Every finding on record at C M Tucker Jr Nursing Care Center Fewell and Stone

Based on review of the facility policy, observations, and interviews, the facility failed to store and label medications and biologicals appropriately for 3 of 6 medication carts reviewed. Loose pills and expired medications were observed on the medication carts. In addition, the facility failed to label open medications.Findings include: Review of the facility policy titled Labeling and Storage of Drugs and Biologicals revealed under the Purpose section the following: In coordination with the licensed pharmacist, the facility provides for the accurate labeling to facilitate consideration of precautions and safe administration of medications, and safe and secure storage of all medications. During observation of Medication Cart 2 on the 120 Unit at 10:50 AM, the following was observed:(1) Ozempic 4 milligrams/3 milliliters (mls) Lot # RAR0280 with an expiration date of 5/31/28 with no open date.(1) Novolog 100 units/ml Lot #RZ7006 with an expiration date of 12/31/27 with no open date. The above was confirmed by Licensed Practical Nurse (LPN)2 at the time of the observation Observation of Cart 2 on the 120 Unit at 2:25 PM revealed the following:(49) Lisinopril 20 milligrams(mgs) tablets Lot #M05308 with an expiration date of 04/26. Observation of Cart 1 on the 120 unit revealed the following:Wixela(Fluticasone Propionate/Salmeterol) 500/50 micrograms(mcg) Lot #62005654 with an expiration date of 4/27 with an illegible open date. The above was confirmed by LPN 2 at the time of the observation. During an observation on 08/19/26 at 3:01 PM, of Medication Cart 1 on Unit 124 ([NAME]). The following was observed inside the interior drawers:Eleven (11) loose pills of assorted colors not contained within their original blister packs or labeled storage containers.During an interview on 08/19/26 at 03:16 PM, LPN1 stated, My expectations are that loose medications should not be there and should be thrown out. They should be disposed of in the pill buster instead of collecting in the medication cart.During an interview on 08/19/26 at 3:32 PM, the Director of Nursing(DON) stated, My expectation is that nurses thoroughly clean and wipe down their medication carts and review all medication expiration dates. They are responsible for properly disposing of expired medications, removing them from the cart, and reordering any items that need replacement. Nurses receive random audits conducted by the Assistant Director of Nursing, DON, Infection Control Preventionist, and shift supervisor to ensure compliance.

Based on review of the facility policy, record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 out of 38 opportunities for error. The medication error rate was 5.26%. Findings include: Review of the facility policy titled Medication Administration states under the Purpose section the following: To provide residents with safe, accurate medication administration. The Guidelines section states the following: 1. Medications will be administered following the six (6) rights of medication administration a. The right order(valid prescriber order); d. The right dose; f. The right practices(correct, accepted standards of practice and manufacturer's specifications). Review of Resident (R)62's Face Sheet revealed the facility admitted R62 on 05/28/26 with diagnoses, which included but not limited to, Vitamin D Deficiency, Muscle Weakness, and History of Falling. Review of R62's physician's orders revealed orders for Oyster Shell Calcium + D oral Tablet 500-50mg-mcg(Calcium Carbonate-Cholecalciferol give 1 tablet by mouth two times a day for supplement and Thera-M oral Tablet(Multiple Vitamins w/Minerals) give 1 tablet by mouth in the morning for Prophylaxis. During observation of the medication pass on 8/18/26 at 9:10 AM, Licensed Practical Nurse(LPN)4 was observed to administer Oyster Shell Calcium 500 milligrams(1) tablet and Thera vitamin(1) tablet. During an interview on 8/18/26 at 2:05 PM, LPN 4 confirmed the Oyster Shell Calcium did not contain the Vitamin D and the Thera Vitamin did not contain the minerals as ordered. During an interview on 8/19/26 at 1:42 PM, Registered Nurse (RN)1 stated the expectation during medication pass is to follow the physician orders.

Based on a review of facility policy, record review, and interview, the facility failed to protect Resident (R)1 from physical abuse. Specifically, Certified Nursing Assistant (CNA)1 pinched the nose of R1, resulting in R1 suffering injuries to the face.On 12/17/25 at 7:28 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/19/25. The IJ was related to 42 CFR 483.25 - Freedom from Abuse, Neglect, and Exploitation.On 12/18/25 the facility provided an acceptable IJ Removal Plan. On 12/18/25 the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The SA is considering the IJ at Past Non-Compliance as of 09/19/25.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings include:Review of the facility policy titled Freedom From Abuse, Neglect and Exploitation with a last revision date of 01/2017 revealed, To keep residents free from abuse, neglect, and corporal punishment of any kind by any person. For the purpose of this policy, abuse will be identified as willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish. 1. Staff will be trained in the types of abuse and neglect. 2. Staff will be trained and knowledgeable in how to react and respond to resident behavior. 3. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately.Review of the facility Timeline of Events dated 09/15/25 between 8:00 AM and 8:30 AM revealed: [Certified Nursing Assistant (CNA)1] was assisting [R1] with ADL care. [Licensed Practical Nurse (LPN)1] was outside of [R1's] room preparing his medication. [LPN1] heard [R1] yelling but she could not understand what was being said. [CNA1] exited resident's room and stated [R1 called her a n****r b***h [LPN1] stated that there was nothing she could do about it. [LPN1] told [CNA1] that she could switch assignments if she wanted to. [CNA1] stated No, I have something for that. [LPN1] finished prepping the resident's medication. [LPN1] entered the resident's room. [CNA1] informed [LPN1] in a joking tone that she had pinched the resident's nose for calling her those ugly words. [LPN1] responded that she was not doing any incident reports today. [CNA1] stated, I did not do that. Approximately 04:00 PM [LPN1] went in to [R1's] room to do his wound treatment. [CNA1] immediately entered [R1's] room behind [LPN1]. [R1's] nose, mid forehead and above right eyebrow was discolored and purple. [LPN1] informed [CNA1] that she was writing this incident up. [CNA1] went and got a cream off of the treatment cart and stated, put this on it, this will clear it up. [LPN1] stated that she was not putting that cream on the resident. [LPN1] reported the incident to the supervisor. [CNA1] was removed from the unit by [Registered Nurse (RN)1] and taken to the supervisor's office. [CNA1] admitted to pinching the resident's nose. [CNA1] stated that she was triggered by the resident calling her a n****r b***h. [CNA1] remained in the supervisor's office while [RN1] notified the Director of Nursing and Administrator. Director of Nursing and Administrator took over the investigation. [CNA1] was suspended and escorted from the facility. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, oropharyngeal phase, restlessness and agitation and vascular dementia.Review of R1's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/09/25 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 99 due to the resident being rarely or never understood. Further review of the MDS revealed R1 had not exhibited any physical or verbal behaviors during the look back period.Review of R1's Progress Notes revealed no progress notes in R1's medical record related to this incident.Review of R1's Care Plan revealed R1 had potential for escalating behaviors when receiving care from staff at times, related to mood disorder, evidenced by using racial profanity and attempting to strike out with a start date of 09/19/25 after the incident. Approaches included ensure resident safety, discontinue care, and report behaviors to the nurse. Review of CNA1's Witness Statement dated 09/15/25 at 5:15 PM revealed, I was working with [R1] this morning doing patient care about to get him wash up he call me out my name the N word and a b***h. [R1] was saying that most of the time I was in their. I told him don't talk to me like that talk to me like you want me to talk to you and he still calling me out my name. I playful pinch his nose I did not do it to hurt him and then I turn him, he hit his head and nose on the bedrell [sic]. I walk out room I told [LPN1] that him was calling me out my name (and before I play pintch [sic] him, his nose was already red.) She ask me do I want to change with someone. I think I told [LPN1] no but I don't remember what all I said.Review of LPN1's Witness Statement dated 09/15/25 at 5:10 PM revealed, [CNA1] reported that [R1] called her a n****r b***h. I told her that if she wanted to switch with someone else, she can. [CNA1] stated, no, I got something for that. [CNA1] later stated she pinched [R1's] nose. When assessed, noticed bruising on tip of [R1's] nose. Notified nursing supervisor.Review of RN1's Witness Statement dated 09/15/25 at 6:00 PM revealed, [LPN1 reported that [CNA1] states [R1] kept calling her a n****r b***h. [LPN1] asked [CNA1] if she wanted or needed to swap assignments. Stated [CNA1] said No, I got something for that. [LPN1] stated [CNA1] later notified her that she'd pinched resident afterbeing questioned about bruising on resident's face. [LPN1] also reported [CNA1] states [R1] hit his face on rail during ADL care. [RN1] assessed [R1]. [R1] had 1.5 L x 2 W cm bruising to tip of nose. 3 cm L x 5 cm linear bruising to forehead and 2 cm bruising to right eyebrow. [R1] alert and oriented to self and confused at baseline. [R1] denies knowing what happened. Spoke with [CNA1], says she pinched resident on the nose after being called a n****r b***h multiple times with physical aggression. [CNA1] [NAME] that she did not hit [R1]. States [R1] also hit face on bed rail during ADL care. Director of Nursing and Nursing Home Administrator notified. Provider notified. Attempt family x3 left voicemail to return call. During an interview on 12/17/25 at 1:00 PM, CNA1 stated that she was unable to speak with me at this time. This surveyor asked if she would call back at a time that she could talk. CNA(1) stated, I will try.During an interview on 12/17/25 at 2:52 PM, RN1 who was the nurse supervisor, stated the nurse on the cart came to me and told me that CNA1 had reported that she pinched R1 on the nose because he was calling her out of her name. The resident kept calling her a n****r b***h. I went and got CNA1 and brought her into the supervisor's office to get her side of the story. She admitted to pinching the resident's nose. She stated that she felt triggered by the words the resident used. I kept CNA1 in the office and I notified the Director of Nursing and the Administrator. They took over from there. During an interview on 12/17/25 at 3:02 PM, LPN1 stated, between 8:00 AM and 8:30 AM during ADL care. I was outside the door preparing medications. CNA1 came out of R1's room and said that the resident called her a n****r b***h. I told CNA1 that there was nothing that I could do about it. She could switch assignments if she wanted to. CNA1 stated, No, I have something for that. I finished prepping R1's meds. I entered the resident's room. CNA1 informed me that she had pinched the resident's nose in a joking tone. I stated that I was not doing any incident reports today. CNA1 stated I didn't do that. I didn't do that. Between 3:00 PM and 3:30 PM, I went to do the wound treatment for R1. CNA1 immediately came into the resident's room behind me. R1's nose was discolored and purple. I informed CNA1 that I was writing this up. CNA1 left the room and went and got cream off of the treatment cart. She came back in the room and stated, Put this on it. It will clear it up. I stated that I was not putting that on the resident. After finishing his treatment, I reported what happened to the supervisor.During an interview on 12/16/25 at 5:15 PM, with the Administrator and Director of Nursing (DON), revealed the incident occurred on 09/15/25 around 8:00 AM or 8:30 AM. The incident was not reported to administration until 4:35 PM on 09/15/25 by the RN Supervisor. CNA1 was removed from the floor. CNA1 was interviewed. CNA1 stated that she pinched the end of R1's nose like you would a child that won't behave because he called her a b***h and a n****r b***h. CNA1 stated that when she turned the resident, he hit his head on the side rail. CNA1 stated that she reported R1's behavior to the nurse. CNA1 stated that she declined reassignment, and she may have said more but she cannot remember. CNA1 was very emotional and stated that she has been having a rough time with personal issues and she thinks the resident may have triggered her. CNA1 stated that it was not her intention to hurt the resident. The DON stated, the employee was suspended pending the outcome of the investigation. A head to toe assessment was completed on the resident which verified a dark purple area to the tip of resident's nose. The police were notified on 09/17/25 at 8:00 PM. We were instructed to call back later for a case number. The Administrator stated, all staff have been re-educated on the abuse policy, including different types of abuse, what and when to report abuse. Also, what to do when a resident is abusive verbally/physically. Education was completed on 09/19/25. Any staff that were not available will have their education completed at the beginning of the next shift or via phone. Staff are educated on abuse when hired and at least annually thereafter. The DON stated, the resident abuse was substantiated on the evening of 09/15/25. CNA1's employment was terminated by phone on 09/18/25.On 12/18/25 the facility provided an acceptable IJ Removal Plan, which included the following:Stone Pavilion supports and enforces that each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. Our fundamental goal for our residents is to provide the goods or services that are necessary to attain or maintain the highest level of physical, mental, and psychosocial well-being.Past non-compliance planElement 1: Initial corrective action:The staff member reported she pinched the nose, there was some purplish hue.She was removed from care; a statement was obtained and was immediately put on administrative leave. She had also stated that the resident was combative, and his head hit the side rail and some redness was noted.A report was completed and provided to the authorities including Certification, Veterans Association, Ombudsman, VA contract monitor, Medical Director and local authorities.The resident had a psychosocial visit completed by the Social Services Director. The resident did not show any signs of psychosocial changes and remained pleasantly confused.Resident Protection:The resident was provided safety and interviewed for any feelings of fear or anxiety.The resident had no recollection of the occurrence and denied any pain. The tip of his nose was a purplish color.Resident continues to have pain monitored and has shown no s/s or verbalizations of pain.The resident was re-evaluated for side rail need. It was determined that he no longer utilized the side rails for turning/positioning. The 1/4 rails were removedCare plan review: Updated for the plan to reflect staff should discontinue care and report to the nurse when a residents physical or verbal behaviors escalate.Element 2: Identify and protect other residents.Other residents that were provided care by the accused staff member was completed.Those residents that were interviewable were interviewed and had no concerns about their care.Non interview able residents had a body check completed by a licensed nurse, there were no skin issues noted.Completed interviews with the other staff members providing care on that unit, they identified nothing unusual and did not see any discoloration on the resident's nose.The residents responsible party was notified and occurrence explained in full. The responsible party, his sister, was appreciative that she was notified and stated we needed to do what we needed to do.Completed review of risk reports last 30 days. No concerns related to potential abuse.Completed review of grievance process for previous 30 days, no concerns related to potential abuse were identified.Completed resident council minutes, review no concerns related to potential abuse.Element 3: Systemic changes to prevent recurrence:Root cause analysis:After review, it was noted that the involved staff member did not follow general protocol regarding residents who are combative or abusive in nature. Abuse training includes removing self from the situation and returning later when a resident's behavior escalates. The QAPI committee determined that re-education was warranted on the abuse policy which was started immediately and that the plan as written followed the Facility Assessment and QAPI Standard.Policy and procedure revision:The policy as written is comprehensive regarding abuse. All staff are being updated on the current policy with emphasis on removing self from a resident with escalating physical or verbal behaviors and notifying the nurse for assistance/guidance.Staff educationTopic and Personnel:All staff have been re-educated on the abuse policy, including different types of abuse, what and when to report abuse. Also, what to do when a resident is abusive verbally/physically. Education was completed on 9/19/25. Any staff that were not available will have their education completed at the beginning of the next shift or via phone. Staff are educated on abuse when hired and at least annually thereafter.Hiring practices:Include background checks and reference checks to prevent hiring individuals with a history of abuse or misconduct as well as providing orientation that includes abuse. The accused staff member file was reviewed and completed as per practice.Disciplinary action:The accused staff member was immediately placed on administrative leave. In conclusion of the investigation, it was determined that as the accused staff member admitted that she pinched the resident's nose and there was discoloration to said nose, the facility separated employment on 9/19/25.Element 4: Monitor Performance to ensure sustainability.Continued monitoring:Questionnaires (audits) that test the fundamental knowledge of abuse prevention for staff and how to deal with escalating behaviors will be completed randomly 5 days a week for 12 weeks and results will be taken to, and reviewed in, the QAPI Process x 3 months or until compliance is attained and maintained at 100%.Element 5: Completion datesThe corrective action was completed, and Stone Pavillion alleges compliance on 9/19/25.

