Every finding on record at Bear Mountain Health and Rehabilitation

Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 7 of 9 residents reviewed for activities (Residents #10, #41, #11, #57, #8, #56, #9). The residents expressed not being able to leave the facility made them feel sad and sometimes depressed and angry. The findings included: A review of the activity calendars from May 10, 2025 to July 2026 revealed activities were scheduled inside of the facility during the week and on the weekends. There was one outside of the facility activity scheduled on 2/5/26. Observation of the facility location on 7/13/26 at 8:00 AM revealed it was located in a rural area that was within an 8-to-10-minute driving distance to numerous local and commercial shops, grocery stores, fast food, and sit-down restaurants. a. Resident #10 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #10 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #10 was cognitively intact. An interview conducted with Resident #10 (Resident Council President) on 7/13/26 at 3:00 PM during the Resident Council meeting revealed there had been no scheduled activities outside of the facility in a very long time with the exception of when two other residents were chosen to go out to eat a few months ago. She stated she felt it was unfair that only two residents got to go and no other outside activities had been scheduled for anyone else. Resident #10 reported they had discussed with the Activities Director about scheduling activities outside of the facility and she believed the Activities Director had spoken with the Administration about it, but they currently only had one van that held two people in wheelchairs, so they didn't have enough transportation to accommodate everyone and the van was always tied up with doctor's appointments. Resident #10 stated not having the opportunity to participate in activities outside of the facility made her feel sad and sometimes depressed. She revealed she felt like the facility could do something to assist with them being able to leave the facility on a group activity even once every other month. Resident #10 stated she would like to be able to go to a restaurant and order her own meals and socialize with other people, or go to the store shopping. b. Resident #41 was admitted to the facility on [DATE]. An Annual MDS dated [DATE] indicated Resident #41 felt that it was very important to have activities that included going outside of the facility and somewhat important doing things in a group setting. The assessment further indicated Resident #41 was cognitively intact. An interview conducted with Resident #41 on 7/13/26 at 3:00 PM during a Resident Council meeting revealed there had been no scheduled activities outside of the facility in over a year. He reported that he knew the facility's van was small and only held a couple of wheelchairs and was always tied up with doctor's appointments, but he would be happy if he could just ride along somedays to those appointments in order to get out of the building and stop looking at the same four walls. Resident #41 stated he felt like a prisoner in the facility and felt like no one understood how hard it was to be there and not ever be able to go out and do things. He reported that he was still a regular person who enjoyed being out in the community. Resident #41 was observed to become tearful during the Resident Council meeting and excused himself from the meeting. c. Resident #11 was admitted to the facility on [DATE]. An MDS dated [DATE] indicated Resident #11 felt that it was very important to have activities that included going outside of the facility and somewhat important doing things in a group setting. The assessment further indicated Resident #11 was cognitively intact. An interview conducted during the Resident Council meeting on 7/13/26 at 3:00 PM with Resident #11 revealed there had been no scheduled activities outside of the facility since she had been there. She revealed not having scheduled activities outside of the facility made her feel sad and sometimes depressed and she was in agreement with other Resident Council members that she would also like to have scheduled activities that included going out to eat at a restaurant or going shopping. d. Resident #57 was admitted to the facility on [DATE]. An Annual MDS dated [DATE] indicated Resident #57 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #1 was cognitively intact. An interview conducted with Resident #57 on 7/13/26 at 3:00 PM during a Resident Council meeting revealed there had not been a scheduled group activity outside of the facility over the past year at least. He agreed with other Resident Council members that they couldn't go outside of the facility for an activity because they only had one van that held only two people. Resident #57 stated not being able to leave the facility and participate in group activities made him feel sad and sometimes angry. He reported that going outside of the building for activities would be a nice break from his otherwise boring days. e. Resident #8 was admitted to the facility on [DATE]. An Annual MDS dated [DATE] indicated Resident #8 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #8 was cognitively intact. An interview conducted with Resident #8 on 7/13/26 at 3:00 PM during a Resident Council meeting revealed there had been no scheduled activities outside of the facility over the past year. He was observed nodding his head in agreement with the other Resident Council members that they had discussed this in the past but they only had one van that held only two people and it was tied up with doctor's appointments. Resident #8 was also in agreement with the other Resident Council members that not being able to leave the facility and participate in group activities made him feel sad and sometimes depressed and he would also enjoy being able to go to a restaurant, order his own food, and socialize with other people outside of the facility. f. Resident #56 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #56 felt that it was very important to have activities that included going outside of the facility and somewhat important to him doing things in a group setting. The assessment further indicated Resident #56 was cognitively intact. An interview conducted with Resident #56 on 7/13/26 at 3:00 PM during a Resident Council meeting revealed he had been at the facility for just a few months and had not been out of the facility for any activities. He was observed nodding his head in agreement with the other Resident Council members that they felt trapped and wanted to go out but did not have a big enough van to provide transportation for everyone and that the van they did have was always tied up with doctor's appointments. Resident #56 also nodded his head and stated yes in agreement with the other Resident Council members that not being able to leave the facility and participate in group activities made him feel sad and he would also enjoy being able to go to a restaurant and/or go shop for her own personal items. g. Resident #9 was admitted to the facility on [DATE]. An admission MDS dated [DATE] indicated Resident #9 felt that it was very important to have activities that included going outside of the facility but not very important doing things in a group setting. The assessment further indicated Resident #9 was cognitively intact. An interview conducted with Resident #9 on 7/13/26 at 3:00 PM during a Resident Council meeting revealed there had been no scheduled activities outside of the facility for at least a year. She agreed with the other Resident Council members that they had discussed with the Activities Director during Resident Council meetings about scheduling activities outside of the facility, but their current van only held two people, and they didn't have a way to accommodate or transport everyone. Resident #9 stated not having the opportunity to participate in activities outside of the facility made her feel trapped and she would like to go out somewhere. An interview conducted with the Activities Director on 7/14/26 at 12:15 PM revealed she had been working as the Activities Director at the facility for about seven months and part of her responsibilities were scheduling and implementing resident activities inside and outside of the facility for each month. She stated since she began working at the facility as the Activities Director, she had only been able to schedule one resident activity outside of the facility due to transportation issues. She reported that activity was scheduled in order to get one of their very younger residents, Resident #25, out of the facility for a few hours and because the van only held two people the facility chose another resident (Resident #55) who got along well with the Resident #25 to accompany her during the outing. The Activities Director reported that Resident #25 got to choose where they went for that outing. The Activities Director revealed that a lot of residents reported to her that they were very upset that they did not get to go, however, she could not remember the residents that told her they were upset. She revealed she did not know when the last scheduled group outing was. She stated that currently the facility only had one van which could only accommodate two residents at a time and was primarily used for medical appointments. The Activities Director revealed she had brought the issue to Administration several times throughout the year and they were trying to work on organizing a fishing trip in September. She stated she had tried to call van rental companies and talk to their sister facility about borrowing a van but none of that had worked out. She reported she tried to do a dine in experience monthly from local restaurants of the residents' choice but understood that was not the same as residents being able to leave the facility and eat a meal at a restaurant. She confirmed that activities outside of the facility for those residents who could participate were important for their overall well-being and allowed them some independence and socialization outside of the facility. During an interview conducted with the Administrator on 7/15/26 at 1:30 PM revealed there had been no activities scheduled outside of the facility in over a year due to transportation. She stated the facility currently only had one van that was only able to accommodate two residents at a time and was primarily used for medical appointments. She confirmed they had scheduled an outing for one of their very young residents earlier in the year but due to transportation only one other resident was able to go along, and the facility chose the other resident based on who they felt got along well with the very young resident. She indicated that they were trying to schedule a fishing trip in September for whoever wanted to attend. The Administrator stated she agreed that activities outside of the facility were important for residents and they had shared with her their frustrations about not being able to go out.

Based on record review, Responsible Party, resident and staff interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to starting them for 2 of 5 residents reviewed for unnecessary medications (Resident #12 and Resident #3). The findings included: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. A review of the physician's orders in Resident #12's medical record indicated an active order which started on 7/15/25 for Buspirone (an anti-anxiety medication) oral tablet 10 milligrams – give 1 tablet by mouth two times a day for agitation/restlessness. This order was entered into Resident #12's medical record by Unit Manager #1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was rarely/never understood and had severely impaired cognitive skills for daily decision making. Resident #12 had no behavioral symptoms, and received antianxiety medications. Further review of Resident #12's medical record indicated no information whether Resident #12's Responsible Party (RP) was informed in advance of the risks and benefits of initiating Buspirone. A phone interview with Resident #12's RP on 7/15/26 at 9:21 AM revealed that a nurse called him on 7/14/26 and told him that they just wanted to check if he was fine with Resident #12 receiving Buspirone. Resident #12's RP stated prior to 7/14/26, he had not been informed by the facility that Resident #12 had been receiving Buspirone and they had not obtained his consent for Resident #12 to receive this medication. He added that the hospice nurse was the one who told him that Resident #12 had been receiving Buspirone. Resident #12's RP further stated that he was fine with Resident #12 receiving Buspirone as long as she was not getting other medications which worked the same way. An interview with Unit Manager #1 on 7/14/26 at 2:39 PM revealed she remembered receiving the order for Resident #12 to start on Buspirone and she entered this order in her medical record on 7/15/25. Unit Manager #1 stated that she knew they were supposed to notify Resident #12's RP and obtain consent for Resident #12 to receive this medication, but the Director of Nursing was responsible for obtaining consents. Unit Manager #1 stated that she did not know why there was no consent for Buspirone in Resident #12's medical record. An interview with the Director of Nursing (DON) on 7/15/26 at 1:42 PM revealed she was responsible for obtaining the psychotropic medication consents and she usually did this whenever there were new orders for psychotropic medications. The DON stated that she reviewed all new orders daily and she would have obtained consents if there were new orders for psychotropic medications. The DON further stated that she would have called the guardian or Responsible Party for residents who were unable to give consents, and in Resident #12's case, it was just missed and she took full responsibility for not obtaining consent for Resident #12 to receive Buspirone. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included depression and anxiety disorder. A review of physician's orders in Resident #3's medical record indicated an active order which started on 1/21/26 for Duloxetine (an anti-depression medication) oral capsule delayed release particles 30 milligrams (mg) - give 1 capsule by mouth two times a day for depression. The medical record also revealed an active order dated 4/23/26 for Buspirone (an anti-anxiety medication) oral tablet 15 mg – give 1 tablet by mouth three times a day for anxiety. The significant change Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #3 was cognitively intact, had no behavioral symptoms, and received medications for depression and anxiety disorder. Further review of Resident #3's medical record revealed no consent form to indicate whether she had been informed in advance of the risks and benefits of taking Duloxetine and Buspirone. In an interview on 7/15/26 at 12:13 PM with Resident #3, she stated she had spoken to staff earlier in the year about her depression and knew they had started Duloxetine but didn't remember talking about risks and benefits or signing a consent form. Resident #3 further stated sometime after that she had asked for something more for anxiety and had known they started Buspirone but didn't remember talking about risks and benefits or signing a consent form. On 7/15/26 at 1:42 PM an interview was conducted with the Director of Nursing (DON) who explained the process for obtaining consent for psychotropic medications. The DON stated she reviewed all new resident orders and if there was a new order for a psychotropic or antipsychotic medication she would physically go to the resident, explain the risks and benefits and get their signed consent. She revealed if the resident couldn't understand she would call their Responsible Party (RP) to explain and get their consent to start the medication. The DON explained she didn't remember why Resident #3 did not have consent forms for Duloxetine and Buspirone, and they had just gotten missed. During an interview with the Administrator on 7/15/26 at 1:49 PM she stated the expectation was that all new resident orders for medications were to be reviewed and written consent obtained for psychotropic medications. She explained the facility had a process in place for this that included daily review of all new medication orders, explaining the risks and benefits of psychotropic medications, and getting written consent from the resident or their RP. The Administrator further explained if residents or responsible parties had not consented to psychotropic medication use it would have put them at risk for not knowing why they were on these medications or understanding the medication's risks and benefits.

Based on observation and staff interviews, the facility failed to discard an expired medication from 1 of 2 medication carts (West-Front Hall) reviewed for medication labeling and storage.The findings included: On 07/14/26 at 8:54 AM, an observation was made of the West-Front hall medication cart with Unit Manager #1. The third drawer on the right side, which was a locked drawer, held a plastic bag that contained an unopened package of two naloxone nasal spray bottles (medication used in emergencies to reverse the effects of a life-threatening opioid emergency). The bag had a pharmacy label with the name of a resident no longer at the facility with a date dispensed of 5/7/22 and a manufacturer's expiration date of 6/30/24. In an interview with the Unit Manager #1 on 7/14/26 at 8:55 AM she stated she had worked on that cart many times but never saw the naloxone package before. She explained that the controlled medications were kept in the second drawer on the right side which was also a locked drawer, and the third drawer was an extra locked drawer in case they had an overflow of controlled medications which rarely happened on that cart. Unit Manager #1 further explained because the drawer didn't get used much this medication package must have been overlooked by nurses and Medication Aides when checking their carts.The Director of Nursing (DON) was interviewed on 7/14/26 at 9:27 AM and confirmed the third drawer on the West-Front hall was for extra controlled medication storage and used infrequently. The DON stated nurses and Medication Aides working on the medication carts were supposed to check carts at the beginning of their shift to ensure that discontinued or expired medications were removed and disposed of or returned to pharmacy. The DON explained Unit Managers would also periodically check the carts for discontinued or expired medications, but this naloxone package had been overlooked and should have been removed from the cart when that resident had been discharged . In an interview with the Administrator on 7/14/26 at 2:26 PM she stated residents should have current medications as dispensed by the pharmacy and there should not be any discontinued or expired medications on the carts because they could cause a mix up or be given to residents when no longer effective.

Based on record review, staff, Pharmacist, and Medical Director interview, the facility failed to transcribe and implement orders for diabetes care according to the hospital discharge summary for a resident with diabetes. The hospital discharge summary ordered sitagliptin/metformin (Janumet extended release). The facility instead entered and administered metformin, omitting the sitagliptin component and the extended-release formulation. This deficient practice occurred for 1 of 3 residents reviewed for providing care according to professional standards (Resident #1).Findings included:A hospital Discharge summary dated [DATE] included the following medication order: metformin-sitagliptin (Janumet extended release (XR) 100 milligram (mg)-1000 mg oral tablet, 1 tablet by mouth daily for diabetes. According to manufacturer's information, metformin-sitagliptin is a combination of two medications and is marketed under the brand name of Janumet extended release XR.Resident #1 was admitted to the facility on [DATE]. Her diagnoses included Type-2 diabetes mellitus.A physician order dated 8/28/25 entered by Nurse #1 read, metformin 1000 mg tablet give one tablet by mouth once a day.Resident #1's August 2025 and September 2025 medication administration record (MAR) included an order that read, metformin oral tablet 1000 mg give one tablet by mouth one time a day for diabetes mellitus. The start date of the medication on the MAR was 8/29/25. The MAR documented she received the medication on 8/30/25, 8/31/25, 9/1/25, 9/2/25, 9/3/25, 9/4/25, 9/5/25, 9/6/25, and 9/7/25. The MAR documented the medication was discontinued on 9/8/25.Nurse #1 was unavailable for interview.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS documented that she received hypoglycemic medication.An interview was conducted with Pharmacist #1 on 12/29/25 at 4:12 PM. Pharmacist #1 stated an order was received from the facility on 8/28/25 for metformin 1000 mg. daily. The Pharmacist said there was not an order for Janumet for Resident #1 from the facility. The Pharmacist reported metformin and Janumet were not the same medication. She explained Janumet XR was a combination medication containing sitagliptin and metformin and was an extended-release medication. She said extended-release medication lasted longer because it was released slowly over a 24-hour period. She stated the order the pharmacy had received from the facility was for metformin immediate release. The Pharmacist explained extended-release medication was absorbed over time so it lasted longer and said immediate release medication should be given every 12 hours. Pharmacist #1 said Resident #1 would not get as much glycemic control (management of blood glucose levels) over time if she was only taking immediate release metformin one time a day. The pharmacist felt it was a significant medication error because Resident #1 was only getting the metformin which was only half of the combination medication (Janumet) she was supposed to be getting.An interview was conducted with the Medical Director on 12/29/25 at 4:43 PM. The Medical Director said if Resident #1 had poor oral intake, then she did not need the Janumet and said metformin would be a better choice for her. She said it was a medication error but that she did not think it had negative effect or hurt Resident #1.An interview was conducted with the Director of Nursing (DON) on 12/30/25 at 12:17 PM the DON stated Janumet XR was ordered for Resident #1 on her hospital discharge summary. She said Nurse #1 entered the wrong medication for Resident #1 in the electronic computer system. She reported one nurse was supposed to enter the admission orders into the electronic computer system and then a second nurse was supposed to review and confirm the orders to make the orders active. The DON explained Nurse #1 had entered and confirmed the admission orders for Resident #1 and the orders had not been checked by a second nurse. The DON stated she thought the error would have been caught if the orders had been checked by a second nurse.An interview was conducted with the Administrator on 12/30/25 at 4:19 PM. The Administrator said orders should be put in according to the hospital discharge summary and entered accurately into the electronic computer system. She stated from her knowledge there was a two-step process for putting in and checking admission orders. The Administrator explained Nurse #1 was a new nurse and thought she may not have known the facility process.

Based on record review, and staff, Clinical Practice Manager, and Physician Assistant (PA) interviews, the facility failed to notify the medical provider of abnormal laboratory results for 1 of 1 resident reviewed for notification of laboratory results (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included Type-2 diabetes mellitus, hypertension (high blood pressure), long-term use of anticoagulants (blood thinning medication), metabolic encephalopathy (confusion caused by chemical imbalances in the body), malignant neoplasm of the pancreas (pancreatic cancer), hypo-osmolality (excess water relative to solutes such as electrolytes) and hyponatremia (low sodium level), anemia (low red blood cells), hypothyroidism (thyroid disorder), and a disorder of urea cycle metabolism (body cannot properly remove ammonia from the body).An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment.A physician order dated 9/4/25 entered by the PA read, comprehensive metabolic panel (CMP) (lab that checks electrolytes, blood sugar, protein levels, kidney, and liver function) with estimated glomerular filtration rate (GFR) (checks kidney function), complete blood count (CBC) with differential (lab that counts different blood cells in the body to help diagnose infections, anemia, and other conditions). The order specified the labs were scheduled for 9/5/25.Resident #1's electronic medical record contained laboratory results for a CMP with GFR and a CBC with differential. The lab report showed that the samples were collected on 9/5/25 at 1:06 PM and received at the lab on 9/5/25 at 10:24 PM. The report indicated the lab reported date (date the laboratory results were sent to the facility) was 9/6/25 at 1:00 AM. The record documented that the PA reviewed the results on 9/9/25 at 10:43 AM.-The CMP lab results dated 9/5/25 showed that Resident #1's sodium level was 150 (135-145 normal range, high sodium blood levels indicate dehydration). Her chloride level was 117 (95-107 normal range, high chloride level in the blood indicates dehydration, kidney disease, or acid-base imbalances). Her non-fasting glucose level was 190 (normal range 70-139). Her alkaline phosphatase level (liver function lab) was 679 (normal range 40-142) and her Aspartate Aminotransferase AST level (liver function lab) was 61 (normal range 9-40)-The CBC lab results dated 9/5/25 showed Resident #1 had a high white blood cell count of 13 (normal range 4-11, a high white blood cell count is an indicator of possible infection). Her hemoglobin (red blood cells that carry oxygen) was 9.8 (12-16 normal range) and her hematocrit (percentage of your total blood volume that is made up of red blood cells) was 28.5 (normal range 36-48).There was no documentation in Resident #1's electronic medical record from 9/5/25 through 9/8/25 indicating that staff had notified the medical provider of the lab results.An interview was conducted with Nurse #2 on 12/30/25 at 2:09 PM. Nurse #2 worked the night shift (7:00 PM-7:00 AM) on 9/5/25 and 9/6/25. She could not recall if in September 2025 labs were uploaded electronically into the resident's electronic medical record or if lab results were faxed to the facility. She explained that the process of receiving lab results had changed at some point and that the results were now faxed to the facility, but she could not remember when it changed. Nurse #2 stated that when the lab results were automatically uploaded electronically into the resident record it was passed on in the shift change report that the oncoming nurse needed to look for lab results on that shift. She did not recall receiving lab results for Resident #1 or notifying a provider about any results on 9/5/25 or 9/6/25. She stated that if she had received the labs during her shift, she would have documented that she received them and identified the provider she notified. Nurse #2 stated when lab results came back, they were supposed to be called to the provider immediately if there were abnormal or critical results. Nurse #2 stated if there was nothing documented in Resident #1's electronic medical record by her then she did not receive the lab results or contact a medical provider. An interview was conducted with Nurse #3 on 12/30/25 at 3:10 PM. Nurse #3 worked the day shift (7:00 AM-7:00 PM) on 9/6/25. He did not recall any lab work for Resident #1 or calling the provider to report any abnormal labs for Resident #1 on 9/6/25. He stated that if he had called the provider or received orders, he would have made a note about it in Resident #1's electronic medical record. Nurse #3 explained it was standard practice to call lab results to the provider if there were abnormal results. He stated it was typically passed on in the shift change report if they were waiting on lab results for a resident or the Director of Nursing (DON) would tell him to look out for labs if they were waiting on lab results. Nurse #3 said otherwise he would not know who had lab results pending unless he went into each resident's individual electronic medical record and opened the results tab to look for results. Nurse #3 stated unless he opened every resident's individual lab result tab in the electronic medical record every shift he would not know if there were lab results back. Nurse #3 reported there was not a way for the electronic computer system to highlight lab results returning to his knowledge. He did not recall anything specific or standing out about Resident #1 on 9/6/25 but stated he would have documented it in the medical record if he had called lab results to a medical provider so everyone would be aware.An interview was conducted with the PA on 12/30/25 at 11:29 AM. The PA reviewed the labs for Resident #1 and stated the lab results were received on 9/6/25 at 1:00 AM and that they should have been reported to the on-call provider. The PA explained that when she was in the building lab reports that had not been reviewed by a provider would populate in the electronic computer system under lab results for the entire building and she reviewed them. The PA stated Resident #1's labs should have been called to the on-call provider on 9/6/25 due to her high sodium level, elevated liver enzymes, and high white blood cell count. The PA stated Resident #1's hemoglobin and hematocrit levels might possibly raise concern, but that she would be more concerned about the other abnormalities. The PA explained she would be more concerned about correcting Resident #1's sodium level and why her white blood cell count was elevated. The PA stated if the lab results had been called to her, she would have ordered additional fluid resuscitation, and she would have done an immediate (STAT) repeat of her labs to determine if her white blood cell count had gone down any. A telephone interview was conducted on 12/30/25 at 2:39 PM with the Clinical Practice Manager for the facility provider group. She stated there were no phone calls placed from the facility on 9/6/25 to the on-call service.An interview was conducted with the DON on 12/30/25 at 12:17 PM. The DON stated lab results were automatically sent from the lab and electronically uploaded to the resident's electronic medical record. She reported that unless the nurse opened the individual residents electronic medical record and checked the lab results tab they would not see the lab results nor would the staff know that pending lab results were back. The DON explained it should be passed on in the nurse shift change report if lab results were pending so the nurse would know to check the residents electronic record for the lab results. The DON stated if it was not passed on in shift change report then the nurse could check the lab log to see what labs had been drawn for that day. The DON explained nurses were supposed to call and notify the provider of lab results if there were any lows or highs next to the values on the report, critical results, or for anything that was out of normal range. She stated if lab results were called to an on-call provider the nurse would make a progress note about it and carry out any new orders that were received. The DON explained the reported date on the lab result was the date the facility received the lab results. The DON confirmed that Resident #1's lab results were received by the facility on 9/6/25 at 1:00 AM. The DON stated she did not see a progress note by a nurse to indicate the labs had been reported to the provider and could not say for sure if the provider was notified of Resident #1's lab results. The DON reviewed Resident #1's labs that were drawn on 9/5/25 and confirmed they were not reviewed by the PA until 9/9/25. After reviewing the lab report results, the DON said Resident #1's sodium was high, chloride was high, glucose was high, and white blood cells were high. The DON stated yes the labs should have been called to the provider. The DON explained she normally checked all the labs but had been on vacation that week. She said the Unit Managers were supposed to cover for her and make sure everything was done while she was on vacation but there had only been one Unit Manager at the time.An interview was conducted with the Administrator on 12/30/25 at 4:19 PM. The Administrator stated that abnormal lab results should be called immediately to the provider when they were received from the lab. She stated she was not sure where the breakdown in communication was or what happened with Resident #1's labs that were reported to the facility on 9/6/25. The Administrator explained there were different nurses working in the building that week who were not the facility's typical staff and who had not worked in the building for a while. She explained she thought the facility had more agency nurses working in the building that week who were not the facility's routine agency nurses. She stated the DON had been on vacation that week and when the DON was not there, the oversight of the labs and ensuring the provider was contacted was different. The Administrator stated the unit managers were supposed to follow up on things like labs when the DON was gone but said there was a transition in unit managers during that time and there had been only one unit manager.

Based on observations, record review and staff interviews, the facility failed to promote care in a dignified manner for 1 of 2 residents who were assisted with meals (Resident #2). Staff were observed standing beside the resident's bed while feeding assistance was provided. The finding included: Resident #2 was admitted to the facility on [DATE] with diagnoses including dysphagia and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #2 with intact cognition. The assessment indicated Resident #2 was dependent on staff for eating and receiving a mechanically altered diet. During a continuous breakfast observation on 05/07/25 from 9:01 AM to 9:10 AM, Resident #2 was observed seated at approximately 45-degree angle in her bed. Her breakfast tray was brought into the room by Nurse Aide (NA) #1 and placed on top of the overbed table in front of Resident #2. NA #1 stood on the left side of the bed. She set up the tray and started feeding Resident #2 while she was standing and not at eye level with Resident #2. A folding chair was available in the room and NA #1 did not use it. An interview was conducted with Resident #2 on 05/07/25 at 9:20 AM. She stated that she did not like the staff to stand over her when receiving feeding assistance. During an interview conducted on 05/07/25 at 9:30 AM, Unit Manager #1 (UM) stated all the NAs had received training in feeding and it was her expectation for the NAs to sit at eye levels with the residents when providing feeding assistance. She could not explain why it happened but stated she would notify the Administrator immediately. An interview was conducted with NA #1 on 05/07/25 at 10:11 AM. She explained she had worked at different nursing facilities and received conflicting trainings related to feeding assistance, and it confused her. She did not know it was a dignity issue by not sitting at eye level beside the resident while providing feeding or eating assistance. During an interview conducted on 05/07/25 at 10:51 AM, the Administrator expected nursing staff to pay attention to residents' dignity when providing care or feeding assistance. The Administrator indicated she would re-train all the nursing staff to ensure all dependent residents who needed feeding assistance would receive it with dignity. An interview was conducted with the Director of Nursing (DON) on 05/8/25 at 10:59 AM. She expected all nursing staff to focus on dignity issues when providing care or feeding assistance.

