Every finding on record at Asheboro Rehabilitation and Healthcare Center

Based on record reviews, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate (Resident #88) and failed to secure two oxygen cylinders stored in a resident's room (Resident #12) for 2 of 3 residents reviewed for respiratory care (Resident #88 and #12).The findings included: Resident #88 was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 had impaired memory and severely impaired decision-making skills. She was coded with the use of oxygen. A review of Resident #88’s active physician orders included an order dated 5/27/25 for oxygen at 2 liters via nasal cannula as needed for shortness of breath. On 8/10/25 at 2:49 PM, Resident #88 was observed lying in bed with her eyes closed and oxygen flowing via a nasal cannula. The oxygen regulator on the concentrator was set at 1.5 liters flow when viewed horizontally at eye level. Resident #88 was observed lying in bed on 8/11/25 at 2:03 PM with oxygen flowing via a nasal cannula. The oxygen regulator on the concentrator was set at 1.5 liters flow when viewed horizontally at eye level. An observation was made with Nurse #1 of Resident #88’s oxygen concentrator on 8/12/25 at 3:00 PM, who stated the oxygen regulator on the concentrator was set at 1.5 liters when viewed horizontally at eye level. Nurse #1 verified Resident #88 was ordered to receive 2 liters of oxygen and adjusted the rate. Nurse #1 stated that oxygen rates were checked when she provided medications throughout the day but was unable to state why she didn’t notice Resident #88 was not receiving the ordered rate of oxygen. During an interview with the Director of Nursing on 8/13/25 at 11:45 AM, she indicated it was her expectation for oxygen to be delivered at the ordered rate. 2. Resident #12 was admitted to the facility on [DATE]. A review of Resident #12’s physician orders revealed an order dated 5/30/25 for supplemental oxygen at 2 liters per minute continuous for hypoxia. A review of Resident #12’s quarterly Minimum Data Set (MDS) dated [DATE] revealed his cognition was severely impaired and he had supplemental oxygen. MDS revealed that Resident #12 required continuous oxygen while he was a resident. On 8/10/25 at 2:15pm an observation was made of Resident #12 laying in his bed wearing continuous oxygen via nasal cannula delivered at 2 liters per minute. Also observed were two free-standing unsecured oxygen E cylinders stored upright in the room between the wall and a cabinet on the left as you enter Resident #12’s room. On 8/10/25 at 2:45pm the Director of Nursing (DON) was notified by the surveyor of the unsecured oxygen tanks in Resident #12’s room. During an observation at 4:30pm on 8/10/25 the oxygen tanks were observed to have been removed from Resident #12’s room. During an interview with Nurse Aide (NA) #1 on 8/12/25 at 1:22pm the NA explained full oxygen tanks were stored in one locked room with upright holders on the floor and empty tanks were stored in a different locked room with upright holders on the floor. NA #1 reported oxygen tanks were not stored in a resident’s room unless the tank were in a holder on the back of the resident’s wheelchair. On 8/12/25 at 1:27pm an interview was conducted with Nurse #3 who explained the oxygen cylinder tanks should be stored in the oxygen storage room in holders. The Nurse stated she did not notice the oxygen cylinders stored in Resident #12’s room earlier this week. During an interview with the DON, in the presence of the Administrator, on 8/13/25 at 11:15am. The DON explained the oxygen cylinders should be stored in the transport caddy or in the oxygen storage room and should not be left in a resident’s room unsecured.

Based on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of falls for 1 of 7 residents (Resident #97) reviewed for MDS accuracy.The findings included:Resident #97 was readmitted to the facility on [DATE] with diagnoses that included Dementia.A review of Resident #97's medical record revealed she had falls on 06/25/25 and 07/02/25 with no injuries. Resident #97 also had falls on 07/06/25 and 07/11/25 with minor injuries.A significant change Minimum Data Set (MDS) assessment, dated 07/29/25, indicated Resident #97's cognition was severely impaired and was coded for one fall with no injury since the last assessment (quarterly dated 06/24/25).An interview was conducted with the MDS Coordinator on 08/13/25 at 1:21 PM. The MDS Coordinator reviewed the MDS assessment dated [DATE] as well as Resident #97's medical record. The MDS Coordinator confirmed Resident #97 had 4 falls since the last assessment on 06/24/25 and should have been coded for 2 falls with no injuries and 2 falls with minor injuries. She stated it was an oversight.An interview was conducted with the Director of Nursing (DON) and the Administrator on 08/13/25 at 1:46 PM. The DON stated the MDS assessments should be coded accurately to reflect Resident 97's condition.

Based on record review and interviews with staff, the facility failed to refer residents (Residents #2 and Resident #66) for a level II Preadmission Screening and Resident Review (PASRR) for newly diagnosed serious mental illness for 2 of 2 residents reviewed for PASRR.1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar type depression, dementia, anxiety disorder, and frontotemporal neurocognitive disorder. She was admitted with a level 1 PASRR as of 10/25/24 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Record review revealed Resident #2 was diagnosed on [DATE] with schizoaffective disorder. There was no evidence that a referral for level II PASRR screening was completed. Resident #2's annual Minimum Data Set, dated [DATE] indicated she was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. An interview was conducted on 08/11/25 at 3:34 PM with the Social Worker (SW). The SW verified she was responsible for ensuring residents with a newly evident diagnosis of a serious mental illness were referred for a level II PASRR evaluation. She explained a PASRR level II screening request should have been sent at the time Resident #2 was newly diagnosed with schizoaffective disorder on 03/27/25. She verified Resident #2 had not been referred for level II evaluation at any point after the new diagnosis through present day. The SW stated she reviewed the discharge summary when a resident went to the hospital and the physician, nurse practitioner, and/or psychiatry notes to check for new diagnosis. An interview was conducted on 08/13/2025 at 12:40 PM with the Administrator in conjunction with the Director of Nursing (DON). The Administrator stated he wasn't aware a level II PASRR needed to be requested if there was a new mental health diagnosis. The DON agreed. 2. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE], and a PASRR level I was completed. According to a letter dated 2/2/24 the facility received from the State of North Carolina, a level II PASRR was halted on 2/2/24 due to the resident not meeting the criteria for a mental illness. The letter further explained no further level I screening was required unless a significant change occurred with the individual’s mental status which suggested a psychiatric disorder that was not dementia. Resident #66 was diagnosed with unspecified psychosis not due to a substance or physiological condition on 5/2/24. A review of the active medication orders revealed Resident #66 was prescribed Seroquel extended release 24 hour (an antipsychotic medication) 50 milligrams for unspecified psychosis with behaviors with a start date of 6/3/25. There was no documentation regarding a new level II PASRR request in Resident #66's chart after the new mental health diagnosis or the addition of an antipsychotic medication. Review of Resident #66's comprehensive Minimum Data Set (MDS) dated [DATE] assessed the resident moderately cognitively impaired and revealed the resident had been evaluated by Level II PASRR and determined to have a serious mental illness. During an interview with the Social Worker (SW) on 8/12/25 at 2:25 PM she revealed a PASRR level II referral was supposed to have been completed when a resident had a significant change of condition or a newly added mental health diagnosis. It was further revealed by the SW she believed Resident #66 already had a level II determination after she received the PASRR letter from the State of North Carolina on 2/2/24. She stated she thought the letter “H” included with the resident’s PASRR number meant the determination for a level II PASRR was completed and was indefinite without need to submit anything further for the resident. An interview was conducted with the Administrator with the Director of Nursing (DON) present on 8/13/25 at 12:40 PM. The Administrator stated he wasn’t aware a level II PASRR needed to be requested if there was a secondary diagnosis of a mental health condition. He stated the facility should verify they were completing PASRRs correctly. The DON agreed the facility should make sure the PASRR was correct for each resident.

Based on record review and staff interviews, the facility failed to follow a urology order to change the indwelling urinary catheter monthly for 1 of 2 residents reviewed for urinary catheters (Resident #47).The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (condition where urine flow is blocked or reversed) and neuromuscular dysfunction of the bladder (a condition where the nerves controlling bladder function are damaged). A review of Resident #47's medical record indicated he was admitted from the hospital on 5/16/25 and had been utilizing a urinary catheter while at home. A review of Resident #47's physician orders included the following: - An order dated 5/16/25 for indwelling catheter care- cleanse with soap and water every shift. - An order dated 5/16/25 to monitor the urinary catheter output every shift. - An order dated 5/20/25 to change the indwelling urinary catheter when occluded or leaking. - An order dated 5/21/25 to anchor the urinary catheter tubing for safety. Check every shift for placement. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was cognitively intact and was coded for an indwelling urinary catheter being present. A review of Resident #47's Treatment Administration Records (TARs) from May 2025 through August 2025 indicated that the urinary catheter was changed on 6/23/25 and 7/10/25 due to leaking. Review of a urology progress note dated 7/22/25 indicated the nursing facility was to change the urinary catheter every month. A review of Resident #47's active physician orders did not include an order to change the urinary catheter monthly. Resident #47's August 2025 Medication Administration Record (MAR) and TAR were reviewed, and no entry was noted to change the urinary catheter every month which should have been scheduled for 8/22/25. On 8/12/25 at 3:00 PM, an interview occurred with Nurse #1. She had been the nurse assigned to Resident #47 on 7/22/25 when he returned from the urology appointment. Nurse #1 reviewed the urology progress note dated 7/22/25 and confirmed the provider had requested the nursing facility to change Resident #47's urinary catheter monthly. She stated that she had carried out all the other orders from the urology appointment on 7/22/25 but didn't see the order to change the urinary catheter monthly. Nurse #1 felt it was an oversight. Nurse #1 explained that the nurse assigned to residents that go out to appointments were responsible for transcribing any orders they returned with from the visit. In the past there was a unit manager that reviewed the specialist progress notes to ensure the orders were transcribed completely and accurate but at the time of Resident #47's appointment on 7/22/25 there was no unit manager. The Director of Nursing (DON) was interviewed on 8/13/25 at 11:45 AM and reported any resident that returned from a specialist appointment with new orders should be transcribed correctly and accurately.

Based on record reviews, observations, Registered Dietitian (RD) and staff interviews, the facility failed to ensure the enteral tube feed (a method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) formula was specified in the active physician's order for Resident #3. This failure had been ongoing since June 2025. In addition, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for Resident #11 and Resident #88 which had the potential for bacterial growth and contamination. The deficient practice affected 3 of 4 residents reviewed for enteral feeding management (Resident #3, Resident #11 and Resident #88).The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke and diabetes type 2. A review of Resident #3's physician orders included the following:- - An order dated 1/18/25 through 6/18/25 for Glucerna 1.5 calories via a pump at 55 milliliters (ml) per hour from 8:00 PM to 12:00 noon.- - The order dated 6/18/25 read two times a day for Nutritional Support. Administer 55 ml per hour via pump continuously for 12 hours or until total nutrient is delivered. On at 8:00 PM and off at 8:00 AM. This order did not indicate which type of formula to provide to Resident #3. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had moderately impaired cognition and received 51% or more of her total calories and more than 501 ml of fluids per day by enteral feedings. A review of the June 2025, July 2025 and August 2025 Medication Administration Records (MARs) read two times a day for Nutritional Support. Administer 55 ml per hour via pump continuously for 12 hours or until total nutrient is delivered. On at 8:00 PM and off at 8:00 AM. An interview occurred with Nurse #1 on 8/12/25 at 3:00 PM. She had been assigned to care for Resident #3 on the 3:00 PM to 11:00 PM shift on 7/22/25, 7/29/25 and 7/31/25. Nurse #1 stated that she always provided Glucerna 1.5 formula for Resident #3 when she was assigned to her on the 3:00 PM to 11:00 PM shift. Nurse #1 reviewed the current active orders and verified the order dated 6/18/25 did not contain which enteral feeding formula to provide to Resident #3. Nurse #1 stated she didn't realize the current order didn't specify which enteral feeding formula to provide, just that she knew Resident #3 had received Glucerna 1.5 in the past. A phone interview occurred with the Registered Dietitian on 8/12/25 at 3:37 PM. She was able to review Resident #3's current physician orders and confirmed the order she wrote on 6/18/25 did not include which tube feed formula to provide to Resident #3. The Registered Dietitian explained that on 6/18/25 she adjusted Resident #3's infusion time for the enteral tube feed and felt it was an oversight not to have specified which tube feed formula to use. A phone interview was conducted with Nurse #6 on 8/12/25 at 6:19 PM. Nurse #6 had been assigned to Resident #3 on the 3:00 PM to 11:00 PM shift on 8/11/25 and stated that she had always provided Resident #3 Glucerna 1.5 for her tube feed. Nurse #6 further stated that she was unaware the current order didn't specify which enteral formula to use. A phone interview occurred with Nurse #7 on 8/13/25 at 8:58 AM. She had been assigned to Resident #3 on the 3:00 PM to 11:00 PM shift on 8/6/25. Nurse #7 stated she noticed the current order didn't specify which formula to use but she knew Resident #3 had been on Glucerna 1.5 at one point and was a diabetic. A phone interview was completed with Nurse #10 on 8/13/25 at 11:40 AM who was assigned to care for Resident #3 on the 3:00 PM to 11:00 PM shift on 8/4/25. She recalled providing Glucerna 1.5 to Resident #3 at the time of her tube feeding and stated that she didn't notice the current order did not specify which formula to use, just that she knew Resident #3 had used Glucerna 1.5 before. The Director of Nursing was interviewed on 8/13/25 at 11:45 AM and stated that she would expect the tube feeding orders to specify which formula to provide. A phone interview occurred with Nurse #12 on 8/13/25 at 1:56 PM. She had been assigned to care for Resident #3 from 7:00 PM to 7:00 AM on 8/2/25, 8/3/25, 8/9/25 and 8/10/25. She recalled providing Glucerna 1.5 for Resident #3's tube feed and had not noticed the current order did not include which tube feed formula to provide to Resident #3. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), esophageal obstruction, and severe protein-calorie malnutrition. A review of Resident #11's physician orders included the following:- - An order dated 4/2/24 for the feeding tube to be flushed with 15 milliliters (ml) of water before and after each medication administration.- -An order dated 4/3/24 for tube feed formula 1.5 calories from 9:00 PM to 9:00 AM running at 85 ml per hour for 12 hours. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had moderately impaired cognition and received 51% or more of her total calories and more than 501 ml of fluids per day by enteral feedings. During an observation of Resident #11 on 8/10/25 at 10:50 AM, the plastic syringe used to provide medications and flush the feeding tube was noted in a plastic bag hanging from the feeding pump pole with the plunger in the barrel of the syringe. Droplets of a clear liquid were noted in the tip of the syringe. Nurse #2 was interviewed on 8/10/25 at 10:57 AM and explained that she had provided Resident #11 with her medications and water flush via the feeding tube that morning. She stated that she was not aware the plunger should be removed from the barrel of the syringe and stored separately. The Director of Nursing was interviewed on 8/13/25 at 11:45 AM and stated the plunger for the enteral feeding syringe should be removed from the barrel and stored separately due to the potential for bacterial growth in the syringe tip. 3. Resident #88 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury and dysphagia. A review of Resident #88's physician orders included the following:- - An order dated 1/19/25 for nothing by mouth (NPO) status.- - An order dated 1/20/25 to flush feeding tube with 30 milliliters of water before and after each medication administration. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 had severely impaired cognitive skills for daily decision-making and received 51% or more of her total calories and more than 501 ml of fluids per day by enteral feedings. During an observation of Resident #88 on 8/10/25 at 2:49 PM, the plastic syringe used to provide medications and flush the feeding tube was noted in a plastic bag hanging from the feeding pump pole with the plunger in the barrel of the syringe. Droplets of a clear liquid were noted in the tip of the syringe. Nurse #2 was interviewed on 8/10/25 at 2:51 PM and explained that she had provided Resident #88 with her medications and water flush via the feeding tube that morning. She stated that she was not aware the plunger should be removed from the barrel of the syringe and stored separately. The Director of Nursing was interviewed on 8/13/25 at 11:45 AM and stated the plunger for the enteral feeding syringe should be removed from the barrel and stored separately due to the potential for bacterial growth in the syringe tip.

Based on observation, record review and Nurse Practitioner (NP) and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when Nurse #1 failed to perform hand hygiene between residents during 2 of 3 medication administration observations and failed to perform hand hygiene before donning gloves and after glove removal during administration of eye drops. This deficient practice was for 1 of 5 staff members observed for infection control practices (Nurse #1).A review of the facility policy titled Medication Administration (not dated): Preparation instructions stated in part: Perform hand hygiene before preparing and administering medications. A review of the facility policy for administering eye drops (not dated) stated in part: perform hand hygiene, apply gloves, administer eye drops, remove gloves, and perform hand hygiene.A continuous observation was started on 08/13/25 at 8:11 AM and ended at 8:26 AM of Nurse #1 preparing and administering Resident #60 and Resident #48's medications. Nurse #1 was observed at the medication cart collecting the needed supplies and medications for Resident #60, surveyor accompanied Nurse #1 into the room, and Nurse #1 sat the medication cup on the bed side table. Resident #60 picked up the cup of medications and took them sitting the cup back on the bed side table. Nurse #1 picked up the empty medication cup and the water cup and exited the room. Nurse #1 did not perform hand hygiene at any time before preparing or administering Resident #60's medications. Nurse #1 went back to the medication cart and immediately started preparing Resident #48's medications without performing hand hygiene. At 8:20 AM an observation was made of Nurse #1 collecting the needed supplies and medications for Resident #48. Once in the room, Nurse #1 set down the cup of water and the medication cup, put on disposable gloves and proceeded with handing Resident #48 the medication cup and water. Nurse #1 was then observed administering eye drops to Resident #48. Nurse #1 removed her gloves and threw them away before proceeding to the medication cart in the hallway. Nurse #1 did not perform hand hygiene at any time during the continuous observation of preparing or administering medications to Resident #48.In an interview with Nurse #1 on 08/13/25 at 8:27 AM she stated she was aware she should have performed hand hygiene between residents and before donning gloves and after removing her gloves when administering eye drops. She further revealed she did not perform hand hygiene because she was nervous, and she forgot to do so. An interview was conducted on 08/13/25 at 10:44 AM with the NP. She stated staff should wash hands or use hand sanitizing gel between residents during medication administration. They should also wash their hands prior to and after eye drop administration to prevent cross contamination of bacteria. An interview was conducted on 08/13/25 at 1:43 PM with the Director of Nursing (DON) in conjunction with the Infection Preventionist (IP). The DON stated nurses were to perform hand hygiene between each resident when care was provided including medication administration. She also stated nurses were to wash hands prior to and after eye drops are administered. She indicated Nurse #1 should have performed hand hygiene between residents and prior to and after the administration of eye drops. The IP Nurse agreed with the DON.

Based on observations and staff interviews, the facility failed to maintain a clean toilet seat and an environment that was free of urine odor in residents' rooms. This deficient practice affected 1 of 4 residents reviewed for a safe, clean, comfortable, homelike environment (Resident #62). The findings included: An initial observation completed on 8/10/25 at 10:50 AM revealed Resident #62’s bathroom had yellow staining on the left front of the toilet seat. In addition, the trash can in the bathroom had 2 soiled adult undergarments rolled up inside, and the resident’s room and bathroom smelled strongly of urine. During subsequent observations on 8/11/25 at 1:18 PM and 8/12/25 at 2:40 PM Resident #62’s room and bathroom continued to have strong urine odors, and the yellow staining on the toilet seat remained. Wetness was noted on the floor surrounding the front of the toilet and seeping towards the doorway during the observation on 8/12/25. Resident #62 resided in his room during all observations, and he did not have a roommate during the survey. An interview and observation were conducted with the Housekeeping Director on 8/12/25 at 2:45 PM. He stated on the weekends the housekeeper scheduled for the hall Resident #62 resided on began cleaning rooms at the top of the hallway first then gradually worked down the hall completing each room. Based on his estimation of the time it took to clean a room; he stated housekeeping had probably not reached Resident #62’s room during the time of the observation on 8/10/25 because the weekend staff didn’t report for duty until 8:30 AM. He indicated stains did not typically come off toilet seats with cleaning products, and it was the responsibility of Maintenance to change the toilet seats out if there were stains. He indicated housekeeping staff had finished cleaning Resident #62’s room on 8/12/25 at the time of the interview. The Housekeeping Director further stated he completed a walkthrough of each resident’s room once housekeeping staff completed all rooms, but he had not conducted a walkthrough yet that day. The Housekeeping Director accompanied this surveyor to Resident #62’s room on 8/12/25 and agreed with this surveyor that the room had a strong odor of urine upon entering. He acknowledged the yellow staining on the left front of the toilet seat and stated, “there appears to be urine on the bathroom floor around the toilet”. He then indicated he would have housekeeping clean the resident’s room immediately. The Maintenance Director was interviewed on 8/13/25 at 8:48 AM and stated he completed facility equipment checks daily, such as functioning doorways, magnetic locks, water temperatures, and the general appearance of the hallways. However, he stated specific items that needed repair in the resident’s rooms were relayed to him by a work order. He indicated he had not received a work order regarding the toilet seat in Resident #62’s bathroom notifying him the toilet seat needed to be replaced. A review of the work orders he had on file did not reveal a work order for replacement of the toilet seat. The Maintenance Director added a work order for the toilet seat to be removed in Resident #62’s room during the interview and stated he would have the seat changed out. An observation completed on 8/13/25 at 9:00 AM revealed Resident #62’s room was clean and no longer smelled of urine. On 8/13/25 at 1:15 PM the Administrator was interviewed, and he stated housekeeping should clean the resident’s room daily and ensure there are no strong odors in the resident’s room.

Based on observations and staff interviews, the facility failed to ensure nurse staffing data was posted daily for 1 of 4 days of the survey conducted 8/10/25 through 8/13/25 (8/10/25).Findings included: During the initial tour of the facility on 8/10/25 at 10:00 AM, the posting of the daily staffing data was dated 8/8/25. An interview was conducted with Nurse Aide #3 on 8/10/25 at 3:40 PM who stated she was filling in for the scheduler who was currently on vacation. She indicated the scheduler did not work on the weekends, and it was up to the nursing staff to post the daily schedule on the weekends. On 8/10/25 Nurse #4 entered the facility from her reported break at 10:00 AM and stated, I am an agency nurse, and this is my first day working. I don't know anything, and I can't help you. The Director of Nursing was interviewed on 8/10/25 at 3:36 PM who stated the scheduler was responsible for posting daily staffing when she worked, but the hall nurse was responsible for the daily posting on the weekend. The Administrator was interviewed on 8/13/25 at 12:50 PM who stated the facility's scheduler went on vacation Friday, but he expected the facility to accurately post the daily schedule.