Based on review of the facility policy, video footage, and interviews, the facility failed to ensure Resident (R)45 was free from physical abuse from Certified Nursing Assistant (CNA)1. Findings include: Review of the facility policy titled, Protection from Harm Policy last revised, November 2024 revealed A significant aspect of residents' rights is the right to be free from abuse/neglect. The facilities of C. M. [NAME], Jr. Nursing Care Center have a 'zero tolerance' for any type of abuse. A. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. G. Mistreatment means inappropriate treatment or exploitation of a resident. I. Physical Abuse means hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. Review of R45's Face Sheet revealed R45 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, depression, difficulty in walking, history of falling, other lack of coordination, and unsteadiness on feet. Review of R45's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/25, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. Review of surveillance video footage provided by the facility, recorded on 05/13/25 at 3:23 PM, revealed R45 in the unit day area attempting multiple times to headbutt, punch, and kick CNA1. CNA1 then attempted to move in front of R45, who tripped her with his foot/leg. CNA1 then turned to face R45, grabbed and lifted his leg to her hip level, held it there for a few moments, then dropped it back down while saying something to R45 before walking away and the video ends. Review of CNA1's Notice of Termination dated 04/24/25, revealed, After reviewing statements and video footage for Friday, April 18, 2025, you were observed in the main hallway on your unit turning a patient around in his wheelchair. This action resulted in the resident becoming combative, and he began swinging his fist and kicking his feet at you. You grabbed the patient's legs, saying to him, I'm not the one! You then dropped the patients' legs back to the floor. During an interview with R45 on 05/13/25 at 3:29 PM, revealed he could not recall anything from the incident with CNA1. R45 stated he tried to avoid negative encounters if he can. The resident denies being fearful for his life. During an interview with the Physical Therapist (PT) on 05/14/25 at 10:08 AM, revealed the incident occurred in the day area on Unit 122 (secure/all male unit). R45 was considered a new admission at that time. The PT stated she was coming down the main center hall. Once she reached the entrance to the day area, she saw R45 head-butt CNA1. The PT explained she was distracted by another resident on her left side. She turned around and walked back towards R45 because he was her patient that day for therapy. She saw R45 punching CNA1 but was unable to recall if he connected with the punches. The PT expressed uncertainty about whether he tried to kick the CNA or attempted to trip her. She observed CNA1 standing in front of the resident, locking his wheelchair and grabbing his legs at her waist level. CNA1 said something to the resident about a problem, but she couldn't recall exactly what was said at that time. The tone of her (CNA1) voice was stern. The PT reported that she walked up to intervene, expressing that she was taken aback and instructed everyone to step away to cool off. R45's nurse was nearby at the cart. The PT stated she notified the DON (Director of Nursing) about the incident. The PT mentioned that R45 has a history of behaviors; however, he had not displayed them with her. During a phone interview with Licensed Practical Nurse (LPN)1 on 05/14/25 at 10:27 AM, revealed she witnessed the event and was R45's nurse on the day of the incident. R45 was a new admission at the time and had a history of dementia with behaviors. LPN1 stated that while she was standing at the med cart, she saw CNA1 forcibly move R45's wheelchair. R45 responded by trying to headbutt CNA1 by throwing his head backward. CNA1 then walked beside R45, and he attempted to punch her. CNA1 then walked in front of R45's wheelchair, where he tried to trip her and then kicked at her. CNA1 then grabbed both of R45's legs and pulled them up into the air while telling the resident, I'm not the one, in a loud, aggravated tone, and then dropped his legs down, slightly rocking R45's wheelchair before walking off. LPN1 stated that initially, she was in shock; she assessed the resident, and he appeared to be fine at baseline with no injuries following the encounter. During a phone interview with CNA1, on 05/14/25 at 11:20 AM, revealed she had been employed at the facility for approximately a year. CNA1 confirmed that she was R45's aide and recalled the encounter with R45. CNA1 stated that she began to move R45's wheelchair from the middle of the hallway. R45 started to attempt to headbutt her in the stomach/abdomen area. CNA1 stated she turned R45 away from other residents, and he began to punch and kick her. CNA1 admitted to grabbing R45's legs and lifting them to her hip level before releasing them. She indicated that she was not going to bend over and place R45's legs on the ground. CNA1 reported that she told R45, I'm not the one that bothered you, I'm not the one and noted that other staff and residents were present during this encounter. CNA1 mentioned that she was suspended pending investigation, and a few days later terminated due to the allegation of physical abuse. During an interview with the Facility Administrator (FA) in the presence of the Director of Nursing (DON) on 05/15/25 at 1:51 PM, revealed he is responsible for the investigating and submissions of reportable's, with the assistance of the DON. The FA revealed he was notified of R45's incident related to physical abuse on 04/18/25 by the DON. The FA states he was told that R45 became aggressive with CNA1, and CNA1 lifted R45's legs and held his legs up for a few seconds, then dropped them back down. The protocol was followed, and CNA1 was suspended following the allegation and escorted from the facility. The FA stated that, per clinical staff, R45 was assessed and had no apparent injuries. R45's Representative (RP), and Medical Director (MD) were notified of the alleged event. The FA revealed he ran the video footage back and saw CNA1 lift R45's legs immediately after R45 attempted to trip her. She held his legs up at her waist height for a moment. She then dropped R45's legs to the floor and returned to assisting other residents. The FA agrees that the lifting of the resident's legs to her waist height and dropping them was not acceptable and deems these actions to have been unnecessary. CNA1 should have walked away and allowed R45 to cool down, but she did not follow the process. Three unsuccessful attempts were made to contact R45's RP via phone on 05/13/25 at 3:40 PM, 05/14/25 at 10:05 AM, and 1:07 PM.

Based on observation and interview, the facility failed to ensure food was handled in a sanitary manner to prevent cross-contamination in the main kitchen. This deficient practice had the potential to affect all residents who request alternative and/or extra trays from the kitchen. Findings include: During a dining observation on 05/13/25 at approximately 11:25 AM, both independent and dependent residents were observed being brought into the main dining room, located outside the main kitchen, along with facility staff. The Dining Services Supervisor (DSS) and a Dietary Aide (DA) transported retherm carts into the dining room. The DA opened one of the retherm carts and removed six individual covered meal trays that had not been served. These trays were untouched and were removed directly from the hot box compartment of the cart. The DA then transported these six trays to the soiled area of the kitchen. The trays were placed one by one on a two-tiered metal cart located near the dishwasher, two soiled trash cans and a bucket containing a soiled mop and dirty mop water. The DA then returned to the dining room, performed hand hygiene, and began assisting nursing aides with passing out meal trays to residents. During an interview on 05/13/25 at 11:45 AM, the Dining Services Supervisor (DSS) acknowledged the observation and findings. The DSS stated that the trays placed on the metal cart were extras and that if nobody needed an extra tray or a substitution, they would be discarded. The DSS stated that regardless of whether a resident needs an extra tray or not, meals that could potentially be eaten do not need to be stored in that area. During an interview on 05/13/25, at 2:06 PM, the Dining Services Manager (DSM) stated that her expectation is that substitution or extra trays are to remain on the cart to prevent potential cross-contamination. She stated the trays are not to be placed in soiled work areas if there is a potential for consumption. The DSM stated that to alleviate the concern, she would discuss the issue with the dietary staff. During an interview on 05/15/25 at 11:08 AM, the Director of Nursing (DON) stated that trays are to be kept in the retherm cart until the nursing department confirms whether any residents need additional or extra trays. The DON stated that once all residents have eaten and there is no need for extra trays, then the trays can be removed from the hot box and discarded.

Based on review of facility policy, observations, and interviews, the facility failed to ensure the protection of Resident (R)36's privacy during patient care. Specifically, during a dressing change, Laundry Staff 1 entered the resident's room without requesting permission to enter. Findings include: Review of the facility policy titled Clean Dressing Change effective April 2024, states, 1. Every resident has the right to privacy. No one should enter a resident's room without first knocking on the door, waiting for a response and only entering with permission. If there is no response, then knock again, and announce your name and the reason for entering the room. Review of R36's Face Sheet revealed R36 was admitted to the facility on [DATE], with diagnoses including but not limited to: injury at T7-T10 of thoracic spinal cord, pressure ulcer of unspecified site, stage 4, paraplegia, pressure ulcer of right buttock, stage 4, and pressure ulcer of left buttock, unstageable. Review of R36's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R36 was cognitively intact. During an observation on 05/15/25 at 2:41 PM, Laundry Staff 1 knocked on R36's door and proceeded to come into the room. Registered Nurse (RN)2 and Certified Nursing Assistant (CNA)2 yelled patient care several times. Laundry Staff 1 continued to enter the room. Laundry Staff 1 left the door wide open and proceed to get the laundry out of the room. During an interview on 05/15/25, at an unspecified time, Laundry Staff 1 stated, I didn't hear the staff telling me not to enter the room. I just come in and get the linen baskets and leave the room. During an interview on 05/15/25 at 3:48 PM, the Director of Nursing (DON) stated, My expectation with the staff is if anyone knocks on the door I expect for them not to enter the room if staff says they are conducting patient care.

Based on review of facility policy, observation and interview, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. Findings include: Review of an undated facility policy titled Storage of Medication on Units states, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility policy titled Medication Administration: Oral effective October 2024, states, Procedure: . Key Points/Rationale: No medications or scissors should be on Top of medication cart when nurse steps away. During an observation on 05/14/25 at 8:22 AM, Registered Nurse (RN)1 walked away from the medication cart on Hall 122 with Metoprolol (a blood pressure medication) sitting on top of the cart. RN1 then leaves and enters a residents room. During an interview on 05/15/25, RN1 stated, It is not my regular procedure of leaving medications on the cart. I thought I took it with me. During an interview on 05/15/25 at 3:48 PM, the Director of Nursing (DON) stated, [RN1] is a night nurse. She was helping filling a shift. She was nervous. She did come tell me she may have forgot to do something.

