Every finding on record at Camellia Gardens Center for Nursing and Rehab

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours for Federal Fiscal Year (FY) 2025 Quarter 2 (January through March 2025), Quarter 3 (April through June 2025), and Quarter 4 (July through September 2025). This was for 3 of 3 quarter's reviewed for sufficient nurse staffing. Findings included:a. The PBJ report for FY 2025 revealed for Quarter 2 (January 1 through March 31, 2025) there were no RN hours on the following dates: 2/16/25, 3/15/25, and 3/16/25The daily staff schedules conflicted with the PBJ information. The schedules indicated there was an RN scheduled for at least 8 hours per day on the following dates: 2/16/25, 3/15/25, and 3/16/25 b. The PBJ report for FY 2025 revealed for Quarter 3 (April 1 through June 30, 2025) there were no RN hours on the following dates: 4/5/25, 4/6/25, 4/12/25, 4/13/25, 4/19/25, 4/20/25, 4/26/25, 4/27/25, 5/3/25, 5/10/25, 5/11/25, 5/17/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 6/1/25, 6/8/25, 6/12/25, 6/15/25, 6/22/25, 6/23/25, 6/28/25, 6/29/25, and 6/30/25. The daily staff schedules conflicted with the PBJ information. The schedules indicated there was an RN scheduled for at least 8 hours per day on the following dates: 4/5/25, 4/6/25, 4/12/25, 4/13/25, 4/19/25, 4/20/25, 4/26/25, 4/27/25, 5/3/25, 5/10/25, 5/11/25, 5/17/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 6/1/25, 6/8/25, 6/12/25, 6/15/25, 6/22/25, 6/23/25, 6/28/25, 6/29/25, and 6/30/25. c. The PBJ report for FY 2025 revealed for Quarter 4 (July 1 through September 30, 2025) there were no RN hours on the following dates: 7/5/26, 7/6/25, 7/12/25, 7/13/25, 7/19/25, 7/20/25, 7/26/25, 7/27/25, 8/2/25, 8/3/25, 8/9/25, 8/10/25, 8/16/25, 8/17/25, 9/3/25, 9/6/25, 9/7/25, 9/13/25, and 9/14/25. The daily staff schedules conflicted with the PBJ information. The scheduled indicated there was an RN scheduled for at least 8 hours per day on the following dates: 7/5/25, 7/6/25, 7/12/25, 7/13/25, 7/19/25, 7/20/25, 7/26/25, 7/27/25, 8/2/25, 8/3/25, 8/9/25, 8/10/25, 8/16/25, 8/17/25, 9/3/25, 9/6/25, 9/7/25, 9/13/25, and 9/14/25. During an interview on 1/30/26 at 10:26 a.m. the Regional Nurse Consultant revealed that the dates identified with no RN hours on the PBJ reports for FY 2025 Quarter 2, Quarter 3, and Quarter 4 were inaccurate. She stated on each of the dates identified with no RN hours the facility had RN coverage for a minimum of 8 consecutive hours per day. She explained that she and the Minimum Data Set (MDS) Nurse, who was an RN, both worked shifts to ensure the requirement for RN coverage was met. She explained that since she and the MDS Nurse were both salary employees, they did not clock in or out, so their hours did not show on timecards. She stated the corporate office had to manually adjust and input any hours for salary nursing staff who worked to cover shifts. In an interview on 1/30/26 at 2:14 p.m. the Administrator explained that the corporate office was not always consistent with the process of manually adjusting and inputting nursing staff hours for payroll data to accurately reflect nursing staff hours on the PBJ reports submitted to CMS. She further explained that this was why the PBJ reports for FY 2025 Quarter 2, Quarter 3, and Quarter 4 had multiple dates with inaccurate data for RN hours. She revealed the problem had now been resolved in the first quarter of 2026. The Administrator stated that when she noticed the discrepancy in September 2025, she notified the Regional Business Office Manager and the error was fixed. Telephone calls to the Regional Business Office Manager on 2/29/26 at 2:23 p.m. and on 2/30/26 at 11:04 a.m. went unanswered and a return call was not received.

Based on record review, and resident and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccination for 5 of 5 residents reviewed for immunizations (Resident #8, Resident #5, Resident #2, Resident #32, and Resident #44) and failed to maintain documentation related to staff COVID-19 vaccination status.The findings included:The facility's policy titled Infection Prevention and Control Program last reviewed 1/01/26 indicated that the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy further noted that the Infection Preventionist (IP) was responsible for the oversight of the program. The facility policy titled COVID-19 Vaccination implemented on 3/01/23 indicated that it was the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering our residents and staff the COVID-19 vaccine. The policy further noted that the facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of such. 1a. Resident #8 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic kidney disease, and chronic obstructive pulmonary disease (COPD).The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment and was coded as not up to date on the COVID-19 vaccination.Resident #8's immunization record revealed that the resident received the COVID-19 vaccination at the facility on 8/06/24. There was no documentation that the resident had been offered, given, or refused additional doses of the COVID-19 vaccination. An interview was conducted with the Unit Manager on 1/30/26 at 10:26 am who revealed she was unable to provide any documentation regarding COVID-19 vaccination status for Resident #8.b. Resident #5 was admitted to the facility on [DATE] with diagnoses which included diabetes and chronic obstructive pulmonary disease (COPD).The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact and was coded as not up to date on the COVID-19 vaccination. Resident #5's immunization record revealed Resident #5 last refused the COVID-19 vaccination on 12/13/23. There was no documentation that Resident #5 had been offered, given, or refused any additional doses of the COVID-19 vaccination.An interview was conducted with the Unit Manager on 1/30/26 at 10:26 am who revealed she was unable to provide any documentation regarding COVID-19 vaccination status for Resident #5.c. Resident #2 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic kidney disease, and vascular dementia.The Minimum Data Set (MDS) quarterly assessment revealed Resident #2 had severe cognitive impairment and was coded as not up to date on the COVID-19 vaccination. Resident #2's immunization record revealed the resident last refused the COVID-19 vaccination in 2023. There was no documentation that the resident had been offered, given, or refused additional doses of the COVID-19 vaccination.An interview was conducted with the Unit Manager on 1/30/26 at 10:26 am who revealed she was unable to provide any documentation regarding COVID-19 vaccination status for Resident #2.d. Resident #32 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), and hypertension.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #32 was cognitively intact and was coded as not up to date on the COVID-19 vaccination. Resident #32's immunization record revealed no documentation that the resident had been offered, given, or refused the COVID-19 vaccination.An interview was conducted with the Unit Manager on 1/30/26 at 10:26 am who revealed she was unable to provide any documentation regarding COVID-19 vaccination status for Resident #32.An interview was conducted with Resident #32 on 1/30/26 at 4:20 pm who revealed she was unable to recall if the COVID-19 vaccine had been offered to her. e. Resident #44 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic kidney disease, and obstructive sleep apnea (OSA).The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #44 was cognitively intact and was coded as not up to date on the COVID-19 vaccination. Resident #44's immunization record revealed no documentation that the resident had been offered, given, or refused the COVID-19 vaccination.Resident #44 was interviewed on 1/30/26 at 4:24 pm. Resident #44 revealed he was not sure if he had been offered the COVID-19 vaccination this past year.An interview was conducted with the Unit Manager on 1/30/26 at 10:26 am who revealed she was unable to provide any documentation regarding COVID-19 vaccination status for Resident #44.An interview was conducted with the Infection Preventionist (IP) on 1/30/26 at 10:21 am who revealed she had been the facility's IP for approximately one and a half years. The IP stated she had offered the COVID-19 vaccination to residents, but she stated no residents had wanted to have the vaccine since she had been the IP at the facility. The IP stated she was unable to locate any documentation that she had offered COVID-19 vaccinations to the residents and she was unable to recall if she had any residents sign the declination form. During an interview on 1/30/26 at 1:00 pm with the Director of Nursing (DON) she revealed she had been at the facility for approximately four months, and she had not focused on the COVID-19 vaccinations for residents since taking the position. The DON confirmed that the facility had not offered the COVID-19 vaccination to residents since she had been employed at the facility and the facility was unable to locate any documentation that the residents were offered the vaccine in 2025. An interview with the Administrator was conducted on 1/30/26 at 10:54 am who revealed the DON was ultimately responsible for the oversight of the resident COVID-19 vaccinations because the IP reported to the DON. The Administrator stated the IP was responsible for offering, administering, and documentation of resident COVID-19 vaccinations. The Administrator stated she was not sure why the COVID-19 vaccinations would not have been offered to residents because she was told by the IP that the vaccinations were offered. 2. The facility was unable to provide documentation of COVID-19 vaccination status for staff. During an interview on 1/30/26 at 11:57 am with Nurse Aide #1 she revealed she did not recall the facility offering information on the COVID-19 vaccination or giving the vaccine to staff during the last year. An interview was conducted with the Infection Preventionist (IP) on 1/30/26 at 10:21 am who revealed she had been the facility's IP for approximately one and a half years. The IP stated that she was not responsible for maintaining the staff COVID-19 vaccination status records. The IP stated she was not sure who was responsible for tracking staff COVID-19 vaccinations, but she stated she believed that department managers were responsible for their respective staff. During an interview on 1/30/26 at 1:00 pm with the Director of Nursing (DON) who revealed she had not managed the staff COVID-19 vaccination status logs at the facility, and she was not sure who was responsible to do so. The DON stated the facility offered the COVID-19 vaccine for staff, but she was not sure who received the vaccine and who kept the records. The Administrator was interviewed on 1/30/26 at 10:54 am. The Administrator revealed that she and the nursing management team, which included the IP, Unit Manager, and DON were working together to track the COVID-19 vaccinations. The Administrator stated the information was forwarded via email as the vaccinations were provided to the corporate office and she would try to obtain the information. The Administrator was unable to provide any further documentation regarding the staff COVID-19 vaccination status.

Based on record review, observation, and staff interviews, the facility failed to date a multi-dose vial of medication when opened in 1 of 2 medication storage refrigerators reviewed for medication storage (Nurse's Station #1 medication room). The findings included: On [DATE] at 2:57 p.m., an observation was completed of the medication storage room with the Director of Nursing (DON). The observation revealed one multi-dose vial of opened Tuberculin Purified Diluted solution (used in a skin test to help diagnose tuberculosis) without an opened date written on the vial, located in the medication refrigerator. A review of the manufacturer's instruction label on the bottle indicated the medication should be discarded 30 days from the date medication was opened. An interview was completed on [DATE] at 3:18 p.m. with the DON. She indicated it was the Unit Manager's responsibility to check the medication room for expired or undated opened medications. The DON stated the undated medication should have been discarded or returned to the pharmacy. An interview was completed on [DATE] at 3:24 p.m. with the Unit Manager. The Unit Manager stated she, along with the staff nurses check the medication room for expired and undated opened medications. The Unit Manager stated she was unaware of why the vial was not dated when opened by the nursing staff member. The Unit Manager was unable to recall when she last checked the medication room and medication room refrigerator for expired or undated medications. An interview was completed on [DATE] at 2:08 p.m. with the Administrator. She stated all multi-dose medication vials should be dated when they are opened.

Based on record reviews, and staff, resident and Resident Representative (RR) interviews, the facility failed to notify the resident and Resident Representative in writing of the reason for the transfer/discharge to the hospital and/or failed to provide a copy of the bed hold policy to the resident or Resident Representative. This affected 3 of 3 residents reviewed for transfer to the hospital (Resident #1, Resident #60 and Resident #34). The findings included:1. Resident #1 was admitted to the facility on [DATE].The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact.Review of Resident #1's face sheet revealed she was her own RR.a. The nursing progress note dated 2/15/25 revealed Resident #1 was sent to the hospital.The medical record indicated Resident #1 was transferred to the hospital on 2/15/25 and returned to the facility on 2/20/25. The medical record was reviewed, and there was no documentation that Resident #1 received written notification of the reason for her transfer/discharge to the hospital or a copy of the bed hold policy.b. The nursing progress note dated 10/27/25 revealed Resident #1 was sent to the hospital.The medical record indicated Resident #1 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The medical record was reviewed and there was no documentation that Resident #1 received written notification of the reason for her transfer/discharge to the hospital. Resident #1 did receive the bed hold policy for the 10/27/25 hospital transfer.An interview was conducted with Resident #1 on 1/30/26 at 4:00 PM. Resident #1 confirmed that she was her own Resident Representative. Resident #1 stated she had not received a written notification of the bed hold policy or the transfer/discharge notice when she was transferred to the hospital. An interview was conducted with the Social Worker on 1/30/26 at 3:50 PM who revealed the Business Office Manager was responsible for providing residents and the RR with copies of the bed hold policy when a resident was transferred to the hospital. The Social Worker further stated that she was not aware that she was to notify the resident and resident RR in writing of transfer/discharge to the hospital. An interview was conducted with the Business Office Manager on 1/30/26 at 4:00 PM. The Business Office Manager stated that she had access to the electronic medical record remotely and followed up with the resident or Resident Representative within 24 hours of the resident being transferred to the hospital about the bed hold policy. The Business Office Manager stated a handwritten copy of the bed hold policy was sent to the resident or RR the next day after the resident was transferred to the hospital. The Business Office Manager stated she was not sure what happened with the bed hold policy for Resident #1. The Business Office Manager confirmed she could not locate evidence she had provided the bed hold policy for either of Resident #1's transfers to the hospital. The Business Office Manager stated she was not responsible for the written notification of transfer/discharge. She stated the Social Worker was responsible for written notification.During an interview with the Administrator on 1/30/26 at 4:28 PM, she stated the Social Worker was responsible for notifying the resident and Resident Representative in writing of transfer/discharge to the hospital. The Administrator further stated the Business Office Manager was responsible for making sure the bed hold policy was completed and mailed to the Resident Representative. The Administrator was unable to provide an explanation as to why the bed hold policy or the transfer/discharge notice had not been sent for Resident #1.2. Resident #60 was admitted to the facility on [DATE].The quarterly MDS assessment dated [DATE] revealed Resident #1 could not complete the Brief Interview for Mental Status (BIMS) and was determined to have moderately impaired cognitive skills for daily decision-making. The nursing progress note dated 1/3/26 revealed Resident #60 was transferred to the hospital.The medical record indicated Resident #60 was transferred to the hospital on 1/3/26 and returned to the facility on 1/13/26. The medical record was reviewed and there was no documentation that Resident # 60 or the RR received written notification of the reason for her transfer/discharge to the hospital or a copy of the bed hold policy.An interview was conducted with Resident #60's RR on 1/30/26 at 2:34 PM. The RR stated she had not received written notification of transfer/discharge or a copy of the bed hold policy when Resident #60 went to the hospital.An interview was conducted with the Social Worker on 1/30/26 at 3:50 PM who revealed the Business Office Manager was responsible for providing residents and the RR with copies of the bed hold policy when a resident was transferred to the hospital. The Social Worker further stated that she was not aware that she was to notify the resident and resident RR in writing of transfer/discharge to the hospital. An interview was conducted with the Business Office Manager on 1/30/26 at 4:00 PM. The Business Office Manager stated that she had access to the electronic medical record remotely and followed up with the resident or resident's RR within 24 hours of the resident being transferred to the hospital about the bed hold policy. The Business Office Manager stated a handwritten copy of the bed hold policy was sent to the resident or RR the next day after the resident was transferred to the hospital. The Business Office Manager stated she was not sure what happened with the bed hold policy for Resident #60. The Business Office Manager confirmed she could not locate evidence she had provided the bed hold policy for Resident #60's transfer to the hospital. The Business Office Manager stated she was not responsible for the written notification of transfer/discharge. She stated the Social Worker was responsible for written notification.During an interview with the Administrator on 1/30/26 at 4:28 PM, she stated the Social Worker was responsible for notifying the resident and Resident Representative in writing of transfer/discharge to the hospital. The Administrator further stated the Business Office Manager was responsible for making sure the bed hold policy was completed and mailed to the Resident Representative. The Administrator was unable to provide an explanation as to why the bed hold policy nor the transfer/discharge notice had not been sent for Resident #60.3. Resident #34 was admitted to the facility on [DATE].The quarterly MDS dated [DATE] revealed Resident #34 was cognitively intact.The medical record indicated Resident #34 was transferred to the hospital on 1/8/26. The medical record was reviewed and there was no documentation that Resident #34 or the RR received a copy of the bed hold policy. An interview was conducted with Resident #34's Representative on 1/30/26 at 8:52 AM. The RR stated she had not received a copy of the bed hold policy when Resident #34 was transferred to the hospital on 1/8/26. The RR stated she had coordinated Resident #34's surgery date with the Director of Nursing and knew that Resident #34 would be returning to the facility to the same bed afterwards. During the interview, Resident #34's RR stated she did receive written notification of the resident's transfer to the hospital.An interview was conducted with the Director of Nursing (DON) on 1/30/26 at 10:06 AM. The DON stated that the week that Resident #34 was transferred to the hospital the Business Office Manager was out of the office and the DON tried to help. The DON stated that she had communicated with the Resident Representative about Resident #34's upcoming surgery by email but she did not email the bed hold policy to Resident #34's Representative. The DON indicated she was not aware that the bed hold policy needed to be mailed to the RR. An interview was conducted with the Administrator on 01/30/2026 at 1:51 PM. The Administrator stated that the Business Office Manager was responsible for making sure the bed hold policy was completed and mailed to the Residents' Representative. The Administrator was unable to explain what happened with the bed hold policy since the Business Office Manager was out or why the bed hold form was not mailed to the RR.

