Every finding on record at Fletcher Rehabilitation and Healthcare Center

Based on record reviews and staff interviews, the facility failed to submit a request for an updated Preadmission Screening and Resident Review (PASRR) evaluation for residents with new diagnoses of mental illness for 3 of 7 residents reviewed for PASRR (Residents #34, #41, and #42). The findings included: 1.Record review for Resident #34 revealed that a PASRR Level I evaluation had been completed on [DATE]. The evaluation recommended resubmitting paperwork for a new PASRR evaluation if a new mental health diagnosis was suspected or if there was a significant change in condition. Resident #34 was admitted to the facility on [DATE] with diagnoses that included stroke, dementia, hypertension and hyperlipidemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was not currently considered by the state PASRR process to have a serious mental illness or intellectual disability. Her active psychiatric diagnoses included anxiety disorder and and post traumatic stress disorder (PTSD). She received antidepressant medication during the MDS assessment look-back period. Review of the medical record revealed no documented evidence that a request was submitted for updated PASRR screening. During an interview conducted on [DATE] at 10:06 AM, the Social Worker (SW) stated he had been responsible for submitting requests for PASRR evaluations. The SW further stated he did not have a reason as to why a referral for an updated PASRR had not been completed for Resident #34; however, after reviewing the resident's diagnoses, he stated one should have been submitted. During an interview conducted on [DATE] at 11:03 AM, the Regional Director of Operations stated the SW was responsible for submitting requests for updated PASRR evaluations. She stated the SW received psychiatric provider documentation after each visit and should have reviewed this documentation for new diagnoses. She confirmed that an updated PASRR evaluation request should have been submitted. During an interview conducted on [DATE] at 2:11 PM, the former Administrator stated the SW had been responsible for submitting PASRR evaluation requests. 2. A Level II PASRR Determination Notification dated [DATE] with an expiration date of [DATE] revealed Resident #41 was appropriate for nursing home placement for a 60-day period and further approval must be obtained through screening if Resident #41's stay was extended beyond the end date. The Level II PASRR Determination Notification directions for further approval and screening revealed it must be obtained through NC Medicaid Uniform Screening Program and was the admitting facility's responsibility for initiating screening through a Level II evaluation process within 5 calendar days of the PASRR expiration date ([DATE]). Resident #41 was admitted to the facility on [DATE] with diagnoses including narcissistic personality disorder, delusional disorder, and bipolar disorder. Resident #41 had resided as a resident at the facility since [DATE]. Review of the Medical Doctor's (MD) progress note dated [DATE] revealed Resident #41 was seen for the initial history and physical after being admitted to the facility on [DATE]. The MD's note included Resident #41 diagnoses of narcissistic personality disorder, delusional disorder, and bipolar disorder and indicated aripiprazole (antipsychotic) 10 milligrams (mg) was started in the hospital but since admission on [DATE], Resident #41 refused all psychotropic medications. Review of Resident #41's medical records revealed the facility did not submit a request for further approval and screening for a Level II evaluation process within 5 calendar days of the PASRR expiration date ([DATE]) through the NC Medicaid Uniform Screening Program. During an interview on [DATE] at 10:07 AM, the SW confirmed Resident #41's Level II PASRR Determination Notification expired on [DATE]. The SW revealed when a resident was admitted he checked their PASRR Determination Notification to ensure it was active and it was his responsibility to request further approval and screening through NC Medicaid Uniform Screening Program when expired. The SW revealed he had not realized Resident 41's PASRR expired on [DATE]. During an interview on [DATE] at 11:03 AM, the Regional Director of Operations revealed it was the SW's responsibility to verify and track PASRR and was expected to keep a log that included PASRR expiration dates. The Regional Director of Operations confirmed Resident #41's Level II PASRR Determination Notification expired and stated the SW should have requested an evaluation prior to the expiration date on [DATE]. 3. A Level I PASRR notification letter dated [DATE] was observed in Resident #42's record. No further PASRR documentation was discovered. Resident #42 was admitted on [DATE] with diagnoses including major depressive disorder. Review of Resident #42's diagnoses list included major depressive disorder added [DATE], post-traumatic stress disorder (PTSD) added [DATE], and anxiety disorder added [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact and included diagnoses of depression, anxiety, and PTSD. She received antipsychotic and antidepressant medications. Review of Resident #42's care plan last reviewed on [DATE] identified PTSD with interventions requiring monitoring of psychiatric symptoms and medication effectiveness. The care plan also directed staff to observe and document target behaviors. A psychiatric progress note dated [DATE] reported Resident #42 had diagnoses including chronic depression, PTSD, and generalized anxiety disorder. The note documented continued treatment with duloxetine (treats anxiety and depression), and aripiprazole (antipsychotic) with no medication changes indicated. Review of the [DATE] Medication Administration Record (MAR) noted Resident #42 had received the prescribed psychotropic medications as ordered. Aripiprazole 5 milligrams (mg): take 0.5 tablet by mouth daily at bedtime for PTSD, and major depressive disorder. Bupropion (antidepressant) 300 mg: take 1 capsule by mouth daily for major depressive disorder. Duloxetine 60 mg: take 1 capsule by mouth daily for major depressive disorder and anxiety disorder. During an interview on [DATE] at 10:05 AM with the Social Services Director he stated he was responsible for PASRR referrals for new psychiatric diagnoses. He explained he did not consistently inquire about new mental health diagnoses from providers and was not always informed of new diagnoses or psychotropic medication changes. He stated Resident #42 should have been referred for a Level II PASRR evaluation when she received the new diagnoses of PTSD and anxiety disorder and was unsure how this was missed. An interview on [DATE] at 11:03 AM with the Regional Director of Operations revealed that Social Services was responsible for monitoring PASRR needs, tracking expiration dates, verifying new qualifying diagnoses, and requesting Level II evaluations. She confirmed Resident #42 should have received Level II evaluations when PTSD and anxiety disorder were diagnosed. An interview on [DATE] at 2:10 PM with the former Administrator revealed Resident #42 should have had a Level II PASRR evaluation each time new qualifying diagnoses were identified.

Based on record review and staff interviews, the facility failed to submit a request for Preadmission Screening Resident Review (PASRR) for a newly admitted resident with a serious mental illness diagnoses for 1 of 7 residents reviewed for PASRR (Resident #8).Findings included:A Level I PASRR Determination Notification dated 09/04/25 revealed Resident #8 did not meet the federal definition for mental illness, the PASRR remained valid, and no further screening was required unless a significant change occurred with the individual's status that suggest a diagnosis of mental illness.Review of Resident #8's hospital Discharge summary dated [DATE] included the mental illness diagnoses bipolar disorder with recurrent episode depressed and PTSD (Post Traumatic Stress Disorder). Resident #8 was admitted to the facility on [DATE]. Resident #8's cumulative diagnoses included bipolar disorder with recurrent episode depressed, personality disorder, and PTSD.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #8's active psychiatric/mood disorder diagnoses included depression, bipolar disorder, and PTSD. The list of high-risk medications revealed Resident #8 received antipsychotic and antidepressant medications during the MDS assessment review period (04/10/26 through 04/15/26). Review of Resident #8's medical records revealed a Level I PASRR Determination Notification dated 09/04/25. Review of the Psychiatry initial consult dated 04/21/26 noted Resident #8's significant history of bipolar disorder, major depressive disorder, and PTSD. The list of psychotropic medications included perphenazine (antipsychotic) 4 milligrams (mg) take 2 tablets every night at bedtime. During an interview on 09/03/26 at 10:16 AM, the Social Worker (SW) confirmed he was responsible for PASRR and explained for a newly admitted resident he reviewed their mental health diagnoses listed on the face sheet and listed in the facility's electronic medical records. The SW explained a Level I PASRR did not expire unless the resident had a change of condition or new mental health diagnosis. He confirmed Resident #8 was admitted on [DATE] with bipolar and PTSD mental illness diagnoses and he did not submit a request for PASRR reevaluation and stated he should have. During an interview on 09/03/26 at 11:03 AM, the Regional Director of Operations revealed the SW was responsible for ensuring PASRR evaluations were up to date when a resident was admitted with mental illness diagnoses and to submit a request for PASRR evaluation if not. The Regional Director of Operations confirmed Resident #8 was admitted on [DATE] with mental illness diagnoses and the SW should have submitted a request for a PASRR evaluation.

Based on record review, observations, and resident, and staff interviews, the facility failed to provide setup assistance with oral hygiene for 1 of 3 residents reviewed for activities of daily living (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including thoracic vertebrae fractures (T1 through T6) with routine healing and diabetes mellitus. Review of the Kardex (a care plan reference guide) utilized by Nurse Aide (NA) staff specified Resident #1's routine oral care included brush teeth, rinse dentures, clean gums and rinse with mouthwash. The activities of daily living care plan revised on 1/9/26 revealed Resident #1 had a self-care performance deficit related to thoracic vertebrae fractures, weakness, and pain. Interventions included provide partial to moderate set up assistance with oral care. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1's cognition was intact, his upper extremity range of motion was impaired on both sides, and he needed setup or clean-up assistance with oral hygiene. An observation and interview with Resident #1 was conducted on 3/24/26 at 12:38 PM. Resident #1 revealed he had an upper denture and his own lower teeth and stated he could not recall the last time he was provided setup assistance for oral care. Resident #1 showed his upper denture had a buildup of a white colored substance on the gums and teeth. Resident #1 revealed he could brush his upper denture and lower teeth if given a toothbrush and toothpaste but did not know if he had a denture cup. There was no denture cup observed in Resident #1's bathroom or room. An interview with NA #1 was conducted on 3/25/26 at 8:50 AM. NA #1 confirmed she was assigned to provide care for Resident #1 on 3/24/26 and 3/25/26 on day shift. When asked if oral hygiene was provided for Resident #1, NA #1 stated Resident #1 had his own teeth he could brush, and she provided setup assistance for oral hygiene. NA #1 explained for setup assistance she sat Resident #1 up in the bed or in the wheelchair and gave him a toothbrush and toothpaste for him to perform oral hygiene. NA #1 stated to her knowledge Resident #1 did not have an upper denture and there was no denture cup in his room to indicate he did. NA #1 did not state she provide Resident #1 setup assistance with oral hygiene on 3/24/26 or 3/25/26 during her shift. During an observation on 3/25/26 at 11:48 AM, there was no change in the appearance of Resident #1's upper denture that continued to have a buildup of a white colored substance on the gums and teeth. An interview and observation with the Director of Nursing (DON) was conducted on 3/25/26 at 11:48 AM. The DON observed Resident #1 had an upper denture. Resident #1 removed his upper denture to show that it continued to have a buildup of a white colored substance around the gums and teeth. The DON stated oral hygiene included brushing teeth and dentures and was done daily. She revealed a denture cup should have been provided for Resident #1 to soak his upper denture overnight and confirmed Resident #1 did have a toothbrush but there was no denture cup in the room or bathroom. During an interview on 3/25/26 at 3:58 PM, the Administrator stated she expected NA staff to review the Kardex that specified if a resident had dentures and that oral hygiene was offered daily. The Administrator stated oral hygiene was done daily and she expected NA #1 to be aware Resident #1 had an upper denture and his own lower teeth and setup assistance for oral hygiene was provided.

Based on observation, record review, and staff interviews, the facility failed to safely transfer a dependent resident from the bed to the reclining wheelchair using a mechanical lift which resulted in an avoidable injury for 1 of 3 residents reviewed for accidents (Resident #1). On 11/18/25 around 6:30 AM, Nurse Aide #1 independently transferred Resident #1 to the reclining wheelchair and was unhooking the sling straps when the mechanical lift tilted and the sling bar of the mechanical lift hit Resident #1 above the left eyebrow causing a laceration. Resident #1 was sent to the Emergency Department for evaluation, a Computed Tomography (CT, detailed x-ray imaging of the inside of the head) revealed no negative findings, the laceration was repaired with sutures and Resident #1 returned to the facility the same day (11/18/25).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury (TBI, injury to the brain caused by an external force), abnormal posture, and contracture of muscles-multiple sites.The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severely impaired cognitive skills for daily decision making. He had impairment on both sides of the upper and lower extremities and was totally dependent on staff for self-care, transfers and ambulation.An Activity of Daily Living (ADL) care plan, last revised 09/12/25, revealed Resident #1 had an ADL self-care performance deficit related to TBI and contractures. Included was an intervention that noted Resident #1 required a mechanical lift and 2-person assistance for all transfers. Review of Resident #1's electronic health record revealed Resident #1 was not prescribed an anticoagulant. A nurse progress note dated 11/18/25 at 6:33 AM written by Nurse #1 revealed Resident #1 sustained a laceration above the left eye after bumping it on the mechanical lift during a transfer.A second nurse progress note dated 11/18/25 at 7:40 AM written by Nurse #1 revealed Resident #1 was sent to the Emergency Department (ED) via Emergency Medical Services (EMS) transport.During a phone interview on 12/12/25 at 11:12 AM, Nurse Aide (NA) #1 revealed she was no longer employed at the facility and confirmed she was assigned to provide Resident #1's care on 11/17/25 to 11/18/25 during the hours of 7:00 PM to 7:00 AM. NA #1 confirmed she had transferred Resident #1 from his bed to the wheelchair using a mechanical lift without additional staff assistance on 11/18/25. NA #1 explained as she was getting Resident #1 ready for the day toward the end of her shift, she independently used the mechanical lift to transfer Resident #1 from the bed and lowered him down inside the reclining wheelchair. NA #1 recalled as she was unhooking the sling straps, the mechanical lift tilted and the sling bar of the mechanical lift hit Resident #1 in the face. NA #1 stated at first, she thought Resident #1 was ok, she finished unhooking the straps and then noticed that he was bleeding. NA #1 stated she then went and informed Agency Nurse #2 what had happened. NA #1 stated they had been instructed to always have 2-person assistance when using a mechanical lift and prior to transferring Resident #1, she had reached out to other staff to see if anyone was available to help but no one was. NA #1 stated she knew she shouldn't have transferred Resident #1 on her own but at the time thought that she could do it without additional staff assistance.During a phone interview on 12/12/25 at 11:28 AM, Agency Nurse #2 revealed she had worked during the hours of 7:00 PM to 7:00 AM on 11/17/25 to 11/18/25 but was not assigned to provide care to Resident #1. Agency Nurse #2 recalled it was a hectic morning on 11/18/25 when NA #1 came to inform her that Resident #1 had gotten hit with the sling bar of the mechanical lift during a transfer. Agency Nurse #2 stated she could not recall all the details that NA #1 had told her about what happened but did remember NA #1 stating she had transferred Resident #1 on her own using a mechanical lift without additional staff assistance. Agency Nurse #2 recalled when she and Agency Nurse #1 assessed Resident #1's injury, the laceration above the left eyebrow was open and they both felt he would need stitches to repair. Agency Nurse #2 stated upon assessment Resident #1 seemed to be at his normal baseline, smiling and not displaying any indicators of pain. During a phone interview on 12/11/25 at 2:50 PM, Agency Nurse #1 confirmed she was Resident #1's assigned nurse from 11/17/25 to 11/18/25 during the hours of 7:00 PM to 7:00 AM but did not witness the incident. Agency Nurse #1 stated from what she could recall, she was told by NA #1 that sometime between 6:30 AM and 7:00 AM, as NA #1 was transferring Resident #1 from the bed to the reclining wheelchair, the sling bar of the mechanical lift hit Resident #1 in the face. Agency Nurse #1 stated when she got to the room to assess Resident #1, he had a laceration above his left eyebrow. She stated the bleeding was mostly controlled at that point and she applied first aid. Agency Nurse #1 stated the laceration was open and she immediately knew that Resident #1 would need to go the hospital for stitches to repair the laceration. Agency Nurse #1 stated when she assessed Resident #1, he was smiling, appeared at his normal baseline and did not display any indicators of pain. Agency Nurse #1 explained both she and NA #1 knew that transfers using a mechanical lift required 2-person assistance and when she asked NA #1 why she did not ask her or another staff member to assist with the transfer, NA #1 never gave her a reason. Agency Nurse #1 stated Resident #1 was sent out to the hospital for treatment, and the laceration was repaired with stitches but could not recall how many. She stated when Resident #1 returned back to the facility later that same day (11/18/25) he was still at his normal baseline. A Hospital ED After Visit Summary note dated 11/18/25 for Resident #1 revealed Resident #1 was seen for evaluation and treatment of a facial laceration. The note indicated a head CT was obtained and looked good (no negative findings). The laceration was repaired with sutures and Resident #1 was sent back to the facility with orders for an antibiotic ointment to be applied twice a day for seven (7) days and to keep the laceration covered, clean and dry. Review of Resident #1's November 2025 treatment administration record revealed a physician order dated 11/18/25 to apply bacitracin ointment (topical antibiotic used to prevent infection in minor skin injuries) 500 unit/grams to the left upper eyebrow every shift for 7 days. The treatment was started on 11/18/25 during the evening shift (7:00 PM to 7:00 AM) and completed on 11/25/25 during the day shift (7:00 AM to 7:00 PM). Treatments were initialed each shift as completed per the physician order except for 11/19/25 during the day shift and 11/20/25 during the evening shift.During an observation on 12/11/25 at 9:21 AM, Resident #1 was lying in bed in fetal position with noticeable bilateral hand contractures. Resident #1 was alert and smiled when greeted but provided no response other than repetitive verbalizations. He had a thin, red healing scar above the left eyebrow that was approximately 2 to 2.5 inches in length with no signs of infection or bruising noted. Resident #1 displayed no signs of discomfort or pain.During an interview on 12/12/25 at 3:05 PM, the Director of Nursing (DON) stated she was informed by a nurse working the morning of 11/18/25 that Resident #1 was being sent out to the ED due to a facial laceration, but the nurse had not witnessed what had happened. The DON stated the laceration above Resident #1's left eyebrow was repaired while at the ED with approximately 4 or 5 stitches and he returned to the facility that afternoon (11/18/25). The DON stated when she and the Administrator spoke with NA #1 about what happened, NA #1 admitted to transferring Resident #1 independently using a mechanical lift and NA #1 explained during the transfer, the mechanical lift tilted causing the sling bar to hit Resident #1 in the face. The DON stated NA #1 was immediately suspended and subsequently terminated due to not following the facility's policy which required 2-person assistance with mechanical lift transfers. The DON stated it was an unfortunate but avoidable accident as NA #1 had received previous training on mechanical lifts but just made the bad decision not to follow the facility policy. The DON stated an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held to discuss the incident, and a decision was made to develop and implement a corrective action plan on 11/18/25. During interviews on 12/12/25 at 1:02 PM and 3:30 PM, the Administrator confirmed she was notified via the facility group nurse chat (messaging system) of the transfer incident on 11/18/25 involving Resident #1. The Administrator stated when interviewed, NA #1 admitted she had transferred Resident #1 using a mechanical lift without additional staff assistance. She recalled NA #1 explained that when lowering Resident #1 into the reclining wheelchair, the sling bar swung and hit Resident #1 in the face causing a laceration that required stitches to be repaired. The Administrator stated NA #1 informed the nurse right away and recalled NA #1 felt very remorseful about the incident. The Administrator verified that NA #1 had received training, along with other nursing staff, back in April 2025 regarding the facility's policy on safe transfers using a mechanical lift that required 2-person assistance. The Administrator stated she felt it was an unfortunate accident. She explained although NA #1 was a good NA, she made a bad decision not to follow facility policy by transferring Resident #1 independently with the mechanical lift and that was why the decision was made to terminate NA #1's employment. The Administrator verified on 11/18/25 they held an Ad Hoc QAPI meeting to discuss the incident and the decision was made to implement an internal plan of correction that included staff re-education, audits and monitoring with no further concerns identified. The facility provided the following Corrective Action Plan with a completion date of 11/20/25:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 11/18/25, Nursing Aide (NA) #1 transferred Resident #1 independently, not following the facility policy. During transfer the lift tilted, causing the arm to hit Resident #1 in the left eye which caused a laceration head injury during transfer. Resident #1 was assessed by the nurse and transferred to the hospital for higher level of care. Nursing Aide (NA) #1 was re-educated by the Director of Nursing on the facility mechanical lift policy and safe lifting policy on 11/18/25. NA #1's employment was terminated on 11/21/25.Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents using mechanical lifts have the potential to be affected. This was determined utilizing the transfer evaluation/therapy recommendations. Transfer evaluation assessments were reviewed in the individual electronic medical record for each resident to ensure mechanical lifts status were updated and correct. Therapy recommendations were reviewed for each resident to ensure transfer evaluation and therapy recommendations were updated and correct. No concerns were identified. Audits were completed on 11/18/2025 by the Director of Nursing.The Director of Nursing/Designee completed skin assessments on all residents that required mechanical lifts. No concerns were identified. Audits were completed on 11/18/2025.Residents that use mechanical lifts with a Brief Interview for Mental Status (BIMs) score of 13 or higher were interviewed by the Social Service Director to ensure they did not have any concerns with use of mechanical lift. No concerns were identified. Audits were completed on 11/18/25. The Regional Clinical Director reviewed all incident reports for the last 30 days to ensure there were no issues with transfers using mechanical lifts. No concerns were identified. This audit was completed on 11/19/2025.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 11/18/25, the Director of Nursing or Designee educated all nursing staff, including agency staff on the facility mechanical lift policy and safe lifting policy with emphasis on ensuring 2 staff were present with all lift transfers. All Nursing Staff including Licensed Nurses and Nursing Aide (NA) will perform mechanical lift use competency prior to the start of their shift which will be completed by the Director of Nursing/Nursing Administration. This education was completed on 11/18/25. This education will be added to the facility orientation program for all newly hired nursing staff, including new agency staff and will be the responsibility of the Director of Nursing. An ADHOC Quality Assurance Performance Improvement Committee Meeting was held on 11/18/2025 to discuss, review and approve the plan that had been initiated and implemented by the Director of Nursing on 11/18/2025. The Quality Assurance Performance Improvement Committee also reviewed the policy and procedure for mechanical Lift and Safe Lifting Policy. The decision to monitor the plan was also decided during the Quality Assurance Performance Improvement Committee meeting on 11/18/2025. Root Cause Analysis was completed and determined that the Nurse Aide failed to follow the facility policy and procedure for mechanical Lift use.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. To monitor and maintain ongoing compliance, the Director of Nursing or designee will observe 2 lift transfers randomly on all shifts weekly for 8 weeks to ensure proper use of mechanical lift and to ensure that 2 staff members are present. The Director of Nursing or designee will interview 3 residents with a Brief Interview for Mental Status (BIMs) of 13 or higher on lift use weekly for 8 weeks. The Director of Nursing or designee will randomly interview 4 staff members on all shifts weekly for 8 weeks. These audits will be completed by January 27, 2026. The DON or designee will be responsible for reporting results of these audits to the facility's monthly QAPI committee meeting for 3 months. The QAPI committee will make recommendations and changes as indicated based upon the findings of these audits. Compliance Date: 11/20/2025. The Corrective Action plan was validated on 12/12/25 and concluded the facility had implemented an acceptable corrective action plan on 11/20/25. Alert and oriented residents who required a mechanical lift for transfers were interviewed and confirmed there were 2-staff present when utilizing the mechanical lift. Nursing staff interviewed on all shifts confirmed receipt of education on the facility's mechanical lift policy that included performing a return demonstration. Nursing staff were able to verbalize how to prepare for and perform a safe transfer using a mechanical lift and that all mechanical lift transfers required 2-person assistance. Staff also verbalized they would wait for someone to assist before attempting a mechanical lift transfer. Review of the audits and monitoring tools revealed they were completed as outlined in the facility's corrective action plan with no concerns noted as identified. The corrective action plan date completion date of 11/20/25 was validated.

