Every finding on record at Autumn Care of Marion

Based on observation, record review, and interviews with Guardian, witnesses, resident, Psychiatric Provider, Nurse Practitioner (NP), and staff, the facility failed to provide the necessary supervision to prevent Resident #1 from exiting the facility unsupervised and without staff's knowledge through one of two doors that did not alarm when opened. Resident #1 was at risk for falls, her diagnoses included dementia, and she had been identified with a decline in cognition with signs of increased confusion and disorientation in the months prior to March 2026. Staff reported these signs included getting lost in the hallways, not being able to figure out how to get back to her room and forgetting that she required supervision to smoke. On 3/2/26 around 10:00 AM an unknown individual found Resident #1 outside of the facility in her wheelchair on the opposite side of the road as the facility, in the roadway, trying to self-propel up the road. Staff were unaware the resident had left the facility without supervision. In addition, not all staff were aware Resident #1 had exited the facility to understand the need for heightened awareness for her safety and whereabouts. Resident #1 was not injured; however, there was a high likelihood of serious harm, injury, or death with risks that included getting lost, falling with an inability to get out of harm's way, and/or getting hit by a car. Additionally, the facility failed to ensure staff were aware of Resident #1's unsupervised exit. The deficient practice affected 1 of 3 reviewed for accidents.Immediate Jeopardy began on 3/2/2026 when Resident #1 exited the facility unsupervised and without staff's knowledge. Immediate Jeopardy was removed on 3/5/2026 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure all staff and providers are aware of the elopement, education is completed and monitoring systems put into place are effective.The findings included:Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) following cerebral infarction, anxiety and depression.The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was [AGE] years old and cognitively intact. She had age related nuclear cataracts (a slow-developing, common eye condition where the center [nucleus] of the eye's lens gradually hardens and yellows, causing blurry vision) and her vision was assessed as adequate with corrective lenses. Resident #1 had no functional limitations with range of motion and she utilized a wheelchair. She required partial/moderate assistance with upper body dressing and substantial/maximum assistance with lower body dressing, putting on/taking off footwear, and transfers. She was independent with self-propelling her wheelchair.The active care plan as of 3/1/26 revealed Resident #1 was care planned for requiring supervised leave of absences and her mental function varied over the course of the day related to medical conditions. Resident #1's care plan also included the risk for decreased/ impaired vision and the risk for falls secondary to decreased mobility, abnormal gait, muscle weakness. There were no interventions documented for the for care planned problem areas.Resident #1's active physician orders as of 3/1/26 included Namenda (used to treat moderate to severe dementia) 5 milligrams (mg) two times a day.An interview with Nurse #2 was conducted on 3/24/26 at 1:57 PM. Nurse #2 reported that Resident #1 has had a decline the last couple of months prior to March 2026 with increased episodes of confusion and increased anxiety, as well as several urinary tract infections beginning sometime in January 2026. Nurse #2 explained that Resident #1 would get lost in the hallways some days and could not figure out how to get back to her room. She further explained that the resident would forget she required supervision when she went out to smoke. Nurse #2 reported that Resident #1 was changed from independent to supervised smoking in late January due to her not being able to hold the cigarette well. Nurse #2 reported she was not aware of any changes to Resident #1's supervision except with smoking. An interview with Nurse #3 on 3/24/26 at 12:54 pm revealed she had been caring for Resident #1 for about five years and knew her pretty well. Nurse #3 reported that Resident #1 had been declining over the last several months prior to March 2026. She indicated the resident had been seen by the psychiatric provider and the Nurse Practitioner (NP) and her dementia medications had been adjusted. Nurse #3 went on to say that Resident #1 would get confused and disoriented while moving down the hallway and would become anxious and have to be redirected. Nurse #3 reported that it had become more difficult to redirect Resident #1 in the last several weeks. Nurse #3 explained that in several instances Resident #1 did not remember she now required supervision to smoke and would become angry when she asked to go out and the staff had to remind her she had to wait for someone to take her. Nurse #3 reported that Resident #1 was changed from independent to supervised smoking in late January due to her not being able to hold the cigarette well. During an interview with Nurse Aide (NA) #1 on 3/24/26 at 1:14 PM she stated that Resident #1 had become more confused over the last several months, had episodes of increased anxiety, and became more difficult to redirect. NA #1 indicated that Resident #1 would often become disoriented when she was out on the halls and when she (NA #1) would attempt to redirect her the resident became upset. NA #1 reported she had made the nurse responsible for Resident #1 aware anytime she noticed a change in Resident #1, she stated she did not remember which nurses she told. A progress note written by the Director of Nursing (DON) on 3/2/26 at 10:30 AM indicated Resident #1 attempted elopement and was intercepted. The resident continually stated, I just want to go home. The DON indicated reorientation to the resident's situation was attempted without success. The Psychiatric Provider was in the facility and assessed the resident. The Nurse Practitioner (NP) was also in the facility and assessed the resident with new orders given. A wanderguard (electronic wander management bracelet) was placed on Resident #1 for safety and her guardian was made aware. The note indicated Resident #1 had never attempted to show any signs that she would attempt elopement. An interview with the DON on 3/24/2026 at 2:58 PM revealed on the morning of 3/2/2026 management staff were in the morning meeting and Witness #2 came into the conference room telling them a resident was outside. He reported that the staff in the morning meeting immediately left the conference room to locate the resident. The DON stated that they (staff) were all shocked when they discovered it was Resident #1, as this was not normal for her. He reported that when they found Resident #1, she was on the road just past the gravel parking lot. He stated Resident #1's mentation was altered, she was what I would describe as manic. He reported that it was difficult to make the resident understand the danger she was in on the road and why she needed to return to the facility. The DON reported Resident #1 was difficult to convince to come back to the facility, as she kept attempting to propel herself via wheelchair further up the hill on the road stating she needed to go and take care of her son. He indicated they were able to get Resident #1 back to the facility and the Psychiatric Provider was in the facility, so he asked her to assess Resident #1. The DON stated that during the assessment Resident #1 was not making a lot of sense and referred to her adult son as a baby. The DON revealed that he was aware Resident #1 had experienced a decline over the last several months and had several medication changes. He explained that Resident #1 had become more confused and had been changed from an independent to supervised smoker back in January due to the increased confusion. He reported that when Resident #1 was returned to the facility on 3/2/26 he asked Nurse #4 to place a wanderguard on Resident #1 and do an elopement assessment. The DON stated he told Nurse #4 to use the progress note he completed (completed by the DON on 3/2/26 at 10:30 AM) as a resource to complete the elopement assessment. The DON was unable to explain why he wrote in the progress note that Resident #1 attempted elopement and was intercepted by staff. The DON reported that Resident #1 did elope and was found down the road below the gravel parking lot. He reported that he felt sure he had verbally reported to all staff that Resident #1 had actually left the facility and went down the road and had not just attempted elopement. He revealed he did not keep track of the staff he verbally reported this information to. He reported that he felt that it was important for all staff to know that Resident #1 had actually left the building and went down the road and not that she just attempted to elope because an attempt to elope is a lot less dangerous than an actual elopement. The DON spoke about how Resident #1 exited the facility on 3/2/26. He indicated it was determined that Resident #1 exited out the side door of the facility. He explained that the side door of the facility and the front door of the facility were the only two exterior doors that did not alarm when opened. He further explained that the side door had a wanderguard alarm on it only prior to Resident #1's unsupervised exit on 3/2/26 and Resident #1 did not have a wanderguard in place until after the unsupervised exit. The DON indicated the side door was the only door that could not be easily visualized by the receptionist. An observation of the facility was conducted on 3/24/26 at 4:30 PM. The facility was a one-story construction that visitors could enter via the paved or the gravel parking lot. Immediately outside of the side door of the facility was an approximately 50-foot wheelchair ramp that led by the side of the front porch to the front of the facility and into the main paved parking lot of the facility. At the end of the wheelchair ramp to the right led to a paved hill that was used to enter and exit the paved parking lot. The entrance/exit to the paved parking lot had ditches filled with six-to-eight-inch jagged rocks and led out into a well-traveled main road that had a posted speed limit of 35 miles per hour and had blind curves on each side of the facility's driveway, which made it difficult to see any oncoming traffic. To the left of the wheelchair ramp led back to the front of the facility. Straight ahead of the wheelchair ramp led across the paved parking lot and into a gravel parking lot of the facility. Resident #1 was found on the opposite side of the road from the facility on the two-lane roadReview of weather data from Weather Underground for 3/2/26 at 10:00 AM revealed the recorded temperature was 56 degrees Fahrenheit with light winds and no precipitation. Review of google earth revealed that there was 47 feet from the side door of the facility to the end of the wheelchair ramp, 157 feet from the end of the wheelchair ramp to the main road and 258 feet from facility parking lot to where Resident #1 was found. The slope out of the parking lot was 8.9 degrees. An interview with Assistant Director of Nursing (ADON) #1 revealed that on the morning of 3/2/26 management staff were in the conference room for morning meeting when Witness #2 came into the room and reported that a resident was out on the road. ADON #1 reported that everyone in the room went out to find the resident. She indicated that when they found Resident #1 she was just past the gravel parking lot and was on the opposite side of the road from the facility, in her wheelchair, in the road. ADON #1 stated Resident #1 was upset, not easy to console, and was adamant that she must continue down the road and not go back to the facility when staff got to her. She reported Resident #1 was stating she wanted to go home to see her son. ADON #1 reported they wheeled Resident #1 back into the building, assessed her and she began to calm down. ADON #1 recalled that Resident #1 did not have any injuries. ADON #1 reported Resident #1 had not indicated in the past that she wanted to leave the facility. ADON #1 stated Resident #1 had experienced a decline over the last several months prior to 3/2/26 and was not safe to be outside without supervision. A telephone interview with Witness #1 on 3/24/26 at 2:00 PM revealed that on the morning of 3/2/26 she was on the front porch of the facility and remembered seeing Resident #1 coming down the ramp beside the front porch of the facility and observed her go out into the paved parking lot in front of the facility. Witness #1 reported she assumed the resident was going outside to enjoy the morning. Witness #1 reported she (Witness #1) continued into the facility to get her family member who she was visiting and came back out to the porch where they were joined by Witness #2. Witness #1 stated she didn't remember seeing Resident #1 when she returned to the front porch of the facility. Witness #1 reported there may have been five to eight minutes between her seeing Resident #1 and when another visitor came to the porch to tell Witness #2 and her (Witness #1) that someone (Resident #1) was in a wheelchair down the road. Witness #1 stated that Witness #2 went inside to tell the staff about Resident #1 being in the road. Witness #1 reported that a lot of the staff came out of the facility and went down the road, and a few minutes later came back pushing Resident #1 in her wheelchair. A telephone interview with Witness #2 on 3/24/26 at 1:49 PM revealed she was sitting on the front porch of the facility on 3/2/26 around 10:00 AM with Witness #1 and someone, who Witness #2 assumed was a family member of another resident, came up onto the porch and told her there was a lady in her wheelchair across the road heading up around the curve. Witness #2 reported she went inside the facility and when she saw no one at the front desk she went to the conference room to let the staff know that Resident #1 was out in the road in her wheelchair. Witness #2 reported all the staff in the conference room went out to get Resident #1 and she observed a passerby standing with Resident #1 on the opposite side of the road down past the gravel parking lot. An interview with Nurse #2 conducted on 3/24/26 at 1:57 PM revealed she was at the morning meeting with all department heads on 3/2/26. She reported that on the morning of 3/2/26 she was sitting on the side of the table in the conference room where she could see out the windows into the hallway. She stated she saw Resident #1 come down the hall self-propelling in her wheelchair around 10:00 AM, which was not unusual for Resident #1 as she frequently visited the front desk. Nurse #2 reported that several minutes later Witness #2 came into the conference room and said Resident #1 was outside. Nurse #2 stated everyone in the conference room ran out to get Resident #1. She stated the resident was found just past the gravel parking lot area, on the opposite side of the road as the facility in the roadway trying to self-propel herself via wheelchair up the road. Nurse #2 reported there was a passerby outside with the resident trying to get her out of the road when she (Nurse #2) arrived. Nurse #2 did not know who the passerby was. An interview with NA #1 on 3/24/26 at 1:14 PM indicated she was familiar with the elopement on 3/2/26 involving Resident #1 and was her assigned aide on that day. NA #1 revealed Resident #1 was sitting at the nurse's station around 9:30 AM on the morning of 3/2/26. NA #1 reported that was Resident #1's normal routine as she waited at the nurse's station for someone to take her out to smoke. NA #1 stated that a while later she noticed Resident #1 was no longer at the nurse's station. She was unable to recall the time but reported she was still doing morning rounds so it was sometime before 10:30 AM. She indicated the next time she saw Resident #1 she (the resident) was being pushed down the hall in her wheelchair by the DON. NA #1 reported she was made aware by one of the nurses, she could not recall which one, that Resident #1 had attempted elopement from the facility but didn't succeed. NA #1 stated she was not aware through present date that Resident #1 had gotten out of the building and went down the road. NA #1 reported she was not aware of any other occasions where Resident #1 had tried to elope, and Resident #1 had never said anything to her about wanting to leave or needing to care for her adult son. During an interview on 3/24/26 at 10:50 AM with Resident #1 she stated she left the building in her wheelchair (on 3/2/26) and went down the hill of the paved parking lot and up the road. She reported she did not go through the gravel parking lot because she knew she could not push her wheelchair through the gravel. Resident #1 stated she was wearing a sweatshirt, long pants, socks and shoes, and her toboggan (winter hat). Resident #1 reported she felt like something was wrong with her adult son and she needed to be the one caring for him. Resident #1 indicated she wasn't sure why she felt she needed to leave on 3/2/26 to go take care of her son, she just felt like her son needed her and she should be the one caring for him. She stated she did not let anyone know that she was leaving the facility and was unsure why she didn't tell anyone. Resident #1 indicated she had gotten out to the road via wheelchair and had passed the gravel parking area when two people, who she thought were from the nearby church, stopped her and told her they were afraid she was going to get hit by a car. Resident #1 reported she didn't remember where those people went, she reported she thought they stayed there with her until the Administrator and DON got there. Resident #1 stated that the Administrator and DON came and got her and brought her back to the facility. She stated she liked it at the facility but was concerned about her adult son and who was taking care of him.During a follow-up interview on 3/24/26 at 5:03 PM with Resident #1 she stated she did not have a cell phone to call for help on 3/2/26 if she needed it and was not wearing a coat because she did not think she needed a coat.An interview was conducted with Resident #1's State Appointed Guardian on 3/24/26 at 10:04 AM. The Guardian reported that she had been made aware by the facility that Resident #1 had been having increased confusion and increased anxiety prior to March 2026. She reported she had noticed Resident #1 was repeating herself a lot during their visits and was more concerned about the well-being of her adult son. The Guardian reported that these changes had led her to begin the process of filing for full guardianship. She explained that full guardianship gave her the ability to make all decisions regarding personal, care, residence, medical treatment and financial affairs for Resident #1. She further explained that at the time of the 3/2/26 incident she had limited guardianship which gave the guardian limited power only in areas where the person could not make decisions. Resident #1's State Appointed Guardian reported that she obtained guardianship over Resident #1 because the resident had not demonstrated the ability to make sound decisions, and there was no family member who could make sound decisions on Resident #1's behalf. Resident #1's State Appointed Guardian reported that Resident #1 had a son that was blind and Resident #1 had previously been his primary caregiver and the Guardian believed that this contributed to Resident #1 wanting to leave the facility on 3/2/26. Interview with Nurse #4 on 3/24/26 at 12:57 PM revealed she was asked by the DON and the ADON #1 on 3/2/26 to put a wanderguard on Resident #1. Nurse #4 reported the DON also asked her to fill out an elopement assessment on Resident #1 on 3/2/26, and to read his 3/2/26 progress note about the attempted elopement for the information she would need to complete the assessment. Nurse #4 stated the progress note did not have a location as to where Resident #1 was found. She explained that she made the DON aware that the progress note did not include a location and the DON stated he would complete that part of the assessment. Nurse #4 reported she spoke with Resident #1 before completing the assessment on 3/2/26 and Resident #1 stated she wanted to go home and take care of her son. Nurse #4 reported that Resident #1 was crying and repeating she was sorry for leaving when Nurse #4 spoke to her. Nurse #4 stated she was not given any details on the elopement or attempted elopement of Resident #1 by the DON or by Resident #1. Nurse #4 reported she did not know through present date (3/24/26) that Resident #1 had left the building on 3/2/26. She explained that the progress note completed by the DON led her to believe it was an attempted elopement and the resident had been intercepted by staff. An interview with Nurse #5 on 3/24/26 at 12:41PM indicated she had given Resident #1 her medications between 7:45 and 8:00 AM on the morning of 3/2/26 and she noted no concerns with Resident #1 at that time. She reported Resident #1 was in her room in her wheelchair at the time and she was dressed. Nurse #5 reported the next time she saw Resident #1 was at approximately 11:00 AM when Nurse #4 was putting a wanderguard bracelet on her. Nurse #5 reported the DON and Assistant Director of Nursing (ADON) #1 explained to Nurse #5 that Resident #1 had attempted to leave the facility. Nurse #5 reported that to present date (3/24/26) she had not been made aware that Resident #1 had left the building. Nurse #5 stated Resident #1 had never told her (Nurse #5) that she wanted to leave the facility and had never expressed needing to leave to care for her adult son. A Psychiatric Provider note dated 3/2/26 indicated Resident #1 was seen for psychiatric follow up due to staff request. Per the DON, Resident #1 attempted elopement, and was intercepted by staff. Resident #1 was continually stating I just want to go home. The DON stated Resident #1 was placed on every 15-minute checks for 24 hours due to attempted elopement. Per the DON, Resident #1 had no prior history of exit seeking behavior. Resident #1 was followed for a known history of depression, anxiety, and a recent diagnosis of dementia. Per staff, Resident #1 had ongoing confusion. Resident #1 was a fair historian. Resident #1 was assessed after attempted elopement and she stated, I just wanted to go home. Staff discussed with resident she was not safe to go home and needed help with activities of daily living. Resident #1 stated I know, I know I can't go, there's no one to take care of me. She then repeated, I just want to go home. She stated, I need to care for my child, he needs me, it should be me taking care of him. Resident #1 was referring to her grown son who had impaired vision. She stated they were good to her at facility, but she did not like being away from home. When asked if there was any trigger or inciting event, Resident #1 initially stated no. She later stated she was upset that she could not go outside and smoke when she wanted to. Resident #1 was a supervised smoker. The resident stated, I know I shouldn't have done that; I won't do it again. The Psychiatric Provider indicated she discussed Resident #1 with the NP who stated she was ordering a head computed tomography scan (CT scan) to evaluate for possible CVA (cerebrovascular accident) or vascular changes due to history of past CVA. Also discussed increasing Namenda for dementia. Resident #1 now had a wanderguard in place. An interview with the Psychiatric Provider on 3/24/26 at 2:12 PM revealed she was at the facility on 3/2/26 when it was reported to her that Resident #1 had attempted to leave the facility and was intercepted by staff. The Psychiatric Provider revealed that to present date (3/24/26), she did not recall anyone reporting to her that Resident #1 actually left the building. The Psychiatric Provider reported the staff had already interviewed the resident prior to her assessment on 3/2/26, however, during the interview with the Psychiatric Provider the resident told her a very different story than what she had told the facility staff. The Psychiatric Provider could not remember the details of what Resident #1 told her. The Psychiatric Provider stated that it was out of the ordinary for Resident #1 to attempt to leave the facility and she found Resident #1 to be very confused and tearful on 3/2/26. The Psychiatric Provider indicated Resident #1 had been treated for a UTI, so she assumed that played a part in her disposition on 3/2/26, although she was not being treated for an active infection. The Psychiatric Provider reported Resident #1 had been experiencing increased confusion and depression over the last three months prior to 3/2/26 and her Cymbalta (a medication used to treat depression) had been increased. The Psychiatric Provider indicated that she has had no further concerns with Resident #1 since 3/2/26. Interview with the NP on 3/24/26 at 1:50 PM revealed she was made aware on 3/2/26 that Resident #1 had gotten out of the building on the morning of 3/2/26 and someone found her outside in the gravel parking lot. The NP reported she had had no concerns about Resident #1 leaving the facility prior to 3/2/26. The NP indicated Resident #1's cognition had been declining, which included increased confusion and depression, and she had been treated for several UTI's in the last three months prior to 3/2/26. The NP stated she had consulted with the Psychiatric Provider after the elopement and increased Resident #1's Nameda (a medication used to treat dementia). The NP indicated that after the elopement she also ordered a CT scan and it did show Resident #1 to have encephalomalacia, (softening of the brain tissue consistent with dementia). The NP reported she spoke with Resident #1 after the incident on 3/2/26 and the resident was apologetic for leaving but could not tell the NP why she left, only that she wanted to go home. The NP reported she did not know who found Resident #1 or how long she had been outside the facility. The NP reported she had not had any new concerns since the incident on 3/2/26. The NP reported that due to Resident #1's increased confusion, decreased mobility and being wheelchair bound her risk of being outside the facility unassisted included turning the wheelchair over and sustaining an injury, getting lost, or kidnapped and/or being hit by a car. The NP stated Resident #1 should not have been outside unassisted. An interview with the Maintenance Director on 3/24/26 at 2:08 PM revealed he was unsure if the side door that Resident #1 went out of was locked during business hours prior to 3/2/26. He reported the door did not alarm when Resident #1 went out because it only had a wanderguard alarm on it and Resident #1 did not wear a wanderguard bracelet at that time. He reported that the only exterior door that did not have an alarm now was the front door. He reported that the front door was monitored all day by the front desk receptionist or a member of management and then was locked at 5:00 PM when the management staff went home. During an interview with Nurse #3 on 3/24/26 at 12:54 pm she reported that she had been off for several days prior to 3/2/26 and upon returning to work she was reading thru the recent progress notes of the residents in her care and found the progress note completed by the DON alerting her to Resident #1's attempted elopement. Nurse #3 revealed that to present date (3/24/26) no one had told her that Resident #1 had actually left the facility. An interview with the Administrator on 3/24/26 at 3:20 PM revealed that on 3/2/26 the morning meeting was being held in the conference room, and the meeting was about over when Witness #2 came into the room to let staff know that a resident was in the road. The Administrator reported that she and the staff were able to catch up to Resident #1 and that she was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator stated the staff were able to get Resident #1 back into the building. She reported that Resident #1 had never indicated that she wanted to leave the facility prior to 3/2/26 and the staff were surprised by this event. The Administrator explained that Resident #1 did worry about her blind son a lot and she (the Administrator) had discussed with Resident #1's guardian that the adult son lived right down the road with other family members. The Administrator indicated she was aware that Resident #1 had started having some increased confusion a few months ago and a lot of diagnostics were completed, such as labs and scans, as well as medication changes, but she was unsure what medications had been changed. The Administrator revealed that the Psychiatric Provider and the NP both were able to assess Resident #1 on 3/2/26. The Administrator reported that Resident #1 went out the side door of the facility and that prior to 3/2/26 the side door did not alarm unless there was a wanderguard close by. The Administrator further stated the Maintenance Director put an alarm on the side door that sounded anytime the door was opened on 3/2/26 after Resident #1 was returned to the facility and management also put signs out at the nurses' station to make the nursing staff aware of the alarm. The Administrator reported that a wanderguard was placed on Resident #1's ankle for safety. The Administrator stated she was not sure why all staff did not know that Resident #1 had actually got out of the building and she would need to speak to the DON about his progress note on 3/2/26 that indicated the elopement was attempted as she was unsure why the DON would have written that. The Administrator reported she felt that it was important for all staff to know that Resident #1 had actually left the building and went down the road and not that she just attempted to elope. She explained that an actual elopement presented much more danger than just an attempted elopement. The Administrator indicated that it was not safe for Resident #1 to be out of the facility unsupervised. The Administrator was notified of immediate jeopardy on 03/24/26 at 6:00 PM.The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; On 3/2/2026, Resident #1 experienced an unsupervised exit from the facility through a side exit door and was observed off facility property by a family member, which alerted staff. The resident was immediately returned to the facility without injury by the Administrator, Director of Nursing, and Assistant Director of Nursing. The Administrator and Director of Nursing (DON) conducted an immediate review of the incident on 03/02/2026. The Administrator and DON determined the root cause to be that the side exit door did not have an alarm system installed that alerted staff to any opening of the door at the time of the incident, which allowed Resident #1 to exit the facility without staff awareness.Immediately upon the resident's return to the facility on 3/2/2026, the following actions were taken:The Administrator and DON contacted Resident #1's guardian, primary care provider, and Medical Director on 3/2/2026.Resident #1's nurse completed a head-to-toe nursing assessment on 3/2/2026, and no injuries were noted.The Administrator and Director of Nursing (DON) interviewed Resident #1. During the interview, Resident #1 verbalized a desire to go home to care for her son. The Administrator reassured Resident #1 that her son is cared for by a full-time caregiver.The Director of Rehabilitation Services completed a Brief Interview for Mental Status (BIMS) assessment on 3/2/2026, with a score of 8/15 (a score of 8 indicates moderate cognitive impairment). Resident #1's nurse completed an elopement risk assessment on 3/2/2026, and Resident #1 was identified as high risk for elopement. At the time of[TRUNCATED]