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 (PASARR) and high-risk drug classes usage that involved anticoagulant, antipsychotic, and opioid medications for 3 of the 7 sampled residents (Residents #11, #24, and #52). Findings included: a. Resident #11 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and peripheral vascular disease. A review of the Medication Administration Records (MAR) for January 2025 revealed Resident #11 did not receive any anticoagulant throughout the month. Instead, the MAR indicated that he received 1 tablet of enteric-coated aspirin 81 milligrams (mg) by mouth once daily since 01/20/25. The quarterly MDS assessment dated [DATE] coded Resident #11 with intact cognition. The Medication section of the MDS indicated Resident #11 had received anticoagulant during the 7-day assessment periods. b. Resident #24 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and bipolar disorder. Resident #24's medical record revealed he had completed PASARR Level II assessment on 03/25/24. A review of the annual MDS assessment dated [DATE] revealed the Identifying Information section indicated Resident #24 had not been evaluated by PASARR Level II and determined to have a serious mental illness and/or mental retardation or a related condition. The quarterly MDS assessment dated [DATE] assessed Resident #24 with intact cognition. The Medication section indicated Resident #24 had received anticoagulant, antipsychotic, and opioid during the 7-day assessment periods. A review of the MAR for February 2025 revealed Resident #24 did not have any order to receive anticoagulant, antipsychotic, or opioid throughout the month. c. Resident #52 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident. Review of Resident #52's physician's orders revealed an order dated 9/27/24 for Aspirin 81 mg by mouth daily. Resident #52 significant change Minimum Data Set (MDS)assessment dated [DATE] indicated she had severe cognitive impairment and was dependent on staff for most activities of daily living. The MDS coded Resident # 52 for high-risk drug class for anticoagulant use. During an interview conducted on 05/06/25 at 1:18 PM, the MDS Coordinator acknowledged that the coding of anticoagulant for Resident #11, Resident #24, and Resident #52 were incorrect. She explained it was due to her perception of considering aspirin as an anticoagulant, and it was her oversight. She confirmed Resident #24 had completed a PASARR Level II assessment on 03/25/24. She could not explain why she coded Resident #24 as never been evaluated by Level II PASARR in the annual MDS assessment dated [DATE]. She added it was an error to code Resident #24 as receiving anticoagulant, antipsychotic, and opioid for the quarterly MDS assessment dated [DATE] as he was not receiving any of the above medications during the 7-day assessment periods. During an interview conducted on 05/08/25 at 10:59 AM, the Director of Nursing (DON) stated it was her expectation for all the MDS assessments to be coded accurately according to the established medication categories. An interview was conducted with the Administrator on 05/07/25 at 10:51 AM. She stated it was her expectation for the MDS Coordinator to code all MDS assessments correctly before submission.

Based on staff interview and medical record review, the facility failed to refer a resident with newly diagnosed serious mental illnesses for Pre-admission Screening and Annual Resident Review (PASARR) Level II screening for 1 of 2 residents reviewed for PASARR (Resident #36). The findings included: A review of Resident #36's medical records revealed he had a PASRR Level I evaluation completed in 2023. Resident #36 was admitted to the facility on [DATE] with diagnoses including bipolar disorder. A review of Resident #36's list of cumulative diagnoses revealed a new diagnosis of bipolar disorder with an onset date of 03/13/24 was documented in his medical record. A review of physician's order dated 03/14/24 revealed Resident #36 had an order to receive 1 tablet of Depakote 500 milligrams (mg) delayed release by mouth 2 times daily for mood symptoms related to bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #36 with intact cognition. The Section A1500 indicated he was not currently considered by the state PASARR Level II process to have a serious mental illness and/or intellectual disability or a related condition. During an interview conducted on 05/06/25 at 9:16 AM, the MDS Coordinator confirmed the facility had failed to refer Resident #36 for a PASARR Level II evaluation according to the annual MDS assessment dated [DATE]. She stated Resident #36 was diagnosed with bipolar disorder during admission and should have a PASARR Level II evaluation. She added the referral was typically handled by the Social Services Director (SSD). An interview was conducted with the SSD on 05/06/25 at 11:03 AM. She confirmed she was responsible for reviewing medical records of newly admitted residents and making a referral for PASARR evaluation as indicated. She acknowledged that Resident #36 should have a referral for PASARR Level II screening as he was diagnosed with bipolar disorder during admission. She could not explain why Resident #36 was overlooked and attributed the error as an oversight. During an interview conducted on 05/06/25 at 11:48 AM, the Corporate MDS Director stated Resident #36 was admitted with bipolar disorder should be referred for a PASARR Level II evaluation. It was his expectation for the SSD to follow the regulation guidance to ensure a referral for PASARR Level II evaluation was in place as indicated. An interview was conducted with the Administrator on 05/07/25 at 10:51 AM. She stated the regulation guidance should be followed and a request for a PASRR Level II evaluation should be made when a resident was diagnosed with a new serious mental health condition such as bipolar disorder. During an interview conducted on 05/08/25 at 10:59 AM, the Director of Nursing (DON) expected the SSD to follow the established guidelines to coordinate PASARR Level II as indicated in a timely manner.

Based on observations, record review, and Medical Director (MD), resident and staff interviews, the facility failed to readjust medication orders after those orders had been updated which resulted in the resident missing one dose of five medications for 1 of 1 resident reviewed for pharmacy services (Resident #36). The finding included: Resident #36 was admitted to the facility on [DATE] with diagnoses including stroke, insomnia, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #36 with intact cognition. The assessment indicated Resident #36 had adequate hearing and vision with clear speech. During the initial interview conducted with Resident #36 on 05/05/25 at 1:13 PM, he stated he disliked nursing staff waking him up around midnight at times to administer his medications. A review of medication administration records (MAR) on 05/05/25 revealed Resident #36 had the following 5 active physician's orders to receive medications once daily at either 8:00 PM or 10:00 PM: 1. Atorvastatin 20 milligrams (mg), 1 tablet by mouth once daily at 10 PM for cholesterol. 2. Depakote delay release 500 mg, 2 tablets by mouth once daily at 10 PM for bipolar disorder. 3. Ezetimibe 10 mg, 1 tablet by mouth once daily at 10 PM for cholesterol control. 4. Melatonin 3 mg, 3 tablets by mouth once daily at 10 PM for insomnia. 5. Trazodone 50 mg, 2 tablet by mouth once daily at 8 PM for sleep. An interview was conducted with Unit Manager #2 (UM) on 05/06/25 at 2:58 PM. She stated Resident #36 voiced a complaint that morning about getting his medications late at night. After she had submitted his concerns in the doctor's communication log, the physician had approved to switch most of Resident #36's evening medications to around 6:00 PM and the orders had been updated. A subsequent review of MAR on 05/07/25 revealed the above 5 active evening medication orders had been discontinued on 05/06/25 at around 10:30 AM. New orders for each of the 5 evening medication were in place and they would be started 05/07/25 at 6:00 PM. Resident #36 received the last dose of the above 5 medications on 05/05/25 at 8:00 PM and 10:00 PM respectively before the discontinuation, but did not receive any of the above 5 medications on 05/06/25 at 6:00 PM. During an interview conducted on 05/07/25 at 5:45 AM, Resident #36 stated he had received some medications around 6:30 PM on 05/06/25. After that, he did not receive any more medications, and he went to sleep. He could not confirm whether he had received atorvastatin, depakote, trazodone, melatonin, or ezetimibe on 05/06/25 in the evening as he always took the pills without looking at them during medication pass. Resident #36 denied feeling any difference since 05/06/25 evening and stated he slept well on the night of 05/06/25. He added nursing staff notified him that they had changed his evening medications to an earlier hour, and he was very pleased with the changes. During the interview, Resident #36 appeared to be alert and oriented without showing any signs and symptoms of pain, distress, or other behavioral issues. An interview was conducted on 05/07/25 at 5:48 AM with the Medication Aide #1 (MA) who provided care for Resident #36 from 7:00 PM on 05/06/25 to 7:00 AM on 05/07/25. She did not recall administering depakote, melatonin, trazodone, ezetimibe, or atorvastatin to Resident #36 as those medications did not appear on the computer during the evening medication pass on 05/06/25. During an interview conducted on 05/07/25 at 5:55 AM, Nurse #1 confirmed Resident #36 did not receive depakote, melatonin, trazodone, ezetimibe, or atorvastatin on 05/06/25 in the evening. She stated those orders did not appear on the computer as they had been deleted, and the new orders would not be started until a day later on 05/07/25 in the evening. Nurse #1 indicated the new orders should be restarted on the same day on 05/06/25. Otherwise, those orders would not appear on the computer during the evening medication pass on 05/06/25. During an interview conducted on 05/07/25 at 9:57 PM, Nurse #2 stated that he worked on 05/06/25 from 7 AM to 7 PM and confirmed he did not administer Depakote, melatonin, trazodone, ezetimibe, or atorvastatin to Resident #36 on 05/06/25 in the evening as those orders did not appear on the computer during the evening medication pass. An interview was conducted with the Director of Nursing (DON) on 05/07/25 at 7:01 AM. She acknowledged that she was the nursing staff who had updated Resident #36's medication orders on 05/06/25 after she was made aware of the concerns brought up by Resident #36. She stated when she updated the orders, the computer would start the new orders on the next day as a default. She forgot to readjust those orders to avoid a gap after the new orders were in place on 05/06/25. She attributed the errors to her oversight. An interview was conducted with the MD on 05/8/25 at 3:35 PM. She stated missing just one dose of depakote for bipolar disorder along with trazodone, ezetimibe, atorvastatin, and melatonin would not have any significant impact to Resident #36 behavior. It was her expectation for nursing staff to change or update approved medication orders correctly. During an interview conducted on 05/07/25 at 10:51 AM, the Administrator expected nursing staff to stay focus and make readjustment as needed when changing or updating medication orders to avoid creating any gaps in medication administration.

Based on record review, observation, and staff interviews, the facility failed to intervene effectively when two residents became agitated and were yelling at each other in a common area. Resident #44 was cognitively impaired and had a history of violent behaviors caused Resident #229 to sustain a skin tear by hitting her on the hand with a cellphone. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #229). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, schizophrenia (psychiatric disorder), vascular dementia with mood disturbance, aphasia (brain disorder that affects the ability to communicate) following cerebral infarction, bipolar disorder (mood disorder), anxiety disorder, violent behaviors. Resident #44 was a current resident at the facility. The quarterly minimum data set (MDS) dated [DATE] revealed Resident #44 had moderate cognitive impairment. The MDS documented she had no behavior or rejection of care. Resident #44 had a care plan dated 8/27/23 and last revised on 7/28/24 that read: [Resident #44] has potential to be physically aggressive related to dementia, history of harm to others, and poor impulse control. A care plan intervention dated 8/28/23 read, when Resident #44 becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive staff to walk calmly away and approach later. Resident #229 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia following cerebral infarction affecting left non dominant side, adjustment disorder with mixed anxiety and depressed mood (psychiatric disorder). Resident #229 was discharged from the facility to another care facility on 1/24/25. The quarterly minimum data set (MDS) dated [DATE] revealed Resident #229 was cognitively intact. The MDS documented that she had no behaviors or rejection of care. Resident #229 had the following care plans in place: -A care plan dated 10/19/23 that read, Resident #229 has potential to be verbally aggressive related to cognitive deficits. The care plan interventions included assessing her understanding of the situation, allowing time for her to express self and feelings towards the situation. -A behavior problem care plan related to making false accusations dated 12/20/23. The behavior care plan interventions included intervening as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to an alternative location as needed. - A care plan dated 9/11/24 that read Resident #229 has the potential to be physically aggressive r/t anger, poor impulse control, she will throw things such as cups and dishes when trying to get attention. The care plan interventions included providing physical and verbal cues to alleviate anxiety, giving positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Additional care plan interventions included when Resident #229 becomes agitated to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, If response is aggressive, staff to walk calmly away, and approach later. Review of a facility incident reported dated 7/28/24 completed by the Director of Nursing (DON) for Resident #229 revealed she had received a skin tear from another resident. The incident report indicated the other resident had a cell phone in her hand and struck Resident #229 on the right hand after Resident #229 had said don't open the door. The report indicated there was a misunderstanding and the other resident had thought Resident #229 was saying not to let her boyfriend in. The incident report revealed first aid was provided to Resident #229's right hand skin tear and both residents were separated. An order dated 7/28/24 for Resident #229 read: Right hand, clean with normal saline, apply antibiotic ointment and cover with band aid daily until resolved for skin tear. An interview was conducted on 5/5/25 at 11:04 AM with Resident #44. Resident #44 was asked if she recalled ever having any issues or an altercation with another resident at the facility. Resident #44 answered by shaking her head no. Resident #44 declined to answer further questions. Resident #229 was unable to be contacted for interview. An interview with Nurse Aid (NA) #1 was conducted on 5/7/25 at 1:27 PM. NA #1 recalled the incident between Resident #44 and Resident #229 that occurred on 7/28/24. She reported there had been bears outside the facility main entrance door and several residents were gathered in the lobby watching the bears. NA #1 recalled she thought there had been a total of four residents in the lobby including Resident #44 and Resident #229. NA #1 reported she and NA #2 had been in the lobby also watching the bears at the time of the incident. She stated Resident #44 had been standing at the facility entrance glass door in the lobby with her boyfriend. NA #1 recalled Resident #229 had been sitting in her wheelchair at the back corner of the lobby diagonally to where Resident #44 was standing looking out the main door watching the bears. NA #1 explained Resident #229 had been agitated and scared of the bears. She recalled Resident #229 was yelling loudly the bears were going to get inside and eat everybody. NA #1 reported Resident #44 yelled shut up at Resident #229, then Resident #229 yelled shut up back at Resident #44. She reported Resident #229 then continued to yell about the bears and Resident #44 yelled shut up again. NA #1 stated Resident #44 did not really talk but had a select vocabulary of words she could say and shut up was one of them. NA #1 recalled Resident #44 turned and began walking toward the back of the lobby, NA #1 stated she had thought Resident #44 was leaving and going back to her room. NA #1 stated that instead Resident #44 approached Resident #229 and swung at her using her left hand that was holding her cell phone. She reported Resident #229 put her hand up to protect her face and Resident #44 struck Resident #229 on the hand with the cell phone. NA #1 stated another staff member came and separated Resident #44 and Resident #229, but she could not remember who the staff was. NA #1 reported she was aware Resident #44 had a history of aggressive behaviors and becoming easily agitated when someone did something she did not like or if she was provoked. NA #1 stated she thought Resident #229 yelling shut up at Resident #44 would be provoking. NA #1 reported everyone in the lobby was focused on the bears and excited about the bears at the time of the incident. NA #1 agreed she could have intervened when Resident #229 and Resident #44 had shown signs of agitation by yelling shut up, by verbally redirecting them, or removing Resident #229 who was scared and anxious about the bears. NA #1 reported she had been focused on the bears at the time like everyone else in the lobby because the bears were so close to the facility entrance and there were baby bears that she had not thought about it at the time. An interview was conducted with NA #2 on 5/8/24 at 10:54 AM. NA #2 stated she recalled the incident between Resident #44 and Resident #229 that occurred on 7/28/24. She reported she had been in the lobby when the incident happened but did not see the incident happen. She recalled there had been maybe four Residents in the lobby at the time gathered and watching the bears that were outside the main facility entrance doors. She recalled there had been another staff member in the lobby and another staff member that had walked by the lobby, but she could not remember who the staff members were. NA #2 reported she heard Resident #44 and Resident #229 yell shut up back and forth. She thought they had said shut twice before the incident happened. She stated she could not remember all the details of the incident. NA #2 recalled Resident #44 walking toward the back of the lobby where Resident #229 had been sitting. NA #2 explained she had thought Resident #44 was going back to her room but instead she must have hit Resident #229. She stated she had not seen Resident #44 hit Resident #229 but heard Resident #229 say she [Resident #44] hit me. NA #2 said she was not sure who had separated Resident #44 and Resident #229 after the incident, she reported it had been a staff member but did not remember who the staff member was. NA #2 stated she had never seen or heard of Resident #44 hit anyone before and did not know she was going to hit Resident #229. She reported at the time of the incident she had not worked at the facility long. NA #2 said she had heard Resident #44 say shut up up before but was not aware of Resident #44 having a history of aggressive or violent behaviors. She could not recall where Resident #44 had hit Resident #229. An interview was conducted with Nurse #4 on 5/8/25 at 1:30 PM. He recalled the incident from 7/28/24 with Resident #44 and Resident #229. He remembered an NA came and got him from the nursing station and told him the two residents were arguing in the lobby about the bears or letting someone in or out of the building. Nurse #4 recalled the NA told him Resident #44 had put hands on Resident #229 and that it was an altercation they believed was physical. Nurse #4 said when he went to the lobby, he separated Resident #44 and Resident #229. Nurse #4 stated he assessed Resident #229 after the incident; he did not remember the skin tear on her hand. He said he just remembered Resident #229 was stuck on the bears and explaining the incident was not her fault. He recalled Resident #229 calmed down with reassurance. Nurse #4 explained he was aware of Resident #44's history of being easily agitated and having aggressive behaviors. He further explained Resident #44 was usually calm unless she was provoked. Nurse #4 said Resident #44 was provoked by direct confrontation such as someone cursing or arguing with her. He stated he had not seen Resident #44 on her own be the first aggressor without provocation. Nurse #4 indicated he reported the incident to the Director of Nursing (DON) and Resident #44 was placed on one-on-one staff supervision after the incident. An interview was conducted on 5/7/25 at 3:44 PM with the DON. She recalled the incident between Resident #44 and Resident #229 that occurred on 7/28/24. The DON stated a staff member called her and reported the incident when it happened. She did not remember who the staff member was who called her. The DON remembered staff had called and told her bears had been outside the front entrance of the building. She said the staff told her Resident #44's boyfriend was outside and trying to get in through the main door. She explained the staff had said Resident #229 was yelling about the bears and had said don't open the door and that was when Resident #44 hit Resident #229 her with cell phone on the hand. The DON stated Resident #44 had become agitated when Resident #229 started yelling shut the door because Resident #229 maybe had thought her boyfriend was going to get eaten by the bears. The DON explained staff separated Resident #44 and Resident #229 after the incident and Resident #229 was placed on one-on-one staff supervision. An interview was conducted with the Administrator and the [NAME] President of Operations (VPO) on 5/8/25 at 5:10 PM. The VPO reported everyone in the building was aware of Resident #44's behaviors. She stated Resident #44 was very quick and she felt like the staff responded quickly and were intervening from what staff had told them. The Administrator said shut up was a common phrase Resident #44 would use when she was agitated. The Administrator said maybe staff should have separated them but that she was not sure because they had been watching the bears. The Administrator said Resident #229 had a very minor injury after the incident on her hand that was superficial. She reported Resident #44 was placed on one-on one supervision after the incident, then monitoring was stepped down to every 15 minutes and then stepped down to every 30 minutes based on her having no further behaviors of incidents.

Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter bag and drainage spout from touching the floor to reduce the risk of infection for 1 of 1 resident (Resident #62). This deficient practice occurred for 1 of 1 resident reviewed with a urinary catheter. Findings included: Resident #62 was admitted to the facility on [DATE] and had been re-admitted to the facility on [DATE]. His diagnoses included chronic obstructive uropathy. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was never/rarely understood and his cognitive skills for daily decisions making were severely impaired. He was documented on the MDS as having an indwelling catheter. Resident #62 had a care plan dated 6/14/24 for long term indwelling catheter. The care plan interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door. An order dated 4/3/25 read, indwelling urinary catheter related to chronic obstructive uropathy. An observation was conducted on 5/5/25 at 11:15 AM of Resident #62 in his room in bed. He was observed to have an indwelling urinary catheter draining to a bedside drainage bag. The bedside drainage bag was observed positioned below bladder level and hanging on the bottom rail of the bed frame. The drainage valve of the catheter bag was observed to be unsecured and resting on the floor. A follow up observation was conducted on 5/5/25 at 12:51 PM of Resident #62's indwelling urinary catheter drainage system. The bedside drainage bag was observed positioned below bladder level and hanging on the bottom rail of the bed frame. The drainage valve of the catheter bag was observed to be unsecured and resting on the floor. An additional observation was conducted on 5/5/25 at 3:04 PM of Resident #62's indwelling urinary catheter drainage system. The bedside drainage bag was observed positioned below bladder level and hanging on the bottom rail of the bed frame. The catheter bag was observed on the floor beside the bed with the drainage valve unsecured and on the floor. An interview was conducted with Nurse Aide (NA) #3 on 5/5/25 at 3:20 PM. She said she was assigned to care for Resident #62 today. She reported she typically checked on his catheter throughout the shift but that it had been a busy day. NA #3 said she had not specifically checked his catheter bag today. She explained she had been in his room to provide care but had not looked at his catheter bag and had not noticed it had been on the ground or that the drainage valve was loose and on the ground. NA #3 stated she was taught urinary catheter drainage bags should be hung on the bed frame and positioned below the level of the bladder so urine could drain properly. NA #3 said the catheter drainage bag and the drainage valve should not be on the floor because it was unsanitary. An interview was conducted with Nurse #3 on 5/5/25 at 13:35 PM. Nurse #3 reported he was Resident #62's assigned nurse today. He was not aware Resident #62's catheter drainage bag and drainage valve were on the floor. Nurse #3 said catheter bags and the drainage valve should not be on the floor because of contamination. An interview was conducted with the Director of Nursing on 5/7/25 at 3:37 PM. The DON stated urinary catheter bags, and the drainage valve should be kept off the floor because of germs and to prevent contamination. The DON explained that urinary catheter bags should be hung on the side of the bed below the level of the bladder when a resident was in bed and the drainage valve should be secured. An interview was conducted with the Administrator on 5/8/25 at 5:10 PM. The Administrator reported urinary catheter drainage bags, and the drainage valve should not be on the floor for infection control reasons. She explained the urinary drainage bag should be hung on the bed frame and positioned below the level of the bladder but should not be touching the floor.

Based on observations, record review, resident, and staff interview the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for medications at bedside (Resident #67). The findings included: Resident # 67 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus with hyperglycemia and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #67 was cognitively intact. Review of Resident #67's medical record revealed no documentation that Resident #67 had been assessed to self-administer medications at bedside. An in-room observation and interview with Resident #67 on 3/4/24 at 11:17 AM revealed a medication cup sitting on Resident #67's overbed table containing 11 pills. Resident #67 stated the nurse had brought her medication to her about 30 minutes prior for her to take. Resident #67 said she told the nurse she would take the pills after she used the bathroom, and the nurse had left the pills for her to take. Resident #67 said she left the pills on her overbed table while she used the restroom and was going to take them soon. On 3/4/24 at 11:45 AM the Administrator was brought to the resident's room. Resident #67 stated to the Administrator she had just taken her medications and the nurse had left the medications for her to take after she used the restroom. The Administrator stated to Resident #67 her medications should have been taken with the nurse present in her room. Nurse #1 was interviewed on 3/4/24 at 3:29 PM and confirmed he had given Resident # 67 her medications but did not watch her take the medications. Nurse #1 stated Resident #67 should have taken her medications before he had left her room. The Director of Nursing (DON) was interviewed on 3/07/24 at 10:44 AM and stated Nurse #1 should have watched the resident take her medications prior to leaving Resident #67's room.

Based on record review and staff interviews, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with new mental health diagnoses for 1 of 2 residents reviewed for PASRR (Resident #23). The findings included: Review of Resident #23's medical record revealed the resident had a PASRR level I completed prior to his admitted d 8/3/17. He was admitted to the facility on [DATE] with diagnoses of bipolar disorder and anxiety disorder. A diagnosis of major depressive disorder was added on 8/29/23. Review of Resident #23's medical records revealed no PASRR level II had been completed. Review of Resident #23's annual Minimum Data Set (MDS) dated [DATE] revealed he had not been evaluated by Level II PASRR. During an interview on 3/6/24 at 2:25 pm, the Interim Administrator and the Social Worker (SW) explained the facility's PASRR process. The SW stated all residents had PASRR when they got to the facility. Their diagnoses determined what kind of PASRR they had. The SW sent resident information to a state contracted vendor to conduct PASRR if they needed one. The SW stated the contractors came and assessed the resident. They determined what level of PASRR the residents would be. This was done to everyone that came in. SW would send another referral if there was a change in condition or if PASRR was getting ready to expire. The contractors came and did another assessment. They also determined expiration dates. There would be expiration dates on the PASRR if a resident was admitted short term such as for rehabilitation, or if resident was scheduled to be discharged to an assisted living facility. The SW sent PASRR referral for any residents with new mental health diagnoses after admission. During a follow up interview on 3/6/23 at 3:02 pm, the SW revealed Resident #23 was not referred for Level II when his diagnosis of major depressive disorder was added on 8/29/23. She stated she missed sending a referral for Level II PASRR for the resident because she was busy trying to orient in her new role as SW, learning care plans and was training on PASRR. She stated she will send in a referral for Resident #23 as soon as possible. During a follow up interview on 3/7/24 at 12:20 pm, the Interim Administrator stated there should have been a referral sent for level II PASRR for Resident #23 when he had a new mental health diagnosis on 8/29/23.

Based on observations, record review, and resident and staff interviews the facility administered a medicated powder without a physician's order for 1 of 1 resident reviewed for professional standards of practice (Resident #21). The findings included: Resident #21 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #21 was cognitively intact. A review of Resident #21's active physician orders for March 2024 revealed that there was not an order for nystatin powder. An in-room observation and interview with Resident #21 occurred on 3/04/24 at 11:08 AM. A bottle labeled nystatin topical powder was observed on Resident #21's overbed table. She stated it was brought to her the previous night and left on the table and the bottle was left in her room often. Resident # 21 stated the nursing assistants applied the powder on to her. Resident # 21's Unit Manager who was Resident #21's assigned nurse was interviewed on 3/04/24 at 11:11 AM and stated he had not noticed the nystatin medication bottle in the resident's room earlier when Resident #21's medications were brought to her. The Unit Manager stated he was not sure how the nystatin powder bottle had gotten into the resident's room, and he did not think Resident #21 had an active order for the medication. The Director of Nursing (DON) was interviewed on 3/07/24 at 10:44 AM and stated the nystatin powder should not have been left with the resident. The DON said Resident #21 needed the nystatin powder on and off again when she developed a rash.

Based on record review and staff interviews, the facility failed to complete quarterly assessments within the regulated time frames for 3 of 3 residents reviewed for completion of quarterly Minimum Data Set (MDS) assessments (Residents # 34, #15, #69). The findings included: 1. Resident #34 was admitted to the facility 8/29/18. The quarterly MDS assessment with an assessment reference date (the last day of the assessment period) of 2/8/24 was reviewed and revealed the assessment was still in progress on 3/6/24. The MDS Coordinator was interviewed on 3/6/24 at 9:25 AM and stated she had been working at the facility for one month and was aware of the late quarterly MDS assessment. The MDS Coordinator stated the facility had been without a MDS Coordinator and had a plan to complete late assessments. The Interim Administrator stated on 3/7/24 at 11:32 AM the MDS quarterly assessments should have been completed on time. The facility was working on a plan to catch up on the late MDS assessments. 2. Resident #15 was admitted to the facility on [DATE]. The quarterly MDS assessment with an assessment reference date (the last day of the assessment period) of 2/12/24 was reviewed and revealed the assessment still in progress on 3/6/24. The MDS Coordinator was interviewed on 3/6/24 at 9:25 AM and stated she had been working at the facility for one month and was aware of the late quarterly MDS assessment. The MDS Coordinator stated the facility had been without a MDS Coordinator and had a plan to complete late assessments. The Interim Administrator stated on 3/7/24 at 11:32 AM the MDS quarterly assessments should have been completed on time. The facility was working on a plan to catch up on the late MDS assessments. 3. Resident # 69 was admitted to the facility on [DATE]. The quarterly MDS assessment with an assessment reference date (the last day of the assessment period) of 2/16/24 was reviewed and revealed the assessment was still in progress on 3/6/24. The MDS Coordinator was interviewed on 3/6/24 at 9:25 AM and stated she had been working at the facility for one month and was aware of the late quarterly MDS assessment. The MDS Coordinator stated the facility had been without a MDS Coordinator and had a plan to complete late assessments. The Interim Administrator stated on 3/7/24 at 11:32 AM the MDS quarterly assessments should have been completed on time. The facility was working on a plan to catch up on the late MDS assessments.

