Autumn Care Of Drexel

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, Medical Director, resident and staff interviews, the facility failed to provide care in a safe manner when staff were assisting a resident (Resident #34) with left side weakness and vascular dementia with incontinent care. The resident was rolled onto her left side then left in her bed unattended with the side rails down. Resident #34 was unable to hold herself up and she fell off the side of the bed onto the floor. The resident sustained a laceration to her nose, bruises to her face, and was transferred to the hospital for treatment. She received medical glue to the laceration on her nose, and a hospital CT (computed tomography) scan revealed the resident had suffered a fractured nose due to the fall. The resident was discharged back to the facility on 4/12/25. Resident #34 stated that this was the worst fall she had suffered and was more painful than the birth of her children. This was reviewed for 1 of 3 residents (Resident #34) for the prevention of accidents.
Findings Included:
Resident #34 was admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis) and hemiparesis (partial weakness) affecting the left non-dominant side and vascular dementia.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and had been assessed as being dependent on staff for all activities of daily living and was frequently incontinent of bladder and bowel. Resident #34 was also assessed as requiring bed rails to assist with bed mobility.
Review of a nursing progress note written by Nurse #3 dated 4/12/25 revealed Resident #34 rolled out of bed while her gown was being changed by Nursing Assistant (NA) #1. Siderails on the bed were down. Resident #34 was lying face-down on the floor beside the bed. Moderate amount of bleeding from a laceration to the bridge of her nose. Pressure bandage was applied to the nose and bruising evident on the face. Resident #34 complained of pain in left hip and her head. Resident #34's Responsible Person (RP) was contacted, and she stated a desire to have Resident #34 go to the emergency room (ER). Nurse Practitioner (NP) notified. Resident #34 was alert and oriented x4, denied dizziness or nausea. Emergency Management System (EMS) called. Resident #34 left the facility via stretcher with EMS in stable condition. Report called to hospital ER charge nurse.
Review of fall incident report written by Nurse #3 dated 4/12/25 revealed Resident #34 rolled out of bed while her gown was being changed by NA #1. Siderails were down and Resident #34 was lying face down on floor beside the bed. Moderate amount of bleeding from a laceration to the bridge of Resident #34 nose, pressure bandage applied. Bruising evident to Resident #34 face and complaints of pain to left hip and head. RP notified and stated her desire for Resident #34 to be sent to ER. NP also notified. Resident #34 was alert and oriented x4 and denied any loss of consciousness, dizziness, or nausea. EMS was called and Resident #34 left facility via stretcher with EMS in stable condition. Report was called to ER nurse.
Review of a hospital Discharge summary dated [DATE] revealed Resident #34 from a local skilled nursing facility, non-ambulatory, was receiving personal care and apparently fell from the bed into the floor. She sustained a significant nasal laceration (deep cut on top of nose), bruises to her face and was brought to the Emergency Department (ED) where she was found to have a fractured nasal bridge. Glue was placed for nasal laceration. Resident #34 was discharged back to the skilled nursing facility in stable and improved condition with orders to follow-up with primary care physician.
Review of a nursing progress note written by Nurse #3 dated 4/12/25 revealed Resident #34 returned from ER via EMS at 6:40 AM in stable condition and alert and oriented X4. Neurological checks remain at baseline. Per report from the hospital ER charge nurse, Resident #34's CT scans were negative for head and neck fractures. Fractured nasal bridge with laceration (glued at ER). No new orders received, follow up with NP. Resident #34 was instructed to leave bed in a low position and call for assistance.
Attempted an interview with Nurse #3 and was unsuccessful.
Review of physician progress note written by the NP dated 4/12/25 revealed Resident #34 was being seen for follow-up from fall out of bed requiring visit to ER. Resident #34 had a fractured nose, laceration on forehead, entire face black and purple, eyes, lips, and nose all swollen. At time of assessment, Resident #34's pain was controlled, mentation intact, and no neurological deficits noted. Resident #34's vitals were also stable, and breathing was within normal limits. NP ordered pain medication every four hours as needed, nose spray, and cold compresses as needed to face. RP was at bedside and aware of the incident and NP noted no other concerns at this time.
Review of NP order for Resident #34 dated 4/12/25 revealed the following:
Hydrocodone Acetaminophen 5/325 milligrams (MG) 1 tablet by mouth every 4 hours as needed for treatment of pain.
Flonase nasal spray 1 spray in each nostril two times per day for edema (swelling)
Cold compress to face every 4 hours as needed for edema
Attempted an interview with NP and was unsuccessful.
Review of fall incident statement provided by Resident #34 dated 4/12/25 revealed Resident #34 rang her call light and NA #1 came in and assisted with her care and noted her brief and gown were wet. NA #1 changed her brief and went to get her gown out of the closet. NA #1 returned, and Resident #34 stated she was going to fall, and she proceeded to roll off of the left side of the bed into the floor. Resident #34 stated her bed rails were down at the time of the fall.
Review of fall incident statement written by NA #1 dated 4/12/25 revealed on 4/12/25 at 2:30 AM, NA #1 provided routine care for Resident #34. Upon entering Resident #34's room observed bed rails were down and assumed was her preference during care. NA #1 elevated Resident #34's bed and began care by rolling Resident #34 onto her left side. As care progressed, NA #1 removed Resident #34's brief and pad and recommended changing her gown. NA #1 proceeded to get Resident #34's gown and her weight began to take her over the left side of the bed resulting in her fall.
A telephone interview was conducted with NA #1 on 4/24/25 at 6:08 PM revealed he was familiar with Resident #34 and provided her care the morning of 4/12/25. He stated that on 4/12/25 around 2:30 AM, he went into Resident #34's room to answer her call-light and she informed him that both her brief and gown were wet, and she needed to be changed. He revealed he elevated Resident #34's bed to right above waist level, rolled her onto her left side and provided Resident #34 incontinence care by cleaning and changing her brief. NA #1 stated he left Resident #34 rolled over onto her left side facing the window, walked over to her closet on the opposite side of the room by the door to get her a clean gown to change into. He revealed as he was coming back towards Resident #34's bed he heard Resident #34 say I'm falling and observed her weight take her over the side of the bed and she fell into the floor between the bed and the air conditioner on the wall. He stated he immediately went to the nurse's desk and informed Nurse #2 of the fall and she and Nurse #3 responded to Resident #34 room and began providing treatment he believed to her nose which was bleeding. NA #1 stated Resident #34 did have quarter bed rails that were not raised, and he was later informed that her bed was also not locked. NA #1 also stated the incident was an accident and human error on his part and that he had since been re-educated on incontinence care, making sure assistive devices such as bed rails were being used, and making sure resident beds were locked.
Attempted an interview with Nurse #2 and was unsuccessful.
Review of fall incident statement provided by Nurse #2 dated 4/12/25 revealed on 4/12/25 NA #1 informed her and Nurse #3 that Resident #34 had fallen while in the middle of changing her. When Nurse #2 arrived at Resident #34's room, she was on the left side of the bed (on floor) face down. Nurse #3 assessed Resident #34 while Nurse #2 started pressure to the bleeding areas. Resident #34 stated I was trying to grab the rail and went over, it was an accident, it wasn't his fault. Resident #34 was lifted off the floor to her bed, was alert and talking. Nurse #2 stayed with Resident #34 until EMS arrived.
An interview and observation with Resident #34 was conducted on 4/23/25 at 2:30 PM and revealed a couple of weeks ago she had suffered a fall from her bed during incontinence care and broke her nose. She stated during the middle of the night she had wet herself through her brief and gown and used her call light to ask for staff assistance. She revealed NA #1 came into her room to answer her call light and she informed him she needed to be changed and that her gown was also wet and needed to be changed. Resident #34 stated NA #1 elevated her bed to about his waist and began changing her brief. She revealed after NA #1 finished changing her brief, he then went over to her closet located on the other side of her room to get her a clean gown. She stated when NA #1 went to get her new gown she was still rolled over onto her left side in bed facing the window and as NA #1 was coming back towards the bed with her gown was when she fell off the side of the bed onto the floor between the bed and the air conditioner and broke her nose. Resident #34 stated she was [AGE] years old, and this was the worst fall she had ever suffered and was more painful than the birth of her three children. Observation of Resident #34 revealed laceration to the top of the nose which appeared scabbed over, faint bruising to both sides of nose and underneath both eyes, and faint bruising on top of both the right and left hand.
An interview was conducted with the Medical Director on 4/23/25 at 2:47 PM revealed he was not as familiar with Resident #34 and believed his NP was notified of Resident #34's fall. He stated to his knowledge NP followed up with Resident #34's fall and fractured nose on 4/12/25 after her return from the hospital. The Medical Director revealed based on Resident #34's diagnosis of muscle weakness and being left alone while rolled onto her side with nothing to hold up her weight could have contributed to her fall. He stated staff should follow guidelines to ensure all residents were safe while receiving care.
An interview was conducted with the Physical Therapy Assistant (PTA) on 4/24/25 at 1:45 PM revealed she was familiar with Resident #34, had provided her with therapy services off and on since her admission. She stated Resident #34 had been referred to therapy due to her most recent fall and was currently receiving therapy services for strengthening and movement for her left-sided weakness. She revealed Resident #34 had minimal use of her left side, wore a splint on her left hand during waking hours and a palm guard during her sleeping hours to prevent contracture of the left hand. Quarter rails had been applied to the bed for assistance with bed mobility, and bed placed in lowered position to assist with any falls. The PTA stated any residents could be considered a fall risk while left alone in their bed and rolled onto their side. Staff should not walk off or leave any residents alone in their beds while rolled onto their sides while providing care. She revealed Resident #34 being left alone and rolled onto her weaker side with nothing to assist her with holding up her weight could have contributed to her fall.
An interview was conducted with the Director of Nursing (DON) on 4/24/25 at 4:07 PM revealed she was familiar with Resident #34. The DON stated she received a telephone call on the morning of 4/12/25 from Nurse #3 stating Resident #34 had fallen off the bed during incontinence care, had bleeding from her nose, bruises to her face, was complaining of pain, the on-call physician had been notified, and they were sending Resident #34 out to the ER for further treatment. She revealed she contacted the Administrator, and the Administrator went into the facility on 4/12/25 and initiated the investigation of the fall. She stated her understanding of the fall was that NA #1 had gone into Resident #34's room to assist with incontinent care and after providing her initial care had gone to the closet to get Resident #34 a clean gown and upon his return to the bed was when Resident #34 fell. The DON revealed Resident #34 was sent to the ER and did return with a fractured nose that was treated with ice packs and pain medication and all other CT scans to her head, neck, hands, and knees were negative for any further injury. She stated Resident #34 had quarter bed rails to assist with her bed mobility that were not raised, and her bed was not locked prior to care. She revealed she believed Resident #34's fall occurred due to human error and oversight on NA #1's part and since the incident all staff had been educated on incontinence care and assuring all resident beds were locked and assistive devices in place prior to providing care.
An interview was conducted with the Administrator on 4/24/25 at 5:17 PM revealed she was familiar with Resident #34. The Administrator stated on the morning of 4/12/25 she received a telephone call from the DON about Resident #34's fall during incontinence care and that she was being sent out to the ER for further evaluation. She revealed she went into the facility on 4/12/25 to begin the investigation on the fall and received statements from NA #1, Nurse #2 and Resident #34 once she returned from the ER. The Administrator stated she also had nursing staff to complete audits on all other residents with assistive devices making sure they were intact during resident care, all resident beds were locked, and that education with staff on incontinence care including audits of staff providing incontinence care was initiated. She revealed her understanding of the fall was that NA #1 had gone into Resident #34's room to provide incontinence care and while NA #1 was retrieving a gown for Resident #34 to be changed into she fell into the floor between her bed and the wall. The Administrator stated Resident #34's bed rails were not raised, and her bed was not locked while NA #1 was providing her care. She revealed Resident #34 was sent out to the hospital ER immediately and CT scan was performed showing her nose was fractured but no other injuries were found. She stated Resident #34 did return to the facility that same day and was seen by the NP who ordered ice packs and pain medication for treatment. The Administrator revealed she believed the incident with Resident #34 was due to human error and oversight on the part of NA #1 and that all staff have been re-educated on incontinent care and making sure residents were not left alone during care, assistive devices including bed rails are in place and all resident beds are locked prior to performing resident care.
The facility provided the following Corrective Action Plan with a correction date of 4/15/25:
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:
Certified Nursing Assistant #1 was performing incontinence care on 04/12/25 and changing Resident #34's gown while she was in bed and the quarter rails were not in a raised position. CNA #1 assisted Resident #34 to turn and the bed was not locked and rolled away from the wall and Resident #34 rolled out of bed onto the floor between bed and wall. Resident #34 was assessed by nurse, Provider and Resident #34's responsible party was notified on 4/12/2025. Resident #34 was sent to hospital on 4/12/2025 for evaluation. Resident #34 returned from the hospital on 4/12/2025 and noted to have a nasal bone fracture. Provider assessed upon return on 4/12/2025 and gave orders for ice packs every 4 hours as needed to face for edema, Flonase nasal spray 1 spray in each nostril two times per day for edema and Hydrocodone acetaminophen 5/325 milligrams every 4 hours as needed for pain. Resident #34 continued to complain of pain and on 4/14/205 Provider ordered chest, thoracic, lumbar, bilateral hands and right knee x rays. Results of x rays were all negative. CNA #1 was suspended by the Director of Nursing on 4/12/205 pending investigation.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice:
The Director of Nursing and or Designee audited current residents who use side rails to ensure they were up while residents were in bed and assessed if the residents still required or requested side rails. This audit was completed on 4/14/2025. The Director of Nursing and or Designee audited current beds in the facility to ensure they were locked. This audit was completed on 4/14/2025. No areas of concern were identified.
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:
To prevent this from happening again the Director of Nursing and or Designee started education on 4/12/2025 for nursing staff including Agency Nursing staff currently working in facility to ensure residents safety during care when resident is in the bed, including not leaving resident unattended while turned in the bed and if walking away from the resident to ensure resident is in a safe position and any assistive devices needed are in place and that the bed is locked prior to providing care. Examples, Bed rails for positioning, pillows and or wedges. This education was provided to all certified nursing assistants by the Director of Nursing and or Designee, also included safe handling during Bed Mobility to include not leaving resident unattended while turned in the bed and if walking away from the resident to ensure resident is in a safe position, adjusting bed to proper height, stand on side of bed to which the resident will roll, Position arms/legs appropriately; position residents arm, which is closest to you, out to the side of their body, flex the resident knee furthest from you, position residents furthest arm across their chest and roll resident towards you by placing one hand behind the residents shoulder and the other on their hip, The Director of Nursing and or Designee observed with return demonstration incontinent care, turning and repositioning in bed and bed mobility with all certified nursing assistants to ensure they were competent. These observations were completed by 4/14/2025. Nursing staff not currently working in facility were educated via phone or in person by the Director of Nursing and or Designee by 4/14/205 and will not be allowed to work until they have received this education. Any Nursing staff on leave or paid time off will be provided the education prior to working their next shift by the Director of Nursing and or Designee. The Director of Nursing has list of any nursing staff that are on leave or paid time off that need this education prior to working. This education will be provided in new hire orientation for nursing staff. Agency nursing staff will receive this education prior to working.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:
To monitor and maintain compliance starting 4/17/2025 the Director of Nursing and or Designee will observe care being provided to 5 residents weekly for 8 weeks and monthly for 1 month to ensure residents safety during care when resident is in the bed, including not leaving resident unattended while turned in the bed and if walking away from the resident to ensure resident is in a safe position and any assistive devices needed are in place and that the bed is locked prior to providing care.
The Administrator and Director of Nursing discussed Resident #34's incident on 4/13/2025 and determined the need to have an ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 4/14/2025 with the Interdisciplinary team to discuss the incident with Resident #34 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 4/14/2025 regarding the incident and the interventions that were put in place for Resident #34 and the plan of correction to prevent further incidents and or accidents.
The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, re-education of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented.
Date of Compliance: April 15, 2025
On 4/24/25, the facility's corrective action plan effective 4/15/25 was validated by the following: Observations of residents being provided incontinence care, assistive devices being used during care including bed rails, and resident beds being in a locked position while in use with no issues or concerns noted. Nursing staff interviews revealed they had received education on providing incontinent care to residents safely, making sure all assistive devices for residents used while in bed or during care were present, and resident beds were locked prior to providing care. Administrative staff interviews revealed they provided staff education on ensuring resident safety, assistive devices were in place and resident beds were locked prior to performing resident care. Administrative staff completed return demonstrations with staff and were also completing weekly audits of resident care to ensure safety of residents during care, positioning of residents during care, resident assistive devices are present and being used correctly, and resident beds are locked prior to providing care. Auditing tools and documents were reviewed from the Facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results.
The facility's action plan was validated to be completed as of 4/15/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Medical Director and Consulting Pharmacist interviews, the facility failed to prevent a significant medication error when Nurse #1 administered 30 units of insulin glargine (a long acting insulin that lasts for 24 hours and does not have a peak of onset) intended for Resident #31 to Resident #16. Resident #16 did not have a diagnosis of diabetes or a physician's order for insulin. Resident #16 was assessed by the Nurse Practitioner (NP) and immediately started on intravenous (IV) dextrose (a solution that contains sugar) fluids for 24 hours. The NP also ordered finger stick blood sugars every hour for 24 hours with instructions to notify the provider if Resident #16's blood sugar was below 90 (Normal range is between 70-99). Resident #16's blood sugar dropped to 61 during the night, Nurse #2 notified the on-call provider and gave Resident #16 eight ounces of orange juice and a snack while she waited for a response from the provider. The on-call provider responded and ordered glucagon (a medication used to increase a resident's blood sugar level) 1milligram (mg) and for Resident #16's blood sugar to be rechecked after 15 minutes. Nurse #2 administered glucagon 1mg subcutaneously (SQ) and the blood sugar recheck was 152. Hypoglycemia (defined as a blood sugar level below 70) can be serious and life threatening if gone untreated; symptoms include tremors, palpitations, anxiety, sweating, dizziness, weakness, drowsiness, confusion, altered mental status, loss of consciousness, or seizures. There was a high likelihood for serious harm. This was for 1 of 3 residents reviewed for unnecessary medications (Resident #16).
The findings included:
Resident #16 was admitted to the facility on [DATE]. Resident #16 did not have a diagnosis of diabetes mellitus.
Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired; Resident #16 was coded that she had not received insulin.
Review of Resident #16's physician's orders dated April 2025 revealed no active orders or insulin.
Review of Resident #16's April 2025 Medication Administration Record (MAR) revealed no active orders for insulin glargine.
Review of Resident #31's physician's orders dated April 2025 revealed an active order for insulin glargine inject 30 units SQ every morning for type 2 diabetes mellitus.
Review of Resident #16's medical record revealed a Nurse Practitioner progress note dated 4/14/2025 read in part: Resident #16 was seen today after she was given 30 units of long-acting insulin. No hypoglycemia. She is alert and seated in her wheelchair, conversant. Seated in wheelchair in no acute distress. Plan: Administer D5W (dextrose 5% in water- an infusion used to provide the body with extra water and calories from sugar) at 75 milliliters (ml) an hour for 24 hours. Close monitoring of blood sugar and vital signs, see orders.
Review of Resident #16's physician's orders from the NP for 4/14/2025 revealed the following:
-Monitor blood sugar for 24 hours- check blood sugar every hour- notify NP if blood sugar is less than 90.
-Monitor for signs and symptoms of hypoglycemia- paleness, shakiness, sweating, headache, hunger/nausea, rapid/irregular heartbeat, fatigue, dizziness/lightheadedness, changes in level of consciousness every hour
-Monitor vital signs every hour x 8 hours then every 4 hours x 4
-Condition change charting for 72 hours related to medication error
-D5W at 75 milliliters (ml) /hour for 24 hours
-D5 1/2NS (dextrose 5% in normal saline- an infusion used to provide the body with extra fluids and calories from sugar) at 75ml/hour for 24 hours
The Nurse Practitioner was not available for interview during the survey.
A nursing progress note written by Nurse #1 on 4/14/2025 at 10:08 am revealed she had made a medication error for Resident #16. The note revealed orders received for intravenous (IV) fluids, blood sugar and vitals were to be checked every hour for 24 hours, resident representative had been notified, and blood sugars were 138 and 129.
A telephone interview was conducted with Nurse #1 on 04/23/25 at 9:41 AM. Nurse #1 stated on 4/14/2025 two residents were sitting at the table in the dining room, and she (Nurse #1) administered insulin to Resident #16, insulin that was ordered for Resident #31. Nurse #1 stated she immediately realized her mistake and reported the error to the NP and received orders to check blood sugars and vitals every hour. Nurse #1 was unsure of the exact amount of insulin she had administered to Resident #16 but stated it was the dose intended for Resident #31. Nurse #1 stated she reported the medication error to the assistant Director of Nursing (ADON) and Director of Nursing (DON) and Resident 16's family member. On 4/14/2025 Nurse #1 was scheduled to work 7am-7pm on a hall she was not normally assigned. Nurse #1 stated she failed to administer the right medication to the right resident when she failed to verify the resident's identity prior to insulin being administered and by administering medication in the dining room and not in the resident's room. Nurse #1 stated as soon as the insulin was administered to Resident #16, Nurse #1 realized Resident #31, who was seated next to Resident #16, was intended to receive the insulin. Nurse #1 stated the medication error was a total mishap, a human error and she was normally more focused. Nurse #1 stated Resident #31 received her insulin as ordered after the medication error with Resident #16.
A nursing progress note written by Nurse #4 on 04/14/2025 at 10:25 am revealed a subcutaneous (SQ) IV was placed in the left lower quadrant of Resident #16's abdomen. D5W was infused at 75 ml per hour for 24 hours.
During a telephone interview on 04/23/25 at 10:49 AM Nurse #4 stated on 4/14/2025 she (Nurse #4) was assigned to Resident #16's hall from 7am to 11pm. Nurse #4 was informed that Nurse #1 had administered insulin to Resident #16 who was not a diabetic and did not require insulin. Nurse #4 assessed and monitored Resident #16 through the rest of her shifts on 4/14/2025 and 7am to 3pm on 4/15/2025. Nurse #4 entered the orders received from the NP and checked Resident #16's blood sugar and vital signs every hour as ordered. Nurse #4 stated she did not observe any hypoglycemic episodes while she monitored Resident #16. Nurse #4 stated Resident #16 was alert to self and place, and some of Resident #16's family had visited Resident #16 on 4/14/2025. Nurse #4 stated the NP orders indicated to notify the NP if Resident # 16's blood sugar went below 90. Nurse #4 stated Resident #16's blood sugars had not been below 90 during her shifts. Nurse #4 stated she instructed the nursing assistants to monitor if Resident #16 did not eat well at meals and extra snacks would be given if needed. Nurse #4 stated Resident #16's vital signs remained stable. During a follow up interview on 4/24/2025 at 9:48am Nurse #4 stated Resident # 16 was not able to communicate with a nurse that she was not supposed to receive insulin.
Review of Resident #16's medical record revealed her blood sugar was 61 documented at 12:35 am on 4/15/2025, and 77 documented at 1:13 am on 4/15/2025 by Nurse #2.
Review of a progress written by Nurse #2 on 04/15/25 revealed that she notified the on-call provider and received orders on 4/15/2025 for Glucagon reconstituted solution 1mg injection- give 1milligram (mg) SQ and recheck blood sugar (BS) in 15 minutes related to low blood sugar. And to check blood sugar at hour of sleep if BS is greater than 90 NO rechecks are required.
During a telephone interview on 4/23/2025 at 10:58 am Nurse #2 stated on 4/14/2025 she was scheduled to work 7pm to 7am and received report that Resident #16 had received the insulin by mistake, Resident #16 was not diabetic. Nurse #2 took over care for Resident #16 at 11pm on 4/14/2025. Nurse #2 stated the facility was out of D5W IV fluids, and new orders were received to start D5 1/2NS at 75ml per hour for remainder of the order. Nurse #2 stated Resident #16's blood sugar dropped to 61 around midnight and Resident #16 was given orange juice and a snack while Nurse #2 waited for a response from the on-call NP. Nurse #2 stated she received the order for glucagon 1mg, and it was administered to Resident #16 as ordered. Nurse #2 stated she stayed with Resident #16 for about 2 hours while the blood sugars were low, and Resident #16 remained alert and able to eat the snacks and drink fluids with no signs of hypoglycemia.
During an interview on 4/23/2025 at 1:40 pm the Medical Director stated if a non-diabetic resident received 30 units of long-acting insulin it could cause hypoglycemic events.
During a telephone interview on 4/24/2025 at 12:44 pm the Consulting Pharmacist stated if a non-diabetic resident received 30 units of long-acting insulin it could have caused blood sugars to drop, pain or hypoglycemic issues.
During an interview on 4/24/2025 at 1:10 pm the Director of Nursing (DON) stated she expected nurses not to administer medications in the dining room and for the correct medication to be administered to the correct resident. The DON stated she expected nurses to follow the 6 medication rights which included the right medication, right dose, right route, right rate and the right time for the right resident. The DON stated that the medication error occurred when Nurse #1 administered insulin in the dining room and failed to verify the identity of the resident prior to medication being administered.
During an interview on 4/24/2025 at 2:18pm the Administrator stated she expected the nurses to follow the 6 medication rights when they administer medication.
The Administrator was notified of immediate jeopardy on 4/23/2025 at 4:15 pm.
The facility provided the following corrective action plan with the completion date of 4/17/2025:
How will corrective action be accomplished for those residents found to have been affected by the deficient practice?
On 4/14/2025 at 8:34 am Nurse #1 administered Lantus 30 units to Resident #16 who did not have an order for Lantus and immediately reported this to the Director of Nursing and the Provider. The Provider immediately assessed Resident #16 and gave orders to check finger stick blood sugar every hour until 9:00am on 4/15/2025, notify Provider if finger stick blood sugar is below 90 milligrams (mg) per deciliter, Dextrose IV solution for 24 hours and monitor for signs and symptoms of hypoglycemia until 4/15/2025. On 4/14/2025 Provider gave order to monitor Resident #16's vital signs every hour for 8 hours and then vital signs every 4 hours for 16 hours. Resident #16's vital signs remained stable throughout monitoring. On 4/15/2025 at 12:30 am Resident #16 finger stick blood glucose was 61 milligrams per deciliter, on call was notified and while awaiting return call Nurse #2 gave 8oz of orange juice and a snack, Resident #16 was alert and oriented with no signs and symptoms of distress. Nurse #2 rechecked Resident #16's finger stick blood glucose at 1:00 am and was 77 milligrams per deciliter, on call Provider returned call at 1:10 am and gave order to administer Glucagon 1mg now times one dose and recheck finger stick blood sugar in 15 minutes. Nurse #2 administered Glucagon 1mg to Resident #16 at 1:15 am and Nurse #2 rechecked Resident #16's finger stick blood glucose at 1:32 am and Resident #16 finger stick blood glucose was 152 milligrams per deciliter. The remaining hourly blood sugar checks were 90 or above.