Based on observation, record review, and interviews with resident, Medical Director, and staff, the facility failed to provide effective supervision to Resident #1, who was deemed unsafe to smoke without supervision and had known non-compliance with the smoking policy, to prevent the resident from smoking while utilizing his portable oxygen tank. On 10/20/25, 10/21/25, and 11/6/25 Resident #1 exited the facility independently and was seen by staff smoking in undesignated smoking areas with his portable oxygen tank present and in use via nasal cannula. The oxygen tank was removed by staff and no harm was caused to the resident on these dates. On 11/10/25 Resident #1 again exited the facility independently and was seen by staff smoking in an undesignated smoking area with his portable oxygen tank present and in use via nasal cannula while Resident #2 was present in the area. Resident #1 stated he lit his cigarette, it flamed up, and he dropped the cigarette and oxygen tubing with nasal cannula onto the ground to stomp out the flame with his foot. Dietary Aide #1 walked by and saw Resident #1's shirt catch fire, she informed the resident, and he took his shirt off to extinguish the flame. Resident #1 was sent to the Emergency Department (ED) for evaluation and identified to have sustained a flash burn (occurs when a lit cigarette ignites the oxygen-saturated air around a person using supplemental oxygen, causing a rapid, intense fire on the face and nose) resulting in singed nose hair in both nostrils and a burn to the upper left lip with the dermis (the inner of the two main layers of skin containing connective tissue, blood vessels, oil and sweat glands, nerves, hair follicles, and other structures) exposed. Supplemental oxygen devices produce enriched oxygen which accelerates combustion; smoking near oxygen devices is a fire hazard and has a high likelihood of resulting in serious harm to all persons nearby from fire and/or an explosion. Additionally, the facility failed have an effective system in place to ensure: the smoking policy was followed; interventions were developed and/or implemented to address unsafe smoking practices; residents with known non-compliance with the smoking policy were monitored to prevent non-compliance from continuing; and supervision was provided for residents who were assessed as unsafe smokers. This deficient practice affected 5 of 5 residents (Residents #1, #2, #5, #4, and #3) reviewed for smoking. Immediate jeopardy began on 10/21/25 when the facility failed to implement effective interventions to prevent a repeat incident of Resident #1 smoking with his portable oxygen tank in use. Immediate jeopardy was removed on 11/14/25 when the facility implemented a credible allegation of immediate jeopardy removal. Example #2 was cited at scope and severity of E. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place, to complete employee in-service training, and to correct deficient practice for Example #2.The findings included:The facility's smoking policy last revised 10/22/24 indicated the following: Smoking was prohibited in all areas except the designated smoking area and safety measures for the designated smoking area included the prohibition of oxygen use. All residents were asked about tobacco use during the admission process and during each quarterly or comprehensive minimum data set (MDS) assessment process. Residents who smoked would be assessed using the Resident Safe Smoking Assessment to determine if resident is safe to smoke at all. Any resident who is deemed safe to smoke, will be allowed to smoke in designated smoking area and in accordance with his/her care plan and all safe smoking measures will be documented on each resident. If a resident did not abide by the smoking policy or care plan, the plan of care may be revised to include additional measures such as prohibited smoking, or even discharge. Smoking materials for residents who smoke were to be maintained by nursing staff. On 11/12/25 at 1:18 PM, an observation was conducted of the designated smoking area that was located to the left of the front entrance to the building. The designated smoking area had a canopy and included ash trays, smoking receptacles, fire blankets, fire extinguisher and fireproof waste bins. 1. Review of the user's manual intended use for Resident #1's portable oxygen tank revealed the portable oxygen tank supplied a high concentration of oxygen and is used with a nasal cannula to deliver oxygen from the oxygen cylinder to the patient. General precautions included a warning which stated this device produces enriched oxygen gas which may cause or intensify fire if it comes in contact with combustible materials, open flames, or sparks and contains gas under pressure that can explode if heated. Smoking and any open flames are strictly forbidden within 5 feet of the cylinder while oxygen therapy is in use.Resident #1 was admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Resident #1's Smoking Screening's dated 10/11/24 and 12/19/24 indicated he was not a smoker. A physician order dated 12/19/24 revealed an order for continuous oxygen therapy at 3 liters per minute (lpm) via nasal cannula every shift every day. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact, required supervision with 1-person physical assist for bed mobility, transferred independently with setup help only, used a walker for mobility, and was on oxygen therapy.The Safe Smoking assessment dated [DATE] completed by Unit Manager #1 revealed Resident #1 was a smoker and used smokeless tobacco. The resident had no history of smoking related incidents. He smoked 1-2 times a day. Resident #1 did have dexterity problems or tremors. The resident was on supplemental oxygen and could be without supplemental oxygen during smoking times. Resident #1 ambulated independently and required supervision while smoking. Resident #1's care plan initiated 7/10/25 revealed the resident was a supervised smoker and the goal was for Resident #1 to be supervised at all times while smoking. There was no documentation of noncompliance in the care plan. The interventions included staff assisting and supervising resident on smoking times. A Nursing Progress Note completed by Nurse #3 dated 7/12/2025 revealed Resident #1 goes outside to smoke with oxygen tank. Resident is non-compliant. Multiple attempts to contact Nurse #3 for interview were unsuccessful.The record indicated Resident #1 was discharged to the hospital on [DATE] for acute hypoxic respiratory failure due to right lower lobe and left middle lobe pneumonia.Resident #1 was readmitted to the facility on [DATE].A physician's order dated 10/17/25 indicated the previous order for continuous oxygen at 3 lpm was changed to 5 lpm via nasal cannula for respiratory failure. An Admission/readmission Screening for smoking dated 10/17/25 indicated resident was a smoker and on 5 lpm of O2 via nasal cannula.During an interview with Confidential Source #2 on 11/14/25 at 12:11 PM it was stated Resident #1 had been seen by Confidential Source #2 on 10/20/25 and 10/21/25 smoking with his oxygen tank present and oxygen in use via nasal cannula around other residents in non-designated smoking areas. Confidential Source #2 stated he or she removed the oxygen tank from Resident #1 and placed the tank inside the building. Confidential Source #2 stated they had reported these 2 specific incidents with Resident #1 to the Administrator and DON. Confidential Source #2 stated nothing was ever done about residents smoking in unauthorized areas. Confidential Source #2 stated no new interventions were implemented. Confidential Source #2 they did not want the facility to know their identify due to fear of being fired. Resident #1's care plan revised on 10/21/25 revealed the resident was a supervised smoker and the goal was for Resident #1 to be always supervised during smoking times. The interventions included staff to assist Resident #1 outside at smoking times and to remove oxygen prior to entering the designated smoking area. There was no documentation about noncompliance included in the care plan. During an interview with Nurse #1 on 11/12/25 at 1:10 PM, she stated the facility had scheduled times for residents who required supervision to smoke. Nurse #1 indicated that assigned staff went outside with the supervised residents who smoked. She further stated that the residents that didn't require supervision were able to go out anytime as long as the residents let the staff know. Nurse #1 stated cigarettes were kept in the medication room in a lock box and the nurse gave the residents 1 cigarette at a time for the unsupervised residents. Nurse #1 indicated residents were only to smoke in the designated smoking area at the side of the building. Nurse #1 stated she was familiar with Resident #1 and he was a smoker. Nurse #1 stated Resident #1 was not a smoker when he was admitted in 2021. She stated Resident #1 used to smoke but had quit. Nurse #1 stated that after 3 years Resident #1 picked up smoking again. She explained that she had been informed by other staff that Resident #1 began smoking again after the death of a loved one. Nurse #1 stated Resident #1 had been assessed for smoking on 6/20/25 and determined to require supervision. Nurse #1 stated an intervention of removing oxygen prior to entering designated smoking area was added to Resident #1's care plan on 10/21/25 because he kept taking his oxygen tank outside when he went to smoke. She explained she heard about staff having to remind Resident #1 to leave his oxygen inside when going to smoke about five times between July 2025 to October 2025. She was unable to recall who these staff were. She further explained she had redirected Resident #1 to leave his oxygen tank inside once in October 2025 when she saw him coming to the backdoor as she was entering at that door to begin her shift. Nurse #1 stated this back door exit did not lead to the designated smoking area. Nurse #1 explained that Resident #1 had a cigarette that was not lit in his hand and was pulling his oxygen tank in his oxygen tank holder. Nurse #1 stated she removed the resident's nasal cannula and oxygen tank and placed the tank inside the building. Nurse #1 stated she retrieved the cigarette from Resident #1 and he did not go out to smoke at that time to her knowledge. Nurse #1 stated she had only witnessed the resident attempting to go outside with a cigarette and oxygen that single time. Nurse #1 indicated an intervention was added to the resident's care plan to remove his oxygen prior to entering the designated smoking area. Nurse #1 stated she had spoken to Resident #1 about the dangers of smoking with oxygen on multiple occasions and he was dismissive. She reported that she had talked with Resident #1 about how he could set himself on fire, cause an explosion in the building, and how he could cause injury to other residents. Nurse #1 stated she felt the resident understood what she was saying but he showed a lack of concern about it. She further stated Resident #1 tended to slip away at times and smoke without supervision. She indicated since Resident #1 ambulated independently he was able to go outside without being noticed. There was no intervention implemented for increased monitoring of Resident #1 to ensure he was supervised while smoking. Nurse #1 added that Resident #1 was allowed to go outside without supervision and not smoke. The Annual MDS assessment dated [DATE] indicated Resident #1 was cognitively intact. He was able to make himself understood and he understood others. Resident #1 was independent for mobility, transferred independently, used no mobility device and was able to dress independently. Resident #1 currently used tobacco and was coded as receiving oxygen therapy. The record indicated Resident #1 was discharged to the hospital on [DATE] for intractable abdominal pain.Resident #1 was readmitted to the facility on [DATE].Admission/readmission Screening for smoking dated 10/26/25 resident was a smoker and on O2 via nasal cannula. A Safe Smoking assessment dated [DATE] completed by the Director of Nursing (DON) revealed Resident #1 currently smoked and had no smoking related incidents. The screen revealed Resident #1 could not verbalize or demonstrate understanding of the facility's smoking policy, or times and place to smoke. The screen revealed Resident #1 was on supplemental oxygen. Resident #1 required supervision while smoking. An interview was conducted with the DON on 11/13/25 at 12:17 PM. The DON stated she began working at the facility on 9/30/25. The DON stated she was not aware of Resident #1 having any smoking related incidents when she completed the 10/26/25 smoking assessment. The DON stated she had observed Resident #1 on multiple occasions walking around outside in front of the building with his oxygen tank. The DON denied seeing the resident smoking with oxygen. The DON reported no staff had reported that Resident #1 was non-compliant with the smoking policies and/or smoked with his oxygen on. Resident #1's medical record revealed an active physician order dated 10/27/25 for continuous oxygen therapy at 3 liters per minute via nasal cannula every shift every day. Resident #1's medical record revealed a physician order dated 10/27/25 for Nicotine Transdermal Patch 24 hour- Apply 1 patch transdermally (the administration of a medication by absorption through the skin) one time a day for Smoking Cessation and remove per schedule. During an interview with Confidential Source #1 on 11/13/25 at 6:44 PM revealed they (Confidential Source #1) saw Resident #1 smoking outside in an undesignated smoking area with his oxygen in use via nasal cannula on multiple occasions and as recently as on 11/6/25 (unable to recall other specific dates). Confidential Source #1 stated the oxygen tank was removed when Resident #1 was discovered smoking. Confidential Source #1 stated they notified the Administrator on each occasion with the most recent incident being on 11/6/25 that Resident #1 was outside smoking in an undesignated smoking area with oxygen in use via nasal cannula Confidential Source #1 stated the Administrator did not respond when it was reported that Resident #1 was outside smoking with his oxygen in use via nasal cannula. Confidential Source #1 stated they were not aware of any interventions that were implemented to prevent Resident #1 from smoking with oxygen or to monitor the resident. Confidential Source #1 stated they were not aware Resident #1 was a supervised smoker. Confidential Source #1 stated there was supposed to be a list of supervised and unsupervised smokers at the nurses' station. Confidential Source #1 stated they had not seen the smoking list. Confidential Source #1 did not want his/her identity known out of fear of retaliation.During an interview with Resident #1 on 11/12/25 at 12:38 PM, Resident #1 reported about three days ago (11/10/25) he was outside walking with his portable oxygen tank that he was rolling in his oxygen tank carrier cart. Resident #1 stated he walked around the building to the back door to smoke. He indicated another resident (Resident #2) was sitting there as well. Resident #1 revealed he was utilizing his oxygen via nasal cannula. Resident #1 stated when he lit the cigarette on 11/10/25 the cigarette flamed up. Resident #1 reported he dropped the cigarette and the oxygen tubing cannula on the ground. He stated he stomped the flame out from the cigarette with his foot. Resident #1 indicated when he looked down at the ground, he noticed the oxygen tubing cannula was on the ground with sparks coming from the cannula. Resident #1 stated he stomped on the cannula tubing to put out the flame. Resident #1 stated he did not recall whether the oxygen cannula and tubing were burned or melted. Resident #1 reported that Dietary Aide #1 had come out of the building and made him aware that his shirt was on fire. Resident #1 stated when he saw the flames on the center chest area of his shirt, he immediately took the shirt off. Resident #1 reported when he came inside the facility, the nurse looked at him and called the ambulance. Resident #1 denied that he had any pain. He stated he went to the hospital where he was treated for burns to his forehead, mustache and side of his mouth. Resident #1 stated he had gotten the cigarette from a visitor and lit the cigarette from a lit cigarette butt on the ground. Resident #1 stated he was not supposed to have the oxygen tank outside with him while he was smoking. Resident #1 verbalized his knowledge that smoking with oxygen could cause a fire. He reported that staff had educated him on the dangers of what could happen if he smoked with oxygen a few times prior to 11/10/25. Resident #1 stated he knew he was supposed to smoke in the designated smoking area where staff could monitor him while he was smoking. Resident #1 stated the facility had scheduled smoking times, but he snuck outside after 5:00 PM on 11/10/25. Resident #1 stated he had gone out to smoke several times prior to 11/10/25 without staff. Resident #1 indicated he sometimes forgot to take his oxygen off when he went out to smoke. He revealed he smoked while his oxygen was flowing via nasal cannula prior to 11/10/25. During an interview with Dietary Aide #1 on 11/13/25 at 2:21PM, she stated it was time for her to end her shift on 11/10/25 at approximately 7:45 PM when she observed Resident #1 and Resident #2 in the employee parking lot outside of the backdoor of the facility. Dietary Aide #1 stated the backdoor was kept locked and there was an access code. Dietary Aide #1 stated Resident #1 was smoking with his oxygen cannula in his nose when she got outside and Resident #2 was sitting in his wheelchair smoking. Dietary Aide #1 stated she looked at Resident #1 and saw the center of his shirt was on fire. Dietary Aide #1 stated she was shocked and afraid of what could happen. Dietary Aide #1 stated she immediately notified the resident that his shirt was on fire and prompted Resident #1 to put the fire out. Dietary Aide #1 stated Resident #1 removed his shirt and put the fire out. Dietary Aide #1 stated she could not remember if she told Resident #1 to put the cigarette out. Dietary Aide #1 stated there was no fire extinguisher or fire blanket in the location to put the fire out. She reported there was only a red fireproof receptacle by the back door. Dietary Aide #1 stated within seconds of making sure the fire was out, she went immediately inside and asked for help from Medication Aide (MA) #1 and Nurse #2. The Dietary Aide stated as soon as she notified Medication Aide #1 and Nurse #2, they immediately rushed to the resident and tried to get Resident #1 to come inside the building. An observation was conducted of the employee parking lot by the back door exit on 11/13/25 at 12:11 PM. There were no windows near the door to allow visibility from the interior of the building. The back door had a keypad. The employee parking lot was accessible to all by walking around the outside of the building to get to the area. There was a red fireproof receptacle sitting on the ground to the left of the back door and a couple of chairs by the exit. There was no fire extinguisher or fire blanket at this location. An interview was conducted with Resident #2 on 11/13/25 at 12:02 PM. (Resident #2's annual MDS assessment dated [DATE] indicated his cognition was intact.) Resident #2 stated he was outside with Resident #1 smoking in the employee parking lot by the back door of the facility the night of 11/10/25. Resident #2 stated he heard this sizzle and then saw a flash of fire about the same time Dietary Aide #1 came out the back door. Resident #2 stated he was afraid because he thought Resident #1 was on fire. Resident #2 stated Dietary Aide #1 was very nervous and immediately notified Resident #1 that his shirt was on fire. Resident #2 stated Resident #1 jumped up from the chair he was sitting in. Resident #2 stated Resident #1 snatched the nasal cannula from his nose and pulled his shirt over his head, threw it on the ground and began stomping on it to put the fire out. Resident #2 stated Dietary Aide #1 made sure the fire was out and then she ran back into the building to get help. Resident #2 stated Resident #1 put his shirt back on, sat back in the chair at the back door and was laughing about the incident. An interview was conducted with MA #1 on 11/13/25 at 11:13 AM. MA #1 stated she was working on the unit on the night of 11/10/25 when Resident #1 received a burn from smoking with his oxygen on. MA #1 stated Dietary Aide #1 ran in the building and was out of breath, appeared alarmed and shouted she had walked out the back and saw Resident #1's shirt on fire. MA #1 stated she went and notified Nurse #2 and went running out the back door. MA #1 stated when she got outside Resident #1 was sitting in the chair beside the door with his shirt lifted. MA #1 stated she did not see any fire when she got to Resident #1 and couldn't recall if she saw any marks on him at that time. MA #1 further stated Resident #1's oxygen tank was sitting in the wheeled tank holder beside the chair Resident #1 was sitting in. MA #1 stated she could not recall if she saw a cigarette in the resident's hand while he was sitting in the chair. MA #1 stated Resident #2 was sitting in his wheelchair in the employee parking lot by the back door. She could not recall if she had seen a cigarette in Resident #2's hand. MA#1 stated she assisted Resident #1 back to his room so the nurse could assess him because he refused to go to the nurse's station. MA #1stated there was a list of supervised and unsupervised smokers kept at the nurse's station. MA #1 stated Resident #1 was listed as a supervised smoker on the smoking list. MA #1 stated Resident #1 reported he had gone out the front door and walked around the building to the employee parking lot by the back door. MA #1 did not know where Resident #1 had gotten the cigarette from or how he lit it. MA #1 stated Resident #1 was not supposed to be out back smoking. During an interview with Nurse #2 on 11/13/25 at 10:31 AM, she stated she was the nurse on duty on the night of 11/10/25 when Resident #1 received a burn from smoking a cigarette with his oxygen on. Nurse #2 stated MA #1 came and notified her that Resident #1 was smoking and had caught fire. Nurse #2 stated she and MA #1 ran out to where Resident #1 was located and he was sitting in a chair at the back door with another lit cigarette in his hand and Resident #2 was present. Nurse #2 stated she told the resident to put the cigarette out. Nurse #2 stated Resident #1 was not wearing the nasal cannula when she approached him outside the back door. Nurse #2 did not recall where the nasal cannula was at that time. Nurse #2 stated she believed Resident #2 had his shirt on when she went to look at him, but she did not recall seeing a burnt area on his shirt. Nurse #2 stated once the cigarette was put out, she asked MA #1 to assist Resident #1 to the nurse's station so she could assess him in the light. Nurse #2 stated she went looking for Resident #1 because about 10 minutes had passed and he had not made it to the desk. Nurse #2 stated she found Resident #1 in the hallway bathroom located beside his room trying to wash his face. Nurse #2 stated she observed Resident #1's mustache was burnt, the smile lines to both sides of his mouth looked red and fleshy, and his forehead had a burn mark. Nurse #2 stated Resident #1 refused at first to go out to the hospital to have the burns looked at. Nurse #2 stated he became aggressive and yelled at her to get out of the bathroom. Nurse #2 stated she called the Director of Nursing about the incident and was told to notify the on-call physician for an order to send resident out to the hospital for evaluation and treatment. Nurse #2 stated she called Emergency Medical Services (EMS) and Resident #1 continued to refuse to be transported to the hospital. Nurse #2 stated when EMS got to the facility, they were able to speak to Resident #1 about the importance of being checked out and he was transferred to the local hospital. During an interview with Nursing Assistant (NA) #1 on 11/14/25 at 2:01 PM, he stated he was the NA that was assigned to Resident #1 on the night of 11/10/25 when Resident #1 received a burn from smoking a cigarette with his oxygen on. NA #1 stated Resident #1 was independent with activities of daily living. NA #1 stated Resident #1 was ambulatory and walked around the facility independently. NA #1 stated Resident #1 was a smoker, but he was not aware Resident #1 required supervision. NA #1 confirmed Resident #1 wore continuous oxygen via nasal cannula and ambulated around with a portable oxygen tank in a wheeled holder. NA #1 stated when he was assigned to provide supervision to take the residents outside to smoke he would remind Resident #1 not to wear his oxygen outside. NA #1 stated there was a list at the nurse's station of supervised and unsupervised smokers but he did not recall Resident #1 being a supervised smoker. NA #1 further stated Resident #1 was usually in the front of the building when he saw the resident smoking which was not a designated smoking area. NA #1 stated he would redirect the residents to the designated smoking area if he saw any resident smoking in an undesignated area. NA #1 stated he would occasionally see residents at the back door with the employees (dietary staff and housekeeping staff) and he would immediately correct the residents and redirect them to go to the designated smoking area. NA #1 reported that on the night of 11/10/25 when Resident #1 received a burn from smoking with his oxygen on he was called outside by Dietary Aide #1. NA #1 stated when he got outside he observed Resident #1's mustache was singed. He did not notice if Resident #1's shirt was burnt. NA #1 reported Resident #1 was laughing about the incident and thought the situation was funny. NA #1 stated he did not recall seeing Resident #2 in the back on 11/10/25.The Emergency Department Discharge summary dated [DATE] revealed Resident #1 was seen for flash burn. Resident #1 was on 3 liters of oxygen for end stage COPD. Resident #1 was smoking a cigarette while he had oxygen on and experienced a flash burn. He was unable to describe the events. Resident #1 was not in pain and did not have any trouble breathing. Resident #1 had singed nose hair in both nares (nostrils) and a burn to the upper left lip with dermis exposed.A Nursing Progress Note completed by Nurse #3 dated 11/11/25 revealed Resident #1 returned to the facility from the emergency department at 2:03 A.M. via transport. Resident #1 was treated for burns. Resident #1 was assisted to bed and denied any pain at that time. During an interview on 11/12/25 at 1:04 PM with Medication Aide (MA) #2 who was assigned to the resident, she stated Resident #1 was a supervised smoker and he required staff assistance to go out to smoke. MA #2 stated most of the time when she observed Resident #1, he would have the oxygen tank sitting by the door away from him when he was smoking. MA #2 was unable to give an estimate of the distance the oxygen tank was from the resident when he was smoking. MA #2 stated Resident #2's oxygen tank should be left inside the building when he went out to smoke. MA #2 stated she had never witnessed Resident #1 smoking with his oxygen tank present. MA #2 stated that staff who were assigned to go outside to supervise smokers were responsible for issuing the smoking materials and making sure the smokers turned the smoking materials back in. During an interview with the Director of Nursing on 11/13/25 at 12:17 PM, the DON stated she received a call from Nurse #2 on 11/10/25 to let her know Resident #1 received a burn from smoking a cigarette with his oxygen on. The DON stated the nurse reported Resident #1 was breathing with his accessory muscles (use of muscles other than primary muscles to help with breathing) and had some burns on his face. The DON stated she instructed Nurse #2 to call the on-call provider. The DON stated Nurse #2 called her back after calling the provider and she told the nurse to get EMS on the way so that they could evaluate the resident. The DON stated she had never witnessed Resident #1 smoking with his oxygen tank. She reported that Resident #1 indicated he had gotten the cigarette from a visitor and lit it from a cigarette butt. The DON stated Resident #1 was a supervised smoker and an intervention was added to remove his oxygen prior to Resident #1 going out to smoke. The DON was unable to explain why the intervention to remove Resident #1's oxygen was added to his care plan on 10/21/25. The DON spoke about the smoking policy and issues the facility was having with residents who smoked. The DON explained that facility had been having a lot of issues with unsupervised residents just wanting to go smoke in any area. The DON stated the smoking policy was being reviewed and education was being conducted with residents about smoking in the designated smoking area. The DON stated the facility did have a designated area for smoking. The DON stated she felt that there were several areas of breakdown in the smoking process. The DON reported that staff had given the residents the code to the exit doors, visitors would bring cigarettes to residents and staff were unaware, and some unsupervised smoking residents had refused to turn in their smoking materials. The DON stated there was a list of supervised and unsupervised residents that smoke at the nurse's station. The DON stated the staff were to refer to the list to verify the residents' smoking status. The DON stated she was not aware there were staff who did not know Resident #1 required supervision when smoking. The DON stated smoking materials were stored at the nurses station and the person assigned to supervise the smokers was responsible for making sure smoking materials were returned. During an interview with the Medical Director on 11/18/25 at 10:35 AM, she stated she was made aware on 11/10/25 that Resident #1 received a burn from smoking a cigarette with his oxygen on. The Medical Director stated she was surprised because she had seen Resident #1 the week prior and he had expressed his desire to stop smoking because he had a medical procedure coming up. The Medical Director stated that she ordered nicotine patches for Resident #1 on 10/27/25. The Medical Director stated she was not aware Resident #1 had smoked with oxygen previously. The Medical Director expressed her concern for Resident #1 smoking with oxygen since it was extremely flammable. She also expressed concern that Resident #1 not only put himself in danger but the entire building. The Medical Director stated when she visited Resident #1 after the incident on 11/12/25 he reported someone else had given him the cigarette and he had lit the cigarette using a lit cigarette butt. The Medical Director further stated she did not feel that Resident #1 understood the gravity of the situation. An interview was conducted with the Administrator on 11/18/25 at 3:30 PM. The Administrator stated Resident #1 should not have been smoking with oxygen on unsupervised and he should have been in the designated smoking area. The Administrator stated Resident #1 should not have been able to obtain smoking material from a visitor. The Administrator stated Resident #1 had not smoked with his oxygen on before to her knowledge. The Administrator denied being told about Resident #1 smoking with oxygen present and in use prior to 11/10/25. The Administrator stated she was not aware that staff did know Resident #1 was a supervised smoker. The Administrator stated there had been smoking list at the nurses' stations since she arrived at the facility at the end of July 2025. The Administrator stated smoking materials were stored at the nurses' station and the person assigned to supervise the smokers was responsible for making sure smoking materials were returned. The Administrator was notified of immediate jeopardy on 11/13/25 at 12:07PM. The facility provided the following immediate jeopardy removal plan: Identify those reci

Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record by failing to document a resident's change in condition requiring Emergency Medical Services (EMS) interventions for 1 of 1 resident reviewed for hospitalization (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD).Review of Resident #1's medical record revealed there was no documentation of a change in condition requiring a transfer to the hospital on [DATE].The Emergency Department Discharge summary dated [DATE] revealed Resident #1 was seen for flash burn. Resident #1 was on 3 liters of oxygen for end stage COPD. Resident #1 was smoking a cigarette while he had oxygen on and experienced a flash burn. Resident #1 was not in pain and did not have any trouble breathing. Resident #1 had singed nose hair in both nares (nostrils) and a burn to the upper left lip with dermis exposed.An interview was conducted with Nurse #2 on 11/13/25 at 10:31 AM, she stated she was the nurse on duty on the night of 11/10/25 when Resident #1 received a burn from smoking a cigarette with his oxygen on. Nurse #2 stated Medication Aide #1 came and notified her that Resident #1 was smoking and had caught fire. Nurse #2 stated she observed Resident #1's mustache was burnt, the smile lines to both sides of his mouth looked red and fleshy, and his forehead had a burn mark. Nurse #2 stated she called Emergency Medical Services (EMS) and Resident #1 was transferred to the local hospital. Nurse #1 stated she did not document the incident in the electronic medical record.An interview was conducted with the Administrator on 11/18/25 at 3:30 PM. The Administrator reviewed the nurse progress notes for 11/10/25. The Administrator confirmed there was no documentation for the 3:00 PM to 11:00 PM shift on 11/10/25.