Based on record review and interviews with staff, Pharmacy Consultant and Nurse Practitioner, the Pharmacy Consultant failed to identify the facility's need to identify target behavioral symptoms, to monitor those symptoms as well as the need to monitor residents for side effects of psychotropic medications (Residents #73, #82 and #68). This was for 3 of 5 residents reviewed for unnecessary medications. The findings included: 1. Resident #73 was originally admitted to the facility on [DATE] with a recent readmitted [DATE]. Her diagnoses included bipolar disorder, depression, anxiety disorder and unspecified psychotic disorder. A review of Resident #73's medical record revealed the following hospitalization for mental health concerns: 2/10/24 through 2/12/24 was seen for suicidal ideations. 3/27/24 through 4/23/24 was seen for bipolar disorder severe with psychotic features. A review of Resident #73's physician orders included an order dated 4/25/24 for Fluphenazine (an antipsychotic medication) 5 milligrams (mg) one tablet by mouth twice a day. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was cognitively intact and displayed no behavior issues. Her mood was coded with feeling down, depressed or hopeless 7 out of 10 days during the 14-day look back period. Resident #73 received an antipsychotic medication. Review of the Pharmacy Consultant medication review notes for Resident #73 from 6/25/24, 7/12/24 and 8/15/24, did not reflect the need for monitoring targeted behaviors and side effects for the use of an antipsychotic medication. A psychiatric progress note dated 8/6/24 indicated Resident #73 endorsed having more episodes of depression, irritability and anxiety. A review of Resident #73's nursing progress notes from 2/1/24 to 9/3/24 included behaviors such as crying, suicidal thoughts, agitation, and restlessness. Resident #73's Medication Administration Records (MAR) from 6/1/24 to 9/3/24 indicated she received Fluphenazine as ordered. The MAR did not list any targeted behaviors or side effects for staff to monitor. An interview with Nurse Practitioner #1 occurred on 9/4/24 at 2:09 PM and stated she would have expected the Pharmacy Consultant to have caught the missing target behaviors and side effect monitoring for Resident #73's antipsychotic medication. A telephone interview was conducted with the Pharmacy Consultant on 9/5/24 at 3:20 PM. She stated she didn't normally review the MARs but reviewed the physician and psychiatric progress notes as well as the nursing notes each month during her medication review. The Pharmacy Consultant stated she understood why target behaviors and side effect monitoring was important in a resident with a history of suicidal thoughts. The Pharmacy Consultant was unable to explain why she did not recommend the need to identify target behaviors and side effect monitoring for Resident #73 in her recommendations. 31227 2. Resident # 82 was admitted on [DATE] with cumulative diagnoses of depression anxiety, dementia with behavioral disturbances, unspecified psychosis and affective mood disorder. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 had moderate cognitive impairment, exhibited no behaviors and was coded for the use of an antipsychotic and an antidepressant. Review of Resident #82 September 2024 Physician orders included the following order dated 4/23/24: Seroquel (antipsychotic) Extended Release 24 hour 50 milligrams give one tablet by mouth in the afternoon for dementia with mood/psychotic disturbances. Another order dated 8/1/24 read Sertraline (antidepressant) 50 milligrams give one tablet by mouth at bedtime for dementia with behaviors, depression and anxiety. Review of the medication administration records (MARs) from November 1, 2023 to September 2024 included an order that was not included on the monthly Physician orders that read: Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in progress note every shift-Order Date 11/10/2023. There was no documented evidence of targeted clinical behavior identification and no clarification of what side effects the staff were to monitor with regard to the antipsychotic versus the antidepressant. A review of a Pharmacist Medication Regime Review dated 11/20/23 read there were no irregularities and no recommendations. This review was completed by the previous Consultant Pharmacist. A review of Pharmacist Medication Regime Review dated 12/15/23 read to see the monthly report for any noted irregularities. This review was completed by the previous Consultant Pharmacist. The monthly pharmacy reports were requested from the Assistant Director of Nursing (ADON) on 9/4/24 but there was nothing listed on the December pharmacy report and the ADON was not able to locate any pharmacy recommendations dated 12/15/23. A review of a Pharmacist Medication Regime review dated 1/19/24 read there were no irregularities and no recommendations. This review was completed by the previous Consultant Pharmacist. A review of a Pharmacist Medication Regime review dated 2/23/24 read there were no irregularities and no recommendations. This review was completed by the current Consultant Pharmacist. A review of a Pharmacist Medication Regime review dated 3/15/24 read there were no irregularities and no recommendations. This review was completed by the current Consultant Pharmacist. A review of a Pharmacist Medication Regime review dated 4/24/24 read there were recommendations and to see the monthly report. This review was completed by the current Consultant Pharmacist. Review of the monthly pharmacy report read her recommendation was to add a stop date of 5/20/24 to the use of Resident #82's as needed (prn) antipsychotic because they must be limited to 14 days and reevaluated. A review of a Pharmacist Medication Regime review dated 5/29/24 read there were no irregularities and no recommendations. This review was completed by the current Consultant Pharmacist. A review of a Pharmacist Medication Regime review dated 6/28/24 read there were no irregularities and no recommendations. This review was completed by the current Consultant Pharmacist. A review of a Pharmacist Medication Regime review dated 7/13/24 read there were recommendations and to see the monthly report. Review of the monthly pharmacy report read her recommendation was to attempted a gradual dose reduction on Resident #82's antidepressant. This review was completed by the current Consultant Pharmacist. A review of a Pharmacist Medication Regime review dated 8/16/24 read there were no irregularities and no recommendations. This review was completed by the current Consultant Pharmacist. An interview was completed with Resident #82 on 9/3/24. She was sitting up in her reclining chair dressed for the day. She was very pleasant and engaging in a conversation regarding her jewelry. There were no observed extrapyramidal symptoms such as movement dysfunction, rigidity, jerking or tremors associated with prolonged use of an antipsychotic medications and no drowsiness, dizziness, insomnia or headaches symptoms associated with antidepressants. An interview was completed on 9/4/24 at 1:54 PM with the ADON who was acting as the Director of Nursing (DON) while she was away. She stated the Consultant Pharmacist reviewed Resident #82's medications for irregularities, accuracy and completeness every month and there was no documentation from the Consultant Pharmacist stating the need to identify her target clinical behaviors or specific side effect monitoring for different psychotropic medications. The ADON stated either the DON or herself reviewed the monthly pharmacy reports and recommendations for all the residents and there was nothing in the monthly reports going back to November 2023 that mentioned anything about the missing monitoring needed on Resident #82. An interview was completed on 9/4/24 at 2:09 PM with NP #1. She stated she would have expected the Consultant Pharmacist to have caught the missing monitoring and since it had been happening since November 2023, she was concerned for all the residents prescribed psychotropic medications. NP #1 stated when residents in their 90's are prescribed antipsychotics and other psychotropics, they require close monitoring for target clinical behaviors to determine if the identified behaviors improved or not and to see if the resident remains free from adverse side effects. An interview was completed on 9/5/24 at10:30 AM with Nursing Assistant (NA) #1. She stated she had worked with Resident #82 a long time and she was never known her to exhibit any sort of negative behaviors. NA #1 stated Resident #82 was always cooperative and pleasant with her. An interview was completed on 9/5/24 at 10:40 AM with Nurse #3. She stated at one time sometime after her admission, it was suspected she was sundowning(late-day confusion) but Resident #82's behaviors have been under control for months. A telephone interview was attempted with the previous Consultant Pharmacist but at the time of exit, she had not returned surveyor's calls. A telephone interview was completed on 9/5/24 at 3:20 PM with the Consultant Pharmacist. She stated when she completes her monthly medication review, she does not normally review the MARs to see if there have been any behaviors but rather she reviews Physician, NP, nursing and Psychiatric notes. She stated after reviewing Resident #82's MARs and only seeing a box to check for behaviors and no side effect monitoring at all, she understood what the missing monitoring was and why target clinical behaviors were important to identify to determine worsening or improvement. She stated both antidepressants and antipsychotics have different side effects and both should be clear on what potential adverse side effects to monitor. She stated she started in February 2024 and that she should have identified this irregularity and acted on it before the now. An interview was completed on 9/5/24 at 3:50 PM with the Administrator. He stated the Consultant Pharmacist had been reviewing Resident #82's medications monthly for irregularities since November 2023 and it was hard to imagine that the previous Consultant Pharmacist and the current Consultant Pharmacist did not identify the missing monitoring needed for the use of psychotropic medications. He stated he expected better from the Consulting Pharmacist. 46725 3. Resident #68 was originally admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, delusional disorders, Alzheimer's disease with late onset, and unspecified psychosis. A review of Resident #68's physician orders included an order dated 6/27/24 for Olanzapine (an antipsychotic medication) 10 milligrams (mg) half a tablet by mouth twice a day and a physician order dated 6/26/24 for Sertraline (an antidepressant medication) 25 milligrams (mg) one tablet by mouth twice a day. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #68 was cognitively impaired and displayed behaviors of physical, verbal abuse, and wandering. Her mood was coded with feeling down, depressed or hopeless 7 out of 11 days during the 14-day look back period. Resident #68 received antipsychotic and antidepressant medication. Review of the Pharmacy Consultant medication review notes for Resident #68 from 6/1/24 to 9/3/24 did not reflect the need for monitoring targeted behaviors and side effects for the use of an antipsychotic medication. A review of Resident #68's social service progress note dated 7/24/24 indicated Resident #68 has had an increase in behaviors which included yelling, agitation, aggression with family members and delusions. Resident #68's Medication Administration Records (MAR) from 6/1/24 to 9/3/24 indicated she received Olanzapine and Sertraline as ordered. The MAR did not list any targeted behaviors or side effects for staff to monitor. An interview with Nurse Practitioner #1 occurred on 9/4/24 at 2:09 PM and stated she would have expected the Pharmacy Consultant to have caught the missing target behaviors and side effect monitoring for Resident #68's psychotropic medication. A telephone interview was conducted with the Pharmacy Consultant on 9/5/24 at 3:20 PM. She stated she didn't normally review the MARs but reviewed the physician and psychiatric progress notes as well as the nursing notes each month during her medication review. The Pharmacy Consultant stated she understood why target behaviors and side effect monitoring was important in a resident with a history of mood and behaviors. The Pharmacy Consultant was unable to explain why she did not recommend the need to identify target behaviors and side effect monitoring for Resident #68 in her recommendations.

Based on record review, staff, Administrator, resident, Nurse Practitioner (NP) #1 and Consultant Pharmacist interviews, the facility failed to identify the targeted clinical behaviors and side effects to be monitored for the use of psychotropic medications for Resident's #82, #73 and #68. The facility also failed to complete a baseline abnormal involuntary movement scale (AIMS) with the initiation of a newly prescribed antipsychotic for Resident #145. This was for 4 of 5 residents reviewed for unnecessary medications. The findings included: 1. Resident # 82 was admitted on [DATE] with cumulative diagnoses of depression anxiety, dementia with behavioral disturbances, unspecified psychosis and affective mood disorder. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 had moderate cognitive impairment, exhibited no behaviors and was coded for the use of an antipsychotic and an antidepressant. Review of Resident #82's comprehensive care included a care area initiated on 10/30/23 and revised on 2/26/24 that read Resident #82 exhibited or was at risk for distressed, fluctuating mood symptoms related to depression, anxiety and affective disorder. She was also care planned initially on 10/30/23 and revised on 2/26/24 for complications related to the use of psychotropic drugs (antidepressant/antipsychotic). Interventions included AIMS testing per protocol, complete behavior monitoring, gradual dose reductions as needed, monitor for changes in mental status and functional level and report to the Physician as indicated, monitor for the continued need of the medication as related to her behaviors and mood and lastly to monitor for side effects and consult the Physician and/or Pharmacist as needed. Review of Resident #82's Physician orders included the following order dated 4/23/24: Seroquel (antipsychotic) Extended Release 24 hour 50 milligrams give one tablet by mouth in the afternoon for dementia with mood/psychotic disturbances. Another order dated 8/1/24 read Sertraline (antidepressant) 50 milligrams give one tablet by mouth at bedtime for dementia with behaviors, depression and anxiety. Review of the medication administration records (MARs) from November 1, 2023 to September 2024 included an order that was not included on the monthly Physician orders that read: Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in progress note every shift-Order Date 11/10/2023. There was no documented evidence of targeted clinical behavior identification and no clarification of what side effects the staff were to monitor with regard to the antipsychotic versus the antidepressant. Review of Resident #82's nursing notes from November 1, 2023, to September 5. 2024 only include 3 nursing notes regarding behaviors, 2 of which were related to new onset of urinary tract infections (UTI's). She was prescribed a prophylactic antibiotic by urology for recurrent UTI's on 2/8/24. An interview was completed with Resident #82 on 9/3/24. She was sitting up in her reclining chair dressed for the day. She was very pleasant and engaging in a conversation regarding her jewelry. There were no observed extrapyramidal symptoms such as movement dysfunction, rigidity, jerking or tremors associated with prolonged use of an antipsychotic medications and no drowsiness, dizziness, insomnia or headaches symptoms associated with antidepressants. An interview was completed on 9/4/24 at 1:54 PM with the Assistant Director of Nursing (ADON) who was acting as the Director of Nursing (DON) while she was away. The ADON stated she was aware of the need to identify and monitor target clinical behaviors when a psychotropic medication was added and also needed to monitor specific side effects for psychotropic medications. The ADON stated whoever entered the original order in November 2023, they did not check off specific behaviors for the antipsychotic or the antidepressant from an already computerized list and the same went for the side effect monitoring. When the order was entered, the person should have checked side effects to be monitored with the antipsychotic and the antidepressant. She stated she would start looking at the residents on psychotropic medications today. An interview was completed on 9/4/24 at 2:09 PM with NP #1. She stated she would have expected the facility to have caught the error that had been happening since November 2023 and there was no excuse because when residents in their 90's are prescribed antipsychotics and other psychotropics, they require close monitoring for behaviors to determine if the identified behaviors improved or didn't and to see if the resident remains free for adverse side effects. An interview was completed on 9/5/24 at10:30 AM with Nursing Assistant (NA) #1. She stated she had worked with Resident #82 a long time and she was never known her to exhibit any sort of negative behaviors. NA #1 stated Resident #82 was always cooperative and pleasant with her. An interview was completed on 9/5/24 at 10:40 AM with Nurse #3. She stated at one time sometime after her admission, it was suspected she was sundowning(late-day confusion) but Resident #82's behaviors have been under control for months. An interview was completed on 9/5/24 at 3:50 PM with the Administrator. He stated all residents prescribed an antipsychotic or any other kind of psychotropic medication require a diagnosis and identification of the target clinical behaviors for which the psychotropic was prescribed. The Administrator stated monitoring the side effects of antipsychotics was necessary due to the adverse side effects that can occur with use of antipsychotics over time. The Administrator further stated monitoring for side effects with all other psychotropic medications was imperative as well especially in the elderly population. 2. Resident #145 was admitted on [DATE] with diagnoses of vascular dementia, major depressive disorder and a cerebral vascular accident (CVA). His admission Minimum Data Set (MDS) dated [DATE] indicated Resident #145 had severe cognitive impairment and exhibited no behaviors. He was coded for the use of an antidepressant. Resident #145 was care planned on 8/22/24 and revised on 8/29/24 for exhibiting or had the potential to demonstrate verbal/physical behaviors related to: cognitive loss/dementia. Review of a NP #1 note dated 8/28/24 read staff report Resident #145 was having increased behaviors and agitation. Review of a Physician order dated 8/28/24 read Seroquel (antipsychotic) 25 milligrams give 1 tablet every 6 hours as needed (prn) for agitation, dementia with behaviors and anxiety x 14 days end date 9/11/24. Review of Resident #145's August 2024 medication administration record (MAR) and September 2024 MAR indicated he received the as needed Seroquel on 8/30/24, 9/2/24, 9/3/24 and 9/4/24. Review of Resident #145's medical record did not include a baseline abnormal involuntary movement scale (AIMS) assessment. The AIMS is an assessment done to determine a baseline and periodically assess for involuntary movement that go along with the use of antipsychotic medications. An interview was completed on 9/4/24 at 1:54 PM with the Assistant Director of Nursing (ADON) who was acting as the Director of Nursing (DON) while she was away. The ADON stated she was under the impression that she had 14 days to complete the AIMS assessment since Resident #145 was a new admission. She then stated she would check to make sure and return with an answer. An interview was completed on 9/4/24 at 2:09 PM with NP #1. She stated she would have expected the facility would completed a baseline AIMS for the use of a prn antipsychotic medication because she was familiar with instances where after the 14 days of using the antipsychotic as needed, the provider often removed the as needed part of the order and prescribed it every day. She stated when that happens, since there was no baseline AIMS completed, there is no reference point to determine if the medication was causing adverse side effects over time. On 9/4/24 at 2:43 PM, the ADON provided a copy of an AIMS she had completed on 9/4/24 with her electronic signature but was back dated to 8/28/24. When asked why she back dated the AIMS to 8/28/24, she stated she still signed off on it 9/4/24. An interview was completed on 9/5/24 at 3:50 PM with the Administrator. He stated an AIMS assessment was to be completed at the time a resident was started on an antipsychotic medication in order to establish a baseline for that resident. 40197 3. Resident #73 was originally admitted to the facility on [DATE] with a recent readmitted [DATE]. Her diagnoses included bipolar disorder, depression, anxiety disorder and unspecified psychotic disorder. A review of Resident #73's medical record revealed the following hospitalization for mental health concerns: 2/10/24 through 2/12/24 was seen for suicidal ideations. 3/27/24 through 4/23/24 was seen for bipolar disorder severe with psychotic features. A review of Resident #73's physician orders included an order dated 4/25/24 for Fluphenazine (an antipsychotic medication) 5 milligrams (mg) one tablet by mouth twice a day. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was cognitively intact and displayed no behavior issues. Her mood was coded with feeling down, depressed or hopeless 7 out of 10 days during the 14-day look back period. Resident #73 received an antipsychotic medication. A psychiatric progress note dated 8/6/24 indicated Resident #73 endorsed having more episodes of depression, irritability and anxiety. A review of Resident #73's active care plan, last reviewed 8/8/24, included the following focus areas: Resident exhibits or has the potential to demonstrate verbal behaviors related to ineffective coping skills, poor anger management, poor impulse control and bipolar with mania. The interventions included to monitor medications for side effects and response contributing to verbal behaviors. Resident is resistive to care related to mood/psychiatric disorder. Will remove shoes and socks and self-ambulates in room and hall, resistive to insulin and personal care. Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to bipolar disorder, anxiety, agitation and depression. The interventions included to observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. Resident is at risk for complications related to use of psychotropic drugs. The interventions included to complete behavior monitoring, monitor for side effects and consult physician and/or pharmacist as needed and monitor for changes in mental status and functional level and report to physician as indicated. A review of Resident #73's nursing progress notes from 2/1/24 to 9/3/24 included behaviors such as crying, suicidal thoughts, agitation, and restlessness. Resident #73's Medication Administration Records (MAR) from 6/1/24 to 9/3/24 indicated she received Fluphenazine as ordered. The MAR did not list any specific behaviors or side effects for staff to monitor. On 9/4/24 at 1:54 PM, an interview occurred with the Assistant Director of Nursing (ADON), who stated there were options in the Electronic Medical Record to enter the monitoring of behaviors and side effects on the MAR for psychotropic medications and felt it was an oversight that this had not been initiated for Resident #73's antipsychotic medication. An interview with Nurse Practitioner #1 occurred on 9/4/24 at 2:09 PM and stated she would have expected the facility to monitor specific behaviors and side effects for Resident #73's antipsychotic medication. Nurse #1 was interviewed on 9/5/24 at 2:24 PM and was familiar with Resident #73. She stated Resident #73 has a history of suicidal thoughts, but her current behaviors were more anxious behavior and crying. She stated there were no specific behavior or side effect monitoring for the use of the antipsychotic medication, but nursing staff would document a progress note if any were observed and report to the physician/Nurse Practitioner. 46725 4. Resident #68 was originally admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, delusional disorders, Alzheimer's disease with late onset, and unspecified psychosis. A review of Resident #68's physician orders included an order dated 6/27/24 for Olanzapine (an antipsychotic medication) 10 milligrams (mg) half a tablet by mouth twice a day and a physician order dated 6/26/24 for Sertraline (an antidepressant medication) 25 milligrams (mg) one tablet by mouth twice a day. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #68 was cognitively impaired and displayed behaviors of physical, verbal abuse, and wandering. Her mood was coded with feeling down, depressed or hopeless 7 out of 11 days during the 14-day look back period. Resident #68 received antipsychotic and antidepressant medication. Review of Resident #68's comprehensive care included a care area initiated on 12/31/21 and revised on 1/30/24 that read Resident #68 exhibited or was at risk for distressed, fluctuating mood symptoms related to depression, anxiety and affective disorder. She was also care planned initially on 12/31/21 and revised on 2/21/24 for complications related to the use of psychotropic drugs (antidepressant/antipsychotic). Interventions included abnormal involuntary movement scale (AIMS)testing per protocol, complete behavior monitoring, gradual dose reductions as needed, monitor for changes in mental status and functional level and report to the Physician as indicated, monitor for the continued need of the medication as related to her behaviors and mood and lastly to monitor for side effects and consult the Physician and/or Pharmacist as needed. Review of the Pharmacy Consultant medication review notes for Resident #68 from 6/1/24 to 9/3/24 did not reflect the need for monitoring targeted behaviors and side effects for the use of an antipsychotic medication. A review of Resident #68's social service progress note dated 7/24/24 indicated Resident #68 has had an increase in behaviors which included yelling, agitation, aggression with family members and delusions. Resident #68's Medication Administration Records (MAR) from 6/1/24 to 9/3/24 indicated she received Olanzapine and Sertraline as ordered. The MAR did not list any targeted behaviors or side effects for staff to monitor. An interview with Nurse Practitioner #1 occurred on 9/4/24 at 2:09 PM and stated she would have expected the facility to monitor specific behaviors and side effects for Resident #68's antipsychotic and antidepressant medications.

Based on record review and staff interviews the facility failed to revise a smoking care plan to reflect a resident's level of supervision needed for smoking for 1 of 3 residents (Resident #77) reviewed for smoking. The findings included: Resident #77 was originally admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction. Review of Resident #77's quarterly smoking assessment dated [DATE] revealed the resident was a safe smoker and did not require supervision. Review of Resident #77's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired and required extensive assistance for most activities of daily living (ADL). Review of Resident #77's care plan revised on 7/5/24 revealed the resident required supervision when smoking. An interview with the MDS coordinator on 9/4/24 at 9:28 am revealed Residents #77's care plan should have reflected the resident being an independent smoker and edited when the smoking assessment was completed on 5/8/24. An interview conducted with the Administrator on 9/6/24 at 9:23 am revealed Resident #77's care plan should have been revised to reflect the resident was an independent smoker. The Administrator further revealed resident care plans reflect the residents care and concerns and were expected to be updated.

Based on record review and staff interviews, the facility failed to transcribe the correct medication administration route for 1 of 1 resident reviewed for gastric feeding tube (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, history of a stroke, dysphagia (difficulty swallowing) and presence of a feeding tube. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 had severe cognitive impairment and received all nutrition and fluids via a feeding tube. Review of the active care plan, last reviewed 7/16/24, revealed Resident #45 required tube feeding for all nutrition and fluids. The active September 2024 physician orders included an order dated 6/20/24 for Guaifenesin Liquid 100 milligrams per 5 milliliters. Give 20 milliliters by mouth three times a day for cough/congestion. All other medications were written to be provided through the gastric feeding tube. The physician orders indicated Resident #45 was to have nothing by mouth (NPO). On 9/5/24 at 10:18 AM, an interview was conducted with Nurse #1 who was working the medication cart for Resident #45's hall and had administered her medications earlier. The nurse confirmed Resident #45 did not receive any medications by mouth and she had not provided her morning dose of Guaifenesin by mouth. Nurse #1 acknowledged the Medication Administration Record (MAR) read for Guaifenesin to be provided by mouth, which was inaccurate as all medications were provided via the gastric feeding tube. The Assistant Director of Nursing (ADON) was interviewed on 9/5/24 at 2:14 PM. She reviewed Resident #45's physician orders and confirmed the route for Guaifenesin was entered as oral instead of via gastrostomy tube (G-tube/feeding tube). She further explained when entering the medication into the electronic medical system the default route was oral, and she felt it was an oversight that the nurse failed to change the route to G-tube. The ADON stated it was her expectation for all medication administration routes to be entered correctly when the order was received and verified. A phone interview occurred with Nurse #2 on 9/6/24 at 10:13 AM. She was the nurse that verified the Guaifenesin order for Resident #45 on 6/20/24. Nurse #2 explained that she verified the order after it had been entered by the Nurse Practitioner in the Electronic Medical System but failed to change the medication route to gastrostomy tube. She stated the default route was by mouth.

Based on record reviews, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of range of motion (Resident #21), medications and PASRR (Pre-Admission Screening and Resident Review- Resident #36). This was for 2 of 21 residents reviewed. The findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included right foot drop and diabetes type 2. An orthopedic progress note dated 6/26/24 indicated that Resident #21 had contractures present to the left and right lower extremity. A quarterly MDS assessment dated [DATE] indicated Resident #21 had intact cognition and was coded with limited range of motion to one side of the upper and lower extremity. An interview occurred with the MDS Nurse on 9/4/24 at 9:49 AM. She reviewed the MDS assessment dated [DATE] and indicated it was an oversight not to have coded Resident #21 with limited range of motion to both lower extremities. On 9/4/24 at 1:00 PM, an observation occurred with Resident #21 who was unable to move her right leg at all, the leg remained in a straight position. She had a contracture to the left leg which she was unable to straighten out and right foot drop was also present. On 9/6/24 at 9:14 AM, the Administrator was interviewed and stated it was his expectation for the MDS assessments to be coded accurately. 46725 2a. Resident #36 was admitted to the facility on [DATE] with diagnosis that included major depressive disorder and schizophrenia. Review of Resident #36's physician orders included an order initiated on 11/6/23 for an antipsychotic medication to be given two times daily. A review of the July 2024 Medication Administration Record revealed Resident #36 was administered antipsychotic medication daily. An annual Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #36's cognition was cognitively impaired. The medications section was coded that she did not receive antipsychotic medication during the 7 -day look back period. On 9/5/24 at 3:28 PM, an interview occurred with the MDS nurse. She explained she had completed the medication section of the MDS and did not code the antipsychotic medication usage section correctly and that it was an oversight. b. A review of the PASRR Level II determination notice dated 3/1/24 indicated Resident #36 was approved for a Level II PASRR. A review of the Resident 36's annual MDS assessment dated [DATE] indicated Resident #36 had a diagnosis of Schizophrenia but was not considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition On 9/5/24 at 12:30 PM, an interview occurred with the Social Worker, and she explained that the facility received notification of the change from a Level I to a Level II PASRR in March 2024 but did not code it correctly on the annual MDS. She further indicated that it was an oversight. An interview was completed on 9/6/24 at 9:23 AM with the Administrator and he indicated that the MDS assessments should accurately reflect the resident's status.