The Resident #1's Responsible Party was notified of medication error on 4/14/2025 at 10:08am.
Nurse #1 was suspended pending investigation on 4/14/2025. The Director of Nursing contacted the Board of Nursing regarding the medication error on 4/15/2025.
How will the facility identify other residents having the potential to be affected by the same deficient practice?
On 4/14/2025 the Director of Nursing and or Designee reviewed the finger stick blood glucose levels of all residents who require glucose monitoring from 4/13/2025 to 4/14/2025, which captured 24 hours prior to incident to ensure residents had no levels that would indicate signs and symptoms of hypoglycemia. The Director of Nursing and or Designee audited residents who had active orders for blood glucose monitoring and insulin on 4/14/2025 to ensure the insulin was administered per orders. No concerns were identified.
On 4/15/2025 the Director of Nursing interviewed cognitively intact residents with Brief Interview Mental Status score of 12 or above to ensure they had no concerns with receiving incorrect medications and cognitively impaired residents with Brief Interview Mental Status score below 12 were assessed by the Director of Nursing and or Designee to ensure no signs and symptoms of hypoglycemia were noted. No concerns were identified.
What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur?
To prevent this from happening again the Director of Nursing and or Designee started education on 4/14/2025 for all Licensed Nurses and Medication Aides including Agency Licensed Nurses and Medication Aides currently working in facility on not administering medications in the dining room and to follow the 6 rights of medication administration, to include the medication is administered to the right resident by verifying using the picture of each resident in the electronic health record. Licensed Nurses and Medication Aides not currently working in facility were educated via phone or in person by the Director of Nursing and or Designee by 4/15/2025 and will not be allowed to work until they have received this education. Any Nurse on leave or paid time off will be provided the education prior to working their next shift by the Director of Nursing and or Designee. The Director of Nursing has list of any Licensed Nurses and/or Medication Aides that are on leave or paid time off that need this education prior to working. The Director of Nursing was educated on 4/15/2025 by the Regional Director of Clinical Services on ensuring any Licensed Nurse or Medication Aide who is on leave or on paid time off received this education prior to their first shift of working. This education will be provided in new hire orientation for all Licensed Nurses and Medication Aides. Agency Licensed Nurses and/or agency Medication Aides will receive this education prior to working. The Director of Nursing called and spoke with each agencies credentialing and/or education specialist regarding education needed for the medication error plan of correction and sent the facility specific plan of correction education packet to the 2 agencies that provide contract staff to this facility 4/14/2025. The agency ensures the Licensed Nurses and or Medication Aides received this education prior to being scheduled at this facility. The Agencies provided confirmation to the Director of Nursing via individual staff education email that all agency Licensed Nurses and/or Medication Aides had received this education prior to working in facility.
The Director of Nursing educated the Scheduler on ensuring continuity of staff to attempt to keep them on the same assignment as much as possible to prevent medication errors. This education was completed on 4/15/2025.
How will the facility monitor its corrective actions to ensure the deficient practice will not recur?
To monitor and maintain compliance starting 4/17/2025 the Director of Nursing and or Designee will observe 3 medication passes for Licensed Nurses and/or Medication Aides weekly to include all three shifts for 8 weeks and then monthly for 1 month to ensure medications are administered as ordered.
Starting 4/17/2025 the Director of Nursing and or Designee will observe 5 residents in Dining Room weekly for 8 weeks and then monthly for 1 month to ensure no medications are being passed in the dining room.
The Administrator and Director of Nursing discussed Resident #16's medication error on 4/14/2025 and determined to have ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 4/15/2025 with the Interdisciplinary team to discuss the incident with Resident #16 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 4/15/2025 regarding the medication error and the interventions that were put in place for Resident #16 and the plan of correction to prevent the medication errors. The Director of Nursing implemented the plan of correction to prevent medication errors on 4/14/2025. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, re-education of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented.
On 4/24/25, the facility's corrective action plan effective 4/17/25 was validated by the following: During medication pass observations of licensed nursing staff reviewing residents with an active order for insulin on their electronic medical chart, checking the resident's picture and room number to assure they had the correct resident, and administering the correct dosage of insulin to the correct resident inside their room with no issues or concerns noted. Licensed Nurses and Medication Aide interviews revealed they had received education on 6 rights of medication administration to include checking resident electronic medical chart to ensure resident order for insulin and name, room number, and picture of resident to receive insulin. They were also educated on administering insulin inside resident rooms and not in the dining room during meals and reporting a medication error immediately to their supervisor.
The facility scheduler received education on trying to schedule nursing staff as much as possible to their same assigned halls consistently to help with continuity of care and prevention of medication errors. Administrative staff interviews revealed they provided staff education and completed weekly monitoring audits of ensuring medications including insulin are not being administered in the dining rooms during mealtimes, medication passes for all three shifts to ensure medications including insulin are administered as ordered to the correct resident. Education and Auditing tools were reviewed, with no new issues noted. Documents were reviewed from the Facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. Medication pass was observed on 4/22/2025 and 4/23/2025 with 0% error rate. The facility's corrective action plan with an IJ removal date of 04/17/25 was validated.
IJ removal date is 04/17/25.

Based on record review and staff interviews, the facility failed to maintain daily posted staffing sheets for 134 of 385 days (9/21/2024-12/31/2024, 1/4/2025, 1/5/2025, 1/11/2025, 1/12/2025, 1/18/2025, 1/19/2025, 1/25/2025, 1/26/2025, 2/1/2025, 2/2/2025, 2/8/2025, 2/9/2025, 2/15/2025, 2/16/2025, 2/22/2025, 2/23/2025, 3/1/2025, 3/2/2025, 3/8/2025, 3/9/2025, 3/15/2025, 3/16/2025, 3/22/2025, 3/23,2025, 3/29/205, 3/30/2025, 4/5/2025, 4/6/2025, 4/12/2025, 4/13/2025, 4/19/2025, 4/20/2025) reviewed for daily posted staffing information.
The findings included:
Review of the daily posted staffing sheets for September 2024 revealed no information was available for the days of 9/21/2024- 9/30/2025
Review of the daily posted staffing sheets for October 2024 revealed no information was available for the days of 10/1/2024- 10/31/2024.
Review of the daily posted staffing sheets for November 2024 revealed no information was available for the days of 11/1/2024- 11/30/2024.
Review of the daily posted staffing sheets for December 2024 revealed no information was available for the days of 12/1/2024- 12/31/2024.
Review of the daily posted staffing sheets for January 2025 revealed no information was available for 1/4/2025, 1/5/2025, 1/11/2025, 1/12/2025, 1/18/2025, 1/19/2025, 1/25/2025, 1/26/2025.
Review of the daily posted staffing sheets for February 2025 revealed no information was available for 2/1/2025, 2/2/2025, 2/8/2025, 2/9/2025, 2/15/2025, 2/16/2025, 2/22/2025, 2/23/2025.
Review of the daily posted staffing sheets for March 2025 revealed no information was available for 3/1/2025, 3/2/2025, 3/8/2025, 3/9/2025, 3/15/2025, 3/16/2025, 3/22/2025, 3/23,2025, 3/29/205, 3/30/2025.
Review of the daily posted staffing sheets for April 2025 revealed no information was available for 4/5/2025, 4/6/2025, 4/12/2025, 4/13/2025, 4/19/2025, 4/20/2025.
An interview was conducted with the scheduler on 4/24/2025 at 10:56 am revealed the scheduler started in the position in January of 2025. The scheduler stated she had been trained by the previous scheduler and received help from the Director of Nursing and Assistant Director of Nursing. The scheduler was not aware daily posted staffing sheets had to be completed on the weekends and verified no posted daily staffing sheet had been completed on the weekends since she had worked as the scheduler. The scheduler was not aware daily posted staffing sheets had to be kept for 18 months. The scheduler thought there had been daily posted staffing sheets for September through December 2024 but they were not able to be located.
During an interview with the Director of Nursing (DON) on 4/24/2024 at 1:10 pm the DON stated the scheduler was responsible to complete and maintain the daily posted staffing sheets. The DON stated there was not a designated staff member to complete daily posted staffing sheets on the weekends. The DON stated the former scheduler and Assistant Director of Nursing had helped to train the new scheduler. The DON was aware the daily posted staffing sheets needed to be completed every day and maintained for 18 months.
During an interview on 4/24/2025 at 2:18pm the Administrator stated the scheduler was responsible for the daily posted staffing sheets. The Administrator expected the daily posted staffing sheets to be completed daily and maintained for 18 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident, staff, family, and physician interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #86). This deficient practice occurred for 1 of 3 residents reviewed for respiratory care and services.
Findings included:
Resident #86 was admitted to the facility on [DATE]. Resident #86 had diagnoses which included myoneural disorder (a neuromuscular disorder which leads to progressive muscle weakness and paralysis which affects breathing).
Review of the Electronic Medical Record (EMR) revealed a physician order for Resident #86 dated 04/17/2025 at 10:17 AM for oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuously to relieve hypoxia.
Review of the baseline care plan dated 04/17/2025 revealed Resident #86 was receiving oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuously to relieve hypoxia.
Resident #86's 5-Day Minimum Data Set (MDS) assessment was in progress and not yet completed.
Review of the Brief Interview for Mental Status (BIMS) dated 04/17/2025 revealed Resident #86 was cognitively intact.
An observation of Resident #86 was completed on 04/21/2025 at 11:53 AM. Resident #86 was in her room sitting up in her wheelchair with her nasal cannula in her nostrils and her portable oxygen tank was set at 2 LPM.
On 04/22/2025 at 11:55 AM Resident #86 was observed lying in bed with her NC in her nostrils and the oxygen concentrator was set at 1.5 LPM.
An additional observation of Resident #86 was made on 04/22/2025 at 4:03 PM. Resident #86 was in her room sitting up in her wheelchair with her NC in her nostrils and the portable oxygen tank was set at 1.5 LPM. Resident #86 was observed to not be in distress.
An interview was conducted with Resident #86 on 04/22/2025 at 4:04 PM. Resident #86 stated she had been on oxygen since she was hospitalized with a severe respiratory illness about a year ago. Resident #86 also stated she does not adjust the oxygen flow rate on her oxygen concentrator or the portable oxygen tank. Resident #86 stated the nursing staff take care of her oxygen settings.
An observation of Resident #86 was conducted on 04/23/2025 at 11:06 AM. Resident #86 was in her room sitting up in her wheelchair with her NC in her nostrils and her portable oxygen tank was set at 2 LPM. Resident #86 was observed to not be in distress.
An interview was completed on 04/23/2025 at 11:10 AM with nursing assistant (NA) #2 who was assigned to Resident #86. NA #2 stated she always made sure the NC was in the resident's nostrils correctly and she checked to make sure the oxygen concentrator was plugged up in the electrical outlet. NA #2 stated she did not do anything with oxygen settings or adjust the oxygen flow rate on the oxygen concentrator or the portable oxygen tank.
An interview was conducted on 04/23/2025 at 12:18 PM with Nurse #5 who was assigned to Resident #86 on 04/22/2025 and 04/23/2025. Nurse #5 stated that all residents receiving oxygen should have a physician's order for oxygen which would include the flow rate. Nurse #5 also stated the flow rate should be set as ordered by the physician. Nurse #5 further stated she checks the oxygen flow rate during her morning rounds and medication pass but she had not checked Resident #86's oxygen settings on 04/23/2025. Nurse #5 further explained if a resident got up to the wheelchair, the NA would turn the portable tank on and set the flow rate.
An interview was conducted with the Assistant Director of Nursing (ADON) on 04/23/2025 at 12:32 PM. The ADON stated the nurses should check to make residents are receiving the correct oxygen flow rate as prescribed by the physician. The ADON stated the licensed nurses should be managing the oxygen flow rates on the oxygen concentrators and the portable oxygen tanks. The ADON further stated the NAs should not be setting, adjusting, or changing the oxygen flow rates on the oxygen concentrator or the portable oxygen tanks.
An interview was conducted with the Medical Director on 04/23/2025 at 2:03 PM. The Medical Director stated all residents receiving oxygen required an active physician's order for the prescribed LPM of oxygen they were to receive. The Medical Director further stated nursing staff should follow the physician's orders for providing oxygen including the prescribed flow rate.
An interview was conducted with NA #3 on 04/24/2025 at 9:00 AM. NA #3 stated the nurses were supposed to adjust the flow rate of oxygen for residents and turn on the oxygen concentrator and the portable oxygen tanks.
An interview was conducted with NA #4 on 04/24/2025 at 9:45 AM. NA #4 stated he did set the oxygen levels on portable oxygen tanks when changing residents from the oxygen concentrator to the portable oxygen tank or if the portable oxygen tank was empty and he needed to replace it with a full tank. NA #4 further explained he usually looked at the settings on the oxygen concentrator for the correct liters and he would set the portable oxygen tank to the same oxygen flow rate as the oxygen concentrator.
An interview was conducted with the Director of Nursing (DON) on 04/24/2025 at 3:53 PM. The DON stated she expected the nursing staff to check the physician's order for the prescribed oxygen flow rate and check to make sure residents were receiving the correct oxygen flow rate. The DON further explained she expected the nursing staff to provide oxygen at the prescribed flow rate as ordered by the physician. The DON explained the NAs should not adjust the flow rate on the oxygen concentrators or the portable oxygen tanks. The DON further explained the NAs should leave the resident on the oxygen concentrator and the nurse should switch the resident over to the portable oxygen tank and set the flow rate as ordered by the physician. The DON also stated oxygen was considered a medication, and the licensed nursing staff should follow the physician's order for the prescribed oxygen flow rate, ensure residents were receiving the correct flow rate of oxygen, and make any adjustments or changes to the flow rate.
An interview was conducted on 04/24/2025 at 4:58 PM with the Administrator. The Administrator stated she expected the nursing staff to follow the physician's order for providing oxygen including the correct flow rate and only the licensed nurses should set, adjust, or change the oxygen flow rate based on the physician's order.

Based on observations and staff interviews, the facility failed to ensure ready to use dishware was cleaned and dried before being stored, food was dated/labeled in the walk-in freezer, walk-in cooler, and dry goods storage area. This occurred for 1 of 2 kitchen observations. This had the potential to affect food served and distributed to 88 of 88 residents who received an oral diet.
The findings included:
The initial tour of the kitchen occurred on 04/21/25 at 9:30 AM with the Dietary Manager. The initial observation of the dishware storage area revealed the following:
a. Dishware that was ready for use was put away and stacked wet.
-4 out of 4 metal serving bins were stacked flat upside down visibly wet with pooled water on the sides and water pooled around the rim.
-22 small plastic bowls stacked right side up. 3 out of 22 bowls were observed with small amount of pooled water in the base of the bowls.
-2 of 8 clear small plastic dessert bowls were stacked right side up with small amount of pooled water in base of the bowls.
b. Dishware that was ready for use was put away/or stacked with food debris/insects on them.
-1 of 4 metal serving bins observed with one piece of red food debris dried to the side.
-2 of 4 plastic bins observed with visible brown sticky substance to the side and bottom. The substance was dull in appearance and sticky when touched.
-1 of 22 small plastic dessert bowls were observed with 2 gnats dead in the bowl in small amount of pooled water.
c. Frozen items in the walk-in freezer were observed with no date on packaging.
-1 of 1 opened box of frozen green beans observed with no date on box.
-1 of 1 opened box of diced green peppers observed with no date on box.
-1 of 1 opened box of French bread observed with no date on box.
-1 of 1 opened box of cookie dough observed with no date on box.
-1 of 1 opened box of biscuit dough observed with no date on box.
d. Opened items in dry good storage area not labeled with opened date/use by date.
-2 of 2 bottles of chocolate syrup observed with no date.
-2 of 2 opened cereal bags observed with no opened date/use by date label.
e. Items in the walk-in cooler were not dated.
-1 of 1 box of strawberries observed with no date on box.
An interview with the Dietary Manager on 04/22/25 at 1:42 PM revealed she stated that dishware was to be cleaned, dried thoroughly, and stored facing down to prevent pooling water, debris, or insects. She stated food stored in the walk-in freezer, dry goods area, and walk-in cooler should be labeled and dated when opened.
An interview with the Administrator 04/23/25 at 2:33 PM revealed she expected food to be labeled and dated, and dishware should be washed, dried thoroughly, and stored before use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and Nurse Practitioner (NP) and staff interviews, the facility failed to prevent an accident when staff was assisting a resident with advanced Parkinson's disease (disorder of the central nervous system that affects movement) to the dining room in her wheelchair without the use of foot pedals. The resident was unable to keep her feet up while in her wheelchair without the assistance of her foot pedals which allowed her foot to drop, causing her shoe to fall off and her shoe to become stuck underneath the wheel of the wheelchair. This caused the wheelchair to stop abruptly and the resident to fall forward out of the wheelchair and hit her head on the floor. The resident sustained a large gash above her left eye and was transferred to the hospital for treatment. She received 11 stitches, and a hospital CT (computed tomography) scan revealed the resident had also suffered a small subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it) due to the fall. The resident was admitted to the hospital for further evaluation and treatment and was discharged back to the facility on 7/26/24 once the hematoma had resolved. This was for 1 of 3 residents reviewed for the prevention of accidents (Resident #1).
Findings Included:
Resident #1 was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, muscle weakness, and history of falling.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and had been assessed as being dependent on staff for all activities of daily living, was a two-person assist for transfers, and required a wheelchair for mobility.
Review of nursing progress note dated 7/21/24 read in part: Resident #1 was sent to the emergency department (ED) by emergency medical services (EMS) via stretcher. Nursing assistant (NA) #1 on hall was pushing resident in wheelchair down the hall towards the dining room for dinner. Nurse #1 was sitting at nurse's station charting when the incident occurred. NA #1 stated Resident #1 shoe came off and she did not see it and went over the shoe with the wheelchair and the resident fell face forward on the floor. Laceration above left eye observed. Compression dressing to area, EMS called, and vital signs (VS) taken. Staff remained with Resident #1 while awaiting EMS. Resident #1's daughter was notified of the incident and stated, she was going to meet her mother at the hospital. The NP was notified of the incident as well as the unit manager (UM) and Director of Nursing (DON).
A telephone interview was conducted with Nursing Assistant (NA) #1 on 8/14/24 at 2:47 PM revealed she was familiar with Resident #1. She stated she had been working on the evening of 7/21/24 and was assigned to Resident #1. She revealed prior to her transporting Resident #1 to the dining room, she and another staff person had assisted Resident #1 from her bed to her wheelchair and did not apply her foot pedals. NA #1 stated when she returned to transport Resident #1 to the dining room, she had forgotten about the foot pedals and as they were moving, she realized she did not have her foot pedals on and asked Resident #1 to hold her feet up. She revealed while transporting Resident #1 down the hall towards the dining room, her foot dropped, and her shoe fell off and became stuck underneath the wheel. She stated she was not aware Resident #1's foot had dropped or her shoe had fallen off and was stuck under the wheel until her wheelchair stopped abruptly, and Resident #1 fell forward from the wheelchair onto the floor. NA #1 revealed she stayed with Resident #1 and hollered for help from Nurse #1 who had been sitting at the nurse desk. She stated Nurse #1 assessed Resident #1, called 911, and applied a compress to a laceration above her left eye until the EMS came and then they took over treatment and transferred Resident #1 to the hospital. She revealed while Resident #1 was at the hospital she received stitches for the laceration above her left eye and a CT scan showed she had suffered a hematoma from the fall, so she was admitted for further treatment. NA #1 stated the Administrator and DON came to the facility that evening and she informed them of what happened, and they educated her on wheelchair and fall safety to include the use of foot pedals and the following day she reenacted for the DON how the fall occurred and continued to receive education and was also observed transferring residents, transporting residents, and making sure all residents had their correct adaptive equipment in place. She also stated that nursing staff had a list of all residents who require any type of adaptive equipment to include foot pedals and when they should be applied. She revealed she had seen Resident #1 being transported without her foot pedals before and was able to hold her feet up and she just didn't think about applying her foot pedals prior to transporting her.
An interview was conducted with Nurse #1 on 8/14/24 at 2:07 PM revealed she was familiar with Resident #1. She stated she had been working on the evening of Resident #1's fall and was sitting at the nurse desk charting when she heard NA #1 down the hall asking for help. She stated when she started down the hall towards the dining room, she observed NA #1 with Resident #1 who was lying in the floor in front of her wheelchair, her shoe was off, and she was bleeding from a laceration over her left eye. She revealed she assessed Resident #1 who was alert and conscious with no complaints of pain and visible signs of injury other than the laceration above the left eye. Nurse #1 stated 911 was called and she applied a compress to Resident #1's laceration above her eye and then once EMS arrived, they took over care and transported Resident #1 to the hospital where she was admitted for treatment of the eye laceration and a hematoma. She revealed she spoke with NA #1 about what happened, NA #1 had stated she was transporting Resident #1 in her wheelchair to the dining room when she dropped her foot, and her shoe fell off. She stated when Resident #1's shoe fell off it became stuck underneath the wheel causing the wheelchair to stop abruptly and Resident #1 to fall forward out of the wheelchair and into the floor. Nurse #1 revealed when NA #1 was asked about Resident #1's foot pedals not being applied to her wheelchair, NA #1 stated she had seen Resident #1 being transported without her foot pedals before and she would hold her feet up, so it just slipped her mind, and she didn't think about applying them prior to transporting her. She stated immediately following Resident #1's fall, she notified the Administrator and DON who came to the facility that evening and began investigating the incident and all nursing staff were educated on wheelchair and fall safety, all resident adaptive equipment and they received an updated list of all residents with required adaptive equipment which included foot pedals, and this list would be updated anytime there was a change with the equipment, new order was added, or a new admission.
Review of hospital Discharge summary dated [DATE] read in part: admitted on [DATE], resident of local skilled nursing facility for the last 5 years, non-ambulatory, was being taken to the dining room via wheelchair and apparently fell from the wheelchair when her shoe came off. She sustained a significant left supraorbital ridge facial laceration (deep cut above left eye socket), contusion to her face and brought to the ED where she was found to have a small left frontal subarachnoid hemorrhage. Neurosurgery was consulted by telemedicine and recommend a follow-up CT scan in 6 hours which was stable. Resident #1 was admitted to the hospital. Resident #1 had advanced Parkinsonism with dysphagia. Resident #1 was discharged back to the skilled nursing facility in stable and improved condition. She is high risk for readmission given disease process. Resident #1 is an extremely high fall risk given her disease process and would always recommend one-to-one supervision with transfers and toileting. Sutures were placed 7/21/24 for left laceration, will need removal in 7-10 days from placement.
Review of nursing progress noted dated 7/26/24 read in part: Resident #1 returned to facility via EMS via stretcher after being sent to ED on 7/21/24 for fall resulting in head injury. Resident #1 had laceration with sutures intact to left eyebrow and a scab to the left knee that was also intact. Small bruises in various stages to her upper extremities were healing. The principal problem and reason for admission to the hospital on 7/21/24 was a subarachnoid hemorrhage following injury which after monitoring at hospital and multiple CT scans had resolved. Resident #1 does have history of advanced Parkinson's disease and upon returning to the facility was at baseline for orientation. Resident #1 will continue to be monitored and antibiotic ointment to be applied to residents sutured laceration above left eyebrow, sutures to be removed in about 3-7 days (sutures placed on 7/21/24). Resident #1 was resting in bed with no complaint of pain or discomfort at this time.
Observation on 8/14/24 at 12:15 PM revealed Resident #1 inside of her room, sitting in her wheelchair waiting to be assisted to the dining room for her lunch meal. Resident #1 was also observed with her foot pedals and kickboard in place. Observations also revealed no issues with Resident #1 being transported to the dining room and assisted with her lunch meal by the Assistant Director of Nursing (ADON).
An interview was conducted with the ADON on 8/14/24 at 1:02 PM revealed she was familiar with Resident #1. She stated she was not working on the evening Resident #1 fell from her wheelchair but was notified of the fall the following morning by the DON. She revealed she was informed Resident #1 was being transported in her wheelchair to the dining room for supper and did not have her foot pedals on her wheelchair which caused her foot to drop, her shoe to come off becoming stuck under the wheel, and the wheelchair stopped abruptly causing Resident #1 to fall into the floor. The ADON stated she was informed that Resident #1 did sustain a laceration above her left eye and was sent out immediately to the hospital for treatment and hospital CT scan showed she had suffered a hematoma which cleared prior to her return. She revealed part of her responsibilities as the ADON was to provide training on resident safety while providing care to all nursing staff and newly hired staff, but that specific wheelchair safety and training was provided by therapy. She stated therapy would also be responsible for making sure an order was in place for residents with required equipment including foot pedals. The ADON revealed since Resident #1's fall, all staff had been educated on the importance of wheelchair and fall safety, also resident checklists for all adaptive equipment including foot pedals were updated to include how and when those should be applied. These checklists were provided to all staff and placed at the nurse station and the list would be updated with any changes, new orders, new admissions, and staff would be notified of the changes.
An interview was conducted with the Director of Therapy on 8/14/24 at 3:08 PM revealed she was familiar with Resident #1 and had previously provided her with therapy services. She stated prior to Resident #1 fall she had not been required, ordered, or care planned to have her foot pedals always applied to her wheelchair. She revealed due to Resident #1 advanced Parkinson's disease she would have good days and bad days and depending on the day would determine her capability of being able to hold her feet up while being transported for short period of time. The Director of Therapy stated the following day after the fall, therapy assessed all wheelchair residents for foot pedal use, updated the resident adaptive equipment list to include application of foot pedals, provided copies of list to all nursing staff, and assisted with educating staff on wheelchair and fall safety and foot pedal applications. She revealed she also assisted the MDS nurses with updating each wheelchair resident's care plans to address how and when foot pedals should be applied.