Based on observation, record review and staff interview, the facility failed to develop a comprehensive person-centered care plan to address smoking for 1 of 5 sampled residents (Resident #4).Based on observation, record review and staff interview, the facility failed to develop a comprehensive person-centered care plan to address smoking for 1 of 5 sampled residents. (Resident #4)The findings included:Resident #4 was admitted to the facility on [DATE].The Safe Smoking screen dated 9/28/25 revealed Resident #4 was safe to smoke independently (unsupervised).The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact and used tobacco. Resident #4 transferred independently and ambulated independently. An observation was conducted of Resident #4 smoking a cigarette on 11/12/25 at 1:32 PM. Resident #4 was standing in the employee parking lot by the back of the facility. There were no other residents present. This area contained a fireproof smoking receptacle.As of 11/12/25, Resident #4 had no care plan related to smoking. An observation was conducted on 11/13/2025 at 3:35 PM. Resident #4 was observed outside of the facility on the left side of the building (if facing the front door from the outside) approximately 100 feet away from the designated smoking area. On 11/13/25 a care plan was initiated related to smoking for Resident #4 that indicated the resident wished to smoke and was assessed as an independent smoker. The interventions included to complete a smoking assessment and reassess quarterly, annually, and with a change of condition that affects the ability to smoke; orient to the facility's designated smoking areas; and provide education on safe smoking practices and review smoking policy with the resident.During an interview with Confidential Source #2 on 11/14/25 at 12:11 PM they (Confidential Source #2) stated they had observed Resident #4 smoking cigarettes on multiple occasions. Confidential Source #2 indicated they specifically recalled an observation in early October 2025 but were unable to recall the other observation dates. Confidential Source #2 stated they did not want the facility to know their identity due to fear of being fired. A phone interview was conducted with the MDS Coordinator on 12/3/25 at 10:30 AM. The MDS Coordinator indicated she had never seen Resident #4 smoking prior to 11/13/25. She explained she observed Resident #4 smoking on 11/13/25 and that was when she initiated a care plan related to smoking. The MDS Coordinator indicated that to her knowledge, no other staff had observed Resident #4 smoking prior to 11/13/25. A phone interview was conducted with the Director of Nursing (DON) on 12/3/25 at 10:32 AM. The DON reviewed Resident #4's care plan and verified that a smoking care plan was not initiated until 11/13/25. The DON stated once the facility learned through observation that Resident #4 smoked, a smoking care plan was initiated. The DON stated Resident #4 had denied smoking when she reviewed the smoking policy with all residents that had Safe Smoking Screening Assessments in late October 2025. An interview was conducted with the Administrator on 12/3/25 at 11:04 AM. The Administrator stated that Resident #4 should have been planned for smoking once he was deemed a safe smoker.

Based on record review, and resident and staff interviews, the facility failed to provide services with dignity and respect for 2 (Resident #1 and Resident #3) of 4 residents reviewed for dignity. A reasonable person would be traumatized by having a nurse aide expose herself, intentionally pass gas nearby, and laugh at their expense. Findings included: Resident #3 was admitted to the facility on [DATE] and had cumulative diagnoses some of which included schizophrenia, chronic pain syndrome, aphasia, major depressive disorder, and adjustment disorder with anxiety. Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition with physical behaviors 1 to 3 days of the assessment period and with verbal behaviors 4 to 6 days of the assessment period. Resident #3 was assessed as rejecting of care 4 to 6 days of the assessment period. Resident #3 was evaluated as dependent on staff for personal hygiene and required substantial assistance from staff for transfers. Resident #3 had a care plan, dated as last reviewed on 1/13/2025, with a focus area for verbally aggressive behavior relative to mental emotional illness and calling staff inappropriate names, and racial slurs toward other residents and staff. Some of the interventions included when Resident #3 became agitated: intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, if the response was aggressive, staff to walk calmly away and approach later. Documentation in a nursing progress note written by Nurse #2 on 1/15/2025 at 9:00 PM revealed, Resident (Resident #3) refused to allow staff to give incontinent care this shift; he sat in his wheelchair in hall and cursed at staff using racial slurs several times; spoke to resident about getting incontinent care and behavior; he stated he didn't need changing and wanted everyone to leave him alone even though he was shown he was very wet by pointing out clothing to him; [10:40 PM] resident was asked to receive incontinent care he refused at end of shift. Resident #1 was admitted to the facility on [DATE]. Documentation on a quarterly MDS assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact. Resident #1 was interviewed on 2/13/2025 at 12:50 PM. Resident #1 revealed the following events as happening at the change of shift at approximately 11:00 PM on 1/15/2025. Resident #1 heard from her room, Resident #3 repeatedly saying Leave me alone. Leave me alone and cursing loudly. From her room Resident #1 could see Resident #3 was sitting in his wheelchair near the nursing desk outside of her room. Approximately six nurse aides were standing around the nursing desk and laughing because Nurse Aide (NA) #3 was dancing around Resident #3 in front of him with her pants pulled down sticking her buttocks in his face. Resident #1 grabbed her ice pitcher, got in her wheelchair, and went into the hallway to see what was happening to Resident #3. Resident #3 kept hollering out, Leave me alone. Leave me alone. NA #3 then turned around and pulled her pants down in the front exposing herself to Resident #3 putting her body right up to his face. Resident #1 stated all the nursing staff were laughing at Resident #3. NA #3 then went around behind Resident #3 pulled down her pants in the back, stuck her buttocks on his back, and passed gas on him. Resident #1 explained that she knew Resident #3 had issues. Resident #1 thought she needed to distract NA #3 to make her leave Resident #3 alone, so she asked NA #3 to get her some ice for her water pitcher. NA #3 told her, I'm not getting no [curse] ice, I'm going home. Resident #1 explained the event did not make her feel good and stated, Nobody should be treated like that. Resident #1 explained the next day she reported the incident during her therapy session. The Rehabilitation Director was interviewed on 2/13/2025 at 2:36 PM. The Rehabilitation Director provided the following information. The Rehabilitation Director confirmed that Resident #1 had reported to her during her therapy session on 1/16/2025 the events of the previous evening with Resident #3 and NA #3. The Rehabilitation Director stated she immediately went to inform the Director of Nursing in person of the concerns reported by Resident #1. In addition, the Rehabilitation Director filled out a grievance form on behalf of Resident #1 and emailed it to the Administrator and Social Services Director that same day. NA #2 was interviewed on 2/13/2025 at 3:25 PM. NA #2 confirmed she worked on 1/15/2025 on the 3:00 PM to 11:00 PM shift. NA #2 indicated on 1/15/2025 at 11:00 PM both the second shift (3:00 PM to 11:00 PM) remained and the third shift (11:00 PM to 7:00 AM) was arriving. NA #2 explained Resident #3 was in the hallway near the nurses' desk cussing and hollering at NA #3. NA #3 turned around and exposed her buttocks and her front perineal area to Resident #3 and then walked away. NA #2 confirmed the nursing staff at the nurses' desk were laughing. NA #2 stated she was not able to recollect accurately which nurse aides and nurses were witnesses to the actions of NA #3 but, she thought Nurse #2, NA #4, NA #5, and NA #6 were all witnesses. NA #2 stated that everything was caught on a camera in the hallway. NA #2 requested that her name not be documented for the interview out of fear for losing her job. NA #4 was interviewed on 2/13/2025 at 4:25 PM. NA #4 confirmed she was working at the facility on the shift beginning on 1/15/2025 at 11:00 PM until 1/16/2025 at 7:00 AM. NA #4 confirmed she was at the nurses' desk when NA #3 pulled down her pants exposing her buttocks and front perineal area to Resident #3 after he called her a racial slur. NA #4 confirmed that all the staff at the nurses' desk were laughing at NA #3 and Resident #3. NA #4 explained that nobody spoke up or intervened because nobody wanted to offend another nurse aide or nurse because it would make it difficult to work together again if someone corrected NA #3. NA #5 was interviewed on 2/14/2025 at 9:11AM. NA #5 revealed she observed NA #3 attempting to put Resident #3 to bed, but he wanted to go smoke. NA #5 indicated Resident #3 was calling NA #3 derogatory names, but the screaming and hollering was too much for her nerves so she went down the hallway without witnessing anything else. Requests for interviews with NA #3, NA #6, and Nurse #2 were not responded to. The facility Administrator was interviewed on 2/13/2025 at 3:05 PM. The Administrator stated NA #3 was suspended and then terminated for her lack of customer service and inappropriate behavior. The Administrator stated there were not six witnesses to the incident. The Administrator was interviewed again on 2/14/2024 at 10:45 AM. He stated that, as a company directive, there were no cameras in the building and no camera footage. The Administrator revealed that the facility was trying to get rid of Resident #3 because he was racist and vulgar to staff.

Based on observation, record review, and staff interviews, the facility failed to provide an environment free of hazards by putting a heater in the hallway and space heaters in 5 (Rooms 102, 103, 104, 105, and 106) of 6 resident rooms reviewed for tripping hazards. Findings included: Observations were made on an initial tour of the facility on 2/13/2025 beginning at 9:04 AM. The facility had an industrial-sized heater in the hallway outside the Admissions Office with a large cord running from the back of the unit. The cord to the industrial sized heater was not taped down but curved out the back of the unit into the admission's office. Residents in wheelchairs were observed to navigate in the hallway around the heater in the hallway. Resident # 9 was observed in his wheelchair attempting to navigate around the industrial heater in the hallway. Resident #9 stated, This is ridiculous with this thing in the hallway. Resident rooms 102, 103, 104, 105, and 106 were observed to have space heaters in the rooms. The cords to the space heaters in the resident rooms were not taped down to the floor. In rooms [ROOM NUMBERS] space heaters were located near the doorway to the room in the pathway to the bathroom, requiring residents in those rooms to roll their wheelchairs around the space heater to get to the bathroom. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 was coded as cognitively intact. An interview and observation were conducted with Resident #16 (room [ROOM NUMBER]B) and Resident #15 (room [ROOM NUMBER]A) on 2/13/2025 at 12:56 PM. Resident #16 was in a wheelchair and Resident #15 was ambulatory with a four-wheel rollator rolling walker. Resident #15 was observed to navigate around the space heater near the entrance of the room to exit the room. Resident #16 stated the facility has been without heat for the rooms in the front of the building for three weeks. Resident #16 explained that a big heater was placed in the hallway and that there were space heaters in each resident's room. An interview was conducted with Resident #18 in room [ROOM NUMBER]A on 2/14/2025 at 12:50 PM. Resident #18 stated his space heater at the entrance to the room did not work because it tripped the circuit breaker when it was turned on. Resident #18 stated he did have to navigate around the space heater, but it did not bother him. An observation was made on 2/14/2025 at 7:20 AM with the Maintenance Director in Resident 16's room. The room contained two space heaters with cords spread out on the floor. An additional observation was made on 2/14/2025 at 12:50 PM in room [ROOM NUMBER]. The room contained a space heater near the entrance and another space heater sitting directly next to the resident near the window of the room. The Administrator was interviewed on 2/13/2025 at 1:35 PM. The Administrator revealed the heating system went out and a part needed to be manufactured due to the age of the system. The Administrator added that an industrial heater was immediately put in the hallway and space heaters in the resident rooms to keep them warm. An interview was conducted on 2/17/2025 at 1:32 PM with the Life Safety Engineering Supervisor for the state agency. The Life Safety Engineering Supervisor revealed it was a life safety code violation to have electric heaters and/or space heaters in the hallways, resident rooms, or resident care areas due to fire risk. The Director of Plant Operations was interviewed on 2/18/2025 at 8:38 AM and the following information was provided. On 1/19/2025 the facility reported having issues with the heat exchanger on the outside heating and air conditioning unit. On 1/20/2025 contractors unsuccessfully attempted to fix the heat exchanger. A new part will be manufactured at the factory within 30 days. On 1/21/2025 the six rooms that contained residents received space heaters and a large electric heater was put in the hallway. The space heaters purchased were unapproved for safety in the facility. The facility has had someone on fire watch all night since the space heaters were purchased for the hallway and resident rooms.