Based on record review and staff and resident interview the facility failed to maintain a complete and accurate medical record when staff documented a resident attempted elopement and was intercepted by staff. This occurred for 1 of 3 residents (Resident #1) reviewed for accurate medical recordThe findings included:A review of a progress note dated 3/2/26 written at 10:30 AM by the Director of Nursing (DON) indicated that Resident #1 attempted elopement and was intercepted. The DON indicated in the note that reorientation was attempted to her situation without success.An interview with the DON on 3/24/2026 at 2:58 PM revealed on the morning of 3/2/2026 management staff were in the morning meeting a visitor came into the conference room telling them a resident was outside. He reported that the staff in the morning meeting immediately left the conference room to locate the resident. He reported that when they found Resident #1 she was on the road just past the gravel parking lot. He stated Resident #1's mentation was altered, she was what I would describe as manic. He reported that it was difficult to make the resident understand the danger she was in on the road and why she needed to return to the facility. The DON reported Resident #1 was difficult to convince to come back to the facility, as she kept attempting to propel herself via wheelchair further up the hill on the road stating she needed to go take care of her son. He indicated they were able to get Resident #1 back to the facility. The DON was unable to explain why he wrote in the progress note that Resident #1 attempted elopement and was intercepted by staff. The DON reported that Resident #1 did elope and was found down the road below the gravel parking lot.An interview with the Administrator on 3/24/26 at 3:20 PM revealed that on 3/2/26 the morning meeting was being held in the conference room and the meeting was about over when a visitor came into the room to let staff know that a resident was in the road. The Administrator reported that she and the staff were able to catch up to Resident #1 and that she was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator reported that Resident #1 went out the side door of the facility. The Administrator reported she was not sure why all staff did not know that Resident #1 had actually got out of the building and she would need to speak to the DON about his progress note on 3/2/26 that indicated the elopement was attempted as she was unsure why the DON would have written that. The Administrator stated she expected all information entered into a resident's medical record to be accurate.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents with new mental health diagnoses for 5 of 7 residents reviewed for PASRR (Resident #5, Resident #12, Resident #51, Resident #71 and Resident #100). The findings include:a. Review of Resident #5's medical record revealed PASRR level I was completed 2/01/22 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #5 was admitted to the facility on [DATE] with diagnosis that included hypertension, diabetes, and readmitted on [DATE] with diagnosis of post-traumatic stress disorder (PTSD) (diagnosed on [DATE]), and major depressive disorder (diagnosed on [DATE]).The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #5's current active diagnoses included post-traumatic stress disorder and major depressive disorder.There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. b. Review of Resident #12's medical record revealed PASRR level I was completed on 1/24/25 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Review of hospital Discharge summary dated [DATE] revealed Resident #12 had a history of Parkinson's disease, heart failure, coronary artery disease, anxiety disorder, major depressive disorder, and psychotic disorder with delusions due to known physiological condition. Resident #12 was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, heart failure, anxiety disorder, major depressive disorder, and psychotic disorder with hallucinations. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12's current active diagnoses included anxiety disorder, major depressive disorder, and psychotic disorder with hallucinations and had received antidepressant and antipsychotic medications within past 7 days. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. c. Review of Resident #51's medical record revealed PASRR level I was completed on 2/04/22 prior to admission to the facility with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #51 was admitted to the facility on [DATE] with diagnosis that included heart failure, diabetes, seizure disorder and readmitted on [DATE] with diagnosis that included heart failure, diabetes, seizure disorder, anxiety disorder (diagnosed on [DATE]), major depressive disorder (diagnosed on [DATE]), and psychotic disorder with delusions (diagnosed on [DATE]). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51's current active diagnoses included anxiety disorder, major depressive disorder, and psychotic disorder with delusions. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. d. Review of Resident #71's medical record revealed PASRR level I was completed 2/06/17 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #71 was admitted to the facility on [DATE] with diagnosis that included hypertension, heart disease, and readmitted on [DATE] with diagnosis to include stroke, heart disease, hypertension, and major depressive disorder (diagnosed on [DATE]). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71's current active diagnosis to include major depressive disorder. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. e. Review of Resident #100's medical record revealed PASRR level I was completed 8/29/14 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #100 was admitted to the facility on [DATE] with dementia, hypertension and readmission on [DATE] with diagnosis to include dementia, anemia, hypertension, major depressive disorder (diagnosed on [DATE]), PTSD (diagnosed on [DATE]) and anxiety disorder (diagnosed on [DATE]). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #100's current active diagnoses included major depressive disorder, PTSD, and anxiety disorder. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. An interview on 2/26/26 at 3:55 PM with the Social Worker (SW) revealed she had started her position as the Social Worker in October 2025. She stated as the facility Social Worker she would be responsible for completing PASRR level II paperwork for residents and had just recently received Social Work training from the corporate office to include when and how to complete and submit PASRR level II paperwork. The Social Worker stated it was her understanding that residents were admitted to the facility with a PASRR level I or level II that had been completed prior to their admission and believed she would be responsible for completing and submitting PASRR paperwork when the resident received a temporary level II that required paperwork be resubmitted after 30, 60, or 90 days or if the resident had received a new mental health diagnosis or had a significant change. She revealed she believed she would be notified during their morning meetings and from the nursing staff of any residents who had received a new mental health diagnosis or had a significant change so the level II paperwork could be completed. The Social Worker stated she was not aware and did not know why the sampled residents did not have an evaluation for a Level II PASRR completed but after reviewing their mental health diagnoses, she believed Level II PASRR evaluations should have been completed. During an interview on 2/26/26 at 4:30 PM with the Administrator, she revealed the Social Worker would be responsible for completing and submitting PASRR paperwork. She stated the new Social Worker had only been in the position for a few months and to her knowledge had just received the training from corporate office on completing and submitting PASRR paperwork. The Administrator revealed she was not aware of the sampled resident's diagnosis or that they did not have a PASRR level II evaluation paperwork completed and did not know why a PASRR level II evaluation request had not been submitted. She stated that her understanding was that a PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis and that according to the sampled resident's diagnoses a PASRR level II should have been completed.

Based on observations, record review and staff interviews, the facility failed to follow their Enhanced Barrier Precautions Policy which included the use of personal protective equipment (PPE) during high contact activities for residents with wounds when the Wound Care Nurse failed to don a gown prior to providing incontinence care and prior to providing wound care on a chronic wound to Resident #74. The deficient practice occurred for 1 of 10 staff observed for infection control practices (Wound Care Nurse).The findings included:Review of the facility's policy last revised on 05/19/2025, titled Enhanced Barrier Precautions Policy read in part: Policy: Enhanced Barrier Precautions (EBP) are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. Definitions: High risk residents: those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and traches) and for all those colonized or infected with a MDRO currently targeted by the CDC.High contact activities: activities that may result in transfer of MDROs to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Procedure:Standard precautions such as hand hygiene always apply. Staff engaging in high-contact activities will don both gloves and gown before initiating the activity and remove the PPE before exiting the room or area where the activity occurred. Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Signage indicating the appropriate type(s) of precautions and indicating that visitors should stop at Nurses Station before entering, will be placed on the resident's door.An observation and interview on 02/23/26 at 11:29 AM with Resident #74 revealed her resting in bed dressed for the day. Resident #74 stated she had a sore on her bottom that was dressed daily. Upon exiting her room, it was noted there was no sign on the door indicating the resident was on Enhanced Barrier Precautions (EBP) and there was no personal protective equipment (PPE) outside her room or on her door.A second observation on 02/24/26 at 9:57 AM revealed no signage on Resident #74's door and no PPE outside her room or on her door. An observation was conducted on 02/24/26 at 10:38 AM of wound care being provided to Resident #74 for her coccyx pressure wound. The Wound Care Nurse walked into Resident #74's room with her wound care supplies in her gloved hands and placed them on the head of the bed on the resident's bed sheet. Without donning a gown, she proceeded to do incontinence care on Resident #74 by cleaning her and putting a clean brief on her. The Wound Care Nurse doffed her gloves, sanitized her hands, and donned clean gloves and without donning a gown proceeded to clean the wound on Resident #74's coccyx area with normal saline. She doffed her gloves, sanitized her hands, donned clean gloves and without donning a gown placed the collagen to Resident #74's wound bed and covered the wound with an absorbent dry dressing. The Wound Care Nurse doffed her gloves sanitized her hands and gathered her trash and left the room. An interview on 02/25/26 at 10:51 AM with the Wound Care Nurse revealed Resident #74 had not been on the list of residents devised by the Infection Preventionist (IP) as needing EBP so her EBP sign was not on her door and PPE not on her door or outside her room. The Wound Care Nurse stated she thought it was odd that Resident #74 was not on precautions but said she wasn't on the list devised by the IP as needing precautions so she had not questioned it. She also stated they had gotten clarification from the IP on the evening of 02/24/26 and learned that it was not only chronic wounds (more than 6 months in duration) but all wounds that required EBP. The Wound Care Nurse stated that once she found out on the evening of 02/24/26 she placed a sign on Resident #74's door and placed a bin outside her door with PPE in it.A telephone interview on 02/25/26 at 4:50 PM with the IP revealed that she kept a list of residents with devices and wounds that required EBP and PPE when providing care to them. The IP stated Resident #74 had not been on the list because she was not aware that Resident #74 had a pressure wound to her coccyx. The IP further stated that the Wound Care Nurse thought the IP was aware of Resident #74's wound but the IP had told the Wound Care Nurse and the Director of Nursing (DON) that she was not aware that Resident #74 had a wound. The IP indicated she would have expected the Wound Care Nurse to have worn a gown when she was providing incontinence care and wound care to Resident #74.An interview with the Director of Nursing (DON) revealed he would have expected Resident #74 to have been on EBP and the Wound Care Nurse to have worn gloves and a gown while providing incontinence care and wound care to the resident.

Based on record review and interviews with the Pharmacist in Charge and staff, the facility failed to have effective systems in place for the return, disposition, and accurate accounting of controlled medications to the pharmacy for 1 of 3 residents reviewed for misappropriation of property (Resident #134). The findings included:Resident #134 was admitted to the facility on [DATE].The physicians order dated 3/29/2025 revealed Resident #134 was to receive oxycodone (a narcotic opioid analgesic prescribed to treat moderate to severe pain by acting on the central nervous system) 5 milligrams (mg) every 6 hours as needed (PRN) for pain.The March 2025 medication administration record (MAR) revealed starting on 3/29/2025 Resident #134 received a total of 4 tablets of oxycodone 5mg. The medication was documented as administered per physician order on 3/29/2025 at 8:25 PM, on 3/30/2025 at 6:33 PM, on 3/31/2025 at 5:51 AM and 8:46 PM. No further doses were documented as administered for the remainder of the month.The April 2025 MAR revealed Resident #134 received a total of one (1) tablet of oxycodone 5mg. The medication was documented as administered on 4/1/2025 at 5:15 PM. No further doses were documented as administered for the remainer of the month.The controlled substance count record dated 3/29/2025 revealed Resident #134 had 7 tablets remaining after the last dose was administered to Resident #134 on 04/01/2025.Resident #134 was discharged from the facility on 04/02/2025.The pharmacy Controlled Substance Prescription Returned to Pharmacy form dated 4/7/2025 and signed by Nurse #1 and Nurse #2 revealed Resident #134's oxycodone 5mg with 7 tablets remaining was being returned to the pharmacy in the Controlled Medication Return Bag #1109772, due to the medication being discontinued. The form was signed as received by the pharmacy on 4/9/2025 and a note was written that read medication was not in the bag have called the facility 2 times since yesterday waiting to hear back from someone at the facility about this issue.The pharmacy Pick-Up Slip dated 4/8/2025 signed by Nurse #3 and the pharmacy driver revealed Controlled Medication Return Bag #1109772 was picked up at the facility on 4/8/2025 and was dated and initialed by the pharmacy on 4/9/2025.The pharmacy return technician who processed the Controlled Substance Prescription Returned to Pharmacy form on 4/9/2025 was unable to be reached due to no longer working for the pharmacy.During a telephone interview on 2/25/2026 at 2:39 PM Nurse #1 verified he had worked on 300 hall on the night of 4/7/2025. Nurse #1 verified he had prepared Resident #134's oxycodone for return to the pharmacy. Nurse #1 stated he took the Controlled Substance Prescription Returned to Pharmacy form to Nurse #2 and had her sign it without having the narcotic cards for Resident #134 and another resident on hand for verification. Nurse #1 stated that leaving the medication in the medication room unattended while he obtained Nurse #2's signature was not proper protocol, and it was a mistake to complete the form that way. Nurse #1 stated he should have had the medications that were being returned with him when he had the second nurse to sign the form so the medications could be verified by the 2nd nurse that signed the form and he should not have sealed the bag by himself. Nurse #1 stated Nurse #2 was not involved with the verification or return of Resident #134's oxycodone except for signing the form. Nurse #1 stated he placed Resident #134's card of narcotics that contained the 7 oxycodone along with another resident's card that contained one tablet of oxycodone and the Controlled Substance Prescription Returned to Pharmacy form in the Controlled Medication Return Bag on his own and sealed the bag and placed it in the locked narcotic drawer of the medication cart. Nurse #1 stated he did not know what happened to Resident #134's oxycodone and did not think the tablets were ever found.During a telephone interview on 2/25/2026 at 3:06 PM Nurse #2 stated Nurse #1 had asked her to sign some paperwork on 04/07/2025 but she was not involved with packaging Resident #134's medications and did not verify the medications that were being returned to the pharmacy. Nurse #2 stated she did not have access to Resident #134's medication and had no idea what happened to them. Nurse #2 stated she did not realize what she had signed with Nurse #1. Nurse #2 stated that when she was called in for the interview about the missing medication, she requested to see the form she had signed, and she was shown the Controlled Medication Return form dated 4/7/2025 that she had signed with Nurse #1. Nurse #2 verified her signature on the paper and stated she should not have signed it without making sure the medications being sent back were present in the return bag. Nurse #2 stated she knew she was supposed to verify the amount of narcotic medications that were being returned if she signed a return form and should have verified, they were in the return bag when it was sealed.During an interview on 2/25/2026 at 10:24 AM Nurse #3 verified her signature on the pharmacy pick up slip dated 4/8/2025. Nurse #3 stated when the pharmacy driver arrived at the facility for pick up 4/8/2025, Nurse #3 verified the serial number on the Controlled Medication Returned Bag matched the serial number on the pharmacy pick up ticket. Nurse #3 and the pharmacy driver signed the pharmacy pick up slip and the Controlled Medication Returned Bag was given to the pharmacy driver. Nurse #3 stated she did not recall the specific bag from 4/8/2025, but the bag would have been sealed properly for the pharmacy driver to accept it, and she would not have handed over an unsealed bag. Nurse #3 stated she did not verify the contents of the bag when it was handed to the pharmacy driver. Nurse #3 revealed the following process when pharmacy picked up controlled medications for return the nurse retrieved the sealed Controlled Medication Returned Bag from the locked narcotic drawer in the medication cart. The nurse and pharmacy driver would verify the serial number on the Controlled Medication Returned Bag matched the serial number on the pharmacy pick up ticket. The nurse and driver would sign the pickup ticket and the pharmacy driver would take possession of the Controlled Medication Returned bag. Nurse #3 stated verifying the contents of the sealed bag was not required, but after the incident in April 2025 she tried to verify the contents when she returned narcotic medication.During an interview on 2/25/2026 at 2:07 PM the Pharmacist in Charge explained when the facility had narcotics to return to the pharmacy, the Controlled Substance Prescription Returned to Pharmacy form was completed which contained the serial number of the Controlled Medication Return Bag, the pharmacy then generated a pick up ticket that contained the serial number that was on the Controlled Substance Prescription Returned to Pharmacy form. When the pharmacy driver arrived at the facility the driver and a nurse at the facility would verify the serial number on the Controlled Medication Return Bag matched the pickup ticket, the pharmacy did not require verification of the return bag contents by the driver. The Pharmacist in charge stated the driver would not accept a bag if the serial number did not match and if the seal of that bag appeared to be tampered with or was not properly sealed. The Pharmacist in Charge retrieved the pharmacy copy of the Controlled Substance Prescription Returned to Pharmacy form dated 4/7/2025 that was signed by Nurse #1 and Nurse #2 and verified the name and initials of the pharmacy return technician and the handwritten note that read medication was not in the bag have called the facility 2 times since yesterday waiting to hear back from someone at the facility about this issue matched the copy provided by the facility. The Pharmacist in Charge added that the 7 oxycodone pills never arrived at the pharmacy so the facility would still be responsible for following up on the missing medications. The Pharmacist in Charge was unable to provide a contact number for the pharmacy return technician.During a telephone interview on 2/25/2026 at 4:40 PM Assistant Director of Nursing (ADON) #1 stated she had spoken to someone from the pharmacy 4/11/2025, but did not recall the person's name or what time the call occurred, regarding Resident #134's missing oxycodone. The ADON #1 recalled Nurse #1 had packaged up narcotics to be returned and had Nurse #2 sign the paperwork. The ADON #1 stated Nurse #2 should have verified the medication since she signed the Controlled Substance Prescription Returned to Pharmacy form. The ADON #1 stated she did not notify the Director of Nursing (DON) or Administrator right away because she was waiting to hear back from the pharmacy to see if the medications had been found. The ADON #1 stated she reported the missing oxycodone to the DON on 4/12/2025. The ADON #1 stated she now knew she was supposed to report missing narcotics immediately to the DON or Administrator so it could be investigated. During an interview on 2/26/2026 at 11:41 AM the DON stated the pharmacy called the facility on 4/10/2025 and when ADON #1 went to answer the phone no one was there. The Pharmacy called back on 4/11/2025 and reported the missing medication to ADON #1. The DON indicated he was not notified until 4/12/2025. The DON stated when he was notified on 4/12/2025 the ADON #1 was waiting to hear back from the pharmacy to see if the pharmacy had found the missing medication. The DON stated on 4/14/2025 when the pharmacy had not found the medication the DON notified the Administrator. The DON stated when Nurse #1 took the form to Nurse #2 to sign, Nurse #1 should also have had the medication for verification and not left the medication unattended while he obtained Nurse #2's signature. The DON stated that when the pharmacy driver picked up controlled medications from the facility the nurse and driver only verified the serial number on the bag and the pickup ticket. The DON stated the missing oxycodone had not been found.During an interview on 2/26/2026 at 12:00 PM the Administrator stated she was notified of the missing narcotics on 4/14/2025, and the medications had not been found. The Administrator stated she expected nurses that signed Controlled Medication Return form to verify the medication that they signed for matched the medication that was placed in the return bag and no staff should sign a Controlled Medication return form without verification of the medications being returned. The Facility presented a corrective action plan that was not accepted by the state agency due to lack of new interventions.