Based on interviews, record review, review of facility policy, and review of the facility's video surveillance the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility. On 07/15/24 at 1:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 07/15/24 at 2:11 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 07/15/24 at 2:11 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/06/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 07/15/24 at approximately 4:45 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The survey team considers the IJ at Past Non-Compliance with a correction date of 07/11/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the Facility's Policy titled, Missing Resident Procedures/Elopement last revised 09/23, stated, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so (42 CFR, section 483.25). Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: wandering, lack of coordination, difficulty in walking, muscle weakness and a history of falling. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 07/03/24 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R1 was moderately cognitively impaired. Further review of the MDS revealed there were no wandering behaviors exhibited. Review of R1's Physician Orders dated 06/27/24, revealed the following order wrist call light for resident. Review of R1's Progress Note dated 07/06/24 at 8:06 PM revealed, resident alert with confusion, Resident remain on close observation, safety maintain by staff. Took all meds whole and tolerated well. wonder guard intact to right ankle. resting in bed with call light in reach. Review of R1's Progress Note dated 07/06/24 at 11:43 PM revealed, At approx. 2200 staff reported to this nurse that resident was not found in his assigned room. At approx. 2210 resident was found by staff outside in courtyard and brought back inside facility. Per resident he said, I was looking for my truck When asked how he got out of the door, resident said, I held the door for 15 seconds just like the sign says No apparent injuries noted. Small indentations and abrasions noted on bilat knees. Wander guard in place to resident right ankle and functioning. Review of R1's Elopement Risk Tool dated 06/27/24 revealed, R1 had noted wandering behaviors occurring for 1 to 3 days. R1 was noted as having a risk of getting to dangerous places. Furthermore, it revealed that R1 had verbalized intent to the facility and was actively exhibiting exit-seeking behaviors. During an interview on 07/15/24 at 11:15 AM, R1 stated that he escaped this place. R1 stated that he just went up to the door and held it for 15 seconds because that is what it says on the door and then he went out. R1 stated he thought his car was in the parking lot and was trying to get to it. R1 then stated that he fell . During an observation and interview on 07/15/24 at 11:57 AM, with the Director of Nursing (DON) and Facility Administrator (FA), the route R1 took to exit the facility was walked through. The DON stated that R1 was new to the facility, and they weren't aware of any exit seeking behaviors. During an interview on 07/15/24 at 12:10 PM, Certified Nursing Assistant (CNA)2 stated that R1 was wearing a black shirt with black shorts. CNA2 could not recall if R1 was wearing shoes or socks. CNA2 also stated that upon R1's return into the facility, he was laughing as he stated that he escaped the VA Hospital. During an observation of the Facility's Surveillance Camera on 07/15/24 at 12:50 PM, it was revealed that, On 07/06/24 at 9:59 PM, R1 was sitting in his wheelchair in the common area near the nurse's station of hall 100. At approximately 10:01 PM, R1 can been seen rolling himself down the hallway and at approximately 10:03 PM, R1 enters the hall for the secured unit. R1 then tries to open and enter the secured unit but is unsuccessful. At 10:06 PM, R1 can be seen entering a door on the secured hall which leads to a canteen like room and a door that leads to outside the facility. Staff members can be seen on footage entering that canteen room at approximately 10:22 PM, and then wheeling R1 back into the hall at approximately 10:27 PM. R1 was noted to be wearing a tee shirt, shorts and yellow non-slip socks. During an interview on 07/15/24 at 4:07 PM, CNA1 stated, R1 was moved up front and was last watching television when she saw him. CNA1 reported that during her last rounds is when she noticed that R1 was not up front and proceeded to R1's room, where he was also not. CNA1 then reported to another staff member that R1 was missing, and she began searching for him. CNA1 stated that she checked each hall, the cafe and even any door she walked past. Furthermore, CNA1 stated that she heard the buzzing, however, she didn't think anything of it. CNA1 reported that upon checking the entrance to the secured unit, she heard the alarm buzzing in the canteen room, where she noticed that the door in there was alarming, and she realized that R1 was outside and alerted the staff member with her to get help. CNA1 found R1 down the sidewalk, past the entrance, on his knees. R1 was then helped back into the facility. According to the Weather Channel, on 07/06/24, the high was 96 F with a low of 74 F. On 07/15/24 at approximately 4:45 PM, the facility provided a removal plan, which included the following: Resident was assessed for injury and was returned to unit for further evaluation and close observation Line of Sight. The resident will be placed on a secure unit for additional evaluation and stay Resident has a wander guard safety monitor. Education was completed with working staff on situational awareness, leadership was contacted, and the film was reviewed. The facility has provided education regarding elopement and reporting. Policy on Code [NAME] and Elopement was shared. Training was provided by the Director of Nursing and lead nursing staff. Residents residing on the open units were assessed for elopement additionally. Residents are assessed for elopement risk quarterly. These assessments are done quarterly per resident's care/treatment team dates. An additional assessment was done considering this event. Fire and Life Safety staff evaluated door to determine that it was functioning properly. Incident discussion with CMT Stone interdepartmental team held via teams 9:00am. Facility entrance codes will be changed every 90 days to ensure integrity of security or as needed. Last dated 6-17-24. The measures associated with this infraction will be included in the facility's monthly Quality Assurance Performance Improvement Meeting report. This meeting is held monthly. The report will include the updated CMS definition of elopement. The report will include updates regarding monitoring of quarterly assessments for elopement reports for 90 days. The facility mitigation plan will be fully completed by 7/11/2024.

Based on review of the facility policy, documentation, and interviews, the facility failed to ensure residents on [NAME] 122, 1 of 2 Units, were free from neglect, when a nurse failed to follow emergency evacuation procedures during a fire emergency. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Abuse) at a scope and severity of J. The IJ began on 12/16/23 at approximately 12:45 AM when the facility fire alarm sounded, and a Code Red was called. Approximately 20 minutes after the alarm sounded the Public Safety Officer (PSO) arrived at [NAME] 120 and informed them they needed to evacuate. He then went to [NAME] 122 and informed the charge nurse that he smelled smoke and that the residents needed to be evacuated, and at that time the Charge Nurse (CN) stated that the residents on their unit were bedridden, and they could not move them. At 1:10 AM, [NAME] 120 began evacuation of their residents. At 1:12 AM, the Fire Marshal arrived at the facility and questioned as to why the residents on 122 were not evacuated. The Facility Administrator (FA) and Director of Nursing (DON) were notified of the IJ on 01/11/2024 at 5:30 PM and provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the state survey agency on 01/12/2024 at 12:30 PM. The IJ was removed on 01/12/2024 at 3:06 PM after the surveyor performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of D that was not IJ for F600. Findings Include: Review of the facility's policy titled, Fire Safety Plan, with a revised date of March 2023 revealed All employees are expected to fully comply with the procedures outlined in the [NAME] Stone Jr., Veterans Home Fire Safety Plan. Furthermore, it stated that if an order is received to evacuate residents, this should be done as quickly and orderly as possible in the following sequence . Review of an Incident Report dated 12/16/23 revealed On December 16, 2023, at approximately 0059 hours, Public Safety Officers were dispatched to Stone Pavilion in reference to a Code Red. Immediately upon arrival, I (PSO) made contact with the Complainant, the Nurse Supervisor (NS) who stated he smelled smoke on Unit #120 near the Electrical /Mechanical room [ROOM NUMBER]. I made entry into room [ROOM NUMBER] and smelled a strong smoke odor, but did not see the presence of smoke. I then instructed the nursing staff of [NAME] #120 to evacuate all patients until the All Clear was issued by Public Safety Dispatch. I then proceeded to [NAME] #122 and made contact with Charge Nurse and instructed her to evacuate all patients and staff from [NAME] #122 and she stated she had walked through the incident area and she did not see any smoke or fire and deemed that it was not necessary to evacuate [NAME] #122. She then stated that she had too many bed-ridden patients to evacuate. The Corporal arrived and assisted the nursing staff of [NAME] #120 with the patient evacuation. I then proceeded back to the incident area where the Captain and the Richland One Fire Department stated a wire inside of the water heater had sparked and caught flames. At this time, the Fire Marshall arrived at approximately 0112 hours and instructed me to assist with the nursing staff and patients of [NAME] #120. The Fire Marshall was instructed by the fire department that the water heaters wires had been disconnected, the patients and nursing staff can re-enter the building and the fire alarm system could be reset. The Fire Captain and Stone Pavilion Administrators arrived and were briefed by the Fire Marshall of the incident. Physical Plant Service staff and the facility Safety Manager were notified via telephone of the incident. Review of a written statement signed by the Fire Marshall (FM) on 01/11/24 revealed Upon my arrival into the facility at 0112 hours, I smelled a strong odor of smoke and proceeded to the incident area, room [ROOM NUMBER] - Electrical/Mechanical where I made contact with Richland County Fire Department Captain. The Cpt. stated there was a shortage within a wire located inside one of the water heaters and they were working on disabling the breaker. At this time, I contacted PSO who stated upon his arrival at the incident area he did not see the presence of fire but due to the strong smoke odor emitting from the area he instructed nursing staffs of Units 120 and 122 to evacuate their patients. PSO, then stated that Charge Nurse of Unit 122 refused his request to evacuate her patients, due to her assessing the incident area herself and not deeming it necessary to evacuate her many bed ridden patients because she saw no presence of fire. When I arrived and spoke with the CN to inquire why she disobeyed a direct order from the PSO, her answer was the same. I explained to her that she is not a Fire Professional and Public Safety Officers are trained to access the situations and instruct staff to respond accordingly and she had no right to refuse his request without definitive knowledge regarding the severity of the present incident. I instructed the CN for future Code Red incidents, if a Public Safety Officer issues direct orders she should respond accordingly with the safety of the patients and fell ow staff members in mind. The CN agreed without query and I proceeded back to the incident area where the engine men had disabled the breaker and instructed Public Safety and Nursing staff to return the patients into the building. The engine men also stated that the wires indeed sparked within the boiler unit, not starting a full blazed fire at the time but had it persisted the possibility would have presented itself. The patients had been returned to their Units safe and sound with no injuries and I was instructed by the Cpt. to reset the fire alarm system and announce the All Clear of the Code Red. This reporting Officer has nothing further to report. During an interview on 01/11/24 at 8:15 AM with the FM, she confirmed the statements of her written report. During an interview on 01/11/24 at 10:19 AM, the CN stated that the PSO told her to evacuate unit 122 and to which she responded, we can't move them, they are all bedridden. CN then stated that she had gone out the door and checked and did not see a reason to evacuate even though she was not qualified to make that decision and that she was aware of it. CN started I felt like it was something that could be extinguished and decided not to evacuate the residents. CN further states that after all clear was given she was reprimanded by the Fire Marshall for not evacuating the residents. CN also reports that she did not think that she had to take orders from the PSO, since he was not her direct supervisor. During an interview on 01/11/24 at 10:54 AM with Certified Nursing Assistant (CNA)1, she stated that when the alarm went off, she was at one end of the hall and CNA2 was at the other end when the PSO came on the unit. CNA1 reports that the two nurses (CN and a Licensed Practical Nurse (LPN)) on the unit were standing there with no one guarding the third door. CNA1 reports no instruction from the CN, nor was she given an order from the CN to evacuate the residents. During an interview on 01/11/24 at 11:14 AM with CNA2, she reported that she was aware of the order to evacuate but that the CN said they were not going to, so they did not. CNA2 further stated that she is aware of facility policy, but she has not received training. During an interview on 01/11/24 at 2:47 PM with the Facility Administrator (FA) he stated that on the night of December 16th he received a call from the night nurse supervisor stating that the fire alarm was going off and he smelled smoke. FA states that it was the PSO who made the judgement call to evacuate the residents and the facility follows the PSO judgement call since they have command in these situations. The FA reported that upon his arrival at the facility the evacuation had been cleared and this is when he learned that a nursing leader delayed evacuation of residents on [NAME] 122. FA stated that it is his expectations that staff members follow the orders of the public safety officer. FA also reports that the actions of the nurse supervisor were egregious which led to her termination from the facility. Facility staff receive annual, quarterly, and monthly fire training and or drills. On 01/12/2024 at 1:27 PM, the facility submitted an acceptable Removal Plan, which included: 1. The facility will provide training on Directive 3.102 Fire Safety to all staff with emphasis on evacuation. 2. The facility's Fire Marshall will assist with training. 3. 100% of Stone employees will receive training by January 12, 2024, end of business. 4. AHOC QAPI meeting held 01/12/2024. 5. All residents were assessed by nursing staff following evacuation. 6. The corrective action will be monitored by the performance improvement department that will audit for 100% compliance of all stone employee's completion of training the Fire Safety with emphasis of evacuation by 02/11/2024. 7. The facility will provide biannual Evacuation Drills in January and July of each year. 8. The measures associated with this infraction will be included in the facilities monthly Quality Assurance Performance Improvement meeting report. This meeting is held monthly and will begin January 2024 and ending in April 2024. The report will include progress towards 100% completion.