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification surveys conducted on 1/28/22 and 12/16/22. This was for a repeat deficiency in the area of quarterly assessments that was originally cited on 1/28/22 during the recertification survey, and subsequently recited during the recertification survey on 12/16/22 and the recertification survey completed on 3/7/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F638 - Based on record review and staff interviews, the facility failed to complete quarterly assessments within the regulated time frames for 3 of 3 residents reviewed for completion of quarterly Minimum Data Set (MDS) assessments (Residents # 34, #15, #69). During the recertification survey on 1/28/22, the facility failed to complete quarterly Minimum Data Set assessments within 14 days of the Assessment Reference Date for 3 of 30 sampled residents. During the recertification survey on 12/16/22, the facility failed to complete quarterly Minimum Data Set assessments within 14 days of the Assessment Reference Date for 6 of 9 residents reviewed for resident assessments. An interview with the Interim Administrator on 3/7/24 at 11:40 AM revealed they held ad hoc QAA meetings all the time to address various issues which included MDS assessments. She stated that one of the reasons why they continued to have issues with MDS assessments was because they weren't strategic with hiring MDS nurses, and they hired whoever applied for the position. She also stated that the other disciplines needed education too in completing their sections on the MDS assessments, and this contributed to the assessments being late. The Interim Administrator stated the current MDS Coordinator had been receiving lots of instruction and education on completing the MDS assessments, and she was positive that she would improve with more time and experience.

Based on observation, record review, resident and staff interviews, Psychiatric Physician's Assistant interview, and the Medical Director interview the facility failed to protect the rights of a resident to be free from abuse. Resident #1 was found bleeding with a laceration to her upper lip, and a bruise to her right index finger and hand. Resident #2 had struck Resident #1 with the bed adjustment remote control causing the laceration to Resident #1's lip and pulled a ring from Resident #1's right index finger. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstruction Pulmonary Disorder (COPD), panic disorder, depression, and anxiety. The quarterly Minimum Data set (MDS) assessment dated [DATE] coded Resident #2 as cognitively intact. She was assessed to need extensive assistance with bed mobility, dressing, toileting, and eating. Resident #2's care plan, dated 2/28/23 revealed she was dependent on staff for meeting emotions, intellectual, physical, and social needs related to debility and depression. Resident #2 was also care planned for Activities of Daily Living (ADL) deficit related to debility and weakness. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, depression, and psychotic disturbance. Resident #1's quarterly Minimal Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired. Resident #1 was coded as independent with bed mobility, toileting, transfers, and used a walker for mobility. The resident was not coded for behaviors and was not receiving antipsychotic medications during the 7-day lookback. A review of Resident #2's physician orders revealed as follows: Duloxetine HCl Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth one time a day for mood symptoms ordered 06/01/2022. Sertraline HCl Tablet 50 MG Give 3 tablet by mouth one time a day for Depression/anxiety/ PTSD ordered 3/17/2023. Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 0.5 tablet by mouth at bedtime related to Alzheimer's Disease ordered on 8/04/2023. Review of the progress note written by Nurse# 1 on 8/4/23 at 11:55 AM revealed the nurse was walking in the hallway when Resident #2 called for help in her room. As Nurse #1 entered the room, she observed Resident #2 lying in bed on her back with a laceration on her upper lip that was bleeding, and her hands had some smears of blood on them. When Nurse #1 asked the resident what had happened, Resident#1 stated that her roommate/husband (Resident #2) had punched her in the face and on her right index finger. The note revealed Resident #1's index finger was bruised and swollen. A progress note written by Nurse #1 at 12:55 PM revealed Resident #1 was sent to the hospital for evaluation. A progress note written by Nurse #1 on 8/4/23 at 11:55 AM for Resident #2 revealed Resident #1 had called out for help and Nurse #1 went into the room and observed Resident #1 lying in bed with a bleeding lip. The nurse asked Resident #2 what happened, and he responded that he had hit his wife (Resident #1) in the face with the remote and pulled the ring off her right index finger. A subsequent progress note written on 8/4/23 at 2:50 PM revealed Resident #2 was taken into custody by law enforcement officers and would be potentially held until Monday related to domestic physical assault resulting in injury. The nursing staff dispensed medication for Resident #2 while in custody. A review of Resident #1's hospital records discharge summary revealed she was evaluated on 8/4/23 and had a 1.5-centimeter-long laceration to her upper lip. The resident received 3 dissolvable sutures and was released back to the facility with an antibiotic. Resident #1 returned to the facility at 7:30 PM on 8/4/23. Nurse #1, the assigned nurse for Resident #1 and #2 on 8/4/23 was interviewed on 8/8/23 at 1:21 PM. Nurse #1 stated she was on her medication cart in the hallway on 8/4/23 and she heard Resident #1 yell for help. Nurse #1 immediately went to check on Resident #1 and she was bleeding from her lip. Resident #1 told Nurse #1 she was hit by Resident #2. Nurse #1 yelled for help and stayed in the room; Resident #2 was sitting on his bed while Resident #1 was lying in her bed. Nurse #2 entered the room and was asked to call the Administrator. Nurse #2 called the Administrator, Unit Nurse Manager, and the Social Worker (SW) and they all went to the residents' room. Nurse #1 asked Resident #2 what happened, and he stated he hit her in the face and her right pointing finger. The SW removed Resident #2 from the room, and he was placed on 1 to 1 monitoring. Nurse #1 then assessed Resident #1 and found her to have a cut on her upper lip and a bruised and bleeding right index finger. Resident #1 told Nurse #1 that her roommate had hit her in the face. The MD was called by Nurse #1 and gave orders for Resident #1 to be sent to the emergency room (ER). Nurse #1 stated the police were called by the Administrator, and Resident #2 was sent to the jail. Nurse #1 stated Resident #2 was cowering and shaking because he was upset with himself for what he had done. Resident #2 told her that he had hit his wife in the face because she kept asking for her medications that she had already been given. Resident #1 was interviewed on 8/8/23 at 2:15 PM. She stated her husband, Resident #2, came up to the edge of her bed and hit her in the mouth and did something to her right hand. Resident #1 stated he had never done anything like that before, and she was not afraid to be around him after the incident happened. She stated she missed him and wanted to see him badly. Resident #1 was observed to have a scabbed area to her upper lip with 3 sutures. Her right hand near her index finger was swollen and bruised with a small, scabbed area. An interview with Resident #2 revealed on 8/10/23 at 10:38 AM Resident #1 was asking him for her pills but the nurse had already given her pills to her. He reported, she asks for her pills often when she has already had them, and I was trying to help her stop asking for the pills. I slapped her in the mouth with the bed remote that was lying beside her, she stuck her right hand up in the air and I grabbed her ring and pulled it off her hand. Resident #2 stated he felt bad for what he did and had never hit her before in [AGE] years of marriage. He stated he missed being with his wife and did not want to lose her. The Unit Manager stated in an interview at 2:45 PM on 8/8/23 that she did not witness the incident that occurred on 8/4/23. The Unit Manager stated she was called to the residents' room because Resident #2 had hit Resident #1. She stated she assessed Resident #2 for injuries while he was isolated from Resident #1 in another room. The Unit Manager stated she had not known Resident #2 to be aggressive or show any behavior like that and while he was with her, he stated he was upset with him-self and looked very remorseful for what he had done to his wife. On 8/8/23 at 3:58 PM the Social Worker (SW) was interviewed and stated she was called to the Resident #1 and #2's room with the Administrator. The SW stated Resident #2 had hit Resident #1 and she called the police. While with Resident #2 in a separate room, he stated to her that he hit Resident#1 with the bed controller on her mouth and took a ring off her finger. The SW said Resident #2 was upset with himself that he had struck Resident #1 and said he felt responsible for her and that he never wanted to harm his wife. She stated the police arrested Resident #2 and he was taken to jail for 48 hours. The police stated to the SW that Resident #2 had to be arrested because the incident had resulted in an injury for Resident #1. Resident #2 did not have any behaviors while being arrested and was sad that he was unable to see his wife. Nurse #2 was interviewed at 2:10 PM on 8/9/23 and stated she was at the nurse's station on 8/4/23 when she heard Nurse #1 call out for help. She went to Resident #1 and Resident #2's room and saw the two residents had been separated by Nurse #1. Resident #1 was lying on her back in her bed, and Resident #2 was sitting on his bed calmly without any aggression. Nurse #2 then went to find more help while Nurse #1 stayed in the room with Resident#1 and Resident #2. The Medical Director (MD) was interviewed on 8/8/23 at 11:50 AM. He reported Resident #2 had not shown aggression prior to the incident on 8/4/23. The MD stated he was notified by the facility on 8/4/23 that Resident #2 had struck Resident #1 and gave an order to send Resident #1 to the ER for evaluation. The MD said he was aware Resident #2 had been arrested and sent to a detention center and was not allowed to see or speak to Resident #1. The MD had assessed Resident #1 earlier on 8/8/23, and said she seemed good, but wanted to see her husband (Resident #2). Prior to the incident, the MD stated he had no concerns with Resident #1 and Resident #2 residing in the same room together and felt they would be safe to room with each other again. An interview conducted with the Psychiatric Physician Assistant (PA) on 8/9/23 at 5:05 PM revealed she had not known Resident #2 to have any aggressive behavior towards his roommate or any other resident since she had been seeing him since December 2022. She stated after the incident she assessed Resident #2 and felt he was remorseful for his actions and stated to her he was embarrassed for what he had done. The Psychiatric PA stated she did not feel Resident# 2 was a threat to any other resident. Resident #2 stated to the Psychiatric PA that Resident #1 was begging for medications that she had already received, he got frustrated and popped Resident #1 with the bed remote and made her lip bleed. The Psychiatric PA stated Resident #2 was not allowed to see or Speak to Resident #1 per court orders until the case has been resolved. On 8/10/23 at 10:38 AM the Administrator was interviewed. He stated Nurse #2 notified him of a situation between Resident #1 and Resident #2. When the Administrator entered the residents' room, he observed Resident #2 shaking his head and saying he did not mean to do that. Resident #2 was placed on 1 to 1 observation and removed from the room and the SW was asked to call the police. The Administrator asked Resident #1 what happened, and Resident #1 stated she aggravated him, and he got up and hit me. When asked if Resident #1 wanted to press charges, she replied no. the Administrator stated EMS arrived and would not take Resident #1 to the hospital until police arrived at the room. The police arrived and the Administrator gave them a statement. The police spoke with Resident #2 and stated they needed to take him to jail for 48 hours because Resident #1 sustained injuries from him. The family of the residents were notified of the incident, and informed Resident #1 was being sent to the hospital and Resident #2 was being sent to the jail. The Administrator stated he began the investigation into the incident and interviewed Nurse #1. Nurse #1 stated to him she was passing medications on the hall, heard Resident #1 call for help and immediately went to the room to see Resident #1 bleeding from her upper lip. Nurse #1 told the Administrator Resident #2 did not have any behaviors prior to the incident. The nursing assistants, therapy, and housekeeping were interviewed for any observation they may have had of Resident #2. They indicated everything was normal with Resident #2 prior to the incident. The Administrator stated when Resident #2 returned from jail on 8/6/23 to the facility, he was placed on 1 to 1 observation until he was cleared for every 15-minute observation by the physician on 8/6/23. The facility did a chart review, medication review, and interviewed all staff who interacted with the resident. Everything with Resident #2 was normal until the incident occurred. On 8/9/23 the Administrator provided the following corrective action plan: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: On 8/4/23, Resident [NAME] (SW) was heard by a staff member calling for help from her room where she resides with husband [NAME] (WW). When the nurse entered the room, SW was in her bed and her mouth was bleeding and her right index finger was bruised and swollen. When the nurse asked SW what had happened, she stated that her husband WW had hit her in the face. (with remote control device) Staff immediately intervened and removed WW from the room, and he was placed on 1:1 supervision. The facility administrator was notified immediately after providing safety for the residents. The nurse completed resident assessment on SW and first aid was administered, notification to MD with orders to send SW to ER for evaluation of injuries. Administration notified and made appropriate calls to police, resident representatives, APS and 2-hour NC State report submitted. Facility investigation initiated to include staff and resident interviews. Asheville Police came to the facility and placed WW under arrest, and he was taken into custody at that time. Facility ensured police were aware of WW's diagnosis of Alzheimer's Disease and dementia. The officer at the facility notified his supervisor of the information but due to it being classified as domestic violence, WW would have to be taken into custody for at least 48 hours. The facility supplied Buncombe County Detention Center with all needed medication and medication administration record to be able to care for WW. SW returned to the facility via ambulance from the emergency department with 3 stitches in place to the inside of lip. No further injuries were noted upon evaluation at the emergency department. Resident WW is a long-term care resident who was admitted to the facility on [DATE] with the primary diagnosis of Alzheimer's Disease, unspecified dementia without behavioral disturbance, major depressive disorder, unspecified atrial fibrillation, osteoarthritis, hypertension, and constipation. On 6/26/23 his BIM score was a 9 (moderately impaired). He receives ongoing psych services and was last seen on 7/18/23 by psych and seen on 7/31/23 by medical provider for follow-up post fall on 7/28/23. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Because all residents are at risk from being physically abused by other residents, the following plan has been formulated to address this issue: On 8/4/23 at 1155 WW was placed on 1:1 staff supervision and assessment completed by the licensed nurses with no apparent injuries until transferred to the Buncombe County Detention Center by Asheville Police Department officer at 1450. On 8/4/23, the Administrator notified the Regional Director of Clinical Services to discuss incident, investigative protocol and corrective action to address incident and prevent any further incidence to other residents at risk. On 8/4/23, All staff were questioned specific to these residents and any situations witnessed that might have been indicative of possible abuse. No areas of concern identified. Staff have not witnessed any abuse, verbal, physical or mental, during their interactions. Family of residents also state there have never been concerns of an abusive relationship between the two. On 8/4/23, education to all staff was initiated on the facility Abuse Policy and on the Behavior Management Policy. Staff not receiving education by 8/8/23 will not be allowed to work until completed. The DON will be responsible for monitoring completion of education. On 8/6/23, WW was released from the Buncombe County Detention Center with orders to not have contact with SW when he returned to facility. On 8/6/23 at 5:00pm Resident #1 returned to the facility on 1:1 supervision and was placed in room [ROOM NUMBER] with an appropriate roommate on opposite unit of Resident #2. On 8/6/23, WW was assessed by on-call medical provider for safety clearance to be placed on every 15-minute checks and removed from 1:1 supervision. The medical provider assessed WW and deemed him safe to proceed on every 15-minute checks with the directive if he attempted to go to the wing his wife was located, he would need to return to 1:1 supervision. Effective 8/6/23 at 7:16pm, Resident #1 removed from 1:1 staff supervision and placed on 15-minute staff supervision as ordered by the licensed Physician. On 8/7/23, WW was seen for an acute visit by medical provider with no new orders received at this time. Psychiatry to continue following and visit scheduled at next available time. On 8/7/23, the IDT had an AdHoc QAPI meeting to review the facility Abuse Policy and further discuss investigation, root cause analysis and corrective plan. Root cause analysis determined that an appropriate plan of care for Resident #1s behaviors was in place and followed and that Resident #1's behavior was related to disease progression and poor impulse control and there were no precipitating behaviors leading up to the incident that the facility staff failed to respond to prevent this occurrence. On 8/7/23, following the AdHoc QAPI meeting, the IDT had a Risk Meeting to ensure all residents are free from abuse from other residents. Residents with a history of or potential for abusive behavior towards others were reviewed to ensure appropriate plans of care are in place and that they are not placed together as roommates. Current facility residents with previous resident-to-resident incidents, residents with diagnosis of PTSD or other neurological disorders and residents with care plans for at risk for aggression towards others were included in review. Effective 8/7/23, the IDT will meet weekly to discuss residents with behaviors to ensure continued effectiveness of care plans. Changes will be made as appropriate. Effective 8/7/23, the Administrator is ultimately responsible for the implementation of this corrective plan. Alleged Date of Compliance: 8/8/23

Based on observations and staff interviews the facility failed to ensure the internal temperature of cooked food for the lunch meal was monitored prior to service. This was for 1 of 2 meal observations. This practice had the potential to serve residents food not within safe temperature ranges to minimize bacterial growth. The finding included: On 07/26/23 at 12:15 PM observation of the lunch meal tray line was already in process with Cook #1 plating the food. Further observation revealed meal trays had already been assembled, loaded onto the meal carts and waiting for delivery. The meal included: sliced pork lion, puree pork, fish patty, roasted potatoes, mashed potatoes, green peas, broccoli, and puree broccoli. The Dietary Manager (DM) was present for the tray line observations and was asked about the system for monitoring food temperatures. The DM explained that the food temperatures should be taken prior to meal service by the Cook and recorded on a log. Review of the temperature log for 07/26/23 revealed no temperatures recorded for the lunch meal. The DM revealed Cook #1 had not taken the temperatures for the lunch meal. At 12:20 PM on 07/26/23 the DM was asked to stop plating and distributing the lunch meal process and obtain temperatures for the food items on the steam table. The Dietary Manager obtained the following food temperatures with a digital thermometer that registered the degrees in Fahrenheit. Food items left to serve were recorded at temperatures of sliced pork lion 181, puree pork 187, fish patty 165, roasted potatoes 209, puree mashed potatoes 166, green peas 167, broccoli 167, puree broccoli 162 degrees (no puree diets left to be served). An interview was conducted with Cook #1 on 07/26/23 at 12:25 PM. The Cook explained that she knew she had to obtain the temperature the food before she started the plating process, but she decided to start the tray line process without measuring the temperatures of the food. The Cook indicated she understood that it was important to obtain the temperatures of the food before plating began to ensure the food was served in the acceptable temperature range. An interview conducted on 07/26/23 at 5:40 PM with the Administrator revealed he expected the food temperatures to be taken and recorded before the meals were plated to ensure the temperatures were within a safe range for consumption.

Based on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification surveys of 1/28/2022 and 12/16/2022. The repeat deficiency was cited on the current complaint investigation of 7/27/23 in the area of Food and Nutrition (F812). The facility's continued failure during three Federal surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: F-812: Based on observations and staff interviews the facility failed to ensure the internal temperature of cooked food for the lunch meal was monitored prior to service. This was for 1 of 2 meal observations. This practice had the potential to service residents' food not within safe temperature ranges to minimize bacterial growth. During the recertification and complaint survey of 1/28/2022 the facility was cited for failing to discard food with visible signs of spoilage and to ensure that dietary staff had all hair covered during meal service. During the recertification and complaint survey of 12/16/2022 the facility was cited for failing to date, remove, or discard potentially hazardous foods stored for use with signs of spoilage, store foods in sealed containers, and store nonperishable foods off the floor. A telephone interview was conducted with the Administrator on 7/27/2023 at 9:07 AM. He indicated he was the head of the QAA committee. The Administrator revealed the facility had provided on-going education to dietary staff on monitoring and documenting food temperatures prior to service for safety. He stated he believed that the new Dietary Manager did not fully understand the QAA process of what issues to report, when an issue is identified to report to the Administrator, and to follow-up with the results of the audits to the Administrator and QAA committee. The Administrator stated he was responsible for ensuring the Dietary Manager understood the QAA process of what identified issue to report, when to report the identified issue, and the follow-up of conducting audits and reporting the results of the audits to himself and QAA committee.

Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician a resident's pain was not controlled after the administration of pain medication. The resident called emergency medical services and was evaluated for abdominal pain and diagnosed with acute cholecystitis (inflammation of the gallbladder) that required admission to the hospital for the surgical removal of the gallbladder for 1 of 2 residents reviewed for hospitalization s (Resident #270). The findings included: Resident #270 was admitted to the facility on [DATE] with diagnoses including a history of cervical spine trauma and quadriplegia. Resident #270 was discharged to the hospital on 11/22/22 and returned to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #270 was assessed as being cognitively intact. Routine and as needed pain medications were received during the lookback period and the resident reported his pain was moderate, frequent, and interfered with sleep and activities. Opioids (narcotic pain medications) were given all 7 days during the lookback period. Review of the Medication Administration Record revealed oxycodone-acetaminophen (a narcotic pain medication) 5-325 milligrams every 6 hours as needed for pain management was given twice on 11/22/22. The first dose at 3:56 PM for a pain level of 7 and the second dose at 10:06 PM for a pain level of 8. Both administrations were documented as being effective. Review of the nurse progress note dated 11/22/22, written by Nurse #4, revealed on 11/22/22 at approximately 9:30 PM Resident #270 complained of bxxxhole pain and asked to be sent to the hospital. Nurse #4 obtained a set of vital signs and explained to the resident those were within normal limits and his pain medication was due soon and there was no clinical reason to send the resident to the hospital. The progress note indicated Resident #270 refused the pain medication stating it didn't work. The Director of Nursing (DON) was notified and agreed to not send the resident to the hospital for lack of a clinical reason however it was his right to call emergency medical service (EMS). Nurse #4 relayed the information to Resident #270 and EMS arrived at the facility at 10:56 PM to transfer the resident to the hospital. Review of the hospital discharge summary revealed Resident #270 was evaluated for abdominal pain using a computed tomography (diagnostic imaging of the inside of the body) and diagnosed with acute cholecystitis. General surgery was consulted and on 11/24/22 Resident #270's gallbladder was surgically removed. During a telephone interview on 12/14/22 at 9:56 AM Nurse #4 revealed after Resident #270 informed her of having anal pain she obtained a set of vital signs and those were within normal limits and gave the pain medication. Nurse #4 stated she didn't recall Resident #270 say the pain medication was ineffective, but her progress note documented what was done. Nurse #4 stated Resident #270 did not appear in distress, and everything had been normal for the resident that day. Nurse #4 stated she called the DON who agreed there was no clinical reason, but it was Resident #270's right to call EMS for transfer to hospital. Nurse #4 confirmed she did not notify the MD for guidance. An interview was conducted on 12/14/22 at 4:21 PM with Resident #270. Resident #270 stated he told the nurse he was having a difficult time breathing and had stomach pain on 11/22/22 and called EMS because the nurse wouldn't. An interview was conducted on 12/16/22 at 4:46 PM with the DON. The DON revealed Nurse #4 called her about Resident #270 wanting to the hospital for anal pain and she didn't think that was a reason to send the resident out based on what the nurse told her. The DON revealed she didn't recall the being informed the pain medication was not effective and if she had her first response would be to call the physician. During an interview on 12/16/22 at 4:29 PM the Medical Director revealed would have expected to be notified Resident #270 was having pain and the medications were not relieving the pain so he could have evaluated the situation.

Based on record review and interviews with the Medical Director and staff the facility failed to complete a thorough assessment of a resident requesting to go to the emergency room due to increased pain. The resident called emergency medical services and was transported to the hospital and diagnosed with acute cholecystitis (inflammation of the gallbladder) that required surgical removal of the gallbladder for 1 of 2 residents reviewed for hospitalization (Resident #270). The findings included: Resident #270 was admitted to the facility on [DATE] with diagnoses including a history of cervical spine trauma and quadriplegia. Resident #270 was discharged to the hospital on 11/22/22. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #270 was assessed as being cognitively intact. Routine and as needed pain medications were received during the lookback period and the resident reported his pain was moderate, frequent, and interfered with sleep and activities. Opioids (narcotic pain medications) were given all 7 days during the lookback period. Review of the Medication Administration Record (MAR) revealed a physician's order for oxycodone-acetaminophen (a narcotic pain medication) 5-325 milligrams every 6 hours as needed for pain management. The MAR revealed from 11/01/22 through 11/21/22 Resident #270 received 19 doses out of 84 available for his pain and doses received were considered effective. No pain medication was administered on 11/18/22 and 11/19/22. On 11/20/22 one dose was administered at 7:38 PM and consider effective. On 11/21/22 one dose was administered at 7:51 PM and considered effective. On 11/22/22 one dose was administered at 3:56 PM and considered effective and a second dose was given at 10:06 PM and considered effective. Review of the nurse progress note dated 11/22/22, written by Nurse #4, revealed on 11/22/22 at approximately 9:30 PM Resident #270 complained of bxxxhole pain and asked to be sent to the hospital. Nurse #4 obtained a set of vital signs and explained to the resident those were within normal limits and his pain medication was due soon and there was no clinical reason to send the resident to the hospital. The progress note indicated Resident #270 refused the pain medication stating it didn't work. The Director of Nursing (DON) was notified and agreed to not send the resident to the hospital for lack of a clinical reason however it was his right to call emergency medical service (EMS). Nurse #4 relayed the information to Resident #270 and EMS arrived at the facility at 10:56 PM to transfer the resident to the hospital. Review of the hospital discharge summary revealed Resident #270 was evaluated for abdominal pain using a computed tomography (diagnostic imaging of the inside of the body) and diagnosed with acute cholecystitis. General surgery was consulted and on 11/24/22 Resident #270's gallbladder was surgically removed. During a telephone interview on 12/14/22 at 9:56 AM Nurse #4 revealed after Resident #270 informed her of having anal pain she obtained a set of vital signs and those were within normal limits and gave the pain medication. Nurse #4 stated she didn't recall Resident #270 say the pain medication was ineffective, but she documented what she did in her progress note. Nurse #4 stated Resident #270 did not appear in distress, and everything had been normal for the resident that day. Nurse #4 stated she called the DON who agreed there was no clinical reason, but it was Resident #270's right to call EMS for transfer to hospital. Nurse #4 revealed Resident #270 did call EMS and was transferred to the hospital. An interview was conducted on 12/14/22 at 4:21 PM with Resident #270. Resident #270 stated he told the nurse he was having a difficult time breathing and had stomach pain on 11/22/22 and had to call EMS because the nurse wouldn't. During an interview on 12/16/22 at 4:46 PM the DON revealed Nurse #4 called her stating Resident #270 complained his bxxxhole was hurting and he needed to go to the hospital. The DON stated she didn't think that was a reason to send the resident out based on what the nurse was telling her and didn't recall the nurse saying the resident's pain medication was not effective. The DON revealed Resident #270 did call EMS that night and was transferred to the hospital. The DON revealed Resident #270 had called EMS the previous weekend and went to the hospital and wasn't admitted and was sent back to the facility the same day. During an interview on 12/16/22 at 4:29 PM the Medical Director revealed would have expected to be notified Resident #270 was having pain and the medications were not relieving the pain so he could have evaluated the situation.