Based on record review and interviews with staff and law enforcement, the facility failed to follow their Abuse, Neglect and Exploitation policy when the Administrator was not immediately notified of an allegation of misappropriation of narcotic medications which resulted in delayed protection of other residents and reporting for 1 of 3 residents reviewed for misappropriation of property (Resident #134). The findings included:The facility's Resident Abuse Policy: Abuse, Neglect and Exploitation indicated it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. The facility staff were to immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies. Once the Administrator and Department of Health and Human Services were notified, an investigation of the allegation or suspicion would be conducted.The Initial Allegation Report completed by the Director of Nursing (DON) dated 4/15/2025 revealed the facility became aware of an allegation of missing Oxycodone (narcotic pain medication) for Resident #134 from the sealed Controlled Medication Return Bag on 4/11/2025. Resident #134 had been discharged from the facility at the time the medication went missing. The report indicated Police Officer #1 was called on 4/15/2025 at 9:30am.During a telephone interview on 2/25/2026 at 4:40 PM Assistant Director of Nursing (ADON) #1 stated she was told on 4/10/2025 by a floor nurse, she could not remember which floor nurse, that pharmacy staff was on the phone related to an issue with narcotic medication sent back to the pharmacy. ADON #1 stated no one from the pharmacy was on the line when she got to the phone on 4/10/2025 and she did not attempt to call the pharmacy back. ADON #1 stated the pharmacy called again on 4/11/2025 and she was informed of the missing Oxycodone for Resident #134. ADON #1 stated she did not inform the DON of the missing Oxycodone until 4/12/2025 because the pharmacy was going to check to see if the medication could be found. ADON #1 stated at that time, she did not know she was supposed to report missing narcotics immediately and since the DON was not at the facility, she thought it could wait to see if the medications were found at the pharmacy before she notified the DON. ADON #1 stated she did not think the missing oxycodone was ever found. She indicated the DON and Administrator conducted the investigation.The Facility Investigation Report completed by the Administrator dated 4/18/2025 was submitted to the State Agency with an investigation summary. The report and summary revealed the facility became aware of possible drug diversion on 4/11/2025 when the pharmacy reported a missing medication card that contained seven tablets of Oxycodone 5 milligrams (mg) that were intended to be returned for Resident #134 from the sealed Controlled Medication Return Bag. The report indicated Nurse #1 and Nurse #2 were suspended pending investigation, and that Nurse #2 was given a do not return notice through the agency. The report indicated Police Officer #1 was notified on 4/15/2025 at 9:30 AM and the case number was listed as pending. During a phone interview on 2/25/2026 at 10:36 AM Police Officer #1 stated he did not recall the facility notifying him of missing Oxycodone in April 2025. Officer #1 stated he had communications, which was the phone number that was listed on the facility's initial report, conduct a search for any calls that came in regarding the facility in April 2025 and there were no calls found. Officer #1 explained that communications tracked every call that was received and kept a record of who the call was assigned to. Police Officer #1 added that the facility emailed him at times for other issues, so he reviewed his emails and did not find any emails related to missing narcotics. He stated that missing narcotics would be considered a crime that would need to be reported.Review of Nurse #1's timecard for April 2025 revealed Nurse #1 worked on the following dates and times after ADON #1 was notified by the pharmacy of the missing Oxycodone for Resident #134 (4/11/2025) and prior to initiation of the facility's investigation:4/12/2025 at 6:33 PM to 4/13/2025 at 6:55 AM4/13/2025 at 6:31 PM to 4/14/2025 at 7:31 AM4/14/2025 at 6:29 PM to 4/15/2025 at 6:57 AMDuring a telephone interview on 2/25/2026 at 2:39 PM Nurse #1 stated he did not recall the exact date he was suspended related to the allegation of drug diversion for Resident #134's Oxycodone in April 2025. The facility provided a copy of an email received from Nurse #2's agency that included the following dates and times that Nurse #2 worked at the facility after ADON #1 was notified by the pharmacy of the missing Oxycodone for Resident #134 (4/11/2025) and prior to the initiation of the facility's investigation:4/10/2025 at 2:30 PM to 4/11/2025 at 7:00 AM4/11/2025 at 2:30 PM to 4/12/2025 at 7:00 AMDuring an interview on 2/26/2026 at 11:41 AM the DON stated he was familiar with the alleged incident of missing narcotic medications for Resident #134 from April 2025. The DON stated the pharmacy called the facility on 4/10/2025 to report issues with narcotic medication that was supposed to be returned, but when ADON #1 answered the phone the pharmacy was no longer on the line. The DON indicated ADON #1 should have called the pharmacy back on 4/10/2025. The DON stated ADON #1 spoke to the pharmacy on 4/11/2025 and was notified of the missing narcotics for Resident #134. The DON stated on 4/12/2025 he was notified by ADON #1 of the missing narcotics for Resident #134 that were supposed to be sent back to the pharmacy. The DON revealed that he did not notify the Administrator of the missing narcotics until 4/14/2025 because at the time incident he did not know missing narcotics was a reportable event. He reported that he was now aware that he should have notified the Administrator of the missing Oxycodone as soon as he was notified on 4/12/2025 because missing narcotics was a reportable incident that needed to be investigated. The DON stated the initial allegation report should have been completed within 24 hours of the facility being made aware of the possible diversion. The DON spoke about law enforcement notification. He reported that he believed he contacted Officer #1 on 4/15/2025, but there was no evidence on his (the DON's) call logs. He indicated he called Police Officer #1 on a direct phone number on 4/18/2025 and left a voice mail, but there was not a police report available. The DON's call log showed a call made Police Officer #1's direct number on 4/18/2025. The DON stated the facility was unable to locate the missing medication or determine how they went missing and the allegation of diversion was unsubstantiated due to lack of evidence.During an interview on 2/26/2026 at 12:00 PM the Administrator stated she was familiar with the alleged incident of missing narcotic medications for Resident #134 from April 2025. The Administrator revealed she was first notified of the missing narcotics by the DON on 4/14/2025. The Administrator indicated that the DON reported that ADON #1 spoke to the pharmacy on 4/11/2025 and was informed of the 7 tablets of Oxycodone missing from the sealed narcotic return bag. ADON #1 then notified the DON of the missing Oxycodone on 4/12/2025. The Administrator stated that when the DON informed her of the missing narcotics on 4/14/2025, an investigation was started. The Administrator stated she should have been notified of the missing narcotics immediately. The Administrator stated she believed law enforcement was verbally notified on 4/15/2025, possibly from her cell phone as she was out of the facility at the time. She verified there was no record of law enforcement notification. The Administrator stated she expected protocol to be followed for reporting missing narcotics, and she should have been notified immediately by ADON #1 on 4/11/2025 and by the DON on 4/12/2025. The Administrator stated the facility was unable to locate the missing medication or determine how they went missing, and the allegation of diversion was unsubstantiated due to lack of evidence.The facility presented a corrective action plan to the State Agency that was not accepted.

Based on record review, observations, and interviews with the resident and staff, the facility failed to secure medications left unattended in a resident's room for 1 of 1 resident reviewed medication storage (Resident #59). Findings included:Resident #59 was admitted to the facility on [DATE].Review of Resident #59's physician orders revealed no active orders for 2% miconazole (antifungal) powder or 10% zinc oxide (topical) protective cream.During an observation of Resident #59's room on 02/23/2026 at 11:29 AM, in clear view on the nightstand beside the bed was a 3 ounce bottle of 2% miconazole antifungal powder and a 2.75-ounce tube of 10% zinc oxide protective cream.During an interview on 02/23/2026 at 11:29 AM, Resident #59 stated that Nurse Aide (NA) staff applied the miconazole powder and zinc oxide cream when incontinence care was done and she did not want to self administer either medication.During an interview and observation on 02/23/2026 at 11:34 AM, NA #1 entered Resident #59's room and stated she was assigned to the hall. She observed the zinc oxide cream and miconazole powder on the nightstand and stated those were from the facility's house stock. NA #1 explained the miconazole powder and zinc oxide cream were applied by NA staff when incontinence care was done but should not have been left in Resident #59's room, and she removed both items.An interview was conducted on 02/25/2026 at 12:17 PM with the Director of Nursing (DON) in the presence of the Administrator. The DON explained that the 2% miconazole powder and zinc oxide cream were stored on the treatment cart and should not have been left in Resident #59's room. The DON added that if Resident #59 needed the miconazole powder or zinc protective cream, a physician's order was required.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide a dependent resident with nail care for 1 of 3 residents reviewed for providing assistance with activities of daily living (Resident #47). The findings included: Resident #47 was readmitted to the facility on [DATE] with diagnoses which included diabetes mellitus and dementia. Review of Resident #47's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required extensive assistance of 1 staff member with bathing and limited assistance of 1 staff member with personal hygiene. According to the assessment there were no behaviors and no rejection of care. Review of Resident #47's care plan dated 06/19/23 revealed a focus area for an activities of daily living (ADL) self-care performance deficit related to dementia, impaired cognition, Parkinson's disease, and diabetes mellitus, among others. The resident is at risk for functional decline as dementia and Parkinson's disease progresses. The interventions read in part: bathing/showering - Resident #47 requires 1 staff assistance, encourage resident to complete as much of the task as he is able following set up assistance, and provide assistance as needed to complete task. Review of Resident #47's nursing progress notes revealed no notes regarding the resident refusing showers or personal hygiene care. Review of the NA's documentation revealed no indication that resident refused care. An observation and interview were conducted on 08/14/23 at 9:55 AM with Resident #47. He was lying on his bed watching TV in his room. His fingernails on both hands were observed to be 1/4 to 1/2 inch beyond the ends of his fingers and some appeared to be jagged on the end. Resident #47 stated he didn't like for his fingernails to be long and said he would like for them to be trimmed but he couldn't do it himself and no one had offered to trim his nails for him. Review of the facility's shower schedule revealed Resident #47 was scheduled for showers on Tuesdays and Fridays on 1st shift (7:00 AM to 3:00 PM). An observation and interview were conducted on 08/15/23 at 3:57 PM with Resident #47. The resident stated he had received his shower this morning. Resident #47 stated the Nurse Aide (NA) had not trimmed his fingernails or asked him if he wanted them trimmed after his shower. The resident further stated he would like for his nails to be trimmed. An observation and interview were conducted on 08/16/23 at 9:43 AM with Resident #47. His nails remained long and he stated staff still had not trimmed his nails. An interview on 08/16/23 at 10:08 AM with Nurse Aide (NA) #1 revealed she had been assigned to care for Resident #47 on 08/15/23 during 1st shift (7:00 AM to 3:00 PM). She stated there had been 5 NAs assigned to the 100 hall yesterday and NA #2 had provided Resident #47 with his shower on 08/15/23. NA #1 explained on shower days if the resident needed to be shaved and their fingernails clipped that was part of the shower. She further explained they were able to clip fingernails and toenails unless the resident was diabetic and then they would let the nurse assigned to the resident know their nails needed to be clipped and the nurse clipped their nails. A telephone interview on 08/16/23 at 2:26 PM with NA #2 revealed she had been assigned to give showers on the 100 hall on 08/15/23. She stated she had given Resident #47 his shower as scheduled on that day. NA #2 further stated she had not trimmed his nails after his shower because he was diabetic and she was not allowed to trim nails on diabetic residents. She explained with diabetic residents the NAs usually told the nurse assigned to them their nails needed to be trimmed once they had given the resident their shower. NA #2 further explained she had not noticed Resident #47's fingernails and had not told Nurse #2 the resident needed his fingernails clipped after his shower. NA #2 said she guessed she just forgot but said it was her responsibility to let the nurse know when diabetic residents needed their fingernails or toenails trimmed. An interview on 08/16/23 at 11:19 AM with Nurse #1 revealed she was assigned to Resident #47 today but had not been assigned to him on 08/15/23. Nurse #1 stated Nurse #2 had been assigned to the resident on 08/15/23. Nurse #1 explained it was the responsibility of the NA to let the nurses know when a diabetic resident needed their fingernails trimmed after their shower and the nurse assigned to the resident would trim their nails. An interview on 08/16/23 at 11:42 AM with Nurse #2 revealed she had been assigned to care for Resident #47 on 08/15/23. Nurse #2 explained the NAs were not allowed to cut diabetic residents' nails but it was their responsibility to let the nurse know after resident's showers if their fingernails or toenails needed to be trimmed. She stated NA #2 had not told her that Resident #47 needed his fingernails to be trimmed after she had given him his shower yesterday. An interview on 08/16/23 at 5:00 PM with the Director of Nursing and Administrator revealed it was the responsibility of the Nurse Aide (NA) to tell the nurse when a diabetic resident needed their nails trimmed after their shower because NAs were not allowed to trim diabetic resident's nails.

Based on observations and staff interviews, the facility failed to secure pre-mixed medications on 1 of 6 medication carts (200 hall medication cart) and discard expired medications in 2 of 6 medication carts (Short hall medication cart and Long hall medication cart). The findings included: 1. An observation of the 200 hall medication cart on 4/12/22 at 8:23 AM revealed 4 plastic cups of clear, colorless liquid were on top of the medication cart. The cups were half-full of approximately 4 ounces of liquid with straws in each cup and were unlabeled with any resident name. The medication cart was locked, and Nurse #1 was observed administering medications to Resident #60 while away from the medication cart. Other staff members were observed walking on the hallway where the 200 hall medication cart was parked. An interview with Nurse #1 on 4/12/22 at 8:28 AM with the Assistant Director of Nursing (ADON) present revealed she had pre-mixed [MEDICATION(S)] with warm water and the 4 cups that were left on top of the 200 hall medication cart contained this solution. [MEDICATION(S)] is a [MEDICATION(S)] used to treat occasional constipation. Nurse #1 stated she had to use warm water to dissolve the medication better and said she had a hard time dissolving [MEDICATION(S)] right before medication administration, so she had to mix it ahead of time and let it sit until it dissolved. Nurse #1 stated she didn't think it was unacceptable to leave the pre-mixed medication on top of the medication cart. An interview with the ADON on 4/12/22 at 8:30 AM revealed she could understand why Nurse #1 had to pre-mix the [MEDICATION(S)] ahead of time in order to dissolve it better, but it was probably not acceptable to leave the pre-mixed medication cups on top of the medication cart and unsecured. An interview with the Director of Nursing (DON) on 4/13/22 at 2:31 PM revealed it was not acceptable that Nurse #1 left pre-mixed [MEDICATION(S)] unsecured on top of the medication cart and she should have pulled and prepared medications right before administration. 2.a. An observation of the Short hall medication cart on 4/13/22 at 10:32 AM with Nurse #2 revealed a sealed bottle of [MEDICATION(S)] tablets available for use on the top drawer labeled with an expiration date of 12/2021 and belonged to Resident #12. [MEDICATION(S)] is a vasodilator (medications that open/dilate blood vessels) used to treat and prevent chest pain. An interview with Nurse #2 on 4/13/22 at 10:35 AM revealed Resident #12 had not received a [MEDICATION(S)] tablet since October 2021 and it had been ordered to be given only if she had chest pain. Nurse #2 stated that was probably why the expired bottle of [MEDICATION(S)] bottle had been missed but all the nurses should be checking the medication carts for expired medications. b. An observation of the Long hall medication cart on 4/13/22 at 10:40 AM with Nurse #3 revealed two opened bottles of [MEDICATION(S)] belonging to Resident #29 available for use on the right third drawer labeled with an expiration date of 1/2022. [MEDICATION(S)] is a [MEDICATION(S)] and ammonia reducer used to treat constipation. Two opened bottles of [MEDICATION(S)] eye drops were also available for use on the top drawer. [MEDICATION(S)] is a medication used to treat [CONDITION(S)]. One of the [MEDICATION(S)] eye drop bottles belonged to Resident #70 and was labeled as having been opened on 2/22/22. The other [MEDICATION(S)] eye drop bottle belonged to Resident #9 and was labeled as having been opened on 2/5/22. Both [MEDICATION(S)] eye drop bottles had a sticker that read discard after 6 weeks after opening. An interview with Nurse #3 on 4/13/22 at 10:44 AM revealed Resident #29 had been refusing to take the [MEDICATION(S)] and this was probably why they had missed the expiration date on the bottles. Nurse #3 stated the [MEDICATION(S)] eye drops were scheduled to be given at 8 PM and both Resident #70 and Resident #9 last received it on 4/12/22. Nurse #3 stated all nurses were supposed to be checking the medication carts for expired medications and the evening shift nurse should have looked at the opened dates on the bottles and discarded the expired eye drop bottles. An interview with the Director of Nursing (DON) on 4/13/22 at 2:31 PM revealed the expired medications should have been discarded and not left on the medication cart available for use. The DON stated all nurses were responsible for checking the medication carts for expired medications and they needed to re-educate all the nurses about this responsibility.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when 1 of 6 staff members (Housekeeper #1) failed to wear full Personal Protective Equipment (PPE) when entering a resident's room on enhanced droplet precautions (Resident #11). In addition, Nurse Aide #1 failed to disinfect a non-dedicated resident medical equipment in between resident use for 1 of 3 residents (Resident #11) reviewed for infection control. These failures occurred during a COVID-19 pandemic. The findings included: 1. The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/2/22 indicated the following statement under Section 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection: *HCP (Healthcare personnel) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The facility's policy entitled, Infection Control - Transmission Based Precautions, revised in April 2016 indicated the following statements under Droplet Precautions: A mask is worn for close contact with infectious resident. Gloves, gown, eye protection are worn adhering to Standard Precaution guidelines. The facility's policy entitled, COVID-19 Testing Guidance, updated on 2/7/22 indicated the following statement: Residents with signs or symptoms must be tested and be placed in full Transmission Based Precautions (TBP) pending results. Follow facility protocol once results are received. A progress note dated 4/11/22 at 10:41 AM indicated Resident #11 was coughing this morning and she was placed on enhanced droplet precautions. COVID-19 antigen and PCR (polymerase chain reaction) tests were obtained. An observation on the 100 hall on 4/11/22 at 9:43 AM revealed an enhanced droplet precautions sign posted on the wall beside Resident #11's door. The sign indicated instructions that all healthcare personnel must: clean hands before entering and when leaving room, wear a gown when entering room and remove before leaving, wear N95 or higher-level respirator before entering the room and remove after exiting, protective eyewear (face shield or goggles) and wear gloves when entering room and remove before leaving. A plastic drawer cart which contained N95 masks, face shields, gowns and gloves was located under the sign and beside Resident #11's door. An observation on 4/11/22 at 12:19 PM revealed Housekeeper #1 cleaning inside Resident #11's room while wearing a surgical mask, a face shield, a gown, and gloves. Resident #11 was present in the room and was observed coughing at intervals. A phone interview with Housekeeper #1 on 4/13/22 at 2:20 PM revealed she did not pay attention to the sign beside Resident #11's door and did not realize she was supposed to change into an N95 mask prior to entering Resident #11's room. Housekeeper #1 stated she had received education on Personal Protective Equipment (PPE) use for rooms on enhanced droplet precautions, but she thought she was only required to wear a gown, a face shield, and gloves in addition to her surgical mask. She also stated that the N95 masks that were available on the cart were too big for her face and they were supposed to order her a size small. An interview with the Infection Preventionist (IP) on 4/13/22 at 1:58 PM revealed Housekeeper #1 should have switched her surgical mask into an N95 mask prior to entering Resident #11's room. The IP confirmed that Housekeeper #1 had received training on PPE use for residents who were placed on enhanced droplet precautions. 2. The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/2/22 indicated the following statement under Environmental Infection Control: Dedicated medical equipment should be used when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. The facility's policy entitled, Infection Control - Transmission Based Precautions, revised in April 2016 indicated the following statement: Care equipment - use disposable non-critical equipment (thermometers, blood pressure cuffs, stethoscope, etc.) or implement resident-dedicated equipment. If common use of equipment is unavoidable, clean and disinfect equipment before use on another resident. A continuous observation on 4/11/22 from 3:39 PM to 3:44 PM revealed Nurse Aide (NA) #1 entering Resident #11's room while pushing a vital sign monitor equipment. NA #1 plugged Resident #11's phone into the charger per Resident #11's request and proceeded to take Resident #11's temperature by placing a disposable probe over the thermometer and putting it inside Resident #11's mouth. When she obtained Resident #11's temperature, she discarded the probe in the trash can and placed the thermometer back into the holder on the vital sign equipment. She obtained Resident #11's blood pressure using the blood pressure cuff on the vital sign equipment and then folded it and placed it back into the holder. NA #1 used hand sanitizer and then washed her hands in Resident #11's room sink prior to leaving Resident #11's room. She did not disinfectant the vital sign equipment that was just used on Resident #11. NA #1 pushed the vital sign equipment and proceeded to go inside Resident #13's room. An interview with NA #1 on 4/11/22 at 3:45 PM revealed she knew she was supposed to sanitize the vital sign equipment before and after using it on each resident. NA #1 stated she used alcohol prep to wipe the thermometer and the inside part of the blood pressure cuff she used on Resident #11. An interview with the Infection Preventionist (IP) on 4/11/22 at 3:56 PM revealed NA #1 should have sanitized the vital sign equipment she used on Resident #11 before using it on another resident. A follow-up interview with the IP on 4/12/22 at 8:25 AM revealed she had talked to NA #1 on 4/11/22 and NA #1 had admitted to her that she did not sanitize the vital sign equipment after she used it on Resident #11. An interview with the Director of Nursing (DON) on 4/13/22 at 2:31 PM revealed all the staff members which included Housekeeper #1 had been told that they should wear an N-95 mask and full PPE when going into an enhanced droplet precaution room. The DON stated he had some N95 masks in his office and Housekeeper #1 should have obtained some from him. He stated Housekeeper #1 had been sized down to a small N95 mask when she was fit-tested , and they had discussed with her that they were ordering her size and they had been available for her to use. The DON also stated NA #1 had told them that she was used to the sign being on the actual door of the resident and not on the wall beside it but she should have received report from the outgoing shift before she took over the hall so she would know Resident #11 had been placed on enhanced droplet precautions. He also stated NA #1 should have sanitized the vital sign equipment prior to using it on each resident.