Based on review of the facility policy, record reviews, and interviews, the facility failed to have systems in place to control, account for, and reconcile controlled medications to prevent loss, diversion, or accidental exposure as evidenced by Resident (R)408 and R409, who received R40's prescribed morphine. On 01/11/2024 at 5:30 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 01/11/2024 at 5:30 PM the Administrator and the Director of Nursing were notified that failure to facility failed to have systems in place to control, account for, and reconcile controlled medications to prevent loss, diversion, or accidental exposure at constituted Immediate Jeopardy (IJ) at F755. On 01/11/2024 at 5:30 PM, the survey team provided the Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 12/02/2023. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 01/12/2024 at 12:30 PM, the facility provided an acceptable IJ Removal Plan. On 01/12/2024 at 12:43 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F755 at a lower scope and severity of D. Findings include: A review of the Policy titled, Controlled Substances, Revised in October 2023 revealed, The purpose of the policy is to establish guidelines for handling controlled substances in the pharmacy and in the nursing units. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Controlled Drugs of Schedules l, lll, lV, and V will be located on the unit to which the resident is assigned. Control drugs are issued to individual residents and are not intended for floor stock use. R408 was admitted to the facility on [DATE] with diagnoses including, but not limited to; vascular dementia with behavioral disturbance, a psychotic disorder with hallucinations, major depressive disorder, and acute respiratory distress. R408 was hospitalized from 11/26/2023 to 11/30/2023 and was placed on end-of-life care upon return to the facility. Resident R408 was given an order for Morphine concentrate 10 milligrams (mg)/0.5 milliliters (ML) oral syringe 5mg/0.25 ml Sublingual on 12/01/2023 at 7:42 PM. The order frequency states, as needed every one hour for three days starting 12/01/2023 and ending on 12/03/2023. Indication for comfort care for observed discomfort or pain every hour as needed. A review of R408's EMAR (Electronic Medication Administration Record) for December 2023, revealed R408 received a dose of Morphine on 12/01/2023 at 8:49 PM. An interview with the Registered Nurse (RN) Supervisor on 01/10/2024 at 12:38 PM revealed on Saturday, 12/02/2023, when she came on duty for her shift, the night shift supervisor showed her the order the MD wrote for Morphine. RN Supervisor stated that she called the on-call Pharmacy, where the Pharmacist told her she could borrow from another resident, R40 located on Unit 120, and the pharmacy would replace it the following Monday. Resident R40 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia, Anxiety, Mood disturbance, and fracture of the right femur. A review of R40's individual controlled substance record for December 2023 revealed an order dated 12/20/23 for Morphine 20MG/ML, 30 ML Solution (SOLN) with directions to give 5 MG. Give 1 syringe (0.25 ML=5MG) sublingually at bedtime 30 min before major ADL (activities of daily living). R40's Controlled Substance Record revealed the following: On 12/02/2023 at 6 PM, doses present were 15 before borrowed for R408 on 12/2/2023. On 12/04/2023, at 10:40, AM, doses present were 11 +1 replaced by pharmacy from RX (prescription)2009501. On 1/1/24 at 10:30 AM, doses present were 6, borrow for R409. On 1/02/2024 at 6:37 AM, doses present were 4 borrow for R409. On 1/02/2024 at 10:30 AM, doses present were 3 borrow for R409. On 1/02/2024 at 1:08 PM, doses present were 2+3 were replaced from R409 RX 2009534. R409 was admitted to the facility on [DATE] with diagnoses including, but not limited to; Alzheimer's disease, dementia with behavioral disturbance, and epilepsy. A review of R409's EMAR for January 2024 revealed resident had an order for morphine concentrate 20 mg/ml oral syringe to receive 5mg/0.25ml starting 01/04 ending 01/04 indication for comfort care, one dose. On 01/04/2024 resident received his one-time dose of Morphine. A review of R409's individual controlled substance record for January 2024, revealed Morphine 20 MG/ML- 30ML SOLN give 0.25 ML (5 MG) sublingually every 30 minutes as needed for severe respiratory distress/pain. On 01/08/2023 at 2:30 PM, doses present were 15 with staff signature. No other day was recorded on the record. An interview on 1/11/2024 at 09:13 AM with the Pharmacy Director states she has been employed since 1983 and normal hours are 8 AM to 4:30 PM; Monday through Friday. When the pharmacy is closed, there is a Pharmacist after hours. The PD stated Physician order are put in MYUNITY (electronic health record system), nursing staff have the option to use an emergency kit, which is located in the building on Unit 120, which contains different types of medications. She stated, The narcotics in the kits include, Morphine oral solution 5 mg/0.25 oral syringe and the quantity is 5. The PD stated that it is not standard practice to give another resident's medication if the medication is not available. The nursing staff is supposed to use the emergency kit. The PD stated she never gave staff approval to use another resident's Morphine to give to another resident to any staff in the building. The PD stated the pharmacy will draw up the syringes per dosage reflected on the order. For emergency kits, they are documented in the emergency kit-controlled substance form. The PD stated in the case that Morphine is not available in the building, the staff is to call the On-Call pharmacy, and they would have to draw up the Morphine and give it to the nursing staff personally. The nurses will sign off on the emergency supply kit, if they must pull emergency medications. An interview with Licensed Practical Nurse (LPN)1 on 01/11/2024 at approximately1:45 PM revealed, On 12/01/2023, R408 had an order for Morphine late afternoon. She signed a syringe out of Unit med cart 2, gave it to the float nurse and the float nurse administered it to R408. LPN1 stated that when the Doctor puts in the order, the nurses then have access to the emergency kit if the medication is not available. LPN1 stated that the pharmacy has given verbal permission if the resident is on the same unit and has the same medications, then it's okay to pull from the resident who already has the medication after hours. The pharmacy is to replace what was borrowed from the resident who had the medication on hand. An interview on 01/11/2024 at 3:53 PM with the Director of Nursing revealed she will have been employed for a year in February 2024. The DON stated protocol for medications is once the physician puts in the order, the nurse is to activate the order in MYUNITY, which is the electronic health record used in the facility. Once the order is activated, the pharmacy fills the order. The pharmacy is located on campus, in another building ([NAME]). The pharmacy will send pharmacy techs to the building, go to the unit where the resident is located, medications are counted with nursing staff and techs, and nurses are to sign off. The DON stated pharmacy hours are Monday through Friday 8 am to 4:30 pm and the facility has an on-call pharmacy, that is available after hours. If the ordered medication is the same as the medication in the E-Kit, the nurses are to utilize that stock of medication, if not available. If a new order for medications is placed during weekend hours, it should be available on E-kit (emergency kit). The E-Kit form is to be filled out when nursing staff has to use medications from the E-Kit in emergencies. The DON stated that there have been times when the narcotics have been a problem, signing off to be exact, and Count should always match what's in your drawer. The DON stated at the end of every nursing shift (shift change), all medications should be reconciled along with emergency kits. If there is a medication available in a kit in another building, the nurses have access to use the medications as well. The DON stated that it is not standard practice for nurses in the building to give a resident another resident's medication. Nurses should always use the E-kit for narcotics that are not available. Training is done upon orientation, and as needed. After orientation, she would give training or the Assistant Director of Nursing (ADON) would provide the training along with the Pharmacist occasionally. The DON stated she thinks the last medication administration training was done in October of 2023. The DON stated that it's not standard practice for the pharmacist to approve when it comes to borrowing a resident's medication. The DON stated the pharmacy does replace what is borrowed, however, she is unsure of how the pharmacy documents are reconciled because the pharmacist is located in another building. Review of the facility's IJ Removal plan included: All Licensed nurses will be educated for the 5 rights of medication administration, back up of pharmacy procedures, emergency kit process and individual substance record will be 100 % completed with nursing and pharmacy by close of business 1.12.2024. An audit of all residents with morphine orders will be completed by 1.11.2024. Audit emergency kits and narcotic removal by 1.11.2024. Emergency QAPI meeting held 1.11.2024. Allegation of Compliance: 1.12.2024

Based on review of the facility policy, observations and interviews, the facility failed to ensure 2 expired medications were removed from storage with resident medications that were in use and failed to remove a cup of 11 unidentified pills, 3 loose small white round pills and 1 container of expired thick and easy iced tea from 3 of 5 medication carts. The facility further failed to remove 2 packages of Algisite M dressings, 5 packages of Optifoam gentle dressings, 5 packages of Telfa non-adherent pads, 3 packages of brown Coban dressings, and 1 bottle of Sterile Plain Packing Strips opened and no longer sterile from, 2 of 2 treatment carts. Findings Include: Review of the facility's policy titled, Storage of Medications On Units revised October 2022, revealed, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and returned to pharmacy if appropriate or disposed of on the units. Observation on 01/10/24 at 12:36 PM of Medication Cart #1 on [NAME] 122 revealed 1 expired Fluticasone Propionate and Salmeterol 250mcg/50mcg with a use by date of 01/04/24. Observation on 01/10/24 at 1:00 PM of Medication Cart #2 on [NAME] 120 revealed 11 unidentified pills that were found in a cup in the top drawer of the medication cart. Observation on 01/10/24 at 1:30 PM of Medication Cart #2 on [NAME] 122 revealed 3 loose round white pills, 1 container of thick and easy iced tea with an expirations date of 01/05/24 and 1 vial of Lidocaine with an open date of 11/03/23 and instructions on the vial to discard 28 days after opening. Observation on 01/10/24 at 1:45 PM of the Treatment Cart on [NAME] 122 revealed 2 packages of Algisite M dressings with an expiration date of 01/01/24, 5 packages of Optifoam gentle dressings with an expiration date of 11/09/23 and 1 bottle of Sterile Plain Packing Strips opened and no longer sterile. Observation on 01/10/24 at 2:15 PM of the Treatment Cart on [NAME] 120 revealed 5 packages of Telfa non adherent pad with an expiration date of 06/03/22 and 3 packages of brown Coban dressings with an expiration date of 12/06/23. During an interview with Licensed Practical Nurse (LPN)1 on 01/10/24 at 12:40 PM, LPN1 stated that the expired fluticasone had been previously lost and was found in the resident's room. LPN1 further stated the medication was placed back into the medication cart instead of being discarded. During an interview on 01/10/24 at 1:10 PM, LPN2 stated that she had pulled and opened the medications to give to the resident but when she got to his room, he was not there so she put the medications in the med cart, so that she would not have to throw them away. During an interview on 01/10/24 at 1:40 PM, LPN3 stated that whoever is available can clean out the medications carts and no one person is designated to do it. LPN3 also stated that she did not know that there was expired tea in the medication cart and that it should not have been in there anyways. LPN3 further reported that the white pills may be from when someone spilled a stock medication in the cart, but she can't be sure. During an interview on 01/10/24 at 3:15 PM with the Treatment Nurse, it was revealed that the facility did not currently have a schedule for cleaning out treatment carts, but that she was actively working on creating one. The Treatment Nurse further stated that she was unaware what the training consists of for the nurses, but that they should be aware of what to do when pertaining to the treatment carts.