Based on observations, record review, interviews with the Wound Care Medical Doctor (MD), the Medical Director and staff, the facility failed to obtain treatment orders for pressure ulcers identified on 04/24/25 resulting in a seven day delay of treatment. Additionally, the facility failed to complete accurate head-to-toe skin checks used to identify new or existing pressure ulcers that include the site (location), type of wound, the length, width, depth, and stage. The skin/wound assessment completed on 05/13/25 indicated the resident's skin was intact with no new pressure ulcer. On 05/14/25 a tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the left heel was identified and measured 4 centimeters (cm) in length and 4.1 cm with width. The deficient practice occurred for 1 of 5 residents reviewed for pressure ulcers (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and moderate protein-calorie malnutrition. The admission data collection tool dated 04/24/25 was documented by Nurse #6 and included Resident #86's skin conditions. The tool noted Resident #86's skin was not intact and identified pressure ulcers were present. The site/location of the pressure ulcers were on the right and left buttock, and sacrum. The information related to the length, width, depth, and stage of the pressure ulcers was left blank. Nurse #6 documented left foot/heel pain was noted and Resident #86's skin integrity was at moderate risk for pressure ulcers. Included was a skin integrity care plan with the goal Resident #86's skin would remain intact without signs of breakdown by next review. Interventions were to provide wound care and preventive skin care per physician's order, weekly skin checks per facility protocol and document findings, turn and reposition frequently to decrease pressure. Resident #86's Treatment Administration Record (TAR) revealed no treatments were administered for pressure ulcers from 04/24/25 through 04/30/25. The baseline care plan dated 04/25/25 completed by the former/interim Director of Nursing (DON) identified Resident #86 had pressure ulcers and/or potential for developing pressure ulcers with the goal the ulcer would show signs of healing and remain free from infection by the review date. Interventions were to administer treatments as ordered and observe effectiveness, reposition and/or turn at frequent intervals, observe dressing to ensure it was intact and adhering, and report loose dressing to the treatment nurse. An interview with the former/interim DON was conducted on 05/14/25 at 4:37 PM. The interim/former DON revealed for a newly admitted resident the baseline care plan, admission data collection, nurse note, and skin assessment needed to be completed and should be done by the admitting nurse. She revealed newly admitted residents were discussed during their next morning Interdisciplinary Team meeting to ensure if pressure wounds were identified treatments orders were care planned and initiated by admitting nurse. The interim/former DON revealed at the time of Resident #86's admission nurse staffing had little to no support and on 04/24/25 there were three other new admissions to complete. The interim/former DON revealed if pressure ulcer wounds were identified on the baseline care plan there should be physician orders in place for treatment and stated she did the best she could with three admissions and sometimes the Interdisciplinary Team meetings were short and might not have the entire team present. The nurse progress note dated 4/25/25 was documented by Nurse #6 and identified Resident #86 as having pressure sores on the middle right and left buttock and sacrum. Nurse #6 noted there was no drainage from the ulcers, the ulcers were red, and all were less than the size of a quarter. A review of Resident #86's head-to-toe skin checks used to identify skin integrity concerns of new or existing pressure ulcers and documentation of the site (location), type of wound, the length, width, depth, and stage completed on 05/01/25 indicated the skin was intact but did note changes to the skin integrity as redness under a dressing but no open areas. On 05/03/25, 05/05/25, and 05/09/25 the checks indicated Resident #86's skin was intact with no changes to skin integrity. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #86 needed setup assistance with rolling left to right in bed and partial to moderate assistance with transfers. The MDS skin conditions indicated there were no unhealed pressure ulcers at stage one (intact skin with non-blanchable redness over a localized area) or higher. A review of the Wound Care MD note dated 04/30/25 revealed Resident #86's visit was rescheduled. There were no other Wound Care MD notes in Resident #86's medical records to indicate the pressure ulcers were evaluated by the provider. An interview was conducted on 05/15/25 at 1:38 PM with the Wound Care MD. The MD revealed she was the wound care provider for the facility and visited every Wednesday. She relied on the facility to inform her which residents she needed to evaluate and was provided a list of who to see. She was not aware of any pressure ulcer wounds for Resident #86 and confirmed on 04/30/25 the visit was rescheduled. She was unsure why Resident #86 fell off her list of residents to evaluate after 04/30/25 and revealed it could have been an oversight. A review of Resident #86's current physician orders revealed on 04/30/25 an order was obtained to cleanse an area on the sacrum with normal saline or wound wash, pat dry and apply a hydrocolloid dressing (a moist insulated bandage used to promote healing) and cover with a clean and dry dressing every day shift for wound care. A review of Resident #86's TAR revealed the physician order was transcribed to cleanse the area to sacrum with normal saline or wound wash, pat dry and apply hydrocolloid dressing, and cover with clean and dry dressing every day shift for wound care. On 05/01/25 wound care treatments were started and continued daily except on 05/02/25, it was noted as Resident #86 refused and on 05/03/25 and 05/06/25 the TAR was blank with no nurse initials to indicate it was done. The nursing daily skilled charting dated 05/13/25 was documented by Nurse #6 and noted Resident #86's skin was intact and there were no changes in the resident's skin integrity. During an interview on 05/14/25 at 4:09 PM, Nurse #6 confirmed she completed Resident #86's admission data collection dated 04/24/25. She described the areas on Resident #86's left, and right buttock and sacrum were not open or draining and were on the surface of the skin. Nurse #6 revealed she did not check if the pressure ulcers were blanchable and she did not measure the wounds. She further revealed she was not aware measuring the pressure ulcers was an expectation until approximately one month later and stated she had not been shown the full process of completing a new admission and learned by word of mouth or after being told she did something wrong. Nurse #6 stated she was not provided education on how to complete the nursing daily skilled charting when hired and had asked for that on many different occasion. Nurse #6 confirmed she completed the nursing daily skilled charting on 05/13/25 and her documentation incorrectly noted Resident #86's skin was intact. Nurse #6 stated it was an error on her part, and she knew Resident #86 continued to have pressure ulcer wounds on his buttock and sacrum and stated she must have hit the wrong button. Nurse #6 revealed she did not visually check Resident #86's skin integrity when she completed her nursing daily skilled charting on 05/13/25 but knew Resident #86's skin was not intact based on the admission assessment she completed on 04/24/25. An observation of Resident #86's head-to-toe skin check was made on 05/14/25 at 12:12 PM with the Unit Manager who completed the check. There was no hydrocolloid dressing in place as ordered on the sacrum. A stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) sacrum pressure ulcer with no visible drainage or odor was identified. Several small, different shaped scattered red and purple areas were observed on the left and right buttock that were blanchable. A non-blanchable deep tissue injury was observed on the left heel that was circular in shape and colored dark purple with surrounding redness. When touched Resident #86 did not verbalize pain. An interview was conducted with Nurse Aide (NA) #3 on 05/14/25 at 12:44 PM and 12:54 PM. NA #3 revealed she was assigned to assist Resident #86 with activities of daily living on 05/14/25 from 7:00 AM through 3:00 PM. NA #3 revealed the care she had provided included emptying the catheter bag and catheter care. NA #3 stated she did not recall if she saw a dressing on the sacrum but did observe the skin on Resident #86's buttock was red, but she did not report that to the nurse. NA #6 revealed Resident #86 was already wearing socks, and she did not observed the resident's left foot and normally she was not assigned to the hall and not very familiar with Resident #86 and did not receive report at the beginning of her shift. An interview was conducted on 05/15/25 at 2:38 PM with Nurse #3. Nurse #3 confirmed she was assigned to complete wound care for residents on 05/14/25. Nurse #3 revealed the Wound Care MD did not see Resident #86 and confirmed the resident was not on the list. Nurse #3 revealed Resident #86's hydrocolloid dressing was in place on the sacrum when she went to provide wound care on 05/14/25. She revealed the hydrocolloid dressing was soiled and she placed a new dressing on the sacrum. A review of Resident #86's head-to-toe skin check dated 05/14/25 documented by the Unit Manager revealed a new pressure ulcer was identified. The new ulcer was located on the left heel and measured 4 cm in length, 4.1 cm in width, had no depth and staged as a deep tissue injury. The existing pressure ulcer on the sacrum measured 3.8 cm in length, 4.9 cm in width, and 0.2 cm in depth and was a stage 2. A review of Resident #86's current physician orders included a Wound MD consult and to treat as needed dated 05/14/25. For a left heel deep tissue injury cleanse the area with mild soap and water, apply a protective foam dressing to heel and secure with stretch gauze every Monday, Wednesday, Friday, and as needed dated 05/14/25. For the resident to wear multi-podus boot (a device used to offload pressure) to left foot while in bed for offloading/skin integrity dated 05/14/25. During an interview on 05/15/25 at 10:43 AM and on 05/16/25 at 4:41 PM, the DON revealed she expected inventions were implemented on 04/24/25 when Resident #86 was admitted with pressure ulcers and measurements of those ulcers were completed and used as a reference for monitoring. She revealed skin assessments were not consecutively completed, and she expected those were done weekly as the facility's standard of practice. The DON revealed the expectation for completing the skin/wound assessments was for the nurse to visually check the resident's skin and identify existing and new skin breakdown. An interview was conducted on 05/15/25 at 9:10 AM with the Medical Director. The Medical Director revealed the Wound Care Nurse completed treatments and notified the Wound Care MD who followed pressure ulcer wounds. The Medical Director revealed he expected pressure ulcer treatments were obtained for Resident #86 when first admitted on [DATE] and the dressing was in place as ordered. He was unsure if Resident #86's pressure ulcers were avoidable and described Resident #86 as being emaciated (thin and frail) weighing 126 pounds on admission with a diagnoses of muscle wasting and atrophy placing the resident at high risk for worsening or developing a pressure ulcer.

