when incontinence care was provided, and the NA was unable to stop Resident #607 from falling. Nurse #8 further revealed the NA stated Resident #607 had not hit her head when she fell from the bed and when Nurse #8 assessed Resident #607, she found skin tears on bilateral lower extremities. NA #8 revealed she did not see any bruising on her forehead. Nurse #8 stated she completed a fall report and contacted the MD. During the interview Nurse #8 revealed the NA should have waited for a second staff member before repositioning or turning Resident #607. A Nursing Progress Note dated 2/9/2022 at 1:13 P.M. completed by the Wound Director read, in part, Nursing Writer notified that resident had a fall with injuries. Into assess resident who had noted skin tears to right elbow, right knee, right inferior leg, and bilateral shins. Also noted with bruising to forehead, bilateral hands and back of Left arm. Treatment orders initiated and applied. An interview was conducted with the Wound Director on 5/18/2022 at 11:50 A.M. During the interview, the Wound Director stated on 2/9/2022 she was asked to assess Resident #607's skin tears from a fall the previous evening. During the interview the Wound Director revealed there was blood on the sheets from huge shearing skin tears on Resident #607's shins, with no active bleeding. The Wound Director further stated Resident #607 had a bruise on her left arm, a skin tear on her right elbow, and a bruise on her forehead. The Wound director revealed Resident #607 stated she had fallen, and her head was hurting. The Wound Director stated due to Resident #607 having a fall and not knowing exactly what happened with the fall, she contacted the Medical Director who was in the building to assess Resident #607. A Physician Progress Note dated 2/9/2022 completed by the Medical Director (MD) read, in part, Wound care team assessed the patient on 02/09/2022 afternoon. They have noticed the patient does have skin tears to the right elbow, right knee, right inferior leg, and bilateral shins. Also noted bruising to the forehead which is light in color and bilateral hands and back of the left arm. The patient is chronically on blood thinners also. Treatment orders were initiated, and I was notified of the findings. I did examine the patient personally in the room after that finding with wound care team. At that time, decision was made to send the patient to the local emergency department for their evaluation and management and further definitive treatment. The patient did not endorse any pain or discomfort to me. At baseline, she was alert and oriented to herself. She did not endorse to me any headache. An interview was conducted with MD on 5/18/2022 at 1:32 P.M. The MD stated he received a phone call from the Wound Director, who asked him to assess Resident #607. The MD stated when he arrived in Resident #607's room, he noticed bruising on her arm and her forehead. The MD revealed Resident #607 did not voice any concerns of pain, was alert, and answered his questions. During the interview the MD stated he was told by staff, Resident #607 slipped out of her bed while staff provided her with personal care. The MD further stated he felt there needed to be two staff members because there were no bars on her bed to prevent her from rolling out. During the interview the MD stated after his assessment and due to bruising on Resident #607's forehead, he felt she needed to be sent to the emergency department for further evaluation. A Nursing Progress Note dated 2/9/2022 at 2:51 P.M. completed by Nurse #9 read, in part, Resident visited by MD. Assessed injuries to forehead and bilateral lower extremities and bilateral upper extremities. Received new order to transfer resident to ED (emergency department) to evaluate and treat. Resident is in bed resting quietly. Hospital records dated 2/8/2022 at 1:36 P.M. revealed history provided by Resident and EMS personnel, indicated Resident #607 present to the ED with a fall that occurred in unknown circumstances where the point of impact was the head. A physician exam was completed and showed a hematoma (a collection of blood outside the blood vessel) to frontal scalp, skin tears to the right upper extremity and bilateral lower extremities. The hospital records stated history was retrieved from Nurse #8 who stated Resident #607 was found with a hematoma to the forehead this morning, unclear cause with presumed fall from bed last night. Hospital records indicated Trauma Surgery consulted to evaluate Resident #607 on 2/9/2022 at 1:07 P.M. The imaging results were as follows: computed tomography (CT) Spine showed a buidlup of fluid throughout the upper spine which may reflect ligamentous injury (an injury caused by an extreme motion) or sequelae of [CONDITION(S)] changes. CT of face revealed no evidence of acute facial fracture, a remote left orbital floor fracture (the bones of the eye socket floor buckled following a blaunt point of impact), and a mild right frontal scalp contusion (bruise). An orthopedic consult not dated 2/9/2022 at 2:32 P.M. revealed Orthopedics were consulted for a left fracture of the upper arm bone at the shoulder joint. Resident #607 had anticipated non-operative management with pain controlled in the ER. Resident #607 was placed in a sling for closed management of the fracture. An interview was conducted on 5/18/2022 at 3:39 P.M. with the Director of Nursing (DON) #2. During the interview, the DON stated she was unsure when she was notified Resident #607 had a fall. The DON stated she recalled as was standard procedure, Resident #607 was sent to the emergency department for further evaluation post fall due to being on blood thinners to ensure no acute issues had developed due to the fall. The DON stated staff should ensure resident safety was maintained when care was provided. An interview was conducted with the Administrator #2 on 5/20/2022 at 12:05 P.M. During the interview Administrator #2 revealed Resident #607 had a bad fall when she resided at the facility that resulted in a bruise on her forehead and the resident being sent to the emergency department for evaluation. Administrator #2 stated she was unaware of the specifics that lead to the fall.

Based on observations, record review, resident and staff interview the facility administration failed to provide effective oversight and leadership to ensure residents were treated with dignity and respect during care and to maintain a supply of adult briefs to meet the needs of residents (Resident #77 and Resident #53). The facility administration additionally failed to provide effective oversight and leadership to ensure residents received incontinence care, nail care and bathing (Resident #77, Resident #111 and Resident #50) and were provided with clean and dry linens (Resident #77, Resident #111 and Resident #610). This was evident for 2 of 12 residents reviewed for dignity, 2 of 2 residents reviewed for accommodation of needs and 4 of 19 residents reviewed for activities of daily living Findings Included: This tag is cross-referenced to: 1. F550 - Based on observations, record review, staff and resident interview the facility failed to treat residents who required assistance with incontinence care in a dignified manner. Resident #77 expressed feelings of embarrassment because she did not have on a brief, was wet and had no linen on her bed. Resident #53 expressed feelings of embarrassment because the staff used 2 briefs and a towel to manage her incontinence because the facility did not have the correct size brief for her. This was evident for 2 of 8 residents reviewed for dignity. 2. F558 - Based on observations, record reviews, resident and staff interviews, the facility failed to provide the proper size briefs for 2 of 3 residents reviewed for accommodation of needs (Resident #53 and Resident #77). This resulted in the residents expressing they felt bad and embarrassed. 3. F677 - Based on observations, record review, staff and resident interviews the facility failed to provide incontinence care (Resident #77, Resident #111), failed to provide clean and dry linens (Resident #77, Resident #111, Resident #610), failed to keep dependent residents' fingernails trimmed and clean (Resident #111), failed to shave a male resident (Resident #111) and failed to provide a shower (Resident #50) for 4 of 7 residents reviewed for activities of daily living (ADL) care.