Based on facility policy review, record review, and interviews, the facility failed to address and resolve concerns of the resident council- related to food, and food substitutions/alternatives for 4 (Residents (R)3, R14, R17 and R19) of 10 residents reviewed for resident council. Findings include: Review of a facility policy titled Resident Council Policy and Procedure Directive, revised April 2022, revealed, Policy Statement: This directive establishes a written plan for administration of the Resident Council and delineates the guidelines for the coordination of the facility wide program. Resident Council Format A 1. The Resident Council provides residents with a mechanism for voicing grievances and for participating in the decision-making process while residing at the E. [NAME] Stone Jr., Veterans Home. 2. It provides a method of communication wherein issues and concerns affecting the welfare of the residents can be discussed and solutions and recommendations pursued. Review of Resident Council meeting minutes reviewed for the month of May 2023, June 2023, July 2023, October 2023, and November 2023, all revealed unresolved concerns from April's resident council meeting about portion size and variety of food being served. Review of the facility's Menu Calendar Report for the week of January 7, 2024 through January 13, 2024, did not reveal/provide available substitutions or meal alternatives. On 01/08/2024 at 10:42 AM, during an interview, the Kitchen Supervisor stated that the facility does not prep/cook the food in the facility. They stated all meals were cooked in a commissary kitchen offsite, and the food was delivered to the facility, via trucks and staff delivered the food to residents. The facility has a rotating 3-week menu. The residents are given the menu and are to communicate verbally with staff on unit what foods they do not like and an email is sent to headquarters on substitution options for the resident. There is no form, and there is no policy on preferences. The Kitchen Supervisor stated we (kitchen staff) would not address concerns or grievances related to food with the residents, the Registered Dietitian (RD) handled those concerns. On 01/09/2024 at 10:36 AM during the Resident Council meeting, residents in attendance voiced concerns about the food being served. The residents stated that the food was bland or overly salty, usually cold, or only slightly warm. The residents also stated that some form of hamburger meat was being served five out of seven days of the week. They stated they were not given substitutions or other choices when they did not want what was being served. The residents stated that they feel as if their concerns/issues about the food are not being heard or addressed. R17 stated that the issue about the food was brought up at every meeting, but nothing was being done about the council's food concerns. On 01/09/2024 at 11:42 AM, Kitchen staff #1 provided a test tray that consisted of meatloaf with gravy, mashed potatoes with gravy, green peas, mandarin oranges, a dinner roll, margarine, and sweet tea. The surveyors tested the tray provided. The meatloaf, resembled a freezer burned compressed meat (hamburger) patty with gravy, was barely warm, bland/flavorless (not seasoned), and dry, even with the gravy. The gravy was lightly seasoned, but not warm. The peas were bland and not seasoned. The mashed potatoes were flavorless, but warm enough to eat with the gravy on top, which gave it some flavor, but not much. Overall, the meal was not palatable, attractive, or appetizing in temperature. On 01/09/2024 at 12:14 PM, Certified Nursing Assistant (CNA)1 stated that substitutions were given if they did not want what is being served but they did not know what was on the extra trays until they arrive at the unit. CNA1 stated that if a resident had a concern/grievance related to the food, the RD handled those concerns. On 01/10/2024 at 12:20 PM, during an interview, the RD stated when the residents received the menu, the meals are ordered a day ahead; residents had to provide a 48-hour notice with any substitutions/alternatives. The RD then sends it out to the Chief Chef at another building. Extra trays are provided in the truck, which include substitutions/alternatives options such as baked chicken or a hamburger. The RD stated that she has not had any complaints related to food or substitutions and that unit staff have not communicated residents' preferences or food concerns, if so the RD will personally go to the resident to address their concerns. On 01/11/24 09:13 AM, during an interview, the Administrator stated concerns brought up during Resident Council were submitted to the department for review. There was about a two to three week turn around and the issue is brought up again to Resident Council with the resolution. The Administrator stated that complaints and requests for alternatives/ food substitutions were addressed by the RD. The facility does not have a form for meal substitutions/alternatives for the residents to complete. The RD will personally go to the resident and speak with them about the concern. Food menus were rotated on a three-week basis to keep residents from having the same meal over and over. The Administrator stated that he had tasted the meals, and they were bland, so he understood the residents' concerns.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure a medication error rate, during medication administration, was less than five (5) percent. The med error rate was 15.15 percent for 5 out of 33 opportunities for error. Findings Include: Review of the facility policy titled, Administration of Medication last revised December 2021, states Insulin will be verified by two medically licensed personnel (RN/LPN/LPP) for accuracy of the medication and dosage prior to administration. Furthermore, it states that The person administering medication must: 2. Be sure to have the right drug and dose for the right patient/resident, give at the right time and by the right route. During an observation and interview on 01/09/24 at 9:12 AM during medication administration, it revealed that Licensed Practical Nurse (LPN)1 drew up 23 units of Lantus insulin for Resident (R) 46 instead of the ordered 24 units. When asked about the amount drawn, LPN1 then stated, Yeah, see it's 23 units. LPN1 did not realize that she had drawn up the incorrect amount until questioned multiple times by surveyor and then checking R46's order again. During an observation on 01/10/24 at 10:01 AM during medication administration, it revealed that while LPN2 was administering medication to R22 the following errors were observed: 1. LPN2 gave R22 1 325 milligrams (mg) tablet of Acetaminophen instead of the ordered 650 mg or 2 tablets. 2. R22 was not given the ordered eye drops (Timolol) 3. R22 was not given the ordered Singulair. 4. R22 was given ordered nausea medication (Ondansetron) during the morning medication pass, a medication that was ordered to be given before lunch ( it should have been given shortly before the resident ate lunch). Review of R22's Physician Orders revealed he was ordered Timolol 0.5% eye drops to be administered two times daily, Singulair 10 mg tablet to be given every morning and Ondansetron 8 mg to be given three times daily. During an interview on 01/10/24 at 10:30 AM with LPN2, it was stated that she was just pulled to work on this ward and did not arrive until 9:00 AM and therefore she documented both the morning and midday medications as given at 9:45 AM, eventhough she did not give the morning medications to the residents. LPN2 also confirmed that she only gave 1 tablet of 325 mg Acetaminophen instead of the ordered 2 tablets to the resident, but insisted that she gave the resident his Singulair. LPN2 had no comment on the remaining medication errors. During an interview on 01/10/24 at 3:05 PM, the Director of Nursing (DON) stated that her expectations for medication administration is that the nurses are to give the ordered medication within the appropriate time frame and as scheduled. DON further stated that if a medication is not given the nurse needs to contact the Physician. DON noted that a high medication error rate can be deadly to the residents, and she expects the nurses to perform the 5 rights of medication during med pass.

Based on review of the facility policy, observations, and interview, the facility failed to follow Infection Prevention and Control procedures on 2 of 2 units for hand hygiene during distribution of meal trays and for a room identified with active COVID-19. Findings include: Review of the facility policy titled, Infection Control for Laundry, with an effective date of January 2023 revealed, Hand Hygiene and Personal Protective Equipment: #2, Good Hand hygiene consists of a 20 second scrub with soap and water or application of hand cleansing gel according to hand hygiene procedure. Handwashing cleansing gels may be used when frequent, casual contact occurs when hands are not visibly soiled, #3, a. states, Before and after contact with each resident on in-use resident device. Review of the facility policy titled, Infection Control with an effective date of October 2023 revealed, Purpose is To identify types and management of transmission-based precautions. Page 4, #3 d states, Remove gloves before leaving the residents room, discard and perform hand hygiene immediately with an anti-microbial agent . #3 e states, Remove and dispose of gown before leaving residents room. Ensure clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other residents or environments . On 1/9/24 at 11:32 AM, an observation of a staff member revealed, she sanitized her hands, donned gloves, and delivered both meal trays to room [ROOM NUMBER]. For bed one, she donned (put on) gloves, opened all items, then removed gloves by folding them into each other. She then unraveled the used gloves and donned one of the used gloves, picked up the straw, opened straw packet and placed it in the drink then removed used glove again. During an interview on 1/9/24 at 11:40 AM, the Admin Specialist/Unit Secretary stated, They pulled me to help out. I took the gloves off, then realized I didn't open his straw, so I didn't want to touch the straw with my hands ungloved, so I opened the used glove again. I should have got another clean glove. On 1/10/24 at 7:47 AM, an observation of room [ROOM NUMBER] revealed it with a Personal Protective Equipment (PPE) cart and disposable trash bin outside the door and the door was wide open. Identification of signage was located on the door identifying the room with active infection. At this time, a Laundry Aide (LA) in the hall with gloves on passed this writer, went into room [ROOM NUMBER] with the gloves and got the laundry basket from the room and did not change or remove the gloves she walked in with. She brought the laundry basket to the door of the laundry room, left it there, then proceeded down the hall into room [ROOM NUMBER] with the same gloves on. She entered the room and was observed not removing or changing the same gloves. She exited the room with the same gloves, with a laundry basket and proceeded to room [ROOM NUMBER], where she left the laundry basket in the hallway, and with same gloves on, retrieved a third basket of soiled resident laundry without changing the gloves. She exited room [ROOM NUMBER] and proceeded in the hallway with both laundry baskets and went to the laundry room. She had three soiled linen laundry baskets and had not changed her gloves. On 01/10/24 at 12:14 PM, an observation of the door of a Covid Positive resident in room [ROOM NUMBER] was observed to be wide open with resident asleep in bed number one and no staff present in hall or in the resident's room. During an interview on 1/10/24 at 8:00 AM, the LA stated, I just walk into the restroom of the resident rooms for the laundry baskets and then go into the laundry room and then I will take my gloves off then. She confirmed she did not remove her gloves when entering into the three separate resident rooms to sanitize her hands. She had her same gloves from three rooms on at time of interview and she pulled her keys from her pockets with same gloves and opened the door to the laundry. During an interview with the Infection Control Practitioner (ICP) on 1/10/24 at 3:00 PM, he stated, room [ROOM NUMBER] bed 1 has active COVID-19. The door of a resident with COVID-19 should remain closed. We keep supplies outside each room, caddies with different sizes. We also place signage. We use a Hexagonal cardboard waste container that is also outside the room. We ask staff to shed PPE into the trash bin upon exiting the COVID-19 rooms. If they remove the PPE in the hallway at the door and place it in the trash container, that is acceptable. However, it is not acceptable to wear a pair of gloves from one room to another to another. The ICP stated, they have to remove gloves and wash their hands between each room and resident.

Based on observations, interviews, and record review, the facility failed to properly store Resident (R)22's respiratory device. R22's Continuous Positive Airway Pressure (CPAP) mask had no covering, when not in use. Findings include: During an observation on 01/08/24 at 11:09 AM, R22's CPAP mask was observed hanging on the wall above the head of the resident's bed, uncovered. Review of the Face Sheet revealed R22 was admitted on [DATE] and had a diagnoses of, but not limited to obstructive sleep apnea, rheumatoid arthritis, and muscle weakness. Review of the Physician Orders revealed that on 06/30/2021, R22 was ordered for the use of a CPAP during the hour of sleeping. Review of the Care Plan initiated on 07/20/21 revealed that the resident had the potential for complications of multiple medical conditions. The interventions included administer Flonase before using CPAP at night. Review of Treatments revealed that from 12/01/23- 01/10/24, R22 used the CPAP every night. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed, R22 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that R22 was cognitively intact. The MDS indicated the use of the CPAP. On 01/10/24 at 11:58 AM, R22's CPAP mask was observed lying over the CPAP machine, uncovered. On 01/10/24 at 12:12 PM, an interview with Licensed Practical Nurse (LPN)2 revealed that she had no knowledge of the facility's CPAP equipment storage policy or practice. She stated that she had not observed the CPAP mask uncovered in the resident's room. She stated that she just got here to pass medications. On 01/10/24 at 3:50 PM, an interview with the Director of Nursing (DON) revealed that the facility has no policy on the storage of oxygen equipment, such as CPAP mask. On 01/10/24 at 3:55 PM, an interview with the Respiratory Therapist (RT) revealed that her standard of practice for storage of the CPAP mask is to hang it on the wall on hook, uncovered. She stated that the facility does not have a policy on the proper storage of CPAP mask or nasal cannula tubing. On 01/11/24 at 03:43 PM, an additional interview with the DON revealed, that R22 does have an order for the use of the CPAP at night. She stated that R22 had been wearing the CPAP at night. She stated that her standard of practice would be to store the CPAP mask in a plastic bag when it is not in use. She stated that the CPAP could be contaminated with mold, bacteria, wetness or damaged if not properly stored. Improper storage could lead to R22 having difficulty breathing and infection could be a possible outcome, depending on what the mask had been exposed to. On 01/12/24 at 8:57 AM, an interview with the facility Administrator revealed that he expected the CPAP be stored in such a way that it was not a tripping hazard. If not stored properly, the device could be damaged. The Administrator stated that he could see the improper storage of the CPAP device being an infection concern.

Based on observations, staff interview, record review, and facility policy review, the facility failed to update and revise the comprehensive care plan for refusals to get out of bed (OOB) for 1 (Resident (R)48) of 3 residents reviewed for activities of daily living (ADLs). Findings include: Review of a facility policy titled, Resident Care Conference: The Development and Review of Resident Health Care and Care Plans, with an effective dated 02/ 2023, revealed Purpose Statement: Resident Care Conferences (RCC) are hereby established for the purpose of providing he most effective utilization of available resources in the planning and re-evaluation of an individualized care and treatment plan which is based on a comprehensive assessment. The RCC of each unit shall meet weekly. Special reviews ae scheduled as needed. All staff engaged in any aspect of the care of residents ae considered members of the RCC. The RCC team is responsible for evaluation of goals and approaches at quarterly, annual, and significant changes. Review of R48's Face Sheet indicated facility admitted resident on 10/31/2023 with a diagnosis of but not limited to, other malaise, alcohol dependence in remission, unilateral primary osteoarthritis, left hip, chronic pain, other spondylosis with radiculopathy lumbar region, feeding difficulties unspecified, acute embolism and thrombosis unspecified deep veins of right lower extremity, nutritional anemia, pressure ulcer of other site, stage 3, adjustment disorder, post-traumatic stress disorder, major depressive disorder, and protein-calorie malnutrition. Review of R48's Comprehensive Minimum Data Set (MDS) dated [DATE], revealed resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates resident is cognitively functional. Resident requires substantial/maximal assistance with eating, oral hygiene, and personal hygiene. Resident totally dependent with showering/bathing, upper body dressing, lower body dressing, toileting hygiene and putting on/taking off footwear. Resident requires substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on side of bed. Resident is totally dependent with chair/chair-to-bed transfer. Resident does not sit to stand due to medical condition or safety concerns. Review of R48's care plan with an effective date of 11/01/2023, revealed R48 is at risk for falls/injury related to cognitive deficits, impaired mobility and medical conditions as evidenced by history of falls, and unable to transfer without assistance. Resident is dependent with transfers by way of Hoyer Lift and uses a Broda chair for mobility. R48's goal will be to be treated and observed for complications through the next review date. Interventions include DEBILITY: Physical Therapy (PT)/Occupational Therapy, staff to assist with all activities of daily living (ADL'S), transfers by way of Hoyer lift by two staff members. HI/Low bed while in use. Observe for signs and symptoms of anemia such as weakness, fainting, breathlessness, difficulty sleeping, notify Medical Doctor as indicated, assess resident for pale skin or gums and bruising. The resident may use adaptive teaspoon/fork/mug ad lib during meals; staff to provide tray set-up and assistance as needed. Review of Physician's Orders dated 10/31/2023 revealed an order for resident to get up out of bed daily with a start date of 10/31/2023. Review of Progress Notes dated 11/07/2023 revealed Occupational Therapy (OT) attempted to R48 today per plan of care, however, resident presents in supine with complaints of (c/o) severe left hip pain. Declined OT treatment or getting out of bed (OOB) to BRODA chair. Let's try it tomorrow, per resident's request. Review of Progress Notes dated 11/17/2023 revealed following skilled Occupational Therapy (OT) treatment yesterday, resident verbalized consent to be out of bed (OOB) and up in BRODA chair on 11/17/23, for social interaction, stimulation, and positioning. However, upon follow up by OT and head Certified Nursing Assistant (CNA) after lunch today, resident declined to be out of bed, stated that he prefers to do it in the morning (instead). Continue OT per Plan of Care (POC). On 01/11/2024 at 1:56 PM, R48 was observed asleep in bed. During an interview on 01/11/2024 at 2:10 PM, Licensed Practical Nurse (LPN)5 stated staff attempted to get R48 up as much as resident wants but the resident refuses. R48 complains about being in pain. LPN5 also stated R48 was given pain medication 30 minutes before any activities of daily living (ADL) are performed. LPN5 also stated any time R48 refused any activity, it is documented. During an interview on 01/11/24 at 2:27 PMm Certified Nursing Assistant (CNA)3 stated, We (staff) will only get R48 up if the resident has a doctor's appointment. R48 complains about being in pain every day and it is just too difficult to get R48 out of bed because it takes at least three (3) people (staff) due to the pain. CNA3 stated staff does not ask or encourage R48 to get OOB. During an interview on 01/11/2024 at 2:51 PM, Director of Nursing (DON) stated rounding and care plan revisions are done quarterly and care plans are updated at that time. We (staff) are aware that R48 refuses to get OOB due to complaints of pain, but staff should encourage R48 to get OOB and this was discussed with R48. The nurses are to give R48 their pain medication 30 minutes prior to any attempted ADLs to help relieve pain. The DON stated currently staff are not required to document a resident's refusal of ADLs but would implement this immediately.

