Every finding on record at Autumn Care of Saluda

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of pressure ulcers for 1 of 2 residents reviewed for pressure ulcers (Resident #2).Findings included:Resident #2 was admitted to the facility on [DATE].Review of Resident #2's admission skin assessment dated [DATE] identified a pressure ulcer located on sacrum (the bone at the base of spine and top inner area of the buttock). The stage of the pressure ulcer was not included in the assessment. Review of a nurse's progress note dated 01/07/26 revealed Resident #2 had a reddened area on the bilateral inner/top area of the buttock that was covered with foam dressing.Review of Resident #2's Medication Administration Record (MAR) revealed a physician's order was transcribed with directions to cleanse the bilateral inner area on the buttock with normal saline and apply a foam border dressing. The treatment was initialed by the nurse to indicate it was done on 01/08/26.Review of a nurse's progress note dated 01/08/26 read in part, Resident #2's dressing to the sacrum was changed. Review of the admission MDS assessment dated [DATE] indicated Resident #2 did not have an unhealed stage one pressure ulcer (intact skin with a localized area of non-blanchable redness usually over a bony prominence) during the look-back period.During an interview on 04/22/26 at 9:48 AM, the MDS Coordinator was asked to clarify if Resident #2 had a pressure ulcer that was present on admission. The MDS Coordinator stated the admission MDS dated [DATE] should have been coded to reflect Resident #2 had a stage one pressure ulcer that was present on admission.During an interview on 04/23/26 at 12:55 PM, the Director of Nursing stated MDS assessments should be coded correctly, and she expected Resident #2's admission MDS assessment dated [DATE] was coded to show a stage one pressure ulcer was present on admission. An interview with the Administrator was conducted on 04/23/26 at 1:26 PM. The Administrator stated Resident #2's admission MDS assessment dated [DATE] should have been correctly coded to reflect a stage one pressure ulcer was present on admission.

Based on record review, observation and staff interviews, the facility failed to complete quarterly smoking risk assessments (assessment of a resident to determine if they are safe to smoke where a score between 0-9 indicates a resident was a safe smoker) for 1 of 2 residents reviewed for smoking (Resident #54).The findings included:Resident #54 was admitted to the facility on [DATE] with diagnoses which included mood disorder, nicotine dependence, and muscle weakness. Review of the facility's smoking policy dated 09/09/25 revealed a smoking risk assessment must be completed upon admission, quarterly, and upon changes in the resident's condition.Review of Resident #54's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and coded for tobacco use.Review of Resident #54's quarterly MDS dated [DATE] revealed the resident was cognitively intact and independent for most activities of daily living (ADL). The MDS indicated Resident #54 was independent for ambulation. Review of Resident #54's smoking risk assessments revealed smoking assessments were completed on 06/05/25 with a score of 7, 08/28/25 with a score of 8 and 02/26/26 which indicated the resident was not a current smoker.Review of Resident #54's care plan updated 04/10/26 revealed the resident was a supervised smoker. The goal was for Resident #54 to follow the facility's smoking policy. Interventions included explaining the facility's smoking policy to Resident #54 as needed and monitoring Resident #54 for unsafe smoking signs.Resident #54 was observed smoking on 04/21/26 at 11:18 AM. Resident #54 was supervised while smoking and no concerns or issues were noted.An interview was conducted with the Social Worker (SW) on 04/22/26 at 10:02 AM, and she revealed smoking assessments were expected to be completed quarterly by the SW. She indicated the computer notified her when the next quarterly smoking risk assessment was pending. She confirmed she completed Resident #54's last quarterly smoking risk assessment on 02/26/26 and that he was a non smoker at that time. The SW stated Resident #54 lost his smoking privileges in January 2026 due to escalating behavior he exhibited towards other residents during designated smoking times. She stated Resident #54's smoking privileges were reinstated on 04/10/26 by the Administrator. She confirmed she updated Resident #54's care plan on 04/10/26 to include smoking but did not complete a new smoking risk assessment. She stated she should have completed the smoking safety assessment due to the change in Resident #54's smoking status.During an interview with the Director of Nursing (DON) on 04/22/26 at 10:12 AM, she revealed Resident #54 had smoked at the facility since his admission but lost his smoking privileges in January 2026 due to escalating behaviors. Resident #54's smoking privileges were reinstated by the Administrator on 04/10/26. The DON stated the SW should have completed a new smoking risk assessment after Resident #54's smoking privileges were reinstated, as that was a change in his smoking status.The Administrator was interviewed on 04/22/26 at 10:23 AM and confirmed he revoked Resident #54's smoking privileges in January 2026 and reinstated them on 04/10/26. His expectation was the smoking risk assessments should be completed quarterly and after changes in a resident's condition, as stated in the smoking policy.

Based on observation, record review and staff and Nurse Practitioner (NP) interviews, the facility failed to effectively supervise a cognitively impaired resident when the resident was able to exit the facility unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervisions to prevent accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included dementia, bipolar disorder, panic disorder, and anxiety disorder.Review of the annual minimum data set (MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired. He displayed no wandering behavior during the look back period and needed supervision with mobility and transfers. Resident #1 had no falls and needed supervision with ambulation. Review of the care plan started on 12/9/24 and last updated on 12/16/25 revealed that Resident #1 waws at risk of elopement- wandering in facility I'm gonna walk out the door - may stand by exit doors, may try to follow behind staff as they exit facility. Goals included Resident #1 will wander safely within specified boundaries. Interventions included approach: 1:1 for elopement attempt. Redirect Resident #1 from front door area as needed- offer coffee, snack, walk in courtyard, offer redirect to room. Provide visual and verbal cues as needed. redirect to snack, coffee, activity as desired. Approach from the front. Walk in step with Resident #1 first before redirecting. Maintain a calm environment and approach to Resident #1.Review of the elopement assessment form dated 12/10/25 revealed that Resident #1 was independent for ambulation. Resident #1 displayed risk factors which included that he exhibited exit seeking behaviors. Resident #1 also verbalized wanting to go home, going on a trip, or going to meet someone. Resident #1 did not accept present residency situation or location. The immediate interventions included continuing his current plan of care. The assessment identified Resident #1 as being at risk for elopement. Review of nursing progress note from Nurse #1 dated 12/16/2025 revealed Resident #1 was noted to be in driveway at 10:42 AM today. Resident #1 was redirected by staff back into facility. A skin assessment was completed immediately on Resident #1. Resident #1 was placed on 1:1 (One-to-one supervision by a staff member). The NP and Resident #1's guardian were made aware of the incident and the need for possible placement in a locked unit and currently being placed on 1:1 for safety. Resident #1's guardian voiced understanding. No injury was noted on Resident #1.An interview on 1/8/26 at 11:10 AM with Nurse #1 revealed that she was the assigned nurse for Resident #1 on 12/16/25. She stated that Resident #1 was dressed in a sweatshirt, pants, socks, and shoes when he eloped from the building. Nurse #1 stated that around 10:10 AM on 12/16/25 Resident #1 was inquiring about leaving the facility and she told Resident #1 he needed to talk to the physician and that it was almost time to go smoke. She stated that Resident #1 left the nurse's station and returned to his room where he lay down in his bed. She stated that Resident #1 had been discussed in the morning meeting regarding an increase in exit-seeking behavior. Nurse #1 further indicated that there were a lot of staff and plumbing vendors going in and out of the building that day. She stated that Resident #1 probably got out of the building by following one of the plumbing vendors. Nurse #1 stated that at 10:42 AM on 12/16/25 she was on side one (the section of the building where Resident #1's room was located) in the common area and she looked out the window and saw Resident #1 standing midway down the driveway that was on the right side of the parking lot. Nurse #1 stated that she immediately ran outside and called out to Resident #1 brought him back into the building and placed him in a wheelchair. She stated that she then completed a head-to-toe assessment with no injuries noted to Resident #1. Nurse #1 then placed Resident #1 on one-to-one with a staff member. She stated that after he was returned to the building Resident #1 had not displayed any further exit seeking behaviors. Nurse #1 stated that when she inquired why Resident #1 had left the building Resident #1 stated that he was going home. An interview with Nurse Aide (NA) #1 on 1/8/26 at 11:31 AM revealed that she saw Resident #1 display exit-seeking behavior one time at 10:30 AM on 12/16/25 before he eloped. She stated that Resident #1 was inquiring about how he could get home. NA #1 indicated she redirected Resident #1 by letting him know she would bring him some coffee, and he walked independently to his room where he sat on his bed. NA #1 revealed that she then brought Resident #1 some coffee while he was sitting on his bed. NA #1 further revealed that Resident #1 had not displayed exit seeking behavior prior to this incident for a very long time. She stated that she could not recall how long it had been exactly, but it had been at least a few months. NA #1 stated that she was aware she needed to keep an eye on Resident #1 because he had been displaying exit seeking behavior, but she still had other residents to care for and was unable to continuously watch him. She stated that she identified a resident who was exit seeking by them wandering around, going to the doors, asking about leaving, or them stating that they want to leave. NA #1 stated that they have a Kardex in the resident's closets which included if the resident had exit seeking behaviors. NA #1 stated that Resident #1's Kardex indicated he had exit seeking behaviors. She stated that when she saw residents with exit seeking behaviors she told her Nurse immediately and they communicate with staff about keeping an eye on those behaviors and resident. Review of the facility investigation completed by the DON revealed that on 12/16/25 at 10:10 AM, Resident #1 was observed in the hall near the Unit Manager's and Scheduler's office doors. At 10:30 AM, Resident #1 was noted to be lying on his bed in his room by Nurse Aide #1. At 10:42 AM, Resident #1 was discovered in the middle of the facility driveway, having had an unsupervised exit from the building. Nurse #1 visualized Resident #1 in the driveway at 10:42 AM and immediately redirected him back into the facility. A skin assessment was completed, and no injuries were noted. Resident #1 was then placed on one-to-one supervision for safety. The Nurse Practitioner (NP) was notified of the incident, along with the guardian. The guardian was informed of the need for possible placement in a locked unit and of the immediate one-to-one supervision put in place; the guardian expressed understanding. In conclusion, because several vendors and staff were entering and exiting the facility that day Resident #1 was able to walk out with a vendor leading to his unsupervised exit of the facility. Referrals were sent out for a memory care unit placement and Resident #1 remained on one-to-one monitoring. On 12/17/25, Resident #1 was accepted to a facility with a locked unit and was transferred there on the same day.An online website named Wunderground was used to obtain the outside weather in the Saluda area on 12/16/25 and noted at 10:54 AM the temperature was 41 degrees with the highest temperature reaching 52 degrees from 10:54 AM to 2:54 PM.An interview with NP on 1/7/26 at 11:48 AM revealed that she was notified about Resident #1's elopement on 12/16/25. She stated that she had not seen him after the elopement because Resident #1 was transferred to a facility with a locked unit the next day on 12/17/25. The NP further revealed that any time she had seen Resident #1 he was always sitting on his bed. She stated that Resident #1 had displayed no signs or symptoms of exit seeking behavior during her previous visits. An interview with the DON on 1/8/26 at 10:55 AM revealed that Resident #1 had been showing increased signs of exit seeking behavior on the morning of 12/16/25. The DON explained that Resident #1 had been asking about leaving and had been standing on side one near the common area doors which were locked with a keypad. She stated that she had discussed Resident #1 had increased exit seeking behavior during the morning interdisciplinary team meeting. After that meeting, she informed staff that they needed to increase their observations of Resident #1 and increased redirection attempts because his exit seeking behaviors had escalated. The DON reported that on 12/16/25, the day Resident #1 eloped from the building, a scrub supply van had been available outside for staff to purchase scrubs, and plumbing services were also entering and exiting through the side one common area door. She stated that she believed the plumbing company may have let Resident #1 out or that he might have left when the plumber entered or exited the building, since the staff were aware of who Resident #1 was. The DON explained that before this incident, staff were typically stationed in the common area when vendors entered or exited through that side door. She further explained that after the incident, vendors and staff were required to use only the front door, which was always locked and required staff to let individuals in and out. An interview with the Administrator on 1/8/26 at 10:59 AM revealed that Resident #1 had exit seeking behavior the morning of 12/16/25 and it was discussed in the morning meeting. He stated that the staff were informed to observe Resident #1 more closely because he had increased exit seeking behavior. The Administrator stated there were vendors going in and out of the doors on the side one common area along with staff and he felt Resident #1 just left with the vendors. He stated that to speak with Resident #1 he gave the impression he was just a visitor. He further revealed that the staff were letting the plumbers in and out of the locked building and/or they were following the staff as they went in and out of the building to the scrub truck. He stated that Resident #1 was spotted in the parking lot at 10:42 AM and was last seen by staff in the building at 10:30 AM. Resident #1 had no injuries and was placed on one-to-one until his transfer to a facility with a locked memory care unit the next day 12/17/25. The Administrator stated that the side one common area doors had since been locked with a code change only he, the DON, and the Maintenance Director had. He stated that all deliveries and staff were to use the main entrance which is locked and have to have a staff member let vendors in and out of the main door. The Administrator stated the door that Resident #1 exited the facility through had an alarm installed after the incident that goes off anytime the door is opened even when the code was used.An observation conducted on 1/8/26 at 11:05 AM with the Administrator and Director of Nursing (DON) revealed that Resident #1's room was located 22 feet from the nursing station and 60 feet from the doors on side one of the common area. When Nurse #1 saw Resident #1 outside of the building he was approximately 150 feet away from the facility, positioned halfway down the driveway and about 50 feet from the road. Traffic at the facility had been low over the previous two days, and Resident #1 was observed walking independently prior to the elopement and when he was spotted in the driveway of the facility. During the observation it was noted that the side one common area exit consisted of double doors equipped with a keypad. These doors faced the parking lot, with a driveway on both the left and right sides. The door from which Resident #1 had exited through was confirmed to have been locked by a keypad, and only the Administrator, DON, and Maintenance Director had access to the code. The facility provided the following Corrective Action Plan with a completion date of 12/20/25:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 12/16/25 Resident #1 had an unsupervised departure from the facility. He walked down to the middle of the facility driveway. Resident was visualized at the driveway and staff immediately brought resident back into the facility. During the investigation on 12/16/25, the Director of Nursing determined that the resident potentially followed a person out the door after they entered or exited. The Provider was notified on 12/16/2025 of the incident by the Director of Nursing. The Guardian was notified on 12/16/2025 of the incident by the Social Worker. Resident was placed on one-on-one supervision immediately on 12/16/2025 and was implemented by the Director of Nursing.Elopement drill completed by Maintenance Director on both shifts on 12/16/2025. Head to toe skin assessment was completed by Nurse #1 of Resident #1 on 12/16/2025. No injuries or adverse effects was noted. Resident #1 was discharged to a secured facility on 12/17/2025. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 12/16/25 when the facility was made aware that Resident #1 had departed the building unsupervised the Director of Nursing completed an immediate head count of other residents in the facility, all other residents were accounted for. The Maintenance Director immediately checked door alarms on 12/16/2025. Doors were found to be in working order. No issues were identified. The Director of Nursing or designee reviewed progress notes for the last 30 days for all residents in the facility for changes in behaviors and reviewed all elopement assessments to ensure they were accurate on 12/16/2025. There were no other residents newly identified at risk for elopement. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Beginning 12/16/25 the Director of Nursing or designee educated all staff in the facility on the facility elopement policy. 1. Upon discovery that a resident cannot be located a head count will be conducted. If the resident is still missing a code green is to be announced on the facility paging system to alert all staff to assist in locating the missing resident. 2. The clinical supervisor will notify the Administrator, the Director of nursing and the attending physician. 3. The highest-ranking staff member will become the team leader and coordinate the search. 4. The team leader will maintain documentation during the search process. 5. The floor plan will be used to ensure a thorough search of the interior. 6. If the resident is not located on the premises the team lead will direct staff to conduct an external search. The team leader will notify the family/legal representative and inquire as the potential whereabouts of the resident. 7. If the resident is not located on the premises the Administrator will notify the local emergency response agencies. The elopement policy also states that an elopement assessment is to be completed on admission, quarterly and as needed. Staff were also educated to report new or increased behaviors or exit seeking behaviors to nursing staff. If a resident is designated as at risk for elopement that should be added to the elopement books at the receptionist desk and at each nurses' station. The facility social worker is responsible for updating and maintaining accuracy of the elopement book. No staff will work until they have received this education provided by Director of Nursing or designee. On 12/16/25 the Administrator informed the Scheduler to ensure all agency staff receive the education prior to working. The Director of Nursing or Designee monitors that any new agency staff signs this education prior to starting their first shift at facility. Verbal education is provided to ensure understanding. The Administrator informed the Payroll Coordinator they are to ensure all newly hired staff receive the education during new hire orientation.On 12/16/25 Director of Nursing and Unit Managers were educated by the Regional Director of Clinical Services to review progress notes for new and increased behaviors to include wandering for the need to complete a new elopement assessment during clinical morning meeting Monday through Friday. Nurse management was also educated to review during clinical morning meeting Monday through Friday, the resident diagnosis for dementia and other cognitive impairment and review with the interdisciplinary team to include the Administrator, Director of Nursing, Medical Records, Nurse Managers, Social Workers, Therapy Director, Environmental Services Director, admission Coordinator, Minimum Data Set Coordinator, and Medical Director, to discuss other assessments to determine cognition and the need for elopement interventions. The Administrator informed the Payroll Coordinator that all newly hired employees receive this education during the new hire orientation. This is completed by the Director of Nursing or designee. Alarm boxes were ordered immediately on 12/16/25 and added to living room doors on side one of the facility, on 12/19/25. These alarms were placed, in addition to the mag lock already in place on doors. This alarm box squeals until it is disengaged with a key, if doors are opened alerting staff. The side two entrance is our main entrance. It is locked at all times and requires a code to enter or exit.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed.On 12/16/25 a Quality Assurance and Performance Improvement (QAPI) meeting was held by the interdisciplinary team, and the decision was made to initiate audits for 12 weeks. On 12/16/25 the Administrator informed the Maintenance Director the week of 12/16/25 he will conduct a monthly elopement drill for three months to ensure the facility responds to an elopement per company policy. Elopement drills will be conducted on all shifts, including the weekends. The Maintenance Director completes door audits Monday through Friday to ensure they are operating properly. Beginning the week of 12/22/25 the Director of Nursing or designee will audit progress notes in the clinical morning meeting from the previous twenty-four hours for new behaviors or increased behaviors that could lead to elopement for 12 weeks. If there were behaviors noted in the resident records they were addressed by nursing and elopement interventions were discussed by the interdisciplinary team. Audits will be reviewed weekly in the QAPI meeting and changes to the plan of correction will be made as needed. Alleged date of compliance for the corrective action plan: 12/20/25The Corrective Action Plan was validated on 1/8/26 and concluded the facility implemented an acceptable corrective action plan on 12/20/25 once the mag lock code was changed and the new alarm box was added and staff were educated on the elopement policy.Review of the audit tool for any new behaviors and increased behaviors that could lead to elopement during the clinical morning meeting for 12 weeks approval that they have completed monitoring for the week of 12/22/25, 12/29/25. and 1/5/26. Review of an elopement or unauthorized absence drill revealed that a drill was completed successfully on 12/16/25 1st, 2nd, and 3rd shifts were completed successfully and on 1/5/26 for first shift. Elopement books were observed at each nurses' station throughout the facility and reception desk. The elopement books contained information and pictures for each resident identified as high risk. Interviews conducted with multiple staff on various shifts and departments were interviewed and verified they received re-education related to elopement in December 2025 and were able to describe facility processes for: what to do when a resident demonstrated elopement/exit seeking behaviors, where the elopement books were located, what information they contained, responding to window/door alarms, making sure entry/exit doors were locked before leaving the area, what door the staff and vendors were to use and what to do in the event of an elopement. The compliance date of 12/20/25 was validated.