Based on observations and staff interviews, the facility failed to discard food with signs of spoilage in 1 of 1 walk-in cooler; date and use or discard open food items on or before the best-by date in 1 of 1 walk-in cooler; date open food items in 1 of 1 dry storage room; date and cover an open food item in 1 of 1 walk-in freezer; and failed to implement their infection control policies when Dietary Aide #1 handled ice in the ice machine used to serve residents with her bare hands and when Dietary Aide #2 failed to remove her gloves and perform hand hygiene after handling dirty dishes and before touching other items in the kitchen. These failures had the potential to affect food served to 71 residents. 1. An initial observation of the walk-in cooler with the Dietary Manager on [DATE] at 10:55 AM revealed the following: a) An opened 16-ounce container of chicken base with the date of ,d+[DATE] written on top of the lid and no use-by date. There was no pre-printed expiration date on the container. b) An opened 16-ounce container of chicken base with the date of ,d+[DATE] written on top of the lid and no use-by date. There was no pre-printed expiration date on the container. c) An opened 16-ounce container of beef base with an illegible date written on top of the lid. There was no pre-printed expiration date on the container. d) A carton of apples stored together and open to air were 2 apples with visible signs of spoilage. One apple had white spots around the surface and one apple had a large, round, brown soft spot at the base of the stem. During an interview on [DATE] at 10:55 AM, the Dietary Manager explained the dates of ,d+[DATE] and ,d+[DATE] that were written on the lids of the chicken base containers were the dates the containers were opened. She stated the containers should have also been labeled with a use-by date which she thought was 30-days after opening. She confirmed the date written on the container of beef base was illegible and was not sure when it was opened and placed in the walk-in refrigerator. The Dietary Manager stated all three containers should have been removed and discarded. The Dietary Manager confirmed the two apples both had visible signs of spoilage and should have been discarded. She stated all dietary staff were responsible for checking the cooler and discarding any food items with signs of spoilage or past the expiration date. During an interview on [DATE] at 9:47 AM, the Administrator revealed she expected for all food items to be labeled, dated and for dietary staff to check the coolers and discard any items that were expired or had visible signs of spoilage. 39037 2. An observation of the dry storage room on [DATE] at 11:35 AM revealed 2 opened and undated bags of egg noodles and one opened and undated bag of croutons sitting on a shelf. An interview with the Regional Director of Operations on [DATE] at 11:40 AM revealed all opened food items should be dated when they were opened, and the Dietary Manager was responsible for ensuring all opened food items were labeled and dated. The Dietary Manager was unavailable for interview throughout the remainder of the survey. An interview with the Administrator on [DATE] at 9:47 AM revealed she expected all opened food items to be dated when opened by the staff member opening the item. 3. An observation of the walk-in cooler on [DATE] at 12:00 PM revealed an undated plastic bag of red potatoes sitting on a shelf. An interview with the Administrator on [DATE] at 9:47 AM revealed she expected all items in the cooler to be dated. 4. An observation of the walk-in freezer on [DATE] at 12:25 PM revealed a box of hamburger patties that were open to air and did not have an opened date. An interview with the Regional Director of Operations on [DATE] at 12:26 PM revealed the hamburger patties should be covered and should have an opened date. An interview with the Administrator on [DATE] at 9:47 AM revealed she expected all food to covered appropriately and should have an opened date. 5. (a). An observation of Dietary Aide #1 on [DATE] at 12:45 PM revealed she opened the ice machine in the kitchen used for resident beverages, removed a handful of ice with her ungloved right hand and touched ice that remained in the ice machine, placed the ice in her personal beverage, closed the lid to the ice machine, and immediately walked out of the kitchen. In an interview with Dietary Aide #1 on [DATE] at 12:50 PM she confirmed she removed ice from the ice machine with her bare hand but stated she had just washed her hands. She declined to answer if she had received training on using the ice scoop to obtain ice instead of reaching directly in the ice machine. An interview with the Regional Director of Operations on [DATE] at 3:15 PM revealed all dietary staff had received training on using the ice scoop to obtain ice rather than obtaining it with their bare hands. He stated all the ice in the ice machine was discarded on [DATE] after Dietary Aide #1 obtained ice without using the scoop. An interview with the Administrator on [DATE] at 9:47 AM revealed she expected staff to use the ice scoop rather than using their bare hands to obtain ice. (b). A continuous observation of Dietary Aide #2 on [DATE] from 1:42 PM until 2:00 PM revealed with gloved hands, she removed the food from dirty dishes and dumped the liquids from used coffee cups and glasses in a plastic bin, loaded the used coffee cups and glasses onto a dishwasher rack, slid the dishwasher rack into the dishwasher and started the dishwasher, wiped the counter where the coffee pots were sitting with a cloth, rinsed out 3 coffee dispensers and placed them back on the shelf with the coffee pots, wiped down the reach-in cooler with a cloth, removed the dishwasher rack containing clean coffee cups and glasses from the dishwasher and sat the rack at the end of the table on the clean side of the dishwasher, loaded a dishwasher rack with used coffee cups and glasses, poured the liquid in the plastic bin from used coffee cups and glasses down the drain, placed the dishwasher rack with dirty coffee cups and glasses into the dishwasher and started the dishwasher, removed her gloves, and walked away from the dishwasher. Dietary Aide #2 did not remove her gloves and perform hand hygiene after handling dirty dishes and before touching other items in the kitchen. An interview with Dietary Aide #2 on [DATE] at 2:00 PM revealed she thought she removed her gloves and performed hand hygiene after touching dirty plates, coffee cups, and glasses and it was an oversight. An interview with the Regional Director of Operations on [DATE] at 3:15 PM revealed he expected dietary staff to remove their gloves and perform hand hygiene any time they moved from a dirty task to a clean task. An interview with the Administrator on [DATE] at 9:47 AM revealed she expected staff to wash their hands after handling dirty dishes.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #3, Resident #6, Resident #36), pressure ulcer (Resident #86, Resident #74), and Preadmission Screening and Resident Review (PASRR), (Resident #23) for 6 of 8 residents reviewed for resident assessments. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included heart disease. The significant change MDS assessment dated [DATE] revealed Resident #3 was coded as receiving anticoagulant medication. Review of the April 2025 medication administration record (MAR) for Resident #3 revealed there was no physician order for anticoagulant medication and none was administered. During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator reviewed the April 2025 MAR for Resident #3 and confirmed she did not receive anticoagulant medication during the MDS assessment period. The MDS Coordinator stated the significant change MDS assessment dated [DATE] was coded incorrectly. During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included heart failure and end-stage renal disease. The significant change MDS assessment dated [DATE] revealed Resident #6 was coded as receiving insulin and hypoglycemic (used to lower blood sugar levels) medication. Review of the March 2025 medication administration record (MAR) for Resident #6 revealed there were no physician orders for insulin or hypoglycemic medication and none was administered. During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator reviewed the March 2025 MAR for Resident #6 and confirmed she did not receive insulin or hypoglycemic medication during the MDS assessment period. The MDS Coordinator stated the significant change MDS assessment dated [DATE] was coded incorrectly. During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately. 3. Resident #23 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and Post-Traumatic Stress Disorder (PTSD). The annual MDS assessment dated [DATE] revealed Resident #23 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. Review of a PASRR Level II determination notification letter provided by the Social Worker (SW) on 05/15/25 revealed Resident #23 had a Level II PASRR effective 05/28/24 with no end date. During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator explained when conducting an audit of Level II PASRR, they realized Resident #23's annual MDS assessment dated [DATE] was not coded correctly to reflect that she had a Level II PASRR. She stated it was an oversight. During an interview on 05/26/25 at 12:55 PM, the SW revealed the MDS Coordinator was the person responsible for coding Level II PASRR on the MDS assessments. The SW explained she tried to audit Level II PASRR weekly, or at the very least, every other week and then emailed the MDS Coordinator an updated list of residents who had a Level II PASRR to use when completing MDS assessments. During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately. 4. Resident #36 was admitted to the facility on [DATE] with diagnoses that included diabetes. The quarterly MDS assessment dated [DATE] revealed Resident #36 was coded as receiving insulin injections daily during the MDS assessment period. Review of the February 2025 medication administration record (MAR) for Resident #36 revealed there was no physician order for insulin and no insulin was administered. During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator reviewed the February 2025 MAR for Resident #36. She confirmed there was no physician order for insulin and he did not receive insulin during the MDS assessment period. The MDS Coordinator stated the quarterly MDS assessment dated [DATE] incorrectly indicated Resident #36 received insulin and it was an oversight. During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately. 5. Resident #86 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (gradual decrease in size of an organ or muscle tissue) multiple sites and moderate protein-calorie malnutrition. A nurse admission data collection dated 04/24/25 revealed Resident #86's skin was not intact and he had pressure ulcers and non-pressure areas/other skin conditions. It was noted Resident #86 had a blister to the mid-back and pressure ulcers to the right buttock, left buttock and sacrum with no measurements specified. An admission nurse progress note dated 04/25/25 revealed in part that Resident #86 had pressure sores in the middle of his right buttock, left buttock and sacrum with no drainage noted and all were less than the size of a quarter. There was no stage (system used to categorize the severity of pressure injuries) or measurements for the pressure ulcers noted. The admission MDS assessment dated [DATE] revealed Resident #86 had no unhealed pressure ulcers or other skin conditions present upon admission. During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator stated she was not sure why the admission MDS assessment dated [DATE] did not reflect Resident #86 had a pressure ulcer based on the nurse admission note dated 04/25/25. The MDS Coordinator explained she did not complete the MDS assessment but if she had, she would have asked the wound nurse, doctor or someone else who would be knowledgeable to clarify what the nurse note didn't include, such as stage of the pressure ulcer. During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately. 39037 6. Resident #74 was admitted to the facility 02/06/25 with a diagnosis including acute (new onset) pancreatitis (inflammation of the pancreas). The Wound Care Physician #1's note dated 02/19/25 revealed Resident #74 was receiving wound care for an unstageable pressure wound with 100% necrotic (dead) tissue to the posterior (back) of his head that was present on admission. Review of Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he had a stage three pressure ulcer (full-thickness skin loss that extends into subcutaneous tissue but doesn't involve muscle or bone) that was not present on admission. An interview with the MDS Coordinator on 05/16/25 at 11:17 AM revealed Resident #74's quarterly MDS assessment should have been coded to reflect he had a pressure ulcer that was present on admission and it was an oversight. An interview with the Director of Nursing (DON) on 05/16/25 at 4:52 PM revealed she expected MDS assessments to be coded correctly. An interview with the Administrator on 05/16/25 at 5:11 PM revealed she expected MDS assessments to be coded correctly.

Based on observations, record review, and resident and staff interviews, the facility failed to provide assistance with oral hygiene and nail care (Resident #86), and showers (Resident #43, #74, and #86) for 3 of 8 dependent residents reviewed for activities of daily living. Findings included: 1 a. Resident #86 was admitted to the facility on [DATE] with diagnoses including obstructive pulmonary disease, pneumonia, and acute respiratory failure. The admission MDS assessment dated [DATE] revealed Resident #86's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #86 had no natural teeth and required setup/cleanup assistance with oral hygiene and partial/moderate assistance with personal hygiene. The care plan revised on 5/11/25 identified Resident #86 had a self-care deficit in performing activities of daily living. The care plan interventions included Resident #86 required assistance from staff with oral care and personal hygiene. During observations and interviews with Resident #86 on 05/12/25 at 9:30 AM, 05/13/25 at 8:39 AM and 05/14/25 at 11:43 AM, the upper denture had a white colored buildup of debris. Resident #86 revealed he had an upper denture but not a lower one and had no difficulty with eating. Resident #86 stated he was not assisted with denture care or oral hygiene and did not know if he had a denture cup or denture brush and was unable to locate those items. The resident went on to say he was able and willing to take care of his own denture care, but due to not being able to locate, or having the supplies to complete the denture care, he was unable to take care of the denture himself. An observation and interview were conducted with the DON on 05/14/25 at 12:11 PM. Resident #86 removed his upper denture upon request to show there was no change and the denture continued to have white colored buildup of debris. The DON stated denture care should have been done daily, Resident #86 should have a denture cup for soaking overnight, a denture brush for cleaning, and she expected assistance with oral hygiene to be provided. An interview was conducted with NA #3 on 05/14/25 at 12:44 PM and 12:54 PM. NA #3 confirmed she worked the 7:00 AM to 3:00 PM shift on 05/14/25 and assigned to assist Resident #86 with activities of daily living including oral hygiene. NA #3 stated she had not assisted Resident #86 with oral hygiene due to the resident taking a long time to eat breakfast. NA #3 stated she was not given report during shift change, typically did not work on that hall, was not familiar with Resident #86, and unsure if he had dentures. During an interview on 05/16/25 at 8:57 AM, the Administrator stated the expectation was for residents to receive assistance with oral hygiene and denture care twice a day, and dentures to be soaked overnight. b. A review of the shower schedule binder located at the nurse station revealed Resident #86's showers were scheduled on Tuesday and Friday to be completed during the 3:00 PM to 11:00 PM second shift. Included in the binder were paper body audits for the Nurse Aide (NA) staff to document skin issues and care provided. There were completed body audit sheets in the binder, but none of them were for Resident #86. A review of NA documentation for the previous 30 days indicated on 04/25/25 Resident #86 refused a shower. On 04/26/25 received a shower and on 05/13/25 refused the shower. There was no further documentation of shower activity or refused showers for Resident #86. An observation and interview were conducted with Resident #86 on 05/12/25 at 9:30 AM. Resident #86 stated he was supposed to get shower today (Monday) and his showers were scheduled twice a week. Resident #86 thought he had a shower on Wednesday (05/07/25) but was not sure. Resident #86's hair was uncombed but not greasy. An observation and interview were conducted with Resident #86 on 05/13/25 at 08:39 AM. Resident #86 stated he did not get a shower yesterday (Monday) and was told he would, but no one came to get him. He thought maybe he was asleep when the person came and stated he did not refuse his shower. Resident #86 stated it does not bother him he missed a shower but does want a shower twice week. Resident #86's hair was observed to be uncombed but not greasy. During an interview on 05/14/25 at 12:44 PM, NA #9 revealed she was the assigned shower person and stated Resident #86 refused his scheduled shower due to be completed on 05/13/25 (Tuesday) when she offered. NA #9 revealed she did not report, or document Resident #86 had refused his shower. During an interview on 05/14/25 at 1:39 PM, the DON stated she would expect if Resident #86 consistently refused showers that documentation would be included in the resident's medical record, progress notes, and care planned. During an interview on 05/16/25 at 9:45 AM, the Administrator stated she expected residents to receive their showers as scheduled and if they did not receive a shower then she or the DON should be notified. c. During observations and interviews with Resident #86 on 05/12/25 at 9:30 AM, 05/13/25 at 8:39 AM and 05/14/25 at 11:43 AM the fingernails on the right and left hand were approximately one forth inch long from the tip of the finger with a black-colored buildup of debris underneath the nails. Resident #86 revealed he did not recall being offered nail care and denied he refused nail care. An interview was conducted with NA #3 on 05/14/25 at 12:44 PM and 12:54 PM. NA #3 confirmed she worked the 7:00 AM to 3:00 PM shift on 05/14/25 and assigned to assist Resident #86 with activities of daily living including personal hygiene and nail care. NA #3 stated she noticed Resident #86's had a black colored buildup under his nails but he had refused nail care from her when offered. An observation and interview were conducted with the DON on 05/14/25 at 12:11 PM. The DON observed Resident #86's fingernails continued to have a buildup of black colored debris and stated nail care was provided during showers/bathing or as needed. Resident #86 agreed to have his fingernails clipped, cleaned, and nail care was provided. During an interview on 05/16/25 at 8:57 AM the Administrator stated nail care was provided during showers or as needed. The Administrator explained she was made aware Resident #86's nail care was not being done, and the resident had refused showers. 37014 2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included incomplete quadriplegia C1-C4 (spinal cord injury between the vertebrae in the upper neck resulting in loss of some motor functions but not all). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition. He had impairment of both sides of the upper extremities and was dependent on staff assistance with self-care tasks, bed mobility and transfers. He displayed no behaviors and did not reject care during the MDS assessment period. A review of Resident 43's comprehensive care plans, last reviewed/revised on 05/07/25, revealed he had an activities of daily living self-care performance deficit related to quadriplegia. Interventions included dependence on staff with showering twice weekly on Wednesday and Saturday and 2-person staff assistance with transfers using a mechanical lift. Review of the master shower schedule revealed Resident #43 was scheduled to receive a shower on Wednesday and Saturday during the hours of 3:00 PM to 11:00 PM. Review of the Nurse Aide (NA) point of care documentation report for 05/01/25 through 05/14/25 revealed no documentation that Resident #43 received his showers on Wednesdays or Saturdays as scheduled. During an observation and interview on 05/11/25 at 11:30 AM and follow-up interview on 05/12/25 at 12:22 PM, Resident #43 was lying in bed with the head of bed slightly elevated and his hair was unkempt. Resident #43 stated he was supposed to receive two showers per week on Wednesday and Saturday, but he did not always receive a shower on Saturdays due to there not being enough help on the weekends. He stated when he did not get a shower, staff did not offer him a bed bath and the last shower he received was this past Wednesday (05/07/25). Resident #43 stated he was supposed to get a shower yesterday (05/10/25) but was told by Nurse Aide (NA) #7 that he wouldn't be getting a shower because they didn't have enough staff. He stated that although he would have liked to have gotten his shower, he knew it wasn't the staff's fault. Resident #43 stated not getting a shower made him feel nasty and embarrassed to be seen this way. During an interview on 05/11/25 at 1:00 PM, NA #8 revealed she worked on 05/10/25 during the hours of 7:00 AM to 3:00 PM and provided care to Resident #43. NA #8 stated there were only 3 NAs for the entire shift and they were not able to get a lot of the residents up out of bed or provide residents with any showers or bed baths. She expressed when working short-staffed, it was very difficult to get resident care provided and they basically had to focus on keeping the residents dry and fed. During an interview on 05/14/25 at 2:45 PM, NA #7 revealed she worked on 05/10/25 during the hours of 7:00 AM to 3:00 PM and provided care to Resident #43. NA #7 stated there were only 3 NAs for the entire shift and they basically had to focus on completing rounds and making sure the residents were kept dry and fed. NA #7 stated she explained to the residents, including Resident #43, that they were short-staffed and they wouldn't be able to get them up out of bed or give them a shower. During a phone interview on 05/15/25 at 2:27 PM, NA #6 confirmed she was assigned to provide Resident #43's care on 05/03/25 and 05/10/25 during the hours of 3:00 PM to 11:00 PM but she did not give him a shower or bed bath during her shifts. NA #6 explained resident showers were almost always provided on first shift (7:00 AM to 3:00 PM) and she usually didn't have to give any showers during her shift unless first shift wasn't able to get them all done. During an interview on 05/16/25 at 4:52 PM, the DON revealed she expected Resident #43 to receive his showers as scheduled. During an interview on 05/16/25 at 9:45 AM, the Administrator stated she expected residents to receive their showers as scheduled and if they did not receive a shower then she or the Director of Nursing (DON) should be notified. 39037 3. Resident #74 was admitted to the facility 02/06/25 with a diagnosis including diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 was cognitively intact and had no rejection of care during the lookback period. Resident #74 had impaired range of motion affecting one side of the upper extremity and required partial/moderate assistance with showers. The activities of daily living (ADL) care plan last revised 02/19/25 revealed Resident #74 had an ADL self-care performance deficit related in part due to a diagnosis of diabetes and interventions included assisting him with showering on Wednesday and Saturday. Review of the master shower schedule revealed Resident #74 was scheduled to receive a shower every Wednesday and Saturday on the 3:00 PM to 11:00 PM shift. Review of shower documentation revealed he did not receive a shower on 05/10/25. There was no documentation in Resident #74's medical record that he received a bed bath if he did not receive a shower. An interview with Resident #74 on 05/12/25 at 9:21 AM revealed he was scheduled to receive his showers on Saturday and Wednesday, but he frequently missed his showers on Saturdays and if he missed his shower on Saturday, he had to wait until Wednesday to receive his shower. He stated he would like to receive his showers as scheduled. Resident #74 stated if he missed a shower he did not want or receive a bed bath instead. In an interview with Nurse Aide (NA) #4 on 05/14/25 at 4:47 PM she confirmed she was assigned to care for Resident #74 on 05/10/25 on the 3:00 PM to 11:00 PM shift. She stated her assigned residents included all residents on 400 hall and all residents on 300 hall until 5:00 PM or 5:30 PM, when another NA came in to help. NA #4 stated from 5:00 PM or 5:30 PM she was assigned to care for all of 400 hall and the bottom half of 300 hall, and she did not have time to give Resident #74 his shower. NA #4 stated she did not specifically notify the nurse on 400 hall that Resident #74 did not receive his shower on 05/10/25 because the nurse was aware she was assigned to the 300 hall and 400 hall. An interview with the Administrator on 05/16/25 at 9:45 AM revealed she expected residents to receive their showers as scheduled and if they did not receive a shower then she or the Director of Nursing (DON) should be notified. An interview with the DON on 05/16/25 at 4:52 PM revealed she expected Resident #74 to receive his showers as scheduled.