Based on review of the facility policy, record review, and interviews, the facility failed to identify and implement preventative measures for 1 of 1 resident with significant weight loss (Resident (R) 26. Findings include: Review of a facility Policy with an effective date of January 10, 2024 revealed, Significant Weight Loss Documentation, #2. RD lists the resident/patient who are at significant weight loss 1 month>=5%, 3 months >=7.5% and 6 months >=10%. #6, RD documents monthly special review note on the resident/patient who has significant wt. loss in 1 month, 3 months and 6 months with nutritional intervention until the weights are stabilized. Record review of R26's weights revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/23 recorded R26 weight as 118 pounds. On 11/13/23, his weight was recorded as 103.8 pounds, and on 12/12/23, his weight was recorded as 102.8 pounds and revealed a 12.88 % weight loss. Record review of an e-mail written by the Registered Dietician dated 1/11/24 addressed to all managers revealed R26 had a significant weight loss from August-November 2023, August weight was 118.4 pounds, November weight was 103.8 pounds, weight loss of 14.6 pounds, (12.3%) over 3 months. Will continue to send Ensure Plus three times a day and to increase Mighty Shakes to three times a day (receives with his meals) and initiating weekly weights x 4 weeks. During an interview on 1/10/24 at 11:49 AM, the Registered Dietician stated, On 8/9/23, he was 118.4 pounds, and on 11/13/23 he was 103, this is a significant weight loss. His December weight is 102.8 pounds, and his weight is still going down. I normally don't wait for a quarterly review to address significant weight loss. If I had picked up on it, I would have written a note and addressed the significant weight loss. He has not yet been addressed for significant weight loss, but he will this week, his Quarterly Assessment is coming up. During an interview with the Director of Nursing (DON) on 1/11/2024 at 9:20 am, she stated, We monitor weights monthly for all residents and follow the physicians' orders for specific weight orders. The floor staff nurses will identify any 5-pound discrepancy, then re-weigh. Then it goes to the dietician. It either goes into myunity, or verbally. The weights are obtained the 1st-10 of the month. We don't have a monthly weight meeting. She said R26 had a significant weight loss. The weight of 118 pounds down to 103 pounds is significant.

Based on observation, interview and facility policy, the facility failed to follow physician order for pressure ulcer dressing change for 1 of 1 resident observed, (Resident (R) 26. Findings include: Review of Clean Dressing Policy Effective September 2022 revealed Procedure/Key Points Rationale page 4 states, MD/NP order is necessary prior to medication application. On 1/10/24 at 10:27 AM, an observation with Registered Nurse (RN)1 of a dressing to two unstageable pressure ulcers located on R26's lower thoracic spine and sacrum. After obtaining consent from R26 for observation, two dressings were observed intact dated 1/6/24 with MW initials. RN1 also confirmed the date as well. She then removed gloves, sanitized hands, and donned gloves and proceeded to complete the dressing change without complaint from R26. Record review of the Treatment Administration Record (TAR) revealed a treatment order to cleanse the skin every two days starting 12/29/2023 to upper thoracic and sacral wound to cleanse with normal saline and pat dry. Apply skin prep to peri wound, apply Medihoney over upper thoracic and sacral wound, cover with bordered foam dressing, change every two days and as needed. On 1/6/2024 the initials on the dressing that was observed on R26 matched the initials dated 1/6/2024 that was signed from the TAR. On 1/8/2024 the initials of another nurse was also noted as signed for the dressing change on the TAR, but those initials did not match the 1/6/2024 dressing that was observed and removed on R26 on 1/10/2024. During an interview on 1/11/2024 at 9:20 AM with the Director of Nursing revealed, With the treatment where R26 dressing was dated 1/6/24, should have been dated 1/8/24. I've already started the process of education. The nurse should have changed the dressing, another nurse signed it off thinking the wound nurse completed the dressing change.

Based on observation, record review and interview, the facility failed to ensure pressure relieving device was in place following physician order and plan of care for 1 of 1 resident reviewed, (Resident (R) 258. Findings include: On 1/9/2024 at 11:09 am, an observation of R258 revealed him asleep in bed. His bilateral lower extremities were hanging off the foot of the bed to the left. He was not wearing Prevalon Boots and his feet were bare. On 1/11/2024 at 8:40 am, an observation of R258 revealed him asleep in bed. Prevalon Boots were not on his feet. His feet were uncovered with the blanket above his feet and were bare. Record review of the Physician orders for R258 dated 11/29/2023 revealed Prevalon Boots for Venous Insufficiency. Review of January 2024 Treatment Administration Record (TAR) for R258 revealed Prevalon Boots all 3 shifts, Day, Evening, and Night Shift signed as administered. Review of the Care Plan dated 11/30/2023 for R258 revealed he is at risk for skin breakdown and an intervention dated 1/10/2024 was added for Prevalon Boots. During an interview with Licensed Practical Nurse (LPN)1 on 1/11/2024 at 8:40 am stated, R258 should have the Prevalon boots on in bed. LPN1 went into R258 room to look for the Prevalon boots. She stated, They aren't in there or in his closet. We had to reorder his Prevalon boots, they are on back order. I don't know what happened to the other pair he had. During an interview with the Director of Nursing (DON) on 1/11/2024 at 9:20 am, she stated, If Prevalon Boots are ordered, they should be applied as ordered and be on the TAR as signing them off by the nurse, I would expect that they be on him in bed or in the room. During an interview with Certified Nursing Assistant (CNA)2 on 1/11/2024 at 11:40 am, She stated, I have limited information, yesterday was my first day with R258, because he has swollen legs, he is supposed to have the boots. He does not have boots to wear. During an interview with Minimum Data Set (MDS) Registered Nurse (RN)1 on 1/11/2024 at 2:00 pm, she stated, Our care plans follow the physician orders. The Prevalon boots should be on him, especially when he is in bed. If they aren't putting them on, they aren't following the orders.

Based on observations, record review, facility policy and interviews the facility failed to carry out activities of daily living necessary services to maintain good grooming, personal, and oral hygiene for Resident (R)45. Findings include: Review of the facility's Shaving the Resident policy, revised 09/22 revealed, Purpose: To safely shave the resident in order to promote cleanliness and provide skin care. Responsible staff: CNA, RN, LPN. Document procedure and any pertinent observations in the Electronic Health Record (EHR) on: Time and date that the procedure was performed. How resident tolerated procedure or any changes in the resident's ability to participate in procedure. Any complaints of discomfort. If resident refuses therapy, the nurse will explore the reasons for the resident's refusal, clarify, and educate the resident as to the consequences of refusal, offer alternative treatments, and continue to provide all other services. If the resident has refused treatment. The care plan reflects CMT's efforts to address the problem. Please notify MD/NP of refusal on rounds. Review of the facility's Mouth Care: Routine revised 09/22 revealed, Purpose: To cleanse the mouth, reduce the risk of mouth infections, and keep lips and oral tissue moist. Responsible staff: RN, LPN, CNA Document procedure and any pertinent observations in the Electronic Health Record (EHR) on: a. Treatment Administration Record (TAR), b. Medication Administration Record (e-Mar), c. Clinical Notes (select the Clinical tab, then the Notes tab to add the Clinical Notes), d. MyUnityPoint of Care under designated tab related to Activities of Daily Living (ADL) care. If resident refuses therapy, the nurse will explore the reasons for the resident's refusal, clarify and educate the resident as to the consequences of refusal, offer alternative treatments, and continue to provide all other services. If the resident has refused treatment, the care plan reflects CMT's efforts to find alternative means to address the problem. On 01/08/24 at 10:33 AM, R45 was observed with white and black facial hair covering the cheeks and chin approximately quarter of inch long. The resident was observed with dry, cracked, peeling lips. On 01/09/24 at 12:10 PM, R45 was observed with white and black facial hair covering the cheeks and chin approximately quarter of inch long. Review of the Face Sheet revealed, the resident was admitted on [DATE] and had a diagnoses of but not limited to: dysphagia following a cerebral infarction, cerebral infarction affecting the right dominant side, hemiplegia following cerebral infarction affecting the right dominant side. Review of the Care Plan Report, initiated 11/27/2023, revealed the resident requires assistance with bathing and grooming. Interventions include: two staff assist for all Activity of Daily Living (ADL) care and shave 2-3 times per week per facility policy. Barber or nursing staff as tolerated. Monitor mouth, tongue, and gums for odor, redness, swelling, coating, sores, cracking, or fissures. Assist resident with oral care during ADL care three times a day (TID) and as needed (prn). R45 is NPO and requires tube feedings related to diagnosis of oropharyngeal dysphagia with potential risk for silent aspiration. Interventions to include to provide oral care and mouth moisteners as ordered and prn. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed, that the Resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. R45 required partial/moderate assist with oral hygiene and was dependent with personal hygiene. Review of Resident Medication Summary revealed an order, dated 12/07/2023 for Biotene Moisturizing Mouth mucosal spray (1 spray), as needed every shift. Indication: dysphagia following cerebral infarction. Nursing staff to ensure clinical staff use every shift as needed for dry lips, mouth when providing ADL and or oral care. Review of Treatments for the months of 12/24 and 01/2024 revealed, Biotene Moisturizing Mouth mucosal spray was not administered on 12/07/23 thru 01/08/2024. Review of the Barber & Beauty revealed that R45's face was shaved on 12/23/23, 12/27/23, and 01/09/24. On 01/09/24 at 12:10 PM an interview with Registered Nurse (RN)3 stated that personal hygiene should be done daily and consists of grooming, bed bath, shower, and mouth care. She states that shaving is a part of personal care hygiene. She also states that she does not know the last time the resident was shaven. On 01/10/2024 at 11:50 AM an interview with the Hair Care Specialist revealed, that she goes around the facility every day and asks residents if they would like to be shaved. She stated that she does not have access to the view the resident's orders. The LPN usually lets her know if a resident needs to be shaved, and if the resident has any contraindications to shaving. She stated that residents are not shaven on the weekends in the Barbershop. She stated that the R45 was shaved on 01/09/2024 and 12/27/2023. She stated that the residents often refuses to be shaved when he is in the bed. She stated that she documents the refusals in the computer. She stated that she is unable to view the entire month of December's documentation of when the resident was shaved and R45 refusal to be shaved. On 01/10/2024 at 12:00 PM, an interview with Certified Nursing Assistant (CNA)3 revealed, that personal hygiene is done daily and includes face washing, pericare, incontinence care, oral care. She agreed that shaving is considered personal hygiene. She stated that the CNA's do not usually shave residents due to the facility having the barber on staff. She stated that she has never asked the resident if he wanted to be shaved. She stated that she would shave him if he requested it. She stated that the resident has never refused care. On 01/11/24 at 11:38 AM, an interview with the Beauty Barber Director revealed, Hair Care Specialist usually goes to R45's bedside and ask him if he wants to get a shave and R45 refuses. The documentation system has not recorded any services or refusal of services from his department. He stated that he had recently found out the documentation has not been recorded from his department. He stated that he does not know how many times that R45 has refused services in the last month. He stated that his expectation is that R45 should be serviced Monday, Wednesday, and Friday at least three times per week. He stated that the standard that he has created as Beauty Bar Director is for R45 to receive services such as shave and haircut at least three times per week according to their individual needs. He stated that he does not have access to the R45 care plans. The DON or Nurse Manager communicates the care plan information to him. On 01/11/24 at 11:52 AM, an interview with CNA3 revealed, that oral care should be done in the morning, daily, and after meals. She stated that she checks teeth, tongue, dry lips in order to determine if oral care is needed. She states that she assists residents with the moist mouth swabs if they have tube feedings such as R45. On 01/11/24 at 3:33 PM, an interview with the Director of Nursing (DON) revealed, that R45 needed assistance with ADL care. She stated that R45 required one person assist with oral care and shaving. She stated that she expects oral care to be done before meals or shaving as needed. She stated that residents go to the barber when ever they want to go. The CNA staff document in MyUnity or can free text notes. DON stated that the barber has their own documentation system that does not alert when shaving is refused. She expected that the Beauty Bar Director to inform the nursing staff when a resident refuses care. DON stated that the care plan and orders should followed by staff. On 01/12/24 at 8:57 AM, an interview with the Administrator revealed, ADL care should be completed routinely and as needed. He stated that the care plan should describe the needs and strengths of the resident. He stated that the care plan should be followed.

