Every finding on record at Big Elm Retirement and Nursing Centers

Based on record review, and resident and staff interviews, the facility failed to afford the resident the right to participate in the care planning process for 2 of 2 residents reviewed for care plans (Resident #31, and Resident #21).The findings included: a. Resident #31 was admitted to the facility on [DATE] with diagnosis of hypertension, diabetes mellitus and respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact. Resident #31’s care plan was last updated on 7/2/25. An interview with Resident #31 on 8/25/25 at 11:45 AM was conducted and the Resident stated she had not been invited to a care plan meeting, and that there was not a family member that would have been invited instead of her. She stated that she would like to be invited to care plan meetings. An interview on 8/28/25 10:25 AM with the Social Worker (SW) was conducted. The SW indicated she had been employed since May 2024. She further indicated that the former Administrator never told her that care plan meetings were to be held for every resident on a quarterly basis. The SW stated she was trained to have care plan meetings only if the family or residents ask for one. The SW added the only care plan meetings conducted were for short-term rehabilitation residents only. The SW stated for the long-term Residents, care plan meetings were done by request, for change in condition, wounds or falls. An interview with the MDS Nurse on 8/28/25 at 10:25 AM was conducted. The MDS Nurse indicated that she was told by the former Administrator not to be involved with the Social Worker’s task to invite the Resident or Responsible Party for a care plan meeting, so she did not intervene when the meetings were not being held. She further indicated that care plan updates were completed quarterly, as needed and annually. An interview with the Director of Nursing (DON) on 8/28/25 at 10:54 AM was conducted. The DON stated that care plan meetings were happening, but the invitation letters or phone calls to invite residents and/or Responsible Parties were not being made. The DON indicated that he dropped the ball in following up on the care plan meetings due to the position changes that had taken place. He explained he had stepped down as Administrator to the DON position until a new DON could be hired. The DON stated the care plan meeting process was that Residents that were alert and oriented were invited to attend and residents that were not alert and oriented had their Responsible Party invited. He further stated that the SW was very involved but did not know that she was supposed to conduct care plan meetings by inviting residents and/or the Responsible Party. He further stated that his expectation was that all Residents and Responsible Parties were invited to the care plan meetings and that documentation of the invitation be it phone call, letter or in person be uploaded into the medical record. b. Resident #21 was admitted to the facility on [DATE] with diagnoses of hypertension, chronic pain, muscle weakness, and lack of coordination. Review of Resident #21’s quarterly Minimum Data Set, dated [DATE] revealed the resident was cognitively intact. Resident #21’s revised care plan was completed on 07/23/25. Review of Resident #21’s medical record revealed no documentation that a care plan meeting had been completed with Resident #21 or the Resident Representative (RR). An interview conducted with Resident #21 on 8/27/25 at 11:17 AM revealed that she had not been invited to her care plan meetings. Resident #21 further revealed she would have attended the care plan meetings if she had been invited. An interview with Resident #21 on 8/25/25 at 2:05 PM was conducted and the Resident stated she had not been invited to a care plan meeting. The resident further revealed she would like to be invited to care plan meetings to discuss goals and plans of possible discharge. An interview on 8/28/25 10:25 AM with the Social Worker (SW) was conducted. The SW indicated she had been employed since May 2024. She further indicated that the former Administrator never told her that care plan meetings were to be held for every resident on a quarterly basis. The SW stated she was trained to have care plan meetings only if the family or residents ask for one. The SW stated for the long-term Residents, care plan meetings were done by request, for change in condition, wounds or falls. An interview with the MDS Nurse on 8/28/25 at 10:25 AM was conducted. The MDS Nurse indicated that she was educated to not be involved in care plan meetings per the prior Administrator. She further indicated that care plan meetings were conducted by the SW. An interview with the Director of Nursing (DON) on 8/28/25 at 10:54 AM was conducted. The DON stated that care plan meetings were happening, but the invitation letters or phone calls to invite residents and/or Responsible Parties were not being made. The DON indicated that he dropped the ball in following up on the care plan meetings due to the position changes that had taken place. He explained he had stepped down as Administrator to the DON position until a new DON could be hired. The DON stated the care plan meeting process was that Residents that were alert and oriented were invited to attend and residents that were not alert and oriented had their Responsible Party invited. He further stated that the SW was very involved but did not know that she was supposed to conduct care plan meetings by inviting residents and/or the Responsible Party. He further stated that his expectation was that all Residents and Responsible Parties were invited to the care plan meetings and that documentation of the invitation be it phone call, letter or in person be uploaded into the medical record.

Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to maintain safety for a severely cognitively impaired resident in a wheelchair when the Activities Director was assisting residents out the double doors at the front entrance of the facility to smoke. After assisting Resident #9 outside, the Activities Director failed to lock the brakes of Resident #9's wheelchair and Resident #9 rolled down the pavement in front of the facility approximately 31 feet and fell out of her wheelchair landing on her left side. Resident #9 sustained skin tears to the left elbow and left AKA (above the knee amputation) stump. Resident #9 also sustained abrasions to the chin, left cheek, lips, and the bridge of the nose with visible bleeding from the nostrils. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, lack of coordination, tobacco use, chronic pain, anxiety and depression.The quarterly MDS dated [DATE] revealed Resident #9 had severe cognitive impairment, rejected care daily, had bilateral lower extremity impairment and used a wheelchair. Resident #9 required substantial to maximal assistance with toileting hygiene, bathing, upper body dressing, rolling left to right and sitting to lying. Resident #9 was dependent on staff for lower body dressing and chair to bed to chair transfers. Resident #9 required supervision or touching assistance with propelling her wheelchair 50 feet with two turns and was dependent on staff for propelling her wheelchair 150 feet.Review of Resident #9's Focused Care Plan for Smoking dated 5/5/2025 indicated the resident would be assessed for smoking and required supervision at all times. The goal stated Resident #9 would abide by the smoking policy and would be supervised during smoking times through the review period. The interventions included to assess Resident #9's compliance with the smoking policy, staff to go out with Resident #9 at smoking intervals per facility protocol, smoking per facility protocol and supervision with all smoking activity.The Focused Care Plan for Risk of Falls related to bilateral above the knee amputation (AKA) dated 5/5/2025 indicated Resident #9 was at risk for falls due to weakness, deconditioning and decreased mobility. The goal stated Resident #9 would have reduced risk for fall injuries through staff assessment and interventions through the review period. The interventions included to anticipate resident needs, educate resident to allow staff to assist her when outside in her wheelchair for safety and to educate resident, family and caregivers about safety reminders and what to do if a fall occurs. An interview with the Activities Director was conducted on 8/26/25 at 3:06 PM. The Activities Director stated on 7/21/2025 she was assisting three (3) residents outside the front entrance of the building to smoke. She stated she positioned Resident #9 next to a garbage can outside the second set of double doors to avoid her wheelchair from rolling and quickly turned to assist the other two (2) residents and to avoid the door from hitting one of the residents. She stated when she turned back around, she observed Resident #9 laying on her left side with her head facing the parking lot yelling help get me up with blood observed around her nose. She notified Nurse #1 who assessed the resident and assisted her back to her wheelchair. She admitted she did not lock the brakes to Resident #9's wheelchair because everything happened so fast. She further stated she was in-serviced the following day by the Administrator (the current Director of Nursing).A progress note from Nurse #1 dated 7/21/2025 at 4:38 PM revealed Resident #9 was found by staff outside of the facility lying on the sidewalk on her left side bleeding from the nose. In addition, the note indicated Resident #9 sustained skin tears to her left elbow, left above the knee amputation (AKA) stump, an abrasion to the left cheek, lips and nose. Nurse #1 indicated the bleeding from the resident's nose was controlled and the resident was assisted back to her wheelchair and to her bed. Nurse Practitioner #1 assessed the resident and placed orders for the resident to be transferred to the hospital for further evaluation. Emergency Medical Service (EMS) arrived at the facility on 7/21/2025 at 5:59 PM to transport Resident #9 to the hospital. On 8/27/2025 at 9:44 AM Nurse #1 was interviewed. She stated she was notified by a Nurse Assistant (NA) that Resident #9 fell outside. She stated that she observed Resident #9 laying on the pavement. She assessed Resident #9 and noted skin tears the left elbow and left above the knee (AKA) stump. Resident #9 was also observed to have blood coming from the nose. Pressure was applied to control the bleeding. Nurse #1 stated Resident #9 was crying in pain but could not recall where the pain was. Nurse #1 assisted Resident #9 back to her wheelchair and escorted the resident to her room for further assessment. The assessment found no additional injuries, resident cognition was at baseline and range of motion (ROM) was intact. Nurse Practitioner #1 was notified, assessed the resident and placed an order for the resident to be transferred to the hospital. Hospital Records with a service date of 7/21/2025 indicated Resident #9 had a Computed Tomography (CT) scan ( medical imaging test that uses X-rays and a computer to create detailed cross-sectional pictures of the inside of the body) of the head, cervical spine (the upper section of the vertebral column consisting of the first seven (7) vertebrae located in the neck), and facial bones with no acute (sudden onset) fractures found.Nurse Practitioner #1 was interviewed on 8/27/2025 at 10:48 AM. She revealed Resident #9 was alert and oriented and allowed to smoke. She stated she could not recall the specific details about the incident. She stated she was concerned Resident #9 sustained a fracture of the nose due to the bleeding and injuries to the face. She further indicated she did not hesitate to place orders for Resident #9 to be transferred to the hospital and that staff handled the incident appropriately.An interview with Maintenance Employee #1 conducted on 8/27/2025 revealed the distance between where Resident #9 was placed outside of the double doors at the front of the facility to where she landed when she fell out of her wheelchair on 7/21/2025, measured approximately thirty-one (31) feet. Observation of the area where the incident occurred found the surface at the front entrance was level and flat, while the area to the left, leading toward the parking lot, had a subtle incline. An interview was conducted with the current DON (the Administrator when the incident occurred) on 8/28/2025 at 1:05 PM. He stated he was notified by Nurse #1 that Resident #9 fell outside of the building during a designated smoking time. He stated Nurse #1 informed him that Resident #9 was observed laying on the ground beside her wheelchair alert with some facial grimacing. He stated Resident #9 said she had pain in the facial area, and some blood was observed to her face. He stated Nurse Practitioner #1 was notified, assessed Resident #9 and recommended to send the resident to hospital for further evaluation and to rule out a facial fracture. He further revealed that no major injury resulted from the fall. He also indicated Resident #9 could propel herself, moving freely around the facility and could lock and unlock the brakes of her wheelchair. He stated prior to the fall that occurred on 7/21/2025, Resident #9 had no prior fall incidents, and that staff are only expected to lock the brakes of wheelchairs for residents who are fall risks. Lastly, he revealed residents had to use the front entrance to smoke instead of the designated smoking area in the back of the building because the doors in the back were being repaired and replaced.