Based on observations, record reviews and staff, resident, and Nurse Practitioner (NP) interviews, the facility failed to provide supervision and a safe smoking environment 1 of 3 residents reviewed for smoking (Resident #1). Resident #1 was admitted to the facility on [DATE] with a documented history of smoking with oxygen in use at another facility and was assessed as being safe to smoke unsupervised. On 10/25/22 the Director of Nursing intervened twice and removed the oxygen tank off the back of Resident #1's wheelchair as he was going out to smoke and provided education both times. No other interventions were initiated, and Resident #1 continued to smoke without supervision. On 10/27/22 Resident #1 was observed smoking unsupervised with oxygen in use via nasal cannula putting himself and other residents at risk for serious adverse outcome. Immediate jeopardy began on 10/25/22 when the Director of Nursing witnessed Resident #1 attempting to go out to smoke with an oxygen tank on the back of his wheelchair and oxygen in use via nasal cannula and no interventions were put in place. The immediate jeopardy was removed on 10/30/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Review of admission correspondence from previous facility received by the Admission Coordinator dated 07/07/22 revealed Resident #1 diagnosis of dependence of supplemental oxygen and nicotine dependence. The admission correspondence also revealed Resident #1 had received a 30-day discharge notice due to breaking smoking policy multiple times, having smoking materials on his person, and smoking in his room with supplemental oxygen which could cause death and or harm to other residents. Admission Coordinator was unavailable for interview. Resident #1 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] and supplemental oxygen dependence. Review of revised facility smoking policy dated July 2017 revealed upon admission residents shall be informed of facility smoking policy to include: oxygen use is prohibited in smoking areas, staff shall consult the Attending Physician and Director of Nursing to determine if safety restrictions need to be placed on a resident's smoking privileges, resident's ability to smoke will be re-evaluated quarterly, upon significant change, and as determined by staff, any smoking-related privileges, restrictions, and concerns shall be noted on care plan and all personnel caring for residents shall be alerted to these issues, and facility may impose smoking restrictions on a resident at any time, if it is determined the resident cannot smoke safely with the available levels of support and supervision. Review of admission smoking assessment dated [DATE] revealed Resident #1 required no supervision and may smoke independently due to no history of smoking-related incidents, safely be without supplemental oxygen during smoking times, and was able to acknowledge understanding of facility smoking policy. The assessment was completed by Nurse #1. A telephone interview was conducted with Nurse #1 on 11/03/22 at 1:35 PM revealed she was familiar with Resident #1 and had completed his admission smoking assessment. She stated Resident #1 had been admitted with oxygen and educated on not smoking while wearing oxygen and to leave oxygen inside when smoking. She revealed she completed the smoking assessment for Resident #1 by observing his abilities to smoke safely and had deemed him a safe smoker. Nurse #1 stated she had no knowledge of Resident #1 previous placement or history of smoking while wearing oxygen and had she known she would have included in smoking assessment, and he would have possibly been deemed a supervised smoker so he could have been monitored more closely. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and was coded as supplemental oxygen dependent and current tobacco use. Review of physician progress note dated 08/03/22 revealed Resident #1 had informed the physician he had a lit a cigarette in his room at his previous facility and had his smoking privileges revoked and had requested a transfer to current facility. Review of admission care plan dated 09/25/22 revealed focus area for smoking for Resident #1. Interventions included instruct Resident #1 about smoking risks and hazards, instruct Resident #1 about facility policy on smoking to include locations, times, and safety concerns, notifying charge nurse immediately if it is suspected Resident #1 had violated facility smoking policy, and observe clothing and skin for signs of cigarette [CONDITION(S)]. The admission care plan also revealed focus area for respiratory for Resident #1. Interventions included oxygen via nasal cannula as per MD order. Review of current physician order dated 10/27/22 revealed Resident #1 to receive supplemental oxygen via nose cannula at 2 liters per minute as needed. There were no prior orders for supplemental oxygen available in Resident #1 electronic medical chart. An interview was conducted with Director of Nursing (DON) on 10/27/22 at 5:59 PM revealed earlier this week (10/25/22) she had witnessed Resident #1 twice on the same day, attempting to go outside and smoke with supplemental oxygen attached to his wheelchair while wearing nasal cannula. She stated both times she had stopped Resident #1 and removed the supplemental oxygen tank from the wheelchair and educated on why it was not safe to smoke with oxygen. She revealed she had not documented incidents, nor had she completed a new smoking assessment and had not notified the Administrator of incidents. Resident #1 was observed on 10/27/22 at 10:20 AM smoking while sitting outside in the designated area with oxygen tank attached to his wheelchair and nasal cannula in place. Resident #1 was receiving supplemental oxygen via nasal cannula tubing at 2 liters. Upon observation, Resident #1 placed cigarette in ash tray and came back into building with oxygen in place. Resident #1 observation and interview conducted on 10/27/22 at 11:26 AM revealed him sitting on his bed receiving supplemental oxygen through room concentrator set at 3 liters via nasal cannula. Resident #1's wheelchair was observed in room with supplemental oxygen tank attached to back of wheelchair. Resident #1 stated he was currently on 3 liters of continuous oxygen and was only able to go without using supplemental oxygen for no more than 45 minutes at a time. He admitted to being outside smoking earlier that morning while wearing his oxygen and stated he did so because he believed the oxygen tank attached to his wheelchair to be almost empty and he had hoped no one would notice. Resident #1 stated he had been at the facility for 2 1/2 months and had been made aware of smoking policy during admission to include not wearing oxygen while smoking. He revealed he had been discharged from his previous facility for smoking in his room while wearing his oxygen and was aware of the danger smoking around oxygen could have caused for himself or others. An interview was conducted with the Nurse Practitioner (NP) on 10/27/22 at 12:09 PM revealed she had previously witnessed residents at the facility outside smoking with supplemental oxygen tanks attached to their wheelchairs and nose cannula in place. She stated she had spoken with the facility administration about residents being outside smoking with supplemental oxygen in place and they were supposed to have educated the residents about the dangers of smoking while using supplemental oxygen and placed no oxygen use signs on the doors leading out to the smoking areas. The NP revealed she had also educated residents about the dangers of smoking while using supplemental oxygen such as the building could blow up or they could catch themselves or other residents on fire. She stated she had assumed residents were continuing to go outside and smoke while using supplemental oxygen due to the different types of residents being admitted to the facility. The NP revealed she had been told Resident #1 had been transferred to the facility because his previous facility was no smoking and he wanted to be at facility where he could smoke. The NP was not aware of Resident #1 being discharged from his previous facility due to smoking in his room while wearing supplemental oxygen and this information should have been used to determine if Resident #1 should be a supervised or unsupervised smoker. An interview was conducted with Administrator on 10/27/22 at 3:36 PM revealed he had not been made aware of Resident #1being observed earlier this morning outside smoking while wearing his supplemental oxygen. The Administrator revealed upon admission, Resident #1 had been assessed for smoking and deemed to be a safe smoker with no supervision and the facility smoking policy had been discussed with Resident #1 and included not wearing oxygen while smoking. He stated he had no knowledge of Resident #1 being discharged from previous facility due to breaking smoking rules and smoking in room with oxygen. The Administrator further stated had this information been available it would have been used as part of Resident #1's smoking assessment and may or may not have determined him to be a supervised smoker. The Administrator revealed no resident should be outside smoking while wearing supplemental oxygen due to causing possible harm to themselves or others and staff should stop any resident immediately if they are witnessed trying to go outside to smoke while wearing oxygen or are outside smoking while wearing oxygen and report to administration. An interview was conducted with Administrator and Regional Director of Operations on 10/27/22 at 6:50 PM revealed they had not been made aware that earlier in the week the Director of Nursing had stopped Resident #1 twice in one day from attempting to go outside and smoke with supplemental oxygen attached to wheelchair with his nasal cannula in place. They stated the Director of Nursing should have notified the Administrator immediately and the incident should have been documented and new smoking assessment completed, and Resident #1 monitored more closely. The Regional Director of Operations revealed she had no knowledge of Resident #1 being discharged from his previous facility due to breaking smoking policy multiple times and smoking in his room while wearing his oxygen. She stated if the facility had known this information, it would have been used during Resident #1 smoking assessment and he would have been closely monitored and deemed a supervised smoker. The facility was notified of immediate jeopardy on 10/28/22 at 11:16 AM. The facility provided the following plan for IJ removal. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to prevent a Resident from smoking with oxygen on. Resident #1 was admitted to the facility on [DATE] with a primary diagnosis of [CONDITION(S)] ([CONDITION(S)]) and use of supplemental oxygen ordered as needed via nasal canula at 2 liters/minute. Director of Nursing verbally educated Resident #1 on admission to remove oxygen, leave it on the wheelchair, and walk as he is able into the smoking area to sit in straight chair without oxygen to smoke, resident verbalized understanding. On 7/27/22, the licensed nurse completed the Safe Smoking Screening and determined that resident is a current smoker with assessment and care plan to smoke independently without staff supervision. The Director of Nursing (DON) stopped Resident #1 twice on Tuesday (10/25/22) as he was going out to smoke with oxygen on and did verbal education with him on both occasions about the importance of removing his oxygen before going outside to smoke. The Director of Nursing did not report what occurred on 10/25/22 and Resident #1 continued to smoke without supervision. On 10/27/22, resident was observed in designated smoking area smoking independently with oxygen cylinder attached to back of wheelchair, by the state surveyor. He took a couple of puffs, put out his cigarette, and then re-entered the facility. The Administrator was informed by the surveyor. The DON did not report what occurred on 10/25/22 and Resident #1 continued to smoke without supervision. On 10/27/22, the licensed nurse completed an updated Safe Smoking Screening and determined that Resident #1 was no longer safe to smoke independently without supervision. Care plan was updated to reflect this change and resident was reeducated on the smoking policy and safety concerns of smoking with oxygen and verbalized understanding and acknowledged via written signature. Effective 10/27/22, Resident #1 will be supervised by staff when smoking during designated smoking times and will not have oxygen in smoking area. Residents who smoke are at risk. All staff, including agency, were questioned to determine if anyone else had observed Resident #1 or any other resident requiring oxygen in the smoking area with oxygen in use or with oxygen equipment on their wheelchair, by 10/29/22. Any resident who has been observed by staff in the past to have been in the smoking area with oxygen on will have updated smoking assessment, signed education, care plan, and be placed on the supervised smoking list. The Director of Nursing will update the list of supervised and unsupervised smokers daily and prn with any new admission or in morning clinical meeting with any resident who has had a change in condition following a safe moving assessment. The updated list will be posted at each nursing station prn with any change. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 10/27/2022, the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Services, VP of Risk Management, Social Worker, Maintenance Director, Activities Director and Medical Director conducted an Ad Hoc QAPI meeting to discuss root cause analysis of the facilities failure to prevent a resident from smoking with oxygen. The facility determined that Resident #1 did not have adequate understanding of the dangers of smoking with oxygen and staff did not immediately implement appropriate interventions when observing a resident's attempts at smoking with oxygen in use. On 10/27/22, the licensed nurses completed updated Safe Smoking Screening Assessments for all current facility smokers to reflect supervised or unsupervised. Care plans were audited for accurate reflection. O2 orders updated to reflect accurate flow rate, and additional directions were added per Medical Director approval with may remove oxygen while smoking. On 10/27/22, Care Plans of all residents who smoke were reviewed and revised to reflect supervised or unsupervised smoking. Those with oxygen dependence care plans were revised to reflect oxygen prohibited during smoking for safety. Completed by Regional Director of Clinical Services and Director of Nursing. On 10/27/22, an updated list of supervised and unsupervised smokers was added to each nurse's station by the Regional Director of Nursing. This list will be updated with each admission and in daily morning clinical meeting for residents who smoke. The Director of Nursing was notified on 10/27/22 of this responsibility and will oversee the process. Effective 10/28/22, the facility provided education to all smokers. Unsupervised smokers were instructed verbally by the Administrator on the danger of oxygen in the smoking area and how to report any observation of oxygen in the smoking area. They were also educated on smoking being restricted to one designated area, not sharing cigarettes or lighters with supervised smokers and keeping all smoking materials in their assigned lock boxes. Any violations of this could result in becoming a supervised smoker or 30-day discharge from facility. The unsupervised smokers signed this education in acknowledgement of understanding. The supervised smokers were educated verbally by the Administrator on the danger of oxygen in the smoking area and how to report any witnessed violations of this and that any unsupervised smokers smoking materials are to be kept by staff and provided during supervised smoking times. All supervised smokers signed this education in acknowledgement of understanding. On 10/28/22, alarms were added to both exit doors by the Maintenance Director to alert staff if a resident attempts to go out to the smoking area unattended. These alarms do not stop unsupervised smokers from exiting out the door independently, it only alerts staff to visualize the resident, when alarm sounds, to see if it is a supervised or unsupervised smoker. On 10/28/22, education was provided to all staff, including agency/contract staff, in person that were working at the time and the on-coming shift and by phone if not working that day. This education was provided by the Administrator, Director of Nursing and the Regional Team on the purpose of the alarms and how to respond. The Administrator and Director of Nursing will ensure that all staff to include contract staff are educated going forward prior to the start of their shift. On 10/29/22 the Regional Team performed an audit to ensure that all were educated to include agency/contract staff. On 10/28/22, the Director of Nursing (DON) was educated by the Administrator on the smoking policy and need for immediate interventions if a resident is witnessed as unsafe such as an incident report, reporting to MD and Administrator, updating Safe Smoking Screening and care plan to reflect supervised smoking status and reeducation to resident on the Smoking policy and smoking safety. Director of Nursing (DON) was educated by the administrator on the requirement of reporting smoking incidents to the Administrator immediately. On 10/28/22, All staff in all departments, including agency/contract staff, were educated by Administrator or Director of Nursing (DON) either in writing or verbally over the phone, of the dangers of oxygen or oxygen equipment in the smoking area, and requirements of supervision for all supervised smokers. Understanding of education provided by phone was validated by asking staff to restate materials taught and also asking questions throughout. Education also includes the smoking policy, removal of oxygen prior to going into the smoking area, the dangers of smoking with O2 in use and what actions to take, such as immediate removal of oxygen from smoking area, ensuring all residents are safe and then immediately notifying the Director of Nursing (DON) and Administrator of the smoking incident for further intervention. One designated smoking area, response to alarms, supervised and unsupervised smoking lists and where they are located, was also included. Newly hired employees will be educated on the above topics by the Director of Nursing (DON) or Unit Manager upon hire. The Director of Nursing and Human Resources Director will ensure that all staff will be educated via their agency/contract staff orientation packet and understand its contents prior to their first assignment at the facility. An audit of the orientation packet was completed on 10/28/22 and a copy of the updated smoking policy was added. The agency/contract staff orientation packet includes the smoking policy and the proper notifications that should be made per the policy if a smoking incident occurs. The education also reviews the items that should be available to ensure safe smoking is able to occur and alerts staff that a list of supervised smokers is located at each nursing station. And finally, the education explains that you should follow the policy and procedure in the event of an emergency staff present in facility during educational session on 10/28/22 attended an in-service however the remainder of staff received in-service by phone. A questionnaire was given by the Administrator and Director of Nursing to ensure staff who were educated via phone call on 10/28/2022 to ensure understanding of the smoking policy, how to report a breach of policy or an incident and safety of residents while in the smoking area. The Director of Nursing and Administrator will ensure that all new staff to include agency/contract staff have completed their new hire packet prior to working a shift. The Director of Nursing and Unit Managers were also educated on 10/28/22 and informed of this responsibility by the Regional Director of Clinical Services and the Administrator. On 10/28/22, All lock box keys were gathered by Maintenance Director, Administrator or Director of Nursing, from supervised smoking residents and assigned to staff for safe keeping. Unsupervised smokers lock boxes will remain outside in the designated cubby, and they are allowed to keep their keys unless they are observed to not follow rules. Effective 10/28/22, All residents will be assessed by a licensed nurse for smoking upon admission, quarterly and with any changes. Any new admission or change in assessment will also require re-education to the smoking policy and smoking contract that will be reviewed with the resident by the Social Worker and signed by the resident. During clinical meetings, all new admissions referrals will be thoroughly examined for previous smoking incidents and risks by the Director of Nursing (DON) or Unit Manager. Education to the Director of Nursing (DON) and Unit Manger was given on 10/28/22 to include this new responsibility. Effective 10/28/2022, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of IJ Removal: 10/30/22 On 11/03/22 the credible allegation for the immediate jeopardy removal was validated and the removal date of 10/30/22 was confirmed. The audit tools completed by the facility on 10/27/22 were reviewed. The physician and nurse practitioner were notified of results from the audits and all smoking assessments and care plans had been updated to reflect any changes to include residents assessed for smoking and receiving supplemental oxygen would become supervised smokers. On 10/28/22, the Regional Clinical Manager and Administrator provided education with the Director of Nursing regarding the revised smoking policy and procedures. Observations, record review and interviews completed on 11/03/22 revealed Observed updated smoking assessments and care plans for each smoker, copies of updated lists of smokers and revised smoking policy available at each nurse's station and signage on door leading out to smoking area stated no oxygen use and supervised smokers must always be accompanied by staff. Interviews with nursing staff revealed the Director of Nursing continued to review list of smokers, revised smoking policy, and any smoking concerns or violations during nurse's morning meeting. On 10/28/22, the Regional Clinical Director, Administrator, and Director of Nursing provided education to all smoking residents regarding the revised smoking policy and procedures. Further review of facility documents and interviews completed on 11/03/22 revealed Observed all smoking residents had signed and dated they had been educated on the revised smoking policy, including immediate need for safe interventions and verbalized understanding by written signature for acknowledgement and understand consequences of failure to follow updated smoking policy and received copies of revised smoking policy and oxygen usage safety sheet. Observations of Also observed supervised smokers confirmed they were outside smoking supervised by staff, oxygen tanks were left inside, and smoking materials were distributed by staff from lockbox. The door alarm to smoking area had been installed and could be heard throughout building to alert staff when residents were going in and out of door. Interviews with staff revealed supervised smokers had set smoking times accompanied by staff, smoking materials were distributed by staff from a lockbox held at the nursing station and oxygen tanks were left inside the hallway or in the resident's room for safety. Interviews with nurses, nurse aides, housekeeping staff, business office manager, activities director, nurse practitioner revealed they received education on revised smoking policy and procedures including smoking area was moved to East Hall only and an all-day alarm was placed on door to alert staff to observe residents coming in and out of door, all oxygen dependent residents are now placed on supervised smoking list and oxygen tanks and tubing must be left in hallways or rooms and cannot be outside, supervised smokers have designated times to smoke and must be supervised by staff at all times and smoking materials contained in lock box and distributed by staff, updated smoking list kept at both nursing stations for review, and report any smoking violations immediately to supervisor, Director of Nursing and Administrator. Staff stated the revised smoking policy including the updated list of smokers allowed them to know who should be supervised and unsupervised and staff rotated accompanying supervised smokers. The staff also stated the door alarm had been helpful by allowing them to be more alert as to who was going in and out to smoke and they believed the overall revisions to the smoking policy was for the better of the residents and staff.

Based on record review and staff, Pharmacist, and Nurse Practitioner interviews, the facility failed to obtain [MEDICATION(S)] (a schedule II narcotic medication used to treat moderate to severe pain) as ordered by the physician for a resident with chronic pain (Resident #2) resulting in three missed doses of the medication. Resident #2 was not administered [MEDICATION(S)] for three days on 9/15/22, 9/16/22 and 9/17/22 resulting in symptoms of nausea and dizziness. Resident #2 called emergency medical services and was transported to the hospital on 09/18/22 where she was administered her medication. This occurred for 1 of 3 residents reviewed for pharmacy services. The findings included: A hospital discharge summary dated 09/13/22 revealed Resident #2 had a history of chronic pain syndrome maintained with the medication [MEDICATION(S)] (narcotic medication used to treat moderate to severe pain). The summary read to continue administering [MEDICATION(S)] 15 milligrams (mg) daily. The summary stated the Physician had verified the order with the resident's [MEDICATION(S)] provider. Resident #2 was admitted into the facility on [DATE] with diagnosis which included chronic pain. Resident #2's Medication Administration Record (MAR) dated September 2022 revealed an order initiated on 09/15/22 for [MEDICATION(S)] [MEDICATION(S)] (HCL) tablet 10 mg give 1.5 tablet orally one time a day for pain. The medication was documented as a (9) not given based on the coding chart located on the back of the MAR on 09/15/22 and 09/16/22. The order was discontinued on 09/16/22. The review of Resident #2's MAR revealed a second order was initiated on 09/17/22 for [MEDICATION(S)] HCL tablet 10 mg by mouth in the morning for pain. The medication was documented as a (9) not given based on the coding chart located on the back of the MAR given on 09/17/22 and 09/18/22. The order was discontinued on 09/18/22. On 10/27/22 at 10:20 AM an interview was conducted with Resident #2. During the interview Resident #2 stated she had come from the hospital to the facility on [DATE] and the facility withheld her medication [MEDICATION(S)] on 09/15/22, 09/16/22 and 09/17/22. She stated she started having withdrawal symptoms of nausea, dizziness and felt like she couldn't move in the bed. The interview revealed she had called for an ambulance on 09/18/22 and was at the hospital from 10:00 AM until 2:00 PM getting the medication [MEDICATION(S)] that the facility could not provide. On 10/27/22 at 11:37 AM an interview was conducted with MA #1. During the interview she stated she had worked during the days of 09/15/22 through 09/18/22. MA #1 stated Resident #2 had to wait 3 days because pharmacy had not delivered the medication [MEDICATION(S)] to the facility. The interview revealed if the medication was not in the facility to ensure it was on order through pharmacy. She stated the Director of Nursing was aware the medication was not in the facility. Review of the hospital records dated 09/18/22 at 10:03 AM revealed emergency medical services reported they did not think the facility was prepared for Resident #2 because she had not received her medication. Resident #2 stated at the hospital she had not had any [MEDICATION(S)] since 09/14/22. The hospital administered Resident #2 [MEDICATION(S)] and discharged her back to the facility. On 10/27/22 at 12:25 PM an interview was conducted with the Nurse Practitioner (NP). During the interview she stated she could not prescribe the medication [MEDICATION(S)]. She stated it was only prescribed by the Medical Director (MD) and she knew Resident #2 had experienced a delay in receiving the medication due to the MD not being in the area at the time of Resident #2's admission and the pharmacy needed a written prescription to fill the medication. The interview revealed Resident #2 was not sent to the facility with a written prescription for the medication. The interview revealed the facility normally did not admit residents who were prescribed [MEDICATION(S)]. She stated they did not call the [MEDICATION(S)] clinic because the MD came into the building on 9/16/22 to write the order for the medication. On 10/27/22 at 5:58 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated she knew Resident #2 had not received [MEDICATION(S)] after she was admitted in September due to the hospital not sending the facility a written prescription. She stated she did not call the hospital or any outside resource to obtain a written prescription. She stated the NP did not have access to get her a prescription, the on-call physician wouldn't prescribe it and the MD was out of town. The interview revealed the MD finally wrote the prescription on 09/16/22, but pharmacy did not fill the prescription until 09/18/22 after the resident had left the facility to go to the hospital. The interview revealed the facility knew Resident #2 was receiving the medication based on her transfer form that was sent to the facility prior to her arrival. On 10/18/22 at 10:35 AM an interview was conducted with Pharmacist #1. During the interview she stated the pharmacy had received the written prescription for [MEDICATION(S)] 15 mg for Resident #2 on 09/17/22 at 2:33 PM. She stated the medication was filled and delivered to the facility on [DATE] during the night delivery per their records.

Based on record review and resident, staff,. Nurse Practitioner and Pharmacist interviews the facility failed to administer [MEDICATION(S)] (a schedule II narcotic medication used to treat moderate to severe pain) to 1 of 3 residents reviewed for pharmacy services (Resident #2). Resident #2 was not administered [MEDICATION(S)] for three days on 9/15/22, 9/16/22 and 9/17/22 resulting in symptoms of nausea and dizziness. Resident #2 called emergency medical services and was transported to the hospital on 09/18/22 where she was administered her medication. The findings included: A hospital discharge summary dated 09/13/22 revealed Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary read to continue administering [MEDICATION(S)] 15 milligrams (mg) daily. The summary stated the Physician had verified the order with the resident's [MEDICATION(S)] provider. Resident #2 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition. Resident #2 was coded for having occasional pain during the MDS assessment with a numeric rating of 3 on a 0-10 scale. Resident #2 was coded for receiving opioids on 3 days during the lookback period. Resident #2's care plan dated 10/01/22 revealed a focus area for risk for altered comfort status related to chronic pain. The goal was for Resident #2 to display a decrease in behaviors of inadequate pain control through the next review date. Interventions included the administration of medication as per orders and observe for effectiveness. Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was documented as not given on 09/15/22 and 09/16/22. The order was discontinued on 09/16/22. A nursing progress note dated 09/15/22 at 3:25 AM revealed Resident #2 had a couple of episodes of verbal aggression related to not getting her medication. The note revealed the medications had not been delivered by pharmacy. The review of Resident #2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was documented as not given on 09/17/22 and 09/18/22. The order was discontinued on 09/18/22. A nursing progress note dated 09/18/22 at 7:10 PM written by Medication Aide (MA) #1 revealed Resident #2 had called 911 multiple times during the morning and wanted to be sent to the hospital due to not receiving the medication [MEDICATION(S)] while in the facility. Resident #2 was sent to the hospital per request to receive [MEDICATION(S)]. The note revealed the medication had just arrived in the facility from pharmacy after the resident had already left to go to the hospital. Resident #2 was transported back to the facility during the evening of 09/18/22 in a pleasant mood with no behaviors after receiving [MEDICATION(S)] at the hospital. On 10/27/22 at 11:37 AM an interview was conducted with MA #1. During the interview she stated she had worked during the days of 09/15/22 through 09/18/22. MA #1 stated Resident #2 had to wait 3 days because pharmacy had not delivered the medication [MEDICATION(S)] to the facility. She stated the resident was verbally aggressive to staff due to not receiving the medication and stated to her that she was sick feeling nauseated and dizzy. The interview revealed she did not recall the resident showing any physical symptoms such as vomiting from not having the medication. The interview revealed once the resident came back from the hospital she was in a much better mood and had no other complaints. She stated they normally didn't accept residents who were on the medication [MEDICATION(S)], so she had never dealt with that situation before. Review of the hospital records dated 09/18/22 at 10:03 AM revealed emergency medical services reported they did not think the facility was prepared for Resident #2 because she had not received her medication. Resident #2 stated at the hospital she had not had any [MEDICATION(S)] since 09/14/22. The record revealed Resident #2 was experiencing mild withdrawal symptoms stating she felt uncomfortable all over. The hospital administered Resident #2 [MEDICATION(S)] and discharged her back to the facility. On 10/27/22 at 10:20 AM an interview was conducted with Resident #2. During the interview Resident #2 stated she had come from the hospital to the facility on [DATE] and the facility withheld her medication [MEDICATION(S)] on 09/15/22, 09/16/22 and 09/17/22. She stated she started having withdrawal symptoms of nausea, dizziness and felt like she couldn't move in the bed. The interview revealed she had called for an ambulance on 09/18/22 and was at the hospital from 10:00 AM until 2:00 PM getting the medication [MEDICATION(S)] that the facility could not provide. Resident #2 stated she had told nursing staff and the doctor, but nobody would listen to her. The review of Resident #2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was documented as administered on 09/19/22 through 09/26/22. A Medical Director (MD) progress note dated 09/21/22 revealed Resident #2 told the MD she was experiencing withdrawal symptoms and having trouble with her [MEDICATION(S)]. The note revealed [MEDICATION(S)] was being prescribed by another Physician and was being tapered off. On 10/27/22 at 12:25 PM an interview was conducted with the Nurse Practitioner (NP). During the interview she stated she could not prescribe the medication [MEDICATION(S)]. She stated it was only prescribed by the MD and she knew Resident #2 had experienced a delay in receiving the medication due to the MD not being in the area at the time of Resident #2's admission and the pharmacy needed a written prescription to fill the medication. The interview revealed Resident #2 was not sent to the facility with a written prescription for the medication. The NP stated the medication [MEDICATION(S)] was a significant medication that needed to be taken as ordered. She stated if a resident stopped taking the medication abruptly, they could go into withdrawal symptoms including nausea, vomiting, or dizziness. The interview revealed the facility normally did not admit residents who were prescibed [MEDICATION(S)]. She stated they did not call the [MEDICATION(S)] clinic because the MD came into the building on 9/16/22 to write the order for the medication. On 10/27/22 at 5:58 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated she knew Resident #2 had not received [MEDICATION(S)] after she was admitted in September due to the hospital not sending the facility a written prescription. She stated she did not call the hospital or any outside resource to obtain a written prescription. She stated the NP did not have access to get her a prescription, the on-call physician wouldn't prescribe it and the MD was out of town. The interview revealed the MD finally wrote the prescription on 09/16/22, but pharmacy did not fill the prescription until 09/18/22 after the resident had left the facility to go to the hospital. The DON stated Resident #2 had expressed no issues of nausea or dizziness to her. The interview revealed the facility knew Resident #2 was receiving the medication based on her transfer form that was sent to the facility prior to her arrival. On 10/18/22 at 10:35 AM an interview was conducted with Pharmacist #1. During the interview she stated the pharmacy had received the written prescription for [MEDICATION(S)] 15 mg for Resident #2 on 09/17/22 at 2:33 PM. She stated the medication was filled and delivered to the facility on [DATE] during the night delivery per their records. Pharmacist #1 stated [MEDICATION(S)] should not be stopped abruptly and if was stopped it could send someone into withdrawal symptoms within 2-3 days. She stated withdrawal symptoms could include nausea, vomiting, tiredness, or headache. She stated the symptoms would not be life threatening.