Based on observations, staff interviews, and record review, the facility failed to have a medication error rate of less than 5% as evidenced by 4 medication errors out of 25 opportunities resulting in a medication error rate of 16% for 2 (Residents #11 and #12) of 5 residents observed during medication administration observation. Findings included: 1-a. On 2/14/2025 at 7:51 AM, Medication Aide (Med Aide) #1 was observed and interviewed as she prepared and administered four medications to Resident #11. Med Aide #1 stated during the preparation of medications for Resident #11 that she did not have the eye drops in the medication cart she needed for Resident #11. Med Aide #1 did not administer eye drops to Resident #11 during the medication pass observation. A review of Resident #11's medication orders revealed the resident had a current order for Carboxymethylcellulose sodium PF (preservative-free) ophthalmic solution to be instilled as one drop in both eyes one time a day for the treatment of dry eyes (ordered on 1/28/2025). Med Aide #1 was interviewed at 1:35 PM. Med Aide #1 confirmed she did not administer the eye drops Carboxymethylcellulose sodium PF ophthalmic solution to Resident #11 and the eye drops were on order. 1-b. On 2/14/2025 at 8:39 AM, Nurse # 3 was observed as she prepared and administered eight medications to Resident #12. The medications administered included one- 325 milligram (mg) tablet of Sodium Bicarbonate administered by mouth, one-667 mg capsule of Calcium Acetate administered by mouth, and one-25 mg capsule of Hydroxyzine Pamoate administered by mouth. A review of Resident #12's medication orders revealed the resident had a current order for one-650 mg tablet of Sodium Bicarbonate to be administered three times a day by mouth for indigestion (ordered on 1/29/2025). A review of Resident #12's medication orders revealed the resident had a current order for two-667 mg capsules of Calcium Acetate to be administered three times a day by mouth after meals for acute kidney injury (ordered on 2/8/2025). A review of Resident #12's medication orders revealed the resident had a current order for one-50 mg capsule of Hydroxyzine Pamoate to be administered three times a day by mouth for anxiety. An interview was conducted with Nurse #3 on 2/14/2025 at 2:05 PM. During the interview the discrepancies in the medication Sodium Bicarbonate, Calcium Acetate, and Hydroxyzine Pamoate amounts prepared and administered versus the current physician orders were discussed. Nurse #3 reviewed the order for the Sodium Bicarbonate for Resident #12 and stated that the pill bottle contained 350 mg tablets while Resident #12 was ordered to have 650 mg of Sodium Bicarbonate. Nurse #3 stated she should have given Resident #12 two-350 mg tablets of Sodium Bicarbonate to fulfill the order. (Two tablets of 350 mg Sodium Bicarbonate would have been equivalent to 700 mg of the medication.) Nurse #3 reviewed the order for the Calcium Acetate for Resident #12 and acknowledged that she had only given one-667 mg capsule of Calcium Acetate at 8:00 AM medication administration time. She stated she knew that she had given Resident #12 two-667 mg capsules of Calcium Acetate at noon on the same day and revealed she should have looked closer at the order and administered two capsules at 8:00 AM. Nurse #3 reviewed the physician's order for Hydroxyzine Pamoate for Resident #12 and looked at the blister packet of medication in the medication cart. (A blister pack is a form of tamper evident packaging where an individual pushes individually sealed tablets or capsules through the foil to take the medication.) Nurse #3 noted that the blister packet of Hydroxyzine Pamoate for Resident #12 was labeled as containing one-25 mg capsule of the medication in each preformed dome. Nurse #3 stated that she should have caught the discrepancy in the medication order and the labeled blister packet of Hydroxyzine Pamoate and administered two capsules to Resident #12 to fulfill the medication order. The Director of Nursing (DON) was interviewed on 1/18/2025 at 2:17 PM. The DON stated that the nurses were supposed to administer medications to the residents as ordered on the Medication Administration Record and that she would have to make sure the medications available on the medication carts matched the orders.

Based on observations, record review, and staff interviews, the facility failed to follow infection control policies and procedures by 1) donning a gown for enhanced barrier precautions during wound care for one (Nurse #1) of two staff members observed for enhanced barrier precautions, 2) performing hand sanitization in between residents during a medication pass observation for one (Medication Aide #1) of two staff members observed for hand hygiene, and 3) using gloves when handling medication during a medication pass observation for one (Nurse #3) of three staff members observed for glove use during care. Findings included: 1. Documentation on the facility's undated infection prevention and control program policy revealed under the heading standard precautions, All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. An observation was conducted on 2/13/2025 beginning at 1:40 PM while Resident #9 received wound care. Resident #9 was observed to have a sign on his room door for contact precautions. The documentation on the sign stated, Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. Nurse #1 and Nurse Aide (NA) #1 were observed to enter the room of Resident #9 and not put on gowns. NA #1 moved the motorized wheelchair of Resident #9 and removed the protective boots on the lower legs and feet. Nurse #1 explained the location of the resident's wounds were on the plantar side of the left and right feet and that the right foot wound had tested positive for MRSA (Methicillin-resistant Staphylococcus aureus). (MRSA is contagious and can spread to others through skin-to-skin contact.) Nurse #1 was observed to provide wound care as ordered to both the left and right feet of Resident #9, including removing soiled bandages, application of treatments, and redressing of the wounds. Directly after the wound care observation on 2/13/2025 at 2:08 PM Nurse #1 was interviewed. Nurse #1 stated that the required PPE was not outside the door of Resident #9. Nurse #1 added that some facilities follow the procedure of putting on a gown before wound care and some do not. Nurse #1 revealed she had already put on a gown for wound care three times that day. Nurse #1 added that she did not get close to Resident #9 while performing wound care. The Director of Nursing was interviewed on 2/13/2025 at 2:10 PM. The Director of Nursing stated that Nurse #1 would need to be reeducated because for a resident on contact precautions, a gown must be worn for the provision of wound care. 2. Documentation on the facility's undated infection prevention and control program policy revealed under the heading standard precautions, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Documentation under the facility's undated Medication Administration policy revealed under policy explanation and compliance guidelines in part, 4. Wash hands prior to administering medication per facility protocol and product; 16. Observe resident consumption of medication; and 17. Wash hands using facility protocol and product. On 2/14/2025 at 7:51 AM, Medication Aide (Med Aide) #1 was observed as she prepared and administered medications to Resident #11. The room door of Resident #11 was observed to have a contact precaution sign on the door. The contact precaution sign indicated hand hygiene was required before entering the room and after leaving the room. Medication Aide #1 did not perform hand hygiene before entering Resident #11's room and did not perform hand hygiene after administering medications to Resident #11. On 2/14/2025 at 8:01 AM, Med Aide #1 was observed as she prepared and administered medications to Resident #13. While in the room waiting for Resident #13 to consume her medications, Med Aide #1 assisted the resident, cutting up the food she was eating. Med Aide #1 did not perform hand hygiene before preparing the medications for Resident #13 nor when she returned to the medication cart after administration. On 2/14/2025 at 8:17 AM, Med Aide #1 was observed as she prepared and administered medications to Resident #14. Med Aide #1 did not perform hand hygiene before preparing the medications for Resident #14 nor when she returned to the medication cart after administration. Med Aide #1 was interviewed on 2/14/2025 at 8:20 AM. Med Aide #1 stated she usually did hand hygiene before preparing medications and after administering medications to residents, but she was just nervous. Med Aide #1 stated she especially performed hand hygiene when residents were on contact precautions. At that point, Med Aide #1 was observed to perform hand hygiene. An interview was conducted with the Director of Nursing on 2/18/2025 at 2:17 PM. The Director of Nursing stated it was her expectation that the nursing staff perform hand hygiene in-between each resident during medication pass administration. 3. Documentation on the facility's undated infection prevention and control program policy revealed under the heading standard precautions, Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Documentation under the facility's undated Medication Administration policy revealed under policy explanation and compliance guidelines in part, 14. Remove medication from source, taking care not to touch medication with bare hand. On 2/14/2025 at 8:39 AM Nurse #3 was observed as she prepared and administered 8 medications to Resident #12. Nurse #3 was observed to put 6 of the 8 medications into her bare hands before putting them in the medication cup and administering the medications to Resident #12. On 2/14/2025 at 8:54 AM Nurse #3 was observed as she prepared and administered 6 medications to Resident #20. Nurse #3 was observed to put the 6 medications into her hand prior to putting them into the medication cup and then administering the medications to Resident #20. Nurse #3 was interviewed on 2/14/2025 at 9:04 AM. Nurse #3 stated she used to remove the medication directly from the container into the medication cup, but she was either losing the pills or they were dropping on the floor. Nurse #3 revealed she now put the medication into her hand so that she did not waste or lose medication. The Director of Nursing (DON) was interviewed on 2/18/2025 at 2:17 PM. The DON stated that a gloved hand could be used to remove pills from a medication card or medication container and then put them into the medication cup. The DON explained putting the medication into a gloved hand would keep the medication from being lost or dropped.

Based on observation, staff interviews, and resident interviews, the facility failed to provide comfortable room temperatures for one (Resident #16) of three residents reviewed for comfortable room temperatures. Findings included: Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 was coded as cognitively intact. An interview was conducted with Resident #16 on 2/13/2025 at 12:56 PM. Resident #16 stated the facility had been without heat for the rooms in the front of the building for three weeks. Resident #16 explained a big heater was placed in the hallway and space heaters in each of the residents' rooms. Resident #16 further explained that when everybody turned on their space heaters to keep warm, the circuit breaker would trip, and a staff member had to go into the Director of Nursing's office and reset the circuit breaker. Resident #16 stated that at night the staff did not have access to the Director of Nursing's office and was often unable to reset the circuit breaker. Resident #16 stated he did not want his door open at night due to the noise from the big heater in the hallway and the television area close to his room. Resident #16 stated it was so cold at night that he had to wear a thick hoodie and multiple blankets, and even then, he could not get warm enough. The facility Administrator was interviewed on 2/13/2025 at 1:35 PM. The Administrator explained a part had to be manufactured to fix the outside heating and air conditioning unit. The Administrator explained the facility had put an industrial heater in the hallway and individual space heaters in each resident's room. The Administrator stated that if the residents in the affected rooms kept their doors open, then the rooms would stay heated. The Administrator added that if the circuit breaker tripped, a staff member would reset the breaker located in the Director of Nursing's office. The Administrator was unaware of staff members not resetting the breaker at night. Interviews and observations were made in Resident #16's room on 2/14/2025 at 7:05 AM. Resident #16 stated his room was too cold this morning and he complained when he had to do self-catheterization, he needed to have the door closed for privacy. Resident #16 demonstrated how the space heater in his room, the adjustable bed, and the television were not working because the circuit breaker was tripped. Resident #16 stated he just wanted to get in bed and wrap up due to the cold temperature in the room, but nothing worked. An interview and observation were conducted with the Maintenance Director on 2/14/2025 at 7:20 AM in Resident #16's room. The Maintenance Director stated that it was his second week working at the facility. He explained the heating and air conditioning unit outside was broken and a part needed to be made. The Maintenance Director was asked if he had a way of measuring the room temperature. The Maintenance Director stated he had a digital thermometer to measure the air temperature. The Maintenance Director removed the sheath from a digital thermometer and held up the thermometer up in the air in the middle of the room with the door open. The room temperature was 73 degrees Fahrenheit in the room on the digital thermometer. The Maintenance Director acknowledged the room temperature did not feel like 73 degrees Fahrenheit. The Maintenance Director indicated the hallway heater would heat Resident #16's room if he left the door open. An additional interview was conducted with the facility Maintenance Director on 2/14/2025 at 11:55 AM. The facility Maintenance Director stated he was permitted to purchase a laser thermometer to measure the air temperatures. The Maintenance Director stated the temperature in Resident #16's room was 71.8 degrees Fahrenheit with the door open. The Maintenance Director did not know what the room temperatures were at night. The Administrator was interviewed on 2/14/2025 at 10:45 AM. The Administrator confirmed the current Maintenance Director had started on 2/3/2025 and would not provide the contact information for the previous Maintenance Director. The Director of Plant Operations was interviewed on 2/18/2025 at 8:38 AM and the following information was provided. On 1/19/2025 the facility reported having issues with the heat exchanger on the outside heating and air conditioning unit. On 1/20/2025 contractors unsuccessfully attempted to fix the heat exchanger. A new part will be manufactured at the factory within 30 days. On 1/21/2025 the six rooms that contained residents received space heaters and a large electric heater was put in the hallway. The facility provided documentation on a typed spreadsheet that listed room temperatures, dates, and hallway temperatures. The spreadsheet was entitled, Temp Log for Rooms 101 to 106. The log listed a daily room temperature and a hall temperature from 1/27/2025 to 2/19/2025. The lowest room temperature listed on the spreadsheet was 71 degrees Fahrenheit and the lowest hallway temperature listed was 72 degrees Fahrenheit. There was no documentation of the time of day, the exact location of the temperature, or who took the temperatures on the spreadsheet.

