Every finding on record at Carolina Rehab Center of Burke

Based on observations, general statues, google maps, record review, staff, resident, and physician assistant interviews, the facility failed to safely transport Resident #1 to his medical appointment. On 08/03/26 while being transported to a medical appointment Resident #1 began to slide out of his wheelchair. The Van Driver, who was a Nursing Assistant (NA) pulled the van over, removed Resident #1's seatbelt and attempted to reposition Resident #1 back in his wheelchair and was unsuccessful. The Van Driver then lowered Resident #1 down onto the floor of the van and called NA #1 with his cell phone and reported what had occurred. NA #1 communicated to the Van Driver that she would alert management and to stay where he was. After the Van Driver notified NA #1 of what occurred he made the decision to drive 0.8 miles through 2 stop lights, with his hazard lights on, going 5 miles per hour to the medical plaza where Resident #1's appointment was located with Resident #1 sitting on the floor of the van unsecured. Driving with Resident #1 unsecured on the floor of the van created a high likelihood of serious injury, serious harm, serious impairment or death. This affected 1 of 3 residents reviewed for supervision to prevent accidents. Immediate jeopardy began on 08/03/26 when the Van Driver removed Resident #1's seat belt, lowered Resident #1 to the floor of the van, and drove 0.8 mile (calculated via Google Maps) with Resident #1 unsecured on the van floor. Immediate jeopardy was removed on 08/28/26 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D, which is no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure staff education and monitor systems put in place are effective.The findings included:Review of the North Carolina General Statue 20-135.2A read in part; each occupant of a motor vehicle manufactured with seat belts shall have a seatbelt properly fastened about his or her body at all times when the vehicle is in forward motion on a street or highway in this State.Resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, other muscle spasms, muscle weakness, and major depressive disorder.Review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed Resident #1 to be cognitively intact with no delusions, behaviors, or rejection of care. Resident #1 was coded as not having any impairments to his upper extremities and impairments on both sides of his lower extremities and required limited assistance with oral hygiene and eating; he needed extensive assistance with upper body dressing, and was dependent on others for toileting, bathing, lower body dressing, putting on and taking off footwear, personal hygiene, bed mobility, and transfers. Resident #1 was coded as receiving scheduled pain medications, did not receive pain medications on an as needed basis, and received non-medication interventions for pain. Resident #1 was coded as reporting pain occasionally with no reported effect on his sleep, therapy, or day to day activities. He was also coded as not having a history of falls and had not fallen since his admission to the facility. Resident #1 was coded as taking antianxiety, antidepressant, and hypnotic medications.Review of Resident #1's progress notes in his electronic health record revealed a note dated 08/03/26 at 2:00 PM, written by Nurse #1, that reported NA #1 notified the writer that the Van Driver had requested assistance after Resident #1 slipped out of his wheelchair while being transported to a doctor's appointment. The notes indicated that Nurse #1 assessed Resident #1 with no redness, bruising, swelling, or other signs of injury. The note reported that Resident #1 stated he just started to slide and there was nothing anyone could do about it. The note stated that Resident #1 denied any pain or discomfort and was in no acute distress.An interview with Resident #1 on 08/24/26 at 11:47 AM revealed he recalled the incident that occurred on 08/03/26. He reported the day of the incident, he had a neurology appointment in Hickory and was being transported in the facility's van and was the first time he had been transported via facility transportation since his admission. He continued, stating when he was loaded into the van, the Van Driver locked his wheelchair in place and then went to put a flimsy seat belt across him. Resident #1 stated he asked the Van Driver if the seat belt was the only thing holding him in his wheelchair to which the Van Driver replied yes. Resident #1 stated the Van Driver then began the journey to the neurology office and while they were on the interstate, he could feel himself bouncing around in his wheelchair. Resident #1 stated once they exited the interstate and turned onto a side road, the van maneuvered over potholes in the road, and he began to realize he was sliding forward. As he started to call out to the Van Driver, he slid forward with his knees hitting the floor of the van and bent backwards with his left arm caught between the lap belt and chest restraint. He reported at that time the Van Driver pulled to the side of the road, got out and attempted unsuccessfully to get him back into his wheelchair. Resident #1 stated when the Van Driver realized he was unable to get him back into his wheelchair; he called the facility for assistance. Resident #1 stated after the Van Driver contacted the facility he decided to continue on to the neurology appointment with Resident #1 still on his knees in the van. Resident #1 reported he did not know how far the van continued to travel with him on his knees but stated he felt that it took approximately 10-15 minutes to get to the destination. Resident #1 reported eventually Nurse #1 and NA #1 arrived at the neurology office and were able to assist the Van Driver in getting Resident #1 back into his wheelchair. Resident #1 reported after he got back into his wheelchair, he continued with his neurology appointment with NA #1 staying back to return to the facility with himself and the Van Driver. Resident #1 reported that on the return trip the seat belt remained loose. An observation was conducted on 08/26/26 at 11:58 of Resident #1's wheelchair. The wheelchair was noted to be a standard size wheelchair. The frame of the wheelchair was noted to be bright orange and had foot pedals on the left and right side at the bottom of the wheelchair. The foot pedals would swing in/out and could be removed if needed. The arms of the wheelchair were attached to the frame of the wheelchair with one vertical plastic piece that was located on the underside in the middle of the arm rest and then attached at the frame at the seat of the chair.An observation of the intersection where the transportation van came to a rest was conducted on 08/25/26 at 6:05 PM and revealed it to be a 7 lane road with a speed limit of 50 miles per hour (mph) with 2 lanes crossing over a 6 lane divided road with a speed limit of 45 mph. One lane turned right (east), two lanes went across the intersection, 2 lanes turned left (west), with two more lanes oncoming in the opposite direction. The intersection did not appear busy with approximately 15-20 vehicles observed moving through the intersection in various directions of travel.An interview with the Van Driver on 08/24/26 at 1:48 PM revealed he was the transportation driver for Resident #1 on 08/03/26 and stated he was the only transportation driver for the facility. The Van Driver reported that when he loaded Resident #1 into the van, he locked the brakes on Resident #1's wheelchair and then secured 4 anchors to the frame of Resident #1's wheelchair. Afterwards, he placed the 3-point harness across Resident #1's abdomen and left shoulder. Once the Van Driver placed the 3-point harness over Resident #1, he tightened the harness, ensured it was snug, and asked Resident #1 if he was comfortable, to which Resident #1 reported he was. The Van Driver indicated Resident #1 never voiced any concern to him about the 3-point harness being loose. The Van Driver stated once Resident #1 was secured he made his way onto the interstate and reported everything seemed to be going well with him checking on Resident #1 multiple times by looking into the rearview mirror and asking if Resident #1 was ok, with no concerns voiced by Resident #1. The Van Driver reported they exited the interstate and were the first vehicle at a stop light waiting to turn left. He turned left when the light turned green and continued down the road towards the destination, he soon noted that there was some broken and uneven pavement ahead and he slowed to about 30-35 miles per hour. While the van was going over the broken pavement, he heard Resident #1 state [Van Driver], I should have told you sooner, but I feel like I'm starting to slide out of my chair. The Van Driver stated when he heard this, he took his foot off of the gas pedal, turned on his hazard lights, and coasted to the side of the road. He reported the van came to a stop at or near a light at an intersection. When they came to a stop, the Van Driver quickly ran to the back of the van to try and get Resident #1 repositioned in his wheelchair. The Van Driver stated when he got to Resident #1, he released Resident #1's seatbelt and tried pulling Resident #1 back into his wheelchair. The Van Driver stated resident had not slid all the way out of the wheelchair, but his bottom had slid to the front edge of the wheelchair seat with Resident #1's shoulders resting on the back of his wheelchair. The Van Driver reported he was able to slide Resident #1 somewhat back into his wheelchair, but when he loosened his grip, he could feel Resident #1 start sliding towards the front of the wheelchair again. Due to not being able to get Resident #1 safely back into his wheelchair, Resident #1 reportedly asked to be sat down on the floor of the van so the Van Driver lowered Resident #1 to the floor of the van on his bottom. He then called NA #1 from his cell phone and notified her of what happened. He stated he was told to stay put and the facility would be sending staff to help get Resident #1 back into his wheelchair. He reported after he got off the phone with the facility, Resident #1 began stating how he did not want to miss his neurology appointment and that he was comfortable where he was on the floor of the van. The Van Driver stated he could see the neurology office from where the van was stopped so after Resident #1 continued to pressure him into continuing to the neurology appointment he did not want to miss, the Van Driver elected to leave his flashers on and proceed to the neurology office at 5 miles per hour partially on the shoulder of the road with Resident #1 sitting on his bottom in the floor of the van unsecured. He stated Nurse #1 and NA #2 had arrived at the neurology office and Nurse #1 assessed Resident #1 for injuries and did not find any. He stated the three staff members then gathered around Resident #1 and lifted him back into his wheelchair. He reported Resident #1 was still insistent that he continue to his neurology appointment, so he was taken into the office and seen by the neurologist. The Van Driver stated that NA #1 remained with he and Resident #1 for the neurology appointment and rode back to the facility in the transportation van. The Van Driver stated the return trip went smoothly with Resident #1 not voicing any complaints of pain or discomfort and when they got back to the facility, he took Resident #1 to his room and notified Nurse #1 that they had returned so she could complete an additional assessment. The Van Driver reported that he did not know how Resident #1 slid down or out of his wheelchair. An interview with NA #1 on 08/25/26 at 10:11 AM revealed she had received a telephone call from the Van Driver on 08/03/26 at 2:03 PM on her cell phone where he informed her that Resident #1 had slid from his wheelchair during transportation to his medical appointment and he required assistance to get Resident #1 back into his wheelchair. She stated she questioned where they were and the Van Driver stated they were not far from the neurology office and he could see the building from where the van was stopped. NA #1 told the Van Driver that she would notify someone and that they would send staff to him shortly. NA #1 stated she reported the phone call from the Van Driver to Nurse #1, and they went and informed the Director of Nursing who told them both to go to the scene and assess Resident #1 and assist him back into his wheelchair. NA #1 stated she and Nurse #1 left the facility and on the way to where the van was, they received another telephone call from the Van Driver informing them that Resident #1 was insistent that he did not miss his appointment and to meet them there. NA #1 stated she believed that when they received the phone call, that the Van Driver was already at the neurology office. NA #1 stated when they pulled into the parking lot, they saw the facility van and pulled in behind it. When they got to the facility's van, she saw Resident #1 on the edge of his seat, with the Van Driver standing in front of him, with his seat belt off, and his knees off the floor. NA #1 stated the 3 staff members (NA #1, Nurse #1, and Van Driver) adjusted Resident #1 back, securely into his wheelchair and then Nurse #1 assessed Resident #1 for injuries and did not find any. She reported she and Nurse #1 asked Resident #1 what happened and he reported whenever the van hit a bump in the road, he could feel himself sliding forward until he started to slide completely out of the wheelchair. She stated Resident #1 stated he knew he should have said something to the Van Driver sooner but did not indicate why he had not. NA #1 reported she remained with Resident #1 and the Van Driver for Resident #1's neurology appointment and rode back in the van with them. She stated the return trip was uneventful. She also reported that on the return trip, the 3-point harness was secure but not snug. NA #1 stated she was assigned to Resident #1 the following day and did not recall him having any complaints of increased pain or discomfort on her first shift (7:00 AM-3:00 PM).An interview with Nurse #1 on 08/24/26 at 2:37 PM revealed she was notified by NA #1 on 08/03/26 that she needed to leave the facility and go assist the Van Driver because Resident #1 was sitting in the floor of the van on the side of the road. Nurse #1 stated she then went to the Director of Nursing and informed her of the situation. She reported that the Director of Nursing instructed NA #1 and Nurse #1 to head to where the van was so Nurse #1 could assess Resident #1 and they could assist the Van Driver in getting Resident #1 back into his wheelchair. As she and NA #1 left the facility, she spoke briefly, in person, with the Physician Assistant and informed her of the situation. She stated the Physician Assistant informed her that she would see Resident #1 as soon as they returned or first thing in the morning if she was gone when Resident #1 returned. She stated the Physician Assistant also told her that if Resident #1 was complaining of pain, she could write an order to send him to the emergency room if that was what Resident #1 wanted, order x-rays, or additional pain medication, and to just keep her updated. Nurse #1 stated as they got closer to where the van was, she and NA #1 received another call from the Van Driver stating that Resident #1 was adamant that he did not want to miss his neurology appointment. Nurse #1 reported she informed NA #1 to tell the Van Driver that he could not go anywhere until they arrived. As Nurse #1 and NA #1 closed in to where their understanding of where the van was pulled to the side of the road, they did not see the van anywhere, so they continued on towards the original destination and found the van in the parking lot of the neurology office. As they entered the van, she saw Resident #1 sitting on his bottom with his legs semi-crossed in front of him. She reported she believed the 3-point harness was still around Resident #1 with the lap belt up, around his armpits and the chest restraint coming straight down and latching to the lap belt at Resident #1's right shoulder. She stated she was most concerned that there may be some abrasions to Resident #1's back from possibly hitting the foot pedals of his wheelchair when he was lowered to the ground. She reported she asked Resident #1 if he was ok and Resident #1 stated he was fine and was not hurting anywhere. Nurse #1 observed Resident #1's extremities for injuries and did not note any swelling, redness, bruising, or abrasions. She stated she completed range of motion tests with Resident #1 with no concerns noted. She then directed the Van Driver to get behind Resident #1 and along with herself and NA #1, the three of them lifted Resident #1 back into his wheelchair. Once Resident #1 was back in his wheelchair, she again asked him if he was ok and Resident #1 reported he was fine and did not voice any complaints of pain or discomfort. She reported Resident #1 stated he wanted to continue with his neurology appointment and NA #1 was left to ride back with the Van Driver and Resident #1 to assist if needed. Nurse #1 stated on her return trip to the facility, she contacted Resident #1's emergency contact and informed her of what happened. Later, she was informed that Resident #1 had returned from his appointment, so she went to Resident #1's room and completed another skin assessment to check for injuries and reported she did not find anything concerning. Review of the neurology progress note dated 08/03/26 revealed he was being seen for follow-up of his multiple sclerosis and severe muscle spasms. Per the note he had not been seen for an extended period. Resident #1 reported he experienced muscle soreness following physical therapy sessions and a recent incident where he fell out of his wheelchair during transport to the clinic. During Resident #1's physical examination, Resident #1 was noted with minimal use of his legs and mildly increased tone (stiffness) throughout.An interview with the Director of Therapy on 08/28/26 at 12:34 PM revealed Resident #1 received therapy services on the following days after the incident: 08/04/26, 08/06/26, 08/07/26, 08/08/26. She reported Resident #1 was seen around 11:00 AM each day and completed various exercises including step therapy using his arms and legs, seated balance, and leg strengthening. The Director of Therapy reported that it was not uncommon for Resident #1 to report being sore due to his medical condition. She reported that he did complain of some mild discomfort on 08/04/26 during his therapy session and it was decided to give him a day of rest on 08/05/26. She reported when Resident #1 returned to therapy on 08/06/26, Resident #1 had the best day he had since his admission and reported he was able to complete 20 full minutes of step therapy and that therapy was able to work with Resident #1 on decreased assistance with his transfers. She also reported Resident #1 did not have any abnormal complaints of pain on 08/06/26.Review of Resident #1's physician orders revealed the following order dated 08/04/26: - Lumbar (back) x-ray - one time only.An interview with the Physician Assistant on 08/25/26 at 3:07 PM she reported on 08/03/26 Nurse #1 informed her that Resident #1 had fallen from his wheelchair during transport to a doctor's appointment. She stated Resident #1 had not returned from his doctor's appointment by the time she left the facility, so she saw him the next morning. She reported when she spoke with Resident #1, he stated he did not hit anything on his body when the incident happened but that he had slid out of his wheelchair and onto his bottom. She stated Resident #1's only complaint when she saw him on 08/04/26 was some vague lower back pain but he also reported he had been up, in his wheelchair most of the day and insinuated to her that the back pain was most likely related to being up for so long. The Physician Assistant continued, stating she went ahead and ordered x-rays out of an abundance of caution, and they returned negative for any acute injury but did show some degenerative disc disease, which she stated could cause the low back pain Resident #1 complained of. She stated Resident #1 was already receiving pain medication for other medical conditions, so no additional pain medications were ordered. She stated over the following days after the incident, Resident #1 appeared to be doing well and attended his therapy sessions. In regard to the Van Driver driving to the neurology office with Resident #1 on the floor of the van and unsecured, she reported even at a slow pace, there were concerns for any resident to be transported unsecured in the floor including potential for an accident that could result in injury or potential death. The Physician Assistant indicated that all residents should be secured in transportation vans when they are in motion for safety purposes. Review of physician progress notes revealed a note dated 08/04/26 written by the Physician Assistant that indicated she saw Resident #1 on 08/24/06 for low back pain following slipping out of personal wheelchair while on way to doctors appointment. Per the note, Resident #1 reported being sore all over but denied any specific pain. The note indicated Resident #1 received a full assessment and the Physician Assistant noted there was no pain with palpation or gross deformities with Resident #1's musculoskeletal examination. The Physician Assistant noted in her progress note that she had ordered a lumbar x-ray but had a high suspicion that the pain was from an exacerbation of Resident #1's chronic pain.Review of the x-ray results of Resident #1's x-rays taken on 08/04/26 revealed there was no acute injury, but some identified degenerative disc disease.An interview with the Director of Nursing on 08/25/26 at 3:26 PM revealed she recalled the incident on 08/03/26. She reported around 2:00 PM on 08/03/26, Nurse #1 came into her office and stated she had been informed that Resident #1 had slid from his wheelchair while in transport to his doctor's appointment and asked what the Director of Nursing wanted to do. The Director of Nursing stated she directed Nurse #1 and NA #1 to go to where Resident #1 was and assess him for injuries and if he were injured, to call 911 and to ensure that the Van Driver stayed where he was until they arrived. The Director of Nursing reported she heard back from Nurse #1 approximately 30 minutes later and was informed that Resident #1 appeared to be ok and there were no injuries reported. She stated at this time she was also informed that the van was found at the neurology office and not on the side of the road. She reported Nurse #1 stated that when they arrived at the neurology office Resident #1 still had his seat belt strapped around him with the lap belt up around his armpits with his butt on floor of the van. The Director of Nursing reported the Van Driver should not have continued to the neurology appointment after he identified that Resident #1 was not secure in his wheelchair and should have stayed, as directed, on the side of the road until assistance arrived due to the potential dangers of additional injury being sustained while in transport. She reported she was informed via telephone call from Nurse #1, that NA #1, Nurse #1, and the Van Driver were able to get Resident #1 back into his wheelchair and that Nurse #1 had left NA #1 with Resident #1 and the Van Driver at the neurology appointment to provide additional assistance on the ride back. The Director of Nursing reported when Resident #1 arrived back to the facility, she took the Van Driver and with the assistance of the Administrator, had him recreate the entire transportation series of events. She reported the Van Driver walked her and the Administrator through each step of the process with the Administrator acting as Resident #1 and they were unable to determine how Resident #1 was able to slide forward in his wheelchair. The Director of Nursing stated she and the Administrator ultimately identified the contributing factor of the incident to be the type of slick material that Resident #1's shorts he was wearing were made of. The Director of Nursing also reported that Resident #1 was also given an additional assessment when he returned to the facility with no injuries noted and he was seen the following day by the facility's Physician Assistant who did not provide any new pain medication orders but did order x-rays which were taken and returned with no findings of any acute injuries. An interview with the Administrator on 08/26/26 at 2:30 PM revealed she was aware of the incident on 08/03/26 and stated it was her understanding from what she was told by the staff and resident involved and her investigation, that Resident #1 slid to the front of his wheelchair during transportation and when the Van Driver was unable to get Resident #1 resituated in his wheelchair, Resident #1 was lowered to the floor of the van. Unfortunately, even after the Van Driver was instructed to remain where he was and wait for assistance, he allowed Resident #1 to pressure him into continuing to his neurology appointment while he was on the floor of the van unsecured. The Administrator stated it was her understanding that the Van Driver left his emergency flashers on and proceeded at a slow pace to the neurology office where Nurse #1 and NA #1 found the van. She stated Resident #1 was assessed at the neurology office by Nurse #1 and was found with no injuries and wanted to continue with his scheduled appointment. NA #1 and the Van Driver stayed with Resident #1 and Resident #1 returned to the facility after the appointment with no issue. She indicated after Resident #1 returned to the facility, he was assessed again by Nurse #1 and again, no injuries were reported. She stated Resident #1 was then seen by the Physician Assistant the following day and x-rays were ordered out of precaution. The x-ray results verified no acute injuries to Resident #1 following the incident. She reported after Resident #1 returned to the facility, she and the Director of Nursing had the Van Driver reenact the events of the incident and they determined that Resident #1's shorts potentially could have been the root cause of the incident as they were slick and slippery against the lift pad. Regarding the Van Driver driving with Resident #1 on the floor of the van to the neurology office, she reported she believed he had been instructed to stay put and stated she expected him to stay where he was until a nurse arrived at the scene.The Administrator was notified of immediate jeopardy on 08/26/26 at 3:12 PM.The facility provided the following credible allegation of immediate jeopardy removal:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Based on staff interviews and observation, Resident #1 was gently lowered to the floor of the transport van by the facility van driver after Resident #1 reported to the Van Driver that he had started to slip downwards in his wheelchair towards the floor of the van on 08/03/2026. Resident #1 was on the way to a doctor's appointment and voiced the van driver that he was sliding. The van driver pulled the van over and lowered Resident #1 to the floor of the van after several attempts to pull him back up in the seat appropriately. The van driver is a nursing assistant and is trained to reposition residents as needed. The van driver called the facility and alerted Nurse Aide (NA) #1 who then alerted Unit Manager UM #1 of what had occurred. Unit Manager #1 proceeded to get Nurse Aide (NA) #1 and leave to go to the location where Resident #1 was. The van driver then proceeded to drive the van approximately 8/10th of a mile to the appointment with Resident #1 on the floor of the van unsecured due to the patient indicating that he was not hurt and needed to get to his appointment. The Van driver then went into the doctor's office and requested assistance from the office staff to aid him in getting Resident #1 off the floor. He was advised by the Office Staff that someone would be out in a few minutes to assist. Upon arrival, Unit Manager #1 performed a head-to-toe assessment on Resident #1. No discolorations or complaints of pain were observed during the assessment. A driver from another transport company that was parked in front of the facility van assisted the facility van driver in getting Resident #1 back into the wheelchair. The Unit Manager assisted the van driver in repositioning Resident #1 back into his wheelchair, and he then proceeded to go into his scheduled doctor's appointment. After the doctor's appointment was completed, Resident #1 was transported by the facility's van driver and NA #1 in accompaniment back to the facility. Resident #1 is alert and cognitively intact. Resident #1's sister was notified by Unit Manager #1 at the time of the event on 08/03/26. No concerns were voiced. The van driver was immediately educated on the securement of wheelchairs and expectations when an incident occurs while being transported in the van by the Administrator when he returned to the facility. The medical provider was notified by the unit manager by phone at the time of the accident on 08/03/26.Root cause analysis was initiated on 8/19/2026 by the Administrator, Director of Nursing, and the Regional Director of Clinical Services.Resident # 1 had on nylon shorts and was sitting on a lift sling. This contributed to Resident #1 sliding down in the wheelchair. Resident #1 has a diagnosis of Multiple Sclerosis. Resident #1 is cognitively intact. Resident #1 was secured in his wheelchair, and the seat belt/harness system applied to Resident #1 according to the Q'straint system procedure. Resident #1 then stated to the van driver that he was not hurt and wanted to proceed to the scheduled appointment. The root cause is Resident #1 wore nylon shorts and was sitting on the lift sling. This caused Resident #1 to begin sliding. After the van driver moved resident #1 to the floor, the van driver drove Resident #1 to his appointment, with Resident #1 sitting on the floor of the van and unsecured. The van driver proceeded to transport the resident to the scheduled appointment after the resident insisted that missing the appointment was not an option. The van driver exercised poor judgment by transporting the resident without ensuring the resident was properly secured. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed Upon return from appointment on 08/03/2026, Resident #1 was assessed a second time including a pain assessment and a skin assessment by Unit Manager. No negative findings.The Medical Provider was notified by the Unit Manager with orders to assess Resident #1 on 08/03/2026. No negative findings were identified.08/04/2026 Medical Provider evaluated Resident #1 in the facility and order received for an x-ray of the lumbar spine.08/04/2026 X-ray obtained with no negative findings.Upon return from appointment on 08/03/2026, the van driver was educated by the administrator on the Q'straint system and provided return demonstration to the Administrator. This was completed on 08/03/2026 using Q'straint procedures that are written manuals and online training.The van driver was educated by the Administrator and Director of Nursing on emergency procedures including what to do if a resident starts to slide into the floor during transportation on 8/3/2026:1. Prepare the environmentEnsure the van is pulled into a safe environment, turn on your hazard lights, and ensure the wheelchair is in a safe position.Unstrap the resident if it will not cause injuries or harm. If it is determined that the resident will obtain injuries, the driver will call 911 immediately.2. Position yourself correctlyStand close to the resident's side, with your feet shoulder-width apart for balance.Use a gait belt if available to maintain control 3. Slide the resident back into the chairWith one hand on the resident's hip and the other on their knee, gently guide them back into the seat4. Secure the residentOnce repositioned, ensure straps are tight but not too tight to cause discomfort and