Based on review of the facility policy, record reviews, and interviews, the facility failed to protect 2 of 2 residents from neglect. Specifically, Certified Nursing Aid (CNA)1 was observed via video surveillance on multiple occasions purposefully withholding fluids from Residents (R)1 and R2. On 10/06/22 the State Survey Agency (SSA) received an initial 24-hour report stating that on 09/02/22 a CNA, later identified as CNA1 was withholding fluids from residents. The facility substantiated the allegations and CNA1 was terminated from employment. On 02/01/23 at approximately 10:30 AM, the SSA determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The Administrator was notified that the allegation of neglect constituted Immediate Jeopardy (IJ) at F600 beginning on 09/02/22. On 02/01/23 at approximately 3:00 PM, the facility provided an acceptable IJ removal plan. Findings include: Review of the facility's Policy Protection from Harm dated November 2022, revealed under, 2.0 Definitions Section H. Neglect is the failure of the facility, its employees or services to a resident that are necessary to avoid physical harm, mental anguish, or mental illness. Further review of the policy revealed under, 6.0 Recognizing Signs and Symptoms of Abuse/Neglect, Some signs/symptoms of abuse/suspected abuse or neglect is: Unexplained weight loss, poor diet consumption. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, psychotic disorder, hearing loss, dysphagia, and difficulty in walking. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/15/22 revealed, R1 scored a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating he was not cognitively intact. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia, Parkinson's Disease, psych disorder, and dermatitis. Review of R2's Quarterly MDS with an ARD of 9/15/22 revealed R2 scored the resident scored a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating he was not cognitively intact. During an interview with the Administrator on 01/25/23 at 12:36 PM revealed, in September 2022 an investigation was conducted due to a staff member stating that CNA1 was removing fluids from resident trays without offering a replacement. This was being done intentionally in order to not provide Activities of Daily Living (ADL) care for the resident who may have episodes of incontinence. The Administrator stated CNA1 was suspended pending investigation and was terminated on September 29th, 2022. The Administrator further stated the primary method of investigation was video footage. The Administrator revealed the video footage and internal investigation discovered incidents consistent enough to establish a pattern that CNA1 was committing the act of neglect. The Administrator concluded that as a result, two residents who were under her care were affected by this practice. During an interview with Physician (PH)1 on 01/25/23 at 1:47 PM revealed, PH1 has had few encounters with CNA1. PH1 stated she never physically saw CNA1 taking fluids off carts, however she did notice a pattern with dehydration among residents in the locked unit. During an interview with the Registered Nurse (RN), via phone call, on 01/25/23 at 2:24 PM revealed, CNA1 told her that she knew what fluids the residents didn't like, and she takes them off their tray. The RN also stated she remembered asking CNA1 if she had spoken to Dietary regarding resident preferences and CNA1 replied No. The RN stated she told CNA1 that an allegation was made, and an investigation is required. The RN also stated that herself and the previous Director of Nursing (DON) pulled the surveillance footage from the unit CNA1 worked on. The DON and RN verified, via the surveillance footage, CNA1 was seen taking resident's fluids off their meal trays and not replacing the fluids with alternatives on multiple different occasions. The RN stated that she immediately picked up the phone in the DON's office and called the Administrator. The RN further stated that once the Administrator was aware CNA1 was caught on surveillance footage, CNA1 was terminated. The RN concluded this was a suspicion the staff had for months; the facility just couldn't prove it. During an interview with the previous Director of Nursing (PDON) on 01/31/23 at 11:15 AM revealed, CNA1 worked on Unit 122 which is the Locked Unit. PDON stated there was an instance with CNA1 a few months back when the RN/Shift Supervisor gave the PDON a report with concerns about CAN1 withholding fluids from residents. The PDON stated that an investigation began once she heard about it. The PDON stated that when she asked CNA1 about the allegation, CNA1 stated to the PDON she took the fluids off the resident's trays because the resident doesn't like the fluid options. The PDON said CNA1 was suspended pending investigation. The PDON stated she spent an extensive amount of time looking back at the video footage. The PDON verified that CNA1 was seen taking fluids off trays and throwing fluids in the trash not offering replacements. PDON revealed she thinks the root of the cause was because CNA1 didn't want to change the resident's briefs, CNA1 was limiting their fluids so she would not have to change as many briefs. The PDON stated she noticed dehydration was a pattern in the locked unit. The PDON stated two residents (R1 and R2) developed a urinary tract infection (UTI) once it was discovered. The PDON concluded CNAs are supposed to chart input and output in the resident's chart and the nursing staff is responsible to ensure that residents are provided with liquids. During an interview with CNA 1 on 01/31/23 at 12:20 PM, via phone call, CNA1 stated, Stop calling me, I'm not talking. During a follow up interview with PH1 on 02/01/23 at 09:34 AM, PH1 confirmed the urinalysis for R1 on 09/14/22 and R2 on 09/27/2022 were positive for UTI. PH1 stated dehydration could have led to the UTIs. Review of video surveillance from 09/02/22 confirmed the allegations. The facility's removal plan included: R1 and R2 are currently placed on Constant Observation Line of Sight (COLS) for all shifts for safety and to ensure that residents are being provided and receiving fluids. To prevent further abuse, staff are currently being educated on the protection from harm policy and staff are currently signing off on the fluid intake checklist to ensure that resident R1 and R2 are receiving and being provided their meals with fluids. February 1, 2023, a supervisor was assigned to the dining area to ensure that all fluids were provided and received during lunch time to all resident to include residents R1 and R2. Also, staff education of protection from harm policy has been implemented as of today February 1, 2023. In addition, Staff will continue to be in-serviced for the next 7 days on the protection from harm policy with a start date of February 1, 2023, with a projected end date of February 15, 2023 The facility has developed a checklist to determine that all fluids are on each resident's tray and that the residents have received them, to include resident R1 and R2. The facility has also assigned staff per unit and dining area to monitor all meals to ensure that residents are receiving all liquids provided to include residents R1 and R2. The use of fluid intake checklist started February 1, 2023, and the projected end date will be May 3, 2023.

Based on record review, interview, and review of facility policy, the facility failed to effectively monitor weights and follow prescribed physician orders for nutritional supplement administration for one resident (Resident (R) 26) who sustained an apparent significant weight loss, out of six residents reviewed for nutritional status. Findings include: Review of R26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/21, revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating the resident had significant cognitive impairment. The assessment identified the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented R26 required set up assistance from staff for meals, weighed 147 pounds (lbs) at the time of the assessment, and had sustained a weight loss of five percent (%) or greater in the last 30 days or 10% or greater in the last six months. Review of hard copy flow sheets titled, Monthly Weights Sheet, revealed the following: The 04/21 Monthly Weights Sheet documented R26 weighed 155.6 lbs on 04/03/21. The 05/21 Monthly Weights Sheet, documented R26 weighed 148.5 lbs on 05/04/21. The 06/21 Monthly Weights Sheet, did not document a weight for R26. The Resident Weight Report, with a date range of 07/01/21 to 10/12/21, which the facility provided from the electronic medical record (EMR), documented the following weights for R26: 07/07/21 - 157.4 lbs; 08/02/21 = 147.2 lbs; 08/17/21 = 139.0 lbs; 09/02/21 = 179.4 lbs; 10/02/21 = 110.0 lbs; and 10/08/21 = 137.6 lbs. Review of the Monthly Weight Sheet documents and the Resident Weight Report form indicated that, if the weights were accurate as documented, R26 sustained a significant weight loss of 11.57% weight loss between 04/03/21 to 10/08/21. Review of the hard copy 06/22/21 Patient Report, under the Laboratory tab, showed that during this period of time, R26 had a Total Protein blood level (total amount of two classes of proteins found in the fluid portion of a person's blood) of 5.2 grams per decilitre (g/dL) indicating the resident's protein level was below the normal range of 6.0 to 8.5 g/dL. The report also documented an [MEDICATION(S)] level (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) of 3.5 g/dL with a reference interval of 3.5 to 4.6 g/dL, indicating R26's level was at the lowest end of the normal range. a. Failure to follow physician orders: Review of the Care Plan Report, regarding Nutritional Status, with a goal date of 11/17/21, documented R26 required a mechanically altered diet related to a history of oropharyngeal dysphagia (swallowing difficulties occurring in the mouth or throat) and chewing difficulties related to missing and worn teeth. The care plan included, but was not limited to, the following interventions: Ensure Plus [type of nutritional supplement] per MD [Medical Doctor] orders- see MD orders. Assess nutrition status quarterly and prn [as needed]. Monitor and record weight monthly and prn. Monitor and record meal intake at each meal. The October 2021 Physician Order Sheet, included an order with start date of 07/16/21 directing staff to provide, Ensure Plus 1 [one] container for meal intake < [less than] 50%. The facility provided an ADL [Activities of Daily Living] Verification Worksheet from the EMR which included all observations between 06/01/21 12:00 AM (EDT) and 10/13/21 8:45 AM (EDT) [sic], and documented meal percentage intakes for R26. Review of the worksheet revealed R26 consumed 50% or less of a meal 175 times out of a total of 245 meals between 07/16/21 through 10/12/21. Review of the Medication Administration Records (MAR) titled, August 2021 Medications, September 2021 Medications, and October 2021 Medications, included the 07/16/21 physician's order for staff to provide, Ensure Plus 1 container for meal intake < 50%. The forms failed to include any evidence that staff administered Ensure as ordered for each meal in which the resident's food consumption was less than 50% during August, September, and October 2021. b. Failure to accurately monitor resident's weight as needed/recommended: Review of the quarterly dietary progress note dated 08/13/21 at 2:06 PM, written by the Registered Dietician (RD) and provided by the facility, revealed R26 averaged a 45% meal percentage intake in the previous seven days, had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In this note, the RD recommended weekly weight monitoring, to get more accurate weight trend [sic]. A Special Review dietary progress note dated 9/29/21 at 9:09 AM written by the RD revealed the weights were, showing inconsistencies .is most likely inaccurate .will recommend to continue weekly weights to get a more accurate weight trend. Review of all weight records provided by the facility revealed that the facility failed to obtain weekly weights as first recommended by the RD on 08/13/21. Weekly weights were not documented between 08/17/21 - 09/02/21, and 09/02/21 - 10/02/21. During an interview on 10/13/21 at 9:25 AM, the RD reported she monitored the nutritional status for all residents to assess if their nutritional needs were being met and made recommendations to the doctors based on her findings. She reported the Certified Nurse Aides (CNAs) were responsible for weighing the residents and she reviewed those weights on a monthly basis. The RD said the facility had been having issues with the weights. She went on to explain the facility previously had a designated staff member who collected all the weights to ensure consistency, however that person left approximately one year ago. Since that time there had not been a designated staff member to obtain the resident weights. The RD stated that if she identified a significant difference from the previous weight, she sent an email to alert the staff to ensure a re-weight was completed but she may not see the reweigh result for a week or two. The RD stated she was not notified by staff of weight discrepancies and did not know the exact facility policy regarding weights. The RD stated in the past she received a monthly email with all the resident weights with reweighs documented in that report, but now she runs her own report. The RD explained the facility recently identified the accuracy of weights had become inconsistent, so in-services were completed with the CNAs, and unit managers began to complete reweighs. She said she received the October 2021 weights from the unit managers over the past two weeks, which appeared to be more consistent. The RD confirmed R26 routinely ate 50% or less of meals in the last three months and staff were to provide an Ensure if that occurred. During an interview on 10/13/21 at 12:25 PM, CNA1 reported R26 frequently ate 50% or less of meals. CNA1 stated that she would give the resident Ensure at times but had no evidence when/if this occurred. During an interview on 10/13/21 at 12:28 PM, Licensed Practical Nurse (LPN) 2 and Registered Nurse (RN) 3 reported CNAs took resident weights and documented them into the electronic medical record. RN3 reported the CNAs were good at notifying the nurses if they saw a change in weight. LPN2 and RN3 were unsure if R26 had lost weight and confirmed his documented weights were inconsistent. RN3 reported the facility previously had a designated staff member who was responsible for weights, but that staff member no longer worked at the facility and no one else had been designated to perform this task. LPN2 and RN3 confirmed staff were to follow physician orders to administer Ensure if the resident ate 50% or less of the meal. During an interview on 10/13/21 at 12:47 PM, RN4 reported she was the manager of the unit on which R26 resided. RN4 stated the facility had identified there was a problem with weight accuracy and was in the process of attempting to correct the issue. She confirmed there had not been a designated staff person to take resident weights for approximately one year. She reported she had a list of residents who were ordered to have weekly weights and confirmed R26 was not on the list. RN4 stated that the RD completed reviews for residents' nutritional status, then made recommendations which went to the physician for review and were implemented if ordered by the physician. She was not aware the RD had made a recommendation to complete weekly weights for R26 or that there was a physician order to provide an Ensure Plus for a meal intake of 50% or less. During an interview on 10/13/2021 at 1:26 PM, R26's physician reported she sometimes received emails from the RD following her review and sometimes did not. The physician stated she may have overlooked the RD's recommendation to conduct weekly weights for R26. The physician said weight monitoring and documentation issues had worsened after the facility's new electronic medical record had been implemented in July 2021. She explained the new system caused difficulty for nurses to view PRN (as needed) orders, such as providing an Ensure if the resident consumed 50% or less of a meal. R26's physician confirmed it was the facility staff's responsibility to complete physician orders. Review of the facility policy titled, Weight Policy, with an effective/revised date of 11/20, revealed, Weights are taken by one designated staff member .When weighing the resident, a resident who has a 5 pound or more weight change is re-weighed to ensure accuracy. Re-weight is completed within 24 hours .Any significant weight change (gain or loss) will be reported to the MD/NP [Medical Doctor/Nurse Practitioner], nutritionalist, and family by the appropriate designee on the unit or charge nurse. Review of the facility policy titled, Nutritional Care Policy, with a review date of 05/21 revealed it did not address the need to follow physician-prescribed orders for nutritional supplements.