Based on record review, psychiatric nurse practitioner (NP) and staff interviews the facility failed to protect the resident ' s right to be free from physical abuse for 1 of 3 residents reviewed for abuse. Resident #1 sustained facial injuries which included lacerations and a bloody nose after being struck by Resident #2 and required evaluation of his injuries in the emergency room . Findings Included: Resident #1 was admitted to the facility 10/23/17 and [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #1 identified he displayed behaviors of wandering and rejection of care for 1 to 3 days of the look-back period. He used a wheelchair for mobility and his cognition was moderately impaired. A care plan for Resident #1 dated 1/9/19 identified he was at risk for elopement related to dementia and wandering. Interventions included to ensure exits and stairwells were coded with alarms or monitored, ensure his room was located on the secured unit, ensure staff are aware of wandering behaviors, monitor whereabouts frequently throughout the day and provide diversional activities. Resident #2 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A care plan dated 8/20/18 for Resident #2 revealed he had the potential to demonstrate physical behaviors (grabbed another resident on the arm, struck another resident in the face, struck roommate on the left side of the head and pulled on his arm). Interventions included resident sent out for psychological exam (8/20/18); analyze key times, places, circumstances, triggers and what de-escalates behaviors and document, assess and anticipate resident ' s needs; monitor and document observed behavior and attempted interventions; psychiatric consults as needed and intervene when resident becomes agitated and before agitation escalates. An annual minimum data set ((MDS) dated [DATE] for Resident #2 indicated he had physical and verbal behaviors directed towards others for 1 to 3 days of the look-back period. He put others at risk for significant physical injury and his behaviors had improved since the last assessment. Resident #2 required limited one-person assistance with bed mobility / transfers, supervision with locomotion on and off the unit, used a wheelchair for mobility and his cognition was intact. Review of a behavior note dated 1/2/19 at 4:52 pm for Resident #2 revealed at approximately 3:50 pm a nurse observed Resident #1 lying on the floor in Resident #2 ' s room. Resident #1 had blood coming from his nose, a hematoma to his right eyebrow area and some shortness of breath as he yelled out for help. Resident #2 was sitting in his wheelchair beside Resident #1. Resident #2 stated he hit Resident #1 because he was in his room and hit him in the eye. The nurse examined both of Resident #2 ' s eyes and no redness or swelling was observed. The nurse explained to Resident #2 that Resident #1 was not aware of his actions and in the future, he needed to use his call button to call for assistance. The Director of Nursing and Assistant Director of Nursing spoke with Resident #2 and he told them he hit Resident #1. The physician for both Resident #1 and Resident #2 was notified of the incident. Resident #1 was sent to the emergency room for evaluation and Resident #2 was sent to the hospital for psychiatric evaluation. Review of the facility investigation for the incident that occurred on 1/2/19 revealed Resident #1 wandered into Resident #2 ' s room which was on the opposite hall of where he resided. Resident #1 was hit by Resident #2 when he wandered into his room. Resident #1 had dementia, ambulated independently and wandered on the locked unit. Resident #2 was alert and oriented. Resident #2 alleged that Resident #1 hit him, so he hit him back. He stated he hit with a closed fist and laughed. Resident #1 had a hematoma, a small laceration on his right eyebrow, a small bruise below his nose and bleeding from his nose. Resident #2 had no redness, bruising or opened areas. The residents were separated. Resident #1 received treatment in house and both residents were sent to the emergency room for evaluation. The local police were notified, and no charges were filed. The allegation of abuse was substantiated. Corrective actions included Resident #1 and Resident #2 have been separated since the incident. Police were notified and interviewed both residents. Resident #1 and Resident #2 were sent to the emergency room for evaluation. Resident #2 was evaluated by psychiatric services at the hospital and seen by the facility psychiatric NP for medication management. Resident #2 resides in a private room and a stop sign was placed across the doorway to deter other residents from entering his room. Review of the police report dated 1/2/19 at 4:23 pm revealed the incident was a non-aggravated simple assault. Resident #1 ' s family did not want to press charges. Review of the hospital record dated 1/2/19 for Resident #1 revealed he was seen in the emergency room for facial abrasions following an assault. He had a CT (computed tomography scan) of his head, facial bones and spine. No fractures were identified, and the resident was returned to the facility with no new orders. Review of the hospital record dated 1/2/19 for Resident #2 revealed he was seen for a psychiatric evaluation. The patient stated he was sitting in his room this afternoon when another resident came into his room, started eating some of his food and sat on his bed. He stated the resident punched him in his left eye and so he punched him in the face. The patient had normal mood and affect. His speech, behavior and thought content were normal. He expressed no homicidal or suicidal ideation. Behavioral health recommended to send back to the facility with no new orders. An observation of Resident #2 on 2/6/19 at 12:40 pm revealed he resided in a private room. He was laying on his bed and was awake. He stated he was doing pretty well. Resident #2 stated he didn ' t recall having any incidents or hitting another resident. An interview on 2/6/19 at 2:12 pm with Nurse #2 revealed she was the unit manager on the secured unit where Resident #2 resided during the incident on 1/2/19. She explained the resident hadn ' t displayed any behavior issues from that time until the altercation on 1/2/19. He typically had a sweet demeanor and didn ' t interact with the other residents except when he went out to smoke. She stated the incident on 1/2/19 was unwitnessed by any staff. Nurse #2 explained they determined during the investigation that Resident #1 wandered into Resident #2 ' s room. Resident #2 reported that Resident #1 hit him first and then he slugged him in the face with a closed fist. Resident #2 did express remorse and said he was sorry. She stated Resident #1 did wander on the unit and occasionally would enter another residents room. Resident #1 couldn ' t speak, mostly smiled and had never displayed any aggressive behaviors towards other residents. Nurse #2 added she believed if Resident #1 was touching Resident #2 ' s things that could have been a trigger for him and he wouldn ' t like someone invading his space. An interview on 2/6/19 at 2:36 pm with the DON revealed when Resident #1 wandered into Resident #2 ' s room he believed Resident #1 was invading his space and taking his food and this triggered his behavior. She added after this incident Resident #2 was sent out to the hospital for another psychiatric evaluation and they felt that he was safe to return to the facility. Resident #2 was seen by the in-house psychiatric NP and she determined the resident was safe to be moved off the secured unit as he no longer displayed elopement behaviors. The DON stated the resident hasn ' t displayed any aggressive behaviors since the incident on 1/2/19. A phone message was left on 2/7/19 at 10:57 am for the NA that was assigned to Resident #2 on 1/2/19. No return call was received. A phone interview was conducted on 2/7/19 at 11:51 am with Nurse #3 who was the nurse for Resident #2 during the incident on 1/2/19. She stated a staff member saw Resident #1 coming out of Resident #2 ' s room with a bloody nose and redness around his eye. Nurse #3 explained Resident #2 told her Resident #1 had entered his room and hit him in the eye. She added this seemed strange to her as Resident #2 had no visible injury to his eye and Resident #1 had never displayed any physical behaviors like that in the past. She stated she notified the DON and both residents were sent out to the hospital for evaluation. Nurse #1 added she explained to Resident #2 if something like that happened he should turn on his call light, so the staff could intervene versus taking the situation into his own hands. She stated Resident #2 stayed in his room most of the day except for going out to smoke. He would occasionally refuse one of his medications but didn ' t display any aggressive behaviors routinely. Nurse #3 added she believed Resident #2 knew what he was doing when he hit Resident #1. A phone interview on 2/7/19 at 12:30 pm with the facility psychiatric NP revealed she was very familiar with Resident #2 and had been working with him since his admission. She stated she spent a considerable amount of time with Resident #2 after the incident on 1/2/19. The resident told her Resident #1 wandered into his room and he asked him to leave. Resident #1 then got on his bed and he asked him to leave again. Resident #1 didn ' t respond to him and that was when he hit him. The NP explained Resident #2 didn ' t understand that Resident #1 had dementia and couldn ' t understand what Resident #2 was asking him to do. She added she discussed in length with Resident #2 that Resident #1 ' s dementia prevented him from understanding. She stated she didn ' t think this was a willful act on the part of Resident #2, but a misunderstanding related to him trying to protect his territory and Resident #1 not being able to understand what Resident #2 was telling him. The NP stated she didn ' t believe Resident #2 was high risk for aggression or aggressive acts in his current condition. An interview with the DON on 2/7/19 at 3:35 pm revealed it was her expectation that residents were free from abuse while residing at the facility.