An interview was conducted with the Administrator and Director of Nursing on 8/14/24 at 3:31 PM revealed they were familiar with Resident #1. The Administrator stated on the evening of 7/21/24, she and the DON were notified by Nurse #1 about Resident #1's fall, the laceration to her left eye, and being sent out to the hospital for treatment. She revealed she and the DON went to the facility and began their investigation of the incident. The Administrator stated she and the DON received statements from Nurse #1 and NA #1 about the fall and were informed NA #1 was transporting Resident #1 in her wheelchair to the dining room when her foot dropped, her shoe fell off becoming stuck under the wheel, and the wheelchair stopped abruptly causing Resident #1 to fall into the floor. She revealed they were also informed NA #1 had not applied Resident #1's foot pedals to her wheelchair which allowed her foot to drop causing her to fall. The DON stated she began education on wheelchair, fall, and transfer safety with NA #1 that evening and the following day completed a reenactment of the incident and continued education with all staff. She revealed all wheelchair residents were assessed for foot pedals and the resident master adaptive equipment list was updated to include foot pedals and copies of list were made available to all staff and at each nursing station. The DON stated the resident list would be updated by therapy with any changes in equipment, new orders received, or with new admissions and MDS nurses would update resident care plans to reflect these changes. She revealed the facility began audits of wheelchair residents requiring foot pedals being applied to wheelchair 3x's week
A telephone interview was conducted with the Nurse Practitioner (NP) on 8/14/24 at 4:29 PM revealed she was familiar with Resident #1. She stated she was notified of Resident #1's fall and continued her treatment for the laceration above her left eye upon her return to the facility. She revealed prior to Resident #1 fall she had never written an order and was not aware of an order from therapy of Resident #1 being required to have her foot pedals applied while being transported in her wheelchair and on occasion had seen Resident #1 able to hold her feet up while being transported in the facility. She stated Resident #1 does suffer from advanced Parkinson's disease and it appeared the disease was progressing, and she would not be able to continue to follow commands as well or hold her feet up for a long period of time. The NP stated after Resident #1 fall, all staff, herself included, had been educated on wheelchair and fall safety, applications of foot pedals and adaptive equipment for residents and when and how those should be applied, and an updated list of all residents and their required adaptive equipment to include foot pedals was provided and a copy was placed at each nurse station. She revealed if a resident has a change with their equipment, new order, or a new admission then she or therapy would let the DON and the MDS nurses know so they could update the list and the resident care plan.
The facility provided the following Corrective Action Plan with a compliance date of 7/24/24:
The facility identified concern with providing supervision to prevent accidents for residents.
Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices.
On 7/21/2024 Resident #1 was assessed by Nurse #1 and made comfortable on the floor because moving her could have caused more damage until her neck and spine were stabilized.
On 7/21/2024 first aid was provided for the laceration to her forehead and pressure was held to stop the bleeding by the Nurse #1.
On 7/21/2024 new orders were received to be sent to the Emergency Department for evaluation and treatment.
On 7/21/2024 Emergency Medical Services were called by nurses.
On 7/21/2024 Responsible Party was made aware of the fall and resident being transported to the Emergency Department.
On 7/21/2024, the Director of Nursing provided 1:1 education to the Certified Nursing Assistant #1 who was transporting the resident in wheelchair regarding the need for foot pedals during transport for any resident who is unable to hold their feet up when in w/c and that feet should be placed on pedals during transport.
On 7/22/2024 the Director of Nursing provided the Certified Nursing Assistant #1 who was transporting Resident #1 in the wheelchair without foot pedals, training on resident handling and proper body mechanics as well as the lift program skills check off.
On 7/22/2024 Certified Nursing Assistant #1 who was transporting Resident #1 in the wheelchair without foot pedals, demonstrated how the incident occurred with the Director of Nursing and Unit Manager.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice
The Director of Nursing and Director of Rehabilitation audited all residents and identified those residents that were unable to propel self or hold their feet up during transport in wheelchairs and if they did not have pedals, they were provided for safety. This audit was completed on 7/22/2024.
On 7/22/2024 the Director of Nursing placed a list of residents who required foot pedals for transport in a wheelchair at each nurse's station.
On 7/22/2024 the Director of Nursing or Designee updated the Master Device list for each resident who required foot pedals for transport in wheelchair. The master device list is a running list with each resident name and room number and their required adaptive equipment.
On 7/22/2024 the Director of Nursing or Designee updated the care plans and resident profile for each resident identified to be at risk to include requiring foot pedals for transport in wheelchair.
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur
On 7/22/2024 the Director of Nursing or Designee educated all staff on when residents are unable to hold their feet up during transport in w/c and required foot pedals prior to transporting in wheelchair and a list of residents requiring foot pedals for transport in wheelchair is provided at each nurse's station. The care plan and resident profile were updated for those residents who require foot pedals for transport in wheelchair. This education was completed on 7/22/2024. Those staff who were not working were educated via phone, during this education staff were asked questions and feedback to obtain understanding of education and were included during observation audits at the facility. This education will be provided to new employees during orientation.
The Director of Nursing or Designee had all Licensed Nurses and Certified Nursing Assistant complete a safety and accident prevention quiz. These quizzes were completed by 7/23/204.
The Director of Nursing or Director of Rehabilitation will evaluate newly admitted residents, provide foot pedals if indicated, and notify MDS nurse who will update residents care plans, profile and the master device list and the nursing station list to reflect need of foot pedals during transport in wheelchair. The MDS nurse will also inform management of any updates to resident care plans regarding adaptive equipment and provide them and therapy with an updated master device list.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained
The Administrator and DON discussed on 7/21/24 and determined to have ADHOC QAPI on 7/22/24. ADHOC QAPI was held on 7/22/2024 with the Interdisciplinary team to discuss the incident with Resident #1 and educate the team on the interventions that were put into place to prevent further incidents. The Interdisciplinary Team discussed the incident and will monitor weekly for 8 weeks and take it to QAPI for the next 3 months for review and recommendations.
The Director of Nursing or Designee will complete an observation audit 3 times per week for 8 weeks then monthly x 1 to ensure that residents that unable to hold their feet up during transport in wheelchair have foot pedals on while being transported in a wheelchair.
Date of Compliance: July 24, 2024
On 8/14/24, the facility's corrective action plan effective 7/24/24 was validated by the following: Observations of residents in wheelchairs with foot pedals applied being transported in the facility with no issues or concerns noted. Nursing staff interviews revealed they had received education on fall safety, wheelchair safety when transporting resident, foot pedals and all adaptive equipment requirements and how and when to use them, accident prevention, notifying therapy or administration if foot pedals are needed, and reviewing the master resident adaptive equipment list to see what equipment each resident should have and how and when it should be applied. The updated master resident adaptive equipment list to include foot pedals was placed at each nurse station as a reminder. Therapy staff interviews revealed they would continue to assess residents for any wheelchair needs to include foot pedals and assist MDS nurses with updating the master resident adaptive equipment list and notifying nursing staff of the changes. MDS nurses received education on updating wheelchair resident care plans to include foot pedals, updating master resident adaptive equipment list anytime there was a change, new order, or new admission, and notifying therapy and administration of the change. Administrative staff interviews revealed they provided staff education and were completing weekly audits of wheelchair residents to assure foot pedals have been applied while being transported in their wheelchairs and also reviewing the master resident adaptive equipment list to assure it was reflecting the status of each resident and being updated when any changes, new orders, or new admission had occurred. Auditing tools were reviewed. Documents were reviewed from the facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. Review of Resident #1's revised care plan dated 7/22/24 revealed her risk for falls characterized by multiple risk factors related to her history of falls and Parkinson's disease. She had a goal to minimize risks for falls and injuries related to falls through the next review. Interventions for Resident #1 included staff education related to wheelchair pedals and transporting residents, 20 inch reclining high back wheelchair with 2-inch pressure relieving cushion, bilateral standard footrests, kick plate and rear anti-tippers, evaluate needs for adaptive equipment, educate/direct the use of assistive devices, and transfers with 2-person assist.
The facility's compliance date of 7/24/24 was validated.

Based on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and failed to remove expired food items in 1of 1 walk-in cooler and 1 of 2 nourishment rooms (First Floor). These practices had the potential to affect food served to residents.
Findings included:
a. An observation and interview were conducted on 2/11/23 at 9:15 AM with Dietary [NAME] #1 in the walk-in cooler revealed eleven sandwiches, six grilled cheese sandwiches, tomato soup in a container with saran wrap on top, and four cups of lima beans which were unlabeled and not dated. The Dietary [NAME] believed the sandwiches and grilled cheese sandwiches were made the day prior but was unsure when they had been prepared and needed to be discarded. The Dietary [NAME] was unable to determine when the other items had been prepared. Observations further revealed leftover roasted potatoes with the expiration/discard date of 02/09/23. Dietary [NAME] #1 stated the dietary staff member that puts the food item in the walk in the cooler was responsible for labeling and dating the container and the roasted potatoes should have been discarded.
b. An observation and interview with Nurse Aide (NA) #1 were conducted on the first floor in the nourishment room on 02/11/24 at 10:00 AM revealed a carton with 18 eggs with no resident ' s name or date, two opened 8-ounce cartons of milk with no resident ' s name or dated opened, an opened 8 ounce bottle of nutritional drink which was not labeled with a resident ' s name or dated, and two wrapped sandwiches that were not labeled or dated. Nurse Aide #1 stated dietary staff checked nourishment rooms daily, but nursing staff had been educated to label items in the refrigerator with resident names and dates. NA #1 indicated these food items should not be in the refrigerator and she discarded them.
An interview conducted with Dietary Aide #2 on 02/13/24 at 9:45 AM revealed Dietary Cooks were responsible for checking items in the kitchen and Dietary Aides were responsible to check nourishment rooms daily. Dietary Aide #2 further revealed she did not know why items in the nourishment room were not labeled. The interview further revealed dietary staff checked the nourishment rooms twice a day and discarded expired and unlabeled items but had not checked the nourishments rooms that morning.
An interview conducted with Dietary Manager (DM) on 02/13/24 at 9:50 AM revealed dietary staff checked the nourishment rooms twice a day and were educated to discard any food items that were not labeled or dated. The DM indicated all food items in the walk-in cooler should have been labeled and discarded appropriately.
An interview conducted with the Administrator on 02/14/24 at 2:40 PM revealed she expected dietary staff to label all dietary items and discard any expired food items as well.

Based on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 07/07/22 and follow-up and complaint investigation survey that occurred on 09/21/22. This was for one deficiency cited in July 2022 in the area of infection control and one deficiency cited in September 2022 in the area of maintain a medication error rate of 5% or less and both were subsequently cited on the current recertification and complaint investigation survey of 02/14/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.
The findings included:
This tag is cross referred to:
F880: Based on record review, observations, resident, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure and did not doff her gloves, sanitize her hands, and don clean gloves after cleansing the hip wound and before applying the treatment to the wound for a resident (Resident #55).
During the recertification and complaint investigation survey conducted on 07/07/22, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy during wound care treatment for 1 of 3 sampled residents reviewed.
F 759: Based on observations, record reviews and staff interviews, the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 32 opportunities resulting in a medication error rate of 6.25% for 2 of 4 residents (Resident #26 and Resident #76) observed during medication administration observation.
During the follow-up and complaint investigation survey conducted on 09/21/22, the facility failed to administer the correct dosage for 3 medications and omission of 2 medications. These errors constituted 5 out of 28 opportunities, resulting in a medication error rate of 17.86% for 2 of 5 residents observed during medication administration.
During an interview on 02/14/24 at 2:38 PM with the Administrator, she reported her quality assurance team met monthly and included the Medical Director, pharmacist, registered dietician, and all the department heads who attend monthly. She reported they currently had Process Improvement Plans (PIPs) addressing abuse and said they would be adding PIPs for infection control and medication compliance. The Administrator stated she felt like repeat tags were due to oversight and human error.

Based on resident interviews and staff interviews the facility failed to have systems in place for providing evening snacks to residents for 5 of 5 halls. The deficient practice had the potential to affect all residents requesting an evening snack.
The findings included:
An interview conducted on 02/13/24 at 6:30 AM with Nurse Aide (NA) #2 revealed she worked second shift and residents during second shift (3:00 PM to 11:00 PM) had not received a bedtime snack on multiple days because staff were unable to get into the nourishment room on either floor. NA #2 further revealed the nourishment rooms had a code that was not provided to them, and the kitchen was locked. The NA indicated she had reported this to a Nurse on duty over the past few months but could not recall which Nurse.
An interview conducted with Nurse #1 on 02/13/24 at 7:20 AM revealed nursing staff were often unable to access the kitchen and nourishment rooms at night to retrieve snacks because the doors had a code that had not been provided to her. The Nurse further revealed she had reported these concerns and was told the code would be written at the nurses ' desk but had not occurred.
An interview conducted during a Resident Council Meeting on 02/13/24 at 1:50 PM revealed residents had not received or been offered snacks in the evenings by nursing staff. The Resident Council President (Resident #58) and Resident #1 both stated nursing staff did not offer evening snacks frequently and when residents asked nursing staff for snacks, they were told nursing staff were unable to get in the nourishment room or there were no snacks available.
An interview conducted with the Dietary Manager (DM) on 02/13/24 at 9:50 AM revealed four weeks ago she was made aware by residents that there were several nights residents had not received a bedtime snack. The DM further revealed dietary staff checked and stocked the nourishment rooms daily and felt that nursing were not offering bedtime snacks as needed for the residents. The DM indicated she had tried to educate staff on providing bedtime snacks to all residents. The DM indicated she was not sure how staff were educated on the codes for the doors on the nourishment rooms.
An interview conducted with the Administrator on 02/14/24 at 2:40 PM revealed she expected there to always be snacks available for residents. The Administrator further revealed nursing staff should know the codes for the nourishment rooms and dietary should be stocking enough for residents as well. The Administrator indicated nursing staff could have asked the Director of Nursing or Unit Managers for the codes to the nourishment rooms.

Based on record review, observations, resident, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure and did not doff her gloves, sanitize her hands, and don clean gloves after cleansing the hip wound and before applying the treatment to the wound for a resident (Resident #55). The Treatment Nurse only doffed her right glove, sanitized her right hand, and donned a clean glove on her right hand after removing the soiled dressing from the resident's hip wound, did not doff her gloves after cleansing the wound, did not sanitize her hands, and did not don clean gloves before proceeding to apply the treatment to the hip wound and covering the wound with a clean border gauze dressing. This occurred for 1 of 3 residents reviewed for wound care.
The findings included:
The facility's policy entitled Hand Hygiene/Handwashing Policy which is part of their Infection Control Policies and Procedures last revised on 05/03/23 under Procedure read in part:
3. Perform hand hygiene:
a. Before and after having direct contact with residents.
b. After removing gloves.
d. After contact with body fluids or excretions, mucous membranes, non-intact skin and/or
wound dressings.
5. Hand Rub Method:
a. Apply a palm full of the product in a cupped hand, covering all surfaces.
b. Rub hands palm to palm.
c. Right palm over left dorsum with interlaced fingers and vice versa.
d. Palm to palm with fingers interlaced.
e. Backs of fingers to opposing palms with fingers interlocked.
f. Rotational rubbing of left thumb clasped in right palm and vice versa.
g. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm
and vice versa.
h. Once dry, your hands are clean.
A wound observation was made on 02/13/24 at 9:30 AM on Resident #55 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on a clean surface on the overbed table. The Treatment Nurse washed her hands with soap and water and donned a clean pair of gloves and proceeded to remove the resident's wound dressing and treatment with her right hand. She walked over to the sink and doffed her right-hand glove, sanitized her right hand, and placed a clean glove on the right hand, walked back over to the resident and cleansed her wound with wound cleanser-soaked gauze. The Treatment Nurse then without doffing her gloves, sanitizing her hands, or donning clean gloves, proceeded to trim and apply the treatment to the wound bed. After applying the treatment, the Treatment Nurse doffed her gloves, sanitized her hands, donned clean gloves, and applied the border gauze dressing to the left hip wound.
An interview on 02/14/24 at 12:21 PM with the Treatment Nurse revealed she did not realize she had not taken her gloves off and sanitized her hands and applied clean gloves after cleansing the wound. She stated she should have doffed her gloves, sanitized her hands, and donned clean gloves prior to applying the treatment to Resident #55's wound. The Treatment Nurse stated she didn't realize it was not appropriate to just cleanse one hand since she had not touched anything dirty with her left hand but said she had touched the resident's skin and should have sanitized both hands. She further stated she was nervous about being watched and just didn't think through the process.
An interview on 02/14/24 at 12:36 PM with the Director of Nursing (DON) revealed she expected the Treatment Nurse to follow the policy and procedure of Hand Hygiene/Handwashing at the facility. The DON stated it was best practice to remove both gloves and sanitize both hands and apply clean gloves to both hands and was not sure why she had not followed that procedure during wound care for Resident #55.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 32 opportunities resulting in a medication error rate of 6.25% for 2 of 4 residents (Resident #26 and Resident #76) observed during medication administration observation.
The findings included:
1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN).
A Physician order dated 05/13/12 revealed Resident #26 was to receive Metoprolol Tartrate 25 mg (milligrams) one tablet by mouth twice a day for hypertension. Instructions on the physician orders read to hold medication for systolic pressure less than 100 or a heart rate less than 60.
During medication pass observation 02/14/24 at 8:15 AM Nurse #2 prepared medications for Resident #26. Nurse #2 was observed taking a Metoprolol Tartrate 25mg tablet out of a blister package and placing it in a medicine cup. The label on the blister package included instructions to hold medication for systolic pressure less than 100 or a heart rate less than 60. Nurse #2 was asked if she had a current set of vitals on the resident and she stated no she did not. Nurse #2 proceeded to Resident #26 room at 8:35 AM and administered the Metoprolol Tartrate 25mg tablet to the resident.
An interview with Nurse #2 on 02/14/24 at 10:12 AM revealed Resident #26 was no longer on daily vitals, so they no longer checked Resident #26 vitals before giving the metoprolol. Nurse #2 revealed she did not notice the instructions on top of the blister package or on the medication administration record.
2. Resident #76 was admitted to the facility on [DATE] with a diagnosis that includes coronary artery disease, and heart failure.
A Physician order dated 12/08/23 revealed Resident #76 was to receive Aspirin (ASA) 81 mg (milligrams) one tablet by mouth once a day for coronary artery disease.
During medication pass observation 02/13/24 at 8:35 AM Medication Aid (MA) # 3 prepared medications for Resident #76. MA #3 was observed taking an ASA 325mg tablet out of an opened stock medication bottle and placing it in a medicine cup. MA #3 proceeded to Resident #76's room at 8:45 AM and administered the ASA 325 mg tablet to the resident.
On 02/13/24 at 9:30 AM an interview and observation were conducted with Medication Aid (MA) #3. MA #3 returned the medication cart and reviewed Resident #76's ASA order and she confirmed the resident had a physician order for ASA 81 mg. She stated that the two bottles of ASA were next to each other in the medication cart, and she just grabbed the wrong bottle. MA # 3 explained she had separated the two bottles of ASA so that this mistake did not happen again.
On 02/14/24 at 12:35 PM an interview was conducted with the Director of Nursing (DON). During the interview, DON was notified of the medication error rate of 6.25%. The DON stated she expected nurses and med aids to check the five rights before medications were given and to check vital signs as ordered when administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, and Hospice Nurse Aide interviews, the facility failed to provide incontinence care to prevent a resident (Resident #45) from having urinary incontinence through her brief, pants, lift pad and onto her wheelchair pad for 1 of 3 residents reviewed for activities of daily living for dependent residents.
The findings included:
Resident #45 was admitted to the facility on [DATE] with diagnoses which included hemiplegia following a stroke, dysphagia, muscle weakness and dementia.
Review of Resident #45's care plan dated 12/07/23 revealed a focus area for the resident having an activities of daily living (ADL) self-care deficit due to stroke with left hemiparesis and resident required extensive to total assistance with ADL. Resident #45 was also at risk for further unavoidable declines related to diagnosis of dementia. The interventions included assist with activities of daily living (ADL), dressing, grooming, toileting, promote independence and dignity, and provide positive reinforcement for all activities, transfers with assist of mechanical lift, and refer to therapy as needed.
Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and dependent on 1-2 staff members for all activities of daily living except eating. The assessment also revealed Resident #45 had less than 6 months life expectancy and was followed by hospice.
An observation on 02/13/24 at 10:17 AM of Resident #45 receiving incontinence care from the Hospice NA revealed when Resident #45 was lifted via mechanical lift from her wheelchair to her bed the wheelchair cushion had a spot that was wet and the Hospice NA wiped it with a paper towel and it was wet with yellow colored liquid. The Hospice NA wiped the liquid from the cushion and cleaned the cushion. As the resident was being lifted from the chair to the bed by the Hospice Nurse Aide (NA) and NA #4, her lift pad was noted to be wet in the area she was sitting on it and her pants were wet in the crotch area from front to back. When the Hospice NA removed Resident #45's brief, it was observed to be saturated from front to back with urine and the brief filling had started to bunch up in areas. The Hospice NA proceeded to clean the resident and applied a clean brief.
Interview on 02/13/24 at 10:47 AM with the Hospice NA revealed she came to see Resident #45 on Monday, Tuesday, and Friday and on Monday provided Resident #45 with a shower and on Tuesday and Friday provided her with a bed bath. The Hospice NA stated she used to come around 1:00 PM and Resident #45 would have been up since early morning and would be wet. She further stated she had found the resident wet before through her clothing but couldn't recall when the last time she found the resident that way.
Interview on 02/13/24 at 1:58 PM with NA #4 and NA #5 who were assigned to the 500 hall residents on 1st shift on 02/13/24 revealed they had changed Resident #45 and gotten her dressed around 7:30 AM before they had gotten her up in the wheelchair. NA #5 stated they had put her back to bed around 9:30 and changed her again but later in the conversation realized it was not Resident #45 they had changed at 9:30 AM but was another resident. NA #4 and NA #5 could not remember getting her back to bed or changing her after 7:30 AM and before she had been changed at 10:17 AM. NA #4 and NA #5 stated they usually did rounds at 7:00 AM, 9:00 AM, 11:30 AM and 1:30 PM for their shift. NA #4 and NA #5 stated she usually drank a lot of fluids during her meals but could not recall having found her wet through her clothing before today. NA #4 stated she heard the Hospice NA say the resident was wet through her clothing but said she didn't see the wetness because she was operating the lift to get the resident back to bed.
Interview on 02/14/24 with Nurse #3 revealed she had been assigned to care for Resident #45 on 02/13/24 and 02/14/24. She stated the staff usually got Resident #45 up around 7:30 so she was up for breakfast and said sometimes 3rd shift got her up if she wanted to get up after they got her dressed. Nurse #3 further stated she was not aware Resident #45 had wet through her clothing on 02/13/24 and said she typically did not find her that way. Nurse #3 stated maintenance and housekeeping had washed the wheelchairs the night before but said she didn't think the NAs would have put her in a wet wheelchair. Nurse #3 said she was not sure why Resident #45 had wet through her clothing because she was not on a diuretic and wasn't sure what or how many fluids, she had to drink at breakfast that morning.
Interview on 02/14/24 at 12:38 PM with the Director of Nursing (DON) revealed she would not expect a resident to go without incontinence care until they were wet through their clothing and was not sure if that had happened with Resident #45 before or not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident with mental health diagnoses upon admission for 1 of 3 residents reviewed for PASRR (Resident #47).
The findings include:
Review of Resident #47's medical record revealed a PASRR level I screening had been completed on 08/08/2018. No further PASRR documentation was discovered in Resident #47's medical record.
Resident #47 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, and dementia with mood disorder.
During an interview on 02/14/24 at 1:20 PM with the Social Worker (SW), she revealed she had been employed as the facility SW for the past 36 years and was responsible for completing PASRR referrals upon resident admission. She revealed she would review a resident's diagnoses once they were admitted to see if they would require a level II PASRR referral to be completed. The SW stated Resident #47 had been admitted from the hospital and she believed she had simply overlooked the date of the previous PASRR determination and the admission diagnoses. She explained that based on Resident #47's admission diagnoses of bipolar disorder and dementia with mood disorder, and the date of the preadmission PASRR level I, she should have completed the paperwork for a PASRR level II referral.
During an interview on 02/14/24 at 2:38 PM with the Administrator she revealed a PASRR level II referral should be completed in a timely manner upon admission for a resident with a mental health diagnosis. She stated based on Resident #47's admission diagnoses of bipolar disorder and dementia with mood disorder, a PASRR level II referral should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with residents, staff and the Nurse Practitioner, the facility failed to assess the ability of a resident to self-administer for 1 of 4 residents observed (Resident#88).
The findings included:
Resident #88 was admitted to the facility on [DATE] with diagnoses of allergies.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 was cognitively intact and needed supervision with most activities of daily living.
A review of Resident #88's medical record indicated no documentation that Resident #88 was assessed for self-administration of medications. Resident #88 did not have a physician's order for self-administration of medications.
A review of Resident #88's order summary for February 2024 indicated an active physician's order for Fluticasone Propionate Nasal Suspension 50 micrograms - two sprays both nostrils in morning for allergies and instructions to shake well.
During an initial observation of a medication pass for Resident #88 on 02/13/24 at 08:00 AM with Medication Aid (MA) #3 for administration of nasal spray to the resident. The MA #3 sat the nasal spray in front of the resident without shaking the vial. The resident administered the nasal spray of two sprays in each nostril independently without shaking the bottle.
An interview with Resident #88 on 02/13/24 at 08:00 AM revealed that he had some confusion about the nasal spray and how many sprays he should use per nostril. Resident #88 stated he was not aware that the nasal spray needed to be shaken before use.
An interview with MA #3 on 02/13/24 at 8:45 AM revealed she always allowed resident #88 to administer his own nasal spray. MA #3 stated she was aware that residents needed to have a physician order and a self-administration assessment before they could be allowed to administer their medications. MA #3 stated she was not aware that Resident #88 did not have a evaluation for self-medication of the medication, and stated she should have checked before the resident was allowed to self- administer any medication.
An interview with the Director of Nursing (DON) on 02/14/24 at 12:35 PM revealed she was not aware that Resident #88 had been self-administrating his nasal spray. The DON stated that before self-administration could occur residents had to be assessed for safety reasons and the doctor had to give a order for self-administration. Her expectation was that staff be aware if a resident could self-administer before they allowed the resident to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from [DATE] to [DATE]). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for osteomyelitis. In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. These failures were for 2 of 3 residents reviewed for pressure ulcers (Resident #36 and Resident #11).
Immediate Jeopardy began on [DATE] when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity level of D.
The findings included:
1. Resident #36 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness, spinal stenosis, atherosclerotic heart disease, hypertension and history of transient ischemic attack and cerebral infarction. She was recently re-admitted on [DATE] from the hospital due to acute encephalopathy and advanced Parkinson's disease.
An admission Skin Evaluation completed by Nurse #1 on [DATE] indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place.
A Weekly Skin Evaluation completed by Nurse #2 on [DATE] indicated Resident #36 had a wound to sacrum and left lower buttock with treatment in place.
The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact, had no rejection of care behaviors and required extensive physical assistance with bed mobility, locomotion, and toilet use. Resident #36 had impairment on one side of her upper extremities and used a wheelchair. The MDS further indicated Resident #36 was frequently incontinent of urine, but she was always continent of bowel. Resident #36 was at risk of developing pressure ulcers/injuries, had moisture-associated skin damage but no pressure ulcers.