Based on record review, observations, and interviews with residents and staff, the facility failed to protect the resident's right to be free from misappropriation of controlled narcotic pain medications for 3 of 4 residents reviewed for misappropriation of property (Resident #46, #1, and #18). Findings included: The facility's Abuse, Neglect, and Exploitation policy, last revised 7/11/24 revealed the facility would not tolerate misappropriation of resident property defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings without consent. a. Resident #46 was admitted to the facility on [DATE]. Resident #46's diagnoses included osteoarthritis and right hip pain. A physician's order dated 4/9/24 revealed Resident #46 received hydrocodone-acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication used to relieve pain) 5-325 milligram (mg) tablet before meals and at bedtime for right hip pain. The significant change in status Minimum Data Set (MDS) dated [DATE] revealed Resident #46's cognition was intact. Resident #46 received scheduled and as needed pain medication, had no presence of pain, and was taking an opioid medication. A review of the controlled narcotic medication declining records for Resident #46 revealed on 4/21/24 at 8:00 AM Nurse #1 signed she removed one tablet of hydrocodone-acetaminophen 5-325 mg and used her signature as the second nurse witness to indicate the medication was wasted. On 4/21/24 at 11:30 AM Nurse #1 signed she removed two tablets of hydrocodone-acetaminophen 5-325 mg and administered both. The wasted and extra dose of hydrocodone-acetaminophen 5-325 mg were subtracted from the amount of medication remaining. A review of the Medication Administration Record (MAR) for Resident #46 revealed on 4/21/24 at 8:00 AM and 4/21/24 at 11:30 AM Nurse #1 initialed she administered one tablet of hydrocodone-acetaminophen 5-325 mg. During an observation and interview on 02/11/25 at 9:51 AM Resident #46 revealed he received scheduled and as needed pain medication. Resident #46 did not recall a time he did not receive his pain medication and stated nurses were good administering his pain medication on time and shared no concerns of uncontrolled pain. Resident #46 showed no signs of pain during the interview. b. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included vascular dementia, spinal stenosis, osteoarthritis, and chronic pain. The annual MDS assessment dated [DATE] revealed Resident #1's cognition was severely impaired. Resident #1 received scheduled pain medication, had no presence of pain, and was taking an opioid medication. A physician's order dated 4/24/24 revealed Resident #1 received oxycodone/acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication used to relieve pain) 5-325 mg give one tablet before meals and at bedtime for chronic pain. A review of the controlled narcotic medication declining record for Resident #1 revealed on 5/17/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone/acetaminophen 5-325 mg and wasted one and administered one. Nurse #1 used her signature as the second nurse witness to indicate the medication was wasted. On 5/24/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone/acetaminophen 5-325 mg and wasted one and administered one. A second nurse signature was included to indicate a witness observed Nurse #1 waste the medication. The two wasted doses of oxycodone/acetaminophen were subtracted from the amount remaining. A review of the MAR for Resident #1 revealed Nurse #1 initialed on 5/17/24 at 8:00 AM and 5/24/24 at 8:00 AM to indicate she administered one tablet of oxycodone/acetaminophen 5-325 mg. During an observation and interview on 02/11/25 at 1:51 PM Resident #1 had no visible signs of pain and stated she was doing good. Resident #1 was unable to confirm she received pain medication. c. Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included chronic pain and left knee pain. A review of the physician order dated 5/8/24 revealed Resident #18 received oxycodone (a narcotic opioid analgesic) extended release 10 mg tablet every twelve hours. The quarterly MDS assessment dated [DATE] revealed Resident #18's cognition was intact. He had received scheduled pain medication, occasionally had pain rated 4 out of 10, and was taking an opioid medication. A review of the controlled narcotic medication declining record for Resident #18 revealed on 5/26/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone 10 mg extended release. Nurse #1 signed she wasted one tablet and administered the other. There was a second nurse signature to indicate a witness verified Nurse #1 wasted the medication. The wasted dose of oxycodone 10 mg extended release was subtracted from the remaining amount. A review of the MAR for Resident #18 revealed on 5/26/24 at 8:00 AM Nurse #1 initialed she administered one oxycodone 10 mg extended release tablet. During an interview and observation on 02/12/25 at 8:48 AM Resident #18 revealed he had chronic back pain back and nerve damage in his leg. Resident #18 stated he received scheduled and as needed pain medication, and it was effective, and he did not recall a time he had not received his pain medication. Resident #18 showed no signs of pain during the interview. A review of the initial 24-hour report revealed on 5/27/24 at 1:00 PM the facility became aware of an alleged diversion of resident drugs when staff noticed double signatures for the same date and time for the administration of residents' narcotic medications with unknown witness signatures for medications being wasted. The report named Resident #1, Resident #18, and Resident #46 and Nurse #1 as the accused employee. Law enforcement was notified on 5/27/24 at 1:15 PM and the State Agency on 5/27/24 at 2:59 PM. A review of the facility's 5-day investigation revealed law enforcement filed criminal charges against Nurse #1 who refused to write a statement and a complete a drug screen test. The investigation revealed audits were completed of residents with narcotic medications, drug diversion education was provided to nurses including agency staff, and medication administration nurse skill checks were done. Resident pain assessments determined there was no harm. The allegation was substantiated and identified the Director of Nursing (DON) as the investigator and included written statements from staff. On 2/13/25 at 11:08 AM an attempt to interview Nurse #1 was unsuccessful. A review of the statement written by Nurse #2 revealed narcotic medication declining records signed by Nurse #1 indicated possible drug diversion and Unit Manager #1 was notified. During a phone interview on 2/13/25 at 5:04 PM Nurse #2 revealed she identified a pattern when Nurse #1 signed the controlled narcotic medication declining records, and she made copies of those records and notified Unit Manager #1. Nurse #2 revealed that when a controlled narcotic medication was wasted a second nurse needed to observe and co-sign the declining record as a witness it was wasted and put in a dissolving solution kept on the med cart. A review of the statement written by Unit Manager #1 revealed on 5/27/24 she was asked to review the narcotic controlled medication records on the days Nurse #1 worked. Her review identified concerns with Resident #46, #1, and #18 records and noted medications were removed and signed twice for the same time and date and she notified the DON. During an interview on 2/14/25 at 11:24 AM Unit Manager #1 revealed on 5/27/24 she reviewed the controlled narcotic medication declining records signed by Nurse #1. She identified controlled narcotic medications were wasted and then administered for the same date and time and she did not recognize the second nurse signature used as a witness. Unit Manager #1 revealed Nurse #1 was removed from the medication cart and the Administrator and DON were notified. After questioned, Nurse #1 was unable to provide an explanation and escorted out of the facility. Unit Manager #1 revealed after drug diversion was identified education was provided to nurse staff on what to look for on the controlled medication declining records and included to check signatures. Unit Manager #1 stated she completed random observations of nurse staff during medication administration, interviewed alert and oriented residents about their pain, and completed pain assessment using the facial pain scale for residents that were unable to make their needs known and voice they were in pain. A review of the DON statement revealed on 5/27/24 she was notified of possible drug diversion and frequent wasting for controlled narcotic medications signed by Nurse #1 with a co-signature that was not familiar. Nurse #1 was interviewed and admitted she had co-signed and there was no second nurse witness to verify narcotic medications were wasted. Nurse #1 did not remember where she wasted the narcotic medications and thought it was either the trash or sharps container. The Unit Manager was instructed to check all sharp containers, and no controlled narcotic medications were found. Nurse #1 was asked to write a statement and provide a urine sample for a drug screen test that she refused and was escorted out of the facility. Interviews were conducted on 2/13/25 at 1:20 PM and 2/14/25 at 10:24 AM with the DON. The DON revealed the investigation focused on reviewing residents controlled narcotic medications records signed by Nurse #1 on the dates she worked and the medication cart she was assigned. The DON stated in all five narcotic medications were diverted. She revealed Resident #46 records identified on 4/21/24 at 8:00 AM Nurse #1 signed she removed one tablet of hydrocodone/acetaminophen 5-325 mg and wasted it without a second nurse witness signature and on 4/21/24 at 11:30 PM signed she removed two tablets of hydrocodone/acetaminophen 5-325 mg. Her review of Resident #1 records identified on 5/17/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone 5-325 mg and wasted one without a witness second nurse signature and on 5/24/24 at 8:00 AM signed she removed two tablets of oxycodone 5-325mg and wasted one with an unknown second nurse signature. Her review of Resident #18 records identified on 5/26/24 at 8:00 AM Nurse #1 signed she removed 2 tablets of oxycodone 10 mg extended release and wasted one with an unknown second nurse signature. The DON revealed Nurse #1 was interviewed and asked to write a statement and take a drug screen test and initially agreed but then declined and stated she needed legal counsel. The Administrator statement revealed on 5/27/24 he conducted an interview with Nurse #1 to discuss the second nurse signature was not recognized. Nurse #1 initially stated she did not remember who the second nurse was then admitted the other signatures were hers and no other nurse witnessed her waste the controlled narcotic medications. Nurse #1 stated she wasted three narcotics in the sharps container then changed her story to she threw them in the trash. No narcotics were found in the sharps container and Nurse #1 was asked to write a statement and she agreed. Nurse #1 was asked to complete a drug screen test and initially agreed then stated she took pain medication for a previous accident then refused to write a statement and complete a drug screen test stating she needed representation. Unit Manager #2 was asked to escort Nurse #1 from building. During an interview on 2/14/25 at 3:35 PM the Administrator revealed he was notified by Unit Manager #1 on 5/27/24 that there was a problem with drug diversion and asked to review the controlled narcotic medication records signed by Nurse #1. The Administrator revealed he noticed something was off with signatures and interviewed Nurse #1 with other Department Head staff present. He revealed Nurse #1 was asked to provide the name of the second nurse signature that witnessed her waste controlled narcotic medication and was unable to provide that information. Nurse #1 was asked to write a statement and take a drug screen test and when she refused was asked to leave the building. The Administrator revealed they started their investigation, and he called the police and reported concerns of drug diversion, and the Police Officer came to facility and a report was made. The Administrator revealed family members or if cognitively intact the resident were notified of the diversion and the DON reported Nurse #1 to the North Carolina Board of Nursing (NCBON). He revealed on 5/27/24 members of Quality Assurance and Performance Improvement (QAPI) put a plan of correction in place and the audit tools were reviewed at following meeting. The Administrator revealed Nurse #2 recognized drug diversion and knew what to look for when reviewing the controlled medication declining records. Review of statement written by Unit Manager #2 revealed controlled narcotic medication declining records signed by Nurse #1 had several instances of the same medication being wasted with an unrecognizable second nurse signature as the witness then removed same medication again. After an interview with Administrator, DON, and Unit Managers, Nurse #1 admitted the second nurse signature was hers and stated she gave the medication. Nurse #1 was informed that the incident would be reported and asked to write a statement and offered a drug screen test. Nurse #1 refused to complete a written statement and declined the drug screen and stated she needed legal representation. Unit Manger #2 escorted Nurse #1 out of the building. During an interview on 2/14/25 at 12:43 PM Unit Manager #2 revealed controlled narcotic medication declining records signed by Nurse #1 identified concerns medications were wasted with an unknown second nurse signature as a witness. Unit Manager #2 revealed Department Heads interviewed Nurse #1 about the unknown second nurse's signature and she admitted it was hers. Unit Manager #2 revealed Nurse #1 was asked to take a drug screen test and stated she was taking pain medication and when asked to provide the prescription she did not and refused a drug screen test. Unit Manager #2 revealed Nurse #1 was asked to write a statement and refused stating she needed lawyer and on 5/27/24 was escorted out of the facility. The facility provided the following corrective action plan with the correction date of 5/30/24: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Upon Discovery on 5/27/24 Nurse #2 observed discrepancies on facility narcotic count sheets Nurse #1 was unable to account for. The facility, in accordance with our Quality Assurance Performance Improvement (QAPI) program, leadership implemented the following corrective action measures: 5/27/24 Facility staff notified Unit Manager of the discrepancies on the narc count sheet. Unit Manager notified Director of Nursing and Nursing Home Administrator. 5/27/24 Director of Nursing immediately replaced Nurse #1 in question with facility Unit Manager. Nurse #1, in question left the facility prior to face to face interview. 5/27/24 Director of Nursing (via phone), Nursing Home Administrator, and Unit Managers interviewed Nurse #1 on discrepancies. Nurse #1 in question refused a drug screen and to write a comprehensive statement. 5/27/24 Director of Nursing and Nursing Home Administrator notified Regional [NAME] President of Operations, Regional Director of Clinical Services, Police Department, Pharmacy Representative, Medical Director, Nurse Practitioner, and families of Resident #1, Resident #46, and Resident #18. During the facility investigation, it was determined there were 5 pills unaccounted for pertaining to Resident #1, Resident #46, and Resident #18. Any missing narcotics would have been obtained from the facility Omni cell (facility dispensing unit for medications, including narcotics) which is owned by the facility and pulled under house stock and not billed to the resident. 5/27/24 Quality Assurance Performance Improvement meeting was completed. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving controlled pain medication have the potential of being affected. The Director of Nursing/Designee completed pain audits on all residents receiving narcotics. 5/27/24 Director of Nursing/Designee completed full narcotic counts on all medication carts. 5/27/24 Director of Nursing/Designee initiated education on medication administration, wasting narcotics, receiving narcotics, administration and wasting of fentanyl patches, notification of narcotic discrepancies. 5/27/24 Director of Nursing/Designee completed a complete pain assessment audit on all residents for anyone that receives narcotics. Interviews completed on all alert and oriented residents with a Brief Interview for Mental Status of 12 or above. A [NAME] Scale was completed on all residents with a Brief Interview for Mental Status below 12 to determine if there was any pain. No negative findings were noted. These audits were completed on 5/28/24. Audits completed on all narcotic sheets to determine if there was any diversion. Five areas were identified for Resident #1, Resident #46, and Resident #18. The Unit Managers completed medication pass observations that was completed on all facility nurses. This audit was started on 5/27/24 and completed on 5/30/24. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur. The Director of Nursing/Designee educated all licensed nurses including agency on drug diversion and medication rights. This education was completed on 5/27/2024, nurses who were not working that day were educated via phone. On 5/27/2024 notification was sent to all agencies that the facility utilized in regard to facility expectation and accountability. Any licensed nurses on PTO/Vacation will be educated prior to working. All newly hired licensed nurses will be educated on said process during orientation. All agency licensed nurses will receive training prior to the start of their next shift. Indicate how the facility plans to monitor its performance and make sure that solutions are sustained. The Director of Nursing/Designee will audit five random narcotic sheets weekly, to ensure that there is no signs of drug diversion. This audit will be completed weekly for 12 weeks then monthly for 2 months. The Director of Nursing/Designee will audit five random residents to ensure that they have no issues with care and services weekly for 12 weeks then monthly for 2 months. The Director of Nursing/Designee will complete medication pass observation on five nurses weekly to ensure meds are passed appropriately and that no diversion is noted. This audit will be completed weekly for 12 weeks and monthly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. The facility completed and accepted an ad hoc QAPI meeting 5/27/24 Root cause analysis: The facility completed a thorough investigation to determine the root cause of the diversion. It is the facility's conclusion that Nurse #1 was addicted to pain medication due to her refusal to take a drug screen and her behavior when questioned regarding the narcotics. Alleged date of compliance: 5/30/24 The facility's corrective action plan with a completion date of 5/30/24 was validated on 2/14/24 by record review, observations, residents, and staff interviews. A review of the QAPI meeting agenda dated 5/27/24 revealed attendees included the Medical Director, Administrator, DON, and Unit Managers for review and approval of their corrective action plan. A review of police report revealed a warrant was issued on 5/27/24 for the arrest of Nurse #1 for embezzlement/diversion of controlled substances by fraud/forgery. The facility census on 5/27/24 was 82 residents. Forty-seven resident interviews were completed on 5/28/24 by the Social Worker. Residents were asked do you have any concern about not getting your medications and any concerns about narcotic medication. A facial pain scale rating system completed on 5/27/24 by Unit Manager #1 who observed 35 residents. A total of 82 residents were reviewed for concerns related to medications and pain with no negative findings. Resident pain evaluations were completed on 5/27/24 that included a numeric pain level, description, and frequency. The pain evaluation for Resident #46 indicated no pain was present. The pain evaluation for Resident #1 indicated no pain was present. The pain evaluation for Resident #18 revealed he was satisfied with his current level of pain rated 7 out 10 and indicated pain was chronic and persistent/daily. A review of the note signed by the Nurse Practitioner on 5/29/24 revealed Resident #46, #1, and #18 were seen and their pain status assessed. The NP noted Resident #46, #1, and #18 pain was at baseline and well controlled on their current medications. Urine drug screen test results were completed on resident who received controlled medications to ensure their medications were received. Results for Resident #46 revealed opiates were present. Results for Resident #1 revealed oxycodone was present. Results for Resident #18 revealed oxycodone was present. A review of the education provided on 5/27/24 revealed the topics reviewed included the process for wasting narcotics with the objective if resident refused or medication was removed by mistake it must be wasted in the dissolving fluid and witnessed and cosigned by a second nurse. Twenty-one nurses signed they had received the education. A review of nurses' skills checkoff for medication administration started on 5/27/24 and completed on 5/30/24 revealed no concerns were identified. Medication administration skill checks continued weekly from 6/6/24 through 8/25/24 then monthly on 09/2024 and 10/2024 with no concerns identified. A review of the notification to the NCBON dated 6/6/24 revealed the DON provided the nurse license number of Nurse #1 and other information obtained from their investigation of drug diversion. A review of controlled narcotic declining records revealed audits continued weekly from 6/7/24 through 8/25/24 then monthly on 09/2024 and 10/2024 with no concerns identified. A review of resident audit tool revealed 5 random residents were asked if needs were met and if they had any concerns with medications continued weekly on 6/5/24 through 8/25/24 then monthly on 09/2024 and 10/2024 with no concerns identified. Observation of medication administration revealed nurses reviewed the physician orders, the medication label, and MAR prior to administering resident medication. Controlled medications were kept locked in a separate storage area on the med cart. Residents with controlled narcotic medications had a declining record that matched the remaining amounts. Declining records were signed by the administering nurses with no controlled narcotic medications wasted. Interviews with nurses including agency nurses revealed they were observed during medication administration. Nurses were able to explain the facility's process for wasting controlled medications in a fluid dissolving liquid and ensure a second nurse observed and signed as the witness. Nurses revealed they review the count of controlled medications with the off-going nurse to ensure the declining records matched the remaining amount of medication and both nurses signed the count was correct before accepting the keys to the medication cart. An interview with Medical Director revealed he attended the QAPI meeting on 5/27/24 and agreed with corrective action plan put in place and reviewed the audits during the next QAPI meeting. Interviews with alert and oriented residents revealed no concerns were identified with uncontrolled pain or medication administration. Interviews with family members of residents unable to make their needs known revealed no concerns were identified related to medication or uncontrolled pain. The completion date of 5/30/24 was validated.

Based on observations and staff interviews, the facility failed to discard potentially hazardous food with signs of spoilage in 1 of 1 walk-in refrigerators, date food items available for residents in 1 of 1 kitchen refrigerators and discard damaged canned goods available for use. This practice had the potential to affect food served to residents. Findings included: a. An observation of the walk-in refrigerator on 02/26/24 at 08:56 AM revealed the following: - A box containing cucumbers with a received date of 12/31/24 that was shriveled with white on the surface. - A box of green bell peppers with a received date of 1/14/25 that was shriveled with black on the surface. b. An observation of the kitchen refrigerator on 02/26/24 at 08:56 AM revealed the following: - 1 ham and cheese sandwich and 1 peanut butter and jelly sandwich that were not dated. c. An observation of the canned goods rack on 02/11/25 at 10:00 AM revealed the following: - An unopened can of catsup with a dent approximately 3 inches wide across the front of it available for use. An interview on 02/11/25 at 10:01 AM with the Certified Dietary Manager (CDM) revealed that the box of cucumbers and the bell peppers should have been thrown away. He further revealed that vegetables should have been held for 7 days only. He stated that both sandwiches should have been dated, and it must have been an oversite. He stated that it was the staff's responsibility to date the sandwiches when they were made. The CDM indicated that the can of catsup must have fallen on the shelf last night and staff must have just placed the can back on the shelf. He further indicated that the can of catsup should have been placed in the damaged canned goods return area. An interview with the Administrator on 02/14/25 at 12:39 PM revealed that his expectation was that food be stored and dated according to regulatory standards, and vegetables that were showing signs of spoilage be thrown away.

