Every finding on record at Asbury Place Kingsport

Based on facility policy review, observation, and interview, the facility failed to ensure expired over-the-counter medications, intravenous (IV) catheters, syringes, blood collection tubes (vacuum-sealed tubes used for collecting, transporting, and processing blood samples for laboratory analysis), and sterile water vials were discarded and not available for resident use, failed to ensure an insulin pen was labeled with the resident's name, and failed to ensure wound care supplies were stored unopened in 1 medication cart of 2 medication carts and 1 medication room of 2 medication rooms observed for medication storage. The findings include:Review of the facility's undated policy titled, MEDICATION STORAGE IN THE FACILITY, revealed .Medications and biological are stored safely, securely, and properly following the manufacturer or supplier recommendations .Outdated, contaminated, or deteriorated drugs and those in containers, which are .without secure closures will be immediately withdrawn from stock .During an observation of the Willow/Dogwood medication cart on 3/31/2026 at 8:47 AM, revealed 3 of the 10 milliliter (ml) sterile water single-dose vials with an expiration date of 11/1/2025, 1 of the 24 gauge (ga) x 0.75 inch (in) shielded IV catheters (a type of small, flexible, and thin plastic tube inserted into a vein to deliver medications, fluids, or blood products directly into the bloodstream) with an expiration date of 12/31/2024, 1 of the 20 ga x 1 in shielded IV catheters with an expiration date of 2/28/2026, and 1 of the 1 ml Syringes (a device used to administer injections) with an expiration date of 12/31/2025. Further observation revealed 1 Insulin Lispro KwikPen (a medication used to treat diabetes) was not labeled with the resident's name and was stored in an unlabeled bag with an opened date of 3/19. During an interview on 3/31/2026 at 9:08 AM, Licensed Practical Nurse (LPN) B stated the sterile water vials, IV catheters, and syringe were expired and should have been discarded. Further interview revealed the Insulin Lispro KwikPen was not labeled with the resident's name. During an interview on 3/31/2026 at 9:15 AM, the Director of Nursing (DON) confirmed the sterile water, IV catheters, and syringe were expired, and the Insulin Lispro KwikPen was not labeled with the resident's name. During an observation of the Willow/Dogwood medication room on 3/31/2026 at 9:22 AM, revealed one box of hemorrhoidal suppositories with an expiration date of 2/2026, 5 blue-top 3 ml blood collection tubes with an expiration date of 3/12/2026. Continued observation revealed 3 open to air sterile wound therapy foam kit packages, available for resident use.During an interview on 3/31/2026 at 9:35 AM, LPN B stated the box of suppositories and the 5 blood collection tubes were expired. LPN B further stated the 3 sterile wound therapy foam kit packages had been opened, was available for resident use, and should have been discarded if not used. During an interview on 3/31/2026 at 9:44 AM, the DON confirmed the opened sterile wound therapy foam kit packages, expired medications, and any expired supplies should have been discarded.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a timely signature on the required Notice of Medicare Non-Coverage (NOMNC) for 1 resident (Resident #56) of 3 residents reviewed for beneficiary notification. The findings include:Review of the facility's undated policy titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS [Centers for Medicaid and Medicare Services]-10123, revealed .The NOMNC must be delivered at least two calendar days before Medicare covered services end .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed .Review of the medical record revealed Resident # 56 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Subarachnoid Hemorrhage, Muscle Weakness, Metabolic Encephalopathy, and Emphysema. Review of a Social Service Note for Resident #56 dated 2/11/2026, revealed .Resident received NOMNC, LCD [Last Covered Day] 2/12/26. Resident did not wish to appeal .Review of a NOMNC document for Resident #56 revealed .Services Will End on 02/12/2026 . The NOMNC was signed by the resident on 2/11/2026. Review of a Discharge Summary Progress Note dated 2/13/2026, revealed .Went over discharge instructions .Patient [Resident #56] assisted to car .During an interview on 4/1/2026 at 9:33 AM, the Social Services Director stated there was no documentation to confirm the NOMNC had been presented timely to Resident #56 and the signature date on the NOMNC was 2/11/2026, which did not fulfill the required two-day notice. During an interview on 4/1/2026 at 9:41 AM, the Administrator confirmed it was her expectation for NOMNCs to be presented to and signed by the resident two days prior to the date of end of coverage.

Based on facility policy review, medical record review, pharmacy record review, observation, and interview, the facility failed to administer a prophylactic antibiotic [medication used to treat a bacterial infection, in prophylactic use it is used to help decrease the risk for a recurring bacterial infection] as ordered by the Physician for 1 resident (Resident #8) of 15 residents reviewed for medications.The findings include: Review of the facility's undated policy titled, Medication Administration Guidelines, revealed .Verify that the name & [and] dose of the medication are correct .Verify each medication against the MAR [Medication Administration Record] .Sign MAR immediately after administering the medications . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Hypertensive Heart Disease. Further review revealed Resident #8 was hospitalized from [DATE]-[DATE], and from 1/1/2026-1/8/2026. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a Physician's Order for Resident #8 dated 9/8/2025, revealed .Nitrofurantoin [medication used to treat certain bacterial infections] Macrocrystals [larger crystals to dissolve and absorb slower] Oral Capsule 100 mg [milligram] .one time a day .for prophylaxis . Review of the MAR for Resident #8 dated 9/8/2025 to 1/23/2026, revealed Nitrofurantoin Macrocrystals 100 mg daily was scheduled a total of 119 days for the time period, as there was 8 days the resident was in the hospital, and 18 days it was held for other antibiotic use. Review of the Pharmacy Delivery reports for Resident #8 dated 9/8/2025 to 1/23/2026, revealed Nitrofurantoin Macrocrystals 50 mg, quantity of 16 capsules, was delivered 9 times between 9/8/2025 to 1/23/2026, which equaled a total of 144 capsules delivered and not the needed supply of 238 capsules to equal the 119 scheduled doses. During an interview on 3/31/2026 at 11:30 AM, the Director of Nursing (DON) confirmed during medication administration, the medication should be compared to the order on the MAR to ensure the correct medicine and correct dose are administered. During an interview on 3/31/2026 at 2:00 PM, the Pharmacist stated Resident #8 was ordered Nitrofurantoin 100 mg as macrocrystals which was only available in the 50 mg capsules. The Pharmacist stated the pharmacy delivered Nitrofurantoin 50 mg capsules to the facility 9 times between 9/8/2025 and 1/23/2026 with directions to administer 2 capsules per dose. During an observation and interview on 4/1/2026 at 12:15 PM, the Administrator reviewed the MAR for Resident #8 from 9/8/2025 to 1/23/2026 which contained documented the Nitrofurantoin 100 mg daily as being administered. The Administrator confirmed there were 119 days in which Resident #8 should have received the medication dosage of 100 mg, the Pharmacy Delivery Manifests showed 144 doses of Nitrofurantoin 50 mg was delivered to the facility of which the resident should have received 2 capsules per dose, and confirmed Resident #8 did not receive the 100 mg daily dosage as ordered as there were not enough doses delivered to the facility by the pharmacy. During an interview on 4/1/2026 at 12:35 PM, the Nurse Practitioner (NP) stated Nitrofurantoin 50 mg was often the dosage used for prophylactic use, but the provider had continued the 100 mg dose as previously ordered for Resident #8. The NP further confirmed Resident #8 was in the hospital from [DATE] to 1/8/2026, and the urine culture obtained was resistant to the Nitrofurantoin. Urine cultures obtained at the facility on 1/27/2026 and 2/18/2026 were also resistant to Nitrofurantoin. The NP stated the Nitrofurantoin dosage of 50 mg administered instead of the prescribed100 mg did not have a negative impact on Resident #8.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain an accurate and complete medical record for 1 resident (Resident #8) of 15 medical records reviewed. The findings include:Review of the facility's undated policy titled, Medication Administration Guidelines, revealed .Verify that the name & [and] dose of the medication are correct .Verify each medication against the MAR [Medication Administration Record] .Sign MAR immediately after administering the medications . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Hypertensive Heart Disease. Further review revealed Resident #8 was hospitalized from [DATE]-[DATE], and from 1/1/2026-1/8/2026. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the Medication Administration Record (MAR) for Resident #8 dated 9/2025 to 1/2026, revealed multiple medications had not been initialed by the nurse as administered to the resident (the documentation areas were left blank). - 9/2025 - blanks on the MAR for multiple medications on 4 days (9/11/2025, 9/16/2025, 9/21/2025, and 9/25/205)- 10/2025 - blanks on the MAR for multiple medications on 7 days (10/13/2025, 10/14/2025, 10/18/2025, 10/19/2025, 10/23/2025, 10/24/2025, and 10/31/2025)- 11/2025 - blanks on the MAR for multiple medication on 7 days (11/2/2025, 11/6/2025, 11/10/2025, 11/11/2025, 11/12/2025, 11/20/2025, and 11/21/2025)- 12/2025 - blanks on the MAR for multiple medications on 10 days (12/2/2025, 12/4/2025, 2/6/2025, 2/11/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/26/2025, 12/27/2025, and 12/30/2025)- 1/2026 - blanks on the MAR for multiple medications on 6 days (1/10/2026, 1/12/2026, 1/15/2026, 1/16/2026, 1/24/2026, and 1/26/2026 During an interview on 3/31/2026 at 11:30 AM, the Director of Nursing (DON) stated the MAR should have been initialed by the licensed nurse when the medications were administered to the resident. The DON stated the nurses failed to accurately complete the documentation on the MAR at the time of the medication administration. During an observation and interview on 4/1/2026 at 12:15 PM, the Administrator confirmed the MAR for Resident #8 from 9/8/2025 to 1/23/2026 contained multiple blanks, the documentation was not complete, and there was no rationale to state if the medications had been omitted or held. The Administrator confirmed the scheduled medications were not documented by the nurse as administered appropriately.

Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to submit a 5 day follow up of the facility's investigation to the State Survey agency for 1 resident (Resident #1) of 4 residents reviewed. The findings include: Review of the facility's Policy titled, Resident Rights-Abuse and Crimes against, revised 6/16/2023 showed .all alleged violations .are reported .to the .state agency responsible for surveying/licensing the facility . continued review showed no procedure or process for submitting a 5 day follow up investigation, after the initial report to the State Survey agency. Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Difficulty in Walking, and Cognitive Communication Deficit, the resident discharged to the hospital on 10/23/2023. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 1 which indicated the resident had severe cognitive impairment. The resident required assistance of one or more staff members with activities of daily living (ADL's). Review of a current care plan showed Resident #1 had the .Potential for fall or injury r/t [related to] impaired cognition, poor safety awareness .Transfer with assist as needed .Ambulation with assist as needed .Bilateral soft mats to bedside .10/6 [10/6/2023] .Recommended 24-7 caregivers. 10/23 [10/23/2023] .Dycem [non-slip material] in wheelchair at all times .10/18 [10/18/2023] .may use broada chair [specialized wheelchair] when OOB [out of bed] .Send to ER [emergency room ] as ordered. 10/23. 10/23/2023] . review showed multiple falls with new interventions in place with each fall. Review of the facility's fall investigation showed on 10/23/2023 Resident #1 was up in his geriatric chair. Resident #1's spouse had came to the facility for a visit near dinner time and requested the resident be put in his recliner at approximately 5:40 PM. CNA A assisted the resident's wife with putting the resident in his recliner and Resident #1's spouse left sometime after dinner. At 8:28 PM, after having just walked by the residents room a few minutes earlier and seeing him in the recliner sleeping, Resident #1 was observed by CNA A lying on the floor on his right side next to his bed and the heater. A hematoma was noted on Resident #1's right forehead, the physician was notified, and orders were received to send the resident to the ER. The diagnosis from the hospital showed a Subarachnoid Hematoma (bleeding in the space between the brain and the tissue covering the brain). Continued review showed no documentation a 5 day follow up investigation had been submitted to the State Survey agency. Review of the State Survey agency INTAKE INFORMATION form showed the above incident was reported to the State Survey agency with .No 5 day follow up added . During an interview on 4/24/2024 at 11:00 AM, the Administrator stated .I checked and there was a 5 day follow up filled out, but it was never finalized so it wasn't turned in . confirming the facility failed to submit a 5 day follow up to the State Survey agency.

Based on facility policy review, observation, and interview, the facility failed to ensure expired food items were discarded and failed to ensure food was properly stored in a walk-in freezer in 1 of 2 kitchens which had the potential to affect 29 residents. The findings include: Review of the facility policy titled, Sanitation & [and] Infection Control Receiving & Storage, dated ,d+[DATE], showed .Proper storage procedures will be utilized for all dry and refrigerated food storage .All items are dated when received to ensure correct product rotation .Items are stored a minimum of 18 inches from the ceiling . Review of the facility policy titled, Sanitation & Infection Control Labeling & Dating, dated ,d+[DATE], showed .All foods will be appropriately wrapped, labeled and dated on food storage guidelines. Appropriate storage .and food rotation procedures are followed . All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. RTE [Ready To Eat] products once opened have a 7-day shelf life .All products are rotated using the first-in, first-out .inventory method . During an observation on [DATE] at 11:00 AM, the walk-in freezer contained a 25-pound box of corn open to air; 1 box of catfish and 1 box salmon touching the ceiling in the freezer blocking sprinklers. Continued observation of the kitchen showed 1 full and ,d+[DATE] loaves of bread with an expired date of [DATE], 4 packs of 6 count English Muffins with an expired date of [DATE]. 1 of the 4 packs of English Muffins was unsealed and open to air. All food items were available for resident use. During an interview on [DATE] at 11:00AM, the Certified Dietary Manager (CDM) confirmed the box of corn was unsealed and open to air, the bread had expired and was available for resident use. The CDM further confirmed the frozen boxes of food had blocked the sprinkler system in the freezer. During an observation of the kitchen on [DATE] at 7:52AM, showed 1 full loaf of gluten free bread had an expiration date of [DATE]. The food item was available for resident use. During an interview on [DATE] at 7:52 AM, the CDM confirmed the 1 loaf of gluten free bread had expired on [DATE] and was available for resident use.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse was properly contained in 1 of 4 dumpsters. The findings include: Review of facility policy titled, Sanitation and Infection Control Garbage & [and] Refuse Disposal, dated 1/2016, showed .All garbage, refuse, glass, tin cans, cardboard, paper .generated within the Food and Nutrition Services department shall be disposed of in a sanitary manner . All items shall be disposed of in appropriate dumpster, food/medical waste versus recyclable materials .All parties utilizing the dumpsters for waste to prevent harborage and feeding of pests .All parties utilizing the dumpsters for waste and/ or recycling purposes are responsible for maintaining the area by ensuring that the dumpster lids are closed and the area around the dumpster is free of waste . During an observation and interview with the Certified Dietary Manager on 5/22/2023 at 11:00AM, showed 1 dumpster had a large trash bag of refuse extending 3/4 out of the top of the dumpster. The Certified Dietary Manager confirmed the refuse trash bag extended out of the top of the dumpster.