Based on record review, observations, and interviews with resident and staff, the facility failed to post cautionary signs for oxygen in use for 1 of 3 residents reviewed for respiratory care (Resident #28). The findings included:Resident #28 was admitted to the facility 07/28/25 with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure,. Review of Resident #28's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and was coded for oxygen use. A physician order for Resident #28 dated 08/15/25 read oxygen at 2 liters per minute via nasal canula to maintain oxygen above 90%.An observation conducted on 08/25/25 at 3:05 PM revealed there was no cautionary signage for oxygen use found anywhere near the entrance of Resident # 28's room. Resident #28 was observed wearing oxygen via nasal cannula at 2 liters per minute (LPM). The oxygen concentrator was observed in Resident #28's room.An observation conducted on 08/27/25 at 9:25 AM revealed there was no cautionary signage for oxygen use found anywhere near the entrance of Resident # 28's room. Resident #28 was observed wearing oxygen via nasal cannula at 2 liters per minute (LPM). The oxygen concentrator was observed in Resident # 28's room.An interview conducted with Unit Manager #1 on 08/28/25 at 11:00 AM revealed she was not aware Resident #24, Resident #23, and Resident #28 did not have an oxygen sign posted outside their rooms but should have. UM #1 stated she and nursing were responsible for hanging cautionary oxygen signs.An interview conducted with the Director of Nursing (DON) dated 08/28/25 at 12:30 PM revealed the facility had recently had renovations and the signs were not put back up. The DON stated he was not aware the signs were not posted, and cautionary oxygen signs were expected to be posted for any residents with oxygen orders.

Based on record review, and resident and staff interviews, the facility failed to provide 1 of 3 residents with quarterly statements of their personal trust fund account managed by the facility (Resident #21). The findings included:Resident #21 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #21 was cognitively intact.Interview with Resident #21 on 08/25/25 at 2:05 PM revealed she had not received any statements since admission but had money in a resident trust fund account. The Resident further revealed she wanted to receive quarterly statements to know how much money she had to spend in her account. Resident #21 stated no staff in the facility had ever discussed the resident's available funds with her.Interview with the Business Office Manager (BOM) on 08/27/25 at 1:20 PM revealed Resident #21 had not received any quarterly statements since admission. The BOM further revealed the facility had been mailing the quarterly statements to the resident's former home address and the resident should have been receiving them. The Business Office Manager indicated Resident #21 had money in a resident trust fund account that was managed by the facility. The BOM stated she was not sure how it was missed but would speak to Resident #21 and would start giving quarterly statements to Resident #21.An interview with the Director of Nursing (DON) on 08/28/25 at 12:30 PM revealed he was not aware Resident #21 had not received quarterly statements. The DON further revealed Resident #21 should receive quarterly statements and be knowledgeable of the money in her account.

Based on observations and interviews, the facility failed to label a container of thickened juice with an open date, discard expired milk, clean grease off the burner valve knobs and burner grates of the stove. Additionally, 3 of 3 dietary workers failed to wear beard coverings. These practices had the potential to affect food served to residents. The findings included: 1. The facility kitchen was toured on [DATE] with the Dietary Manager (DM) at 9:55 AM. a. The walk-in refrigerator was observed to have an open, undated carton of thickened juice. The DM reported the carton should have dated when it was opened. The DM explained thickened liquids were used for 24 hours after opening. The DM discarded the thickened juice. b. The reach-in cooler was observed with the DM at 10:05 AM on [DATE]. A half-gallon of milk was noted with an expiration date of [DATE]. The DM reported the milk should have been discarded on [DATE] and he did not know why it was not thrown away. The DM discarded the expired milk. c. The stove was observed at 10:11 AM on [DATE]. The burner valve knobs were noted to be coated with a sticky substance that did not wipe off. The burner grates were noted to have a black, charred substance and burnt on food covering them, and the grates were shiny with a greasy appearance. The DM reported it had been about a month since the stove had been cleaned, but the kitchen staff wiped off the stove after using it. d. During the tour of the kitchen on [DATE] from 9:55 AM until 10:22 AM, the DM did not wear a beard covering his facial hair. The facial hair on the DM's chin was greater than ,d+[DATE] inch in length. The DM was noted to go in and out of the walk-in refrigerator without a beard covering and was observed assisting the dietary staff with meal preparation for the noon meal that date. 2. An observation of the kitchen was conducted on [DATE] at 11:35 AM. a. The burner grates were noted to have a black, charred substance and burnt on food covering them and the grates were shiny with a greasy appearance. The DM reported he was going to remove the burner grates and soak them to remove the charred substance. b. The DM was observed with his facial hair uncovered during the observation on [DATE]. The DM had facial hair on his chin that measured more than ,d+[DATE] of an inch. The DM was noted to assist the dietary staff with food preparation and was observed entering the walk-in fridge. Dietary Aide #1 was observed preparing the noon meal and checking food temperatures. Dietary Aide #1 was observed to have facial hair on his chin measuring more than ,d+[DATE] inch. Dietary Aide #2 was setting up meal trays and preparing food for the meal. Dietary Aide #2 was observed to have facial hair on his chin measuring more than ,d+[DATE] inch. Both Dietary Aide #1 and #2 were observed without beard coverings. An interview was conducted with Dietary Aide #1 at 11:40 AM on [DATE] and he reported he was aware he needed to wear a beard covering. The DM was interviewed on [DATE] at 11:41 AM and he explained they had run out of beard coverings, and he had reordered stock of beard coverings, but they had not been delivered. The DM reported he and Dietary Aides #1 and #2 would wear a hair net to cover their beards. The DM was interviewed on [DATE] at 12:58 PM. The DM explained all perishable items should have an open date marked on the container, and expired foods should be thrown away on the expiration date. The DM reported he thought the kitchen staff were cleaning the stove burner grates daily, but the staff were not cleaning it, which caused food and grease from cooking to become burnt and charred. The DM reported he and the Dietary Aides had forgotten to wear the beard covering because they were out of stock, but they would use the hair nets until their order was delivered. The Administrator was interviewed on [DATE] at 1:15 PM and she reported the kitchen staff had a high turnover rate and she thought that training was an issue regarding the undated thickened juice, the expired milk, the burnt and charred stove burner grates, and wearing beard coverings.

Based on record review, observations, resident, and staff interviews, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for medication at the bedside (Resident #32). The findings included: Resident #32 was admitted to the facility 8/18/2021 with diagnoses including dementia and heart failure. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #32 to be cognitively intact without behaviors. Review of the medication orders for Resident #32 revealed no over-the-counter antacid had been ordered for her to take. There was no assessment completed related to self-administration of medications. Resident #32 was observed on 7/8/2024 at 11:08 AM and noted on her nightstand at the end of her bed (which was visible from the door into the room) were two bottles of over-the-counter antacid chews. The antacids were noted to be multiple colors, rounded tablets that from a distance resembled candy. One bottle appeared to be full and unopened, the second bottle appeared to have 10 or less antacid chews in the bottle. Resident #32 was interviewed at the time of the observation, and she reported her family purchased the antacids for her to keep in her room. Resident #32 explained she took the chews when she needed an antacid, and she thought the facility was aware of the antacids in her room. Resident #32's room was observed on 7/10/2024 at 10:24 am. The antacids were on the nightstand at the end of Resident #32's bed and visible from the doorway into the room. The Unit Manager (UM) was asked to come to Resident #32's room on 7/10/2024 at 10:25 AM. When the UM was shown the over-the-counter antacid chews, the UM stated, This should not be in her room, and she removed the antacids. The UM reported if a resident wanted over-the-counter medications in their room, the facility needed to do an assessment, get a physician order for the medications, and provide a lock box for the resident to store the over-the-counter medications in and Resident #32 had not had that process completed. The UM reported she was not aware Resident #32 had the over-the-counter antacids in her room. An interview was conducted with Nursing Assistant (NA) #1 on 7/11/2024 at 9:22 AM. NA #1 explained she provided care for Resident #32 frequently and she had not noticed the over-the-counter antacids on her nightstand. NA #1 explained she would remove any over-the-counter medications from resident rooms if she found any. Nurse #3 was interviewed on 7/11/2024 at 9:29 AM. Nurse #3 reported she gave Resident #32 her medications each morning, but she had never noticed the over-the-counter antacids in her room. Nurse #3 explained residents at the facility did not usually have medications at the bedside and she thought an assessment needed to be completed and a lock box provided. The UM was interviewed again on 7/11/2024 at 9:38 AM and she reported Resident #32 was unable to manage over-the-counter medications due to her diagnoses of dementia and forgetfulness. The UM explained Resident #32's family visited her, and they may have brought the over-the-counter antacids for her. The Nurse Practitioner (NP) was interviewed on 7/11/2024 at 10:09 AM and she explained that Resident #32 was unable to manage medications due to her diagnoses of dementia and forgetfulness. The NP reported Resident #32 was not harmed by the over-the-counter antacids, but staff should manage all her medications. The Administrator was interviewed on 7/11/2024 at 1:15 PM. The Administrator reported that Resident #32's family visited her, and Resident #32 also went out with her family so she might have bought the over-the-counter antacids, or the family might have brought them in for her. The Administrator reported she did not know why the staff had not noticed the over-the-counter medications in Resident #32's room. The Administrator reported she expected staff to remove over-the-counter medications in resident rooms if the resident had not been assessed to self-administer the medication.

Based on observations, record review, and staff interviews, the facility failed to maintain a safe environment by storing a chemical disinfectant cleanser spray and a handheld hair dryer with the cord hanging over a mounted power strip for 1 of 1 shower rooms observed. The shower room door was propped open and unlocked when it should have been closed and locked. Findings included: An observation on 07/08/2024 at 12:36 PM of a propped open shower room door revealed an unplugged handheld hair blow dryer hanging over a mounted blue power strip to the left of the shower room sink. A spray bottle of cleanser labeled as deodorizing bathroom cleaner was observed on the top shelf of a metal shelf on the back wall of the shower room. The warning label on the front of the spray bottle read, strong corrosive, sanitizer, irritant, combustible. The label on the back of the spray bottle included if the spray disinfectant came in contact with eyes to flush eyes immediately for 15 minutes. If the contents were swallowed, drink a glass of water to dilute and call the physician immediately. There was no staff observed in the shower room and no residents observed in the hallway outside of the shower room. On 07/08/2024 at 1:22 PM a phone interview was conducted with Nurse Assistant (NA#1). NA #1 reported she was the full-time shower staff and another Nurse Assistant (NA #2) filled in on her days off. NA #1 and she reported the shower room door was always locked unless a staff member was present. NA #1also reported that no disinfectant sprays were stored in the shower room and if needed, it was requested from the housekeeper and returned to the housekeeper after use. NA #1 added that the handheld hair dryer was to be stored in a locked storage drawer in the shower room. An observation and interview with NA #2 on 07/08/2024 at 2:29 PM in the shower room revealed the shower room door was closed and locked. NA #2 obtained the key from the beauty salon. On observation the handheld blow dryer remained unplugged hanging over the mounted blue power strip and the disinfectant spray bottle remained on the top shelf of the metal rack at the back wall of the shower room. NA #2 reported the blow dryer was to be locked in a cabinet drawer also at the back wall. The 5 drawers of the cabinet revealed no lockable drawers. NA #2 revealed she did not know why the disinfectant spray bottle was left in the shower room because she either got the spray from the housekeeper or had the housekeeper come into the shower room to clean equipment. Housekeeper #1 was interviewed at 2:46 PM on 07/08/2024. Housekeeper #1 revealed she had never observed the shower room door propped open; it was always locked. She used the disinfectant spray to clean all equipment 1 to 2 times a day and it was always locked in her housekeeping cart. Housekeeper #1 was unable to explain how the bottle was located in the shower room. On 07/08/2024 in an interview with the Director of Nurses (DON) at 2:58 PM she revealed the shower room door was to be maintained locked at all times and not propped open. The DON went on to explain that only housekeeping should have access to disinfectant spray to clean equipment which was to be stored and locked in the housekeeping cart. The DON also reported she was not aware of a handheld blow dryer not being stored in a locked storage drawer in the shower room, she was also not aware there was not a locked cabinet or drawer in the shower room. The DON revealed there were no wandering residents in the facility at the time. The expectation she explained, is the door to remain locked at all times, no disinfectant items were to be stored in the shower room and all other items were to be locked in a cabinet in the shower room. An observation of the shower room on 07/09/2024 at 8:34 AM revealed the shower room door was locked. On 07/10/24 at 9:13 AM revealed the shower room door was closed and locked. Unit Manager (UM) #1 was interviewed on 07/10/2024 at 2:42 PM. UM #1 revealed she had never observed the shower room propped open because it was always closed, locked and no spray chemicals were to be left in the shower room. UM #1 revealed she was not aware of a handheld blow dryer being used. On 07/11/2024 at 9:16 AM during an interview with the Administrator, she explained she expected the shower room door to be locked at all times, no chemicals were to be stored in the shower room and she expected resident care items in the shower room were to remain locked in a cabinet in the shower room when not in use.