Based on record review, staff, Nurse Practitioner (NP), and Medical Doctor (MD) interviews, the facility failed to notify the physician of a fall when they reported a change in condition to the physician for a severely cognitively impaired resident on blood thinner. In addition, the physician was not notified when there was a delay in a STAT (immediately without delay) x-ray order of the left hip for a resident with a decrease in range of motion in her left hip and pain. The STAT x-ray order was ordered on [DATE] at 12:48 PM and not obtained until [DATE] that showed an acute fracture of the left hip at the intertrochanteric region (the area near the hip joint). On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE]. This practice occurred for 1 of 3 residents reviewed for notification of change (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's disease. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident # with severe impairment in cognition. Record review of the Change in Condition document by Nurse #3 dated [DATE] revealed in part: Resident #1 was assessed due to a change in condition. Her vital signs were obtained and within normal limits. Resident #1 received anticoagulant medication and had no changes in mental or functional status. Resident #1 displayed signs/symptoms of pain and an order was received for a STAT (immediate) x-ray of the left hip for decrease range of motion and pain. Record review of the physician's orders revealed in part: Stat X-ray for left hip for decreased range of motion and pain dated [DATE] at 12:48 PM. Record review of a progress note dated [DATE] at 10:56 AM written by the DON revealed in part: On [DATE] Agency NA #1 took Resident #1 to the shower. Was lowering Resident #1 to the toilet when her foot came off the sit to stand mechanical lift. NA #1stated that she lowered the resident to the floor. Agency NA #1 called for NA #2 to assist with Resident #1. On [DATE] staff NA #2 transferred Resident #1 to her chair and noted resident was unable to hold her foot up while being wheeled. After repositioning and making another attempt, NA #2 immediately notified the NP that something was wrong with Resident #1. NP ordered a STAT x-ray of the left hip related to decreased mobility and pain. Final results of x-ray were received on [DATE]. Results noted an acute fracture of the left hip at the intertrochanteric region. NP notified of results and order received to transfer Resident #1 to the ER for further evaluation and treatment. Resident #1 had remained at her baseline. The Guardian was notified of the incident along with the order for transfer. Resident #1 was currently at the hospital. A phone interview on [DATE] at 10:52 AM with NA #1 (agency) revealed that she was assigned to Resident #1 for a shower only on [DATE]. NA #1 stated that she placed Resident #1 in the sit to stand lift and as she (NA #1) transferred Resident #1 to the toilet, Resident #1 was yelling in shock. She then transferred Resident #1 off the toilet with the sit to stand lift, Resident #1's foot slipped, and she lowered Resident #1 to the floor using the sling from the sit to stand mechanical lift. Once Resident #1 was lowered to the floor, NA #1 stated she stepped out into the hallway and called for help from NA #2. NA #1 stated she had not called a Nurse to assess Resident #1 because Resident #1 had not fallen. NA #1 stated after the shower she told Nurse #1 about the yelling but did not tell her about Resident #1's foot slipping and lowering her to the ground. A phone interview on [DATE] at 12:22 PM with NA #2 revealed that on [DATE] she was in another resident's room when NA #1 came out into the hall and asked her to come into the shower room. When NA #2 entered the shower room, she saw Resident #1 sitting on her bottom on the floor. NA #2 stated that she did not get a nurse to assess Resident #1 because she was told Resident #1 slid down to the floor and she (NA #2) had not thought of that as a fall. NA #2 stated that if she thought Resident #1 had fallen harder, she would have gotten a nurse immediately. NA #2 revealed that she had received education on falls being defined as any descent (action of moving downward, dropping or falling) to the floor by a resident. She stated that she should have told her nurse and had her assess Resident #1 before she was moved. NA #2 stated that she did not tell the NP about the incident in the shower the previous day because she had not associated the foot drag with the shower room incident. An interview on [DATE] at 12:06 PM with Nurse #1 revealed that neither NA #1 nor NA #2 had come to her and spoken about Resident #1 on [DATE]. A phone interview on [DATE] at 10:32 AM with Nurse #2 revealed he was Resident #1's assigned nurse on [DATE] and neither NA #1 nor NA #2 had mentioned anything to him about Resident #1's fall. Nurse #2 stated that during his interactions with Resident #1 on [DATE] she displayed no signs or symptoms of pain. Nurse #2 stated that his next shift was on [DATE] and he got report from the off going nurse (unable to identify) that they were waiting on a hip x-ray to be completed for Resident#1. The nurse did not state if he was aware the x-ray order was STAT and was delayed or that he contacted the physician regarding the delayed x-ray. A phone interview on [DATE] at 12:54 PM with Nurse #3 revealed she was working on [DATE]. She stated that Resident #1 was talking and seemed fine in the morning. Nurse #3 stated that around noon when NA #2 got Resident #1 up and put her in her wheelchair, NA #2 reported she noticed a decrease in range of motion in Resident #1's leg and informed the NP. The NP assessed Resident #1 and ordered a STAT x-ray. Nurse #3 stated that when she did not see the x-ray staff come during her shift, she did not notify anyone because it was not unusual for the x-ray company to take a while to arrive. An interview on [DATE] at 10:27 AM with the NP revealed on [DATE] when she was coming down the hallway, NA #2 stopped her and told her something was wrong with Resident #1's leg. She stated that NA #2 told her when she (NA #2) had provided care to Resident #1 she yelled, and her leg dragged when (NA #2) attempted to push her in the wheelchair. When she assessed Resident #1, she yelled and guarded her left leg upon examination. She ordered a STAT hip x-ray to the left hip for pain and decreased range of motion (ROM) but there was a delay from the x-ray company and the NP was not notified of the delay. The DON notified her on [DATE] of the x-ray results showing a fracture to the left hip and then she had the facility to send Resident #1 to the ER. She stated that had she known there was a delay in the x-ray she would have sent Resident #1 out to the ER sooner. The NP stated that NA #2 had not told her about the fall when she was alerted to Resident #1's pain on [DATE]. The NP further revealed that had she known about Resident #1's fall she would have sent Resident #1 directly to the ER. The NP could not say for certain that the delay in care would have changed the outcome for Resident #1. She stated that when she ordered the STAT x-ray, she expected it to be completed in the evening of [DATE] after she had left for the day. She further revealed that if there was a delay in obtaining the STAT x-ray she expected to be informed of the delay via phone call. Resident #1 was taking antiplatelet medication. An interview on [DATE] at 4:07 PM with the Director of Nursing (DON) revealed that on [DATE] NA #1 that had taken Resident #1 into the shower. Resident #1 slid down with the help from NA #1 who was from an agency. NA #1 called NA #2 into the shower room and NA #2 asked if Resident #1 was ok. She stated that NA #1 and NA #2 moved Resident #1 back into her wheelchair without having a Nurse assess her. Then NA #2 left the shower room and neither NA #1 nor NA #2 told anyone. On [DATE] NA #2 was providing a bed bath to Resident #1 then she got Resident #1 up into her wheelchair to take her to the small dining room and as NA #2 started to push Resident #1 out of the room in her wheelchair she noticed Resident #1's foot dragging. NA #2 adjusted Resident #1's foot and noticed there was a problem. NA #2 got the NP and asked her to assess Resident #1. The NP assessed Resident #1 and ordered a STAT hip x-ray for increased pain and decreased ROM. NA #2 had said nothing about the fall on [DATE] at this point to anyone. On [DATE] in the morning meeting the DON was reviewing the orders from the previous day and she inquired about the x-ray order for Resident #1. The Unit Manager had told her there were no results and she would look into it. As the Unit Manager was looking into it and the x-ray unit company had arrived at the facility to take the x-ray for Resident #1. The x-ray results were given to the NP and the NP wanted to know how this happened. The DON stated that she was looking into what happened, the NP gave orders to send Resident #1 out to the ER for further evaluation and treatment. During the investigation on [DATE] when the DON interviewed NA #2, NA #2 then told the DON about Resident #1's fall in the shower room on [DATE]. The DON further revealed that all STAT orders should be fulfilled within 2 hours and if they had not been the Nurse should notify the DON or the Provider and the that the order had not been completed and the RP that there had been a change in condition. An interview on [DATE] at 10:00 AM with the Medical Director revealed that the NP was notified first and then she called him immediately. The MD stated that the NP then ordered an x-ray for unknown pain and decreased range of motion. He stated that NA #1 and NA #2 should have informed the facility about the fall, and he would have wanted Resident #1 assessed before being moved. The MD stated that he did not feel that the delay in notification had altered Resident #1's outcome. He stated that he expected the facility to inform him about the delay in the STAT x-ray order. The MD stated that he probably would not have sent Resident #1 to the ER for a hip x-ray since they were coming the following morning, but that was a decision for the Provider to make not the staff. Resident #1 was taking antiplatelet medication. An interview on [DATE] at 1:49 PM with the Administrator revealed he expected staff to communicate to the Provider and the RP if there was a delay in a STAT order. The Administrator was notified of Immediate Jeopardy on [DATE] at 4:41 PM. The facility provided the following corrective action plan for removal of Immediate Jeopardy with a completion date of [DATE]. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to notify the MD/NP and RP when Resident #1 fell on [DATE] and failed to notify the NP when there was a delay in a stat x-ray order on [DATE]. C.N.A. #1 and C.N.A #2 failed to notify a Nurse/MD or NP when Resident #1 fell on [DATE] and failed to notify before moving Resident #1 off the floor. C.N.A. #2 informed the NP on [DATE] that Resident #1 was having issues with her foot dragging. C.N.A #2 did not notify the NP of the fall on [DATE]. NP performed an assessment on Resident #1, no bruising or swelling was noted. NP ordered stat x-ray and changed scheduled Tylenol to three times daily for pain. Radiology contacted facility on [DATE] and notified the floor nurse that they would not be able to obtain the stat x-ray until [DATE]. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on [DATE] on proper notification of MD for any delay in stat orders. X-ray results revealed acute fracture of left hip on [DATE]. Facility notified Nurse Practitioner and received orders to send resident to the hospital on [DATE] for evaluation and treatment. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Director of Nursing and/or designee completed education on [DATE] and on [DATE] with all licensed nurses and CNA's including agency staff on notification to MD/NP and RP of all incidents or falls and accidents. Director of Nursing and/or designee completed education on [DATE] and [DATE] with all licensed nurses including agency staff on notification to MD/NP on delay of stat x-rays orders. Interviews were conducted with communicative residents on [DATE], [DATE] and [DATE]. These interviews were conducted to determine if any issues regarding care and services would be identified. No other issues were identified. Unit managers completed skin checks on all residents on [DATE]. Skin checks were completed to ensure there were no signs of injury from an unreported fall, no negative findings were noted. On [DATE] Director of Nursing checked for any other stat x-ray orders and there were none. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Director of Nursing and/or their designee on [DATE] educated 100% C.N.A.'s and licensed nurses including agency staff on reporting of incidents and accidents and reporting protocols and change in condition to physician or nurse practitioner. New hires to the facility are educated with the onboarding procedures. On [DATE] through [DATE] Director of Nursing and/or their designee educated all C.N.A.s and licensed staff including agency staff on reporting of accidents and incidents. On [DATE] the Director of Nursing and/or their designee educated all licensed nurses including agency nurses on stat orders and procedures. This education included notification to physician or NP on a delay of stat orders or other changes of condition for the residents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility made the decision to have an ad hoc QAPI committee meeting on [DATE] as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice beginning on [DATE] for a period of 12 weeks. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders from NP. Director of Nursing and/or their designee will audit results daily for 12 weeks to ensure order for x-rays are completed as ordered. NP was notified of this process on [DATE]. Director of Nursing and/or their designee will audit change of condition and incident reports daily for 12 weeks to ensure physician notification of incidents/accidents and falls has been completed. Director of Nursing and/or designee will have daily huddles with licensed nurses and C.N.A.'s at beginning and end of shift to discuss any change in condition or incidents that may have occurred throughout the shift in order to ensure proper notifications have been made. This is to ensure that MD/NP have been notified of any incidents. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months. Corrective action will be completed: [DATE] The facility alleged a IJ removal date of [DATE]. The Corrective Action plan was validated on [DATE] and verified the facility implemented an acceptable corrective action plan on [DATE] as evidenced by facility documentation and staff interviews. Review of the in-service sign-in sheets dated [DATE], [DATE], and [DATE] revealed all staff/all departments received education staff notification of incidents and accidents and reporting protocols and change in condition to physician or nurse practitioner. Interviews with facility staff revealed they received in-service education regarding the facility's incident reporting protocol and were able to verbalize what to do when a resident had a fall and who to notify of the fall. Review of the facility's monitoring tools dated [DATE] through [DATE] revealed they were completed as outlined in the corrective action plan with no concerns identified.

Based on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to protect a resident's right to be free from neglect when staff disregarded Resident #1's plan of care and transferred the resident without the use of a total mechanical lift and two-person assistance. During the first transfer Resident #1 was assisted to the floor. The following day ([DATE]) the Nurse Practitioner was asked to assess Resident #1 due to her left foot dragging on the floor and x-ray results revealed an acute fracture of the left hip. On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE]. Findings included: This tag is crossed referred to F 689. Based on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to safely transfer a resident from the toilet to the shower chair when one staff member used the sit to stand mechanical lift instead of the total mechanical lift resulting in the resident falling to the floor for 1 of 3 sampled residents reviewed for accidents (Resident #1). On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. NA #1 requested help from NA #2 and they both assisted Resident #1 off the floor without using a mechanical lift. Transfers continued without using the total mechanical lift and assistance from two people. On [DATE] NA #2 reported to the Nurse Practitioner (NP) that Resident #1's left foot dragged the floor when in a wheelchair and asked for her to assess the resident. NA #2 did not inform the NP of Resident #1's fall on [DATE]. The NP assessed Resident #1 and ordered STAT (immediate) x-rays on [DATE]. On [DATE] STAT x-ray results for Resident #1 revealed an acute fracture of the left hip. The Director of Nursing (DON) notified the NP who ordered Resident #1 to be sent out to the hospital for further evaluation and treatment. On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE]. The Administrator was notified of Immediate Jeopardy on [DATE] at 4:41 PM. The facility provided the following corrective action plan with a completion date of [DATE]. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift. X-ray was obtained on [DATE] which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated on [DATE]. The Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room, and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at the facility, CNA #2 has been terminated. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The Director of Nursing and/or designee completed interviews with communicative residents on [DATE], [DATE] and [DATE] regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents on [DATE] to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from the therapy department. Unit managers cross-referenced the lift status to the Kardex and Care Plans. 3. Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Director of Nursing and/or their designee on [DATE] educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents and reporting protocols. Agency staff will be educated prior to the first shift working on proper lifts, facility policies, and reporting all incidents and changes in condition. New hires to the facility are educated with the onboarding procedures. On [DATE] through [DATE] Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers and proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s, reporting of accidents and incidents, following the Kardex for proper transfers and change in condition. On [DATE] through [DATE] the Director of Nursing and/or their designee educated all facility staff on abuse and neglect, definition of abuse/neglect and facility policy for reporting. Staff educated that facility has no tolerance for abuse/neglect and will result in immediate termination. Director of Nursing and/or their designee educated agency staff on abuse/neglect policy, reporting and consequences of abuse/neglect on [DATE]. New staff will be educated upon hire by the Director of Nursing and/or their designee. 4. Indicate how the facility plans to monitor it performance to make sure that solutions are sustained. The facility made the decision to have an ad hoc QAPI committee meeting on [DATE] as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice beginning on [DATE] for a period of 12 weeks. To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week for 12 weeks to ensure residents requiring assist utilizing lifts are receiving the proper transfer. Unit Mangers will select 5 residents weekly over the next 12 weeks that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy. Administrator and/or their designee will audit five (5) random staff members weekly times 12 weeks to ensure that they understand the definition abuse/neglect and the reporting requirements for abuse/neglect. The Social Services Director and/or their designee will interview 5 alert residents and 5 responsible parties per week for 12 weeks to ensure that no abuse/neglect is occurring. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months. Completion date: [DATE] The facility alleged a IJ removal date of [DATE]. The Corrective Action plan was validated on [DATE] and concluded the facility had implemented an acceptable corrective action plan on [DATE]. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on use of mechanical lift transfers that included requiring two-person assistance for all transfers, using the proper lift, identifying a resident's lift status on the Kardex, and lift identifying tag on the door, and gait belt training. Additionally, agency staff along with all facility staff were educated on the facilities abuse/neglect policy, reporting and consequences of abuse/neglect on [DATE]. Staff interviewed all verbalized they were observed performing a mechanical lift transfer after receiving re-education and received re-education regarding the facilities abuse and neglect policies. Review of the monitoring tools of mechanical lift transfers that began on [DATE] and continued weekly for the next 12 weeks were completed as outlined in the corrective action plan with no concerns identified.