Based on observations and staff, Nurse Practitioner (NP), Medical Director (MD) interviews and record review, the facility failed to have systems in place to identify a contracture which resulted in an avoidable wound where 3 fingernails on the resident's left hand punctured 2 areas into the palm of his contracted left hand requiring the need for wound care. The facility also failed to complete and document weekly assessments of the wound (Resident #70). This was for 1 of 2 residents reviewed providing care according to professional standards of practice. The findings included: 1. Resident #70 was admitted on [DATE] with a diagnosis of Parkinson's Disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #70 had severe cognitive impairment, was not coded for rejection of care, required extensive staff assistance with personal hygiene and he was coded for no limitation in range of motion to his upper extremities. Resident #70's care plan dated 5/2/22 last revised on 11/1/22 read he refused care but there was no documentation stating what care he refused. The MDS Nurse was interviewed on 4/20/23 at 10:40 AM. She stated since she coded Resident #70 with no impairment to his left upper extremity, there must have been no observed evidence of it when she completed his quarterly MDS on 10/26/22. Review of a skin assessment completed by Nurse #3 dated 1/3/23 read there were no identified skin injuries or wounds. An interview was completed on 4/20/23 at 11:10 AM with Nurse #3. She stated she completed Resident #70's skin assessment on 1/3/23 and did not remember seeing any concerns to any open areas or injuries to his left hand. Nurse #3 stated she was aware he had some contracting of the fingers on his left hand, but she thought therapy was aware of it. Review of shower and nail care documentation dated 1/4/23 read Nursing Assistant (NA) #4 provided a shower and nail care on 1/4/23 on first shift. An interview was completed on 4/20/23 at 9:37 AM with NA #4. She stated when she showered Resident #70 on 1/4/23, she did not observe the fingernails required trimming. NA #4 stated she did not recall providing nail care on 1/4/23 to Resident #70. Review of an incident report dated 1/4/23 at 10:56 PM and completed by the Treatment Nurse read she was notified by NA #3 that Resident #70 had a wound on his left hand and she observed that the fingernails on his left hand had punctured into his left palm. There was a small amount of bloody drainage noted. The incident report read that his fingernails were clipped, and orders were given to cleanse the wound to left palm with wound cleanser, pat dry, apply calcium alginate (a dressing used to absorb the wound fluid resulting in a gel that maintains a moist environment to minimize bacterial infections) and dry dressing daily. Interviews were completed on 4/20/23 at 9:37 AM with NA #3 and NA #4. Both confirmed they were the facility's shower team. NA #4 stated she provided Resident #70 his nail care on his shower days when he would allow it because he often jerked his hand away, but she could not recall if he did that on 1/4/23. She stated they were supposed to notify the nurse whenever he refused and document it on the shower sheet. NA #4 stated when she showered Resident #70 on 12/1/22, 12/7/22, 12/14/22, 12/21/22 and 1/4/23, she had difficulty opening his hand due to his contracture so she would only wash in inner part of his palm that was visible and only trim the fingernails she could get to whenever Resident #70 would cooperate with her trimming his fingernails. NA #4 stated she could not recall how long or when she started having difficulty opening Resident #70 left hand due to a contracture, but she did not report it to anyone. NA #3 stated she was the aide who first identified Resident #70's fingernails on this left hand had grown so long they punctured his palm and noted difficulty opening his hand to fully see the wounds. She recalled assisting another aide in moving Resident #70 up in his bed when she noticed some bloody drainage and what looked like a hole in his palm, so she let the Treatment Nurse know. NA #3 stated since that happened, they were to file his nails down instead of cutting them. Review of Resident #70's electronic medical record did not include documented evidence of any wound assessments after the wound was identified on 1/4/23. An interview was completed on 4/20/23 at 9:11 AM with the Treatment Nurse. She stated when NA #3 discovered the wounds to Resident #70's hand, she completed an assessment and the incident report. She stated she observed 2 open areas to his left palm. The Treatment Nurse stated the areas presented with a small amount of serosanguineous (clear drainage with tinged blood) drainage but no odor. The Treatment Nurse stated it was not considered a pressure ulcer but rather it was classified on the incident report as an abrasion that was self-inflicted. She recalled calling one of the Physicians on-call who gave her wound care orders on 1/4/23. A few weeks later, she contacted the NP who gave new orders for the Bacitracin. She stated she did not perform any weekly wound assessments on Resident #70's wounds to his left palm because the area was not considered a pressure ulcer but rather a laceration and she understood that they had healed. She stated the nurses were still applying Bacitracin with a dry dressing and gauze wrap for protection every day. She stated the shower team aides were to provide nail care on a resident's shower days. Review of an interdisciplinary team (IDT) note completed by the MDS Nurse dated 1/5/23 read they discussed the wound to Resident #70's left palm identified on 1/4/23 due to his fingernails and interventions were implemented. The intervention was to ensure his fingernails were clipped as needed and treatment orders were in place. Review of an Occupational Therapy (OT) evaluation dated 1/17/23 revealed a referral was made due to increased skin to skin contact in Resident #70's left palm with nursing reporting fingernail marks in his left palm due to the development of a contracture. The goal read Resident #70 would be able to tolerate a left upper extremity orthotic grip splint or a therapy carrot to promote skin integrity and reduce further contracture. An interview was completed on 4/19/23 at 10:58 AM with the OT. He stated he received a referral on 1/17/23 to evaluate concerns about a contracture that developed to Resident #70's left hand. He stated he provided therapy to stretch out the fingers on his left hand and prescribed a palm guard for protection. He stated there was no additional skilled need to continue therapy after 3/3/23. The OT stated the process was for the nursing department to make a referral to therapy about a resident with newly identified in changes in range of motion, but he had not received any referral about Resident #70's left hand until 1/17/23. The OT stated it was difficult to say the contracture could have been avoided but the worsening of his contracture was avoidable if it had been identified earlier. A new wound care order dated 2/14/23 read to cleanse the wound to his left palm with wound cleanser, pat dry, apply Bacitracin (a topical antibiotic ointment) and dry dressing daily. Review of a new Physician order dated 2/24/23 read a palm guard was recommended to Resident #70's left hand and as tolerated and to check his skin integrity every shift. Review of the February, March and April 2023 treatment administration record (TAR) included documented evidence with nurses' initials that treatment was provided as ordered and skin integrity was being checked every shift. Review of the OT discharge summary dated 3/3/23 read Resident #70 was now tolerating a modified palm guard to his left hand. The treatment results were communicated to the IDT. An observation of Resident #70 was completed on 4/17/23 at 11:11 AM. He was in bed with a palm guard to his left hand. An interview was completed on 4/17/23 at 11:11 AM with NA #9. She stated she did not recall if Resident #70's left hand was contracted prior to the injury found on 1/4/23. She stated if it was contracted, she assumed the nurses and therapy already knew about it. NA #9 stated the shower team would be providing Resident #70 a shower today. She also stated the shower team provided his nail care and the nurses applied his palm guard daily. NA #9 stated on the days he received a bed bath, and she was able to clean his left hand, but it was difficult because he didn't like anyone to mess with his hand. An interview was completed on 4/18/23 at 8:57 AM with NA #1 in Resident #70's room. NA #1 stated she completed Resident #70's bed bath and she went ahead and filed his fingernails. An observation was completed of Resident #70's left hand with NA #1. She was able to open his left hand and fingers with some difficultly due to the contracture and his resistance. She stated she had not been assigned Resident #70 in a long time and could not recall if he already had the contracture to his left hand prior to what happened with his fingernails. Observed was a scarred area to his left lower palm where his 3rd and 4th fingernails appeared to have made contact. Another scar was observed to his upper palm that appeared to be from where his 2nd fingernail made contact. There were no observed open areas. A telephone interview was completed on 4/19/23 at 10:15 AM with the NP. She stated she did not recall anyone letting her know about Resident #70's fingernails and resulting wounds in his left palm. She also stated something like that should never occur to any resident in a nursing facility and was avoidable with basic hygiene. An interview was completed on 4/20/23 at 12:20 PM with the MD. He stated what happened to Resident #70 should never happen in the long-term care setting and was unacceptable. The Administrator stated on 4/20/23 at 9:24 AM the shower team was responsible for providing nail care on the resident's shower days and the floor aides provided nail care as needed. The Administrator was interviewed on 4/20/23 at 11:45 AM. She stated Resident #70's should have never developed an injury because of his fingernails.

Based on observations and staff interviews, the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) vents (Rooms #104, #111, #206, #207, #302, #308, #310, #312, #316, #404, #405, #407 and #408). This was for 13 of 16 resident rooms reviewed for comfortable, clean, and homelike environment. The findings included: 1. On 4/17/23 from 10:30 AM to 12:00 PM the following was observed: - room [ROOM NUMBER] PTAC vent had a large amount of grey dust particles and thick yellow material throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had a thick amount of white substance throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had scattered particles of potato chip and a thick white material throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had a large amount of grey dust particles. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had a large amount of dried white material and grey dust particles throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. On 4/19/23 at 2:54 PM, an observation of rooms 302, 308, 310, 312 and 316 was conducted during a round with the Maintenance Director. He explained housekeeping cleaned the outside of the PTAC and anything inside the vents would be cleaned by the Maintenance department. The Maintenance Director added that the PTACs were to be cleaned monthly. He confirmed the vents were dirty with various particles in them and required cleaning. Housekeeper #1 was interviewed on 4/19/23 at 3:03 PM. She explained that housekeepers cleaned the outside of the PTAC units and used a brush to the outer vents to help remove the dust but anything inside the vents would be taken care of by the Maintenance department. The Administrator was interviewed on 4/20/23 at 11:17 AM and stated she would expect the PTACs to be clean. 46203 2. On 4/18/23 from 08:30 AM to 12:00 PM the following was observed: a. room [ROOM NUMBER] PTAC vent had a large amount of grey dust particles throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. b. room [ROOM NUMBER] PTAC vent had a thick amount of grey dust participles throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. c. room [ROOM NUMBER] PTAC vent had scattered grey dust particles and a piece of paper throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. d. room [ROOM NUMBER] PTAC vent had a large amount of grey dust particles. The room was occupied and the PTAC was running at the time of the observation. On 4/19/23 at 2:56 PM, an observation of rooms 404, 405, 407, and 408 was conducted during a round with the Maintenance Director. He explained housekeeping cleaned the outside of the PTAC and anything inside the vents would be cleaned by the Maintenance department. The Maintenance Director added that the PTACs were to be cleaned monthly. He confirmed the vents were filled with various particles in them and required cleaning. Housekeeper #1 was interviewed on 4/19/23 at 3:03 PM. She explained that housekeepers cleaned the outside of the PTAC units and used a brush to the outer vents to help remove the dust but anything inside the vents would be taken care of by the Maintenance department. The Administrator was interviewed on 4/20/23 at 11:17 AM and stated she would expect the PTACs to be clean. 46095 3. On 04/18/23 from 2:32 PM to 3:23 PM the following was observed: a) room [ROOM NUMBER] PTAC vent had a moderate amount of grey dust and lint build up throughout the vent. The PTAC was running at time of observation and the room was occupied. b) room [ROOM NUMBER] PTAC vent had a large amount of grey dust and white particles throughout the vent. The PTAC was running at time of observation and the room was occupied. On 4/19/23 at 02:59 PM an observation of rooms [ROOM NUMBERS] was conducted during a round with the Maintenance Director. He stated the Maintenance department cleaned the filters and grills in the PTAC units once a month. He confirmed the vents in rooms [ROOM NUMBERS] had lint and debris built up in them and need to be cleaned. Housekeeper #1 was interviewed on 4/19/23 at 3:03 PM. She explained that housekeepers cleaned the outside of the PTAC units and used a brush to the outer vents to help remove the dust but anything inside the vents would be taken care of by the Maintenance department. The Administrator was interviewed on 4/20/23 at 11:17 AM and stated she would expect the PTACs to be clean. 41437 4. On 4/18/23 from 09:30 AM to 12:30 PM the following was observed: a. room [ROOM NUMBER] PTAC vent had grey dust particles and white pieces of debris throughout the vent. The room was occupied and the PTAC was running at the time of the observation. b. room [ROOM NUMBER] PTAC vent had grey dust participles and brown and black pieces of debris throughout the vent. The room was occupied and the PTAC was running at the time of the observation. On 4/19/23 at 2:56 PM an interview with the Maintenance Director. He stated housekeeping was responsible for cleaning the outside of the PTAC, and anything inside the vents should have been cleaned by the maintenance department. The Maintenance Director further stated the PTACs were cleaned monthly. He confirmed the vents were filled with various particles in them and required cleaning. Housekeeper #1 was interviewed on 4/19/23 at 3:03 PM. She stated housekeepers cleaned the outside of the PTAC units and the inside of the vents were cleaned by the Maintenance department. The Administrator was interviewed on 4/20/23 at 11:17 AM and stated she would expect the PTACs to be free of dust and debris.

Based on observations, staff interviews and record review, the facility failed to provide scheduled showers for a resident requiring total staff assistance with bathing/showering. This was for 1 (Resident #70) of 3 residents reviewed for activities of daily living. The findings included: Resident #70 was admitted on [DATE] with a diagnosis of Parkinson's Disease. Resident #70's care plan dated 5/2/22 last revised on 11/1/22 read he refused his colostomy bag changes and eating. The care plan also read he refused care but there no documentation stating what care he refused. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #70 was coded with severe cognitive impairment, exhibiting no behaviors and he required total staff assistance with bathing. An observation was completed on 4/17/23 at 11:11 AM. Resident #70 was in bed wearing a facility gown and an odor was noted. Also observed was his hair and facial hair appeared unkept. An interview was completed with Nursing Assistant (NA) #9 who was in the room at the time stated he was supposed to get a shower today. Another observation was completed on 4/18/23 at 8:57 AM. NA #1 and NA #7 were in the room at the time. NA #1 stated she completed Resident #70's bed bath to include washing his contracted left hand and filed his fingernails. Resident #70 appeared clean, groomed and absent of any odors. Review of the shower documentation for Resident #70 was reviewed from 1/1/23 to 4/19/23. In January 2023 the documentation read he received a total of 4 showers on 1/4/23, 1/5/23, 1/11/23 and 1/25/23. In February 2023 the documentation read he refused a shower on 2/2/23 and received a total of 1 shower on 2/22/23. In March 2023 the documentation read he received a total of 2 showers on 3/1/23 and 3/2/23, and in April 2023 he did not receive a shower until 4/19/23. Review of the bed bath documentation for April 2023 read Resident #70 did not receive a bed bath on 4/4/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23 and 4/13/23. The Administrator stated on 4/20/23 at 9:24 AM that Resident #70 was scheduled for his showers on Monday's and Wednesday's and were completed by a shower team consisting of NA # 3 and NA # 4. Interviews were completed on 4/20/23 at 9:37 AM with NA #3 and NA #4. Both confirmed they were the facility's shower team and NA #4 stated Resident #70 was assigned to her to shower. NA #3 stated she was out of work last week and NA #4 stated she was pulled to work the floor Monday 4/17/23 so she did not give Resident #70 his shower. Both NA #4 and NA #3 stated the shower team starting in September and in the beginning they were often pulled to work on the floor, but both stated that it had improved, and they were not pulled off the shower team as much. NA #4 stated most of the time, third shift already had Resident #70 up in his chair, dressed and bathed. A telephone interview was completed on 4/19/23 at 5:35 PM with NA #5. She stated she worked the third shift, and that Resident #70 was not to be gotten up and bathed on third shift. NA #5 stated it was the shower team's responsibility to give a resident's showers. On 4/20/23 at 11:00 AM, NA #6 stated she worked third shift. She stated the facility had a shower team and they completed all the showers. She also stated she did not recall ever getting Resident #70 up and giving a bed bath on third shift. The Administrator was interviewed on 4/20/23 at 11:45 AM. She also stated Resident #70's should be receiving his showers on the days he was supposed to get a shower.

Based on record review, observations, and resident and staff interviews, the facility failed to implement their smoking policy for conducting quarterly smoking assessments, ensuring a resident assessed as an unsafe smoker was supervised, smoking materials were secured, and cigarette butts were disposed of safely for 1 of 3 residents (Resident #69) reviewed for accidents. Findings included: Review of the facility smoking policy read in part, supervised smoking is defined as The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. It further read in part, Smoking materials for supervised smokers will be required to be locked at the nurse's station. No residents will be allowed to maintain their own lighter or matches. Residents will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. The resident should properly dispose of ashes or butts. Resident #69 was admitted to the facility on [DATE] with diagnosis that included Bi-Polar disorder, Parkinson's disease, Dementia, lack of coordination and anxiety. Resident #69's smoking evaluation dated 04/04/22 revealed resident was an unsafe smoker and required direct supervision while smoking due to resident dropping cigarettes a lot due to hand weakness. Resident #69 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired, no behaviors, was assessed as independent with locomotion on and off the unit, and he utilized a wheelchair. Resident #69 ' s care plan, last reviewed on 02/23/23, revealed a focus that read he may smoke with supervision per smoking assessment. The interventions included: assistance with utilization of lighting cigarette, supervise patient with smoking in accordance with assessed needs, ensure that appropriate cigarette disposal receptacles are available in smoking areas, monitor compliance to smoking policy, educate resident on the facility's smoking policy, and maintain patients smoking materials at nurses' station. Resident #69 ' s medical record revealed no evidence of a smoking assessment being completed after 04/04/22. Record review revealed Resident #69 was listed on the smokers list as an unsupervised smoker. An interview was conducted on 04/18/23 at 11:24 AM with the Social Worker (SW). The SW stated she kept the smoking list current and updated to reflect the hall, resident name, and if the smoker was supervised or not supervised. She also stated nursing staff notified her if the status of a resident had been changed or if a resident had been admitted or discharged from the facility. A copy of the list was kept at each nursing station. The SW stated she was unaware Resident #69 was a supervised smoker and she did not recall who or when it was changed to unsupervised on the list. An observation and interview were conducted on 04/18/23 at 9:31 AM with Resident #69. He stated he went outside to smoke when he wanted to and that he was not supervised by staff. He also stated he always kept his cigarettes and lighter in his cooler bag on his wheelchair. Strong odor of burnt cigarettes coming from a small insulated cooler bag located on his wheelchair was noted. Resident #69 stated after he puts the cigarette out, he puts the butts in his cooler bag because he did not want to leave them on the ground. He further stated he made sure the cigarettes were out before putting them in the bag. He verified there were ashtrays in the smoking area, but he did not sit next to one. He indicated he had been smoking unsupervised, keeping his smoking materials, and placing his cigarette butts in his cooler bag for a long time. An interview and observation were conducted on 04/18/23 at 9:36 AM with Nurse #5. He stated Resident #69 always kept his smoking supplies, including his lighter, with him and that he went out to smoke when he wanted to go without supervision. He then stated Resident #69 had been smoking unsupervised since he had been working at the facility which was November of 2022. He verified that smoking assessments were to be performed quarterly by the nursing staff when the system triggered them, and the last documented smoking assessment was dated 04/02/22 which determined he was a supervised smoker. Nurse #5 indicated User Defined Assessment (UDA) for smoking were originally initiated by nursing on admission when a smoking assessment was performed. The system was supposed to automatically schedule the assessment to be completed quarterly. The system generated assessment then appeared in red in the electronic record under assessments for completion. It was unknown why the smoking assessment did not trigger to be completed quarterly. He further stated no smoking assessments were scheduled or due at time of survey. He then stated he was unaware Resident #69 required supervision when smoking because according to the smoking list, he was listed as unsupervised. An observation was made of Nurse #5 retrieving Resident #69 ' s cigarettes and lighter that were in the bottom zipper area of an insulated cooler bag and approximately 8 cigarette butts from the main compartment of the cooler bag which was located on his wheelchair in his room. An interview was conducted on 04/18/23 at 10:45 AM with Nursing Assistant (NA) #9. She stated she worked with Resident #69 once or twice a week. She also stated she was unaware he required supervision while smoking because she had not retrieved smoking items for him in the past, he always kept them with him. She then stated there was a list located at the nurses ' station that specifies who is supervised or not supervised. She further stated the smoking supplies for residents that were supervised during smoking are kept at the nursing station in a locked area. On 04/18/23 from 11:01-11:15 AM a continuous observation was made of Resident #69 in the smoking area. He was sitting in his wheelchair; no staff were observed with resident. He was observed smoking a cigarette, he dropped the lit cigarette onto the ground reached down and retrieved the lit cigarette, smashed it on the bottom of his shoe and proceeded to put the butt into the cooler bag hanging on his wheelchair. An interview was conducted on 04/18/23 at 11:16 AM with Nursing Assistant (NA) #10. She stated she was not aware that Resident #69 was a supervised smoker. She stated he went out whenever he wanted to smoke. An interview was conducted on 04/18/23 at 11:55 AM with Unit Manager #2. She stated she went out and observed Resident #69 in the smoking area periodically and he had been safe with smoking cigarettes. She indicated she had not documented a quarterly smoking assessment on him. She verified the last smoking assessment was performed 04/04/22. She indicated nurses were responsible for completing the User Defined Assessments (UDA ' s) that are appeared in red in the electronic record. An interview was conducted on 04/18/23 at 11:59 AM with the Administrator. She stated if a resident was a supervised smoker all smoking supplies were to be kept at the nurses ' station. She reported if the resident was not a supervised smoker, they could keep their cigarettes but their lighters and/or matches were to be kept at the nurses ' station. She also stated the cigarette butts should be disposed of in the ashtrays located in the smoking area. She then stated she was unaware Resident #69 was smoking unsupervised, that he kept his smoking supplies with him, that a quarterly smoking assessment had not been completed on him quarterly, or that he did not dispose the cigarette butts in a safe manner. She further stated she expected staff to supervise residents that were not deemed safe with smoking alone, keep smoking supplies stored in a safe and secure location, perform quarterly smoking assessments on residents that smoke, and to monitor for safe disposal of cigarette butts.

Based on observations, and staff interviews the facility failed to discard opened food items ready for use by the labeled discard date in 1 of 1 walk-in refrigerators and failed to label, and date opened food left in 1 of 2 nourishment room refrigerators (station 1 reach-in refrigerator). This practice had the potential to affect foods served to residents. The findings included: 1. a. During the initial tour of the main kitchen with the Dietary Manager (DM) on [DATE] at 10:06 AM revealed the following items were observed in the walk-in refrigerator available for use. - One square shaped container with approximately 30 slices of bologna with a label on top of the container that read opened on [DATE] and a discard date of [DATE]. - One square shaped container ,d+[DATE]-,d+[DATE] full of turkey with a label on top of the container that read opened on [DATE] and a discard date of [DATE]. - One square shaped container ,d+[DATE] full of shredded cheese with a label on top of the container that read opened on [DATE] and a discard date of [DATE]. b. On [DATE] at 10:30 AM in station 1 ' s nourishment room refrigerator, the following items were observed with nurse aide (NA) #1: - Small glass covered bowl of pasta salad with no name or date labeled. - Store bought bowl half full of watermelon with a sell by date of [DATE] on label. No name or opened date listed. - 5 prefilled small containers of apple sauce with a poured date of [DATE]. No discard date listed. On [DATE] at 10:31 AM an interview with Nurse Aide #1 was conducted. She stated she throws items away if they were left in station 1 nourishment room refrigerator past 72 hours. On [DATE] at 10:25 AM an interview was conducted with the Dietary Manager in reference to food labeling and discarding food on discard dates. She stated that it was everyone ' s responsibility for labeling food/beverages after opening and discarding foods/beverages on discard/expired dates. She also stated she did daily checks and that it was an oversite that she missed the above items. She further stated, opened foods were to be thrown away 7 days after opening. On [DATE] at 09:50 AM an interview was conducted with the Director of Operations. He stated dietary supplies the nourishment room refrigerators with fresh sandwiches in the evenings and would discard items that have reached the discard date. He also stated nursing staff were responsible for labeling food with a name and date when brought in by families prior to putting them in the nourishment room refrigerators. On [DATE] at 01:45 PM an interview was conducted with the Administrator. She stated all opened food should be discarded no later than the labeled discard date and all items in refrigerators should be labeled with an open/stored date and name if applicable. On [DATE] at 03:30 PM an interview was conducted with the Director of Operations. He stated all opened perishable foods should be discarded no later than the labeled discard date. All items should have a opened or poured date labeled on the item.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey completed on 4/28/2022. This was for 3 deficiencies that were cited in the areas of clean homelike environment, accuracy of assessments, and providing activities of daily living care for dependent residents. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F677- Based on observations, staff interviews and record review, the facility failed to provide scheduled showers for a resident requiring total staff assistance with bathing/showering. This was for 1 (Resident #70) of 3 residents reviewed for activities of daily living. During the facility's recertification survey of record on 4/28/2022, the facility failed to trim and clean dependent residents' nails for 4 of 7 residents reviewed. In an interview with the Interim Administrator on 4/20/2023 at 1:00 PM, she felt the repeat citation was due to staff turnover. She felt the staff would benefit from additional education. 2. F641- Based on record review and staff interview, The facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of feeding tube (Resident #89) and bowel continence (Resident #70). This was for 2 of 23 resident records reviewed. During the facility's survey of record on 4/28/2022, the facility failed to code the MDS assessment accurately in the areas of activities of daily living and falls for 2 of 18 residents reviewed. In an interview with the Administrator on 4/20/2023 at 1:00 PM, she felt the repeat citation in MDS accuracy was felt to be related to human error. 3. F584- Based on observations and staff interviews, the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) vents (Rooms #104, #111, #206, #207, #302, #308, #310, #312, #316, #404, #405, #407 and #408). This was for 13 of 16 resident rooms reviewed for comfortable, clean, and homelike environment. During the facility's survey of record on 4/28/2022, the facility failed to provide adequate lighting for 1 of 1 resident reviewed for environment. An interview with the Administrator was conducted 4/20/2023 at 1:00 PM and indicated the facility had experienced administrative turnover and possibly had failed to keep safeguards in place.