Based on resident and staff interviews, the facility failed to provide mail delivery to the residents on Saturdays for 7 of 7 (Resident #5, #13, #15, #17, #32, #36, and #40) residents interviewed in resident council. Findings included: An interview with members of the resident council on 7/10/24 at 10:02 AM revealed that the facility did not deliver any mail on Saturdays. The members present for the meeting were Resident #5, Resident #13, Resident #15, Resident #17, Resident #32, Resident #36, and Resident #40. All residents that were present indicated they did not receive mail on Saturdays. The residents reported that mail was only delivered during the week. An interview was conducted on 7/10/24 at 10:31 AM with the Activity Director (AD). She revealed the mail was picked up by the Business Office Manager (BOM) from the mailbox and was given to the Social Worker (SW) to deliver daily during the week (Monday through Friday), but not on the weekend. She explained the BOM did not work on the weekend, so the mail was delivered the following Monday. She stated there was no system in place for mail delivery on the weekend and the residents received their weekend mail on Monday. An interview with the Administrative Assistant on 7/10/24 at 11:09 AM revealed she picked up the mail twice a day, not the BOM, from the mailbox and gave it to the SW to distribute during the week (Monday through Friday). The Administrative Assistant explained she put the mail that came in over the weekend in the Director of Nursing's (DON) office on Mondays and the SW would deliver it to the residents. An interview with SW on 7/10/24 at 11:58 AM revealed the Administrative Assistant sorted the mail and delivered the resident mail to her to give to the residents during the week. She explained there was no set time she would receive the resident mail, and the Administrative Assistant handed her a stack of mail daily (Monday through Friday) during the week, and weekend mail was delivered to residents on Monday. The SW stated she did not work on the weekends and was not sure if the mail was checked by anyone else on the weekends. During an interview on 7/11/24 at 1:02 PM, the Administrator revealed the weekend mail was checked by the weekend Unit Manager and personal mail was delivered to the residents over the weekend. She had the expectation that mail would be delivered to residents on the weekend.

Based on observations and staff interviews, the facility failed to maintain lighting and walls in good repair for 2 of 2 areas (resident room [ROOM NUMBER] and nurse's desk) when reviewed for environment. The findings included: An observation on 7/8/24 at 12:05 PM in room [ROOM NUMBER] revealed large black marks and scuffs on the green wall on the left side of Resident #42's bed and three black clusters of marks on the wall behind Resident #38's bed. An observation on 7/10/24 at 12:19 PM at the nurse's desk revealed an uncovered fluorescent light fixture which included two missing bulbs and one burnt out bulb. An interview with the Maintenance Director on 7/11/24 at 11:46 AM revealed there were maintenance request sheets on the door at the nurse's desk. Staff filled them out for any maintenance concerns reported to them by residents or visitors. When the task is completed, the request was signed off by a maintenance staff member. The Maintenance Director stated a paper documentation system worked well for the facility. A facility tour with the Maintenance Director and Administrator occurred on 7/11/24 at 11:50 AM. It revealed they was not aware of the marks and scuffs on the walls in room [ROOM NUMBER] or the uncovered light with burned out and missing bulbs above the nurse's desk. The Maintenance Director stated new round light fixtures were installed as the old ones burned out. This fixture had not been replaced yet. The Maintenance Director had the expectation that staff would have reported these concerns. An interview with the Administrator during the facility tour revealed she was not aware of the marks and marring on the walls in room [ROOM NUMBER] or the uncovered light fixture with the burned out and missing bulbs above the nurse's desk. She stated that the marks were due to furniture and equipment against the walls. She stated Maintenance was in the process of updating resident rooms that were unoccupied and room [ROOM NUMBER] had not been completed as it was occupied.