Based on record review, observations, resident and staff interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, transfers, and incontinence care resulting in residents expressing feelings of being: helpless, dirty, rank, embarrassed, angry, terrible, fed up, sad, treated like a dog, smelly, and forgotten about. This affected 5 of 5 (Residents #9, #39, #28, #13, and #360) sampled residents. Findings included: 1. Resident #9 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #9 was cognitively intact and required extensive to total assistance of 1 staff member for bathing and personal hygiene. During an interview on 01/26/22 at 08:55 AM, Resident #9 expressed she pushed her call bell at 7:30 AM for staff to assist her up out of bed and was still waiting for staff to respond. Resident #9 stated she was not provided her scheduled shower yesterday and was told by staff they would wipe her down really good before her appointment at 1:00 PM but she was afraid the Nurse Aide (NA) would not have her ready in time. Resident #9 added she really wanted a shower and when she didn't get one, it made her feel bad and angry. I don't like not being clean. A follow-up observation and interview was conducted with Resident #9 on 01/26/22 at 10:40 AM. Resident #9 was observed still in bed, wearing a night gown. Resident #9 looked up at the clock and stated she had pushed her call bell again at 10:10 AM for staff to assist her up out of bed to get ready for her appointment. Resident #9 added she felt staff didn't have the time or liked doing anything for her. During an interview on 01/26/22 at 10:47 AM, the MDS Coordinator stated she was covering for the scheduler and confirmed Resident #9's appointment was scheduled at 1:15 PM this afternoon and she would need to be ready to leave the facility by 12:30 PM. The MDS Coordinator voiced Resident #9 started requesting to get up out of bed and ready first thing this morning. The MDS Coordinator stated she would talk with Resident #9 to assure her she would be ready in time. A follow-up observation and interview was conducted with Resident #9 on 01/26/22 at 11:30 AM. Resident #9 was observed still in bed, wearing a night gown. Resident #9 stated she was wet and had pushed her call bell 10 minutes ago for staff to provide incontinence care. Resident #9 was tearful as she voiced being worried that staff would not be able to give her a shower or have her up and ready in time for her appointment. Resident #9 stated, I am so fed up with this place, I don't know what I am going to do. I can't live like this. During an interview on 01/26/22 at 11:36 AM, Nurse #3 stated she was aware that Resident #9 was upset and wanting to get up out of bed. Nurse #3 added staff were fixing to get Resident #9 up out of bed for a shower and ready for her appointment. During an observation and interview on 01/26/22 at 11:50 AM, NA #6 was observed in Resident #9's room getting ready to provide her with care. NA #6 explained she was called in to assist with showers and was asked to assist Resident #9 with getting ready for her appointment. NA #6 verified Resident #9 would be taken for a shower right after she finished with incontinence care. During an interview on 01/26/22 at 11:52 AM, NA #5 explained when she arrived at work, she was originally assigned to work on the east unit but then sent to the west unit to assist with resident care. NA #5 confirmed Resident #9 was on her assignment and was aware she had been requesting to get up out of bed. NA #5 stated she had not assisted Resident #9 up out of bed because NA #6 was going to get her up and give her a shower. NA #5 added she had not noticed Resident #9's call light and was not aware that she was wet and needed changed. A follow-up observation and interview was conducted with Resident #9 on 01/26/22 at 4:58 PM. Resident #9 was sitting up in her wheelchair in her in no apparent distress. Resident #9 stated she felt much better now that she had a shower and made it to her appointment on time. During an interview on 01/28/22 at 4:20 PM, the Director of Nursing (DON) revealed she had received complaints from a lot of residents regarding them not getting their scheduled showers. The DON explained she would like for all residents to get at least 2 showers per week or per their preference; however, when there was only one NA on the unit, it was difficult for them to get showers completed and provide resident care. She was unaware that Resident #9 had requested to get up out of bed since 7:30 AM but did not receive staff assistance until 11:50 AM and would have expected for staff to assist Resident #9 up out of bed when first requested or as soon as possible. The DON added all staff were expected to treat residents with dignity and respect. 2. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #39 was cognitively intact and required extensive assistance of 1 to 2 staff members for bathing and transfers. An observation and interview was conducted with Resident #39 on 01/24/22 at 10:23 AM. Resident #39's hair appeared oily and she stated she had not had a shower or her hair washed. Resident #39 stated she received a shower approximately a week ago but prior to that, she went without a shower for over a month. Resident #39 added she had asked staff every day for a shower but was told there wasn't enough staff available to give one. Resident #39 added, during the time she went without a shower, she went out for an appointment with her hair beyond greasy which made her feel terrible and embarrassed. During an interview on 01/26/22 at 8:09 AM, NA #2 revealed she frequently worked during the hours of 7:00 AM and 7:00 PM and had provided Resident #39's care. NA #2 stated Resident #39 had voiced concerns about not receiving her scheduled showers. NA #2 explained during the past 3 weeks, she was the only NA assigned to the west unit and was not able to provide resident showers or bed baths. NA #2 added when she worked by herself, the best she could do was keep the residents clean, dry and fed. During an interview on 01/27/22 at 11:13 AM, NA #3 revealed she worked during the hours of 7:00 AM to 7:00 PM and often worked short-staffed with only one NA for the entire building or 2 NAs, one on each unit. NA #3 verified residents had complained about not getting their scheduled showers and stated when there were only one or 2 NAs to provide care, resident showers could not be done. During an interview on 01/28/22 at 12:37 PM, NA #4 revealed she frequently worked during the hours of 7:00 AM and 7:00 PM and routinely provided Resident #39's care. NA #4 stated residents had voiced complaints about missing their scheduled showers but when there was one NA for the entire building or one NA on each unit, it was difficult to get resident showers completed because it left no one on the hall to answer call lights and/or provide care. During an interview on 01/28/22 at 4:20 PM, the Director of Nursing (DON) revealed she had received complaints from a lot of residents regarding them not getting their scheduled showers. The DON stated she would never want a resident to feel dirty or embarrassed because of not receiving a shower. The DON added she would like for all residents to get at least 2 showers per week or per their preference; however, when there was only one NA on the unit, it was difficult for them to get showers completed and provide resident care. 3. Resident #28 was admitted to the facility on [DATE]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] assessed cognition was intact for Resident #28 and needs for activities of daily living as total assistance required for bed mobility, transfer, toilet use, personal hygiene, and bathing. There had not been any refusal of care behaviors during the MDS lookback period. Review of the January 2022 bathing records for Resident #28 revealed a shower was given on 1/11/22 and a bed bath on 1/22/22. The bathing record indicated Resident #28 refused a shower on 1/13/22. Resident #28 shower days were scheduled on Tuesday, Thursday, and Saturday. Review of nurse progress notes revealed Resident #28 was sent to the hospital on 1/16/22 and returned to the facility on [DATE]. The Care Plan in place for activities of daily living revised on 1/27/22 identified Resident #28 as having a self-care performance deficit with interventions in place for bathing and showering that include check nail length and trim and clean on bath day and as necessary. An interview was conducted with Resident #28 on 1/24/22 at 2:05 PM. Resident #28 explained she required total assistance with transfer using a mechanical lift and stated there was not enough staff to get her out of bed upon request and not enough staff to give her showers consistently each week. Resident #28 revealed she had gone 3 to 4 weeks without a shower and stated there have been times she could smell her own body odor. Resident #28 revealed it had been almost 3 weeks since her last shower that she only gets whenever there's enough staff and shower days were inconsistent. Resident #28 stated not getting her shower made her feel helpless and forgotten about and saddened her. An observation was made of Resident #28 on 1/24/22 at 2:05 PM. Resident #28's hair appeared greasy, tangled, and was pulled up in a ponytail. An interview was conducted with Nurse Aide (NA) #1 on 1/25/22 at 8:42 AM. NA #1 revealed when she arrived this morning only one NA was in the building, and she had been focusing on providing incontinence care and delivering breakfast trays. An interview was conducted with NA #1 on 1/25/22 at 10:29 AM. NA #1 revealed she was assigned to provide care for Resident #28, and the only NA assigned on the unit. NA #1 revealed when she worked by herself on the unit residents did miss their scheduled shower. An observation was made of Resident #28 on 1/25/22 at 4:16 PM. Resident #28's appearance had not changed, and her hair continued to appear dirty, tangled and pulled up in a ponytail. An interview was conducted with Resident #28 on 1/25/22 at 4:16 PM. Resident #28 revealed she hadn't had her shower at this time after her request during first shift and hoped she would get one tomorrow. Resident #28 stated she mentioned her shower to NA #1, but she was the only NA on the unit. Resident #28 stated since she returned from the hospital her hair hadn't been washed, she hadn't had a complete bed bath or shower. Resident #28 revealed she could smell herself and her hair was greasy, and her last sponge bath consisted of cleaning her peri-area and applying lotion to her body. An interview was conducted with the Director of Nursing (DON) on 1/28/22 at 4:57 PM. The DON revealed she heard complaints from residents not getting showers and had begun an audit. The DON revealed for 1 person to be assigned on the unit it would be difficult to complete care and provide residents their scheduled showers. 4. Resident #13 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #13's significant change Minimum Data Set, dated dated dated [DATE] revealed he was cognitively intact. Resident #13 was independent for bathing with supervision. Interview with Resident #13 on 1/24/2022 at 9:28 AM revealed he had not had a shower in months. Resident #13 indicated there was no shower room for residents. He stated there was a Tub Room on the East Wing with tubs that residents were not allowed to use. Resident #13 revealed the tubs in the Tub Room had hoses that were pulled out of the tubs and used to hose off residents. Resident #13 stated the set-up in the Tub Room resembled a dog washing station and I'm not a dog. He further stated he should have the right to shower like a normal person. Resident #13 disclosed he had a shower stall in his bathroom, but there was no shower head. Observation of the East Wing Tub Room on 1/24/2022 at 10:05 AM revealed 2 tubs and no wall-mounted showers. A single white hose was observed hanging over the side of the tub closest to the door. A shower nozzle approximately 3 inches across was attached to the end of the hose. Observation of Resident # 13's in-room bathroom on 1/25/2022 at 12:03 PM revealed a walk-in shower. A metal pipe was [NAME] out of the wall at approximately 7 feet. There was no shower nozzle present and no cap over the end of the pipe. Interview with Nurse Aide (NA) #1 on 1/25/2022 at 10:29 AM revealed she was familiar with Resident #13. NA #1 stated Resident #13 had complained to her about the shower room set-up and had informed her he felt humiliated about being hosed off. NA #1 stated NAs had gone together as a group (no date could be provided) to the Administrator about their concerns and nothing had been done. Interview with NA #2 on 1/26/2022 at 8:09 AM revealed she was familiar with Resident #13. NA #2 stated Resident #13 was in his right mind, did not like to be treated disrespectfully and had been very vocal with her about not being taken to the dog wash. NA #2 indicated staff had been told by the Director of Nursing (DON) to never use the tubs in the Tub Room or the showers or tubs in resident rooms due to safety concerns. NA #2 further revealed the Administrator, Director of Nursing (DON) and the former Maintenance Supervisor had been told of residents' concerns and there had been no change. Interview with the DON on 1/29/2022 at 4:20 PM revealed she had told staff not to use the tubs in the Tub Room or the tubs / showers in the resident rooms. The DON stated she and the Administrator determined it was unsafe for residents to use the tubs in the Tub Room or the tubs / showers in the residents' rooms. The DON was concerned residents would attempt to use the Tub Room or in-room tubs / showers without assistance and could sustain injuries. The DON stated she had been told Resident #13 viewed the Tub Room as a dog washing station. The DON was not aware of any plans to update, repair or replace fixtures in the Tub Rooms or in-room tubs / showers on the East Wing. Interview with the Administrator on 1/28/2022 at 5:35 PM revealed he was aware of some residents' concerns about not getting showers. The Administrator stated he was not aware of any resident concerns regarding dignity. He stated staff received dignity training and he expected them to maintain resident's dignity. The Administrator indicated plans were in the works to replace the fixtures in the Tub Room on the West Wing, but no plans were currently in the works for work in the East Wing Tub Room. 5. Resident #360 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #360's admission Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact for daily decision making. Resident #360 required assistance of one person for bathing. Observation of Resident #360 on 1/24/2022 at 9:15 AM revealed her lying on her back in bed with a nightgown on. Her hair was greasy and shiny. Interview with Resident #360 on 1/24/2022 at 9:15 AM revealed she had not had a shower, or her hair washed since admission. Resident #360 stated her normal routine at home was to shower and wash her hair every other day. Resident #360 stated she felt rank and dirty. Review of the East Wing Shower Schedule revealed Resident #360 was scheduled for a shower on evening shifts on Mondays, Wednesdays, and Fridays. Review of Resident #360's electronic Activities of Daily Living (ADL) report revealed 29 instances of Nurse Aide (NA) documentation of activity did not occur under the bathing task. There was 1 instance recorded of a bed bath with assistance of 1 person. Interview with NA #2 on 1/26/2022 at 8:35 AM revealed she did not recall ever bathing, showering, or washing the hair of Resident #360. NA #2 stated when she was scheduled to work alone, it was not possible to complete showers. NA #2 stated hair washing was part of the bathing / showering task. Interview with NA #3 on 1/27/2022 at 11:13 AM revealed she did not recall ever bathing, showering, or washing the hair of Resident #360. NA #3 stated there were not enough staff scheduled most days to allow time to complete showers. Interview with NA #9 on 1/28/2022 at 3:30 PM revealed she did not recall ever bathing, showering, or washing the hair of Resident #360. Interview with the Director of Nursing (DON) on 1/28/2022 at 4:04 PM revealed she was not aware Resident #360 had not received a shower or had her hair washed since admission. The DON stated she expected all residents to get at least 2 showers per week or per their preference. The DON indicated the shower schedule was currently on her desk for updating, but she had not had time to complete it as she had been providing resident care so much lately. The DON stated she did not want the residents to feel dirty or rank and expected staff to provide showers and hair washing as scheduled. Interview with the Administrator on 1/28/2022 at 5:39 PM revealed he was aware residents were not getting their showers. He stated if we have not done what we are supposed to do, it is unacceptable.

Based on observations, record reviews, interviews with residents and staff, the facility failed to maintain sufficient staff to assure preferred choices were honored for bathing and requests for transfer in and out of bed; failed to assure consistent showers were provided for residents dependent on staff and as a result of these failures residents expressed feeling that included being helpless and forgotten about. The facility also failed to implement, develop and/or complete baseline and comprehensive care plans and invite residents and their representative to care plan meetings. The facility failed to timely complete and/or transmit comprehensive, quarterly, and significant change Minimum Data Set assessments. These failures affected 15 of 29 residents sampled in the areas of dignity, choices, self-determination, care planning, assessments, and activities of daily living (Resident #6, #7, #9, #10, #11, #12, #13, #28, #36, #39, #41, #57, #58, #109, and #360). The findings included: This tag was cross-referred to: F 550: Based on record review, observations, resident and staff interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, transfers, and incontinence care resulting in residents feeling helpless, dirty, and embarrassed, angry, and forgotten about. This affected 5 of 5 (Residents #9, #39, #28, #13, and #360) sampled residents. F 561: Based on record review, observations, resident and staff interviews, the facility failed to accommodate a resident's request to be assisted out of bed at their preferred time of day (Resident #9) and provide residents with their preferred number of showers per week (Resident #58) for 2 of 4 residents reviewed for choices. F 636: Based on record review and staff interviews, the facility failed to complete and transmit comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes as specified in the Resident Assessment Instrument (RAI) manual for 4 of 30 sampled residents reviewed (Residents #11, #39, #109, and #360). F: 637: Based on record review and staff interviews, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed within 14 days of a resident being admitted into Hospice care for 1 of 1 resident reviewed for Hospice (Resident #7). F: 638: Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for 3 of 30 sampled residents reviewed (Residents #12, #9 and #6). F: 655: Based on record review, resident and staff interviews, the facility failed to complete baseline care plans in conjunction with resident and/or responsible party and failed to provide the resident or their responsible party with a written summary of the baseline care plan for 5 of 5 sampled residents (Resident #109, #10, #39, #36 and #57). F: 656: Based on record review, observations, and interviews with staff the facility failed to implement care plan interventions for 1 of 3 residents reviewed for falls (Resident #57) and 1 of 10 residents reviewed for activities of daily living (Resident #9); the facility also failed to develop a comprehensive care plan for 1 of 1 resident reviewed for hospice (Resident #7) and for 1 of 1 resident reviewed for smoking (Resident #41). F 657: Based on observations, record review and staff interviews, the facility failed to invite residents and/or their representative to participate and provide input in care planning for 3 of 5 sampled residents (Residents #9, #39 and #13) and failed to update the care plan to reflect the current advance directive for 1 of 2 residents (Resident #41) reviewed. This practice had the potential to affect other residents. F 677: Based on record review, observations, interviews with residents and staff the facility failed to provide a shower or a complete bed bath for residents' dependent on staff for activities of daily living care (Resident #28, Resident #9, and Resident #39). An interview was conducted on 1/24/22 at 10:26 AM with Nurse #6. Nurse #6 revealed she had worked at the facility since June 2021, and it was normal for one nurse to be scheduled on the unit. Nurse #6 revealed when she arrived this morning there was one Nurse Aide (NA) for the entire building. Nurse #6 was not sure if facility had found someone to come in but stated it was not unusual to come in and only one NA be in the building. Nurse #6 revealed typically one nurse was assigned to each unit or one Med Aide. Nurse #6 stated residents missed their showers and staff try to get the residents who complain done but sometimes there's not enough time. Nurse #6 stated staffing wasn't getting better, but she was not called in or asked to cover shifts and when she comes in to work finds out the facility was short staffed. During an interview on 1/24/22 at 12:15 PM Nurse Aide (NA) #2 explained she had worked at the facility for two years and normally three NA staff were assigned on each side or at least five NA staff but for the past 6 months she had worked shifts as the only NA in the building. NA #2 stated when she was the only NA resident showers were missed and incontinence care was late and the ability to ensure resident safety was difficult. An interview was conducted with NA #1 on 1/25/22 at 8:42 AM. NA #1 revealed when she arrived this morning only one NA was in the building from night shift. An interview was conducted on 1/25/22 at 5:05 PM with NA #6. NA #6 stated on night shift she had worked as the only NA for the east and west unit. NA #6 revealed on 1/24/22 she worked from 10 AM through 4 AM. During an interview on 1/27/22 at 11:13 AM, NA #3 revealed she worked during the hours of 7:00 AM to 7:00 PM and often worked short-staffed with only one NA for the entire building or 2 NAs, one on each unit. NA #3 verified residents had complained about not getting their scheduled showers and stated when there was only one or 2 NA staff to provide care, resident showers could not be done. NA #3 stated when working day shift, by the time she completed her first resident round breakfast was ready to be served, then there residents who must be supervised for smoking, then it was lunch time and basically all she has time to do is make sure the residents were clean, dry and fed. During an interview on 1/28/22 at 10:48 AM Nurse #4 revealed the facility was often short staffed and there were a lot of days only one NA for entire building and/or for each hall and having one NA made it difficult to get resident showers completed as scheduled. An interview was conducted on 1/28/22 at 2:28 PM with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator explained she did the daily schedule for nursing staff and tried to have two nurses and two Med Aides and four NA staff on first shift. For second shift she tried to have two nurses and three to four NA staff and for night shift 1 nurse and 2 Med Aides. The MDS Coordinator revealed she based the needs of nursing staff on acuity of residents and the facility census and at times there were call outs and currently she didn't have as needed (prn) staff. The MDS Coordinator revealed she used four to five staffing agencies to cover shifts and had heard residents state there's not enough staff and they didn't get a shower. The MDS Coordinator explained she had worked on floor as an NA when someone didn't show up, and when staff called out, she tried to find coverage and if unable either she or the DON came in. The MDS Coordinator revealed management staff were on-call 24 hours a day 7 days a week and due to staffing needs and being pulled to the floor she didn't have much time to complete her job duties as the MDS Coordinator. An interview was conducted with DON on 1/28/22 at 4:14 PM. The DON revealed with the weather and staffing issues she had been pulled to the floor to provide resident care and her regular duties had been put off. During an interview on 1/28/22 at 5:35 PM the Administrator revealed he was aware of issues correlating to staffing including residents missing showers. The Administrator explained resident care came first and when they have all staff showers were done but if there was only one NA it would be difficult for residents to get their showers. The Administrator stated if the facility hadn't done what was supposed to be done that was unacceptable.