Based on record reviews and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in January 2017. This was for one recited deficiency that was originally cited in January 2017 on a complaint investigation survey and subsequently recited in March 2017 on a complaint investigation. The deficiency was in the area of Quality of Care. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The Findings included: This tag is cross referenced to: F309 Quality of care: Based on record review and staff interviews, the facility failed to assess 1 of 2 sampled residents who had a fall resulting to a right femur fracture and right humerus fracture (Resident # 6). During the complaint investigation of 3/28/2017 the facility was cited for failure to assess 1 of 2 sampled residents who had a fall resulting to a right femur fracture and right humerus fracture (Resident # 6). During an interview with the Administrator on 3/28/17 at 3:00 p.m., the Administrator stated after any survey or an accident at the facility related to taking care of the residents, sufficient training was completed. The Administrator stated the current issue was a per instance one-time event. The Administrator stated Nursing Assistant (NA) #1 had received sufficient training related to safe transfer of residents during the orientation and had been aware of the proper protocols of the facility.

Based on observation, record reviews and staff interviews, the facility failed to provide a safe transfer for 1 of 2 sampled residents, resulting right femur fracture and right humerus fracture. (Resident # 6). Findings included: Resident # 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set ((MDS) dated [DATE] revealed the resident had no short or long term memory problems; she needed extensive assistance with 1 person for bed mobility and extensive assistance with 1 person for transfer. Resident # 6's Care Area Assessment (CAA) worksheet dated 7/6/2016 documented Resident requires limited to extensive one person assistance with Activities of daily Living (ADL)'s except set-up for eating. Staff intervention is necessary to identify risk factors and solutions to help prevent decline in ADL's and complications. She is alert and able to make her needs known to staff. She wheels self in wheelchair around unit. She has had one fall since last assessment with no injury. This places her at increased risk for further falls, skin breakdown, dignity issues and weight loss. Further falls may cause fractures, increased pain and decline in overall function. Staff intervention is necessary at this point to identify and address risk factors to prevent further falls from occurring. Resident # 6's care plan dated 1/21/2017 documented the resident is at risk for falls due to decreased mobility. The care plan documented the following interventions: Keep environment free of hazards, Do not leave resident unattended without safety device, Eliminate potential hazards, Give resident verbal reminders not to try to ambulate or transfer without assistance. On 3/12/2017 a nurse's note at 3:21 PM documented Resident with right arm and right leg pain this morning at 8:00 am. Resident # 6 stated she was not sure why it's hurting so bad but wants the doctor to look at it. Resident # 6 has refused going to the hospital at that time. At current time, resident's right arm is very swollen. Resident is requesting to go to the hospital for evaluation. Review of the resident's incident report dated 3/12/2017 revealed under description Resident with pain in right arm after staff assistance with transfer from bed to wheelchair. The incident report under description of resident's injury subheading documented completed interview with the resident, who is usually alert and oriented seems hesitant to clarify what happened. The resident stated she had asked NA (Nurse Assistant) # 1 if her wheelchair was locked when she fell and hit her arm on wheelchair and was under wheelchair when it rolled back. The resident stated NA#1 told her she knew what she was doing. The resident further stated she was hollering for help and she went and got help after NA#1 helped her up after she fell . The report indicated the resident had a fracture of a right femur. Review of the facility's investigation summary note date 3/13/2017 documented Per resident, NA #1 came in; resident showed NA#1 the clothes she wanted to put on and resident reports she was sitting on side of bed. NA #1 assisted with putting clothes on, and then resident requested to have wheelchair placed by the bed. Resident # 6 asked was the wheelchair locked; NA#1 replied yes. Resident # 6 states she attempted to transfer self from bed to wheelchair, and the wheelchair slipped; she fell on the floor and wheelchair was on top of the resident. Resident states that NA #1 assisted her back to chair, she then complained of right arm pain, and the NA#1 apologized. Summary note also documented per NA#1 interview, she assisted resident out of bed to wheelchair with the assistance of another Nurse assistant. NA#1 states that resident started complaining of right arm pain after transferring to wheelchair from bed. Review of the discharge summary dated 3/12/2017 revealed the resident was discharged back to the facility with the [DIAGNOSES REDACTED]. On 3/13/2017 a nurse's note at 5:19 PM documented Writer received call from the doctor from the hospital. The doctor reports that CT (computerized tomography) scan results is a fracture to right femur. Resident is non weight bearing status to right leg per doctor and states that orthopedics will set up appointment for tomorrow. On 3/15/2017 a nurse's note at 2:45 AM documented ace wrap/splint remains in place to right arm/ shoulder, fingers slightly edematous. Review of the orthopedic consultation report dated 3/20/2017 revealed the following treatment plan to the fractured femur Brace to knee PRN (as needed) for comfort, ROM (range of motion) as required. Maintain splints. Observation of Resident # 6 at 7:35 PM on 3/26/17 revealed the resident as alert and talkative. It was noted the resident's right arm as swollen with pitting edema. Right arm was up on pillows. The resident started to talk about an accident but stopped. The resident talked about her arm in a soft cast unlike the old days. She stopped talking after mentioning she had a fall from a wheelchair then she said she went to the hospital. During the interview with Nurse Assistant (NA) # 2 on 3/28/2017 at 10:13 AM, she reported she was not assigned to take care of the resident on 3/12/2017 but she assisted NA#1 to transfer Resident # 6 from the bed to the wheelchair. She reported she was assigned opposite hall from Resident #6's hall. NA# 1 ask her to help transfer resident # 6 to the wheelchair. She went in the room and she saw Resident # 6 was on the bed moaning a little. She stated they put the resident in the wheelchair and after that the resident was complaining about her right arm hurting. During the interview with Med Aide # 1 on 3/28/2017 at 1:30 AM, she reported she was assigned to Resident # 1 on 3/12/2017. She stated it was in the morning when it was reported to her by NA #1 that the resident's arm was swollen. She reported she notified the supervisor who came and did an assessment on the resident. The resident did not want to go to the hospital so she gave her pain medication since her vital signs were stable. She further added the resident went to sleep and woke up around 2:00 pm and both the arm and her leg were swollen. She also reported the ambulance was called and the resident was transferred to the hospital. She added the resident told the EMS (Emergency services) person that the aide dropped her during the transfer to the wheelchair. During the interview with NA # 3 on 3/28/2017 at 2:33 PM, She reported that she on 3/12/2017, was standing at the nurses station writing down her assignment and she heard a loud scream and she found out it was coming from Resident # 6 's room. She went to see what was wrong with the resident. On her way to the resident's room, she ran into NA # 1 coming around the corner wheeling Resident # 6 in the wheelchair. The resident looked up at her and said to her please help me I have pain coming from my arm. She stated she reported the resident's concern to Med Aide # 1. During the interview with the weekend supervisor on 3/28/2017 at 3:00 PM, she reported the resident was in pain after it was reported to her by the Med Aide # 1 that the resident hand and leg were swollen. She stated she suspected the resident had a fall so she called the ambulance and the resident was sent out to the hospital for an evaluation. During the interview with the Administrator on 3/28/2017 at 4:00 PM, she reported that on 3/12/2017 she received a call from the weekend supervisor who was letting her know about a possible fall with Resident # 6 that had happened some time on 7-3 shift. She was informed that the fall resulted in a fracture. She added she went in on Monday morning around 8am and spoke with Resident # 6, she told her that they dropped her, and she asked her how it happened, she then told her she fell when sitting in her wheelchair because the wheels were not locked, and then she said the chair turned over on her. The Administrator said she immediately started looking at staff that had worked with the resident before she had injury. She added NA # 1 was on duty on 3/12/2017 in 7-3 shift, the injury occurred when she was trying to transfer Resident #6 and did not lock the wheelchair. The administrator felt that NA # 1 lifted Resident # 6 from the floor and sat her on the edge of the bed, went and got NA # 2 to assist her and before getting a nurse to assess the resident. She added her expectation was for staff to lock the wheelchair and assist the residents with transfers to prevent accidents. NA# 1 who was accused of not locking the wheelchair before transferring Resident # 6 was unavailable for interview. She (NA # 1) was terminated from employment on 3/16/2017.