An interview with Resident #36 on [DATE] at 10:04 AM revealed when staff came to change her and got her up out of bed this morning, she was wet and had to be changed. Resident #36 stated staff did check in on her during the night to see if she was wet, but she did not recall the name of the nurse aide or the time they came in. She stated she looked up at the clock on the wall and said she had waited for about 30 minutes this morning for them to come change her. Resident #36 stated she typically went to the bathroom before going to bed in the evening which could be anywhere from 6:30 PM to 9:00 PM depending on how long staff took to help her in bed. She was assisted with incontinence care and to bed around 7:30 PM the night before. Resident #36 further stated staff would get her up in the morning before breakfast, she would stay up through lunch, staff would lie her down after lunch, get her up about 30 minutes before supper, and then put her to bed between 6:30 PM to 9:00 PM. Resident #36 stated she never refused to lie down in bed and stated it felt good to get off her bottom for a while. She also did not refuse assistance with positioning on her side in bed and stated staff did come in and offer to turn her. Resident #36 stated she has had a pressure ulcer to her sacrum for a long time and it hurt. She said it felt like something was sticking her all the time.
An interview with Nurse #1 on [DATE] at 3:10 PM revealed she observed an open area on Resident #36's sacrum on [DATE] which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment, so she applied zinc oxide and covered it with a foam dressing to both sacrum and left lower buttock. Nurse #1 stated she thought the pressure ulcer required a different treatment, but she could not remember if she had notified the physician or the Nurse Practitioner about the pressure ulcer and she didn't get an order. Nurse #1 also stated she didn't think she had to complete a wound assessment because wound assessments were usually completed by the Unit Managers whenever they rounded with the Wound Physician Assistant. Nurse #1 further stated Resident #36 always had an issue with her sacral area and they had struggled to keep it intact because Resident #36 liked to sit up in her wheelchair during the day, but she was adamant about having her naps and usually lied down in bed after lunch. Resident #36 also had sensitive skin. Prior to her hospitalization, Resident #36 often rang her call light, was continent of both urine and bowel and walked to the bathroom with staff assistance. After coming back from the hospital on [DATE], Resident #36 got a little weaker, but she was still ambulatory. Nurse #1 also stated Resident #36 did not refuse to be turned to her side but often preferred to lie flat on her back.
An interview with Nurse #2 on [DATE] at 3:36 PM revealed she completed a skin check on Resident #36 on [DATE] and observed a foam dressing on her sacrum. Nurse #2 stated she knew Resident #36 had a pressure ulcer on her sacrum, but she did not remove the dressing to assess the wound underneath. Nurse #2 stated she did not have a reason as to why she did not complete a wound assessment on Resident #36's sacral pressure ulcer. Nurse #2 further stated back in February 2022 prior to Resident #36's hospitalization, staff used to roll Resident #36's wheelchair to the bathroom and assisted her to use the commode but when she came back from the hospital, Resident #36 had a decline and they often had to provide incontinence care to her, but she never refused to be turned on her side while in bed.
The Braden Scale Pressure Ulcer Risk assessment dated [DATE] for Resident #36 indicated she was at moderate risk for developing pressure ulcers due to slightly limited sensory perception, very moist skin, very limited mobility, chairfast, adequate nutrition and problem with friction and shear. Complete lifting without sliding against sheets was impossible.
Resident #36's Treatment Administration Record for [DATE] indicated no treatment orders for Resident #36's sacral pressure ulcer until [DATE] when Unit Manager #1 initiated the following treatment order: Cleanse area to coccyx with wound cleanser. Apply (brand name) occlusive dressing and cover with foam every 3 days.
An interview with Unit Manager (UM) #1 on [DATE] at 3:20 PM revealed she couldn't remember if she had been made aware of an open area on Resident #36's sacrum upon her re-admission to the facility on [DATE] and she was not sure if she had checked her re-admission orders. UM #1 stated all her treatment orders probably got discontinued because there were no orders from the hospital for any treatment to her sacral wound. UM #1 stated Nurse #1 should have initiated a treatment when she observed an open area to Resident #36's sacrum on [DATE] and she should have completed a wound assessment. UM #1 stated she remembered Resident #36's family member telling her to make sure they kept an eye on her sacrum because an area on her sacrum had opened when she came back from the hospital. UM #1 stated she didn't get around to assessing Resident #36's sacrum until [DATE] when Nurse Aide (NA) #1 reported to her that Nurse #3 had been asking her to apply a foam dressing to Resident #36's sacrum and buttocks without the nurse checking the area first. UM #1 stated she observed necrotic tissue covering the ulcer, but she couldn't tell how big it measured. The ulcer did have some drainage but did not have foul odor. UM #1 stated she thought the nurses could initiate wound care orders without consulting with the physician first and she decided on the occlusive dressing based on her previous experience with wound care. UM #1 further stated she did not notify the physician, the Nurse Practitioner, or the Wound Physician Assistant (PA) and just included Resident #36 in the list of residents to be seen by the Wound PA on his next visit at the facility. UM #1 stated she did not think about documenting an assessment or complete measurements of Resident #36's pressure ulcer on [DATE] because she was going to be seen by the Wound PA the next week.
An interview with Nurse #3 on [DATE] at 1:59 PM revealed she couldn't remember doing a skin evaluation on Resident #36, but she had seen her sacral wound progress from being a quarter-sized stage 1 pressure ulcer to being covered with a black necrotic tissue. Nurse #3 denied ever handing a foam dressing to the nurse aides and asking them to place it on Resident #36's sacrum. She recalled placing a dressing according to the treatment record whenever the nurse aides told her Resident #36's dressing was off. She also stated she didn't think she was the first nurse who had discovered the black necrotic tissue, so she didn't think about reporting this to anybody.
A phone interview with Nurse Aide (NA) #1 on [DATE] at 10:19 AM revealed she took care of Resident #36 on the day shift, but she always came in early to help the night shift aides get the residents up in the mornings. NA #1 stated there were multiple times when she would come in early that she would see Resident #36's call light on and her bed would be soaked from urine. At those times, Resident #36 was still continent of urine and whenever she asked Resident #36 if the staff had come to check on her, she told her that they came in and turned her light off, thinking that she was asleep and didn't come back. NA #1 stated there were multiple times when she would come in and observed Resident #36 without a dressing to her sacrum and her clothes would be soaked from drainage from her wound. Whenever she asked the night shift nurse aides, they couldn't tell her anything as to why Resident #36 did not have a dressing on to her sacrum. NA #1 stated Resident #36 always had a soft, boggy, purplish red spot on her sacrum that would close and re-open, but she had no clue as to how she got the hole on her sacrum which had a lot of drainage and smelled really bad. NA #1 reported there had been some nurses who had handed her a dressing to put on Resident #36's sacrum and she did it in order to help out, but she got written up for it when she reported this to UM #1. She also stated that Resident #36 never refused to lie down after lunch and never refused to be turned and repositioned in bed.
A phone interview with Nurse #4 on [DATE] at 7:44 PM revealed she worked with Resident #36 on the night shift, but she didn't remember having to replace her sacral pressure ulcer dressing. Nurse #4 stated she relied on the nurse aides to report to her if her dressing had come off whenever they did their incontinence rounds. Resident #36 usually got up after Nurse #4 had already left, and Resident #36 never refused to be turned and repositioned to her sides when in bed. Nurse #4 stated she had concerns about the nurses not completing skin assessments and wound assessments which were usually scheduled for the day and evening shifts. She stated she would often see alerts on the electronic medical record that they were past due and some of them would even be over 15 days late. Nurse #4 further stated she reported this to UM #1 and the DON, but she wasn't sure if anything had been done about it.
The Wound Evaluation and Management Reports in Resident #36's medical record indicated she was seen by the Wound Physician Assistant (PA) on the following dates:
[DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm (centimeters) in length, 1.5 cm in width and 0.3 cm in depth. The pressure ulcer was covered with excessive necrotic tissue and had mild serous drainage. Will treat with sodium hypochlorite solution moistened gauze and foam daily. No signs of acute infection.
[DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm in length, 1.5 cm in width and 1.5 cm in depth. The pressure ulcer was covered with excessive yellowish necrotic tissue and had mild serous drainage. Wound had remained stable in diameter but increased in depth. No signs of acute infection. Wound was debrided with scalpel. Wound depth increased to 15 mm (millimeters). Will change treatment to collagenase, filling the narrow wound with the collagenase and covering with calcium alginate and foam daily.
[DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm in length, 1.5 cm in width and 1.8 cm in depth. The pressure ulcer was covered with excessive yellowish necrotic tissue. Wound had remained stable in size, but depth had increased due to debridement. Patient had moderate drainage, so a wound culture and sensitivity was taken. Awaiting results. Wound debrided with scalpel removing necrotic tissue. Will order a low air loss mattress and discuss with therapy to get her set up with a pressure relief cushion.
[DATE] - Unstageable pressure ulcer to the sacrum measured 3 cm in length, 1.5 cm in width and 2 cm in depth. Wound now had undermining of 20 mm at 12 o'clock position. Wound culture and sensitivity had an unknown issue last week, so it was redone this week. No exposed bone present at this time. Mild odor and mild drainage present, no erythema or pain. Wound debrided with scalpel. Less necrotic tissue present this week than before. Treated wound with sodium hypochlorite solution moistened gauze, lightly packed in the wound and foam daily.
A phone interview with the Wound Physician Assistant (PA) on [DATE] at 4:56 PM revealed he did not get consulted when an open area was first noted on Resident #36's sacrum on [DATE] nor when they started treatment on Resident #36's sacral pressure ulcer on [DATE] when it got worse. The Wound PA stated he would not have recommended to use the occlusive dressing that was started on [DATE] because he didn't typically use it on the sacrum, and it was not appropriate treatment for the unstageable ulcer that was present on [DATE]. He stated if the facility provided consistent treatment to Resident #36's pressure ulcer, it would have made a difference in preventing the pressure ulcer from worsening. The Wound PA stated Resident #36's pressure ulcer could have been avoided if the facility provided the appropriate treatment and took preventive measures such as offloading and regular skin checks. The Wound PA further stated he expected the nurses to perform skin checks by looking at all surfaces of the skin from head to toe and paying particular attention to skin folds and creases which were susceptible to fungal infections. The Wound PA also stated if a dressing was present, the nurses were supposed to remove the dressing so they could visualize and assess the wound underneath especially for residents who were not currently being treated by him. On [DATE], he noted an increase in drainage, so he did a wound culture and sensitivity after he debrided the wound. He was informed at the facility when he came back on [DATE] that the laboratory had discarded the swab from the week before because they used the wrong tube, so he obtained another one due to the wound's continued decline and it had started undermining. (Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge). When he came back on [DATE], he found out that Resident #36 had been to the Wound Center, so he discharged her from her care. He didn't hear back about the last wound culture and sensitivity done on [DATE] and assumed it was discarded again by the laboratory. He said if he obtained the result from the first wound culture sooner, it could have made a difference in treating Resident #36's pressure ulcer if the infection was superficial. But he couldn't say it would have made a difference if the infection had already reached the bone. And he didn't see any exposed bone after debridement, so he didn't think to do a bone biopsy. The Wound PA stated Resident #36's pressure ulcer was avoidable.
An interview with Unit Manager (UM) #1 on [DATE] at 3:20 PM revealed the first time the Wound PA obtained the wound culture; she was notified by the laboratory that they had to discard it because they couldn't run due to it being too dry. UM #1 did not notify the Wound PA until the next week when he came back and performed a second wound culture. UM #1 was again informed by the laboratory that they had to discard it because they used the wrong swab. UM #1 did not think to notify the Wound PA about the wound culture not being done a second time, but she called the laboratory twice to request for the appropriate culture swabs. No one from the laboratory sent any of the swabs that she had requested.
An interview with the Nurse Practitioner (NP) on [DATE] at 3:10 PM revealed she became aware of Resident #36's sacral pressure ulcer on [DATE] when her family member texted her and asked her if Resident #36 could be seen by the Wound Center. The NP checked the electronic results for the laboratory and found wound cultures on [DATE] and [DATE] that were originally ordered but had been marked out. The NP stated the facility had been having problems with laboratory tests getting missed and not getting followed through. The NP also stated she was aware that Resident #36's pressure ulcer progressed quickly but she was not aware that Resident #36 did not have a treatment order for the wound prior to the Wound PA seeing her. The NP stated the facility physician usually ordered a treatment for a newly identified wound until the resident was seen by the Wound PA, but she was not sure why she didn't get notified of Resident #36's pressure ulcer that was noted on [DATE]. The NP stated the nurses should have notified her on [DATE] when they noted a pressure ulcer on Resident #36's sacrum so a treatment could have been started while they were waiting for her to be seen by the Wound PA.
The Report of Consultation from the Wound Center dated [DATE] for Resident #36 indicated a stage 4 pressure ulcer to the sacrum which measured 2.2 cm in length, 2 cm in width and 2.1 cm in depth. Treatment was changed to skin prep to peri wound, antimicrobial gel wet to dry using 2 inch rolled gauze to pack wound, cover with 4x4 gauze, abdominal pad, and tape. Change daily and as needed for soiled or loose dressing. Referral to an Infectious Disease specialist. Bone culture and pathology done. Prescription for (brand name) antibiotics sent to the facility. Facility to order pressure relief cushion and specialty air mattress.
An Infectious Disease Visit Note dated [DATE] in Resident #36's medical record indicated Resident #36 was seen for sacral osteomyelitis. Bone biopsy was positive for Morganella. (Morganella is a species of gram-negative bacteria known to be a causative organism of opportunistic infections in wound infections.) Intravenous antibiotics were ordered. Resident #36 was currently using a wound vac (vacuum-assisted closure of a wound), had gotten an air mattress, and was waiting on a pressure relief cushion for her wheelchair.
An observation of wound care was made on [DATE] at 2:43 PM on Resident #36 and performed by Nurse #3 and assisted by Nurse Aide (NA) #2. Resident #36 was turned towards her left side while NA #2 stood facing Resident #36 and supported her trunk. Nurse #3 sprayed wound cleanser into the sacral pressure ulcer which measured approximately 2 cm (centimeters) in length, 3 cm in width and 2 cm in depth. The wound bed had beefy red granulation tissue with 20% slough (yellow/white material in the wound bed consisting of dead cells). The skin surrounding the wound was red. Nurse #3 applied skin prep barrier to the surrounding skin and well over towards the right buttock. Nurse #3 cut a piece of green foam that fit exactly into the wound bed and applied it to the wound. She cut a plastic drape in half, cut, and measured a hole to fit the foam and applied it to cover Resident #36's buttocks and sacral area. She cut another piece of green foam approximately 6 inches long and 1 inch wide to serve as a bridge to the foam covering the wound. Nurse #3 placed the bridge over the plastic drape and covered it with another piece of plastic drape. She cut a small piece of the drape at the top and placed the track pad with the tubing towards Resident #36's sacrum. She secured the track pad with another piece of tape and then coiled the tubing into a circle and taped it to Resident #36's right hip. Nurse #3 connected the tubing to the canister that was placed inside the wound vac and turned the machine on. The wound vac was set at 125 mmHg (millimeters Mercury).
The Administrator was notified of Immediate Jeopardy on [DATE] at 1:03 PM.
The facility provided the following IJ Removal Plan with the correction date of [DATE].
*Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:
Resident #36 readmitted on [DATE] and had an identified wound/pressure ulcer without physician notification or ordered treatment. The facility failed to assess, obtain treatment orders from physician, identify deterioration of the pressure ulcer, and process a wound culture which resulted in a serious adverse outcome. A culture was ordered by physician and completed however not resulted by lab. twice from an expired swab and dry specimen. The facility failed to follow up on lab. results and did not ensure lab. supplies were not expired.
Facility completed a full body skin assessment and record review on all current residents on [DATE] by the unit managers. Resident #36 was the only identified resident who has suffered an adverse outcome related to non-compliance. The Regional Director of Clinical Services (RDCS) audited lab. supplies to ensure appropriate supplies on hand.
An assessment of Resident #36 revealed on [DATE], no further deterioration of pressure ulcer, treatment orders in place per physician order, resident being followed by local wound care clinic.
*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 Regional Director of Clinical Services (RDCS) educated the Director of Nursing (DON) and nurse unit managers (UM) of the existing/revised process of labs. on [DATE]. Process is as follows for labs.: A. Licensed nurse records lab. order in electronic medical record. B. Notification of Responsible Party (RP) of order. C. Licensed nurse completes lab. requisition in facility lab. book. D. Licensed nurse completes patient log in facility lab. book. E. Phlebotomist from lab. obtains specimen. F. Licensed nurse receives results via lab. fax. G. Licensed nurse checks off in facility lab. book on patient log. H. Licensed nurse notifies physician of abnormal lab. results or places within normal limits labs. in physician box and notifies RP. Location of lab. supplies for blood specimens are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in DON office in cabinet. If a physician or Nurse Practitioner orders a wound culture, the licensed nurse will obtain the culture, place in lab. refrigerator, complete the lab. requisition and complete the patient log in the facility lab. book. Results are received via lab. fax. In addition, the DON/designee are responsible for tracking lab. results beginning [DATE]. If a licensed nurse is contacted by the lab. about a problem, the licensed nurse will be responsible for notifying physician and reentering the order and obtaining sample. Any pressure ulcers or skin conditions that are referred to wound physician are communicated via order and requested resident information are communicated by DON and/or UM. No licensed nurse can initiate treatments without a physician order.
On [DATE], the RDCS also completed education with DON and unit managers on the process of notification. Notification process is as follows: A. Licensed nurse complete admission skin assessment, and weekly skin assessment in electronic medical record as it is assigned as triggered by electronic medical records system. B. If any deterioration of skin area or new area observed, the licensed nurse notifies physician or Nurse Practitioner immediately, and obtains treatment orders. C. Completes notification of responsible party (RP). D. Reports to the DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). The DON/unit managers along with Wound Nurse Practitioner are responsible for weekly wound/pressure ulcer measurements and assessments. A comprehensive list of wounds will be maintained by the DON/unit managers.
Licensed nurses including agency nurses were in-serviced [DATE] by the DON and unit managers on facility process for labs., facility process for notification, location of lab. supplies, responsibilities and of admission and weekly skin assessments, completing weekly wound assessment. Notification process is as follows: A. Licensed nurse complete admission skin assessment, and weekly skin assessment in electronic medical record as it is assigned as triggered by electronic medical records system. B. If any deterioration of skin rea or new area observed, the licensed nurse notifies physician or Nurse Practitioner immediately, and obtains treatment orders. No licensed nurse can initiate treatments without a physician order. C. Completes notification of responsible party (RP). D. Reports to the DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). If any changes in resident conditions, including skin, deterioration (change in size, appearance, skin color, smell, drainage, redness) of wounds/pressure sores, physical or mental changes the licensed nurse must report findings to physician immediately. Facility process for labs. is as follows: A. Licensed nurse records lab. order in electronic medical record. B. Notification of Responsible Party (RP) of order. C. Licensed nurse completes lab. requisition in facility lab. book. D. Licensed nurse completes patient log in facility lab. book. E. Phlebotomist from lab. obtains specimen. F. Licensed nurse receives results via lab. fax. G. Licensed nurse checks off in facility lab. book on patient log. H. Licensed nurse notifies physician of abnormal lab. results or places within normal limits labs. in physician box and notifies RP. Location of lab. supplies for blood specimens are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in DON office in cabinet. If a physician or Nurse Practitioner orders a wound culture, the licensed nurse will obtain the culture, place in lab. refrigerator, complete the lab. requisition and complete the patient log in the facility lab. book. Results are received via lab. fax.
The nurse aides, including agency nurse aides will be in-serviced by [DATE] by DON/designee on reporting any changes in resident's condition including skin, (such as: redness, drainage, open areas, odor, temperature, and complaints of pain) to the licensed nurse immediately.
DON is responsible for tracking nurses and nurse aides including agency that have received education. The DON/UM are responsible for providing education to current nurses and nurse aides who were not in-serviced by [DATE]. Nurses and nurse aides will not be allowed to work until they receive education.
New nurses and nurse aides hired after [DATE] will receive education during orientation.
The DON/unit managers are responsible for tracking labs. and notification of physician during clinical morning meeting beginning the week of [DATE]. The facilities interdisciplinary team (IDT) will continue to conduct a weekly resident review of all residents with pressure sores to discuss and document pressure ulcers.
The alleged date of IJ removal is [DATE].
The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE].
On [DATE], the facility's credible allegation was validated through record reviews and staff interviews. The facility provided education documentation for all staff on identifying and reporting a change in condition especially in skin integrity. In addition, the facility provided signed education sheets on performing and documenting weekly wound assessments, notification of the physician, Nurse Practitioner and wound doctor of new/worsening pressure ulcers, actions to take if new/deteriorating pressure ulcer observed and what changes in skin integrity to report, following up and processing of laboratory orders and reviewing laboratory process to ensure supplies were within date.
The nursing aides were interviewed and described the different signs of changes in skin integrity to be reported to the nurse during provision of care. The in-service also included reporting all changes in condition and signs of wound infection/wound deterioration to the nurse.
A skin/wound audit was completed on [DATE] for any unreported skin issues and the results were compared with the skin assessment documentation, if the physician was notified, if family was notified and if care plan was updated. This was verified through interviews with the Unit Managers and MDS Coordinator who completed the audits.
The RDCS completed an audit of all laboratory supplies on [DATE] wherein she removed and discarded expired laboratory supplies and validated that all current in house supplies were sufficient in quantity and there were no other expired supplies in house. She also completed a laboratory audit on [DATE] and checked all laboratory orders within the last 7 days if they had obtained the results and if the physician was notified of the results.
2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, hypertension, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was severely cognitively impaired, had no rejection of care behaviors and required extensive physical assistance with bed mobility and transfer. She had impairment to both sides of upper and lower extremities. The MDS further indicated Resident #11 had one stage 3 pressure ulcer, one stage 4 pressure ulcer, one deep tissue injury and one venous ulcer.
Resident #11's care plan revised on [DATE] indicated Resident #36 had impaired skin integrity to left heel, left leg and right leg. Interventions included consult with wound care provider as indicated, elevate heels off mattress per routine, inspect skin during routine care daily, pillows for positioning as needed, turn, and reposition during care rounds and as needed and treatment as indicated to impaired skin.
The Weekly Wound assessment dated [DATE] indicated Resident #36 had a stage 4 pressure ulcer to the right lower extremity posterior that measured 13.5 cm (centimeters) in length, 3 cm in width and 0.5 cm in depth. The wound had moderate serous drainage with pink and red wound bed and faint odor. The wound had maceration to peri wound. She was seen and evaluated by the Wound Physician Assistant.
A physician order dated [DATE] indicated the following treatment for Resident #11's right lower leg pressure ulcer: Cleanse wound on right lower leg using wound cleanser, pat dry. Apply skin prep barrier to [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with resident, staff and the Nurse Practitioner, the facility failed to apply a left-hand splint for 1 of 2 residents reviewed for positioning (Resident #72).
The findings included:
Resident #72 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction affecting left non-dominant side.
A physician order dated 1/2/20 in Resident #72's medical record indicated an order for nurse to ensure that left hand splint was applied every evening shift at bedtime. Document any refusals.
Resident #72's Treatment Administration Record (TAR) for June 2022 revealed an order for: Apply left hand splint at bedtime. Nurse to ensure that left hand splint was applied every evening shift at bedtime. Document any refusals. It was documented as having been applied every night at 9:00 PM. No refusals were documented on the TAR.
A review of the Progress Notes for June 2022 in Resident #72's medical record indicated no documented refusals of left hand splint application.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was moderately cognitively impaired, exhibited no rejection of care behaviors, required extensive physical assistance with activities of daily living and had impairment to both upper and lower extremities on the left side.
Resident #72's care plan revised on 6/14/22 indicated Resident #72 had potential for decreased range of motion related to left hemiparesis and degenerative changes of bilateral shoulders. Interventions included left hand splint as directed, encourage compliance and OT (Occupational Therapy) evaluation and treatment as indicated for new splinting.
During an initial observation and interview with Resident #72 on 6/27/22 at 12:10 PM, Resident #72 was noted to have left-sided weakness with her left hand contracted in a closed-fist position. Resident #72 stated she was unable to move her left arm without assistance from her right arm and that staff was supposed to apply her splint to the left hand at bedtime, but they had not been doing it.
An interview with Resident #72 on 6/28/22 at 7:14 AM revealed staff did not apply her left hand splint at bedtime on 6/26/22 and 6/27/22. Resident #72 stated she didn't refuse to have her splint on and that the staff didn't even come and offer to apply it. Resident #72 stated her hand splint stayed at the foot of her bed the whole night.
An interview with Resident #72 on 6/29/22 at 5:40 AM revealed she was already up in her wheelchair because she wanted to get up early. Resident #72 reported that her left hand splint had not been applied from the night before. Resident #72 stated she was scheduled for a hand specialist appointment on 7/5/22 due to contracture at the joint on her left thumb. Resident #72 stated she was supposed to wear her left hand splint for 6 hours and then to remove it for 2 hours so she could get a break. She was supposed to wear it at night, but they hadn't always been applying it. Resident #72 further stated she remembered the COTA (Certified Occupational Therapy Assistant) doing an education with the nursing staff about her splint and she also posted instructions with pictures on her closet door on how to apply her splint. Resident #72 stated it didn't hurt when her left hand was opened for splint application, and she did not refuse to have it on.
An interview with the Certified Occupational Therapy Assistant (COTA) on 6/29/22 at 7:47 AM revealed they had recently worked with Resident #72 from 6/14/22 to 6/23/22 related to her splint to the left hand and arm. The COTA stated they had to pick Resident #72 back up on 6/14/22 because the Nurse Practitioner had given an order that Resident #72 needed a new orthotic splint due to contractures. The COTA stated Resident #72 didn't need a new splint because she had one which the staff had not been applying to her left hand. The COTA stated the problem with orthotics not being applied stemmed from the facility not having a restorative program to follow through on rehabilitation goals. As a result, the residents had to go through repeat cycle with therapy having to pick them up over and over for the same issues. The COTA further stated she was familiar with Resident #72 who complained to her all the time that nursing had not been applying her left hand splint as ordered. The COTA stated Resident #72 would wear her splint if a staff member put it on her. She said she did not notice any worsening in her left hand contracture from the time they last worked with her. She also did an education with the available nursing staff and showed them how to do the release on Resident #72's left hand so it was easier to apply her splint.
An interview with Nurse Aide (NA) #6 on 6/28/22 at 3:04 PM revealed she took care of Resident #72 on the night shift from 11:00 PM on 6/26/22 to 7:00 AM on 6/27/22. NA #6 stated she did not remember if Resident #72 had her left hand splint on that night, but Resident #72 didn't have it on when she got her up in the morning. NA #6 stated she didn't know Resident #72 was supposed to wear a splint to her left hand at night.