Based on resident interviews, record review and staff interviews, the facility failed to maintain 1 of 3 sampled residents' right to be free from verbal abuse (Resident #59) when Executive Director (ED) #1 threatened to hit Resident #59 causing 4 of 7 residents who witnessed the incident to be afraid, nervous and anxious (Residents #22, #59, #72 and #86). Immediate Jeopardy began on 02/22/17 when Resident #59 was verbally abused by ED #1. Immediate Jeopardy was removed on 03/03/17 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to residents rights to be free from abuse. The findings included: Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #59 as having intact cognition, scoring a 14 out of 15 on the Brief Interview for Mental Status, which measures long and short term memory and temporal orientation. She was coded as understanding others and being understood. She was coded as having no [MEDICAL CONDITION], behavioral symptoms or rejection of care. A note by the Social Worker (SW) dated 02/22/17 at 9:36 AM indicated that Resident #59 was observed at 8:50 AM outside the West Wing exit squatted down between two bushes smoking. She was asked to extinguish her cigarette and return to the covered area at the front entrance to wait for transit to take her to an appointment. According to the note, Resident #59 was informed that her smoking privileges were revoked. An interview with the Director of Nursing (DON) on 02/26/17 at 2:05 PM revealed Resident #59 was observed on 02/22/17 about 9:00 AM near the West Wing emergency exit in the shrubbery smoking and was asked by the SW and Executive Director (ED) #1 to extinguish the cigarette and ED #1 informed Resident #59 that her smoking privileges were revoked. The DON stated later that morning Resident #59's physician notified ED #1 that he smelled a strong odor of cigarette smoke in Resident #66's room, the room adjacent to Resident #59's room. The DON stated both residents' rooms were searched and Resident #59 turned in 2 packs of cigarettes and a lighter. The DON stated Resident #59 was observed in the outside smoking area at 2:00 PM smoking with the other residents. The DON stated she and ED #1 met with the department managers at 3:00 PM on 02/22/17 to discuss Resident #59's violation of the smoking policy and she scheduled a meeting for 4:00 PM on 02/22/17 with all the residents who smoked and asked ED #1 to be at the meeting to reinforce the smoking rules. The DON stated she and ED #1 walked outside to the smoking area around 4:00 PM and observed Resident #59 was smoking a cigarette. The DON stated ED #1 asked Resident #59: What are you doing out here? Why are you smoking? and Resident #59 replied: I'm just out here smoking one last time before I go. The DON stated that ED #1 then told Resident #59: You need to leave. I want you to leave right now. The DON reported that Resident #59 continued to smoke and said: I'm going; I'm going; I'm leaving. Then ED #1 told Resident #59: You need to leave before I hit you. The DON stated she assured the residents that no one was going to hit any of them and asked Resident #59 to go inside and told ED #1 that he needed to relax and that no one was going to hit anybody. The DON stated she could tell that Resident #59 was scared and Resident #59 went inside the facility. The DON stated ED #1 remained outside in the smoking area with her and the other residents while she reviewed the facility's smoking policy and ED #1 talked about safety concerns related to residents smoking in non-designated areas. The DON stated she and ED #1 went back inside but the residents remained outside for their smoke break with other staff. The DON stated she went to look for Resident #59 to make sure she was all right then heard the residents outside in smoking area talking about being upset about what happened. An interview on 02/27/17 at 3:12 PM with Patient Care Assistant (PCA) #1 revealed she was outside supervising the residents on 02/22/17 at the 4:00 PM smoke break. PCA #1 stated Resident #59 came out with the other residents and she told her she wasn't allowed to smoke because her privileges had been revoked. PCA #1 stated Resident #59 told her she was just coming out to talk to the other residents. PCA #1 stated she was lighting another resident's cigarette and heard ED #1 tell Resident #59 to get out of here before I hit you. PCA #1 stated she didn't see Resident #59 smoking. PCA #1 stated the DON moved closer to ED #1 and Resident #59 went back in the building. PCA #1 stated that Resident #29 told ED #1 that she was going to call the Ombudsman and he got mad and went back in the facility. PCA #1 stated the DON reviewed the smoking rules with the residents then she went in the building. PCA #1 stated about 5 minutes later ED #1 came back outside for a split second and told the residents he was going to call the Ombudsman about the incident because what he said was wrong. A second interview with the DON on 02/28/17 at 9:12 AM revealed 11 residents were outside in the smoking area on 02/22/17 at 4:00 PM. The DON stated the residents told her that ED #1 had come back outside but she didn't observe ED #1 outside. The DON stated she met Resident #59 in the hall and went to her office with Resident #59 to get her cigarettes and lighter then walked with her to the front entrance. The DON stated Resident #59 wanted to say good-bye to a friend on the West Wing and as they passed ED #1's office, he came out in the hall and apologized to Resident #59. The DON stated Resident #59 left. An interview with ED #1 on 02/28/17 at 5:00 PM revealed he went outside to the smoke area on 02/22/17 at 4:00 PM after a staff member reported seeing Resident #59 smoking in the outside smoking area with other residents. ED #1 stated he asked Resident #59: What are you doing? and she didn't respond. ED #1 stated he then asked Resident #59: Where did you get that cigarette? and she still didn't respond. ED #1 stated he then said to Resident #59: I can't believe you're out here smoking and Resident #59 replied: I wanted one last cigarette. ED #1 stated he then told Resident #59: You need to put that cigarette out and you need to leave the smoking area but Resident #59 didn't say anything or get up to leave. ED #1 stated he was standing about 10 - 12 feet away from Resident #59. ED #1 stated he then told Resident #59: You need to get up and leave now before I hit you. ED #1 stated he couldn't believe what he had just said and immediately told Resident #59: I just violated your rights. I'm so sorry. I didn't mean that. ED #1 stated Resident #59 left the smoking area and went in the facility. ED #1 stated he remained outside with the DON while she reviewed the smoking rules but he didn't say anything further. ED #1 stated he and the DON came back in the building around 4:30 PM and he told her they needed to report the incident. ED #1 stated someone told him they heard the residents in the smoking area talking about calling the Ombudsman so he stepped back outside in the smoking area briefly to tell the residents he was going to notify the Ombudsman of the incident himself. He was unable to recall the exact time that he went back outside but stated it was between 4:30 PM and 5:00 PM. The ED stated about 5:00 PM he saw Resident #59 in the hall near the West Wing nurses station and he went out to apologize. During a telephone call on 02/28/17 at 7:59 PM with Resident #59 when she was asked if she was abused while she was a resident at the facility, she stated no she wasn't. When asked if anything happened outside on 02/22/17 at the 4:00 PM smoke break and if she was threatened, Resident #59 stated she wasn't threatened but was asked to go back inside which she did. Resident # 59 stated she knew she wasn't supposed to be out in the smoking area and she knew they were just setting an example for the other residents. When asked if ED #1 threatened to hit her- Resident #59 stated he didn't threaten to hit her. She stated he just told her to go back inside. When asked if she ever felt afraid that ED #1 was going to hit her, she stated she didn't feel afraid that he was going to hit her. On 03/01/17 at 2:14 PM Resident #59 came to facility to speak to surveyor and stated she didn't really tell the truth about ED #1 during the phone interview on 02/28/17 because she was afraid of getting in trouble for smoking and also afraid of getting the DON in trouble. Resident #59 stated ED #1 came out in the smoking area and asked her: What are you doing? Resident #59 stated she told him she was having one last smoke break. Resident #59 stated ED #1 asked her: Where did you get that cigarette? She said she told him it fell out in her purse. She said ED #1 then told her: You get in there before I hit you. Resident #59 stated ED #1 had his fists clenched at his side and it really scared her. Resident #59 stated the DON was in the smoking area with them and told her that ED #1 wouldn't hit her. Resident #59 stated she was still shaking when her family arrived to pick her up. Resident #59 stated she was getting ready to leave when ED #1 apologized to her at the West Wing nurse's station. Resident # 72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change MDS dated [DATE] coded Resident #72 as having intact cognition with a BIMS score of 15 out of 15. She was coded as understanding others and being understood. She was coded as having no [MEDICAL CONDITIONS], behavioral symptoms or rejection of care. An interview on 02/27/17 at 10:53 AM with Resident #72 revealed she was in the outside smoking area on 02/22/17 at 4:00 PM when ED#1 came raging through the door and around to the table where another resident was sitting and told her to get out of his building before he hit her. Resident #72 stated ED #1's fist was clenched but then he unclenched his fist and didn't do anything. Resident #72 stated she was frightened because ED #1 was in such a rage and raised his voice and she wasn't sure what he was going to do. Resident #72 stated she didn't feel threatened now but would feel scared if ED #1 came back to the facility. An interview with Resident #29 on 02/27/17 at 10:55 AM revealed she was in the outside smoking area on 02/22/17 at the 4:00 PM smoke break with other residents for a meeting with the DON and ED #1. Resident #29 stated she saw one resident smoking when she went outside and none of the other residents had their cigarettes. Resident #29 stated when ED #1 came out and saw Resident #59 smoking he asked her what she was doing and where she got her cigarettes. Resident #29 stated ED #1 then told Resident #59 to get out of his building right now before he hit her and his fists were balled up. Resident #29 stated the DON very quickly said: No one is going to hit anybody. Then, ED #1 told Resident #59 that he wasn't going to hit her. Resident #29 stated the DON and ED #1 went ahead with the meeting to discuss the smoking rules then went back in the facility. Resident #29 stated she and the other residents were discussing calling the Ombudsman and ED #1 came back outside and told them that he was going to call the Ombudsman about the incident. Resident #29 stated when she came in from the smoking area and past the front entrance ED #1 was at the front door with the men who were working on the door. Resident #29 stated she didn't see ED #1 after that time. Resident #29 stated she was angry about what ED #1 said to Resident #59 because it was very inappropriate for someone in his position to threaten to hit a resident. Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] coded Resident #86 as having intact cognition with a BIMS score of 15 out of 15. She was coded as understanding others and being understood. She was coded as having no [MEDICAL CONDITIONS], behavioral symptoms or rejection of care. An interview on 02/27/17 at 11:06 AM with Resident #86 revealed she was in the outside smoking area on 02/22/17 at the 4:00 PM smoke break with the other residents. Resident #86 stated ED #1 came out the door shouting at another resident and asked her why she was out there and where she got the cigarettes. Resident #86 stated ED #1 was sort of wild-looking and told the other resident to get out of the smoking area before he hit her. Resident #86 stated ED #1's face was red and his fist was clenched at his side. Resident #86 stated she was nervous and anxious because she didn't know what he was going to do. An interview with Resident #66 on 02/27/17 at 11:38 AM revealed she was in the outside smoking area with other residents on 02/22/17 at the 4:00 PM smoke break and heard ED #1 tell Resident #59 to get off the premises before he hit her but he then apologized as soon as he said it. Resident #66 stated it didn't scare her and she didn't feel like ED #1 was going to hit Resident #59. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] coded Resident #22 as having intact cognition with a BIMS score of 15 out of 15. She was coded as understanding others and being understood. She was coded as having no [MEDICAL CONDITIONS], behavioral symptoms or rejection of care. An interview on 02/27/17 at 3:05 PM with Resident #22 revealed she was in the outside smoking area on 02/22/17 at the 4:00 PM smoke break and was sitting beside Resident #59. Resident #22 stated that ED #1 saw Resident #59 smoking and yelled at her that he was so mad he could hit her. Resident #22 said the residents in the smoking area after the incident were discussing calling the Ombudsman when ED #1 came back outside and screamed out at them that he was calling the Ombudsman himself. Resident #22 stated she was upset for 2 days. On 03/01/17 at 9:14 AM, ED #2 was informed of Immediate Jeopardy. The Administration provided an acceptable allegation of compliance on 03/03/17 at 2:45 PM. Allegation of Compliance GLC Asheville March 3rd, 2017 F 223 Abuse The Immediate Plan below was implemented beginning on 2/22/17 to ensure all residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents have the right to exercise his or her rights. · 02/22/17 at or around 4 PM, the facility's Executive Director (ED) entered the facility's outside smoking area and approached resident #59 for smoking after her privileges had been revoked. Where he proceed to verbally abuse #59 by stating to her if she did not leave the facility he would hit her. The Director of Nurses was witness to the event and had resident # 59 come to her side and addressed all the smoking residents: #29, #72, #86, #10, #23, #79, #67, #66, #22, #28 and #75. The Director of Nurses explained that no one was going to be abused, asked if they felt safe and reviewed smoking policy with them. They all replied yes to feeling safe. Then the Executive Director and Director of Nurses reentered the building and the Executive Director went to his office. Then the Director of Nurses heard the outside smoking group talking loudly and she went outside and they stated the Executive Director had come back to the smoking outside door and stated I will be calling the ombudsman to report myself. She asked if they were ok and they all replied yes and she explained to the residents not to worry she would be reporting to all appropriate agencies. · Resident #59 was discharging as previously planned and needed her belongings that were locked in Director of Nursing office and the Director of Nursing proceeded to assist with her discharge and had the MDS Coordinator stay with the Executive Director till she finished assisting resident #59. · The Director of Nurses then called the North Carolina Ombudsman and then the Executive Director's superior, Regional Vice President of Operations, to let him know of the incident and he suspended the Executive Director immediately. · Executive Director was suspended and left the faciity on [DATE] at or around 6:20 PM pending investigation and was terminated on 02/27/17 at 7:45 AM. · The Director of Nurses failed to follow facility abuse policy to immediately remove the Executive Director from facility. She was reeducated on abuse, neglect policy and chain of command by Field Service Clinical Director on 03/01/17 and with any abuse she has the authority to remove her superior in the event of alleged abuse while investigation pending. Maintaining resident's safety at all times. · This incident was reported by Director of Nurses Services to ombudsman on 02/22/17 via voice mail at or around 6 PM. · The 24 hour reportable was started and completed 02/23/17 and sent to North Carolina Department of Health and Human Services · All other residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 03/01/17 the managers interviewed all other interviewable residents for any signs of abuse, understanding of abuse, if they know how to report abuse, and if they have any abuse they would like to report. Beginning on 03/01/17 Department Managers or designee will monitor with daily room rounds by asking the residents if they feel safe, if they want to report any abuse and if they know what abuse is. Beginning 03/01/17 during the residents care plans Social Worker will ask the residents if they feel safe, if they know what abuse is, who do you report abuse to and do you have any abuse to report. · Abuse and Neglect training initiated to all staff on 02/23/17 including: nursing, environmental services, dietary personnel, therapy, and department managers. This in-service was conducted by Social Worker and Assistant Director of Nurses. Training continues to be ongoing for current employees who were not present on 02/23/17 including the types of abuse, mandated reporting requirements, and immediate steps to ensure the residents safety. Staff will not be allowed to work until training on abuse and neglect is completed. · Staff will receive education on the Abuse and Neglect Policy upon hire, and will be reviewed quarterly. This will be conducted by Director of Nursing services, Assistant Director of Nursing Services and Business Office Specialist · A Resident Council Meeting was held on 03/01/17 to review resident rights, reporting of abuse and neglect. Resident Council meeting was conducted by Activity Director and Executive Director. Approximately 12 residents were in attendance. No concerns or complaints were voiced and all felt safe since the Executive Director was gone. The results of the Resident Council Meeting Minutes will be reviewed at Quality Assurance Performance Improvement. · On 03/01/17 an audit of current nursing home employees was conducted by department managers and asked if they felt stressed, burnt out, if they felt unsafe, knew of any abuse or desire to abuse residents. Did they know how to report abuse and who to report it to? · This incident was reported by the new Interim Executive Director to Adult Protective Service on 03/01/17 at 7:30 PM. · The incident was reported by the new Interim Executive Director to North Carolina Board of Administrators via voice mail on 03/01/17. Immediate Jeopardy was removed on 03/03/17 at 5:09 PM when interviews with nursing staff, administrative staff and non-nursing staff confirmed they had received in-service training and knew the different types of abuse and the right of every resident to be free from abuse.

Based on resident interviews, record review and staff interviews, the facility failed to immediately report verbal abuse of a resident by Executive Director (ED) #1 to the Area Vice President (AVP) and also failed to notify the North Carolina Health Care Personnel Investigations (NCHCPI) within 2 hours of the incident. This affected 1 of 3 residents sampled for abuse (Resident #59). Immediate Jeopardy began on 02/22/17 when the Director of Nursing (DON) and Patient Care Assistant (PCA) #1 witnessed the ED verbally abuse Resident #59, but did not immediately report the verbal abuse to the AVP. Immediate Jeopardy was removed on 03/03/17 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to informing the ED and/or AVP of witnessed or alleged incidents of abuse. The findings included: Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #59 as having intact cognition, as understanding others and being understood. She was coded as having no [MEDICAL CONDITION], behavioral symptoms or rejection of care and required supervision of one person for all activities of daily living except eating for which she was independent. A note by the Social Worker (SW) dated 02/22/17 at 9:36 AM indicated that Resident #59 was observed at 8:50 AM outside the West Wing exit squatted down between two bushes smoking. She was asked to extinguish her cigarette and return to the covered area at the front entrance to wait for transit to take her to an appointment. According to the note, Resident #59 was informed that her smoking privileges were revoked and she became upset and stated she wanted to leave that day. An interview with the Director of Nursing (DON) on 02/26/17 at 2:05 PM revealed Resident #59 was observed on 02/22/17 about 9:00 AM near the West Wing emergency exit in the shrubbery smoking and was asked by the SW and ED #1 to extinguish the cigarette and ED #1 informed Resident #59 that her smoking privileges were revoked. The DON stated she and ED #1 met with the department managers at 3:00 PM on 02/22/17 to discuss Resident #59's violation of the smoking policy and she scheduled a meeting for 4:00 PM on 02/22/17 with all the residents who smoked and asked ED #1 to be at the meeting to reinforce the smoking rules. The DON stated she and ED #1 walked outside to the smoking area around 4:00 PM and observed Resident #59 was smoking a cigarette. The DON stated ED #1 asked Resident #59: What are you doing out here? Why are you smoking? and Resident #59 replied: I'm just out here smoking one last time with my family (referring to the other residents) before I go. The DON stated that ED #1 then told Resident #59: You need to leave. I want you to leave right now. The DON reported that Resident #59 continued to smoke and said: I'm going; I'm going; I'm leaving. Then ED #1 told Resident #59: You need to leave before I hit you. The DON stated she assured the residents that no one was going to hit any of them and asked Resident #59 to go inside and told ED #1 that he needed to relax and that no one was going to hit anybody. The DON stated she could tell that Resident #59 was scared and Resident #59 went inside the facility. The DON stated ED #1 remained outside in the smoking area with her and the other residents while she reviewed the facility's smoking policy and ED #1 talked about safety concerns related to residents smoking in non-designated areas. The DON stated she and ED #1 went back inside but the residents remained outside for their smoke break with other staff. The DON stated she went to look for Resident #59 to make sure she was all right. The DON stated she was in the hall near the door to the outside smoking area and heard the residents outside in smoking area talking about being upset about what happened. The DON stated ED #1 went back out to the smoking area, without her knowledge, and told the residents he was going to call the Ombudsman about the incident. The DON stated she called the Ombudsman about 5:00 PM and left a message then called the Area Vice President (AVP) from ED #1's office and informed him of the incident. The DON stated the AVP immediately suspended ED #1 pending further investigation of the incident. An interview on 02/27/17 at 10:53 AM with Resident #72, who was cognitively intact, revealed she was in the outside smoking area on 02/22/17 at 4:00 PM when Resident #59 was outside with the other residents smoking. Resident #72 stated ED#1 came raging through the door and around to the table where Resident #59 was sitting and told her to get out of his building before he hit her. Resident #72 stated ED #1's fist was clenched but then he unclenched his fist and didn't do anything. Resident #72 stated she was frightened because ED #1 was in such a rage and raised his voice and she wasn't sure what he was going to do. Resident #72 stated she didn't feel threatened now but would feel scared if ED #1 came back to the facility. An interview on 02/27/17 at 10:55 AM with Resident #29, who was cognitively intact, revealed she was in the outside smoking area on 02/22/17 at the 4:00 PM smoke break with other residents for a meeting with the DON and ED #1. Resident #29 stated she saw Resident #59 smoking when she went outside and none of the other residents had their cigarettes. Resident #29 stated when ED #1 came out and saw Resident #59 smoking he asked her what she was doing and where she got her cigarettes. Resident #29 stated ED #1 then told Resident #59 to get out of his building right now before he hit her and his fists were balled up. Resident #29 stated the DON very quickly said: No one is going to hit anybody. Then, ED #1 told Resident #59 that he wasn't going to hit her. Resident #29 stated the DON and ED #1 went ahead with the meeting to discuss the smoking rules then they both went back in the facility. Resident #29 stated she and the other residents were discussing calling the Ombudsman and ED #1 came back outside and told them that he was going to call the Ombudsman about the incident. Resident #29 stated when she came in from the smoking area and past the front entrance ED #1 was at the front door with the men who were working on the door. Resident #29 stated she didn't see ED #1 after that time. An interview on 02/27/17 at 11:06 AM with Resident #86, who was cognitively intact, revealed she was in the outside smoking area on 02/22/17 at the 4:00 PM smoke break with the other residents. Resident #86 stated ED #1 came out the door shouting at Resident #59 and asked her why she was out there and where she got the cigarettes. Resident #86 stated ED #1 was sort of wild-looking and told Resident #59 to get out of the smoking area before he hit her. Resident #86 stated ED #1's face was red and his fist was clenched at his side. Resident #86 stated she was nervous and anxious because she didn't know what he was going to do. An interview on 02/27/17 at 11:38 AM with Resident #66, who was cognitively intact, revealed she was in the outside smoking area with other residents on 02/22/17 at the 4:00 PM smoke break and heard ED #1 tell Resident #59 to get off the premises before he hit her but he then apologized as soon as he said it. Resident #66 stated it didn't scare her and she didn't feel like ED #1 was going to hit Resident #59. An interview on 02/27/17 at 3:12 PM with Patient Care Assistant (PCA) #1 revealed she was outside supervising the residents on 02/22/17 at the 4:00 PM smoke break. PCA #1 stated Resident #59 came out with the other residents and she told her she wasn't allowed to smoke because her privileges had been revoked. PCA #1 stated Resident #59 told her she was just coming out to talk to the other residents. PCA #1 stated she was lighting another resident's cigarette and heard ED #1 tell Resident #59 to get out of here before I hit you. PCA #1 stated she didn't see Resident #59 smoking. PCA #1 stated the DON moved closer to ED #1 and Resident #59 went back in the building. PCA #1 stated that Resident #29 told ED #1 that she was going to call the Ombudsman and he got mad and went back in the facility. PCA #1 stated the DON reviewed the smoking rules with the residents then she went in the building. PCA #1 stated about 5 minutes later ED #1 came back outside for a split second and told the residents he was going to call the Ombudsman about the incident because what he said was wrong. An interview on 02/27/17 at 3:27 PM with the SW revealed she and ED #1 were informed by NA #1 on 02/22/17 at 8:30 AM that Resident #59 was outside the West Wing emergency exit smoking. The SW stated she and ED #1 went to investigate and found Resident #59 squatting down between the bushes and the building smoking a cigarette. The SW stated ED #1 then told Resident #59 to extinguish the cigarette and return to the front of the building to wait for transit to take her to an appointment. The SW stated ED #1 also informed Resident #59 that her smoking privileges were revoked. The SW stated she didn't have any first hand knowledge of the incident that occurred in the outside smoking area on 02/22/17 at 4:00 PM. An interview on 02/27/17 at 3:05 PM with Resident #22, who was cognitively intact, revealed she was in the outside smoking area on 02/22/17 at the 4:00 PM smoke break and was sitting beside Resident #59. Resident #22 stated that ED #1 saw Resident #59 smoking and yelled at her that he was so mad he could hit her. Resident #22 said the residents in the smoking area after the incident were discussing calling the Ombudsman when ED #1 came back outside and screamed out at them that he was calling the Ombudsman himself. Resident #22 stated she was upset for 2 days. A second interview with the DON on 02/28/17 at 9:12 AM revealed 11 residents were outside in the smoking area on 02/22/17 at 4:00 PM. The DON stated the residents told her that ED #1 had come back outside but she didn't observe ED #1 outside. The DON stated she met Resident #59 in the hall and went to her office with Resident #59 to get her cigarettes and lighter then walked with her to the front entrance. The DON stated Resident #59 wanted to say good-bye to a friend on the West Wing and as they passed ED #1's office, he came out in the hall and apologized to Resident #59. The DON stated Resident #59 left the building then she and ED #1 went in his office and she called the Ombudsman around 5:00 PM. The DON stated she then called the AVP and reported the incident and the AVP suspended ED #1. The DON stated ED #1 left the building before 5:30 PM. A third interview with the DON on 02/28/17 at 3:07 PM about the facility's abuse policy revealed the DON was familiar with the policy. When asked if she considered ED #1's threat to hit Resident #59 abuse, the DON stated she considered it verbal abuse. When the DON was asked about the facility's policy regarding immediate suspension of an employee who was observed or accused of abusing a resident, she stated she felt like she needed to call the AVP because the staff involved was the administrator. The DON stated if the perpetrator had been any other employee she and the administrator would have gotten the employee's statement and placed them on suspension pending the investigation and immediately removed the employee from the facility. The DON was unable to offer any further explanation as to why she didn't immediately call the AVP and constantly observe ED #1. An interview with ED #1 on 02/28/17 at 5:00 PM revealed he went outside to the smoke area on 02/22/17 at 4:00 PM after a staff member reported seeing Resident #59 smoking in the outside smoking area with other residents. ED #1 stated he asked Resident #59: What are you doing? and she didn't respond. ED #1 stated he then asked Resident #59: Where did you get that cigarette? and she still didn't respond. ED #1 stated he then said to Resident #59: I can't believe you're out here smoking and Resident #59 replied: I wanted one last cigarette with my family(referring to the other residents.) ED #1 stated he then told Resident #59: You need to put that cigarette out and you need to leave the smoking area but Resident #59 didn't say anything or get up to leave. ED #1 stated he was standing about 10 - 12 feet away from Resident #59. ED #1 stated he then told Resident #59: You need to get up and leave now before I hit you. ED #1 stated he couldn't believe what he had just said and immediately told Resident #59: I just violated your rights. I'm so sorry. I didn't mean that. ED #1 stated Resident #59 left the smoking area and went in the facility. ED #1 stated he remained outside with the DON while she reviewed the smoking rules but he didn't say anything further. ED #1 stated he and the DON came back in the building around 4:30 PM and he told her they needed to report the incident. ED #1 stated someone told him they heard the residents in the smoking area talking about calling the Ombudsman so he stepped back outside in the smoking area briefly to tell the residents he was going to notify the Ombudsman of the incident himself. He was unable to recall the exact time that he went back outside but stated it was between 4:30 PM and 5:00 PM. The ED stated about 5:00 PM he saw Resident #59 in the hall near the West Wing nurses station and he went out to apologize. ED #1 stated the DON called the Ombudsman from his office around 5:20 PM then called the AVP. ED #1 stated he thought he left the facility about 6:30 PM. When asked what the Abuse Policy specified as to when he should have left the facility after the incident, he stated he should have left immediately. During a telephone call on 02/28/17 at 7:59 PM, Resident #59 stated she was outside waiting to go to an appointment the morning of 02/22/17 and smoked and staff caught her. Resident #59 stated staff changed her smoking privileges from unsupervised to supervised because it was part of the smoking rules. Resident #59 stated staff were respectful when they told her about the restriction. Resident #59 stated she was in the outside smoking area on 02/22/17 at 4:00 PM and was smoking. She stated she wasn't threatened but was asked to go back inside which she did. Resident # 59 stated she knew she wasn't supposed to be out in the smoking area and she knew they were just setting an example for the other residents. Resident #59 stated ED #1 didn't threaten to hit her. She stated he just told her to go back inside. Resident #59 stated she didn't feel afraid that ED #1 was going to hit her. An interview on 03/01/17 at 1:51 PM with PCA #1 revealed she received training on abuse during her orientation in January 2017 and was instructed to report any observed or alleged abuse immediately to her supervisor. When asked if she thought ED #1's statement to Resident #59 on 02/22/17 at 4:00 PM was abuse, PCA #1 stated she thought it was verbal abuse. PCA #1 stated she didn't report it to anyone because the DON also witnessed the incident. An interview on 03/01/17 at 12:11 PM with the AVP revealed his expectation was that any witnessed or alleged abuse of a resident should be reported immediately and the person accused of abusing a resident should be removed from the facility immediately and the residents protected. The AVP stated he should have been notified immediately after the incident on 02/22/17 at 4:00 PM when ED #1 threatened to hit Resident #59. The AVP stated he was notified on 02/22/17 at 6:16 PM of the incident that occurred on 02/22/17 at 4:00 PM when ED #1 threatened to hit Resident #59. The AVP stated he placed ED #1 on immediate suspension. Another interview on 03/01/17 at 3:15 PM with the DON about the incident on 02/22/17 at 4:00 PM when ED #1 threatened to hit Resident #59, revealed she should have told ED #1 to leave the building and should have made sure he left right away. The DON stated she should have called the AVP immediately following the incident. In an interview on 03/01/17 at 2:14 PM with Resident #59 in the facility, she stated she didn't tell the truth about ED #1 during the phone interview on 02/28/17 because she was afraid of getting in trouble for smoking and also afraid of getting the DON in trouble. Resident #59 stated ED #1 came out in the smoking area and asked her: What are you doing? Resident #59 stated she told him she was having one last smoke break with her family (referring to her friends at the facility). Resident #59 stated ED #1 asked her: Where did you get that cigarette? She said she told him it fell out in her purse. She said ED #1 then told her: You get in there before I hit you. Resident #59 stated ED #1 had his fists clenched at his side and it really scared her. Resident #59 stated the DON was in the smoking area with them and told her that ED #1 wouldn't hit her. Resident #59 stated she was still shaking when her sister arrived to pick her up. Resident #59 stated she was getting ready to leave when ED #1 apologized to her at the West Wing nurse's station. Review of the 24 hour report which was submitted by the facility to the NCHCPI revealed it was signed as completed by the SW on 02/23/17. Review of the fax transmission report revealed it was faxed to the NCHCPI on 02/23/17 at 1:01 PM which was approximately 21 hours after the incident of verbal abuse occurred. On 03/01/17 at 9:14 AM, ED #2 was informed of Immediate Jeopardy. The Administration provided an acceptable allegation of compliance on 03/03/17 at 2:45 PM. Allegation of Compliance GLC Asheville March 3rd, 2017 F 225 · 02/22/17 at or around 4 PM, the Executive Director (ED) entered the facility outside smoking area and approached resident #59 for smoking after her privileges had been revoked. He then proceeded to become verbally abusive to resident #59 by stating to her if she did not leave the facility he would hit her. This was witnessed by Director of Nurses who immediately had resident #59 come to her side and addressed resident #59 and the other residents on the smoking patio: #29, #72, #86, #10, #23, #79, #67, #66, #22, #28 and #75 saying no one was going to hit anyone and reviewed the smoking policy and asked if they felt secure and safe and they replied yes. The Executive Director and Director of Nurses came back into the building and The ED went towards his office. The Director of Nurses failed to follow facility abuse policy and did not have him removed from facility immediately. The Executive Director then went to outside smoking door, opened it, and stated to smoking residents that he was going to report himself to the ombudsman. When the Director of Nurses heard the outside smoking group talking loudly she then went back outside to smoking area and asked if residents were ok and felt safe, and they told the Director Of Nurses that the Executive Director had come back to door way and stated he was reporting himself. She asked if they were ok and all replied yes and she explained to them not to worry as she was going to report to all appropriate agencies. · When she came back into facility Resident #59 was discharging home as previously planned and needed her belongings that were locked in the Director of Nurses office. The Director of Nurses completed this task. While she was completing this task the MDS Coordinator stayed with the Executive Director till she was finished. · The Director of Nurses then took Executive Director to his office and then she called the North Carolina Ombudsman and left voice mail of incident. She then called the Executive Director's superior Regional Vice President of Operations and explained the incident and he suspended the Executive Director effective immediately pending investigation and he left building with Director of Nurses supervising that he didn't go anywhere else in facility. He was officially terminated on 02/27/17 at 7:45 AM · On 02/23/17 the Social Service Director began 24 hour reportable and completed and sent to North Carolina Health and Human Services by 4 PM. · The new Interim Executive Director started on 02/27/17 at or around 11 AM and was educated on the Abuse and Neglect Policy and the Grievance Policy, by the Field Service Clinical Director on 03/01/17. · All other residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 3/1/17 the department managers interviewed all other interviewable residents for any signs of abuse, understanding of abuse, if know how to report abuse, and if they have any abuse they would like to report. Beginning 03/01/17 department managers or designee will monitor with daily room rounds with asking if they felt safe, if they had anything to report, any abuse that they want to report. Beginning 03/01/17 during their care plans Social Worker will ask residents if they feel safe, if they know what abuse is, if they know who to report to and if they have any abuse to report. · Abuse and Neglect training initiated to all staff on 02/23/17 including: nursing, environmental services, dietary personnel, therapy, and department managers. This in-service was conducted by Social Worker and Assistant Director of Nurses. Training continues to be ongoing for current employees who were not present on 02/23/17 and includes the types of abuse, mandated reporting requirements and immediate steps to ensure the residents safety. Any staff that has not completed training will not be able to work until training is complete. · The 5 day reportable was completed by Social Services Director on 3/1/17 and sent to North Carolina Health and Human Services. · The Director of Nurses was re-educated on 03/01/17 by Field Service Clinical Director of Golden Living Center on the Abuse/Neglect policy including the immediate removal of the alleged perpetrator from the building, chain of command and even if it is your superior you have the right to ask them to leave and notify their superior which is Regional vice President of Operations. Graph of chain of command for Golden Living Center with names, titles, contact numbers and their responsibilities was posted at time clock for all staff effective 03/2/17 by 4 PM. · Staff will receive education on the Abuse and Neglect Policy upon hire, and will be reviewed quarterly. This will be conducted by Director of Nursing Services, Assistant Director of Nursing Services and Business Office Specialist · A Resident Council Meeting was held on 3/1/17 to review resident rights, reporting of abuse and neglect. Resident Council meeting was conducted by Activity Director and interim Executive Director. Approximately 12 residents were in attendance. No concerns or complaints were voiced and all felt safe since the Executive Director was gone and happy with new interim Executive Director .The results of the Resident Council Meeting Minutes will be reviewed at Quality Assurance Performance Improvement meeting monthly. · On 03/01/17 an audit of current Golden Living Center employees was conducted and asked if they felt stressed or burnt out, if they felt unsafe, knew of any abuse or desire to abuse residents. Did they know how to report abuse and who to report it to? The new chain of command was reviewed with employees. All employees that were interviewed in person or by phone did not feel stressed or burnt out and knew how to report any signs of abuse. · This incident was reported by Interim Executive Director to Adult Protective Service on 03/01/17 at 7:30 PM. · The incident was reported by Interim Executive Director to North Carolina Board of Administrators on 03/01/17 at 7 PM · The Director of Nurses was re-educated on 03/02/17 at 3:16 PM on 24 hour reportable process according to Federal Regulations through established procedures with reporting abuse immediately. Immediate Jeopardy was removed on 03/03/17 at 5:09 PM when interviews with nursing staff, administrative staff and non-nursing staff confirmed they had received in-service training and knew the different types of abuse and the requirement that any observed or alleged abuse of a resident should be reported immediately to the ED or DON and if the perpetrator was the ED it should be reported to the AVP. Staff confirmed they were provided with a copy of the facility's abuse policy and the chain of command.