Based on observations, record review and staff and resident interviews, the facility failed to assess the self-administration of medications for 2 of 2 residents (Resident #5 and Resident #47) reviewed for self-administration. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5's cognition was intact. Resident #5 had a physician's order dated 02/27/23 for Albuterol Sulfate HFA inhaler 2 puff inhale orally every 4 hours as needed for shortness of breath. Resident #5 was observed on 04/17/23 at 12:15 PM to have the Albuterol Sulfate inhaler on his overbed table. When interviewed, Resident #5 stated he had been using the inhaler since his admission. He stated the facility had always left the inhaler with him, so he did not have to ask every 4 hours to use it. Review of Resident #5's medical records revealed that he did not have an assessment for self-administration of medication nor a physician's order to self-administer medications. An observation and interview conducted with Nurse #3 on 04/19/23 at 9:12 AM revealed Resident #5 had the Albuterol Sulfate inhaler on his bedside table. She stated the resident did not have an order to self-administer medications. She indicated he should have an order and an assessment to self-administer before medications can be left at bedside. She further stated she did not know who was responsible for assessing the resident for self-administration. The Director of Nursing (DON) was interviewed on 04/19/23 at 3:20 PM. The DON stated she had only been the DON for 3 weeks. She stated residents must have a physician's order and an assessment prior to medications being left at beside. The DON added that she did not know Resident #5 was self-administering medications. 2. Resident #47 was admitted to the facility with multiple diagnosis which included unspecified hemorrhoids, constipation, and need for assistance with personal care. Resident #47 had a physician order dated 02/10/22 for Witch Hazel-Glycerin Pads, apply to hemorrhoids topically as needed for hemorrhoids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47's cognition was moderately impaired. Resident #47 was observed on 04/17/23 at 10:19 AM to have the Witch Hazel topical pads at beside. When interviewed, Resident #47 indicated she wanted to keep them at bedside because staff used them every time she had a bowel movement for the treatment of hemorrhoids. Review of Resident #47's medical records revealed that she did not have an assessment for self-administration of medication nor a physician's order to self-administer medications. An observation and interview conducted with Nurse #3 at 04/19/23 at 9:15 AM revealed Resident #47 had the Witch Hazel topical pads at bedside. She stated the resident did not have an order to self-administer medications, and the Witch Hazel topical pads should not have been kept at beside. She stated they should have been kept in the treatment cart and did not know why the Witch Hazel topical pads were in Resident #47's room. The Director of Nursing (DON) was interviewed on 04/19/23 at 3:20 PM. The DON stated she had only been the DON for 3 weeks. She stated residents must have a physician's order and an assessment prior to medications being left at beside.

Based on observation, record review, and interview of staff, resident, and medical staff, the facility failed to protect residents ' right to be free from abuse (Residents #1 and #18) as evidenced by Resident #2 grabbed Resident #18 ' s arm and Resident #2 placed his arm around resident #1 ' s neck in a choke hold. Both altercations required staff to physically remove Resident #2 from both Resident #1 and Resident #18. Resident #1 sustained a neck injury. Both altercations resulted in Resident #2 being sent to an acute care setting for evaluation. This deficient practice affected 2 of 3 sampled residents reviewed for abuse. Immediate Jeopardy began on 8/8/2021 when Resident #2 abused Resident #18 and the facility did not put effective interventions in place to prevent further occurrences of abuse. Resident #2 ' s behavior continued through 8/30/21 when he abused Resident #1. Immediate jeopardy was removed on 9/18/2021 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service and resident education. Findings included: Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had a severely impaired cognition. There were physical and verbal behaviors 1-3 days per week. Wandering was blank. The resident received 6 doses of antipsychotic medication. A nurses ' note dated 7/13/21 documented behaviors were present. Resident #2 was noted wandering through building, entering rooms without permission of others. Resident #2 was redirected and given breakfast, but the wandering continued. Staff noted awareness and redirected back toward nurses ' station 1, when necessary. A nurses ' note dated 8/8/21 revealed Resident #2 was very agitated all morning, increasingly getting worse. Resident #2 went in other residents ' room and took others ' belongings, grabbed trash out of trash cans and threw it all on the floor. Staff tried to calm resident down with no results. Resident #2 then went to a resident room doorway where Resident #18 sat, and he started jerking Resident #18 ' s wheelchair and tried to force her out of her room. Resident #18 yelled and alerted staff to what was happening. Resident #2 then jerked Resident #18 ' s arm. Nurse #1 was in the hallway as this occurred and she tried to intervene and de-escalate the situation. Resident #2 then knocked Nurse #1 backwards into the wall and onto the floor. At this point the Director of Nursing (DON) was notified as well as management. Emergency medical service (EMS) was called to transport Resident #2 to emergency room (ER). Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Cognition was intact. On 9/13/21 at 4:15 pm, Resident #18 was interviewed. Resident #18 remembered when a male resident tried to get in her room. Resident #18 was sitting in her wheelchair in her room doorway blocking the entrance. The male resident (#2) was angry, grabbed her arm and shook her wheelchair. Resident #18 was scared, but not hurt. Since then, when the male resident had tried to get into her room again, she shut her door. On 9/14/21 at 10:55 am an interview was conducted with Nurse #1. Nurse #1 was present for the resident-to-resident altercation with Residents #18 and #2 on 8/8/21. Nurse #1 stated she observed Resident #2 standing over Resident #18 while she was sitting in her wheelchair at her room doorway. Resident #2 attempted to enter Resident #18 ' s room by yelling and shaking Resident #18 ' s wheelchair while she was sitting in it. Nurse #1 stated she tried to reorient Resident #2 and offered to assist him. Resident #2 thought his son was in Resident #18 ' s room. Nurse #1 stated that her attempts to reorient and redirect the resident were not effective and he was still shaking the resident ' s wheelchair. Resident #2 pushed Nurse #1 to the floor. Other staff arrived to separate the two residents. Nurse #1 stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 also wandered into other resident ' s rooms and would take items. Resident #2 ' s wandering was a current behavior. Nurse #1 stated that there was no 1:1 supervision for the resident or additional supervision when he came back (from the ER) 8/31/21. On 9/13/21 at 11:00 am an interview was conducted with Nurse #5 who was assigned to Resident #2. Nurse #5 stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #5 was the assigned nurse on shift for the first incident (8/8/21) with Resident #18 about a month ago. Nurse #5 stated Resident #2 assaulted Resident #18 in the doorway of her room by grabbing her arm and shaking her wheelchair. On 9/14/21 at 11:20 am an interview was conducted with Nurse #5 who was present on 8/8/21 for the resident-to-resident altercation. Nurse #5 stated she was on the hall where Resident #18 was sitting in her wheelchair in her room doorway. Resident #2 approached Resident #18 and grabbed her arm to pull her out of the way and then grabbed the wheelchair and began to shake it. Resident #18 placed her feet on the floor and pushed back to prevent the movement of her wheelchair. The wheelchair continued to shake but was not able to move from the doorway. Resident #2 attempted to gain access to Resident #18 ' s room. Nurse #1 was near and attempted to verbally redirect Resident #2 while he was still shaking Resident #18 ' s wheelchair with her in it. Resident #2 then pushed Nurse #1 to the floor. Additional staff arrived and the two residents were separated. The resident was known to wander in and out of the resident ' s rooms and takes their things and had assaulted staff. Nurse #5 had heard residents (including female) call out into the hall from their room to get this man (Resident #2) out of my room, he does not belong here. Nurse #5 stated that Resident #2 ' s behavior escalated on 8/8/21 instead of accepting redirection and assaulted a staff member. Nurse #5 was concerned that if the staff had not intervened and attempted to redirect and remove the resident, Resident #18 could have been further assaulted and injured. The hospital emergency room (ER) record dated 8/8/21 documented Resident #2 was sent to the ER for confusion and aggression. The resident had been awake for the past 24 hours believing his son was outside talking to him. The record indicated, Short- and long-term memory deficit, anxious, delusional. Agitation due to dementia. Prescription [MEDICATION(S)] 2 mg (milligrams) three times a day as needed for anxiety/agitation. Return to facility with further physician care. Resident #18 was not admitted to the hospital and returned to the facility the next day. On 9/13/2021 at 1:30 pm an interview was conducted with the DON. The DON stated she was aware that a staff member tried to intervene and separate the residents (Residents #2 and 18) and the staff member was pushed to the floor. The DON stated the facility does not have the staffing to provide 1:1 supervision of Resident #2 and increased level of care and supervision that the resident required. A nurses' note dated 8/11/21 revealed, Very agitated (Resident #2) at first of shift fussing with nursing assistant (NA). Resident #2 was redirected easily and sat in a chair at nursing desk most of shift. This note was written by Nurse #2. A nurses' note dated 8/12/21 revealed Resident #2 up and down all shift in and out of residents rooms. He was redirected but continued to go in residents ' rooms. This note was written by Nurse #2. A nurses' note dated 8/14/21 revealed Resident #2 was observed exhibiting bizarre, disruptive behavior in the dayroom. Resident was observed moving chairs and tables around, the resident began to throw chairs and other stationary objects (dayroom is where the resident was placed to supervise, and other residents had access). This writer, Nurse #2, attempted to redirect residents ' behavior but was unsuccessful. There were no other residents present. Resident presented to be harmful to himself, the staff, and other residents. The on-call physician was contacted via telephone and made aware of the situation. An order was received to send the resident to the hospital for evaluation. Emergency medical service (EMS) arrived at the facility, spoke briefly with nursing and resident. The resident walked out of the facility with EMS refusing to sit on the stretcher. At 11:00 pm the resident returned to the facility via EMS. The resident arrived at the facility asleep on a stretcher. The ER physician stated that there were no abnormal findings with the resident. The resident was resting in bed with eyes closed, will continue to monitor for behaviors. This note was written by Nurse #2. On 9/13/21 at 11:00 am an observation was done of Resident #2. The resident was sitting alone in his wheelchair in the common room behind the nurses ' station but was not a 1:1 supervision or increased supervision. On 9/13/21 at 11:00 am an interview was conducted with Nurse #5 who was assigned to Resident #2. Nurse #5 stated Resident #2 was also known to wander into random resident ' s rooms and take their belongings and was throwing furniture in the unit dining room behind the nurses ' station. Nurse #5 stated that the facility had not made any changes to the resident ' s routine to prevent further assaults to other residents. The facility had tried to place the resident in another facility that had a locked dementia unit with increased level of care and no other facility would take the resident due to his behavior. Nurse #5 stated that the resident gets up on his own and tries to ambulate. The resident entered the other resident ' s rooms and was stopped and redirected by staff. Nurse #5 stated that she had informed the DON of the resident ' s behaviors and antipsychotic ([MEDICATION(S)] and [MEDICATION(S)]) medication refusal. The quarterly MDS dated [DATE] documented Resident #2 came from the hospital. Cognition was severely impaired. There were physical and verbal behaviors 1-3 days per week. Wandering was 4 to 6 days per week. The active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received 6 doses of antipsychotic medication. A nurses' note dated 8/27/21 revealed Resident #2 wandered throughout the night try to redirect several times and got agitated with staff. Continued to monitor. This note was written by Nurse #2. A nurses' note dated 8/29/21 revealed Resident #2 was going in and out of other residents ' rooms bothering the resident in the first bed. The resident refused to come out of room stating, This is my son, and you can't make me get out. Resident #2 became increasingly agitated and aggressive with staff. Resident held on to call light, pulled the call light from the wall and started wrapping it up in his hand. Resident #2 tore call light in two. Staff were able to safely remove Resident #2 from another resident ' s room and redirected him to his own room. This note was written by Nurse #4. A nurses' note dated 8/29/21 revealed Resident #2 continued to be combative to staff and attempted to attack other residents. Difficult to redirect. Resident #2 refused all noon time meds. This note was written by Nurse #4. Nurse #4 was attempted to be contacted for interview, but contact was unsuccessful. On 9/14/21 at 12:55 pm an interview was conducted with Nurse #2 who was assigned to Resident #1 on 8/30/21 at the time of a resident-to-resident altercation at her medication cart. Resident #1 was sitting in her wheelchair at the medication cart and Nurse #2 took her blood for glucose testing. Resident #2 came over to Resident #1 and was mumbling something. Resident #2 thought Resident #1 was someone else and was confused. The two residents were arguing. Nurse #2 turned away to draw up insulin and heard Resident #1 yell. Nurse #2 turned back and observed Resident #2 with his arm around Resident #1 ' s neck. Nurse #2 called for help and Nurse #6 arrived and both staff removed Resident #2 ' s arm from around Resident #1 ' s neck. The residents were separated. Resident #2 was placed on 1:1 supervision until EMS and police arrived to take Resident #2 to the ER. Resident #1 complained of pain in her neck. Physician was notified and a neck x-ray was ordered. Resident #1 was admitted to the facility on [DATE]. Her quarterly MDS dated [DATE] documented adequate hearing, understood/understands and clear speech. She had no memory problems. Resident #1 ' s statement dated 8/31/21 documented she was sitting in the hallway on 8/30/21 next to the medication cart getting her blood sugar checked. Resident #1 was choked by Resident #2. Nurse #2 and Nurse #6 had to get Resident #2 ' s arm off Resident #1 ' s neck. The nurses checked Resident #1 to make sure she was okay. Resident #2 was removed up the hall with the NA. A radiology report dated 8/31/21 for Resident #1 resulted in a neck x-ray after injury of mild [CONDITION(S)] changes and straightening of the cervical spine. This could be due to muscle spasm, ligamentous injury, or simply positional. Advise was for cat scan or magnetic resonance imaging (pictures of inside the body) if clinical ambiguity remains. Cat scan or magnetic resonance imaging (outside of the facility) was not completed while the resident was in the facility. Psychiatry note dated 8/30/21 documented by the psychiatric family nurse practitioner (FNP) resident worsening agitation and aggressiveness. Resident will not take medications. Recommend inpatient admission for behaviors aggressiveness and combativeness are worsening. Unable to treat due to resident refusing medication and will more than likely require forced medication protocol that cannot be done in an outpatient environment. The FNP spoke to the social worker and administrator about the resident ' s behavior. On 9/15/21 at 11:10 am an interview was conducted with FNP psych. FNP stated that she documented in her note that because of Resident #2 ' s behavior, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Summary of investigation submitted with the 5-day report for resident-to-resident altercation dated 8/30/21 documented that Resident #2 placed his arm around the neck of Resident #1 and choked her. Two staff separated the residents in altercation. Resident #1 was assessed for injury and received a neck x-ray. Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Hospital Emergency Department (ED) record dated 8/30/21 documented Resident #2 was sent from the facility to be evaluated for altercation with another resident (#1) and behaviors/acting out. Medical exam was negative. History of acute mental changes, unknown cause. Cat scan (xray) of the head revealed report for no acute abnormality. Moderate to severe apparent old ischemic white matter disease. Medication administered intramuscular (IM): [MEDICATION(S)] 1 mg (anxiety) 8:19 pm; [MEDICATION(S)] (antipsychotic)100 mg by mouth (PO) 10:39 pm; and [MEDICATION(S)] 1 mg IM 10:39 pm. On 8/31/21 at 8:15 am [MEDICATION(S)] 1 mg IM was administered and at 8:35 am [MEDICATION(S)] 1 mg IM was given. Neurological assessment revealed he was disoriented x 4. Poor judgement, attention/concentration, short term memory loss, poor safety awareness, and restlessness. Normal motor response. Resident was admitted to a room for observation for 24 hours. Dementia with behavioral disturbance, unspecified dementia type: new and requires workup. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was still upset and was given [MEDICATION(S)] with improvement of symptoms. CT scan resulted atrophy (of the brain). The resident did not have an abnormal gait. The resident likely had an episode of behavioral outburst secondary to worsening dementia. The resident was clinically stable for discharge back to the facility. [MEDICATION(S)] 50 mg at bedtime for agitation prescription provided for as needed. Recommend physician follow-up and assess for medication adjustments. The resident was not admitted and returned the next morning. A review of the nurses ' notes from 8/8/21 through 9/13/21 documented that the resident frequently refused his medication or spit them out (documented as refusal). A review of Resident #2 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCL ([MEDICATION(S)]) (antidepressant) 10 mg (milligram) ordered for 8 days was refused 4 times from 8/16/21- 8/23/21. [MEDICATION(S)] HCL 10 mg ordered twice a day was refused 11 times from 8/1/21 - 8/24/21. [MEDICATION(S)] 10 mg (for anxiety) twice a day was refused on 12 occasions and 2 doses had no documentation from 8/1/21- 8/30/21. [MEDICATION(S)] 2 mg (for anxiety) every 8 hours as needed 14 days for agitation. There was no documentation of administration. Resident #2 ' s behavior was documented on each of 3 shifts for 30 days and had 16 occurrences of behavior and 6 shift assessments had no documentation. [MEDICATION(S)] 50 mg (antipsychotic) every 24 hours as needed for agitation at bedtime for 14 days was documented as started on 8/31/21. There was no documentation as given. [MEDICATION(S)] 0.25 mg (antipsychotic) twice a day mix with liquid of choice was refused on 8 occasions and no documentation on 2 occasions for time period 8/1/21 - 8/24/21. The medication was changed to in the evening only and scheduled for 8/24/21 - 8/30/31 received 6 of 8 doses. [MEDICATION(S)] 0.25 mg liquid mix with drink of choice each morning for time period 8/25/21 - 8/30/21 administered all days (6). The facility physician adjusted medications as follows: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = 1 ml) each morning in drink of choice. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2 ' s MAR for September 2021 documented the following: [MEDICATION(S)] 10 mg twice a day for anxiety. There were 5 refusals and there were 4 times Resident #2 was sleeping and none given. The timeframe was 9/1/21 - 9/16/21. [MEDICATION(S)] 50 mg every 24 hours for 14 days as needed for agitation. None were documented as given. The timeframe was 8/31/21 - 9/3/21. [MEDICATION(S)] 50 mg every 12 hours for 14 days as needed for agitation documented with 2 doses, given on 9/5/21 and 9/6/21. The timeframe was 9/3/21 - 9/7/21. [MEDICATION(S)] 50 mg every 12 hours for 14 days as needed for agitation/[CONDITION(S)]. None were documented as given out of 14 days. The timeframe was 9/7/21 - 9/21/21. [MEDICATION(S)] 1 mg/ml give 0.5 ml in the evening mix with drink of choice. Documented the resident refused on 9/1/21 and was discontinued. [MEDICATION(S)] 1mg/ml give 0.5 ml in the morning mix with drink of choice for time period 9/3/21 - 9/16/21. The resident refused 1 dose out of 11. [MEDICATION(S)] 1 mg/ml give 0.5 ml in evening mix with drink of choice for time period 9/2/21 - 9/13/21. The resident refused 1 dose and 2 not given resident was sleeping out of 11. The resident was monitored each shift for behavior and wandering episodes from 9/1/21 - 9/12/21 and had documented behaviors on 5 occasions. Behaviors were documented for day shift 9/1 and 9/10/21, evening shift 9/1 and 9/12/21, and night shift 9/1/21. On 9/13/2021 at 1:30 pm an interview was conducted with the DON. The DON stated she had been seeking placement for Resident #2 at three other facilities with a locked unit on 8/31/21 (2) and 9/6/21 (1) but had not been successful (no available bed). The DON stated that the resident does wander in the halls and sometimes entered a resident ' s room and must be removed/ redirected. The resident was being observed in the hall dining room and had no 1:1 supervision. The DON was aware that the resident had refused and spat out his [CONDITION(S)] and antipsychotic medication prescribed for his behaviors during the month of August 2021 and that the psychiatric FNP recommended the resident have forced medication administration that could not be provided in the facility and would need to be transferred on 9/30/21. On 9/14/2021 at 3:20 pm an interview was conducted with the Medical Director (MD). The MD stated that he was aware of the second (Resident #1) resident-to-resident altercation by Resident #2 but not the first altercation (Resident #18) until yesterday when he spoke to the DON. The MD was aware the resident was not taking his medication. The MD was aware that the resident entered other residents ' rooms, but not that there were resident complaints of unwanted entry until now. The MD stated that he had not committed the resident because he was concerned that they would just send him back. The MD stated that there was nowhere to send the resident to meet his needs. The facility cannot force medication. The resident would have a better quality of life if he was receiving his medication. The MD stated that interventions were needed to protect the other residents from harm. The MD stated that he would work with the DON to order intramuscular and sublingual medication to improve medication compliance and send the resident out to the ED when behaviors begin to escalate and not try to manage at the facility. On 9/15/21 at 9:15 am an interview with the DON was conducted. The DON went to the County Court before the Magistrate for involuntary commitment on 9/15/21 with comprehensive documentation and two physician letters. Magistrate stated I have seen this for years, you should be able to handle the resident in your facility, denied. The resident will just wind up returning to the facility. The DON stated that she does not have the staff to continue with 1:1 supervision. On 9/15/21 at 10:05 am interview with the DON was conducted. She stated that a referral was sent to a psychiatric facility on 9/15/21. A second psychiatric facility also declined the resident on 9/15/21 due to county boundaries of where they will accept. The Administrator was notified of immediate jeopardy on 9/16/21 at 2:03 pm. Facility respectfully submits the below allegation of Immediate Jeopardy removal for F600. ? Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: On 8/8/2021, Resident #2 grabbed Resident #18 ' s wheelchair and arm that was unwanted and unexpected. Center Staff immediately separated residents. Center Staff immediately sent Resident #2 out for evaluation. Upon Resident #2 ' s return to the Center, he was evaluated Psych Services and a medication review was completed. On 8/30/2021, Resident #2 placed his arm around Resident #1 ' s neck. Center Staff immediately separated residents. Center Staff immediately placed Resident #2 on one-on-one supervision until Resident #2 was sent out for evaluation. Upon Resident #2 ' s return to the Center, he was evaluated Psych Services and a medication review was completed. Once the current Center Executive Director was notified on 9/14/2021 of the altercations, he immediately placed the resident on one-on-one supervision. Resident #2 remained on one-on-one supervision until resident #2 was sent to the emergency room for an unrelated medical condition on 9/16/2021 where he remains. Resident #1 was immediately assessed by the nursing staff for injuries following the incident on 8/30/2021. Approximately thirty minutes later, Resident #1 had complaints of pain. As a result, the Physician was notified and an X-Ray was ordered. Results of the X-Ray on 8/30/2021 were inconclusive for injury (X-Ray did show [CONDITION(S)] changes, but no fracture was identified) and the Physician ordered an MRI due to the Resident ' s inability to cooperate with the lateral view of the X-Ray. Resident #1 discharged from the facility against medical advice prior to the completion of the MRI. Resident #18 was immediately assessed by nursing staff on 8/8/2021 for any injuries with none noted. Resident remains at the Center at this time. Safety interviews were completed with Resident #18 on 8/9/2021, 8/30/2021, and 9/16/2021 in which the Resident stated she felt safe and had not been harmed by a staff or resident. Physician advised the nursing staff to continue to monitor Resident #18 for any changes and to notify Physician if changes occurred. Resident #18 has been evaluated by a Physician on 8/24/2021 with no change since last physician visit or acute findings noted, with no new orders received. All residents in the center have the potential to be affected. Center Nurse Executive and Unit Managers completed skin checks for residents with BIMs 8 and under on 9/16/2021. No signs or symptoms of abuse were noted. Center Social Worker completed safety interviews with Residents with a BIMs 9 and above on 9/16/2021 to ensure residents felt safe in the Center. No residents voiced concerns over their safety within the Center. In addition, the Center Nurse Executive and Unit Managers completed an audit by 9/17/2021 of all nursing documentation within the last 30 days to ensure that any episodes of [CONDITION(S)] were care planned. ? Specify action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action will be complete: Upon Resident #2 ' s return to the Center, Resident #2 will be placed on one-on-one supervision until Resident #2 is safely transferred to another location which specializes in behavioral management. On 9/16/2021 education was completed with Center Leadership (Center Executive Director and Center Nurse Executive) on Genesis Abuse Prohibition Policy (Identification, Prevention, Reporting, and investigating) by Senior Executive Director. A Post Test was completed. Prevention strategies to include utilization of additional agency staff and utilizing staff from sister-Centers to meet sufficient numbers of staff to implement any additional supervision needed. On 9/16/21 education was initiated for all current staff to include Full Time, Part Time, Per Diem, and Agency Staff (Licensed Nurses, Nurses ' Aides, therapy, Dietary, Housekeeping, laundry, maintenance and department heads) on Genesis Abuse Prohibition Policy by the Center Executive Director, Center Nurse Executive, Nurse Practice Educator and Unit Managers. No staff shall work until Abuse Prohibition education has been received. This education will be included for all new hires. A Post Test was completed for all staff. Prevention strategies to include utilization of additional agency staff and utilizing staff from sister-Centers to meet sufficient numbers of staff to implement any additional supervision needed. Education to be completed for all staff by 9/17/2021. Center instituted on 9/16/2021, in addition to the shift-to-shift report already being completed, residents with new or worsening behaviors that possibly could threaten the safety or be an allegation of abuse are evaluated. All new or increasing behaviors and allegations of abuse will be discussed with physician notification and care planned as appropriate. Update to process was communicated to all Licensed Nurses on shift-to-shift report including new or worsening behaviors, up and to include allegations of abuse. Center Nurse Executive is responsible for implementation and monitoring. The Center Nurse Executive and Unit Managers will monitor nursing documentation for all residents daily for two weeks, weekly times four weeks, and monthly thereafter for new or increasing behaviors, and implementation of care plans. Any deviation from procedure will be addressed upon identification, reviewed with the Clinical Team (Center Nurse Executive, Nurse Practice Educator, and Unit Managers) and referred to the Physician for additional guidance. All residents ' progress notes will be reviewed as specified and the review documented on the Morning Clinical Meeting Sheet. The Center Executive Director will report and investigate all allegations of abuse to authorities. Alleged date Immediate Jeopardy was removed, 9/18/2021. Center Executive Director is responsible for the implementation of this plan. The credible allegation was validated on 9/22/21. Interviews were conducted to confirm abuse/neglect education was provided. On 9/20/21, a review of two in-services ' documentation for abuse and neglect was done. The in-service education completed on 9/16/21 included wandering. Oriented residents were interviewed, and audits documented that no residents had concerns for abuse or general concerns completed by 9/18/21. On 9/22/21 at 11:45 am an interview was conducted with alert and oriented residents, individually, to determine if facility staff interviewed them regarding abuse/neglect, residents wandering into their room, and to whom to report concerns. The residents recalled being interviewed this past week regarding abuse and/or resident wandering. On 9/22/21 at 12:10 pm an interview was conducted with the Administrator. The Administrator stated that staff was hired 9/16/21 and provided 1:1 supervision of Resident #2. The resident was currently in the hospital from an unrelated cause and supervision would be initiated upon return until placement in a facility that could meet his needs. Staff in-service had been completed for abuse and resident wandering. The immediate jeopardy was removed on 9/18/21.