Based on record review and staff and physician assistant interviews, the facility failed to reorder a resident's diazepam (a medication used to treat anxiety, muscle spasms, and seizures) for 24 hours after they administered the last dose which resulted in the resident missing 5 doses of the medication for 1 of 3 residents reviewed for provide pharmaceutical services to meet the needs of residents (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, other muscle spasms, muscle weakness, and major depressive disorder.Review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed Resident #1 to be cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. Resident #1 was coded as taking antianxiety, antidepressant, and hypnotic medications.Review of Resident #1's physician orders revealed the following:- diazepam oral tablet 2 milligrams (mg) - give 2 tablets by mouth 3 times a day for muscle spasms per [nurse practitioner] orders. This order was written on 06/17/26.- diazepam oral tablet 2mg - give 2 tablets by mouth at bedtime for spasms, 2 tablets equal 4mg. This order was written on 06/17/26.Review of Resident #1's July 2026 medication administration record (MAR) revealed he was provided a scheduled dose of diazepam 2 mg on 07/13/26 at 11:00 AM by Agency Nurse #1. Additional review revealed that Resident #1 was scheduled for another dose of diazepam on 07/13/26 at 5:00 PM and did not receive it due to the medication not being available as indicated on the medication administration record with a code of 9. On 07/14/26 Resident #1 did not receive his scheduled doses of diazepam at 5:00 AM, 11:00 AM, or 5:00 PM as indicated on the medication administration record with a code of 9 for the 5:00 AM and 11:00 AM doses. The 5:00 PM dose was coded with an H, for a physician hold of the medication. Further review of the MAR revealed the nurse staff who signed off as the medication being unavailable was Agency Nurse #1 on 07/13/26 at 5:00 PM and Agency Nurse #2 on 07/13/26 at 11:00 PM and again on 07/14/26 at 5:00 AM.Multiple attempts to reach Agency Nurse #1 via telephone were unsuccessful.Multiple attempts to reach Agency Nurse #2 via telephone were unsuccessful.An interview with Resident #1 on 08/24/26 at 11:47 AM revealed in July, he was told several times that his diazepam was not available and did not get his scheduled doses. Stated during that time his pain increased and it affected his ability to participate in his therapy activities as much as he would have liked.An interview with Unit Manager #1 on 08/25/26 at 2:24 PM revealed the facility had an emergency supply of medications available if there happened to be a delay in prescriptions arriving to the facility or if there was a delay in receiving refill requests but that the emergency supply of medications the facility kept did not include diazepam. She reported that when a hall nurse or medication aide noticed that a resident's medication was getting low or had run out, a refill request was placed with the pharmacy, either by calling in a refill request to the pharmacy, or requesting a written prescription from the provider. She stated the pharmacy has a 3:00 PM cut off time for same day delivery and any medications placed at 3:00 PM or earlier typically arrived on the same day with the 10:00 PM medication run from the pharmacy.An interview with the Pharmacist on 08/25/26 at 12:39 PM revealed the pharmacy received a refill request for Resident #1's diazepam on 07/14/26 at 1:40 PM. The Pharmacist reported that the pharmacy filled the prescription and it left the pharmacy at 7:00 PM and according to their records, the medication was received by the facility at 9:40 PM on 07/14/26.An interview with the Director of Nursing on 08/25/26 at 3:26 PM revealed that while she was not working at the facility in July 2026, she was familiar with the facility's policy for reordering medications. She reported that when a resident was running low on medications, the nurse was expected to either gather a handwritten prescription from one of the facility's providers, or have the provider complete an electronic prescription to the pharmacy. She stated if a resident was completely out of a medication, the nurse was expected to check the facility's emergency supply to see if they happened to have it available until the prescription was able to be refilled and delivered to the facility from the pharmacy. The Director of Nursing stated in Resident #1's case, the hall nurse (Agency Nurse #1) should have immediately spoken to the provider on 07/13/26 after she administered the last available dose of diazepam and requested that it be refilled so it could be received as soon as possible and if the medication would not have been received by the pharmacy before the next scheduled dose, it would have given the facility time to either have a substitute medication available, if approved by the provider, or have the medication refilled at a nearby pharmacy so Resident #1 would not have to miss a dose of his diazepam.An interview with the Administrator on 08/31/26 at 1:47 PM revealed Agency Nurse #1 should have followed the policy and procedures of the facility that included notification to the provider immediately after the administration of Resident #1's last diazepam dose. The Administrator also reported that Agency Nurse #1 also could have notified herself or the Director of Nursing so the medication could get refilled as soon as possible. The Administrator continued and stated that running out of Resident #1's diazepam at 11:00 AM on 07/13/26 and not requesting a refill until 1:40 PM on 07/14/26 was too long of a delay and that Agency Nurse #1 should have had communication with the provider, the Director of Nursing, or herself.An interview with the Physician Assistant on 08/25/26 at 3:19 PM revealed she had the ability to electronically prescribe medications and indicated she would have requested a refill of Resident #1's diazepam on 07/13/26 if she had been made aware. The Physician Assistant also reported the missed doses of diazepam could increase some discomfort but stated residents typically can tolerate a few missed doses of diazepam. She continued, stating that diazepam builds up in a person's system and it can linger for a long time, especially in residents who had taken the medication for an extended period, like Resident #1. She stated she did not believe that the missed doses of Resident #1's diazepam would cause him to have any withdrawal type symptoms.

Based on record reviews, and Responsible Person and staff interviews, the facility failed to ensure a resident's Do Not Resuscitate (DNR) goldenrod form (a portable physician's order printed on goldenrod colored paper that communicates an individual's wishes regarding resuscitation efforts for emergency responders) and Medical Orders for Scope of Treatment (MOST) form (outlines health care and end-of-life care instructions) stating DNR and Do Not Intubate (DNI) (intubation is a medical procedure where a tube is inserted into the airway to support breathing) were provided to Emergency Medical Services (EMS) upon emergent transfer to the hospital on Sunday 6/22/25. As a result of the resident having no advance directive information conveyed to the hospital, the resident was listed as a full code (all possible life saving measures), was intubated and placed on a mechanical ventilator (a machine that moves air in and out of the lungs) as part of his treatment. The resident's Responsible Person stated that Resident #101 was very specific about not wanting to be resuscitated or intubated and wished to have comfort measures only due to having to previously witnessed a family member intubated and not wanting that for himself. The facility later provided the hospital with resident's DNR and MOST form paperwork, he was extubated (medical procedure where the breathing tube is removed from the airway), and comfort measures were put into place as per his advance directive wishes. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #101).Findings included: Resident #101 was admitted to the facility on Friday 6/20/25 with diagnoses including dementia, history of falls, and muscle weakness. A physician order located in the electronic health record dated 6/20/25 revealed Resident #101's code status was DNR. A telephone interview conducted with the Director of Marketing on 8/19/25 at 9:10 PM revealed she reviewed Resident #101's completed and signed original portable DNR goldenrod form and MOST form showing he was a DNR and DNI inside the facility's medical records box on 6/22/25. A change in condition progress note written by Nurse #1 dated 6/22/25 revealed Resident #101 had a change in condition that included altered level of consciousness and a fall. Resident #101 was located on the floor at his bedside, lying face down with profuse bleeding from right forehead, pressure was applied to head, and Emergency Medical Services (EMS) was called to transport the resident to the hospital emergently. Attempted to contact Nurse #1 for interview and she was unable to be reached. The EMS record dated 6/22/25 revealed EMS was dispatched for emergency response related to a fall with possible head injury. EMS arrived on the scene to find Resident #101 lying face down on the floor with staff holding pressure to the resident's head with a towel. Facility staff advised that while they were passing trays to other residents outside Resident #101's room they heard him fall and went in to find him on the floor. Facility staff stated that when they first arrived Resident #101 was awake and speaking to them and as time progressed, he became less responsive to any stimuli. Resident #101 had equal and reactive pupils but were noted to be sluggish, he would open eyes to painful stimuli but had no other responses. Vital signs were obtained and were within normal limits. Facility staff handed the crew a packet of paperwork that had a face sheet and a medication list. EMS questioned the facility staff regarding code status of Resident #101 and any related paperwork. The facility staff on scene advised that Resident #101 was full code to the best of their knowledge as they had no other paperwork. EMS confirmed and facility staff advised they had not been told or given paperwork to suggest anything other than a full code status. Resident #101 was transferred to the stretcher and secured with assistance from facility staff on scene and without incident. The hospital was notified of incoming trauma patient and updates provided. Resident #101 was monitored throughout transport with no significant changes noted. Bleeding remained controlled with no changes noted. Vital signs were monitored throughout transport with no significant changes noted. Resident #101 was transferred into room with assistance from hospital staff on scene without incident. Report was given to hospital staff on scene and facility paperwork was copied by hospital registration for staff. Attempts to contact EMS for interviews were unsuccessful. Hospital records dated 6/22/25 revealed Resident #101 presented for evaluation after an unwitnessed fall at his rehabilitation living facility. Facility staff found Resident #101 unresponsive and not communicating. Upon EMS arrival, Resident #101 was responsive to pain only and had a large scalp laceration. On hospital arrival, Glasgow Coma Scale (clinical tool used to measure level of consciousness) was 4 (score of 8 or less indicates more severe injury) and Resident #101 was promptly intubated, placed on mechanical ventilation, and stabilized. However, later when the paperwork was brought from the facility it was realized that Resident #101 was a DNR and DNI. Resident #101 was extubated, family wishes were honored, and Resident #101 was made comfort care. A telephone interview was conducted with Resident #101's Responsible Person (RP) on 8/19/25 at 4:29 PM revealed Resident #101 was admitted to the facility on [DATE]. He stated on 6/22/25 he had just returned home from visiting with Resident #101 when he received a telephone call around 5:30 PM from Nurse #1 stating Resident #101 had fallen inside of his room, hit his head, and was bleeding from a cut on his head. He revealed Nurse #1 stated Resident #101 was being transported by EMS to the nearest hospital. The RP revealed that once he arrived at the hospital and was allowed back to see Resident #101, he observed the resident had been intubated and placed on a ventilator. He stated Resident #101 had completed his advance directives paperwork prior to being admitted to the facility and was very specific about not wanting to be resuscitated or intubated and wished to have comfort measures only due to having to watch a family member be intubated and not wanting that for himself. He (the RP) revealed they asked the hospital staff about Resident #101's DNR form and MOST form stating that he did not want to be resuscitated or intubated and the hospital staff stated they did not receive any paperwork from the facility regarding Resident #101's advance directives and as a result he was being treated as a full code (all life save measures). The RP was familiar with the Director of Marketing from the facility, so he called her (the Director of Marketing) to see if there was a way to have the facility to send over Resident #101's advance directive paperwork. The RP indicated the Director of Marketing went to the facility herself and picked up the original paperwork and brought it over to the hospital. He revealed once the hospital received the advance directive paperwork, they discussed with him (the RP) and his family if they still wanted to proceed with Resident #101's advance directive wishes. They all agreed to proceed as the resident wished, and Resident #101 was then extubated. The RP stated seeing anyone be intubated and then having to be extubated would be awful enough but having to watch his mother sit and cry while his father was being put through the procedure was something he would not wish for anyone. He revealed he did not understand why the facility did not send the advance directive paperwork for Resident # 101, especially since those had been completed prior to his admission to the facility and were his wishes. A telephone interview conducted with the facility Director of Marketing on 8/19/25 at 9:10 PM revealed she was familiar with Resident #101 and his family. She stated on the evening of 6/22/25 she had received a telephone call from Resident #101's RP stating the facility did not send the advance directive paperwork to the hospital that stated Resident #101 was a DNR and DNI and that because the hospital had not received the paperwork they had to treat Resident #101 as a full code, had intubated him, and placed him on a ventilator. She revealed Resident #101's RP stated he had tried to call the facility several times with no answer and asked if she could locate Resident #101's advance directives paperwork and have it sent to the hospital to show Resident #101's advance directive wishes. The Director of Marketing stated she attempted to call the facility with no answer, so she drove to the facility to locate Resident #101's advance directive paperwork and take it to the hospital herself. The Director of Marketing revealed when she arrived at the facility she did speak with Nurse #1 who stated she had sent the facility transfer paperwork with Resident #101 but did not include his advance directives paperwork as she was not able to locate them. The Director of Marketing stated after locating Resident #101's advance directives paperwork she was able to take the original forms to the hospital herself. She revealed once the hospital received the original advance directive forms, they were able to discuss Resident #101's wishes with his family and Resident #101 was extubated and placed on comfort care. The Director of Marketing revealed that to her knowledge original advance directive forms were to be placed inside of the advance directive books located at each nurse station and she did not know why the originals for Resident #101 had been placed inside of the medical record box. An interview conducted with the Administrator on 8/20/25 at 11:06 AM revealed she was familiar with Resident #101 and the incident that occurred on 6/22/25. She stated she believed Nurse #1 did send transfer paperwork with Resident #101 but was aware she did not include the advance directives. The Administrator stated Nurse #1 could not locate Resident #101's advance directives paperwork prior to him leaving for the hospital which caused Resident #101 to be treated as a full code until the facility was able to locate the paperwork and provide it to the hospital. She revealed typically when the facility had a new admission, and the advance directive was completed at the facility then the paperwork would be placed inside of the physician notebook to be signed. She stated once the advance directive paperwork was signed by the physician the paperwork was placed into the medical records box to be scanned into the resident's electronic health record, and the original was then placed inside of the advance directive notebook located at the nurse's desk. The Administrator revealed she believed Resident #101's advance directives were completed and signed prior to his admission to the facility and were placed into the medical records box to be scanned into Resident #101's electronic health record (EHR) instead of being placed inside the advance directive notebook. She stated she would expect advance directive forms to be placed inside of the advance directive notebook by the licensed nursing staff so they can be accessed. Licensed nursing staff should also make sure advance directives were sent with residents to appointments, transfers, or discharges. The Administrator stated Nurse #1 should have reviewed EHR to ensure Resident #101's code status and if she had any questions she should have contacted her supervisor. The facility was notified of immediate jeopardy on 8/20/25 at 7:04 PM. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility failed to ensure that Resident #101's Do Not Resuscitate (DNR) goldenrod and Medical Order of Scope of Treatment (MOST) form was sent with him upon emergent transfer to the hospital on 6-22-25 between 5:30pm and 6:00pm. He had a fall earlier in the day that resulted in a laceration to his head and had to be sent out to the hospital. The family was notified of the need to send Resident #101 to the hospital due to the fall, as well as the Medical Provider by Nurse #2. Nurse # 1 communicated to the Emergency Medical Service (EMS) staff he was a DNR but could not produce the actual DNR document for EMS staff, who then treated him as a full code. When he was treated at the hospital, initially he was treated as a full code and was intubated. The Director of Marketing later found the DNR/goldenrod and took it to the hospital around 11:30 pm when it was located. We were unable to determine who actually put the documents in the medical records box, however only licensed nursing staff receive and process the admission packet. The DNR had been put in the medical records box to scan into the record, but because of the patient being admitted around 6:15PM on Friday the 20th, it was not scanned into the medical record and then placed in the DNR binder at the nurses' station therefore at the time of the emergent need, it was not available. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents with a code status of Do No Resuscitate and Do Not Intubate were at risk with this deficient practice. All residents with code status were audited by reviewing the Physician's order for the patient's code status in the electronic medical record against the documents contained in the DNR book located at each nurses' station on 7-10-25. This was completed by the Director of Nursing (DON) to ensure that the DNR/goldenrod and MOST Form is available in the DNR book. No negative findings noted upon completion of the audit for code status. An Audit for advance directives including FULL CODE/ DNR and/or MOST forms was completed on 7-10-25 by the Director of Nursing and ongoing with any new admissions /readmissions/ significant changes. The audit was performed by checking the current patient charts in the facility for advance directive orders for FULL CODE/ DNR and MOST form. If it was indicated for the resident to have a DNR and/or MOST form, there was an audit of the original forms that are kept in DNR book to ensure that the orders and the DNR and/or MOST forms matched. No other discrepancies were found. All orders for DNR and/ or a MOST form matched with the resident order indicated. The DNR/MOST Book contains the DNR and/ or MOST form and are located at each nurses station. All Advance Directives are also scanned in the Medical Records under the Document Tab by the Medical Records Coordinator. Code status for each patient whether DNR or Full Code are in the electronic Physician orders and is visible under the information bar on the electronic Medication Administration Record (eMAR) and the electronic Kardex. The medical record box was checked and there were no DNRs and/ or MOST forms in the box waiting to be uploaded to the medical record by the Director of nursing on 6-23-25 and continues daily. The Director of Nursing or designee also checks this box on the weekends and after hours by coming in or calling the facility. All new admissions/readmissions/ significant changes after the 100% audit completed on 7-10-25 were audited for compliance by the DON from 7-11-25 onward and continues at this time. Director of Nursing also completed an audit of all admissions/re-admissions/significant changes from the last 30 days (6-11-25 to 7-10-25) to identify any issues with the DNR and/or MOST form not being available. Quality Assurance and Process Improvement (QAPI) determined that the root cause was placing the original copy of the DNR in the Medical Record Box instead of placing the original in the DNR/MOST book when reviewed on 6-26-25 during QAPI. Therefore, the new process of copying the original DNR and / or MOST form to put in the Medical Records Box instead of the original will alleviate not having the original readily available to be sent for any transfers.No other emergent transfers were affected as evidenced by no issues reported to the facility and documents in the eMAR. An audit of all emergent transfers to the hospital was completed for the last 30 days to validate there were no issues was also completed by the Director of Nursing on 7-10-25. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education will be completed by 7-10-25 by Director of Nursing for all licensed nurses to ensure that if a patient comes in with a DNR/Goldenrod and /or a MOST form upon admission, it is immediately placed in the DNR book, and a copy is provided to medical records. If a patient transfers out of the facility for a medical need, the original Goldenrod and/or MOST form must accompany that patient to the hospital. The Director of Nursing used the following education based on nursing policy and procedure #303. The DON provided the following education to all licensed nurses: 1. If a resident admits with a signed DNR and /or MOST, a copy of the DNR is to be made and placed in the medical record box for uploading instead of the original form. 2. The ORIGINAL DOCUMENT is to then be placed in the DNR book immediately located at each nurse's station.3. If the patient is transferred out for any reason, the ORIGINAL DOCUMENT will be sent with the patient Based on #1 education listed above, the process of having a copy of the DNR and/ or MOST form to be placed in the medical record box for uploading will ensure having the DNR and/ or MOST form also noted in the medical record aside from the original being in the DNR book located at each nurses' station. Not putting the original copy in the medical record box for uploading will ensure that the original is not lost and is readily available in the DNR Book for any transfers. The code status will be placed on the 24- hour report sheet by the admitting licensed nurse upon admission/ readmission or any significant changes. The licensed nurse will verify the DNR and / or MOST status, then update the physician order in the medical record. The licensed nurse will then place the original copy in the DNR Book at the nurses' station and update the 24- hour report sheet that nurses utilize when giving shift reports. Licensed nursing staff were educated by the Director of Nursing began on 6-30-25 with completion by 7-10-25. The orders are reviewed by the nursing leadership team (consisting of the DON, SDC, Unit Manager #1 and Unit Manager #2) during the Monday to Friday clinical morning meeting and update the DNR Book and the report sheets at that time as needed. The Night Supervisor and Weekend Supervisor and On-call Nurse will review and report to DON as needed for any off hours and weekend admissions/readmissions / significant changes. The Regional Director Clinical services (RDCS) provided this education on 6-30-25. Licensed floor nursing staff, including any nurse manager or nurses assigned to a cart who has not received education by 07/10/25 will not be allowed to work until education is completed. Education will be provided by the Director of Nursing or designee. A roster of all licensed staff maintained by the Director of Nursing are checked off as they are educated. Any PRN (as needed by licensed staff) or agency licensed nurse working within the building must acknowledge understanding prior to working their shift as evidenced by being able to state the location of the DNR Binder and awareness of sending the DNR and /or MOST form with any transfers. The education will be completed by the Director of Nursing or designee prior to their first shift.New licensed floor nursing staff will receive education within the orientation process by the Staff Development Coordinator (SDC) or designee. The Director of Nursing informed the SDC of the need to include this in orientation class for any licensed nurse on 7-9-25 to start with the next orientation class. Any PRN (as needed licensed staff) and agency licensed nurse working within the building must acknowledge understanding before working. Each new licensed employee will be able to state their awareness of following process #1 to #3:1. If a resident admits with a signed DNR and /or MOST, a copy of the DNR is to be made and placed in the medical record box for uploading instead of the original form. 2. The ORIGINAL DOCUMENT is to then be placed in the DNR book immediately located at each nurse's station.3. If the patient is transferred out for any reason, the ORIGINAL DOCUMENT will be sent with the patient Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Quality Assurance and Process Improvement (QAPI) meeting was held on 6-26-25 with the Interdisciplinary Team (IDT) that consists of the Administrator, Medical Director, Director of Nursing, Discharge Director, Medical Records Director, Dietary Manager, Director of Rehabilitation, Minimum Data Set (MDS) Nurse, Human Resource Manager, Activities Director). The IDT team determined that a Plan of Correction was needed and developed the Plan of Correction for approval to follow for QAPI to ensure monitoring and compliance. The IDT team decided to audit and monitor FULL CODE /DNR /MOST documents in the DNR/MOST book and in the Electronic Medical Record for all new admissions/readmission / significant changes daily for 4 weeks, then 5 times per week for 4 weeks, then 3 times per week for 4 weeks for 4 weeks to ensure ongoing compliance. The audit will be completed by matching the Physician order for all code status to the electronic medical record and the DNR/MOST book located at each nurse's station. The DON or designee will complete the required audits as outlined above. Results will be reviewed upon completion of audits with QAPI team monthly for the next 3 months minimum to determine success and potential need for continuation or until substantial compliance is achieved. Alleged Date of Immediate Jeopardy Removal and Compliance: 7/11/25 The facility's corrective action plan was validated on 8/25/25 by the following: Interviews with licensed nursing staff, admissions coordinator, Director of Marketing, Social Worker, and medical records revealed they had received education on resident advanced directives paperwork. They stated when a new admission arrived at the facility with completed advanced directive paperwork, a copy of the paperwork was to be placed inside the medical records box to be scanned into the resident's electronic health record (EHR) and the original was to be placed inside of the advanced directive notebook located at each nurse desk. They revealed if a resident completed their advanced directive paperwork upon their arrival to the facility or anytime during their stay at the facility the original paperwork was to be placed inside the physician notebook located at each nurse desk and then once signed by the physician the original would then be placed inside the advanced directive notebook and a copy of the paperwork placed inside the medical records box to be scanned into the resident's EHR. They stated the original advanced directive was to be sent as part of the facility packet anytime a resident was leaving the facility for an appointment, transfer to the hospital, or discharged from the facility. They were able to demonstrate the process, and observations were made of all residents original advanced directive forms located in the advanced directive notebook at each nurse desk and copies of advanced directives were located inside the medical records box waiting to be scanned into the resident's EHR. Review of facility orientation education for new hires and contract staff included education on advanced directive process. Reviewed the audit and monitoring tools with no issues noted. Interviews with the Administrator and the DON revealed they had received training from their corporate regarding the advanced directive process and making sure all original advanced directives were placed inside the advanced directive notebooks, copies were placed inside the medical records box for scanning, only advanced directives that needed a physician signature were placed inside the physician notebook, and original advanced directive was included with facility paperwork for any resident appointments, transfers, or discharges. The facility's immediate jeopardy removal date and compliance date of 7/11/25 was validated.