Based on record review and staff interviews, the facility failed to assess 1 of 2 sampled residents who had a fall resulting to a right femur fracture and right humerus fracture (Resident # 6). Findings included: Resident # 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set ((MDS) dated [DATE] revealed the resident had no short or long term memory problems; she needed extensive assistance with 1 person for bed mobility and extensive assistance with 1 person for transfer. Resident #6's Care Area Assessment (CAA) worksheet dated 7/6/2016 documented Resident requires limited to extensive one person assistance with Activities of daily Living (ADL)'s except set-up for eating. Staff intervention is necessary to identify risk factors and solutions to help prevent decline in ADL's and complications. She is alert and able to make her needs known to staff. She wheels self in wheelchair around unit. She has had one fall since last assessment with no injury. This places her at increased risk for further falls, skin breakdown, dignity issues and weight loss. Further falls may cause fractures, increased pain and decline in overall function. Staff intervention is necessary at this point to identify and address risk factors to prevent further falls from occurring. Resident # 6's care plan dated 1/21/2017 documented the resident is at risk for falls due to decreased mobility. The care plan documented the following interventions: Keep environment free of hazards, Do not leave resident unattended without safety device, Eliminate potential hazards, Give resident verbal reminders not to try to ambulate or transfer without assistance. On 3/12/2017 a nurse's note at 3:21 PM documented Resident with right arm and right leg pain this morning at 8:00 PM. Resident # 6 stated she was not sure why it's hurting so bad but wants the doctor to look at it. Resident # 6 has refused going to the hospital at that time. At current time, resident's right arm is very swollen. Resident is requesting to go to the hospital for evaluation. Review of the resident's incident report dated 3/12/2017 revealed under description Resident with pain in right arm after staff assistance with transfer from bed to wheelchair. The incident report under description of resident's injury subheading documented completed interview with the resident, who is usually alert and oriented seems hesitant to clarify what happened. The resident further stated she was hollering for help and she went and got help after NA#1 helped her up after she fell . The report indicated the resident had a fracture of a right femur and a right humerus. Review of the facility's investigation summary note date 3/13/2017 documented Per resident, NA #1 came in; resident showed NA#1 the clothes she wanted to put on and resident reports she was sitting on side of bed. NA #1 assisted with putting clothes on, and then resident requested to have wheelchair placed by the bed. Resident # 6 asked was the wheelchair locked; NA#1 replied yes. Resident # 6 states she attempted to transfer self from bed to wheelchair, and the wheelchair slipped; she fell on the floor and wheelchair was on top of the resident. Resident states that NA #1 assisted her back to chair, she then complained of right arm pain, and the NA#1 apologized. Summary note also documented per NA#1 interview, she assisted resident out of bed to wheelchair with the assistance of another Nurse assistant. NA#1 states that resident started complaining of right arm pain after transferring to wheelchair from bed. Review of the discharge summary dated 3/12/2017 revealed the resident was discharged back to the facility with the [DIAGNOSES REDACTED]. Observation of Resident # 6 at 7:35 PM on 3/26/17 revealed the resident as alert and talkative. It was noted the resident's right arm as swollen with [MEDICAL CONDITION]. Right arm was up on pillows. During the interview with Nurse Assistant (NA) # 2 on 3/28/2017 at 10:13 AM, she reported she was not assigned to take care of the resident on 3/12/2017 but she assisted NA#1 to transfer Resident # 6 from the bed to the wheelchair. She reported she was assigned opposite hall from Resident #6's hall. NA# 1 ask her to help transfer resident # 6 to the wheelchair. She went in the room and she saw Resident # 6 was on the bed moaning a little. She stated they put the resident in the wheelchair and after that the resident was complaining about her right arm hurting. During the interview with Med Aide # 1 on 3/28/2017 at 1:30 AM, she reported she was assigned to Resident # 1 on 3/12/2017. She stated it was in the morning when it was reported to her by NA #1 that the resident's arm was swollen. She reported she notified the supervisor who came and did an assessment on the resident. The resident did not want to go to the hospital so she gave her pain medication since her vital signs were stable. During the interview with the Administrator on 3/28/2017 at 4:00 PM, she reported that on 3/12/2017 she received a call from the weekend supervisor who was letting her know about a possible fall with Resident # 6 that had happened some time on 7-3 shift. She was informed that the fall resulted in a fracture. She added she went in on Monday morning around 8am and spoke with Resident # 6, she told her that they dropped her, and she asked her how it happened, she then told her she fell when sitting in her wheelchair because the wheels were not locked, and then she said the chair turned over on her. The Administrator said she immediately started looking at staff that had worked with the resident before she had injury. She added NA # 1 was on duty on 3/12/2017 in 7-3 shift, the injury occurred when she was trying to transfer Resident #6 . The administrator felt that NA # 1 lifted Resident # 6 from the floor and sat her on the edge of the bed, went and got NA # 2 to assist her before getting a nurse to assess the resident. She added her expectation was for staff to lock the wheelchair and assist the residents with transfers to prevent accidents.