Based on observation, record review, resident and staff interview, the facility failed to have sufficient nursing staff to supervise a confused ambulatory resident (Resident #2) which resulted in two resident-to-resident altercations (Resident #18 and #1) on 8/8/21 and 8/30/21 with injury to Resident #1, and failed to provide staff assistance to get a resident out of bed daily (Resident #9) for 3 of 20 residents sampled. Immediate Jeopardy began on 8/8/2021 when Resident #2 abused Resident #18 and the facility did not put effective interventions in place to prevent further occurrences of abuse. Immediate Jeopardy was removed on 9/18/2021 when the facility implemented a credible allegation of Immediate Jeopardy removal. Example 2 will remain out of compliance at severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy). The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: Cross Referred to tag: F600: Based on observation, record review, and interview of staff, resident, and medical staff, the facility failed to protect residents ' right to be free from abuse (Residents #1 and #18) as evidenced by Resident #2 grabbed Resident #18 ' s arm and Resident #2 placed his arm around resident #1 ' s neck in a choke hold. Both altercations required staff to physically remove Resident #2 from both Resident #1 and Resident #18. Resident #1 sustained a neck injury. Both altercations resulted in Resident #2 being sent to an acute care setting for evaluation. This deficient practice affected 2 of 3 sampled residents reviewed for abuse. The Administrator was notified of the immediate jeopardy on 9/16/2021 at 2:03 pm. On 9/18/2021 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following: Facility respectfully submits the below allegation of Immediate Jeopardy Removal Plan for F725 ? Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: The current Center Executive Director was notified on 9/14/2021 of Resident #2 ' s unwanted entry into other Resident rooms and two physical resident-to-resident altercations. The Center Executive Director immediately placed Resident #2 on one-on-one supervision. Resident remained on one-on-one supervision until the resident was sent to the emergency room for an unrelated medical condition on 9/16/2021 where he remains. All residents in the Center have the potential to be affected. Center Nurse Executive and Unit Managers completed an audit on 9/17/2021 of all nursing documentation for the past thirty days to ensure that staffing levels were adequate to provide care and supervision that meet every resident's needs. Upon review of the documentation, no other resident incidents requiring additional staffing coverage were identified. ? Specify action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action will be complete: On 9/16/2021, education was completed with the Center Scheduler and Center Nurse Executive on Sufficient Nursing Staff by the Center Executive Director. Education to include maintaining adequate staffing levels to provide care and supervision that meet every resident's needs. When the need for staff is identified, increased agency requisitions are fulfilled to fit the Center ' s current need. Additionally, the Center utilizes local sister-Centers to provide staffing support as needed. The Center has the capability to place a hold on admissions based on staffing needs of the Center. Center implemented nursing on-call program effective 9/17/2021. Facility Assessment will be reviewed by the Quality Assurance and Performance Improvement Committee on 9/17/2021 through an Ad-hoc QAPI Meeting and monthly thereafter as part of the QAPI Meeting schedule. On 9/16/2021 Education was initiated for all current clinical staff to include Full Time, Part Time, Per Diem, and Agency Staff (Licensed Nurses, Nurses ' Aides, Therapy) on ensuring that resident needs are being met according to the numbers of staff needed to implement the care plan and prevent abuse by the Center Executive Director, Center Nurse Executive, Nurse Practice Educator and Unit Managers. Education to include ensuring the needs of all residents are met and notification to Center Executive Director and/or Center Nurse Executive regarding any potential staffing concerns and/or resident needs. No staff shall work until this education is received. This education will be included for all new hires. The Center Executive Director will meet five days a week and every Friday to include weekend coverage review beginning 9/17/2021 with the Center Nurse Executive, Center Workforce Manager, and Center Scheduler to ensure adequate staff levels daily for two weeks, weekly times four weeks, and monthly thereafter to ensure sufficient staffing to meet the needs of the residents. Alleged date Immediate Jeopardy was removed, 9/18/2021. Center Executive Director is responsible for the implementation of this plan. Credible allegation was validated on 9/22/21: On 9/22/21 a review of morning meetings for census and acuity to determine staffing levels for staffing documentation was done. On 9/22/21 at 12:45 pm an interview was conducted with the Administrator. The Administrator stated that he increased staff for 1:1 supervision of Resident #2 by facility usage of agency nursing staff and planned to obtain nursing assistant staff from the organization ' s sister facilities to meet staffing needs. The Administrator also stated and provided documentation on 9/22/21 that was validated of each morning huddle meeting that evaluated the staffing according to the census and acuity. Cross referred: F561: Based on observation, record review, staff and resident interview, the facility failed to honor a resident ' s choice to get out of bed each day for 1 of 20 residents sampled (Resident #9).

Based on record review, observation, and staff interview, the facility neglected to provide the supervision and monitoring to prevent a cognitively impaired resident who displayed wandering behaviors from 2 incidents of unsupervised exits from the facility for 1 of 1 residents (Resident #48) sampled with wandering behaviors. Resident #48 was found unsupervised outside of the facility on 4/9/18 and 5/16/18. On both occasions, Resident #48 was self-propelling his wheelchair on the sidewalk adjacent to the facility parking lot. The resident was returned inside of the facility with no injuries following both of these unsupervised exits from the facility. The facility also failed to protect Resident #51 from staff to resident abuse for 1 of 1 residents sampled for abuse. Immediate Jeopardy began on 4/9/18 when staff neglected to supervise and monitor Resident #48' s whereabouts and as a result he was found outside by Nursing Assistant #1 in his wheel chair on a side walk approximately 90 feet away from the facility ' s front door without supervision at approximately 8:00 PM. Immediate Jeopardy was removed on 1/25/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Example #2 related to Resident #51 was cited at a scope and severity of a D where a plan of correction is required. The findings included: 1. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #48 ' s (MONTH) (YEAR) physician's order [REDACTED]. The wanderguard was to be checked for function and placement every shift. A nursing note dated 1/11/18 at 5:41 AM indicated Resident #48 ' s wanderguard was not on his ankle. Resident #48 ' s room was searched but was unable to be located. The resident was asked where his bracelet was, and he reported he was unable to recall what happened to it. Resident #48 was noted to have been hovering at exits and exhibiting exit seeking behaviors during the previous shift. The wanderguard was unable to be replaced as there were no additional wanderguards at the facility. The Maintenance Director was informed of the need for an additional wanderguard. The physician's order [REDACTED].#48 ' s wanderguard was changed on 2/1/18 to indicate the wanderguard was to be placed on his wheelchair rather than on his right lower extremity. A nursing note dated 2/20/18 indicated Resident #48 was exit seeking and wandering the facility hallway by self-propelling his wheelchair. A nursing note dated 2/21/18 indicated Resident #48 insisted that he needed to leave and had somewhere to go (he) even tried to rally other residents telling them he had a truck and they needed to leave. A Lift-Transfer-Repositioning Evaluation dated 2/28/18 for Resident #48 indicated he was able to transfer independently using a cane and wheelchair. The quarterly MDS assessment dated [DATE] indicated Resident #48 ' s cognition was severely impaired. He was noted with no behaviors and no wandering. Resident #48 required the supervision of 1 with bed mobility, transfers, and walking in corridor. He was assessed as requiring supervision of 2 or more for locomotion on/off unit. Resident #48 required the limited assistance of 1 with walking in room. He had no functional impairment with range of motion and he utilized a wheelchair. Review of Resident #48 ' s care plan, which was reviewed by staff on 3/18/18, contained the focus area of the risk for elopement related to Resident #48 ' s expressed desire to leave the facility and multiple attempts made by the resident to exit the facility. The interventions indicated a wanderguard was in place and was to be utilized and monitored per facility protocol. a. An incident report dated 4/9/18 completed by Nurse #1 indicated Resident #48 was found outside the facility without supervision. Nursing Assistant (NA) #1 brought Resident #48 back into the facility from the facility ' s parking lot at 8:00 PM. His wanderguard was on his wheelchair and was functioning properly at the time of the elopement. The door alarm was also functioning at the time of the elopement. Resident #48 was noted as last seen at 7:30 PM self-propelling in his wheelchair in the hallway by the dining room located near the front entrance of the facility. Resident #48 was interviewed and was unable to recall what happened. This incident report indicated a physical evaluation of Resident #48 was not completed after the incident. The report also indicated an elopement evaluation and care plan update were not completed. The summary of the interview with Resident #48 ' s assigned nurse, Nurse #1, indicated she heard the alarm sounding and she started to walk up the hall when an NA (unnamed) told her Resident #48 went out the front door. The summary of the interview with Resident #48 ' s assigned NA (unnamed) indicated she was on her break at the time of incident. The root cause/conclusion was indicated to be Resident #48 ' s confusion and his wish to go home. The corrective actions indicated that all doors were checked for functioning and all wanderguards on residents were checked for functioning with no issues identified. An observation was conducted with the Maintenance Director on 1/24/19 at 3:27 PM of the area where Resident #48 was found outside of the building unsupervised on 4/9/18 (as described by NA #1 during interview). This location was a cement sidewalk located directly next to the parking lot of the facility. This parking lot led to a well-traveled roadway with a speed limit of 45 miles per hour (mph). The Maintenance Director measured the distance from the facility ' s front door to Resident #48 ' s identified location and noted the distance as approximately 90 feet. A review of the weather conditions per Weather Underground ' s website (www.wunderground.com) for Asheboro ' s weather history indicated the temperature on 4/9/18 at 7:55 PM was 52 degrees Fahrenheit (F) and there was no precipitation. The following information was obtained from staff interviews and observations related to Resident #48 ' s unsupervised exit from the facility on 4/9/18 at approximately 8:00 PM. - A phone interview was conducted with NA #1 on 1/24/19 at 2:37 PM. She confirmed she was the first staff to respond to the wanderguard door alarm on 4/9/18 when Resident #48 had an unsupervised exit from the building at approximately 8:00 PM. She stated she was not assigned to Resident #48 and she was unsure which NA was assigned to him at the time of the 4/9/18 incident. She reported that she was completing care for one of her residents in their room when she first heard the front door alarm. She indicated that she was working on the 400 hall which led straight up to the front door of the facility. She revealed that the alarm was sounding for about 2 minutes when she exited her resident ' s room and proceeded up the 400-hall corridor to the front door of the facility. NA #1 stated she walked up to the front door to see why the alarm was going off and she saw that a visitor had exited the building and was in the parking lot and Resident #48 was self-propelling in his wheelchair on the sidewalk adjacent to the facility ' s parking lot. She confirmed no staff were present with Resident #48 outside of the building. She stated that she thought Resident #48 followed the visitor out of the front door of the facility. She explained that a numerical code was used to unlock the door and that facility staff and visitors were all aware of the code. She stated that after the visitor entered the code and exited the door that Resident #48 followed behind the visitor engaging the audible wanderguard alarm when he crossed the threshold of the front door. NA #1 stated she exited the building and pushed Resident #48 back into the building by wheelchair. She indicated he had no injuries. NA #1 was unable to recall what Resident #48 was wearing when he was found outside, and she was unable to recall when the door alarm ceased sounding. She reported the alarm was very loud and was easily heard from inside the resident rooms. She was unable to explain why she was the first staff to respond to it. NA #1 stated that Resident #48 was known to be an exit seeker and that he self-propelled his wheelchair throughout the facility all the time. - A phone interview was attempted with Nurse #1 on 1/24/19 at 11:50 AM and 1:17 PM. She was unable to be reached. Nurse #1 was assigned to Resident #48 at the time of his 4/9/18 unsupervised exit from the facility. - A phone interview was conducted with NA #2 on 1/25/18 at 8:20 AM. She stated that she was working on 4/9/18 at the time of Resident #48 ' s unsupervised exit from the facility. She was uncertain which NA was assigned to Resident #48 during the time of this incident, but she stated she had not thought it was her. She confirmed that she heard the front door alarm go off and that NA #1 was the first staff to respond to the alarm. She revealed that when any door alarms went off the staff were supposed to respond immediately. NA #2 was unable to explain why she had not responded to the front door alarm and why no other staff had responded to the alarm prior to NA #1 on 4/9/18 when Resident #48 exited the building unsupervised. NA #2 stated that Resident #48 was known to be an exit seeker and that he self-propelled his wheelchair throughout the facility all the time since admission through present. - A phone interview was conducted with the facility ' s former Administrator on 1/24/19 at 3:55 PM. She stated that she was the Administrator at the time of Resident #48 ' s unsupervised exit from the facility on 4/9/18 at approximately 8:00 PM. The 4/9/18 incident report for Resident #48 was reviewed with the former Administrator. She reported that the root cause of the incident was staffs ' failure to respond immediately to the front door alarm which allowed Resident #48 to follow a visitor out of the facility and self-propel his wheelchair on the sidewalk adjacent to the parking lot of the facility. She indicated that after the incident she believed an inservice was conducted by the unit managers on the elopement procedure. The former Administrator stated that Resident #48 was known to be an exit seeker and that he had removed his wanderguard from his ankle on more than one occasion. She explained that one time he used a butter knife he had kept from one of his meals to remove it and another time he stretched it out until he was able to pull it off. She stated his wanderguard ' s placement was moved to his wheelchair to prevent him from removing it. - An interview was conducted with the Corporate Nurse/former interim Director of Nursing (DON) on 1/24/19 at 2:45 PM. She indicated she was not working at the facility at the time of Resident #48 ' s unsupervised exit on 4/9/18. She stated that based on the inservice records, re-education on elopement procedures was provided to staff on 4/12/18 through 4/15/18. She revealed that the records showed 53 of the 62 staff who were employed at the facility at the time of the 4/9/18 elopement received the inservice. She confirmed all staff employed at the facility were not inserviced on the elopement procedure after Resident #48 ' s unsupervised exit on 4/9/18. b. An incident report dated 5/16/18 completed by Nurse #2 indicated Resident #48 was found outside the facility without supervision. A facility visitor notified Dietary Aide #1 and Dietary Aide #2 that Resident #48 was outside unsupervised at 7:15 PM. Dietary Aide #1 pushed Resident #48 back into the building by wheelchair. Resident #48 was interviewed, and he stated, I ' m going home. The incident report indicated a physical evaluation was conducted with no identified concerns and the care plan was updated. The summary of the interview with Resident #48 ' s assigned nurse (unnamed) indicated an active fire drill was conducted that evening and residents were assisted to their rooms. Rounds were made during the fire drill and Resident #48 was observed attempting to exit his room and was assisted back to the room on multiple occasions. Dietary staff alerted nursing staff that Resident #48 was observed sitting in his wheelchair on the sidewalk adjacent to the parking lot of the facility without supervision. The summary of the interview with Resident ' s assigned NA (unnamed) provided the same information as his assigned nurse. The root cause/conclusion indicated a fire drill was conducted and the exit doors were unlocked and Resident #48 self-propelled out of the facility. The corrective actions indicated the care plan was updated. An observation was conducted with the Maintenance Director on 1/24/19 at 3:27 PM of the area where Resident #48 was found outside of the building unsupervised on 5/16/18 (as described by Dietary Aide #1 during interview). This location was a cement sidewalk located directly next to the parking lot of the facility. This parking lot led to a well-traveled roadway with a speed limit of 45 miles per hour. The Maintenance Director measured the distance from the front door to Resident #48 ' s identified location and noted the distance as approximately 65 feet. A review of the weather conditions per Weather Underground ' s website (www.wunderground.com) for Asheboro ' s weather history indicated the temperature on 5/16/18 at 7:00 PM was 70 degrees F and there was no precipitation. The following information was obtained from staff interviews and observations related to Resident #48 ' s unsupervised exit from the facility on 5/16/18 at approximately 7:15 PM. - An interview was conducted with Dietary Aide #1 on 1/24/19 at 1:31 PM. She confirmed she was working on 5/16/18 at the time of Resident #48 ' s unsupervised exit from the facility. She stated that they had a fire drill at the facility that evening but she was unable to recall a specific time. She stated that after the fire drill she and Dietary Aide #2 were in the kitchen when a facility visitor knocked on the kitchen door and informed them that a resident was outside of the building. Dietary Aide #1 indicated she went into the dining room to look out the window and she saw Resident #48 self-propelling in his wheelchair on the sidewalk adjacent to the facility ' s parking lot. She reported that there was no staff outside with Resident #48. She stated that she went outside and pushed Resident #48 back into the building by wheelchair. She reported that Dietary Aide #2 went to get nursing staff to let them know Resident #48 was found outside unsupervised by a facility visitor. She stated she was unable to recall what Resident #48 was wearing at the time of the incident. Dietary Aide #1 was asked how Resident #48 got out of the building and she indicated that he must have gotten out during the fire drill when the doors to the facility were unlocked. She revealed that she had not known then and still had not known now who was responsible for monitoring the exit doors during a fire drill. - A phone interview was conducted with Dietary Aide #2 on 1/24/19 at 4:04 PM. She confirmed she was working on 5/16/18 at the time of Resident #48 ' s unsupervised exit from the facility. She stated that there was a fire drill at some point that evening and after the fire drill a visitor came to the kitchen door and told her and Dietary Aide #1 that a resident was outside without supervision. She reported that Dietary Aide #1 went to get Resident #48 and she went let nursing staff know he was found outside unsupervised by a facility visitor. Dietary Aide #2 was asked how Resident #48 got out of the building and she indicated that he must have gotten out during the fire drill when the doors to the facility were unlocked. She revealed that she had not known then and still had not known now who was responsible for monitoring the exit doors during a fire drill. - A phone interview was attempted with Nurse #2 on 1/24/19 at 1:16 PM. She was unable to be reached. Nurse #2 wrote the incident report related to Resident #48 ' s 5/16/18 unsupervised exit from the facility. - A phone interview was conducted with NA #2 on 1/25/18 at 8:20 AM. She stated that she was working on 5/16/18 at the time of Resident #48 ' s unsupervised exit from the facility. She was uncertain which NA was assigned to Resident #48 during the time of this incident, but she stated she had not thought it was her. She confirmed that there was a fire drill that evening and that during fire drills the exit doors were unlocked and the wanderguard system was disengaged. She stated that Resident #48 must have gotten out when doors were unlocked and since the wanderguard system was disengaged the alarm had not gone off when he went out the door. She was asked who was supposed to monitor the exit doors during a fire drill and she stated that she thought it was dietary staffs ' responsibility. - An interview was conducted with the Maintenance Director on 1/24/19 at 12:04 PM. He stated he had worked at the facility for over two years. The 5/16/18 incident report related to Resident #48 ' s unsupervised exit during a fire drill was reviewed with the Maintenance Director. He stated that during a fire drill all exit doors, 5 in total, were unlocked and the wanderguard system was disengaged. He indicated that staff were responsible for monitoring the exit doors throughout this time as a resident was able to leave the facility without an alarm sounding. The Maintenance Director was asked if staff education on the fire drill was provided after the 5/16/18 unsupervised exit for Resident #48. He indicated he was unable to recall when the last fire drill procedure inservice was conducted. - A phone interview was conducted with the former Administrator on 1/24/19 at 3:55 PM. She stated that she was the Administrator at the time of Resident #48 ' s unsupervised exit from the facility on 5/16/18 at approximately 8:00 PM. The 5/16/18 incident report for Resident #48 was reviewed with the former Administrator. She revealed that an investigation into the incident had not been conducted because she knew Resident #48 exited the building during the fire drill when the wanderguard system was disengaged. The former Administrator additionally revealed that the root cause of the incident was staffs ' failure to monitor the exit doors during a fire drill. She indicated that after the incident she believed an inservice was conducted on the fire drill procedures. She was unable to recall who was responsible for providing this inservice and was unable to recall if all facility staff had received the inservice. - An interview was conducted with the Corporate Nurse/former interim DON on 1/24/19 at 2:45 PM. She indicated she was not working at the facility at the time of Resident #48 ' s unsupervised exit on 5/16/18. She stated that based on the inservice records, there was no evidence staff education was provided related to the fire drill procedure after Resident #48 ' s unsupervised exit on 5/16/18. An elopement evaluation was completed for Resident #48 on 5/17/18. Resident #48 was noted as an elopement risk related, in part, to his ability to self-propel wheelchair, history of actual elopement, history of wandering that placed him at significant risk of getting to a dangerous place, his expressed desire to leave, and exit seeking behaviors of hovering near exits and restlessness/agitation. On 5/17/18 Resident #48 ' s care plan related to the risk for elopement was updated with the intervention of monitoring the nature and circumstances of attempted elopement and adjust care delivery appropriately. An observation was conducted of Resident #48 on 1/22/19 at 10:05 AM. He was self-propelling his wheelchair in the hallway of his unit of the facility. His wanderguard was located on his wheelchair. An observation was conducted of Resident #48 on 1/23/19 at 2:00 PM. He was self-propelling his wheelchair in the hallway of his unit of the facility. His wanderguard was located his wheelchair. On 1/24/19 a review of the facility ' s protocol for wanderguard ' s, dated 5/1/16, was conducted and indicated that wanderguard bracelets were to be inspected per the manufacturer ' s recommendations. An interview was conducted with the Corporate Nurse/former interim DON on 1/24/19 at 2:45 PM. She stated she was aware that Resident #48 ' s wanderguard was placed on his wheelchair (initiated 2/1/18). She revealed that the manufacturer of the wanderguard had not been consulted to verify if placement on a wheelchair was in accordance with their recommendations. A phone interview was conducted with the Product Sales Manager for the manufacturer of the facility ' s wanderguards on 1/24/19 at 5:07 PM. He indicated that their wanderguard transmitter was not recommended to be installed or strapped onto any equipment. He stated that this would apply to wheelchairs. He reported that the transmitter was to be attached directly to the resident ' s ankle or wrist to ensure proper functioning. An interview was conducted with the current Administrator on 1/25/19 at 6:10 PM. She stated that she began working at the facility recently and she was not present for either of Resident #48 ' s unsupervised exits from the facility (4/9/18 and 5/16/18). The Administrator indicated she was aware that Resident #48 ' s wanderguard had been placed on his wheelchair. She revealed she was not aware this placement was against the manufacturer ' s instructions. She indicated that the manufacturer should have been consulted prior to placing the wanderguard on Resident #48 ' s wheelchair on 2/1/18. She reported the wanderguard was moved to Resident #48 ' s ankle on 1/25/19 to comply with the manufacturer ' s recommendations. The Administrator indicated she expected residents known to be an elopement risk to be monitored closely to prevent an unsupervised exit. She additionally indicated she expected staff to respond immediately to a wanderguard alarm and for all exit doors to be monitored by a staff member during a fire drill and/or actual fire to prevent a resident from exiting the building without supervision. The Administrator acknowledged that the facility had not provided the necessary supervision and monitoring to prevent Resident #48 from exiting the facility unsupervised on 4/9/18 and 5/16/18. She additionally acknowledged that the facility failed to follow the manufacturer ' s instructions for wanderguard placement, failed to respond immediately to a wanderguard alarm, and failed to monitor the exit doors during a fire drill. The Administrator and DON were notified of the Immediate Jeopardy on 1/23/18 at 5:20 PM. On 1/25/19 at 7:23 AM the facility provided the following credible allegation of Immediate Jeopardy removal: - The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; The resident was admitted to the facility on [DATE]. Per the care plan initiated on admission and the Elopement assessment dated [DATE], the resident was identified as elopement risk. Resident # 48 had a wander guard bracelet on his wheelchair, due to previous removal of wander guard bracelet from his ankle. Resident had previously been more independent with ambulation, however as evidenced by MDS completed shortly after this event on 4/19/18, resident did not walk in corridor, and required limited assistance of one person for locomotion on unit. Resident # 48 wandered to the front of the facility at approximately 7:30 pm and was noted by a staff member NA (nurses ' aide) AC, to be near the front door following after another resident and a visitor.NA AC called Licensed Practical Nurse (LPN) HM to assist. Resident was found in parking lot of facility. LPN HM, and NA AC assisted resident # 48 back inside the facility without incident or injury. There is no documented assessment of resident for this date. Physician was notified by LPN HM on 4/9/18 at 8:10 pm, and POA, Resident #48 ' s family member, was notified on 4/9/18 at 8:30 pm (as documented on Risk Event Summary Report) -All exit doors were checked and all wander guards were checked at the time of the incident and all doors and bands were found to be functioning, according to the Event Summary Report (Incident Report). Event Summary report does not indicate who completed this audit or when completed. Facility cannot locate documentation of follow up post this event. Education was completed for 53 staff members related to Elopement Protocol on 4/12/18 -4/15/18. Elopement Protocol Addresses response to door alarms. There were a total of 62 employees at the time of this event, including agency staff. On 5/16/18 the facility had a fire drill conducted by the local fire department, at approximately 7:00 pm. The drill was conducted by the fire department personnel activating a pull alarm. Once the drill was completed, the alarm was silenced by the fire department personnel at an unknown time, (somewhere between 7:00 - 7:20 pm) however the fire department personnel failed to reset the system as is the normal process when fire drill is conducted by fire department, however it is the facility ' s ultimate responsibility to ensure the system is reset, this is normally completed by the Maintenance Director. The Maintenance Director reports that normally he is alerted in advance to the Fire Departments plan to conduct and onsite fire drill, but that on this occasion 5/16/18 it was a new Fire Department Personnel and he did not notify him in advance. The above-mentioned delay in reset of the system, left the centers 5 exit doors unsecured. These doors are normally wanderguarded. Staff failed to monitor the 5 unsecured exit doors during this time. Protocol calls for all doors to be monitored during a fire drill, by staff on duty at time. At 7:01pm the Fire Department called the maintenance director to notify him that they were conducting a Fire Drill, at 7:04 pm the alarm company called the maintenance director to inform him of the alarm sounding. At 7:05 pm the charge nurse on duty, (Unable to determine who this staff member was) called the maintenance director and informed him of drill and they did not know how to reset the alarms. Maintenance director drove into facility to reset alarm, arriving at approximately 7:30 pm at which time he reset the alarms. During this 30-minute time frame the doors were not being monitored. Staff on duty were not trained on how to reset the alarm -Staff had not previously been trained on monitoring the doors. This was an unscheduled drill completed by the local Fire Department as they routinely do in(NAME)County. During the time that the system was down, and the doors were not secure, Resident # 48 was found by the dietary aide LC, she stated that a visitor came and knocked on the kitchen door and told her a resident was outside. Kitchen staff LC noted resident # 48 outside of the facility on the sidewalk near the front entrance - approximately 65 feet from the front entrance, seated in her wheel chair. Resident # 48 was safely returned by dietary staff member LC to the center without injury or incident. LPN AA assessed resident and documented vital signs on the Risk Management Event Summary (Incident Report). The Nurse Practitioner was notified of event on 5/17 at 7:55 a.m., by LPN AA. (Which is within 24 hours of event that had no injury. Resident family member was notified of event on 5/16 at 8:00 pm by LPN AA. Since the event on 5/16/18, Resident # 48 has had no further incidents of exiting the facility unaccompanied. Facility is unable to locate an investigation, staff education, or monitoring post this event. Facility has had several leadership positions (Administrators and Directors of Nursing) turn over since 5/16/18. Therefore, there is no evidence or documentation that the dietary aide LC was interviewed post this event. - The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Education was initiated on 1/24/19 at 8:00 a.m. regarding policy on Neglect and covered that not following resident ' s care plan can lead to neglect. This education was conducted by the Nursing Leadership team (Supervisors, Director of Nursing, and Regional Nurse). All staff on the schedule on 1/24/19 were educated on this, no staff shall work until they receive this education. Nursing Supervisor educating night shift staff on 1/24/19 as they come on shift to ensure compliance. Nursing Supervisor also made telephone call education to multiple staff members on 1/24/19. Education was initiated at approximately 2:00 pm on 1/23/19 by the Nursing Leadership, (Director of Nursing, Supervisors, regional nurse and Administrator) on the process for ensuring that the Fire Alarm System is reset, and doors secure after every Fire Drill. Education also included that in the event that the system cannot be reset immediately, and/or the doors cannot be secured, the staff on duty at time of drill, as stated in policy, are to monitor the exits and complete a head count and account for the whereabouts of all residents, in particular the residents at risk for Elopement. Education is at 98% for all employees, any staff that have not received this training will not work until they have completed the education. Education was completed on Elopement procedure beginning on 4/12 and completed on 4/15/18. Total of 62 staff members employed at time of this event. 53 were educated post event. This education included agency staff. 100% audit was completed on 1/23/19 by the nursing leadership team (Supervisors, Direct of Nursing and regional nurse) of all current residents at risk for Elopement -5 current residents at risk for Elopement. The audit included ensuring that they had secure bracelet in place, that the function and placement of bracelet is checked per protocol, and that Elopement Risk Book was up to date along with the care plans. No discrepancies noted in audit. All current at-risk residents found to have a current Elopement Assessment on file. The facility staff completed a 100% head count of all current residents on 1/23/19 at 2:00 pm to ensure all residents accounted for. This was completed by the nursing leadership team (nursing supervisors, Director of Nursing and Regional Nurse). Elopement Assessments completed/updated for all current residents by the nursing leadership team (supervisors, Director of Nursing and regional nurse) this was initiated on 1/23/19 and will be completed on 1/24/19. No additional residents found to be at risk. Four of the 5 residents identified at risk have their wander guards on their ankles. Resident # 48 had his Wander guard on his wheel chair. Resident # 48 has had Wanderguard removed from wheel chair and place on his ankle, per manufacturer ' s recommendations. (On 1/25/19) - The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; Charge nurse on 100 hall on all three shifts, will assign staff members to be responsible for monitoring the doors in the event of a fire drill/fire alarm. Licensed nurses will be educated by the nursing leadership (supervisors, Director of Nursing and Regional Nurse) that it is the responsibility of charge nurse to assign staff members each shift on the staffing assignment sheets that they will be responsible to monitor doors in the event of a fire or fire drill. Staffing assignments are reviewed by a