Based on observations, record review, and staff interviews, the facility failed to prevent physical and verbal abuse from staff for one (Resident #4) of three residents reviewed for physical and verbal abuse. Findings included: On 2/13/2025 at 10:55 AM the Director of Nursing (DON) provided a list of alert and oriented residents which included Resident #10 and did not include Resident #4 or Resident #3. Resident #4 was admitted to the facility on [DATE] with diagnoses of C5-C7 vertebrae incomplete quadriplegia, adjustment disorder with mixed disturbance of emotions and conduct, post-traumatic stress disorder, scoliosis, and major depressive disorder. (C5-C7 incomplete quadriplegia refers to a spinal cord injury at the C5 to C7 vertebrae in the neck, resulting in paralysis affecting all four limbs due to damage to the nerves controlling movement in that area.) Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact with verbal behaviors one to three days of the assessment period. Documentation on the care plan for Resident #4, dated as last reviewed on 12/16/2024 revealed a focus area for [Resident #4] has verbally aggressive-verbal threats, cursing at staff and other residents relative to mental/emotional illness, poor impulse control and [Resident #4] has potential to be physically aggressive relative to anger, post-traumatic stress disorder diagnosis. Both focus areas had the intervention, When the resident becomes agitated: intervene before agitation escalates; guide away from the source of distress; engage calmly in conversation; if the response is aggressive, staff to walk away calmly, and approach later. Resident #4 was interviewed on 2/13/2025 at 11:05 AM and she revealed the following information. Resident #4 revealed on 1/3/2025 she argued with Resident #3 earlier in the day. Around lunchtime, Resident #4, Resident #3, and Resident #10 were in the hallway getting ready to go out to smoke. Resident #3 was cussing at Resident #4 and Resident #4 was cussing at Resident #3. The Director of Nursing (DON) and Nurse Aide (NA) #1 took all three of the residents, Resident #3, Resident #4, and Resident #10, outside to go to smoke cigarettes. Resident #3 continued to cuss and threaten Resident #4, and Resident #4 was cussing back at him as they sat smoking. The DON told Resident #4 to be quiet. Resident #4 explained she felt like the DON was only telling her to be quiet while Resident #3 was allowed to sit and swear at her. Resident #4 revealed she told the DON she was not going to tell her to shut her mouth. Resident #4 revealed she did call the DON a [female dog] and '[racial slur], and the DON began to argue with her. Resident #4 stated she moved her wheelchair forward toward the DON and the DON shoved her and hit her. Resident #4 revealed the DON began to shout at her and Resident #4 screamed out that the DON hit her. NA #1 just stood there. The DON then fled into the building. Resident #4 called the police, and they came to the facility. Resident #4 indicated the police told her she would have to go to the police station to make a report. Resident #4 also called local Adult Protective Services and the state long-term care complaint line. Resident #4 said the DON was suspended but then returned to the facility in a few days as if nothing happened. A photograph, dated 1/3/2025, was observed on the telephone of Resident #4 depicting a visible bruise on the left side of her face near her chin. Resident #4 explained she showed the picture to the Administrator and to the facility Social Worker. An additional photograph was observed on the phone of Resident #4, of a note from Resident #10 dated 1/3/2025 explaining Resident #10 was a witness to the altercation. On the evening of 1/29/2025 Resident #4's electric wheelchair was taken from her with the pretense she had hit someone with the wheelchair, but she was not told who. Resident #4 felt the removal of her wheelchair was in retaliation for her calling adult protective services, who opened an investigation. There was no documentation in the medical record of Resident #4 using her wheelchair to run into staff or residents in January 2025. On 2/13/2025 at 12:45 PM, the DON requested that Resident #10 be removed from the list of residents deemed alert and oriented. Resident #10 was admitted to the facility on [DATE] and has diagnoses of adjustment disorder with mixed disturbance of emotions and conduct as well as anxiety disorder. Documentation on a care plan dated as last reviewed on 1/22/2025 for Resident #10 revealed she had a focus area for a behavior problem related to anxiety as well as episodes of fabrication. Documentation on a recent Brief Interview for Mental Status dated 2/5/2025, Resident #10 scored 15 out of 15, indicating she was cognitively intact. An interview was conducted with the facility Psychiatric Mental Health Nurse Practitioner (PMHNP) #1 on 2/19/2025 at 11:42 AM. PMHNP #1 indicated he saw Resident #10 weekly and provided the following insight into the reliability of the information provided by Resident #10. PMHNP #1 confirmed Resident #10 had anxiety and very negative thoughts. PMHNP #1 thought Resident #10 complained about the facility services and was unrealistic about her complaints. In addition, PMHNP #1 thought Resident #10 could be manipulative, telling people what they wanted to hear. Resident #10 was interviewed on 2/17/2025 at 5:55 PM. Resident #10 related the following events as occurring on 1/3/2025. Resident #10, Resident #3, and Resident #4 were in the hallway. Resident #3 and Resident #4 were arguing. Resident #10 stated, It was a big thing. Resident #10 indicated a nurse aide (NA #1), and a nurse (DON) took the three residents, Resident #10, Resident #3, and Resident #4, outside to smoke cigarettes. Resident #10 stated she sat in her usual spot in the smoking area with a full view of the building door and the smoking area. Resident #3 and Resident #4 continued to argue then Resident #4 and the nurse (DON) started to argue. Resident #4 did not run her wheelchair into the nurse (DON). The nurse (DON) acted like she wanted to fight Resident #4 and pushed Resident #4. Resident #10 confirmed the nurse (DON) did not slap or hit Resident #4 but pushed her. After that, Resident #4 was very upset. The nurse (DON) acted like she wanted to beat Resident #4 up. The nurse aide (NA #1) stopped the nurse (DON) and pulled her away. The nurse aide (NA #1) laughed like the whole thing was funny. The nurse aide (NA #1) tried to break them up and the nurse went back into the building. Resident #10 and Resident #4 also went back into the building. Resident #10 stated that nobody had asked her what had happened except for the police. Resident #10 added that other residents had asked her what had happened, but she did not tell them because she did not gossip. Resident #10 revealed the police told her the nurse (DON) had the right to defend herself. The nurse aide (NA #1) saw everything that happened that day. NA #1 was interviewed on 2/13/2025 at 1:03 PM and provided the following information. NA #1 stated Resident #3 and Resident #4 were fussing in the hallway. The DON was trying to calm Resident #4 down. The DON and NA #1 took Resident #4, Resident #10, and Resident #3 outside through the side door to smoke in the smoking area. Resident #4 put her wheelchair in drive and hit the DON with her wheelchair. The DON turned around and went back into the building. The DON did not do anything. The DON did nothing wrong. The DON was interviewed on 2/14/2025 at 7:25 AM. The DON described the following events and made the following statements. Resident #3 and Resident #4 were always getting into it, cursing and hollering. The DON came out of her office and told Resident #3 and Resident #4 to keep it down. The DON described the scene as chaos with visitors and a new resident in the hallway working with therapy. The DON stated she knew it had to stop. The DON stated she was trying to move Resident #3 away from Resident #4, but the two residents would not stop. The DON stated she took the residents out the back door with the help of NA #1 to the smoking area. Resident #4 would not stop swearing and kept on talking. The DON stated she told Resident #4 to be quiet. Resident #4 responded to the DON telling her, You can't tell me what to do. The DON turned to walk away from the table area. Resident #4 brought her wheelchair close to the DON and was getting mad. Resident #4 called the DON a Black [racial slur] [female dog]. The DON stated she told Resident #4 to be quiet and the DON walked to the door of the building. The DON was observed to demonstrate how as she turned, Resident #4 hit her left leg. The DON stated she almost fell , and she braced herself on the wheelchair of Resident #4 to catch herself. Resident #4 then screamed, You hit me. You hit me. The DON stated she then knew she had to go. The DON stated Resident #4 threatened her. The DON restated that she almost fell . The DON explained if her hand touched Resident #4 it was because she was trying to catch herself from falling and defend herself from Resident #4. The DON stated her arms were flaring and then corrected herself saying her arms were flying to prevent Resident #4 from hitting her. The DON explained she worked too many years to have a resident say she hit them. The DON stated, Do you think I would hit a resident? I know not to hit a resident. That would be my job. I would be fired if I hit a resident. Resident #4 is always up here talking loudly. I'm not going to ignore it. The DON stated she never said anything mean to Resident #4 and just told her to leave her alone. The DON stated she then went back into the building and sat down in her office because Resident #4 had tried to hit her with the wheelchair and then corrected herself and stated, She hit me with the wheelchair. The DON confirmed she did make contact with Resident #4 to defend herself but did not hit her. The DON stated the Administrator and the police spoke with her that day. Confidential Source #1 was interviewed on 2/13/2025 at 4:30 PM. Confidential Source #1 revealed the DON came to him/her directly after she returned to the building on 1/3/2025 and stated, I know they will fire me. I hit her twice. I just hit her. I was gonna pull her out of that chair. She called me a [racial slur]. Confidential Source #1 stated the DON confessed to hitting Resident #4 twice. Confidential Source #1 stated that if he/she came forward, he/she was certain he/she would lose his/her job because he/she thought the facility was trying to cover up what happened. Confidential Source #1 was interviewed again on 2/14/2025 at 11:56 AM. Confidential Source #1 reiterated the DON came back into the building from the side door directly after the incident outside on 1/3/2025. Confidential Source #1 confirmed the DON confessed she had hit Resident #4 because Resident #4 was calling the DON a racially charged name. Confidential Source #1 indicated he/she was told the DON had a right to defend herself. Confidential Source #1 revealed Resident #4 had aggression and had run into people with her wheelchair previously on several occasions, even having her wheelchair taken away from her by the facility previously. Confidential Source #2 was interviewed on 2/13/2025 at 5:20 PM and provided the following description of what was witnessed on 1/3/2025. Confidential Source #2 was outside in a side trailer working with the door open. Confidential Source #2 heard a commotion with people shouting and cursing in the smoking area. Confidential Source #2 heard a hit and turned around to see the DON shouting at Resident #4 saying Come on, Come on right up in Resident #4's face. Resident #4 was screaming, She hit me. She hit me. Confidential Source #2 stated, [DON] just lost it on [Resident #4]. NA #1 was standing there telling the DON to just Stop. Stop. The DON then went into the side door of the building. Confidential Source #2 stated the DON was suspended but returned to the facility in about 4 or 5 days. Confidential Source #2 confirmed he/she did not witness the DON hit Resident #4. Confidential Source #2 was told the DON had the right to protect herself, but it would set a bad precedent if it was known the DON hit Resident #4. Confidential Source #2 said there should be a video of the incident taken by the facility camera. Confidential Source #2 did not want his/her identity known out of fear of retaliation. Confidential Source #3 was interviewed on 2/14/2025 at 1:45 PM and again at 4:09 PM. The following information was provided. Confidential Source #3 witnessed Resident #4 using her power wheelchair to run into Resident #3's wheelchair on the morning of 1/3/2025. Confidential Source #3 indicated the altercation between Resident #3 and Resident #4 was reported to the Administrator and the Social Worker immediately after it happened. Later in the day, on 1/3/2025, Confidential Source #3 went to the nursing office in the back of the building for a risk management meeting that was to start at noon. As Confidential Source #3 entered the door, the DON confessed, I hit [Resident #4] two times. Confidential Source #3 immediately told the DON she must go to the Administrator to inform him what happened. Confidential Source #3 then walked with the DON directly to the Administrator. Confidential Source #3 then walked back to attend the risk management meeting in the nursing office and did not discuss what he/she heard with anyone else. Confidential Source #3 did not want the interview information used knowing he/she would be fired for revealing information. Confidential Source #3 did not know if anyone else heard the statement made by the DON in the office doorway. The Unit Manager (Nurse #4) was interviewed on 2/14/2025 at 3:15 PM and she provided the following information. Nurse #4 stated she was at the nursing station in the back hall of the building after the risk management meeting on 1/3/2025 when she saw the DON coming down the hall and she was distressed and very emotional. The DON told Nurse #4 she was going home. Nurse #4 stated she pulled the DON into the office next to the nursing station to calm her down. Nurse #4 explained the DON was shaken up and shocked because Resident #4 had run her wheelchair into her. NA #1 was reinterviewed on 2/14/2025 at 3:38 PM. NA #1 explained with the following information and additional details. Resident #4 was in the hallway swearing and cussing at Resident #3. The DON decided the residents should be taken out to smoke. The DON and NA #1 took Resident #3, Resident #4, and Resident #10 one at a time out the door to smoke. Outside Resident #4 tried to run the DON over with her wheelchair. The DON tried to run away. The DON was hit in the foot with the wheelchair of Resident #4. NA #1 explained it happened so fast he was not able to verify if the DON was swinging her arms. NA #1 was adamant that the DON never touched Resident #4 nor made contact with Resident #4 other than being hit by the wheelchair of Resident #4. Resident #4 was cussing at the DON but no direct contact was made. NA #1 reiterated it happened too fast for him to recall any more information. Documentation on a police report dated 1/3/2025 at 12:04 PM revealed the incident involved a simple assault with a hit with fist. The case was deemed closed, by other means. The narrative on the police report was redacted. There were no witnesses listed. The victim was listed as Resident #4 and others involved were listed as the DON. Offender number one was listed as the DON and offender number two was Resident #4. Both the DON and Resident #4 were listed as suspects. Documentation in the police report revealed there were no injuries. An interview was conducted with the Administrator on 2/14/2025 at 10:45 AM. The Administrator stated he completed his five-day investigation and determined Resident #4 ran her wheelchair into the DON causing her to lose her balance. The Administrator revealed the facility investigation concluded the abuse of Resident #4 was unsubstantiated. The Administrator revealed the full narrative of what happened, and the investigation results were submitted to the state. He stated that, as a company directive, there were no cameras in the building and no camera footage. An interview was conducted with the Administrator and a Nurse Consultant on 2/18/2025 at 3:22 PM. The Nurse Consultant and the Administrator confirmed that the DON and NA #1 were interviewed as a part of the investigation. The Administrator stated there was nobody else to interview because nobody else was outside at the time of the altercation on 1/3/2025 to interview except for the three residents. The Administrator stated Resident #3 told him Resident #4 hit the DON with the wheelchair and Resident #10 did not see anything. The Administrator added that Resident #10 was not an interviewable resident. The Administrator stated on 1/3/2025 he heard hollering, so he walked outside toward the smoking area. The Administrator confirmed while outside he encountered NA #1 and Resident #4. Resident #4 told the Administrator that the DON hit her. The Administrator stated the police arrived 15 to 20 minutes later. The Administrator revealed he went to the DON's office and that was where he found her. The Administrator stated he did not see the picture of the bruise on the face of Resident #4. The Administrator confirmed all the investigation information was provided.