Based on record review, observations and staff interviews, the facility failed to discard expired vials of influenza vaccine in 1 of 3 medication rooms (Jasmine medication room), failed to date an opened insulin pen and discard loose pills in 1 of 4 medication carts (Dogwood medication cart).The findings included:1.An observation of the [NAME] medication room with Unit Manager (UM) #1 on 8/19/25 at 1:50 PM revealed five unopened vials and two opened vials of influenza vaccine labeled with an expiration date of 6/30/25. These influenza vaccine vials were available for use in the medication room refrigerator.An interview with UM #1 on 8/19/25 at 1:58 PM revealed the Infection Preventionist or the third shift nurses were responsible for checking the medication room for expired medications. UM #1 stated she knew they had just ordered some influenza vaccine from the pharmacy for the upcoming flu season. During the interview, further observation of the pharmacy label on the bag which contained the expired influenza vaccine vials indicated the vials were delivered to the facility from the pharmacy on 11/7/24. UM #1 stated the expired vials should have been sent back to the pharmacy after they expired.An interview with the Infection Preventionist (IP) on 8/20/25 at 10:20 AM revealed she had just checked the medication rooms on 8/17/25 and she did not observe the expired influenza vials inside the [NAME] medication room refrigerator. The IP stated she checked the medication rooms for expired medications at least once a week or as needed whenever a resident was discharged . She stated that she would have gotten rid of the expired influenza vials if she had observed them during her weekly audits.An interview with the Director of Nursing (DON) on 8/20/25 at 10:30 AM revealed the IP cleaned out the medication rooms weekly and whenever there were discharges. The DON stated the IP normally looked for any expired medications and she would return them to the pharmacy or destroy them if they could not be returned. The DON further stated that she was surprised about hearing about the expired flu vials because the IP told her that she had just checked the [NAME] medication room, and they had not given a flu shot since May 2025 because it was not flu season. 2.An observation of the Dogwood medication cart with Nurse #1 on 8/19/25 at 1:59 PM revealed an undated opened Insulin lispro pen available for use in the top drawer.Review of the manufacturer's instruction for Insulin lispro indicated it expired 28 days after opening, whether it was in a vial, cartridge, or pen, as long as it was stored at room temperature. After 28 days, any remaining insulin should be discarded, even if it still looks and feels normal. Further observation of the Dogwood medication cart revealed a plastic cup with a handwritten resident name containing 18 loose pills stored inside the narcotic drawer.An interview with Nurse #1 on 8/19/25 at 2:00 PM revealed she didn't notice the undated open pen of Insulin lispro, but that it should have been dated when it was opened because it expired 28 days after opening. Nurse #1 stated she was not aware of the loose pills in the narcotic drawer and did not notice them whenever she counted the narcotics with the outgoing nurse. Nurse #1 stated the loose pills looked like morning medications for Resident #124 but denied that she placed the loose pills in the narcotic drawer and that she gave Resident #124 his morning medications.An interview with the Director of Nursing (DON) on 8/20/25 at 10:30 AM revealed the insulin pen should have been dated when it was opened because it was only good for 28 days after opening. The DON stated that the nurses were not supposed to keep loose pills in the medication carts, and that the nurses were supposed to be checking the medication carts daily.

Based on record review, and physician assistant (PA) and staff interviews, the facility failed to maintain accurate advance directives throughout the medical record for 1 of 5 residents reviewed for advance directives (Resident #46). Resident #46 was admitted to the facility on [DATE].Review of an admission progress note dated 8/7/2025 indicated Resident #46 was alert and oriented to person, place, time and situation. Review of Resident #46's Physician's orders, revealed an order dated 8/7/2025 that read code status (DNR). Review of a provider progress note dated 8/8/2025 indicated Resident #46 was seen by the Physician Assistant (PA) and the PA discussed advance directives with Resident #46 and verified Resident #46 wanted to be a Do Not Resuscitate (DNR) and that a MOST form and goldenrod (DNR form) was signed. Resident #46's advance directives care plan, initiated on 8/10/2025 specified the Resident was Full Code. Care plan goals listed as: Honor residents advance directive choices, referral to physician as needed for advanced directive changes, review advance directives with resident as needed. Review of the Code Book (a binder that contained paper copies of residents' advance directives and code status) revealed Resident #46's paper medical record contained a signed Medical Orders for Scope of Treatment (MOST) form that indicated Resident #46's preference for a Do Not Resuscitate (DNR) status in the event he had no pulse and was not breathing. The form was signed by Resident #46 and dated 8/8/2025. Review of the profile page of Resident #46's electronic health record revealed Resident #46's code status was listed as a DNR. During an interview on 8/18/2025 at 1:14 PM Nurse #4 stated a Resident's advance directives/code status was located on a resident's profile in the electronic medical record, or a paper copy in the Code Book at the nurse's station. Nurse #4 verified Resident #46 had DNR listed on his profile in his electronic medical record and had a MOST form and DNR form in the Code Book. During an interview on 8/19/2025 at 9:23 AM Nurse #6 stated when a resident was admitted if they don't have advance directives in place, they are a full code until advanced directives could be discussed with the resident or the residents Responsible Party (RP). Nurse #6 recalled when Resident #46 admitted , no advance directives arrived with the resident, the following day the PA had a discussion with Resident #46 and the MOST form and DNR form was completed and signed. Nurse #6 stated she thought the MDS nurses updated the advance directive care plan when a resident's code status changed. Nurse #6 stated she thought the Unit Managers passed on the change in code status. During an interview on 8/19/2025 at 10:15 AM Nurse #5 stated you could find residents' Code status in the Code Book or in their electronic medical record. Nurse #5 stated if a resident had a change in condition, the nurse was responsible for updating the new order in the computer so the resident's profile would be correct and stated it was reported at shift change. Nurse #5 stated she thought the unit managers would report the change in status. Nurse #5 stated she was not aware that an email needed to be sent to the Social Worker if a resident had a change in code status. During an interview on 8/19/2025 at 9:43 AM the MDS Nurse stated the Social Worker was responsible for updating advance directive care plans. During an interview on 8/19/2025 at 9:45 AM the Social Worker stated when a resident had a change in code status, she was normally notified by the unit manager and then updated the care plan. The Social Worker verified Resident #46's care plan read Full Code, but there was an order for DNR, and Resident #46's electronic medical record read DNR. The Social Worker stated she had not been notified of the change, but it would be corrected. During an interview on 8/19/2025 at 9:49 AM Unit Manager #1 stated an email should be sent to the Social Worker when a resident had a change in code status, so the care plan can be updated. The Unit Manager #1 stated any nurse or unit manager could send the email to the Social Worker. During an interview on 8/19/2025 at 11:13 AM the Physician Assistant (PA) stated she had a discussion with Resident #46 regarding his advance directives on 8/8/2025. The PA stated the MOST form was discussed with Resident #46 in detail and Resident #46 understood and wanted to be a DNR. The PA stated she expected a resident's code status to be correct and match throughout the entire paper and electronic medical record. During an interview on 8/19/2025 1:15 PM the Director of Nursing (DON) stated when a resident has a change in code status that typically the nurse will go in and change the order and make sure the paper forms are completed. The DON stated most of the time she was notified, and it would be discussed in the morning meeting, and the Social Worker could make needed changes to the care plan. The DON stated that any nurse or unit manager should let the Social Worker know and the nurse who changed the order was responsible. The DON stated a resident's code status should match throughout the entire medical record.During an interview on 8/19/2025 at 11:18 AM the Administrator stated she was not completely familiar with the process nursing followed for changes in resident code status, but she expected it to be correct and consistent throughout the entire medical record.

Based on record review and staff interviews and observation, the facility failed to post census information for 322 of 323 days reviewed for daily nurse staffing (October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, July 2025 and 8/1/2025-8/19/2025).Review of the daily nurse staffing sheets from 10/1/2024 through 8/18/2025 revealed there was no census information entered. Observation of the daily nurse staffing sheet dated 8/19/2025 revealed the census was entered. During an interview on 8/19/2025 at 11:30 AM the Scheduler stated she was responsible for completing and posting the daily nurse staffing sheet. The Scheduler stated she had been in her current position for about two years and was not aware until 8/19/2025 that the census needed to be completed on the daily nurse staffing sheet and the Director of Nursing (DON) had informed her this morning that the census needed to be completed on the daily nurse staffing sheet for all three shifts. The Scheduler stated she had completed the census section today and would continue to fill the form out completely. During an interview on 8/19/2025 at 1:00 PM the DON stated she was not aware the census had to be completed for all three shifts, or that it had not been completed on any daily nurse staffing sheets since 10/1/2025. The DON stated the Scheduler would enter the census on the daily nurse staffing sheets from now on. During an interview on 8/19/2925 at 1:15 PM the Administrator stated she was unaware the census had not been entered on the daily nurse staffing sheets. The Administrator stated she thought it was adjusted throughout the day as residents were admitted and discharged . The Administrator stated she expected the daily nurse staffing sheets to be filled out completely and correctly.