Based on facility policy review, observation, and interview, the facility failed to ensure appropriate hand hygiene practices were followed during meal service on 1 of 3 hallways observed during meal service. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 1/1/2017, showed .handwashing/hand hygiene as the single most important means of preventing the spread of infection .All personnel will follow the handwashing procedure to prevent the spread of infection and disease to other personnel, residents, and visitors. Employees will perform appropriate handwashing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions and as additionally needed .When to wash hands .Before and after each resident contact .Before handling food tray or preparing food . During an observation and interview on 5/22/2023 at 12:30 PM, Certified Nursing Assistant (CNA) #2 was observed retrieving a meal tray from a meal cart without performing hand hygiene, entered a resident room, set up the meal tray for the resident, positioned the resident's overbed table, and exited the room without performing hand hygiene. Continued observation showed CNA #2 obtained a second meal tray from the meal cart, entered another resident's room, set up the meal tray, and exited the room without performing hand hygiene. Interview with CNA #2 confirmed he had failed to perform hand hygiene during the meal service. During an interview on 5/24/2023 at 9:15 AM, the Director of Nursing (DON) confirmed it was her expectation for staff to perform hand hygiene between rooms during meal tray delivery.

Based on facility policy review, observation, and interview, the facility failed to ensure kitchen equipment was maintained in good repair in 1 of 2 kitchens. The findings include: Review of the facility policy titled, Manual Can Opener Maintenance, dated 1/2017, showed .Can Opener Blade and Gears must be checked for wear quarterly .Look for wear on blade or dulling of blade and wear on gears .if wear on blade is present, blade should be replaced . During an observation and interview with the Certified Dietary Manager on 5/22/2023 at 11:00 AM, showed a can opener on the kitchen preparation table with a frayed blade which had the potential to introduce metal shards into the canned food. The Certified Dietary Manager confirmed the can opener blade was frayed and used for resident food preparation.