Based on record review and Medical Doctor (MD), Nurse Practitioner (NP) and staff interviews, the facility failed to assess Resident #1 by a nurse after a fall and prior to getting her off the floor. Additionally, the facility failed to ensure a STAT (immediate) order for x-ray was executed resulting in delayed care. On 4/24/24 Nurse Aide (NA) #1 transferred Resident #1 from her bed to the sit to stand lift and transported Resident #1 to the shower room. During a transfer in the shower room from the toilet to the sit-to-stand lift Resident #1's foot slipped and NA #1 had to lower Resident #1 to the floor. NA #1 called for assistance from NA #2. NA #1 and NA #2 did not notify the Nurse that Resident #1 had fallen. An assessment for injury was not completed by a Nurse prior to Resident #1 being moved. On 4/25/24 the NP placed a STAT order for left hip x-ray at 2:00 PM. The facility was made aware there was a delay in the STAT x-ray and did not inform the NP. The results of the x-ray were available on 4/26/24 at 11:38 AM when the Director of Nursing (DON) notified the NP of the results. The NP sent Resident #1 to the hospital. A change in condition report indicated Resident #1 suffered pain and the final x-ray noted a fracture of Resident #1's left hip. This deficient practice affected 1 of 3 residents. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, mild protein-calorie malnutrition, cerebral infarction (a disruption of blood flow to the brain), severe vascular dementia, history of falling, unsteadiness on feet, abnormalities of gait and mobility, reduced mobility, and lack of coordination. An Activity of Daily Living (ADL) care plan, last revised 03/08/24, revealed Resident #1 had an ADL self-care performance deficit related to mobility, weakness, pain, temporal sclerosis (scarring of the temporal lobe of the brain), polymyalgia rheumatica (an inflammatory disorder that causes muscle pain and stiffness). Included was an intervention that noted Resident #1 required a total mechanical lift with a sling and two-person assistance for all transfers. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with severe impairment in cognition and had no impairment of the upper and lower extremities. Resident #1 required total dependence on staff assistance with bed mobility (roll left and right), toilet transfers, and tub/shower transfers. Resident #1 took antiplatelet and hypoglycemic medications and had no previous falls. A phone interview on 5/7/24 at 10:52 AM with NA #1 (agency) revealed that she was assigned to Resident #1 for a shower only on 4/24/24 and had worked at the facility for approximately one month. She stated she gathered her items and the sit to stand mechanical lift and went to Resident #1's room. NA #1 stated she transferred Resident #1 from her bed with the sit to stand lift proceeded to the shower room where she placed Resident #1 on the toilet. She then transferred Resident #1 off the toilet with the sit to stand lift, Resident #1's foot slipped, and she lowered Resident #1 to the floor using the sling from the sit to stand mechanical lift. Once Resident #1 was lowered to the floor, NA #1 stated she stepped out into the hallway and called for help from NA #2. NA #2 came to help NA #1. NA #1 explained what happened to NA #2 and NA #2 replied that Resident #1 yelled like that sometimes. NA #1 and NA #2 then performed a 2-person physical assist to get Resident #1 up off the floor to her wheelchair. NA #1 stated she had not called a Nurse to assess Resident #1 because NA #1 did not think lowering Resident #1 to the floor qualified as a fall. She stated after the shower she told Nurse #1 about the yelling but did not tell her about Resident #1's foot slipping and lowering her to the ground. A phone interview on 5/7/24 at 12:22 PM with NA #2 revealed that on 4/24/24 she was in another resident's room when NA #1 came out into the hall and asked her to come into the shower room. When she entered the shower room, she saw Resident #1 sitting on her bottom on the floor. She asked NA #1 what happened, and NA #1 stated that Resident #1 slid out of the sit to stand mechanical lift. She asked NA #1 if Resident #1 was alright and NA #1 got on each side of Resident #1, grabbed her by the pants, placed their arms under Resident #1's arms, lifted her into a wheelchair and then NA #2 left the shower room. NA #2 stated that she did not get a nurse to assess Resident #1 because she was told Resident #1 slid down to the floor and she (NA #2) had not thought of that as a fall. She stated that if she thought Resident #1 had fallen harder, she would have gotten a nurse immediately. NA #2 revealed that she had received education on falls being defined as any descent (action of moving downward, dropping or falling) to the floor by a resident. She stated that she should have told her nurse and had her assess Resident #1 before she was moved. She stated that she did not tell the NP about the incident in the shower the previous day because she had not associated the foot drag with the shower room incident. A phone interview on 5/8/24 at 10:32 AM with Nurse #2 revealed he was Resident #1's assigned nurse on 4/24/24 and neither NA #1 nor NA #2 had mentioned anything to him about Resident #1's fall. He stated that during his interactions with Resident #1 on 4/24/24 she displayed no signs or symptoms of pain in the day room and later on in resident #1's room. He stated that his next shift was on 4/26/24 and he got report from the off going nurse that they were waiting on a hip x-ray to be completed for Resident #1. When the x-ray results were received on 04/26/24 and revealed that Resident #1 had a hip fracture, she was sent out to the emergency room (ER). An interview on 5/7/23 12:06 PM with Nurse #1 revealed that she was not involved in the incident related to Resident #1's fall on 04/24/24. She stated that she worked on 4/24/24, but she was not Resident #1's assigned nurse. She further revealed that neither NA #1 nor NA #2 had come to her and spoke to her about Resident #1. A phone interview on 5/7/24 at 12:54 PM with Nurse #3 revealed she was not working on 4/24/24 the day of the incident but was working the day after the incident on 4/25/24. She stated first thing in the morning (4/25/24) she went into Resident #1's room and she was lying flat on her back. Resident #1's vital signs and they were fine. She stated that Resident #1 was talking, and she seemed fine. She stated that around noon when NA #2 got Resident #1 up and put her in her wheelchair, NA #2 reported she noticed a decrease in range of motion in Resident #1's leg and informed the NP. The NP immediately assessed Resident #1 and ordered an x-ray. She stated she received no mention in shift report the morning of 4/25/24 of Resident #1's fall in the shower room the previous day. She stated that Resident #1 had not displayed any signs or symptoms of pain like yelling, moaning, grimacing, or guarding. She stated she did not see the x-ray staff come during her shift. Record review of the Change in Condition document by Nurse #3 dated 04/25/24 revealed in part: Resident #1 was assessed due to a change in condition. Her vital signs were obtained and within normal limits. Resident #1 received anticoagulant medication and had no changes in mental or functional status. Resident #1 displayed signs/symptoms of pain and an order was received for a STAT (immediate) x-ray of the left hip for decrease range of motion and pain. An interview on 5/7/24 at 10:27 AM with the NP revealed on 4/25/24 when she was coming down the hallway, NA #2 stopped her and told her something was wrong with Resident #1's leg. She stated that NA #2 told her when she (NA #2) had provided care to Resident #1 she yelled, and her leg dragged when (NA #2) attempted to push her in the wheelchair. When she assessed Resident #1, she yelled and guarded her left leg upon examination. She stated that Resident #1 was normally up in her wheelchair with a very calm personality, and she was not herself that day. The NP observed no bruising when she did a skin check. She ordered a STAT hip x-ray to the left hip for pain and decreased range of motion (ROM) but there was a delay from the x-ray company and the NP was not notified of the delay. The DON notified her on 4/26/24 of the x-ray results showing a fracture to the left hip and then she had the facility to send Resident #1 to the ER. She stated that had she known there was a delay in the x-ray she would have sent Resident #1 out to the ER sooner. She stated that NA #2 helped NA #1 on 4/24/24 when Resident #1 had the fall in the shower. The NP stated that NA #2 had not told her about the fall when she was alerted to Resident #1's pain on 4/25/24. She further revealed that had she known about Resident #1's fall she would have sent Resident #1 directly to the ER. The NP could not say for certain that the delay in care would have changed the outcome for Resident #1. She stated that communication with falls was very great at this facility, and this seemed like an anomaly (something that deviates from what is standard, normal or expected). She stated that when she ordered the STAT x-ray, she expected it to be completed in the evening of 04/25/24 after she had left for the day. She further revealed that if there was a delay in obtaining the STAT x-ray she expected to be informed of the delay via phone call. She stated that when a STAT order was placed, for example in the morning, it should be completed by the time she left at 5 PM. Record review of the physician's orders revealed in part: Stat X-ray for left hip for decreased range of motion and pain dated 4/25/24 at 12:48 PM. Tylenol Oral Tablet 325 milligrams (MG) (Acetaminophen), give 650 mg by mouth three times a day for pain started on 4/25/2024. Record review of the radiology report dated 4/26/24 at 11:28 AM revealed there was an acute fracture of left hip. Record review of the medication administration record (MAR) for April 2024 revealed that the acetaminophen was documented as administered per the physician's order until Resident #1's discharge to the hospital. Review of Resident #1's daily pain scale from 4/24/24 through 4/26/24 revealed her pain was documented as 0. Record review of the shower sheets from March 2024 through April 2024 revealed skin assessments were completed with no concerns noted. An interview on 5/7/24 at 4:07 PM with the DON revealed that on 4/24/24 NA #1 that had taken Resident #1 into the shower. Resident #1 slid down with the help NA #1 who was from an agency. NA #1 called NA #2 into the shower room and NA #2 asked if Resident #1 was okay. She stated that NA #1 and NA #2 moved Resident #1 back into her wheelchair without having a nurse assess her. Then NA #2 left the shower room and neither NA #1 or NA #2 told anyone. On 4/25/24 NA #2 was providing a bed bath to Resident #1 then she got Resident #1 up into her wheelchair to take her to the small dining room and as NA #2 started to push Resident #1 out of the room in her wheelchair she noticed Resident #1's foot dragging. NA #2 adjusted Resident #1's foot and noticed there was a problem. NA #2 got the NP and asked her to assess Resident #1. The NP assessed Resident #1 and ordered a STAT hip x-ray for increased pain and decreased ROM. NA #2 said nothing about the fall on 4/24/24 at this point to anyone. On 4/26/24 in the morning meeting the DON was reviewing the orders from the previous day and she inquired about the x-ray order for Resident #1. The Unit Manager told her there were no results and she would look into it. As the Unit Manager was looking into it, the x-ray unit company had arrived at the facility to take the x-ray for Resident #1. The x-ray results were given to the NP and the NP wanted to know how this delay happened. The DON stated that she was looking into what happened, the NP gave orders to send Resident #1 out to the ER for further evaluation and treatment. The DON then shared the information with the Administrator and an investigation began for an injury of unknown origin. During the investigation on 4/26/24, NA #2 told the DON about Resident #1's fall in the shower room on 4/24/24. The DON notified the NP and the Administrator and implemented risk tools. She further revealed that all STAT orders should be fulfilled within 2 hours and if they had not been the Nurse should notify the DON or the Provider that the order had not been completed. Record review of a progress note dated 4/26/24 at 10:56 AM written by the DON revealed in part: On 4/24/24 Agency NA #1 took Resident #1 to the shower. Was lowering Resident #1 to the toilet when her foot came off the sit to stand mechanical lift. NA #1 stated that she lowered the resident to the floor. Agency NA #1 called for NA #2 to assist with Resident #1. On 4/25/24 staff NA #2 transferred Resident #1 to her chair and noted resident was unable to hold her foot up while being wheeled. After repositioning and making another attempt, NA #2 immediately notified the NP that something was wrong with Resident #1. NP ordered a STAT x-ray of the left hip related to decreased mobility and pain. Final results of x-ray were received on 4/26/24. Results noted an acute fracture of the left hip at the intertrochanteric region. NP notified of results and order received to transfer Resident #1 to the ER for further evaluation and treatment. Resident #1 had remained at her baseline. Resident #1 was currently at the hospital. An interview on 5/8/24 at 10:00 AM with the Medical Director revealed that the NP was notified first and then she called him immediately. He stated that the NP then ordered an x-ray for unknown pain and decreased range of motion. He stated that NA #1 and NA #2 should have informed the facility about the fall, and he would have wanted Resident #1 assessed before being moved. He stated that he did not feel that the delay in care had altered Resident #1's outcome. He stated that he expected the facility to inform him about the delay in the STAT x-ray order. He stated that he probably would not have sent Resident #1 to the ER for a hip x-ray since they were coming the following morning, but that was a decision for the Provider to make not the staff. He further stated that STAT to him meant completing it the day it was ordered, roughly 4-6 hours. He stated if a resident was lowered to the ground, he expected them to be assessed before they were moved. An interview on 5/8/24 at 1:49 PM with the Administrator revealed that an x-ray was ordered on 4/25/24. On 4/26/24 the results of an x-ray revealed that Resident #1 had a leg fracture and that was when they had discovered something had happened. The DON and himself investigated the incident. During the first interview NA #2 revealed Resident #1 had a fall on 4/24/24. The NP ordered Resident #1 to be sent out to the hospital for further evaluation and treatment. He stated this was a very unusual incident because they pride themselves on thorough communication. They started staff education that Friday 4/26/24. He stated he expected staff to communicate to the Provider if there was a delay in a STAT order and he would have to defer to the Medical Director for an appropriate time frame for STAT orders. The Administrator was notified of Immediate Jeopardy on 5/8/24 at 4:41 PM. The facility provided the following corrective action plan with a completion date of 5/4/24. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to have resident assessed by a nurse after the fall and prior to getting her off the floor. The facility failed to report the fall and improper transfer the next day when CNA #2 reported the resident having issues with her foot dragging. On 4/25/24 Nurse Practitioner was notified by C.N.A. #2 that resident could not move her left foot. Nurse Practitioner performed an assessment on resident, no bruising or swelling was noted. Nurse Practitioner ordered stat x-ray and changed Tylenol order to three times daily for pain. Radiology contacted facility on 4/25/24 and notified the floor nurse that they would not be able to obtain the stat x-ray until 4/26/24. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on 5/3/24 on proper notification to MD for any delay in stat orders. X-ray results revealed acute fracture of left hip on 4/26/24. Facility notified Nurse Practitioner and received orders to send resident to the hospital on 4/26/24 for evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated on 4/26/24. Director of Nursing conducted an interview with C.N.A. #2 which revealed the incident on 4/24/24 and a conclusion on how the fracture occurred. C.N.A. #2 confirmed that resident was on the floor in the shower room and C.N.A #2 assisted C.N.A #1 in returning resident to chair. C.N.A #1 cannot return to the facility, CNA #2 has been terminated from the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Director of Nursing and/or designee completed interviews with communicative residents on 5/2/24 and 5/3/24 regarding care and services provided to identify any unreported incidents or other injury of unknown origin. No other issues were identified by residents. Head to toe skin assessments were completed on all residents by Unit Managers on 4/26/24. This was done to ensure there were no signs or symptoms of injuries related to incidents not being reported. No negative findings were noted from residents. The Director of Nursing checked for any other stat x-ray orders on 4/26/24 and there were none. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Director of Nursing and/or their designee completed education of 100% C.N.A.'s and licensed nurses on 4/29/24 which included, safe transfers, reporting of incidents and accidents, and reporting protocols and change in condition. This includes having a licensed nurse assess a resident after all falls and/or incidents. Agency staff will be educated prior to first shift working on proper lifts, facility policies, and reporting all incidents and change in condition. New hires to the facility are educated with the onboarding procedures. On 5/2/24 through 5/3/24 the Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on reporting of incidents and accidents and the definition of a fall. Agency staff were educated prior to taking an assignment. On 4/26/24 the Director of Nursing and/or their designee completed 100% education of all licensed nurses on stat orders. This education included notification to MD/NP if stat order has been delayed. Agency nurses are educated on STAT orders prior to first shift working. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility made the decision to have an ad hoc QAPI committee meeting on 5/3/24 as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice beginning on 5/6/24 for a period of 12 weeks. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders daily from NP. Director of Nursing and/or their designee will audit results daily for 12 weeks to ensure orders for x-rays are completed as ordered. NP was notified of this process on 5/3/24. Director of Nursing and/or their designee will randomly audit five (5) staff members weekly for 12 weeks to monitor knowledge of reporting of incidents, falls and what is considered a fall. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months. Corrective action will be completed: May 4, 2024 The facility alleged a IJ removal date of 5/4/24. The Corrective Action plan was validated on 5/16/24 and concluded the facility implemented an acceptable corrective action plan on 5/04/24 as evidenced by facility documentation and staff interviews. Review of the in-service sign-in sheets dated 4/29/24 revealed all staff/all departments received education that a resident that had a fall must be assessed by the nurse and the MD/provider must be immediately notified. Interviews with facility staff revealed they received in-service education regarding the facility's fall protocol and were able to verbalize what to do when a resident had a fall and who to notify of the fall. Interviews with nurses revealed they received additional education on 4/29/24 regarding the change to the facility's fall protocol and verbalized they were to call the MD/provider immediately anytime a resident had a fall with or without injury and regardless if the resident was on anticoagulant medication. Review of the facility's monitoring tools dated 4/26/24 through 5/16/24 revealed they were completed as outlined in the corrective action plan with no concerns identified.