Based on observations and staff interviews the facility failed to date and cover an open food item and discard food with signs of spoilage in 1 of 1 walk-in cooler; date an open beverage item and date milkshakes to identify their use-by date in 1 of 1 reach-in cooler; label and date open food items and discard expired beverages in 1 of 1 dry storage room; date an open food item in the food preparation area of 1 of 1 kitchen; and maintain clean refrigerators in 3 of 3 nourishment rooms (,d+[DATE] hall, 300 hall, and 200 hall). This failure had the potential to affect food served to residents. Findings included: 1. An initial tour of the walk-in cooler on [DATE] at 09:30 AM revealed the following: (a). a 3-pound bag of sliced ham that was undated and open to air (b). a box containing tomatoes with brown spots An interview with the Dietary Manager on [DATE] at 09:30 AM revealed all opened food items should be dated when they were opened and should be covered to prevent spoilage by the person placing the item in the cooler. She stated all dietary staff should be checking produce daily for spoilage and discard if needed. An interview with the Administrator on [DATE] at 06:00 PM revealed she expected dietary staff to follow their policy regarding dating food items, storing food, and discarding spoiled food items. 2. An observation of the reach-in cooler on [DATE] at 09:40 AM revealed the following: (a). an opened and undated 48-ounce bottle of prune juice (b). 9 fully thawed 4-ounce manufactured milkshakes with no label to indicate the date they were removed from the freezer or the expiration date An interview with the Dietary Manager on [DATE] at 09:40 AM revealed all opened beverage items should be dated when opened and manufactured milkshakes should have a date they were removed from the freezer. She stated staff who opened beverages were responsible for dating them at the time they were opened. The Dietary Manager stated staff who removed manufactured milkshakes from the freezer were responsible for dating the milkshakes and they were only good for 14 days after being thawed. An interview with the Administrator on [DATE] at 06:00 PM revealed she expected dietary staff to follow their policy regarding dating food items. 3. An observation of the dry storage room on [DATE] at 09:52 AM revealed the following: (a). 8 46-ounce boxes of honey thickened water with a use-by date of [DATE] (b). 1 46-ounce box of honey thickened apple juice with a use-by date of [DATE] (c). 2 46-ounce boxes of honey thickened apple juice with a use-by date of [DATE] (d). 1 46-ounce box of honey thickened tea with a use-by date of [DATE] (e). 1 opened and undated 10-pound bag of rice (f). 1 opened and undated 10-pound bag of elbow noodles An interview with the Dietary Manager on [DATE] at 09:52 AM revealed staff were responsible for dating items when they were opened and staff who stocked items in the dry storage room were responsible for checking for expired items and discarding them if needed. An interview with the Administrator on [DATE] at 06:00 PM revealed she expected dietary staff to follow their policy on dating items when opened and discarding expired items. 4. An observation of the food preparation area of the kitchen on [DATE] at 09:58 AM revealed an undated bin of sugar. An interview with the Dietary Manager on [DATE] at 09:58 AM revealed the bin of sugar should have an expiration date and she was not sure why it wasn't dated. An interview with the Administrator on [DATE] at 06:00 PM revealed she expected dietary staff to follow their policy on dating opened food items. 5. (a). An observation of the ,d+[DATE] hall nourishment room refrigerator on [DATE] at 12:40 PM revealed multiple dried stains to the shelves and drawers of the refrigerator. (b). An observation of the 300 hall nourishment room refrigerator on [DATE] at 12:45 PM revealed multiple dried brown stains to the shelves of the door. (c). An observation of the 200 hall nourishment room refrigerator on [DATE] at 12:55 PM revealed multiple dried yellow stains to the shelves and door of the refrigerator. An interview with the Dietary Manager on [DATE] at 04:26 PM revealed dietary staff who stock nourishment rooms should clean the refrigerators as needed daily. An interview with the Administrator on [DATE] at 06:00 PM revealed she expected nourishment room refrigerators to be clean.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of oxygen therapy, functional limitation in range of motion, dialysis, hospice and prognosis, hypoglycemic medication (used to help reduce the amount of sugar in the blood), and Preadmission Screening and Resident Review (PASRR) for 6 of 20 sampled residents (Residents #23, #71, #130, #74, #38, and #6). Findings included: 1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included pneumonia. A physician's order dated 06/04/24 for Resident #23 read, oxygen at 1-2 liters per minute (LPM) via nasal cannula. Review of the June 2024 Treatment Administration Record (TAR) for Resident #23 revealed oxygen at 1-2 LPM was initialed as administered twice daily per physician order. The admission Minimum Data Set (MDS) dated [DATE] for Resident #23 did not reflect he received oxygen therapy during the MDS assessment period. During an interview on 08/01/24 at 9:49 AM, the MDS Coordinator reviewed the June 2024 TAR for Resident #23 and confirmed the admission MDS assessment dated [DATE] did not accurately reflect that he received oxygen therapy during the MDS assessment period. She stated it was an oversight. During an interview on 08/01/24 at 5:58 PM, the Administrator stated she expected MDS assessments to be completed as accurately as possible to reflect an accurate picture of the resident. 2. Resident #71 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of surgical neck of right humerus (upper arm bone). A physician order dated 06/27/24 for Resident #71 read, non-weight bearing to right upper extremity. A physician order dated 06/27/24 for Resident #71 read, ensure sling to right arm is in place every shift. Review of the July 2024 Treatment Administration Record (TAR) for Resident #71 revealed the right arm sling was initialed as in place per physician order. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had no impairment of her upper extremities. During an interview on 07/31/24 at 9:20 AM, the MDS Assistant revealed Resident #71 had impairment on the upper extremity due to a right arm fracture. The MDS Assistant stated it was an oversight that the admission MDS assessment dated [DATE] did not reflect Resident #71 had impairment on one side of the upper extremities. During an interview on 07/31/24 at 9:25 AM, the MDS Coordinator stated Resident #71's admission MDS assessment dated [DATE] should have reflected she had impairment on one side of the upper extremity and it was an oversight. During an interview on 08/01/24 at 5:58 PM, the Administrator stated she expected MDS assessments to be completed as accurately as possible to reflect an accurate picture of the resident. 3. Resident #130 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence on renal dialysis. A physician order dated 07/22/24 for Resident #130 read in part, dialysis three times a week on Tuesday, Thursday and Saturday. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #130 received dialysis and hemodialysis upon admission but did not receive either while a resident. During an interview on 07/31/24 at 9:20 AM, the MDS Assistant stated it was an oversight that Resident #130's admission MDS assessment dated [DATE] did not accurately reflect she received dialysis while a resident. During an interview on 07/31/24 at 9:25 AM, the MDS Coordinator stated it was an oversight that Resident #130's admission MDS assessment dated [DATE] did not accurately reflect she received dialysis while a resident. During an interview on 08/01/24 at 5:58 PM, the Administrator stated she expected MDS assessments to be completed as accurately as possible to reflect an accurate picture of the resident. 39037 4. Resident #74 was admitted to the facility 07/13/24 with a diagnosis including diabetes. Review of Resident #74's physician orders revealed an order dated 07/13/24 for insulin deglu[DATE] units per milliliter (ml) inject 30 units subcutaneously (under the skin) one time a day for diabetes. Resident #74 had a physician order dated 07/17/24 to discontinue insulin deglu[DATE] units once a day and begin insulin deglu[DATE] units subcutaneously at bedtime. Resident #74 had a physician order dated 07/18/24 to discontinue insulin deglu[DATE] units at bedtime and begin insulin deglu[DATE] units subcutaneously at bedtime. Resident #74 had an order dated 07/16/24 for insulin lispro 100 units per ml inject 4 units subcutaneously one time only for diabetes. Review of Resident #74's July 2024 Medication Administration Record (MAR) revealed he received insulin as ordered. Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE] did not reflect he received hypoglycemic (medication to lower blood sugar) medication during the look-back period. An interview with the MDS Coordinator on 08/01/24 at 4:44 PM revealed Resident #74's admission MDS dated [DATE] should have been coded to indicate he received hypoglycemic medication during the past 7 days, and it was an oversight. An interview with the Administrator on 08/01/24 at 6:04 PM revealed she expected the MDS assessment to be coded to reflect an accurate picture of the resident. 5. Resident #38 was admitted to the facility 08/24/22 with diagnoses including malnutrition and adult failure to thrive (a syndrome of physical and cognitive decline in older adults). Review of Resident #38's medical record revealed he began receiving hospice services on 06/11/24. Review of a significant change in status Minimum Data Set (MDS) dated [DATE] revealed he was not coded as having a condition or chronic disease that may result in a life expectancy of less than 6 months or that he was receiving hospice services. An interview with the MDS Coordinator on 08/01/24 at 4:34 PM revealed Resident #38's significant change in status MDS dated [DATE] should have reflected he had a life expectancy of less than 6 months and was receiving hospice services, and it was probably an oversight. An interview with the Administrator on 08/01/24 at 6:04 PM revealed she expected the MDS assessment to be coded to reflect an accurate picture of the resident. 37538 6. Resident #6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Record review revealed a PASRR Level II determination notification letter dated 09/16/19 with no expiration date for Resident #6. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 08/01/24 at 9:26 AM the Regional Social Worker confirmed Resident #6 had a Level II PASRR determination for the diagnosis of schizophrenia. During an interview on 08/01/24 at 5:58 PM the Administrator revealed she expected the MDS to be as accurate as possible to reflect an accurate picture of the resident.

Based on observations, record review, and staff interviews the facility failed to keep emergency tracheostomy (surgically created airway in the front of the neck) supplies needed for an unplanned extubation (removal of airway tube) or emergency supplies for mechanical ventilation (ambu bag) at bedside and easily accessible for immediate use in an emergency (Resident #56). The facility also failed to post cautionary and safety signs that indicated the use of oxygen (Resident #39, Resident #71, and Resident #23). This affected 4 of 4 residents reviewed for respiratory services. Findings included: 1. Resident #56 was admitted to the facility 07/12/24 with diagnoses including respiratory failure with hypoxia (lack of oxygen), tracheostomy status, and pneumonia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact and received tracheostomy care. An observation of Resident #56 on 07/30/24 at 2:15 PM revealed she was sitting in her wheelchair in her room. She was observed to have a tracheostomy in place with oxygen at six liters being delivered via a tracheostomy collar. No ambu bag or obturator (a curved tube which helps keep the tracheostomy open in the event of extubation) were observed in Resident #56's room. An observation of Resident #56 on 07/31/24 at 10:35 AM revealed she was resting quietly in bed with her tracheostomy in place and she was receiving six liters of oxygen through her tracheostomy collar. No ambu bag or obturator were observed in Resident #56's room. An observation of the Infection Prevention (IP) Nurse on 07/31/24 at 10:54 AM revealed she placed an ambu bag in Resident #56's room. An observation of Resident #56 on 07/31/24 at 11:14 AM revealed the area around her tracheostomy tube was cleaned and fresh gauze was applied by the Staff Development Coordinator (SDC) Nurse and IP Nurse. No obturator was observed in Resident #56's room. An interview with the IP Nurse on 07/31/24 at 11:33 AM revealed 2 spare inner cannulas were kept at Resident #56's bedside and she wasn't sure if an obturator was available in the facility. In a follow-up interview with the IP Nurse on 07/31/24 at 3:15 PM she stated she was able to locate an obturator in a tracheostomy kit and she placed the tracheostomy kit in the dresser beside Resident #56's bed. She stated she placed an ambu bag In Resident #56's room earlier on 07/31/24. The IP Nurse stated she was not sure how long an ambu bag and obturator had not been present in Resident #56's room. An interview with the SDC Nurse on 08/01/24 at 9:58 AM revealed she had been employed in the SDC role for approximately a year. She stated she provided education to nursing staff regarding how to clean tracheostomies, but she did not provide education regarding what to do in the event of an accidental extubation. The SDC Nurse stated she was unsure if an ambu bag or obturator needed to be present in a resident's room if they had a tracheostomy. An interview with the Director of Nursing (DON) on 08/01/24 at 5:24 PM revealed every resident with a tracheostomy should have an obturator and ambu bag readily accessible to them in the event of an emergency. She stated she considered storing an ambu bag on the crash cart as being readily accessible and obturators were available in tracheostomy kits that were kept in the supply room. The DON stated if a resident with a tracheostomy did not have a tracheostomy kit in their room, nursing staff had access to the supply room. 37014 2. a. Resident #23 was admitted to the facility on [DATE]. A physician's order for Resident #23 dated 06/04/24 read, oxygen at 1-2 liters per minute (LPM) every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and did not receive oxygen therapy during the MDS assessment period. Review of Resident #23's Treatment Administration Record (TAR) for June 2024 and July 2024 revealed he had received continuous oxygen at 1-2 LPM via nasal cannula each shift since 06/04/24. An observation conducted on 07/29/24 at 10:44 AM revealed Resident #23 lying in bed, sleeping soundly and receiving supplemental oxygen via nasal cannula at 1.5 LPM. There was no sign posted on the door or doorframe of Resident #23's room to indicate oxygen was in use. Subsequent observations conducted on 07/30/24 at 9:35 AM, 07/31/24 at 9:18 AM and 08/01/24 at 12:50 PM revealed Resident #23 sitting in his wheelchair in the room receiving supplemental oxygen via nasal cannula. There was no sign posted on the door or doorframe of Resident #23's room to indicate oxygen was in use. b. Resident #39 was admitted to the facility on [DATE]. A physician's order for Resident #39 dated 07/17/24 read, oxygen at 2 liters per minute (LPM) via nasal cannula every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition and received oxygen therapy during the MDS assessment period. Review of Resident #39's Treatment Administration Record (TAR) for July 2024 revealed she had received continuous oxygen at 2 LPM via nasal cannula each shift. An observation conducted on 07/29/24 at 10:50 AM revealed Resident #39 sitting in her wheelchair in the room receiving supplemental oxygen via nasal cannula at 2 LPM. There was no sign posted on the door or doorframe of Resident #39's room to indicate oxygen was in use. Subsequent observations conducted on 07/30/24 at 9:36 AM and 07/31/24 at 9:20 AM revealed Resident #39 in her room receiving supplemental oxygen at 2 LPM. There was no sign posted on the door or doorframe of Resident #39's room to indicate oxygen was in use. c. Resident #71 was admitted to the facility on [DATE]. A physician's order for Resident #71 dated 06/27/24 read, oxygen at 2 liters per minute (LPM) via nasal cannula every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had intact cognition and received oxygen therapy during the MDS assessment period. Review of Resident #71's Treatment Administration Record (TAR) for July 2024 revealed she received continuous oxygen at 2 LPM via nasal cannula each shift. An observation conducted on 07/29/24 at 10:50 AM revealed Resident #71 lying in bed receiving supplemental oxygen via nasal cannula at 2 LPM. There was no sign posted on the door or doorframe of Resident #71's room to indicate oxygen was in use. Subsequent observations conducted on 07/30/24 at 9:36 AM and 07/31/24 at 9:20 AM revealed Resident #71 in her room receiving supplemental oxygen at 2 LPM. There was no sign posted on the door or doorframe of Resident #71's room to indicate oxygen was in use. During an interview on 08/01/24 at 9:59 AM, the Staff Development Coordinator stated for dignity reasons, they did not post oxygen cautionary signage on the doors of residents' rooms. During an interview on 08/01/24 at 2:37 PM, Nurse #2 revealed she had questioned using oxygen cautionary signage and was told that since it was a non-smoking facility, they did not have to post oxygen cautionary signage on the room doors or doorframes of residents receiving supplemental oxygen as long as the signage was posted on the door of the main entrance to the facility. During an interview on 08/01/24 at 4:53 PM, the Director of Nursing revealed the facility used to post oxygen cautionary signage on the doors of residents' rooms receiving supplemental oxygen but was told that since they were a non-smoking facility, oxygen cautionary signage only had to be posted on the facility's entrance and exit doors.

Based on observations, record review, and interviews the facility failed to educate nursing staff to ensure emergency tracheostomy supplies were immediately available to provide respiratory care needs for 1 of 1 resident reviewed for tracheostomy (surgically created airway in the front of the neck) care. This was for 5 of 5 nurses (Staff Development Coordinator Nurse, Infection Preventionist Nurse, Nurse #1, Nurse #2, and Nurse #3) reviewed for competency. Findings included: Resident #56 was admitted to the facility 07/12/24 with diagnoses including respiratory failure with hypoxia (lack of oxygen), tracheostomy status, and pneumonia. Observations of Resident #56's room on 07/30/24 at 2:15 PM and 07/31/24 at 10:35 AM revealed no ambu bag (a device for mechanical ventilation) or obturator (a curved tube which helps keep the tracheostomy open in the event of dislodgement) were observed in her room. An interview with the Staff Development Coordinator (SDC) Nurse on 08/01/24 at 9:58 AM revealed she had been employed in her current role around a year and she was responsible for orienting and educating all new nursing staff and providing ongoing education to existing nursing staff. She explained new nursing staff received education regarding performing tracheostomy care and suctioning during orientation and she also provided education to existing nursing staff when a new resident with a tracheostomy was admitted to the facility. The SDC Nurse stated she usually contacted respiratory therapy personnel to provide additional education on tracheostomy care when a resident with a tracheostomy was admitted to the facility, but she had not had time to set up education with respiratory therapy since Resident #56 had been admitted . She stated she did not provide any education to nursing staff regarding emergency procedures in the event of a tracheostomy tube dislodgement because respiratory therapy personnel provided education on emergency tracheostomy care. The SDC Nurse stated she was not sure if an ambu bag and an obturator needed to be present or readily available in a resident room if the resident had a tracheostomy. Review of the facility's educational classes revealed respiratory therapy personnel last provided classes on tracheostomy care (how to clean a tracheostomy) and suctioning on 07/05/23, 07/06/23, and 07/07/23. There was no documentation that respiratory therapy personnel provided education on emergency procedures in the event of a tracheostomy tube dislodgement. An interview with the Infection Preventionist (IP) Nurse on 08/01/24 at 10:24 AM revealed she switched to the infection prevention role in March 2024. The IP Nurse stated she received education on cleaning and suctioning a tracheostomy but could not recall receiving any education since beginning employment on emergency procedures in the event of tracheostomy tube dislodgement. A telephone interview with the Respiratory Therapist (RT) on 08/01/24 at 11:35 AM revealed the facility usually notified him when they admitted a new resident with a tracheostomy and he or another respiratory therapist came to the facility and provided staff with additional education. He stated topics he reviewed with nursing staff included removing and replacing tracheostomy ties, removing the inner cannula (tube), cleaning the stoma (opening of the tracheostomy), suctioning, and the importance of always keeping an obturator and ambu bag at the bedside in the event of dislodgement. The RT stated he could not recall the exact date, but the last time he provided tracheostomy training for nursing staff was in July 2023. A telephone interview with Nurse #1 on 08/01/24 at 12:07 PM revealed she had been employed at the facility since 2021 and she had received periodic education regarding tracheostomy suctioning and cleaning of the tracheostomy, but she could not recall receiving education on the importance of having an obturator readily available in the event of tracheostomy becoming dislodged. She stated an ambu bag was available on the code cart, which was kept at the nursing station. An interview with Nurse #2 on 08/01/24 at 2:36 PM revealed she had been employed at the facility for 3 years. She stated from her previous employment at another facility she was used to residents with a tracheostomy always having an obturator and ambu bag at their bedside, but she had been informed at this facility as long as an ambu bag was available on the code cart that was fine. Nurse #2 stated she could not recall receiving any education from the facility regarding obturator use or storage. An interview with Nurse #3 on 08/01/24 at 3:14 PM revealed she worked prn (as needed) at the facility, and she could not recall receiving any training from the facility regarding the procedure for tracheostomy dislodgement, including what supplies needed to be readily available. She stated the only education she received from the facility for residents with a tracheostomy was to make sure suction was available and to provide tracheostomy care at least once a shift. An interview with the Director of Nursing (DON) on 08/01/24 at 5:24 PM revealed every resident with a tracheostomy should have an obturator and ambu bag readily accessible to them in the event of an emergency. She stated she considered storing an ambu bag on the crash cart as being readily accessible and obturators were available in tracheostomy kits that were kept in the supply room. The DON stated if a resident with a tracheostomy did not have a tracheostomy kit in their room, nursing staff had access to the supply room. She stated education regarding tracheostomy care was provided as part of the orientation process for nursing staff and periodically when a new resident with a tracheostomy tube was admitted . The DON stated inner cannulas were available in Resident #56's room instead of an obturator and further education would be provided to nursing staff.

Based on record review and staff interviews the facility failed to revise an advance directive care plan for 1 of 20 residents whose care plans were reviewed for accuracy (Resident #38). Findings included: Resident #38 was admitted to the facility 08/24/22. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired. Review of the form Medical Orders for Scope of Treatment (MOST) dated 06/18/24 revealed Resident #38 had Do Not Resuscitate (DNR) Physician orders. Resident #38's electronic medical record revealed a Physician order dated 06/19/24 for Do Not Resuscitate/Do Not Intubate (place a breathing tube). Review of Resident #38's advance directive care plan last revised 07/16/24 revealed he had an advance directive of full code (providing life-saving measures). Interventions included honoring Resident #38's advance directive choices, referring him to the Physician as needed for advance directive changes, and reviewing advance directives with the resident as needed. An interview with the MDS Coordinator on 08/01/24 at 4:34 PM revealed Resident #38's advance directive care plan should have been updated on 06/18/24 to reflect he was a DNR, and she was not sure why his care plan had not been revised. An interview with the Administrator on 08/01/24 at 6:04 PM revealed she expected care plans to be revised to reflect an accurate picture of the resident.

Based on record review, resident and staff interviews, the facility failed to develop an individualized, person-centered Activities of Daily Living (ADL) care plan that included how much staff assistance was needed to care for a resident who required assistance with ADL for 1 of 2 sampled residents reviewed for ADL (Resident #71). Findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of surgical neck of right humerus (upper arm bone) and displaced fracture of base of neck of right femur (upper bone of the leg). The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #71 had intact cognition and required substantial to maximum assistance with toileting hygiene, personal hygiene, shower/bathing, upper/lower body dressing, putting on/taking off footwear, bed mobility, and transfers. Resident #71's comprehensive care plans, last revised on 07/16/24, included a plan that addressed her need for assistance with ADL. The only intervention listed was for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to evaluate and treat as needed. During an observation and interview on 07/29/24 at 11:16 AM, Resident #71 was lying in bed with bilateral bed rails in the upright position and a sling on her right arm. Resident #71 stated she had broken her arm and hip when she fell at home and was admitted to the facility to receive therapy before returning back home. Resident #71 stated she needed staff assistance with most ADL tasks but was able to hold onto the bed rails with her left hand to help as much as she could when staff were providing her care. During an interview on 07/31/24 at 9:20 AM, the MDS Assistant reviewed Resident #71's ADL care plan and confirmed the only intervention listed was for PT, OT, ST to evaluate and treat as needed. The MDS Assistant explained the care plan should include interventions relating to care needs, such as transfer status and use of bed rails, so that staff would know what level of care to provide. The MDS Assistant stated it was an oversight and Resident #71's ADL care plan should have reflected her care needs. During an interview on 07/31/24 at 9:25 AM, the MDS Coordinator verified Resident #71's ADL care plan did not include specific interventions that addressed her care needs and it was an oversight. During an interview on 08/01/24 at 5:58 PM, the Administrator stated she would expect for care plans to be developed to accurately reflect the resident's needs.

Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in the physical or mental status for a resident with a serious mental health diagnosis for 1 of 1 resident reviewed for PASRR (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A PASRR Level II determination notification letter dated 09/16/19 revealed Resident #6 had a Level II PASRR with no end date and no limitation unless there was a change in condition. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 08/01/24 at 9:26 AM the Regional Social Worker confirmed there was no request made for a PASRR reevaluation when Resident #6 had a significant change of condition in April 2024. She revealed a request for PASRR should have been done by the previous Social Worker but at that time a change was made in her employment status. The Regional Social Worker confirmed there was no oversight in place to ensure a PASRR request was completed for Resident #6, and stated the new Social Worker was still in training and had just started her position. An interview was conducted on 08/01/24 at 5:10 PM with the Director of Nursing (DON). The DON stated PASRR was the responsibility of the Social Worker, and she was not knowledgeable in the process for requesting PASRR for residents. During an interview on 08/01/24 at 6:39 PM the Administrator revealed she expected PASRR requests for reevaluation to be completed and it was the responsibility of the Social Worker to complete.

Based on record review, family and staff interviews, the facility failed to immediately notify a resident's Responsible Party of a medication change for 1 of 1 sampled resident (Resident #23). Findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses that included dementia. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #23 with severe impairment in cognition. Review of Resident #23's profile revealed his family member was listed as his Responsible Party (RP). A Physician Assistant (PA) progress note dated 07/24/24 revealed in part, staff administered Resident #23's as needed (PRN) Lorazepam at times which was reported to be generally effective. The plan was to change Resident #23's current order for PRN Lorazepam from every 8 hours to every 12 hours and start scheduled Lorazepam (medication used to treat anxiety) 0.25 milligrams (mg) once daily at 4:00 PM. The PA noted the medication change was discussed at length with Resident #23's private sitter. A physician order entered by the PA with a start date of 07/24/24 read, Lorazepam 0.5 milligram (mg) - give 0.5 (1/2) tablet by mouth one time a day for anxiety, note dose. A physician order entered by the PA with a start date of 07/24/24 read, Lorazepam 0.5 mg every 12 hours PRN anxiety for 14 days. During a telephone interview on 07/30/24 at 9:57 AM, Resident #23's RP revealed the private sitter was just a companion and not able to make decisions regarding Resident #23's care. The RP stated she had met with Unit Manager #1 and the Administrator on previous occasions and requested they send her weekly emails to provide updates on Resident #23's condition to include any medication changes. The RP stated she was not notified his Lorazepam medication had changed until she was contacted on Sunday morning (07/28/24) by facility staff to let her know that he had fallen. During an interview on 08/01/24 at 1:54 PM, the PA revealed she did not speak with Resident #23's RP on 07/24/24 when a scheduled dose of Lorazepam was added for Resident #23 but she had discussed the medication change with Resident #23's private sitter who was in agreement with the plan and had appeared to have been texting Resident #23's RP. During an interview on 08/01/24 at 4:53 PM, the Director of Nursing (DON) revealed they met with Resident #23's RP and agreed on weekly emails to communicate any updates. The DON stated she knew that Unit Manager #1 had communicated with Resident #23's RP via email but she was uncertain if or when Unit Manager #1 had informed the RP of the medication change and she would have to touch base with her (Unit Manager #1) when she returned from vacation. During an interview on 08/01/24 at 5:58 PM, the Administrator revealed Resident #23 had a private sitter that was very involved in his care and when staff discussed anything with the private sitter, she sent text messages to Resident #23's RP and they had assumed the private sitter was informing the RP. The Administrator stated she would expect for staff to have called Resident #23's RP to inform them of the medication change and not rely on the private sitter to inform them.

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys conducted on 4/15/21 and 2/9/23. This was for a repeat deficiency in the area of infection control that was cited on 4/15/21 and 2/9/23 during the recertification and complaint investigation surveys, and subsequently recited during the complaint investigation survey completed on 2/17/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F880 - Based on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after incontinence care and before donning new gloves to cleanse a wound and change gloves and perform hand hygiene between different wounds for 3 of 3 wound care observations on 1 of 3 residents reviewed (Resident #6). During the recertification survey on 2/9/23, the facility failed to implement their infection control policies when a staff member failed to perform hand hygiene after doffing used gloves and donning clean gloves while providing incontinence care to a resident. During the recertification and complaint investigation survey conducted on 4/15/21, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 2 of 2 staff members failed to discard their masks after providing care to 11 of 11 residents on the quarantine hall and went to care for 5 of 5 residents on a non-quarantine hall, failed to wear an N95 or higher respirator and failed to prevent 1 of 11 quarantined residents from leaving the quarantine hall, all reviewed for infection control practices. These observations occurred during a global pandemic. An interview with the Administrator on 2/17/24 at 2:58 PM revealed they continue to do rounds, watch their staff, and ensure that they were doing proper care. The Administrator shared that if they see any issues with hand hygiene, they continue to educate their staff, but they were focused on hand hygiene during incontinence care. The Administrator stated they were not focused on hand hygiene during wound care but even though the facility had a treatment nurse, the hall nurses were just as responsible for providing wound care and they should know about hand hygiene.

Based on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after incontinence care and before donning new gloves to cleanse a wound, and failed to change gloves and perform hand hygiene between different wounds for 3 of 3 wound care observations on 1 of 3 residents reviewed (Resident #6). The findings included: The facility's policy Handwashing Requirements with an effective date of 2/6/20 indicated the following list of some situations that require hand hygiene: j. Before and after changing a dressing m. Before and after assisting a patient with toileting (handwashing with soap and water) r. After removing gloves or aprons t. After any contact with potentially contaminated materials (used wound/treatment dressings) Listed under Gloves included the following information: Change gloves during patient care when moving from a contaminated body site to a clean body site. An observation of wound care by Nurse #1 on Resident #6 was made on 2/17/24 at 10:45 AM. After Nurse #1 unfastened Resident #6's brief to perform wound care on her right buttock, a moderate amount of brown stool was observed on Resident #6's brief. Resident #6's right buttock pressure ulcer dressings had already been removed prior to the observation. Nurse #1 wiped off the stool from Resident #6's buttocks with disposable wipes and changed Resident #6's brief. Nurse #1 removed her gloves and proceeded to put on new gloves without performing hand hygiene. She then sprayed wound cleanser onto a gauze and wiped one of the pressure ulcers on Resident #6's right buttock. She sprayed wound cleanser onto another gauze and wiped the other pressure ulcer on Resident #6's right buttock. She then applied calcium alginate (absorbent dressing) to one ulcer and honey-fiber dressing to the other ulcer and covered both ulcers with a foam dressing. Without removing her gloves and doing hand hygiene, Nurse #1 proceeded to perform wound care to Resident #6's right heel. Nurse #1 removed a dressing from Resident #6's right heel which had moderate amount of serosanguineous drainage. She sprayed wound cleanser on a gauze pad and wiped the ulcer on Resident #6's right heel. She then painted the right heel with a povidone-iodine swab. Nurse #1 stated to Resident #6 that she was going to let the povidone-iodine dry on the right heel before covering it with a dressing. Without removing her gloves and performing hand hygiene, Nurse #1 proceeded to perform wound care to Resident #6's left heel which did not have a dressing on. Nurse #1 sprayed wound cleanser on a gauze pad and wiped the ulcer on Resident #6's left heel. Nurse #1 then painted the left heel with a povidone-iodine swab. Without changing her gloves, Nurse #1 applied a dressing to cover Resident #6's right heel. She then applied a sock to Resident #6's left heel. Nurse #1 discarded all unused supplies, removed her gloves and applied hand sanitizer to both hands. An interview with Nurse #1 on 2/17/24 at 11:04 AM revealed she usually provided wound care to Resident #6 on the weekends when the treatment nurse was not working. Nurse #1 stated she knew she was supposed to perform hand hygiene after removing her gloves and after providing incontinence care to Resident #6, but it did not cross her mind during the wound care observation. Nurse #1 further stated that she had not been told that she was supposed to change gloves and perform hand hygiene when doing dressing changes on multiple wounds. She also stated that she was not aware that she was supposed to change gloves when working with different areas of the body. Nurse #1 explained that Resident #6 normally had her heels painted with povidone-iodine, but the right heel must have been draining which was why she had a dressing on to her right heel. An interview with the Director of Nursing (DON) on 2/17/24 at 11:29 AM revealed Nurse #1 should have changed her gloves and perform hand hygiene after doing incontinence care and while providing wound care to Resident #6. The DON stated Nurse #1 probably thought her gloves were clean and it was fine to wear the same gloves while painting Resident #6's heels with povidone-iodine. The DON further stated she was not sure about the dressing that was observed on Resident #6's right heel. She also shared that the facility had a treatment nurse who usually did Resident #6's dressings but they would need to do further education.

Based on record reviews and family member, staff, and Medical Director interviews, the facility failed to prevent significant medication errors when Medication Aide #1 administered medications prescribed for Resident #2 to Resident #1 which include Clonazepam (a medication to treat anxiety), Buspar (a medication to treat anxiety), Gabapentin (anticonvulsant medication), Seroquel (antipsychotic medication) and Trazodone (antidepressant) for which he had no diagnosis and all had the potential side effects of dizziness and drowsiness. Resident #1 was sent to the emergency department on 12/08/23 for further evaluation where it was determined he had an accidental drug overdose as evidenced by Resident #1 having altered mental status and drowsiness. Resident #1 was admitted into the hospital for observation after continued altered mentation and no return to normal baseline and was discharged on [DATE]. This deficient practice affected 1 of 3 residents reviewed for significant medication errors (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included atrial fibrillation, cardiomyopathy, lung disease and pneumonia. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. The resident was not coded as receiving antidepressant, antipsychotic, or antianxiety medications. Review of the December 2023 physician orders for Resident #1 revealed the following medications: - Cefdinir (antibiotic) 300 milligrams (mg) 1 capsule by mouth every 12 hours for a urinary tract infection for 10 days - Eliquis (anticoagulant) 5 mg 1 capsule by mouth every 12 hours for deep vein thrombosis prevention - Sotalol (beta blocker) 80mg 1 capsule by mouth every 12 hours for atrial fibrillation. Resident #2 was admitted to the facility on [DATE]. Review of the December 2023 physician orders for Resident #1 revealed the following medications: - Clonazepam 0.5 milligram (mg) 1 tablet by mouth every 12 hours for bipolar disorder. - Buspar 30 mg 1 tablet by mouth every 12 hours for anxiety. - Gabapentin 400 mg 1 tablet by mouth four times a day for neuropathic pain - Remeron 15 mg 1 tablet by mouth at bedtime for bipolar disorder - Seroquel 100mg 2.5 tablets by mouth at bedtime for bipolar disorder - Trazodone100 mg 1 tablet by mouth at bedtime for insomnia An incident report dated 12/08/23 written by Nurse #1 revealed Resident #1 had received Resident #2's medication which included: Clonazepam 0.5 mg, Buspar 30 mg, Gabapentin 400 mg, Remeron 15 mg, Seroquel 100mg and Trazodone 100 mg. The report revealed Resident #1 did not receive his scheduled medication. The incident was reported to the on-call physician at 9:30 PM after the Medication Aide had immediately reported the medication error to Nurse #1. Nurse #1 assessed the resident; Resident #1 was noted to be in no acute distress. Resident #1 was noted to be alert and oriented when he left the facility. A follow up was conducted with Resident #1's family members regarding the medication error. The family members stated Resident #1 had some sedation in the hospital but otherwise was doing well following the incident. An interview conducted on 1/11/24 at 9:31 AM with Medication Aide (MA) #1 revealed on 12/8/2023 she was completing her medication pass at 9:30 PM with two residents left to medicate (Resident #1 and Resident #2). MA #1 stated she was in a hurry to complete the medication pass because the computer system was turning red indicating the medications were late. She stated she removed both residents' medication from the medication cart at the same time and had both cups of medication in her hand when walking down the hall into Resident #1's room. MA #1 stated she handed Resident #1 a cup of medications and as he was swallowing, she realized she had given Resident #1 Resident #2's medications. She stated she immediately realized the mistake and notified Nurse #1 she had given Resident #1 the incorrect medication. The interview revealed Nurse #1 told her to obtain vital signs on Resident #1 while she notified the on-call physician. She stated Resident #1's vital signs were within normal range, and he was alert after the incident. She stated Emergency Medical Services EMS) arrived to transport Resident #1 to the hospital for an evaluation. The interview revealed Resident #1 was alert and not drowsy prior to leaving the facility. Resident #1's documented vital signs dated 12/08/23 at 9:30 PM revealed the following: blood pressure 116/71 (normal range systolic (top number) less than 120 and diastolic (bottom number) less than 80), temperature 96.6 (normal range 97 to 99), pulse 77 beats per minute (normal range 60-100), respirations 16 breaths per minute (normal range 12-20), oxygen saturation 95% (normal range 92% or greater) on room air. An interview conducted on 1/11/24 at 9:41 AM with Nurse #1 revealed she was working on the night of 12/08/23 when Medication Aide #1 came to her and stated she had administered the wrong medication to Resident #1. The interview revealed she asked MA #1 to obtain vital signs on the resident while she called the on-call physician. She stated she did not recall the name of the on-call physician but that she was given orders to send Resident #1 to the hospital for an evaluation. Nurse #1 stated she then went into Resident #1's room to assess him and noted he had no change of condition and did not seem drowsy prior to EMS arrival. Hospital records dated 12/08/23 revealed Resident #1 was evaluated in the Emergency Department (ED) due to being given the wrong patient's medication at the nursing facility. Resident #1 was noted to be awake but drowsy upon arrival at the hospital. Resident #1 was treated with intravenous fluids in the ED and the physician noted Resident #1 to be oriented and to answer questions appropriately. In the ED Resident #1 denied any shortness of breath, chest pain, nausea, vomiting, diarrhea, or abdominal pain. Resident #1 was noted to be non-toxic in appearance, sleepy but arousable. Resident #1 was given a diagnosis of encephalopathy due to an accidental overdose. The ED conducted lab work, electrocardiogram, and imaging studies all of which were noted to be negative for abnormal findings. The resident was admitted into the hospital for observation. A toxicology lab report dated 12/09/23 at 12:55 AM revealed negative for benzodiazepines, amphetamines, barbiturates, and opiates in Resident #1's blood work. Resident #1 was discharged from the hospital on 12/12/23. An interview conducted on 1/11/24 at 8:48 AM with Family Member #1 revealed she was contacted on 12/08/23 at 10:00 PM by Nurse #1. She stated Nurse #1 told her that a Medication Aide had administered the wrong medication to Resident #1 and that he had been sent to the hospital for an evaluation. The interview revealed Resident #1 had some drowsiness from the incident but no other symptoms. She stated she did not want the resident to go back to the facility, so he finished inpatient rehabilitation at the hospital and was discharged home with home health. An interview conducted on 1/11/23 at 11:17 AM with the facility Medical Director (MD) revealed on 12/8/23 Resident #1 received a number of medications prescribed for another resident. He stated Resident #1 had not received a toxic dose of any of the medications and had not experienced any extreme sedation or respiratory depression from the medication. The MD stated it was an unacceptable error made by the facility staff but Resident #1 did not have any significant adverse effects from receiving the medication other than drowsiness. The MD stated he had reviewed Resident #1's labs, his kidneys were in good condition and the medication he received would have been out of his system within 48 hours. He stated the hospital had given the resident a diagnosis of encephalopathy due to receiving several sedative medications that he normally did not take. He stated the diagnosis would have come from Resident #1 having an altered mental status upon his arrival to the hospital. An interview conducted on 1/11/24 at 1:47 PM with the Director of Nursing (DON) revealed on 12/08/23 she was notified by Nurse #1 that a medication error had occurred. The DON stated Nurse #1 had immediately contacted the on-call physician and obtained orders to send Resident #1 to the hospital for an evaluation. The interview revealed the nurses and medication aides in the facility should not be pre-pulling two residents' medication at the same time. The DON stated the error had occurred because the Medication Aide had pre-pulled the medication and removed both residents' medication at the same time creating the possibility for error. An interview conducted on 1/11/24 at 2:51 PM with the Administrator revealed the DON had notified her of the medication error. She stated Nurse #1 had immediately notified the physician, assessed the resident, and notified the resident's family member following the incident. The Administrator stated the staff did everything they should have after the incident occurred. She stated nursing staff should have provided the correct medication to the correct resident.

Based on record review and staff and resident interviews, the facility failed to have physician orders for tracheostomy (an opening surgically created through the neck into the trachea) care and provide nursing supervision of tracheostomy care as specified in the resident's plan of care for 1 of 1 resident reviewed for tracheostomy care (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses including throat cancer with tracheostomy. Resident #3 care plan dated 12/29/23 revealed the resident prefers to provide trach care with supervision of nurse. The goal was that the resident will have their preferences honored if possible. Interventions is to review resident's preferences with them as needed. Review of Resident #3 care plan dated 10/10/23 and revealed at risk for complications secondary to a tracheostomy secondary to history of cancer care plan. The goal was for the resident not to have complications related to having a trach. Interventions were: change trach tie as ordered, humified oxygen as order, monitor skin integrity under trach collar, nebulizer treatments as ordered, observe for signs and symptoms of respiratory complication including infection and respiratory blockage, oxygen per orders, SLP referral as indication, suction as needed, tracheostomy care per orders, and trach tie changes. A review of physician orders revealed the following: - A physician order dated 12/21/23 for okay to lavage tracheostomy as needed. This order was discontinued on 1/08/24. - A physician order dated 11/1/23 to change inner cannula every night shift and as needed and tracheostomy care every shift. This order was discontinued on 1/08/24. - On 1/16/2024 a new order for humified oxygen at 4 Liters via tracheostomy mask. Review of medical records revealed that Resident #3 was sent to the emergency department for evaluation on 1/08/23 and returned to the facility the same day. An interview and observation were conducted with Resident #3 on 1/22/24 at 12:05 PM. She stated that she did her own tracheostomy care, and that staff did not assist her. The Resident reported staff assessed and suctioned her tracheostomy when she asked them to or was having trouble and needed to be suctioned. Resident #3 explained that [NAME] hospital taught her how to care for her tracheostomy before she was discharged . The Resident further stated that nursing staff did not watch her do tracheostomy care and a third shift nurse gave her supplies when she needed to change her tracheostomy. Resident #3 tracheostomy was clean and clear. No mucous was noted, tracheostomy straps were clean, and resident showed no signs of difficulty breathing. An interview with Nurse #2 on 1/22/24 at 12:55 PM. She stated she has taken care of resident #3 but has never provided tracheostomy care and has only suctioned Resident #3 a few times when the resident has asked for it to be done. Nurse #2 stateed she was not very comfortable taking care of the tracheostomy, but that the Resident #3 knew how to take care of it. An interview with Nurse #3 on 1/22/24 at 1:03 PM revealed Resident #3 was independent with caring for her tracheostomy, and they only suctioned as needed. She noticed they are having to suction more often, but she stated this was due to the resident's condition. Nurse #3 confirmed she had received tracheostomy care training from the facility and would be able to care for the resident if she had to when it came to tracheostomy. Interview with Respiratory Therapist (RT) on 1/22/24 at 2:06 PM revealed she worked with Resident #3 and provided education concerning her tracheostomy and the progression of her cancer. The RT stated she has changed and cleaned Resident #3's tracheostomy during visits, and with the new humified oxygen and resident letting staff suction her she had noticed some improvement with mucous plugs. An interview with the Medical Director (MD) at 1:11 PM revealed that Resident #3 was receiving humidified oxygen through her nasal cannula, but as her disease has progressed, she has been put on humified tracheostomy oxygen at 4 Liters on 1/16/24 and this seemed to be helping the resident with preventing the tracheostomy from clogging. The Medical Director was not aware that there were no orders for tracheostomy care on the resident's chart. The MD stated that the resident anxiety is very high when it comes to her tracheostomy and airway and would demand to go to the hospital to have it checked out. The MD further stated Resident #3 was not accepting of her prognosis and is seeking a second opinion, but there was nothing else that can be done for her metastatic cancer. Interview with the Director of Nursing (DON) on 1/22/24 at 1:30 PM revealed the DON was not aware there were no active orders for Resident #3's tracheostomy care. The DON stated she thought the resident was care planned as preferring to do her own tracheostomy care and was not aware the care plan stated with nursing supervision.