Based on review of facility policy, medical record review, review of a facility investigation, observations, and interviews, the facility failed to prevent elopement for 1 resident (Resident #1) of 4 residents reviewed. The facility's failure to ensure adequate supervision after being assessed on admission as a risk for elopement with exhibited aimless, wandering behaviors throughout the night requiring redirection, placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #1 eloped from the facility on 6/18/2022 and was located 75 feet in the parking lot of the independent living side of the building. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/9/2022 at 5:00 PM. The facility was cited Immediate Jeopardy for F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 6/18/2022-8/11/2022 and was removed on 8/12/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/10/2022 at 5:00 PM, and the corrective actions were verified onsite by the surveyor on 8/12/2022. The findings included: Review of the facility's policy titled Hazardous Wandering and Elopement revised 6/16/2022 showed .Hazardous Wandering: the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction .the wandering places the resident at significant risk of getting to a dangerous place .Elopement: A situation in which a resident with impaired cognition and/or demonstrated lack of safety awareness or judgment successfully leaves the organization or a secured area as defined by the organization, undetected or unsupervised by staff .A Risk Assessment will be completed on admission to Skilled Nursing .If identified as at risk for hazardous wandering or elopement, the resident's care plan will include strategies and interventions to maintain the resident's safety .if a resident is missing .initiate a search of the building(s) and premises .when the resident returns to the facility, the director of nursing services or charge nurse shall .Examine the resident for injuries .contact the attending physician .Notify the resident's legal representative .and report to state agencies . Review of the facility's Policy titled ELOPEMENT, undated, showed .To provide for the safe return of at risk residents who leave the facility unaccompanied .All staff members will promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .if resident is not located within 10 minutes, the Administrator will notify the local authorities of the situation .the interdisciplinary care plan team will review and update the plan of care to include interventions to prevent elopement . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Disease of Spinal Cord, Fracture Right Lower Leg, and [CONDITION(S)]. Resident #1 discharged to the hospital on 6/30/2022. Review of facility Clinical Notes Report for Resident #1 showed .06/17/2022 .11:30 AM .Patient entered facility at 10:26 AM .Patient alert to self and time, but is confused .Wife states patient is still foggy headed .Instructed patient not to get up without assistance and always use call bell and wait for help. Patient verbalized understanding, but is confused and forgetful . Review of the facility's Wandering/elopement risk evaluation form dated 6/17/2022 for Resident #1 showed .The resident is cognitively impaired and independently ambulatory: Yes .Resident is wandering aimlessly: Yes .Resident is actively exhibiting exit-seeking behavior: Yes .Interventions: Elopement prevention care plan initiated or updated .06/17/2022 02:00 PM . Review revealed .if evaluation indicates 'Yes' to any question, consider initiating a care plan or service plan for elopement risk . Review of a Nurse Practitioner (NP) progress note dated 6/17/2022 for Resident #1 showed .He is having some acute confusion post-op [after surgery] although his wife reports this is better. He was having some altered mental status beforehand .He is pleasant and conversational, oriented to person and situation . Review of Resident #1's care plan dated 6/17/2022 showed .He exhibits wandering behaviors .Assess potential physical causes for wandering (need for toileting, water, food .) .Redirect [Resident #1] when wandering is observed .Wander guard [elopement deterrent device] as ordered STATUS: Active (Current) .Staff to perform checks for elopement risk as ordered .STATUS: Active (Current) . Review revealed no dates were documented as to when each intervention was implemented. Review of facility Clinical Notes Report for Resident #1 showed .06/18/2022 .4:03 AM .Resident was assisted back to bed about 2:15 am after multiple wandering episodes. CNA [Certified Nurse Assistant] was completing round. Nurse was with another resident. CNA went to check on patient and noticed he was not in his room. Room sweep was done starting at therapy [at end of dogwood hall], dogwood [rooms 25-36], willow [rooms 16-24] and Magnolia [rooms 1-15]. Sweep continued into independent living. Nurse went out apartment sliding doors to check grounds, resident was noted to be at the other side of parking lot pushing w/c [wheelchair]. Nurse arrived to patient assisted into w/c and brought back into facility. Resident stated 'thank you, that was a nice walk down memory lane' Physical assessment done with no injury noted. Elopement assessment completed, wander guard [elopement deterrent device] applied to left ankle and DON notified . Review of physician's orders for Resident #1 showed .Wander Guard .Order Date: 6/18/2022 .Starting 6/18/2022 .Treatment .Order Date: 6/18/2022 .q [every] 15 min [minutes] checks for elopement risk . Review of a Wandering/elopement risk evaluation form dated 6/18/2022 for Resident #1 showed the resident was reassessed for elopement risk .The resident has previously attempted to leave a residence or other place unescorted: Yes .The resident has a history of elopement: Yes .number of occurrences .1 .Approximate date of last elopement: 06/18/2022 .Resident is actively exhibiting exit-seeking behavior: Yes .Interventions: Elopement deterrent device implemented. Elopement prevention care plan initiated or updated .06/18/2022 04:06 AM . The form showed after the resident eloped on 6/18/2022 an elopement deterrent device was implemented. Review of the facility's investigation dated 6/18/2022 showed Resident #1 was admitted to the facility on [DATE] and on 6/18/2022, after multiple wandering episodes at approximately 2:15 AM, the resident was assisted to bed at approximately 2:25 AM. CNA #1 went to check on the resident and he was not in his room, room sweeps were started throughout the facility and continued into the independent living area. Licensed Practical Nurse (LPN) #2 walked through the independent living area and exited through the main entrance and found Resident #1 pushing his wheelchair around the parking lot. LPN #2 escorted the resident back into the facility, a physical assessment was completed with no injury noted, a wander guard was applied, and the resident was placed on 15 minute checks. Review revealed at the time of the elopement the census on the unit was 17. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 7, indicating the resident had severe cognitive impairment. The resident exhibited wandering behaviors 1 to 3 days placing the resident at risk of getting to a potentially dangerous place. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of facility Clinical Notes Report for Resident #1 showed .Addendum Note Currently utilizing one on one supervision .06/29/2022 .03:14 AM Currently sleeping in bed. Was restless and pacing aimlessly at the beginning of the shift. Was confused, staff redirected and reoriented multiple times with minimal results. Wander guard in place. Patient continues to be monitored q [every] 15 mins [minutes] . During an interview on 8/8/2022 at 9:15 AM, in the independent living side of the building where Resident #1 had exited the building, the Receptionist was describing the function of the sliding glass doors that were the main entrance to the independent living side. The Receptionist stated .this is the independent living side of the building .the doors will open from the inside. The residents on this side have keys to get back in . The doors opened from the inside and outside, except at night when they would only open from the inside, and the residents on the independent living side had keys to get back in if they were on the outside at night after they were locked. During an interview on 8/8/2022 at 11:00 AM, the Nurse Practitioner (NP) stated .when I assessed him [Resident #1] on admission [6/17/2022] he was laying in the bed pleasant and talking .he came in, he had been having multiple falls. He had a neck injury and hit his head and he had had some anesthesia so he was confused and the wife had said that he was always like that with the anesthesia .she did say that he was having some altered mental status beforehand .as his stay continued he became more confused . During an interview on 8/8/2022 at 11:45 AM, LPN #1 stated .when he [Resident #1] first got here he came by ambulance by himself .his wife came about an hour later .he was asking for her. He was confused. He thought he could go get her and we reoriented him to where he was and he wandered out in the hall looking for her before she got here and when she arrived he was fine .I checked exit-seeking on the form [Wandering/elopement risk evaluation form] because he was coming out of his room at first wanting to go find her. He did not actually go to the door I marked it based on how he was when he first arrived and once his wife got here, she didn't seem concerned that he was going to try to get out of the building. She was more concerned of him getting up on his own .I didn't think he would try to exit and when I left, by the end of the day, I didn't think he would and his score was low. It was only a 3 [3 out of 9 on the form] .after he exited the building, he had the wander guard and he had q 15 minute checks from then until he left .wander guard was checked every shift that it was on him and where it was located .if he got to any of the doors, they would all lock with the wander guard on .he never got to the doors after that. He was just wheeling around in his wheelchair looking for his wife .he didn't seem any different after it happened and he didn't have any physical injury .we had plenty of staff to watch him. We had eyes on him pretty much the whole time . Observation on 8/8/2022 at 1:30 PM, with the Facility Director, showed it was 342 feet from Resident #1's room on the skilled unit to the parking lot on the independent living unit and 85 feet to the end of the parking lot of the independent living unit. During a telephone interview on 8/9/2022 at 8:50 AM, CNA #1 stated .the occurrence happened so fast .it was around 2:00 [2:00 AM] I had just stepped in another room to change another patient and I had just looked at the man [Resident #1] and [CNA #2] told me she was taking her break .before I went into the other patient's room, I checked on him [Resident #1]. He was in his room and I was in the other patient's room less than 5 minutes and then I went back to check on him and he was not there. I let the nurse [LPN #2] know and we started searching every room, every hall and where we don't even have patients [magnolia closed unit] and I don't know how she [LPN #2] found him so fast. It all happened so fast .he was active. He was like ready to go. He was set on getting out of there. He was on the move .I did not find him in the parking lot [LPN #2] did and she said he was in the parking lot on the assisted living side .he got down there while we were looking for him over on the skilled side. He was very fast .there is no way it was more than 10 minutes from the time he was gone until he was found and he was okay. He wasn't hurt .after that happened, she [LPN #2] put the wander guard on him and we checked him way more often than every 15 minutes .he didn't attempt to leave after that on any of my shifts .he needed more attention. He needed one-on-one and we didn't have that there were no other residents that needed to be watched like that that night and I have never encountered anyone like him before. He was set on not being there and he was so confused . During a telephone interview on 8/9/2022 at 8:55 AM, CNA #2 stated .we had under 20 people [residents] .I was actually outside for most of what happened. I had a 30 minute break I was taking .about 2 [2:00 AM] I took my break and let them know I was going on break. It was [LPN #2], a nurse - she does not work there anymore, and [CNA #1]. She was the other CNA that was there that night. I told them I was taking my break .whenever I went back in after my break he [Resident #1] was back already. They had already found him .I remember making sure where he was before I went on break because he did like to wander. He was in the hall outside of his room. His room was 28 near the nurses desk .I took a 30 minute break and I didn't know he was gone until they told me .they put a wandering alarm on him after that .the night he got out there was 2 CNA's and a nurse. I'd say that is very sufficient staff. That's a pretty good amount of people for less than 20 .from my understanding [LPN #2] assumed that he had somehow went all the way out there while they were searching the therapy room .[LPN #2] told me he must have went through the sliding doors on the independent living side because all the other doors were locked .she said it was in the parking lot .she said he was visible from the front doors that he had walked out of .he wasn't hurt, and he acted the same . During a telephone interview on 8/9/2022 at 12:00 PM, the former Administrator stated .he [Resident #1] was admitted on the same day that he eloped .he was walking around the building. He would just walk up and down the hallways throughout the day with no real purpose .that Saturday morning [6/18/2022] he had gotten up out of bed and was wandering. We feel like he exited the building through the sliding glass doors at the residential living entrance. It was about 2:10 or 2:15 in the morning .[LPN #2] informed me of the incident .they did a sweep throughout the facility .we didn't put a wander guard on him from the time of admission. That was the immediate response at the time that he eloped and we did 15 minute checks on him . During an interview on 8/9/2022 at 12:50 PM, the Administrator stated .I think the root cause is the elopement risk evaluation form. Education on what needs to be put in place based on the 'yes' answers on that form is what needs to be done .it was marked 'yes' he's [Resident #1] wandering aimlessly, 'yes' he's actively exit seeking, and 'yes' that he was cognitively impaired and independently ambulatory .there is a reason why you fill these out when someone comes in .any of those marked 'yes' on that form would constitute implementing having that discussion with the physician and family member of having a wander guard in place for safety or one-on-one supervision .the form was filled out appropriately, but the interventions were not put into place and if that would have happened, he would not have gotten out that night . Observation on 8/9/2022 at 1:15 PM, with the Administrator, of the assumed route Resident #1 took when he exited the building, showed Resident #1 walked to the right of the building. He was located 75 feet into the parking lot near the right of the building. During a telephone interview on 8/9/2022 at 3:05 PM LPN #2 stated .he [Resident #1] was admitted that day [6/17/2022] .he was in and out of his room pushing his wheelchair up and down the hall. He sat with me at the nurses station a little bit .I don't recall him actively exit-seeking, but he was going up and down the halls .he wasn't looking for doors. He would go down to the physical therapy doors and then he would walk back up the hallway. He wasn't trying to get into physical therapy .I didn't get that impression from report that he was at risk for elopement. Family was with him for a little while when I got there .it was around round time for the CNA's, and I was with a patient and we had assisted him back to bed multiple times .when the CNA [CNA #1] went in to do her checks around 2:00 AM, she told me he was not in his room .we did a sweep starting with his room. We checked every room, every bathroom and swept the entire building .there were 2 CNA's and me .he was found in the parking lot of the independent living apartments .he was walking in the right-hand side of the parking lot. He was walking towards me pushing his wheelchair .he was at the end of the building on the right .he was found in less than 10 minutes. Everything happened fast .I got him and brought him back in the building, evaluated him for injury and he didn't have any, and contacted the [DON] and the acting Administrator .the Administrator came and the DON came and I put a wander guard on him and he had 15 minute checks .the doctor was notified of the incident .there was a new elopement risk assessment completed .he was in a red shirt and pajama pants. It was a nice night. It wasn't hot or cold. He did have shoes on. He had them on all night . Facility corrective actions included: All residents have been assessed by assigned nurse for wandering/elopement on 8/9/2022, confirming the elopement risk form has been completed correctly, with appropriate intervention(s) in place as necessary. No residents were identified by assigned nurse as being at risk for elopement. No residents were identified as being completed incorrectly at risk by assigned nurse. Education on how to interpret the form for elopement risk initiated by the DON on 8/9/2022 and was completed for all nursing healthcare center associates by 8/11/22. All new admissions will be assessed by admitting nurse for wandering/elopement as a part of the admission assessment. Residents identified as being at risk for wandering/elopement will have individualized interventions implemented by admitting nurse, as reflected in care plan, including but not limited to: elopement deterrent device, medication evaluation, diversional activities, redirecting, and one-to-one (1:1) sitter. Elopement deterrent device(s) (Wander Guard) will be placed on residents by assigned nurse per physician order. Residents with elopement deterrent device(s) will be assessed for functioning, placement, and skin integrity every shift by nursing associates. Residents exhibiting agitation or increased anxiety, contributing to wandering/risk of elopement, will be referred to provider by identifying nurse for potential medication intervention. Educational in-services were conducted by DON and/or NHA (Nursing Home Administrator) and will continue to be offered to all nursing associates on hazardous wandering and elopement. Education was started on 8/9/2022 by DON and was completed by 8/11/22 for all nursing associates. Nursing associates not scheduled to work in the facility will be contacted by phone and educated accordingly by DON. NHA verified completion of education by all nursing associates by reviewing sign-in sheets against associate roster to ensure all nursing associates received education. New associates receive education as part of the onboarding/orientation process. The wandering/elopement assessment will be audited by the DON, or designee, on all new admissions for two weeks, to conclude on 8/25/2022. Two random audits of the wandering/elopement assessment will be completed on two new admissions per week, to conclude on 9/8/2022. One random audit of the wandering/elopement will be completed on two admissions for the next two months, to conclude on 11/3/2022. The Quality Assurance Performance Improvement committee (QAPI), which is comprised of but not limited to the Licensed NHA, Interim DON, and Medical Director convened an ad hoc meeting, conducted by the NHA, to review remedy on 8/11/2022. All elopement risk assessments were reviewed in comparison to the facility's census list dated 8/9/2022 (28 residents). Documentation showed the assessments were scored and interpreted correctly with no residents identified as being at risk. During an interview on 8/10/2022 at 10:00 AM, the Administrator confirmed the assessments were completed with no residents identified as being at risk for wandering/elopement. Education sign-in sheets on how to interpret the elopement risk assessments was reviewed and confirmed utilizing a staff roster in comparison to in-service staff sign-in sheets. Interviews conducted with 2 Registered Nurses (RNs) and 3 LPNs confirmed the education was completed and understood. All elopement risk assessments were reviewed in comparison to the facility's census list dated 8/9/2022. Documentation showed no residents were identified as at risk for wandering/elopement. Review of the facility's census list dated 8/12/2022 showed a current census of 27 and no new resident admissions. Education on hazardous wandering and elopement was reviewed and confirmed utilizing a staff roster in comparison to in-service staff sign in sheets. Interviews conducted with 3 CNAs, 2 RNs, and 3 LPNs confirmed their knowledge and understanding of the education provided. Review of 3 personnel files confirmed the education was provided as part of the orientation process. Interviews with 2 CNAs and 1 LPN confirmed education was provided on hazardous wandering and elopement and understood. Review of facility's QAPI meeting documentation dated 8/11/2022 showed the Administrator, DON, Medical Director, and other staff members attended the meeting in which the above corrective actions were discussed. Noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction (POC).

Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to report an allegation of abuse timely to the State Survey Agency within the federally required time frame of 2 hours for 1 resident (Resident #1) of 3 residents reviewed for abuse. The findings include: Review of the facility's policy titled Resident Rights/Abuse of Residents last revised 11/14/2016 showed .Verbal Abuse is any use of oral .gestured language .that includes .demeaning and derogatory language or terms directed at residents .regardless of the resident's ability to comprehend .Resident Incidents must be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse .to .state survey agency . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 4 indicating the resident had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADL's). Review of the facility's investigation showed on 4/17/2022 at 9:00 AM, in the dining room the Housekeeping Manager witnessed Certified Nurse Assistant (CNA) #4 yelling at [Resident #1] very close to Resident #1's face saying you don't tell me what to do, you are not my boss Continued review of the investigation revealed Resident #1 stated Do you know how I can get rid of this dog that won't stop following me? and then CNA #4 mimicked the bark of a dog. During an interview on 5/10/2022 at 2:00 PM, the Director of Nursing (DON) stated .[ the Housekeeping Manager] called me and sent me a text when it happened .the staff did corroborate that CNA #4 was very loud and belittling and yelling in close proximity to the patient's [Resident #1] face .no I didn't report it within 2 hours of it happening .it was after 7:00 [7:00 PM] when I reported it, it happened around 9:00 [9:00 AM] that day .