Based on record review, staff interviews, and observations, the facility failed to prevent 2 of 2 cognitively impaired sampled residents (Residents #1 and #2) from exiting the facility while unsupervised. On 09/26/16 Residents #1 and #2 exited the facility while unsupervised and were found by a staff member walking in the facility ' s parking lot. Immediate Jeopardy (IJ) began on 9/26/16 at 7:30PM when Nurse #1 observed Resident #1 and Resident #2 unsupervised outside the facility. The IJ was abated on 9/30/16 at 12:20 PM when the facility provided an acceptable allegation of compliance. The facility remains out of compliance at a lower scope and severity at a D level (an isolated deficiency at no actual harm with a potential for no more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: 1. a. Resident #1 was admitted to the facility ' s 5th floor secure unit on 9/7/16 with [DIAGNOSES REDACTED]. An Elopement Risk assessment dated [DATE] revealed Resident #1 was cognitively impaired with poor decision making skills, had a [DIAGNOSES REDACTED]. Resident #1 was assessed to have been at risk for elopement at the time of the assessment. A review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1, had long and short term memory problems, disorganized thinking and wandering behavior. Activities of Daily Living (ADLs) were completed independently, except locomotion on the unit, which required supervision, and dressing and toileting, which required extensive assistance. Resident #1 was able to steady himself during transfers and ambulation. A Care Plan dated 9/13/16 revealed: Resident (Resident #1) is at risk for elopement. Goals included: Resident will suffer no injuries related to (r/t) wandering behaviors through next review. Resident will not leave facility unescorted by family, visitors or staff through next review. Interventions included: Ensure resident ' s (brand name of an alarming bracelet worn to prevent resident elopements) is in place and functioning each shift. Ensure resident ' s room is located on secure unit. Ensure staff is aware of resident ' s wandering behaviors. Monitor resident ' s whereabouts frequently throughout the day. Ensure exits and stairwells are coded with alarms. Utilize a check in and out log. On 9/26/16, the Care Plan revealed: Exit seeking behavior noted. (Brand name of an alarming bracelet worn to prevent resident elopements) replaced. On 9/27/16 the Care Plan was reviewed and updated to continue the plan of care. A Care Area Assessment (CAA) for Resident #1 dated 9/14/16 was reviewed and revealed a problem r/t cognitive loss/dementia. It was noted No amount of reorientation/reminders will be sufficient enough to help resident be able to make sense of things. It was also noted (Resident #1) is a confused, ambulatory resident with Alzheimer ' s dementia. He has difficulty communicating needs and wanders throughout the facility. A physician order [REDACTED]. A nursing note dated 9/26/16, and signed by Nurse #2 read, Resident (Resident #1) left unit with another resident (Resident #2) and was found in courtyard with that resident without harm to the bother (both). Check(ed) his (Resident #1) alarm, found it was not working, (a) new device was placed on resident after testing with no further issue. A review of an incident report dated 9/26/16 for Resident #1 revealed Resident #1 was located on the facility grounds with another resident (Resident #2) and brought back into the building by a nurse (Nurse #1). Resident #1 was noted to ambulate independently and was disoriented. 1. b. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the facility ' s 5th floor (secured unit). A review of the quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired, had delusions present, wandering was present daily. ADLs required supervision for transfers, walking in room, walking in corridor, locomotion on unit, dressing, and eating. Balance during transfers and ambulation was steady at all times without assistance. Active [DIAGNOSES REDACTED]. A CAA dated 5/5/16 was reviewed and revealed Resident #2 showed signs of disorganized thinking and inattention, had a [DIAGNOSES REDACTED]. A Care Plan dated 5/12/16 and updated 9/13/16 revealed care planning r/t Resident #2 being at risk for elopement r/t exit seeking behaviors (stands at elevator, pushes keys on code pad, resident wanders constantly. Goals included: Resident will not leave the secured unit or facility grounds without supervision from staff and/or family through the next review. Interventions included: ensure (brand name of an alarming bracelet worn to prevent resident elopements) is in place and working properly q (every) shift. Obs (observe) for safety (provide (brand name alarming bracelet) if ordered). Interventions were updated 9/26/16 and included: Exit seeking behavior noted. (Brand name alarming bracelet) replaced. physician's order [REDACTED]. A review of the Quick Medication Administration (Quick MAR- an electronic charting system used by the facility which indicated the ordered (brand name alarming bracelet) checks were completed) dated 9/1/16 through 9/30/16 revealed staff initials present each shift for Resident #1 and Resident #2. An interview was conducted with the Director of Nursing (DON) on 9/29/16 at 2:45 PM. She stated, If the (brand name alarming) bracelet isn ' t checked there won ' t be any initials in the box. We chart by exception so if something was wrong with the (brand name alarming bracelet) there would be a notation. There are no notations, so the (brand name alarming bracelets) were working. A review of a nursing note dated 9/26/16 and signed by Nurse #2 revealed, Resident (Resident #2) alert on tonight. Patient was found out in courtyard with another resident. Her alarm was not working. New alarm place(d) on resident after activation and tested with no other issue. A review of an incident report dated 9/26/16 revealed Resident #2 was located on the facility grounds. The report also indicated, (Resident #2) with another resident (Resident #1) managed to get off the unit, were immediately brought up to unit from outside front door. Heard alarm going off, nurse went to check all exits when 3rd floor nurse (Nurse #1) brought residents back up to floor. The resident's condition at the time was disoriented, and ambulated independently. An interview was conducted with Nursing Assistant (NA) #4 on 9/28/16 at 7:40 PM. She stated, I typically care for (Resident #2). She frequently exhibits exit seeking behaviors like saying she ' s going home, pushing the buttons on the elevator, and pushing on all the doors. I check on her every hour, which is easy because she basically follows me around. I know the elevator won ' t move if a resident wearing a (brand name alarming bracelet) gets on it. All the doors up here (5th floor) have alarms on them because this is the only unit considered a secured unit. An interview was conducted with Nurse #1 on 9/28/16 at 9:15PM. She stated, I work 3pm-11pm. On Monday night (9/26/16) I was out at my car to get some money. As I was walking out of the facility I saw 2 residents walking outside in the parking lot. I recognized them so I took them up to the 5th floor. It was raining earlier that day, but not when they were outside. They weren't wet or anything. Their (brand name alarming bracelets) were on. I took the elevator up to the 5th floor, with both residents and told their nurse (Nurse #2) they were outside. I don't think the elevator should have worked if their (brand name alarming bracelets) were working. An interview was conducted with Nurse #2 on 9/28/16 at 8:45PM. She stated, I typically work 3pm-11pm. I was working on the 5th floor Monday night (9/26/16). Right after supper, they started putting people to bed and an alarm started going off. So we stopped what we were doing and started searching for which door alarm was ringing. The panel said fire door on the long hall so I told one of the nursing assistants (NA #1) to see if anybody had gone out. Nobody was visible from the doorway. So then we started searching the unit to see if a resident was gone. We found out 2 residents (Resident #1 and Resident #2) had gotten out. When the nurse from downstairs (Nurse #1) brought them back upstairs we assessed them and then just went on with the rest of the night. They had (brand name alarming bracelets) on, but they weren't working. They had gone to the elevator doors several times during supper time. The (brand name) alarming bracelets weren't working when they got back from outside so I put new ones on. I tested them and documented that they were working. (Resident #2) always exhibits exit seeking behavior, but we've always caught her, until this time. An interview with NA #1 was conducted on 9/28/16 at 7:15PM. She stated, The alarm to the back stairs was going off while I completed incontinent care for another resident. I made sure the resident I was doing incontinent care on was safe, lowered his bed, covered him up, and made sure he was mostly clean. Then I went down the long hall to