Based on observations, record reviews, resident, staff and Nurse Practitioner interviews, the facility failed to administer pain medication as ordered and requested for 2 of 4 residents (Resident #329 and Resident #330) reviewed for management of pain. The findings included: 1. Resident #329 was admitted to the facility on [DATE] with diagnoses which included post partial traumatic amputation of left great toe, further amputation of bone of the left great toe and incision and drainage of second and third toes, cellulitis, osteomyelitis, chronic pain, and open wound left foot. Review of Resident #329's orders for pain medication dated 02/02/23 revealed the following: Lyrica oral capsule 100 milligrams (mg) - give 1 capsule by mouth three times a day for pain effective 02/02/23. Percocet oral tablet 10 mg - 325 mg (Oxycodone with Acetaminophen) - give 2 tablets by mouth every 8 hours as needed for pain effective 02/02/23 and discontinued on 02/04/23. Review of the nursing admission note dated 02/02/2023 revealed Resident #329 was alert and oriented to person, place, time, and situation. The assessment also revealed the resident was in frequent pain over the last 5 days which made it hard for her to sleep at night and had limited her day-to-day activities. At the time of the assessment, Resident #329 indicated her pain level was a 7 on a scale of 0 to 10 and her facial expressions during the assessment revealed she was in pain. Review of her Medication Administration Record (MAR) revealed Resident #329 was medicated for her pain level of 7 with Oxycodone with Acetaminophen 10-325 mg - 2 tablets at 9:30 PM on 02/02/23 and was recorded as effective. Review of her care plan dated 02/02/2023 revealed a focus area for being at risk of pain related to her surgical wound. The interventions included administer medications as ordered, administer pain medication as indicated, notify MD (medical doctor) as indicated, observe for physical indicators of pain and pain assessment as needed. Review of Resident #329's orders for pain medication dated 02/04/23 revealed the following: Oxycodone - Acetaminophen oral tablet 10-325 mg - give 2 tables every 6 hours as needed for pain for 2 days effective 02/04/23 and discontinued on 02/06/23. Review of a progress note written by the Nurse Practitioner (NP) on 02/06/23 revealed staff were asking about the resident's pain medication regimen because the resident's pain was not being controlled on the current regimen. Plan was to clarify the order for Percocet which was changed to 2 tablets by mouth scheduled every 8 hours instead of as needed (prn), Oxycodone was changed to 10 mg tablet by mouth every 4 hours as needed (prn) for pain for 10 days. Review of Resident #329's orders for pain medication dated 02/06/23 revealed the following: Oxycodone hydrochloride (HCl) oral tablet 10 mg - give 1 tablet by mouth every 4 hours as needed for pain for 10 days effective 02/06/23 with end date of 02/16/23. Percocet oral tablet 10 mg - 325 mg (Oxycodone with Acetaminophen) - give 2 tablets by mouth three times a day for pain effective 02/06/23. Scheduled to be given at 6:00 AM, 2:00 PM and 11:00 PM effective on 02/06/23 at 2:00 PM. Norco oral tablet 5 mg-325 mg (Hydrocodone-Acetaminophen - give 2 tablets by mouth one time only for 1 day effective 02/06/23 at 1:22 PM. Observation and interview on 02/07/22 at 8:49 AM revealed Resident #329 sitting in bed with her foot elevated on a pillow. The resident's bandage to her left foot was clean and intact. Resident #329 stated her pain medication had not been right since admission and her pain level had gone up to an 8 out of 10 on 02/06/2023 before she received her pain medication. She described her pain as achy stabbing pain in her foot and she was moving in her bed but did not have facial expressions of pain. Observation and interview on 02/09/23 at 8:39 AM with Resident #329 revealed she was having more pain this morning than on the morning of 02/08/23 and said she had not slept well all night due to pain in her joints, especially her shoulder and knee. She stated her pain was in both legs, knees and shoulder and said her right knee was especially painful. Resident #329 stated her Percocet had worked well at the hospital and she didn't understand why it was not working at the facility except that last evening and this morning she had only received one pill instead of 2. Resident #329 further stated she thought her pain medication had been changed on 02/07/23 and that she was supposed to get 2 Percocet instead of the 1 pill she had gotten on 02/08/23 at 11:00 PM and on 02/09/23 at 6:00 AM. She currently stated her pain level was at a 7 out of 10. She described her pain as aching and stabbing when she moved her foot. Review of the narcotic sheet on 02/09/23 at 8:59 AM for Resident #329's Percocet and her pill card revealed the resident had only received 1 tablet of Percocet 10-325 mg at 11:00 PM on the evening of 02/08/23 and 1 tablet of Percocet 10-325 mg on the morning of 02/09/23 at 6:00 AM instead of the 2 tablets that were ordered to be given. Review of the Medication Administration Record (MAR) for Resident #239 revealed she had requested and received Oxycodone HCl oral tablet 10 mg 1 tablet by mouth every 4 hours as needed for pain on 02/09/22 at 9:22 AM. Resident #239's pain medication was brought to the attention of the Unit Manager on 02/09/23 at 10:13 AM. The Unit Manager immediately notified the NP of the error. The NP wrote a one-time order for the resident to receive another dose of Percocet since she had only been given 1 pill for 2 consecutive times. Interview on 02/09/23 at 11:20 AM with Nurse #1 assigned to care for Resident #329 on 7:00 AM to 7:00 PM shift revealed she had given the resident a prn pain pill around 9:20 AM for complaints of pain at a level of 6 out of 10. Nurse #1 stated the resident had not brought to her attention that she had not received her pain medication as ordered last evening on 02/08/23 or earlier this morning on 02/09/23 at 6:00 AM but said she had asked for and received prn pain medication this morning. Nurse #1 did confirm that according to the narcotic sheet and pill card the resident had only received 1 pill instead of 2 on the evening of 02/08/23 and the morning of 02/09/23. Phone interview on 02/09/23 at 2:33 PM with Nurse #2 who cared for Resident #329 on 02/08/23 from 7:00 PM to 02/09/23 at 7:00 AM revealed she had only given Resident #329 one pill at 11:00 PM and 1 pill at 6:00 AM because she had not noticed the order read to give her 2 pills. Nurse #2 stated she was used to orders reading to give 1 pill for pain and had not read or noticed the resident's order called for her to have 2 pills. She further stated she gave 1 pill out of habit because that was what was usually ordered for residents. Interview on 02/09/23 at 3:31 PM with the Nurse Practitioner (NP) revealed she had worked with Resident #329 on trying to get her pain under control by adjusting her medication on 02/07/23. The NP stated the resident's pain seemed to be better controlled now and said it had been brought to her attention that she had not gotten her full dose of Percocet on 02/08/23 at 11:00 PM or 02/09/23 at 6:00 AM. The NP further stated the resident had however received a prn dose of her medication that was ordered for break through pain. The NP indicated her pain seemed to be better controlled since changing her pain medication on 02/07/23 and said she would have expected Nurse #2 to have administered her pain medication as ordered unless there had been a clinical reason not to and then the NP said she would have expected Nurse #2 to have notified her as to why the dosage was not given as ordered. Interview on 02/09/23 at 4:31 PM with the Unit Manager for Rehab revealed she had heard Nurse #2 who had worked 7:00 PM on 02/08/23 to 7:00 AM on 02/09/23 had not given Resident #329 her full dose of pain medication as ordered. The Unit Manager for Rehab stated Resident #329's pain medication should have been administered as ordered by the NP unless she was too sedated to receive the medication or the resident had refused the full dose of the medication. Interview on 02/09/23 at 4:55 PM with the Director of Nursing revealed she did not understand why the resident had not notified the nurse when she gave her the medication that she was supposed to have 2 pills instead of 1 pill; however, Nurse #2 should have given the resident the medication as it was ordered by the NP. 2. Resident #330 was readmitted to the facility on [DATE] with diagnoses which included right hip replacement, chronic pain, anemia, and history of pulmonary embolism. Review of her nursing admission note dated 02/04/23 revealed she was alert and oriented to person, place, time and situation. The assessment also revealed the resident was in occasional pain over the last 5 days and was complaining of moderate pain at a level of 8 out of 10 at the time of the assessment. The assessment also indicated the resident was on prn (as needed) pain medication. Review of her Medication Administration Record (MAR) revealed Resident #330 was medicated for her pain level of 8 with Oxycodone Hydrochloride (HCl) oral tablet 15 mg by mouth at 5:29 PM and was recorded as effective. Review of Resident #330's medications for pain effective 02/03/23 revealed the following: Oxycodone HCl oral tablet 15 mg - give 1 table by mouth every 6 hours as needed for pain effective 02/03/23. Fentanyl transdermal patch 72 hour 50 micrograms (mcg) per hour - apply 1 patch trans dermally one time a day every 3 days for pain and remove per schedule effective 02/03/23 and discontinue 02/07/23. Review of her care plan dated 02/04/23 revealed a focus area for being at risk of pain related to her surgical incision. The interventions included administer medications as ordered, administer pain medication as indicated, notify MD (medical doctor) as indicated, observe for physical indicators of pain, and pain assessment as needed. Review of a progress note written by the Nurse Practitioner (NP) on 02/06/23 revealed the resident had asked about her pain medication because her pain was not being controlled on the current regimen. Plan was to change her Oxycodone HCl oral tablet 15 mg to every 4 hours scheduled for 7 days and then transition to every 6 hours and continue her Oxycodone HCl every 6 hours as needed for pain. Review of Resident #330's medications for pain effective 02/06/23 revealed the following: Oxycodone HCl oral tablet 15 mg - give 1 tablet by mouth every 4 hours for pain for 7 days effective 02/06/23 until 02/13/23. Observation and interview with Resident #330 on 02/07/23 at 8:41 AM revealed her lying in bed watching TV and stated on 02/06/23 she had requested pain medication around 2:00 PM because she knew it was time, she could have it and didn't want her pain to get to a higher level before she received her medication. Resident #330 stated she didn't receive her medication until later in the evening around 10:00 PM and by that time her pain level had reached a 9 out of 10. She further stated she went from 8:41 AM to 10:00 PM without receiving another dose of her pain medication. Resident #330 described her pain as achy and stabbing when she turned certain ways in the bed. Review of her Medication Administration Record (MAR) on 02/07/23 revealed Resident #330 had a scheduled dose of pain medication at 6:00 PM that was blank on the MAR. She did receive her 11:00 PM scheduled dosage of pain medication. Review of the narcotic sheet on 02/07/23 at 11:34 AM for Resident #329's Oxycodone and her pill card revealed the resident had not received a dosage of medication at 2:00 PM as requested on 02/06/23 and had not received a scheduled dosage of her medication at 6:00 PM on 02/06/23. Review of Resident #330's medication orders for pain effective 02/07/23 revealed the following: Fentanyl transdermal patch 72 hour 50 micrograms (mcg) per hour - apply 1 patch transdermally one time a day every 3 days for pain and remove per schedule effective 02/07/23. Interview on 02/07/23 at 2:13 PM with Medication Aide (MA) #1 revealed she had taken care of Resident #330 on 02/06/23 from 11:00 AM to 7:00 PM. She stated she didn't recall the resident requesting pain medication at 2:00 PM and had not given her any pain medication on her shift. She stated she didn't recall why she had not given the scheduled pain medication on 02/06/23 at 6:00 PM unless the order had not been confirmed to show up on the MAR prior to her leaving her shift at 7:00 PM. Interview on 02/09/23 at 3:31 PM with the Nurse Practitioner (NP) revealed prior to her admission to the facility Resident #330 took a lot of pain medication. The NP stated she had worked with the resident on 02/06/23 on trying to get her pain under control by adjusting her pain medication and stated the resident seemed to be better controlled after the changes. The NP further stated she would expect the nurses to administer Resident #330's pain medication as ordered unless there was a clinical reason not to and then she said she would want the nurses to notify her as to why it was not given as ordered. Interview on 02/09/23 at 4:36 PM with the Unit Manager for Rehab revealed she was not sure why the scheduled dose of Oxycodone had not been administered to Resident #330 on 02/06/23 unless it had not been confirmed and shown up on the MAR to be given at that time. She stated she expected the MA to administer medications as requested and ordered to the residents unless they are over-sedated and then she would expect the MA to notify the supervising nurse so she could alert the NP. Interview on 02/09/23 at 4:59 PM with the Director of Nursing (DON) revealed she had spoken with Resident #330 and she had told her also that she had requested medication at 2:00 PM on 02/06/23 and had not received it. The DON also revealed she had spoken with MA #1 who had explained she did not recall the resident requesting pain medication at that time on 02/06/23. The DON stated it was difficult to determine what time the scheduled 6:00 PM dose of pain medication was confirmed for Resident #330 and said it may not have been in time for the MAR to alert her to give the 6:00 PM dosage but said she expected the MAs and nurses to administer pain medication as requested by the residents as ordered by the NP or MD (medical doctor).

Based on record review, observations, staff, and Speech Language Pathologist interviews the facility failed to assist a dependent resident with mealtime assistance for 1 of 5 residents reviewed for activities of daily living (Resident #46). Findings included: Resident #46 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes, dementia, and cognitive communication deficit. Review of admission minimum data set (MDS) dated [DATE] revealed Resident #46 was severely cognitively impaired and required supervision with set-up only for eating. Review of dining services communication sheet written by the Speech Language Pathologist dated 12/09/22 revealed an order for Resident #46 to have no straws, must be sitting upright in wheelchair during meals, and nursing staff to assist with feeding to ensure safety with meal intakes. Observation of Resident #46 on 02/07/23 at 1:32 PM revealed her sitting up in bed, lunch meal in a Styrofoam tray sitting on bedside table, the food was untouched, and the supplement was not opened. Observation of Resident #46 on 02/08/23 at 1:35 PM revealed her sitting up in bed with her lunch meal Styrofoam tray on bedside table, the supplement was sitting on top of food inside of the tray and had not been opened and Resident #46 was using her fingers to move food around but was not eating. An interview conducted with Nursing Assistant #2 (NA) on 02/09/23 at 3:44 PM revealed she was familiar with Resident #46 and had provided her with her lunch tray yesterday and today. She stated she only helped with set-up for Resident #46 and had no knowledge of her requiring assistance during mealtimes. She revealed she picked up Resident #46's tray after lunch and recorded her meal intake which was 0-25%. NA #2 stated nursing staff were supposed to inform them of changes with resident mealtime requirements. An interview conducted with the Speech Language Pathologist (SLP) on 02/08/23 at 2:32 PM revealed he was familiar with Resident #46 and had worked with her during therapy. He stated he had made recommendations for nursing staff to assist Resident #46 during mealtimes to increase her meal intakes. An interview conducted with the Unit Manger on 02/09/23 at 4:00 PM revealed she was vaguely familiar with Resident #46. She stated she would receive the dining communication sheet from speech therapy and would give a copy to dietary and she would keep a copy to update any new orders, make notes in the resident chart, and update resident task list before sending a copy to medical records. The Unit Manager reviewed recommendations from speech therapy on the dining communication sheet for Resident #46 and stated nursing staff should have been assisting Resident #46 during mealtimes to provide encouragement and cueing and observing meal intake so they could report to nursing supervisor any issues with Resident #46 and decrease in meal intakes and not taking supplements.