Based on record review and staff interview, the facility failed to implement policies and procedures that promote a culture of safety and open communication in the workplace and prohibit potential retaliation for staff who report abuse allegations. Confidential Source #1, Confidential Source #2, and Confidential Source #3 all stated they did not come forward with information related to an abuse allegation due to a fear of retaliation. This was for 1 (Resident #4) of 3 residents reviewed for investigation of abuse allegations. Findings Included: Documentation on the facility's abuse, neglect, and exploitation policy, dated as last reviewed on 4/1/2024 revealed, The Company will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. Documentation in an initial state agency report submitted to the state agency on 1/3/2025 at 3:20 PM revealed that Resident #4 stated she was struck by a nurse, who was suspended. The nurse in the initial investigation report was identified as the Director of Nursing (DON). Documentation on an investigation report submitted to the state agency on 1/10/2025 at 10:55 AM in part revealed in the summary of the facility investigation, Resident (#4) followed her (DON) to the door and struck nurse (DON) on her leg with her (Resident #4's) electric scooter and started to swing her arms and legs at nurse (DON). Nurse (DON) put up her arms up to deflect the attempts by Resident (#4) to strike nurse. Nurse went back into center. Confidential Source #1 was interviewed on 2/13/2025 at 4:30 PM. Confidential Source #1 revealed the DON came to him/her directly after she returned to the building on 1/3/2025. Confidential Source #1 stated the DON confessed to hitting Resident #4 twice. Confidential Source #1 stated that if he/she came forward, he/she was certain he/she would lose his/her job because he/she thought the facility was trying to cover up what happened. Confidential Source #1 stated he/she was conflicted about providing the information because he/she would be protecting vulnerable residents, but he/she would lose his/her job. Confidential Source #2 was interviewed on 2/13/2025 at 5:20 PM and described what was witnessed on 1/3/2025. Confidential Source #2 was outside in a side trailer working with the door open and witnessed an altercation between Resident #4 and the DON. Confidential Source #2 said there should be a video of the incident taken by the facility camera confirming what he/she witnessed. Confidential Source #2 did not want his/her identity known out of fear of retaliation and agreed only to provide information if his/her identity would not be known to the facility's administration. Confidential Source #3 was interviewed on 2/14/2025 at 1:45 PM and again at 4:09 PM. Confidential Source #3 described a confession overheard from the DON admitting to hitting Resident #4 on 1/3/2025. Confidential Source #3 did not want the interview information used knowing he/she would be fired for revealing information. Confidential Source #3 was certain facility administration would find a reason to fire him/her if it were known he/she came forward to support the claim of Resident #4 with what he/she heard from the DON. An interview was conducted with the Administrator and Nurse Consultant on 2/18/2025 at 3:22 PM. The Administrator was adamant the only people in the smoking area on 1/3/2025 who witnessed the altercation between Resident #4 and the DON were the three residents, Nurse Aide (NA) #1, and the DON. The Administrator stated he completed the investigation, and the Nurse Consultant stated she interviewed the DON and NA #1. The Administrator revealed that every building has staff who are afraid to talk despite being told they do not have to fear for their jobs if they come forward, but he did not know how to make the staff believe it. The Nurse Consultant confirmed the facility would not fire someone who came forward with information. The Administrator and the Nurse Consultant indicated they did not know how to prove or disprove an allegation of abuse if the confidential sources were not identified.

Based on record review, resident interview, and staff interviews, the facility failed to complete a thorough investigation following an abuse allegation by not assessing the alleged victim for injury for one (Resident #4) of three resident abuse investigations reviewed. Findings included: Documentation on the facility's abuse, neglect, and exploitation policy, dated as last reviewed on 4/1/2024, revealed under the heading of protection of the resident examining the alleged victim for any sign of injury, including a physical examination or psychological assessment if needed. Documentation in an initial state agency report submitted to the state agency on 1/3/2025 at 3:20 PM revealed that Resident #4 stated she was struck by a nurse, who was suspended. The nurse in the initial investigation report was identified as the Director of Nursing (DON). Documentation on an investigation report submitted to the state agency on 1/10/2025 at 10:55 AM in part revealed in the summary of the facility investigation, Resident (#4) followed her (DON) to the door and struck nurse (DON) on her leg with her (Resident #4's) electric scooter and started to swing her arms and legs at nurse (DON). Nurse (DON) put up her arms up to deflect the attempts by Resident (#4) to strike nurse. Nurse went back into center. There were no resident skin assessments and no skin assessment of Resident #4 directly after the altercation on 1/3/2025 in the facility file. Resident #4 was interviewed on 2/13/2025 at 11:05 AM and she confirmed that neither a skin assessment nor an assessment of her injuries was completed after the incident on 1/3/2025. A photograph, dated 1/3/2025, was observed on the telephone of Resident #4 depicting a bruise on the left side of her face near her chin. Resident #4 explained that she had shown the picture to the Administrator and the Social Worker. There was no documentation or statements from the Administrator or the Social Worker in the facility file regarding a photo taken by Resident #4 depicting a bruise on the left side of her face near her chin. An interview was conducted with the Administrator on 2/14/2025 at 10:45 AM. The Administrator stated he completed his five-day investigation and determined Resident #4 ran her wheelchair into the DON causing her to lose her balance. The Administrator revealed the facility investigation concluded the abuse of Resident #4 was unsubstantiated. The Administrator revealed the full narrative of what happened, and the investigation results were submitted to the state agency. An interview was conducted with the Administrator and a Nurse Consultant on 2/18/2025 at 3:22 PM. The Administrator confirmed all the investigation information was provided. The Administrator and the Nurse Consultant would not confirm or deny a skin assessment of Resident #4 was completed on 1/3/2025. The Administrator stated he did not see the picture of the bruise Resident #4's face.

Based on record review, and staff and pharmacy interviews, the facility failed to have an effective system in place for putting new admission orders into the electronic record to ensure pharmacy delivery, resulting in four missed doses of antibiotics for one (Resident #7) of two residents reviewed for pharmacy services. Findings included: Resident #7 was admitted to the facility on [DATE] from the hospital and discharged back to the hospital on 1/28/2025. Resident #7 had a diagnosis of osteomyelitis. Documentation on a discharge summary from the hospital dated 1/21/2024 revealed Resident #7 was started on intravenous Vancomycin and Cefepime for osteomyelitis of the left elbow planned for a six-week (1/7/25-2/18/25) course via peripherally inserted central catheter (PICC line). (A PICC line is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein above the heart.) Vancomycin and Cefepime are antibiotics used to treat infection. The current discharge medication list for Resident #7 included: 1 gram (g)/250 milliliters (ml) IVPB (intravenous piggyback) of Vancomycin in 0.9% sodium chloride to be injected into the vein daily for 31 days and 2 g/110 ml IVPB Cefepime in 0.9% sodium chloride to be injected into the vein every 12 hours for 31 days. Documentation in the nursing progress notes written by Nurse #7 for Resident #7 revealed he was admitted to the facility on [DATE] at 3:02 PM. Documentation on a physician order dated 1/21/2025 written by Nurse #4 revealed an order was entered into the electronic medical record of Resident #7 for 1 g/250 ml Vancomycin in 0.9% sodium chloride to be injected into the vein. The order type was selected as Other Orders (MAR). There was no evidence that a physician's order for Cefepime was entered into the electronic medical record for Resident #7 on 1/21/2025. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/21/2025 at 5:00 PM or 1/22/2025 at 5:00 AM. Documentation on the MAR revealed Resident #7 did not receive an IV Vancomycin dose on 1/22/2025 at 6:30 AM. Documentation in the physician orders revealed an order was initiated on 1/21/2025 at 3:00 PM for 5 ml Heparin 10 units/ml flush solution and 10 ml normal saline flush solution to be used intravenously every shift to maintain the PICC line. The order type was selected as, AHR Medication Orders. AHR stands for admission, transfers, and discharge report. Documentation on the MAR revealed Resident #7 was administered the Heparin flush on 1/21/2025 on the evening shift (3:00 PM to 11:00 PM) and the night shift (11:00 PM to 7:00 AM shift) by Nurse #5. Nurse #5 was interviewed on 2/19/2025 at 3:40 PM. Nurse #5 confirmed she was assigned to care for Resident #7 for the evening shift on 1/21/2025 and the night shift ending at 7:00 AM on 1/22/2025. Nurse #5 confirmed she did administer the Heparin and normal saline flush for the PICC line for Resident #5 as ordered on the 1/21/2025 evening shift and the night shift. Nurse #5 stated she did not have the antibiotics (Vancomycin or Cefepime) from the pharmacy to give Resident #5 on 1/21/2025 or 1/22/2025. Documentation in the nursing progress notes for Resident #7 dated 1/22/2025 at 8:28 AM written by Nurse #7 revealed, Notified NP (Nurse Practitioner) from [Medical Group name] that both antibiotic prescriptions [were discontinued] because it initially entered under other instead of pharmacy, therefore pharmacy did not receive [prescription]. Called pharmacy, writer advised to re-enter medications under pharmacy. Unable to enter medications, attempted to provide verbal order. Sent to voice mail. NP aware. Advised that MD (Medical Doctor) will be in office this shift and see if she can enter order and verify that verbal order was taken. Nurse #7 was interviewed on 1/18/2025 at 12:33 PM. Nurse #7 indicated when Resident #7 was admitted on [DATE] and Nurse #4 assisted with the admission orders. Nurse #7 revealed on the morning of 1/22/2025 she realized the antibiotics required for Resident #7 did not come in from the pharmacy. Nurse #7 stated the orders for the antibiotics were put in as the order type of other and those orders had to be discontinued. Nurse #7 further explained that if the order type selected had been AHR Medication Orders, the medication orders would have been sent directly from the electronic health record to the pharmacy. Nurse #7 explained she was initially unable to change the antibiotic orders, so she was on the phone with the IV (intravenous) department at the pharmacy for 20 minutes as they walked her through how to enter the orders for the IV antibiotics into the electronic medical record so the pharmacy would receive them. Nurse #7 indicated the pharmacy delivered medications to the facility between 12:00 AM and 3:00 AM so, Resident #7 was not able to receive the antibiotics until 1/23/2025. Nurse #7 did not know and could not remember if the IV antibiotics ordered for Resident #7 were in the automated medication dispensing system. Nurse #7 explained she was orienting a new nurse on 1/22/2025 on the 7:00 AM to 3:00 PM shift and she did not have time to look in the automated dispensing system or the backup pharmacy. Nurse #4 was interviewed on 2/18/2025 at 9:17 AM. Nurse #4 confirmed she put the initial orders for Resident #7 into the electronic medical record for transmission to the pharmacy. Nurse #4 stated that as the Unit Manager she helped the nursing staff with new admissions. Nurse #4 stated it looked like the orders were changed in the electronic medical record and the facility was awaiting the arrival of the antibiotics from the pharmacy. Nurse #4 explained that if an order type was entered as other then the order does not go to the pharmacy to be filled, and the nurses do not have to check off the order as being completed on the MAR. Nurse #4 stated the facility not receiving the antibiotics for Resident #7 was either a pharmacy issue or the physician changed the orders. Nurse #4 did not have an explanation why she entered the order in as other for the antibiotic Vancomycin. Nurse #4 also did not know why the order for Cefepime was not entered on 1/21/2025 for Resident #7, but she would look into it. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/22/2025 at 5:00 PM. The Medication Administration note dated 1/22/2025 at 9:02 PM by Nurse #6 stated, Rescheduled awaiting pharmacy. Nurse #6 was interviewed on 2/19/2025 at 3:53 PM. Nurse #6 confirmed he was assigned to care for Resident #7 for the IV administration of Cefepime on 1/22/2025 at 5:00 PM. Nurse #6 stated that if the Cefepime was not documented as administered then he did not have the IV antibiotic Cefepime to administer to Resident #7. Pharmacist #1 from the facility pharmacy was interviewed on 2/18/2025 at 1:04 PM. Pharmacist #1 stated the pharmacy received Resident #7's prescriptions for Vancomycin and Cefepime on 1/22/2025 with a start date of 1/23/2025. Pharmacist #1 stated the IV antibiotics Vancomycin and Cefepime for Resident #7 were delivered to the facility at 1:11 AM on 1/23/2025. Pharmacist #1 stated the only orders received on 1/21/2025 for intravenous administration for Resident #7 were for the Heparin and normal saline flush. The Director of Nursing (DON) was interviewed on 1/18/2025 at 2:17 PM. The DON stated she knew that the facility would not have the Vancomycin and Cefepime to administer to Resident #7, so she called the hospital requesting they send the IV Vancomycin and Cefepime with Resident #7. The DON revealed that Resident #7 was already en route when she called. The DON indicated that if the antibiotics were not available for Resident #7 upon admission, then the facility would have added additional doses to the end of the six-week antibiotic administration timeline so he would have received all the ordered doses. The DON did not think the antibiotics Vancomycin and Cefepime were actually in the automated medication dispensing system to be administered to Resident #7 upon his admission. The Medical Doctor (MD #1) for Resident #7 was interviewed on 2/19/2025 at 1:35 PM. MD #1 stated she did not think it was a realistic expectation for the facility to have been able to provide the scheduled Cefepime dose on 1/21/2025 scheduled at 5:00 PM to Resident #7 because he had just been admitted to the facility. MD #1 conceded Resident #7 should have gotten the antibiotics he needed when he was admitted .