the stairs and turned off the alarm. I didn't see anyone so I went down to the 3rd floor from the 5th floor, and didn't see anyone. Then I came back upstairs and finished my resident's incontinence care. After I finished, I realized I had run out of washcloths and towels so when I was going to get more of them I saw a nurse (Nurse #1) getting off the elevator with 2 residents that had gotten off the unit. When residents with (brand name) bracelets get near the elevator or the exit door near the day room, an alarm goes off. The door locks. If they get on the elevator the doors won't close. (Resident #2) frequently exhibits exit seeking behaviors like taking another resident ' s hand and saying stuff like, 'Let's get out of here.' or 'Let's go home' stuff like that. If she (Resident #2) sees a door she tries to open it, and she pushes the elevator buttons but doesn't know the code. An interview was conducted with Nurse #3 on 9/28/16 at 3:47PM. She stated, I ' m the Unit Coordinator for the 2nd floor. I was working Monday night when the alarm went off for one of the exit doors. I looked at the panel and saw it was a fire exit door at the end of the long hall. I went to the doors and checked. There were no residents there. Then I went down to the ground floor and checked all the doors. Since I didn ' t see any residents I went back upstairs. The alarm was still going off when I got back upstairs. I filled out the incident reports. She also stated, If a fire door alarm goes off we are supposed to do a head count. To my knowledge, they did a head count and that ' s when they realized there were 2 residents missing. An interview was conducted on 9/28/16 at 7:50 PM with the facility Administrator. She stated, I was told (Residents #1 and #2) went out a door that isn't connected to the (brand name) alarming system. It's alarmed, and if you push on it for 15 seconds it opens, and the alarm starts if you don't push the code in before pushing the bar. It's everybody's responsibility to pay attention to alarms. It wouldn't have mattered if the (brand name alarming bracelets) were working or not because of the door they left from. (Resident #1 and Resident #2) had a (brand name alarming bracelet) on. Whether or not it was working wouldn't have mattered because of where they exited from. The weather that night was rainy. It had been raining earlier. The staff are supposed to call a Code Pink if they discover a resident is missing. They find out who it was, what door was alarming, go through the door and down the stairs to the bottom, search the building, do a head count, notify the Director of Nursing (DON) and Administrator, and the resident is hopefully found immediately. If the missing resident or residents aren't found within 15 minutes we search the perimeter, call the police, call the family, and call the doctor. On Monday night (9/26/16) they did a head count, notified the DON, and notified me. By the time (Nurse #3) got to the alarm the residents were already back in the building. They (Resident #1 and #2) came down the stairs, exited the building, did a round around the building and a staff member's family saw them. The family called the staff member, but then another staff member (Nurse #1) saw them while she was outside so she brought them upstairs. An interview was conducted on 9/29/16 at 8:55 AM with the Maintenance Director. He stated, I became Maintenance Director about 3 weeks ago. I was a maintenance tech before that. All fire exit doors are checked daily. They have a 15 second delay to open. The alarm sounds immediately. The 5th floor elevator doors and the door by the dayroom are the only doors connected to the (brand name) alarming system on the 5th floor, and I check them daily too. If there's a malfunction I fix it immediately. Like on Tuesday (9/27/16) when I came in and found out the exit door to the resident smoking area (facing 1st Street) had a magnet at the top that wasn't functioning, and the sensitivity was too low. That door is connected to the (brand name) alarming system. I have called the (brand name) alarming system company and they are coming on Friday to check all the doors and make recommendations to improve our (brand name) alarming system. An interview was conducted with Nurse #5 on 9/29/16 at 3:30 PM. She stated, We were in-serviced on elopements last month. If a fire door alarm goes off I check the door, go through the door and go all the way down to the ground floor to look for a resident. Other staff members do a head count. If a resident is missing we do a facility wide check, and check outside. We call the DON, the Administrator, the doctor, the family, and the police if necessary. (Resident #1) is a wanderer and elopement risk. She constantly walks and will take other residents with her. She sometimes goes to the doors and pushes on them, and sometimes she just stands by them. An interview was conducted on 9/29/16 at 12:45 PM with the Doorman/Valet/Security. He stated he was working Monday night (9/26/16) and did not see the 2 residents come through the lobby. He also stated there was someone in the lobby every day from 11:00 AM through 7:00 AM the next morning. He stated his duties included making sure no residents go out the front or back door, he assisted residents off the elevator if they wanted to get snacks, and answered the telephone. He also stated, I knew the (brand name) alarming system wasn't working on the exit door that faces 1st Street because it hasn't been working for about a month. An interview was conducted with the Staff Development Coordinator (SDC) on 9/30/16 at 9:45 AM. She stated, Elopement Risk Assessments are completed on all residents at admission. We have an admission nurse (Nurse #4) that completes all admission assessments. If she isn ' t here the unit manager or weekend supervisor completes the assessments. The staff get trained on elopement/wandering risks during orientation and as needed. If an exit alarm goes off, the staff are supposed to check all resident rooms, and do a head count. Each NA does her assigned hall and the nurse checks behind them to verify their results. The process shouldn ' t take more than 15 minutes. If a resident is missing, a Code Pink is called, a staff member from the floor where the resident resides goes down to the 2nd floor to check the alarm panel and locates which door alarm is going off. Once the door is identified, the staff member is to go through the door, down the steps to the ground floor, and exit the building to look for the residents. This happens while other staff members are completing the head count. If the resident can ' t be immediately located, the police are called, the family and physician is called, and a perimeter search is conducted. An interview was conducted with Nurse #4 on 9/30/16 at 10:10 AM. She stated, Elopement Risk Assessment are completed on every resident at the time of their admission. If I ' m not here there is a designated staff member to complete the assessments, usually the Unit Manager. If a resident is an elopement risk I notify the DON and Unit Manager, initiate a (brand name alarming bracelet), and work on placing the resident on the 5th floor. That is our secured unit. Elopement risk gets communicated to the MDS and care plan nurses, and the Unit Manager. The Unit Manager places the (brand name alarming bracelet) on the resident. An interview was conducted on 9/30/16 at 4:00 PM with the facility medical director. He stated, She (Resident #2) has been here for several years. She walks independently with a lot of residents around her. She tries every door and door knob. If the elevator opens she jumps in. She pushes on all the doors constantly. She is steady on her feet and physically capable of going down 5 flights of steps. (Resident #1) is a newer admission to me, and I ' ve seen him once. He wears a (brand name alarming bracelet) and I think is physically able to go down 5 flights of stairs. An observation was made of the fire exit door located at the end of the 'long hall' on the 5th floor on 9/27/16 at 7:30 PM. An audible alarm sounded immediately when the horizontal metal bar was pushed. The door remained locked for approximately 15 seconds, with the alarm sounding, and then opened to a stairwell. There were sixty-seven (67) steps from the 5th floor to the ground level where the Resident #1 and Resident #2 eloped. The door at the ground level opened directly to the outside of the facility, perpendicular to a 2 lane road with a posted speed limit of thirty-five (35) miles per hour. An observation was made on 9/28/16 at 8:00 AM of the area outside the facility where Residents #1 and #2 were observed by a staff member on 09/26/16. The area was approximately 50 feet from an entry/exit door located at the back side of the building, with an asphalt (black top) surface which sloped downward away from the facility. Vehicles were observed parked perpendicular (at an angle of 90 degrees) to the facility beyond a single lane designed for vehicle traffic. Observations of both Resident #1 and Resident #2 was made on 9/28/16 at 4:30PM: Resident #2 was observed ambulating independently throughout the unit holding the hand of another resident. She was also observed turning the door knobs on exit doors and pressed the code key buttons for the elevator. She stated, I ' m going home. Staff re-directed her and she continued ambulating throughout the unit. A (brand name alarming bracelet) was in place on her right ankle. Resident #1 was observed seated in the activity room with a (brand name alarming bracelet) on his right ankle. He was observed watching television. An observation was made on 9/30/16 at 11:00 AM of Resident #2 on the 5th floor. Resident #2 was observed walking without assistance throughout the unit with a steady gait, a (brand name alarming bracelet) was visible around her right ankle, and she was observed going to the opened elevator doors and getting on. The elevator alarm sounded, and the doors remained open until Resident #2 exited the elevator and continued walking away from the opened doors. The facility administrator was notified of the IJ on 9/30/16 at 10:00 AM. On 9/30/16 from 8:00 AM through 12:20 PM, validation of the credible allegation submitted by the facility administrator was reviewed. · (Brand name alarming system) assessment for function and placement was completed for residents with a (brand name) on 9/27/16. · Elopement risk Assessments were completed on 9/27/16 for all residents in the building with quarterly assessments due. No additional residents were identified. · Quick MAR was updated on 9/29/16 to reflect MD (physician) orders to check (brand name) placement and function every shift to add results. · The fire door panel on the 2nd floor was re-labeled on 9/29/16 to easily identify doors. · Code Pink drills will continue monthly on all shifts effective 9/27/16 for twelve months, and then quarterly indefinitely. · Staff education on elopement policy and procedures was initiated on 9/26/16 and completed by 9/29/16 using group in-servicing, 1 on 1 education, and group messaging. No staff will be allowed to work prior to receiving training. · (Company name) care representative is scheduled 9/30/16 to assess and implement additional (brand name) alarms for remaining doors on the 5th floor. · Staff members will be posted at all exit doors on the 5th floor until new (brand name) alarming units are in place. · Staff members will be posted at all exit doors on 200, 300, and 400 halls indefinitely until those residents requiring a (brand name alarming bracelet) are transferred to the 5th floor. · Residents on the 5th floor, identified as a non-elopement risk due to non-ambulatory status, will be transferred to other units. · Residents that are identified as elopement risk, and require a (brand name alarming bracelet), will be transferred to the secured unit (5th floor) as soon as beds become available. · Alarm and Resident Elopement in-servicing logs dated 9/26/16 and 9/27/16 were reviewed and revealed no concerns. · The DON, or designee, completed Elopement QAPI (Quality Assurance and Performance Improvement) audits on 9/27/16 and will complete an elopement QAPI audit monthly and report results to the QAPI committee effective 9/27/16. · An interview was conducted with Nurse #2 on 9/28/16 at 8:45PM and she was able to describe the elopement training and protocol. · An interview was conducted with Nurse #5 on 9/29/16 at 3:30 PM and she was able to describe the elopement training and protocol. · An interview was conducted with Nurse #3 on 9/29/16 at 3:47 PM and she was able to describe the elopement training and protocol. · An interview was conducted with the SDC nurse on 9/30/16 at 9:45 AM and she was able to describe the elopement training and protocol. · An interview was conducted with NA #1 on 9/30/16 at 11:02 AM and she was able to describe the elopement training and protocol. · An interview was conducted with NA #2 on 9/30/16 at 11:55 AM and she was able to describe the elopement training and protocol. · An observation was made on 9/30/16 at 12:20 PM of staff posted at all exits doors on the 200, 300, 400, and 500 hall which were the four facility hallways where residents resided. · An interview was conducted with NA #3 on 9/30/16 at 12:00 PM and she was able to describe the elopement training and protocol. · An interview was conducted with the Administrator on 9/30/16 at 12:05 PM. She stated, We have tripled the staff here today so they can monitor the exit doors. We started monitoring the doors on Wednesday 9/28/16 after 3:00 PM. The company representative for the (brand name) alarming system is here now to check the system and make recommendations for improvement. As of now, there is a staff member posted at every exit door and I have told all staff not to reassign door monitors under any circumstances. Management staff will be called in if necessary to ensure the doors are monitored at all times until the (brand name) alarming system representative ' s recommendations are completed. Immediate jeopardy was removed on 9/30/16 at 12:20 PM. Observations revealed staff members posted at each fire exit door on the 200, 300, 400, and 500 Halls. Interviews with direct care staff and licensed staff confirmed they had received in-servicing on responding to resident elopements. The (brand name alarming system) was being assessed and tested by a company representative. Observations revealed (brand name alarm bracelets) were present on 5th floor residents who were ambulatory, the DON, or designee, had completed Elopement QAPI (Quality Assurance and Performance Improvement) audits, and an observation of the (brand name alarming system) for the elevator was confirmed it was functioning properly.

Based on staff interviews and record review the facility failed to update the care plan for 1 of 1 resident with urethral erosion. (Resident #277) Findings include: Resident #277 was re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident's care area assessment (CAA) summary, dated 1/27/11, revealed a CAA for "Urinary Incontinence and Indwelling Catheter." The indwelling catheter was in place on admission due to unstageable pressure ulcers on his sacrum and left hip. The CAA read in part, "Resident does have a catheter in place. He has several pressure ulcers to sacrum, hip, and lower extremities." He is at increased risk for pressure ulcers due to his impaired mobility, impaired cognition, incontinence, and existing pressure ulcers." Will proceed to care plan to help manage skin integrity and provide ADLs (activities of daily living). The CAA summary for pressure ulcer was dated 1/27/11. It was noted, "Resident was admitted to facility with several pressure ulcers to bilateral lower extremities, left hip, and sacrum." The most recent minimum data set (MDS), dated [DATE] revealed the resident had severe cognitive impairment. He was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use and bathing. He required extensive assistance for personal hygiene. Resident #277 had no noted behaviors on the MDS. The resident was incontinent of bowel and had an indwelling urinary catheter. Resident #277's care plan included a care plan, dated 5/6/11, for "Potential for infection related to use of indwelling catheter." The goal was for the resident not to experience any adverse effects related to the use of the indwelling catheter through the next review. The interventions included; catheter care every shift and as needed, maintain a closed drainage bag below level of bladder. Monitor for signs and symptoms of urinary tract infection: fever, and change in color, consistency, and odor of urine. The staff was to report any unusual findings immediately to the physician. A care plan titled "Potential for impaired skin integrity related to decreased mobility, contractures, pressure sore left hip, sacral wound and pressure ulcers to bilateral feet", dated 5/6/11, noted the goal was for the resident to not experience any adverse effects from any skin integrity issues through the next review. The interventions included; staff to report to nurse any red or open areas, ensure appropriate pressure relieving devices in place during repositioning. Monitor skin daily during care for any changes. Report any abnormal observations to the physician. During an interview, on 5/12/11 at 1:37PM, MDS nurse #1 indicated if a resident had a wound (penile erosion) it should be noted on their care plan. MDS nurse #1 was not sure why the wound to the penis was not mentioned on the care plan. An interview was conducted on 5/12/11 at 2:06PM with MDS nurse #3. She stated the care plans should be revised and updated at least quarterly and annually. MDS nurse #3 indicated if a resident had a wound, it should be noted on their care plan with interventions in place. The nurse was not sure why the penile erosion wound was not care planned. During an interview, on 5/12/11 at 2:06PM, the director of nursing (DON) indicated she expected the care plans to be updated quarterly, annually and if a resident had a history of [REDACTED].