Based on review of facility policy, record review, and interviews, the facility failed to ensure an assistive device was implemented to prevent injury for one (Resident (R)12) of three residents reviewed for falls out of a sample of eighteen residents. R12, who had a history of previous falls and orders for hip protectors, sustained a fall that resulted in a right hip fracture after the facility failed to provide this assistive device designed to prevent injury. Findings include: Review of the facility's policy, titled Fall Prevention & Management Program, reviewed 06/20, revealed the purpose was to provide guidelines for falls and repeat fall preventive intervention. Review of the policy revealed that for all residents, Individualize equipment specific to resident's needs. Review of R12's hard-copy medical record included a Face Sheet, which indicated R12 had diagnoses including Alzheimer's disease, dementia, spondylosis, [CONDITION(S)] and lack of coordination. R12's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/21 revealed the resident was severely cognitively (SC) impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15. Per this MDS, R12 was independent in ambulation. Review of Physician Orders dated 06/01/21- 06/30/21, in R12's medical record under the Physician Orders tab, revealed that since at least 05/26/21 when all orders were reviewed, the resident had an order for protective/adaptive device: wear hipsters while out of bed [OOB]. Review of the Care Plan Report provided by the facility, with a goal date of 10/13/21 revealed the resident had a history of falls including, but not limited to 03/23/19, and 03/23/21. The Care Plan revealed Falls were listed as a problem, noting the resident was at risk for falls r/t [related to] dementia with [CONDITION(S)], taking [MEDICATION(S)] for sleep, BIMS of 03 (SC), sun downing and wandering behavior. Review of the interventions listed on the care plan revealed that they included, Please have resident wear hipsters while OOB per MD [physician] order. Per this care plan, R12 used a rollator for mobility. Review of Nursing Progress Notes dated 06/14/21 at 3:13 PM, in the medical record under the Progress Notes tab, revealed R12 was found on the floor outside his room. The resident had gone outside his room without his walker. He complained of leg pain and pointed to his right upper thigh. He had external rotation of the right foot and was only moving his toes; he did not want to move his leg. The physician and family were notified, and the resident was sent to the emergency room . Review of an investigation folder provided by the facility, titled STONE PAVILION INCIDENT REPORT, dated 06/14/21, revealed R12's accident was an unwitnessed fall. Review of an Orthopedic Surgery Consult Note dated 06/14/21 revealed the fall resulted in a right intertrochanteric (hip) fracture which required surgical repair. Review of a statement in the investigation report by a former facility employee revealed, I heard resident yelling he was hurting and for someone to help him. I assisted resident to his feet with another co-worker, then we lower him back to the floor. We call for assistance. Review of the fall investigation revealed that the investigation form included a section listing various interventions/devices, and measures that could be in place at the time of the fall. The instructions on the form stated staff should check the form if the listed device was in place. The instructions further noted that staff were to check a different column if the device was ordered but was not in use at the time of the fall. Review of both columns revealed that hipsters were included on the list as one of the devices whose presence was to be assessed. However, there were no check marks in either column or evidence anywhere throughout the investigation that the hipsters were in place per the physician's order. An interview with the Director of Nursing (DON) on 10/13/21 at 5:07 PM revealed that none of the staff involved in R12's fracture on 06/14/21 were available for interview. The DON revealed that if the form was not checked to show that an intervention (i.e. hipsters) was in place, it meant that the device/intervention was not in use at the time of the fall. In addition, further interview with the DON revealed that staff should not have picked the resident up off the floor prior to an assessment of the resident, explaining that this against what we do. The DON stated that the resident's injury could be worsened by getting the resident up prior to assessment. An interview was conducted on 10/13/21 at 6:04 PM with the physician who immediately responded to R12's fall/injury. The physician confirmed that R12 was not wearing the protective device (hipsters) at the time of the fall. Further interview with the physician revealed that she initially was unaware that staff had assisted the resident up from the floor prior to assessment, as the resident was still on the floor when the doctor got there. The physician added she later learned that the resident was gotten up prior to assessment, and confirmed that this should not have occurred, as it could have caused more pain or displacement.

Based on record review, interview and review of facility files, the facility failed to ensure each resident received adequate supervision to prevent accidents. Resident #1, at risk for falls, was left unattended sitting on the side of an elevated bed and fell off the bed (1 of 4 resident review for falls). The findings included: Review of the facility Accident/Incident Report dated 06/26/2016 at 6:30 AM documented Resident #1 was observed on the floor in his/her room between the beds lying on his/her right side. S/he had a 8.0 x 7.0 centimeter raised area on the right side of his/her forehead. The physician was notified. The resident was assessed and denied pain, s/he stated, I had the urinal, I don't know what happened. Review of Resident #1's medical record indicated his/her [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] coded the resident as having clear speech, understood and understands. S/he was coded as having a BIMS (brief interview of mental status) of 13. S/he required extensive to total dependence of 1 except transfer, which required 2 persons assist. Review of the Quarterly MDS dated [DATE] coded the Resident with a BIMS of 15. Review of Resident #1's medical record revealed a Nurse's Progress Notes dated 06/26/2015 at 7:00 AM that stated, Reported by LPN (Licensed Practical Nurse) #1, resident on the floor, at bedside. Observed resident on floor at bedside on his/her right side. Resident alert and verbal, s/he denies pain . Observed on floor at 6:30 AM, bedside, on his/her (R) (right) side. Has raised red area 8.0 x 7.0 cm (centimeters), skin intact. Pupil size equal bilat (bilateral) . Head injury protocol initiated, doctor notified . When asked what happened, resident stated, 'I had the urinal, but I don't know what I was doing'. Further review of the Nurse's Notes revealed the resident continued to be assessed and on 06/28/2015 at 3:05 PM s/he complained of pain on the right side with problems breathing. The physician gave an order to send the resident to the emergency room . Review of the emergency room report dated 06/28/2015 stated, .Resident fell out of bed 6/26/15 - c/o (complains) now that his/her (R) (right) side hurts when breathing . Assessment: (1) R 5th rib fx (fracture) . (2) UTI (urinary tract infection) . Recommendations and instructions: Rx (prescription) Tramadol 50 mg (milligrams) tid (three times a day) prn (as needed) pain; stay active as possible; repeat UA (urinalysis) in 10-14 d (days) . Review of the Radiology Report dated 06/28/2015 at 5:17 PM stated, .Bones and soft tissues: right posterior lateral fifth nondisplaced rib fracture . Review of the physician's orders [REDACTED]. 1 tab po 3 times /day x 10 d pain; 3) Tylenol 325 mg 2 tab po q 4 h prn pain x 10 d . Review of the Care Plan updated 05/26/2015 identified the risk for falls as of 02/18/2015 with approaches that included: 2 staff and use of mechanical lift for all transfers ., ensure urinal is always beside him or within reach, remind him of where it is placed, essential bed and chair alarm, hi/lo bed, keep in lowest position . In an interview with the surveyor on 08/26/2015 at 6:45 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor what time the incident happened? S/he stated there should be a note in the chart. S/he referred to the chart and stated that Licensed Practical Nurse (LPN) #1 had written the note and in the note it was 6:30 AM on 06/26/2015. CNA #1 stated, I woke him/her up, bathed and dressed him/her. S/he asked for the urinal, the bed was raised from bathing him/her. I turned around, walked to the door to give him/her privacy. Another resident was in the hall and yelled for help with wheelchair, I went to help. The nurse was passing meds (medications) right at his/her door, s/he went in. I went in behind her/him and we saw that s/he had fallen. S/he said s/he was alright, s/he told her/him what happened, we got him/her back in bed. CNA #1 was asked to walk to the unit and show the surveyor how the incident happened. CNA #1 placed a wheelchair approximately 3 feet from the door to indicate where the resident who yelled for help was positioned. S/he also indicated that the bed was approximately 2 feet off the floor when Resident #1 fell . S/he indicated that LPN #1 was at the next room with the med cart, approximately 1 foot from the Resident #1's door. CNA #1 stated s/he knew the bed should have been in the lowest position. During the interview CNA #1 stated that Resident #1 could hold the urinal and put it on the bedside table.

Based on observation, record review and interview, the facility failed to implement a care plan for falls for Resident # 1 (1 of 4 sampled residents reviewed for falls and implementation of the plan of care). Cross refer to F323 as it relates to the failure of the facility to provide adequate supervision to prevent potentially serious harm and or injury. The findings included: Review of the facility Accident/Incident Report dated 06/26/2016 at 6:30 AM documented Resident #1 was observed on the floor in his/her room between the beds lying on his/her right side. S/he had a 8.0 x 7.0 centimeter raised area on the right side of his/her forehead. The physician was notified. Review of Resident #1's medical record indicated his/her [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] coded the resident as having clear speech, understood and understands. S/he was coded as having a BIMS (brief interview of mental status) of 13. S/he required extensive to total dependence of 1 except transfer, which required 2 persons assist. Review of the Quarterly MDS dated [DATE] coded the Resident with a BIMS of 15. Review of Resident #1's medical record revealed a Nurse's Progress Notes dated 06/26/2015 at 7:00 AM that stated, Reported by LPN (Licensed Practical Nurse) #1, resident on the floor, at bedside. Observed resident on floor at bedside on his/her right side. Resident alert and verbal, s/he denies pain . Observed on floor at 6:30 AM, bedside, on his/her (R) (right) side. Has raised red area 8.0 x 7.0 cm (centimeters), skin intact. Pupil size equal bilat (bilateral) . Head injury protocol initiated, doctor notified . When asked what happened, resident stated, 'I had the urinal, but I don't know what I was doing'. Further review of the Nurse's Notes revealed the resident continued to be assessed and on 06/28/2015 at 3:05 PM s/he complained of pain on the right side with problems breathing. The physician gave an order to send the resident to the emergency room . Review of the emergency room report dated 06/28/2015 stated, .Resident fell out of bed 6/26/15 - c/o (complains) now that his/her (R) (right) side hurts when breathing . Assessment: (1) R (right) 5th rib fx (fracture) . (2) UTI (urinary tract infection) . Recommendations and instructions: Rx (prescription) [MEDICATION NAME] 50 mg (milligrams) tid (three times a day) prn (as needed) pain; stay active as possible; repeat UA (urinalysis) in 10-14 d (days) . Review of the Care Plan updated 05/26/2015 identified the risk for falls as of 02/18/2015 with approaches that included: . hi/lo bed, keep in lowest position . In an interview with the surveyor on 08/26/2015 at 6:45 AM Certified Nurse Aide (CNA) #1 stated s/he knew the bed should have been in the lowest position.

On the days of the complaint inspection, based on observations, record review and interviews the facility failed to ensure that Resident #1's environment remains as free of accident hazards as possible. Resident #1 injured on 11/08/2010 when a Certified Nurse Aide (CNA) bathed him alone, was care planned to have two people with bathing. The review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. Following the injury the care plan was updated on 11/09/2010 to include padded edges to the nightstand and closet, observation on 11/17/2010 revealed no padded edges. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." On 11/09/2010 the care plan was updated with an intervention to include "Pad night stand and closet." Review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around "to grab things" while providing care. CNA #1 stated, "I turned away for a few seconds and the resident rolled out of bed. CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/30/2010 CNA #1 stated that she was not aware that two people were needed when providing care. She stated that she used the Nursing Guide to Care sheet, which did not address how many people were needed to provide care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA providing care for the resident at the time of the incident. RN #1 stated he was not aware that the resident was a two-person assist. An observation on 11/17/2010 at 10:00 AM revealed the closet edges were not padded as ordered; at 10:40 AM the Director of Nurses confirmed that the closet edges were not padded appropriately.

On the days of the complaint inspection, based on record review and interviews the facility failed to ensure that care plans were followed for 1 of 5 sampled residents reviewed. Resident #1 care planned as a total assist with two care givers with bathing, dressing and grooming, was injured on 11/08/2010 when Certified Nurse Aide #1 provided care unassisted. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around "to grab things" while providing care. CNA #1 stated, "I turned away for a few seconds and the resident rolled out of bed." CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA providing care for the resident at the time of the incident.