Based on record review, observation, and staff interview, the facility failed to provide supervision or interventions to prevent accidents for 2 of 5 sampled residents (Residents #48, and #1) reviewed for accidents. The facility failed to supervise a cognitively impaired resident who displayed wandering behaviors from exiting the facility while unsupervised (Resident #48). Resident #48 was found unsupervised outside of the facility on 4/9/18 and 5/16/18. On both occasions, Resident #48 was self-propelling his wheelchair on the sidewalk adjacent to the facility parking lot. The resident was returned inside of the facility with no injuries following both of these unsupervised exits from the facility. The facility also failed to provide planned fall risk interventions for Resident #1. Immediate Jeopardy began on 4/9/18 when Resident #48 was found outside by Nursing Assistant #1 in his wheel chair on a side walk approximately 90 feet away from the facility' s front door without supervision at approximately 8:00 PM. Immediate Jeopardy was removed on 1/25/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Example #2 related to Resident #1 was cited at a scope and severity of a D where a plan of correction is required. The findings included: 1. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #48 ' s (MONTH) (YEAR) physician's order [REDACTED]. The wanderguard was to be checked for function and placement every shift. A nursing note dated 1/11/18 at 5:41 AM indicated Resident #48 ' s wanderguard was not on his ankle. Resident #48 ' s room was searched but was unable to be located. The resident was asked where his bracelet was, and he reported he was unable to recall what happened to it. Resident #48 was noted to have been hovering at exits and exhibiting exit seeking behaviors during the previous shift. The wanderguard was unable to be replaced as there were no additional wanderguards at the facility. The Maintenance Director was informed of the need for an additional wanderguard. The physician's order [REDACTED].#48 ' s wanderguard was changed on 2/1/18 to indicate the wanderguard was to be placed on his wheelchair rather than on his right lower extremity. A nursing note dated 2/20/18 indicated Resident #48 was exit seeking and wandering the facility hallway by self-propelling his wheelchair. A nursing note dated 2/21/18 indicated Resident #48 insisted that he needed to leave and had somewhere to go (he) even tried to rally other residents telling them he had a truck and they needed to leave. A Lift-Transfer-Repositioning Evaluation dated 2/28/18 for Resident #48 indicated he was able to transfer independently using a cane and wheelchair. The quarterly MDS assessment dated [DATE] indicated Resident #48 ' s cognition was severely impaired. He was noted with no behaviors and no wandering. Resident #48 required the supervision of 1 with bed mobility, transfers, and walking in corridor. He was assessed as requiring supervision of 2 or more for locomotion on/off unit. Resident #48 required the limited assistance of 1 with walking in room. He had no functional impairment with range of motion and he utilized a wheelchair. Review of Resident #48 ' s, care plan which was reviewed by staff on 3/18/18, contained the focus area of the risk for elopement related to Resident #48 ' s expressed desire to leave the facility and multiple attempts made by the resident to exit the facility. The interventions indicated a wanderguard was in place and was to be utilized and monitored per facility protocol. a. An incident report dated 4/9/18 completed by Nurse #1 indicated Resident #48 was found outside the facility without supervision. Nursing Assistant (NA) #1 brought Resident #48 back into the facility from the facility ' s parking lot at 8:00 PM. His wanderguard was on his wheelchair and was functioning properly at the time of the elopement. The door alarm was also functioning at the time of the elopement. Resident #48 was noted as last seen at 7:30 PM self-propelling in his wheelchair in the hallway by the dining room located near the front entrance of the facility. Resident #48 was interviewed and was unable to recall what happened. This incident report indicated a physical evaluation of Resident #48 was not completed after the incident. The report also indicated an elopement evaluation and care plan update were not completed. The summary of the interview with Resident #48 ' s assigned nurse, Nurse #1, indicated she heard the alarm sounding and she started to walk up the hall when an NA (unnamed) told her Resident #48 went out the front door. The summary of the interview with Resident #48 ' s assigned NA (unnamed) indicated she was on her break at the time of incident. The root cause/conclusion was indicated to be Resident #48 ' s confusion and his wish to go home. The corrective actions indicated that all doors were checked for functioning and all wanderguards on residents were checked for functioning with no issues identified. An observation was conducted with the Maintenance Director on 1/24/19 at 3:27 PM of the area where Resident #48 was found outside of the building unsupervised on 4/9/18 (as described by NA #1 during interview). This location was a cement sidewalk located directly next to the parking lot of the facility. This parking lot led to a well-traveled roadway with a speed limit of 45 miles per hour (mph). The Maintenance Director measured the distance from the facility ' s front door to Resident #48 ' s identified location and noted the distance as approximately 90 feet. A review of the weather conditions per Weather Underground ' s website (www.wunderground.com) for Asheboro ' s weather history indicated the temperature on 4/9/18 at 7:55 PM was 52 degrees Fahrenheit (F) and there was no precipitation. The following information was obtained from staff interviews and observations related to Resident #48 ' s unsupervised exit from the facility on 4/9/18 at approximately 8:00 PM. - A phone interview was conducted with NA #1 on 1/24/19 at 2:37 PM. She confirmed she was the first staff to respond to the wanderguard door alarm on 4/9/18 when Resident #48 had an unsupervised exit from the building at approximately 8:00 PM. She stated she was not assigned to Resident #48 and she was unsure which NA was assigned to him at the time of the 4/9/18 incident. She reported that she was completing care for one of her residents in their room when she first heard the front door alarm. She indicated that she was working on the 400 hall which led straight up to the front door of the facility. She revealed that the alarm was sounding for about 2 minutes when she exited her resident ' s room and proceeded up the 400-hall corridor to the front door of the facility. NA #1 stated she walked up to the front door to see why the alarm was going off and she saw that a visitor had exited the building and was in the parking lot and Resident #48 was self-propelling in his wheelchair on the sidewalk adjacent to the facility ' s parking lot. She confirmed no staff were present with Resident #48 outside of the building. She stated that she thought Resident #48 followed the visitor out of the front door of the facility. She explained that a numerical code was used to unlock the door and that facility staff and visitors were all aware of the code. She stated that after the visitor entered the code and exited the door that Resident #48 followed behind the visitor engaging the audible wanderguard alarm when he crossed the threshold of the front door. NA #1 stated she exited the building and pushed Resident #48 back into the building by wheelchair. She indicated he had no injuries. NA #1 was unable to recall what Resident #48 was wearing when he was found outside, and she was unable to recall when the door alarm ceased sounding. She reported the alarm was very loud and was easily heard from inside the resident rooms. She was unable to explain why she was the first staff to respond to it. NA #1 stated that Resident #48 was known to be an exit seeker and that he self-propelled his wheelchair throughout the facility all the time. - A phone interview was attempted with Nurse #1 on 1/24/19 at 11:50 AM and 1:17 PM. She was unable to be reached. Nurse #1 was assigned to Resident #48 at the time of his 4/9/18 unsupervised exit from the facility. - A phone interview was conducted with NA #2 on 1/25/18 at 8:20 AM. She stated that she was working on 4/9/18 at the time of Resident #48 ' s unsupervised exit from the facility. She was uncertain which NA was assigned to Resident #48 during the time of this incident, but she stated she had not thought it was her. She confirmed that she heard the front door alarm go off and that NA #1 was the first staff to respond to the alarm. She revealed that when any door alarms went off the staff were supposed to respond immediately. NA #2 was unable to explain why she had not responded to the front door alarm and why no other staff had responded to the alarm prior to NA #1 on 4/9/18 when Resident #48 exited the building unsupervised. NA #2 stated that Resident #48 was known to be an exit seeker and that he self-propelled his wheelchair throughout the facility all the time since admission through present. - A phone interview was conducted with the facility ' s former Administrator on 1/24/19 at 3:55 PM. She stated that she was the Administrator at the time of Resident #48 ' s unsupervised exit from the facility on 4/9/18 at approximately 8:00 PM. The 4/9/18 incident report for Resident #48 was reviewed with the former Administrator. She reported that the root cause of the incident was staffs ' failure to respond immediately to the front door alarm which allowed Resident #48 to follow a visitor out of the facility and self-propel his wheelchair on the sidewalk adjacent to the parking lot of the facility. She indicated that after the incident she believed an inservice was conducted by the unit managers on the elopement procedure. The former Administrator stated that Resident #48 was known to be an exit seeker and that he had removed his wanderguard from his ankle on more than one occasion. She explained that one time he used a butter knife he had kept from one of his meals to remove it and another time he stretched it out until he was able to pull it off. She stated his wanderguard ' s placement was moved to his wheelchair to prevent him from removing it. - An interview was conducted with the Corporate Nurse/former interim Director of Nursing (DON) on 1/24/19 at 2:45 PM. She indicated she was not working at the facility at the time of Resident #48 ' s unsupervised exit on 4/9/18. She stated that based on the inservice records, re-education on elopement procedures was provided to staff on 4/12/18 through 4/15/18. She revealed that the records showed 53 of the 62 staff who were employed at the facility at the time of the 4/9/18 elopement received the inservice. She confirmed all staff employed at the facility were not inserviced on the elopement procedure after Resident #48 ' s unsupervised exit on 4/9/18. b. An incident report dated 5/16/18 completed by Nurse #2 indicated Resident #48 was found outside the facility without supervision. A facility visitor notified Dietary Aide #1 and Dietary Aide #2 that Resident #48 was outside unsupervised at 7:15 PM. Dietary Aide #1 pushed Resident #48 back into the building by wheelchair. Resident #48 was interviewed, and he stated, I ' m going home. The incident report indicated a physical evaluation was conducted with no identified concerns and the care plan was updated. The summary of the interview with Resident #48 ' s assigned nurse (unnamed) indicated an active fire drill was conducted that evening and residents were assisted to their rooms. Rounds were made during the fire drill and Resident #48 was observed attempting to exit his room and was assisted back to the room on multiple occasions. Dietary staff alerted nursing staff that Resident #48 was observed sitting in his wheelchair on the sidewalk adjacent to the parking lot of the facility without supervision. The summary of the interview with Resident ' s assigned NA (unnamed) provided the same information as his assigned nurse. The root cause/conclusion indicated a fire drill was conducted and the exit doors were unlocked and Resident #48 self-propelled out of the facility. The corrective actions indicated the care plan was updated. An observation was conducted with the Maintenance Director on 1/24/19 at 3:27 PM of the area where Resident #48 was found outside of the building unsupervised on 5/16/18 (as described by Dietary Aide #1 during interview). This location was a cement sidewalk located directly next to the parking lot of the facility. This parking lot led to a well-traveled roadway with a speed limit of 45 miles per hour. The Maintenance Director measured the distance from the front door to Resident #48 ' s identified location and noted the distance as approximately 65 feet. A review of the weather conditions per Weather Underground ' s website (www.wunderground.com) for Asheboro ' s weather history indicated the temperature on 5/16/18 at 7:00 PM was 70 degrees F and there was no precipitation. The following information was obtained from staff interviews and observations related to Resident #48 ' s unsupervised exit from the facility on 5/16/18 at approximately 7:15 PM. - An interview was conducted with Dietary Aide #1 on 1/24/19 at 1:31 PM. She confirmed she was working on 5/16/18 at the time of Resident #48 ' s unsupervised exit from the facility. She stated that they had a fire drill at the facility that evening but she was unable to recall a specific time. She stated that after the fire drill she and Dietary Aide #2 were in the kitchen when a facility visitor knocked on the kitchen door and informed them that a resident was outside of the building. Dietary Aide #1 indicated she went into the dining room to look out the window and she saw Resident #48 self-propelling in his wheelchair on the sidewalk adjacent to the facility ' s parking lot. She reported that there was no staff outside with Resident #48. She stated that she went outside and pushed Resident #48 back into the building by wheelchair. She reported that Dietary Aide #2 went to get nursing staff to let them know Resident #48 was found outside unsupervised by a facility visitor. She stated she was unable to recall what Resident #48 was wearing at the time of the incident. Dietary Aide #1 was asked how Resident #48 got out of the building and she indicated that he must have gotten out during the fire drill when the doors to the facility were unlocked. She revealed that she had not known then and still had not known now who was responsible for monitoring the exit doors during a fire drill. - A phone interview was conducted with Dietary Aide #2 on 1/24/19 at 4:04 PM. She confirmed she was working on 5/16/18 at the time of Resident #48 ' s unsupervised exit from the facility. She stated that there was a fire drill at some point that evening and after the fire drill a visitor came to the kitchen door and told her and Dietary Aide #1 that a resident was outside without supervision. She reported that Dietary Aide #1 went to get Resident #48 and she went let nursing staff know he was found outside unsupervised by a facility visitor. Dietary Aide #2 was asked how Resident #48 got out of the building and she indicated that he must have gotten out during the fire drill when the doors to the facility were unlocked. She revealed that she had not known then and still had not known now who was responsible for monitoring the exit doors during a fire drill. - A phone interview was attempted with Nurse #2 on 1/24/19 at 1:16 PM. She was unable to be reached. Nurse #2 wrote the incident report related to Resident #48 ' s 5/16/18 unsupervised exit from the facility. - A phone interview was conducted with NA #2 on 1/25/18 at 8:20 AM. She stated that she was working on 5/16/18 at the time of Resident #48 ' s unsupervised exit from the facility. She was uncertain which NA was assigned to Resident #48 during the time of this incident, but she stated she had not thought it was her. She confirmed that there was a fire drill that evening and that during fire drills the exit doors were unlocked and the wanderguard system was disengaged. She stated that Resident #48 must have gotten out when doors were unlocked and since the wanderguard system was disengaged the alarm had not gone off when he went out the door. She was asked who was supposed to monitor the exit doors during a fire drill and she stated that she thought it was dietary staffs ' responsibility. - An interview was conducted with the Maintenance Director on 1/24/19 at 12:04 PM. He stated he had worked at the facility for over two years. The 5/16/18 incident report related to Resident #48 ' s unsupervised exit during a fire drill was reviewed with the Maintenance Director. He stated that during a fire drill all exit doors, 5 in total, were unlocked and the wanderguard system was disengaged. He indicated that staff were responsible for monitoring the exit doors throughout this time as a resident was able to leave the facility without an alarm sounding. The Maintenance Director was asked if staff education on the fire drill was provided after the 5/16/18 unsupervised exit for Resident #48. He indicated he was unable to recall when the last fire drill procedure inservice was conducted. - A phone interview was conducted with the former Administrator on 1/24/19 at 3:55 PM. She stated that she was the Administrator at the time of Resident #48 ' s unsupervised exit from the facility on 5/16/18 at approximately 8:00 PM. The 5/16/18 incident report for Resident #48 was reviewed with the former Administrator. She revealed that an investigation into the incident had not been conducted because she knew Resident #48 exited the building during the fire drill when the wanderguard system was disengaged. The former Administrator additionally revealed that the root cause of the incident was staffs ' failure to monitor the exit doors during a fire drill. She indicated that after the incident she believed an inservice was conducted on the fire drill procedures. She was unable to recall who was responsible for providing this inservice and was unable to recall if all facility staff had received the inservice. - An interview was conducted with the Corporate Nurse/former interim DON on 1/24/19 at 2:45 PM. She indicated she was not working at the facility at the time of Resident #48 ' s unsupervised exit on 5/16/18. She stated that based on the inservice records, there was no evidence staff education was provided related to the fire drill procedure after Resident #48 ' s unsupervised exit on 5/16/18. An elopement evaluation was completed for Resident #48 on 5/17/18. Resident #48 was noted as an elopement risk related, in part, to his ability to self-propel wheelchair, history of actual elopement, history of wandering that placed him at significant risk of getting to a dangerous place, his expressed desire to leave, and exit seeking behaviors of hovering near exits and restlessness/agitation. On 5/17/18 Resident #48 ' s care plan related to the risk for elopement was updated with the intervention of monitoring the nature and circumstances of attempted elopement and adjust care delivery appropriately. An observation was conducted of Resident #48 on 1/22/19 at 10:05 AM. He was self-propelling his wheelchair in the hallway of his unit of the facility. His wanderguard was located on his wheelchair. An observation was conducted of Resident #48 on 1/23/19 at 2:00 PM. He was self-propelling his wheelchair in the hallway of his unit of the facility. His wanderguard was located his wheelchair. A phone interview as conducted with the Product Sales Manager for the manufacturer of the facility ' s wanderguards on 1/24/19 at 5:07 PM. He indicated that their wanderguard transmitter was not recommended to be installed or strapped onto any equipment. He stated that this would apply to wheelchairs. He reported that the transmitter was to be attached directly to the resident ' s ankle or wrist to ensure proper functioning. An interview was conducted with NA #7 on 1/24/19 at 1:52 PM. She stated that she had worked at the facility for 8 years and was familiar with Resident #48. She reported that Resident #48 was known to have exit seeking behaviors from his admission through present. She stated that he self-propelled his wheelchair all over the building. NA #7 reported that Resident #48 made statements of wanting to get out of the facility and that one day he was going to leave this place. She indicated that Resident #48 had a wanderguard on his wheelchair. NA #7 revealed she was unaware that Resident #48 had two unsupervised exits from the facility. She was asked who was responsible for responding to an exit door alarm and she stated that all staff were to respond to the alarm immediately whether or not they were assigned to the resident. She was then asked who was responsible for monitoring the exit doors during a fire drill and she stated that she was unsure who was assigned this responsibility but indicated her awareness that the exit doors needed to be monitored to prevent a resident from leaving the building. An interview was conducted with Nurse #3 on 1/24/19 at 3:34 PM. She stated that she had worked at the facility for over a year and that she regularly worked with Resident #48. She reported that Resident #48 was known to have exit seeking behaviors from his admission through present. She stated that he self-propelled his wheelchair all over the building. She reported that Resident #48 had a wanderguard on his wheelchair because he kept removing the wanderguard when it was placed on his ankle. Nurse #3 revealed she was only aware of the 5/16/18 unsupervised exit for Resident #48. She stated she had not known he had two unsupervised exits. She was asked who was responsible for responding to an exit door alarm and she stated that all staff were to respond to the alarm immediately whether or not they were assigned to the resident. Nurse #3 was then asked who was responsible for monitoring the exit doors during a fire drill and she stated that she was unsure who was assigned this responsibility but indicated her awareness that the exit doors needed to be monitored to prevent a resident from leaving the building. An interview was conducted with the current Administrator on 1/25/19 at 6:10 PM. She stated that she began working at the facility recently and she was not present for either of Resident #48 ' s unsupervised exits from the facility (4/9/18 and 5/16/18). The Administrator indicated she was aware that Resident #48 ' s wanderguard had been placed on his wheelchair. She revealed she was not aware this placement was against the manufacturer ' s instructions. She reported the wanderguard was moved to Resident #48 ' s ankle on 1/25/19 to comply with the manufacturer ' s recommendations. The Administrator indicated she expected residents known to be an elopement risk to be monitored closely to prevent an unsupervised exit. She additionally indicated she expected staff to respond immediately to a wanderguard alarm and for all exit doors to be monitored by a staff member during a fire drill and/or actual fire to prevent a resident from exiting the building without supervision. The Administrator and DON were notified of the Immediate Jeopardy on 1/23/18 at 5:20 PM. On 1/25/19 at 7:23 AM the facility provided the following credible allegation of Immediate Jeopardy removal: - The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; The resident was admitted to the facility on [DATE]. Per the care plan initiated on admission and the Elopement assessment dated [DATE], the resident was identified as elopement risk. Resident # 48 had a wander guard bracelet on his wheelchair, due to previous removal of wander guard bracelet from his ankle. Resident had previously been more independent with ambulation, however as evidenced by MDS completed shortly after this event on 4/19/18, resident did not walk in corridor, and required limited assistance of one person for locomotion on unit. On 4/9/18, Resident # 48 wandered to the front of the facility at approximately 7:30 pm and was noted by a staff member NA (nurses ' aide) AC, to be near the front door following after another resident and a visitor. NA AC called Licensed Practical Nurse (LPN) HM to assist. Resident was found in parking lot of facility. LPN HM, and NA AC assisted resident # 48 back inside the facility without incident or injury. There is no documented assessment of resident for this date. Physician was notified by LPN HM on 4/9/18 at 8:10 pm, and POA, Resident #48 ' s family member, was notified on 4/9/18 at 8:30 pm (as documented on Risk Event Summary Report) -All exit doors were checked and all wander guards were checked at the time of the incident and all doors and bands were found to be functioning, according to the Event Summary Report (Incident Report). Event Summary report does not indicate who completed this audit or when completed. Facility cannot locate documentation of follow up post this event. Education was completed for 53 staff members related to Elopement Protocol on 4/12/18 -4/15/18. Elopement Protocol Addresses response to door alarms. There was a total of 62 employees at the time of this event, including agency staff. On 5/16/18 the facility had a fire drill conducted by the local fire department, at approximately 7:00 pm. The drill was conducted by the fire department personnel activating a pull alarm. Once the drill was completed, the alarm was silenced by the fire department personnel at an unknown time, (somewhere between 7:00 - 7:20 pm) however the fire department personnel failed to reset the system as is the normal process when fire drill is conducted by fire department, however it is the facility ' s ultimate responsibility to ensure the system is reset, this is normally completed by the Maintenance Director. The Maintenance Director reports that normally he is alerted in advance to the Fire Department ' s plan to conduct an onsite fire drill, but that on this occasion 5/16/18 it was a new Fire Department Personnel and he did not notify him in advance. The above mentioned delay in reset of the system, left the centers 5 exit doors unsecured. These doors are normally wanderguarded. Staff failed to monitor the 5 unsecured exit doors during this time. Protocol calls for all doors to be monitored during a fire drill, by staff on duty. At 7:01pm the Fire Department called the maintenance director to notify him that they were conducting a Fire Drill, at 7:04 pm the alarm company called the maintenance director to inform him of the alarm sounding. At 7:05 pm the charge nurse on duty (Unable to determine who this staff member was) called the maintenance director and informed him of drill and they did not know how to reset the alarms. Maintenance director drove into facility to reset alarm, arriving at approximately 7:30 pm at which time he reset the alarms. During this 30 minute time frame the doors were not being monitored. Staff on duty were not trained on how to reset the alarm -Staff had not previously been trained on monitoring the doors. This was an unscheduled drill completed by the local Fire Department as they routinely do in(NAME)County. During the time that the system was down and the doors were not secure, Resident # 48 was found by the dietary aide LC, she stated that a visitor came and knocked on the kitchen door and told her a resident was outside. Kitchen staff LC noted resident # 48 outside of the facility on the sidewalk near the front entrance - approximately 65 feet from the front entrance, seated in her wheel chair. Resident # 48 was safely returned by dietary staff member LC to the center without injury or incident. LPN AA assessed resident and documented vital signs on the Risk Management Event Summary (Incident Report). The Nurse Practitioner was notified of event on 5/17/18 at 7:55 a.m., by LPN AA. (Which is within 24 hours of event that had no injury. Resident sister was notified of event on 5/16/18 at 8:00 pm by LPN AA. Since the event on 5/16/18, Resident # 48 has had no further incidents of exiting the facility unaccompanied. Facility is unable to locate an investigation, staff education, or monitoring post this event. Facility has had several leadership positions (Administrators and Directors of Nursing) turn over since 5/16/18. Therefore, there is no evidence or documentation that the dietary aide LC was interviewed post this event. - The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Education was initiated at approximately 2:00 pm on 1/23/19 by the Nursing Leadership, (Director of Nursing, Supervisors, regional nurse and Administrator) on the process for ensuring that the Fire Alarm System is reset and doors secure after every Fire Drill. Education also included that in the event that the system cannot be reset immediately and/or the doors cannot be secured, the staff on duty at time of drill, as stated in policy, are to monitor the exits and complete a head count and account for the whereabouts of all residents, in particular the residents at risk for Elopement. Education is at 98% for all employees, any staff that have not received this training will not work until they have completed the education. Education was completed on Elopement procedure beginning on 4/12/18 and completed on 4/15/18. Total of 62 staff members employed at time of this event. 53 were educated post event. This education included agency staff. 100% audit was completed on 1/23/19 by the nursing leadership team (Supervisors, Direct of Nursing and regional nurse) of all current residents at risk for Elopement - 5 current residents at risk for Elopement. The audit included ensuring that they had secure bracelet in place, that the function and placement of bracelet is checked per protocol, and that Elopement Risk Book was up to date along with the care plans. No discrepancies noted in audit. All current at risk residents found to have a current Elopement Assessment on file. The facility staff completed a 100% head count of all current residents on 1/23/19 at 2:00 pm to ensure all residents accounted for. This was completed by the nursing leadership team (nursing supervisors, Director of Nursing and Regional Nurse). Elopement Assessments completed/updated for all current residents by the nursing leadership team (supervisors, Director of Nursing and regional nurse) this was initiated on 1/23/19 and will be completed on 1/24/19. No additional residents found to be at risk. Four of the 5 residents identified at risk have their wander guards on their ankles. Resident # 48 had his Wander guard on his wheel chair. Resident # 48 has had Wanderguard removed from wheel chair and place on his ankle, per manufacturer ' s recommendations (on 1/25/19) - The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; Charge nurse on 100 hall on all three shifts, will a (TRUNCATED)