Based on facility policy review, medical record review, review of facility investigation, and interview the facility failed to prevent abuse for 1 resident (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy titled Resident Rights/Abuse of Residents last revised 11/14/2016 showed .Any type of resident abuse .is strictly prohibited .Willful means the individual must have acted deliberately .Verbal Abuse is any use of oral .gestured language .that includes .demeaning and derogatory language or terms directed at residents .regardless of the resident's ability to comprehend . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview for Mental Status (BIMS) score was 4 indicating the resident had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADLs). Medical record review of a psychiatric evaluation dated 4/12/2022 for Resident #1 showed patient [Resident #1] has .[CONDITION(S)] and agitation .responding to internal stimuli staff reports this has increased since last gradual dose reduction . Medical record review of a psychiatric evaluation dated 4/19/2022 showed .delusional thoughts and agitated behaviors .Reasonable to wean [MEDICATION(S)] [antipsychotic medication] and start [MEDICATION(S)] [antipsychotic medication] at this time to target psychotic symptoms . Medical record review of a psychological diagnostic interview dated 4/26/2022 for Resident #1 showed .Patient denies a history of trauma that is consistent with [CONDITION(S)] [post traumatic stress disorder] Depression and anxiety [CONDITION(S)] - Dementia related . Review of the facility's investigation showed on 4/17/2022 at 9:00 AM, in the dining room the Housekeeping Manager witnessed Certified Nurse Assistant (CNA) #4 yelling at [Resident #1] very close to Resident #1's face saying you don't tell me what to do, you are not my boss Continued review of the investigation revealed Resident #1 stated Do you know how I can get rid of this dog that won't stop following me? and then CNA #4 mimicked the bark of a dog. During an interview on 5/10/2022 at 8:45 AM, CNA #1 stated .[CNA #4] brought her [Resident #1] to the dining room they were waiting to eat and [Resident #1] can be very irrational and combative at times and she was trying to get out of her wheelchair [Resident #1] was facing me and [CNA #4] was standing between us [Resident #1] stands up and she tries to push [CNA #4] away and she [CNA #4] got in her [Resident #1's] face and said 'you're not getting help with anyone except for me'. She was in her face and said it in a belittling manner .I didn't see it all the housekeeper [Housekeeping Manager] saw it . During a telephone interview on 5/10/2022 at 10:15 AM, the Housekeeping Manager stated .it was Easter Sunday [4/17/2022] .it was in the dining room .I noticed a CNA [CNA #4] saying to the patient [Resident #1] 'you don't tell me what to do you're not my boss' in a directive manner, like she was in her face .the resident goes like 'can you help me? there's a red dog following me' and the CNA went like 'who is the dog?' and the CNA mimicked a dog and she barked at the patient . During an interview on 5/10/2022 at 2:00 PM, the Director of Nursing (DON) stated .all the allegations were proven that [CNA #4] was verbally abusive towards the patient [Resident #1] .after we concluded we called her [CNA #4], and she came in and we terminated her for the verbal abuse of the resident .

Based on facility policy review, medical record review, review of a facility investigation, and interview, the facility failed to ensure medications were not left in a resident's room unattended for 1 resident (Resident #1) of 3 residents reviewed for medication administration The findings include: Review of the facility's policy titled .MEDICATIONS - ADMINISTRATION AND DISPOSITION undated showed .When a dose of .medication is removed from the container for administration but refused by the resident or not given for any reason .it must be destroyed . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of a facility investigation dated 10/4/2021 showed on 10/3/2021 at 7:25 PM, Certified Nurse Assistant (CNA) #1 discovered a medication cup with medication in it located on the bedside table in Resident #1's room. CNA #1 immediately notified License Practical Nurse (LPN) #1 who removed the medications from the resident's room. During a telephone interview on 11/1/2021 at 11:00 AM, CNA #1 stated .it was between 6:30 and 7:15 in the evening [10/3/2021] when I actually found them [medications] .the patient [Resident #1] turned on her light and asked for a shot .I told her I would ask the nurse .while I'm in here let me take some of the stuff off of your table for you .I saw a medicine cup with pills in it and I turned and seen [LPN #1] in the hall and I told her there are pills sitting in here you need to come get them .she [LPN #1] called .[Director of Nursing] . During an interview on 11/1/2021 at 2:15 PM the Director of Nursing confirmed medications were left in Resident #1's room and the facility failed to follow facility policy.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 resident (#190) was free from significant medication errors of 5 residents observed for medication administration. The findings include: Review of the facility policy Medication Administration, undated, revealed .Medications are administered in accordance with written orders of the attending physician . Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Order dated 1/7/20 for Resident #190 revealed, .Eliquis (medication used to thin the blood) 5mg (milligram) 1 TABLET oral Two Times Daily starting 1/7/20 . Observation of medication administration on 1/7/20 at 7:40 AM, on the Magnolia Hallway, revealed Licensed Practical Nurse (LPN) #1 administering medications to Resident #190. Continued observation revealed the LPN administered Eliquis 5mg 2 tablets to Resident #190. Interview with LPN #1 on 1/7/20 at 8:30 AM, on the Magnolia Hallway, confirmed Resident #190 received Eliquis 5mg 2 tablets, during the AM medication administration. Continued interview confirmed the current physician's order was for Eliquis 5mg 1 tablet oral two times daily starting 1/7/20. Further interview confirmed a medication error had occurred. Interview with the Director of Nursing on 1/7/20 at 3:15 PM, in the conference room, confirmed the LPN had administered Eliquis 5mg 2 tablets an incorrect dosage of Eliquis to Resident #190. Continued interview confirmed a significant medication error had occurred.

Based on the manufacturer's instruction review, observation, and interview, the facility failed to ensure dishes were cleaned in a sanitary manner for 34 of 52 residents on census. The findings include: Review of the manufacturer's instructions revised (MONTH) 2012 revealed .Minimum Temperatures using High-Temperature Sanitizing .Two-Tank Models .Wash Tank .150 (degrees) .Final Rinse .180 (degrees) . Observation and interview of the dishwasher with the Food Service Manager (FSM) on 12/17/18 at 9:50 AM, in the kitchen, revealed the dishwasher had a washing temperature of 142 degrees and a final rinse temperature of 175 degrees. Continued interview with the FSM revealed the washing temperature should have been at 150 degrees and the final rinse temperature should have been at 180 degrees. Interview with the lead dish washer on 12/17/18 at 9:57 AM, in the kitchen revealed the dishwasher had not maintained appropriate wash and final rinse temperatures since 12/13/18. Interview with the FSM on 12/18/18 at 3:30 PM, in the conference room, confirmed the dishwasher was a high temperature two-tank model machine. Continued interview confirmed the wash and final rinse temperatures had not been properly maintained since 12/13/18 and the FSM had not been notified until 12/17/18.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure proper administration of medication for 1 resident (#3) of 7 residents reviewed for medication administration; and failed to notify the physician and complete a falls investigation after a fall for 1 resident (#26) of 3 residents reviewed for falls of a total of 26 sampled residents. The findings include: Review of the facility policy, Medication Administration, dated 3/2005 revealed .Take medication(s) .to resident .Administer medication according to specific procedure such as oral, topical, injection .Reposition resident for comfort with call light in reach . Review of the facility policy FALLS reviewed (MONTH) (YEAR), revealed .All residents who fall must be assessed for injury .and follow-up investigation of fall .notification will be made in the following manner .Physician .If after hours notify physician by telephone, on the next business day .A Fall Investigation form must be initiated at the time of the fall by the charge nurse .The Fall Investigation should be attached to the completed Incident Report . Medical record review revealed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 12/17/18 at 9:54 AM, in the resident's room, revealed resident #3 sitting in wheelchair with 7 unidentified medications poured out on the resident's over-bed table. Continued observation revealed no other residents or facility staff was present in the resident's room. Further observation revealed no wandering residents were on the hallway close to resident's room at this time. Interview with the Licensed Practical Nurse (LPN) #1 on 12/17/18 at 9:57 AM, outside the resident's room, revealed the LPN had left the medications in the Resident's room for Resident #3 to take (self-administer). Continued interview confirmed the LPN failed to ensure the resident's medication was properly administered to the resident prior to exiting the resident's room. Interview with the Director of Nursing (DON) on 12/17/18 at 2:04 PM, in the conference room, confirmed the facility had not followed their policy to ensure medication was properly administered. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the discharge Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 12, indicating the resident had moderately impaired cognition. Further review revealed the resident had had one fall, with no injury. Medical record review of the facility's standing orders revealed .Falls-notify MD/NP (Physician or Nurse Practitioner) and assess for injury . Medical record review of a facility accident report dated 11/20/18 revealed the resident was lowered to the floor during a transfer from the toilet to the wheel chair with assist of 2 staff members. Further review revealed the Physician was not notified of the fall. Continued review revealed no documentation a fall investigation had been completed. Interview with the Assistant Director of Nursing on 12/19/18 at 8:27 AM, in the conference room, confirmed the facility failed to notify the Physician of the resident's fall, and failed to complete a fall investigation following the resident's incident on 11/20/18.