Based on resident and staff interviews and record review, the facility failed to implement its abuse policy in the areas of protection of the resident and reporting of abuse within 2 hours. The facility failed to separate the perpetrator from the resident, to supervise the alleged perpetrator until he left the facility and to immediately notify the Area Vice President (AVP) of the verbal abuse. This affected 1 of 3 residents sampled for an abuse investigation (Resident #59). Immediate Jeopardy began on 02/22/17 when the facility did not follow its policy to immediately report a verbal threat made by Executive Director (ED) #1 to abuse Resident #59 and did not immediately protect Resident #59. The Director of Nursing (DON) and Patient Care Assistant (PCA) #1 witnessed the incident but did not immediately report the verbal abuse to the AVP as required according to the facility's abuse policy. The DON allowed the perpetrator to remain in the building without supervision for 2 additional hours. Immediate Jeopardy was removed on 03/03/17 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to protecting residents from being abused and following the abuse policy. The findings included: The facility's Abuse and Neglect policy with a revision date of 11/18/16 included: *Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that she will never be able to see her family again. *Identification: Incidents identified as potential violations shall be reported as stated in the Reporting Section of this policy. *Protection: If the suspected perpetrator is an employee, the ED shall place the employee on immediate investigatory suspension while completing the investigation. *Reporting: It is the responsibility of each individual employee to immediately report any reasonable suspicion of a crime, and all allegations of mistreatment, neglect, abuse, injury of unknown origin and/or misappropriation of resident property to the designated supervisor in charge at the time. For purposes of reporting immediately means as soon as possible but not to exceed 2 hours in the event of serious injury or death of patient involved in a report or 24 hours for all other reports or shorter if State law/regulations require a report within a shorter timeframe. It is the responsibility of the designated supervisor to immediately communicate any report of an alleged violation to the ED. The ED shall also notify immediate management. The ED shall ensure that alleged violations are reported promptly to the regional/area Vice President. During an interview on 02/26/17 at 2:05 PM, the DON stated she and ED #1 walked outside to the smoking area around 4:00 PM and observed Resident #59 was smoking a cigarette. Resident #59's smoking privileges had been revoked prior to this time. The DON stated ED #1 asked Resident #59: What are you doing out here? Why are you smoking? and Resident #59 replied: I'm just out here smoking one last time with my family (referring to the other residents) before I go. The DON stated that ED #1 then told Resident #59: You need to leave. I want you to leave right now. The DON reported that Resident #59 continued to smoke and said: I'm going; I'm going; I'm leaving. Then ED #1 told Resident #59: You need to leave before I hit you. The DON stated she assured the residents that no one was going to hit any of them and asked Resident #59 to go inside and told ED #1 that he needed to relax and that no one was going to hit anybody. The DON stated she could tell that Resident #59 was scared and Resident #59 went inside the facility. The DON stated ED #1 remained outside in the smoking area with her and the other residents while she reviewed the facility's smoking policy and ED #1 talked about safety concerns related to residents smoking in non-designated areas. The DON stated she and ED #1 went back inside but the residents remained outside for their smoke break with other staff. The DON stated she went to look for Resident #59 to make sure she was all right then heard the residents outside in smoking area talking about being upset about what happened. The DON stated ED #1 went back out to the smoking area, without her knowledge, and told the residents he was going to call the Ombudsman about the incident. The DON stated she called the Ombudsman about 5:00 PM and left a message then called the Area Vice President (AVP) from ED #1's office and informed him of the incident. The DON stated the AVP immediately suspended ED #1 pending further investigation of the incident. An interview on 02/27/17 at 3:12 PM with PCA #1 revealed she was outside supervising the residents on 02/22/17 at the 4:00 PM smoke break. PCA #1 stated Resident #59 came out with the other residents and she told her she wasn't allowed to smoke because her privileges had been revoked. PCA #1 stated Resident #59 told her she was just coming out to talk to the other residents. PCA #1 stated she was lighting another resident's cigarette and heard ED #1 tell Resident #59 to get out of here before I hit you. PCA #1 stated she didn't see Resident #59 smoking. PCA #1 stated the DON moved closer to ED #1 and Resident #59 went back in the building. PCA #1 stated that Resident #29 told ED #1 that she was going to call the Ombudsman and he got mad and went back in the facility. PCA #1 stated the DON reviewed the smoking rules with the residents then she went in the building. PCA #1 stated about 5 minutes later ED #1 came back outside for a split second and told the residents he was going to call the Ombudsman about the incident because what he said was wrong. An interview with the DON on 02/28/17 at 3:07 PM about the facility's abuse policy revealed the DON was familiar with the policy. When asked if she considered ED #1 threatening to hit Resident #59 abuse, the DON stated she considered it verbal abuse. When the DON was asked about the facility's policy regarding immediate suspension of an employee who was observed or accused of abusing a resident, she stated she felt like she needed to call the AVP because the staff involved was the administrator. The DON stated if the perpetrator had been any other employee she and the administrator would have gotten the employee's statement and placed them on suspension pending the investigation and immediately removed the employee from the facility. The DON was unable to offer any further explanation as to why she didn't immediately call the AVP and constantly observe ED #1. An interview with ED #1 on 02/28/17 at 5:00 PM revealed he was outside in the smoke area on 02/22/17 at 4:00 PM with the DON. ED #1 confirmed that he told Resident #59: You need to get up and leave now before I hit you. ED #1 acknowledged that he should not have said it. ED #1 stated he stepped back outside in the smoking area briefly to tell the residents he was going to notify the Ombudsman of the incident himself. ED #1 stated he thought he left the facility about 6:30 PM. When asked what the Abuse Policy specified as to when he should have left the facility after the incident, he stated he should have left immediately. He stated he was completing some documentation in his office and that was why he didn't leave immediately. An interview on 03/01/17 at 1:51 PM with PCA #1 revealed she received training on abuse during her orientation in January 2017 and was instructed to report any observed or alleged abuse immediately to her supervisor. When asked if she thought ED #1's statement to Resident #59 on 02/22/17 at 4:00 PM was abuse, PCA #1 stated she thought it was verbal abuse. When asked if she reported it to anyone, PCA #1 stated she didn't report it to anyone because the DON also witnessed the incident. An interview on 03/01/17 at 12:11 PM with the AVP revealed his expectation was that any witnessed or alleged abuse of a resident should be reported immediately and the person accused of abusing a resident should be removed from the facility immediately and the residents protected. The AVP stated he should have been notified immediately after the incident on 02/22/17 at 4:00 PM when ED #1 threatened to hit Resident #59. The AVP stated he was notified on 02/22/17 at 6:16 PM of the incident that occurred on 02/22/17 at 4:00 PM when ED #1 threatened to hit Resident #59. The AVP stated he placed ED #1 on immediate suspension. Another interview on 03/01/17 at 3:15 PM with the DON about the incident on 02/22/17 at 4:00 PM when ED #1 threatened to hit Resident #59, revealed she should have told ED #1 to leave the building and should have made sure he left right away. The DON stated she should have called the AVP immediately following the incident. On 03/01/17 at 9:14 AM, ED #2 was informed of Immediate Jeopardy. The Administration provided an acceptable allegation of compliance on 03/03/17 at 2:45 PM. Allegation of Compliance GLC Asheville March 3rd, 2017 F 226 For deficiencies concerning the facility's development of and implementation of policies and procedures: On 03/01/17 The Field Service Clinical Director and the Regional Area Vice President reviewed all the components of the abuse and neglect policy that was revised on 11/18/16 which includes the 2 hour time frame for reporting abuse allegations to the appropriate agencies. The Executive Director, Director of Nurses and Social Service Director will review and educate all employees including contract staff on policies and procedures to protect residents from any form of abuse. The verbal inservices with a copy of the abuse policy was given to all employees who worked 3/1/17. All absent staff will be educated on policies and procedures to protect residents from any form of abuse prior to being allowed to work. *02/22/17 at or around 4 PM, the Executive Director (ED) entered the facility's outside smoking area and approached resident #59 for smoking after her privileges had been revoked. He then proceeded to become verbally abusive to resident #59 by stating to her if she did not leave the facility he would hit her. This was witnessed by Director of Nurses who immediately had resident #59 come to her side and addressed resident #59 and the other residents on the smoking patio: #29, #72, #86, #10, #23, #79, #67, #66, #22, #28 and #75. The Director of Nurses explained that no one was going to hit anyone, reviewed the smoking policy and asked if they felt secure and safe and they replied yes. The Executive Director and Director of Nurses came back into the building and the ED went towards his office. The Director of Nurses failed to follow the facility's abuse policy by not protecting the residents by removing him from facility immediately. The Executive Director then went to outside smoking door opened it and stated to smoking residents that he was going to report himself to the ombudsman. When the Director of Nurses heard the outside smoking group talking loudly she then went back to outside to smoking area and asked if residents were ok and felt safe, and they told the Director of Nurses that the Executive Director had come back to doorway and stated he was reporting himself. She asked if they were ok and all replied yes and she explained to them not to worry as she was going to report to all appropriate agencies. When the Director of Nurses came back into facility Resident #59 was being discharged home as previously planned and needed her belongings that were locked in the Director of Nurses office. While the Director of Nurses was completing this task she had the MDS Coordinator stay with the Executive Director till she was finished. The Director of Nurses then took Executive Director to his office and then she called the North Carolina Ombudsman and left voice mail of incident at or around 6 PM. She then called the Executive Director's superior, Regional Vice President of Operations, and explained the incident and he suspended the Executive Director effective immediately pending investigation with Director of Nurses supervising that he didn't go anywhere else in facility. Executive Director was suspended and left the building on 02/22/17 at or around 6:20 PM. He was officially terminated on 02/27/17 at 7:45 AM. *On 02/23/17 the Social Service Director began 24 hour reportable and completed and sent to North Carolina Health and Human Services by 4 PM. *The new Interim Executive Director started on 02/27/17 at or around 11 AM and was educated on the Abuse and Neglect Policy and the Grievance Policy by the Field Service Clinical Director on 03/01/17. Abuse and Neglect training was initiated to all staff on 02/23/17 including: nursing, environmental services, dietary personnel, therapy, and department managers, this in-service was conducted by Social Worker and Assistant Director of Nurses. Training continues to be ongoing for current employees who were not present on 02/23/17. Training includes the types of abuse, mandated reporting requirements with the 2 hour time frame and immediate steps to ensure the residents safety, and included the 24 hour reporting done by Director of Nurses. Staff will not be allowed to work until training on abuse and neglect has been completed. The Director of Nurses was re-educated on 03/01/17 by Fields Service Clinical Director of Golden Living Center on the Abuse/Neglect policy including the immediate removal of the alleged perpetrator from the facility. This included proper chain of command and her ability to remove her Superior if needed The Director of Nurses was re-educated on 03/02/17 at 3:16 PM on 24 hour reportable process according to Federal Regulations through established procedures with reporting abuse no later than 2 hours after allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. Staff will receive education on the Abuse and Neglect Policy upon hire by Director of Nursing Services, Assistant Director of Nursing Services, Social Service Director and Business Office Specialist. In addition to the computer orientation it will be a person to person in service concerning abuse and neglect allowing employees the opportunity to have an adequate understanding of the policy. The abuse policy will be reviewed quarterly. This will be conducted by Director of Nursing Services, Assistant Director of Nursing Services and Business Office Specialist. All computer orientation will be completed before employee will be allowed to work and will be monitored by Assistant Director of Nursing effective 03/03/17. The Business Office Manager will run compliance report Monday thru Friday to verify all new employees have completed computer training. A Resident Council Meeting was held on 03/01/17 to review resident rights, reporting of abuse and neglect. Resident Council meeting was conducted by Activity Director and interim Executive Director. Approximately 12 residents were in attendance. The results of the Resident Council Meeting Minutes will be reviewed at Quality Assurance Performance Improvement. The residents voiced no complaints or concerns and were very happy that the Executive Director was gone. The Interim Executive Director who started on 02/27/17 was educated on the Abuse and Neglect Policy, the Grievance Policy and chain of command for reporting any allegations of abuse by the Field Service Clinical Director on 03/01/17. On 03/01/17 an audit of current Golden Living Center employees was conducted and asked if they felt unsafe, knew of any abuse or have the desire to abuse residents. Did they know how to report abuse and who to report it too? This was conducted by Nursing managers. · Immediately after the incidence occurred on 02/22/17 the Executive Director verbalized to the Director of Nursing and MDS Coordinator that he was frustrated with Resident #59 and her continuous non-compliant behavior to rules and regulations happening over and over had increased his stress level. · This incident was reported to ombudsman on 2/22/17 via voice mail at or around 6pm · A 24 hour reportable was completed on 02/23/17 and sent to North Carolina Department of Health and Human Services. · The 5 day reportable Investigation was completed 03/01/17 and was sent to North Carolina Department of Health and Human Services. · This incident was reported to Adult Protective Service on 03/01/17 at 7:30 PM. · The incident was reported to North Carolina Board of Administrators via voice mail on 03/01/17. Immediate Jeopardy was removed on 03/03/17 at 5:09 PM when interviews with nursing staff, administrative staff and non-nursing staff confirmed they had received in-service training and knew the different types of abuse and the requirement that any observed or alleged abuse of a resident should be reported immediately to the ED or DON and if the perpetrator was the ED it should be reported to the AVP. Staff confirmed they were provided with a copy of the facility's abuse policy and the chain of command. Interviews with the DON, ED #2 and Field Service Clinical Director revealed training was provided to ED #2 and the DON on the requirement that any observed or alleged abuse by the ED should be immediately reported to the AVP and the accused perpetrator should immediately be removed from the facility.

Based on resident and staff interviews and record reviews, the administration failed to protect a resident from abuse when the Executive Director (ED) failed to maintain an abuse free environment when he verbally abused a resident; the Director of Nursing (DON), who was next in charge in the chain of command, did not immediately remove an alleged perpetrator from resident care areas and failed to follow the policy on reporting to the Area Vice President (AVP) immediately a witnessed incident of verbal abuse of a resident. Immediate Jeopardy began on 02/22/17 at 4:00 PM when Resident #59 was verbally abused by ED #1. The Director of Nursing (DON) and Patient Care Assistant (PCA) #1 witnessed ED #1 threatening to hit Resident #59. The DON allowed the perpetrator to remain in the building without supervision for 2 additional hours. Neither the DON or PCA #1 notified the AVP immediately of the incident. Immediate Jeopardy was removed on 03/01/17 at 5:09 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to protecting residents from being abuse, notifying the AVP and following the facility's abuse policy and procedure. The findings included: Cross refer to F 223: Based on resident interviews, record review and staff interviews, the facility failed to maintain 1 of 3 sampled residents' right to be free from verbal abuse (Resident #59) when Executive Director (ED) #1 threatened to hit Resident #59 causing 4 of 7 residents who witnessed the incident to be afraid, nervous and anxious (Residents #22, #59, #72 and #86). Cross refer to F 225: Based on resident interviews, record review and staff interviews, the facility failed to immediately report verbal abuse of a resident by Executive Director (ED) to the Area Vice President (AVP) and also failed to notify the North Carolina Health Care Personnel Investigations (NCHCPI) within 2 hours of the incident. This affected 1 of 3 residents sampled for abuse (Resident #59). Cross refer to F 226: Based on resident and staff interviews and record review, the facility failed to implement its abuse policy in the areas of protection of the resident and reporting of abuse within 2 hours. The facility failed to separate the perpetrator from the resident, to supervise the alleged perpetrator until he left the facility and to immediately notify the Area Vice President (AVP) of the verbal abuse. This affected 1 of 3 residents sampled for an abuse investigation (Resident #59). On 03/01/17 at 9:14 AM, ED #2 was informed of Immediate Jeopardy. The Administration provided an acceptable allegation of compliance on 03/03/17 at 2:45 PM. Allegation of Compliance GLC Asheville March 3rd, 2017 F 490 a facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain, the highest physical, mental, psychosocial well-being of each resident 2/22/17 at or around 4pm, the Executive Director (ED) entered the facility outside smoking area and approached resident #59 for smoking after her privileges had been revoked. He then proceeded to become verbally abusive to resident #59 by stating to her if she did not leave the facility he would hit her. This was witnessed by Director of Nurses who immediately had resident #59 come to her side and addressed resident #59 and the other residents on the smoking patio: #29, #72, #86, #10, #23, #79, #67, #66, #22, #28 and #75. The Director of Nurses assured them that no one was going to hit anyone and reviewed the smoking policy and asked if they felt secure and safe and they replied yes. The Executive Director and Director of Nurse came back into the building and ED went towards his office. The Director of Nurses failed to follow facility abuse policy and did not have him removed from facility immediately. The Executive Director then went to outside smoking door opened it and stated to smoking residents that he was going to report himself to the ombudsman. When the Director of Nurses heard the outside smoking group talking loudly she then went back to outside to smoking area and asked if residents were ok and felt safe. They told the Director Of Nurses that the Executive Director had come back to doorway and stated he was reporting himself. She asked if they were ok and all replied yes and she explained to them not to worry as she was going to report to all appropriate agencies. When she came back into facility Resident #59 was discharging home as previously planned and needed her belongings that were locked in the Director of Nurses office she completed this task. While she was completing this task the MDS so Coordinator stayed with the Executive Director till she was finished. The Director of Nurses then took Executive Director to his office and called the North Carolina Ombudsman and left voice mail of incident. She then called the Executive Director's superior, Regional Vice President of Operations, and explained the incident and he suspended the Executive Director effective immediately pending investigation and he left building at or around 6:20 PM with Director of Nurses supervising that he didn't go anywhere else in facility. He was officially terminated on 02/27/17 at 7:45 AM. The new Interim Executive Director started on 02/27/17 at or around 11 AM and was educated on the Abuse and Neglect Policy and the Grievance Policy by the Field Service Clinical Director on 03/01/17. The Director of Nurses was re-educated on 03/01/17 by Field Service Clinical Director of Golden Living Center on the Abuse/Neglect policy including the immediate removal of the alleged perpetrator from the building, chain of command and even if it is your superior you have the right to ask them to leave and notify their superior which is Regional Vice President of Operations, and the Grievance Policy. Graph of chain of command for Golden Living of Asheville with names, titles, contact numbers and their responsibilities was posted at time clock for all staff effective 03/02/17 by 4 PM. -The Area Vice President and Field Service Clinical Director will educate the facility leadership and staff on recognizing signs and symptoms in self and others of being burnt out, frustrated, and angry. Education will include how to develop and implement solutions for addressing signs of being burnt out, frustrated and/or angry with residents. Education will include how to maintain composure when working with residents that pose challenges. Education will include escalating identification of burn out, frustration and anger to the employee's supervisor. This is to begin the week of March 6, 2017 -Facility leadership will meet with resident council to request that they notify someone immediately if they feel they are not being treated respectfully. First meeting was 02/28/17, then 03/01/17 and next scheduled Resident Council meeting will be 03/20/17. The Area Vice President and Field Service Clinical Director will educate the facility leadership and staff on the chain of command and the abuse and neglect protocol, including but not limited to, the remedies for failing to report abuse, neglect and/or mistreatment of [REDACTED]. They met on 03/01/17 to begin training with facility leadership on the above. A Graph of chain of command with contact numbers and their responsibilities is posted at time clock that is accessible to all employees. *All other residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 03/01/17 the department managers interviewed all other interviewable residents for any signs of abuse, understanding of abuse, if know how to report abuse, and if they have any abuse they would like to report. Beginning 03/01/17 department managers or designee will monitor with daily room rounds with asking if they felt safe, if they had anything to report and any abuse that they want to report. Beginning 03/01/17 during their care plans Social Worker will ask residents if they feel safe, if they know what abuse is, if they know who to report to and if they have any abuse to report. Any staff that has not completed abuse and neglect in-service will not be able to work until training is complete. The facility will review and educate all employees including contract staff on policies and procedures to protect residents from any form of abuse. The verbal in services with a copy of the abuse policy was given to all employees who worked 03/01/17. All absent staff will be educated prior to being allowed to work in facility. To ensure the quality of care is provided to all residents by keeping them safe and free of harm, any staff that has not completed abuse and neglect in-service will not be able to work until training is completed. On 03/01/17 an audit of current Golden Living Center employees was conducted by department managers and asked if they felt stressed or burnt out, if they felt unsafe, knew of any abuse or desire to abuse residents. Did they know how to report abuse and who to report it to? All responses were positive and no one felt unsafe or overly stressed. The facility will have monthly all staff meetings and discuss stressors, the population of our residents and coping mechanisms to deal with challenging residents. A Psychologist for Golden Living of Asheville has agreed to come to facility to meet with the residents and employees separately to discuss burnout, dealing with stress and coping mechanisms. She is setting up schedule for week of March 6, 2017. As changes take place from the corporate standpoint as far as the progression of leasing out Golden Living Center the staff will be kept informed on monthly basis at in-services to keep them up to date and try to prevent any stressors. Golden Living Center of Asheville's Interim Executive Director will be kept up to date by Regional Vice President and will speak to staff monthly. Golden Living of Asheville will form an Employee Engagement Program with a goal to create a cultural atmosphere that is cohesive to residents and employees to help prevent the risk of abuse and decrease stress. We will have one staff member from each department on the committee and will invite the Resident Council President and Vice President, along with 2-3 Long Term Care Residents to be a part of the program. The program will meet monthly and discuss any stressors, upcoming events and plan events to include residents and employees together to make for a more cohesive working environment. All employees will complete a Caring For the Caregiver in-service to inform them of the challenges they are facing as being a caregiver is one of the most challenging jobs and they need ways to cope and reduce stress, and explain useful ways that others can help to reduce stress with teamwork and to encourage employees to ask for help as needed. Immediate Jeopardy was removed on 03/03/17 at 5:09 PM when interviews with residents revealed they were aware of what constituted abuse, felt comfortable reporting abuse and knew to whom they could report abuse. Interviews with nursing staff, administrative staff and non-nursing staff confirmed they had received in-service training and knew the different types of abuse and the requirement that any observed or alleged abuse of a resident should be reported immediately to the ED or DON and if the perpetrator was the ED it should be reported to the AVP. Staff confirmed they were provided with a copy of the facility's abuse policy and the chain of command. Interviews with the DON, ED #2 and Field Service Clinical Director revealed training was provided to ED #2 and the DON on the requirement that any observed or alleged abuse by the ED should be immediately reported to the AVP and the accused perpetrator should immediately be removed from the facility.