Based on observations and staff interviews the facility failed to remove a mold-like substance from 1 of 1 kitchen ice machines. Findings included: An observation on 10/29/18 at 9:20 AM of the kitchen's ice machine revealed mold-like substance on the upper inner part of the ice machine where ice was stored. The Dietary Manager (DM) was able to easily remove part of the mold-like substance from the ice machine with a dish cloth. An interview with the Dietary Manager at the time of the observation revealed she would not expect to find a mold-like substance in the ice machine and that it would be emptied and cleaned immediately. The Dietary Manager also stated the ice machine was last cleaned at the end of last month by dietary staff. The dietary staff member who cleaned the ice machine last month was not available for interview. An interview with the Administrator on 11/01/18 at 3:31 PM revealed there should not be a mold-like substance in the ice machine as it was cleaned monthly.

Based on observations, record reviews and staff and resident interviews, the administration failed to operationalize a safe environment free from abuse for 1 of 3 sampled residents (Resident #71) and ensure resident needs were met for 8 of 14 sampled residents (Residents #27, #28, #46, #66, #71, #79, #123, and #174). Immediate jeopardy began on 10/23/17 when Resident #71 was struck by a flying object from a meal tray thrown by a nurse aide. Nurse #1 permitted the nurse aide to continue to pass trays on that unit due to short staffing. Immediate Jeopardy was removed on 11/19/17 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy Removal. The facility remains out of compliance at a scope and severity level of E (Pattern no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete employee education and ensure monitoring systems put into place are effective and sufficient to meet the care needs of the residents. The findings included: 1. Cross Refer to F223: Based on record review, resident interview, and staff interviews, the facility failed to provide an environment that maintained 1 of 3 residents' right to be free from abuse (Resident #71). 2. Cross Refer to F226: Based on record review, and staff interviews, the facility failed to implement their abuse policy and procedures related to the prevention, protection and investigation for 1 of 3 residents who were reviewed for abuse investigations (Resident #71). 3. Cross Refer to F353: Based on observations, record reviews, resident interviews, family interviews, and staff interviews, the facility failed to provide sufficient staffing to care for 8 of 14 sampled residents (Residents #27, #28, #46, #66, #71, #79, #123, and #174). The Administrator and Regional Clinical Nurse were informed of Immediate Jeopardy on 11/16/17 at 6:18 PM. The facility provided an acceptable credible allegation of immediate jeopardy removal on 11/19/17 at 11:57 AM as follows: The plan of correcting the specific deficiency. The plan should address the process that lead to the deficiency cited. The areas of concern identified on 10/23/17 Nurse aide (NA) #2 was not removed from her duties by Nurse #1 when she became upset and threw objects including a computer mouse and a resident's meal tray. This resulted in Resident #71 being hit with object and NA #2 was allowed to continue working before calling the Director of Nursing. An investigation was conducted by the Administrator and Director of Nursing and Facility Reportable Incident submitted on 10/23/17 and 5 Day on 10/27/17. The (Name of City Law Enforcement) were notified of the incident on 10/23/17 and no charges filed on 10/23/17, the resident was assessed for injury by licensed nurse and had no negative outcome On 11/16/17 the facility started another investigation related to incident of 10/23/17 for resident #71 occurrence due to additional findings, during state survey interviews. This was conducted by the Administrator of (Name of Nursing Facility). It was identified that NA #2 was not immediately suspended and returned to care while Director of Nursing was being notified by the Nurse on duty. On 11/16/17 the Nurse #1 and NA #2 from 10/23/17 occurrence were suspended pending investigation. NA #2 and Nurse 1 was terminated and removed from payroll system on 11/17/17 11/16/17 statements obtained for those staff in original investigation The procedure for implementing the acceptable plan of correction for the deficiency cited. All residents in the facility have the potential to be affected. Interviewable residents were interviewed on 11/17/17 by Department Managers regarding care issues and staffing. No new negative findings were noted. Residents who are non-interviewable had complete body checks completed by licensed nurses on 11/17/17. No new care concerns identified. When identifying the root cause of the outburst by the Nurse Aide #1 (NA). The NA#1 stated it occurred due to being frustrated related to staffing. To prevent this from recurring the Administrator and Regional Clinical Services Director started immediate in-house education on 11/16/17 related to F223 Abuse and F226 development and implementation of policy and procedures (screening/training/prevention/ identification/ investigation/protection and reporting response. 11/16/17 the Administrator re-educated department heads on abuse and policy and procedures. Department heads completed education for staff on duty and the education will continue through 11/17/17. This education was performed to ensure staff was properly trained on abuse and aware that abuse would not be tolerated at the facility. Education will continue via telephone and staff will not be permitted to work until education is received. New hires will be educated on the abuse policy and procedure upon hire. The Regional Vice President of Operation re-educated the Licensed Nursing Home Administrator on abuse, policy and procedures and conducting a proper/thorough investigation on 11/17/17. Administrator implemented a staffing initiative on 10/24/17 to ensure sufficient nursing services and sufficient staff in order to use resources efficiently and effectively. Administrator implemented a staffing initiative on 10/24/17 related to sufficient nursing services and sufficient staff with the following elements: Human Resource Manager to evaluate current nursing and nurse aide vacancies and Update log weekly 10/24/17 Since 10/24/17 we have received 16 NA applications and hired 15 of those applicants. Since 10/24/17 we have received 7 nurse applications and hired 5 of those applicants. Administrator and Director of Nursing evaluated staffing and identified overstaffing on day shift, adequate staffing on night shift and understaffing on evening shift. Staffing was adjusted by implementing a master schedule to even out the staffing on days and evenings 10/24/2017. Administrator improved recruiting online on various web site on 10/26/2017 which has increased the number of applicants and new hires. Evaluated weekly by Human Resources Manager. - Administrator secured 2 Agency contracts to assist with staffing 10/26/2017 - Administrator implemented Wage/Salary review and increase 11/10/2017 for nurses and nurse aides - Administrator initiated Sign On Bonus/referral bonus $650.00/$500.00 for nursing and nurse aide positions 10/26/2017 - Administrator implemented shift bonus for nurses and nursing assistants for those picking up extra shifts on 8/28/17. - Administrator initiated a new Aide College program-10/26/2017- This is a contract with the local community college to sponsor a nursing assistant student who is attending their program or who to desires to attend the program. Facility is paying for tuition, books, and certification test in return for 6 months employment. - Administrator and regional support staff on daily staffing call to discuss needs and ongoing recruitment efforts 10/24/17 - Administrator placed signs throughout community advertising for NAs on 11/10/2017. On 11/13/17 the Administrator educated the department managers on the Manager On Duty (MOD) policy and Department head duties. This process is new to the facility and provides for management/administrative coverage on weekends both scheduled and at random based on the needs of the center, to include management rounds and addressing concerns or allegations of abuse which will be handled immediately the MOD who will notify the Administrator and the Director of Nursing. The Nurse assigned to 300 hall is the designated nurse in charge in the absence of the Administrator immediately of any allegations of abuse or concerns. To prevent this from recurring the Administrator was educated by the Regional Vice President of operations regarding F490 Administration as it relates to the regulation and abuse policy and procedure including reporting and investigation on 11/17/17. The Administrator will continue with the staffing initiative indicated above and will have a daily staffing meeting to assure resources are used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Adjustment of resources will be made as needed and department heads/nursing management/ancillary staff will be assigned duties that they are able to perform if needed. 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. The facility will call in available staff if needed and utilize agency staffing if needed to monitor and maintain ongoing compliance: The facility Administrative/Department Managers will start abuse questionnaires with all staff on 11/17/17 related to abuse and policy and procedures (7 elements). The audits will be completed on 3 staff, 3 x weekly. Any negative findings will be addressed immediately. The facility will conduct an Ad H(NAME) QUALITY ASSURANCE PERFORMANCE IMPROVEMENT meeting on 11/17/17 with the facility IDT team, the Regional Team and the Medical Director to review. To monitor and maintain ongoing compliance the Department Managers will complete interviews on 3 residents 3 x weekly to ensure there are no issues related to care and staffing. Any negative findings will be addressed immediately. The title of the person responsible for implementing the acceptable plan of correction is the Administrator. Date of Alleged Compliance is: 11/19/17 Immediate jeopardy was removed on 11/19/17 when interviews with direct and supervisory staff confirmed they had been inserviced and knew the facility's abuse policy and procedures including that suspected staff had to be removed from resident care immediately, witnesses had to be interviewed, and documentation had to be included in the nursing notes including event information, assessment information and notification information. The staff knew signs of burnout and what to do if they were feeling burned out or observed other coworkers with signs of burnout. In addition, observations and interviews with staff confirmed the facility had made adjustments in the master schedule to assure that staffing on all shifts was evenly distributed and staff were given actual assignments for covering resident care. Confirmation was obtained that the facility engages contracts for agency coverage for nurse aide vacancies and that the bonus incentive was implemented. The facility supervisory staff also confirmed the hiring of several new employees and their schedule for orientation. Supervisory staff interviews confirmed they had been inserviced on the new Manager On Duty assignment and the expectation of obtaining appropriate nursing staff coverage during their oversight.

Based on observations, record reviews, resident interviews, family interviews, and staff interviews, the facility failed to provide sufficient staffing to care for 8 of 14 sampled residents (Residents #27, #28, #46, #66, #71, #79, #123, and #174). The facility failed to assign nurse aides in the number to prevent abuse, provide residents with incontinence care, toileting, and showers, provide training to agency staff so they were aware of their responsibilities for personal care and tray set up, and make assignments so nurse aides were aware of the individual residents and care needed for residents relating to toileting and showers. Immediate Jeopardy began on 10/23/17 when a nurse aide threw a meal tray into the hallway, due to staffing frustrations and an object from that meal tray hit Resident #71 as she was propelling her wheelchair nearby. The nurse aide was permitted to continue working with residents during the meal. Immediate Jeopardy for tags F223 and F226 was removed on 11/19/17 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy Removal. This tag was left out of compliance at a lower scope and severity of E (Pattern no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) due to example #3, and examples #4, #5, and #6 are at the scope and severity level D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy). The findings included: 1.Cross Refer to F223: Based on record review, resident interview, and staff interviews, the facility failed to provide an environment that maintained 1 of 3 residents' right to be free from abuse (Resident #71). 2.Cross Refer to F226: Based on record review, and staff interviews, the facility failed to implement their abuse policy and procedures related to the prevention, protection and investigation for 1 of 3 residents (Resident #71 who were reviewed for abuse investigations. The Administrator and Regional Clinical Nurse were informed of Immediate Jeopardy on 11/16/17 at 6:18 PM. The facility provided an acceptable credible allegation of immediate jeopardy removal on 11/19/17 at 11:57 AM as follows: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited. The areas of concern identified on 10/23/17 Nurse aide (NA)#2 was not removed from her duties by Nurse #1 when she became upset and threw objects including a computer mouse and a resident's meal tray. This resulted in Resident #71 being hit with object and NA#2 was allowed to continue working before calling the Director of Nursing. When identifying the root cause of the outburst by the NA, she stated it occurred due to being frustrated related to inadequate staffing. Administrator implemented a staffing initiative on 10/24/17 related to sufficient nursing services and sufficient staff with the following elements: Human Resource Manager Evaluate Current nursing and nurse aide Vacancies nurse aides and licensed nurses and Update log weekly 10/24/17 a. Since 10/24/17 we have received 16 NA applications and hired 15 of those applicants. b. Since 10/24/17 we have received 7 nurse applications and hired 5 of those applicants. Administrator and Director of Nursing evaluated staffing and identified overstaffing on day shift, adequate staffing on night shift and understaffing on evening shift. Staffing was adjusted by implementing a master schedule to even out the staffing on days and evenings 10/24/2017. Administrator improved recruiting online on numerous web sites on 10/26/2017 which has increased the number of applicants and new hires. Evaluated weekly by Human Resources Manager. Administrator secured 2 Agency contracts which will be utilized to cover current staffing vacancies 10/26/2017. Administrator initiated Sign On Bonus/referral bonus $650.00/$500.00-10/26/2017. Administrator implemented shift bonus for nurses and nursing assistants for those picking up extra shifts on 08/28/17. Administrator initiated a new Aide College program-10/26/2017- This is a contract with the local community college to sponsor a nursing assistant student who is attending their program or who to desires to attend the program. Facility is paying for tuition, books, and certification test in return for 6 months employment. Administrator and regional support staff attend daily staffing call to discuss needs and ongoing recruitment effort Administrator implemented Wage/Salary review and increase 11/10/2017. Administrator placed signs throughout community advertising for NAs on 11/10/2017. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. On 11/13/17 the Administrator educated the department managers on the Manager On Duty (MOD) policy and Department head duties. The MOD will be implemented 11/19/2017. This process is new to the facility and provides for management/administrative coverage on weekends both scheduled and at random based on the needs of the center, to include management rounds and addressing concerns or allegations of abuse which will be handled immediately by the MOD who will notify the Administrator and the Director of Nursing. The Nurse assigned to 300 hall is the designated nurse in charge in the absence of the Administrator immediately of any staffing concerns. All residents have the potential to be affected. Residents were interviewed on 11/17/17 by facility department managers regarding care related to staffing. No new negative findings were identified. To prevent this from recurring the Administrator and Director of Nursing were educated by the Regional Vice President of Operations regarding Sufficient Staffing and ongoing staffing plan. The facility will continue with the staffing initiative indicated above and will continue to have a daily staffing meeting to assure sufficient nursing staffing is available during morning meeting to meet the resident's needs. Adjustment of resources will be made as needed and department heads/nursing management/ancillary staff will be assigned duties that they are able to perform if needed. The facility will call in available staff if needed and utilize agency staffing if needed. Resident council minutes will be reviewed monthly by the Administrator to identify any issues related to care and staffing. Resident concern forms will be reviewed daily to ensure any issues related to care and staffing are investigated and resolved by the Administrator and the Director of Nursing. 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. To monitor and maintain ongoing compliance the department managers will complete interviews on 3 residents 3 x week x 4 weeks, weekly x 4 then monthly x 1 to ensure there are no issues related to care and staffing. Any negative findings will be addressed immediately to the administrator. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement meeting for further review and recommendations. The Administrator will conduct an Ad H(NAME) Quality Assurance Performance Improvement meeting on 11/17/17 with the facility Interdisciplinary team, the Regional Team and the Medical Director to review. The title of the person responsible for implementing the acceptable plan of correction is the Administrator. Date of Alleged Compliance is 11/19/17 Immediate Jeopardy was removed on 11/19/17 when observations and interviews with staff confirmed the facility had made adjustments in the master schedule to assure that staffing on all shifts was evenly distributed and staff were given actual assignments for covering resident care. Confirmation was obtained that the facility engages contracts for agency coverage for nurse aide vacancies and that the bonus incentive was implemented. The facility supervisory staff also confirmed the hiring of several new employees and their schedule for orientation. Supervisory staff interviews confirmed they had been inserviced on the new Manager On Duty assignment and the expectation of obtaining appropriate nursing staff coverage during their oversight. 3. Cross refer to F312: Based on observations, record reviews, and interviews the facility failed to provide incontinent care (Resident #27, #28, and #79) and assistance with tray set up (Resident #123) for 4 of 11 sampled residents reviewed for activities of daily living. 4. Cross Refer to F224: Based on observations, record reviews and staff interviews, the facility failed to provide incontinence care when needed to 3 of 12 sampled residents (Residents #27, #28, and 79). 5. Cross Refer to F241: Based on observations, record reviews and staff interviews, the facility failed to provide incontinence care to 3 of 12 sampled residents resulting in 2 residents (Resident #27 and #28) eating while wet with urine and 1 resident's (Resident #79) request for incontinence care forgotten by staff. 6. Cross Refer to F242: Based on record reviews and resident and staff interviews, the facility failed to provide residents' with their preferred number of showers a week for 3 of 5 resident reviewed for choices (Resident #46, #66, and #174). The staffing interview was deferred to the Assistant Director of Nursing (ADON)/Acting DON by the Administrator and was conducted on 11/17/17 at 5:38 PM. The Acting DON stated staffing was becoming an issue at the end of the summer when staff were leaving due to salary and a proposal was made to corporate for a salary adjustment which did not happen until this month. The Acting DON explained when the previous DON came at the end of September 2017 she started a track schedule and a blue dot system for covering the assignment and absences which the nurse aides (NAs) did not like either. As a result more NAs resigned. The interview further revealed the goal was to have 10 NAs on the 7:00 AM to 3:00 PM (day) shift and the 3:00 PM to 11:00 PM shift (evening) and 6 to 7 NAs on the 11:00 PM to 7:00 PM (night) shift which had become difficult to cover beginning in September 2017 especially for the evening and night shifts. The Acting DON noted the facility covered the schedule by asking staff to come in early or stay over, trade shifts, offering bonuses for extra shifts, and having a nurse take an NA assignment. The Acting DON added he had stayed more times than he could count when there was not adequate coverage or call outs. Currently, the facility had 17 NA positions to be filled and had a contract with two agencies for NAs. He indicated the facility had 3 NAs starting orientation the following week.