Based on record review, Police Department Detective, resident and staff interviews the facility failed to implement their abuse policies and procedures by failing to immediately initiate preventative and protective measures to safeguard all residents from exploitation and misappropriation of property when the facility became aware of an allegation of the Social Services Coordinator exploiting 2 residents at the Assisted Living Facility (ALF) operated by the same company and on the same campus as the skilled nursing facility (SNF). There was a high likelihood of misappropriation of property and/or exploitation leading to the loss of financial resources and irreplaceable personal belongings for all 45 residents who resided in the SNF. These losses would cause a reasonable person severe psychosocial harm with feelings of hopelessness, despair, anger, anxiety, humiliation, shame and/or embarrassment. Immediate Jeopardy began on [DATE], when the facility failed to immediately implement measures to protect all residents from exploitation and misappropriation when they discovered the Social Services Coordinator had misappropriated property from 2 ALF residents who resided on the same campus. The Immediate Jeopardy was removed on [DATE] when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of F (no actual harm with potential for more than minimal harm that is not immediate Jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: The Facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy Statement, which was reviewed and revised on ,d+[DATE], indicated, in part, the facility will ensure all residents are protected from the possibility of abuse or the potential for further abuse. The policy further indicated that needed investigations will be conducted with residents' safety as the foremost concern in order to protect the resident from future harm. A Personnel Change Form dated [DATE] indicated the Social Services Coordinator was promoted from her Medication Aide position at the ALF to the Social Services Coordinator position at the Skilled Nursing Facility. An observation on [DATE] at 9:30 am revealed the skilled nursing section of the facility was 0.3 miles from the assisted living section of the facility and both were located on the same campus. The Administrator was interviewed on [DATE] at 2:08 pm and stated the Social Services Coordinator was hired as a Medication Aide (MA) at the facility's ALF on [DATE] and was promoted to the Social Services Coordinator position at the SNF on [DATE]. The Administrator stated the employees from the SNF and the ALF could work at both facilities. The Administrator stated the Director of Nursing (DON) received a phone call on [DATE] from a resident who resided at the ALF and the resident told the DON the Social Services Coordinator had taken a $50 gift card and had not returned it. The Administrator stated she and DON spoke with the Social Services Coordinator about the card because staff members were not allowed to take money or gift cards from residents, and they were not allowed to shop for residents. The Administrator stated they began an investigation and interviewed the residents of the ALF on [DATE]. The Administrator stated on [DATE] another resident at the ALF reported she gave her bank card and pin number to the Social Services Coordinator and there was money missing from her personal bank account. The Administrator stated they called the police on [DATE]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 1:23 pm and she stated that on [DATE] one ALF resident reported that the Social Service Coordinator had taken their $50 gift card. She reported that on [DATE] the facility became aware of another ALF resident who had money taken from personal bank account by the Social Service Coordinator. During a follow up interview with the DON on [DATE] at 3:40 pm, she stated she and the Administrator had interviewed a few of the residents at the Skilled Nursing Facility (SNF), but not all the residents that were cognitively intact when they realized two residents from the ALF had money misappropriated. The DON also stated they did not document which residents were interviewed and she could not remember who she had interviewed. The DON provided a census for [DATE] with the names of residents of the SNF with the alert and oriented residents highlighted but she was not able to state which residents were interviewed. The census had 45 residents listed and 25 residents were highlighted as alert and oriented. On [DATE] at 3:05 pm a follow up interview was conducted with the Administrator, and she stated they had interviewed some of the residents of the SNF and she thought she had interviewed 3 residents at the SNF, but they had not documented which residents were interviewed. The Administrator stated she thought the DON and Resident Care Coordinator had assisted with interviewing the SNF residents. The Administrator stated they had interviewed only the residents that they thought the Social Services Coordinator had visited. On [DATE] at 3:20 pm an interview was conducted with the Resident Care Coordinator who stated after the ALF resident reported the Social Services Coordinator took her $50 gift card another ALF resident came to her and reported the Social Services Coordinator had her bank card and pin number and money was missing from her account. The Resident Care Coordinator stated the second resident from the ALF had about $200 dollars withdrawn from her bank account. The Resident Care Coordinator stated she did not remember anyone interviewing the residents at the SNF after the Social Services Coordinator was terminated on [DATE] and she had not assisted with resident interviews at the SNF. The Executive Director (ED) of the facility was interviewed by phone on [DATE] at 1:46 pm and he stated he was the Administrator at the time the Social Services Coordinator was hired for a Medication Aide position at the facility's ALF. The ED stated the facility had completed a background check for the Social Services Coordinator on [DATE] that had shown she had felony charges in the past of felony to obtain property under false pretense, felony of forgery, felony of robbery with dangerous weapon, felony identity theft, and felony conspiracy. He also stated the charges were over [AGE] years old, and the Social Services Coordinator had explained the charges were due to a domestic situation. On [DATE] at 5:47 pm the Administrator provided a Plan of Correction for Misappropriation of Property indicated to be for the SNF and ALF (per the Administrator) which began on [DATE]. The Administrator stated the facility had not interviewed all the residents that were alert and oriented and had not notified the responsible parties of residents that were cognitively impaired. The Administrator also revealed the facility did not do any ongoing monitoring because the Social Services Coordinator was terminated. She explained the facility felt there wasn't anything to monitor after the termination occurred. The plan of correction provided by the Administrator stated the facility had investigated and substantiated a misappropriation of resident property by an employee, the Social Services Coordinator, involving two ALF residents. The employee in question was terminated because of the investigation. As a corrective action the facility conducted education on Abuse, Neglect and Misappropriation of Property with all staff. The in-service was conducted on [DATE] by the Staff Educator and was attended by all staff. The Staff Educator reinforced resident's rights and what constitutes Misappropriation as well as the obligation to report any suspected misappropriation. The facility provided the in-service attendance records for the abuse education which was conducted on [DATE]. The facility did not provide audits for monitoring of residents for abuse or misappropriation, or interviews with the residents who resided in the SNF when the misappropriation was reported on [DATE]. A news article from the Salisbury Post dated [DATE] indicated the former Social Services Coordinator from the facility was arrested for 3 counts of felony exploitation of an elder or disabled adult and 1 count of felony identity theft after a 6-month investigation. The Social Services Coordinator allegedly withdrew $45,000 from Resident #15' life savings over a period of several months while the Social Services Coordinator was living in Resident #15's house. The article indicated Resident #15 was a SNF resident. On [DATE] at 1:12pm an interview was conducted with Resident #15 who resided at the SNF. She verified the Social Services Coordinator had exploited and stole thousands of dollars from her. She stated the Social Services Coordinator had tricked her into giving her account information. Resident #15 also stated she did not know if the Social Services Coordinator took the money from her account before or after she was terminated from the facility. The Nurse Aide Registry reviewed on [DATE] indicated the following: The Social Services Coordinator had 1 substantiated finding(s) of Fraud Against a Resident, which occurred while the individual was employed in a Nursing Facility. This information was entered on the Registry on [DATE]. The Social Services Coordinator had 1 substantiated finding(s) of Misappropriation of Resident Property, which occurred while the individual was employed in a Nursing Facility. This information was entered on the Registry [DATE]. The Social Services Coordinator had 1 pending investigation(s) for an allegation of Fraud Against a Resident and 1 pending investigation(s) of Misappropriation of Resident Property. During an interview with the Detective from the Kannapolis Police Department on [DATE] at 5:39 pm he stated the Social Services Coordinator was arrested and charged with Exploitation of a Disabled or Elderly Adult for taking funds from Resident #15's private bank account. The Detective stated the Social Services Coordinator had coerced Resident #15 into allowing her to live in her home and the Social Services Coordinator obtained bank account information from the home that allowed her to add herself to Resident #15's account. The Detective stated Resident #15 had several thousands of dollars stolen by the Social Services Coordinator. The Detective also stated he would not doubt if there were other residents that were exploited at the Skilled Nursing Facility but Resident #15 suffered the most loss. The Administrator was notified of the Immediate Jeopardy on [DATE] at 5:47 pm. On [DATE] the facility provided the following plan for immediate jeopardy removal: Identification of recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of non-compliance. On [DATE] an adult care home bed resident reported to the Director of Nursing that she had given the social worker (the Terminated Social Worker) a gift card to pay bills and the bills were not paid. The Administrator immediately began an investigation and interviewed the resident and the Terminated Social Worker. Upon admitting to taking the resident's gift card, the Terminated Social Worker was terminated to safeguard the other residents from the possibility of further misappropriation. A 24-hour report was filed with the Health Care Personnel Registry (HCPR) on February 17 and a 5 day investigation was completed which provided information detailing the use of the gift card and the inappropriate use of another adult care home bed resident's bank card. The facility took the following additional steps to safeguard residents: 1. Ten of fourteen alert and oriented skilled nursing residents were interviewed by the Administrator and Director of Nursing on [DATE] regarding any unauthorized use of personal property. 2. On [DATE], all Staff were trained on abuse, neglect, misappropriation, and exploitation by Staff Development 3. The Activities Director discussed misappropriation, exploitation, and who to report any suspicions to during the Resident Council Meeting held in [DATE] to all residents in attendance. No concerns of misappropriation or exploitation were reported at that time. 4. The facility Administrator and Business Office Manager conducted an audit of Resident Trust accounts on [DATE], to ensure all accounts were accurate. No discrepancies or mishandling of funds were identified. Several days after attending the [DATE] in-service the Maintenance Director approached the Director of Nursing and informed her that the Terminated Social Worker was renting a house from Resident #15. At that time the Administrator and Director of Nursing interviewed Resident #15 who stated that she did allow the Terminated Social Worker to rent the house of her deceased husband, but she was unaware of money missing from her savings account. The Director of Nursing assisted Resident #15 in contacting her sister due to the Director of Nursing's knowledge of the Terminated Social Worker's previous misappropriation. As a result of this conversation, Resident #15's sister agreed to come to the facility to discuss this matter in person. During the in-person discussion, (on or about [DATE]) Resident #15's sister expressed a concern that the former Terminated Social Worker was living at the resident's house. The Director of Nursing advised her to review any external accounts that the Terminated Social Worker may have gained access to while living at the resident's house. In front of Resident #15, the Director of Nursing, Unit Manager, and sister contacted the bank to which point the police were notified and a report filed. The Administrator and Executive Director were notified, and the discussion was had whether or not to complete a 24 hour initial report and a 5 day working report. The decision was made by the Executive Director that it was reasonable not to complete a 24-hour report since the allegations involved a former employee and a criminal investigation was ongoing by the police department there was no specific allegation as to what if any property was misappropriated and the facility was not privileged to any personal information. The facility did make efforts to protect Resident #15 and others on the information from the Maintenance Director about the former employee renting and living in the resident's house. Administrator and Director of Nursing interviewed nine alert and oriented residents who were residents when the Terminated Social Worker worked at the Facility. At that time, all interviewed residents stated they had no concerns regarding any of their personal property being misappropriated and no concerns about exploitation. The police were notified and as aforementioned, the employee had been terminated in February 2022, over a month before the alleged incident. On [DATE] the Administrator received a call from the local Police Department that a former employee had been arrested in connection with a case involving Resident #15 and the case involved a Terminated Social Worker who had been terminated on [DATE]. The police department stated that he could not share information as it was an ongoing investigation. The facility was unaware of any details of allegations and the account was an outside account, not managed by the facility. The Administrator was contacted by the healthcare personnel registry to ask questions regarding the news report. At that time, it was recommended that a 24-hour report and investigation be completed which the Administrator did on [DATE] even though the facility felt it could not adequately investigate the incident as this was an external matter which was being handled by the police department and not associated with the workplace. The Terminated Social Worker had not been employed by the facility for over six months; therefore, the residents were protected from any further misappropriation/exploitation. The facility mailed a letter from the Executive Director on [DATE] to all responsible parties as well as self-responsible residents informing them of the alleged misappropriation and exploitation and requesting that they notify the facility of any concerns regarding their accounts. The Resident #15 was interviewed by Administrator on [DATE] after the facility was contacted by the police department and the resident stated that she allowed the Terminated Social Worker to rent the house of her deceased husband. She stated she was unaware of money missing from her savings account. Later a news report was on television where it disclosed an alleged amount however the facility is unaware of the details as of [DATE]. The current facility Social Worker (the Current Facility Social Worker) has contacted the responsible parties for non-interviewable residents for interviews to inquire about the integrity of their property and exploitation. This was completed on [DATE]. All alert/oriented residents were interviewed regarding misappropriation and exploitation by the Current Facility Social Worker on [DATE]. Specify the action the facility 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. 100% of staff were notified by the Administrator and Director of Nursing of the issues involving the Terminated Social Worker and were advised to report to administration any issues involving suspected misappropriation or exploitation of residents on [DATE]. In service training was conducted by Administrator and Director of Nursing to 100% of staff to discuss issues related to handling of resident funds, misappropriation of resident funds, and how and when to reports suspicions of abuse, neglect, and exploitation on [DATE]. The Administrator has been in-serviced on the investigation of misappropriation of resident property and exploitation by the Executive Director on [DATE] to include reviewing the investigation process. This includes interview of alert and oriented residents, what to do for non-interviewable residents and documentation of efforts during the investigation. The education to Administrator included the need to provide protection to residents once an allegation is made to prevent further incidents. All staff were educated on Misappropriation and Exploitation policy and procedure to include what to observe for as evidence of possible exploitation and misappropriation and reporting. Administration will be in-serviced by the administrator on [DATE]. Staff were asked to observe for signs such as residents upset, missing items, and secretive behavior of other staff when interacting with residents. All future newly hired staff will receive training during orientation. The Administrator is responsible for overall immediate jeopardy removal. Alleged Date of IJ Removal: [DATE] On [DATE], the facility's credible allegation for immediate jeopardy removal was validated by the following: -Review of the education provided to all staff related to misappropriation of resident funds, abuse, neglect, and exploitation. -Interview with SW, nursing managers, housekeepers, therapists, and nursing staff to review education provided and procedure for identifying misappropriation, abuse, neglect, and exploitation. -Review of the interviews conducted by the facility with alert and oriented residents. -Review of audits completed by the facility. -Review of the interviews conducted by the facility with the Responsible Parties of residents that were not alert and oriented. The facility's date of the immediate jeopardy removal plan of [DATE] was validated on [DATE].

Based on observation, staff interviews and record review the facility failed to date thawing food items in one of one walk-in refrigerator when they were removed from the freezer. This practice had the potential to affect food served to residents. The findings included: 1. An initial observation of the walk-in refrigerator conducted on 3/20/23 from 10:02 AM to 12:17 PM with the Dietary Manager (DM) revealed the following food items did not have a date to indicate when the item was pulled from the freezer or a use by date: - Four - five-pound bags of frozen egg scrambled thawing in box - Raw flattened chicken breasts in a plastic bag approximately 10 pieces - Box of flattened chicken breasts in the box - One box of bacon with approximately one pound of bacon remaining - 15-pound box of bacon date put in freezer - 10-pound box of Sausage patty links - 20-pound box of beef stew meat still frozen - Two pounds of cooked roast beef slices An interview was completed with the DM on 3/20/23 at 10:19 AM who stated that when items are pulled from the freezer there should be a label to indicate the day the item was pulled from the freezer, and a use by date. The item should be used within a 72-hour period once thawed. The DM stated that food is rarely left over as he orders food every Wednesday and Saturday. DM explained that food for today Monday 3/20/23 came in on Saturday as food is used quickly within 3-4 days from when it arrives, so he knew exactly when the food was put into the refrigerator. An interview was completed with the Administrator on 3/23/23 at 11:02 AM who stated that she would expect the food which was pulled from the freezer to have a date of when it was taken out of the freezer and a use by date.

Based on record reviews, observation and staff interviews the facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey of 10/29/2021 in the area of kitchen sanitation, food procurement, storage, preparation and service and cited during the recertification survey of 3/29/23. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. This tag is cross referred to: F812-Based on observation, staff interviews and record review the facility failed to date thawing food items in the walk-in refrigerator when they were removed from the freezer. This practice had the potential to affect food served to residents. During the facility's recertification survey on 10/29/2021 F812 was cited for failure to maintain refrigerator temperatures below 41 degrees Fahrenheit in their walk-in refrigerator. On 3/23/2023 at 5:47 pm the Administrator provided the facility's Quality Assurance and Performance Improvement Committee (QAPI) minutes and stated the committee meets monthly and works on issues brought to the committee by their Quality Indicator report. She stated the facility strived to improve any issues brought to the committee through their Quality Indicators, staff concerns and satisfaction surveys, and any grievance from residents or family members.