Based on record review, and staff, Pharmacist and Medical Doctor interviews, the facility failed to administer four doses of antibiotics and one dose of insulin upon admission for one (Resident #7) of two residents reviewed for significant medication errors. Findings included: Resident #7 was admitted to the facility on [DATE] from the hospital. Resident #7 had diagnoses of diabetes and osteomyelitis. Documentation on a discharge summary from the hospital dated 1/21/2024 revealed Resident #7 was started on intravenous Vancomycin and Cefepime for osteomyelitis of the left elbow planned for a six-week (1/7/25-2/18/25) course via peripherally inserted central catheter (PICC line). (A PICC line is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein above the heart.) Vancomycin and Cefepime are antibiotics used to treat infection. The current discharge medication list for Resident #7 included: 1 gram (g)/250 milliliters (ml) IVPB (intravenous piggyback) of Vancomycin in 0.9% sodium chloride to be injected into the vein daily for 31 days; 2 g/110 ml IVPB Cefepime in 0.9% sodium chloride to be injected into the vein every 12 hours for 31 days; and; and 10 units of Glargine insulin injected subcutaneously once daily. Insulin is used to treat diabetes mellitus. Documentation in the nursing progress notes written by Nurse #7 for Resident #7 revealed he was admitted to the facility on [DATE] at 3:02 PM. a. Documentation on a physician order dated 1/21/2025 written by Nurse #4 revealed an order was entered into the electronic medical record of Resident #7 for 1 g/250 ml Vancomycin in 0.9% sodium chloride to be injected into the vein. There was no evidence that a physician's order for Cefepime was entered into the electronic medical record for Resident #7 on 1/21/2025. Nurse #4 was interviewed on 2/18/2025 at 9:17 AM. Nurse #4 confirmed she put the initial orders for Resident #7 into the electronic medical record for transmission to the pharmacy. Nurse #4 stated that as the Unit Manager she helped the nursing staff with new admissions. Nurse #4 did not have an explanation why she entered the order in as other for the antibiotic Vancomycin. Nurse #4 also did not know why the order for Cefepime was not entered on 1/21/2025 for Resident #7, but she would look into it. Nurse #4 stated she did not know why Resident #7 missed the initial doses of his intravenous antibiotics. Nurse #4 did not know if the facility had intravenous antibiotics in the automated medication dispensing system. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/21/2025 at 5:00 PM or 1/22/2025 at 5:00 AM. Documentation on the MAR revealed Resident #7 did not receive an IV Vancomycin dose on 1/22/2025 at 6:30 AM. Documentation in the physician orders revealed an order was initiated on 1/21/2025 at 3:00 PM for 5 ml Heparin 10 units/ml flush solution and 10 ml normal saline flush solution to be used intravenously every shift to maintain the PICC line. Documentation on the MAR revealed Resident #7 was administered the Heparin flush on 1/21/2025 on the evening shift (3:00 PM to 11:00 PM) and the night shift (11:00 PM to 7:00 AM shift) by Nurse #5. Nurse #5 was interviewed on 2/19/2025 at 3:40 PM. Nurse #5 confirmed she was assigned to care for Resident #7 for the evening shift on 1/21/2025 and the night shift ending at 7:00 AM on 1/22/2025. Nurse #5 confirmed she did administer the Heparin and normal saline flush for the PICC line for Resident #5 as ordered on the 1/21/2025 evening shift and the night shift. Nurse #5 stated she did not have the antibiotics from the pharmacy Vancomycin or Cefepime to give Resident #5 on 1/21/2025 or 1/22/2025. Nurse #5 stated she did not know if the antibiotics were in the automated medication dispensing system. Nurse #5 confirmed she did have access to the automated medication dispensing system. Nurse #5 explained she would not have been able to get the IV antibiotics out of the automated medication dispensing system if they were in there, because the facility did not have the required two Licensed Practical Nurses on her shift to open the automated medication dispensing system. Nurse #7 was interviewed on 1/18/2025 at 12:33 PM. Nurse #7 revealed on the morning of 1/22/2025 she realized the antibiotics required for Resident #7 did not come in from the pharmacy. Nurse #7 explained she was initially unable to change the antibiotic orders, so she was on the phone with the IV (intravenous) department at the pharmacy for 20 minutes as they walked her through how to enter the orders for the IV antibiotics into the electronic medical record so the pharmacy would receive them. Nurse #7 indicated the pharmacy delivered medications to the facility between 12:00 AM and 3:00 AM so, Resident #7 was not able to receive the antibiotics until 1/23/2025. Nurse #7 did not know and could not remember if the IV antibiotics ordered for Resident #7 were in the automated medication dispensing system. Nurse #7 explained she was orienting a new nurse on 1/22/2025 on the 7:00 AM to 3:00 PM shift and she did not have time to look in the automated dispensing system or the backup pharmacy. Documentation on the Medication Administration Record (MAR) revealed Resident #7 did not receive an IV Cefepime dose on 1/22/2025 at 5:00 PM. The Medication Administration note dated 1/22/2025 at 9:02 PM by Nurse #6 stated, Rescheduled awaiting pharmacy. Nurse #6 was interviewed on 2/19/2025 at 3:53 PM. Nurse #6 confirmed he was assigned to care for Resident #7 for the IV administration of Cefepime on 1/22/2025 at 5:00 PM. Nurse #6 stated that if the Cefepime was not documented as administered then he did not have the IV antibiotic Cefepime to administer to Resident #7. Nurse #6 revealed the facility did not have IV antibiotics in the automated medication dispensing system. Pharmacist #1 from the facility pharmacy was interviewed on 2/18/2025 at 1:04 PM. Pharmacist #1 stated the pharmacy received Resident #7's prescriptions for Vancomycin and Cefepime on 1/22/2025 with a start date of 1/23/2025. Pharmacist #1 stated the IV antibiotics Vancomycin and Cefepime for Resident #7 were delivered to the facility at 1:11 AM on 1/23/2025. Pharmacist #1 stated the only orders received on 1/21/2025 for intravenous administration for Resident #7 were for the Heparin and normal saline flush. Pharmacist #1 revealed Resident #7 did not need to miss any doses of antibiotics because both the Vancomycin and Cefepime were in the automated medication dispensing system. The Director of Nursing (DON) was interviewed on 1/18/2025 at 2:17 PM. The DON stated she knew that the facility would not have the Vancomycin and Cefepime to administer to Resident #7, so she called the hospital requesting they send the IV Vancomycin and Cefepime with Resident #7. The DON revealed that Resident #7 was already en route when she called. The DON revealed that she did not think the IV Vancomycin and IV Cefepime were in the automated medication dispensing system on 1/21/2025 when Resident #7 was admitted . Pharmacist #1 was interviewed again on 1/18/2025 at 2:59 PM. Pharmacist #1 revealed that according to the pharmacy documentation, from 1/21/2025 through 1/22/2025, the facility had three vials of 1g of Vancomycin and three vials of 2 g of Cefepime in addition to full IV boxes with additional IV Vancomycin and IV Cefepime in the backup supply. Documentation on an inventory snapshot of the automated medication dispensing system dated 1/21/2024 through 1/22/2024 revealed the facility had three vials of 2 g Cefepime solution and three vials of 1g Vancomycin solution listed. The Medical Doctor (MD #1) for Resident #7 was interviewed on 2/19/2025 at 1:35 PM.MD #1 stated that Resident #7 shouldn't have missed the antibiotics and there were ways to mitigate this if the hospital had worked with the facility to provide the initial doses of the needed antibiotic. MD #1 explained Resident #7 would not have any long-term effects from missing the initial doses of Vancomycin and Cefepime when he was first admitted . MD #1 further explained his creatinine level was fine, and the antibiotics stayed in the system for a while. (Vancomycin may cause serious effects to kidneys for which creatinine levels are monitored.) b. Documentation on a physician order dated 1/21/2025 written by Nurse #4 revealed an order was entered into the electronic medical record for Resident #7 for 10 units of Glargine solution 100 units/ml injected subcutaneously one time a day for diabetes. This order was supposed to start on 1/22/2025 at 9:00 AM but was discontinued on 1/21/2025 at 4:15 PM by Nurse #4. There was no documentation on the Medication Administration Record (MAR) of 10 units of Glargine solution 100 units/ml administered to Resident #7 on 1/22/2025 at 9:00 AM. The documentation on the MAR revealed the order was discontinued on 1/21/2025 at 4:15 PM so, there was no space on the MAR requiring documentation of administration at 9:00 AM on 1/22/2025. Nurse #4 was interviewed on 2/18/2025 at 9:17 AM. Nurse #4 stated she thought the insulin order for Resident #7 was changed on 1/21/2025 and did not arrive until the next day as an explanation for why the order for insulin was discontinued on 1/21/2024. Nurse #7 was interviewed on 2/18/2025 at 12:33 PM. Nurse #7 stated on 1/22/2025 she was orienting a new nurse on the medication cart from 7:00 AM to 3:00 PM. Nurse #7 stated she did not recall anything about insulin for Resident #7. An interview was conducted with Pharmacist #1 from the facility pharmacy on 2/18/2025 at 1:04 PM. Pharmacist #1 revealed that the insulin Glargine was available to the facility on [DATE], in a backup fridge kit. Pharmacist #1 revealed that the pharmacy received the order for the insulin Glargine for Resident #7 on 1/21/2025 with the medication filled and delivered to the facility on [DATE] at 3:17 AM. The Director of Nursing was interviewed on 1/18/2025 at 2:17 PM. The Director of Nursing did not know why Resident #7 did not receive the 10 units of Glargine insulin on 1/22/2025 at 9:00 AM or if there was communication with the physician. The Medical Doctor (MD #1) for Resident #7 was interviewed on 2/19/2025 at 1:35 PM. MD #1 stated a possible reason for not administering the Glargine insulin to Resident #7 was because of a therapeutic interchange. (A therapeutic interchange is when a doctor switches a patient's prescription to a different drug that has similar therapeutic effects.) MD #1 stated Resident #7 should have been able to get the medications he was ordered to receive.

Based on staff interviews and record review, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week for 48 of 180 days reviewed. Findings include: The Nursing Staff Schedule and the Daily Staffing Form were reviewed from 8/1/23 through 8/29/24. The Nursing Staff Schedule and the Daily Staffing Form indicated an RN was not scheduled for at least eight consecutive hours a day on the following dates: 8/5/23, 8/26/23, 8/27/23, 9/9/23, 9/10/23, 9/23/23, 11/5/23, 11/17/23, 11/19/23, 12/3/23, 12/10/23, 12/24/23, 12/25/23, 12/28/23, 1/1/24, 1/6/24, 1/7/24, 1/20/24, 1/21/24, 1/26/24, 2/4/24, 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/13/24, 2/14/24, 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/21/24, 2/23/24, 2/24/24, 2/25/24, 2/26/24, 2/28/24, 2/29/24, 3/2/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/12/24, and 3/14/24. Telephone interviews with the prior Director of Nursing (DON) and Scheduler were attempted but calls and messages were not returned. During an interview with the Administrator on 8/29/24 at 10:22 A.M. she revealed it was the responsibility of DON and the Scheduler to ensure 8 hours of consecutive RN coverage daily was met. The Administrator explained there had been staffing changes and things have improved.

Based on record review, Resident Council group interview and staff interviews, the facility failed to resolve and communicate the facility's efforts to address resident concerns voiced during 3 of 10 Resident Council meetings in October 2023, January 2024, and June 2024. Findings included: During a Resident Council group interview conducted on 8/27/24 at 1:08 PM, residents present shared an ongoing issue with the resolution of concerns voiced during Resident Council meetings. The Resident Council minutes for the period October 2023 through July 2024 were reviewed and revealed the following: Resident Council minutes dated November 2023 included no documentation of the facility's response to a concern voiced during the previous meeting of 10/26/23 which included one resident who requested money and did not receive it until 3 weeks later. Resident Council minutes dated 1/25/24 indicated residents voiced concerns related to having to beg for ice on 1st and 2nd shifts, clothing lost in laundry and yet to be found and waiting a long time to be put to bed after returning to the facility. Resident Council minutes dated 2/29/24 revealed no response from the facility for the previous month concerns. Resident Council minutes dated 06/27/24 indicated residents voiced concerns related to cold food, not enough variety at all meals, and laundry returned to other residents. Resident Council minutes dated 7/25/24 included no documentation of the facility's response to the concerns voiced during the previous meeting. An interview was conducted with the Activities Director on 8/27/24 at 1:47 PM. She revealed that when complaints were made in Resident Council meetings, she brought them to the Administrator who then delegated to department heads. The Activities Director stated she was not involved in the resolution process, unless the concern was related to activities. During an interview with the Administrator on 8/28/24 at 11:50 AM, she revealed that all grievances, including Resident Council complaints, were forwarded to the Grievance Official, who was the Social Worker (SW). The grievances were discussed in the daily morning meeting and then the complaints were distributed to the designated department heads. She stated Resident Council complaints should be included on the grievance log, and the resolution should be included in the written grievance form. A letter would then be sent to the complainant. The Administrator indicated that the department heads probably still had not yet returned the resolutions from the months of October 2023, January 2024, and June 2024. The SW was interviewed on 8/28/24 at 12:08 PM. She revealed that the Activities Director wrote up the grievances from Resident Council meetings and presented them in the daily morning meeting. The SW then delegated the complaints to the assigned department heads. The department heads were then supposed to return the resolutions to her, she logged them and wrote the resolution letter. The Administrator then signed the grievance and resolution letter and returned them back to the SW. The SW stated that all complaints from Resident Council should be attached to the meeting minutes as the resolution to previous grievances. She indicated the problem was that grievance responses were often not returned from the department heads; therefore, she could not create a resolution letter. The Social Worker could not recall if the issues from the October 2023, January 2024, and June 2024 Resident Council meetings were discussed in morning meetings or if the resolutions from the department heads were handed back to her. During a follow-up interview with the SW on 8/28/24 at 12:16 PM, she revealed that if a Resident Council grievance was discussed in the daily morning meeting, then she took notes on the grievance details. If she recorded the grievance, then she followed up with the department heads. She did not always receive the grievances discussed from Resident Council meetings. The SW stated that grievances should be resolved within 48 hours of the initial complaint. She indicated that there was not a thorough process in place to log the grievances and check their status. The SW stated she was not notified that she was the Grievance Official, but rather the Administrator thus far. During a follow-up interview with the Administrator on 8/29/24 at 10:37 AM, she revealed that the department heads were not returning the grievance resolutions to the SW. They were supposed to resolve the issue and then bring it to the SW to log and communicate the resolution to Resident Council members. The Administrator indicated that the SW should follow-up with the department heads if the resolutions were not returned, and the complaints should have been resolved within 72 hours.

Based on record review, resident and staff interviews the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 5 of 65 residents reviewed for advance directives. (Residents #1, #5, #28, #29, and #47). The findings include: a. Review of Resident #1's medical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include heart failure, chronic obstructive pulmonary disorder, and anemia. He held a physician order for full code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. b. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that include diabetes, chronic kidney disorder, and seizures. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. The Medical Orders for Scope of Treatment form was signed by the Nurse Practitioner on 7/9/24. There were not any signatures by Resident #5 or their responsible party (RP). Only a note was documented on the form that the RP was called via telephone on 7/8/24. The MOST form was blank and not filled out. Resident #5's RP was interviewed on 8/28/24 at 10:32 AM. She revealed that she had assisted with Resident #5's admission paperwork and could not recall if Advance Directive Care Planning was discussed by a facility staff member. c. Review of Resident #28's medical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include diabetes, seizures, and anemia. She held a physician order for full code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #29's medical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include stroke, hypertension, and diabetes. He held a do not resuscitate physician order for code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. e. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegia, emphysema, and seizures. She held a physician order for full code status. There was no documentation in the record for education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. An interview was conducted on 8/26/24 at 2:33 PM with the Regional Nurse Consultant. She stated all that was available from the facility for Advance Directives was the Medical Orders for Scope of Treatment (MOST) form stored in binders at the nurses' stations. The Administrator was interviewed on 8/29/24 at 10:44 AM. She revealed that education/discussion of Advance Directives should have been documented for each resident in the facility. The Administrator stated that residents should be reassessed for advance directives every 3 months or when there was a significant change in condition.