Based on record review and Physician and staff interviews the facility failed to monitor the clotting time of a resident's blood which led to the laboratory test being missed four times that resulted in an elevated bleeding time for 1 of 3 residents reviewed on [MEDICATION NAME] (blood thinner) therapy (Resident #139). Resident #139 admitted to the hospital and received treatment to reduce his elevated bleeding time. Immediate Jeopardy began on 10/21/17 when staff failed to monitor the blood clotting time of Resident #139, who was on [MEDICATION NAME] 10 milligrams (mg), per the resident's standing orders. Immediate Jeopardy was removed on 11/19/17 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #139's History and Physical from the hospital dated 10/10/17 revealed Resident #139 had a series of hospitalization s. He was discharged [DATE] after being admitted with [DIAGNOSES REDACTED] bleed while on Xarelto (a blood thinner). He was transfused a total of 4 units of blood during that stay. Resident #139 was subsequently readmitted on [DATE] with a possible [MEDICAL CONDITION] embolism with low clot burden as well as left lower lobe infiltrate. He was seen by hematology who recommended converting from Xarelto (blood thinner) to [MEDICATION NAME] (blood thinner). He was discharged on [DATE] and reported back to hospital on [DATE] for weakness. The hospital records didn't say what date the [MEDICATION NAME] was changed to [MEDICATION NAME] but he was discharged on [MEDICATION NAME] 10 mg as below. Review of the hospital discharge summary dated 10/18/17 revealed the impression/plan for Resident #139 was as follows: continue [MEDICATION NAME], check International Normalized Ratio (INR) daily (laboratory test to check clotting time of blood), goal INR 2-3. Review of the hospital discharge summary dated 10/18/17 revealed Resident #139's anticoagulation therapy would be monitored by the Facility Physician. The next INR was due 10/21/17. The INR on 10/18/17 was 1.9 with a target INR of 2-3. Review of the care plan dated 10/18/17 revealed Resident #139 received anticoagulant use with a goal for no complications related to anticoagulant use. The interventions included: administer medications as ordered. Monitor for behavior changes. Monitor for signs and symptoms of internal/external bleeding. Monitor labs as ordered. Protect from injury. Review of the admission Minimum (MDS) data set [DATE] revealed Resident #139 was moderately cognitively impaired and received anticoagulants during the assessment period. Review of the facility Standing Orders for Anticoagulants was: INR will be performed monthly on all residents receiving [MEDICATION NAME]. If a resident is receiving upon admission or is started on medication, an INR will be performed every other day for 1 week, then every other week x 4, then monthly, unless otherwise ordered by MD. Review of the facility physician orders [REDACTED]. [MEDICATION NAME] 10 milligrams (mg) every afternoon for anticoagulation therapy. No orders for INR testing. Review of the facility PT/INR/[MEDICATION NAME] Flowsheet revealed the INR was checked on 10/19/17 with a result of 2.1 with no change in orders for [MEDICATION NAME] 10 mg once a day. Resident #139 missed INR checks on 10/21/17, 10/23/17, 10/25/17 and 10/27/17 per the standing orders. Review of a nurse's note dated 10/27/17 at 4:38 PM revealed Resident #139 reported shortness of breath and a dark purple raised area was noted on his inner right calf. The physician was notified and an order was received for Resident #139 to sent to the emergency room for evaluation and treatment. Review of a hospital discharge summary dated 10/28/17 revealed Resident #139 presented at the ED on 10/27/17 for bilateral lower extremity [MEDICAL CONDITION] with extensive bruising and confusion. A family member reported they had noticed extensive bruising developing in both feet 2 days ago and given his medical history they had requested an evaluation. The Physician noted extensive bruising of the right lower extremity, a large hematoma on the top of of his right foot, and bruising on his left foot. Review of the hospital laboratory test results revealed an INR of 7.8 on 10/27/17. The plan was to hold the [MEDICATION NAME], give Vitamin K (a medication used to reverse [MEDICATION NAME]), and consider Fresh Frozen Plasma (a blood product made from the liquid portion of whole blood) if there was further swelling of the hematoma. Resident #139 was transferred to a larger local hospital due to respiratory distress on 10/28/17. Review of a hospital admission History and Physical dated 10/28/17 revealed Resident #139 was seen in the emergency room for swelling, shortness of breath and a concern of possible clots. The report stated his INR was elevated at 7.8 and a large central line was placed to correct his INR. He responded partially to Vitamin K and was given 2 units of Fresh Frozen Plasma. An interview conducted on 11/17/2017 at 4:20 PM with the facility physician revealed he reviewed Resident #139's INR one time (on 10/19/17) during his stay at the facility and it was in the therapeutic range. He stated the INR should have been checked after that per standing orders and any result above 3 or below 2 should have been called to him. He further stated it was his expectation for the nurses to enter the standing orders for the INR checks to be completed and the results called to him. He stated he was unaware Resident #139's INR's weren't being checked per the standing orders and should have been. An interview conducted on 11/17/2017 at 6:44 PM with Nurse #2 revealed she worked the 11:00 PM to 7:00 AM shift on the night Resident #139 was admitted to the facility. She stated the 3:00 PM to 11:00 PM nurse entered all of Resident #139's admission orders [REDACTED]. She stated the nurse that enters the admission orders [REDACTED]. She stated INR standing order should have been entered for Resident #139 for every other day INR checks because he was admitted on [MEDICATION NAME]. She further stated she had administered Resident #139's [MEDICATION NAME] but had never checked his INR. An interview conducted on 11/17/17 at 7:00 PM with Nurse #3 revealed she admitted Resident #139 on 10/18/17 and put his orders in the computer. She stated she put his order for [MEDICATION NAME] 10 mg in the computer but she did not put the standing order for every other day INR checks in the computer. She stated she should have put the order for INR checks with the [MEDICATION NAME] order but overlooked it. She further stated she had administered Resident #139's [MEDICATION NAME] but had never checked his INR. A follow up interview conducted on 11/18/17 at 9:17 AM with the facility Physician revealed an INR value of 7.8 was a critical lab value and had the INR checks been done it could have been avoided. An interview conducted on 11/18/17 at 11:32 AM with the Director of Nursing (DON) revealed it was the nurse admitting the resident responsibility to enter the standing orders for INR checks to be done if the resident was on [MEDICATION NAME]. He stated the Risk Round Team that consisted of Administrative Nurses checked all new admission orders [REDACTED]. He stated the INR should have been checked every other day for 1 week then once a week for 4 weeks then once a month. An interview conducted with the Administrator on 11/19/17 at 7:30 AM revealed it was her expectation for the admitting nurse to put in the standing order for INR checks for residents admitted on [MEDICATION NAME]. She stated she did not know how the order was missed during Risk Round Checks. She further stated the INR should have been checked every other day for a week then once a week for 4 weeks then once a month. The Administrator, DON, and the Regional Director of Clinical Services were informed of Immediate Jeopardy on 11/19/17 at 1:11 PM. On 11/19/17 at 4:56 PM, the facility provided the following Credible Allegation of Compliance: F329 Unnecessary Medication Use The Plan of Correcting the specific deficiency Resident # 139 was admitted to this facility on 10/18/17. Resident was on [MEDICATION NAME] upon admission. Licensed Nurse #3 failed to follow the policy for transcribing standing orders related to the monitoring of INRs, and the risk rounds failed to identify the missed transcription of the standing INR orders. As a result, facility failed to monitor Resident #139's INR on four occasions including; 10/21/17, 10/23/17, 10/25/17 and 10/27/17. Resident #139 was hosptalized on [DATE] and found to have an elevated INR level of 7.8. The Procedure for Implementing the Acceptable Plan of correction for the specific deficiency cited. All resident that receive [MEDICATION NAME] have the potential to be affected. An audit was completed on 11/17/17 by Director of Nursing of current residents currently receiving [MEDICATION NAME] to validate INR orders entered in Point Click Care (PCC) and on the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) flowsheet. No negative findings related to monitoring. An audit was completed on 11/19/17 by licensed nurse of residents. admitted from 10/18/17 - 11/19/17 to validate INR orders entered in Point Click Care (PCC) and on the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) flowsheet. No negative findings related to monitoring. On 11/17/17 management staff began re-educating nurses on the policy and procedure as it relates to transcription of orders including ordering of lab for INR monitoring. Re-education is complete as of 11/19/17. Education with Nurse # 3 was completed on 11/17/17. To prevent this from recurring the admitting nurse will enter the order into PCC and transcribe onto the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) flowsheet. The transcription of the order and placement on the flowsheet will then be validated by a second nurse on the same shift. To complete validation of accuracy, the administrative nurses will review the transcription of [MEDICATION NAME] orders in PCC and placement of INRs on a flowsheet and on the PCC treatment administration record (TAR) as part of weekday morning risk meeting. The monitoring procedure to assure the Plan of Correction is corrected and the specific deficiency cited remains corrected and in compliance with regulatory requirements. Nursing management will complete an audit of residents with orders for [MEDICATION NAME] 3 x weekly to validate transcription of INR standing orders into PCC TAR and to the flowsheet. Any identified discrepancies will be corrected immediately and the prescribing physician will be notified. In addition nursing management will audit 3x weekly results of INRs to validate notification of Physician of abnormal INRs results. The title of the person responsible for implementing the acceptable plan of correction is the Director of Nursing and Administrator. Date of Alleged Compliance is: 11/19/17 Immediate Jeopardy was removed on 11/19/17 at 5:38 PM when interviews with Nurses confirmed they had received in-service training on how to follow standing orders for INR checks for residents on [MEDICATION NAME].

Based on record review and Physician and staff interviews the facility failed to transcribe a physician standing orders for a laboratory test to monitor the clotting time of a resident's blood which led to the laboratory test being missed four times that resulted in an elevated bleeding time for 1 of 3 residents reviewed on [MEDICATION NAME] (blood thinner) therapy (Resident #139). Resident #139 admitted to the hospital and received treatment to reduce his elevated bleeding time. The facility also failed to confirm a therapeutic exchange for a physician ordered medication which resulted in a 2 day delay in administration of a medication ordered for bursitis for 1 of 1 resident reviewed for pharmaceutical services (Resident #66). Immediate Jeopardy began on 10/21/17 when staff failed to monitor the blood clotting time for Resident #139, who was receiving [MEDICATION NAME] 10 milligrams (mg) once a day per, per the resident's physician's standing orders. Due to staff not transcribing Resident #139's physician's standing orders staff did not monitor the resident's blood clotting time on 10/21/17, 10/23/17, 10/25/17 and 10/27/17. Immediate Jeopardy was removed on 11/19/17 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The facility was cited at F281 for example #2 at a scope and severity level of D. The findings included: 1. Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum (MDS) data set [DATE] revealed Resident #139 was moderately cognitively impaired and received anticoagulants during the assessment period. Review of Resident #139's History and Physical from the hospital dated 10/10/17 revealed Resident #139 had a series of hospitalization s. He was discharged [DATE] after being admitted with [DIAGNOSES REDACTED] bleed while on Xarelto (a blood thinner). He was transfused a total of 4 units of blood during that stay. Resident #139 was subsequently readmitted on [DATE] with a possible [MEDICAL CONDITION] embolism with low clot burden as well as left lower lobe infiltrate. He was seen by hematology who recommended converting from Xarelto (blood thinner) to [MEDICATION NAME] (blood thinner). He was discharged on [DATE] and reported back to hospital on [DATE] for weakness. The hospital records didn't say what date the [MEDICATION NAME] was changed to [MEDICATION NAME] but he was discharged on [MEDICATION NAME] 10 mg as below. Review of the hospital discharge summary dated 10/18/17 revealed the impression/plan for Resident #139 was as follows: continue [MEDICATION NAME], check International Normalized Ratio (INR) daily (laboratory test to check clotting time of blood), goal INR 2 to 3. Review of the hospital discharge summary dated 10/18/17 revealed Resident #139's anticoagulation therapy would be monitored by the Facility Physician. The next INR was due 10/21/17. The INR on 10/18/17 was 1.9 with a target INR of 2 to 3. Review of the facility Standing Orders for Anticoagulants was: INR will be performed monthly on all residents receiving [MEDICATION NAME]. If a resident is receiving upon admission or is started on medication, an INR will be performed every other day for 1 week, then every other week x 4, then monthly, unless otherwise ordered by MD. Review of the care plan dated 10/18/17 revealed Resident #139 received anticoagulant use with a goal for no complications related to anticoagulant use. The interventions included: administer medications as ordered. Monitor for behavior changes. Monitor for signs and symptoms of internal/external bleeding. Monitor labs as ordered. Protect from injury. Review of the facility physician orders [REDACTED]. -[MEDICATION NAME] 10 milligrams (mg) every afternoon for anticoagulation therapy. -No orders for INR testing. Review of the facility PT/INR/[MEDICATION NAME] Flowsheet revealed the INR was checked on 10/19/17 with a result of 2.1 with no change in orders for [MEDICATION NAME] 10 mg once a day. Resident #139 missed INR checks on 10/21/17, 10/23/17, 10/25/17 and 10/27/17 per the standing orders. Review of a nurse's note dated 10/27/17 at 4:38 PM revealed Resident #139 reported shortness of breath and a dark purple raised area was noted on his inner right calf. The physician was notified and an order was received for Resident #139 to sent to the emergency department (ED) for evaluation and treatment. Review of a hospital discharge summary dated 10/28/17 revealed Resident #139 presented at the ED on 10/27/17 for bilateral lower extremity [MEDICAL CONDITION] with extensive bruising and confusion. A family member reported they had noticed extensive bruising developing in both feet 2 days ago and given his medical history they had requested an evaluation. The Physician noted extensive bruising of the right lower extremity, a large hematoma on the top of of his right foot, and bruising on his left foot. Review of the hospital laboratory test results revealed an INR of 7.8 on 10/27/17. The plan was to hold the [MEDICATION NAME], give Vitamin K (a medication used to reverse [MEDICATION NAME]), and consider Fresh Frozen Plasma (a blood product made from the liquid portion of whole blood) if there was further swelling of the hematoma. Resident #139 was transferred to a larger local hospital due to respiratory distress on 10/28/17. Review of a hospital admission History and Physical dated 10/28/17 revealed Resident #139 was seen in the emergency room for swelling, shortness of breath and a concern of possible clots. The report stated his INR was elevated at 7.8 and a large central line was placed to correct his INR. He responded partially to Vitamin K and was given 2 units of Fresh Frozen Plasma. An interview conducted on 11/17/2017 at 4:20 PM with the facility physician revealed he reviewed Resident #139's INR one time (on 10/19/17) during his stay at the facility and it was in the therapeutic range. He stated the INR should have been checked after that per standing orders and any result above 3 or below 2 should have been called to him. He further stated it was his expectation for the nurses to enter the standing orders for the INR checks to be completed and the results called to him. He stated he was unaware Resident #139's INR's weren't being checked per the standing orders and should have been. An interview conducted on 11/17/2017 at 6:44 PM with Nurse #2 revealed she worked the 11:00 PM to 7:00 AM shift on the night Resident #139 was admitted to the facility. She stated the 3:00 PM to 11:00 PM nurse entered all of Resident #139's admission orders [REDACTED]. She stated the nurse that enters the admission orders [REDACTED]. She stated INR standing order should have been entered for Resident #139 for every other day INR checks because he was admitted on [MEDICATION NAME]. An interview conducted on 11/17/17 at 7:00 PM with Nurse #3 revealed she admitted Resident #139 on 10/18/17 and put his orders in the computer. She stated she put his order for [MEDICATION NAME] 10 mg in the computer but she did not put the standing order for every other day INR checks in the computer. She stated she should have put the order for INR checks with the [MEDICATION NAME] order but overlooked it. A follow up interview conducted on 11/18/17 at 9:17 AM with the facility Physician revealed an INR value of 7.8 was a critical lab value and had the INR checks been done it could have been avoided. An interview conducted on 11/18/17 at 11:32 AM with the Assistant Director of Nursing (DON)/Acting DON revealed it was the nurse admitting the resident responsibility to enter the standing orders for INR checks to be done if the resident was on [MEDICATION NAME]. He stated the Risk Round Team that consisted of Administrative Nurses checked all new admission orders [REDACTED]. He stated the INR should have been checked every other day for 1 week then once a week for 4 weeks then once a month. An interview conducted with the Administrator on 11/19/17 at 7:30 AM revealed it was her expectation for the admitting nurse to put in the standing order for INR checks for residents admitted on [MEDICATION NAME]. She stated she did not know how the order was missed during Risk Round Checks. The Administrator, DON, and the Regional Director of Clinical Services were informed of Immediate Jeopardy on 11/19/17 at 1:11 PM. On 11/19/17 at 4:56 PM, the facility provided the following Credible Allegation of Compliance: F281 Meeting Professional Standards The Plan of Correcting the specific deficiency Resident # 139 was admitted to this facility on 10/18/17. Resident was on [MEDICATION NAME] upon admission. Licensed Nurse #3 failed to follow the policy for transcribing standing orders related to the monitoring of INRs, and the risk rounds failed to identify the missed transcription of the standing INR orders. As a result, facility failed to monitor Resident #139's INR on four occasions including; 10/21/17, 10/23/17, 10/25/17 and 10/27/17. Resident #139 was hosptalized on [DATE] and found to have an elevated INR level of 7.8. The Procedure for Implementing the Acceptable Plan of correction for the specific deficiency cited. All resident that receive [MEDICATION NAME] have the potential to be affected. On 11/17/17 management staff began re-educating nurses on the policy and procedure as it relates to transcription of orders including ordering of lab for INR monitoring. Re-education is complete as of 11/19/17 or prior to their next scheduled shift to work. New hires will be educated on the policy during orientation and prior to transcribing orders in to PCC. Education with Nurse # 3 was completed on 11/17/17. To prevent this from recurring the admitting nurse will enter the order into Point Click Care (PCC) and transcribe onto the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) flowsheet. The transcription of the order and placement on the flowsheet will then be validated by a second nurse on the same shift. To complete validation of accuracy, the administrative nurses will review the transcription of [MEDICATION NAME] orders in PCC and placement of INRs on a flowsheet and PCC treatment administration record as part of weekday morning risk meeting. The monitoring procedure to assure the Plan of Correction is corrected and the specific deficiency cited remains corrected and in compliance with regulatory requirements. Nursing management will complete an audit of residents with orders for [MEDICATION NAME] 3 x weekly to validate transcription of INR orders into PCC and to the flowsheet. Any identified discrepancies will be corrected immediately and the prescribing physician will be notified. The title of the person responsible for implementing the acceptable plan of correction is the Director of Nursing. Date of Alleged Compliance is: 11/19/17 Immediate Jeopardy was removed on 11/19/17 at 5:38 PM when interviews with Nurses confirmed they had received in-service training on how to transcribe standing orders for INR checks for residents on [MEDICATION NAME]. 2. Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 was cognitively intact with adequate vision and clear speech. Review of care plan dated 02/09/17 revealed Resident #66 was at risk for pain related to left superior pubic fracture and [MEDICAL CONDITION]. The goal was for Resident #66 to maintain comfort to the highest degree possible through next review. Interventions included administered pain medication as ordered, monitored effectiveness and reported unrelieved pain to the physician. Review of Resident #66's physician order [REDACTED]. The order was sent electronically to the pharmacy on the evening of 10/13/17. Review of Resident #66's electronic Medication Administration Record (eMAR) revealed [MEDICATION NAME] 200 mg was not given and was discontinued on 10/14/17. an order for [REDACTED]. [MEDICATION NAME] was discontinued after Resident #66 completed the 5-days therapy on 10/20/17. During an interview on 11/14/17 at 10:15 AM, Resident #66 stated she thought she would receive [MEDICATION NAME] for her bursitis in October but she had no idea why she had did received the medication as soon as it was ordered. Resident #66 added she did receive [MEDICATION NAME] on the morning of 10/16/17 and for a 5-days of therapy. She denied suffered any pain during the weekend when she was supposed to receive the [MEDICATION NAME]. During an interview on 11/16/17 at 5:37 PM, Nurse #7 explained whenever there was a prescription order, the nurse who received the order had to input and submit the order electronically to the pharmacy. Nurse #7 stated she sent Resident # 66's [MEDICATION NAME] order to the pharmacy on 10/13/17 evening. She could not explain why the facility waited until 10/16/17 to start Resident #66's [MEDICATION NAME] therapy. During a phone interview on 11/17/17 at 8:57 AM, the Pharmacist stated the pharmacy received the [MEDICATION NAME] order electronically on 10/13/17 at 5:56 PM. Since the order came in after the 5:00 PM cut off time, it would be delivered on the next day. The Pharmacist explained the facility had a formulary agreement regarding therapeutic interchange. Any order for [MEDICATION NAME] 200 mg would be automatically switched to [MEDICATION NAME] 7.5 mg and the pharmacy would send an Order Pending Confirmation electronically. The nurse who provided care for the specific resident was required to confirm the order with the physician before it could be started. According to the Pharmacist, the [MEDICATION NAME] order was filled on 10/13/17, late evening, and the medications were delivered to the facility on [DATE] at 2:35 AM. Per the Academy of Managed Care Pharmacy, therapeutic interchange was defined as the practice of replacing, with the prescribing physician's approval, a prescription medication originally prescribed for a patient with a chemically different medication. During an interview on 11/17/17 at 9:44 AM, the Assistant Director of Nursing (ADON)/Acting DON explained whenever there was a therapeutic interchange, the nurse had to acknowledge the Order Pending Confirmation tab so that the order would appear on the eMAR and the resident would start to receive the medication. In this case, the nurses who provided care for Resident #66 on 10/14/17 morning through 10/15/17 evening had failed to confirm the order electronically in a timely manner. When the order was finally confirmed on 10/16/17 morning, Resident #66 started to receive her [MEDICATION NAME]. During an interview on 11/17/17 at 10:01 AM, Nurse #4 acknowledged she was the nurse who failed to confirm Resident #66's [MEDICATION NAME] order on the morning of 10/14/17. Nurse #4 stated she had been working for the facility since September 2017. She was unaware of the requirement to confirm the order as she had never been trained on handling Order Pending Confirmation electronically. During an interview on 11/17/17 at 4:10 PM, the Assistant Director of Nursing (DON)/Acting DON stated he expected the nurse to check for outstanding order pending confirmations at the beginning of the shift and before medication pass. The DON attributed the incident as lack of training. It was his expectation for all the medication orders to be filled and administered as ordered in a timely manner.