Based on record review and staff interviews, the facility failed to include documentation in the medical record education regarding the benefits and potential side effects of the Influenza and Pneumococcal immunization, and if residents received the Influenza or Pneumococcal immunization or did not receive the Influenza Pneumococcal immunization due to medical contraindication or refusal for 4 of 5 residents reviewed for infection control (Resident #149, #11, #42, and #34). The findings included: 1.a. Resident #11 was admitted to the facility 7/17/2022. A review of the medical record revealed an immunization record with Tuberculosis (TB) testing documented, without TB test results. No documentation was found related to education regarding the benefits and potential side effects of the immunizations, or influenza or pneumonia immunization status. Unit Manager (UM)#1 located the admission paperwork, in the Admissions office, that had documentation that Resident #11 declined influenza and pneumonia vaccines on 11/1/2022. UM #1 was interviewed on 3/22/2023 at 3:00 PM. UM#1 reported the documentation for Resident #11 was in the admission office. UM#1 reported that she was not aware the immunization records should be in the medical record. 1.b. Resident #34 was admitted to the facility 8/18/2021. A review of the medical record revealed the immunization record did not include information related to Influenza and pneumonia immunization, no documentation was found related to education regarding the benefits and potential side effects of the immunizations, or influenza or pneumonia immunization status. UM #1 was unable to locate the immunization records for Resident #34. The Administrator found the immunization records for Resident #34 in the admission department. The immunization record documented Resident #34 received the influenza immunization 10/27/2022, the pneumonia immunization 3/5/2018. 1.c. Resident #42 was admitted to the facility 1/3/2023. A review of the medical record revealed an immunization record with TB testing and results documented. No documentation was found related to education regarding the benefits and potential side effects of the immunizations, or influenza or pneumonia immunization status. UM #1 was unable to locate the immunization records for Resident #42. The Administrator found the immunization records for Resident #42 in the Admission department. The immunization record documented Resident #42 declined the influenza and pneumonia immunization on 1/3/2023. 1.d. Resident #149 was admitted to the facility 3/7/2023. A review of the medical record revealed no information was documented on the immunization record. No documentation was found related to education regarding the benefits and potential side effects of the immunizations, or influenza or pneumonia immunization status. UM #1 located the admission paperwork that had documentation that Resident #149 declined the influenza and pneumonia immunization on 3/7/2023. Documentation on the admission paperwork indicated Resident #149 had received the influenza immunization in September 2022. UM #1 was interviewed on 3/22/2023 at 3:00 PM. UM #1 reported the documentation was in the Admission office. UM #1 reported she was unable to locate immunization record information for Resident #34 or #42. UM #1 reported sometimes the Infection Control nurse kept the immunization records in her office. UM#1 reported that she was not aware the immunization records should be in the medical record. On 3/22/2023 at 4:14 PM, the Infection Control nurse was interviewed. The Infection Control nurse reported that she was not aware that the immunization records should be in the medical records for each resident including education related to the benefits or potential side effects of the vaccines. The Infection Control nurse reported she had been keeping their immunization records in her office. The Director of Nursing (DON) was interviewed on 3/23/2023 at 11:25 AM. The DON reported she was aware the immunization information needed to be in the resident medical records. The DON explained the Infection Control nurse was keeping copies of the immunization records in her office, and the Admission Department was keeping the original copy of the immunization records in their office The DON reported that the medical record for each resident should have accurate and up to date immunization information. The Administrator was interviewed on 3/23/2023 at 1:17 PM. The Administrator reported that the Admissions Department and the Infection Control nurse were keeping different parts of the immunization records in their respective offices and neither department was aware the immunization records were required to be in the medical record.

Based on record review and staff interviews the facility failed to include the status for COVID-19 vaccination in the medical record, failed to include education regarding the benefits or potential side effects of the COVID-19 vaccination, and failed to document COVID-19 vaccination declinations for 3 of 5 resident reviewed for infection control (Resident #11, #42, #149). The findings included: 1.a. Resident #11 was readmitted to the facility 7/17/2022. A review of the medical record revealed an immunization record with Tuberculosis (TB) testing documented, without TB test results. No documentation was found related to COVID-19 immunization status or education regarding the benefits or potential side effects of the COVID-19 vaccination. Unit Manager (UM)#1 located the admission paperwork, in the Admissions office, that had documentation that Resident #11 declined COVID-19 immunization on 11/1/2022. UM #1 was interviewed on 3/22/2023 at 3:00 PM. UM#1 reported the documentation for Resident #11 was in the admission office. UM#1 reported that she was not aware the immunization records should be in the medical record. 1.b. Resident #42 was admitted to the facility 1/3/2023. A review of the medical record revealed an immunization record with TB testing and results documented. No documentation was found related to COVID-19 immunization status or education regarding the benefits or potential side effects of the COVID-19 vaccination. UM #1 was unable to locate the immunization records for Resident #42. The Administrator found the immunization records for Resident #42 in the admission department. The immunization record documented Resident #42 received the COVID-19 immunization 2/20/2021, 3/10/2021, and 11/19/2021. 1.c. Resident #149 was admitted to the facility 3/7/2023. A review of the medical record revealed no information was documented on the immunization record. No documentation was found related to COVID-19 immunization status or education regarding the benefits or potential side effects of the COVID-19 vaccination. UM #1 located the admission paperwork that had documentation that Resident #149 declined the COVID-19 immunization on 3/7/2023. Documentation on the admission paperwork indicated Resident #149's family member would bring in her COVID-19 immunization record with the administration dates of the immunization. UM #1 was interviewed on 3/22/2023 at 3:00 PM. #1 reported the documentation was in the admission office. UM #1 reported she was unable to locate immunization record information for Resident #34 or #42. UM #1 reported sometimes the Infection Control nurse kept the immunization records in her office. UM#1 reported that she was not aware the immunization records including education regarding the benefits or potential side effects of the COVID-19 immunization should be in the medical record. On 3/22/2023 at 4:14 PM, the Infection Control nurse was interviewed. The Infection Control nurse reported that she was not aware that the immunization records including education regarding the benefits or potential side effects of the COVID-19 immunization should be in the medical records for each resident. The Infection Control nurse reported she had been keeping their immunization records in her office. The Director of Nursing (DON) was interviewed on 3/23/2023 at 11:25 AM. The DON reported she was aware the immunization information needed to be in the resident medical records. The DON explained the Infection Control nurse was keeping a copy of the immunization records in her office, and the admission department was keeping the original copy of the immunization records in their office. The DON reported that the medical record for each resident should have accurate and up to date immunization information. The Administrator was interviewed on 3/23/2023 at 1:17 PM. The Administrator reported that the admissions department and the Infection Control nurse were keeping different parts of the immunization records in their respective offices and neither department was aware the immunization records were required to be in the medical record.

Based on record review and staff interview the facility failed to develop a comprehensive care plan for 2 of 2 residents reviewed for Level II Preadmission Screening and Resident Review (PASRR) (Resident #6 and Resident #39). Findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included epilepsy and bipolar disorder. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had no cognitive impairment and was noted as currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition. The Level II PASRR Conditions were not indicated. Review of the comprehensive care plans for Resident #6, most recently updated on 02/20/23, did not reveal a care plan was in place addressing his identified Level II PASRR status. An interview conducted with the MDS nurse on 03/21/23 at 3:38 PM revealed she was not aware that a care plan was needed for the Level II PASRR status for Resident #6. On 03/23/23 at 9:35 AM an interview with the Administrator revealed care plans needed to be resident specific and updated as required. 2. Resident # 39 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and intellectual disability. Review of an annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had significant cognitive impairment and was noted as currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition. The Level II PASRR Conditions noted Intellectual Disability. Review of the comprehensive care plans for Resident #39, most recently updated on 02/17/23, did not reveal a care plan was in place addressing his identified Level II PASRR status. An interview conducted with the MDS nurse on 03/21/23 at 3:38 PM revealed she was not aware that a care plan was needed for the Level ll PASRR status of Resident #6. On 03/23/23 at 9:35 AM an interview with the Administrator revealed care plans needed to be resident specific and updated as required.

Based on Record review and staff interviews the facility failed to provide a notice of transfer/discharge to the Resident or the Office of the State Long Term Care Ombudsman when the resident discharged from the facility to the hospital for 1 of 1 resident reviewed for hospitalization (Resident # 35). The findings included: Resident #35 was admitted to the facility on [DATE]. She was noted as being her own responsible person. A quarterly Minimum Data Set, dated dated dated [DATE] coded Resident #35 as being cognitively intact. A review of Resident #35's record revealed she had been discharged to the hospital on the following dates: 10/5/22, 12/10/22 and 2/22/23. No notice of transfer/discharge form was discovered as submitted to Resident #35 or to the Office of the State Long Term Care Ombudsman. An interview was completed with the Social Worker (SW) on 3/22/23 at 2:18 PM who stated that she would send a notice of transfer/discharge form for any discharge in the community including the facility's retirement center but not to the hospital. The SW stated that she was new to the position and was not aware that when a resident would go to the hospital a transfer/discharge notice was needed. An interview was completed with the Administrator on 3/22/23 at 2:44 PM who stated that a notice of transfer discharge should be completed for every single discharge regardless of where they are going, and this would include a hospital.