Based on observations, record review and Medical Director, Family Nurse Practitioner and staff interviews, the facility failed to provide supervision necessary to prevent 1 of 1 resident who was at risk for elopement from exiting the facility (Resident #216). The facility also failed to implement action to keep two residents separated to prevent 1 of 1 resident (Resident #216) from becoming agitated and slapping another resident (Resident #46) in the face. Immediate Jeopardy began on 10/11/17 when Resident #216 eloped from the facility without staff's knowledge that he was outside without supervision. Resident #216 had exited the building from the 400 Hall exit door and into the parking lot in front of a storm drain when he was found by Nurse #1 who assisted him back to the building. The storm drain was observed to measure 80 feet from the outside door of 400 Hall to the storm drain and it was 188 feet and 2 inches from the storm drain to the road. Nurse #1 indicated Resident #216 had no injuries and returned to the facility without resistance. Immediate Jeopardy was removed on 11/17/17 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The facility was cited at F323 for example #2 at a scope and severity level of D. The findings included: 1. Resident #216 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's admission assessment/screening dated 09/21/17 revealed Resident #216 had short and long term memory impairment and wandered aimlessly. Further review revealed a comment which read wandering in and out of other resident's rooms. Review of the care plan, created on 09/27/17, revealed Resident #216 was an elopement risk/wanderer related to being disoriented to place and impaired safety awareness. The goals were for his safety to be maintained and he would not leave the facility unattended through the next review date. The interventions included: identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Wander Alert: ensure in place and functioning. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #216's cognition was severely impaired. The MDS indicated he had displayed continuous and non-fluctuating behaviors of inattention, disorganized thinking and altered level of consciousness. The MDS further indicated Resident #216 had displayed wandering behavior 1 to 3 days during the 7 day assessment period. Review of Resident #216's electronic medical record revealed the following nurses' notes: A note written by Nurse #10 on 09/28/17 at 3:38 PM read in part, Resident #216 was alert but confused. Attempted to enter another patient's room, difficult to redirect but staff was able to redirect him away from patient's door. A note written by Nurse #8 on 10/02/17 at 6:08 PM read in part, Resident #216 is alert and oriented to self, has trouble verbalizing needs due to cognitive impairment, always close to staff and in high traffic areas to be in view of staff. Resident has a wander guard on his wheelchair because he will not let staff apply wander guard so when resident gets close to the doors, the alarm goes off and notify staff. A note written by Nurse #9 on 10/10/17 at 7:57 PM read in part, Resident #216 was very agitated, in and out of other rooms and given Ativan for discomfort. Tried to redirect resident but was unsuccessful. A note written by Nurse #8 on 10/11/17 at 2:17 PM read in part, Resident #216 was alert and oriented to self but due to cognitive impairment has a hard time making sense or keeping a straight thought. Tolerated medications with no difficulty noted at this time. Wander guard is in place on wheelchair due to resident refusing to left staff place it on wrist. Wander guard is activated and will go off when resident is close to an exit door. A note written by Nurse #8 on 10/12/17 at 12:19 PM read in part, wander guard is in place on wheelchair due to resident refusing to let staff place it on wrist. Wander guard is activated and will go off when resident is close to an exit door. A review of the facility's elopement investigation and plan of correction dated 10/11/17 revealed Resident #216 was found outside in the parking lot by the therapist with no injuries. Administration was notified and an investigation initiated which included a root cause analysis to determine how Resident #216 had gotten outside the facility and interviews with facility staff. The facility's investigation concluded the alarm on the exit door at the end of 400 Hall had been unarmed on 10/10/17 for deliveries and the alarm was not reactivated after the deliveries were made which had allowed Resident #216 to exit the building on 10/11/17. Once identified by the facility, the exit door at the end of 400 Hall had been immediately secured. The facility initiated a plan of correction that included education of nursing staff, maintenance staff, non-direct care staff and vendors. The monitoring procedure included daily and indefinite audits of all facility doors by the Maintenance Director to be reviewed by the Administrator. Review of the elopement statement (undated) for Resident #216 written by Nurse #1 read in part, on Wednesday, October 11, 2017 at approximately 3:45 PM I was leaving work. I was pulling out of the parking lot on the facing left hand side of the building and I saw Resident #216, sitting in his wheelchair to move. I pushed Resident #216 to the cement sidewalk and there we met the Discharge Planning Assistant (DPA). I told her I found Resident #216 in the parking area. I then pushed Resident #216 to the porch area who wanted to stay outside. Resident #216 wanted to sit on the wooden bench on the porch area in the shade with other residents. The DPA went into the building to get help. I assisted Resident #216 transferring from wheelchair to bench. At this point, the Receptionist came out and told Resident #216 to get back in the wheelchair, it was too hot outside and assisted him back inside. Review of the elopement statement dated 10/12/17 for Resident #216 written by the DPA read, As I was leaving work I found Nurse #1 pushing Resident #216 back onto the sidewalk. Nurse #1 claimed he had been found in the parking lot by self and his wheelchair was stuck in a drain. I helped talk Resident #216 into returning to the building. Then I told the Receptionist and they went out to Resident #216 and relieved Nurse #1. I then proceeded to warn admission staff. Resident #216 did not appear to be harmed. I also do not see how he got out of the building. Review of the elopement statement dated 10/12/17 for Resident #216 written by the Receptionist read in part, on the date of 10/11/17, after hearing from down the hall that the resident was outside, I went over to the main outside door and saw the resident sitting on one of the benches. There was another resident with family sitting on the bench located next to Resident #216. I walked out and sat next to Resident #216 who was unaware how he had gotten outside. After a short talk, we decided it was too hot and we needed to get inside. There were no issues with getting him back into the building and from the front lobby he went back to his hall. Review of the elopement statement dated 10/11/17 for Resident #216 written by Nurse Aide (NA) #8 read in part, At approximately 3:50 PM on 10/11/17 I witnessed Resident #216 sitting in his wheelchair at the nurses' station, he was acting his normal self. I walked past him sitting there on my way to answer a call light. When I finished with my resident and exited the room I was informed at around 4:00 PM that Resident #216 had gotten out of the facility and the Admissions person had brought him back in. He was not injured and didn't seem any different for the rest of the shift. An interview on 11/14/17 at 2:52 PM with the Receptionist revealed Resident #216 exited the building through an unlocked door off of one of the units and out into the parking lot. She was unable to recall the exact date this occurred but stated it happened around 5:00 PM, possibly on a weekday, within a couple of weeks after his admission to the facility. The Receptionist was not sure who found Resident #216 in the parking lot but thought it might have been the DPA. The Receptionist recalled that after staff assisted Resident #216 to the front of the building, he requested to sit on one of the benches and the Receptionist went outside to sit with him until he could be coaxed back inside. She stated he was agreeable to returning back inside the building and had done so without resistance. The Receptionist added she wrote a statement of the incident and gave to the Administrator. An interview on 11/14/17 at 3:50 PM with the DPA revealed she could not recall the exact day Resident #216 eloped but stated it occurred on a weekday at approximately 4:45 PM. She explained she had clocked out and walked out the front of the building toward the parking lot when she noticed Nurse #1 assisting Resident #216 back toward the building. The DPA indicated she walked back toward the front of the building with Resident #216 and Nurse #1 when he requested to sit outside on one of the benches. She stated Nurse #1 stayed with him while she went inside to get assistance from the Receptionist and to inform Administration. She added she wrote a statement of the incident and gave it to the Administrator. An interview was conducted on 11/15/17 at 8:10 AM with the Administrator who confirmed an investigation was immediately initiated when she was informed Resident #216 had been located outside the facility without supervision on 10/11/17. The Administrator stated they had determined the alarm on the exit door at the end of 400 Hall had been unarmed for a delivery and not rearmed after the delivery was made. She added the exit door at the end of 400 Hall was not wander guard protected. The Administrator confirmed the door was secured as soon as it was discovered and a plan of correction was implemented which included a facility-wide audit of all exit doors and in-service education on door alarms was provided to staff. An interview on 11/15/17 at 8:33 AM with Nurse #1 revealed she was leaving for the day when she noticed Resident #216 sitting in his wheelchair out in the parking lot unattended on 10/11/17. Nurse #1 indicated he did not appear injured and she immediately assisted him back toward the front of the building where they met the DPA who was also leaving at the time. Nurse #1 recalled it was a nice day and she assisted Resident #216 out of his wheelchair to sit on the bench at his request when they got to the front of the building. Nurse #1 was unsure how long Resident #216 had been sitting out in the parking lot prior to her intervention. She added she wrote a statement of the incident and gave it to the Administrator. An observation of the parking lot where Resident #216 had been located was conducted on 11/15/17 at 8:56 AM with Nurse #1. She walked to left side of the building to an area in the middle of the parking lot where a water drain grate was located. She explained he was faced toward the road and the back wheels of his wheelchair had been situated right in front of the water drain grate. A follow-up interview on 11/15/17 at 10:00 AM with Nurse #1 revealed she clocked out of work about 3:45 PM on 10/11/17, went straight to her car and started to drive out of the parking lot when she noticed Resident #216. Nurse #1 estimated she noticed Resident #216 at 3:50 PM and it took her approximately 5 minutes to assist him back toward the front of the building. A follow-up interview on 11/15/17 at 5:30 PM with the Administrator revealed the plan of correction put into place on 10/11/17 when Resident #216 eloped from the building stated the therapist had been the one to find him in the parking lot but it was actually Nurse #1. The Administrator confirmed they did not provide inservice education to the NA staff because nursing staff were the only ones that were authorized to unlock exit doors. An interview and tour was conducted on 11/15/17 at 5:37 PM with the Maintenance Director. The Maintenance Director used a multi-foot tape measure to determine the distance measurements for the area of the parking lot where Resident #216 had been located. The area was observed to measure 188 feet and 2 inches from the road to the front of the water drain grate and was 80 feet from the outside door of 400 Hall to the front of the water drain grate. The Maintenance Director confirmed the exit door had been unarmed to allow a delivery sometime between 2:00 PM and 3:00 PM on 10/10/17 and he was unaware it was still unarmed until 10/11/17 when Resident #216 had exited the building. An interview on 11/15/17 at 7:06 PM with NA #8 revealed she was assigned to care for Resident #216 on 10/11/17 when she was informed he had exited the building. NA #8 stated it shocked her how quickly he got out of the facility and verified she saw Resident #216 sitting by the nurses station at approximately 3:45 PM prior to him exiting the building. The Administrator and Corporate Nurse Consultant were informed of Immediate Jeopardy on 11/16/17 at 6:13 PM. On 11/17/17 at 6:45 PM, the facility provided the following Credible Allegation of Compliance: 1. On 10/11/17 Resident #216 exited the facility by the 400 Hallway exit door, which was unlocked and unalarmed. Resident #216 made it to the storm drain, in his wheel chair, which is eighty feet from the exit door to the storm drain and became stuck on the decline of the pavement around the storm drain and was not able to proceed any further. The resident was at that point, one hundred and eighty-eight feet at the bottom of an incline from the highway. The resident had the potential of reaching the highway if he had not become stuck on the storm drain incline. On 10/11/17 at 3:50 PM the Minimum Data Set Coordinator had clocked out and was leaving for the day when she noted the resident at the storm drain. She assisted the resident to the sidewalk where she pushed the resident to the porch area and assisted him from his wheelchair to the bench. The receptionist came out and assisted the resident back into his wheelchair and returned the resident back into the building. The door that the resident exited from was immediately secured and alarm reset. During the investigation by the Administrator on October 12, 2017 it was discovered that the Maintenance Director had not been checking the magnetic lock since his hire date of 09/27/2017 to ensure that they were secure and alarmed as intended. On October 12, 2017 the Administrator educated the Maintenance Director that as a routine practice the doors will be checked daily Monday through Friday by him and the Weekend Manager on Duty would be tasked with checking the doors on the weekend. The Administrator educated the Department Heads who are the managers on duty and was completed on October 12, 2017. In an effort to determine why the door was unsecured it was discovered that the previous Housekeeping Director had made arrangements with a vendor to unlock the side door on the 400 Hall side of the building near the parking lot for deliveries. The vendor had made a delivery and the door was not relock and alarm reset upon completion of the delivery. When this was discovered the Maintenance Director, called the vendor and spoke to the dispatcher and the delivery driver and informed them that deliveries would not be allowed through any doors other than the service hall door at the rear of the building where deliveries are intended to be delivered. 2. On 10/11/17 the door on 400 Hall door was secured and all other doors in the facility providing access to the outside of the building were checked to ensure that they were secured and the alarm armed. On October 12, 2017 the Maintenance Director was educated on checking doors every day Monday - Friday and Manager on Duty for the weekend would check them on the weekends. Between October 12 and October 18, 2017 Nurses (were the only staff that had access to the keys) on staff were educated that the exit doors are not to be opened for any reason other than an emergency and no deliveries are to be received through the exit doors. All deliveries are to be received in the rear of the building at the delivery entrance. A cover was installed over the alarm box that has a lock which can only be opened by the nurse manning the Jasmine and Dogwood medication cart. This would allow for only the Maintenance Director and the one nurse on each hall would be able to alarm and unarm the magnetic lock door. The Maintenance Director on 11/17/17 installed magnetic alarm switches to each exit door to allow an audible sound if the door is opened. 3. The Maintenance Director enters his checks in to the Preventative Maintenance Work-order System and prints their assigned day and notifies Administrator and Maintenance, so that results can be entered into the Preventative Maintenance Work-order system. This will be accomplished by the Maintenance Director and Managers on Duty indefinitely. 4. The administrator will be responsible to ensure that the plan of correction is implemented, audit findings will be reviewed at the Quality Assurance Performance Improvement Committee Monthly, indefinitely for review and revision as needed. Immediate Jeopardy was removed on 11/17/17 at 6:45 PM when observations revealed the alarms/chimes were functioning at each exit door, observations of residents identified with wandering behaviors revealed their wander guards to be in place and interviews with the Maintenance Director, Housekeeping Director and nursing staff confirmed they had received in-service training on codes and door alarms. 2. Resident #216 was admitted to facility on 09/21/17 with [DIAGNOSES REDACTED]. Review of the facility's Admission Assessment/Screening - Nursing form dated 09/21/17 for Resident #216 read in part, admitted from hospital. Short and long term memory impairment. Resident wanders aimlessly in and out of other resident rooms. Behaviors checked were resistive and aggressive. Review of the care plans for Resident #216 revealed the following: Resistance to Care related to dementia, initiated on 09/22/17 and revised on 09/25/17, included a goal he would cooperate with care through the next review date. Interventions included to allow him to make decisions about treatment, give clear explanation of all care activities prior to and as they occur each contact and praise when behavior is appropriate. Impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease and impaired decision making, initiated on 09/22/17 and revised on 11/9/17, included a goal he would develop skills to cope with cognitive decline and maintain safety by the next review date. Interventions included for staff to administer medications as ordered, ask yes/no questions in order to determine his needs, reduce any distractions, provide him with necessary cues - stop and return later if he becomes agitated, 1:1 sitters as indicated, and monitor/document/report as needed any changes in cognitive function. Physical aggression potential related to dementia, poor impulse control and sexually inappropriate behavior, initiated on 09/27/17 and revised on 11/7/17, included a goal that he would not harm self or others through the next review date. Interventions included for staff to administer medications as ordered, assess and anticipate resident's needs, provide physical and verbal cues to alleviate anxiety, assist to set goals for more pleasant behavior, monitor/document/report as needed any signs or symptoms of resident posing danger to self and others, proceed with discharge if behavior cannot be managed within facility, Psychiatric consult as indicated, and intervene when the resident becomes agitated. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #216's cognition was severely impaired. The MDS indicated he had displayed physical and verbal behavior directed toward others and other behavioral symptoms not directed toward others 1 to 3 days during the assessment period which interfered with his care, participation in social activities and put others at risk of injury. Review of the initial Psychiatric Evaluation dated 10/02/17 for Resident #216 revealed in part, seen for reduction in assaultive and inappropriate behavior. Family member present and reports episodes of hallucinations. Staff and family member report that his mood 'changes quickly.' It is reported he grabs and swings at staff. Since he has been at this facility, he has been sent to the hospital twice due to his behaviors in which he was returned back to the facility. Due to his level of dementia, his answers to my questions are unreliable. Short term and long term memory poor. Medications were initiated with instructions to monitor for changes in mood and behavior. Review of the nurses' notes related to Resident #216's behaviors revealed the following entries: A note written by Nurse #8 on 10/02/17 at 6:08 PM read in part, Resident #216 is alert and oriented to self, has trouble verbalizing needs due to cognitive impairment, always close to staff and in high traffic areas to be in view of staff. A note written by Nurse #9 on 10/10/17 at 7:57 PM read in part, Resident #216 was very agitated, in and out of other rooms and was given Ativan for comfort. Tried to redirect but was unsuccessful. A note written by Nurse #8 on 10/11/17 at 2:17 PM read in part, Resident #216 was alert and oriented to self, able to verbalize needs majority of the time but due to cognitive impairment resident has a hard time making sense or keeping a straight though. Tolerated medications with no difficulty noted at this time. A note written by Nurse #6 on 10/17/17 at 6:45 PM read in part, Late Entry: Resident #216 became combative after nurse tried to redirect from going out the door, his fists clenched, he screamed 'get out of my way or I'll kill you.' A note written by Nurse #3 on 10/26/17 at 9:29 AM read in part: Resident #216 went into another resident's room, was resistive to leave room, combative and clung onto door handle. Resident #216 began to curse and swing his hands at all nurses and started to growl and yell. A note written by Nurse #2 on 10/28/17 at 2:00 AM read in part, staff is one on one with resident and unable to redirect with snacks, coloring, or TV. Patient is resistant to diversions and becomes aggressive frequently. Patient with this nurse entire shift with multiple corrections made to not touch nurse or staff. Continues to attempt to pull meds from cart while on med pass. A note written by Nurse #4 on 11/4/17 at 4:21 AM read in part, patient was verbally and physically abusive to a patient (Resident #46) by telling her to shut up and then proceeding to slap patient. The two patients were separated and Administrator, the cops and family members were notified. Separating the two was effective. A telephone interview on 11/14/17 at 5:23 PM with Nurse #4 revealed she was employed through an agency and was assigned to work 3:00 PM to 11:00 PM on 200 Hall the night she witnessed Resident #216 slap another resident (Resident #46). Nurse #4 recalled it was her first day at the facility and Resident #216 had just recently been moved to 200 Hall. She explained Resident #216 was sitting out in the middle of the hall with another resident, who repeatedly yelled out, when they started hollering back and forth, telling each other to shut up. She stated he got up from his wheelchair, went over to the other resident and gave her a pat on the shoulder. She indicated Resident #216 sat back down as she instructed and both residents calmed down. She added it was not an aggressive incident and felt no other interventions were needed at the time. Nurse #4 stated later that evening when the other resident (Resident #46) started hollering out again, Resident #216 became agitated and she turned in time to see him slap Resident #46 across the face. Nurse #4 stated she assisted Resident #216 back to his wheelchair and he sat back down. Nurse #4 added Resident #216 was taken to another hall, the police were contacted by the Administrator and they came to the facility to talk to him. She indicated Resident #216's family member came to the facility after the incident, he had calmed down and there were no further incidents. An interview on 11/15/17 at 8:10 AM the Administrator confirmed she had been informed Resident #216 had slapped another resident (Resident #46) the evening of 11/03/17. She stated the incident occurred around 6:00 PM and was witnessed by an agency nurse assigned to his hall. The Administrator stated she personally contacted both resident's families to inform them of the incident and the agency nurse contacted the police. She indicated the police came to the facility to talk with Resident #216 but they did not fill out a police report since both residents had dementia and the other resident's family had not wanted to press charges. The Administrator stated the other resident (Resident #46) had a red mark on her face after the incident but when assessed the next day there was no bruising or other negative outcome. She added that it was difficult for facility staff to provide constant supervision to Resident #216 and after the incident on 11/03/17 agency staff were utilized to ensure Resident #216 had one on one supervision. A telephone interview on 11/15/17 at 5:48 PM with the Medical Director (MD) confirmed she was aware of Resident #216's behaviors and stated they looked for alternate placement for Resident #216 but this facility had been the only option for him at the time. She explained he had dementia with aggressive behaviors and had been hospitalized twice since his admission. The MD stated she felt the facility was following their protocols to keep him and other residents safe. An interview on 11/16/17 at 9:02 AM with the Family Nurse Practitioner (FNP) revealed she was unaware Resident #216 had slapped another (Resident #46) resident and confirmed he was severely impaired with cognition, decision making and safety awareness. The FNP stated Resident #216 was often aggressive and directed it toward anyone who attempted to provide redirection. She added a sitter was the most effective intervention for his behaviors.