Based on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to safely transfer a resident from the toilet to the shower chair when one staff member used the sit to stand mechanical lift instead of the total mechanical lift resulting in the resident falling to the floor for 1 of 3 sampled residents reviewed for accidents (Resident #1). On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. NA #1 requested help from NA #2 and they both assisted Resident #1 off the floor without using a mechanical lift. Transfers continued without using the total mechanical lift and assistance from two people. On [DATE] NA #2 reported to the Nurse Practitioner (NP) that Resident #1's left foot dragged the floor when in a wheelchair and asked for her to assess the resident. NA #2 did not inform the NP of Resident #1's fall on [DATE]. The NP assessed Resident #1 and ordered STAT (immediate) x-rays on [DATE]. On [DATE] STAT x-ray results for Resident #1 revealed an acute fracture of the left hip. The Director of Nursing (DON) notified the NP who ordered Resident #1 to be sent out to the hospital for further evaluation and treatment. On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE]. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, mild protein-calorie malnutrition, cerebral infarction (a disruption of blood flow to the brain), severe vascular dementia, history of falling, unsteadiness on feet, abnormalities of gait and mobility, reduced mobility, and lack of coordination. An Activity of Daily Living (ADL) care plan, last revised [DATE], revealed Resident #1 had an ADL self-care performance deficit related to mobility, weakness, pain, temporal sclerosis (scarring of the temporal lobe of the brain), polymyalgia rheumatica (an inflammatory disorder that causes muscle pain and stiffness). The care plan included an intervention that noted Resident #1 required a total mechanical lift with a sling and two-person assistance for all transfers. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with severe impairment in cognition and had no impairment of the upper and lower extremities. Resident #1 required total dependence on staff assistance with bed mobility (roll left and right), toilet transfers, and tub/shower transfers. Resident #1 used antiplatelet and hypoglycemic medications. A phone interview on [DATE] at 10:52 AM with NA #1 (agency) revealed that she was assigned to Resident #1 for a shower only on [DATE] and had worked at the facility for approximately one month. She stated she gathered her items and the sit to stand mechanical lift and went to Resident #1's room. NA #1 stated she transferred Resident #1 from her bed with the sit to stand lift proceeded to the shower room where she placed Resident #1 on the toilet. She then transferred Resident #1 off the toilet with the sit to stand lift, Resident #1's foot slipped, and she lowered Resident #1 to the floor using the sling from the sit to stand mechanical lift. Once Resident #1 was lowered to the floor, NA #1 stated she stepped out into the hallway and called for help from NA #2. NA #2 came to help NA #1. NA # 1 explained what happened to NA #2 and NA #2 replied that Resident #1 yelled like that sometimes. NA #1 and NA #2 then performed a two-person manual lift to get Resident #1 up off the floor to her wheelchair. NA #1 stated she had not called a Nurse to assess Resident #1 because NA #1 stated Resident #1 had not fallen. NA #1 got another mechanical lift pad, placed it around Resident #1, transferred Resident #1 with the sit to stand mechanical lift to the shower chair and gave her a shower without further incident. She stated that she transferred Resident #1 back to her wheelchair with the sit to stand mechanical lift and transported her to the dayroom. She stated after Resident #1 was transported to the dayroom, she told Nurse #1 about Resident #1 yelling but did not tell her about Resident #1's foot slipping from the mechanical lift and being lowered to the ground. NA #1 stated that she had not received orientation or education on resident transfers or lift equipment from the facility but had completed a checkoff list with her agency. NA #1 also stated that she was not educated on how to access resident care plans and she followed staff directions for resident care. Record review of the shower sheet dated [DATE] revealed that Resident #1 was given a shower with no identified concerns and no skin issues noted and was signed by NA #1. A phone interview on [DATE] at 12:22 PM with NA #2 revealed that on [DATE] she was in another resident's room when NA #1 came out into the hall and asked her to come into the shower room. When she entered the shower room, she saw Resident #1 sitting on her bottom on the floor. She asked NA #1 what happened, and NA #1 stated that Resident #1 slid out of the sit to stand mechanical lift. She asked NA #1 if Resident #1 was alright, and NA #1 stated that Resident #1 was okay. She stated she and NA #1 got on each side of Resident #1, grabbed her by the pants, placed their arms under Resident #1's arms, lifted her into a wheelchair and then NA #2 left the shower room. She further revealed that Resident #1 was supposed to use a total mechanical lift but that Resident #1 can stand well which was why she chose to use the sit to stand mechanical lift and had used the sit to stand mechanical lift to transfer Resident #1 prior to the incident. She stated that the Kardex is located at the nurse's station with all resident's lift requirements as well as it being on the resident's closet doors. She stated that she was Resident #1's assigned NA on [DATE] and she had not instructed NA #1 on how to transfer Resident #1. She stated that she worked from 7:00 AM to 3:00. She stated that Resident #1 had not displayed any signs or symptoms of pain or discomfort during her afternoon observations of her on [DATE]. NA #2 stated that she had not thought to use the mechanical lift to get Resident #1 off the floor. She stated that she provided incontinence care to Resident #1 on [DATE], transferred her with the sit to stand lift to her wheelchair with no signs or symptom of pain or discomfort and Resident #1 was not yelling, moaning, screaming, or guarding her leg. She stated that when she went to take Resident #1 to the day room on [DATE], she noticed her foot dragging and went and told the NP. She stated that she did not tell the NP about the incident in the shower the previous day because she had not associated the foot drag with the shower room incident. A phone interview on [DATE] at 10:32 AM with Nurse #2 revealed he was Resident #1's assigned nurse on [DATE] and neither NA #1 nor NA #2 had mentioned anything to him about Resident #1's fall. He stated that during his interactions with Resident #1 on [DATE] she displayed no signs or symptoms of pain. He stated that his next shift was on [DATE] and he got report from the off going nurse that they were waiting for a hip x-ray to be completed for Resident#1. When the x-ray results were received on [DATE] and revealed that Resident #1 had a hip fracture, she was sent out to the emergency room (ER). An interview on [DATE] at 12:06 PM with Nurse #1 revealed that residents had a care guide posted on the door or in the resident's closet regarding how to transfer the residents and the information was also posted in the Kardex (NA guide that contains individualized care information) that was in a book at the nursing station desk. An observation of the Kardex and resident care guides revealed they contained information on what type of lift and how many people to utilize with each specific type of lift were posted in the resident's rooms and at the nurses station. Record review of the Change in Condition document by Nurse #3 and dated [DATE] revealed in part: Resident #1 was assessed due to a change in condition. Her vital signs were obtained and within normal limits. Resident #1 received anticoagulant medication and had no changes in mental or functional status. Resident #1 displayed signs/symptoms of pain and an order was received for a STAT (immediate) x-ray of the left hip for decrease range of motion and pain. An interview on [DATE] at 10:27 AM with the NP revealed on [DATE] when she was coming down the hallway, NA #2 stopped her and told her something was wrong with Resident #1's leg. She stated that NA #2 told her when she (NA #2) had provided care to Resident #1 she yelled, and her leg dragged when (NA #2) attempted to push her in the wheelchair. When she assessed Resident #1, she yelled and guarded her left leg upon examination. She stated that Resident #1 was normally up in her wheelchair with a very calm personality, and she was not herself that day. The DON notified her on [DATE] of the x-ray results showing a fracture to the left hip and then she had the facility to send Resident #1 to the ER. She stated that NA #2 helped NA #1 on [DATE] when Resident #1 had the fall in the shower. The NP stated that NA #2 had not told her about the fall when she was alerted to Resident #1's pain on [DATE]. She further revealed that had she known about Resident #1's fall she would have sent Resident #1 directly to the ER. Record review of the physician's orders for Resident #1 revealed in part: - Tylenol Oral Tablet 325 milligrams (MG) (Acetaminophen), give 650 mg by mouth three times a day for pain started on [DATE]. - STAT X-ray for left hip for decreased range of motion and pain dated [DATE] at 12:48 PM. Record review of the radiology report dated [DATE] at 11:28 AM revealed there was an acute fracture of the left hip. An interview on [DATE] at 4:07 PM with the DON revealed that on [DATE] NA #1 that had taken Resident #1 into the shower. She stated agency staff were given a rundown (information that was necessary for care delivery) from all nursing staff about the residents they would be caring for and told any nursing staff was a resource for questions they may have about giving care to the residents. She stated all total mechanical lifts required 2-person assistance. She stated that Resident #1 was a total lift for transfers and staff should have used the correct mechanical lift with 2-persons during the transfer. An interview on [DATE] at 10:00 AM with the Medical Director revealed the staff should have used the correct mechanical lift for Resident #1. He stated that those interventions were in place for the safety of the residents and the staff. He stated that if NA #1 and NA #2 had not used the incorrect mechanical lifts Resident #1 would not have fallen and acquired a fracture. He stated that NA #1 and NA #2 should have informed the facility about the fall, and he would have wanted Resident #1 assessed before being moved. He stated that the fall was directly related to Resident #1's death. He stated that if Resident #1 had not fallen, she would not have fractured her hip, and therefore would not have needed surgery which she did not recover from. An interview on [DATE] at 1:49 PM with the Administrator revealed going forward he and the DON will be reviewing skills for all agency staff to ensure they have the required skills to provide safe patient care. His expectation was that nursing staff use the correct mechanical lifts that were care planned. He stated that Resident #1's fall with major injury was avoidable if staff had followed the care plan. He stated that any change of plane (an unintentional change in position that results in coming to rest on the ground or floor) that happens to a resident was considered a fall. On [DATE] at 2:24 PM an observation of NA #3 and the Unit Manager revealed a total lift used with a 2-person assist during transfer of Resident #2. A green sling was secured to the lift and the brakes locked, the resident was lifted out of wheelchair; the lift brakes were unlocked, and Resident #2 was moved slowly over bed and lowered without difficulty. NA #3 stated she had training upon hire and recently related to the proper use of a total mechanical, sit-to-stand lift, and use of gait belt when transferring a resident. She explained a total lift transfer was used for Resident #2 because he cannot bear weight and always to used 2-person assistance; sit-to-stand was used when for resident that can bear weight and use a 1-person assist. She further stated the nurses helped with 2-person assist total lift transfers if the NAs were busy. The Administrator was notified of Immediate Jeopardy on [DATE] at 4:41 PM. The facility provided the following corrective action plan with a completion date of [DATE]. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift. X-ray was obtained on [DATE] which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated on [DATE]. Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at facility, CNA #2 has been terminated. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Director of Nursing and/or designee completed interviews with communicative residents on [DATE], [DATE] and [DATE] regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents on [DATE] to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from therapy department. Unit managers cross referenced the lift status to the Kardex and Care Plans on [DATE]. 3. Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Director of Nursing and/or their designee on [DATE] educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents, reporting protocols, and what constitutes a fall, which is a change of plane. Director of Nursing and/or their designee educated agency staff on [DATE] on proper lifts, facility policies, reporting all incidents and accidents, change in condition and what constitutes a fall, which is a change of plane. New hires to the facility are educated with the onboarding procedures by the Director of Nursing and/or their designee. On [DATE] through [DATE] Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers. Education also included proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s. Staff were educated on how to report accidents and incidents, how to understand the Kardex for proper transfers, and how to report change of condition with residents. Director of Nursing and/or designee educated Agency staff on [DATE] prior to taking an assignment on the units and completed return demonstration to ensure understanding and compliance with education. 4. Indicate how the facility plans to monitor it performance to make sure that solutions are sustained. The facility made the decision to have an ad hoc QAPI committee meeting on [DATE] as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice beginning on [DATE] for a period of 12 weeks. To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week for 12 weeks to ensure residents utilizing a lift are receiving the proper transfer. Unit Mangers will select 5 residents weekly over the next 12 weeks that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months. Corrective action will be completed: [DATE] The facility alleged a IJ removal date of [DATE]. The Corrective Action plan was validated on [DATE] and concluded the facility had implemented an acceptable corrective action plan on [DATE]. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on use of mechanical lift transfers that included requiring two-person assistance for all transfers, using the proper lift, identifying a resident's lift status on the Kardex, and lift identifying tag on the door, and gait belt training. Staff interviewed all verbalized they were observed performing a mechanical lift transfer after receiving reeducation. Review of the monitoring tools of mechanical lift transfers that began on [DATE] and continued weekly for the next 12 weeks were completed as outlined in the corrective action plan with no concerns identified.

Based on record review and staff interviews the facility failed to ensure all nursing staff, including agency staff, received orientation to include the location of resident care guides or the Kardex (nurse aide guide that contains individualized care information) and verify competencies including resident transfers and total and sit to stand lifts prior to providing care for the residents in the facility. On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. NA #1 requested help from NA #2 and they both assisted Resident #1 off the floor without using a mechanical lift. Transfers continued without using the total mechanical lift and assistance from two people. On [DATE] x-ray results for Resident #1 revealed an acute fracture of the left hip. The Director of Nursing (DON) notified the NP who ordered Resident #1 to be sent out to the hospital for further evaluation and treatment. On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE]. This was for 1 of 5 staff members reviewed for competency. Findings included: Record review of the competency checklist dated [DATE] from the agency for NA #1 revealed for transfers it stated the skill as transfer patient and it was marked as previous training and experience. There was no additional information to indicate knowledge of using mechanical lifts. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, mild protein-calorie malnutrition, cerebral infarction (a disruption of blood flow to the brain), severe vascular dementia severe, history of falling, unsteadiness on feet, abnormalities of gait and mobility, other reduced mobility, and lack of coordination. An Activity of Daily Living (ADL) care plan, last revised [DATE], revealed Resident #1 had an ADL self-care performance deficit related to mobility, weakness, pain, temporal sclerosis (scarring of the temporal lobe of the brain), polyphagia rheumatic (an inflammatory disorder that causes muscle pain and stiffness). The care plan included was an intervention that noted Resident #1 required a total mechanical lift with a sling and two-person assistance for all transfers. A phone interview on [DATE] at 10:52 AM with NA #1 (agency) revealed that she was assigned to Resident #1 for a shower only on [DATE] and had worked at the facility for approximately one month. She stated she gathered her items and the sit to stand mechanical lift and went to Resident #1's room. NA #1 stated she transferred Resident #1 from her bed with the sit to stand lift, proceeded to the shower room where she placed Resident #1 on the toilet. She then transferred Resident #1 off the toilet with the sit to stand mechanical lift, Resident #1's foot slipped, and she lowered Resident #1 to the floor using the sling from the sit to stand mechanical lift. Once Resident #1 was lowered to the floor, NA #1 stated she stepped out into the hallway and called for help from NA #2. NA #2 came to help NA #1. NA # 1 explained what happened to NA #2 and NA #2 replied Resident #1 yelled like that sometimes. NA #1 and NA #2 then performed a two-person manual lift to get Resident #1 up off the floor to her wheelchair. NA #1 got another mechanical lift pad, placed it around Resident #1, transferred Resident #1 with the sit to stand mechanical lift to the shower chair and gave her a shower without further incident. She stated she transferred Resident #1 back to her wheelchair with the sit to stand mechanical lift and transported her to the dayroom. NA #1 stated she had not received orientation or education on resident transfers or lift equipment from the facility but had completed a check list with her agency. NA #1 also stated that she was not educated on how to access resident care plans in the electronic health record nor that they were located at the nursing station, she was also unaware of the Kardex information, the care guide, and she followed nursing staff directions for resident care. A phone interview on [DATE] at 12:22 PM with NA #2 revealed that on [DATE] she was Resident #1's assigned NA on [DATE] and she had not instructed NA #1 on how to transfer Resident #1 because NA #1 never asked her. She explained she was familiar with the Kardex system, how to use the care guides, and where each of those were located. A phone interview on [DATE] at 10:32 AM with Nurse #2 revealed he was Resident #1's assigned nurse on [DATE] and NA #1 had not mentioned anything to him about Resident #1 or asked about a care guide. An interview on [DATE] 12:06 PM with Nurse #1 revealed residents had a care guide posted on the door or in the resident's closet regarding how to transfer the residents and the information was also posted in the Kardex that was in a book at the nursing station desk. An interview was conducted on [DATE] at 12:12 PM with the Director of Nursing (DON) and the Scheduler. The Scheduler revealed she received a packet from the staffing agency with a skills competency check off sheet for NA #1. The Scheduler further revealed she had no clinical background and when she received packets from the staffing agency, she reviewed the skills competency check off sheet and just asked questions about skill checkoff received from agencies, to the DON or Unit Manager if she had any questions about the skills of agency staff. When the DON and Scheduler were shown NA #1's skills competency check off sheet and asked to describe what patient transfers meant the DON responded the Scheduler did what not know what that meant and the Scheduler nodded her head in agreement. An interview on [DATE] at 4:07 PM with the DON revealed that NA #1 (agency) had not received orientation. She stated agency staff were given a rundown (basic resident care information not including Kardex or care guide locations) from facility staff about the residents they would be caring for and told any nursing staff was a resource for questions they may have about giving care to the residents. She further revealed she had the Scheduler review NA #1's competency skills paperwork that was sent over from the staffing agency, but she (DON) had had not done a skills competency check off with NA #1 prior to her providing resident care. An interview on [DATE] at 1:49 PM with the Administrator revealed he and the DON would be reviewing skills for all agency staff to ensure they have the required skills to provide safe patient care. His expectation was that nursing staff use the correct mechanical lifts that were care planned. He stated Resident #1's fall with major injury was avoidable if staff had followed the care plan. The Administrator was notified of Immediate Jeopardy on [DATE] at 4:41 PM. The facility provided the following corrective action plan with a completion date of [DATE]. 1. Address how corrective action will be accomplished for those residents found to have been affected by this deficient practice. The facility failed to ensure that the competency skills of C.N.A. #1 were verified prior to providing care to Resident #1 and failed to ensure that C.N.A #1 knew the location of the care guide information for the care of Resident #1 prior to the transfer of Resident #1 that resulted in a fall with major injury. C.N.A. #2 asked C.N.A. #1 about what type of transfer Resident #1 needed and was guided to use the sit to stand lift for Resident #1's transfer. Resident #1 was care planned to be transferred using a total lift, C.N.A. #2 advised C.N.A. #1 to utilize a sit to stand which resulted in a left hip fracture. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Director of Nursing and/or their designee on [DATE] and [DATE] completed education with facility licensed nurses and C.N.A.'s on lift competency with return demonstration. Licensed agency nurses and C.N.A.'s were educated on proper lift competency with return demonstration on [DATE]. Education was also provided on where licensed nurses and C.N.A.'s can locate current lift status on [DATE]. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Director of Nursing and/or their designee educated all licensed nurses and C.N.A.'s, including agency staff on location of resident care guides. All new facility licensed nurses and C.N.A.'s will receive education from the unit managers on the location of the resident care guides during their orientation. Unit Managers were notified of this responsibility on [DATE]. All licensed nurses and C.N.A.'s from an agency are required to come in prior to their first shift to receive lift training and review facility policies. This training is completed by the Director of Nursing and/or their designee. The nursing scheduler is responsible for scheduling agency staff for this orientation. The nursing scheduler notified the agencies on [DATE] of this requirement. Each agency staff is now required to read through facility policies and procedures related to resident care which are located at each nurse's station in the Agency Orientation book. They are to acknowledge understanding of these policies by signing the Policy Acknowledgement Sheet. Agency staff are required to complete lift competency prior to working, this is completed by the Director of Nursing and/or their designee. The facility is requiring the agency to provide the skills checklist of each agency staff member for review prior to working. The Director of Nursing and/or their designee will review the skills check list to ensure that they have the skills to meet the needs of our residents. The Director of Nursing and/or their designee completed lift competencies with return demonstration for all licensed nurses and C.N.A.'s and agency staff on [DATE]. New hires will be educated Director of Nursing and/or designee on facility policies and lift competencies upon hire. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility made the decision to have an ad hoc QAPI (Quality Assurance and Process Improvement) committee meeting on [DATE] as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice beginning on [DATE] for a period of 12 weeks. The Director of Nursing and/or their designee will audit five (5) agency staff, licensed staff and C.N.A.'s, to the location of the care guides for the residents. The Director of Nursing and/or their designee will audit five (5) facility and agency C.N.A.'s weekly for 12 weeks observing lift transfers. Any negative observations will be corrected immediately. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and or their designee for review and/or revision as needed for three (3) months. Corrective action will be completed: [DATE] The facility alleged a IJ removal date of [DATE]. The Corrective Action plan was validated on [DATE] and concluded the facility had implemented an acceptable corrective action plan on [DATE]. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on use of mechanical lift transfers that included requiring two-person assistance for all transfers, using the proper lift, identifying a resident's lift status on the Kardex, and lift identifying tag on the door, and gait belt training. Staff interviewed all verbalized they were observed performing a mechanical lift transfer after receiving re-education. Review of the monitoring tools of mechanical lift transfers that began on [DATE] and continued weekly for the next 12 weeks were completed as outlined in the corrective action plan with no concerns identified.