Based on observations, staff interviews and record reviews, the facility failed to maintain refrigerator temperatures below 41 degrees Fahrenheit in 1 of 2 refrigerators (the walk-in refrigerator). This practice had the potential to affect the food served to all residents. The findings included: An observation on 10/26/2021 at 11:21am of walk-in refrigerator, noted temperature was 46 degrees Fahrenheit (F). The refrigerator door was not sealed closed. Review of the temperature log located on the outside panel of the refrigerator for 10/26/2021, for October 2021, showed that 23 out of 26 dates had temperatures ranging from 42-50 degrees Fahrenheit. An interview was conducted with the Certified Dietary Manager (CDM) and Assistant Dietary Manager (ADM) on 10/26/2021 at 11:21am. During the interview the CDM and ADM stated that they had submitted a work order to Maintenance Department, for the refrigerator door not sealing correctly. They further stated it would take 10 weeks for a new door to arrive. Observation of refrigerator door at this time, showed that the seal on the right side of the door was hanging off from the top right-hand side of the door. At this time, the CDM provided documentation of an email showing a new door was ordered on 10/4/21 by the Administrator. An observation on 10/26/2021 at 5:15pm of walk-in refrigerator, showed the temperature was 47 degrees F. Inside were milk, eggs, cheese and juice. A thermometer located inside the refrigerator showed the temperature was 42 degrees F at this observation. Observation on 10/27/2021 at 9:26am of walk-in refrigerator, showed the temperature was 45 degrees F, inside of refrigerator were milk, eggs, cheese and juice. Temperatures were obtained by the CDM with a digital thermometer of two cartons of milk in the refrigerator at this time. One milk observed to be 36.8 degrees F and a second milk was observed to be 41.9 degrees F. Interview with CDM on 10/27/2021 at 9:26am, CDM stated a refrigerator truck had been ordered to use and would be delivered to the facility on [DATE]. Interview with the Cook on 10/27/2021 at 9:50am, stated that she was responsible for monitoring refrigerator temperatures and that she had been unaware that the temperatures were too high until 10/27/2021. Review of the temperature log with the Cook for October 2021 showed that 19 out of the 27 days had the Cook's initials for having checked the temperature of the refrigerator when it was above 41 degrees F. When asked if she had reported the 19 high temperatures in October 2021, the Cook was unable to remember when or if she had reported the high temperatures to her Supervisor. Further review of the refrigerator temperature log on 10/28/2021 showed the temperature for the October 27th was 50 degrees F and on the October 28th the temperature was 43 degrees F. An interview with the Registered Dietitian (RD) on 10/28/2021 at 2:00pm, indicated she was not aware that the temperature in the walk-in refrigerator was out of range until 10/26/2021, when the CDM called her and reported it. She advised the CDM to discard the food in the refrigerator, purchase new food and place it in the food truck. RD stated that she was new to her role and made observations on 8/21 and 9/21 and did not recall the temperatures being above 41 degrees F until it was reported on 10/26/2021. RD stated that staff should have notified her prior to 10/26/2021 to get direction on whether to replace the food. RD stated that the facility had replaced parts of the door and ordered a new door. A follow up interview with CDM on 10/28/2021, at 4:14pm, she stated that she was new to the position and that prior to her, the ADM was in charge of the kitchen. CDM stated the food from the refrigerator should not have been served. She stated that staff monitored the temperature of food and milk in the refrigerator, but she was unable to produce documentation to support that. CDM stated that the food in the walk-in refrigerator has been discarded on 10/28/2021 and that the process would be to check the food temperature prior to serving and if the temperature was too high, to not served it. Interview with the Administrator and Executive Director on 10/28/2021 at 4:52pm, both stated that they were aware of the temperatures of the walk-in refrigerator and they were working to replace the door. Stated they became aware that the walk-in unit door was not working and had the refrigeration company service the unit and ordered new door on 10/4/2021. Administrator stated that staff checked the milk prior to serving, but could not provide documentation of any temperatures, she further stated that the milk temperature had been checked a couple of weeks ago (beginning of October) and that the milk temperature was fine. Administrator stated that the staff probably did not know that they should report the temperatures were too high. Both the Administrator and Executive Director stated that the staff should obtain temperatures inside of the refrigerator, log the temperature and then report to the Supervisor any temperatures outside of 41 degrees Fahrenheit.

Based on observations, record review, local health department representative interview, staff interviews and the Centers for Disease Control (CDC) COVID-19 Data Tracker for [NAME] county transmission rate, the facility failed to follow CDC guidance regarding appropriate Personal Protective Equipment (PPE) for counties of high county transmission rates when 1 of 1 staff members (Activities Director) failed to wear eye protection when conducting a Resident Council meeting with 4 of 4 residents (Resident # 26, Resident #27, Resident #33, and Resident #34), when 3 of 3 staff members (Infection Preventionist, Medication Technician (MT) #1 and MT #2) failed to wear eye protection when providing care to 3of 3 residents (Resident #33 and Resident #7, Resident #1) and when 1 of 1 staff members ( NA #1) failed to wear eye protection when providing snacks to 3 of 3 residents (Resident #2, Resident #13, Resident #31). These practices had the potential to affect all residents who receive care from the facility staff. This failure occurred during a COVID-19 pandemic. The findings included: On 10/25/21 and 10/26/2021 the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker was reviewed. The CDC Covid-19 Data Tracker revealed that the county where the facility was located had a high level of community transmission for COVID-19. CDC guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 9/10/2021 indicated the following information under the section Implement Universal Use of Personal Protective Equipment for Healthcare Personnel (HCP): * If [CONDITION(S)]- CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), Healthcare Personnel (HCP) working in facilities working in counties with substantial or high transmission should also use PPE (Personal Protective Equipment) as described below including: Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The facility did not have a policy that corresponded to the 9/10/21 Centers for Medicare and Medicaid Services (CMS) memo related to using community transmission rate and what PPE would be required. An initial Director of Nursing (DON) interview on 10/26/2021 at 10:55 AM revealed staff were to wear a surgical mask while in the facility. If a resident was on transmission-based precautions, then staff should have full PPE in place based on precautions. During a Resident Council meeting on 10/26/2021 at 4:15 PM, the Activities Director was observed to be within 6 feet of 4 residents (Resident #26, Resident #27, Resident #33, and Resident #34) without wearing eye protection. The Infection Preventionist was observed on 10/27/2021 at 8:47 AM in a Resident #33's room assisting the resident with oxygen. The Infection Preventionist was within 6 feet of the resident without wearing eye protection. During an observation and interview on 10/28/2021 at 9:39 AM with Medication Technician (MT) #1, the MT was observed providing wound care to Resident #7 without wearing eye protection. The MT indicated she only wore eye protection when she was irrigating a wound or if there was a chance body fluid would be splashed in her eyes. During an observation and interview with Nursing Assistant (NA) #1 on 10/28/2021 at 10:14 AM, NA #1 was observed to be providing snacks to Resident #2, Resident #13 and Resident #31 without wearing any eye protection. NA #1 indicated that she only wore eye protection when there was a COVID outbreak or when she was providing resident care. An observation and interview with MT #2 on 10/28/2021 at 10:19 AM during medication administration revealed MT #2 was not wearing any eye protection while administering medications to Resident #1. MT #2 indicated that she would wear eye protection if there was a Covid outbreak or if there was a chance body fluid would get in her eyes. An Infection Preventionist interview on 10/28/2021 at 6:15 PM revealed she was aware of the most recent CDC guidance regarding wearing eye protection in a COVID-19 high transmission rate county. The Infection Preventionist verbalized the CDC guidance was a recommendation and was not mandated. The Activities Director was interviewed on 10/29/2021 at 12:20 PM. She revealed she was not wearing eye protection when she was within 6 feet of residents because there was not a COVID-19 outbreak in the facility. The Activities Director further indicated the facility was following CDC guidance which was that staff were to wear surgical masks. An interview with the [NAME] County Health Department Director of Nursing (DON) on 10/29/2021 at 1:36 PM confirmed the facility was in [NAME] County and the transmission rate for COVID-19 was high. An interview with the DON was completed on 10/29/2021 at 2:57 PM. The DON revealed the facility read the CDC guidelines as recommendations not mandates. The DON further indicated the staff were advised to wear eye protection only when doing procedures that body fluids could be splashed into their eyes such as irrigation of wounds, nebulizer treatments and suctioning.

Based on record review, resident, and staff interviews, the facility failed to communicate the facility's efforts to address group concerns verbalized during Resident Council meetings for 3 consecutive months (August 2021, September 2021, October 2021) for 4 of 4 residents (resident #26, #27, #33 and #34) that participated in the Resident Council group meeting. The findings Included: The Resident Council minutes for the period August 2021 through October 2021 were reviewed on 10/26/21 at 2:17 PM. The Resident Council minutes revealed the following: · Resident Council minutes dated August 2021 indicated residents had voiced concerns related to menus and staffing on weekends. · Resident Council minutes dated September 2021 indicated residents had voiced concerns related to laundry and dietary specifically to food. There was no evidence of the facility's response to the concerns voiced during the previous meeting had been reviewed or discussed. · Resident Council minutes dated October 2021 indicated residents had voiced concerns related to soiled linen and clothing being left on the floor, not enough toilet paper or paper towels in the bathroom. There was no evidence of the facility's response to the concerns voiced during the previous meeting had been reviewed or discussed. The facility's concern log was reviewed on 10/26/21 at 3:33 PM which revealed no documented concerns from the Resident Council from August 2021 through October 2021. On 10/26/21 at 4:15pm an interview was conducted with the Resident Council group. Resident #26, #27, #33 and #34 were in attendance. The Residents stated they do not always receive feedback from staff when group concerns were voiced. The Resident Council group stated that concerns with staffing on the weekends, menus specifically to food, not enough toilet paper or paper towels in the bathrooms, laundry and soiled linen and clothing being left on the floor remain on-going with no feedback or resolution reviewed or discussed with the group. The Resident Council group stated that individually they have to ask departments for answers to their concerns that were voiced during the Resident Council meetings. On 10/27/21 at 3:54pm an interview with the Activity Director (AD) revealed that she follows-up with other departments after resident council during QAPI meetings which residents were not allowed to attend. There was no concern form in place to document concerns from Resident Council or how they were resolved. The AD stated that she verbally informed the departments of their concerns from August 2021 until October 2021. The AD explained that she would verbally update resident council with any information that she received but had no system in place to determine if prior concerns of the Resident Council were resolved. On 10/27/21 at 4:09 PM an interview with Social Worker (SW) revealed she does not attend Resident Council. The AD would come to her if she was not able to resolve an issue, but she had not received any concern forms from Resident Council. On 10/28/21 at 8:59am an interview with the Assistant Administrator revealed that follow up to Resident Council concerns would be discussed and documented in the QAPI meeting to address the voiced Resident Council's concerns and report back to that group. A determination would be made as to whether or not the Resident Council group was satisfied with the resolutions. If there were still problems or concerns, then the facility would need to continue addressing the issue until a resolution was reached. The Assistant Administrator verbalized that residents did not attend the QAPI meeting.

Based on observations and staff interviews, the facility failed to secure 1 of 1 treatment carts when left unattended by the Medication Technician (Med Tech) #1. The findings included: On 10/26/21 at 11:47 AM during initial facility walk through, observation of the facility treatment cart on the 100 Hall was observed to be unattended and unlocked. During the observation, four staff members passed by the unlocked treatment cart including a staff member escorting a resident down the hall. Med Tech #1 returned to the treatment cart at 11:50 AM to get more supplies and locked the cart. Med Tech #1 was interviewed on 10/26/21 at 11:59 AM about the facility treatment cart. She explained that she was performing wound care on a resident and when she came back to the treatment cart to get more supplies, she realized the cart was unlocked and she locked it. She was aware the treatment cart was to be locked at all times when unattended and verbalized leaving the treatment cart open was an oversight. Nurse #1 was interviewed on 10/26/21 at 12:43 PM about the process for locking a facility treatment cart. She stated the process was for staff to lock the treatment cart if not within eyesight of the treatment cart. The facility treatment cart was observed with Nurse #1 to contain the following items: triple antibiotic ointment, [MEDICATION(S)] cream, [MEDICATION(S)], venelex wound dressing cream, iodine swab sticks, dakins solution, biofreeze, [MEDICATION(S)] and wound cream. The Director of Nursing (DON) was interviewed on 10/28/21 at 8:55 AM and stated when a nurse needed to step away from the medication cart or treatment cart, the cart was to be locked at all times.