Based on observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents received bathing, incontinence care and personal hygiene assistance as needed and requested for 4 of 8 sampled residents (Residents #35, #43, #74, and #86) reviewed for activities of daily living. This tag is cross-referenced to: F 677: Based on observations, record review, resident and staff interviews, the facility failed to provide assistance with incontinence care upon request (Resident #35), oral hygiene and nail care (Resident #86), and showers (Resident #43, #74, and #86) for 4 of 8 dependent residents reviewed for activities of daily living. During an interview on 05/11/25 at 10:05 AM and follow-up interview on 05/14/25 at 12:55 PM, Confidential Staff Member #1 revealed for the past few months staffing had been ok during the week but had been short on the weekends. Confidential Staff Member #1 stated this past weekend on (05/10/25) there were only 3 Nurse Aides (NA) for the entire shift (7:00 AM to 3:00 PM) and they weren't able to get many residents up out of bed or provide residents with bathing assistance. Confidential Staff Member #1 stated when working short staffed, they were only able to complete rounds and primarily focused on keeping the residents clean, dry and fed. During an interview on 05/11/25 at 10:09 AM and follow-up interview on 05/15/25 at 8:48 AM, Medication Aide (MA) #1 revealed weekend staffing had been short since she had been working at the facility. MA #1 revealed on 05/10/25 she was assigned to a medication cart and there were only 3 Nurse Aides (NAs) during the shift to provide resident care. MA #1 explained while working on the medication cart, she helped the NAs as she could and she did assist with providing incontinence care to 2 residents but did not provide any residents with bathing assistance. MA #1 stated there were only 2 other nurses working with her today (05/11/25) and they were all behind with getting the residents morning medications passed. She explained when short-staffed and covering more than one hall, it was difficult for them to get the medications passed on time and she just did the bed she could. During an interview on 05/11/25 at 10:15 AM, Nurse #1 revealed she worked every weekend and they usually had to work short-staffed. Nurse #1 explained staffing was really good when she first started her employment in February 2025 but since then, staff either called-out or just not showed up to work and administration wasn't always able to get the shifts covered at the last minute. Nurse #1 stated yesterday (05/10/25) there were 3-4 staff members that called out which left her covering the rehab hall with 17 residents who all required max assistance and she just did her best to focus on her priorities which were getting medications passed, fluids passed and feeding assistance provided. She stated today (05/11/25) there were only 2 nurses (including herself) and a MA and they were all behind on getting residents morning medications passed on time. Nurse #1 stated when working short-staffed, she felt rushed and it was very difficult to get everything done in a timely manner. During an interview on 05/11/25 at 10:28 AM, Nurse #2 revealed staffing was hit or miss with some days/shift being better than others. Nurse #2 stated today had been rough as they only had 2 Nurses (including herself) and a MA. Nurse #2 stated she was covering 2 resident halls and still had not finished the morning medication pass. Nurse #2 expressed when working short-staffed, it was difficult to get things done timely and residents were getting their medications late. During an interview on 05/11/25 at 3:33 PM, NA #10 revealed she only worked weekends and some days staffing was good and other days they might only have 1-2 NAs for the entire shift. NA #10 expressed when working short-staffed, it was rough getting dinner served, making rounds every 2 hours and answering call-lights quickly. She explained she might not get to take a break but she did her best to make sure everything was done for the residents, it just took her longer. During an interview on 05/11/25 at 11:30 AM, the former Interim Director of Nursing (DON) confirmed staffing had been a challenge. She explained they had been utilizing a lot of agency staffing to supplement the schedule but still had a lot of call-outs. The former Interim DON stated this past Friday (05/09/25) she worked all day on the weekend schedule (5/10/25 and 5/11/25), had the shifts covered and then staff either called-out or didn't show up for their scheduled shift(s). The former Interim DON stated the previous DON had switched back to 8-hour shifts, which made it even more difficult to get shifts covered, especially the 3:00 PM to 11:00 PM shift, and they had recently made the decision to go back to 12-hour shifts which she hoped would get them back on the right track with ensuring there was adequate staff coverage each shift. During a Resident Council group interview on 05/13/25 at 10:26 AM, Resident #70, Resident #63, Resident #41, Resident #14, Resident #11, Resident #18, Resident #23, Resident #69, and Resident #42 all voiced there was an issue with the facility being short-staffed on the weekends and as a result, showers were not given as scheduled and call-lights took longer to be answered by staff. During an interview on 05/16/25 at 5:38 PM, the Staffing Scheduler revealed daily staffing coverage was based on the resident census and/or acuity (level of care an individual required) needs of the residents. She stated facility staff were currently scheduled for 8-hour shifts with the following preferred minimums: on the day shift (7:00 AM to 3:00 PM) she tried to have 4 nurses and 7-8 NAs; on the evening shift (3:00 PM to 11:00 PM) she tried to have 4 nurses and 5-6 NAs; and on the night shift (11:00 PM to 7:00 AM) she tried to have 2 nurses and 4 NAs. The Staffing Scheduler confirmed staffing had been a challenge, especially on the weekends. The Staffing Scheduler explained she made the schedule out a month in advance and for shifts needing coverage, she started with in-house staff to request volunteers and then reached out to staffing agencies to fill in the gaps. She stated she would get the shifts covered but then at the last minute, staff would call-out or not show up as scheduled. When that happened, they tried to find someone to cover the shift but if unable, she or other administrative nursing staff would help out. The Staffing Scheduler revealed the current open positions at the facility were 2 Nurses and 2-3 NAs for the day shift, 3 Nurses and 2 NAs for the evening shift, and 1 full-time nurse, 1 part-time nurse and 1-2 NAs for the night shift. During an interview on 05/16/25 at 8:39 AM, the Administrator confirmed staffing was a challenge and she realized it was an area that needed more attention. She stated that they were actively trying to hire more staff and in the interim, they were using several different staffing agencies to supplement the schedule. The Administrator stated with the current resident census, only having 2-3 NAs on first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM) was not adequate and explained they were supposed to be able to get agency staffing coverage last minute but it didn't always happen. The Administrator stated she felt that part of the reason for the current staffing issues was due to the previous administration had changed back to 8-hour shifts because facility-hired staff had threatened to quit; however, agency staff did not want to work 8-hour shifts, they wanted to work longer hours. She stated agency staff would sign up for shifts and then call-out or not show up for the shift because they were able to find more hours elsewhere. She stated they had recently made the decision to return back to 12-hour shifts, which she felt would help with having adequate staffing coverage.

Based on record review and staff interviews, the facility failed to provide effective orientation to a new nurse on the facility's admission process when Nurse #6 failed to obtain and document code status information, obtain treatment orders for pressure ulcers, and complete accurate head-to-toe skin checks used to identify skin breakdown and new or existing pressure ulcers. In addition, the facility also failed to ensure nursing staff were able to demonstrate the competency and skills necessary for providing care to meet the individual care needs of residents when Nurse Aide (NA) #3 failed to inform the nurse she had noticed a resident's skin was red and irritated during catheter care, Nurse #1 failed to identify a resident prior to administering medication prescribed for another resident, Nurse #7 failed to request a prescription from the physician when refilling a controlled medication, and Nurse #8 failed to utilize the medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications). This occurred for 5 of 8 staff reviewed for competency (Nurse #6, NA #3, Nurse #1, Nurse #7 and Nurse #8). Findings included: This tag is crossed referenced to: F 578: Based on record review, Medical Director (MD) interview, and staff interviews, the facility failed to obtain and document an advanced directive that included code status information upon admission for 1 of 4 residents reviewed for advance directive (Resident #283). F 686: Based on observations, record review, interviews with the Wound Care Medical Doctor (MD), the Medical Director and staff, the facility failed to obtain treatment orders for pressure ulcers identified on 04/24/25 resulting in a seven-day delay of treatment. Additionally, the facility failed to complete accurate head-to-toe skin checks used to identify new or existing pressure ulcers that include the site (location), type of wound, the length, width, depth, and stage. The skin/wound assessment completed on 05/13/25 indicated the resident's skin was intact with no new pressure ulcer. On 05/14/25 a tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the left heel was identified and measured 4 centimeters (cm) in length and 4.1 cm with width. The deficient practice occurred for 1 of 5 residents reviewed for pressure ulcers (Resident #86). F 690: Based on record review, observations, and interviews with the Medical Director, resident and staff, the facility failed to monitor the resident's urinary catheter for complications of skin breakdown and ensure the catheter tubing was kept clean. A buildup of a white colored substance was observed on the urinary meatus (the opening at the tip of the penis where urine exits the body) where the catheter tubing was inserted, on the scrotum and between the skin folds of the groin. There was redness and irritation present on the genitals and skin folds between the groin and a strong odor resembling yeast. The deficient practice occurred for 1 of 3 residents reviewed for catheters (Resident #86). F 760: Based on observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a significant medication error when Nurse #1 administered antidepressant, diuretic, blood pressure, hypoglycemic (oral medication used to treat diabetes) and steroid medications to Resident #283 that were prescribed for Resident #86. In addition, the facility failed to request a prescription from the physician to avoid a gap in medication administration when refilling a controlled medication and failed to utilize medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications) which resulted in the Resident #11 missing 3 doses of nerve pain medication, 3 doses of diabetic medication, and 1 dose of insulin. This deficient practice occurred for 2 of 2 residents reviewed for significant medication error (Resident #283 and Resident #11). During an interview on 05/11/25 at 10:40 AM the Administrator revealed there had been a recent change in administration, the Director of Nursing (DON) just started her position the week prior and the Assistant DON was starting her position this week. During follow-up interviews on 05/16/25 at 8:30 AM and 6:36 PM, The Administrator revealed she realized there were issues with staff orientation and training dating back to the previous DON and management team. She stated they had put performance improvement plans in place to work on the various issues and going forward, the current DON and Assistant DON would be responsible for ensuring skills competencies for nursing staff were completed annually. The Administrator expressed she felt they now had a strong management team in place, and she had no doubt that processes would be fixed and improvement achieved but it would take time for them to get things turned around.

Based on observations, record review, and interview with an individual resident, resident council and staff, the facility failed to serve the lunch meal at the scheduled times and in accordance with resident preferences on 05/11/25 and 05/12/25 in the main dining room for 2 of 3 meal observations. Findings included: Review of the facility's mealtimes revealed lunch was to be served at 12:00 PM in the main dining room. An observation of the lunch meal being served in the main dining room on 05/11/25 revealed meal trays arrived at 12:38 PM. An observation of the lunch meal being served in the main dining room on 05/12/25 revealed meal trays arrived at 12:48 PM. An interview with Resident #49 on 05/12/25 at 12:48 PM in the main dining room revealed she was frustrated at having to wait so long to receive her lunch meal. Resident #49 was admitted to the facility 01/09/25. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact and required set-up assistance with eating. A Resident Council group interview was conducted on 05/13/25 at 10:26 AM with Resident #70, Resident #63, Resident #41, Resident #14, Resident #11, Resident #18, Resident #23, Resident #69, and Resident #42 in attendance. The residents voiced that meal trays were often served late regardless if they ate in their rooms or in the main dining room. The Dietary Manager was unavailable for an interview. An interview with the Regional Director of Operations on 05/14/25 at 3:15 PM revealed he and the Administrator recently met and revised the meal schedule in an attempt to ensure meals were sent out in a timely manner. He stated he felt it was still a new process but he felt the change in scheduled meal times would ensure meals were sent to the main dining room and halls on time. An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected residents to receive meals at their scheduled serving time.

Based on observations, record review, and staff interviews the facility failed to implement their infection control policies when Nurse Aide (NA) #3 and NA #5 did not don (put on) a gown while providing incontinence care to Resident #31 who required enhanced barrier precautions (EBP) due to the presence of a pressure ulcer and failed to follow their Hand Hygiene policy when NA #3 did not remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment while providing incontinence care to Resident #31; when Nurse #4 and Nurse #5 did not don gowns while providing pressure ulcer care to Resident #45 who required EBP due to the presence of a pressure ulcer; and failed to follow their Hand Hygiene policy when NA #1 and NA #2 did not remove their soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment while providing incontinence care to Resident #35. These deficient practices occurred for 6 of 11 staff members observed for infection control practices (NA #3, NA #5, Nurse #4, Nurse #5, NA #1, and NA #2). Findings included: Review of the facility's Hand Hygiene/Handwashing Policy last revised 06/01/24 read in part as follows: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. Perform hand hygiene before and after having direct contact with residents, after removing gloves, and after contact with body fluids or excretions and wound dressings. Review of the facility's Enhanced Barrier Precautions policy last revised March 2024 read in part as follows: Enhanced barrier precaution (EBP) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, providing hygiene, and changing briefs. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds (i.e. pressure ulcers). Indwelling medical devices include urinary catheters and feeding tubes. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk. 1. An observation of Resident #31's door on 05/15/25 at 10:43 AM revealed a sign taped on the door indicating she was on EBP and a shelf containing gowns was hanging on the door. A continuous observation of NA #3 and NA #5 on 05/15/25 from 11:04 AM until 11:13 AM revealed they both performed hand hygiene, donned gloves, entered Resident #31's room, pulled back the bed covers, unfastened her brief, and rolled Resident #31 on her left side. NA #3 performed incontinence care for stool by removing the stool with a resident care wipe, discarded the soiled wipe in a trash bag, placed a clean brief under Resident #31, and assisted the resident to roll on her right side. NA #5 assisted with positioning the clean brief under Resident #31. NA #3 fastened Resident #31's brief, removed her gloves, opened the resident's closet doors, removed a shirt and pants, closed the closet door, applied clean gloves and placed the shirt and pants on Resident #31, placed the mechanical lift sling under the resident, removed her gloves and performed hand hygiene. NA #3 and NA #5 did not don a gown before entering Resident #31's room and NA #3 did not remove her gloves and perform hand hygiene after cleaning stool and before touching other items in the resident's room. A joint interview with NA #3 and NA #5 on 05/15/25 at 11:13 AM revealed they did not know that the sign on Resident #31's meant they were supposed to don a gown when providing care. They stated the EBP sign had been on Resident #31's door for quite a while but they had not received any education on when to use EBP precautions. NA #3 stated she should have removed her gloves after cleaning stool and performed hand hygiene before touching other items in Resident #31's room and it was an oversight. An interview with the Director of Nursing (DON) on 05/15/25 at 12:40 PM revealed staff should follow the EBP signage on the door and don gowns before providing care. She stated gloves should be removed and hand hygiene should be performed after cleaning stool and before touching other items. An interview with the Administrator on 05/16/25 at 6:33 PM revealed she expected staff to follow EBP signage and to remove gloves and perform hand hygiene after cleaning stool and before touching other items. 47683 2. An observation on 05/15/25 at 2:55 PM of Nurse #4 and Nurse #5 entering Resident #45's room that had a sign on the door for Enhanced Barrier Precautions which instructed staff to don gloves and gown. Nurse #4 and Nurse #5 entered the room and informed Resident #45 they were going provide wound care, washed their hands, and applied clean gloves. Nurse #4 and Nurse #5 proceeded to position Resident #45 to provide wound care. This surveyor stopped Nurse #4 and Nurse #5 and asked about the sign for Enhanced Barrier Precautions. Nurse #4 and Nurse #5 stopped what they were doing, removed their gloves, sanitized their hands and put on gowns and new gloves. A joint interview with Nurse #4 and Nurse #5 on 05/15/25 at 3:05 PM revealed that they should have put gowns and gloves on. Nurse #5 stated that they had been trained on Enhanced Barrier Precautions. Nurse #4 stated that they overlooked the Enhanced Barrier Precautions sign and PPE hanging on the door. An interview with the DON/ Infection Preventionist on 05/15/25 at 3:39 PM revealed that her expectation was for staff to put on the appropriate PPE for all residents who are on Enhanced Barrier Precautions when providing direct resident care such as wound care. An interview with the Administrator on 05/16/25 at 10:06 AM revealed that her expectation was for staff to put on the appropriate PPE for the residents who were on Enhanced Barrier Precautions when providing direct patient care such as wound care. 37538 3.During a continuous observation on 05/13/25 from 12:23 PM through 12:35 PM, NA #1 and NA #2 entered the room of Resident #35 and closed the door. Upon entry to the room NA #1 and NA #2 had gloves on and stated they had performed hand hygiene prior to donning. NA #1 and NA #2 used a mechanical lift to transfer Resident #35 from the chair to bed to provide incontinence care. Resident #35's brief was heavily soiled with a bowel movement that had leaked onto her inner thighs and pants. Both NA #1 and NA #2 removed Resident #35 pants. NA #1 unfastened Resident #35's brief and used moistened wipes to clean bowel movement from the front perineal area and between the skin folds. NA #2 repositioned Resident #35 onto her side and NA #1 continued to wipe bowel movement from the buttock until clean and removed the absorbent pad and soiled brief. Wearing the same gloves NA #1 placed a clean absorbent pad and clean brief underneath Resident #35. NA #2 repositioned Resident #35 onto her back and used moistened wipes to clean bowel movement from the resident's inner thighs. Wearing the same gloves used to clean bowel movement both NA #1 and NA #2 fastened the clean brief and covered Resident #3 with the bed linens. Wearing the same gloves NA #1 repositioned the pillow underneath Resident #35's head and NA #2 moved the mechanical out of the way. Both NA #1 and NA #2 removed their gloves when exiting the room and performed hand hygiene. NA #1 washed her hands using soap and water at a sink located in the nutrition room and NA #2 sanitized her hands with an alcohol based rub located by the nurse station. During an interview on 05/13/25 at 12:35 PM, NA #1 and NA #2 revealed they were trained to remove their gloves after contact with body fluids including urine and bowel movement and to perform hand hygiene after gloves were removed. NA #1 and NA #2 revealed it was an oversight on their part they did not remove their gloves and perform hand hygiene as trained. An interview was conducted on 05/15/25 at 12:40 PM with the DON. The DON revealed gloves were removed and hand hygiene performed after contact with bowel movement as needed. An interview was conducted with the Administrator on 05/16/25 at 6:33 PM. The Administrator revealed for incontinence care when stool/bowel movement was cleaned gloves were removed and hand hygiene performed.