An interview with NA #4 on 6/29/22 at 5:45 AM revealed she was not sure why Resident #72 did not have her splint on when she worked with her on 6/28/22 on the night shift. NA #4 stated she sometimes saw Resident #72 wearing her left hand splint and sometimes not, but she didn't know who was responsible for applying it.
An interview with Nurse #8 on 6/29/22 at 7:00 AM revealed she worked with Resident #72 on 6/27/22 and 6/28/22 from 7:00 PM to 7:00 AM. Nurse #8 stated she thought the nurse aides were supposed to be applying Resident #72's left hand splint whenever she went to bed. Nurse #8 stated she couldn't remember if she had checked behind them to make sure her left hand splint was on. She knew they were supposed to remove it whenever they got her out of the bed, but she hadn't gotten around to checking if she even had the left hand splint on from the night before.
An interview with the Nurse Practitioner (NP) on 6/29/22 at 3:10 PM revealed she had written an order on 6/9/22 for Resident #72 to see a hand specialist for contracture to her left hand. The NP stated she didn't think Resident #72's current splint was good enough for her and she might need a new splint. The NP also stated Resident #72 would tell her all the time that nursing did not apply her left hand splint. The NP said she wasn't sure if she had been refusing or if staff forgot to come back and apply the splint to her left hand.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed the nurses should have applied Resident #72's left hand splint as ordered by the physician and documented accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff and the Nurse Practitioner, the facility failed to administer oxygen as prescribed by the physician for 1 of 2 residents reviewed for oxygen therapy (Resident #11).
The findings included:
Resident #11 was admitted to the facility on [DATE] with diagnoses that included obstructive hydrocephalus, hypertension, and anemia.
Resident #11's care plan initiated on 3/25/21 indicated Resident #11 required oxygen as needed. Interventions included to administer oxygen as ordered, monitor oxygen saturation as ordered and observe for signs and symptoms of dyspnea (shortness of breath).
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was severely cognitively impaired, had impairment to both sides of the upper and lower extremities and used oxygen therapy while a resident at the facility.
A physician order dated 4/8/22 for Resident #11 indicated oxygen therapy at 1.5 liters per minute via nasal cannula every shift.
Resident #11's Treatment Administration Record (TAR) for June 2022 included an order for oxygen therapy at 1.5 liters per minute via nasal cannula every shift but there was no order to check oxygen saturation every shift.
An observation of Resident #11 on 6/27/22 at 10:27 AM revealed Resident #11 sitting in a geriatric chair in her room with an oxygen tank behind her. Resident #11 had a nasal cannula on which was connected to the oxygen tank and the oxygen was set at 3 liters per minute.
A second observation of Resident #11 on 6/28/22 at 8:45 AM revealed Resident #11 sitting in a geriatric chair in her room with a nasal cannula on her nose. The nasal cannula was connected to an oxygen concentrator which was running at 3.5 liters per minute.
During an observation of care on Resident #11 on 6/29/22 at 5:45 AM, she did not have a nasal cannula on, and her oxygen concentrator was turned off. Resident #11 did not show any signs of respiratory distress.
An interview with Nurse Aide (NA) #4 and NA #5 on 6/29/22 at 7:20 AM revealed Resident #11 did not have her oxygen on all night, and they didn't know she was supposed to get oxygen on their shift.
An interview with Nurse #8 on 6/29/22 at 7:00 AM revealed she remembered checking Resident #11's oxygen saturation before midnight and it was between 93% and 95% but she couldn't remember if she had her oxygen on at that time. Nurse #8 stated she was not sure whether Resident #11 was supposed to receive continuous oxygen because it was not specified in the order. Nurse #8 checked Resident #11's oxygen saturation at 7:10 AM and it was 97% on room air. Nurse #8 stated she remembered the oxygen concentrator not being on when she came in at 7:00 PM the night before and she also remembered the nurse from the day before telling her that she had just changed Resident #11's oxygen tubing and nasal cannula.
An interview with Nurse #5 on 6/29/22 at 5:44 PM revealed she worked on 6/27/22 and 6/28/22 with Resident #11 but didn't remember looking at the rate at which her oxygen tank or oxygen concentrator had been set on. Nurse #5 stated she checked to make sure the oxygen tank had enough oxygen left and the humidifier on the concentrator had enough fluid. She also stated she changed Resident #11's oxygen tubing and nasal cannula on 6/28/22 and they probably forgot to switch her to her oxygen concentrator when they put her to bed the night before.
An interview with the Nurse Practitioner on 6/29/22 at 3:33 PM revealed the nurses should administer Resident #11's oxygen according to the physician's order and they should let her know if oxygen was no longer needed so she could re-evaluate the resident and discontinue the order for oxygen.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed the nurses should have made sure Resident #11's oxygen was delivered per physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interviews, and dialysis staff, the facility failed to serve breakfast before dialysis for 1 of 1 resident reviewed for dialysis (Resident #34).
Findings included:
Resident #34 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and dependence on renal dialysis.
Review of Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact and required limited assistance for majority of Activities of Daily Living (ADL).
An interview conducted with Resident #34 on 6/28/22 at 8:50 AM revealed her dialysis schedule was Monday, Wednesday, and Fridays. Resident #34 further revealed she had missed breakfast at least four times in the last three months due to kitchen and nursing staff not being organized.
An interview conducted with a Nurse from the dialysis center on 6/28/22 at 3:20 PM revealed Resident #34 had stated to dialysis staff that she had missed breakfast a few times. The dialysis Nurse further revealed Resident #34 did not have a low blood sugar but complained about facility staff being unorganized and being very hungry when she returned to the facility.
An interview conducted with Nurse Aide (NA) #10 on 6/29/22 at 11:50 AM revealed Resident #34 had missed breakfast twice before her dialysis appointment in the last two months. NA #10 further revealed dietary staff were supposed to serve Resident #34 breakfast at 7:00 AM on dialysis days and would consistently forget.
An interview conducted with the Dietary Manager on 6/30/22 at 5:30 PM revealed she was aware Resident #34 had missed breakfast before going to dialysis. The Dietary Manager further revealed Resident #34 was supposed to receive breakfast between 7:00 AM to 7:30 AM on dialysis days. The Dietary Manager stated there had been ongoing miscommunication between nursing and kitchen staff.
An interview conducted with the Dietician on 6/29/22 on 2:50 PM revealed she had not been made aware Resident #34 had missed meals before dialysis. The Dietician further revealed she would expect Resident #34 to eat before dialysis so Resident #34 did not become weak.
An interview conducted with the Nurse Practitioner (NP) on 6/29/22 at 4:00 PM revealed she had not been made aware Resident #34 had missed meals before dialysis. The NP further revealed she would expect Resident #34 to eat before dialysis so Resident #34 did not become weak and received full nutrition.
An interview conducted with the Administrator on 7/1/22 at 12:35 PM revealed she was not aware Resident #34 had missed breakfast before dialysis. The Administrator further revealed she expected for Resident #34 to not miss any meals and dietary staff to be on time with meals.

Based on observations, record review, resident and staff interviews, the facility failed to provide sufficient nursing staff which resulted in personal hygiene and incontinence care not being performed (Residents # 39 and Resident #10). The facility failed to ensure a maintenance program for maintaining function was provided for 2 of 2 residents (Resident #58 and Resident #39) reviewed for Activities of Daily Living.
The findings included:
The tag was cross-referred to:
F550: Based on observations, record reviews, resident and staff interviews, the facility failed to treat residents in a dignified manner when 1 of 4 residents (Resident #39) was not provided toileting before wetting herself, her clothing and the floor, and failed to provide incontinence care to 1 of 4 residents prior to the resident (Resident #10) wetting through her brief and through her clothing onto her bed pad.
F676 Based on observations, record reviews, resident, Certified Occupational Therapy Assistant (COTA), Physical Therapy Assistant (PTA), and staff interviews, the facility failed to provide a maintenance program to prevent decline in the ability to ambulate for 2 of 2 sampled residents (Resident #58 and Resident #39) reviewed for maintaining activities of daily living.
An interview was conducted on 6/29/2022 at 9:36AM with Nurse Aide (NA) #1. She stated she mainly worked on 400 and 500 halls. She revealed when the facility was short staffed, residents would not get put back to bed after lunch until 9:30-10:30PM, because Agency staff refused. NA #1 stated the facility used Agency staff to fill in the holes on the schedule and if they (agency staff) did not want to do something, they would refuse. She stated there had been a time, recently, where she was the only NA (second shift) assigned to 48 residents. NA #1 stated she was not able to complete her assignment on that day because there was not enough time or help to complete everything with so many residents. NA #1 indicated she had reported staffing issues to the Director of Nursing and the Administrator several times in the past few months.
An interview with NA #11 was conducted on 6/30/2022 at 9:46AM. She stated there had been times when the facility was short-staffed especially since covid-19. She revealed staffing on the weekends was still bad because agency staff did not want to work weekends.
Interview with NA #3 on 6/30/2022 at 10:37AM revealed she had worked at the facility through an agency. She stated on Monday, June 27, 2022, on 2nd shift, she had to work 5 hours by herself on the hall with residents that required extensive to total assistance by staff for their care.
An interview was conducted with Unit Manager (UM) #1 on 6/30/2022 at 4:03PM. She revealed on Sunday, 6/26/2022, when she arrived at work for first shift, there had been 5 call outs. She stated the call outs left the facility with only 1 NA upstairs and 4 downstairs, and she had to pull 2 NAs from downstairs to upstairs so they would have at least 1 NA per hall. UM stated each one of those NAs performed showers, personal care, incontinence care, turned and repositioned residents, assisted residents to the bathroom, assisted residents with feeding, passed, and picked up trays and answered call lights, by themselves on their assigned hall. She stated she assisted the NAs and much as she could, but everything that needed to be done was not done. She indicated she had reported staffing issues to the Director of Nursing and the Administrator on several occasions in the past couple of months.
Interview with the Staffing Coordinator on 7/1/2022 at 8:37AM revealed she had been at this position for 2 years and she was also a NA. She stated the facility had been short-staffed recently, but she reached out to different Staffing Agencies to help find coverage. She stated the facility currently has 7 open Nurse positions and 8 open Nurse Aide positions. The Staffing Coordinator stated she helped on the floor when needed and helped cover the weekends when staffing was short. For recruitment, the facility has advertised in newspapers and on-line, offered sign-on bonuses, and increased staff pay. She stated Unit Managers and the Director of Nursing had assisted on the floor when necessary.
An interview was conducted with the Administrator and Regional Director of Clinical Services (RDCS) on 7/1/2022 at 11:27AM. The Administrator stated she was aware of the staffing challenges in the facility, the staffing shortages had been reported to her by hall staff, unit managers, and the Director of Nursing. She revealed she was tasked with finding staff and had to utilize Staffing Agencies to cover the open shifts. She stated Agency staff sometimes did not show up for the shifts they had signed up for and this presented problems for the facility. Administrator stated Unit Managers and Department Managers assisted with answering call lights and doing what they could for the residents. All staff, including herself, had to answer call lights. Administrator indicated she offered bonuses to staff who worked an extra shift or agreed to stay over their shift to assist. She revealed the facility did not have a Restorative Program and relied on nursing staff to ambulate residents. RDCS stated the facility had recently hired 26 Nurse Aides. The Administrator stated staff had come to her about not being able to do their jobs and about the long hours they had to work. She stated the facility was actively recruiting staff to fill the open positions. She stated her expectation was for the facility to have enough staff to take care of the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation and interviews with family member, staff and Wound Center staff, the facility failed to provide training to ensure 2 of 7 nurses (Nurse #2 and Nurse #3) were competent and demonstrated skills in providing care to 1 of 1 resident (Resident #36) reviewed for wound vac (vacuum-assisted closure of a wound) application.
The findings included:
Resident #36 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness, spinal stenosis, atherosclerotic heart disease, hypertension and history of transient ischemic attack and cerebral infarction. She was recently re-admitted on [DATE] from the hospital due to acute encephalopathy and advanced Parkinson's disease.
A physician order dated 4/22/22 in Resident #36's medical record indicated an order for wound vac to wound continuously at 125 mmHg (millimeter Mercury) and to change wound vac in the evening every Monday, Wednesday, and Friday.
Resident #36's care plan revised on 4/26/22 indicated Resident #36 had potential for skin breakdown related to weakness, impaired mobility, and episodes of bladder incontinence. She had a history of moisture-associated skin damage to buttocks/sacrum and now had a stage 4 pressure wound to the sacrum. Interventions included wound vac as directed. Wound vac, also known as vacuum-assisted closure of a wound, is a type of therapy to help wounds heal. It is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate (drainage) and promote healing in acute or chronic wounds.
The Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact, had no rejection of care behaviors and required extensive physical assistance with bed mobility, locomotion, and toilet use. Resident #36 had impairment on one side of her upper extremities and used a wheelchair. The MDS further indicated Resident #36 was frequently incontinent of urine, but she was always continent of bowel. Resident #36 was at risk of developing pressure ulcers/injuries and had one stage 4 pressure ulcer.
A phone interview with Resident #36's family member on 6/30/22 at 8:19 AM revealed she went with Resident #36 to her Wound Center appointment on 6/27/22 and they noted that the wound vac was applied incorrectly when a barrier was not applied between the bridge foam and the skin which caused red areas to her left buttock. Resident #36's family member stated she had voiced her concerns to the Administrator about the nurses requiring more training and education on the application of wound vac, but she wasn't sure what was done about it. Prior to this, on 5/2/22 at around 5:00 PM, Resident #36's wound vac was not working because it had lost seal and needed to be re-applied. The nurse on the hall did not know how to change the wound vac. The Administrator got UM #1 to come and change the wound vac and UM #1 made a comment to her that the nurses at the facility could use more education and training on wound vac application. On 5/4/22, Resident #36's family member went with the resident to her appointment at the Wound Center and Wound Center staff had made a comment to her that they would suggest to the facility to consider training their nurses on wound vac application due to multiple issues observed with Resident #36's wound vac.
An In-service Sign-off Sheet dated 6/3/22 indicated an in-service was conducted by Unit Manager #1 and Unit Manager #2 on wound vac application with the objective of all nurses to be able to successfully apply and maintain wound vac. The sign-off sheet was signed by 6 nurses that included Nurse #3. Nurse #2 did not sign the sheet.
An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed she and UM #2 conducted an in-service on wound vac application to all nurses who could be assigned to Resident #36. UM #1 stated she talked to the nurses and provided them with a written step by step instructions on the procedure. On the day she conducted the in-service, Resident #36's wound vac was not scheduled to be changed so she didn't get to demonstrate the procedure but some of the nurses were able to watch her do the procedure on a later date. However, she did not watch any of the nurses return demonstrate and she did not evaluate their understanding and competency of the wound vac application.
An interview on 6/28/22 at 3:36 PM with Nurse #6 who was an agency nurse revealed she did not attend the in-service on wound vac on 6/3/22 but she had watched UM #1 do the procedure once on 6/16/22. Nurse #6 stated she had to change Resident #36's wound vac on 6/27/22 for the first time but prior to the procedure, UM #1 had talked her through as to what she needed to do. UM #1 did not watch her change Resident #36's wound vac dressing on 6/27/22.
An interview with Unit Manager (UM) #2 on 6/30/22 at 6:02 PM revealed she received a phone call on 6/27/22 from the Wound Center about Nurse #6 not having applied Resident #36's wound vac correctly. Nurse #6 didn't put enough foam on the wound and the foam that she applied didn't fill the hole completely. She also did not put skin prep barrier and clear tape under the bridge. UM #2 stated Nurse #6 was instructed on what she needed to do prior to the procedure but she didn't have time to check Resident #36's wound vac to make sure it was applied correctly. UM #2 stated she told all the nurses who worked with Resident #36 to come get her if they needed help with Resident #36's wound vac application. She also stated it was hard to give instructions to agency nurses because of the high turnover with working at the facility and there was always a new nurse working on the hall. UM #2 stated the only time she received a phone call from the Wound Center was on 6/27/22 but Resident #36 always came back from her appointment with detailed instructions on how to do the wound vac dressing and it always indicated to consider wound vac in-service for facility staff.
An observation of wound care was made on 7/1/22 at 2:43 PM on Resident #36 and performed by Nurse #3 and assisted by Nurse Aide (NA) #2. Resident #36 was turned towards her left side while NA #2 stood facing Resident #36 and supported her trunk. Nurse #3 sprayed wound cleanser into the sacral pressure ulcer which measured approximately 2 cm (centimeters) in length, 3 cm in width and 2 cm in depth. The wound bed had beefy red granulation tissue with 20% slough (yellow/white material in the wound bed consisting of dead cells). The skin surrounding the wound was red. Nurse #3 applied skin prep barrier to the surrounding skin and well over towards the right buttock. Nurse #3 cut a piece of green foam that fit exactly into the wound bed and applied it to the wound. She cut a plastic drape in half, cut, and measured a hole to fit the foam and applied it to cover Resident #36's buttocks and sacral area. She cut another piece of green foam approximately 6 inches long and 1 inch wide to serve as a bridge to the foam covering the wound. Nurse #3 placed the bridge over the plastic drape and covered it with another piece of plastic drape. She cut a small piece of the drape at the top and when she was about to place the track pad, she asked NA #2 how she was supposed to position it. NA #2 told Nurse #3 she didn't know. Nurse #3 ended up placing the track pad with the tubing towards Resident #36's sacrum. She secured the track pad with another piece of tape and then coiled the tubing into a circle and taped it to Resident #36's right hip. Nurse #3 connected the tubing to the canister that was placed inside the wound vac and turned the machine on. It took a minute before suction was visible on the foam on Resident #36's sacral area but it was set at 125 mmHg.
An interview with Nurse #3 on 7/1/22 at 3:21 PM revealed that the length in which she cut the bridge foam was based on her observation from the dressing done at the Wound Center. Nurse #3 stated she always positioned the track pad with the tubing going towards Resident #36's sacrum because whenever she positioned it the other way, the tubing ended up getting kinked more.
A follow-up interview with Unit Manager (UM) #1 on 7/1/22 at 3:36 PM revealed after inspecting the wound vac dressing applied by Nurse #3, she noted that the bridge wasn't long enough because it was sitting at Resident #36's right buttock. UM #1 stated the bridge should be placed farther out all the way to the right hip so that when Resident #36 got turned towards her right side, she won't be laying on the track pad. At the same time, the track pad was applied backwards and should have been placed with the tubing going out and not towards Resident #36's sacrum. UM #1 also stated Nurse #3 shouldn't have coiled the tubing the way she did because this would cause the tubing to kink and potentially cut off the suction from the wound vac. UM #1 stated she had shown Nurse #3 several times how to change the wound vac dressing on Resident #36 but had not watched her return demonstrate. UM #1 said she never received a call from the Wound Center, but they always made it clear on the paperwork that Resident #36 came back with if they had issues with the wound vac. On 5/25/22, the Wound Center staff sent a sample foam that measured exactly how much foam they wanted placed on the wound. UM #1 stated the consult indicated that the facility staff needed to put more foam on the wound bed.
A phone interview with a Wound Center nurse on 6/30/22 at 2:41 PM revealed the Wound Center had recommended an in-service with the nurses at the facility regarding wound vac application due to multiple concerns observed whenever Resident #36 came to her Wound Center appointments. A lot of times, the nurses would forget to place a transparent drape in between the bridge foam and the skin causing more redness to intact skin. There were also times when they had applied the track pad directly on the sacrum on top of the foam which caused more pressure to the area. At other times, the tubing was positioned on the buttock which was not acceptable because this could cause more pressure areas on the buttocks. The Wound Center nurse stated this did not cause deterioration of the pressure ulcer or delay in healing, but it posed the potential to do so.
An interview with the Director of Nursing (DON) on 7/7/22 at 2:22 PM revealed he had heard nurses report to him that the Wound Center had issues with the way the wound vac was applied at the facility. He said the Unit Managers had done several in-services with the nurses especially the ones who were assigned to Resident #36 on how to change her wound vac dressing. They had reported to him that they watched the nurses return demonstrate wound vac application on Resident #36.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed all nurses on all shifts should be in-serviced and educated on Resident #36's wound vac application through hand-outs and sign-in sheets for accountability. The Administrator stated the nursing administrative team had an open-door policy for questions and nurses were expected to ask questions and say something to the DON or the unit managers if there was a procedure they weren't sure of. The Administrator also stated it was best practice to have the nurses be checked off on wound vac application to determine if they had retained any of the instructions provided to them.

Based on observations and interviews the facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes. This failure had the potential to impact 80 of 82 residents who received oral nutrition.
The findings included:
Interview with Resident #58 (400 hall) on 6/27/2022 at 10:34 AM revealed the meal trays were not delivered at a consistent time. Resident #58 stated she did not receive her breakfast tray until 9:30 AM to 10:00 AM and the lunch tray did not arrive until 1:00 PM to 1:30 PM. Resident #58 further disclosed the dinner trays did not arrive until 6:00 PM to 6:30 PM.
Interview with Resident #64 (500 hall) on 6/27/2022 at 10:53 AM revealed the mealtimes were not consistent. Resident #64 stated meals were at least an hour late every day. According to Resident #64, she had made the Administrator aware of the inconsistent mealtimes, but there had been no changes.
Interview on 6/28/2022 at 7:30 AM with Nurse #12 revealed 4 or 5 dietary staff members quit a few months ago. Nurse #12 stated the lack of dietary staff meant the upstairs main kitchen was the only one staffed. The downstairs kitchen was no longer open due to lack of dietary staff to operate that kitchen. According to Nurse #12, meals were late every day (breakfast as late as 10:30 AM and lunch as late as 2:30 PM) because there were so few staff to work in the kitchen.
Observation and interview with Resident #34 (500 hall) on 6/28/2022 at 8:59 AM revealed she was eating a breakfast meal she had ordered and had delivered from an outside restaurant. Resident #34 stated she did not like the dinner meal last night and was hungry.
Interview with Resident #24 (500 hall) on 6/28/2022 at 9:05 AM revealed she sometimes did not receive her breakfast tray until after 10:00 AM and her lunch tray around 2:30 PM.
Observation of a meal schedule was posted in the hallway beside the dining room door on 6/28/2022 at 5:04 PM. The scheduled mealtimes were as follows:
Breakfast - 7:45 AM
Lunch - 11:45 AM
Dinner - 4:30 PM
The posting further indicated meals were served in the following order:
Upstairs dining room
Downstairs Assisted Diners
100 hall
200 hall
300 hall
400 hall - downstairs
500 hall - downstairs
A continuous observation of the lunch meal delivery on 6/28/2022 at 12:01 PM revealed the following:
12:01 PM - residents assisted to upstairs dining room
12:01 PM - overhead page indicated 100 and 200 hall dining carts were available for pick up
12:02 PM - 100 hall dining cart delivered to hall by Nurse Aide (NA)
12:05 PM - first dining room resident served
12:11 PM - 200 hall cart delivered to hall by NA
12:26 PM - overhead page indicated 300 hall dining cart was available for pick up
12:30 PM - 300 hall dining cart delivered to hall by NA
12:35 PM - overhead page indicated 400 and 500 hall dining carts were available for pick up
12:38 PM - 400 and 500 hall dining carts were taken to downstairs residents by NAs
A continuous observation of the dinner meal delivery on 6/28/2022 at 5:04 PM revealed the following:
5:23 PM - overhead page indicated 100 hall dining cart was available for pick up
5:38 PM - overhead page indicated 200 hall dining cart was available for pick up
5:44 PM - overhead page indicated 300 hall dining cart was available for pick up
5:56 PM - overhead page indicated 400 hall dining cart was available for pick up
6:07 PM - overhead page indicated 500 hall dining cart was available for pick up
An interview with the Certified Occupational Therapy Assistant (COTA) on 6/29/2022 at 8:19 AM revealed dietary staffing was very low which necessitated non-dietary staff to step up to help. The COTA stated she had worked in the kitchen to assist with making coffee on several occasions.
Interview with NA #1 on 6/29/2022 at 9:44 AM revealed mealtimes were erratic. The NA stated the inconsistency was related to very few staff in the kitchen.
Interview with the Registered Dietician (RD) #4 on 6/29/2022 at 1:13 PM revealed there was not enough dietary staff on a regular basis to keep the kitchen running smoothly and on time.
Interview with [NAME] #1 on 6/30/2022 at 11:18 AM revealed he did not have enough staff to maintain consistent meal delivery times. [NAME] #1 indicated he never knew how many staff would be in the kitchen on any given day. [NAME] #1 also disclosed at least 2 more staff were needed in the kitchen on a daily basis to make the schedule work. [NAME] #1 stated there had not been a reliable dishwasher since he had worked at the facility (1 month). [NAME] #1 revealed dietary staff pitched in to run the dishwasher when they could.
Interview with Unit Manager (UM) #1 on 6/30/2022 at 4:23 PM revealed meal delivery timing was very erratic due to low dietary staffing.
An interview with the Dietary Manager (DM) on 6/27/2022 at 9:41 AM revealed she was struggling to maintain staff. The DM indicated the previous DM and 4 or 5 of the dietary staff quit in November 2021. At that time, she was promoted to DM and made sure meals were prepared and menus followed. The DM revealed 3 or 4 dietary aides had since been hired, but none of them had maintained their employment, leaving the department understaffed. The DM disclosed having an understaffed kitchen staff meant meals were not served on time according to the schedule, but dietary staff were doing the best they could.
Interview with the facility Administrator on 7/1/2022 at 11:19 AM revealed she was aware of low dietary staffing. The Administrator further disclosed she was aware NAs were scraping plates after meals. The Administrator indicated recruitment efforts were ongoing for dietary staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to honor food preferences for 2 of 2 sampled residents reviewed (Residents #24 and #50).
Findings included:
1. Resident #24 was admitted to the facility on [DATE].
The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #24 was cognitively intact and required set-up help only with meals.
A physician's order for Resident #24 dated 05/20/22 read, magic cup (frozen nutritional supplement) two times a day on lunch and dinner tray.
During interviews on 06/27/22 at 12:18 PM and 06/28/22 at 9:05 AM, Resident #24 revealed she was only able to eat certain food items due to gastroesophageal reflux disease (GERD; occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach). Resident #24 stated she was not able to eat most of the meals served because the food was either too spicy, had no taste at all or she was served items she did not like and as a result had lost weight. Resident #24 indicated the Dietary Manager (DM) and Registered Dietician (RD) were both aware of her food preferences but she still received food items she could not eat.
An observation of the lunch meal on 06/27/22 at 1:09 PM revealed Resident #24 received an orange cream magic cup, chocolate cupcake and a vegetable medley. A review of the meal ticket that was on her meal tray revealed a standing order for one magic cup - berry only and her dislikes included chocolate, vegetable blend, broccoli, and cauliflower.
An observation of the lunch meal on 06/28/22 at 1:06 PM revealed Resident #24 received an orange cream magic cup, Salisbury steak with gravy, creamed corn, and diced potatoes. A review of the meal ticket that was on her meal tray revealed a standing order for one magic cup - berry only and a note that read, no gravy per resident's request.