Based on facility and medical record reviews and staff, resident, and family interviews, the facility failed to monitor a resident, who was assessed as an unsafe smoker and had no system in place to monitor safe smokers to assure there was no sharing of smoking materials for two (2) of ten (10) sampled residents. (Residents #1 and #4). Immediate jeopardy began on [DATE] when the facility assessed Resident #1 as an unsafe smoker. On the morning of [DATE] Resident #1 smoked in his room while utilizing oxygen via nasal cannula resulting in a fire. Resident #1 expired [DATE] due to burns received in that fire. On the same date, Resident #2 was admitted to a local acute care facility and treated for [REDACTED]. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee education. The findings are: An undated facility Smoking Policy specified residents, visitors, or staff would not be permitted to smoke inside the facility. The only areas in which residents or staff would be allowed to smoke were in the courtyards located on each side of the dining room and on the covered areas off the living rooms. The Smoking Policy did not address unsafe smoking, monitoring, reassessing these residents, or how the facility was monitoring to indicate safe smokers were not providing smoking materials for unsafe smokers. 1. Resident #1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's medical record revealed a Safe Smoking Assessment form completed on admission signed by Licensed Nurse (LN) #1 and dated [DATE]. The following statement was observed documented at the bottom of the form, "Hx (history) of smoking, presently does not smoke". A review of a progress note dated [DATE] at 11:07 AM and signed by LN #6 revealed Resident #1 refused a Nicotine patch that morning. The note continued Resident #1 stated he did not want the patch, he wanted to smoke. Continued medical record review revealed a Safe Smoking Assessment form completed by the MDS (Minimum Data Set) Coordinator and dated [DATE]. Documentation on this form noted Resident #1 was determined to be a safe smoker. The admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively intact and required limited staff assistance for transfers, ambulation, dressing, and hygiene. The MDS also assessed Resident #1 was a tobacco user. Care Area Assessments (CAA) dated [DATE] specified Resident #1 was alert and oriented to his room number, year and month but not the day of the week. The CAAs also noted the resident had episodes at times of forgetfulness and being impulsive and required reminders for safety. A review of care plans (CP) for Resident #1 revealed a CP dated [DATE] identified the resident as a safe smoker and he would follow safe smoking practices. CP goals specified Resident #1 would comply with administration smoking policy with no accidents or injury related to smoking through the next review. Interventions included: all staff would encourage the resident to have supervision with smoking and the Social Worked (SW) would ensure the resident smoked only in designated areas and would relinquish any ignition source in his possession upon request. A review of a progress note dated [DATE] and signed by LN #5 revealed Resident #1 experienced a second fall in four (4) days. The note specified Resident #1 experienced an unobserved fall. He reported he attempted to sit down on his rolling walker when he misjudged location of the seat and fell . The documentation specified as of [DATE], the resident required accompaniment when going to the smoke porch. A CP related to falls was updated on [DATE] with an intervention that specified accompaniment/supervision while on the smoke porch. Further medical record review revealed a third Safe Smoking Assessment form signed by LN #2 and dated [DATE]. Documentation on this form noted Resident #1's short term memory was not intact and he did not have adequate memory or recall ability. Further documentation specified Resident #1 did not demonstrate safe techniques for putting out ignition source and disposing of ash. Additional documentation noted the resident did not demonstrate the ability to physically hold the smoking device while smoking. The assessment deemed Resident #1 as an unsafe smoker. Comments on this assessment specified the resident's cigarettes and lighter would be kept in the medication cart and a staff member must accompany the resident to the designated smoking area and to assist him while smoking. It also stated Resident #1 understood these precautions. Review of a nursing progress note dated [DATE] and signed by Licensed Nurse #3 revealed at approximately 5:20 AM staff responded to a fire alarm with extinguishers to room 314 B. Thick dark smoke was observed inside the room. Staff attempted to put out the fire with extinguisher. 911 was called by this nurse. Resident #1 was removed from his room by staff through the window. The note further specified the resident was transported to an acute care facility for treatment. On [DATE] at 11:12 AM an interview was conducted with Nursing Assistant (NA) #1. He stated on [DATE] he responded to a fire alarm that sounded in the facility shortly after 5:00 AM. NA #1 stated the facility's fire panel indicated the alarm came from a resident room. As he approached that room, he observed Resident #1 standing between the B bed (bed closest to the window) and the window. NA #1 reported the resident was on fire and a nasal cannula used to administer oxygen was lying on the bed. NA #1 specified flames were shooting out of the cannula causing the bed to burn which prevented him from getting near the resident. NA #1 stated a fire extinguisher was utilized to put out the fire on the resident's clothing and with assistance of other staff members, the resident was removed from the room through the window. He further stated another staff member was with Resident #1 until the emergency medical assistants arrived. NA #1 stated he went back into the building and removed Resident #2 from the A bed (bed closest to the room door) and physically carried him outside of the building. On [DATE] at 11:48 AM an interview was conducted with LN #7. who was on duty on [DATE] when the fire occurred. LN #7 stated he assisted with removing Residents #1 and #2 from the building. He stated Resident #1 sustained burns over his upper body and thighs. LN #7 stated the fire department and emergency medical assistants arrived to the facility and the fire department extinguished the fire in the residents' room. LN #7 added the other residents on the hall of the fire were evacuated by facility staff to an area past the fire doors. Review of a [DATE] History and Physical (H&P) and a Discharge Summary from an acute care facility revealed Resident #1 was transported via air ambulance after sustaining burn injuries around 5:30 AM. He was alert and responsive when attended by the emergency medical team at the scene of the fire. Upon arrival to the acute care facility around 7:00 AM, he was nonresponsive. Initial evaluation revealed Resident #1 had sustained approximately 55% of total body surface area with full-thickness burns and an inhalation injury resulting in swelling of the airway. The H&P specified Resident #1's prognosis was grave. After family consultation, comfort measures were initiated. The Discharge Summary documented Resident #1 expired on [DATE] due to the severity of the burns sustained in the fire. An interview with the Director of Nursing (DON) and Administrator on [DATE] at 9:02 AM revealed residents that were assessed as unsafe smokers required staff supervision when smoking. The DON stated this was explained to residents at the time of their admission. The DON described an unsafe smoker was someone who could not hold or put out a cigarette. The DON added cognition was taken into consideration and was part of the smoking assessment. The DON stated residents who were assessed as safe smokers were allowed to keep their cigarettes and ignition sources in their possession. All smoking materials for residents who were assessed as unsafe smokers were kept locked on the medication carts. Further interview revealed smoking was not allowed when oxygen was in use. The DON stated if a resident failed to comply with the rules, the facility would consider this a reason for discharge. The DON stated Resident #1 was not smoking at the time of his admission due to his illness. The DON explained about a week after admission as the resident began to regain his strength, he asked to smoke. He was assessed at that time as a safe smoker. The DON stated after the resident's second fall, he was reassessed and determined to be an unsafe smoker, mainly to have supervision present to prevent falls. The DON stated to her knowledge, Resident #1 did not have smoking materials of his own. He would rummage through the ashtrays for butts and ask facility staff for cigarettes. The DON continued Resident #1 had to borrow a cigarette and lighter each time he smoked. The DON stated it was not usual routine for staff to search him because he never gave them cause. To her knowledge, he never attempted to smoke in the building or with oxygen in place. The DON and Administrator stated they had never observed Resident #1 with a lighter or attempting to smoke with oxygen in place. An interview with Housekeeper #1 on [DATE] at 1:47 PM revealed she assisted with cleaning Resident #1's room after the fire. She stated she found two (2) cigarettes, whole and unsmoked, under a tissue box on Resident #1's over bed table. An interview with Resident #16 was conducted [DATE] at 4:15 PM. Resident #16 was assessed as alert and oriented on the latest MDS dated [DATE] and was assessed as a safe smoker. This resident stated she observed Resident #1 on the smoking porch unattended by facility staff on the afternoon of [DATE]. She stated Resident #1 was picking cigarette butts out of the ashtrays. She asked him if he was supposed to be out there unattended. Resident #16 stated he gave an answer she could not understand. An interview with NA #2 on [DATE] at 4:30 PM revealed she took a lighter from Resident #1 around [DATE] or [DATE], after he was deemed an unsafe smoker. She stated when she asked the resident where he got the lighter, he replied he did not know. An interview via phone with Resident #1's family member on [DATE] at 9:45 AM revealed he had visited Resident #1 on [DATE]. The family member stated he brought the resident a pack of cigarettes and took him out to smoke. The family member stated he left the cigarettes and lighter which he thought was green in color with Resident #1. A review of a Fire Inspector's (FI) report dated [DATE] revealed on [DATE] at approximately 5:53 AM on [DATE] the FI arrived on the scene at the long term care facility following a structural fire. The report specified two (2) residents of the facility were pulled from the room where the fire occurred by facility staff. Both were attended by staff and responding emergency personnel. The report specified the burned resident was air lifted to a burn center and the second resident was transported by ambulance to a local acute care center due to smoke inhalation. In the report, the FI described the affected room as follows: Two (2) beds were noted in the room. The A bed near the doorway had no damage. The B bed next to the window had fire damage to the mattress and linens. A lighter, blue in color, was noted on the top seat of a rolling walker which was located to the right of the B bed. Lying in the floor underneath the walker was a partially consumed cigarette butt with the brand name still visible. An oxygen generator was located to the right of the B bed. The plastic tubing that runs from the machine to the resident's nasal cannula was melted. Portions of the tubing was melted and stuck to the bed linens, bed controls and a chair located beside the oxygen generator. The FI report documented electrical and provindential causes were eliminated via investigation. The report specified this fire was ruled as being caused by the direct involvement of human hand by misuse of smoking material. 2. Resident # 4 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] indicated no cognitive impairment and supervision of staff was needed for transfers and ambulation. A review of a Safe Smoking assessment dated [DATE] and signed by Licensed Nurse (LN) #8 revealed Resident #4 was assessed as a safe smoker. Review of an e-mail dated [DATE] from Unit Manager (UM) #1 sent to the Director of Nursing (DON) revealed UM#1 had interviewed Resident #4 that day. The e-mail specified Resident #4 can no longer ask Resident #1 to go smoke and offer him cigarettes. UM #1 explained Resident #1 needed staff supervision to keep him safe and Resident #4 could not provide that supervision. The e-mail documented Resident #4 understood and would no longer offer him cigarettes. A review of Resident #4's medical record revealed a progress note dated [DATE] and signed by LN #9 at 3:08 PM. The note specified Resident #4 and her Responsible Party were notified of the smoking policy change effective this date. The policy change directed residents were no longer allowed to keep cigarettes or ignition sources in their rooms. These items would be stored in the medication carts and given to residents as requested. Additional review of Resident #4's medical record revealed a progress note dated [DATE] and signed by LN #6 at 12:43 PM. The note specified the resident was upset and wanted her cigarettes. LN #6 wrote Resident #4 stated the cigarettes were hers and the facility didn't need to keep them for her. LN #6 documented she explained the new smoking policy again. Continued review of Resident #4's medical record revealed a progress note dated [DATE] and signed by the Director of Nursing (DON). The note specified Resident #4 admitted she gave cigarettes to another resident in the facility and encouraged him to go out and smoke with her. The note specified Resident #4 stated she did not think it was fair that the other resident had to wait on staff to give him smoking materials, nor was it fair for him to have to be observed smoking when she could do it. An interview with the DON on [DATE] at 1:19 PM revealed on the morning of [DATE] when Resident #1 experienced his second fall, Resident #4 was the person who found him. The DON continued Resident #4 had difficulty summoning help. The DON stated after the conversation between UM #1 and Resident #4 documented in the e-mail, she felt confident Resident #4 would comply with the facility's request for her not to assist Resident #1 with smoking. The DON stated the facility felt there was no reason to monitor this situation because of the concern Resident #4 expressed for Resident #1's safety when he fell . An interview with UM #1 on [DATE] at 12:47 PM revealed Resident #4 had witnessed a fall experienced by Resident #1 on [DATE]. She was speaking to Resident #4 on [DATE] regarding this fall. UM #1 stated during this conversation Resident #4 offered information that she asked Resident #1 to go smoke with her and she would give him a cigarette and light it for him. An interview with Resident #4 via phone on [DATE] at 12:58 PM revealed she did give Resident #1 cigarettes and light them for him. She stated she observed Resident #1 smoking without staff supervision after his cigarettes were taken away. An additional interview with the DON on [DATE] at 11:56 AM revealed it was her understanding Resident #4 gave Resident #1 cigarettes after he was assessed as an unsafe smoker. The Administrator was informed of Immediate Jeopardy on [DATE] at 3:30 PM for Resident #1 and Resident #4. The facility presented a credible allegation of compliance which included: Correction for Resident #1 ? Resident # 1 transferred to the hospital on [DATE] and passed away there on that date. Correction for Resident # 2 ? Resident # 2 transferred the hospital on [DATE]. ? Resident #2 was discharged from the hospital to another skilled facility on Wednesday, [DATE] and does not plan to return to this facility. 2. Correction for current residents at risk: ? On [DATE] Unit Manager spoke with resident # 4, who reported to her that she (resident # 4) had provided resident # 1 with cigarettes and lit his cigarette for him. Unit Manager explained to resident # 4 she can not do this because these unsafe smoking interventions were in place for resident # 1's safety. Resident # 4 verbalized understanding and agreed to comply. ? Smoking materials were collected from each resident who was identified as a current smoker. Admissions Director and Business Office Manager retrieved the smoking material from the patients who smoked on [DATE]. ? On [DATE], safe smoking assessments and care plans for all residents who were smokers were reviewed by Unit Managers, Resident Assessment Coordinator, Director of Discharge Planning, and Activity Director. All smokers were found to be appropriately assessed and care planned. Care Plan Confirm sheets (Resident Care Guides) were printed and placed in the Care Plan Confirm Books on each Unit on [DATE] by the Unit Managers. This information was used to communicate with Certified Nursing Assistants patients smoking needs. ? On [DATE], 17, 18, 19, 20 and 23, a safe smoking audit was conducted by the Activity Director, Staff Development Coordinator and Unit Manager. The audit looked at 100% of smokers in the facility and checked for the following: 1) Resident room number 2) Name 3) Oxygen user 4) Smoking Assessment Date, 5) Interdisciplinary Team Members Present on Assessment, 6) Requires supervision, 7) Smoking items kept with nurses, 8) Care plan present, 9) Care Plan matches smoking assessment 10) Education on smoking provided on admission. Any issues identified were corrected by Unit Manager at time of audit. ? On [DATE], Director of Nursing conducted an in-service for 100 % of all direct care nursing staff, housekeepers, nurse managers and department managers who were on duty and all oriented patients, regarding the importance of having no smoking materials in patient rooms. Any materials found in patient rooms would be held by nursing for the patient and returned per the patient's smoking plan. ? Additionally, 100% of all facility employees were in-serviced by Director of Nursing, Staff Development Coordinator, Unit Manager, Dietary Manager, Activity Director, Billing Coordinator, and Occupational Therapist, regarding additions to the current smoking policy. Each individual that was not physically present for in-service was contacted by telephone. The following were reviewed with each employee regarding the facility smoking policy: 1) No resident and/or family members of residents would be permitted to share smoking materials with other residents. 2) A condensed list of current residents who are unsafe smokers will be kept in the front of the Care Plan Confirm notebooks that are kept at each nurse's station with their individual needs listed. All residents that are unsafe smokers are listed in every Care Plan Confirm notebook, regardless of their assigned unit. 3) Cigarettes and other smoking materials will now be kept with the lighters (for all smokers, whether they require supervision or not) locked on the nurse's medication carts. 4) Until further notice, there will be only one staff member, the Director of Discharge Planning designated to buy cigarettes for residents who cannot buy for themselves. She will then deliver those smoking materials to the patient's nurse to be locked in the medication cart. 5) For those patients that require supervision while smoking, the smoking schedules are posted in the yellow Care Plan Confirm notebooks located at each nurse's station. ? On [DATE] signs were posted at entrances and exit to the smoke porches regarding prohibition of sharing smoking materials. ? On [DATE], Unit Manager notified each family member of the smoking residents by phone regarding the new policy prohibiting sharing of smoking materials. ? Beginning [DATE] and ending [DATE], with resident permission, ,[DATE] shift nursing assistants assigned to the care of residents who smoke observed the resident rooms and belongings for smoking materials each evening. ? [DATE], one resident, # 4, expressed a desire to be discharged home due to dissatisfaction with having to relinquish smoking materials on [DATE]. A discharge plan was prepared. ? One resident, # 12, found out of compliance, lighter in possession, on [DATE]; resident was discharged on [DATE] with home health services. ? Care plans for each resident who smoked were re-checked and updated on [DATE] by Resident Assessment Coordinator, Unit Manager, and Nurse Consultant to indicate resident and family notification of changes. ? On [DATE], Staff Development Coordinator, Unit Managers, Therapy Director, Dietary Managers, Resident Assessment Coordinator, Activity Assistant, Medical Records Director, Admission Director, and Human Resource Director, Maintenance Director, Business Office Manager, Administrative Registered Nurse, and Billing Coordinator completed 100% of facility staff were in-serviced. In-service included Review of Smoking Policy, the new location of smoking materials and the use of lock box for smoking materials. The lock box will be located in the 200 Hall Pantry. With the lock box there will be a sign out sheet, for monitoring of smoking materials. A list of unsafe smokers will be kept in front of care plan confirm notebook and on the locked box, smoking schedule revision for unsafe smokers who require supervision, and failure to adhere to policy may result in initiation of the discharge process. ? On [DATE], Social Worker contacted family members of each smoker by telephone and updated them on the changes to smoking rules dated [DATE]. ? On [DATE] Unit Manager updated care plans for each patient who smokes. Care plan confirm sheets (Resident Care Guide) were updated. ? [DATE] all current smokers signed Smoking Policy indicating there is no smoking the facility. ? [DATE] 100% of all nursing staff were in-serviced on, 1) Inventory Sheet for each individual resident 2) Upon admission they must notify all patient/Responsible Party (Smokers and Non-smokers) of "No Smoking", obtain a signature and place on chart 3) Revision of Admission Check List to include information about smoking policy and no smoking in facility. ? [DATE] The Administrator in-serviced Business Office Manager, Billing Coordinator, Admission Director and Admission Coordinator on the Smoking Education Form to be used during Admission Process. 3. ? Amendments to smoking policy dated 2003 were made on [DATE] by Staff Development Coordinator to include: 1) A patient who wishes to smoke will be evaluated by the Interdisciplinary Team upon admission to determine safety and ability to handle smoking material. 2) Smoking is prohibited where oxygen is being used or stored. 3) Smoking is prohibited indoors 4) Those residents who are determined to be unsafe smokers are required to have staff supervision while smoking, will be supplied with any safety device needed, and will adhere to smoking schedule 5) Smoking materials (cigarettes, lighters, and matches) will be stored in a locked area that will be accessed only by staff. 6) Patients who are unsafe smokers are not allowed to have smoking material in their possession. 7) Patients who are safe smokers will be provided their smoking materials upon request and will return the smoking material after smoking. 8) Sharing of smoking materials with residents, by residents, staff, family members, or other visitors is prohibited. 9) Failure to comply with the smoking policy may result in the initiation of the discharge process. ? When a resident expresses a desire to smoke is admitted to the facility, the following process is performed by the admitting nurse that is on duty: ? Upon admission, collect smoking materials from the resident and signed into the Smoking Material Lock Box. ? Review and provide a copy of the smoking policy to the resident and family ? Remove all smoking materials from resident's possession and place in the locked ? Complete safe smoking assessment within 24 hours. (If the patient request to smoke prior to completion of the 24 hours the nurse will accompany patient for observation to assist in completion of smoking assessment) ? Develop a care plan to address the needs for all residents who smoke or wish to smoke. ? Print care plan confirm sheets placed in notebooks on all units for the nursing assistants ? Forward copy of the safe smoking assessment to the Unit Manager for Interdisciplinary Team review during the next morning meeting ? Obtain patient signature on smoking schedule and place on the chart ? Document resident comprehension of verbal education and policy review on smoking. ? Director of Discharge Planning (or Activity Director in the absence of Discharge Planner) will obtain smoking materials for those residents unable buy cigarettes for themselves. The Director of Discharge Planning (or Activity Director) will then label those materials and secure in the locked location. ? On [DATE] copies of the revised Smoking Policy, effective on that date were placed in the file cabinets for nurses use to continue to aid in the education of new admissions regarding the smoking policy. 100 % of all staff nurses were in-serviced by Director of Nursing and Staff Development Coordinator. In-service included education of this policy with each new admission during the admission process. ? No Smoking in Facility Document added to Admission packet to be reviewed and signed by Responsible Party or Resident. The information will be presented and signed by the Admissions Director or Admissions Coordinator and counter signed by Responsible Party or Resident to acknowledge receipt and understanding prior to or at time of admission. The Activity Director and two Nursing Assistants have educated all current residents about the "No Smoking" in building. 100% of all current residents educated and signed on the "No Smoking" in the building and are aware a breech of this may result in the initiation of discharge. If the patient was unable to sign, then the Responsible Party was called and annotated on the Carolina Rehab Center of Burke Smoking Policy and countersigned by the educator. 4. ? The 200 Hall nurse will monitor the sign out sheet located with the locked box for smoking materials at each shift change daily. If any smoking material was not returned the nurse will follow up immediately in order to locate the missing smoking materials. If unable to locate smoking materials the 200 Hall nurse will notify the administrator and director of nursing immediately. Results of every shift check will be reviewed 5 times weekly by unit manager for a period of 2 weeks, then 3 times weekly for a period of 2 weeks, then weekly for a period 4 months and on-going.. The results will be reported to the Quality Assurance Committee monthly for a period of 6 months to review for revisions and compliance. ? Admitting Nurse completes the Admitting Check of List that includes 1) Safe Smoking Assessment, 2) Smoking Care Plan 3) Review of Smoking Policy and Education regarding no smoking inside the facility. The Admitting Check Off List will be reviewed by the unit manager. The Unit Manager will ensure documentation of the smoking education including a copy of the policy was provided to each patient who expresses a desire to smoke. This will be monitored 5 times weekly by unit manager for a period of 2 weeks, then 3 times weekly for a period of 2 weeks, then weekly for a period 4 months and on-going. The results will be reported to the Quality Assurance Committee monthly for a period of 6 months to review for revisions and compliance. ? Administrator will review each admission chart to ensure completion of required Smoking Education. This will be done after admission. The Smoking Education Audit will be completed to check and ensure that 1) Smoking Education Form Used 2) Signature of Responsible Party/Resident 3) Signature of Admissions Representative. This will be monitored 5 times weekly by unit manager for a period of 2 weeks, then 3 times weekly for a period of 2 weeks, then weekly for a period 4 months and on-going. The results will be reported to the Quality Assurance Committee monthly for a period of 6 months to review for revisions and compliance. Immediate Jeopardy was removed on [DATE] at 2:48 PM with interviews of direct care and licensed nursing staff who confirmed they received in-service training on [DATE]. Interviews with direct care staff and licensed nursing staff revealed awareness of the facility's changed smoking policy and systems in place to monitor use of smoking materials and not sharing smoking materials with residents. Interviews with residents deemed safe smokers revealed they were aware of systems in place to monitor smoking materials and knew not to share smoking materials with other residents. Interviews with facility staff involved in admissions revealed they were aware of new forms utilized during the admission process to inform residents of the facility smoking policy. Observations of staff correctly implementing measures to ensure residents were safe and adequately supervised while smoking and cigarettes and lighters were stored as planned. Review of safe smoking assessments to ensure residents were correctly assessed as being safe smokers.