Based on observation, record review, and interviews with residents and staff, the facility failed to ensure resident's accessibility to the light switch located behind the bed and failed to provide a bed with adequate length to prevent a resident's feet from hanging off at the end of the mattress for 2 of the 2 residents reviewed for accommodation of needs (Residents #58 and #43). The findings included: 1. Resident #58 was admitted to the facility on [DATE]. The quarterly MDS assessment dated [DATE] coded Resident #58 with intact cognition and impairment on one side of his upper and lower extremities. The MDS indicated walking between locations inside the room for more than 10 feet was not attempted during the assessment period due to medical condition or safety concerns. During an observation conducted on 05/12/25 at 11:43 AM, the switch for the light fixture behind Resident #58's bed was attached with a broken cord 2.5 inches in length. The switch cord was 5 feet from the floor and 6 feet from the bed. Resident #58 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #58 on 05/12/25 at 11:45 AM. He stated he was bedbound and unable to stand up and walk. He recalled the switch cord was broken since he moved into his room a few months ago. He did not have any control of the light fixture behind his bed as he could not stand up to reach the broken switch cord on the wall. He enjoyed reading before bedtime and had to rely on nursing staff to switch off the light fixture before sleeping. It was frustrating and inconvenient as he had to ask for assistance repeatedly. He wanted the maintenance staff to fix the switch cord to accommodate his needs immediately. Subsequent observation conducted on 05/13/25 at 11:49 AM revealed the switch cord for the light fixture behind Resident #58's bed remained inaccessible. During joint observation and subsequent interviews with Nurse Aide (NA) #2 and Nurse #2 on 05/13/25 at 12:15 PM, both nursing staff acknowledged that the broken switch cord needed to be fixed as soon as possible. NA #2 stated she provided care for Resident #58 frequently in the past few weeks and she had notified the Maintenance Manager about the broken switch cord. However, she did not follow up with the Maintenance Manager. Nurse #2 stated she had provided care for Resident # 58 frequently, but she did not notice the switch cord was broken and inaccessible for Resident #58. An interview was conducted with the Maintenance Director on 05/13/25 at 12:33 PM. He stated he walked through the facility at least once daily to identify repair needs. He also depended on nursing staff to report repair needs either verbally or with work order via facility website electronically. He could not recall receiving any work orders for Resident # 58's broken switch cord so far. He acknowledged that all the broken switch cords needed to be fixed immediately to accommodate residents' needs. During an interview conducted on 05/14/25 at 8:45 AM, the Director of Nursing expected the staff to be more attentive to residents' living environment and reported repair needs in a timely manner. It was important to accommodate residents' needs and ensure full accessibility to their light fixture. A phone interview was conducted with the Administrator on 05/16/25 at 10:46 AM. She stated it was her expectation for all the residents to have full accessibility to their light fixture to accommodate their needs all the time. 37014 2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included incomplete quadriplegia C1-C4 (spinal cord injury between the vertebrae in the upper neck resulting in loss of some motor functions but not all). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition. He had impairment of both sides of the upper extremities and was dependent on staff assistance with self-care tasks, bed mobility and transfers. It was noted Resident #43 had a height of 75 inches. During an observation and interview on 05/11/25 at 11:30 AM, Resident #43 was observed sitting up in bed watching TV. The head of the bed was slightly elevated, Resident #43's head was aligned with the top edge of the mattress and the footboard had been removed from the bed frame. Resident #43's legs were in a straight position with his ankles resting on the bottom edge of the mattress and his feet extending past edge of the mattress. Resident #43 stated when he was first admitted to the facility, he was placed in a bed that was very narrow and shortly afterwards, he could not recall when, the facility brought him another bed that was much wider. Resident #43 stated he was 76 inches tall and the Maintenance Director told him that the bed he was currently in was 80 inches in length but anytime he was positioned up in bed, his feet hung off the end of the bed. Resident #43 stated it was an uncomfortable position for him to have his feet extending past the bottom edge of the mattress. Additional observations on 05/12/25 at 12:22 PM and 05/13/25 at 9:20 AM revealed Resident #43 lying supine (face upward) in bed with the head of the bed elevated and his feet extending past the bottom edge of the mattress. During an observation and interview on 05/13/25 at 9:40 AM, the Maintenance Director revealed he had removed the footboard of the bed so that Resident #43's feet wouldn't press up against it. He stated he had been in and out of Resident #43's room several times since then but had not noticed his feet extending past the edge of the mattress. The Maintenance Director stated Resident #43's current bed was 80 inches in length and wasn't sure if he could order one any longer but he would research to see what he could find. During an observation and interview on 05/14/25 at 8:45 AM, the Director of Nursing (DON) confirmed Resident #43 was positioned correctly up in bed and his feet still extended past the bottom edge of the mattress. The DON expressed the back of Resident #43's ankles rested at the bottom edge of the mattress which was concerning because that was a vulnerable area and he was already at risk for skin breakdown. The DON stated she would have expected for someone to have noticed and gotten him a longer bed so that his feet didn't extend past the bottom edge of the mattress. During an interview on 05/16/25 8:39 AM, the Administrator revealed that most of the times when she had been in Resident #43's room, he was either up in his wheelchair or he was lying in bed with his feet covered and she hadn't noticed his feet extending past the edge of the mattress. The Administrator stated she would have hoped that someone would have noticed Resident #43's bed was not long enough but no one had voiced any concerns to her. She explained there were bed extensions that could have been placed on Resident #43's bed or his bed switched out with one that would extend in length which would have prevented his feet from extending past the edge of the mattress.

Based on record review, Medical Director (MD) interview, and staff interviews, the facility failed to obtain and document an advanced directive that included code status information upon admission for 1 of 4 residents reviewed for advance directive (Resident #283). Findings included: Resident #283 was admitted to the facility on [DATE] with diagnosis that included acute respiratory failure with hypoxia (a condition where the lungs fail to adequately oxygenate the blood, leading to low oxygen levels in the blood and tissues). Review of the admission progress note dated 4/25/25 at 11:00 PM and written by Nurse #6 revealed there was no mention of Resident #283's advanced directive or code status. A phone interview on 05/14/25 at 4:09 PM with Nurse #6 revealed she admitted Resident #283 on 4/25/25. She stated that she had not been shown the full process of completing a new admission and learned by word of mouth when asking another nurse or after being told she had done something wrong. She stated that she had asked other nurses on many different occasions to show her the admission process, but it never happened. Nurse #6 further revealed that she had not asked about Resident #283's code status during the admission process on 04/25/25. An interview on 5/16/25 at 12:33 PM with the former DON revealed that when a resident was admitted to the facility the admitting nurse should review the residents advanced directive wishes with them and begin filling out the advanced directive form. She stated that she was not sure why Resident #283's advanced directive was never filled out as it should have been completed upon admission. She further revealed that the admitting nurse should also have put the order for the code status in the medical record. She stated that if the Social Worker was available to begin the advanced directive form with the resident, the Social Worker would hand the advanced directive form to the admitting nurse and the admitting nurse would place the initial order. The admitting nurse would then communicate to the Nurse Practitioner (NP) or the MD about the new advanced directive form and code status orders. An interview on 5/15/25 at 3:38 AM with the MD revealed that normally on admission a staff member obtained the resident's code status and put in an order. Then the staff member notified him, and he confirmed that with the resident. He further revealed that the code status was usually gotten from the hospital paperwork. An interview on 5/16/25 at 5:21 PM with the Administrator revealed that she was familiar with Resident #283. The Administrator indicated that the admitting nurse should have asked for Resident #283's code status. She stated that Resident #283's admission paperwork wasn't done either and she was not sure why. She further stated that part of the admission paperwork involved advanced directives. She stated that her expectation was that residents had an advanced directive completed and code status ordered upon admission.

Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician when pressure ulcers were identified on admission for 1 of 5 residents reviewed for pressure ulcers (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and moderate protein-calorie malnutrition. The admission data collection assessment dated [DATE] identified Resident #86 had existing pressure ulcers on the right, and left buttock and sacrum. A review of Resident #86's physician orders revealed no wound care treatments were put in place until 04/30/25. During an interview on 05/14/25 at 4:09 PM, Nurse #6 confirmed she was the admitting nurse when Resident #86 arrived at the facility, and she completed the admission data collection assessment dated [DATE]. She revealed when Resident #86's was admitted she identified pressure ulcers on the left, and right buttock and sacrum she described as red in color with no open skin or drainage and were on the surface of the skin. Nurse #6 revealed she did not notify the physician to obtain wound care orders on 04/24/25 but did report the pressure ulcers to the oncoming nurse. She revealed she wrote a note in the communication book for the Nurse Practitioner (NP) to see Resident #86 on the next scheduled visit to the facility and the NP came to the facility to see residents on Monday through Thursday. An interview with the former DON was conducted on 05/14/25 at 4:37 PM. The former DON revealed if pressure ulcer wounds were identified on the admission data collection assessment dated [DATE] the admitting nurse should notify the physician and obtain wound care orders. A review of the Medical Director progress note revealed Resident #86 was seen on 04/25/25 for a new patient assessment. The Medical Director's physical exam of the skin noted Resident #86 had no rashes. The Medical Director's plan of treatment indicated nursing was instructed to notify the provider or the on-call provider of any new or worsening changes in condition. The progress note did not mention pressure ulcers and no wound care orders were provided. An interview was conducted on 05/15/25 at 9:10 AM with the Medical Director. The Medical Director revealed he wanted to be notified when a resident was identified as having pressure ulcers. He further revealed wound care treatments should have been implemented when Resident #86 was admitted with existing pressure ulcers on 04/24/25. During an interview on 05/16/25 at 8:57 AM, the Administrator revealed the admitting nurse (Nurse #6) was responsible for notifying the physician when Resident #86's pressure ulcers were identified on 04/24/25 to obtain treatment orders.

Based on observations, record review, interviews with the resident and staff, the facility failed to protect a resident's right to be free from neglect when Nurse Aide (NA) #1 disregarded a resident's request for incontinence care and did not check the resident for incontinence prior to going on break (Resident #35). Resident #35 was left sitting in a chair in her room that had a strong odor resembling bowel incontinence for approximately one hour. When Resident #35's incontinence care was provided her brief was heavily soiled with a bowel movement that had leaked onto her inner thighs and clothing. Resident #35 voiced she could smell herself and it was not the first time that had happened to her. The deficient practice occurred for 1 of 2 residents reviewed for abuse/neglect. Findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, vascular dementia, cerebrovascular accident, hemiparesis (weakness) and hemiplegia (partial or total paralysis) affecting the left non-dominate side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's cognition was intact with no rejection of care behaviors during the lookback period. Resident #35's range of motion was impaired on both sides of the upper and lower extremities, she was always incontinent of bladder and bowel, and dependent on staff for transfers and toileting hygiene. The care plan revised on 4/03/25 identified Resident #35 had a self-care deficit in performing activities of daily living related to a stroke with hemiplegia and hemiparesis, incontinence, and vascular dementia. The care plan interventions included Resident #35 was dependent on two staff for toilet use. A continuous observation was conducted on 05/13/25 from 11:52 AM through 12:35 PM in conjunction with an interview with Resident #35. Resident #35 stated she needed incontinence care and Nurse Aide (NA) #1 was aware she needed to be changed. When asked how long she had waited Resident #35 stated, It's been a while but gave no specific time. In the room there was a strong odor resembling bowel movement. Resident #35 stated she could smell herself and this was not the first time this had happened. NA #1 was observed to enter and exit the room at 12:18 PM and again at 12:23 PM. Resident #35 was sitting in a reclined position in a chair and continued to need incontinence care. The strong odor resembling incontinence remained in the room and had lingered onto the hallway. At 12:35 PM, NA #1 and NA #2 provided a two person transfer and moved Resident #35 from the chair to the bed using a mechanical lift. When Resident #35's brief was removed it was heavily soiled with bowel movement. The bowel movement had leaked from the brief onto Resident #35's left and right inner thighs and clothing. The bowel movement was moist and had not dried on to Resident #35's skin and when removed there were two areas of intact pink colored skin resembling previously healed scar tissue. An interview was conducted with NA #1 on 05/13/25 at 12:35 PM. NA #1 confirmed Resident #35 stated she was incontinent prior to her (NA #1) going on break at 11:30 AM. NA #1 revealed she did not physically check Resident #35 for incontinence at that time and stated there was no odor resembling incontinence. NA #1 described Resident #35 as having attention seeking behaviors that included saying she was incontinent but was not. NA #1 revealed she did not provide Resident #35 incontinence care when she returned from break at 12:00 PM due to it being almost time for her to begin delivering meal trays and she was told not to provide incontinence care for residents during meal tray service. An interview was conducted on 05/16/25 at 10:43 AM with the Director of Nursing (DON). It was explained Resident #35 requested incontinence care prior to NA #1 going on break at 11:30 AM but it was not provided until 12:35 PM. The DON stated it was poor quality of care to not provide incontinence care, and she would expect incontinence care to be provided when a resident asked to be changed. The DON stated she would expect incontinence care was completed regardless if it was during meal tray service or meal time. During an interview on 05/16/25 at 6:04 PM the Administrator stated she never told nurse or NA staff incontinence care was not provided during meal tray service. The Administrator stated she expected if Resident #35 asked to be changed, NA #1 would have done the care before going on break and was poor customer service it was not done. The Administrator stated it was not neglect as she did not think NA #1 intentionally neglected Resident #35 request for incontinence care.

Based on record review and staff interviews, the facility failed to complete the Care Area Assessment (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 1 of 1 sampled resident reviewed for comprehensive assessment (Residents #48). The findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, aphasia, dementia, and cognitive communication deficit. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #48 with severely impaired cognition. A review of Section V (Care area assessment summary) of the annual MDS assessment dated [DATE] revealed a total of 9 care areas were triggered for Resident #48. The MDS Coordinator did not provide any information in analysis of findings for 8 of the 9 triggered areas to describe the nature of Resident #48's problems, possible causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for the following triggered care areas: 1. Visual functions 2. Communication 3. Functional abilities 4. Urinary incontinence and indwelling catheter 5. Falls 6. Nutritional status 7. Pressure ulcer/injury 8. Psychotropic drug use During an interview conducted on 05/13/25 at 12:53 PM, the MDS Coordinator confirmed 8 of the 9 triggered care areas for Resident #48's annual MDS dated [DATE] were submitted without providing pertinent information in the analysis of findings in Section V to address the underlying causes and contributing factors of the triggered areas. She indicated Resident #48's annual MDS dated [DATE] was completed by the MDS Coordinator who worked remotely. The MDS Coordinator indicated she had only worked part-time (3 days per week) during the past 3 months. An interview was conducted with the Director of Nursing on 05/14/25 at 8:45 AM. She stated all the CAAs must be individualized and completed comprehensively. It was her expectation for the MDS Coordinators to complete the analysis of findings for all the triggered areas in Section V comprehensively before submission. An attempt to conduct a phone interview on 05/14/25 at 4:36 PM with the MDS Coordinator who completed Resident #48's annual MDS dated [DATE] was unsuccessful. During a phone interview conducted with the Administrator on 05/16/25 at 10:46 AM, she expected the MDS Coordinator to follow MDS guidelines to ensure all the CAAs include at least the nature of problems, causative factors, and reasons to proceed to care plan before submission.