Based on record review, staff interview, psychologist interview, and physician interview the facility restrained 1 of 1 resident (Resident #83). 4 Staff held Resident #83 to provide incontinence care and receive an injection of [MEDICATION NAME] (sedative) following resident to resident altercation. The Immediate Jeopardy started on 3/6/15 with Resident #83 being held down and received personal care and was administered a sedative due to aggressive behaviors. The Administrator was notified of Immediate Jeopardy on 5/21/15 at 1:30 pm. The Immediate Jeopardy was removed on 5/22/15 when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete training on restraints for 100% of the staff and to implement the monitoring of its corrective action. The findings included: Resident #83 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent minimum data set (MDS) assessment dated [DATE] indicated Resident #83 required extensive assistance to complete activities of daily living with the use of two + person physical assist. The MDS further indicated Resident #83 rejected care 4 to 6 days. Resident #83 was coded as being cognitively impaired as evidenced by a brief interview for mental status (BIMS) score of 99 indicating the resident was unable to complete the interview. Review of Resident #83's care plan dated 3/12/15 indicated a Problem/Need of; Resident #83 required assistance with activities of daily living (ADL) related to recent hospitalization for malnutrition, depression and decubitus ulcer. He has weakness and deconditioning, decreased mobility, history cardiovascular accident and history of gunshot wound. He does refuse care at times and is physically abusive to staff at times. The Goal stated, Resident #83 will have ADL needs met by staff assistance or participation as evidenced by he will receive care needed daily though review period. The approaches included; staff to document the amount of care provided on the ADL documentation, out of bed in wheelchair daily as tolerated. Assist with wheelchair locomotion. Encourage Resident #83 to roll wheelchair as able. He can propel himself slowly-staff push him as needed; Nursing assistant (NA) to monitor Resident #83 participation and document per ADL charting, check pads/briefs throughout shift: providing incontinence care when soiled. Review of Resident #83's behavior report revealed the following behaviors; 3/6/15 stated, NA's have been told he has to be changed event though he clearly states he does not want to be touched .took 3 employees getting hit kicked and punched to change him. On 3/6/15 Resident #83 was extremely combative to the point of hurting himself and hurting staff. Took 4 people to change him. Review of Resident #83 physician note dated 3/6/15 indicated a chief complaint of episodes of agitation and combative behavior. Resident #83 had past medical history of [REDACTED]. The note stated, He had been found to be agitated and combative and the nursing staff. He had scratched one of the NA's and had tried to hit another NA that was performing activities of daily living care. So physician visit was requested. The assessment and plan identified behavior disturbance/[MEDICAL CONDITION]: discussed with the patient about it, he refuses to talk at this time. We'll start him on [MEDICATION NAME] 0.5mg by mouth every 6 hours when necessary for severe anxiety or agitation to be given before activities of daily living care. He's presently on [MEDICATION NAME] 15 milligrams (mg) by mouth at bedtime and [MEDICATION NAME] 100mg by mouth daily, we will continue with these. Well refer him to psychiatry. Review of Resident #83's physician order [REDACTED]. Physician order [REDACTED]. Review of Resident #83's psychological assessment note dated 3/12/15 identified a chief complaint of depression. The note stated Resident #83 is a patient being followed with a [DIAGNOSES REDACTED]. Then rolls back over, answers a few more questions, then stops talking. His speech is soft, and somewhat difficult to understand when he speaks so low. He does report some depression and some anger. When I asked what about, he shrugs his shoulders and says guess. Staff report he curses at them, and can be resistive and irritable at times with them. He denies any troubles sleeping and eating, and says he is not depressed. He denies any anxiety. Shakes his head no when asked about suicidal or homicidal thoughts, and denies any hallucinations currently or in the past. He denies any manic symptoms as well. He seems to have a hard time processing information during the interview, and gets frustrated at this, and is when he ends interview. The Recommendations indicated, 1) patient is having trouble settling in here. Suspect some of anger is over losing independence. Will increase [MEDICATION NAME] to 30mg qhs and monitor and 2) follow up the Resident #83 in one to three months' time or as needed (PRN) Review of Resident #83's nurses note dated 3/22/15 at 4:00pm stated, Resident #83 was attempting to go in room [ROOM NUMBER](Resident #26), Resident #26 of that room told Resident #83 it was not his room. Resident #83 kicked Resident #26 on her left lower leg. Resident #83refused to get out of Resident #26 room, so this nurse pulled his wheelchair out into the hallway. Resident #83 began to use foul language toward this nurse attempt to hit staff. Nurse's note dated 3/22/15 at 4:15pm stated, Called doctor informed him of what happened, new order to give 1mg [MEDICATION NAME] intramuscularly (IM), now also called Administrator in training informed her also. Left message for DON and family member to return call. Nurse's note dated 3/22/15 at 4:30pm reveled IM [MEDICATION NAME] 1mg given to resident in right thigh, took 4 people to help hold Resident #83. Was kicking, hitting staff attempted to hit staff. Interview with Nurse#3 (nurse who provided the [MEDICATION NAME]) on 5/20/15 at 4:09 am via telephone described Resident #83 as combative. Resident #83 would kick and bite. On 3/22/15 NA#3 stated that Resident #83 had gone directly across the hall to Resident #26 room. Staff attempted to reorient Resident #83 but he became aggressive with staff. Nurse #3 stated he contacted the physician and was provided an order to give the resident [MEDICATION NAME] IM. The resident was very combative and it took 4 staff to provide the injection. Nurse #3 stated he used the wrong descriptive words when he wrote it took 4 staff to hold down Resident #83. Nurse #3 stated he meant to write that they stood him up to provide the injection. 2 staff to support the resident in standing the resident to prevent the resident from kicking and one staff that stood in front of the resident. Nurse #3 stated he was unsure exactly what the 3rd staff was doing but he assumed they were holding resident #83 ' s hands so he couldn ' t scratch or hit. The nurse indicated he was standing behind the resident to give the injection. Interview with NA #6 on 5/20/15 at 5:05pm revealed on she was working on the day Resident #83 hit resident #26. NA #6 stated she did not witness the incident. On 3/22/15 NA #6 stated she heard a commotion going and observed staff trying to block Resident #83 from entering the Resident #26's room. Resident #83 was observed to be trying to push his way back in the room. NA#6 stated she was asked by Nurse #3 for assistance but she was unavailable to assist. NA#6 did recall 3 people assisting Nurse #3 with Resident #83's [MEDICATION NAME] injection. NA# 6 was unable to recall which staff were in the room other than Nurse #3. Review of Physician order [REDACTED]. Review of Resident #83's psychological assessment dated [DATE] revealed, Resident #83 is a patient being followed with a [DIAGNOSES REDACTED]. Staff report he is still irritable at times, but does still seem to have the physical aggression he had before. He still does not answer a lot of questions. He denies any suicidal thoughts, and denies and homicidal thoughts. He is not very compliant with meds and says he is sleeping and eating fine. The current medications included [MEDICATION NAME] 100mg daily and Remron 30mg qhs. The assessment revealed unspecified [MEDICAL CONDITION], rule out dementia. The recommendations were as follows: 1) patient seems to be slowly adjusting to environment here. Will be difficult given his physical impairments and age, but will continue to have staff provide support wherever they can. He declines therapy. Continue meds but not taking consistently. Will monitor and 2) follow up with the patient in one to four months' time or as needed (PRN) Review of Resident #83 physician note dated 5/7/15 indicated a chief complaint of refusal to have labs drawn. The note further indicated Resident #83 continued to be noncompliant with treatment and scheduled lab work he was scheduled. The note stated, His [MEDICATION NAME] was recently changed to liquid form and [MEDICATION NAME] was changed to orally disintegrating tablet (ODT) . The assessment indicated behavior disturbances/[MEDICAL CONDITION]: he is presently on [MEDICATION NAME] 100mg by mouth daily and [MEDICATION NAME][MEDICATION NAME] by mouth daily. He is on [MEDICATION NAME] 0.5mg by mouth every 6 hours when necessary for severe anxiety or agitation. We ' ll continue to monitor him closely. Continue to follow psychiatry recommendations. No other intervention is needed. Physician order [REDACTED]. Interview with Nurse #1 5/20/15 at 11:26am revealed Resident #83 would get very agitated quickly any time he was approached to provide incontinent care or assist with activities of daily living. He usually wants to be left alone. Stated she did not work with him often but when she had attempted Resident #83 tried to knock items off meal try. When staff change him it takes 2 people and sometimes 3. Resident #83 tries to bite, kick and curses at us. Some holds his arms from hitting, one staff on each side while one staff dries him off. He will move his head and attempt to bite staff. Interview with NA#1 on 5/20/15 at 11:35am revealed Resident #83 would curse, kick, hit, scratch, and bite staff when care was provided. NA#1 further indicated Resident #83 had taken out his penis in an attempt to urinate on staff. Resident #83 had kicked at other residents. Resident #83kicked Resident #26 and Resident #61. NA#1 was not working when Resident #83 kicked the 2 residents. Resident #83 had been aggressive with her as well as evidenced by kicking her. NA#1 stated Resident would go without care occasionally due to refusals of care. Resident #83 would kick when he was being changed. In the instance the resident was becoming combative with care it could take 3 staff to change him. NA#1 stated one staff to change him, one staff at holding his legs, and one person holding his arms. 2 staff had to hold him for her to provide him care. Resident #83 was able to independently propel his wheelchair with his feet. He would occasionally go into other residents rooms. Staff indicted staff occasionally used interventions such as putting on geri-sleeves to prevent the resident from scratching them when providing care. Staff prevent Resident #83 from biting them by moving out of the way. NA#1 stated Resident #83 was doing better the last 3 days due to putting resident #83's antidepressant in his nutritional supplement. Interview with NA#2 on 5/20/15 at 11:53am revealed Resident #83 displayed behaviors when care was provided. NA#2 stated she assisted staff with care when needed. NA#2 stated it took 3 staff to provide Resident #83 care. One staff would hold the resident's legs one staff would hold residents arms. Resident #83 would scratch staffs arms and kick. Interview with the facility Social Worker on 5/20/15 at 12:01pm revealed Resident #83 commonly refused care. Resident #83 behaviors were described as biting, kicking, and hitting. Staff were to provide the resident with redirection in instances he was agitated. The social worker indicated she was unaware of the situation in which Resident #83 was held by staff to provide [MEDICATION NAME] IM. The social worker indicated in the instance Resident #83 refused or became combative staff should have called the Doctor to make him aware or he should have allowed time to calm prior to providing the medications. In the instance the resident was still aggressive the resident could have been sent out to a behavioral unit for treatment. Interview with the Director of Nursing (DON) on 5/20/15 at 2:18pm described Resident #83 behaviors as kicking, scratching, pinching, spitting and has pulled out his penis in an attempt to urinate on staff. Several of the facility staff had been scratched by Resident #83 enough to draw blood. The DON stated occasionally it only took one staff to provide Resident #83 care and sometimes it took 2. One staff to do the care and one staff holding him over while the care is being done. The third staff would be available for getting supplies for care when needed. The DON stated she was unaware of the incident that involved 4 staff persons to provide Resident #83 with a sedative. It is not facility practice to hold down a resident to medicate them. Staff should have left the resident alone as long as the resident was safe. It is further not facility practice to hold down a resident to provide ADL care. Interview with the Administrator on 5/20/15 at 2:53pm Resident #83 was resistive to care. Resident #83 was further described as combative towards staff as evidenced by scratching, pinching staff. The Administrator indicated he was unaware of Resident #83 attempting to urinate of staff. The Administrator indicated he would imagine it would take 2 staff to provide the resident with activities of daily living but was unaware that staff were having to hold the resident to provide care. The Administrator indicated it was not common practice for staff to hold down a resident to provide treatment or care and it could be considered restraint or could be an allegation of abuse. Interview with the psychologist on 5/21/15 at 9:46am revealed he was aware that Resident #83 had hit a couple of residents in the facility. The psychologist indicated that problem is that Resident #83 was not compliant with his medications. The Psychologist indicated Resident #83 won't engage with psych so I was difficult understanding his needs. Resident #83 also would not comply with medications making stabilizing the resident difficult. The medical issues Resident #83 had could contribute to Resident #83 behaviors. The psychologist continued with he may need to look at a different category of medications. Psych indicated he receives information regarding Resident #83's behavior by talking with nursing and NA's that work with him, and going through nursing notes. Nursing staff will review with psych if they have issues that come up within my visits as evidenced by phone calls. Resident #83 only gives me a few words and then ignores me. Indicated he has been in contact with the physician and discussions have taken place about what medications could be crossed or mixing medications into food or drinks. The psychologist indicated he was at the mercy of what the facility could manage and what they can't manage. If they felt like they were managing they hold off until the next visit to communicate concerns. It comes down to what the facility is comfortable with managing in regards to behaviors. (Interventions) Interview with the physician on 5/21/15 at 11:09am revealed Resident #83 had been followed by psychology on a couple of occasions. The physician described Resident #83 as very complicated. He won't let me check him. He falls to the ground and I'm afraid one day he is going to hurt himself. The physician stated he didn't want to do anything with the resident because he didn't want to harm the resident. The named resident is on [MEDICATION NAME] as needed, [MEDICATION NAME] and [MEDICATION NAME]. The physician indicated he talked to the psych and some of the resident's problems don't have a solution. The physician indicated he was aware the resident hit someone a month or two ago. He recalled being contacted by the facility about the altercations. The physician indicated he wasn't surprised about the aggression due to the resident not taking his medications. The Physician stated, What do you do? The resident is very young and doesn't have anything acute. The physician indicated he was unaware it took 4 staff to administer Resident #83 with a sedative on 3/22/15. Staff should have left the resident alone as long as he was safe. Giving him 15 min 4:00 until 4:15pm they should have given him time to de-escalate. The physician stated he didn't give antipsychotic medication until the psychologist offered them. The physician indicated he was against the resident being held down in the instance he was refusing medication or treatment. The physician indicated he was unaware staff were having to hold resident down to provide care. The Administrator was notified of Immediate Jeopardy on 5/21/15 at 1:30 pm. Allegation of Compliance accepted on 5/22/15 F221- Restraints 1) The facility is currently restraint free and attempts to remain restraint free. In this episode it was identified staff had to hold the resident 83 down to perform assistance with ADL care and in one instance had to administer an as needed intramuscular [MEDICATION NAME] shot by securing his combative arms and legs so they could administer the shot · As of 05/21/2015 Resident #83 has been assessed and care plan updated to include interventions to prevent this resident from a physical altercation(s) with another resident(s). The interventions include the following: (Exhibit 1) 1. Identify S/S of agitation and anxiety 2. Remove to quiet and safe environment away from other residents to allow to calm down if showing S/S of agitation 3. Do not argue back with Resident #83 4. Talk in a calm and quiet voice 5. Encourage to verbalize his feelings 6. Provide emotional support 7. Alternate activity with rest periods 8. Obtain Resident #83 attention prior to engaging resident in conversation or providing care 9. Inform Resident #83 what you are going to do before performing care 10. Determine source of agitation and/or anxiety 11. Evaluate preference for sleep pattern, meal times, getting out of bed, favorite activities 12. Maintain safe distance to honor his personal space 13. Allow to return to public setting when he no longer demonstrates S/S increased agitation of anxiety 14. Administer orders per MD for anxiety as ordered 15. Evaluate effectiveness and side effects of medication 16. Minimize distractions as much as possible 17. Offer favorite food or drink 18. Report changes in behavior to the nurse 19. Avoid embarrassment and ask onlookers to leave 20. Notify MD, DON, psychiatrist, and RP if unable to calm him down As needed for this definition includes having, nearly having, or visibly/audibly showing anger or agitation in public, and/or any attempts to strike or kick another resident where this resident instigated a physical altercation with another resident at the facility. · Specific assigned nursing staff (CNAs, LPNs, and/or RNs) will monitor the resident through q 15 minute checks while resident is in his wheelchair. The 100 hall nurse, who is also responsible for resident #83, is responsible for ensuring that the q 15 minute checks of resident #83 are being completed timely and documented in full. In the event this nurse is unable to complete the q 15 minute checks herself, she will directly assign responsibility to the 200 Hall nurse. In addition, all staff have been trained to observe this resident and will assist in meeting the q 15 minute checks as assigned. The assigned personnel will check on resident and his whereabouts and potential agitation levels. If the resident is agitated or shows agitation in a public setting staff will intervene by taking resident back to his room or to an area where he is not around others to allow time for his behavior or agitation to subside. The director of nursing and the resident ' s attending physician will be notified that the resident is agitated or exhibiting combative behaviors. Staff will ensure that when the resident is showing these behaviors he will be monitored by 1:1 staff supervision to ensure safety of other residents until behaviors subside. The nurse will be responsible for documenting such behaviors in the patient ' s medical record. · The daily location/behavioral checks will be documented by the staff member on a q 15 minute observation sheet (see exhibit 1) and reviewed by the director of nursing or nurse in charge for monitoring of interventions to achieve goals. In the event behaviors do not calm following the interventions and he continues to refuse care and be combative, the resident may be discharged from the facility through involuntary commitment to protect the safety of other residents and to seek other treatment for [REDACTED]. · The facility administrator has reviewed its protocols on managing combative residents while also protecting the safety of the staff while performing care. The facility nursing staff (CNAs, RNs, and LPNs) will be required to complete an in-service on 05/22/2015 or before beginning their next respective shift if unable to make that in-service date. The in-service will review handling of combative residents, how to manage the behaviors of Resident #83 when he is refusing care with staff and being combative toward them, staff protecting themselves in the event the combativeness is endangering their safety, and reporting to one another from shift to shift when residents have been agitated or combative on prior shifts through report to alert oncoming staff of potential behaviors. The in-service (Exhibit 3) will be completed by 05/22/2015 and for all nursing personnel (CNAs, LPNs, RNs) and will include the resident 83 ' s combative behaviors, interventions, and how caregivers should attempt care, and what they should do in the event they are unable to perform care on this individual due to his combativeness/resistant toward their care. It will be part of the in-service that staff are not allowed to physically restrain this resident or any resident unless the employee ' s safety is in danger where they need to protect themselves and how to properly and safely remove themselves from a combative situation and notify a supervisor. Any incidences of this nature will be immediately reported to the physician and the director of nursing for additional interventions as directed. 2) All nursing personnel (CNAs, LPNs, and RNs) will be in serviced on 5/22/2015 or before their next respective shift on what to do in the event they have a resistive or combative resident who is refusing to allow staff to provide care. At no time will it be allowed for any staff member to physically restrain a patient to administer care unless that resident is directly jeopardizing the safety of that caregiver. Nursing staff have also been in serviced on what they are to do in the event a resident is combative toward them, how to protect themselves, how to manage patient when he is refusing his care and to report the incident to a supervisor who in turn will seek additional interventions and notify appropriate personnel for interventions. · The facility has reviewed its training of nursing staff (CNAs, LPNs, RNs) in dealing with difficult and/or combative resident to include when a resident completely refuses to be cared for and that other interventions are to be tried. (Exhibit 2) All employees are subject to the facility progressive disciplinary policy and infractions will result in immediate termination of employment for staff that violate this policy. (Exhibit 3) 3. The nursing personnel (CNAs, LPNs, and RNs) will be in serviced on 5/22/2015 or before their next respective shift on what to do in the event they have a resistive or combative resident who is refusing to allow staff to provide care. At no time will it be allowed for any staff member to physically restrain a patient to administer care unless that resident is directly jeopardizing the safety of that caregiver. Nursing staff have also been in serviced on what they are to do in the event a resident is combative toward them, how to protect themselves, and to report the incident to a supervisor who in turn will seek additional interventions and notify appropriate personnel for interventions. All employees are subject to the facility progressive disciplinary policy and infractions will result in immediate termination of employment for staff that violate this policy.