Based on record review and interviews with resident, staff, physician, Dietitian and Nurse Practitioner (NP), the facility failed to provide same day notification to the medical provider of a resident's unsupervised exit from the facility (Resident #48), failed to notify the medical provider of repeated medication refusals and increased behaviors (Resident #16), failed to notify the medical provider of a resident's unintended weight loss (Resident #18); failed to notify the physician of behaviors, expressions of feeling unloved and that nobody cared (Resident #69) for 4 of 4 residents reviewed for physician notification. The findings included: 1. Resident #18 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of Resident #18's weight record revealed in (MONTH) (YEAR) the resident weighed 178 pounds. A review of Resident #18 ' s Dietary note dated [DATE] revealed the resident had experienced a significant weight loss, and a house supplement three times a day was recommended. Resident #18 had a physician order [REDACTED]. A review of Resident #18 ' s care plan revealed a focus initiated on [DATE] that identified the resident as being at risk for nutrition/hydration alteration related to cognitive impairment and [MEDICAL CONDITION] and significant weight loss. The goal was adequate intake to prevent significant weight change or skin breakdown, interventions were house supplement, 12 ounces of beer each day as requested, regular liberalized diet with extra chocolate milk, offer alternatives and snacks, and monitor intake and weight. A review of Resident #18 ' s physician progress notes [REDACTED]. A review of Resident #18 ' s annual Minimum (MDS) data set [DATE] revealed the resident had clear speech and usually understands and understood. The resident had severely impaired cognition. The resident required extensive assistance of 2 staff for bed mobility and of 1 staff for all other activities of daily living including eating. The resident ' s active [DIAGNOSES REDACTED]. The resident received a therapeutic diet and did not indicate significant weight loss. The resident ' s weight was 163 pounds. The nutrition care assessment area was triggered and documented as addressed in the care plan. Care plan was not changed at this time. Review of the resident ' s weight record revealed the resident lost a total of 15 pounds (or 8.4 percent body weight of his body weight) from (MONTH) (YEAR) to (MONTH) 2019. Review of the resident ' s medical record revealed there were no dietician notes documented in the record between [DATE] to [DATE]. A review of Resident #18 ' s dietician notes dated [DATE] revealed the resident had significant weight loss of 16% over the past 6 months. No new interventions were recommended. The resident ' s needs were probably being met. The dietician will update the resident ' s care plan. The resident ' s diet was liberal with ice cream. Further review of the medical record revealed no nutritional interventions were implemented from [DATE] to [DATE], to stabilize the resident ' s weight or to prevent further weight loss. On [DATE] at 11:30 am an interview was conducted with the Dietician who stated that she was aware of Resident #18's weight loss over time and of 16.1% over the past 6 months [DATE]. The resident ' s weights were not consistently done each month. The resident had house supplement three times a day added on [DATE]. The resident has had a steady weight loss with a known decrease in intake over the past month. The Dietician stated that the resident was at nutrition deficit risk and was discussed at the weekly meeting with nursing staff and management over the past 2 months. The Dietician stated that since the resident was taking his house supplement and continued to lose weight there should have been additional intervention. The resident is currently at his lowest weight since admission to the facility. The Dietician stated that the resident ' s physician was not informed. On [DATE] at 4:55 pm an interview was conducted with the Director of Nursing who stated she expected the Dietician to follow and address weight loss and to inform the physician of significant weight loss. On [DATE] at 5:20 pm an interview was conducted with Resident #18 ' s physician who stated he was not made aware of the resident ' s significant weight loss and that adding [MEDICATION NAME] would not be appropriate to improve appetite and weight gain. The physician felt the dietician should have addressed the resident ' s weight loss with new, appropriate weight gain interventions. The physician felt with additional weigh loss intervention the weight loss could have been avoided. 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #16 ' s quarterly Minimum (MDS) data set [DATE] revealed documentation that the resident was sometimes understood and sometimes understands. Cognition was intact. The resident required total dependence for all transfers including toileting, and extensive assistance for bathing and dressing. The resident ' s active [DIAGNOSES REDACTED]. The resident received scheduled pain management. A review of Resident #16 ' s care plan dated [DATE] revealed the resident had goals and interventions for self-care deficit, verbal behaviors, poor impulse control, communication deficit, pain, and was at risk for [MEDICAL CONDITION] medication complication (intervention was to inform the physician of changes in mental status and functional level and to monitor for continued need for medication related to mood and behavior). Nurses' note dated [DATE] refused all meds makes me sick (Nurse #9). A review of the resident ' s nurses ' notes from [DATE] to [DATE] revealed there was no documentation that the physician or nurse practitioner was informed of the resident ' s medication refusal and/or increased behaviors A review of the physician and nurse practitioner communication book for timeframe [DATE] to [DATE], which was stored at the nurses ' station, revealed there was no communication to the medical staff that the resident had frequently refused his medication, had increased behaviors and frequently refused personal care. A review of the resident ' s (MONTH) (YEAR) medication administration record (MAR) revealed out of 31 days the resident refused the following medication: [MEDICATION NAME] twice a day refused on 15 occasions Aspirin once a day refused on 9 occasions Atorvastatin once a day refused on 20 occasions [MEDICATION NAME] three times a day refused on 20 occasions [MEDICATION NAME] twice a day refused on 22 occasions [MEDICATION NAME] once a day refused on 15 occasions [MEDICATION NAME] once a day refused on 20 occasions [MEDICATION NAME] once a day refused on 20 occasions [MEDICATION NAME] once a day refused on 20 occasions [MEDICATION NAME] once a day refused on 20 occasions Trazadone once a day refused on 18 occasions A review of the resident ' s (MONTH) (YEAR) MAR revealed out of 30 days the resident refused the following medication: [MEDICATION NAME] twice a day refused on 20 occasions Aspirin once a day refused on 18 occasions Atorvastatin once a day refused on 20 occasions [MEDICATION NAME] three times a day refused on 36 occasions [MEDICATION NAME] twice a day refused on 26 occasions [MEDICATION NAME] once a day refused on 11 occasions [MEDICATION NAME] twice a day refused on 27 occasions [MEDICATION NAME] once a day refused on 22 occasions [MEDICATION NAME] once a day refused on 18 occasions [MEDICATION NAME] once a day refused on 17 occasions Trazadone once a day refused on 17 occasions A review of Resident #16 ' s physician progress notes [REDACTED]. The resident was compliant with medication. The plan was to continue with current medication. A review of the resident ' s (MONTH) (YEAR) MAR revealed out of 31 days the resident refused the following medication: [MEDICATION NAME] twice a day refused on 17 occasions Aspirin once a day refused on 13 occasions Atorvastatin once a day refused on 8 occasions [MEDICATION NAME] three times a day refused on 20 occasions [MEDICATION NAME] twice a day refused on 21 occasions [MEDICATION NAME] once a day refused on 4 occasions [MEDICATION NAME] refused on 8 occasions [MEDICATION NAME] twice a day refused on 19 occasions [MEDICATION NAME] 5 mg once a day refused on 13 occasions [MEDICATION NAME] once a day refused on 8 occasions [MEDICATION NAME] once a day refused on 18 occasions [MEDICATION NAME] once a day refused on 17 occasions Trazadone once a day refused on 17 occasions A review of the resident ' s (MONTH) 2019 MAR revealed out of 24 days the resident refused the following medication: [MEDICATION NAME] twice a day refused on 28 occasions Aspirin once a day refused on 11 occasions Atorvastatin once a day refused on 21 occasions [MEDICATION NAME] three times a day refused on 42 occasions [MEDICATION NAME] twice a day refused on 31 occasions [MEDICATION NAME] once a day refused on 15 occasions [MEDICATION NAME] refused on 19 occasions [MEDICATION NAME] twice a day refused on 27 occasions [MEDICATION NAME] 5 mg once a day refused on 13 occasions [MEDICATION NAME] once a day refused on 19 occasions [MEDICATION NAME] once a day refused on 19 occasions [MEDICATION NAME] once a day refused on 19 occasions Trazadone once a day refused on 19 occasions On [DATE] at 10:10 am an observation was done of the resident who was lying in his bed with his eyes closed. The resident ' s hair appeared slick and his nails were long and dirty. The resident had a low voice tone and was oriented to self and situation. On [DATE] at 10:10 am an interview was conducted with Resident #16 who stated that he wanted his nails cleaned. The resident voice no concerns. The resident stated that he took his medication this morning. On [DATE] at 9:30 am an interview was conducted with Nurse Assistant (NA) #14 who stated she was familiar and assigned to Resident #16. The resident had a history of [REDACTED]. NA #14 commented that lately his refusal of care had increased. NA #14 commented that he accepted morning care and it was noted that the resident ' s nails were long and dirty. NA #14 went back to take care of the resident ' s nails and he refused, the nurse was informed, and the nurse was also unable to intervene. On [DATE] at 10:40 am an interview was conducted with Nurse #11 who stated that she was regularly day shift assigned to Resident #16. Nurse #11 commented that the resident had lately more frequently refused care and his medication. The nurse would try and return to offer care but had continued to decline the care. Nurse #11 stated that she was aware that the resident had refused multiple doses of his [MEDICAL CONDITION] medication for several weeks. Nurse #11 stated that other shift nurses had reported the same. Nurse #11 stated that she had not called the physician to inform him of the resident ' s repeated, long-term refusal of his medication. Nurse #11 commented that the resident had a right to refuse. Nurse #11 agreed that the resident had increased behaviors of refusing care and increased occasions of refusing medication. Nurse #11 stated that she was aware the resident had verbal outburst of foul language recently which was considered increased behaviors. Nurse #11 agreed that the resident ' s refusal to take his [MEDICAL CONDITION] medication placed him at risk for increased behaviors and depression. On [DATE] at 1:10 pm an interview was conducted with Nurse #9 who stated she was familiar with Resident #16 and frequently assigned on evening shift. Nurse #9 stated that she recalled that the resident had frequently refused his medication and had documented last month that the resident informed her the medication made him sick. Nurse #9 did not inform the physician or nurse practitioner at that time. Nurse #9 stated that she placed a note in the physician ' s communication book stored at the nurses ' station about the resident ' s refusal. She could not remember when. Nurse #9 commented that the staff were aware of the resident ' s medication refusal and that the refusals were documented on the MAR. Nurse #9 commented that the refusals had become more frequent and this information was not provided to the Director of Nursing (DON) or the resident ' s physician. On [DATE] at 4:55 pm an interview was conducted with the DON who stated she expected staff to inform her and the resident ' s physician of medication refusal after 3 occasions and to monitor the resident ' s behavior in relation to [MEDICAL CONDITION] medication refusals. On [DATE] at 5:00 pm an interview was conducted with Resident #16 ' s physician who stated he was not informed that the resident repeatedly refused his medication and had increased behaviors. The physician stated that he expected staff to inform him of any resident changes. The physician commented he would see the resident on his next visit to the facility. 3. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 ' s cognition was severely impaired. He was assessed with [REDACTED]. Resident #48 ' s plan of care included the focus area of the risk for elopement related to his expressed desire to leave the facility and multiple attempts made by the resident to exit the facility. Resident #48 was noted to have removed his own wanderguard. This area was initiated on [DATE] and revised on [DATE]. An incident report dated [DATE] completed by Nurse #2 indicated Resident #48 had an unsupervised exit from the facility. He was found outside of the facility without supervision by a facility visitor at approximately 7:15 PM. This incident report indicated the Nurse Practitioner (NP) was notified the following morning ([DATE] at 7:55 AM). A phone interview was attempted with Nurse #2 on [DATE] at 1:16 PM. She was unable to be reached. Nurse #2 wrote the incident report related to Resident #48 ' s [DATE] unsupervised exit from the facility. A phone interview was conducted with the NP on [DATE] at 4:45 PM. He stated that he was not the NP at the facility at the time of the [DATE] unsupervised exit for Resident #48. He indicated that as a medical provider, he expected the facility to notify him or the physician as soon as possible after an incident of a resident ' s unsupervised exit from the building. He stated that the following day was not an acceptable timeframe for notification. A phone interview was conducted with Resident #48 ' s physician/facility ' s Medical Director on [DATE] at 5:15 PM. He stated that he expected the facility to notify him or his NP as soon as possible after an incident of a resident ' s unsupervised exit from the building. He stated that the following day was not an acceptable timeframe for notification. An interview was conducted with the current Administrator on [DATE] at 6:10 PM. She stated that she expected the physician and/or NP to be notified as soon as possible after an incident of a resident ' s unsupervised exit from the building. She indicated that the following day was not an acceptable timeframe for notification. 4. Resident #69 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #69's admission orders [REDACTED]. Resident #69's admission Minimum Data Set ((MDS) dated [DATE] indicated he was cognitively intact, with no mood disturbance and exhibited no behaviors. In an interview on [DATE] at 11:00 AM, Resident #69 stated he was diagnosed with [REDACTED]. Resident #69 started waving his arms, became tearful and stated his children had not come to see him since his admission and that made him sad. He stated he did not understand why his kids did not care about him anymore. Resident #69 went on to state he experienced shell shock after returning from Vietnam and it affected his first marriage that resulted in a divorce. He stated his second wife died a year ago. Review of Resident #69's nursing notes from [DATE] to [DATE] read a nursing note dated [DATE] at 9:04 PM, Resident #69 was exhibited an incident of jerking motions with arms requiring staff to assist him with eating on several occasions, multiple occasions of Resident #69 yelling out for staff and multiple request for snacks. During an interview on [DATE] at 4:45 PM, the Corporate Nurse/Former Interim Director of Nursing (DON) stated the Psychiatric Nurse Practitioner(PNP) was at the facility ,[DATE] times weekly. She stated if Resident #69 was experiencing any mood or behavior concerns, it was her expectation that he received a referral for a Psychiatric evaluation. During an interview on [DATE] at 10:35 AM, the Social Worker (SW) stated she completed the cognition, mood and behaviors section on Resident #69's admission MDS dated [DATE] and she did not note any concerns in those areas. The SW stated that staff had not reported any cognition, mood or behaviors concerns and she did not read his nursing notes. During an interview on [DATE] at 11:50 AM, the PNP stated she was asked to evaluate Resident #69 earlier this morning and that he was tearful during the evaluation and he stated he felt unloved. The PNP stated she changed his antidepressant and added a medication for [MEDICAL CONDITION] and planned to continue to see Resident #69. During an interview on [DATE] at 3:30 PM, Nursing Assistant (NA) #10 stated Resident #69 was very inpatient and had stated he felt unloved but he never cried in front of her. She stated she did not report how Resident #69 felt to anyone. During an interview on [DATE] at 3:35 PM, Nurse #14 stated Resident #69 was very needy and inpatient with frequent episodes of yelling out for staff to come and feed him or bring him a snack. She stated Resident #69 can feed himself. She stated she did not report how he was feeling to anyone but documented any behaviors in his nursing notes. During an interview on [DATE] at 8:45 AM, Nurse #3 stated she had never seen Resident #69 crying, but he had expressed feelings of being upset that his kids had not come to see him and that nobody cared about him. She stated she did not report how he was feeling to anyone but documented the behaviors of Resident #3 yelling rather than using his call bell and him saying he could not feed himself insisting that staff feed him. She stated she was not aware of any reason Resident #69 could not feed himself. She stated it seemed unusual for him to request to be fed. During a telephone interview on [DATE] at 3:45 PM, Physician #2 stated he was not aware of the mood and behaviors issues exhibited by Resident #69 and he expected Resident #69 receive a Psychiatric evaluation if he was experiencing any mood or behaviors concerns. He stated Resident #69 was a very sick man and recently was discharged from the hospital after a very prolonged stay. During an interview on [DATE] at 5:50 PM, the Administrator stated it was her expectation that the staff would have identified and notified Physician #2 about his behaviors, expressions of feeling unloved and that nobody cared for a possible Psychiatric evaluation.