Based on record review, resident interview, and staff interviews, the facility failed to provide an environment that maintained 1 of 3 residents' right to be free from abuse (Resident #71). Immediate Jeopardy began on 10/23/17 when a nurse aide threw a meal tray into the hallway and an object from that meal tray hit Resident #71 as she was propelling her wheelchair nearby. Immediate Jeopardy was removed on 11/19/17 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy Removal. The facility remains out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: Resident #71 was admitted to the facility on [DATE]. Her diagnoses included [MEDICAL CONDITION] following a cerebral infarction, muscle weakness and [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #71's annual Minimum Data Set ((MDS) dated [DATE] coded her with moderately impaired cognition and requiring extensive assistance with most activities of daily living skills. The Care Area Assessment (CAA) related to cognition dated 07/23/17 stated Resident #71 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS). The CAA noted she had confusion, forgetfulness and she showed signs of age related cognitive loss although she had no diagnoses of dementia. It was noted her BIMS scored varied. She was at risk for cognitive changes. On 11/13/17 at 10:07 AM during an interview, Resident #71 denied she had been abused and denied she had been hit by a meal tray or anything. A follow up interview was conducted on 11/17/17 at 9:46 AM, Resident #71, when asked again about a tray incident, stated she recalled a tray being thrown but denied being hit by anything. She stated it happened so fast she did not know what to think and thinks it scared her a little. She further stated that the nurse aide involved was a good worker. Review of a 24 hour initial report sent to the Health Care Personnel Investigations on 10/23/17 at 7:44 PM, revealed that a staff member reported that Nurse Aide (NA) #2 tossed a meal tray on 10/23/17 at 5:30 PM and that Resident #71 was wet with water. Review of the investigation revealed written statements were obtained by the nurse on duty (Nurse #1), the Nurse Aide (NA) #1 who witnessed the incident, and NA #2 who was alleged to throw the tray. The written statement from NA #1 dated 10/23/17 stated that approximately at 5:30 PM, NA #2 threw a computer mouse out of the nurse's station and across the hall barely missing a resident. NA #2 then went to the kitchen to obtain the tray cart and NA #1 told her to chill. NA #2 then grabbed a tray off the cart and flung it across the hall. Items went flying everywhere including a glass full of water that hit (Resident#71) in the face. When asked what her problem was, NA #2 grabbed her stuff and walked out of the door. After (NA #1) checked on (Resident #71) (NA #1) reported it to the nurse who heard the incident. An interview was conducted with NA #1 on 11/15/17 at 8:23 AM. She recalled that on 10/23/17 she and NA #2 worked a 12 hour shift. Around supper time, an announcement over the speaker was made that the trays for this hall were ready. Then a nurse called the nursing station to make sure staff heard the announcement. Then NA #2 threw a mouse into the hall and left to get the tray cart. Upon return NA #1 told NA #2 to calm down and NA #2 then threw a tray off the cart with a cup hitting Resident #71. NA #2 left the unit and NA #2 told Nurse #1. A phone follow up interview with NA #1 on 11/16/17 at 4:17 PM revealed Resident #71 was about an arms length away from NA #2 when she threw the tray and NA #1 saw a cup of water hit Resident #71's left lower jaw. Resident #71 never reacted and was not injured. NA #1 stated she was intending on telling Nurse #1 about the mouse being thrown in the hall by NA #2, however, before she could leave the floor, NA #2 had thrown the tray. The written statement from NA #2 dated 10/23/17 stated NA #2 had gotten very frustrated at work, to the 'breaking point.' I was about to pass out trays when someone told me I 'needed to chill', which set me over the edge. So, without thinking or being aware of who or what was around me, I took a tray from the cart and flung it across the hall. I did not know it affected (Resident #71), because she kept rolling by. The written statement also included that she did not think she caused them any more trouble than what all the staff has, by not being able to care for their needs to the fullest. It was not possible for two people to take care of 50 people like they should be taken care of. It's barely possible for 3 people to prove the care that is necessary for the residents at this facility. She stated she was frustrated because she felt as if there was too much that she could not handle and she didn't think anyone should have to work under the conditions that the staff are expected to work under at this facility. A phone interview was conducted with NA #2 on 11/16/17 at 9:54 AM. She stated there were only 2 aides on the 100 hall. NA #2 got frustrated when a nurse called after the overhead announcement that the trays were ready. She stated she threw the mouse into the hall and went to get the trays. Her coworker (NA #1) told her several times she should chill out in a reprimanding way. After being told several times, NA #2 stated she took a tray off the cart and threw it into the hall. She then left the hall. She stated she was frustrated due to short staffing for months and not being able to give the residents the care that was needed. A follow up interview with NA #2 on 11/16/17 at 4:29 PM revealed she probably knew Resident #71 was rolling by but did not realize how close she was. She found out later an item hit Resident #71. A written statement from Nurse #1 dated 10/23/17 stated at 5:30 PM she heard a loud noise from the main dining room. The sound came from the day room on the 100 hall. NA #2 started walking down the hall with her coat and purse and Nurse #1 asked NA #2 what happened. NA #2 stated 'you can have this I'm done.' Nurse #1 wrote she went down the hall and Resident #71's shirt and pants were wet. Resident #71 stated 'that girl's mad and throwing stuff.' Resident #71 stated a plate hit her knee and she was wet. Resident #71's skin was checked and found no bruising or redness. The statement continued at 5:37 I called (name of) DON and informed her of the situation. Nurse #1 was interviewed via phone on 11/16/17 at 10:04 AM. Nurse #2 stated that she heard a noise and started to head up the hall when NA #2 passed her with her coat and purse saying she had enough and was leaving. Nurse #1 saw the tray and food all over the floor and Resident #71's shirt was 'soaked'. Resident #71 stated her knee hurt a little but she was alright and that girl was really mad. Nurse #1 helped NA #1 pick up the mess and tried to obtain information about what happened. NA #2 then came back in after about 30 minutes and Nurse #1 tried to gather information before calling administration. NA #2 stated she had not intended to hit anyone. NA #2 showed remorse and was calm when she returned from the break room. Nurse #1 stated she did not think NA #2 would endanger anyone. NA #2 apologized and Nurse #1 informed NA #2 she would call her boss. Nurse #1 stated NA #2 asked to continue working and Nurse #1 agreed as long as she did not throw anymore trays. Nurse #1 called the Administrator and DON and was instructed to take statements, not write up an incident report but to complete the 24 hour form and fax it to the Health Care Personnel Investigations unit and send NA #2 home. Nurse #1 stated that in hindsight she would have sent her home immediately and would have done so if there had been more aides to pass 30 trays and assist on the floor. No one was available to help. During a follow up phone interview on 11/16/17 at 3:57 PM, Nurse #1 stated she learned about NA #2 throwing the mouse when she took NA #1's statement. She stated if she knew NA #2 had thrown a mouse earlier, she would have sent her home immediately after she threw the tray despite short staffing. She stated she thought the tray incident was an isolated incident. Nurse #1 stated NA #2 worked on the floor after the tray incident for approximately 10 minutes before the DON spoke to her on the phone and instructed her to leave. Interview with the Administrator on 11/16/17 at 11:59 AM revealed she unsubstantiated the abuse following the investigation after a discussion with corporate and they felt it had to do with burnout. Education was provided to NA #2. The Administrator stated NA #2 should not have been permitted to work on the floor after throwing the tray. Interview with the DON on 11/16/17 at 12:11 PM revealed she received a call on 10/23/17 from Nurse #1 around 5:30 to 6:00 PM. She learned that NA #2 was frustrated, threw a tray and left the building. Nurse #1 called the DON back after NA #2 returned, within 7 to 8 minutes, asking what she should do next. DON instructed Nurse #1 to put NA #2 in an office and obtain a written statement and then escort her out of the building. Per the undated Summary of the investigation of the 10/23/17 incident written by the DON, NA #2 was removed from the hall immediately, was educated on employee burnout and how to handle work related stress prior to allowing her to return to work. The allegation of abuse was unsubstantiated due to no intent of harm. The Administrator and Regional Clinical Nurse were informed of Immediate Jeopardy on 11/16/17 at 6:18 PM. The facility provided an acceptable credible allegation of immediate jeopardy removal on 11/19/17 at 11:57 AM as follows: The Plan of Correcting the specific deficiency. The original allegation on 10/23/17 for Resident #71 was investigated and a Facility Reportable Incident was submitted by the administrator. The area of concern identified on 10/23/17 Nurse Aide (NA) #2 was not removed from her duties by Nurse #1 when she became upset and threw objects including a computer mouse and a resident's meal tray. This resulted in Resident #71 being hit with an object and NA#2 was allowed to continue to work before calling the Director of Nursing. An investigation was initiated by the Administrator and Director of Nursing on 10/23/17. An investigation was conducted by the Administrator and Director of Nursing and Facility Reportable Incident submitted on 10/23/17 and 5 Day on 10/27/17. The(NAME)Police were notified of the incident on 10/23/17 and no charges filed On 10/23/17 the resident was assessed for injury by licensed nurse and had no negative outcome On 11/16/17 the facility started another investigation related to incident of 10/23/17 for resident #71 occurrence due to additional findings during state survey interviews. This was conducted by the Administrator of Autumn Care of Drexel. It was identified that NA#2 was not immediately suspended and returned to care while Director of Nursing was being notified by the Nurse#1 on duty. On 11/16/17 the Nurse#1 and NA#2 from 10/23/17 occurrence were suspended pending investigation. NA#2 and Nurse#1 was terminated and removed from payroll system on 11/17/17 11/16/17 statements obtained for those staff in original investigation The Procedure for Implementing the Acceptable Plan of correction for the specific deficiency cited. All residents have the potential to be affected. On 11/13/17 management staff was educated by the Administrator on the new Manager-On-Duty (MOD) process and implemented on weekends beginning on 11/19/17. This process is new to facility and provides for management /administrative coverage on weekends both scheduled and at random based on the needs of the center, to include management rounds and addressing concerns or allegation of abuse which will be handled immediately by the Manager on Duty who will notify Administrator and Director of Nursing. The Nurse assigned to 300 Hall is the designated nurse in charge in the absence of the Administrator or Director of Nursing and will notify the Director of Nursing and Administrator immediately of any allegations of abuse or concerns. To prevent this from recurring the Administrator and Regional Clinical Consultant started immediate in-house education on 11/16/17 related to F223 Abuse and F226 development and implementation of policy and procedures (screening/training/prevention/ identification/ investigation/protection/ reporting response and burnout. This education was performed to ensure staff was properly trained on abuse and aware that abuse would not be tolerated at the facility. 11/16/17 the Administrator re-educated department heads on abuse and policy and procedures Department heads completed education for staff on duty and the education will continue through 11/17/17 Education will continue via telephone and staff will not be permitted to work until education is received. New hires will be educated to abuse policy and procedure upon hire. The Regional Vice President of Operation re-educated the Licensed Nursing Home Administrator on abuse, policy and procedures and conducting a proper/thorough investigation on 11/17/17 11/17/17 random staff interviews were conducted by Nursing Home Administrator related to abuse/reporting/ witnessing abuse and knowledge of abuse procedure. On 11/17/17 the Business office manager completed an employee file audit to ensure appropriate pre-employment screening was completed for NA#2 and all other staff, including new hires. Resident council minutes and resident concern forms for the last 3 months were reviewed by the Administrator of NA #2. No negative findings. On 11/17/17 Facility resident interviews were conducted by Department Managers for those residents that are interviewable related to abuse. There were new negative findings. On 11/17/17 body checks were completed for those residents that are not interviewable completed by Licensed Nurses. There were new negative findings. The monitoring procedure to assure the Plan of Correction is corrected and the specific deficiency cited remains corrected and in compliance with regulatory requirements. To monitor and maintain ongoing compliance: The facility Administrative/Department Managers will start abuse questionnaires with all staff on 11/17/17 related to abuse and policy and procedures (7 elements). The audits will be completed on 3 staff, 3x weekly. Any negative findings will be addressed immediately Administrator or Director of Nursing. On 11/17/17 resident questionnaires will be conducted with 3 residents 3x weekly related to abuse. Any negative findings will be addressed immediately by Administrator of Director of Nursing. The facility will conduct an Ad H(NAME) Quality Assurance Performance Improvement meeting on 11/17/17 with the facility Interdisciplinary team, the Regional Team and the Medical Director to review. The title of the person responsible for implanting the acceptable plan of correction is the Administrator. Date of Alleged Compliance is: 11/19/17

Based on record review, and staff interviews, the facility failed to implement their abuse policy and procedures related to the prevention, protection and investigation for 1 of 3 residents who were reviewed for abuse investigations. Immediate Jeopardy began on 10/23/17 when a nurse aide threw a meal tray into the hallway and an object from that meal tray hit Resident #71 as she was propelling her wheelchair nearby and missed hitting Resident #23. The nurse aide was permitted to continue working with residents during the meal. Immediate Jeopardy was removed on 11/19/17 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy Removal. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: The facility's Resident Abuse Policy, last revised 03/03/17, revealed Abuse was defined as including such actions such as the willful infliction of injury. The policy continued stating Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury. Under the section of prevention was the deployment of staff on each shift in sufficient numbers to meet the needs of the residents. Under the section of how to investigate allegations included interview of all witnesses. The policy also indicated that if a staff member is accused or suspected of abuse, the Facility will immediately remove staff member from the resident care area and the accused staff member will remain under direct supervision until statement is complete. The policy also noted that there should be documentation in the nurses' notes including the results of the resident's range of motion, body assessment, vital signs, and notification of the physician and responsible party. Resident #71 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #71's annual Minimum Data Set ((MDS) dated [DATE] coded her with moderately impaired cognition and requiring extensive assistance with most activities of daily living skills. Review of a 24 hour initial report sent to the Health Care Personnel Investigations on 10/23/17 at 7:44 PM, revealed that a staff member reported that Nurse Aide (NA) #2 tossed a meal tray on 10/23/17 at 5:30 PM and that Resident #71 was wet with water. Review of the investigation revealed written statements were obtained by the nurse on duty (Nurse #1), the Nurse Aide (NA) #1 who witnessed the incident, and NA #2 who was alleged to throw the tray. The written statement from NA #1 dated 10/23/17 stated that approximately at 5:30 PM, NA #2 threw a computer mouse out of the nurse's station and across the hall barely missing a resident. NA #2 then went to the kitchen to obtain the tray cart and NA #1 told her to chill. NA #2 then grabbed a tray off the cart and flung it across the hall. Items went flying everywhere including a glass full of water that hit (Resident#71) in the face. When asked what her problem was, NA #2 grabbed her stuff and walked out of the door. After (NA #1) checked on (Resident #71) (NA #1) reported it to the nurse who heard the incident. An interview was conducted with NA #1 on 11/15/17 at 8:23 AM. She recalled that on 10/23/17 she and NA #2 worked a 12 hour shift. Around supper time, an announcement over the speaker was made that the trays for this hall were ready. Then a nurse called the nursing station to make sure staff heard the announcement. Then NA #2 threw a mouse into the hall and left to get the tray cart. Upon return NA #1 told NA #2 to calm down and NA #2 then threw a tray off the cart with a cup hitting Resident #71. NA #2 left the unit and NA #2 told Nurse #1. After 10 to 15 minutes, NA #2 came back and finished passing trays. A phone follow up interview with NA #1 on 11/16/17 at 4:17 PM revealed Resident #71 was about an arms length away from NA #2 when she threw the tray and NA #1 saw a cup of water hit Resident #71's left lower jaw. Resident #71 never reacted and was not injured. She again stated NA #2 continued to pass trays for about 20 minutes until NA #2 was instructed to write a statement. NA #1 stated she was intending on telling Nurse #1 about the mouse being thrown in the hall by NA #2, however, before she could leave the floor, NA #2 had thrown the tray. The written statement from NA #2 dated 10/23/17 stated NA #2 had gotten very frustrated at work, to the 'breaking point. I was about to pass out trays when someone told me I 'needed to chill', which set me over the edge. So, without thinking or being aware of who or what was around me, I took a tray from the cart and flung it across the hall. I did not know it affected (Resident #71 and Resident #23), because they kept rolling by .After the tray, I got my things, told (Nurse #1) I was done, and went in the break room with intentions of clocking out. When I got to the break room, I came to my senses and decided to go back and finish the shift. A phone interview was conducted with NA #2 on 11/16/17 at 9:54 AM. She stated there were only 2 aides on the 100 hall. NA #2 got frustrated when a nurse called after the overhead announcement that the trays were ready. She stated she threw the mouse into the hall and went to get the trays. Her coworker (NA #1) told her several times she should chill out in a reprimanding way. After being told several times, NA #2 stated she took a tray off the cart and threw it into the hall. She then left the hall and went to the break room but decided she had bills to pay and did not want to abandon her duties so she finished her shift via passing out trays and feeling a resident until her shift ended. She stated she was then placed on burn out leave for two days and allowed to return to work. She recalled the Director of Nursing meeting with her. She stated she was frustrated due to short staffing for months and not being able to give the residents the care that was needed. A follow up interview with NA #2 on 11/16/17 at 4:29 PM revealed she probably knew Resident #71 and her roommate (Resident #23) were rolling by but did not realize how close they were. She found out later an item hit Resident #71. NA #2 stated Nurse #2 let her pass trays which she did so and continued to work on the hall for approximately 45 minutes. She was interviewed by the Director of Nursing (DON) via phone that day and in person later. A written statement from Nurse #1 dated 10/23/17 stated at 5:30 PM she heard a loud noise from the main dining room. The sound came from the day room on the 100 hall. NA #2 started walking down the hall with her coat and purse and the nurse asked NA #2 what happened. NA #2 stated 'you can have this I'm done.' Nurse #1 wrote she went down the hall and Resident #71's shirt and pants were wet. Resident #71 stated 'that girl's mad and throwing stuff.' Resident #71 stated a plate hit her knee and she was wet. Resident #71's skin was checked and found no bruising or redness. The statement continued at 5:37 PM (NA #2) came back in the facility and asked if she could finish her shift stating 'I don't want to be got for abandonment.' I called (name of) DON and informed her of the situation. Nurse #1 was interviewed via phone on 11/16/17 at 10:04 AM. Nurse #2 stated that she heard a noise and started to head up the hall when NA #2 passed her with her coat and purse saying she had enough and was leaving. Nurse #1 saw the tray and food all over the floor and Resident #71's shirt was soaked. Resident #71 stated her knee hurt a little but she was alright and that girl was really mad. Nurse #1 helped NA #1 pick up the mess and tried to obtain information about what happened. NA #2 then came back in after about 30 minutes and Nurse #1 tried to gather information before calling administration. NA #2 stated she did not intended to hit anyone. NA #2 showed remorse and was calm when she returned from the break room. Nurse #1 stated she did not think NA #2 would endanger anyone. NA #2 apologized and Nurse #1 informed NA #2 she would call her boss. Nurse #1 stated NA #2 asked to continue working and Nurse #1 agreed as long as she did not throw anymore trays. Nurse #1 called the Administrator and DON and was instructed to take statements, not write up an incident report but to complete the 24 hour form and fax it to the Health Care Personnel Investigations unit and send NA #2 home. Nurse #1 did not think NA #2 finished her shift. Nurse #1 stated that in hindsight she would have sent her home immediately and would have done so if there had been more aides to pass 30 trays and assist on the floor. No one was available to help. During a follow up phone interview on 11/16/17 at 3:57 PM, Nurse #1 stated she learned about NA #2 throwing the mouse when she took NA #1's statement. She stated if she knew NA #2 had thrown a mouse earlier, she would have sent her home immediately after she threw the tray despite short staffing. She stated she thought the tray incident was an isolated incident. Nurse #1 stated NA #2 worked on the floor after the tray incident for approximately 10 minutes before the DON spoke to her on the phone and instructed her to leave. Interview with the Administrator on 11/16/17 at 11:59 AM revealed she only interviewed NA #2 not the other witnesses. She further stated that the facility unsubstantiated the abuse following the investigation after corporate and they discussed it and felt it had to do with burnout. Education was provided to NA #2. The Administrator stated NA #2 should not have been permitted to work on the floor after throwing the tray. Interview with the DON on 11/16/17 at 12:11 PM revealed she received a call on 10/23/17 from Nurse #1 around 5:30 to 6:00 PM. She learned that NA #2 was frustrated, threw a tray and left the building. Nurse #1 called the DON back after NA #2 returned, within 7 to 8 minutes, asking what she should do next. DON instructed Nurse #1 to put NA #2 in an office and obtain a written statement and then escort her out of the building. The DON stated she did not talk to NA #1 about what happened and thought the Administrator interviewed NA #1. Review of the time clock documentation revealed NA #1 clocked out on 10/23/17 at 6:48 PM. Review of the nursing notes revealed no notes regarding Resident #71 being hit with an object from a tray thrown by a nurse aide, no physical assessment of the resident and no documentation of notification to the physician or responsible party per the facility's abuse policy. On 11/16/17 at 2:41 PM, the Administrator stated there should have been a nursing note or documentation of the nurse's assessment of Resident #71 after the incident. Nurse #1 stated during telephone interview on 11/16/17 at 3:57 PM that when she called administration on 10/23/17 to obtain guidance, she asked if she should write an incident note or document the incident somewhere and was told by both the Administrator and the Director of Nursing (DON) she did not need to document anything unless administration later instructed her to. Administration just wanted the 24 hour report faxed to the Health care Personnel Investigations. Record review revealed a skin assessment was completed on 10/24/17 at 12:56 AM by the DON which stated no current skin issues but did not specify anything about the incident or specifics relating to her knee or face (which were noted as being struck). The DON resigned prior to obtaining an interview relating to the skin assessment. The Administrator stated during interview on 11/16/17 at 2:41 PM that the nurse should have documented her skin assessment following the incident. A telephone interview with Nurse #1 on 11/16/17 at 3:57 PM revealed she was told not to make any nursing notes or additional documentation in the record and not to fill out an incident report by both the administrator and the DON. Per the Summary of the investigation written by the DON, NA #2 was removed from the hall immediately, was educated on employee burnout and how to handle work related stress prior to allowing her to return to work. The allegation of abuse was unsubstantiated due to no intent of harm. The Administrator and Regional Clinical Nurse were informed of Immediate Jeopardy on 11/16/17 at 6:18 PM. The facility provided an acceptable credible allegation of immediate jeopardy removal on 11/19/17 at 11:57 AM as follows: F226 Development/implementation of policy and procedures The Plan of Correcting the specific deficiency. The original allegation on 10/23/17 for Resident #71 was investigated and a Facility Reportable Incident was submitted by the Nurse #1 per the instruction of the Director of Nursing. The area of concern identified on 10/23/17 Nurse Aide (NA) #2 was not removed from her duties by Nurse #1 when she became upset and threw objects including a computer mouse and a resident's meal tray. This resulted in Resident #71 being hit with an object and NA#2 was allowed to continue to work before calling the Director of Nursing. This investigation did not include documented interviews of all witnesses and lacked documentation in the medical record. An investigation was initiated by the Administrator and Director of Nursing on 10/23/17. An investigation was conducted by the Administrator and Director of Nursing and Facility Reportable Incident submitted on 10/23/17 and 5 Day on 10/27/17. The(NAME)Police were notified of the incident on 10/23/17 and no charges filed On 10/23/17 the resident was assessed for injury by licensed nurse and had no negative outcome On 11/16/17 the facility started another investigation related to incident of 10/23/17 for Resident #71 occurrence due to additional findings, during state survey interviews. This was conducted by the Administrator of Autumn Care of Drexel. It was identified that NA#2 was not immediately suspended and returned to care while Director of Nursing was being notified by the Nurse#1 on duty. On 11/16/17 statements obtained for those staff in original investigation On 11/16/17 the Nurse #1 and NA #2 from 10/23/17 occurrence were suspended pending investigation. NA #2 and Nurse #1 was terminated and removed from payroll system on 11/17/17 The Procedure for Implementing the Acceptable Plan of correction for the specific deficiency cited. All residents have the potential to be affected. On 11/13/17 management staff was educated by the administrator on the new Manager-On-Duty (MOD) process and implemented on weekends beginning on 11/19/17. This process is new to facility and provides for management /administrative coverage on weekends both scheduled and at random based on the needs of the center, to include management rounds and addressing concerns or allegation of abuse which will be handled immediately by the Manager on Duty who will notify Administrator and Director of Nursing. The Nurse assigned to 300 Hall is the designated nurse in charge in the absence of the Administrator or Director of Nursing and will notify the Director of Nursing and Administrator immediately of any allegations of abuse. Also the Nurse will remove the alleged abuser. To prevent this from recurring the Administrator and the Regional Clinical Services Director started immediate in-house education on 11/16/17 related to Abuse and development and implementation of policy and procedures (screening/training/prevention/ identification/ investigation/protection/ reporting response and burnout. This education was performed to ensure staff was properly trained on abuse and aware that abuse would not be tolerated at the facility. - 11/16/17 the Administrator re-educated department heads on abuse and policy and procedures - Department heads completed education for staff on duty and the education will continue through 11/17/17 - New Hires will continue to be educated on abuse policy and procedure upon hire. - Education will continue via telephone and staff will not be permitted to work until education is received. - The Regional Vice President of Operation re-educated the Licensed Nursing Home Administrator on abuse, policy and procedures and conducting a proper/thorough investigation on 11/17/17 The monitoring procedure to assure the Plan of Correction is corrected and the specific deficiency cited remains corrected and in compliance with regulatory requirements. To monitor and maintain ongoing compliance: The facility Administrative/Department Managers will start abuse questionnaires with all staff on 11/17/17 related to abuse and policy and procedures (7 elements). The audits will be completed on 3 staff members 3x weekly. Any negative findings will be addressed immediately by the Administrator or Director of Nursing. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement committee for further review and recommendations. The facility will conduct an Ad H(NAME) Quality Assurance Performance Improvement meeting on 11/17/17 with the facility Interdisciplinary team, the Regional Team and the Medical Director to review. The title of the person responsible for implanting the acceptable plan of correction is the Administrator. Date of Alleged Compliance is: 11/19/17 Immediate Jeopardy was removed on 11/19/17 when interviews with direct and supervisory staff confirmed they had been inserviced and knew the facility's abuse policy and procedures including that suspected staff had to be removed from resident care immediately, witnesses had to be interviewed, and documentation had to be included in the nursing notes including event information, assessment information and notification information. The staff knew signs of burnout and what to do if they were feeling burned out or observed other coworkers with signs of burnout.