Based on record review, pharmacist interview, physician interview and staff interview, the facility failed to ensure the consultant pharmacist requested a Digoxin blood level for one (1) of four (4) sampled residents who received Digoxin (Resident # 1). Findings include: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the resident's clinical chart revealed Resident #1 received Digoxin 250 micrograms (mcg) daily. There was not a physician's orders [REDACTED]. Lexi-Comp's Geriatric Drug Dosage Handbook 12th edition stated, in part,"Digoxin is used in the treatment of [REDACTED]. Symptoms of acute overdosage/ toxicity included vomiting and hyperkalemia (excess potassium)." Medical record, hospital discharge summary dated /01/07/2011 and laboratory reports were reviewed. Resident #1 was admitted to the hospital with [REDACTED]. A list of hospital medications included Digoxin 250 micrograms (mcg). A Digoxin level was not noted in Resident #1's facility record. On 02/03/2011, Resident #1 had a potassium level of 5.5 (normal 3.5-5.1). Her physician ordered Kayexalate 30 Grams (GM) given for hyperkalemia (elevated potassium). Physician's progress note dated 01/10/2011 indicated Resident #1 had a [DIAGNOSES REDACTED]. Consultant pharmacist note dated 01/19/2011 indicated there were no labs. Risk medications included Digoxin. No recommendations were noted. On 02/08/2011, consultant pharmacist note indicated Resident #1 had received Kayexalate 30 GM. Labs noted did not include a Digoxin level. Risk meds included Digoxin. No recommendations were noted. History and Physical from (name) hospital dated 02/18/2011 revealed Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 was admitted to (name) hospital with nausea, vomiting and confusion. She had evidence of acute renal insufficiency and Digoxin toxicity. She was evaluated by Cardiology and treated with intravenous fluids. During a telephone conversation on 3/21/2011 at 11:05 AM., the consultant pharmacist stated Digoxin is noted as a Risk medication. That would have alerted her to make sure labs (Digoxin blood level) would be drawn every six months and Resident #1 was admitted in January 2011. When asked if the elevated potassium, use of Kayexalate, weight loss and [DIAGNOSES REDACTED].#1. During a telephone conversation on 3/21/2011 at 7:35 PM., Resident #1's physician (MD) stated resident #1 was very sick during her stay in the facility. She had multiple [DIAGNOSES REDACTED]. He had not ordered a Digoxin blood level and did not receive a recommendation for a Digoxin blood level from the pharmacy consultant. On 3/28/2011 at 8:22 AM., the Director of Nursing stated the consulting pharmacist reviews residents' medications once a month. She stated the pharmacist consultant did not make any recommendations to obtain a Digoxin level for Resident #1 and stated Digoxin levels are obtained every six months per protocol. She expected the pharmacist consultant to monitor medications and report to her and the physician any need for laboratory monitoring of medications.