Based on record review, observations, and staff and Physician interviews, the facility failed to monitor weight loss, prevent continued weight loss and evaluate existing interventions for weight loss for 1 of 5 residents reviewed for nutrition (Resident #18). Resident #18 experienced an unintended 15-pound (8.4 percent) weight loss during a four month period as a result of no interventions being implemented by the facility to prevent him from losing weight. Findings included: Resident #18 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of Resident #18 ' s weight record revealed the following weights: May (YEAR): 206 pounds August (YEAR): 194 pounds September (YEAR): 178 pounds A review of Resident #18 ' s Dietary note dated 9/20/18 revealed the resident had experienced a significant weight loss, and a house supplement three times a day was recommended. Resident #18 had a physician order [REDACTED]. A review of Resident #18 ' s care plan revealed a focus initiated on 9/23/18 that identified the resident as being at risk for nutrition/hydration alteration related to cognitive impairment and [MEDICAL CONDITION] and significant weight loss. The goal was adequate intake to prevent significant weight change or skin breakdown, interventions were house supplement, 12 ounces of beer each day as requested, regular liberalized diet with extra chocolate milk, offer alternatives and snacks, and monitor intake and weight. A review of Resident #18 ' s physician progress notes [REDACTED]. A review of Resident #18 ' s annual Minimum (MDS) data set [DATE] revealed the resident had clear speech and usually understands and understood. The resident had severely impaired cognition. The resident required extensive assistance of 2 staff for bed mobility and of 1 staff for all other activities of daily living including eating. The resident ' s active [DIAGNOSES REDACTED]. The resident received a therapeutic diet and did not indicate significant weight loss. The resident ' s weight was 163 pounds. The nutrition care assessment area was triggered and documented as addressed in the care plan. Care plan was not changed at this time. Review of Resident #18 ' s (MONTH) and (MONTH) (YEAR) and (MONTH) 2019 Medication Administration Record [REDACTED]. Review of Resident #18 ' s weight record revealed the following weights: November (YEAR): 172 pounds December (YEAR): weight not obtained January 2019: 163 pounds Review of the resident ' s weight record revealed the resident lost a total of 15 pounds (or 8.4 percent body weight of his body weight) from (MONTH) (YEAR) to (MONTH) 2019. Review of the resident ' s medical record revealed there were no dietician notes documented in the record between 09/20/18 to 1/11/19. A review of Resident #18 ' s dietician notes dated 1/11/19 revealed the resident had significant weight loss of 16% over the past 6 months. No new interventions were recommended. The resident ' s needs were probably being met. The dietician will update the resident ' s care plan. The resident ' s diet was liberal with ice cream. Resident #18 had a physician order [REDACTED]. Further review of the medical record revealed no nutritional interventions were implemented from 9/11/18 to 1/23/19, to stabilize the resident ' s weight or to prevent further weight loss. On 1/23/19 at 9:30 am an observation was done of Resident #18 who was traveling freely around the facility in his power scooter. The resident had garbled speech and was rarely understood. The resident was of thin stature in his body and his cheek bones were pronounced. An observation was done on 1/24/19 at 12:00 pm of Resident #18's lunch in the main dining room which revealed the resident had consumed 1/4 of his beer and 25% of his meal with assistance and then wanted to smoke. Staff was observed to encourage the resident to eat. No other food or nutritional supplement options were offered or asked of preference to the resident by staff. On 1/23/19 at 1:30 pm an interview was done of the assigned Nurse #7 who stated that she knew Resident #18 had an order for [REDACTED].#7 stated that the weight record reviewed was the only place for weight documentation and if the date was left blank the weight was not done. She was not aware of the resident refusing to be weighed. Nurse #7 stated that the night shift was responsible to weigh the resident early in the morning and document. Nurse #7 stated that night shift had not informed her when they were not able to weigh the resident. On 1/24/19 at 11:30 am an interview was conducted with the Dietician who stated that she was aware of Resident #18's weight loss over time and of 16.1% over the past 6 months 1/11/19. The resident ' s weights were not consistently done each month. The resident had house supplement three times a day added on 9/13/18. The resident has had a steady weight loss with a known decrease in intake over the past month. The resident was known to decline his food intake and asked for his chocolate house supplement. The medication [MEDICATION NAME] was restarted 1/16/19 in hope that would improve the resident's appetite and compliance with intake because the weight loss began after the [MEDICATION NAME] (anti-psychotic) was discontinued last summer. A recent intervention of his 1 daily beer was changed from dinner to lunch. The Dietitian stated that the facility has magic cup frozen desert supplement and protein supplement, but these were not considered. The resident's intake has been approximately 25-75%. The resident had been taking his supplement three times a day per nursing. The Dietician stated that the resident was at nutrition deficit risk and was discussed at the weekly meeting with nursing staff and management over the past 2 months. The Dietician stated that since the resident was taking his house supplement and continued to lose weight there should have been additional intervention. The resident is currently at his lowest weight since admission to the facility. The Dietician stated that the resident ' s physician was not informed. The Dietician stated that [MEDICATION NAME] was not an appetite stimulator, it was an anti-psychotic. The Dietician also commented that she should have addressed the continued weight loss with a second nutritional supplement and that the care plan goal was not met. On 1/25/19 at 1:50 pm an interview was conducted with Nursing Assistant #19 (NA) who was familiar with Resident #18 and stated that the resident will eat 100% of food ordered in; he does not eat in-facility meals very well. Food ordered in was occasional. The resident was offered ice cream and chocolate milk. The resident received a supplement from the nurse. The resident does not like the meal-substitution sandwiches. Facility staff were aware that the resident's appetite had declined over the past three months. The NA stated the resident usually ate about 25% of his meal and required minimal assistance. On 1/25/19 at 4:00 pm an interview with the night shift nurse was attempted and was unsuccessful. On 1/25/19 at 4:55 pm an interview was conducted with the Director of Nursing who stated she expected the dietician to follow and address weight loss and to inform the physician of significant weight loss. On 1/25/19 at 5:20 pm an interview was conducted with Resident #18 ' s physician who stated he was not made aware of the resident ' s significant weight loss and that adding [MEDICATION NAME] would not be appropriate to improve appetite and weight gain. The physician felt the dietician should have addressed the resident ' s weight loss with new, appropriate weight gain interventions. The physician felt with additional weigh loss intervention the weight loss could have been avoided.

Based on record review, observation, and staff, resident, psychiatric and facility nurse practitioners, and physician interviews, the facility failed to provide timely, necessary psychiatric services (Residents #16 and #2) and failed to provide a psychiatric evaluation (Resident #69) for 3 of 5 residents reviewed for unnecessary medication. Findings included: 1. Resident #69 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #69's admission orders [REDACTED]. Resident #69's admission Minimum Data Set ((MDS) dated [DATE] indicated he was cognitively intact, no mood disturbance and exhibited no behaviors. He was coded for supervision with eating. He coded as having received 6 doses of an antidepressant during the look back period. The Care Area Assessment (CAA) was triggered for [MEDICAL CONDITION] medications. The CAA indicated Resident #69 would be care planned for [MEDICAL CONDITION] medications related to his Depression. Review of Resident #69's care plan dated [DATE] indicated he was at risk for sadness/depression due to his [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:00 AM, Resident #69 stated he was diagnosed with [REDACTED]. Resident #69 started waving his arms, became tearful and stated his children had not come to see his since his admission and that made him sad. He stated he did not understand why his kids did not care about him anymore. Resident #69 went on the state he experienced shell shock after returning from Vietnam and it affected his first marriage that resulted in a divorce. He stated his second wife died a year ago. Review of Resident #69's nursing notes from [DATE] to [DATE] read a nursing note dated [DATE] at 9:04 PM, Resident #69 was exhibited an incident of jerking motions with arms requiring staff to assist him with eating on several occasions, multiple occasions of Resident #69 yelling out for staff and multiple request for snacks. During an interview on [DATE] at 4:45 PM, the Corporate Nurse/Former Interim Director of Nursing (DON) stated the Psychiatric Nurse Practitioner(PNP) was at the facility ,[DATE] times weekly. She stated if Resident #69 was experiencing any mood or behavior concerns, it was her expectation that he received a referral for a Psychiatric evaluation. During an interview on [DATE] at 10:35 AM, the Social Worker (SW) stated she completed the cognition, mood and behaviors section on Resident #69's admission MDS dated [DATE] and she did not note and concerns in those areas. The SW stated that staff had not reported any cognition, mood or behaviors concerns and she did not read his nursing notes. During an interview on [DATE] at 11:50 AM, the PNP stated she was asked to evaluate Resident #69 earlier this morning and that he was tearful during the evaluation and he stated he felt unloved. The PNP stated she changed his antidepressant and added a medication for [MEDICAL CONDITION] and planned to continue to see Resident #69. During an interview on [DATE] at 3:30 PM, Nursing Assistant (NA) #10 stated Resident #69 was very inpatient and had stated he felt unloved but he never cried in front of her. She stated she did not report how Resident #69 felt to anyone. During an interview on [DATE] at 3:35 PM, Nurse #14 stated Resident #69 was very needy and inpatient with frequent episodes of yelling out for staff to come and fed him or bring him a snack. She stated Resident #69 can feed himself. She stated she did not report how he was feeling to anyone but documented any behaviors in his nursing notes. During an interview on [DATE] at 8:45 AM, Nurse #3 stated she had never seen Resident #69 crying, but he had expressed feelings of being upset that his kids had not come to see him and that nobody cared about him. She stated she did not report how he was feeling to anyone but documented the behaviors of Resident #3 yelling rather than using his call bell and him saying he could not feed himself insisting that staff feed him. She stated she was not aware of any reason Resident #69 could not feed himself. She stated it seemed unusual for him to request to be fed. During a telephone interview on [DATE] at 3:45 PM, Physician #2 stated he was not aware of the mood and behaviors issues exhibited by Resident #69 and he expected Resident #69 receive a Psychiatric evaluation if he was experiencing any mood or behaviors concerns. He stated Resident #69 was a very sick man and recently was discharged from the hospital after a very prolonged stay. During an interview on [DATE] at 5:50 PM, the Administrator stated it was her expectation that the staff would have identified and notified Physician #2 about his behaviors, expressions of feeling unloved and that nobody cared for a possible Psychiatric evaluation. 2. Resident #2 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan for Resident #2 was initiated on [DATE] by the Social Worker (SW) and included, in part, the focus area of a Preadmission Screening and Resident Review (PASARR) level 2 related to his [DIAGNOSES REDACTED]. This A psychotherapy note dated [DATE] indicated an initial visit was made with Resident #2. This note indicated that psychotherapy was to be continued with Resident #2 as needed. Resident #2' s care plan was updated on [DATE] with the initiation of a focus area for risk of complications related to the use of [MEDICAL CONDITION] medications. The interventions included, in part, monitor for side effects. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had a PASARR level 2 related to serious mental illness. His cognition was assessed as intact and he had no reported issues with his mood. Resident #2 had verbal behaviors and rejection of care on 1 to 3 days during the MDS look back period. He received antipsychotic medication and antidepressant medication on 7 of 7 days. Resident #2 ' s care plan was updated on [DATE] with the addition of a focus area for the potential for physical behaviors related to ineffective coping. The interventions included, in part, monitor the nature and circumstances of the physical behaviors. Resident #2 ' s care plan was updated on [DATE] by the SW with the initiation of the focus area for exhibiting/or at risk for distressed/fluctuating mood symptoms related to anxiety/fear. The interventions included, in part, monitor for signs/symptoms of worsening anxiety/fear and monitor for signs and symptoms of worsening anger/agitation. A Nurse Practitioner note dated [DATE] indicated Resident #2 reported feeling anxious. A physician's order [REDACTED]. This order was handwritten by the physician on a hard copy physician's order [REDACTED]. An NP note dated [DATE] indicated Resident #2 reported feeling anxious. The NP indicated Resident #2 was referred for psychotherapy. An NP note dated [DATE] indicated Resident #2 again reported feeling anxious. The NP note indicated she was going to refer Resident #2 for an evaluation with the Psychiatric Nurse Practitioner (PNP). A physician's order [REDACTED]. This order was located in two locations: (1) hard copy physician's order [REDACTED].#13. A review of the medical record revealed Resident #2 was not seen by the PNP for an initial psychiatric evaluation after the [DATE] physician's order [REDACTED]. An interview was conducted with the SW on [DATE] at 3:42 PM. The SW indicated she was familiar with Resident #2 and was aware he had a level 2 PASRR, was on [MEDICAL CONDITION] medications, exhibited behaviors, distressed mood, anxiety, and fear. She was asked what her responsibilities were for ensuring a resident with the previously mentioned mental health and behavioral issues received appropriate psychiatric services. The SW stated that she was not involved with the referral process for psychiatric services. She explained that she thought the nurses on the halls placed any psychiatric referrals in a hard copy book located at the nurse ' s station. She was asked if she had any knowledge of what psychiatric services Resident #2 had received. She reported that Resident #2 had a psychotherapy visit shortly after his admission and she thought he had seen the PNP as well. She was unable to explain why Resident #2 had not been seen for psychotherapy after the initial visit ([DATE]) until [DATE]. She was additionally unable to explain why Resident #2 ' s initial psychiatric evaluation with the PNP ([DATE]) was conducted over 3 months after his admission ([DATE]). An interview was conducted with Nurse #13 on [DATE] at 3:45 PM. She stated that the hall nurses placed referrals for psychiatric services in a hard copy book. She indicated this was the only way for the psychiatric provider to know what residents they were supposed to see. The electronic order dated [DATE] for a referral to the PNP for Resident #2 was reviewed with Nurse #13. She confirmed that she had entered this electronic order. She revealed she was unable to recall if she placed this referral into the hard copy book for the psychiatric provider. An interview was conducted with the Corporate Nurse/former interim Director of Nursing (DON) on [DATE] at 3:42 PM. Resident #2 ' s [DATE] physician's order [REDACTED]. She was unable to explain why there was a delay in the obtainment of both psychotherapy and a psychiatric evaluation for Resident #2. A phone interview was conducted with the NP on [DATE] at 4:45 PM. He stated he just began working at the facility in mid-December (YEAR) on an interim basis as the other NP was out on leave. He indicated that as a medical provider, he expected referrals for psychotherapy and psychiatric evaluation by the PNP to be obtained within a business week. A phone interview was conducted with Resident #2 ' s physician/facility ' s Medical Director on [DATE] at 5:15 PM. He stated that he expected referrals for psychotherapy to be obtained within 1 week and referrals for psychiatric evaluation by the PNP to be obtained within 2 weeks. Resident #2 ' s [DATE] physician's order [REDACTED]. He indicated he was unaware that there was a delay with the obtainment of these referrals for Resident #2 and revealed this had not met his expectations. An interview was conducted with the current Administrator on [DATE] at 6:10 PM. She stated it was her expectation that orders for psychiatric services to be obtained within 1 to 2 weeks if routine and as soon as possible for emergent needs. 3. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #16 ' s quarterly Minimum (MDS) data set [DATE] revealed documentation that the resident was sometimes understood and sometimes understands. Cognition was intact. The resident required total dependence for all transfers including toileting, and extensive assistance for bathing and dressing. The resident ' s active [DIAGNOSES REDACTED]. The resident received scheduled pain management. A review of Resident #16 ' s care plan dated [DATE] revealed the resident had goals and interventions for self-care deficit, verbal behaviors, poor impulse control, communication deficit, pain, and was at risk for [MEDICAL CONDITION] medication complication (intervention was to inform the physician of changes in mental status and functional level and to monitor for continued need for medication related to mood and behavior). A review of the resident ' s nurses ' notes from [DATE] to [DATE] revealed there was no documentation that the physician or nurse practitioner was informed of the resident ' s medication refusal and/or increased behaviors A review of the physician and nurse practitioner communication book for timeframe [DATE] to [DATE], which was stored at the nurses ' station, revealed there was no communication to the medical staff that the resident had frequently refused his medication and had increased behaviors. On [DATE] at 10:10 am an interview was conducted with Resident #16 who stated he had not seen the doctor in a long time. The resident voiced no concerns. On [DATE] at 9:30 am an interview was conducted with Nurse Assistant (NA) #14 who stated she was familiar and assigned to Resident #16. The resident had a history of [REDACTED]. NA #14 commented that lately his refusal of care and behaviors had increased. On [DATE] at 10:40 am an interview was conducted with Nurse #11 who stated that she was regularly day-shift assigned to Resident #16. Nurse #11 commented that the resident had lately more frequently refused his medication and had increased verbal behaviors with refusal of care. Nurse #11 agreed that the resident ' s refusal to take his [MEDICAL CONDITION] medication placed him at risk for increased behaviors and depression. Nurse #11 was not aware that the psychiatric service had not seen the resident since (MONTH) of (YEAR). On [DATE] at 3:10 pm an interview was conducted with the facility psychiatric nurse practitioner (PNP) who stated she saw Resident #16 months ago and has not seen him since returning to the facility recently. The PNP had planned on continuing services for the resident but her psychiatric services were suspended for several months. The PNP had increased the resident ' s [MEDICATION NAME] for depression in (MONTH) (YEAR) and would have seen the resident (MONTH) (YEAR) if the services were not suspended. The PNP stated that since return she had seen the urgent residents first and those placed in her communication book at the nurses' station. The PNP stated she had not had time to see Resident #16 since she returned to the facility a couple of months ago. The PNP also stated that staff had not informed her verbally or in writing that Resident #16 had refused his medication, including [MEDICAL CONDITION] medication, and had increased behaviors. The PNP could not recall the dates of psychiatric services suspension and requested the time frame be obtained from Administration. On [DATE] at 4:30 pm an interview was conducted with the Administrator who stated that the psychiatric nurse practitioner services were suspended for several months but could not provide the exact dates and did not know why there was a suspension. The Administrator was new to the facility and was not present during the suspension. On [DATE] at 5:00 pm an interview was conducted with Resident #16 ' s physician who stated he was not informed that the resident repeatedly refused his medication and had increased behaviors and that the psychiatric nurse practitioner had not evaluated the resident since (MONTH) (YEAR). The physician stated he expected to be informed by staff if a resident needed and had not received psychiatric care. The physician commented he would see the resident on his next visit to the facility.

Based on observation, medical record review, resident and staff interviews, the facility failed to prevent staff to resident abuse for one of three residents reviewed for abuse. Resident #1 sustained bruising and pain when a staff member transferred her from her wheelchair to her bed by grabbing her wrists. Resident #1 was physically abused when a nursing assistant physically placed her into bed against her wishes which resulted in the resident experiencing bruises to her left upper arm, top of left hand, right elbow, and right upper arm and pain. The findings included: Resident #1 was admitted to the facility 9/25/17. Cumulative [DIAGNOSES REDACTED]. A care plan originally dated 12/24/17 and last reviewed on 6/25/18 indicated Resident #1 was at risk for injury or complications related to the use of anticoagulation therapy. Interventions included, in part, anticoagulants given as ordered. Labs as ordered. Observe for complaints of pain of bone, abdomen or joint. Observe for active bleeding, i.e. hematuria, bruising, etc. A care plan dated 4/1/18 and last reviewed on 6/25/18 stated Resident #1 exhibited or was at risk for bruising/skin tears as evidenced by frail fragile skin. Interventions included, in part, observe skin condition daily with ADL (activities of daily living) care and report abnormalities. A quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact. She required extensive assistance of one person for bed mobility and two-person assist with transfers and toilet use. A review of physician orders [REDACTED].#1 had orders for [MEDICATION NAME] (corticosteroid) 5 milligrams by mouth daily and [MEDICATION NAME] (anti-blood clotting medication) 75 milligrams by mouth daily. A skin assessment dated [DATE] revealed Resident #1 had a skin tear on the left medial shin/calf area. No bruises were noted. A twenty-four-hour facility reported incident report dated 7/12/18 at 12:52 PM stated the facility was made aware of the incident on 7/12/18 at 10:40 AM. The incident date was 7/11/18. Resident #1 stated Nursing Assistant (NA#3) hurt her while putting her to bed on 7/11/18. Bruises were noted to the left upper arm, top of left hand, right elbow, and right upper arm. Additions/ changes/ updates added to the facility reported incident stated, per Resident #1, she told NA#3 when she approached her that she did not want to go to bed, but the aide proceeded to grab her arm to put her in bed. The resident told the aide Stop, you ' re hurting me and I ' m going to have a big bruise tomorrow. She stated the aide replied, I ' m not hurting you and proceeded to place her in bed turning her fast and hard. Resident #1 was tearful about the incident but easily comforted. NA #3 was terminated 7/18/18. The allegation was substantiated. Other employment actions: alleged perpetrator—NA#3 was suspended pending investigation. Training was initiated immediately to refresh staff on proper technique for a gait belt transfer of resident. Corrective actions taken-- NA#3 was suspended. Abuse training initiated immediately. Training initiated to refresh staff on proper technique for a gait belt transferring of residents. Will report to the board of nursing. Alert and oriented residents were questioned to rule out alleged abuse. Cognitively impaired residents had skin checked. Other staff questioned. Pain evaluation, skin check and change in condition of involved resident. Law enforcement was notified on 7/12/18 at 12:35 PM. A review of the police report dated 7/12/18 revealed no charges were filed. A skin assessment dated [DATE] at 10:40 AM revealed the following: bruising to the bilateral upper extremities with a bruise on the left upper extremity that measured 10 centimeters (cm) x 10.5 cm, the left hand 6.5 cm x 6.5 cm and the right upper arm that measured 2 cm x 2 cm. A change in condition form dated 7/12/18 stated bruising was noted to the left upper arm, top of left hand and right upper arm. The back of the left-hand ecchymosis (bruised area) area measured 6.5 cm x 6.5 cm; right elbow discoloration 3.5 cm x 2 cm; left upper arm ecchymosis area 10 cm x 10.5 cm. right upper arm ecchymosis 2 cm x 2cm. with Resident #1 noting pain in left upper arm. A Lift transfer repositioning evaluation form dated 7/13/18 stated Resident #1 could weight bear and stand consistently for a stand to pivot transfer. A gait/ transfer belt was required for transfers. The evaluation did not specify one or two -person assist. A review of NA#3 ' s employment record revealed she was hired on 5/15/18 and received abuse training on 5/18/18. An x-ray report dated 7/13/18 stated the following: Conclusion: x-rays were completed for the left elbow joint, left forearm, left hand and wrist, left shoulder and left humerus with no fracture or other significant bone or joint abnormality noted. As part of the investigation, the Social Worker conducted an interview with Resident #1 on 7/12/18 at 10:40 AM. The interview was part of the witness investigation statements. Resident #1 stated that last night (7/11/18) a nursing assistant came into her room and told Resident #1 that she was going to put her to bed. Resident #1 said she told the nursing assistant that she didn ' t want to go to bed. However, the nursing assistant insisted that she was told to put her to bed and she was going to proceed with putting her to bed. Resident #1 reported that the nursing assistant grabbed her arm to transfer her to the bed and the resident yelled out Let go of me. You are hurting me. Resident #1 stated the nursing assistant responded, I ' m not hurting you. The resident resounded You are hurting me and I ' m going to have a big bruise on me tomorrow. Resident #1 said the nursing assistant continued to get her ready for bed and proceeded to change her brief. Resident #1 included She turned me so fast and hard. I thought I was going to roll out of bed. When asked to describe the nursing assistant, the resident gave a description and name of NA#3. Resident #1 was noted to be cognitively intact at the time of the interview. On 7/31/18 at 9:40 AM, an interview was conducted with Resident #1. When asked about the incident that occurred the evening of 7/11/18. She was unsure of the exact time, but it was nearing bedtime. She said she told NA#3 that she wasn ' t ready for bed. NA#3 grabbed her by both wrists, got her out of her wheelchair and put her on the bed. Resident #1 stated NA#3 was rough anyway and she told her that she was hurting her. After she was in bed, she told NA#3 that she hurt her arm. NA#3 was not her regular nursing assistant. Resident #1 said her roommate was in the room but was asleep at the time the incident occurred. A witness statement given by NA #3 dated 7/12/18 at 11:10 AM was reviewed. NA #3 stated she did not remember taking care of Resident #1 on 7/11/18. She said she helped everyone even if they were not on her assignment and might have helped Resident #1 to bed. NA#3 stated she was very gentle with all residents and she did put a few to bed. NA#3 stated she remembered seeing bruises on Resident #1 ' s arm several days ago but did not report it to the nurse. NA#3 stated she helped Resident #1 a lot, felt like this was a conspiracy and that the nurse told Resident #1 to say NA#3 was the one who bruised her. On 8/2/18 at 10:32 AM, a telephone interview was conducted with NA #3. She said she was nice to her residents and very [MEDICATION NAME] and caring. When asked about the incident with Resident #1 on 7/11/18, she said Resident #1 was not on her assignment and she did not put her to bed that night. NA#3 added that she had put her in bed in the past but needed to use 2 people and she didn ' t do anything wrong. A witness statement given by NA#2 via telephone dated 7/12/18 at 4:40 PM was reviewed. NA#2 stated she provided care for Resident #1 on evening shift (3:00 PM—11:00 PM) on 7/11/18 but did not put her to bed that evening. NA#2 said she was running behind and asked NA#3 to put Resident #1 to bed. She said she did not see Resident #1 after that since it was 10:30 PM. NA#2 stated she asked NA#3 how it went and she said fine. On 7/31/18 at 5:01 PM, an interview was conducted with NA#2 and she stated that Resident #1 was on her assignment on 7/11/18. She stated Resident #1 used her call bell to notify staff of her needs. NA#2 stated Resident #1 needed assistance to change her brief, transfer to the bed and get dressed. She said she asked Resident #1 what time she wanted to go to bed on 7/11/18 and Resident #1 wanted to go to bed between 9:30 PM--10:00PM. NA#2 stated, during the evening of 7/11/18, NA#3 was helping her and said she would assist with putting Resident #1 into bed. She indicated it was around 9:45PM—10:00 PM. NA#2 stated she did not see Resident #1 after she was put into bed by NA#3. On 7/31/18 at 4:10 PM, an interview was conducted with the Center Nurse Executive. She stated Resident #1 did not tell anyone about the incident until 7/12/18. When Resident #1 got up on 7/12/18, she went around and told everybody that NA#3 had been rough with her and put her to bed when she didn.t want to go to bed and NA#3 caused bruises to her left arm. She told the Activity Director who brought her to the Center Nurse Executive ' s office, the Administrator and gave her whole statement to the Social Worker regarding the incident that occurred on 7/11/18 related to the bruises and not letting her go to bed when she wanted. The Center Nurse Executive said she suspended NA#3, obtained interviews from the alert and oriented residents on NA #3 ' s assignment and nursing staff performed skin checks on the remainder of nursing assistants on NA #3 ' s assignment. The investigation concluded the incident did occur on 7/11/18 and NA#3 was terminated. On 7/31/18 at 4:48 PM, an interview was conducted with Nurse #1 who worked on 7/11/18 during the evening shift. She stated she was not aware of the incident with Resident #1and NA#3 until 7/12/18 when the Center Nurse Executive called her. She said she was on the hall providing care and administration of medications until around 11:00PM—11:15 PM on 7/11/18 and did not hear any screaming, no disruption. When she came in to talk to the Center Nurse Executive on 7/12/18, Resident #1 asked her didn ' t she hear her screaming? She said she did not hear anything out of the ordinary on 7/11/18 and did not hear Resident #1 screaming. On 8/1/18 at 11:35 AM, a second interview was conducted with the Center Nurse Executive who stated all facility staff should be educated regarding choices and abuse and that all resident ' s choices be honored. All residents should be free from abuse and abuse would not be tolerated at the facility.