Based on observations, record reviews, and interviews the facility failed to provide incontinent care (Resident #27, #28, and #79) and assistance with tray set up (Resident #123) for 4 of 11 sampled residents reviewed for activities of daily living. The findings included: 1. Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 06/13/17 revealed Resident #28 was admitted with a history incontinence of bowel and bladder and was a risk for complications related to incontinent episodes. Interventions included to check and change per routine and as needed; and check for wetness on rounds during the night and as needed. Review of the Care Area Assessment (CAA) for Urinary Incontinence dated 06/22/17 revealed Resident #28 had episodes of incontinence of both bowel and bladder and required assistance with activities of daily living. It was noted despite her risk factors she had no complications related to incontinence. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 had severely impaired cognition and required extensive assistance with transfer, dressing, personal hygiene, and toilet use. The quarterly MDS indicated Resident #28 was always incontinent of bowel and bladder and noted no urinary toileting program had been attempted. Rejection of care was not observed. Observations of Resident #28 on 11/14/17 revealed at 4:20 PM she was observed self propelling in the hall wearing a pair of pink pants. The crotch area of the pants were visibly wet and a faint urine odor was noted as well. At 5:05 PM Resident #28 was observed in her room and the crotch area of her pants remained visibly wet. Nurse #11 entered Resident #28's room at 5:24 PM and Resident #28 stated she had a headache. Resident #28's pants were visibly wet and a faint urine odor was noted as well. At 5:25 PM Nurse #11 wheeled Resident #28 to the dining room and asked her to rate her pain. Nurse #11 returned to the dining room at 5:31 PM and administered medication to Resident #28. Her pants remained visibly wet and the urine odor was noticeable when standing next to her wheelchair. Nurse Aide (NA) #16 served and set up Resident #28's supper tray at 5:33 PM and exited the dining room. An interview with NA #17 on 11/14/17 at 5:33 PM revealed she was one of three NAs assigned to the 200 hall that evening and she did not get there until 4:00 PM. NA #17 stated the NAs worked together and did not have a specific resident or room assignment. NA #17 stated the other NAs had already started rounds before she arrived but they typically checked and changed everyone on the hall. NA #17 was not observed checking on Resident #28 at any time during a continuous observation from 4:20 PM until 5:25 PM when she was wheeled into the dining room by Nurse #11. An interview with NA #18 on 11/14/17 at 5:39 PM revealed she did not assist with incontinence rounds that afternoon because she was giving showers. NA #18 was not observed checking on Resident #28 at any time during a continuous observation from 4:20 PM until 5:25 PM when she was wheeled into the dining room by Nurse #11. During an interview on 11/14/17 at 5:44 PM NA #16 was asked which residents were checked and changed during rounds at the beginning of the shift. NA #16 stated they had checked and changed the residents that were in bed and the residents that turned on their call lights. NA #16 was not observed checking on Resident #28 at any time during a continuous observation from 4:20 PM until 5:25 PM when she was wheeled into the dining room by Nurse #11. An interview with Nurse #11 on 11/14/17 at 5:50 PM revealed she did not notice Resident #28's pants were wet with urine or check her for incontinence before taking her to the dining room. An interview was conducted with the Administrator on 11/14/17 at 5:54 PM. The Administrator stated it was not acceptable for a resident to be taken to the dining room or served a meal wearing pants wet with urine. The Administrator further stated she expected the NAs to check every resident on rounds at the beginning of the shift. The interview further revealed the Administrator thought the nurse had given the NAs a room assignment. 2. Resident #27 was originally admitted to the facility on [DATE] and recently readmitted on [DATE]. His [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] coded him with severely impaired cognition, having no behaviors, requiring extensive assistance with bed mobility, transfers, toileting and hygiene, and being frequently incontinent of bowel and bladder. The MDS noted no toileting program. Under bathing, the MDS noted the activity did not occur. a. The Care Area Assessment for incontinence dated 11/03/17 stated he was at risk for increased episodes of incontinence as well as complication. The current care plan initiated 05/05/16 included a goal for Resident #27 to be assisted with elimination needs as needed through 01/02/18. Interventions included to monitor and assist with any incontinent episodes; provide assistance with toileting, pericare and clothing management as indicated and per resident request. The Kardex Report, a care guide for nurse aides (NA) of individual resident care needs, revealed that incontinent care was to be provided as needed and staff should offer toileting with care rounds. Resident #27 was observed on 11/13/17 at 11:24 AM with a slight urine odor. On 11/14/17 at 8:10 AM, he was observed wheeling himself down the hall towards the dining room. He was wearing light blue thin pants which were observed to have a wet area around his crotch and darker dried rings at the edges of the wet area. A urine odor was observed as he passed the surveyor in the hall. At 8:12 AM NA #6 pushed him to the dining room door. He remained in the dining room through breakfast. Then at 9:35 AM, Resident #27 was observed in his room in his wheelchair with yellow dark stained light blue pants and the dried stain could be seen on his outer right thigh extending from his knee toward his bottom. Resident #27 was observed again on 1/14/17 at 9:42 AM and his crotch was very wet from his crotch to his knee on the inner thigh. A urine odor was evident. Staff entered the room across the hall at 9:46 AM. The odor of urine was strong in the hallway at this time and the surveyor could see his wet pants from the hall. At 9:48 AM the wound physician and Nurse #8 entered the room to provide wound care to Resident #27's roommate. Both the physician and Nurse #8 left Resident #27's room at 9:56 Am and continued on rounds. Resident #27 was still visibly wet from the hall. Resident #27 remained with the same wet blue pants, wetness observed under the right thigh when observed at 10:04 AM. The urine odor was noted from the hallway at 10:07 AM. Incontinence care was observed on 11/14/17 at 10:39 AM after NA #9 and #11 had provided care to his roommate. NA #9 and NA #11 stated they had not planned on caring for Resident #27 at this time. They pushed Resident #27 into the bathroom and removed his clothes. His blue pants and socks were soaked through with urine and his pants had dried urine stains on the legs. NA #9 stated at this time This is bad. On 11/14/17 at 10:46 AM, interviews were conducted during a group interview with NA #7, NA #8, NA #10, and an orientee NA #12, who were on the hall where Resident #27 resided. They all stated that they had no specific assignment regarding room/resident assignments they just pitched in and helped everyone. NA #7 produced the assignment sheet which listed the staff and the showers to be given and who was to pass ice but room numbers were not assigned. NA #7 stated the assignments depend on the number of nurse aides present. Sometimes they start providing care for residents at one end of the hall and others start at the other end of the hall and if enough, some start care in the middle. She further stated there were 2 other nurse aides at the far end of the hall where Resident #27 resided. NA #7, NA #8, NA #10 and NA #12 all stated they had not provided Resident #27 any care this morning. NA #6 stated at 11/14/17 at 10:51 AM that she did not notice Resident #27 was wet when she pushed him down the hall toward the dining room. On 11/14/17 at 10:53 AM, NA #9 stated she had not given him care this morning. Review of the assignment sheet on 11/14/17 at 10:57 AM revealed NA #9 was now assigned to Resident #27, as room assignments had been added next to staff names. Further interview with NA #9 stated she was not assigned to work this date and just came in to help. She had no assigned rooms as of 5 minutes prior to this conversation. She stated they usually do not have assigned rooms. She stated there should have been enough coverage for those who actually started the shift on time. Interview with NA #11 on 11/14/17 at 11:09 AM revealed she was from an agency and this was her 3rd day in this facility. She stated there was no specific assignment of rooms, they just went from room to room to provide resident. Care. NA #11 stated she had received report from 3rd shift NA that Resident #27 took care of himself. She further stated that she had not given him care this morning and it would make it easier if there was an actual resident assignment provided to the staff. During an interview on 11/17/17 at 4:14 PM, the Assistant Director of Nursing/ Acting Director of Nursing stated regardless of staffing levels, resident care was always the first priority for nursing staff. Other than answering call lights in a timely manner, it was his expectation for NAs to provide incontinent care immediately even when they were doing rounds. Follow up interview on 11/19/17 at 5:12 PM revealed he expected nurse aides to have and know their assignments to provide the necessary care and services including checking and changing incontinent residents as needed. b. The Care Area Assessment for activities of daily living (ADL) dated 11/03/17 stated Resident #27 had a recent illness and he was at risk for the inability to improve his ADL abilities. The current care plan, initiated 05/05/16 and with a target goal of 01/02/18 for the problem of Resident #27 exhibiting self care performance had a goal for him to participate with ADL as able. Under bathing it was noted he required assistance of 1 with bathing and showers. The Kardex Report, a care guide for nurse aides (NA) of individual resident care needs, revealed that his showers were due on Tuesdays and Fridays. Review of the bathing assignments per room/bed provided by the facility, revealed Resident 27's room/bed was not on the list to be captured for showers. Review of the ADL documentation in the medical record completed by nurse aides, revealed he had not been showered from 09/22/17 through 09/30/17; from 10/06/17 through 11/15/17. Resident #27 was observed to have urine odors on 11/13/17 at 11:24 AM and 11/14/17 at 8:10 AM. Interview with the Assistant Director of Nursing/Acting Director of Nursing (ADON) on 11/17/17 at 4:23 PM, the ADON stated that upon admission the activity staff asked about bathing preferences. The nurse then took this information and placed it on the shower schedule. The ADON stated the shower team who completed all showers on first shift was dissolved and the showers then spread over first and second shift by the DON (no longer employed). He stated generally showers for the beds by the doors were scheduled for first shift and the beds by the windows were scheduled for second shift. However, this change had not been updated in the computer system and therefore did not allow staff to document showers given per the new schedule. ADON then provided a new system developed by the previous DON to document showers based on the new schedule. Review of these forms starting on 10/23/17 revealed Resident #27's room/bed was not listed on any sheet from 10/23/17 through 11/19/17 revealing no documentation that he received any showers. Nurse Aide #15 was interviewed on 11/17/17 at 5:14 PM. She stated she cared for Resident #27 and went by the written assignment sheet for providing him showers. She stated she had never given him a shower on second shift. 3. Resident #123 was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) dated 04/03/17 for nutrition stated she received a regular ground meat diet with nectar thick liquids and ate in the day room where she had supervision. The quarterly Minimum (MDS) data set [DATE] coded her with severely impaired cognition, requiring extensive assistance with all activities of daily living skills including eating and she was receiving a therapeutic diet. Resident #123 was seen by speech therapy from 10/13/17 through 11/01/17. Per the discharge summary dated 11/01/17, Resident #123 safely tolerated mechanical soft solids and nectar thick liquids with mild overt signs and symptoms of penetration/aspiration. This was an improvement from having had moderate overt signs and symptoms of penetration/aspiration during initial assessment on 10/13/17. Nursing notes dated 11/01/17 at 12:56 PM revealed that Resident #123 was noted chocking multiple times on mechanical soft diet and order was changed to pureed. On 11/15/17 at 8:38 AM Nurse Aide (NA) #12 was observed delivering and setting up her meal tray. She received her food pureed with a small container of bread crumbs off to the side. The bread crumbs were never opened or added to the food even when NA #15 sat and assisted feeding her at 9:18 AM. On 11/16/17 at 9:00 AM NA #13 set her meal tray up, uncovered the container of bread crumbs and Resident #123 began to feed herself. NA #13 did not mix the bread crumbs into the pureed food. NA #13 was interviewed on 11/16/17 at 9:14 AM. She stated that the bread crumbs were used to thicken food but had never seen a pureed diet receive bread crumbs. She stated she had asked NA #12 about them and he stated the crumbs were to make the food thicker and she could add it to the food if she wanted. Interview with the corporate dietician revealed that for pureed diets, the bread crumbs were the substitute for the bread per the menu for pureed diets. She stated the staff were to mix the breadcrumbs into a food item with tray set up. She further stated that the nurses were responsible for educating staff on the need to mix the bread crumbs into the food at tray set up. 4. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #79 was cognitively intact and able to make decisions of daily care. She required extensive assistance with 2 + persons physical assist with transfer, toileting, bed mobility, dressing, personal hygiene and bathing. Resident #79 was coded with impairment on right upper & lower extremities. The MDS further indicated Resident #79 was frequently incontinent with bladder and was occasionally incontinent with bowel. Review of care area assessments revealed Resident #79 required assistance with most of her activities of daily living (ADL) due to right above knee amputation (AKA). She was at risk for decline in her functional ADL abilities. Review of care plan dated 05/18/17 revealed Resident #79 was dependent on staff for toileting assistance. Interventions included providing toileting assistance or incontinence care routinely as needed and encouraging Resident #79 to call for assistance at the first urge. During an interview on 11/15/17 at 10:51 AM, Resident #79 stated she activated the call light on 11/14/17 at around 5:00 AM as she was soaking wet in bed. It took NA #3 about 5 minutes to answer her call light. When she told NA #3 that she was soaking wet and needed to be changed, NA #3 replied he had to finish rounding on his residents and promised her to come back in a few minutes. NA #3 turned off the call light before leaving the room. Resident #79 waited for almost one hour without having any nursing staff addressing her incontinent needs. When she activated the call light again at around 6:00 AM, NA #3 came back and asked her what she needed? NA #3 then provided incontinent care and apologized indicating they were short of staff. Resident #79 stated she was upset, felt embarrassed, disregarded and forgotten as she had to wait in soaking wet condition for almost an hour. During an observation on 11/15/17 at 10:59 AM, Resident #79 was alert and oriented, cognitively intact, able to voice her needs verbally and had AKA on her right leg. During an interview on 11/15/17 at 12:05 PM, Nurse #4 stated all NAs were required to complete their assigned rounds in a timely manner. However, as a nurse, she expected NAs to provide incontinent care as needed during the rounds as resident care had a higher priority. During a phone interview on 11/15/17 at 12:43 PM, NA #3 confirmed he worked third shift on the 100 Hall that ended on the morning of 11/14/17 and he was taking care of Resident #79. He was not familiar with the residents as it was his second week working in the facility and his first time working at 100 Hall. He started the last morning rounds at around 5:00 AM and he was overwhelmed with call lights as there were only 2 NAs working at on 100 Hall to provide care for around 50 residents. He could not recall answering any call light for incontinent care at around 5:00 AM or promising any resident to come back when he was doing his rounds. NA #3 stated if he knew Resident #79 was in soaking wet that morning, he would have addressed her incontinent needs immediately. During an interview on 11/16/17 at 8:28 AM, NA #4 confirmed he worked with NA #3 on third shift on the 100 Hall that ended on the morning of 11/14/17. He could not remember seeing NA #3 responding to Resident #79's call light at around 5:00 to 6:00 AM as he was busy with resident care. He stated if a resident was asking for incontinent care during his rounds, he would take care of the resident first, then continue with the rounds. It was NA #3's first night working at 100 hall. With only 2 NAs working on 100 Hall for third shift, the work load was overwhelming for NA #3. He agreed resident care should be prioritized over the rounds at all times. During an interview on 11/17/17 at 4:14 PM, the Assistant Director of Nursing (DON)/Acting DON stated regardless of staffing level, resident care was always the first priority for nursing staff. Other than answering call lights in timely manner, it was his expectation for NAs to provide resident care immediately even when they were doing rounds. He also expected NAs to leave the resident call lights on until they could actually provide the assistance requested.