Based on observations, staff interviews, nurse practitioner interviews and record review the facility failed to securely anchor the tubing of an indwelling catheter to prevent pulling or reduce trauma on the catheter tubing, failed to assess and promptly treat a penile erosion for 1 of 1 sampled residents with indwelling catheters. (Resident #277) Findings include: Resident #277 was re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident's Care Area Assessment (CAA) summary, dated 1/27/11, revealed a CAA for "Urinary Incontinence and Indwelling Catheter." The CAA read in part, "Resident does have a catheter in place. He has several pressure ulcers to sacrum, hip, and lower extremities." He is at increased risk for pressure ulcers due to his impaired mobility, impaired cognition, incontinence, and existing pressure ulcers." Will proceed to care plan to help manage skin integrity and provide ADLs (activities of daily living). Review of the nurse's notes revealed a re-admission note dated, 4/18/11 completed by MDS nurse #1. The nurse noted the resident had open areas to his left and right ankle, left hip, sacrum, behind his left ear and also a healing area to left outer ear. A non-blanchable area was noted to the right hip. No mention was made of an assessment being completed to the penis area. No mention was made of the resident having any type of healed penile erosion. The wound care notes dated 4/19/11 noted the TN (treatment nurse) had assessed and measured the residents wounds. The TN noted the following wounds; left hip stage 4, sacral wound stage 4, left inner malleolus stage 3, left heel unstageable, right outer malleolus stage 3, right ischium possible deep tissue injury. No mention was made in regards to the assessment of the penis area. No mention was made of a healed wound to the penis. Review of the "Resident Weekly Skin Check Sheet", dated 4/19/11 found no mention of any wound to the penis. A nurse's note, dated 4/25/11 read in part, "cna (nursing assistant) reported residents penis swollen. This nurse assessed, small amount of [MEDICAL CONDITION] noted at head of penis. No drainage noted at this time (name of physician) notified orders received to change cath (catheter)." A new indwelling catheter was inserted without difficulty, yellow urine noted with some mucus and small pus like area at the meatus (opening of the urinary tract). A culture was obtained from the drainage along with a urinalysis and culture and sensitivity. On 4/26/11 a nurse's note revealed the resident was started on antibiotics after the urinalysis results were back. The catheter was draining yellow urine with mucous noted and a small amount of drainage noted from around the meatus. Review of the "Resident Weekly Skin Check Sheet", dated 4/26/11 found no mention of any wound to the penis. The next treatment note (done by the TN) was dated 4/28/11. There was no mention of a wound to the penis (open or healed). The culture results for the penis were reported on 4/28/11. The results noted "Normal Genital Tract Flora." The most recent minimum data set (MDS), dated [DATE] revealed the resident had severe cognitive impairment. He was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use and bathing. He required extensive assistance for personal hygiene. Resident #277 had no noted behaviors on the MDS. The resident was incontinent of bowel and had an indwelling urinary catheter. The MDS revealed the resident had multiple unstageable pressure ulcers during the look back period. The treatment note dated 5/4/11 did not make mention of any wounds to the penis. Resident #277's plan of care, dated 5/6/11, included "Potential for infection related to use of indwelling catheter." The goal was for the resident not to experience any adverse effects related to the use of the indwelling catheter through the next review. The interventions included; catheter care every shift and as needed, maintain a closed drainage bag below level of bladder. Monitor for signs and symptoms of urinary tract infection: fever, and change in color, consistency, and odor of urine. The staff was to report any unusual findings immediately to the physician. A care plan titled "Potential for impaired skin integrity related to decreased mobility, contractures, pressure sore left hip, sacral wound and pressure ulcers to bilateral feet", dated 5/6/11, noted the goal was for the resident to not experience any adverse effects from any skin integrity issues through the next review. The interventions included; staff to report to nurse any red or open areas, ensure appropriate pressure relieving devices in place during repositioning. Monitor skin daily during care for any changes. Report any abnormal observations to the physician. Review of the "Resident Weekly Skin Check Sheet", dated 5/6/11 found no mention of any wound to the penis. A verbal order, dated 5/9/11 and obtained by the TN read in part, "Tx (treatment) penile erosion (with) 1. clean (with) wound cleanser 2. cover (with) Xeroform gauze 3. (change) q (every) day & PRN (as needed)- keep (catheter) attached to leg to limit movement." On 5/10/11 the treatment note did not mention any wounds to the penis and no measurements could be found. A wound care observation and interview was conducted on 5/11/11 at 9:32AM with the treatment nurse (TN). The resident had an indwelling urinary catheter. The TN cleansed the open area around the tip of the penis. The open area resembled a widened track. The area was red with a small amount of mucus type drainage noted. He referred to the area as"penile erosion" and stated the resident came back from the hospital (4/18/11) with the erosion. The resident did not have a leg strap on at the time. His catheter tubing was tangled in between his legs (which were contracted). Resident #277 displayed facial expressions of discomfort when the penile erosion was cleaned and when the catheter tubing was adjusted. The TN stated the resident might have removed the catheter strap. The TN then placed a new anchorage system on the resident's thigh to prevent tension or pulling on the indwelling catheter. The TN indicated he had measured the penis wound and that information could be found in "Integumentary/Skin Concerns" notes for the resident. The TN could not provide a reason as to why no treatment was initiated to the penile erosion until 5/9/11. During an interview on 5/11/11 at 4:27PM, nurse practitioner (NP) #1 stated she had viewed the penile wound since the resident had been readmitted . She stated it was a little swollen and red. She acknowledged not seeing the wound since shortly after re-admission but stated the wound care staff was very good about informing her of new areas and keeping her updated. The NP indicated she was not sure if anchoring the catheter tubing would help prevent any skin breakdown to the penis area. A follow up interview was conducted with the TN on 5/12/11 at 9:06AM. The TN indicated he thought he charted about applying the leg anchoring device but "clearly he did not." He reviewed the TN notes and could not find any notes in regards to the assessment and measurement of the penile erosion. He stated he thought he measured the wound but "has no excuse" for why the information was not there. The TN stated it was everyone's responsibility to maintain the urinary catheter. He stated the catheter tubing should be anchored to the resident's leg to prevent tension and pulling. During an interview on 5/12/11 at 9:25AM, nurse #2 stated the resident has had the open area to the penis since his last hospital admission. She did not think it had changed. Only the TN does the measurements. Nurse #3 stated there was not much treatment they could have done for the penis wound. During a follow up wound care observation on 5/12/11 at 9:47AM measurements of the penile erosion were obtained by the TN. The penile erosion measured 1.3 centimeters (cm) by 1cm, with a depth of 0.2cm. Nurse #2 stated there was no change to the wound since the resident had been readmitted . Neither the TN nor nurse #2 could provide a clear answer as to why the wound had no treatment until the verbal order was obtained on 5/9/11. The resident's catheter tubing was secured to his thigh. On 5/12/11 at 1:48PM NP #1 provided some information on "Securing the Indwelling Catheter." The information was from "Lippincott's Nursing Center.Com." The article read in part, "Optimal management of an indwelling catheter includes securing the catheter to the thigh or abdomen in a way that prevents the catheter or its retention balloon from exerting excessive force on the bladder neck or urethra." During an interview on 5/12/11 at 2:19PM the director of nursing stated the catheter tubing should be secured on the leg of residents who had indwelling catheters. An interview was conducted on 5/12/11 at 3:18PM with MDS nurse #1. The nurse stated she thought the resident might have had a healed erosion to the penis before going to the hospital. When he returned from the hospital, she did his initial skin assessment. She thought there was "like a slit or erosion (to the penis), the skin was intact like someone had a scar but not as bad as that." MDS nurse #1 stated she did not think the resident was at increased risk for open areas to the penis if he had a history of [REDACTED].