An observation of the supper meal on 06/28/22 at 6:15 PM revealed Resident #24 received 2 grilled cheese sandwiches and no magic cup with her meal. A review of the meal ticket that was on her meal tray revealed a standing order for one magic cup - berry only.
An observation of the lunch meal on 06/29/22 at 1:03 PM revealed Resident #24 received stew, roll, brussels sprouts, and an orange cream magic cup. A review of the meal ticket that was on her meal tray revealed a standing order for one magic cup - berry only and her dislikes included brussels sprouts.
During an interview on 06/30/22 at 5:23 PM, the DM stated Resident #24 changed her food preferences frequently. The DM was unaware Resident #24 had been served an orange cream magic cup with her meals all week in addition to food items listed as a dislike or that she did not receive a magic cup with her supper tray on 06/29/22. She explained the dietary aides were supposed to be reading the meal tickets to ensure supplements were provided as ordered and residents weren't served foods that were listed as a dislike.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated staff needed to be re-educated to remain diligent during food service and check the meal tickets to ensure supplements were provided as ordered and residents weren't served food listed as a dislike.
2. During an observation of the supper meal on 6/28/22 at 6:00 PM, Resident #36 was served two ham and cheese sandwiches with lettuce on them. A review of the meal ticket that was on the tray indicated Resident #36's dislikes included lettuce and salad.
An interview with Resident #36's family member on 6/28/22 at 6:15 PM revealed Resident #36's family members normally rotated during the lunch and supper meals to make sure Resident #36 got served food according to her preferences and the consistency that she would be able to eat. He stated he went ahead and removed the lettuce from the sandwiches and just set them aside on the plate instead of asking the kitchen staff for another plate.
An interview was conducted with the Dietary Manager (DM) on 6/30/22 at 5:23 PM. The DM stated the dietary aides were supposed to be reading the cards or meal tickets to make sure they didn't serve the residents food that were on their dislikes list. She stated the dietary aides should have read Resident #36's meal ticket before serving her supper tray.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed the staff need to be re-educated on checking the meal tickets to prevent serving the residents any of their food dislikes and make sure staff remained vigilant during food service. The Dietary Manager also helped with looking at the meal tickets, but she wasn't always at the facility during the supper service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to provide effective leadership and implement effective systems to manage pressure ulcers, laboratory tests and physician notification. This failure affected 2 of 3 residents reviewed for administration (Resident #36 and Resident #11).
Immediate Jeopardy began on 3/3/22 when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition that involved Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.
The findings included:
This tag is cross-referred to:
F-580: Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral osteomyelitis. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36).
F-686: Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from 3/3/22 to 3/10/22). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for osteomyelitis. In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. These failures were for 2 of 3 residents reviewed for pressure ulcers (Resident #36 and Resident #11).
An interview with the Regional Director of Clinical Services (RDCS) on 6/30/22 at 6:59 PM revealed one of the factors that contributed to the facility's not having effective leadership was due to the facility's lack of Administrative nurses to help the Director of Nursing. The RDCS stated the facility had experienced a quick turnover of Administrative nurses including an Assistant Director of Nursing who was supposed to oversee the unit managers on the floor. They had recently hired 2 unit managers, but they sometimes got pulled to work on the hall and away from their Administrative duties.
The Administrator was notified of Immediate Jeopardy on 7/1/22 at 1:03 PM.
The facility provided the following IJ Removal Plan with the correction date of 7/3/22.
I. Facility failed to provide effective leadership and implement systems to manage pressure ulcers, laboratory tests and physician notification.
II. Regional team to include the Regional [NAME] President of Operations and the Regional Director of Clinical Services identified there were breakdown in the execution of critical clinical services.
a. Regional team immediately provided oversight and education to the leadership staff.
b. Policies related to pressure ulcers and notification for change in condition were reviewed to assure they would be appropriate for the center, and they were deemed to be appropriate. Issues related to pressure ulcers and notifications were not policy driven but issues were identified with implementation of the policy, so education occurred. The center's process for handling labs. and laboratory supplies was reviewed and found to be inadequate, so process was updated and put into place effective 7/2/22.
c. Education to the Administrator and DON was provided by the Regional [NAME] President of Operations and the Regional Director of Clinical Services.
d. Education included policies and implementing systems for oversight and execution of critical nursing systems identified in the immediate jeopardy. These were completed on 7/2/22.
1. Education to the pressure ulcer policy was completed and implemented on 7/2/22.
2.
Education for updated process for laboratory testing and acquiring laboratory supplies was completed and implemented on 7/2/22.
3. Notification for resident change in condition policy and procedure was educated and implemented on 7/2/22.
4. Leadership education also included the company's QAPI process and morning clinical meeting process. Completed 7/2/22.
III. Regional team member will participate in each QAPI meeting with the center for the next 3 months to assure appropriate issues are identified and follow-up is put into place.
IV. Regional team member will participate in the center's morning clinical meeting on a weekly basis for the next 30 days to assure meeting is thorough and captures any clinical issues that need to be addressed.
V. Regional team member will review all audits and in-services related to this plan for the next three months on a weekly basis and repeat in-servicing as appropriate.
VI. The Regional team will randomly audit 3 resident charts per week for the next three months to assure accuracy of pressure ulcer documentation, lab. testing compliance and appropriate physician notification.
VII. Regional team has set an expectation that the center will hold QAPI meetings monthly. Clinical morning meetings and daily stand-up meetings will be held daily Monday through Friday according to policy.
VIII. Regional team will conduct a weekly leadership meeting that involves the Regional [NAME] President or designee, Regional Director of Clinical Services or designee, the facility Administrator and facility Director of Nursing for the next 3 months. Other regional or corporate staff will be invited as appropriate. This leadership meeting will review progress to the plan of correction for the current survey, review process or policy changes that have been implemented for effectiveness and discuss any current issues needing addressed on a clinical level.
Date of removal for alleged IJ is 7/3/22.
The credible allegation for the immediate jeopardy removal was validated on 7/7/22 with a removal date of 7/3/22.
A root cause analysis was completed by the Regional [NAME] President of Operations which identified the following root causes for the IJ concerns identified at the survey: new leadership, agency staffing and adherence to company systems.
The audit tools completed by the facility on skin status and laboratory results were reviewed. The physician/Nurse Practitioner were notified of results from the audits for additional follow-up as needed.
On 7/2/22, the Regional [NAME] President of Operations provided education with the new Administrator and Director of Nursing on identifying issues with immediate jeopardy cited and discussed with them the components of the regulations for F-580, F-686, and F-835. The education also included QA (Quality Assurance) roles and responsibilities, morning stand-up, clinical stand-up, pressure ulcer policy, policy on resident change in condition, laboratory process, correction plans and monitoring processes.
Interviews with nurses and nurse aides revealed they received education on identifying any changes in resident condition including skin issues, changes in vital signs and daily habits and reporting these changes to the nurses and the medical providers.
An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was conducted on 7/2/22 with the following key personnel in attendance: Administrator, Regional Director of Clinical Services, Regional [NAME] President for Operations, Nurse Practitioner and Director of Nursing. They discussed conducting weekly risk meetings to put practice back in place to ensure IDT discusses key resident conditions, makes recommendations and changes to care plans as needed.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when 8 of 8 staff members (Nurse #5, Nurse #10, Nurse Aide #5, Nurse Aide #4, Nurse Aide #7, Nurse #11, Nurse Aide #1 and Nurse Aide #2) failed to wear eye protective gear while providing care to 7 of 7 residents reviewed for infection control (Resident #1, Resident #60, Resident #232, Resident #11, Resident #14, Resident #9 and Resident #36). In addition, Nurse #5 failed to change gloves and perform hand hygiene during wound care on Resident #11 and Nurse #3 failed to perform hand hygiene and clean equipment used during wound care on Resident #14. These failures were for 2 of 3 residents reviewed for wound care (Resident #11 and Resident #14). These failures occurred during a COVID-19 pandemic.
The findings included:
1. A review of the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker on 6/27/22 indicated that the county where the facility was located had a high level of community transmission for COVID-19.
The CDC guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/2/22 indicated the following information under the section Implement Universal Use of Personal Protective Equipment for HCP (Healthcare Personnel):
*HCP working in facilities located in counties with substantial or high transmission should also use PPE (Personal Protective Equipment) as described below including:
Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters.
The facility's policy entitled, Recommended use of personal protective equipment (PPE) for Health care settings for Coronavirus Disease, dated 9/10/21 indicated when the community transmission level is red/high or orange/substantial, anyone on the COVID-free unit or green unit should wear an N95 mask and eye protection for patient care encounters.
a. During an observation on the 200 hall on 6/27/22 at 4:01 PM, Nurse #5 administered medications to Resident #1 while wearing a KN95 mask and no eye protective gear. At 4:04 PM, Nurse #5 proceeded to Resident #60's room while carrying a medication cup. Nurse #5 was still wearing a KN95 mask and no eye protective gear.
An interview with Nurse #5 on 6/27/22 at 4:12 PM revealed she had to wipe her goggles because there were fogging up and forgot to put them back on. Nurse #5 stated she knew she was supposed to wear eye protection with all resident care encounters.
b. On 6/29/22 at 5:40 AM, Nurse #10 was observed pushing Resident #232 in her wheelchair in the hallway. Nurse #10 was wearing a surgical mask and no eye protective gear.
An interview with Nurse #10 on 6/29/22 at 6:10 AM revealed she had left her face shield at the nurses' station when she started to push Resident #232 and she forgot to put it on. Nurse #10 knew she was supposed to wear eye protective gear when interacting with any of the residents at the facility.
c. During observation of care on Resident #11 on 6/29/22 at 5:40 AM, Nurse Aide (NA) #5 was observed exiting the room while wearing a surgical mask and no eye protective gear. At 5:45 AM, NA #5 re-entered Resident #11's room wearing a face shield and a surgical mask. NA #5 helped NA #4 provide incontinence care to Resident #11. NA #4 was observed wearing a surgical mask and no eye protective gear.
An interview with NA #5 and NA #4 on 6/29/22 at 5:50 AM revealed NA #5 didn't see any face shields at the front lobby when she had come in to work so she hadn't worn one all shift. NA #4 stated she had taken her goggles off because they had fogged up and forgot to put them back on. Both nurse aides stated they had been educated that they were supposed to wear eye protection while providing care to the residents.
d. NA #7 was observed exiting Resident #14's room on 6/29/22 at 5:58 AM. NA #7 was wearing a surgical mask with no eye protective gear.
An interview with NA #7 on 6/29/22 at 5:59 AM revealed she had just provided care to Resident #14 while wearing no eye protective gear. NA #7 stated she was told that they had to wear eye protection, but she took them off when she did her rounds because she got hot.
e. On 6/29/22 at 6:15 AM, Nurse #11 was observed administering medications to Resident #9 while wearing an N95 mask but no eye protective gear.
An interview with Nurse #11 on 6/29/22 at 6:20 AM revealed she thought she only had to wear face shields or goggles when there was an active COVID-19 case in the building. Nurse #11 stated a staff member had signed her in at 11:00 PM and did not say anything to her about having to wear eye protection.
f. During an observation of incontinence care on Resident #36 on 7/1/22 at 7:56 AM, NA #1 and NA #2 were both wearing a surgical mask with no eye protective gear.
An interview with NA #1 and NA #2 on 7/1/22 at 8:00 AM revealed both nurse aides knew they were supposed to wear eye protection when working with the residents, but NA #2 forgot to obtain one when she came in and NA #1 left her goggles in the car and hadn't had a chance to get it.
An interview with the Regional Director of Clinical Services (RDCS) on 6/30/22 at 6:59 PM revealed the Director of Nursing (DON) was responsible for infection control at the facility but he was currently unavailable for interview. The RDCS who was covering for the DON stated they had provided education to the staff that because the county transmission level was still high, they required them to use an N95 mask and face shield or goggles during all resident care encounters. The RDCS stated it was hard to get agency staff to follow their infection control policies and some had given them attitude whenever they were told about they were supposed to do.
2. The Centers for Disease Control and Prevention (CDC) guidance entitled, Hand Hygiene Guidance, last reviewed on 1/30/20 indicated the following information: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately after glove removal. Gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care, if moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.
The facility's policy entitled, Hand Hygiene/Handwashing Policy, last revised on 7/14/21 indicated the following statements: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. Perform hand hygiene: b. after removing gloves, d. after contact with body fluids or excretions, mucous membranes, non-intact skin and/or wound dressings and e. if moving from a contaminated body site to a clean body site during resident care.
a. An observation of wound care by Nurse #5 on Resident #11 was made on 6/29/22 at 12:53 PM. Resident #11 had just received a shower wherein her wound dressing to each leg had been removed. Nurse #5 was observed washing both hands prior to putting gloves on to start the procedure. Nurse #1 proceeded to wipe Resident #11's wound to the back of her right leg with wound cleanser-soaked gauze, packed it with sodium hypochlorite-soaked gauze and covered the wound with a piece of calcium alginate. Without removing her gloves and doing hand hygiene, Nurse #5 proceeded to do the same dressing to the back of Resident #11's left leg. Nurse #5 wrapped the left leg with a roll bandage and secured it with tape. Then she applied a foam dressing to cover the wound on the right leg and wrapped it with a roll bandage and secured it with tape while using the same pair of gloves. After the procedure, Nurse #5 removed her gloves and washed her hands in the sink.
An interview with Nurse #5 on 6/29/22 at 5:44 PM revealed she was nervous while performing wound care on Resident #11 and forgot to change her gloves and do hand hygiene after removing her gloves. Nurse #5 stated she knew she was supposed to have done one leg at a time to prevent cross-contamination of the wounds. She also stated she was not used to doing wound care and had worked at facilities where they had a treatment nurse.
An interview with the Regional Director of Clinical Services (RDCS) on 6/30/22 at 6:59 PM revealed the Director of Nursing (DON) was responsible for infection control at the facility but he was currently unavailable for interview. The RDCS who was covering for the DON stated Nurse #5 should have provided wound care to Resident #11 by doing one leg at a time and she should have changed her gloves and washed her hands in between.
b. An observation of wound care by Nurse #3, accompanied by Unit Manager (UM) #1, was made on 06/30/22 at 11:10 AM. Nurse #3 was observed washing both hands with soap and water, dried them and donned her gloves. Nurse #3 removed her scissors from her pocket and proceeded to cut the old dressing off Resident #14's right leg. After removing the old dressing from the right leg, she removed her gloves and donned a new pair of gloves without washing or sanitizing her hands. Nurse #3 proceeded to wipe the opened blister wound on Resident #14's right leg with wound cleanser-soaked gauze, and patted it dry with clean, dry gauze. With the same scissors that had not been cleaned after taking off the old dressing, Nurse #5 cut the PolyMem dressing (non-adherent dressing that facilitates healing, relieves pain, and reduces inflammation to the wound bed) to fit the area of the wound. Nurse #5 then cut the ABD pad (abdominal gauze pad that absorbs wound drainage) to fit the area of the wound and placed it over the PolyMem and wrapped the leg with a roll bandage and secured it with paper tape. Without removing her gloves or performing hand hygiene she moved to Resident #14's left leg and used the same scissors to cut off the old dressing on the left leg. Without removing her gloves or sanitizing her hands she proceeded to clean the opened blister wound on the back of Resident #14's left leg with wound cleanser-soaked gauze, and patted it dry with clean, dry gauze. With the same scissors that still had not been cleaned, she cut the PolyMem dressing to fit the area of the wound on the left leg and placed it on the wound and the remaining ABD pad over the wound bed and wrapped the leg and wound with roll bandage and secured it with paper tape. Nurse #5 then removed her gloves washed her hands with soap and water and removed the remaining dressing items from the resident's room.
An interview on 06/30/22 at 2:04 PM with Nurse #5 revealed she did not realize she had not cleaned her scissors after cutting the old dressings off the resident's leg and before cutting the PolyMem dressing. She stated she knew she was supposed to clean them but forgot. Nurse #5 further stated she knew she was supposed to sanitize or wash her hands when taking off gloves and before putting on new gloves but was nervous and forgot to do so. She indicated she should have changed gloves when she moved from the right leg to the left leg but had forgotten to do that as well.
An interview on 06/30/22 at 4:17 PM with Unit Manager (UM) #1 revealed she noticed during the dressing change performed by Nurse #3 that she did not sanitize her hands between glove changes and that she had not cleaned her scissors after cutting off the old dressings and before cutting the dressing to fit Resident #14's wounds. UM #1 stated she also noticed Nurse #3 did not change her gloves or sanitize her hands when moving from the right leg wound to the left leg wound.
An interview with the Regional Director of Clinical Services (RDCS) on 6/30/22 at 6:59 PM revealed the Director of Nursing (DON) was responsible for infection control at the facility but he was currently unavailable for interview. The RDCS who was covering for the DON stated Nurse #3 should have provided wound care to Resident #14 by cleaning her scissors after removing an old dressing and before cutting a new dressing to be placed on the wound area and she should have changed her gloves and washed her hands in between clean and dirty procedures and when moving from one wound area to the next wound area.

Based on record review and staff interviews, the facility failed to implement their policy for all employees to be vaccinated or have an approved accommodation prior to employment and failed to have a process for tracking vaccination status for 3 of 5 staff members (Housekeeper #1, Housekeeper #2, and Nurse #14) reviewed for COVID-19 vaccination of facility staff. The facility was currently in outbreak status due to a staff member testing positive for COVID-19 on 06/23/22. All residents tested negative for COVID-19 on 06/24/22.
The findings included:
A review of the facility's Employee COVID-19 Vaccination Policy dated 05/21/21 and revised on 04/05/22 stated under the policy section that all employees were required to receive an FDA (Food and Drug Administration) authorized and/or approved COVID-19 vaccination as required by the Centers for Medicare and Medicaid Services (CMS), unless a reasonable accommodation from the requirement due to disability, medical condition, or sincerely held religious belief, practice or observance was requested and approved. Under the procedure section, the policy read in part, that all staff unless they receive an approved exemption (or a request is pending) or vaccine was temporarily delayed due to CDC (Centers for Disease Control and Prevention) recommendation (e.g., because of a recent COVID-19 infection) were to receive the first dose of the COVID-19 vaccine series before beginning employment. The policy further read, an employee who had received the first dose of a two-dose series but not the second dose must always wear an N95 and was required to be tested for COVID-19 twice weekly. After the employee received their second dose or a single dose of a one-dose series, they would follow the masking and testing rules of the facility. For a two-dose series, once an employee received the first dose of the COVID-19 vaccine the employee was required to then receive the second dose of the vaccine series timely per manufacturer guidelines. The employee would be removed from the schedule and placed on unpaid leave for failure to receive the second dose of the vaccine in a timely fashion. For applicants, they were notified of the vaccination policy prior to hire. After an offer of employment was made but prior to the individual starting work, the individual was required to provide proof of full vaccination or receive the first dose of COVID-19 vaccine series or request and receive an approved accommodation. The individual would not begin work until the first dose was received or an approved accommodation had been granted.
A review of the National Healthcare Safety Network (NHSH) data reported the week of 06/26/22 indicated 93.2% of the staff had completed COVID-19 vaccinations.
A review of the facility's COVID-19 Status for Providers listed 98 staff members and indicated one staff member was partially vaccinated and overdue for her second dose of a two-dose series (Nurse #14), two staff members were not vaccinated and had not applied for or received an accommodation (Housekeeper #1 and Housekeeper #2), and two staff members had received approved accommodations. The facility's vaccination rate with accommodations was 96.9%.
A phone interview on 06/30/22 at 10:45 AM with Nurse #14 revealed she had only had one dose of a two-dose series of COVID-19 vaccine. She stated her first dose was on 05/20/22 and she should have already gotten her second dose, but it had slipped her mind. Nurse #14 further stated she was scheduled to receive her second dose of the COVID-19 vaccination on 07/01/22 at the facility. She indicated she had worked at the facility with only one dose of the vaccine since 5/20/22 but stated she had worn an N95 mask and goggles while providing resident care.
A phone interview was attempted with Housekeeper #2 on 06/30/22 at 11:00 AM but her phone had been disconnected and the facility was unable to produce another contact number. Housekeeper #2 had not received any COVID-19 vaccinations according to the facility's records.
A phone interview on 06/30/22 at 11:10 AM with Housekeeper #1 revealed she was hired on 06/22/22 and had told the Director of Housekeeping during orientation that she was not vaccinated for COVID-19 but was willing to take the vaccination. She stated the Director of Housekeeping told her she could get her vaccine during the COVID-19 clinic at the facility. Housekeeper #1 further stated she had worked 6 days in a row since being hired and no one had said anything else to her until she was contacted by the Human Resources representative at the facility 06/29/22 and told she could not come back to work until she received her first vaccine on 07/01/22 at the facility. Housekeeper #1 indicated she had worn an N95 and goggles while working at the facility those 6 days.
The Infection Preventionist (Director of Nursing) was not available for interview during the survey.
An interview on 07/01/22 at 11:19 AM with the Administrator and Regional Director of Clinical Services (RDCS) revealed there was not a spreadsheet for staff like the one they had developed for residents which tracked vaccinations. The Administrator stated it was clear to her after this process of gathering pieces of information that it needed to be streamlined into a spreadsheet and one person given the responsibility of keeping up with the information. The RDCS indicated going forward they were going to put the information into a spreadsheet to help them keep track of everyone working in the building and to ensure they have everyone's vaccine status. According to the Administrator and the RDCS Housekeeper #1 and Housekeeper #2 should never have been hired prior to receiving their first dose of COVID-19 vaccine and said Nurse #14 should have been reminded her second dose of vaccine was overdue. The Administrator explained the scheduler was responsible for tracking vaccine status for agency staff, the Director of Nursing who served as the Infection Preventionist was responsible for tracking vaccine status for facility staff and the Human Resources representative was responsible for tracking vaccine status for vendors and providers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, and staff interviews, the facility failed to ensure resident privacy by not having a privacy curtain for 1 of 1 resident (Resident #58) reviewed for privacy.
The findings included:
Resident #58 was admitted to the facility on [DATE].
Review of Resident #58's quarterly Minimum Data Set (MDS) assessment revealed she was moderately cognitively impaired.
Observation and interview on 06/27/22 at 10:34 AM revealed Resident #58 had no privacy curtain around her bed. The resident stated it had been that way for a long time, maybe several months. She stated they had taken it down to wash it and never brought it back and hung it back up. Resident #58 stated she received bed baths in her room when the Nurse Aides (NAs) did not have time to take her for a shower and they pulled the curtain between the resident and her roommate but there was no curtain to pull around her bed on her side of the room.
Observation on 06/28/22 at 8:30 AM revealed there was no privacy curtain around 401-W to allow for her privacy.
Observation on 06/29/22 at 2:30 PM revealed there was no privacy curtain around 401-W to allow for her privacy.
Observation on 06/30/22 at 9:20 AM revealed there was no privacy curtain around 401-W to allow for her privacy.
Interview on 06/30/22 at 2:26 PM with the Director of Housekeeping revealed he expected all rooms to have privacy curtains around the beds and was not aware there was not a privacy curtain around Resident #58's bed. The Director of Housekeeping stated he depended on the housekeepers and other staff to make him aware of any rooms needing privacy curtains. He further stated angel rounds were made on residents each day by department heads and no privacy curtain is something they should have noticed and reported. The Director of Housekeeping indicated it was unacceptable for residents not to have privacy curtains.
Interview on 07/01/22 at 11:31 AM with the Administrator revealed she was not aware Resident #58 did not have a privacy curtain around her bed. The Administrator stated privacy curtains was one of many things angel rounds were supposed to notice and report. She explained that angel rounds were rounds made by department heads to check on residents and ask how they were doing, if they needed anything, and a general look at their room to be sure it was clean and there were no needs expressed by the resident. The Administrator indicated housekeeping and other staff that are in and out of the room should have noticed and reported the resident not having a privacy curtain around her bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to implement an effective pest control program to control the presence of flies in the hallways and resident rooms. This was evident in 1 of 2 resident care halls downstairs (400-hall) and 1 of 12 rooms (room [ROOM NUMBER]).
The findings included:
An observation on 06/27/22 at 12:16 PM revealed a fly in room [ROOM NUMBER] flying around both residents (Resident #39 and Resident #10) while they were eating their lunch.
An observation on 06/28/22 at 11:37 AM revealed a fly in room [ROOM NUMBER] flying around the room while the residents were in their room talking with one another and watching TV.
An observation and interview on 06/29/22 at 11:45 AM revealed a fly in room [ROOM NUMBER] flying around the room. Resident #39 and Resident #10 stated there was always a fly in their room and it tried to pitch on anything they were eating and both residents stated they were aggravated they had a fly in their room trying to get on their food. Resident #39 stated she had mentioned having a fly in their room to Nurse Aide (NA) #9 today. Resident #39 indicated they had flies in the hall and in their room quite often but could not recall exactly how long they had been bothered with them.
An interview on 06/29/22 at 5:04 PM with NA #9 revealed she had seen flies in several of the rooms on the 400 hall and said Resident #39 had complained to her about flies in her room just today. NA #9 stated she had reported it to Nurse #12.
An observation on 06/29/22 at 3:50 PM revealed a fly in the 400-hall flying around outside the Assistant Director of Nursing's (ADON) office.
An interview on 06/29/22 at 3:59 PM with Unit Manager #1 revealed she had observed a fly in the 400-hall outside the ADONs office and observed the fly in the office.
A follow up interview on 06/30/29 at 4:12 PM with Unit Manager (UM) #1 revealed it had been reported to her on 06/29/22 by Nurse #12 there were several rooms on the 400-hall with flies in their room. One of the rooms mentioned was room [ROOM NUMBER] where Resident #39 and Resident #10 resided. UM #1 stated there were a lot of flies out where the employees go to smoke and there was a resident who often opened the door leading out to that smoking area. UM #1 further stated she suspected that was where the flies were coming from on the 400-hall. UM #1 indicated they had problems with flies especially in the summer, but they were treated and said it was probably time for another treatment with the pesticide company. She stated she discussed the reports of flies with the management team at their evening staff meeting on 06/29/22 and the Maintenance Director was going to spray the hall and rooms and if that didn't take care of the flies, he was going to contact the pesticide company for recommendations and treatment.
An interview on 07/01/22 at 9:52 AM with the Maintenance Director revealed he had been at the facility for 2 months in his role. He stated it had been reported to him during an evening staff meeting on 06/29/22 that there were flies observed on the 400 hall and in some of the resident rooms. The Maintenance Director further stated he had been on the 400 and 500 hall and only saw flies near the 500-hall exit door and had found a barrel of trash outside the door and took it to the dumpster and told staff to keep all trash away from the hallway doors. He indicated he had informed the department heads on 06/30/22 at a staff meeting if they saw any more flies to let him know and he could spray for them. The Maintenance Director further indicated there were no fly lights at the exit doors to the building to prevent them entering the building. He explained the facility had a contract with an insecticide company for monthly maintenance and if his spraying for the insects did not get rid of them, he would contact the company to come treat for flies.