Based on record review and interviews with staff, Nurse Practitioner (NP), Director of Nursing (DON) and Administrator, the facility failed to protect the resident's right (Resident #1) to be free of abuse when Resident #2's family member (facility Housekeeper) pulled Resident #2's TV remote from Resident #1's hands. Resident #1 sustained a fracture of his left index finger that required no surgical intervention. This deficient practice occurred for 1 of 1 resident reviewed for abuse. Findings Included: Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke, paralysis of the right side and legal blindness. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #1 as severely cognitively impaired with no behaviors noted. Resident #1 was care planned (2/7/23) for altered or at risk for altered behaviors and/ or mood with a history of yelling, cursing, paranoid, history of cycling through roommates, history of many room changes due to anger, and behavior. Resident non-compliant with care. Resident with a history of suddenly becoming angry and verbally aggressive with roommates and history of hoarding objects. Interventions included to allow the resident to vent his thoughts and feelings. Use reorientation, validation. Approach in a calm, relaxed manner. Identify what helps calm the resident down when upsent such as snacking, talking, reminiscing, walking, and reapproaching. The Activities Assistant was interviewed on 12/12/23 at 10:06 AM and stated that she was working on 11/12/23 but was unable to remember what time the interaction with Resident #1 had occurred. The Activities Assistant said she walked into Resident #1's room to take him to an activity. She noticed Resident #1 had a TV remote laying in his lap. The Activities Assistant asked Resident #1 to leave the TV remote for his roommate (Resident #2) to use while he was in the activity. Resident #1 then stated to the activities assistant he was not leaving the TV remote with that f--- retard. The activities assistant told Resident #1 he should not talk to Resident #2 that way and then took Resident #1 to the nursing station to calm down. She saw Resident #2's family member/housekeeper who was working in housekeeping at the facility on 11/12/23. She asked the family member if the TV and TV remote belonged to Resident #2, and he stated yes, and Resident #1 does not share it. The Activities Assistant stated she did not witness or hear any altercation with Resident #2's family member and Resident #1. Resident #2's family member/housekeeper's statement dated 11/12/23 was reviewed and read in part as follows. On 11/12/23, the Family Member had an altercation with Resident #1. The Family Member spoke with Resident #1 when his shift as a housekeeper had ended. The Family Member told Resident #1 the TV remote and TV was Resident # 2's, and he needed to share it. The Family Member said to Resident #1, I heard you are having a bad day and I hope it gets better for you. Resident #1 replied to the Family Member that he was not having a bad day; it was the retard that was having a bad day as Resident #1 pointed towards Resident #2. The Family Member wrote he reached for the TV remote the Resident #1 was holding, and Resident #1 pulled the remote up to his chest and grabbed the remote with both hands. The Family Member pulled the bottom of the remote down from Resident #1. The Family Member wrote he did not grab Resident #1's finger or attempt to break it. After freeing the TV remote, the Family Member rolled Resident #1 to the nurses' station and told Nurse #2 Resident #1 needed to stay in a different room as Resident #1 was calling Resident #2 a F----retard. The Family Member wrote he was not mad at Resident #1 and he wished the best for Resident #1. Resident #2's family member was not available for interview. Resident #1's assigned Nurse #2 on 11/12/23 was interviewed on 12/12/23 at 9: 23 AM. Nurse #2 stated Nurse Aide (NA) #1 notified her that Resident #1 had been speaking ugly to his roommate. Nurse #2 was going back towards the nursing station, when she saw Resident #2 and his family member/housekeeper leaving the room. The family member told Nurse #2 that Resident #1 had said to Resident #2 he was retarded, and the family member did not want Resident #1 to remain in the room with Resident #2. The family member did not mention there had been an incident with Resident #1. Nurse #2 then notified the Unit Manager about Resident #1's language toward Resident #2, and the Unit Manager instructed Nurse #2 to move Resident #1 to a different room. Nurse #2 stated she moved Resident #1 to another room, and Resident #1 did not mention an altercation with Resident #2's family member or complain of any pain or discomfort to his hand or finger. Nurse #1 stated in an interview on 12/11/23 at 3:40 PM on 11/13/23 sometime after breakfast, she was notified by Nurse #2= that Resident #1's hand was swollen and bruised. Nurse #1 stated she asked Resident #1 what had happened to his hand. Resident #1 told her Resident #2's family member tried to break his fingers. Nurse #1 said she notified the Director of Nursing (DON), and the DON told her to get an order for an x-ray of his hand. NA #1 was interviewed on 12/12/23 at 9:12 AM and stated she was working on 11/13/23 as a Medication Aide and noticed Resident #1's left hand and finger was bruised and swollen. NA #1 stated she notified Nurse #1 about Resident #1's hand. The Unit Manager wrote a progress note dated 11/13/23 at 4:31 PM that read in part Resident #1 was brought to Nurse #1 with discoloration of left index finger. Resident #1 was asked what happened and the resident stated his roommates' family member tried to break his finger. Resident #1's left index finger was noted to be purple/red with edema noted into hand. The Nurse Practitioner (NP) was notified, and an order was received for a left-hand x-ray. Resident #1's pain level was 2 out of 10. A review of Resident #1's radiological report dated 11/14/23 found a fracture on the second finger of the left hand. The fractured finger was not displaced. A review of Resident #1's orthopedic progress noted dated 11/15/23 confirmed a fractured left index finger. The treatment plan was to buddy tape the bases of the middle finger and index finger for 1 month and change the tape as needed. The NP progress note dated 11/14/23 was reviewed. The progress note read in part Resident #1 was being seen for left hand and index finger bruising and swellings. An urgent orthopedic referral was placed. Therapy will screen and provide stabilization until the appointment with orthopedics. On exam, Resident #1's pain appears mild and had prn Tylenol available. A request for a psychiatry consult to see the resident and evaluate for any post-traumatic stress concerns. The NP who assessed Resident #1 was interviewed on 12/12/23 at 1: 06 PM. The NP stated she assessed Resident #1 on 11/13/23. The NP stated the resident had obvious bruising on his middle-left finger along the side and on the palm of his left hand and Resident #1 was able to make a fist with his hand. The NP stated Resident #1 told her his roommates family member tried to break his finger. The NP said the x-ray came back positive for a fracture, and the following day (11/15/23) the Resident went to see orthopedics who gave orders to buddy tape his affected finger. The NP stated Resident #1 did to go to the hospital, had mild pain and a standing order for Tylenol and was not sure how often he was taking it. A review of Resident #1's Medication Administration Record (MAR) for November and December 2023 revealed Resident #1 received Tylenol on 11/16/23 and 11/19/23. On 12/11/23 at 10:45 AM Resident #1's left middle and index fingers were observed to be tapped together. Resident #1 did not appear in any pain or distress. Resident #1 was not able to recall the incident. Resident #2 was interviewed on 12/11/23 at 3:12 PM and was not able to recall the incident. A review of nursing progress notes dated 11/14/23 written by the DON read on 11/12/23 the Unit Manager was notified Resident #1 was not getting along with his roommate. The Unit Manager instructed Nurse #2 to move Resident #1 to another room for the night. On 11/13/23 at approximately 3:30 PM NA #1 brought the resident to the Unit Manager with concern of bruising and swelling noted on the left index finger as well as the left palm of the hand. The DON was notified and instructed the Unit Manager to notify the NP and obtain an order for an X-ray. DON notified Administrator and an immediate investigation began. When speaking to Resident #1 he stated, his roommate's family member tried to break his finger. Resident #1 had not verbalized anything prior to this. Resident #1 had no complaints of pain. The Administrator notified Resident #2's family member (also employed by housekeeping) of suspension pending investigation. The completed X-ray noted an acute fracture involving the medial corner of the proximal phalanx of the left second finger. Resident #1 was ensured to be safe. A head-to-toe assessment completed on Resident #1 with no other concerns noted. The initial state report was completed. The Saluda police notified with a police investigation initiated. A message was left for Resident #1's adult protective services guardian to call the facility. Resident/Staff interviews initiated. Psych services notified. Head to toe skin assessments completed on residents with a BIMS score less than 12 with no issues or concerns for further abuse noted. Abuse policy education-initiated facility wide and completed. Resident #2's family member/housekeeper was interviewed by Administrator and DON and currently remains suspended. The Administrator and DON were interviewed together on 12/12/23 at 2:37 PM. The DON stated the nursing Unit Manager called her on 11/12/23 in midafternoon to report Resident #1 and his roommate were not getting along. The DON stated she instructed the Unit Manager to move Resident #1 to another room for the night. The next day, on 11/13/23 an NA noticed Resident #1's finger and hand was swollen and bruised. The Unit Manager looked at Resident #1's hand and notified the DON. Resident #1 told the Unit Manager that Resident #2's family member/housekeeper tried to break his finger. The DON said the NP was then called to get an x-ray order and to assess Resident #1. The DON stated the Administrator was notified about the incident, and Resident #2's family member/housekeeper was suspended immediately after being interviewed and pending an investigation, and was terminated on 11/17/23. Resident #1 was interviewed by multiple facility staff and his story was consistent. Resident #1 told DON and other staff that his roommates family member who worked as a housekeeper had tried to break his finger. The DON stated Resident #1 had a complete head to toe assessment completed on 11/13/23 that did not find anything additional. The Administrator stated he notified the police of the incident that the investigation included interviewing staff who might have seen or heard anything. The Administrator stated that the investigation revealed the incident occurred on 11/12/23 and was witnessed by Resident #1's roommate and the family member/housekeeper. The Administrator stated the family member told him he went to Resident #1's room to tell Resident #1 that the TV remote belonged to Resident #2, and he needed to share it. Resident #1 told the family member he was not giving the TV remote to that F----retard. The family member went to take the TV remote from Resident #1, and Resident #1 held on to the remote with both hands while the family member pulled the TV remote from Resident #1. Resident #2's family member/housekeeper stated he did not intend to hurt the resident and the resident did not complain of any pain. The facility provided the following corrective action plan with a completion date of 11/17/23. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 11/12/23, Unit Manager was notified Resident #1 and his roommate (Resident #2) were not getting along by Charge Nurse, Resident #1 was immediately moved to another room. On 11/13/23 Unit Manager was notified Medication Aide of swelling and bruising of Resident #1's Left Index Finger. Head to toe assessment completed of Resident #1 on 11/13/23 and no other injuries were noted. Resident #1 stated dead head tried to break my finger, who Resident #1 identified as the Resident #2's family member/housekeeper. With bruising noted we also had an allegation of abuse on Resident #1, staff member was immediately notified and suspended on 11/13/23 and told not to come to the building until interviewed by Administrator and Director of Nursing. Police and Adult Protective Services notified on 11/13/23 due to bruising on left hand of Resident #1 and residents' #1's statement regarding the incident. Two View X-Ray completed of Resident #1's left hand on 11/13/23 and noted an acute fracture of the left second finger. Nurse Practitioner ordered Urinary Analysis for Resident #1 on 11/14/23, also ordered therapy consult and sent order for therapy referral. Resident #1 went to an orthopedic appointment on 11/15/23 with new orders to buddy tape fingers. Psych referral initiated on 11/14/23 via tele-visit, medication changes initiated for Resident #1. Staff member was terminated on 11/17/23 following investigation. An initial report for the allegation of abuse was reported on 11/13/23 and our investigative report was reported on 11/17/23, which substantiated the allegation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Social Worker conducted interviews and educated all alert and oriented residents on November 14, 2023 on abuse and neglect and how to report abuse and neglect with no concerns noted. Director of Nursing completed skin checks on all residents with a BIMs score of 12 or less (impaired cognition) on November 13, 2023, with no concerns noted. Staff interviews initiated regarding the incident on 11/13/23. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Director of Nursing/Designee educated all staff including agency staff and as needed staff on 11/13/23 on abuse and neglect policy and reporting. This education was completed in person or via phone for those not working or on leave of absence, these individuals were required to sign the attendance sheet when they returned to work. Two Educational programs were added to Relias program (Staff Education On-Line) on 11/14/23, Abuse, Neglect and Exploitation in the Elder Care Setting and Recognizing Abuse, Neglect and Exploitation. These programs include a final exam that staff member must score an 80 or above to pass the course. This training included recognizing abuse, neglect and exploitation as well as reporting abuse, neglect and exploitation. It also included training on care giver burnout, risk factors for committing abuse, preventing abuse. The course titled Abuse, Neglect, and Exploitation in the Elder Care Setting also included education on person centered care and providing care to residents regarding approaching those residents with behaviors. This education was completed by all staff by 11/17/23. New hires will be educated upon hire. During Concierge rounds, which are rounds completed by facility managers Monday through Friday, of assigned rooms and residents, managers will monitor for abuse and care concerns and report immediately to their supervisor, this will be added to their round sheets for monitoring. The Supervising Nurse or Manager on Duty will complete these rounds on the weekends. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Administrator/Designee will complete three staff interviews weekly for 4 weeks and monthly for two months on what to do if they see or hear abuse and who to report it to and how to deal with difficult or agitated residents. Director of Nursing/Designee will interview 5 residents weekly for 8 weeks then monthly for three months to ensure there are no issues with abuse/neglect with the residents. Director of Nursing/Designee will conduct observations of 3 residents weekly for four weeks then monthly for two months of Certified Nursing Assistants interactions with residents to ensure no issues with abuse/neglect. Results of the interviews/audits will be presented monthly to the QAPI committee meeting by the Director of Nursing/Designee for review/revision as needed for three months. 5. Include dates when corrective action will be completed. November 17, 2023 The facilities action plan was validated on 12/12/23 and confirmed the compliance date of 11/17/23. concluded the facility had implemented an acceptable corrective action plan effective on 11/17/23. The corrective action plan was validated by the following: 1.On 12/11/23 a review of the initial report for the allegation was verified reported on 11/13/23 and concluded on 11/17/23. 2. Every resident had a head-to-toe assessment completed and was verified. 3. On 12/11/23 and 12/12/23 interviews with facility staff and agency staff verified they had received education on abuse and neglect. 4.On 12/11/23 and 12/12/23 interviews with alert and oriented residents verified they had been provided with education on abuse and neglect. 5.A review of the facilities monitoring book verified three staff interviews had been conducted weekly for 4 weeks. Further review found 5 residents had been interviewed weekly and ongoing for 8 weeks to ensure no concerns with abuse and neglect. The DON or designee had conducted observations of 3 residents with NAs for 4 weeks with no concerns of abuse or neglect. 6.Resident #2's family member was verified to be terminated from the facility on 11/17/23. 7. A review of the November QAPI verified the audits were included in the meeting. The compliance date of 11/17/23 was validated.

Based on a lunch meal tray line observation, record review, and staff interviews the facility failed to serve correct portions of food according to the planned menus. This failure had the potential to affect 61 residents receiving a regular diet texture and 6 residents receiving a pureed diet texture. Findings included: 1. The menu for the lunch meal on 10/31/23 for residents receiving a regular texture diet was 2 ounces of baked chicken, a half-cup of au-gratin potatoes, and a half-cup of mixed vegetables. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed Cook #2 began plating food and used tongs to place a mixture of bone-in and boneless chicken thighs for residents receiving a regular diet texture. There was no consistent size to the pieces of chicken thighs being served. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she confirmed the chicken being served at the lunch meal was a mixture of boneless and bone-in chicken thighs. When the surveyor asked her how she could verify residents were receiving the correct portion size, she stated she could not because she did not have a working scale. In an interview with the Registered Dietician (RD) on 10/31/23 at 1:20 PM she confirmed there was no way to accurately ensure residents receiving a regular diet texture were getting the correct portion size according to the menu without weighing the chicken, but the plates looked like they contained at least two ounces of chicken. She stated she expected menu portion sizes to be followed. An interview with Cook #2 on 10/31/23 at 2:08 PM revealed the diet spreadsheet contained information on portion size and residents receiving a regular diet should have received two ounces of chicken. She stated she was instructed by the Dietary Manager to mix boneless and bone-in chicken thighs for the lunch meal and without a scale she was not able to ensure residents received the correct portion size. Cook #2 stated she tried to look through the pieces of chicken and if a piece appeared small, she plated 2 pieces of chicken. A follow-up interview with the Dietary Manager on 11/01/23 at 9:02 AM revealed she expected dietary staff to follow portion sizes as directed by the menu. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to follow menu portion sizes. 2. The menu for the lunch meal on 10/31/23 for residents receiving a regular texture diet was 2 ounces of baked chicken, a half-cup of au-gratin potatoes, and a half-cup of mixed vegetables. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed Cook #2 began plating au-gratin potatoes for residents receiving a regular diet using a number 12 scoop. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she confirmed the au-gratin potatoes were to be served in a half-cup portion and was not sure if Cook #2 was using the correct sized scoop because she could not locate the diet spreadsheet. In an interview with the Registered Dietician (RD) on 10/31/23 at 1:20 PM she confirmed residents receiving a regular diet texture were to receive half-cup portions of au-gratin potatoes. She stated Cook #2 used a number 12 scoop which contained one-third of a cup of au-gratin potatoes and she should have used a number 8 scoop, which contained a half-cup portion. She stated she expected menu portion sizes to be followed. An interview with Cook #2 on 10/31/23 at 2:08 PM revealed the diet spreadsheet contained information on portion size and residents receiving a regular diet should have received a half-cup portion of au-gratin potatoes. She stated she was instructed by the Dietary Manager to use the number 12 scoop instead of the number 8 scoop for au-gratin potatoes served at the lunch meal. A follow-up interview with the Dietary Manager on 11/01/23 at 9:02 AM revealed she expected dietary staff to follow portion sizes as directed by the menu. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to follow menu portion sizes. 3. The lunch menu for residents receiving a pureed diet texture on 10/31/23 was 3.25-ounces of chicken, a half-cup portion of au-gratin potatoes, and a 3.25-ounce portion of green beans. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed Cook #2 began plating chicken and mixed vegetables for residents receiving a pureed diet using a number 12 scoop for both food items. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she stated mixed vegetables were substituted for green beans for residents receiving a pureed diet. She stated she was not sure if Cook #2 was using the correct sized scoop to serve pureed chicken and mixed vegetables because she could not locate the diet spreadsheet. In an interview with the Registered Dietician (RD) on 10/31/23 at 1:20 PM she confirmed residents receiving a pureed diet texture were to receive a 3.25-ounce portion of chicken and a 3.25-ounce portion of mixed vegetables. She stated Cook #2 used a number 12 scoop which contained 2.8-ounces of chicken and 2.8-ounces of mixed vegetables and she should have used a number 10 scoop for the chicken and a number 10 scoop for the mixed vegetables. She stated she expected menu portion sizes to be followed. An interview with Cook #2 on 10/31/23 at 2:08 PM revealed the diet spreadsheet contained information on portion size and residents receiving a pureed diet should have received a 3.25-ounces of chicken and 3.25-ounces of mixed vegetables. She stated she was instructed by the Dietary Manager to use the number 12 scoop instead of a number 10 scoop to plate the chicken and mixed vegetables served at the lunch meal. A follow-up interview with the Dietary Manager on 11/01/23 at 9:02 AM revealed she expected dietary staff to follow portion sizes as directed by the menu. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to follow menu portion sizes.