Based on facility policy review, medical record review, and interview the facility failed to ensure POLST (physician orders life sustaining treatment ) forms were completed for 3 residents (#30, #38,and #99) of 26 sampled residents. The findings include: Review of the facility policy, Health Care Decision Making- Advance Directives, revised 12/7/16 revealed .3. The wishes of the resident are carried out according to the resident's advance health care directives and POLST form . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 11/12/18 revealed the Physician had not signed or dated the form. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form revealed the form was signed and dated by the Physician on 11/28/18. Further review revealed the date prepared was blank. Medical record review revealed resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form revealed the POLST was blank and was not completed upon admission. Interview with the Director of Nursing (DON) on 12/18/18 at 2:07 PM, in the conference room, confirmed it is her expectation for the POLST forms were to be completely filled out, signed, and dated.

Based on facility policy review, medical record review, observation, and interview, the facility failed to assess 1 resident (#38) for self-administration of medication of 7 residents reviewed for medication administration of 26 residents sampled. The findings include: Review of the facility policy MEDICATION- SELF ADMINISTRATION reviewed (MONTH) 1, 2007 revealed .Upon admission a determination shall be made as to the capability of a Resident to self-administer medication .A Resident who is alert and oriented may self administer medication if determined capable by the Director of Health Services and ordered by the physician .The Charge Nurse will notify the resident's physician and obtain an order, if one had not already been obtained, for medications to be kept in the resident's apartment in a secure area .The Charge Nurse will monitor use of the medications and record self-administration on the Medication Administration Record [REDACTED]. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Observation and interview of Resident #38 on 12/17/18 at 10:30 AM, in the resident's room, revealed the resident lying on the bed with two bottles of prescription eye drops on the nightstand at the bedside. Continued interview revealed the resident was self-administering the eye drops and was aware of the administration times. Observation of Resident #38 on 12/18/18 at 9:58 AM, in the resident's room, revealed two bottles of prescription eye drops sitting on the bedside table. Observation of Resident # 38 on 12/18/18 at 3:12 PM, in the resident's room, revealed two bottles of prescription eye drops on the over bed table. Medical record review of the Physician's Orders revealed no order for the prescription eye drops. Observation and Interview with the Assistant Director of Nursing (ADON) on 12/18/18 at 3:17 PM, in the resident's room, revealed two bottles of prescription eye drops used for [MEDICAL CONDITION] (eye condition that can cause [MEDICAL CONDITION]) in the residents room. Continued interview with Resident #38 revealed the eye drops had been brought from home. Interview with the ADON on12/18/18 at 3:21 PM, at the nurse's station, confirmed the resident had no Physician's order for the use of [REDACTED]. Interview with the Director of Nursing on 12/18/18 at 3:23 PM, at the nurse's station, revealed it is her expectation for residents to have physician's order for any medication kept in the room and for a self-administration assessment to be completed.

Based on medical record review, observation, and interview, the facility failed to notify the physican of a signficant weight loss for 1 resident (#114) of 3 residents reviewed for nutrition, of 45 sampled residents reviewed, resulting in an 18.8 pound (10.6%) weight loss in 21 days (harm) for Resident #114. The findings included: Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's weights revealed the following: 1/4/17: 176.8 pounds (lbs) 1/5/17: 176.8 lbs 1/7/17 175.4 lbs 1/23/17: 159 lbs (17.8 lb (10%) loss in 19 days) 1/25/17: 158 lbs (18.8 lb (10.6%) loss in 21 days) Medical record review of the Physicians Recapulation orders dated January 2017, revealed .weigh resident: every one day for three days starting 1/5/17 . Interview with the Registered Dietician (RD) on 1/25/16 at 12:44 PM, at the Nurses Station, revealed .his (resident's) weight on 1/23/17 was 159 pounds which is a severe weight loss . Telephone interview with the resident's physician on 1/25/17 at 3:10 PM revealed .this is the first I have heard about this weight loss .the facility had told me back some time ago he had some weight loss but not this acute loss . Further interview confirmed .if an issue with the weights comes up they should call me .they did not call me . Refer to F325

Based on medical record review and interview, the facility failed to complete timely Minimum Data Set (MDS) assessments for 2 residents (#114 and #145) of 45 sampled residents. The facility's failure to complete the MDS assessments resulted in a failure to identify a significant weight loss of 18.8 pounds (10.6%) in 21 days (harm) for Resident #114. The findings included: Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed there was not a 5 day MDS assessment (due 1/9/17) or a 14 day MDS assessment (due 1/18/17) available in the medical record. Medical record review of the resident's weights revealed the following: 1/4/17: 176.8 pounds (lbs) 1/5/17: 176.8 lbs 1/7/17 175.4 lbs 1/23/17: 159 lbs (17.8 lb (10%) loss in 19 days) 1/25/17: 158 lbs (18.8 lb (10.6%) loss in 21 days) Interview with the MDS coordinator on 1/24/17 at 2:17 PM, in the MDS office, confirmed Resident #114's MDS 5 day and 14 day assessments were not completed. Continued interview confirmed .No, I haven't done it yet . Interview with the Director of Nursing (DON) on 1/25/17 at 3:22 PM, in the private dining, confirmed if the facilty had completed the MDS as scheduled, the severe weight loss loss would have been identified prior to 1/25/17. Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed there was not a 5 day MDS assessment (due 1/12/17) or a 14 day MDS assessment (due 1/21/17) available in the medical record. Interview with the MDS coordinator on 1/24/17 at 3:24 PM, in the MDS office, confirmed the 5 day and the 14 day MDS assessment for Resident #145 was not completed. Further interview confirmed .I'm behind . See F325