An interview on 07/01/22 at 11:24 AM with the Administrator revealed she was not aware there were issues in the building with flies until it was mentioned in a staff meeting on 06/29/22 and the Maintenance Director was spraying the hall and would spray specific rooms for flies. She stated it was her expectation that observations of any insects be reported immediately to the Maintenance Director so he can take care of the issue immediately. The Administrator further stated any staff member could report sightings of insects to the Maintenance Director or the Maintenance Assistants so they could take care of the problem. She indicated she expected all halls and rooms to be free of all insects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to document a resident's change in condition requiring hospitalization for 1 of 1 sampled resident (Resident #67). The facility also failed to maintain accurate Treatment Administration Records (TAR) related to the application of hand splints and administration of oxygen for 2 of 3 sampled residents (Residents #11, and #72).
The findings included:
1. Resident #67 was admitted to the facility on [DATE] with diagnoses that included diabetes and hemiplegia and hemiparesis (weakness or complete paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side.
Review of Resident #67's medical record revealed she was sent out to the hospital on [DATE] for evaluation, admitted for treatment and returned to the facility on [DATE].
Review of Resident #67's nurse progress notes revealed no entry dated 06/19/22 describing Resident #67's change in condition, why she was transferred to the hospital, what time she left the facility or who was notified. The only nurse progress noted regarding Resident #67's hospital transfer was an entry dated 06/24/22 that read in part, Resident #67 returned to the facility at 2:15 PM following hospitalization for altered mental status.
During an interview on 07/01/22 at 10:10 AM, Unit Manger (UM) #1 stated when residents were sent out to the hospital for evaluation, nursing staff should enter a progress note that included a description of the resident's change in condition, reason for the hospital transfer, when the physician or Nurse Practitioner were notified, vitals, and what time the resident left the facility. UM #1 reviewed Resident #67's medical record and confirmed there was no progress note or assessment completed on 06/19/22 to indicate why or what time she was sent out to the hospital.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated she would have expected for the nurse to have documented Resident #67's change in condition in a progress note or assessment to indicate the reason for the hospital transfer, who all were notified, and the time she left the facility.
2. A physician order dated 1/2/20 in Resident #72's medical record indicated an order for nurse to ensure that left hand splint was applied every evening shift at bedtime. Document any refusals.
Resident #72's Treatment Administration Record (TAR) for June 2022 revealed an order for: Apply left hand splint at bedtime. Nurse to ensure that left hand splint was applied every evening shift at bedtime. Document any refusals. It was documented as having been applied at 9:00 PM on 6/26/22 by Nurse #9 and on 6/27/22 and 6/28/22 by Nurse #8. No refusals were documented on the TAR.
An interview with Nurse #8 on 6/29/22 at 7:00 AM revealed she worked with Resident #72 on 6/27/22 and 6/28/22 from 7:00 PM to 7:00 AM. Nurse #8 stated she thought the nurse aides were supposed to be applying Resident #72's left hand splint whenever she went to bed. Nurse #8 stated she couldn't remember if she had checked behind them to make sure her left hand splint was on. She knew they were supposed to remove it whenever they got her out of the bed, but she hadn't gotten around to checking if she even had them on from the night before. She couldn't remember why she had documented that Resident #72 had her splint on without checking it first.
A phone interview was attempted on 6/30/22 at 11:13 AM, 7/1/22 at 9:07 AM and 7/1/22 at 9:23 AM with Nurse #9 with no return call.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed the nurses should have applied Resident #72's left hand splint as ordered by the physician and documented accordingly.
3. A physician order dated 4/8/22 for Resident #11 indicated oxygen therapy at 1.5 liters per minute via nasal cannula every shift.
Resident #11's Treatment Administration Record (TAR) for June 2022 included an order for oxygen therapy at 1.5 liters per minute via nasal cannula every shift. The TAR indicated that oxygen was administered to Resident #11 at 1.5 liters per minute on 6/27/22 and 6/28/22 on day shift by Nurse #5 and on 6/28/22 on the night shift by Nurse #8.
An interview with Nurse #5 on 6/29/22 at 5:44 PM revealed she worked on 6/27/22 and 6/28/22 with Resident #11 but didn't remember looking at the rate at which her oxygen tank or oxygen concentrator had been set on. Nurse #5 stated she checked to make sure the oxygen tank had enough oxygen left and the humidifier on the concentrator had enough fluid. Nurse #5 couldn't explain why she had documented giving Resident #11 oxygen at 1.5 liters per minute when it wasn't the rate it had been set at.
An interview with Nurse #8 on 6/29/22 at 7:00 AM revealed she remembered checking Resident #11's oxygen saturation before midnight and it was between 93% and 95% but she couldn't remember if she had her oxygen on at that time. Nurse #8 stated she was not sure whether Resident #11 was supposed to receive continuous oxygen because it was not specified in the order. Nurse #8 stated she remembered the oxygen concentrator not being on when she came in at 7:00 PM the night before and she also remembered the nurse from the day before telling her that she had just changed Resident #11's oxygen tubing and nasal cannula. Nurse #8 stated she couldn't remember why she had documented Resident #11 had received oxygen when it had been off the whole night shift.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed the nurses should have made sure Resident #11's oxygen was delivered per physician's order and documented according to what they had administered to Resident #11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to treat residents in a dignified manner when 1 of 4 residents (Resident #39) was not provided toileting before wetting herself, her clothing and the floor, and failed to provide incontinence care to 1 of 4 residents prior to the resident (Resident #10) wetting through her brief and through her clothing onto her bed pad.
The findings included:
1. Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atherosclerotic heart disease, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, and muscle weakness.
Review of Resident #39's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate vision, was cognitively intact and required extensive assistance of 2 staff members with transfers and toileting. The MDS also revealed Resident #39 was occasionally incontinent of bowel and bladder.
Review of Resident #39's physician orders for June 2022 revealed the following order:
Furosemide 20 milligrams (mg) by mouth every morning.
Review of Resident #39's care plan dated 06/09/22 revealed a focus area for resident having a self-care deficit and requiring up to extensive assistance with activities of daily living related to generalized, chronic weakness, debility secondary to multiple diagnoses and neuropathy. The interventions included assistance of 2 staff with toileting, promote independence and provide positive reinforcement for all activities attempted, refer to therapy (physical therapy (PT), occupational therapy (OT), and speech therapy(ST)), and transfers with sit to stand lift.
An observation and interview on 06/27/22 at 12:16 PM revealed Resident #39 in her wheelchair in her room. The resident stated about a week ago she had put on her call light for assistance to the bathroom (could not remember the time or day) and stated it was 45 minutes before anyone came to answer the light. She stated she had timed the response by the clock on the wall in her room. The resident further stated when the Nurse Aide (NA) (could not remember her name) responded and assisted her up on her feet she wet herself and her clothing and the floor where she was standing. She stated it made her feel like crap. Resident #39 indicated she knew when she had to go to the bathroom and did not want to lose her continence because she had to wait for assistance to the bathroom.
A phone interview was attempted on 06/29/22 at 9:20 AM, 06/29/22 at 5:00 PM and 06/30/22 at 12:00 PM with NA #15 who had taken care of Resident #39 with no return call.
An interview on 07/01/22 at 11:18 AM with the Administrator and Regional Director of Clinical Services revealed they expected all residents to be treated with respect and dignity. The Administrator stated it was her expectation that residents be toileted in a timely manner and said no one should have to wait 45 minutes for assistance with toileting.
2. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type II diabetes, hypertension, cardiac arrhythmia, generalized weakness and debility.
Review of Resident #10's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required total assistance of 2 staff with transfers, and extensive assistance of 2 staff with toileting. The MDS also revealed she was always incontinent of bowel and bladder.
Review of Resident #10's care plan dated 06/22/22 revealed a focus area for resident having a self-care deficit requiring assistance with activities of daily living related to generalized weakness and debility. The interventions included assistance of 2 staff with toileting, promote independence, provide positive reinforcement for all activities attempted, refer to therapy PT, OT and ST and transfer with total lift.
An interview on 06/27/22 at 12:22 PM with Resident #10 revealed Nurse Aides (NAs) would come into her room when she rang her call light to have her brief changed and turn the light off without providing incontinence care. She stated there had been days she had gone all day without being changed and had wet through her pants and said this had happened several times last week. She stated it last happened on Saturday during the day shift and the NAs had to change her pants because she had wet through them. She stated it made her feel like they had forgotten about me and my needs.
A phone interview was attempted on 06/29/22 at 9:20 AM, 06/29/22 at 5:00 PM and 06/30/22 at 12:00 PM with NA #15 who had taken care of Resident #10 with no return call.
An interview on 07/01/22 at 11:18 AM with the Administrator and Regional Director of Clinical Services revealed they expected all residents to be treated with respect and dignity. The Administrator stated it was her expectation that residents be provided incontinence care every 2 hours and as needed and said no one should be wetting through their clothing waiting on care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident and staff interviews, the facility failed to provide a resident written notification explaining the reason for a room change and failed to provide the resident with the opportunity to see the new room location and meet the new roommate prior to the room change for 1 of 1 sampled resident (Resident #38).
Findings included:
Resident #38 was admitted to the facility on [DATE].
The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #38 with moderate impairment in cognition. The MDS indicated Resident #38 could make herself understood and was able to understand others.
Review of Resident #38's medical record revealed she was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 06/09/22. There was no evidence in the medical record that Resident #38 was provided a written notice of the room change.
During an interview on 06/27/22 at 12:42 PM, Resident #38 stated when she was moved to room [ROOM NUMBER], she was not informed she would be changing rooms until the day she was moved. Resident #38 added she was not provided the opportunity to see the new room location or meet her new roommate prior to the move. Resident #38 stated she was not informed why she was moving to a new room and when she asked the SW, she was told it was because she had requested to move. Resident #38 voiced she never asked to move to another room.
A staff progress note written by the Admissions Director on 06/29/22 at 12:30 PM read in part, Late entry: When Admissions Director spoke to Resident #38 regarding room change to 502 on 06/09/22 she was agreeable and requested to be placed on a list for 200 hall. Was explained she was 3rd in line and she was agreeable. Social Worker (SW) will assist as needed.
During an interview on 06/29/22 at 11:24 AM, the SW explained the Admissions Director completed resident room changes and typically typed up a notice to give to staff to make them aware of the room change and notified the resident and/or family. The SW stated the rooms located on 100 Hall, where Resident #38 previously resided, were reserved for residents newly admitted to the facility that require isolation related to COVID-19 and/or rehab services. She added residents were informed upon admission if they needed a long-term bed, they would have to move to a room on another hall; however, if the resident did not want to move to a particular room, they could remain in the room on 100 Hall until another room was available. The SW recalled when Resident #38 resided on 100 Hall, she did not like having so many new roommates and had requested a more permanent room on another hall. The SW was not sure if the Admissions Director discussed the room change with Resident #38 or took her to see room [ROOM NUMBER] and meet her new roommate prior to the room change on 06/09/22.
During an interview on 06/29/22 at 5:22 PM, the Admissions Director recalled on 06/09/22 she had discussed the room change with Resident #38. The Admissions Director explained she did not take Resident #38 to see the room, meet her new roommate or provide her with a written notice prior to the room change since Resident #38 had been agreeable to the move.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated when contemplating a room change, staff were expected to discuss the room change with the resident and take the resident to tour the new room prior to the move to see if the resident had any concerns. The Administrator added residents should be given the choice as to whether or not they wanted to change rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interviews the facility failed to honor a resident's preference for their scheduled shower days for 1 of 6 residents (Resident #34) reviewed for Activities of Daily Living (ADL).
The findings included:
Resident #34 was admitted to the facility on [DATE] with diagnosis which included muscle weakness.
Review of Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact and required limited assistance and set up only with bathing.
Review of the bathing schedule for the facility revealed Resident #34 was scheduled for showers on Tuesdays and Fridays during the second shift.
Review of Resident #34's bathing chart revealed no evidence Resident #34 received a shower on any Sunday in the month of June 2022.
An interview conducted with Resident #34 on 6/28/22 at 8:50 AM revealed she had gone to dialysis on Mondays, Wednesdays, and Fridays. Resident #34 further revealed she received showers on Tuesdays and Fridays on second shift but preferred an additional shower on Sundays before her dialysis appointment on Monday. Resident #34 stated she had requested multiple times to receive a shower on Sundays but rarely got one.
An interview conducted with Nurse Aide (NA) #10 on 6/29/22 at 11:50 AM revealed Resident #34 had requested for showers on Sundays. NA #10 further revealed Resident #34 needed little assistance with showers but they were unable to give the shower on Sundays due to a shortage of staffing on weekends.
An interview conducted with NA #3 on 6/30/22 at 10:15 AM revealed Resident #34 had requested to receive a shower on Sunday before her dialysis appointments on Monday. NA #3 further revealed several Sundays Resident #34 did not receive a shower because there was not enough staff. NA #3 stated she had failed to report to the Unit Manager that Resident #34 preferred a shower on Sundays.
An interview conducted with the Unit Manager on 6/30/22 at 2:05 PM revealed she was not aware Resident #34 had requested for an additional shower on Sundays. The Unit Manager further revealed Resident #34 needed little assistance and she expected for Resident #34 to receive an additional shower on Sundays if it was preferred.
An interview conducted with the Administrator on 7/1/22 at 12:35 PM revealed she was unaware Resident #34 had not received showers on Sundays. The Administrator further revealed she expected for Resident #34 to receive a shower on Sunday if it was preferred and she would add Sundays to Resident #34's shower schedule.

Based on record review, resident and staff interviews, the facility failed to document, resolve and communicate the facility's efforts to address repeated concerns voiced during Resident Council meetings for 7 of 7 residents who regularly attended the monthly meetings (Residents #10, #13, #16, #29, #34, #39, and #72).
Findings included:
During a Resident Council group interview conducted on 06/30/22 at 2:33 PM, residents all reported an ongoing issue with the resolution of concerns voiced during Resident Council meetings. The residents all stated they felt facility staff did not address their concerns as they had to bring up the same issues month after month. The residents all agreed the main issues they repeatedly brought up during monthly Resident Council meetings were regarding the quality of food served and staffing, such as having to wait long periods of time for assistance with toileting and not receiving bathing assistance regularly.
The facility's grievance/concern logs for the period July 2021 through June 2022 were reviewed. Concerns filed on behalf of the members of the Resident Council were recorded as follows: September 2021 related to laundry, October 2021 related to meals and laundry, April 2022 related to food, laundry, call lights and restorative nursing, and May 2022 related to melted ice cream on meal trays, medication administration and not receiving fresh ice water during each shift.
The Resident Council minutes for the period July 2021 through June 2022 were reviewed and revealed no documentation of concerns voiced by residents attending the monthly meeting. In addition, there was no documentation indicating the facility's response to concerns investigated were discussed with the members during subsequent Resident Council meetings.
During an interview on 06/30/22 at 3:33 PM, the Activity Director (AD) confirmed either she or the Activities Assistant attended and recorded the minutes for the Resident Council monthly meetings. The AD explained when residents voiced concerns and/or issues during the monthly meetings, she wrote them on a concern form and delivered the form to the Social Worker or Administrator who distributed them to the appropriate department manager to investigate. She explained once the resolution to the concern was provided to her, she reviewed it with the Resident Council at the next scheduled meeting. The AD confirmed the residents who regularly attended Resident Council meetings brought up the same concerns month-to-month, mainly related to staffing and food. The AD shared she did not write down the specific concerns or resolution on the monthly minutes but did verbally discuss with the residents what was or had been done to address their concerns.
During an interview on 07/01/22 at 11:20 AM, the Administrator explained resident concerns voiced during Resident Council meetings were submitted to her or the SW on a concern form, given to the appropriate department manager to address, and resolution discussed with the members of the Resident Council at the next monthly meeting. The Administrator stated she was aware of the repeated concerns residents had voiced related to food and care not being provided timely and voiced the residents should not have to bring up the same concerns over and over. She explained a lot of the resident concerns dealt with staffing and they were actively hiring Nurse Aides but were not having as much luck finding Nurses. The Administrator stated she would expect for the minutes to include what concerns were voiced or resolved from meeting to meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 13 sampled residents reviewed for advanced directives (Resident #60).
Findings included:
Resident #60 was admitted to the facility on [DATE] with multiple diagnoses that included atrial fibrillation (an irregular, often rapid heart rate), coronary artery disease (heart disease), and adult failure to thrive.
Review of Resident #60's physician's orders revealed an active order for a DNR code status effective 05/20/22.
The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #60 with intact cognition.
Resident #60's advanced directive care plan, last reviewed/revised on 06/06/22, revealed his wishes would be honored relative to a Do Not Resuscitate (DNR) code status.
A Full Measures document, dated and signed by Resident #60 on 06/06/22, read in part this resident does not currently have a DNR order in effect and is to receive Full Measures, meaning if the resident were to need emergency medical treatment, facility staff is to provide resuscitative, life-sustaining and/or life-support services.
Review of Resident #60's Electronic Medical Record (EMR) on 06/28/22 at 4:50 PM revealed his code status was listed as DNR on the profile page.
Review of the Code Status notebook located at the nurses' station on 06/30/22 at 5:00 PM revealed a Full Measures document for Resident #60 with an effective date of 06/06/22.
During an interview on 06/30/22 at 6:12 PM, Unit Manager (UM) #2 explained when residents were admitted to the facility, an order for code status was entered into the resident's EMR based off the information received from the hospital. She added the Admissions Director would later review code status with the resident and/or their representative when completing the admission paperwork, scan the updated form for DNR or Full Measures into the resident's EMR, place a hard copy in the Code Status notebook and notify the UM or nurse to enter a physician's order. UM #2 confirmed the active physician's order for Resident #60's DNR code status dated 05/20/22 conflicted with the Full Measures document signed by Resident #60 on 06/06/22 and filed in the Code Status notebook. The UM #2 explained if the EMR and Code Status notebook conflicted, nursing staff would follow the code status with the most recent effective date. UM #2 was unaware of the conflicting code status orders for Resident #60 and stated his code status should have been updated on 06/06/22 to reflect his wishes for Full Measures.
During an interview on 06/30/22 at 6:49 PM, the Admissions Director explained when a resident admitted to the facility, the admitting nurse entered the resident's code status into their EMR based on the paperwork received from the hospital. When she met with the resident and/or their representative to complete the admission paperwork, their preference for code status was discussed and new documents were filled out according to the resident's wishes. She then scanned the signed code status documents into the resident's EMR, filed an updated copy in the Code Status notebook located at the nurses' station and informed the administrative team via group text message for the appropriate nurse/manager to update the resident's code status order in the EMR. The Admissions Director could not recall for certain if she had sent a group text message on 06/06/22 informing the administrative team Resident #60's code status changed to Full Measures per his request.
During an interview on 06/30/22 at 6:30 PM, the Administrator stated the initial order for a resident's code status was entered into their EMR based off the information received from the hospital; however, a resident could decide to change their code status at any time and their preferences would be honored. The Administrator stated Resident #60's code status should have been updated in both his EMR and the Code Status notebook to accurately reflect his code status preference when he signed the Full Measures paperwork on 06/06/22.
During a follow-up interview on 07/01/22 at 11:20 AM, the Administrator stated it was her expectation the code status in a resident's EMR and the Code Status notebook matched and were consistent with the resident's preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral osteomyelitis. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36).
Immediate Jeopardy began on 3/3/22 when the facility failed to notify the physician or Nurse Practitioner and obtain treatment orders for new pressure ulcer identified on Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.
The findings included:
Resident #36 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness, spinal stenosis, atherosclerotic heart disease, hypertension and history of transient ischemic attack and cerebral infarction. She was recently re-admitted on [DATE] from the hospital due to acute encephalopathy and advanced Parkinson's disease.
An admission Skin Evaluation completed by Nurse #1 on 3/3/22 indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place.
An interview with Nurse #1 on 6/28/22 at 3:10 PM revealed she observed an open area on Resident #36's sacrum on 3/3/22 which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment, so she applied zinc oxide and covered it with a foam dressing to both sacrum and left lower buttock. Nurse #1 stated she thought the pressure ulcer required a different treatment, but she could not remember if she had notified the physician or the Nurse Practitioner about the pressure ulcer and she did not obtain an order.
Resident #36's Treatment Administration Record for March 2022 indicated no treatment orders for Resident #36's sacral pressure ulcer until 3/10/22 when Unit Manager #1 initiated the following treatment order: Cleanse area to coccyx with wound cleanser. Apply (brand name) occlusive dressing and cover with foam every 3 days.
An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed she couldn't remember if she had been made aware of an open area on Resident #36's sacrum upon her re-admission to the facility on 3/3/22 and she was not sure if she had checked her re-admission orders. UM #1 stated she remembered Resident #36's family member telling her to make sure they kept an eye on her sacrum because an area on her sacrum had opened when she came back from the hospital. UM #1 stated she didn't get around to assessing Resident #36's sacrum until 3/10/22 when Nurse Aide (NA) #1 reported to her that Nurse #3 had been asking her to apply a foam dressing to Resident #36's sacrum and buttocks without the nurse checking the area first. UM #1 stated she observed necrotic tissue covering the ulcer, but she couldn't tell how big it measured. The ulcer did have some drainage but did not have foul odor. UM #1 stated she thought the nurses could initiate wound care orders without consulting with the physician first and she decided on the occlusive dressing based on her previous experience with wound care. UM #1 further stated she did not notify the physician, the Nurse Practitioner, or the Wound Physician Assistant (PA) and just included Resident #36 in the list of residents to be seen by the Wound PA on his next visit at the facility.
An interview with Nurse #3 on 6/30/22 at 1:59 PM revealed she couldn't remember doing a skin evaluation on Resident #36, but she had seen her sacral wound progress from being a quarter-sized stage 1 pressure ulcer to being covered with a black necrotic tissue. Nurse #3 stated she didn't think she was the first nurse who had discovered the black necrotic tissue, so she didn't think about reporting this to anybody.
A phone interview with Resident #36's family member on 6/27/22 at 4:33 PM revealed she didn't find out about Resident #36's worsened pressure ulcer until 3/14/22 when a nurse aide asked her if she had seen Resident #36's bottom recently. Resident #36's family member stated, it looked terrible, it had an odor and looked deep. She said she informed UM #1 that she wanted the wound clinic to look at Resident #36, but she was told that they were going to get the in-house wound care provider to look at her.
A phone interview with the Wound Physician Assistant (PA) on 6/30/22 at 4:56 PM revealed he did not get consulted when an open area was first noted on Resident #36's sacrum on 3/3/22 nor when they started treatment on Resident #36's sacral pressure ulcer on 3/10/22 when it got worse. On 3/31/22, he noted an increase in drainage, so he did a wound culture and sensitivity after he debrided the wound. He was informed at the facility when he came back on 4/7/22 that the laboratory had discarded the swab from the week before because they used the wrong tube, so he obtained another one due to the wound's continued decline and it had started undermining. (Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge). When he came back on 4/14/22, he found out that Resident #36 had been to the Wound Center, so he discharged her from her care. He didn't hear back about the last wound culture and sensitivity done on 4/7/22 and assumed it was discarded again by the laboratory. He said if he obtained the result from the first wound culture sooner, it could have made a difference in treating Resident #36's pressure ulcer if the infection was superficial.
An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed the first time the Wound PA obtained the wound culture; she was notified by the laboratory that they had to discard it because they couldn't run it due to it being too dry. UM #1 did not notify the Wound PA until the next week when he came back and performed a second wound culture. UM #1 was again informed by the laboratory that they had to discard it because they used the wrong swab. UM #1 did not think to notify the Wound PA about the wound culture not being done a second time, but she called the laboratory twice to request for the appropriate culture swabs.
An interview with the Nurse Practitioner (NP) on 6/29/22 at 3:10 PM revealed she became aware of Resident #36's sacral pressure ulcer on 4/11/22 when her family member texted her and asked her if Resident #36 could be seen by the Wound Center. The NP checked the electronic results for the laboratory and found wound cultures on 4/1/22 and 4/8/22 that were originally ordered but had been marked out. The NP stated the facility had been having problems with laboratory tests getting missed and not getting followed through. The NP also stated she was aware that Resident #36's pressure ulcer progressed quickly but she was not aware that Resident #36 did not have a treatment order for the wound prior to the Wound PA seeing her. The NP stated the facility physician usually ordered a treatment for a newly identified wound until the resident was seen by the Wound PA, but she was not sure why she didn't get notified of Resident #36's pressure ulcer that was noted on 3/3/22. The NP stated the nurses should have notified her on 3/3/22 when they noted a pressure ulcer on Resident #36's sacrum so a treatment could have been started while they were waiting for her to be seen by the Wound PA.
The Report of Consultation from the Wound Center dated 4/13/22 for Resident #36 indicated a stage 4 pressure ulcer to the sacrum which measured 2.2 cm in length, 2 cm in width and 2.1 cm in depth. Treatment was changed to skin prep to peri wound, antimicrobial gel wet to dry using 2 inch rolled gauze to pack wound, cover with 4x4 gauze, abdominal pad, and tape. Change daily and as needed for soiled or loose dressing. Referral to an Infectious Disease specialist. Bone culture and pathology done. Prescription for (brand name) antibiotics sent to the facility. Facility to order pressure relief cushion and specialty air mattress.
An Infectious Disease Visit Note dated 4/25/22 in Resident #36's medical record indicated Resident #36 was seen for sacral osteomyelitis. Bone biopsy was positive for Morganella. (Morganella is a species of gram-negative bacteria known to be a causative organism of opportunistic infections in wound infections.) Intravenous antibiotics were ordered. Resident #36 was currently using a wound vac (vacuum-assisted closure of a wound), had gotten an air mattress, and was waiting on a pressure relief cushion for her wheelchair.
The Administrator was notified of Immediate Jeopardy on 7/1/22 at 1:03 PM.
The facility provided the following IJ Removal Plan with the correction date of 7/3/22.
*Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:
Facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36. The nurse who completed the admission assessment on Resident #36 and did not notify the physician or Nurse Practitioner of the pressure ulcer or obtain treatment orders. Resident #36's wound deteriorated over seven days to a stage 4 and there was no notification to the physician or Nurse Practitioner.
Facility completed a total body skin assessment and record review on all current residents on 7/1/22 by the unit managers to find no missed notifications or deterioration of residents' wounds, pressure sores or changes in skin integrity.
An assessment of Resident #36 revealed on 7/2/22, that there was no further deterioration on the wound, treatment orders in place per physician order, resident being followed by the local wound care clinic.
*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.