Based on observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a medication error when Nurse #1 administered an antidepressant, diuretic, hypoglycemic and blood pressure medications to Resident #283 that were prescribed for Resident #86. This deficient practice occurred for 1 of 2 residents reviewed for medication errors (Resident #283). The findings included: 1. Resident 283 was admitted to the facility on [DATE] with diagnosis that included parkinsonism, type 2 diabetes mellitus, chronic kidney disease stage 3, myocardial infarction type 2 (a heart attack that occurs due to an imbalance between the hearts oxygen supply and demand), hypertension (high blood pressure), and edema (swelling). Review of the 5-day Prospective Payment System (PPS) assessment dated [DATE] revealed that Resident #283 was cognitively intact. He received antidepressant, anticoagulant, antibiotic, diuretic, antiplatelet, and hypoglycemic medications. Review of the change in condition communication form written by Nurse #1 and dated 4/28/25 at 8:50 AM revealed Resident #283 was administered the wrong medications as follows: Lexapro (antidepressant) 10 milligrams (MG), Lasix (diuretic) 40 MG, Jardiance (a medication used to treat type 2 diabetes) 10 MG, Lisinopril (a medication used to treat high blood pressure) 40 MG, Metoprolol extended release (ER, a medication used to treat high blood pressure) 12.5 MG, and Prednisone (steroid medication used to treat many diseases and conditions that are associated with inflammation) 40MG. Resident #283 was informed of the medication that was given in error and the plan to notify the provider now. Things that made the condition or symptom worse were unknown. Things that made the condition or symptoms better were noted as keeping Resident #283 and the family informed and monitoring Resident #283's vital signs every 15 minutes for 2 hours, then every 30 minutes for one hour, then every 4 hours. Other relevant information noted Resident #283 was provided with a list of medications given in error. Each medication was explained, including the indications for use and possible side effects. Resident #283's vital signs remained normal. Mental status changes included Resident #283 became anxious when informed of the medication errors, all questions were answered, and he was seen by the Nurse Practitioner (NP) within 30 minutes. The NP assured Resident #283 he would be ok, and he seemed less anxious after the NP visit. Resident #283 had no functional status, respiratory, abdomen, or urine changes noted. The NP determined that Resident #283 did not need to be sent to the hospital, but staff would continue to monitor him at the facility. An interview on 5/15/25 at12:03 PM with Nurse #1 revealed that she was Resident #283's assigned nurse on 4/28/25 during the hours of 7:00 AM to 3:00 PM. Nurse #1 stated that she entered Resident #283's room and called him by Resident #86's name but she did not think he had heard her because he had his continuous positive airway pressure (CPAP, a machine that is used to treat sleep apnea and other breathing disorders) machine on. She stated that his nasal canula needed to be put on and there was no oxygen tubing in the room, so she left the room to go get Resident #283 oxygen tubing. Nurse #1 stated it was at this point she felt very overwhelmed and when she returned to the medication cart, she pulled out Resident #86's medications to administer to Resident #283. Nurse #1 stated she then reentered Resident #283's room and administered the medications. After Resident #283 took the medications, she called him by Resident #86's name and Resident #283 replied that was not his name. Nurse #1 stated she realized she had administered the wrong medications to Resident #283 and immediately took his vital signs, called the physician, and notified the Director of Nursing (DON). Nurse #1 further stated she also printed off a list of the medications that she had given Resident #283 in error and notified him that she would be monitoring him every 15 minutes. Nurse #1 recalled Resident #283 stating that he was scared but he refused the offer to go to the hospital. Nurse #1 further revealed that Resident #283 never displayed any side effects from having received the wrong medications. Review of the April 2025 MAR for Resident #86 revealed the following medications prescribed for Resident #86 that were administered to Resident #283 in error on 04/28/25: - Jardiance (medication used to lower blood glucose levels) 10 mg - one tablet by mouth one time a day for congestive heart failure. - Lasix (diuretic) 40 mg - one tablet by mouth one time a day for edema (swelling). - Lexapro (antidepressant) 10 mg - one tablet by mouth one time a day for depression. - Lisinopril (antihypertensive) 40 mg - one tablet by mouth one time a day for hypertension. - Metoprolol Succinate (antihypertensive) ER 25 mg - give 0.5 tablet by mouth one time a day for hypertension. Review of the April 2025 medication administration record (MAR) for Resident #283 revealed physician orders for the following routine medications to be administered at 8:00 AM daily: - Aspirin (antiplatelet) 81 MG - one tablet by mouth one time a day for supplement - Bumetanide (diuretic) 1 MG - one tablet by mouth one time a day for chronic kidney disease. - Citalopram (antidepressant) 20 MG - one tablet by mouth one time a day for depression. - Glucotrol extended release (oral hypoglycemic) 5 MG - one tablet by mouth one time a day for diabetes. - Valsartan (antihypertensive) 320 MG - give 0.5 tablet by mouth one time a day for hypertension. - Famotidine (treats gastroesophageal reflux) 20 MG - one tablet by mouth one time a day for gastroesophageal reflux disease (GERD, chronic condition where stomach acid flows back into the esophagus causing heartburn). - Enoxaparin injection (anticoagulant) 40 MG/0.4 milliliter (ml) - inject 0.4 ml (40 mg) under the skin in the morning and at bedtime. - Sodium Bicarbonate (treats heartburn) 650 MG - one tablet by mouth two times a day for supplement. - Multivitamin with minerals - one capsule by mouth two times a day for supplement. - Carbidopa-Levodopa (medication used to treat Parkinson's disease) oral tablet 25-250 mg - one tablet by mouth four times a day for Parkinson's. Further review of Resident #283's April 2025 MAR revealed all 8:00 AM medications were held on 04/28/25 except for the Carbidopa-Levodopa 25-250 mg. Review of the vitals monitoring form for Resident #283 initiated on 04/28/25 at 9:00 AM revealed his vitals (temperature, pulse, respiratory rate, blood pressure, and oxygen saturation) were checked every 15 minutes for the first 2 hours, then every 30 minutes for one hour, then every 4 hours for 24 hours, and then every shift for 48 hours with no issues noted. Review of a nurse progress note written by the former DON dated 4/28/25 revealed that Resident #283 was seen by the NP after a reported medication error. There were no adverse effects noted for Resident #283. Resident #283 and his family chose not to be transferred to the hospital. Monitoring was put in place immediately and vital signs were stable. Review of a NP progress note dated 4/28/25 revealed in part, that Resident #283 was found sitting up in his bed, tearful. Nursing staff told the NP that Resident #283 had received medications that were not prescribed to him. The NP assessed Resident #283 and found his vital signs were within normal limits and instructed nursing staff to continue ongoing assessment of Resident #283's vital signs. Resident #283's heart, lung and bowel sounds were all normal and there was slight trace edema on the lower extremities (legs). Resident #283 had oxygen via nasal cannula present on admission and was alert and oriented. Resident #283's medications were reviewed. An interview on 5/16/25 at 12:33 PM with the former DON revealed that she recalled Resident #283. The former DON stated that when Nurse #1 made a medications error on 4/28/25, Nurse #1 informed Resident #283, the NP and the DON. She stated that she and Nurse #1 assessed Resident #283 after the medication error and put in place continued monitoring every 15 minutes. The former DON further revealed that Resident #283's vital signs remained stable after the incident. The former DON indicated that she reviewed the 5 rights of medication administration education with all nurses and medication aides (MA). She stated that there were no adverse effects noted for Resident #283. The former DON stated that Nurse #1 should have identified Resident #283 prior to pulling the medications and then again before administering the medications by asking Resident #283 to state his name, since Resident #283 was alert and oriented and a new resident. She stated that the facility offered to take Resident #283 to the hospital, but he declined. An interview on 5/15/25 at 11:20 AM with the NP revealed that Nurse #1, who administered the wrong medications, called her when she was on her way to the facility. The NP stated that she told Nurse #1 to lock her cart, tell the DON, and assess Resident #283. The NP stated that when she arrived at the facility, she assessed Resident #283 and reviewed the medications that were given in error. The NP stated that she offered to send Resident #283 to the hospital, but he refused. She further revealed that she informed Nurse #1 to hold his regular medications for the remainder of the day. The NP stated that the medications Resident #283 received in error were similar to the medications that he was prescribed. She further stated that he suffered no ill effects to his health or well-being because of the medication error. The NP stated that after she was done assessing Resident #283, she went to speak with the DON about the medication error. She revealed that she checked on Resident #283 the following day and he remained stable and continued to refuse transfer to the hospital. An interview on 5/16/25 at 3:36 PM with the Medical Director revealed that he was familiar with Resident #283 and was aware of the medication error. The Medical Director stated that the doses of the medication Resident #283 received in error were low and the medications were similar to what Resident #283 was prescribed. He stated that they had no negative effect on Resident #283 and they did not harm him. An interview on 5/16/25 at 5:21 PM with the Administrator revealed that Nurse #1 gave the wrong medication to Resident #283 and she was very up front about it and notified Resident #283, the NP, and the family. She stated that she was not sure why the medication error occurred. The Administrator stated that there were 2 new admissions that day and maybe Nurse #1 got confused. She stated that Nurse #1 should have asked Resident #283's name before she pulled the medications and then asked him again before she gave the medications to him. The Administrator stated that Resident #283 was monitored for 48 hours after the medication error occurred and he had no adverse effects because of the error. She stated that her expectation was that the 7 rights of medication administration were completed which included verifying the right resident got the right medications before medication was administered.

Based on record review, observations, and interviews with the Medical Director, resident and staff, the facility failed to monitor the resident's urinary catheter for complications of skin breakdown and ensure the catheter tubing was kept clean. A buildup of a white colored substance was observed on the urinary meatus (the opening at the tip of the penis where urine exits the body) where the catheter tubing was inserted, on the scrotum and between the skin folds of the groin. There was redness and irritation present on the genitals and skin folds between the groin and a strong odor resembling yeast. The deficient practice occurred for 1 of 3 residents reviewed for urinary catheters (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and acute and chronic congestive heart failure. A review of Resident #86's active physician orders included tamsulosin (a medication used to promote urine flow) give 0.4 milligrams at bedtime for urine retention started 04/24/25; empagliflozin (sodium-glucose cotransporter-2 inhibitors) give a 10 mg tablet one time a day for congestive heart failure started 4/26/25; provide catheter cleansing and perineal hygiene daily and as need if soiled; monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria, or leakage around the catheter started 04/28/25. There were no orders for antifungal medications or treatments for skin redness and irritation. The baseline care plan dated 04/25/25 identified the placement of an indwelling urinary catheter with the goal Resident #86 would not show signs or symptoms of a urinary tract infection. Interventions included position catheter bag and tubing below the bladder and hand washing before and after delivery of care. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86's cognition was moderately impaired, partial to moderate assistance was needed with toileting hygiene, an indwelling urinary catheter was in place and always incontinent of bowel. No genitourinary diagnoses were checked. The MDS indicated Resident #86 had no rejection of care behaviors during the lookback period. A review of Resident #86's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 05/01/25 through 05/14/25 revealed the physician's order to provide catheter cleansing and perineal hygiene daily and as need if soiled; monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria, or leakage around the catheter were not included. There was no treatment order for skin related redness or irritation, or for the use of an antifungal powder or cream. A review of the Nursing Daily Skilled Charting dated 05/13/25 included a skin/wound assessment and indicated Resident #86's skin was intact and there were no skin integrity changes. Nurse #6 documented the assessment. An observation was made on 05/14/25 at 12:12 PM of Resident #86's catheter care provided by the Unit Manager (UM). When the brief was removed, the skin on Resident #86's genitals including the urinary meatus where the catheter tubing was inserted and skin folds between the groin was red and irritated. There was a buildup of a white colored substance on the genitals and between the groin skin folds and a strong odor resembling yeast was present. The UM revealed it appeared Resident #86's catheter care had not been done and noted the presence of a strong odor resembling yeast. The UM cleaned the catheter tubing, genitals and between the skin folds and removed the white substance from Resident #86's skin and revealed it appeared an antifungal powder had been applied. There was a small area of skin on the scrotum that was peeling and red. There was no drainage or leakage noted from the catheter insert site. Resident #86 tolerated catheter care and did not voice pain when asked by the UM. During an interview on 05/14/25 at 12:12 PM, Resident #86 revealed he did not refuse catheter care. Resident #86 revealed he was unsure why the urinary catheter was placed and did not recall the last time catheter care was provided. Resident #86 did not share he was itching or had pain related to his urinary catheter. An interview was conducted on 05/14/25 at 4:09 PM with Nurse #6. Nurse #6 confirmed she completed the Nursing Daily Skilled Charting on 05/13/25. Nurse #6 revealed she did not visually check Resident #86's skin integrity when she completed the skin/wound assessment. An interview was conducted on 05/14/25 at 12:44 PM with Nurse Aide (NA) #3, Resident #86's assigned NA. NA #3 confirmed she worked the day shift on 05/14/25 starting at 7:00 AM and was assigned to provide catheter care for Resident #86. NA #3 stated she had emptied Resident #86's catheter bag and checked for a bowel movement and there was no incontinence. NA #3 revealed she had done catheter care earlier today (05/14/25) and cleaned the catheter tubing at the insert site. When asked if she cleaned the perineal area and between the skin folds to remove a white substance NA #3 stated, yes. NA #3 revealed she noted Resident #86's skin was red, but did not report it to the nurse. During an interview on 05/14/25 at 1:39 PM and 05/15/25 10:43 AM, the Director of Nursing (DON) stated it was obvious NA #3 had not provided Resident #86's catheter care based on the observation made by the UM and surveyor. The DON revealed catheter care was provided as needed and she expected it was done. The DON revealed the expectation for completing the skin/wound assessments was for the nurse to visually check the resident's skin and identify existing and new skin breakdown. During an interview on 05/16/25 at 8:57 AM, the Administrator stated it appeared NA staff were just emptying Resident #86's catheter bag. The Administrator revealed Resident #86 should be check every two hours for bowel incontinence and at some point someone should have noticed his catheter needed cleaned and his perineal hygiene care needed to be done. During an interview on 05/16/25 at 3:43 PM, the Medical Director stated catheter care should be done as ordered and if not provided could put Resident #86 at risk of an infection. When asked about the strong body odor resembling yeast and the skin redness, the Medical Director stated Resident #86 received empagliflozin a medication that could cause yeast. He revealed on 04/22/25 Resident #86 could not urinate and the catheter was placed at the hospital then Resident #86 was admitted to facility with no instructions for a trial to remove it. The Medical Director revealed based on his initial visit progress note dated 04/26/25 Resident #86 was put on tamsulosin (a medication used to increase urine flow) for urinary retention and in a male that was obstructive uropathy and why the urinary catheter was in place. During an interview on 05/16/25 at 4:03 PM in the presence of the Medical Director, Resident #86 was unsure why he needed an indwelling urinary catheter. The Medical Director explained to Resident #86 a voiding trial period would be started, and the urinary catheter would be removed and if Resident #86 could urinate the catheter was not needed.