Based on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove expired food in 1 of 1 dry goods storage room; maintain clean stove, oven, shelves, and floor in 1 of 1 kitchen; cover, label, and date open beverage and food items, discard food with signs of spoilage, and maintain a clean reach-in cooler for 1 of 1 reach-in cooler; cover, label, and date food items and maintain a clean reach-in freezer for 1 of 1 reach-in freezer; restrain facial hair during food preparation; maintain 1 of 1 garbage disposal in working order; and ensure food items were labeled and dated in 1 of 2 nourishment rooms (A/B hall). Findings included: 1. An initial tour of the walk-in cooler on [DATE] at 10:27 AM revealed the following: (a). multiple dried brown stains were observed on the floor and multiple areas of a black/brown substance to all walls of the cooler (b). an opened and undated 46-ounce bottle of vegetable juice sitting on a shelf in the cooler (c). a tray containing 11 bowls of undated dessert sitting on a shelf An interview with the Dietary Manager on [DATE] at 2:05 PM revealed all food and beverage items should be labeled and dated when opened and it was everyone's job to label and date items when placing them in the cooler. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food and beverages were labeled and dated. The Dietary Manager stated there was not a regular cleaning schedule for cleaning the cooler, but it was cleaner than it was when she began employment at the end of [DATE]. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected the cooler to be clean and free of debris and for all food and beverage items to be labeled and dated. 2. An initial tour of the walk-in freezer on [DATE] at 10:31 AM revealed the following: (a). scattered debris on the floor of the freezer (b). a 5-pound tube of ground beef was sitting on the floor of the freezer under a shelf. (c). an undated 10-pound box of sausage was partially open to air and the exposed sausage was dried out (d). a box of sweet potatoes, ground beef patties, potato portions, and french fries was sitting on the floor of the freezer An interview with the Dietary Manager on [DATE] at 2:05 PM revealed all food items should be labeled, dated, and covered when opened and it was everyone's job to label and date items when placing them in the freezer and discard food items that showed signs of spoilage. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food items were labeled, dated, and covered. The Dietary Manager stated there was not a regular cleaning schedule for cleaning the freezer, but it was cleaner than it was when she began employment at the end of [DATE]. She stated the last food delivery was on [DATE] and she was not sure why there were food items on the floor. The Dietary Manager confirmed that no food items should be stored on the floor. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected the freezer to be clean and free of debris, all food items should be covered or discarded if they showed signs of spoilage, and no food items should be stored on the floor. 3. An initial tour of the dry storage room on [DATE] at 10:34 AM revealed the following: (a). 2 boxes of salad dressing, 2 boxes of vegetable oil, a box of instant potatoes, peanut butter, hot cocoa, and grits were sitting directly on the floor (b). 3 bags of opened but undated pasta (c). 2 packs of 24 count flour tortillas with a best by date of [DATE] (d). 8 packs of 12 count flour tortillas with a best by date of [DATE] An interview with the Dietary Manager on [DATE] at 2:05 PM revealed all food items should be dated when opened and it was everyone's responsibility to date food when it was opened. She stated the last food delivery was [DATE] and she was not sure why food items were stored on the floor. The Dietary Manager confirmed that no food items should be stored on the floor. She confirmed food should be used or discarded on or before the best by date and all staff should be checking for expired food. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected all opened food items to be dated, expired food to be used or discarded on or before the best by date, and no food items should be stored on the floor. 4. An observation of the kitchen on [DATE] at 10:40 AM revealed scattered debris and multiple areas of dried black substance to the floor, a thick dried layer of black debris to the stove, multiple dried splatters to the bottom shelf of a table, and multiple areas of dried debris to the oven door. An interview with the Dietary Manager on [DATE] at 2:05 PM revealed the kitchen floor, stove, shelf, and oven should be clean and free of debris but it was cleaner than it was when she began employment at the end of [DATE]. She stated there was not a cleaning schedule and she had not been able to do as much cleaning as she would like due to having to frequently work as a cook or a dietary aide. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected the kitchen floors, stove, oven, and shelf to be clean and free of debris. 5. An observation of the reach-in cooler on [DATE] at 11:00 AM revealed the following: (a). an undated packet of sliced turkey that was open to air (b). an opened and undated container of butter (c). an undated container of chopped lettuce with multiple brown areas to the lettuce (d). an opened and undated 33.8-ounce bottle of water (e). multiple scattered areas of dried debris to cooler doors An interview with the Dietary Manager on [DATE] at 2:05 PM revealed all food and beverage items should be labeled and dated when opened and it was everyone's job to label and date items when placing them in the cooler and discard food items that showed signs of spoilage. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food and beverages were labeled, dated, and covered. The Dietary Manager stated there was not a regular cleaning schedule for wiping down the outside of the cooler, but it was cleaner than it was when she began employment at the end of [DATE]. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected all food items to be labeled and dated, no food items should be left open to air, food should be used or discarded before showing signs of spoilage, and the cooler should be clean and free of debris. 6. An observation of the reach-in freezer on [DATE] at 11:05 AM revealed the following: (a). an undated bag of hashbrowns open to air that were dried out (b). an undated box of biscuits open to air (c). 2 bags of english muffins with ice crystals (d). an open and undated bag of omelets (e). multiple scattered areas of dried debris to freezer doors An interview with the Dietary Manager on [DATE] at 2:05 PM revealed all food and beverage items should be labeled and dated when opened and it was everyone's job to label and date items when placing them in the cooler and discard food items that showed signs of spoilage. She confirmed food should not be left open to air and the english muffins should have been discarded due to being freezer-burned. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food and beverages were labeled, dated, and covered. The Dietary Manager stated there was not a regular cleaning schedule for wiping down the outside of the freezer, but it was cleaner than it was when she began employment at the end of [DATE]. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected food to be dated when opened, food should not be left open to air, food with freezer-burn should be discarded, and the freezer should be clean and free of debris. 7. An observation of Cook #1 on [DATE] at 11:10 AM revealed he was slicing tomatoes and did not have a restraint in place to cover his facial hair. In an interview with Cook #1 on [DATE] at 11:10 AM he confirmed he was not wearing a restraint for his facial hair and stated he was not sure if the kitchen stocked restraints for facial hair. An interview with the Dietary Manager on [DATE] at 2:05 PM revealed the kitchen did have facial hair restraints and they were in her office, but staff probably did not know where they were. She stated facial hair should be restrained any time food was being prepared or served. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected staff to restrain facial hair when in the kitchen. 8. An observation of the garbage disposal on [DATE] at 11:15 AM revealed a dish pan sitting beneath the disposal filled approximately three fourths of the way with brown water. An interview with the Dietary Manager on [DATE] at 2:05 PM revealed the garbage disposal was leaking and the dish pan was in place to collect drainage. She stated the garbage disposal had been leaking since she began employment at the end of [DATE] and maintenance was waiting for a part to arrive to fix the disposal. An interview with the Maintenance Director on [DATE] at 3:50 PM revealed he had fixed the garbage disposal periodically in the past, but he was not aware of the garbage disposal currently having a leak. He stated he relied on dietary staff to notify him of any equipment that was in need of repair. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected dietary staff to notify maintenance if there were any kitchen items that needed repair. 8. An observation of the A/B hall nourishment room refrigerator on [DATE] at 2:30 PM revealed there was an opened and undated bowl of soup and an undated and unlabeled bowl of unidentifiable leftover food. An interview with the Dietary Manager on [DATE] at 2:30 PM revealed she was not sure who was responsible for checking the refrigerator for unlabeled and undated food or discarding food that wasn't labeled or dated. An interview with the Administrator on [DATE] at 6:16 PM revealed he expected dietary staff to check nourishment rooms daily for unlabeled and undated food items.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on [DATE]. This was for one repeat deficiency originally cited in the area of food procurement-store/prepare/serve that was subsequently recited on the current recertification and complaint investigation survey of [DATE]. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F 812: Based on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove expired food in 1 of 1 dry goods storage room; maintain clean stove, oven, shelves, and floor in 1 of 1 kitchen; cover, label, and date open beverage and food items, discard food with signs of spoilage, and maintain a clean reach-in cooler for 1 of 1 reach-in cooler; cover, label, and date food items and maintain a clean reach-in freezer for 1 of 1 reach-in freezer; restrain facial hair during food preparation; maintain 1 of 1 garbage disposal in working order; and ensure food items were labeled and dated in 1 of 2 nourishment rooms (A/B hall). During the recertification and complaint investigation survey of [DATE], the facility failed to label or date food items stored in the refrigerator, discard expired food items, ensure frozen food was kept solid, and store food items away from soiled surfaces. An interview with the Administrator on [DATE] at 6:41 PM revealed that the breakdown with the kitchen was the turnover with the Certified Dietary Manager (CDM). The Administrator further revealed that steady leadership was the key to a successful kitchen and dining experience. He stated the facility had a plan in place that included rebuilding the entire department from scratch. He stated that that this is an issue they will continue to discuss in their monthly Quality Assurance and Performance Improvement (QAPI) meetings.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary and staffing concerns voiced by residents during Resident Council meetings for 7 of 9 months reviewed (February 2023, April 2023, May 2023, June 2023, July 2023, September 2023, and October 2023). Findings included: The Resident Council minutes for the period January 2023 through October 2023 were reviewed and revealed the following: Resident Council minutes dated 02/22/23 noted in part, residents voiced staffing concerns that third shift agency staff talked loudly in the halls, did not answer call lights, and wore ear buds to talk on their cellphones. In addition, food on the meal trays were served cold and ice cream was not kept cold. Resident Council minutes dated 03/29/23 noted the staffing and dietary concerns voiced during the previous month's meeting were reviewed and reported as resolved. There were no new staffing or dietary concerns noted as voiced during the meeting. Resident Council minutes dated 04/26/23 noted in part, residents voiced dietary concerns related to menu inconsistency and meals being served late. In addition, residents voiced staffing concerns with third shift staff being too loud and Nurse Aides (NAs) taking too long to answer call lights. Resident Council minutes dated 05/31/23 noted in part, the Administrator and Director of Nursing (DON) addressed the previous month's concerns related to staffing and dietary and all were noted as resolved. Under New Business it was noted residents voiced concerns that NAs took too long to provide assistance when requested. Resident Council minutes dated 06/28/23 noted the staffing concerns voiced during the previous month's meeting were reviewed and noted as resolved. Under New Business it was noted residents voiced concerns with NAs talking on their cellphones. Resident Council minutes dated 07/26/23 noted the staffing concerns voiced during the previous month's meeting were reviewed and noted as resolved. Under New Business it was noted residents voiced continued concerns with NAs cellphone use. Resident Council minutes dated 08/30/23 revealed no indication that the concerns voiced during the previous month's meeting regarding cellphone use were reviewed, resolved or remained ongoing. There were no new staffing or dietary concerns noted as voiced during the meeting. Resident Council minutes dated 09/27/23 noted in part, there was no old business to review from the previous month's meeting. Under New Business it was noted residents voiced concerns that staff were eating resident snacks from the snack cart and requested dietary use plate warmers on meal trays to keep food warm. Resident Council minutes dated 10/25/23 noted the dietary and staffing concerns voiced from the previous month's meeting were reviewed and noted as resolved. Under new business it was noted residents voiced concerns with being served cold food, cold coffee, and melted ice cream. The facility's grievance logs for the period January 2023 through September 2023 were reviewed. Grievances filed on behalf of the Resident Council related to the concerns voiced during the monthly meetings were all noted as resolved. During an interview on 10/29/23 at 2:05 PM, the Dietary Manager revealed she attended Resident Council Meetings and was aware of the food concerns voiced by residents. The Dietary Manager did not provide any explanation as to what was or had been done to address the food concerns. A Resident Council group interview was conducted on 11/01/23 at 10:01 AM with Resident #14, Resident #16, Resident #19, Resident #33, Resident #47, Resident #65, Resident #74, Resident #75, Resident #78 and Resident #80 in attendance. The residents all reported ongoing dietary concerns, specifically with meals being served cold. The residents were in agreement that when meals were served not everyone received a bottom plate warmer just a cover over the plate and the food was usually cold and ice cream melted by the time they were served their meal tray. In addition, residents stated there was inconsistency in what they had ordered for lunch or dinner and what they actually received. The residents also reported ongoing staffing concerns regarding agency staff at night taking too long to answer their call lights and staying on their cellphones. The residents all stated they had voiced these concerns during previous meetings and the usual follow-up they received from staff was we are working on it. The residents stated while they felt facility staff tried to address the concerns voiced during the Resident Council meetings, they hadn't noticed much improvement and they really didn't receive feedback from administration on the efforts that had been made or attempted to resolve the concerns. During an interview on 11/01/23 at 3:17 PM, the Social Worker (SW) revealed she attended the Resident Council meetings to transcribe the minutes and any concerns voiced, she documented them on a grievance form and turned them into the appropriate Department Manager to address. The SW confirmed residents did bring up repetitive concerns during the monthly meetings, mainly related to dietary and staffing. She explained typically, the resolution was discussed individually with the person voicing the concern. During the next Resident Council meeting, they reviewed the general concern under old business to see if the concern was resolved or remained ongoing but did not have an in-depth group discussion on the attempts being made to address the repeated concerns. During an interview on 11/01/23 at 3:47 PM, the Activity Director revealed while she facilitated the Resident Council meeting, the SW, who also attended, documented the minutes and concerns voiced by the residents. The Activity Director stated for the past year and a half, the residents attending the Resident Council meetings brought up the same concerns month-to-month related to food, dietary and staffing. The Activity Director explained that when concerns were voiced during the meeting, they were addressed and usually discussed with the individual who voiced the concern. She stated during the next Resident Council meeting, they reviewed the general concern under old business to see if it was resolved or remained ongoing but didn't necessarily discuss in detail the efforts being made to address the repeated concerns. During an interview on 11/01/23 at 6:16 PM, the Administrator stated he was aware there had been repeated dietary and staffing concerns voiced during Resident Council meetings. The Administrator explained he did try to discuss resolution efforts with the Resident Council group regarding the concerns they voiced but realized he could definitely improve on his communication to them so they felt more part of the solution and better informed.

Based on observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 4 sampled residents observed with medications at bedside (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, diabetes, and left shoulder pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition. Review of the medical record revealed no documentation that Resident #64 was assessed for self-administration of medications. During an observation and interview on 10/31/23 at 1:05 PM, Resident #64 was sitting up on the side of his bed with the overbed table pulled directly in front of him and placed on top of the overbed table was his lunch tray and a medicine cup containing 2 round white pills. Resident #64 explained earlier that morning he had 3 teeth pulled and the pills in the medicine cup were the Tylenol he requested for pain that Nurse #1 had left for him to take. Resident #64 stated he was capable of taking his medications on his own but the nurse usually stayed in the room with him while he took his medications. During an interview on 10/31/23 at 1:11 PM, Nurse #1 revealed she usually stayed in the room with Resident #64 as he took his oral medications; however, when she brought Resident #64 his PRN (as needed) Tylenol for pain, she got distracted when staff brought him his lunch tray. Nurse #1 explained she left the medications with Resident #64 and returned to her medication cart to continue with her medication pass. Nurse #1 stated Resident #64 had not been assessed to self-administer medications and she should have remained in the room with Resident #64 while he took his oral medications. During interviews on 10/31/23 at 2:40 PM and 11/01/23 at 5:45 PM, the Director of Nursing (DON) stated nurses were expected to wait at bedside for the resident to take their oral medications prior to leaving the room and not leave medications unattended at the resident's bedside. The DON confirmed Resident #64 had not been assessed to self-administer his medications and stated Nurse #1 should have stayed in the room with Resident #64 while he took his oral medications. During an interview on 11/01/23 at 6:16 PM, the Administrator stated nursing staff knew to stay in the room with the resident while they took their oral medications. He further stated nursing staff should never leave medications unattended in the resident's room.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR) and wandering behavior for 3 of 22 sampled residents reviewed (Residents #10, #26 and #83). Findings included: 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder and depression. a. Review of an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document revealed Resident #10 had a time-limited Level II PASRR with an effective date of 09/02/22 and expiration date of 10/02/22. The admission MDS assessment dated [DATE] indicated Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. b. Review of an undated NC MUST inquiry document revealed Resident #10 was re-evaluated on 02/06/23 by PASRR due to a change of condition and issued a new Level II PASRR effective 02/09/23 with no expiration date. The significant change MDS assessment dated [DATE] indicated Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. During an interview 11/01/23 at 2:59 PM, the MDS Coordinator revealed she completed the section related to Level II PASRR on MDS assessments and confirmed that Resident #10 had a Level II PASRR. The MDS Coordinator stated it was an oversight on her part that Resident #10's MDS assessments dated 09/09/22 and 03/20/23 did not accurately reflect she had a Level II PASRR and modifications would be submitted. During an interview on 11/01/23 at 6:16 PM, the Administrator stated it was his expectation for MDS assessments to be completed accurately. 39037 2. Resident #26 was admitted to the facility 02/08/19 with multiple diagnoses including anxiety disorder and depression. Review of an undated North Carolina Medicaid Screening Tool (NC MUST) inquiry document revealed Resident #26 had a time-limited Level II Preadmission Screening and Resident Review (PASRR) with an effective date of 09/09/20 and expiration date of 06/27/21. Review of an undated NC MUST inquiry document revealed Resident #26 was re-evaluated due to a change in condition and issued a new Level II PASRR effective 06/28/21 with no expiration date. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. During an interview 11/01/23 at 2:59 PM, the MDS Coordinator revealed she completed the section related to Level II PASRR on MDS assessments and confirmed that Resident #26 had a Level II PASRR. The MDS Coordinator stated it was an oversight on her part that Resident #26's MDS assessment dated [DATE] did not accurately reflect she had a Level II PASRR. During an interview on 11/01/23 at 6:16 PM, the Administrator stated it was his expectation for MDS assessments to be completed accurately. 3. Resident #83 was admitted to the facility 08/28/23 with multiple diagnoses including non-Alzheimer's dementia and heart failure. Review of Resident #83's behavior care plan last updated 09/11/23 revealed she wandered and at risk for elopement. Interventions included placing Resident #83 in a room close to the nurse's station and utilizing distractions to decrease wandering. The quarterly Minimum Data Set (MDS) dated [DATE] did not reflect Resident #83 had wandering behavior during the lookback period. In an interview with the Social Worker (SW) on 11/01/23 at 3:13 PM she confirmed she coded Section E on Resident #83's quarterly MDS dated [DATE]. She stated it was her understanding if a behavior was care-planned, it did not have to be coded on the MDS. In a follow-up interview with the SW on 11/01/23 at 4:12 PM she confirmed Resident #83 had wandering behavior during the lookback period. She stated she misunderstood coding guidelines for behavior and the MDS dated [DATE] should have reflected that Resident #83 had wandering behaviors. In an interview with the Administrator on 11/01/23 at 6:16 PM he stated it was his expectation MDS assessments be completed accurately.

Based on record review, observations, and interviews with staff, the facility failed to secure medicated creams that were in clear view at the bedside for 3 of 4 residents reviewed for medication storage (Resident #37, Resident #9, and Resident #57). Findings included: 1. Resident #37 was admitted to the facility on [DATE]. Her current diagnoses included dementia and arthritis. The annual Minimum Data Set, dated dated dated [DATE] revealed Resident #37's cognition was assessed as severely impaired. Review of Resident #37's physician orders revealed no current order for the use of a triad hydrophilic wound dressing cream. A standing physician's order was in place for the use of a moisture barrier cream and included directions to apply for 7 days. During observations on 10/29/23 at 1:58 PM and 10/31/23 at 11:03 AM in the room of Resident #37, in clear view on top of the nightstand were two tubes of medicated cream. One 2.5-ounce tube labeled triad hydrophilic wound dressing cream that included the active ingredient zinc oxide and one 5-ounce tube labeled moisture barrier cream with the active ingredient 12% zinc oxide. An observation and interview were conducted on 11/01/23 at 4:49 PM with the Director of Nursing (DON). The DON observed both tubes of the medicated cream on the top of the nightstand and explained those could not be kept in the room of Resident #37. She revealed standing orders were in place for the use of the moisture barrier cream and it was kept on the treatment cart and applied by the nurse and for the use of triad hydrophilic wound dressing cream a physician order would need to be in place and the cream applied by the nurse and kept on the treatment cart. During an interview on 11/01/23 at 5:43 PM the DON stated it was ultimately her responsibility to follow up on medications by doing random spot checks of resident rooms. She further stated the nurses should check resident rooms for medications at the bedside. 39037 2. Resident #9 was admitted to the facility 02/11/20 with diagnoses including heart failure and quadriplegia (paralysis that affects all four limbs). The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed no current order for the use of zinc oxide cream. During observations on 10/29/23 at 12:42 PM, 10/20/23 at 8:27 AM, 10/31/23 at 8:46 AM, and 11/01/23 at 8:14 AM, in clear view on top of a shelf in Resident #9's room was a 15-ounce container of medicated cream with the active ingredient 25% zinc oxide. An interview with Resident #9 on 10/29/23 at 12:43 PM revealed the zinc cream was applied by staff but had not been applied for a while. An observation and interview were conducted on 11/01/23 at 4:22 PM with the Director of Nursing (DON). The DON observed the medicated cream on the shelf and explained it could not be kept in Resident #9's room. She stated a physician order would need to be in place for the use of zinc oxide cream and the cream should be applied by the nurse and kept on the treatment cart. In a follow-up interview with the DON on 11/01/23 at 5:43 PM she stated it was ultimately her responsibility to follow up on medications by doing random spot checks of resident rooms. She also stated nurses should check resident rooms for medications left at the bedside. 3. Resident #57 was admitted to the facility 12/28/21 with diagnoses including diabetes and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact. Review of Resident #57's physician orders revealed no current order for the use of antifungal cream. Observations on 11/01/23 at 8:14 AM and 11/01/23 at 3:55 PM in clear view on top of Resident #57's dresser was a tube of antifungal cream with the active ingredient 2% miconazole nitrate. An interview with Resident #57 on 11/01/23 at 8:15 AM revealed staff applied the antifungal cream after he used the bathroom. An observation and interview conducted on 11/01/23 at 4:22 PM with the Director of Nursing (DON). The DON observed the medicated cream on the shelf and explained it could not be kept in Resident #57's room. She stated a physician order would need to be in place for the use of antifungal cream and the cream should be applied by the nurse and kept on the treatment cart. In a follow-up interview with the DON on 11/01/23 at 5:43 PM she stated it was ultimately her responsibility to follow up on medications by doing random spot checks of resident rooms. She also stated nurses should check resident rooms for medications left at the bedside.

Based on observations and staff interviews the facility failed to label or date food items stored in the refrigerator; failed to discard expired food items; failed to ensure frozen food was kept solid; and failed to store food items away from soiled surfaces for 2 of 2 refrigerators located in 2 of 2 nourishment rooms (side one and side two). This practice had the potential to affect food served to residents. The findings included: 1. An observation of the side two nourishment room was made on [DATE] at 1:40 PM with the Director of Nursing (DON). The refrigerator in the nourishment room contained a half used, 59-ounce opened container of peach flavored punch with an expiration date of [DATE]. A 4-ounce container of cottage cheese with an expiration date of [DATE] labeled with a resident's name that no longer resided at the facility. A thawed, frozen dinner, single entrée of spaghetti with meat sauce with an expiration date of [DATE] with no name. Two containers of leftover food with no name or date. An interview was conducted with the DON on [DATE] at 1:54 PM. The DON revealed food stored in the nourishment room should be labeled with the resident's name and date when placed in refrigerator or freezer and expired foods should be discarded. The DON revealed it was the staff member who placed the food item in the refrigerator or freezer responsibility to label with the name of the resident it was for and date when they placed the food item. The DON revealed dietary staff were responsible for keeping the nourishment room refrigerators and freezers clean but indicated it was a team effort and would expect staff to be aware of unlabeled and expired food items. An interview was conducted on [DATE] at 6:36 PM with the Administrator. The Administrator stated the issues of cleanliness, non-labeled, and expired food items was unfortunate, and the facility had done a lot of training and he expected the nourishment room refrigerators to be clean. 2. An observation of the side one nourishment room was conducted on [DATE] at 1:54 PM with the DON. The refrigerator was located in the designated staff breakroom. The freezer section contained approximately 10 frozen and unwrapped corn dogs placed in a plastic grocery bag with no name or date. The freezer section also contained an individual serving of frozen macaroni and cheese with no name. The refrigerator section contained the following: three containers of leftover food with no name or date, half of a large pizza in a box with no name or date, a quartered watermelon dated [DATE] with no name, one 12-inch and one 6-inch submarine sandwich with no name or date, a 16-ounce of organic tofu with an expiration date of [DATE] labeled with the name of a resident, a 8-ounce container of goat cheese with an expiration date of [DATE] labeled with a resident's name, a opened 8-fluid ounce supplement drink with no name or open date, five half-pint cartons of whole milk with an expiration date of [DATE], four half-pint cartons of whole milk with an expiration date of [DATE], and one carton with an expiration date of [DATE]. All the items above were discarded by the DON. The inside of the refrigerator appeared unclean with dried, brown colored debris on the shelves of the door, pieces of cardboard stuck to the shelves on the inside of the refrigerator, and a buildup of dried debris in both storage bins. An interview was conducted with the DON on [DATE] at 1:54 PM. The DON revealed food stored in the nourishment room should be labeled with the resident's name and date when placed in refrigerator or freezer and expired foods should be discarded. The DON revealed it was the staff member who placed the food item in the refrigerator or freezer responsibility to label with the name of the resident it was for and date when they placed the food item. The DON revealed dietary staff were responsible for keeping the nourishment room refrigerators and freezers clean but indicated it was a team effort and would expect staff to be aware of unlabeled and expired food items. An observation and interview were conducted on [DATE] from 2:22 PM through 2:42 PM with the Dietary Manager (DM). The DM observed the refrigerator was not clean and all the items removed by the DON. The DM stated it was the responsibility of dietary staff to clean the refrigerators in the nourishment rooms which included to discard food items with no name or date and expired items. The DM revealed nourishment room refrigerators were to be cleaned weekly and stated it had not been done. An interview was conducted on [DATE] at 6:36 PM with the Administrator. The Administrator stated the issues of cleanliness, non-labeled, and expired food items was unfortunate, and the facility had done a lot of training, and he expected the nourishment room refrigerators to be clean. The Administrator revealed having a refrigerator designated for residents in the staff break room was not a good idea.