Regional Director of Clinical Services (RDCS) completed education to Director of Nursing (DON) and unit managers (UM) on 7/1/22. The facility process is as follows: a. Licensed nurse completes admission skin assessment, and weekly skin assessment in electronic medical record; b. If any deterioration of skin area or new area observed, the licensed nurse notifies and documents physician or Nurse Practitioner immediately and obtains treatment orders, c. Licensed nurse is to complete notification and documentation of responsible party, d. Notification of DON and/or unit managers by calling or tiger texting (which is a secure web-based communication).
All licensed nurses including agency nurses were in-serviced by 7/2/22 from DON or unit manager on completing and documenting admission skin assessments and weekly skin assessments. Licensed nurses are responsible for immediate notification of physician or Nurse Practitioner when they observe any deteriorating wound/pressure ulcer, new wounds/pressure ulcers, or significant change in condition and obtaining physician orders for treatments. Facility requires that all licensed nurses or agency licensed nurses notify and document significant changes in residents' condition, new wounds, or changes in pressure ulcer condition. Licensed nurses are responsible for notification and documentation of responsible party. Licensed nurses are responsible for notification to DON/UM via call or tiger texting.
Nurse aides including agency nurse aides have been in-serviced by 7/2/22 by DON/designee on reporting any change in resident condition, such as skin conditions, poor intake, no urine output, observation of new areas to skin, mental status changes, physical abilities, and breathing changes to the licensed nurse immediately.
DON is responsible for tracking nurses and nurse aides including agency that have received education. The DON/UM are responsible for providing education to current nurses and nurse aides who were not in-serviced by 7/2/22. Nurses and nurse aides will not be allowed to work until they receive education.
New nurses and nurse aides hired after 7/2/22 will receive education during orientation.
Beginning the week of 7/4/22, the DON or designee will review five random resident's medical record per week for any change in resident condition, such as skin conditions, poor intake, no urine output, observation of new areas to skin, mental status changes, physical abilities, and breathing changes to ensure any negative changes have been communicated to the physician/Nurse Practitioner.
The alleged date of IJ removal is 7/3/22.
The credible allegation for the immediate jeopardy removal was validated on 7/7/22 with a removal date of 7/3/22.
A review of in-service education records from 7/1/22 to 7/2/22 revealed education was provided to nurses and nurse aides on topics that included reporting any changes in the residents' baseline condition such change in vital signs, change in activity, and change in daily habits to the nurse. Any new orders, changes in residents' conditions, reports, skin integrity issues and laboratory results that have not been addressed need to be communicated timely to the physician/Nurse Practitioner, family, and the Director of Nursing.
Interviews with the nursing staff revealed they had been educated on when to report a resident's change in condition as well as who to report the change in condition to. They also verbalized the different signs of changes and what observations to look for while working with the residents at the facility. The nurses stated they had been educated on notifying the physician of changes such as a new pressure wound or open area, any signs of wound infection and any wound deterioration.
The laboratory book was observed at the nurses' station, and it included an audit tool that included information on the resident's name, laboratory test order date, laboratory test ordered, date the results were obtained, any critical laboratory test results and the date and time the medical provider was notified.

Based on observation and staff interviews, the facility failed to protect the private health information for 1 of 7 sampled residents (Resident #17) for medication administration by leaving confidential medical information unattended and exposed in an area accessible to the public on 1 of 4 medication carts (100 hall).
The findings included:
A continuous observation was made on 6/29/22 from 8:30 AM to 8:36 AM of an unattended medication cart (100 hall medication cart) parked in the hallway in front of Resident #233's room. Nurse #7 left the MAR (Medication Administration Record) visible on the medication cart computer when she went into Resident #233's room. During the observation, the MAR for Resident #233 showed a picture of the resident, her room number, list of her medications and diagnoses on the computer screen which were exposed for others to read and were not covered up. During this time, a housekeeper was observed in the hallway right next to Resident #233's door.
On 6/29/22 at 8:37 AM, Nurse #7 exited Resident #233's room and stood in front of the 100 hall medication cart. Nurse #7 stated she knew she shouldn't have left the computer screen open, but she had to go into Resident #233's room and talk to the resident about letting the nurse aides get her up. Nurse #7 stated she realized that she had to maintain privacy and confidentiality of Resident #233's medical information and to not leave it exposed for other people to read.
An interview with the Administrator on 7/1/22 at 3:41 PM revealed she had expected the nurses to maintain confidentiality of medical records by minimizing the computer screen or locking it before stepping away from it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accept a resident back into the facility upon her arrival from the hospital, resulting in the resident being transported back to the hospital that was located approximately 1 ½ hours from the facility for 1 of 2 sampled residents reviewed (Resident #379).
Findings included:
Resident #379 was admitted to the facility on [DATE] with multiple diagnoses that included adult failure to thrive, severe-protein calorie malnutrition, and burns involving 60-69 percent (%) of body surface with 50-59% 3rd degree burns.
The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #379 with intact cognition. The MDS noted Resident #379 reported frequent pain at a level of 9 (numerical rating scale of 1 to 10 with ten being the most severe) that made it hard for her to sleep at night and limited her day-to-day activities due to the pain.
Review of Resident #379's medical record revealed she was discharge to the hospital on [DATE].
A hospital Discharge summary dated [DATE] read in part, A Percutaneous Endoscopic Gastrostomy (PEG tube which is the placement of a feeding tube through the skin and the stomach wall directly into the stomach) was recommended in the temporary short-term until her oral intake improved. Resident #379 and family member in agreement and PEG tube placed on 11/08/21. Diet at discharge: soft-mechanical diet with tube feeds. Will discharge to Skilled Nursing Facility (SNF) on Tuesday, 11/09/21.
A hospital progress note dated 11/10/21 read in part, Resident #379 was discharged on 11/09/21 to the SNF. On arrival to the SNF, she was sent back to us due to the PEG-tube. The SNF stated they could not manage her PEG-tube.
Review of Resident #379's medical record revealed she was readmitted to the facility from the hospital on [DATE].
Resident #379 discharged to the community on 01/23/22 and was unable to be interviewed.
During an interview on 06/29/22 at 5:22 PM, the Admissions Director revealed the Corporate Hospital Liaison reviewed Resident #379's discharge referral on 11/09/21 and approved her for readmission but did not notify anyone at the facility. The Admissions Director was notified by the Hospital Case Manager the afternoon of 11/09/21 that Resident #379 was returning to facility and she had a PEG tube. The Admissions Director recalled the former Director of Nursing (DON) instructed her to notify the Hospital Case Manager the facility would not be able to accept Resident #379 back as they did not have the supplies or formula to manage Resident #379's PEG tube feedings. When she spoke to the Hospital Case Manager to let her know they could not accept Resident #379 back at this time, the Hospital Case Manager stated they would have to accept her since she was already enroute back to the facility and the Admissions Director informed the Hospital Case Manager they would have to send Resident #379 back to the hospital when she arrived. The Admissions Director stated when Resident #379 arrived at the facility, the former DON met Emergency Medical Services (EMS) outside and informed them the facility wasn't able to accept Resident #379 back and they would have to transport her back to the hospital. The Admissions Director explained the facility purchased PEG tube supplies from their medical equipment company and they weren't able to get the supplies Resident #379 needed on 11/09/21. She added a few days later, they received the supplies and Resident #379 returned to the facility. The Admissions Director stated it was never the facility's intention not to accept Resident #379 back to the facility and the only reason her return to the facility was delayed was because they were not informed in time of her pending discharge from the hospital for them to order the necessary supplies for Resident #379's tube feedings.
A telephone attempt on 06/29/22 at 7:53 PM for interview with the former DON was unsuccessful.
A telephone attempt on 07/01/22 at 3:16 PM for interview with the Corporate Hospital Liaison was unsuccessful.
During an interview on 07/01/22 at 3:45 PM, the Administrator revealed on 11/09/21 the Corporate Hospital Liaison had approved Resident #379's return from the hospital without notifying the facility. When the former DON reviewed the discharge summary and noticed Resident #379 had a PEG tube, the Corporate Hospital Liaison was informed they would need to delay Resident #379's readmission for a day or so to allow them the time to get the necessary supplies and formula Resident #379 would need. The Administrator explained by the time they had notified the Corporate Hospital Liaison and she spoke to the Hospital Case Manager, Resident #379 was already enroute back to the facility. The Administrator confirmed the former DON met EMS outside upon their arrival and informed them Resident #379 would need to go back to the hospital which was located approximately 1 ½ hours from the facility. The Administrator was unaware of the order on the discharge summary indicating Resident #379 could have a mechanical soft diet with tube feedings. The Administrator stated had she known that on 11/09/21, Resident #379 would have been allowed to return to the facility and there would have been no reason for them to send her back to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD) for 1 of 3 sampled residents reviewed for Resident Assessments (Resident #31).
Findings included:
Resident #31 was admitted to the facility on [DATE].
Review of Resident #31's electronic medical record revealed an admission MDS assessment with an ARD of 02/08/22. The MDS assessment was noted as completed on 03/07/22.
During an interview on 06/30/22 at 9:35 AM, the MDS Coordinator stated they realized there was an issue with MDS assessments not being completed on time during a COVID-19 outbreak at the facility. The MDS Coordinator explained they got behind when a lot of residents on the assisted living hall tested positive for COVID-19 and were moved to a skilled hall which created a lot more MDS assessments that had to be completed. The MDS Coordinator reviewed Resident #31's admission MDS dated [DATE] and confirmed it was not completed within the regulatory time frame.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated she would expect for MDS assessments to be completed within the regulatory timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments to reflect a pressure ulcer for 1 of 3 residents reviewed for wound care (Resident #36) and the Pre-admission Screening and Resident Review (PASRR) level for 3 of 3 residents reviewed (Resident #14, Resident #379, and Resident #50).
The findings included:
1. Resident #36 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and muscle weakness.
An admission Skin Evaluation completed by Nurse #1 on 3/3/22 indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place.
The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was at risk of developing pressure ulcers/injuries, had moisture-associated skin damage but no pressure ulcers.
The Care Area Assessment (CAA) dated 3/23/22 for pressure ulcer/injury indicated Resident #36 had been seen by the wound doctor for her skin breakdown. These areas of moisture had history of actual breakdown. The areas were not coded as pressure ulcer during this assessment. However, after this ARD (Assessment Reference Date), it was noted to be worse. According to the wound doctor, there is now an unstageable ulcer.
An interview with Nurse #1 on 6/28/22 at 3:10 PM revealed she observed an open area on Resident #36's sacrum on 3/3/22 which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment.
An interview with the MDS Coordinator on 7/7/22 at 1:19 PM revealed when she had seen the skin evaluation completed by Nurse #1 on 3/3/22 about the open area on Resident #36's sacrum, she left a note for one of the unit managers, but she couldn't remember which one, in order to verify if the open area was a pressure ulcer. The MDS Coordinator stated she couldn't recall if the unit manager got back to her with an answer. She further stated this issue was something she would normally question and ask the nurse about, but she didn't ask Nurse #1 because she didn't always work at the facility. She explained that when she completed the CAA right before she transmitted the 3/9/22 MDS, she saw a note from the wound doctor about Resident #36 having an unstageable ulcer. The MDS Coordinator stated she didn't go back and code the pressure ulcer on the MDS because she wasn't sure if the open area observed on 3/3/22 was the same unstageable ulcer seen by the wound doctor on 3/17/22.
An interview with the Administrator on 7/7/22 at 2:41 PM revealed the MDS Coordinator should have coded Resident #36's pressure ulcer on her MDS if the pressure ulcer started on 3/3/22 and it was within the 7-day look back period.
2. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety, depression, and psychotic disorder.
A North Carolina Medicaid Uniform Screening Tool (NC MUST) document dated 03/22/22 revealed Resident #50 had a Level II PASRR with an expiration date of 04/29/22.
The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability.
During an interview on 06/30/22 at 11:40 AM, the Social Worker (SW) revealed she was responsible for completing the PASRR section on MDS assessments. The SW confirmed Resident #14 had a Level II PASRR as indicated on the determination letter dated 03/22/22. The SW explained she did not realize it needed to be coded on the MDS as a Level II PASRR if the PASRR was only for a 30, 60 or 90 day period and had to be reevaluated through the PASRR process when a longer period was needed. The SW stated it was a misunderstanding of the process and a modification would be submitted to accurately reflect Resident #14 had a Level II PASRR.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's PASRR status.
3. Resident #379 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety, depression, and post-traumatic stress disorder.
An undated North Carolina Medicaid Uniform Screening Tool (NC MUST) document revealed Resident #379 had a Level II PASRR with an expiration date of 12/22/21.
The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #379 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability.
The re-admission Minimum Data Set (MDS) dated [DATE] revealed Resident #379 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability.
During an interview on 06/30/22 at 11:40 AM, the Social Worker (SW) revealed she was responsible for completing the PASRR section on MDS assessments. The SW confirmed Resident #379 had a Level II PASRR. The SW explained she did not realize it needed to be coded on the MDS as a Level II PASRR if it the PASRR was only for a 30, 60 or 90 day period and had to be reevaluated through the PASRR process when a longer period was needed. The SW stated it was a misunderstanding of the process and a modification would be submitted to accurately reflect Resident #379 had a Level II PASRR.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's PASRR status.
4. Resident #50 was admitted to the facility on [DATE] with multiple diagnoses that included dementia, schizophrenia, and bipolar disorder.
A North Carolina Medicaid Uniform Screening Tool (NC MUST) document dated 08/08/17 revealed Resident #50 had a Level II PASRR with no expiration date.
The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability.
During an interview on 06/30/22 at 11:40 AM, the Social Worker (SW) confirmed she was responsible for completing the PASRR section on MDS assessments. The SW confirmed Resident #50 had a Level II PASRR. The SW explained she did not realize it needed to be coded on the MDS as a Level II PASRR when dementia was the primary diagnosis. The SW stated it was a misunderstanding of the process and a modification would be submitted to accurately reflect Resident #50 had a Level II PASRR.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's PASRR status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop comprehensive, individualized care plans that addressed Preadmission Screening and Resident Review (PASRR) Level II status for 2 of 3 sampled residents reviewed for PASRR (Resident #14 and #379).
Findings included:
1. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety, depression, and psychotic disorder.
A North Carolina Medicaid Uniform Screening Tool (NC MUST) document dated 03/22/22 revealed Resident #14 had a Level II PASRR with an expiration date of 04/29/22.
A PASRR Level II Determination Letter for Resident #14 dated 04/29/22 indicated she had a Level II PASSAR with an expiration date of 07/28/22 and noted nursing facility placement was appropriate for a 90-day period.
Review of Resident #14's active care plans, last reviewed/revised 06/21/22, revealed no care plan that addressed her Level II PASRR status.
During an interview on 06/30/22 at 11:40 AM, the Social Worker (SW) revealed she was responsible for developing PASRR care plans for residents with a Level II PASRR. The SW confirmed Resident #14 had a Level II PASRR as indicated on the determination letter dated 04/29/22. The SW explained she did not realize it was considered a Level II PASRR when the PASARR was only effective for a 30, 60 or 90 day period and had to be reevaluated through the PASRR process when a longer period was needed. The SW verified a Level II PASRR a care plan was not developed for Resident #14 and stated it was a misunderstanding of the process.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated it was her expectation that residents with a Level II PASRR would have care plans developed that reflected their PASRR needs.
2. Resident #379 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety, depression, and post-traumatic stress disorder.
An undated North Carolina Medicaid Uniform Screening Tool (NC MUST) document revealed Resident #379 had a Level II PASRR with an expiration date of 12/22/21.
A PASRR Level II Determination Notification letter for Resident #379, with an effective date of 12/28/21 and no expiration date, revealed nursing facility placement was appropriate with specialized services that consisted of individual/group psychotherapy.
Review of Resident #379's care plans, last reviewed/revised 12/30/21, revealed no care plan that addressed her Level II PASRR status or the specialized services needed as described in the PASRR Level II Determination Notification letter.
Resident #379 discharged to the community on 03/01/22.
During an interview on 06/30/22 at 11:40 AM, the Social Worker (SW) revealed she was responsible for developing PASRR care plans for residents with a Level II PASRR. The SW confirmed Resident #379 had a Level II PASRR as indicated on the determination letter dated 12/28/21. The SW explained, initially, Resident #379's PASARR had an expiration date and she did not realize it was considered a Level II PASRR when the PASARR was only effective for a 30, 60 or 90 day period and had to be reevaluated through the PASRR process when a longer period was needed. The SW verified a Level II PASRR care plan was not developed for Resident #379 and stated it was a misunderstanding of the process.
During an interview on 07/01/22 at 11:20 AM, the Administrator stated it was her expectation that residents with a Level II PASRR would have care plans developed that reflected their PASRR needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident, Certified Occupational Therapy Assistant (COTA), Physical Therapy Assistant (PTA), and staff interviews, the facility failed to provide a maintenance program to prevent a decline in the ability to ambulate for 2 of 2 sampled residents (Resident #58 and Resident #39) reviewed for maintaining activities of daily living.
The findings included:
1. Resident #58 was admitted to the facility on [DATE] with diagnoses which included osteoarthritis, and rheumatoid arthritis.
Resident #58's quarterly MDS dated [DATE] revealed she was moderately cognitively impaired, required extensive assistance of 1 staff for transfers, did not walk in her room, walked in corridor with limited assistance of 1 staff member, and used a walker and wheelchair for mobility.
Observation and interview on 06/27/22 at 10:34 AM of Resident #58 revealed her in her room sitting in her wheelchair. Resident #58 stated she would like for the facility to have a restorative program so she could walk in the hallway daily with her walker. She said she had not asked anyone to assist her because she knew they were busy and short staffed and didn't have time to help her ambulate in the hallway.
Interview on 06/29/22 at 8:07 AM with the COTA revealed there had not been a restorative program at the facility for over a year and said residents had not maintained their mobility once discharged from therapy. She stated the progress the residents had made with therapy had all diminished due to not having a restorative program. The COTA further stated therapy had written up programs for each resident to follow with restorative but the carry over was not there from therapy to restorative. She indicated Resident #58 did well in therapy and would get to the point she could ambulate 125 to 150 feet in the hallway with her walker and then when she was discharged there was no maintenance program to keep her going. The COTA further indicated if restorative was working with her after therapy, she could be walking in the hall with her walker instead of being in her wheelchair all day. According to the COTA the resident was last discharged from therapy on April 29, 2022.
Interview on 06/29/22 at 5:14 PM with Nurse Aide (NA) #12 revealed she was often assigned to Resident #58 from 7:00 AM to 7:00 PM. She stated when they had a restorative program the resident was able to walk in the hallway the length of the hallway with her walker but stated since the facility no longer had a restorative program, she doesn't walk but just sat in her wheelchair. NA #12 stated with their current workload there was not enough time in their shift to walk residents.
Interview on 06/29/22 at 5:35 PM with Nurse #12 revealed she was the permanent nurse assigned to the resident during day shift from 7:00 AM to 3:00 PM. She stated Resident #58 had done well ambulating with her walker when they had a restorative program and was able to walk the length of the hallway and walk to the bathroom. Nurse #12 further stated when the program was stopped the resident quit asking to walk because the NAs were too busy to help her. She indicated the resident would probably do well with a restorative program and would be able to ambulate with her walker instead of sitting in her wheelchair all day.
Interview on 07/01/22 at 10:34 AM with PTA revealed he had worked with Resident #58 multiple times and stated she had done well with ambulating with her walker. He stated the resident was transferring with minimum to moderate assistance depending on the day and how her knees were feeling that day and was ambulating about 100 to 125 feet with her walker. The PTA further stated if there was a restorative program it would prolong her ability to ambulate, and she would not need therapy as often. He indicated a restorative or maintenance program would be beneficial for her to continue ambulating with her walker.
Interview on 07/01/22 at 11:31 AM with the Administrator and Regional Director of Clinical Services (RDCS) revealed there had not been a maintenance or restorative program in place at the facility for about a year due to staffing. The Administrator stated they relied on the NAs to ambulate the residents and maintain their abilities. The Administrator further stated the Nurses could also assist with ambulating residents. The Administrator indicated they were staffing about 90% of positions with agency staff and it posed a problem when they were not engaged with the residents like full time staff. She indicated they had hired 26 new NAs and they were beginning to look at promoting a NA to a lead position to be able to get restorative back in place. The Administrator further indicated corporate was looking at incorporating restorative in with therapy.
2. Resident #39 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness.
Review of her annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, required extensive assistance of 2 staff members with transfers, did not walk in her room or the corridor, and used a wheelchair for mobility.
Observation and interview on 06/27/22 at 10:34 AM of Resident #39 revealed her in her room sitting in her wheelchair talking with her roommate. She stated she had been walking with assistance to the bathroom but since physical therapy had discharged her no one would walk with her to the bathroom. Resident #39 stated the Nurse Aides (NAs) came in and got her up with the sit to stand lift and then put her in the wheelchair and that is where she remained for the day. Resident #39 further stated no one has time to assist me with walking to the bathroom.
Interview on 06/29/22 at 8:40 AM with Certified Occupational Therapy Assistant (COTA) revealed Resident #39 had been on the caseload for therapy and was recently discharged on May 31, 2022, with the recommendation for a maintenance program with nursing. The COTA stated Resident #39 had been walking 30 feet with contact guard assistance (required hand contact on the resident because of occasional loss of balance) once she was lifted with the sit to stand. She further stated once Resident #39 was up on her feet she did well with walking to the bathroom but said there was no maintenance program with nursing and the residents did not maintain their abilities once they were discharged from therapy. The COTA explained there had not been a maintenance or restorative program at the facility for over a year due to staffing.
Interview on 06/29/22 at 5:14 PM with Nurse Aide (NA) #12 revealed she was often assigned to Resident #39 from 7:00 AM to 7:00 PM. She stated when they had a restorative program the resident was able to walk with 2 staff assist to the bathroom but stated since the facility no longer had a restorative program, she doesn't walk but just sat in her wheelchair. NA #12 further stated she and the other NAs working on the halls did not have time to walk residents with all the other responsibilities they were assigned.
Interview on 06/29/22 at 5:35 PM with Nurse #12 revealed she was the permanent nurse assigned to the resident during day shift from 7:00 AM to 3:00 PM. She stated Resident #39 had done well ambulating to and from the bathroom when they had a restorative program. Nurse #12 further stated when the program was stopped the resident stopped asking to be walked to the bathroom and just started transferring from her wheelchair to the toilet. She indicated the resident would probably do well with a restorative program and would be able to ambulate to and from the bathroom instead of sitting in her wheelchair all day and just transferring to and from the toilet.
Interview on 07/01/22 at 10:34 AM with Physical Therapy Assistant (PTA) revealed he had worked with Resident #39 and said she was recently discharged from therapy on May 31, 2022. He said once she was up on her feet, she was able to walk 30 feet with contact guard assistance. He stated that enabled her to walk to the bathroom and back with assistance instead of being in her wheelchair all day. The PTA further stated if there was a maintenance program such as restorative that would have prolonged her ability to ambulate to the bathroom and would have maintained her walking. He indicated a maintenance or restorative program would be beneficial for Resident #39.
Interview on 07/01/22 at 11:31 AM with the Administrator and Regional Director of Clinical Services (RDCS) revealed it had been about a year since they were able to offer a maintenance or restorative program due to overall staffing issues with Nurse Aides. The Administrator and RDCS stated they relied on the NAs to ambulate the residents and maintain their abilities. The Administrator further stated the Nurses could also assist with ambulating residents. The Administrator indicated they were staffing about 90% of positions with agency staff and it posed a problem when they were not engaged with the residents like full time staff. She further indicated they had hired 26 new NAs and they were beginning to look at promoting a NA to a lead position to be able to get restorative back in place. The Administrator explained that corporate was looking at incorporating restorative in with therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff and the Nurse Practitioner, the facility failed to obtain culture swabs from the laboratory needed to collect a specimen for a wound culture ordered by the physician for a resident with a suspected wound infection for 1 of 3 residents reviewed for quality of care (Resident #70).
The findings included:
Resident #70 was admitted to the facility on [DATE] with diagnoses that included hypertension and diabetes.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 was severely cognitively impaired, required extensive physical assistance with activities of daily living and had no skin conditions.
The Physician Orders dated [DATE] in Resident #70's medical record indicated orders for: culture wound to left shoulder for infected boil/cyst, warm compress daily for 3 days to cyst on left shoulder and Doxycycline 100 mg (milligrams) give 1 tablet by mouth two times a day for wound infection for 10 days.
A progress note dated [DATE] at 7:12 PM by Nurse #7 indicated no adverse reactions to Doxycycline 100 mg by mouth twice a day x 10 days related to wound infection. Continue to await laboratory to provide swabs to collect culture and sensitivity to boil to left shoulder.
An interview with Nurse #7 on [DATE] at 12:44 PM revealed when she worked with Resident#70 on [DATE], she was told by the nurse before her that the swab that was collected for her wound culture was discarded because they used the wrong culture swab. Nurse #7 was told that laboratory was supposed to be sending the right swab for them to use.
A phone interview with Nurse #4 on [DATE] at 10:11 PM revealed she worked night shift from 11:00 PM on [DATE] to 7:00 AM on [DATE] and received report that they still needed to do a wound culture on Resident #70's boil on her left shoulder. Nurse #4 stated she was unable to obtain the wound culture because the swabs that were available were all expired. Nurse #4 stated that she observed a whole box of expired culture swabs, and she went ahead and discarded them. She told the phlebotomist who came in early that morning that the facility was waiting on the laboratory to bring them the right culture swabs. Nurse #4 said the phlebotomist told her that she wasn't aware of this but that she would bring them some the next day.
A progress note dated [DATE] at 3:21 PM by Nurse #2 indicated a wound culture for boil to left shoulder was obtained and placed in refrigerator.
An interview with Nurse #2 on [DATE] at 12:45 PM revealed when she obtained the wound culture on Resident #70 on [DATE], the boil had already dried so she just rubbed the tip of the swab on the skin where the boil was.
An interview with the Nurse Practitioner (NP) on [DATE] at 10:40 AM revealed she had seen Resident #70 on [DATE] and she had observed a boil on her left shoulder. The NP stated when she touched it she had expressed some pus coming out of it which was why she had ordered a warm compress, wound culture, and Doxycycline. The NP stated she did not expect the wound culture to be done before the antibiotic therapy, but she had expected it to have been done within 1-2 days of when she had given the order. The NP looked at the laboratory results on the laboratory website and noted that Resident #70's wound culture was done on [DATE] with partial results received on [DATE]. The NP stated the facility had a system-wide problem with the laboratory and there was no excuse for a wound culture to be done after antibiotic therapy was completed.
An interview with the Administrator on [DATE] at 3:41 PM revealed the Director of Nursing was supposed to oversee obtaining the laboratory supplies and she didn't know what happened with the culture swabs.