Based on observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a significant medication error when Nurse #1 administered a steroid medication to Resident #283 that were prescribed for Resident #86. In addition, the facility failed to request a prescription from the physician to avoid a gap in medication administration when refilling a controlled medication and failed to utilize medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications) which resulted in the Resident #11 missing 3 doses of nerve pain medication, 3 doses of diabetic medication, and 1 dose of insulin. This deficient practice occurred for 2 of 2 residents reviewed for significant medication error (Resident #283 and Resident #11). The findings included: 1. Resident #283 was admitted to the facility on [DATE] with diagnosis that included parkinsonism, type 2 diabetes mellitus, chronic kidney disease stage 3, myocardial infarction type 2 (a heart attack that occurs due to an imbalance between the hearts oxygen supply and demand), hypertension (high blood pressure), and edema (swelling). Review of the 5-day Prospective Payment System (PPS) assessment dated [DATE] revealed that Resident #283 was cognitively intact. He received antidepressant, anticoagulant, antibiotic, diuretic, antiplatelet, and hypoglycemic medications. Review of the change in condition communication form written by Nurse #1 and dated 4/28/25 at 8:50 AM revealed Resident #283 was administered the wrong medications as follows: Lexapro (antidepressant) 10 milligrams (MG), Lasix (diuretic) 40 MG, Jardiance (a medication used to treat type 2 diabetes) 10 MG, Lisinopril (a medication used to treat high blood pressure) 40 MG, Metoprolol extended release (ER, a medication used to treat high blood pressure) 12.5 MG, and Prednisone (steroid medication used to treat many diseases and conditions that are associated with inflammation) 40MG. Resident #283 was informed of the medication that was given in error and the plan to notify the provider now. Things that made the condition or symptom worse were unknown. Things that made the condition or symptoms better were noted as keeping Resident #283 and the family informed and monitoring Resident #283's vital signs every 15 minutes for 2 hours, then every 30 minutes for one hour, then every 4 hours. Other relevant information noted Resident #283 was provided with a list of medications given in error. Each medication was explained, including the indications for use and possible side effects. Resident #283's vital signs remained normal. Mental status changes included Resident #283 became anxious when informed of the medication errors, all questions were answered, and he was seen by the Nurse Practitioner (NP) within 30 minutes. The NP assured Resident #283 he would be ok, and he seemed less anxious after the NP visit. Resident #283 had no functional status, respiratory, abdomen, or urine changes noted. The NP determined that Resident #283 did not need to be sent to the hospital, but staff would continue to monitor him at the facility. An interview on 5/15/25 at12:03 PM with Nurse #1 revealed that she was Resident #283's assigned nurse on 4/28/25 during the hours of 7:00 AM to 3:00 PM. Nurse #1 stated that she entered Resident #283's room and called him by Resident #86's name but she did not think he had heard her because he had his continuous positive airway pressure (CPAP, a machine that is used to treat sleep apnea and other breathing disorders) machine on. She stated that his nasal canula needed to be put on and there was no oxygen tubing in the room, so she left the room to go get Resident #283 oxygen tubing. Nurse #1 stated it was at this point she felt very overwhelmed and when she returned to the medication cart, she pulled out Resident #86's medications to administer to Resident #283. Nurse #1 stated she then reentered Resident #283's room and administered the medications. After Resident #283 took the medications, she called him by Resident #86's name and Resident #283 replied that was not his name. Nurse #1 stated she realized she had administered the wrong medications to Resident #283 and immediately took his vital signs, called the physician, and notified the Director of Nursing (DON). Nurse #1 further stated she also printed off a list of the medications that she had given Resident #283 in error and notified him that she would be monitoring him every 15 minutes. Nurse #1 recalled Resident #283 stating that he was scared but he refused the offer to go to the hospital. Nurse #1 further revealed that Resident #283 never displayed any side effects from having received the wrong medications. Review of the April 2025 MAR for Resident #86 revealed the following significant medication prescribed for Resident #86 was administered to Resident #283 in error on 04/28/25: - Prednisone (steroid) 20 mg - two tablets by mouth one time a day for pneumonia, chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe) for 5 days. Review of the April 2025 medication administration record (MAR) for Resident #283 revealed physician orders for the following routine medications to be administered at 8:00 AM daily: - Aspirin (antiplatelet) 81 MG - one tablet by mouth one time a day for supplement - Bumetanide (diuretic) 1 MG - one tablet by mouth one time a day for chronic kidney disease. - Citalopram (antidepressant) 20 MG - one tablet by mouth one time a day for depression. - Glucotrol extended release (oral hypoglycemic) 5 MG - one tablet by mouth one time a day for diabetes. - Valsartan (antihypertensive) 320 MG - give 0.5 tablet by mouth one time a day for hypertension. - Famotidine (treats gastroesophageal reflux) 20 MG - one tablet by mouth one time a day for gastroesophageal reflux disease (GERD, chronic condition where stomach acid flows back into the esophagus causing heartburn). - Enoxaparin injection (anticoagulant) 40 MG/0.4 milliliter (ml) - inject 0.4 ml (40 mg) under the skin in the morning and at bedtime. - Sodium Bicarbonate (treats heartburn) 650 MG - one tablet by mouth two times a day for supplement. - Multivitamin with minerals - one capsule by mouth two times a day for supplement. - Carbidopa-Levodopa (medication used to treat Parkinson's disease) oral tablet 25-250 mg - one tablet by mouth four times a day for Parkinson's. Further review of Resident #283's April 2025 MAR revealed all 8:00 AM medications were held on 04/28/25 except for the Carbidopa-Levodopa 25-250 mg. Review of the vitals monitoring form for Resident #283 initiated on 04/28/25 at 9:00 AM revealed his vitals (temperature, pulse, respiratory rate, blood pressure, and oxygen saturation) were checked every 15 minutes for the first 2 hours, then every 30 minutes for one hour, then every 4 hours for 24 hours, and then every shift for 48 hours with no issues noted. Review of a nurse progress note written by the former DON dated 4/28/25 revealed that Resident #283 was seen by the NP after a reported medication error. There were no adverse effects noted for Resident #283. Resident #283 and his family chose not to be transferred to the hospital. Monitoring was put in place immediately and vital signs were stable. Review of a NP progress note dated 4/28/25 revealed in part, that Resident #283 was found sitting up in his bed, tearful. Nursing staff told the NP that Resident #283 had received medications that were not prescribed to him. The NP assessed Resident #283 and found his vital signs were within normal limits and instructed nursing staff to continue ongoing assessment of Resident #283's vital signs. Resident #283's heart, lung and bowel sounds were all normal and there was slight trace edema on the lower extremities (legs). Resident #283 had oxygen via nasal cannula present on admission and was alert and oriented. Resident #283's medications were reviewed. An interview on 5/16/25 at 12:33 PM with the former DON revealed that she recalled Resident #283. The former DON stated that when Nurse #1 made a medications error on 4/28/25, Nurse #1 informed Resident #283, the NP and the DON. She stated that she and Nurse #1 assessed Resident #283 after the medication error and put in place continued monitoring every 15 minutes. The former DON further revealed that Resident #283's vital signs remained stable after the incident. The former DON indicated that she reviewed the 5 rights of medication administration education with all nurses and medication aides (MA). She stated that there were no adverse effects noted for Resident #283. The former DON stated that Nurse #1 should have identified Resident #283 prior to pulling the medications and then again before administering the medications by asking Resident #283 to state his name, since Resident #283 was alert and oriented and a new resident. She stated that the facility offered to take Resident #283 to the hospital, but he declined. An interview on 5/15/25 at 11:20 AM with the NP revealed that Nurse #1, who administered the wrong medications, called her when she was on her way to the facility. The NP stated that she told Nurse #1 to lock her cart, tell the DON, and assess Resident #283. The NP stated that when she arrived at the facility, she assessed Resident #283 and reviewed the medications that were given in error. The NP stated that she offered to send Resident #283 to the hospital, but he refused. She further revealed that she informed Nurse #1 to hold his regular medications for the remainder of the day. The NP stated that the medications Resident #283 received in error were similar to the medications that he was prescribed. She further stated that he suffered no ill effects to his health or well-being because of the medication error. The NP stated that after she was done assessing Resident #283, she went to speak with the DON about the medication error. She revealed that she checked on Resident #283 the following day and he remained stable and continued to refuse transfer to the hospital. An interview on 5/16/25 at 3:36 PM with the Medical Director revealed that he was familiar with Resident #283 and was aware of the medication error. The Medical Director stated that the doses of the medication Resident #283 received in error were low and the medications were similar to what Resident #283 was prescribed. He stated that they had no negative effect on Resident #283 and they did not harm him. An interview on 5/16/25 at 5:21 PM with the Administrator revealed that Nurse #1 gave the wrong medication to Resident #283 and she was very up front about it and notified Resident #283, the NP, and the family. She stated that she was not sure why the medication error occurred. The Administrator stated that there were 2 new admissions that day and maybe Nurse #1 got confused. She stated that Nurse #1 should have asked Resident #283's name before she pulled the medications and then asked him again before she gave the medications to him. The Administrator stated that Resident #283 was monitored for 48 hours after the medication error occurred and he had no adverse effects because of the error. She stated that her expectation was that the 7 rights of medication administration were completed which included verifying the right resident got the right medications before medication was administered. 36217 2. Resident #11 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus with diabetic polyneuropathy. The care area assessment dated [DATE] revealed Resident #11 was diagnosed with diabetic polyneuropathy and bilateral osteoarthritis of knee with chronic pain. She was cognitively intact and had reported experiencing almost constant pain within the 7-day review period. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #11 with intact cognition. She had adequate vision and hearing with clear speech. The MDS indicated Resident #11 received both scheduled and as needed (PRN) pain medications, insulin, antianxiety, antidepressant, and hypoglycemic during the 7-day review period. The care plan for pain initiated on 03/27/25 revealed Resident #11 had pain related to osteoarthritis. The goals were for her to verbalize adequate pain relief through the review date. Interventions included anticipating Resident #11's need for pain relief and responding immediately to any complaint of pain. The physician's orders dated 03/17/25 revealed Resident #11 had obtained orders to receive insulin glargine (a long-acting insulin used to control high blood sugar) 8 units subcutaneously once daily for diabetes and 2 tablets of metformin (an oral antidiabetic medication used to treat diabetes) 500 milligrams (mg) by mouth twice daily for diabetes. On 03/19/25, the physician started Lyrica (a fibromyalgia agent used to treat nerve pain) 100 mg, 1 capsule by mouth 3 times daily for pain. A review of nurse's progress notes dated 05/11/25 at 6:04 AM, 05/12/25 at 8:37 AM, and 05/12/25 at 6:12 PM revealed 3 different nurses working in 3 different shifts documented metformin was unavailable and it was not administered to Resident #11. A further review of nurse's progress notes dated 05/12/25 at 7:33 AM revealed Nurse #7 documented the pharmacy needed prescription of Lyrica for Resident #11. She notified the Nurse Practitioner (NP) regarding the need of a prescription for Lyrica immediately. Then, she checked on Resident #11 who stated she did not have any pain or discomfort at that time. On 05/12/25 at 8:23 PM, Nurse #8 documented insulin glargine was unavailable. He could not find the insulin in the medication cart or refrigerator. A review of Pyxis records and inventory list revealed 251 different medications were kept in the Pyxis for emergency uses. Further review of the Pyxis Inventory Replenishment Report dated 05/11/25 revealed the facility had 8 tablets of Metformin 500 mg and one 3 milliliters (ml) pen of insulin glargine in the Pyxis. The Medication Administration Records (MAR) revealed Resident #11 did not receive 3 doses of metformin scheduled on 05/11/25 at 8 AM, 05/12/25 at 8 AM and 6 PM; 3 doses of Lyrica scheduled on 05/11/25 at 8 PM, 05/12/25 at 6 AM and 2 PM; and 1 dose of insulin glargine scheduled on 05/12/25 at 9 PM. A further review of Resident #11's medical records revealed the refill order for Lyrica was submitted to the pharmacy by Nurse #7 on 05/11/25 at 2:50 AM when there were 2 tablets remaining in the medication cart. The last tablet of Lyrica was administered on 05/11/25 at 2 PM. When Nurse #7 called on 05/12/25 at 7:30 AM to follow up with the Lyrica order, the pharmacy staff stated they needed the prescription as it was a controlled medication. Nurse #7 notified the NP to submit a prescription for Lyrica immediately. When Lyrica arrived at the facility on 05/12/25 at 11 PM, Resident #11 had already missed 3 doses of Lyrica. On the other hand, both metformin 500 mg and insulin glargine were available in Pyxis but not being administered by the nurse. During an interview conducted on 05/12/25 at 3:31 PM, Resident #11 stated she had not received her Lyrica for 3 days and added she started to feel the pain since 05/10/25. She wanted to know why her Lyrica had not been refilled yet and indicated this was not the first time it had happened. A further review of MAR indicated Resident #11 had missed 3 doses of Lyrica at the time of interview on 05/12/25 at 3:31 PM, but not 3 days. She received Lyrica 3 times per day until she missed the first dose on 05/11/25 at 8 PM, then 2 more doses on 05/12/25 at 6 AM and 2 PM. Further review of MAR revealed Resident #11 had a scheduled order of hydrocodone/acetaminophen (a semi-synthetic opioid used to treat pain) 5/325 mg that was discontinued on 05/06/25, and a new order of tramadol (an analgesic/opioid used to relieve pain) was initiated on 05/12/25. During a phone interview conducted on 05/15/25 at 1:23 PM, Nurse #7 stated she was the nurse who submitted the refill order of Lyrica for Resident #11 on 05/11/25 morning when 2 tablets remained in the medication cart. She recalled she could not put in a STAT order as she did not even have a prescription when submitting the refill order through the computer system. When she returned to work on 05/12/25 in the morning and found that Lyrica had still not arrived at the facility, she called the pharmacy to follow up and was told that the pharmacy needed a prescription. She could not recall whether she had told the pharmacy staff to code this Lyrica order as a STAT order during the phone call. She notified the NP that the pharmacy needed a prescription for Resident #11's Lyrica and went to check Resident #11. She recalled Resident #11 did not appear to be in pain or distress. She explained to Resident #11 that the pharmacy needed a prescription, and she had notified the NP about it. She asked Resident #11 if she was suffering any nerve pain Resident #11 replied that she was okay. During a subsequent observation and interview conducted on 05/12/25 at 4:12 PM, Resident #11 appeared to be calm, pleasant, and free of signs and symptoms of pain or distress. She stated her nerve pain was okay and manageable, but she was upset about not getting her Lyrica as ordered. An interview was conducted with Nurse #8 on 05/13/25 at 4:44 PM. He stated Resident #11's Lyrica was delivered from the pharmacy on 05/12/25, arrived at the facility around 11:00 PM, and was administered right after receiving it. He stated he could not find metformin and insulin glargine in the medication cart or refrigerator on 05/12/25 in the evening and added he did not check for both medications in Pyxis. Nurse #8 acknowledged that he did not check with the pharmacy on 05/12/25 in the evening to ensure both medications had been re-ordered. During an interview conducted on 05/13/25 at 4:53 PM, the Interim Director of Nursing stated the facility had Pyxis that provided emergency medications including several narcotics and controlled substances as needed. Not only did the facility have metformin and insulin glargine in the Pyxis, but the facility also had a back-up pharmacy approximately 0.25 miles from the facility. She did not receive any notification regarding availability of metformin and insulin glargine on 05/12/25. Otherwise, she could have gotten both medications from Pyxis. She stated Pyxis had 8 tablets of metformin 500 mg and one insulin glargine pen on regular basis and this resources should be fully utilized. She stated the pharmacy would not dispense any controlled medication such as Lyrica without a prescription issued by the physician. It was her expectation for nurses to start refilling procedures at least 5 days before the last pill was used to avoid a gap, especially controlled medication that required a prescription. A phone interview was conducted with the Pharmacy Manager on 05/15/25 at 12:20 PM. He stated the pharmacy computer system received the refill order of Lyrica for Resident #11 on 05/11/25 at 2:50 AM. As the order was not coded as a STAT (signified the order needed to be done immediately, with the highest priority) order and the pharmacy did not receive a refill prescription from the physician, the pharmacy could not process and fill the medication until the next day after the prescription for Lyrica was received on 05/12/25 at 9:07 AM. Lyrica was filled and then placed in the pharmacy totes at 3:17 PM and delivered to the facility as a regular order. He stated the delivery typically arrived at the facility before mid-night. The Pharmacy Manager stated if the facility staff specified it was a STAT order, they would try to deliver it to the facility within the specified time frame. Otherwise, the pharmacy had designated a back-up pharmacy locally near the facility. He confirmed the facility had Pyxis for medication needed after hours or emergency, and it consisted of insulin glargine and metformin 500 mg, but not Lyrica 100 mg. He indicated tramadol could alleviate nerve pain, but not to a great extent. He stated if the refilled order for Lyrica was submitted with a prescription and specified as a STAT order, the pharmacy could have filled and delivered the ordered Lyrica to the facility on [DATE] before midnight. He stated nurses should retrieve both metformin 500 mg and insulin glargine in Pyxis instead of charting it as missed doses. A phone interview was conducted on 05/16/25 at 9:57 AM with the MD. He stated Resident #11 had a personality disorder and drug seeking behavior. Almost each time he visited her, she would ask for more pain medications, including Lyrica. He stated Resident #11 had been taking Lyrica since 03/19/25 and it typically took approximately 35 hours to be fully eliminated from the body. As Resident #11 was out of Lyrica for approximately 24 hours, clinically, she should still have certain level of Lyrica in her system to prevent her from triggering nerve pain. In addition, Resident #11 received Depakote 500 mg daily for bipolar disorder which had also been used as off-label to treat neuropathic pain. Resident #11 used to have an order of Norco 5/325 mg for 14 days and it was just discontinued on 05/06/25, about a week before Lyrica was run out. Besides, Resident #11 was taking other medications such as trazodone, clonazepam, and methocarbamol which could alleviate her pain level. He stated there were many factors that could affect her pain level and Resident #11 could have confused about muscular pain versus nerve pain. He would not rule out the possibility of Resident #11 experiencing nerve pain 24 hours without Lyrica, but the chances were very low. It was his expectation for the nursing staff to start the refilling process at least a few days before the supply ran out, especially for those controlled substances that required a prescription. He also expected nursing staff to pay attention to the content of Pyxis and fully utilize it as needed as indicated. During a phone interview conducted on 05/16/25 at 10:46 AM, the Administrator expected nursing staff to submit refill order at least 3-5 days before the medication ran out and ensure refill order for controlled medication was submitted with the prescription. It was her expectation for all nursing staff to be proficient in the content of Pyxis and fully utilized it as needed as indicated.

Based on resident interview, staff interviews and record review the facility failed to provide adequate supervision to prevent a fall, which resulted in a fracture, for 1 of 1 sampled resident reviewed for accidents (Resident #14). The findings included: Resident #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14's quarterly "Fall Risk Review" assessment completed on 08/27/13 assessed the resident as being at high risk for falls. Further record review revealed Resident #14 did not have any quarterly "Fall Risk Review" assessments completed from 08/28/13 to 01/19/14. Resident #14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact with no memory problems and required extensive assistance with dressing. The MDS assessed the resident as requiring extensive assistance for transfers with staff providing weight bearing support with one person physical assistance. The MDS also assessed the resident as having unsteady balance during transitions and walking and only able to stabilize with staff assistance. Review of Resident #14's care plan, which was reviewed by facility staff on 11/12/13, contained a "Problem/Need" which identified the resident as being at risk for falls related to mobility impairment and medication regime. The goal specified for the resident not to experience any injuries related to falls through the next assessment period. Review of Resident #14's Nursing notes revealed she experienced the following falls on 12/21/13 and 01/01/14 while being assisted by a nursing assistant in a shower room: Nursing note of 12/22/13 at 4:13 PM: "on 12/21/13 @ 4:30 PM, Res. (resident) was in shower room with CNA, attempted to stand at rail, res. states her knee gave out and she slid to floor, MAEW (moves all extremities well) for res. denies pain or discomfort, assisted res. back into w/c, no acute distress noted, will con't to moniter (sic)." Nursing note of 01/02/14 at 1:18 AM: "Res. fell (lowered to ground) while in shower room @ 4PM. CNA states residents legs gave out while standing at the shower bar and had to lower res. to the floor. Res. c/o (complained of) L) knee pain, no other inj. noted. (Name of Physician's Assistant), PA here and evaluated res. and ordered a L) knee x-ray... Will cont. to monitor. VSS (vital signs stable), afebrile." Review of Resident #14's 01/02/14 hospital discharge information revealed she experienced a fractured left knee joint. Review of Resident #14's Quarterly MDS assessment dated [DATE] revealed she was cognitively intact with no memory problems. The MDS assessed the resident as requiring extensive assistance with two person physical assist with transfers. On 06/18/14 at 2:40 PM an interview was conducted with Resident #14. During the interview Resident #14 voiced a concern regarding her fall on 01/01/14 when Nursing Assistant (NA) #4 was attempting to dress her in a facility shower room. Resident #14 stated prior to this fall she was attempting to hold on to a support bar in the shower room as the NA was placing a brief on her. The resident stated she told the NA to stop placing the brief on her until she could get a better hold of the support bar in the shower room, but the NA then told her to wait a minute and continued applying the brief without supporting her. The resident stated that she tried to hold onto the bar, but her knees gave out and she fell to the floor. The resident explained that she hit her knee against a wall in shower room and it hurt "really bad". The X-ray at the hospital revealed she had a fractured knee. The resident stated that she believed her fall on 01/01/14 could have been avoided if the NA would have supported her as she was losing her grip on the shower room bar instead of continuing to place a brief on her at the time of the fall. The resident also explained that a week prior to her 01/01/14 fall she experienced another fall in the shower room, which did not result in injury, when only one NA was assisting her with care. On 06/18/14 at 4:00 PM an interview was conducted with the facility's Assistant Director of Nurses (ADON). The ADON stated that Resident #14 was identified as a high risk for falls on her quarterly 08/27/13 "Fall Risk Review". The ADON explained the "Fall Risk Review" assessment is a tool which assesses numerous possible risk factors and evaluates a resident's overall risk for falls. The ADON stated this assessment should be conducted every three months, but staff failed to conduct a quarterly "Falls Risk Review" for Resident #14 from 08/28/13 to 01/19/14. The ADON further explained that Resident #14 had many risk factors which made her a high risk for falls. The ADON stated that Resident #14 required a minimum of extensive assistance with one person physical assistance with transferring and dressing when she fell in the shower room on 01/01/14 while being assisted by NA #4. On 06/19/14 at 2:20 PM MDS Coordinator #1 was interviewed. MDS Coordinator #1 stated that prior to Resident #14's injurious fall on 01/01/14 it was verbally communicated to nursing staff that the resident may need additional assistance and support during the provision of care to prevent further falls because the resident had experienced two prior falls during the month of December 2013. MDS Coordinator #1 confirmed the facility failed to meet Resident #14's care plan goal to not experience any injuries related to falls when she fell in the shower room, while being assisted by NA #4, which resulted in a knee fracture on 01/01/14. MDS Coordinator #1 stated that NA #4 was no longer employed at the facility and was unavailable for interview. On 06/19/14 at 3:00 PM the facility's ADON was interviewed regarding the facility's investigation of Resident #14's fall on 01/01/14. The ADON stated during the facility's investigation NA #4 said the resident's legs gave out and she was lowered to the shower room's floor during the fall on 01/01/14. The ADON further explained that Resident #14, who is interviewable, was not interviewed as part of the facility's investigation to obtain her version of how the fall occurred and how it could have possibly been prevented. The ADON stated NA #4 should have provided the necessary assistance and support when requested by the resident to prevent the fall on 01/01/14.