Based on record reviews and staff interviews the facility failed to complete Care Area Assessments that addressed the underlying causes and contributing factors for Cognitive Loss/Dementia, Communication, Activities of Daily Living, and Urinary Incontinence for 8 of 26 sampled residents (Resident #27, #28, #38, #46, #60, #64, #71, and #123). The findings included: Resident #28 was admitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 had severely impaired cognition, could make herself understood, and usually understands. The admission MDS noted Resident #28 required extensive assistance with all her activities of daily living and was frequently incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary for Cognitive Loss/Dementia revealed Resident #28 had a [DIAGNOSES REDACTED]. The CAA Summary and analysis of findings did not analyze how Resident #28's cognitive impairment affected her day to day function and care or include her strengths and weaknesses. An interview was conducted with the Social Worker (SW) on 11/17/17 at 2:10 PM. The SW stated she had been doing MDS assessments and CAA Summaries for several years. The SW noted when completing the assessment she interviewed the resident if they were able, talked with staff, reviewed the notes for the look back period, and made some observations of the resident. She typically included why the resident had the cognition issue, what had been going on, and the risk of the cognition problem when writing the analysis of findings. The SW further stated that years ago she was told she was putting too much information in the CAA Summary and analysis of findings. The SW confirmed she had completed Section C (Cognitive Patterns) and the CAA Summary for Cognitive Loss/Dementia for Resident #28's admission MDS and indicated she could have added more resident specific information. 2. Resident #27 was originally admitted to the facility on [DATE] and recently readmitted on [DATE]. His diagnoses included muscle weakness, [MEDICAL CONDITION], diastolic heart failure, adult failure to thrive and dementia. The significant change Minimum (MDS) data set [DATE] coded him with severely impaired cognition, having moderately impaired hearing loss without hearing aids, having no behaviors, requiring extensive assistance with bed mobility, transfers, toileting and hygiene, and being frequently incontinent of bowel and bladder. Review of the Care Area Assessments (CAA) completed 11/03/17 revealed there was no description of his strengths, weakness, or how the triggered area impacted his day to day routine or care needs as follows: a. The cognition CAA stated Resident #27 was a long term placement and his baseline mental functioning varied. He had a diagnoses of dementia and considering his age, dementia and multiple comorbid diagnoses, he remained at risk for further cognitive declines and increasing dependence on others to meet his daily needs. The CAA summary did not indicate how the resident's cognition affected his ability to make decisions or how his memory affected his ability to do things for himself. b. The urinary incontinence CAA stated Resident #27 had a diagnoses of dementia and urinary obstruction with a recent hospitalization of cholelithiasis (gall stones). He has experienced episodes of incontinence and required assistance with transfers, toileting, dressing, hygiene and incontinent care. He verbalized understanding to alert nurse of any signs or symptoms of complications related to incontinence. The CAA summary did not indicate how the frequent incontinence episodes (coded on the MDS) affected him, his skin integrity, or his abilities to care for his needs. c. The CAA for communication stated that Resident #27 was hard of hearing and did not utilize hearing aids. He heard best out of his right ear and understood if you spoke directly into his right ear. The speaker may need to adjust voice or tone or repeat communication to be sure he heard what was said. A consult was not indicated or desired at this time. The Care Area Assessment summary did not indicate the resident had been seen by an audiologist, that hearing aids had been recommended, or if a decision had been make about having the resident fitted for hearing aids. Interview with the MDS Nurse #1 on 11/17/17 at 11:24 AM revealed she completed the communication and urinary incontinence CAA. She gathered her information for MDS and CAAs from observing the resident, talking to the resident, reviewing the medical record, and talking to staff. She stated she then tried to paint a picture of the resident in the CAA describing the problem and why the facility would care plan the problem. During a follow up interview with MDS Nurse #1 on 11/18/17 at 8:22 AM, she stated that she was unaware of Resident #27's visit to the audiologist and if she had been aware of the appointments and recommendations for hearing aids, she would have added that information in the CAA. Interview on 11/17/17 at 2:10 PM with the Social Worker who completed the cognition CAA revealed that she typically would include in the CAA why the resident had a cognition issue such as due to age and disease, the risks and complications of the cognition problems and explain why she would care plan the issue. She stated she did not add the specific details describing the individual resident in the CAA summary. 3. Resident #123 was admitted to the facility most recently on 08/05/17. Her diagnoses included [MEDICAL CONDITIONS], major [MEDICAL CONDITIONS], and dementia. The significant change Minimum (MDS) data set [DATE] coded her with severely impaired cognition with no mood or behavior symptoms. She was coded as requiring extensive assistance with most activities of living skills (ADL). The Care Area Assessment (CAA) summaries did not include a description of the problem or how the problem impacted her day to day function as follows: a. The cognition CAA dated 04/07/17 stated Resident #123 had active dementia and since admission she had scored as having impaired cognitive skills using the brief interview for mental status assessment tool. The CAA continued stating 'given the progressive declining nature of her dementia disease process, she remains at risk for declines impacting all aspects of her life. She remained long term placement with increasing dependence on others to meet her basic needs.' The CAA summary did not indicate how the resident's cognition affected her ability to make decisions or how her memory affected her ability to do things for herself. b. The ADL CAA dated 04/14/17 stated that due to Resident #123's history and diagnoses, she was at risk for a decline in her functional ADL abilities resulting in requiring more assistance and a care plan would be developed. The CAA summary did not describe the amount of assistance required, possible complications due to inactivity, any strengths or weakness that impacted her abilities to care for any of her ADL. Interview with the MDS Nurse #1 on 11/17/17 at 11:24 AM revealed she completed the communication and urinary incontinence CAA. She gathered her information for MDS and CAAs from observing the resident, talking to the resident, reviewing the medical record, and talking to staff. She stated she then tried to paint a picture of the resident in the CAA describing the problem and why the facility would care plan the problem. She stated that Resident #123's significant change was due to her coming off hospice services. Interview on 11/17/17 at 2:10 PM with the Social Worker who completed the cognition CAA revealed that she typically would include in the CAA why the resident had a cognition issue such as due to age and disease, the risks and complications of the cognition problems and explain why she would care plan the issue. She stated she did not add the specific details describing the individual resident in the CAA summary. 4. Resident #71 was admitted to the facility on [DATE]. Her diagnoses included [MEDICAL CONDITION] following a cerebral infarction, muscle weakness and [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #71's annual Minimum Data Set ((MDS) dated [DATE] coded her with moderately impaired cognition and requiring extensive assistance with most activities of daily living skills. The Care Area Assessment (CAA) related to cognition dated 07/23/17 stated Resident #71 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS). The CAA noted she had confusion, forgetfulness and she showed signs of age related cognitive loss although she had no diagnoses of dementia. It was noted her BIMS scored varied. She was at risk for cognitive changes. There was no description as to how her cognition affected her abilities to make decisions day to day, why she experienced the cognitive changes, or how her memory affected her abilities to do things for herself. Interview on 11/17/17 at 2:10 PM with the Social Worker who completed the cognition CAA revealed that she typically would include in the CAA why the resident had a cognition issue such as due to age and disease, the risks and complications of the cognition problems and explain why she would care plan the issue. She stated she did not add the specific details describing the individual resident in the CAA summary. 5. Resident #38 was admitted to the facility on [DATE]. Her diagnoses included heart failure, [MEDICAL CONDITION] disease, anxiety disorder and major [MEDICAL CONDITION]. The significant change Minimum (MDS) data set [DATE] coded her with severely impaired cognitive skills, and having no moods or behaviors and requiring extensive assistance with most activities of daily living skills. The Care Area Assessment summary related to cognition dated 08/08/17 stated that given the progressive, declining course of the resident's dementia disease and diagnosis, she remained at risk for further cognitive decline and development of behaviors issues, increasing dependence on other to meet basic daily needs and social isolation. There was no description as to how her cognition affected her abilities to make decisions day to day or how her memory affected her abilities to do things for herself. Interview on 11/17/17 at 2:10 PM with the Social Worker who completed the cognition CAA revealed that she typically would include in the CAA why the resident had a cognition issue such as due to age and disease, the risks and complications of the cognition problems and explain why she would care plan the issue. She stated she did not add the specific details describing the individual resident in the CAA summary. 6. Resident #46 was admitted to the facility on [DATE] with current diagnoses of heart failure, end stage [MEDICAL CONDITION] and non-Alzheimer's dementia. Review of the annual Minimum (MDS) data set [DATE] revealed Resident #46 was severely cognitively impaired with no mood or behavior symptoms. Review of the Care Area Assessment (CAA) for cognition dated 10/16/17 revealed Resident #46 was a long term resident of the facility and upon admission his family reported he had a history from a young age of memory/cognitive loss related to [MEDICAL CONDITION] from a motor vehicle accident in his early 20's. Resident #46's history of [MEDICAL CONDITION] and [MEDICAL CONDITION] put him at risk for complications including continued long term care, increasing dependence on others to meet his daily needs, physical declines, and social isolation. The CAA summary did not indicate how the resident's cognition affected his ability to make decisions, interact with staff, communicate needs, or how his memory affected his ability to do things for himself. Interview on 11/17/17 at 2:10 PM with the Social Worker who completed the cognition CAA revealed that she typically would include in the CAA why the resident had a cognition issue such as due to age and disease, the risks and complications of the cognition problems and explain why she would care plan the issue. She stated she did not add the specific details describing the individual resident in the CAA summary. 7. Resident #64 was admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION] and non-Alzheimer's dementia. Review of the admission Minimum (MDS) data set [DATE] revealed Resident #64 was severely cognitively impaired with no mood or behavior symptoms. Review of the Care Area Assessment (CAA) for cognition dated 09/18/17 revealed Resident #64 would remain at risk for continued cognitive decline related to the progression of her dementia and Alzheimer's diagnoses. Complications may include continued long term placement, increasing dependence on others to meet daily needs, and social isolation. The CAA summary did not indicate how the resident's cognition affected her ability to make decisions, interact with staff, communicate needs, or how her memory affected her ability to do things for herself. Interview on 11/17/17 at 2:10 PM with the Social Worker who completed the cognition CAA revealed that she typically would include in the CAA why the resident had a cognition issue such as due to age and disease, the risks and complications of the cognition problems and explain why she would care plan the issue. She stated she did not add the specific details describing the individual resident in the CAA summary. 8. Resident #60 was admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION], weakness and [MEDICAL CONDITION]. Review of the annual Minimum (MDS) data set [DATE] revealed Resident #60 was cognitively intact and required only supervision to limited assistance with activities of daily living (ADL). Review of the Care Area Assessment (CAA) dated 06/21/17 revealed Resident #60 was at risk for decline in her functional ADL abilities due to her diagnoses, history and medication use. The CAA summary did not indicate how her ADL function affected her daily routine or her ability to do things for herself. An interview conducted on 11/17/17 at 11:24 with MDS Nurse #1 revealed she completed the ADL CAA for Resident #60. She stated she gathered her information from observations, record review and Nurse Aide documentation and staff interviews. She stated she tried to paint a picture of the resident in the CAA summary by describing the problem and why it would be care planned. She stated she did not add specific details about the resident in the summary.

Based on observations and staff interviews, the facility failed to unclog resident sink with poor drainage on 1 of 3 halls. 1 of 26 rooms was affected on 100 hall (Room #112). The facility failed to repair broken resident doors with sharp splintered wood on 2 of 3 halls. 1 of 26 rooms was affected on 100 hall (Room #112) and 1 of 13 rooms was affected on 200 hall (Room #202). The facility failed to repair and repaint walls with holes on 2 of 3 halls. 2 of 13 bathrooms were affected on 100 hall (Bathroom #113/114, # 115/116) and 1 of 5 bathrooms was affected on 200 hall (Bathroom # 202/203). The facility failed to repair or replace bathroom with broken or stained caulking on 3 of 3 halls. 3 of 13 bathrooms were affected on 100 hall (Bathroom # 113/114, #115/116, #121/122), 2 of the 5 bathrooms were affected on 200 hall (Bathroom #202/203, #204/205), and 2 of the 9 bathrooms were affected on 300 hall (Bathroom #304/305, # 314/315). The facility failed to label and cover bed pan, wash basin and fracture pan found on the floor near commode on 2 of 3 halls. 2 of 13 bathrooms were affected on 100 hall (Bathroom #113/114, # 123/124) and 1 of 9 bathrooms was affected on 300 hall (Bathroom # 304/305). The facility failed to repair bathroom floor with broken tiles on 1 of 3 halls. 2 of 5 bathrooms were affected on 200 hall (Bathroom #201, #204/205). The facility failed to clean bathroom floor with dirty stains on 1 of 3 halls. 2 of 5 bathrooms were affected on 200 hall (Bathroom #201, # 202/203). The facility failed to repair heater/air conditional (AC) unit and bathroom sink that were pulling away from the wall in 1 of 3 halls. 1 of 13 rooms was affected on 200 hall (Room #203) and 1 of 5 bathrooms was affected on 200 hall (Bathroom #202/203). The facility failed to cover plungers found on the floor near the commode on 2 of 3 halls. 1 of the 5 bathrooms was affected on 200 hall (Bathroom #204/205) and 2 of the 9 bathrooms were affected on 300 hall (Bathroom #304/305, #316/317). In addition, the facility failed to control odors in the facility and maintain an elevated toilet seat in clean and sanitary condition. The findings included: 1. The following observations were related to facility's failure to unclog resident sink with poor drainage: a. Observation of Room #112 on 11/14/17 at 3:28 PM revealed the sink was clogged up with poor drainage. Subsequent observations made on 11/15/17 at 10:32 AM and at 3:36 PM revealed the sink remained clogged. 2. The following observations were related to facility's failure to repair broken resident room and bathroom doors with sharp splintered wood at the lower edges: a. Observation of Room #112 on 11/14/17 at 3:28 PM revealed the lower edges of the room door and the bathroom door were broken with sharp splintered wood. Subsequent observations made on 11/15/17 at 10:32 AM and at 3:36 PM revealed the doors remained in disrepair. b. Observation of Room #202 on 11/14/17 at 3:49 PM revealed the lower edges of the bathroom door was broken with sharp splintered wood. Subsequent observations made on 11/15/17 at 10:47 AM and at 4:03 PM revealed the door remained in disrepair. 3. The following observations were related to facility's failure to repair and repaint the walls with holes: a. Observation of Bathroom #113/114 on 11/14/17 at 3:31 PM revealed a hole approximately 1 inch in diameter in the wall behind the commode. Subsequent observations made on 11/15/17 at 10:35 AM and at 3:39 PM revealed the hole remained in disrepair. b. Observation of Bathroom #115/116 on 11/14/17 at 3:35 PM revealed a hole approximately 1 inch in diameter in the wall behind the commode. Subsequent observations made on 11/15/17 at 10:37 AM and at 3:42 PM revealed the hole remained in disrepair. c. Observation of Bathroom #202/203 on 11/14/17 at 3:49 PM revealed the wall below the sink approximately 5 inches in diameter was unevenly patched and the wall at both sides of the sink approximately 6 x 6 inches were touched up with different color. Subsequent observations made on 11/15/17 at 10:47 and at 4:03 PM revealed the wall remained in disrepair. 4. The following observations were related to facility's failure to repair or replace bathrooms with broken, cracked, discolored or stained caulking around the base of the commode or along the bathtub: a. Observation of Bathroom #113/114 on 11/14/17 at 3:31 PM revealed the caulking around the base of the commode was stained. Subsequent observations made on 11/15/17 at 10:35 AM and at 3:39 PM revealed the caulking around the base of the commode remained stained. b. Observation of Bathroom #115/116 on 11/14/17 at 3:35 PM revealed the caulking around the base of the commode was stained. Subsequent observations made on 11/15/17 at 10:37 AM and at 3:42 PM revealed the caulking around the base of the commode remained stained. c. Observation of Bathroom #121/122 on 11/14/17 at 3:37 PM revealed the caulking around the base of the commode was stained. Subsequent observations made on 11/15/17 at 10:40 AM and at 3:50 PM revealed the caulking around the base of the commode remained stained. d. Observation of Bathroom #202/203 on 11/14/17 at 3:49 PM revealed the caulking around the base of the commode was stained and the caulking along the bathtub was broken. Subsequent observations made on 11/15/17 at 10:47 AM and at 4:03 PM revealed the caulking around the base of the commode and along the bathtub remained unchanged. e. Observation of Bathroom #204/205 on 11/14/17 at 4:04 PM revealed the caulking around the base of the commode was discolored. Subsequent observations made on 11/15/17 at 10:55 AM and at 4:10 PM revealed the caulking around the base of the commode remained discolored. f. Observation of Bathroom #304/305 on 11/14/17 at 4:09 PM revealed the caulking around the base of the commode was cracked and discolored. Subsequent observations made on 11/15/17 at 11:00 AM and at 4:14 PM revealed the caulking around the base of the commode remained unchanged. g. Observation of Bathroom #314/315 on 11/14/17 at 4:12 PM revealed the caulking around the base of the commode was stained. Subsequent observations made on 11/15/17 at 10:40 AM and at 3:50 PM revealed the caulking around the base of the commode remained stained. 5. The following observations were related to facility's failure to label and cover bed pan, wash basin and fracture pan found on the floor near commode: a. Observation of Bathroom #113/114 on 11/14/17 at 3:31 PM revealed an unlabeled and uncovered bucket with lid on the floor near the commode. Subsequent observations made on 11/15/17 at 10:35 AM and at 3:11 PM revealed the bucket remained unchanged. b. Observation of Bathroom #123/124 on 11/14/17 at 3:39 PM revealed an unlabeled and uncovered bed pan on the floor near the commode. Subsequent observations made on 11/15/17 at 10:42 AM and at 3:15 PM revealed the bed pan remained unchanged. c. Observation of Bathroom #304/305 on 11/14/17 at 4:09 PM revealed an unlabeled and uncovered wash basin under the sink. In addition, an unlabeled and uncovered fracture pan observed on the floor at the back of the commode. Subsequent observations made on 11/15/17 at 11:00 AM and at 3:26 PM revealed the wash basin and fracture pan remained unchanged. 6. The following observations were related to facility's failure to repair bathroom floor with broken tiles: a. Observation of Bathroom #201 on 11/14/17 at 3:44 PM revealed the tiles on the bottom row of the bathroom wall approximately 6 x 30 inches were broken. Subsequent observations made on 11/15/17 at 10:45 AM and at 3:58 PM revealed the tiles remained unchanged. b. Observation of Bathroom #204/205 on 11/14/17 at 4:04 PM revealed the tiles near the base of the commode were cracked. Subsequent observations made on 11/15/17 at 10:55 AM and at 4:10 PM revealed the tiles remained unchanged. 7. The following observations were related to facility's failure to clean bathroom floor with dirty stains: a. Observation of Bathroom #201 on 11/14/17 at 3:44 PM revealed the floor at the corners was dirty with visible stains. Subsequent observations made on 11/15/17 at 10:45 AM and at 3:17 PM revealed the floor remained dirty. b. Observation of Bathroom #202/203 on 11/14/17 at 3:49 PM revealed the floor was dirty with visible stains around the bathtub and at the corners. Subsequent observations made on 11/15/17 at 10:47 AM and at 3:20 PM revealed the floor remained dirty. 8. The following observations were related to facility's failure to repair the heater/AC unit and bathroom sink that were pulling away from the wall: a. Observation of Room #203 on 11/14/17 at 3:58 PM revealed the heater/AC unit was approximately 1 inch pulling away from the wall. Subsequent observations made on 11/15/17 at 10:52 AM and at 4:07 PM revealed the condition of the heater/AC unit remained unchanged. b. Observation of Bathroom #202/203 on 11/14/17 at 3:58 PM revealed the sink was approximately 1 inch pulling away from the wall. Subsequent observations made on 11/15/17 at 10:52 AM and at 4:07 PM revealed the condition of the sink remained unchanged. 9. The following observations were related to facility's failure to cover the plungers found on the floor near the commode: a. Observation of Bathroom #204/205 on 11/14/17 at 4:04 PM revealed the plunger was uncovered on the floor near the commode. Subsequent observations made on 11/15/17 at 10:55 AM and at 3:21 PM revealed the plunger remained uncovered. b. Observation of Bathroom #304/305 on 11/14/17 at 4:09 PM revealed the plunger was uncovered on the floor near the commode. Subsequent observations made on 11/15/17 at 11:00 AM and at 3:26 PM revealed the plunger remained uncovered. c. Observation of Bathroom #316/317 on 11/14/17 at 4:15 PM revealed the plunger was uncovered on the floor near the commode. Subsequent observations made on 11/15/17 at 11:07 AM and at 3:30 PM revealed the plunger remained uncovered. During an interview on 11/15/17 at 2:21 PM, Housekeeper #1 stated daily cleaning of resident rooms included trash removal, window cleaning, dusting, floor sweeping and mopping, and bathroom cleaning. She received 3 days of housekeeping training from her supervisor during job orientation. On average, she cleaned about 16 resident rooms daily and required to perform deep cleaning for 2 rooms per week on Friday. She would report to the maintenance department when she observed any maintenance related issues. She added the plungers should be covered with plastic bag and put it in the corner of the bathroom. She denied her workload was overwhelming. During an environment tour and interview on 11/15/17 at 2:41 PM, the Housekeeping Manager (HM) stated she had 14 staff under her leadership, in which 4 among the 14 staff were part-time employees. For the first shift, she assigned 4 housekeepers for cleaning resident rooms, 1 housekeeper cleaning common areas, and 3 staff to do laundry. She scheduled 1 housekeeper and 1 laundry staff on second shift. She audited each housekeeper's works at least 2 times monthly and follow up with feedbacks for performance enhancement. The HM stated she had not been able to be fully staffed in the past 6 months. As she had to perform housekeeper's task frequently, she did not have sufficient time to supervise her staff to ensure optimum cleanliness of the facility. After the tour to the areas of concern, the HM agreed those issues needed to be addressed as soon as possible. During an environmental tour and interview on 11/15/17 at 4:13 PM the Maintenance Manager (MM) confirmed there were 27 bathrooms and 56 bedrooms in the skilled side of the facility. He acknowledged that the above areas of concern were in disrepair and needed to be fixed as soon as possible. According to the MM, he was the only maintenance staff in the facility in the past 7 to 8 months. The facility hired one maintenance assistant about 1 month ago. The work load was heavy and overwhelming. He made routine rounds at least 4 to 5 times daily to look for maintenance tasks that needed to be addressed for bed rooms, bath rooms, hallways, and other common areas. He relied on staff to report maintenance concerns via verbal reports or work orders. However, the MM stated he was unaware of the above areas of concern as the staff did not communicate maintenance related issues with him. The work orders folders were located at each nurse station and he checked at least 2 to 3 times daily. The MM added maintenance work was prioritized with safety concerns addressed first, equipment issues addressed second and cosmetic issues addressed third. During an interview on 11/17/17 at 9:00 AM, NA #5 stated she would check resident's bathroom on her rounds to ensure the toilet was clean, odorless, and free of clutter. Devices such as bed pan, urinal and fracture pan were covered in the plastic bag and labeled with resident's name. During an interview on 11/17/17 at 4:03 PM, the Assistant Director of Nursing (DON)/Acting DON stated it was his expectation for residents to live in a clean environment and in proper repair. Other than staffing issues, the Acting DON attributed the incident as a result of lack of communication among the staff, housekeeping department, and maintenance department. During an interview on 11/17/17 at 4:48 PM, the Administrator stated it was her expectation for the staff to maintain the facility at the highest level of cleanliness as possible and in proper repair. All the identified housekeeping and maintenance issues should be addressed accordingly and in a timely manner. 10. Resident #27's room was observed to smell of urine on 11/14/17 at 2:17 PM. The urine odor was observed around this resident's room from the hallway on 11/14/17 at 4:11 PM. On 11/15/17 at 9:15 AM the bedroom smelled of urine. An interview with the housekeeper #1 on 11/15/17 at 12:25 PM revealed she has noticed a urine odor in this room before. She stated she mopped around the toilet and used air freshener to clear up the odor. The bedroom of Resident #27 smelled of stale urine when observed on 11/15/17 at 4:51 PM and on 11/16/17 at 8:04 AM. Housekeeper #2 stated during interview on 11/16/17 at 8:13 AM that she had noticed an odor form this room. She stated that she sprays an air freshener when she noted it. She stated the facility started a deep cleaning schedule for rooms on 10/25/17. There was no record of which rooms had been deep cleaned prior to this date and she noted Resident #27's room had not been deep cleaned since the documentation began. She further stated that this room had to be sprayed regularly as he often stored soiled briefs in his closet. She stated she routinely checked his closet for soiled briefs. The urine odor was noticeable from the hall when observed on 11/17/17 at 8:24 AM. The Assistant Director of Nursing/Acting Director of Nursing stated on 11/19/17 at 5:12 PM that he expected staff to notify him of rooms that continuously smelled of urine. 11. Observations of shared bathroom for rooms 304/305 on 11/14/17 at 9:33 AM revealed the elevated toilet seat had areas of dried brown matter covering the entire circumference of the underside of the seat opening. A subsequent observation on 11/15/17 at 8:14 AM revealed the elevated toilet seat remained unclean as observed the previous day. An interview with Housekeeper #2 on 11/15/17 at 8:14 AM revealed she had worked at the facility for almost two years and confirmed she was assigned to the 300 hall that day. Housekeeper #2 stated residents' rooms and bathrooms were cleaned daily and the toilets were cleaned and disinfected including the seat and the underside of the seat. On 11/15/17 at 2:49 PM Housekeeper #2 was observed leaving the 300 hall with her cart. An observation of the elevated toilet seat in the shared bathroom for rooms 304/305 on 11/15/17 at 2:29 PM revealed the elevated toilet seat had areas of dried brown matter covering the entire circumference of the underside of the seat opening. On 11/15/17 at 2:53 PM Housekeeper #2 confirmed she was done for the day. Housekeeper #2 was asked when and how she cleaned and disinfected the elevated toilet seats in the bathrooms. Housekeeper #2 stated she moved the elevated toilet seat away from over the toilet and sprayed it with a disinfectant and wiped down all of the surfaces including the underside of the seat. Housekeeper #2 could not recall if she cleaned and disinfected the elevated toilet seat in the shared bathroom for rooms 304/305 that day. An interview was conducted with the Housekeeping Supervisor on 11/15/17 at 3:13 PM. The Housekeeping Supervisor stated the Housekeepers were expected to spray the sink and toilet with disinfectant and return to clean the bathroom after they have cleaned the residents' room. The Housekeeping Supervisor explained the entire toilet including the lid, seat, bowl and base were to be scrubbed. The interview further revealed the entire seat top and underside should be cleaned as well. On 11/15/17 at 3:14 PM the Housekeeping Supervisor was accompanied to the shared bathroom for rooms 304/305 and observed the condition of the elevate toilet seat. The Housekeeping Supervisor stated it was not acceptable and would be cleaned immediately.