Based on observations, record review, and staff interviews the facility failed to prevent mouse activity as evidence by droppings found on the floor in the designated area used to store food for 1 of 1 kitchen dry storage areas reviewed for pest control. The findings included: Review of the most recent contracted pest exterminator document dated 04/18/22 revealed mice baits were placed by the dumpster. The document did not indicate there was evidence of mice inside the facility. On 05/09/22 at 9:59 AM an initial tour of the kitchen revealed mouse droppings were observed on the floor in the dry food storage area. The food products were being stored on a shelf off the floor. The floor had debris including a bread crouton and appeared it had not been cleaned. During an interview and observation on 05/09/22 at 10:00 AM the Dietary Manager (DM) revealed the kitchen floor was swept and mopped at least daily. The DM observed the mouse droppings on the floor of the dry food storage area and stated he was not aware of mice activity in the kitchen. During an interview on 05/11/22 at 4:03 PM the DM revealed the cleaning schedule of the kitchen did not include to sweep and mop the dry food storage area but was expected to be done at the end of the day before dietary staff left. The DM stated he should have checked before he left on 05/08/22 to ensure the dry food storage area was swept and mopped but didn't. An interview was conducted with the Administrator on 05/12/22 at 6:36 PM. The Administrator revealed the facility had a contract with a pest control company who came monthly and when needed. The Administrator revealed he was not aware of mouse activity in the kitchen, and it was his expectation dietary staff kept the kitchen clean and if there were issues those would be addressed.

Based on record review and interviews with staff, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to administer the correct medications to a resident when Medication Aide (MA) #1 administered medications prescribed for Resident #3 to Resident #1. Resident #1 received 5 medications which included antidepressant, antihistamine, opioid pain medication, muscle relaxant, and antiepileptic. After the incident, the on-call physician ordered to monitor Resident #1's vital signs (VS) every 2 hours and notify her if any acute change in condition occurred. Resident #1 became unresponsive approximately 12 hours later. He received 4 doses of [MEDICATION(S)] and required initiation of bag valve mask (BVM) ventilation before Emergency Medical Services (EMS) arrived. [MEDICATION(S)] is an antidote used to reverse the effects of opioid overdose. BVM is a handheld tool used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths. Resident #1 was transferred to the emergency room (ER) for evaluation of altered mental status (AMS). He returned to the facility the following day on 02/11/2022. This failure occurred for 1 of 3 sampled residents reviewed for significant medication error (Resident #1). The findings included: Resident #1 admitted to the facility on [DATE] from an acute hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with moderate impairment in cognition. He required extensive assist to total dependent with 1 to 2 or more persons assist in his activities of daily living (ADL) except eating. Resident #1 did not exhibit behavioral symptoms and was receiving insulin, antidepressant, and diuretic daily in this assessment. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Insulin [MEDICATION(S)] solution, 40 units once daily at bedtime (long-acting insulin) [MEDICATION(S)] 400 mg 3 times daily (anticonvulsant) The facility's medication variance report dated 02/10/22 indicated on 02/09/22 at 8:15 PM, MA #1 had completed medicating Resident #2 and began preparing medications for Resident #3 when Resident #2 began talking very loudly to MA #1. Once MA #1 completed preparing the medications, she accidentally went into the wrong resident's room and mistakenly administered medications to Resident #1. MA #1 immediately realized the mistake and immediately notified Nurse #1. Nurse #1 notified the Director of Nursing (DON) immediately and was ordered to call the on-call physician. Orders received from the on-call physician to monitor Resident #1's VS every 2 hours and notify the on-call physician again if any acute change in condition occurred. MA #1 gave Resident #1 the following medications prescribed for Resident #3: 1 capsule of [MEDICATION(S)] 60 mg (antidepressant) 1 tablet of [MEDICATION(S)] 50 mg (antihistamine) 1 tablet of [MEDICATION(S)] extended release (ER) 30 mg (opioid analgesic) 1 tablet of [MEDICATION(S)] 20 mg (muscle relaxant) 1 tablet of [MEDICATION(S)] 150 mg (anti-epileptic) 1 capsule of [MEDICATION(S)] 300 mg (anticonvulsant) Further review of the medication variance report revealed Resident #1's VS were monitored at least once every 2 hours after the incident on 02/09/22 evening through the next morning at 7:00 AM. All the VS were within the normal limits. When the DON assessed Resident #1 on 02/10/22 at 8:15 AM, she noticed Resident #1 responded to voice stimuli when his name was called. The DON remained in the room. At around 8:30 AM, Resident #1 began to display periods of apnea and sternal rub was conducted and Resident #1 opened his eyes and then became unresponsive. Apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. Sternal rub is the application of painful stimuli with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli. The NP was in the facility and was alerted to Resident #1's room. Order for [MEDICATION(S)] was received from the NP and instructed to administer with no signs of improvement. After the NP administered another dose of [MEDICATION(S)], reaction to the second dose was noted as Resident #1 responded to voice stimuli. BVM ventilation was initiated by the NP. At around 8:50 AM, EMS was notified to transport Resident #1 to ER. NP remained at bedside providing BVM ventilation. At approximately 9:15 AM, EMS arrived and transported Resident #1 to ER. During a phone interview with MA #1 on 02/22/22 at 3:05 PM, she stated when she was passing medication on the evening of 02/09/22 around 8:30 PM, she was preparing Resident #3's medications and Resident #2 began yelling loudly. She put the medications in the medication cart drawer because she needed to address Resident #2's needs. MA #1 stated she was distracted when she came out from Resident #2's room about 5-10 minutes later. She thought the medications in the medication cart were for Resident #1 and gave Resident #3's medications to Resident #1. Then, she felt that she was not 100% sure the medications were for Resident #1. When started to check Resident #3's medications, the first medication popped up was the [MEDICATION(S)]. She immediately realized that she had given the medications to the wrong resident. She notified Nurse #1 immediately. Nurse #1 called the DON. The DON wanted Nurse #1 to call the on-call physician. She stated Resident #1 had only received his insulin at 8 PM before receiving Resident #3's medications. A phone interview was conducted with Nurse #1 on 02/23/22 at 11:03 AM. She stated on 02/09/22 around 8:45 PM, MA#1 told her that she had given medications to the wrong resident. She called the DON immediately and ordered NA#1 to perform VS for Resident #1. The VS were within normal limits. Resident #1 remained alert and was able to talk. She did give Resident #1 insulin at around 8 PM before the incident. She checked his blood glucose (BG) after the incident, and it was 256 milligram/deciliter (mg/dl). The DON wanted her to call the On-call physician and she gave the on-call physician the list of medications that were given in error, allergy status, and list of Resident #1's routine medications. The on-call physician ordered her to monitor Resident #1's VS every 2 hours and to notify her of any acute changes. All other medications for Resident #1 were held after the incident. She focused on respiratory status, level of arousal, and the VS. She recalled she rounded Resident #1 more than once every two hours that night and his VS were within the normal limits. Resident #1 slept deeply as expected but she was able to arouse him on each visit. When she left at 7 AM, Resident #1 was still sleeping. During an interview with the MD on 02/23/22 at 8:50 AM, he supported the on-call physician's decision to monitor Resident #1's VS every 2 hours, provide supportive measures as needed, and report any acute changes to the on-call physician as needed after the incident. He stated had Resident #1 been sent to the hospital, they would have done the same thing. As Resident #1 did not get any cardiac medications, the MD indicated the measures ordered by the on-call physician were sufficient to handle the situation after the incident unless acute change occurred. An interview was conducted with Nurse #2 on 02/23/22 at 12:02 PM. As the unit manager on 02/10/22 morning, she was alerted by Nurse #3 to assess Resident #1 around 8:30 AM. During her initial assessment, Resident #1 was able to open his eye but unable to say anything. Around 10 minutes later, Resident #1 was unable to open his eyes and kept falling asleep. The NP ordered Resident #1 to be sent to the ER for evaluation and the EMS arrived within 10 minutes. The NP checked Resident #1's VS before EMS arrived. She administered the first dose of intramuscular (IM) [MEDICATION(S)] as ordered by the NP and the NP administered the second dose of intranasal [MEDICATION(S)] before EMS arrived. Resident #1 did not have any response to the first dose of [MEDICATION(S)] but had a weak response to voice stimuli after the second dose. She stated once she entered Resident #1's room, she and the NP stayed with Resident #1 until EMS arrived and took over. A phone interview was conducted with the on-call physician on 02/23/22 at 12:48 PM. She recalled receiving a call from Nurse #1 on 02/09/22 before 9:00 PM regarding the medication errors related to Resident #1. She asked Nurse #1 the list of medications that were given in error, Resident #1's routine medications, and his allergy status. After she had reviewed all the medications and determined Resident #1 was not allergic to any of the medications in error, she ordered Nurse #1 to monitor Resident #1's VS every 2 hours and call her immediately if Resident #1 experienced any acute change. An interview was conducted with the DON on 02/23/22 at 1:18 PM. She recalled she was not in the facility when the incident occurred 02/09/22. During the interview, she referred to the incident timelines in the medication variance report and stated some of the times in the timelines were approximated to her best knowledge. After Nurse #1 informed her of the medication error on 02/09/22 evening. She directed Nurse #1 to call the on-call physician and follow the directions. The only medication Resident #1 received before the incident in that evening was 40 units of [MEDICATION(S)]. She stated Resident #1 was doing okay after the incident until the next morning when he was found unresponsive. When she assessed Resident #1 around 8:15 AM, he was arousable and able to tell his name, but appeared very sleepy. She went ahead to get a set of VS and it was within normal limits. After she stayed in the room for about 15 minutes, Resident #1 became increasingly sleepy and harder to be aroused. She called the NP who was in the facility and Nurse #2 to assess Resident #1. She left the room a few minutes after the NP and Nurse #2 arrived as she needed to prepare Resident #1's paper work for transfer to the ER. The NP and Nurse #2 stayed with Resident #1 until EMS arrived. She stated once the acute change occurred around 8:30 AM, Resident #1 was never left alone in the room until EMS arrived. The NP ordered to send Resident #1 to ER for evaluation. She stated Resident #1 became unresponsive right before sending out with EMS. Resident #1 admitted to the hospital for 1 day and returned to the facility on [DATE] evening. Right after the incident, she completed in-service that included the 5 Rights and ways to handle distractions during medication administration for all the nurses and MAs on 02/10/22. She started to audit nursing staff for medication pass and the first round completed without any issues on 02/17/22. She completed the medication pass skill checks for all the nurses and MAs on 02/21/22. During a phone interview conducted with the NP on 02/23/22 at 1:35 PM, she stated she was in the facility on 02/10/22 morning. When she assessed Resident #1, he was unresponsive to voice and painful stimuli and continued to snore. His respirations were shallow, and skin was cold and clammy. She ordered to give 2 rounds of [MEDICATION(S)] before the EMS arrived. Resident #1 did not have any response after the first dose of IM [MEDICATION(S)] except a small response to painful stimuli. About 5 minutes later, she administered the second dose of intranasal [MEDICATION(S)]. Resident #1 had a weak response to voice stimuli. Resident #1 was completely unresponsive before the EMS arrived. She stated the fire department crews who arrived before the EMS gave 2 more doses of intranasal [MEDICATION(S)] before the EMS arrived. She added she stayed with Resident #1 since she arrived his room on 02/10/22 morning until the EMS took over. A phone interview was conducted with Nurse #3 on 02/24/22 at 11:01 AM. As the hall nurse for Resident #1 on 02/10/22 morning, she performed the first assessment for him around 7:20 AM. Resident #1 initially appeared unresponsive but was able to open his eyes with voice and touch stimuli. She recalled Resident #1 took several deep breaths, then returned to sleeping state. She conducted a set of VS, and it was within the normal limits. Shortly after the DON arrived, she noted Resident #1 began to have 10-15 seconds of apnea repeatedly. The DON told her to alert Nurse #2 to come over to assist. She was in and out of the room at that time. She stated the DON left Resident #1's room shortly after the NP arrived. The NP and Nurse #2 stayed with Resident #1 until EMS arrived. EMS report dated 02/10/22 indicated a call was received from the facility at 9:11 AM and the EMS arrived the facility at 9:23 AM. Upon arrival to Resident #1's room at 9:24 AM, Resident #1 was found with altered mental status in the bed with crews from fire department and the NP performing BVM ventilation. Four doses of [MEDICATION(S)] had been administered prior to EMS arrival by either the facility staff or the fire department crews. Resident #1's respirations were shallow but remained conscious and responded to voice stimuli. The first set of vital signs was conducted at 9:36 AM with blood pressure (BP) 144/66, pulse (P) 84, respiration rate (RR) 12, and oxygen saturation (O2) 96%. The EMS departed the facility with Resident #1 at 9:48 AM and arrived at the hospital at 10:15 AM. Review of Hospital Emergency Department Discharge summary dated 02/11/22 revealed Resident #1 was admitted on [DATE] at 10:11 AM. Resident #1 presented to the ER with altered mental status and was minimally arousable. He arrived with BVM ventilations due to shallow breathing. His oxygen level was maintained at saturation of 94% on 2 liters nasal cannula. Resident #1's BG was 72 mg/dl, and the Glasgow Coma Scale (GCS) was 7 according to EMS. The GCS is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. A person's GCS score could range from 3 (unresponsive) to 15 (responsive). The initial VS taken atER on [DATE] at 10:19 AM was BP 135/74, RR 20, P 84, O2 95%. Resident #1 did withdraw from painful stimuli. The second set of VS taken at 10:42 AM was BP 142/56, RR 11, P 68, O2 91%. Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the hospital and monitored closely in progressive level of care. His level of alertness gradually improved and was discharged back to the facility on [DATE]. The Administrator was notified of Immediate Jeopardy on 02/24/22 at 5:30 PM. The facility provided the following corrective action plan with a completion date of 02/12/22. Resident #1 received medications that were not prescribed for him. Root cause was determined to be distraction during a medication administration. On the evening of 02/09/22, Resident #1 was administered medications by Medication Aide #1 (MA#1) that were not ordered for him. The on-call provider and the Director of Nursing (DON) were notified of the medication error. The provider gave an order to monitor in place and to assess vital signs (VS) once every 2 hours. On 02/10/22, the Nurse Practitioner (NP) and DON assessed the Resident #1 for a decline in condition. The NP gave the order to send to the emergency room (ER) for further medical workup. Due to the acute change in condition at around 8:45 AM, the NP and staff remained with Resident #1 all the times until emergency medical service (EMS) arrived and took over care for the resident. Resident #1 was transported to the hospital and admitted on [DATE]. Resident #1's emergency contact was notified of the error and the transfer to the hospital. The facility pharmacy consultant was also made aware of the medication error, in addition to the facility medical director. MA#1 was removed from the responsibility of medication administrator effective 02/10/22. All residents have the potential to be affected by this deficient practice. On 02/10/22 the DON completed walking rounds and interviewed alert residents to see if there were concerns with medication errors and to observe non alert residents to determine if there was a decrease in level of alertness that could be indicative of administration of wrong medication. There were no negative findings or concerns. The DON and designee entered *name alert notices in the electronic health record for those residents currently in the facility that have similar names to help deter medication errors related to wrong resident with similar names. The DON monitored and reminded staff to avoid distractions during the medication pass as rounds were completed. To prevent this from recurring, by 02/10/22, all staff who are responsible for medication administration, will be educated by the DON on the facility medication administration policy including the requirement of facility staff to verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. In addition, the DON will provide education in ways of reducing distractions including stopping and restarting the medication administration process when distracted or unsure, the nurse will not multitask during the medication administration, one resident will be completed before moving on to another resident, no pre-pulling of medications as well as educating staff on not distracting the nurses during the medication administration. On 02/10/22, an ad hoc Quality Assurance (QA) meeting was held to discuss the plan. 10 facility staffs included the Medical Director, Administrator, and DON had participated this meeting. In an abundance of precaution, as an additional educational support in order to strengthen MA #1's skill set, MA #1 was required to complete a course in Relias, which is a comprehensive educational training program that educates and tests staff members proficiency in assigned specific areas, on avoiding medication errors. Starting on 02/11/22 a medication competency assessment was performed on each nurse and medication aide. No issues related to medication error noted after this event. The medication aide also received one on one education with the DON on adhering to the rights of medication pass and limiting distractions during the medication pass. During routine rounds the DON and or designee will observe medication pass to ensure distractions are limited and nurses are completing medication administration to the correct resident. DON or designee will immediately remove distractions if observed and provide education as needed. To monitor and maintain ongoing compliance, beginning 02/14/22, the DON or clinical manager will document observations of medication administration for 5 nurses per week for 8 weeks to ensure the residents remain free from medication errors. In addition, any new nurse hires or agency will be required to complete a medication competency assessment as well as the same education that was provided on 02/10/22 prior to employment. Any negative observations that would require the nurse or medication aide to be stopped, an additional training will be immediately conducted. The affected resident's RP and the MD/NP will be made aware of any negative findings. Beginning 02/14/22, the results of the audits will be forwarded to the facility Quality Assurance and Performance Improvement (QAPI) committee monthly, for review and recommendations. The committee reserves the right to modify the auditing as they feel appropriate if negative findings are reviewed. The facility DON is responsible for compliance. Date of Compliance is 02/12/22. The facility's alleged correction date of 02/12/22 was verified by the following: On 02/28/22, the facility's corrective action plan with correction date of 02/12/22 was validated on-site by record review, observations, and interviews with resident and staff. A full-scale medication pass was conducted from 02/22/22 through 02/23/22. No concerns related to medication errors were identified. It consisted of 25 medications and involved 7 different residents, 3 different halls, and 4 different nurses. Nurses were seen applying the 5 Rights of medication administration during medication passes. They were observed checking resident's picture in the computer, verifying the name plate at the door, and asking alert-oriented residents open-ended question for resident's name before administering medication. For residents who were nonverbal, nurses referred to another nursing staff to confirm residents identify if they remained unsure before administering medication. None of the nurses were seen multitasking or pre-pulling medication during the medication administration observation. Nurses completed medication pass for one resident before moving on to another resident. When they became distracted or unsure during the medication pass, they stopped and restarted the medication pass process. Interviews with nursing staff for both shifts revealed they had been re-educated per the documentation of in-services provided related to effective identification of the right resident through the 5 Rights, ways to minimize distractions, and handling of distractions during medication administration. Nurses were knowledgeable about the 5 Rights of medication administration and ways to handle distractions during medication pass. Interviews with alert and oriented residents revealed nursing staff had been asking open-ended questions for their name before administering medication. The medication records of sample residents were reviewed with focus on medication error. No concerns related to medication errors were identified. Review of in-service records revealed on 02/10/22, the DON completed the in-person in-services that included the 5 Rights of medication administration and ways to handle distractions during medication pass. All other nurses or medication aides not in the facility on 02/10/22 received the in-services via telephonic voice message system. The in-service sign-in sheet indicated all 15 nurses and 4 medication aides had received the re-education on 02/10/22. Review of monitoring tools revealed the management staff had completed audits and monitoring per the audit tools and monitoring documentation provided. This F760 was corrected on 02/12/2022.