Based on observations, record reviews, staff interviews and resident interviews, the facility failed to develop a comprehensive care plan with individual goals and interventions which addressed 1 of 7 sampled residents for smoking safety. (Resident #104). Immediate Jeopardy began on 04/15/13 when the facility did not develop a plan of care which addressed Resident #104's smoking with oxygen and failure to follow the facility's smoking policy. The goal was not specific to Resident #104's noncompliance with the smoking policy and the interventions were not specific as to Resident #104's repeated possession of smoking materials, smoking in non-smoking areas on the non-smoking premises, and smoking with oxygen in use. Immediate jeopardy was removed on 04/26/13 at 5:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective. The findings included: The facility provided evidence in the form of a letter dated 10/30/12 "To Whom It May Concern" which informed the reader that on 11/01/12 the facility became a smoke free building. The policy was effective for all residents, families and visitors. The policy stated new residents admitted to the facility must adhere to the policy on admission. The policy stated "Smoking is prohibited on the grounds of Golden Living Center including outside building entrances, courtyards, parking lots and inside building. 'No Smoking' signs will be posted in the restricted areas." The facility's smoking policy last reviewed and revised April 2013 stated that "While Golden Living Center-Asheville will continue to allow residents who chose to smoke tobacco products the privilege of smoking in approved areas and at approved times. Smoking will only be allowed as outlined in this policy and will be monitored for compliance and enforced. This policy will be distributed upon admission to each resident and their responsible party." The guidelines included: *All material related to smoking will be stored at the nursing stations; *Each resident smoker will be assessed for their own individual abilities and circumstances and care planned for this ability; *Smoking is not permitted inside the building. The designated area for smoking is located in the facility courtyard; *Oxygen use is prohibited in smoking areas; *Smoking times are established and smoking is permitted only in the designated area and during acceptable weather; *Any resident, visitor or associate who does not comply with the facility rules regarding smoking may be asked to forfeit smoking or visiting privileges. If the danger of lack of compliance is serious enough, it may warrant discharge in accordance with state and federal law. Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident #104 signed the "Acknowledgement of No Smoking Policy" on 03/05/13 which stated the resident had been informed that the current law was that residents sign acknowledgement that smoking was prohibited inside all long term care facilities. The admission Minimum Data Set for Resident #104, dated 03/12/13 coded her moderately impaired in decision making skills, feeling down, requiring limited assistance for bed mobility, transfers, walking in room, hygiene and toileting. She was coded as being unsteady and needed assistance to stabilize her balance. There was no smoking assessment and no care plan specific to smoking. The resident's desire and attempts to smoke were revealed as follows: *Nursing notes dated 03/13/12 at 3:44 PM revealed Resident #104 "requested to smoke today, explained the facility smoking policy." *Nursing notes dated 03/15/13 at 12:05 AM stated that the nurse took a cigarette lighter from Resident #104. The resident was noted to be going up and down the hall, rolled to back door and stated she wanted to go outside to smoke. Per the nursing note, the nurse explained the resident was using oxygen and was unable to be around open flames. *On 04/04/13 at 3:58 PM, a social service note stated the social worker (SW) met with Resident #104 regarding the smoking policy due to resident inquiring about smoking on campus. An interview with the SW on 04/24/13 at 10:55 AM revealed that on 04/04/13 it was brought to the SW's attention that Resident #104 was caught smoking out the back door in the parking area the weekend before (March 30-31st). The SW stated either a nurse aide or a manager on duty (she could not recall specifically who) informed her on 04/04/13 about the previous weekend event so she spoke to Resident #104 about the smoking policy and possible discharge from the facility for noncompliance. Resident #104 voiced understanding. The SW stated on 04/25/13 at 3:17 PM that she originally developed a care plan on 04/04/13 relating to Resident #104's smoking. The focus of the care plan initiated 04/04/13 was the resident was "At risk for smoking related injury related to history of smoking incidents." The goal was "will have no smoking related injuries." The only intervention was "Review smoking policy with patient and or family." Additional evidence of Resident #104's non-compliance with smoking included: *Social Service Note dated 04/15/13 at 3:15 PM revealed that the housekeeping staff informed the SW that Resident #104 was attempting to smoke outside the back hall exit door. The resident denied this and stated she was going to use her phone. Per the note, the SW encouraged Resident #104 to use the patio areas and the resident stated she did not like the non-smoking patio area. SW informed the resident she could go out on the smoking patio during smoke breaks with other residents but she could not smoke per the policy. The note continued "Resident was then caught smoking by DNS (Director of Nursing Services) and ED (Executive Director) and was informed she could not smoke. SW informed her again of the policy and the resident voiced understanding. Interview with the DNS on 04/24/13 at 3:13 PM revealed she and the ED were coming down the hall on 04/15/13 when they saw Resident #104 smoking outside in the smoking area under the canopy. When DNS and ED got outside, Resident #104 denied smoking, but there was evidence on the ground of ashes and the DNS saw a cigarette and lighter in her lap blanket. The DNS stated she was wearing the oxygen tubing nasal cannula in her nose, however, stated the tank was observed turned off which was on the back of her wheelchair. The DNS stated she removed the cigarette and lighter, handed them to the ED and had the SW speak to the resident again about the policy. The care plan was not changed after this event. A nursing note dated 04/20/13 at 1:38 PM stated "Staff reported that earlier resident was smoking in her bathroom. Resident denied this but later admitted it and lighter was removed by nurse from room. Patient teaching was done regarding danger of smoking with 02 (oxygen) use. Resident stated she understood and that it would not happen again." Review of the "Verification of Investigation" dated 04/20/13 at 2:41 PM revealed a nurse aide reported Resident #104 was smoking in her bathroom and resident was on oxygen. This form stated the recommendations and interventions were: *education to the resident; *education to staff regarding the smoking policy; and *a smoke detector was placed in Resident #104's bathroom. A care plan addressing behaviors initiated on 03/19/13 was updated on 04/22/13 with a hand written addition to the focus of the resident smoking in her bathroom. There was no goal to this additional focus and the interventions added included "smoke detector to be placed in res. BR (resident's bathroom)" and "educate res on dangers of smoking in facility." On 04/24/13 at 10:55 AM the SW was interviewed and stated on 04/22/13 it was brought to her attention during morning meeting that Resident #104 was caught smoking in her bathroom over the weekend. The SW stated a smoke detector was placed in the resident's bathroom, staff were educated not to allow the resident to go out back unsupervised, staff educated to redirect the resident to patio areas and the nurses were educated to maintain good documentation of smoking incidents. She stated that she then updated the care plan relating to smoking with the new focus addition that Resident #104 was non-complaint with the smoking policy. SW stated the goals were included in the computer software and the goal to have no smoking related injuries was the closest care plan goal to the problem available. The SW stated she could have edited and developed a more appropriate goal but did not. She also stated that the only time a care plan was discussed was after the incident where Resident #104 was caught in the bathroom smoking. Per the SW that was when the behavior care plan was updated with the addition of the smoke detector in the bathroom and re-educating the resident. The SW stated she failed to include the staff education, and the additional visual checks the staff were to do on Resident #104 anytime they passed her room in an attempt to see smoking materials she may have in her possession. She stated no plan was developed to prevent Resident #104 from obtaining smoking materials while out of the facility or from visitors and from hiding them in her possession. Interview with SW on 04/24/13 at 1:10 PM revealed the Assistant Director of Nursing Services (ADNS) added the smoke detector and education to the behavior care plan. On 04/24/13 at 12:59 PM, Resident #104 was interviewed and admitted to smoking in the bathroom once and got in trouble for it. She stated she used to have a lighter and cigarette but gave them to the nurse. She stated she also smoked outside once but took her oxygen off. Resident #104 was observed transferring herself from the wheelchair to the bed. She was observed with very shaky arm and leg movements of both extremities. Interview with the DNS on 04/24/13 at 3:13 PM revealed staff had been educated to report smoking materials found, to watch Resident #104 more closely, to reeducate the resident on the smoking policy and to be aware that a smoke detector had been placed in the resident's bathroom. There was nothing planned to check the resident for smoking materials when she left the facility and returned or had visitors. On 04/25/13 at 2:58 PM, the ADNS stated she updated the care plan on Monday (04/22/13) at the clinical start up meeting. She stated staff discussed behaviors but had not developed a care plan for non-complaint smoking even though she had been caught smoking outside on the premises. She stated that staff just followed the behavior care plan approaches. On 04/25/13 at 3:17 the SW stated she updated the care plan relating to smoking on 04/24/13 to include the resident's noncompliance under the focus area. She stated she did not add any other interventions. She further stated that a care plan was never discussed in morning meetings to address Resident #104's smoking until 04/22/13 with the addition of the smoke detector under the behavior care plan. On 04/25/13 the Executive Director was informed of the immediate jeopardy. An acceptable allegation of compliance was received on 04/26/13 which stated: Golden Living Center Asheville is alleging abatement of jeopardy on 4/25/13. On 4/25/13 the Executive Director was notified of an Immediate Jeopardy related to a Care Plan for resident #104 that did not address the resident's high risk for and history of non-compliance with the facility smoking policy. Immediately upon notification of the Immediate Jeopardy the following was initiated: ? On 04/04/13, Social Services Director developed a Smoking Care Plan. On 4/25/13 at approximately 3:30 pm Social Services Director updated resident #104's care plan to include verbiage related to the resident's history of being non-compliant with the smoking policy, specifically: ? 04/04/13, Smoking Care Plan Developed ? 04/04/13, Review smoking policy with patient and/or family ? 04/21/13, Added smoke alarm to resident bathroom ? 04/24/13, Initiated 1:1 continuous direct staff supervision while in residence ? 04/25/13, Offer substitutions for smoking such as nicotine patches, electronic cigarettes ? 04/25/13, Searched resident room and belongings for smoking materials. ? 04/25/13, Staff will report immediately to supervisor/charge nurse any breach of the smoking policy. ? On 4/25/13 at 5:30 pm, the Reimbursement Consultant began educating the Interdisciplinary Team, which includes Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Director of Clinical Education, Dietary Manager, Registered Nurse Assessment Coordinator about: ? updating resident #104's Care Plan who was non-compliant with the Smoking Policy to include all of the above interventions dated 04/25/13. ? Specific interventions were added to Care Plan with non-compliance of Smoking Policy as of 04/25/13. ? On 4/24/13 at approximately 5:30 pm the Nursing Services Consultant reassessed all center residents regarding smoking history or a potential risk for smoking in the future. Center identified 6 smoking residents that were grand-fathered in as of 11/1/12, who answered yes to being a smoker on the smoking assessment. Therefore, a new smoking safety assessment was completed and the Care Plans were audited and updated to include the following interventions: ? 04/25/13, 1:1 continuous direct staff supervision for 72 hours, and then re-evaluate for those residents found in breach of the smoking policy. ? 04/25/13, Educated regarding smoking policy and hazards of non-compliance of Smoking Policy ? On 4/24/13 at approximately 6:00 pm the Social Services Director re-educated all 6 smoking residents regarding the smoking policy. ? On 4/25/13 at 5:30 pm, the Reimbursement Consultant began educating the Interdisciplinary Team, which includes Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Director of Clinical Education, Dietary Manager, Registered Nurse Assessment Coordinator about: ? Specific examples related to time frames for auditing and updating Care Plans when presented with non-compliance of Smoking Policy ? All newly admitted residents will be reviewed by the Nursing and Social Services Interdisciplinary Team during the next daily Clinical Start-Up meeting after admission to discuss smoking history and determine potential future smoking risks and ensure Care Plan interventions address risk of non-compliance with Smoking Policy for residents deemed high risk. ? On 4/26/13, Social Services will mail letter to all family members regarding smoking policy, residents not allowed to have smoking materials in their possession and that if out of facility, will be required to relinquish smoking materials to facility staff upon return to facility. Family members will be re-educated at the next scheduled Family Night on May 29, 2013. ? On 04/25/13 at 5:15 pm, as a result of finding smoking paraphernalia in the residents' rooms on 4/24/13, Care Plans for two of the six identified smoking residents were updated to include: ? 04/25/13, Initiated 1:1 staff supervision secondary to non-compliance with smoking policy for 72 hours; then re-evaluate ? 04/25/13, Educate each resident regarding hazards of non-compliance with smoking policy ? Monitoring of the Systems includes: ? Until 05/24/13, the Director of Nursing will review each new resident's Smoking Assessment to determine appropriate level of risk and appropriate Care Plan interventions based upon resident's history of tobacco use. ? Until 05/24/13, the Executive Director will review 10% of new resident Care Plans to ensure appropriate interventions are in place according to Smoking Policy and resident's history of tobacco use. ? The Executive Director will present all results associated with changes to residents' care plans, and any changes thereof, to the Quality Assurance and Process Improvement Committee each month beginning May 2013 for three months and then quarterly beginning August 2013 and ending December 2013. Immediate jeopardy was removed on 04/26/13 at 5:30 PM when interviews with nursing staff and other staff confirmed they had received in-service training on the facility's updated smoking policy and the development of a care plan for residents who verbally express a desire to smoke or exhibit behaviors indicating a desire to smoke. Record reviews were also done to verify current smoking assessments and care plans for all affected known residents with a history of smoking. Observations were completed to ensure smoking was supervised, smoking materials were secured, and staff knew who the grandfathered residents were who were permitted to smoke in the facility's courtyard.

Based on observations, record reviews, staff interviews and resident interviews, the facility failed to supervise and implement interventions for 1 of 7 sampled residents who was non-compliant regarding the facility's smoking rules and smoking while wearing oxygen. (Resident #104). Immediate Jeopardy began on 04/15/13 when Resident #104 smoked on the facility premises wearing oxygen with no interventions made by staff other than reminding the resident of the nonsmoking policy. Immediate jeopardy was removed on 04/26/13 at 5:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective. The findings included: The facility provided evidence in the form of a letter dated 10/30/12 "To Whom It May Concern" which informed the reader that on 11/01/12 a new policy went into effect which made the facility a smoke free building. The policy was effective for all residents, families and visitors. The policy stated new residents admitted to the facility must adhere to the policy on admission. The policy stated "Smoking is prohibited on the grounds of Golden Living Center including outside building entrances, courtyards, parking lots and inside building. 'No Smoking' signs will be posted in the restricted areas." The facility's smoking policy last reviewed and revised April 2013 stated that "While Golden Living Center-Asheville will continue to allow residents who chose to smoke tobacco products the privilege of smoking in approved areas and at approved times. Smoking will only be allowed as outlined in this policy and will be monitored for compliance and enforced. This policy will be distributed upon admission to each resident and their responsible party." The guidelines included: *All material related to smoking will be stored at the nursing stations; *Each resident smoker will be assessed for their own individual abilities and circumstances and care planned for this ability; *Smoking is not permitted inside the building. The designated area for smoking is located in the facility courtyard; *Oxygen use is prohibited in smoking areas; *Smoking times are established and smoking is permitted only in the designated area and during acceptable weather; *Any resident, visitor or associate who does not comply with the facility rules regarding smoking may be asked to forfeit smoking or visiting privileges. If the danger of lack of compliance is serious enough, it may warrant discharge in accordance with state and federal law. Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident #104 was also under the care of Hospice services for end stage COPD and pain management. Resident #104 signed the "Acknowledgement of No Smoking Policy" on 03/05/13 which stated the resident had been informed that the current regulation under House Bill 1294 was that residents sign acknowledgement that smoking was prohibited in all long term care facilities. Resident #104 was her own responsible party. Nursing notes dated 03/05/13 included the resident was "Alert and oriented x 3, although appears very drowsy. Makes needs known verbally. Answers questions appropriately, voice with soft tone." Review of the History and Physical/Admit Note dated 03/08/13 revealed Resident #104 was transferred to this facility from a sister facility via a Hospice house. This admit note stated the resident had reported she quit smoking. The "assessment/plan" per this note stated she was oxygen/steroid dependent, had questionable ongoing tobacco use and questionable history of substance abuse. There was nothing ordered to address her possible tobacco addiction. The admission Minimum Data Set for Resident #104, dated 03/12/13, coded her moderately impaired in decision making skills (scoring a 12 out of 15 on the Brief Interview for Mental Status), feeling down, requiring limited assistance for bed mobility, transfers, walking in room, hygiene and toileting. She was unsteady and needed assistance to stabilize her balance. There was no care plan which addressed her previous tobacco use. Indications that Resident #104 had desires/behaviors of smoking were: A. Nursing notes dated 03/13/12 at 3:44 PM revealed Resident #104 "requested to smoke today, explained the facility smoking policy. Res (Resident) tearful, reported to ADNS (Assistant Director of Nursing Services)." There was no evidence in the medical record that the physician was notified of Resident #104's desire to smoke. B. Nursing notes dated 03/15/13 at 12:05 AM stated that the resident was denying she received her narcotic medication and demanded to have a breathing treatment which was not ordered. She was noted as going through her bag and took out a cigarette lighter. The resident was noted to be going up and down the hall, rolled to back door and stated she wanted to go outside to smoke. Per the nursing note, the nurse explained the resident was using oxygen and was unable to be around open flames. The resident went to the nursing desk and stated she was a little confused. There was no indication in the medical record that the physician was notified of her desire to smoke. The note did not address what happened with Resident #104's lighter. C. Review of nursing notes from 03/16/13 through 04/03/13 revealed no indication of Resident #104 expressing or showing any desire to smoke. On 04/04/13 at 3:58 PM, a social service note stated the social worker (SW) met with Resident #104 regarding the smoking policy due to resident inquiring about smoking on campus. The SW informed the resident that as of 11/01/12 no new admissions were allowed to smoke on facility campus. Per the note, the resident stated she does not smoke at the facility and understood the policy. SW informed the resident that going against the policy could mean discharge to another facility. Resident #104 voiced understanding. An interview with the SW on 04/24/13 at 10:55 AM revealed that on 04/04/13 it was brought to the SW's attention that Resident #104 was caught smoking out the back door in the parking area the weekend before (March 30-31st). The SW stated either a nurse aide or a manager on duty (she could not recall specifically who) informed her on 04/04/13 about the previous weekend so she spoke to Resident #104 on 04/04/13 about the smoking policy and possible discharge from the facility for noncompliance. Resident #104 voiced understanding. Interview on 04/24/13 at 5:00 PM with the medical record clerk who also worked as Manager on Duty (MOD) revealed that she worked 03/31/13. She stated she saw Resident #104 going out the back door. Resident #104 told the medical record clerk she was going outside to smoke with one of the nurse aides. The medical record clerk stated she went out the back and a nurse aide (she could not recall who) agreed to sit with Resident #104. The medical records clerk stated she did not stay and see if smoking occurred. She further stated that supervised residents smoke in the courtyard and she thought staff smoked in the back. She stated she could not recall if Resident #104 was wearing oxygen. The medical records staff stated she was not familiar with the facility's nonsmoking policy. She further stated she did not report this incident until this past Monday's (04/22/13) morning meeting. A care plan initiated 04/04/13 had the focus that Resident #104 was "At risk for smoking related injury related to history of smoking incidents." The goal was "will have no smoking related injuries." The only intervention was "Review smoking policy with patient and or family." D. Notes dated 04/15/13 at 3:15 PM by the SW revealed that the housekeeping staff informed the SW that Resident #104 was attempting to smoke outside the back hall exit door. The resident denied this and stated she was going to use her phone. Per the note, the SW encouraged Resident #104 to use the patio areas and the resident stated she did not like the non-smoking patio area. SW informed the resident she could go out on the smoking patio during smoke breaks with other residents but she could not smoke per the policy. The 04/15/13 note continued "Resident was then caught smoking by (Director of Nursing Services) DNS and (Executive Director) ED and was informed she could not smoke. SW informed her again of the policy and the resident voiced understanding. Interview with the DNS on 04/24/13 at 3:13 PM revealed she and the ED were coming down the hall on 04/15/13 when they saw Resident #104 smoking outside in the smoking area under the canopy. When DNS and ED got outside, Resident #104 denied smoking, but the DNS said she had seen the resident putting out her cigarette on the concrete slab and there was evidence on the ground of ashes. The DNS said she then saw a cigarette and lighter in her lap blanket. The DNS stated she was wearing the oxygen tubing nasal cannula in her nose, however, stated the tank on the back of her wheelchair was observed turned off. The DNS stated she removed the cigarette and lighter, handed them to the ED and had the SW speak to the resident again about the policy. Per the DNS, she assumed Resident #104 obtained the cigarettes and lighter when she went off the facility premises which she was allowed to do independently as she was her own responsible party. The DNS stated she had spoken to Resident #104's family member about the smoking materials and behaviors several times. There was no documentation provided regarding this intervention. There was no evidence in the medical record indicating that the physician was notified of Resident #104 smoking or any request for interventions to address her nicotine addiction. Interview with the SW on 04/24/13 at 10:55 PM revealed that because of Resident #104's smoking, a meeting was held on 04/19/13 with the resident and Hospice to discuss smoking issues. During this meeting, Resident #104 denied smoking and announced she was planning discharge to the community. E. A nursing note dated 04/20/13 at 1:38 PM stated "Staff reported that earlier resident was smoking in her bathroom. Resident denied this but later admitted it and lighter was removed by nurse from room. Patient teaching was done regarding danger of smoking with 02 (oxygen) use. Resident stated she understood and that it would not happen again." Review of the "Verification of Investigation" dated 04/20/13 at 2:41 PM revealed a nurse aide reported Resident #104 was smoking in her bathroom and resident was on oxygen. This form stated the recommendations and interventions were: *education to the resident; *education to staff regarding the smoking policy; and *a smoke detector was placed in Resident #104's bathroom. On 04/24/13 at 1:20 PM, NA #2 stated she had clocked out on 04/20/13 around noon and was heading out the back door when she smelled smoke from Resident #104's room. Upon closer inspection, she found Resident #104 in the bathroom with her oxygen tubing in place and the room smelled very strongly of smoke. At that time NA #3 entered the room and took over Resident #104's care. NA #2 stated when she got to her car she called the ADNS at home about the incident. On 04/24/13 at 2:53 PM the ADNS stated she received a call from NA #2 at home about the smoke in the bathroom and she called the DON and the MDS Coordinator who was the manager on duty. Per the ADNS Resident #104's request to smoke was discussed in morning meetings and that the SW spoke to the resident many times. The ADNS stated the plan since this weekend was to install a smoke detector in the bathroom and check on Resident #104 more frequently. Staff were also educated to report if they see lighters or cigarettes. ADNS stated the resident goes out of the facility and has visitors and it is suspected that was where she was obtaining smoking materials. The ADNS stated nothing was in place to check Resident #104 for smoking materials after having visitors or going out of the facility and returning. On 04/24/13 at 12:49 PM, MDS Coordinator, who was the manager on duty when Resident #104 was caught smoking in the bathroom, was interviewed. The MDS Coordinator stated this past Saturday, the ADNS called her after receiving a phone call from a nurse aide that Resident #104 was caught smoking in the bathroom. The MDS Coordinator went to Resident #104 who agreed not to smoke anymore and handed the MDS Coordinator her lighter. The pack of cigarettes was empty. The MDS Coordinator stated she called the DNS who instructed the MDS Coordinator to give an in-service to first and second shift staff about the facility's smoking policy and to instruct staff not to allow smoking privileges for residents who were not in the facility prior to the change to a non-smoking facility (grandfathered in). The MDS Coordinator stated that staff were to let the nurse know right away if they saw Resident #104 with a lighter or cigarette. The MDS Coordinator provided this inservice per the DNS's instructions on 04/20/13. Interview with the DNS on 04/24/13 at 3:13 PM revealed she instructed the MDS Coordinator who was manager on duty on 04/20/13 to educate the first and second shift on reporting smoking materials found, to watch Resident #104 more closely, to reeducate the resident on the smoking policy, and to remove smoking materials. Resident #104's smoking was discussed in morning meeting on 04/22/13. Per the DNS, Resident #104 was permitted to sign herself out and leave the building either with friends or by herself in a cab. She stated it was against Resident #104's rights to search her room or person when she returned from outings and there was nothing no plan to check the resident for smoking materials when she left the facility and returned or had visitors. On 04/24/13 at 12:59 PM, Resident #104 was interviewed and admitted to smoking in the bathroom once and got in trouble for it. She stated she also smoked outside once but took her oxygen off. Resident #104 was observed transferring herself from the wheelchair to the bed. She was observed with very shaky arm and leg movements of both extremities. On 04/24/13 at 10:55 AM the SW was interviewed and stated on 04/22/13 it was brought to her attention during morning meeting that Resident #104 was caught smoking in her bathroom over the weekend. Resident #104 originally denied it and then later admitted it. She promised she would not do it again. On Monday 04/22/13, the SW reviewed the nonsmoking policy again with Resident #104. It was also discovered that Resident #104 had no discharge plans and was staying in the facility. The SW stated she speculated that when Resident #104 left the faciity on outings, she got lighters and cigarettes. The SW stated she explained to the resident this date the possibility of discharge if the behavior continued. The SW stated a smoke detector was placed in the resident's bathroom, staff were educated not to allow the resident to go out back unsupervised, staff were educated to redirect the resident to patio areas, and the nurses were educated to maintain good documentation of smoking incidents. The behavior care plan initiated on 03/19/13 was updated on 04/22/13 by the ADNS with the focus of the resident smoking in her bathroom. There was no goal to this additional focus area and the the interventions added included "smoke detector to be placed in res. BR (resident's bathroom)" and "educate res on dangers of smoking in facility." The smoking care plan was updated on 04/24/13 to include the resident's noncompliance with the smoking policy under the focus area. No other interventions were added on this care plan. On 04/24/13 at 4:55 PM the DNS, in the absence of the ED, was informed of the immediate jeopardy. An acceptable allegation of compliance was received on 04/26/13 which stated: ? Golden Living Center Asheville is alleging abatement of jeopardy on 4/25/13. On 4/24/13 the Director of Nursing was notified of an Immediate Jeopardy related to unsafe smoking regarding resident #104. Immediately upon notification of the Immediate Jeopardy the following was initiated: ? On 4/24/13 at approximately 5:00 pm Director of Nursing compiled timeline of root cause information for resident #104. Findings included interviews with staff to determine any observation regarding resident smoking and/or having smoking materials, review of resident medical record to determine education that had been completed with resident surrounding smoking protocol at the center, and any information included in resident #104's plan of care regarding smoking and/or non-compliance with smoking protocol. ? On 4/24/13 at 4:55 pm., resident #104 was placed on continuous 1:1 direct staff supervision until safe discharge can be coordinated. Facility staff were educated on required replacement protocols for breaks and shift changes. ? On 4/24/13 at 4:55 pm, resident #104 was notified and a room search was conducted by the Nursing Services Consultant. Resident was noted to have a package of cigarettes and a lighter in her possession that was confiscated by facility staff and locked in appropriate storage area. ? On 04/25/13, Resident #104's Care Plan has been reviewed and revised by the Nurse Specialist to include the following: ? 04/21/13, added smoke alarm to resident bathroom ? 04/24/13, continuous 1:1 direct staff supervision until safe discharge can be coordinated ? 04/25/13, Offer substitutions for smoking such as nicotine patches, electronic cigarettes ? 04/04/13, Review smoking policy with patient and/or family ? 04/25/13, Searched resident room and belongings for smoking materials. ? On 4/24/13 at approximately 5:00 pm the Nursing Services Consultant notified all facility residents that room searches would be conducted. Room searches were completed on 4/24/13 at approximately 6:00 pm. Two separate residents were found to possess smoking paraphernalia in their room; items were confiscated and 1:1 supervision for 72 hours initiated. ? On 04/24/13, the smoking assessment and smoking safety assessment were completed for all center residents with up-to-date information. These quarterly assessments (pink forms) will be completed quarterly, annually and with a significant change. On 4/24/13, reviewed and revised the Smoking Policy "Any non-compliance that has the potential to affect the health and/or safety of residents may result in discharge pursuant to state and federal laws; grand-fathering in of current smoking residents as of 11/01/12 and that future admissions would be non-smoking." ? On 4/24/13 at approximately 5:30 pm the Nursing Services Consultant reassessed all center residents regarding smoking history. Center has 6 residents who answered yes to the "Smoking Assessment" questionnaire; thus prompting a new "Smoking Safety Assessment" and updates to Care Plans to address safe smoking. ? On 4/24/13 at approximately 6:00 pm the Social Services Director re-educated all smoking residents regarding the newly revised smoking policy. ? On 4/24/13 at 9:00 pm, resident #104 was re-educated on the center smoking policy by the Social Services Director. ? On 4/26/13, Social Services will mail letter to all family members regarding smoking policy, residents not allowed to have smoking materials in their possession and that if out of facility, will be required to relinquish smoking materials to facility staff upon return to facility. Family members will be re-educated at the next scheduled Family Night on May 29, 2013. ? On 4/24/13 at 6:00 pm, the Nursing Services Consultant began educating present facility staff about the Smoking Policy, designated smoking areas, protocols regarding resident safety, and interventions when residents are non-compliant with smoking policy, including immediate reporting to the supervisor/charge nurse on duty of any breach of the smoking policy. Education continued on 4/25/13 by the Nursing Services Consultant and the Assistant Director of Nursing Services for facility staff present. On 4/24/13 and 4/25/13, competency tests were administered to all staff to ensure understanding of policy and safety hazards. On 04/25/13, all unscheduled staff were telephoned and informed that they must complete required education by 04/26/13 at 4:30 pm or prior to their next scheduled work shift. ? Monitoring of the System includes: ? On 4/24/13 at approximately 5:00 pm the Executive Director was notified via phone, who reviewed the updated Smoking Policy and gave final approval to the revised policy. ? All newly admitted residents will be reviewed by the Nursing and Social Services Interdisciplinary Team during the next daily Clinical Start-Up meetings after admission to discuss smoking history and determine potential future smoking risks. The manager on duty will provide daily visits for seven days regarding smoking history and potential risks for smoking, provide education to resident of smoking policy and potential safety hazards, offer smoking alternatives per resident request and physician orders, and referral to psyche services as needed. ? Quarterly communication to center's smoking residents, their families or POAs regarding smoking policy, its adherence and the maintenance of smoking materials in locked area. ? Department Managers will observe and document on internal "Ace Round" form, a minimum of 26 assigned smoke breaks per month during daily facility rounds to include visualization of safe smoking practices, appropriate supervision, and general compliance with smoking policy for 6 months. Staff will validate using a checklist for receipt of cigarette and disposal. Staff will maintain container of cigarettes and disperse one at a time. All smoking materials will be kept under lock and key. ? Daily until safely discharged , the Executive Director will visit resident #104 and assess room for any smoking materials and validate his/her understanding of the Smoking Policy. ? Until 05/10/13, 30% of staff will be interviewed regarding smoking policy, knowledge of center smoking residents, and resident safety. From 05/13/13 to 06/01/13, an additional 15% of staff will be interviewed regarding smoking policy, knowledge of center smoking residents, and resident safety. After 06/02/13, 20% staff will be interviewed regarding smoking policy, knowledge of center smoking residents, and resident safety on a calendar quarterly basis. ? The Executive Director will present all monitoring results, and any changes thereof, to the Quality Assurance and Process Improvement Committee each month beginning May 2013 for three months and then quarterly beginning August 2013. Immediate jeopardy was removed on 04/26/13 at 5:30 PM when interviews with nursing staff and other staff confirmed they had received in-service training on the facility's updated smoking policy and action to take when a resident requests to smoke or is found to have smoking materials in their possession. Record reviews were also done to verify current smoking assessments and care plans. Observations were completed to ensure smoking was supervised, smoking materials were secured, and staff knew who the grandfathered residents were who were permitted to smoke in the facility's courtyard.