Based on review of facility policy, medical record review, observation, and interview, the facility failed to identify and implement interventions for a significant weight loss for 1 resident (#114) of 3 residents reviewed for nutrition, of 45 sampled residents reviewed. The facility's failure to identify and implement interventions resulted in an 18.8 pound (10.6%) weight loss in 21 days (harm) for Resident #114. The findings included: Review of facility policy Weight Management last revised on 1/1/17 revealed .the interdisciplinary Team (IDT) will coordinate carefully to ensure proper weight management for all residents .(1) each resident will be weighed upon admission, the following 2 days, then weekly or monthly as directed by the IDT in coordination with the physician .(2) the weights will be documented in the medical record and periodically reviewed by the IDT .(3) each resident's care plan will address significant weight changes .(4) any significant weight change will be addressed by the IDT, to include the Registered Dietician (RD) . Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's weights revealed the following: 1/4/17: 176.8 pounds (lbs) 1/5/17: 176.8 lbs 1/7/17 175.4 lbs 1/23/17: 159 lbs (17.8 lb (10%) loss in 19 days) 1/25/17: 158 lbs (18.8 lb (10.6%) loss in 21 days) Medical record review of a Nurse's Note dated 1/4/17 at 5:45 PM revealed .has a PEG tube, placed yesterday .tube feedings continuously, and advancing slowly to 75 cc/hr .weight 176.8 pounds . Medical record review of the resident's Care Plan dated 1/4/17 revealed .keep head of bed elevated .provide enteral feedings as ordered .dietary consult as needed . Medical record review of the Physicians Recapulation orders dated January 2017, revealed .Diet: tube feeding .at 30 cc (cubic centimeters)/hr (per hour) .continuous starting 1/5/17 .weigh resident: every one day for three days starting 1/5/17 . Medical record review of a Physician's progress note dated 1/5/17 revealed .recently hospitalized [MEDICAL CONDITION], dehydration, and [MEDICAL CONDITION] with [MEDICAL CONDITION] .while in the hospital he was not eating or taking adequate nutrition or fluids so a PEG tube was inserted for nutritional support . Medical record review of a Nutritional assessment dated [DATE], with no time, revealed .diet order: Puree .supplements: none; meal intake: 0% today r/t (related to) being out of it . Further review revealed .height 72 (inches) .weight: 177 pounds .IBW (Ideal Body Weight): 178 lbs .chewing/swallowing difficulty yes, PEG tube . Further review revealed .tube feeding order: (tube feeding) @ 75 ml/hr (milliliters per hour) with 30 ml/hr flush . Further review revealed .pt. (patient) at TF (tube feeding) goal tolerating well. Current TF providing 82% of estimated needs to promote wound healing. Pt. also on Pureed diet, but hasn't been alert enough to eat today. Altered GI (gastrointestinal) function r/t advanced age also pureed diet, need for TF . Further review revealed .recommend continue (tube feeding) at 75 ml/hr with 30 ml water flush. Will follow to see if intake of pureed diet is sufficient to supplement TF intake . Medical record review of a Nurses Note dated 1/10/17 at 6:40 AM revealed .abdomen soft and non-tender .T/F ongoing as ordered. Tube feeding placement checked by auscultation .0 (no) residual noted . Medical record review of a Physician's Office Visit Note dated 1/11/17 at 12:24 PM, revealed .seen today per nursing request. Patient is currently on [MEDICATION NAME] (antibiotic) for [MEDICAL CONDITION] ([MEDICAL CONDITION] infection causing diarrhea) .recently hospitalized [MEDICAL CONDITION], dehydration, [MEDICAL CONDITION] with [MEDICAL CONDITION], PNA (pneumonia), and mental status changes . Further review revealed .physical exam: general, well developed, well nourished, alert and frail .abdomen: normal bowel sounds, non-tender, no abdominal mass palpated, soft PEG tube in place . Further review revealed .diet: puree and tube feedings . Medical record review of the Interdiscplinary Team (IDT) report dated 1/11/17 revealed the resident's tube feedings and weights was not discussed. Medical record review of a Nurses Note dated 1/13/17 at 10:10 AM revealed .feeding via peg tube pump at 75 cc/hr, check for residual . Medical record review of a Nurses Note dated 1/15/17 at 11:44 PM revealed .T/F (tube feeding) placement checked by auscultation with 0 residual noted. T/F running as ordered . Medical record review of a Speech Therapy (ST) note dated 1/16/17 at 6:32 PM revealed .patient seen with continuous feeds turned off to promote appetite .tolerated puree and NTL (nectar thick liquids) with no overt s/s (signs and symptoms) of aspiration, fatigue, or respiratory decline . Medical record review of the IDT report dated 1/18/17 revealed the resident was not discussed in the meeting related to the tube feedings or weights. Medical record review of a Speech Therapy note dated 1/20/17 at 1:35 PM revealed .patient agreed to sit upright for meal .patient then set up and tolerated puree diet with no overt s/s of aspiration .ate approximately 50% of meal. Patient's daughter called from out of town .discussed plan for .bolus feeds vs. continuous feeding . Medical record review of a Nurses Note dated 1/23/17 at 11:29 PM revealed .patient does have TF running as ordered. 0 residual noted by aspiration. Placement checked by auscultation . Observation on 1/25/17 at 12:30 PM, in the resident's room, revealed the resident was lying on the bed and the tube feeding was turned off. Interview with the Registered Dietition (RD) on 1/25/17 at 12:44 PM, at the Nurses Station, revealed .the resident is on continuous tube feedings at 75 ml/hr .we have advanced him to a puree diet and ST said he was only eating 25% of his meal .his weight on 1/23/17 was 159 pounds which is a severe weight loss .I would normally ask for a re-weigh if I saw this drastic weight loss but he is out of the building now at a doctor's appointment . Interview with Licensed Practical Nurse (LPN) #3 on 1/25/17 at 2:30 PM, at the Magnolia Nurse's Station, revealed .we have weekly IDT meetings and discuss residents with weight loss .we had not discussed this resident for weight loss . Interview with the RD on 1/25/17 at 2:35 PM, in the conference room, revealed .during my first evaluation I wanted to make sure the resident was stable and I was not 100% sure what the resident needed as far as supplemental feedings (versus) continuous feedings .I wanted to establish a baseline for the resident . Further interview revealed .my understanding was the tube feedings were being stopped prior to meals to see if the patient could eat and until the ST saw the patient .I was made aware of this (the tube feedings being stopped for meals) last week . Further interview revealed .I asked for a re-weigh on 1/16/17 but I was never told if the weight was done or what the weight was .I did not write for the tube feedings to be held, it may have been the ST .I am not sure how long this had been going on . Further interview revealed .his weight on 1/23/17 was 159 pounds and revealed a severe weight loss .I did not see the weight until today . Continued interview revealed .the IDT meets weekly but I do not remember discussing the patient related to weight loss or tube feedings .the weight on 1/16/17 would have certainly established a baseline for any weight loss . Telephone interview with the resident's physician on 1/25/17 at 3:10 PM revealed .this is the first I have heard about this weight loss .the facility had told me back some time ago he had some weight loss but not this acute loss . Further interview revealed .he has dementia and had some infections which were being treated with antibiotics .he has a PEG tube with tube feedings ordered .the RD and ST have been following him . Continued interview revealed .I do have input related to the tube feedings .we were trying to get him to 75 cc/hr and add a puree diet to see if he could eat . Interview with the Director of Nursing on 1/25/17 at 3:22 PM, in the private dining room, revealed .I was not made aware of the tube feeding being stopped prior to meals until today .If I had known this I would have certainly evaluated the situation more closely to see what needed to be done . Further interview revealed .if the tube feedings were being held at any time there should be documentation by the ST, the RD, and the nurses related to when the feedings were stopped, why they were stopped, when they were started back, but there is no documentation . Further interview revealed .apparently the ST had asked the feedings to be stopped prior to meals to see how much residual was in the tube feedings .the nurses note indicated no residual . Further interview revealed .I do not remember the weights for the resident being discussed in the IDT .the RD is instrumental in addressing weight loss . Continued interview revealed .I was not aware the RD had asked for a re-weigh on 1/16/17 . Further interview confirmed the tube feedings were withheld without a physician's orders [REDACTED].