Based on observations, record review, staff interviews and family interview the facility failed to develop a comprehensive care plan for one (1) of two (2) cognitively impaired sampled residents, who was assessed as being at risk for elopement. Resident #7 eloped from the facility on 01/21/11 while unsupervised and was found approximately 0.2 miles away from the facility by staff. (Resident #7) Immediate Jeopardy began on 01/21/11 when Resident #7 eloped from the facility without staff's knowledge that he was outside without supervision. Immediate jeopardy was removed on 01/28/11 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 (an isolated deficiency, no actual arm with 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 findings are: Resident #7 was admitted to the facility from a hospital setting on 12/16/10 with a [DIAGNOSES REDACTED]. Review of Resident #7's hospital notes, from the facility that he was discharged from on 12/16/10, revealed the following: 12/14/10 2:00 p.m.: "Pt (patient) attempted to go off floor multiple times states "I have got to go home", combative at times; constant redirection and distraction performed. Dr. (physician's Name) notified; nurses are advised to distract pt. Will continue to monitor closely." 12/14/10 2:30 p.m.: "Dr. (physician's name) on the floor, will order 1:1 observation." 12/14/10 3:30 p.m.: "Maintain close observation and constant redirection with minimal result." 12/14/2010 11:50 p.m.: "Patient is alert but seems confused from the start of this tour. Insisted of (sic) going home and to speak with MD (Physician). PRN (As needed) medication for agitation was given, calmed down around 1800 (6:00 p.m.) and advised (sic) to go back to bed. PEG (percutaneous endoscopic gastrostomy) tube remains intact and patent and received feeding 2x from this tour. Remains on 1:1. will continue to monitor." 12/15/10 1:38 p.m.: "Patient needed 1:1 yesterday since he was constantly trying to get out of ward." Review of Resident #7's Admission "Interdisciplinary Assessment" of 12/16/10 revealed he was identified as being at risk for elopement. This assessment specified that staff should initiated a care plan for potential elopement because Resident #7 was assessed as being a new admission, was ambulatory, had a history of [REDACTED]. Review of Resident #7's "Interim/Admission Care Plan", developed on 12/16/10 contained the following information for the area of elopement: "#18. FALLS/SAFETY RISK /ELOPEMENT RISK Goal: Resident will remain free of injuries and falls. 12/16/10 Keep call bell in reach. 12/16/10 Encourage use of call light. 12/16/10 Assess for contributors, (BP stand/sit, pain, etc) 12/16/10 Therapy referral as needed. 12/16/10 Instruct on safety measures. 12/16/10 Assess footware for proper fit and non-skid soles. 12/16/10 Mobility alarm/Wander alarm. 12/16/10 Neuro checks if strikes head." A nursing note written by Nurse #1 on 12/22/10 for the 3:00 p.m. to 11:00 p.m. shift specified that Resident #7 tried to get out of exit door under canopy two times. Review of the facility's Nursing twenty four (24) hour report for 12/22/10 specified that Resident #7 was "exit seeking". On 01/27/11 at 3:00 p.m. an interview was conducted with Nurse #1 who documented that Resident #7 tried twice on 12/22/10 to get out an exit door. Nurse #1 stated that Resident #7 would go to the facility's canopy door, which is locked, to look out and say he was ready to go. Nurse #1 further explained that the resident would also come to nurse's desk and a lot of times say that he was ready to go home. Nurse #1 stated that she would redirect Resident #7 back to his room which she felt was effective to keep him from eloping. Further interview with Nurse #1 on 01/27/11 at 4:15 p.m. revealed that she documented the Resident #7's behavior on 12/22/10 as "exit seeking" because she observed him going to the facility's canopy door twice on this date. Review of Resident #7's Minimum Data Set (MDS) of 12/29/10 assessed him as being independent with walking in room and in corridor, having moderately impaired cognitive skills for daily decision making, exhibiting wandering behaviors which occurred every one (1) to three (3) days and was at risk of getting (wandering) to dangerous place. Resident #7's Behavioral Symptoms assessment dated [DATE] specified: "Resident does have dx (diagnosis) of severe dementia. Resident attempted to exit the facility door x (times) 1 (NN 12/22/10). Resident was easily redirected. Resident's daughter brought in a television for his room, which has kept him more satisfied in his room." The assessment noted that staff would proceed to care plan to address the resident's wandering behaviors. Review of Resident #7's current plan of care, which was reviewed by staff on 12/29/10, revealed that on 12/23/10 staff developed a "Problem/Need" which addressed his [DIAGNOSES REDACTED]. lost." Further review of the resident's plan of care revealed that staff did not develop a plan to address the resident's risk of elopement until after he successfully eloped from the facility on 01/21/11. A nurse's note written by Nurse #2 on 12/30/10 at 11:00 p.m. specified that Resident #7 was "exit seeking" two times. Review of the 12/30/10 twenty four (24) hour nursing report revealed no exit seeking behaviors were documented for Resident #7. On 01/27/11 at 3:07 p.m. an interview was conducted with Nurse #2 who documented that Resident #7 was "exit seeking" on 12/30/10. Nurse #2 stated that Resident #7 would always talk of wanting to leave the facility and would stand by doors and windows looking outside. Nurse #2 explained that she documented Resident #7's actions on 12/30/10 as "exit seeking" because she observed him standing at an exit door on two (2) occasions, but did not recall him touching the door or the door's handle. Nurse #2 stated that she redirected Resident #7 when he was going toward an exit door. A nurse's note written on 01/19/11 at 10 p.m. by Nurse #2 specified: "After daughter left res. (resident) was exit seeking. Wanting to go home & see his wife. Wanted to go out and check on his car. We called his daughter and he talked to her. But that still did not calm res (resident) down. [MEDICATION NAME] given that did seem to help some. Is in bed now awake (with) peg tube feeding being administered." Review of the Nursing twenty-four (24) hour report for 01/19/11 specified that Resident #7 was "exit seeking". On 01/27/11 at 3:07 p.m. an interview was conducted with Nurse #2 who documented that Resident #7 was "exit seeking" on 01/19/11. Nurse #2 stated that she documented Resident #7's actions on 01/19/11 as "exit seeking" because she observed him coming out of his room wearing his hat and coat and walking toward an exit door. Nurse #2 stated she redirected him when she observed him going toward the door and felt that redirection was effective in keeping him from going outside the facility. Nurse #2 stated that she did not actually see Resident #7 touching an exit door on 01/19/11. Nurse #2 did not recall that Resident #7 had a plan of care in place which addressed his exit seeking behaviors. A nurse's notes written by Nurse #3 on 01/21/11 at 2:30 p.m. specified that Resident #7 was up and about on hallway and stated; "I'm going home." Staff spoke with him and he went to lie down on his bed. Another nurse's note written by Nurse #3 on 01/21/11 at 3:00 p.m. specified that; This nurse came out of another resident's room and staff was saying that Resident #7 had been found outside of the facility. An interview was conducted with Nurse #3 on 01/27/11 at 8:05 a.m. Nurse #3 stated that on 01/21/11 at approximately 2:30 p.m. Resident #7 told her that he was going home. She redirected him back to his room and a little later observed him lying on his bed watching television. Nurse #3 stated that approximately twenty (20) minutes later she was informed by staff that Resident #7 was found outside of the facility and had been safely returned to the building. Nurse #3 stated that Resident #7's behaviors exhibited on 01/21/11 included making comments about going home were normal for him. Nurse #3 stated that she believed that everyone was aware to keep an eye on Resident #7 because of his risk for elopement. Nurse #3 explained that she would redirect him when he exhibited this behavior. Nurse #3 stated that she could not recall if elopement risk was on Resident #7's care plan, but stated it should have been Activity of Daily Living (ADL) care sheet. Observations of Resident #7 on 01/25/11 at 3:30 p.m. revealed he was going from door to door trying to open them while on the facility's secured unit (the 400 hallway). He then asked how to get out of the building. Interview with Resident #7's Responsible Party on 1/27/11 at 10:55 A.M. revealed that Resident #7 had a history of [REDACTED]. The family member stated that when the staff discovered that Resident #7 had eloped from the facility on 01/21/11 they notified her immediately. The facility's incident report of Resident #7's elopement from the facility on 01/21/11 was reviewed. The investigation specified that on 01/21/11 at 2:30 p.m. nursing staff observed Resident #7 lying in bed being content. The investigation revealed that on 01/21/11 Resident #7 wandered from the facility's "canopy door" and was observed outside of the facility by an employee. After staff returned Resident #7 to the facility the resident informed staff that "I waited for someone to open door & I went out of it ". The investigation specified that the actions taken by the facility on 01/21/11 included; moving Resident #7 to the facility's secured unit (400 hallway) for safety measures. The outside temperatures on 01/21/11 in Fletcher, NC (the facility's location) per the Weather Channel Internet service, was a low temperature of 22 degrees Fahrenheit and a high temperature of 33 degrees Fahrenheit. Nursing Assistant (NA) #4 who observed Resident #7 outside of the facility on 01/21/11, was interviewed on 01/27/11 at 5:15 p.m. NA #4 stated that on 01/21/11 at around 3:00 p.m. she was driving to work when she thought she saw Resident #7 walking down the road in front of the facility. NA #4 stated that she continued to drive into work, quickly entered the facility to see if Resident #7 was in his room and found that he was not there. NA #4 stated she then alerted NA #5 and a nurse about possibly seeing Resident #7 walking down the road in front of the facility as she drove into work. NA #4 stated that she and two other staff members immediately left the facility to search for Resident #7 and found him walking beside the roadway. NA #4 stated that when Resident #7 was found he appeared uninjured and was cooperative with staff. Resident #7 stated to the staff who found him that he was going to Fletcher and that "Locked doors are meant to get out of." The facility's Social Worker (SW) was interviewed on 01/26/11 at 5:05 p.m. and 6:10 p.m. The SW stated that it was her responsibility for developing the care plans for residents with behavior issues including risk of elopement and wandering. The SW confirmed that Resident #7 was assessed as being an elopement risk when he was admitted to the facility on [DATE] and his initial care plan of 12/16/10 identified elopement as an area of concern. The SW further stated that a care plan, with specific planned interventions that addressed Resident #7's risk for elopement should have been developed on 12/23/10 or 12/29/10. The SW further stated that Resident #7's 12/29/10 Behavioral Symptoms Care Area Assessment (CAA) Summary was triggered for further staff review, but the issue of elopement risk was not care planned by staff. The SW confirmed that an elopement care plan for Resident #7 was not developed until after he eloped from the facility on 01/21/11. The SW explained that if an elopement care plan would have been developed for Resident #7 the care plan's goal would have specified for Resident #7 to not exit the facility while unsupervised. The SW also stated that the planned approaches contained within Resident #7's elopement care plan would have included the following: redirect behaviors, sit with one to one, call daughter/family, walk with resident and take outside to courtyard, monitor increase behavior and decreased cognitive functions, monitor whereabouts, notify social worker of change in behaviors. Nursing Assistant (NA) #1, who worked with Resident #7, was interviewed on 01/27/11 at 8:00 a.m. NA #1 stated that Resident #7 would act like he was going to therapy, but he was looking for a way to get out of the facility. Resident #7 would also tell her that he was waiting for his ride. NA #1 stated that she would attempt to redirect Resident #7 by taking him to watch the television. Nursing Assistant (NA) #2, who regularly worked with Resident #7, was interviewed on 01/27/11 at 8:27 a.m. NA #2 stated that Resident #7 would often tell her, "I have to go home." NA #2 stated that when Resident #7 would make statements about leaving or going home she would tell him that she needed to check with the physician. NA #2 explained that she knew to closely watch Resident #7 and believed that other staff also knew to watch him very closely. NA #2 stated that if Resident #7 was not getting enough staff attention he would wander from his room into the hallways and would stand at exit doors looking outside with his arms crossed. NA #2 stated that she remembered two (2) to three (3) days before Resident #7 eloped from the facility (which occurred on 01/21/11) when he rang his call bell three (3) times within a fifteen (15) minute time period and said that he wanted to go home. NA #2 stated that she informed a nurse about these statements, but was unsure if any actions were taken. NA #2 stated that when possible she would try to check on Resident #7 every thirty (30) minutes, redirect him to his room when needed and converse with him to keep his mind off leaving the facility. NA #2 stated to her knowledge there was no information on Resident #7's ADL book/flow sheet or on his care plan which addressed him as being at risk of elopement prior to his 01/21/11 elopement from the facility. Nursing Assistant (NA) #3, who worked with Resident #7, on 01/21/11 during the 7:00 a.m. to 3:00 p.m. shift, was interviewed on 01/27/11 at 8:55 a.m. NA #3 stated that on 01/21/11 Resident #7 asked all day if anyone was coming for him and she told him no. NA #3 further stated that on 01/21/11 at approximately 2:10 p.m. she last observed Resident #7 when she conducted her last resident checks. NA #3 stated that on 01/21/11 before 3:00 p.m. she was informed that Resident #7 had been found outside and was being brought back the facility. NA #3 stated that she did not recall Resident #7's care plan or his care card specifying that he was an elopement risk or being made aware of any planned interventions to be implemented to prevent him from eloping from the facility. NA #3 stated that she did recall NA #2 telling her to watch Resident #7 closely because he would leave his room and would try to get out of here. Nursing Assistant (NA) #5, who was one of the staff members that found Resident #7 walking outside of the facility by a roadway on 01/21/11, was interviewed on 01/27/11 at 9:15 a.m. NA #5 stated that on 01/21/11 NA #4 came to his office and informed him that she thought she had seen Resident #7 walking down the road in front of the facility. NA #5 stated that NA #4 and a nurse went to attempt to locate Resident #7 at around 3:00 p.m. and found him walking along the side the road which runs in front of the facility. NA #5 stated that when Resident #7 was found he was wearing his coat and hat. The resident said that he was not cold, was going to the house and had exited the facility by waiting for the door to open. On 01/27/11 at 9:30 a.m. NA #5 showed surveyors the location where staff found Resident #7 walking outside of the facility on 01/21/11. The location was approximately 0.2 miles away from the facility along a three lane roadway with a posted speed limit of thirty five (35) miles per hour. NA #5 stated that the distance from the facility's canopy exit, where staff believed Resident #7 exited the facility on 01/21/11, to where he was found by staff was a total of 410 steps. Observations of the facility's canopy exit with NA #5 revealed its exit door was secured by magnetic locks and required a security code to enter and exit. The canopy exit door was also observed to have a walkway that led from the door to the facility's parking lot. Interview on 01/27/11 at 1:50 p.m. with the Director of Nurses (DON) confirmed that Resident #7 eloped from the facility while unsupervised on 01/21/11 and was returned to the facility by staff uninjured. The DON explained that with the exception of the facility's front door which should be monitored by a staff member, residents were unable to get out of the facility without entering access/exit codes, but explained that a visitor probably let Resident #7 out one of the facility's secured doors. The DON stated that when Resident #7 was admitted to the facility the staff at the resident's prior facility reported to her that he had made attempts to exit the unit where he resided. The DON stated the facility did not utilize a Wanderguard system to prevent residents from eloping, but had exit doors equipped with automatic magnetic locks and had signs posted on each exit door instructing staff and visitors to not let residents out of the building. The DON stated that Resident #7's 12/16/10 initial care plan did mention elopement, but his care plan developed on 12/29/10 did not address his risk of elopement. The DON stated that a care plan which addressed Resident #7's elopement behaviors was not developed until after his 01/21/11 elopement. The DON also confirmed that Resident #7's care card, which was utilized to inform staff of his behaviors and care needs, did not address wandering or exit seeking behaviors until it was updated on 01/27/11. The DON further explained that staff were expected to monitor Resident #7's whereabouts and redirect him as needed. The DON stated that she did not observe Resident #7 and was not made aware of any exit seeking behaviors until 01/20/11. The DON specified that on 01/20/11 she observed Resident #7 bringing his clothes to the front of the facility and he told her that he was going to take his clothes out to his car. The DON explained that on 01/21/11 staff discussed moving Resident #7 to the facility's "secured 400 hallway" in response to her 01/20/11 observation and the resident's increased behaviors, but he eloped from the facility on 01/21/11 before this room change could be made. The DON explained that following Resident #7's elopement from the facility on 01/21/11 he was moved to the facility's secured unit (400 hallway) and the facility began assessing all residents for elopement risk. Nurse #4, who cared for Resident #7, was interviewed on 01/27/11 at 2:50 p.m. and at 3:30 p.m. Nurse #4 stated that a couple of times she observed Resident #7 turning door handles of exit doors. Nurse #4 stated that these observations of Resident #7 were not recent observations, but occurred sometime after he was taken off isolation (in January 2011). Nurse #4 stated that because Resident #7 had a [MEDICAL CONDITION] she was more concerned about him drinking out of the water fountain than exiting the facility. Nurse #4 further explained that she did not document or report her observations of Resident #7 turning exit door handles. Interview with the facility's Administrator on 01/27/11 at 1:45 p.m. confirmed that on 01/21/11 Resident #7 eloped from the facility and was found by staff walking along side the roadway located in front of the facility. The Administrator stated the facility's investigation of this elopement concluded that Resident #7 probably exited the facility's "canopy door" when a visitor was either coming into or exiting from the facility. The Administrator stated that the facility had a policy entitled "Elopement Risk Review", to prevent resident elopements. However, the Administrator explained that this policy needed to be amended because it contained many planned measures which involved the use of a Wanderguard system and the facility was not equipped with a Wanderguard system. The Administrator stated that the facility's policy addressing a resident risk for elopement was currently being revised in order to address specific measures that were to be taken by staff to prevent a resident from eloping from the facility. Further interview with the facility's Administrator on 01/27/11 at 3:50 p.m. confirmed that the facility's elopement risk policy did specify that CNA (Certified Nursing Assistant) assignment sheets were to be updated to identify a resident who was assessed as an elopement risk, but Resident #7's information did not identify him as an elopement risk until after his elopement on 01/21/11. The Administrator explained that if a nurse observed a resident exhibiting exit seeking behaviors they were expected to document the behavior and to note it on the twenty-four hour nursing report, staff should then assess the resident's actual risk for elopement and when needed update the resident's care plan to address this behavior. On 01/27/11 at 12:50 p.m. a Nurse Practitioner (NP), who was familiar with Resident #7, was interviewed. The NP stated that on 01/20/11 she ordered [MEDICATION NAME] for Resident #7 in order to relieve his restlessness and anxiety. The NP stated that she had discussed the resident's exit seeking behaviors with one of Resident #7's family members and the family wanted the resident placed on [MEDICATION NAME]. The NP further explained that she thought the facility was utilizing a Wanderguard system to prevent residents from exiting the facility while unsupervised, but after Resident #7's elopement on 01/21/11 she was informed that that the facility did not have a Wanderguard system in place. The Administrator was notified of the immediate Jeopardy on 1/27/11 at 5:00 p.m. The facility provided a credible allegation of compliance on 1/28/11 at 3:45 p.m. The following interventions were put into place by the facility to remove the Immediate Jeopardy: During the afternoon of 1-21-11, Resident #7 left the facility and was brought back to the facility by the staffing coordinator and a certified nursing assistant. On 01/21/11 Resident #7 was assessed by the ADON and found to be uninjured. After the elopement of 01/21/11 Resident #7 was moved to the 400 hall, which is accessed by an additional magnetically locking door. This room change for Resident #7 occurred on 1/21/11 at 4:45pm. Prior to being moved to the facility's 400 hallway nursing staff performed 15 minute location checks on Resident #7 to ensure his safety until he was moved. The care plan for Resident #7 was updated by the social worker on 1-21-11 and his care card was updated by the ADON on 1-27-11 to include information regarding his potential risk for elopement. Additional Corrective actions taken by the facility included: ? 1-21-11 The admissions director made sure that there were signs on the exit doors asking visitors not to assist resident with exiting the facility. ? 1-21-11 The Facility's magnetically locking doors were checked for proper function by the ADON with no malfunctioning doors identified. ? 1-21-11 A QA meeting was held at 4:45pm to review Resident #7's elopement and an action plan was developed. Administrator and ADON oversaw this process. ? Beginning on 01/21/11 Elopement Risk Assessments were completed on every resident in the facility. These Elopement Risk Assessments were completed by the Director of Nursing, the Assistant Director of Nursing, and RN Supervisor between 1-21-11 and 1-27-11. Based on these assessments an additional resident (#18) was identified as being at risk for elopement. The care plan for Resident # 18 was updated on 1-21-11 by social worker to address his potential for elopement. The care card for Resident #18 was updated to address potential for elopement on 1-21-11 by the ADON. ? 01/21/11 and 01/22/11 inservices were presented to staff regarding elopement and what to do in the event of an elopement by the ADON. ? 01/27/11 The DON, ADON, MDS coordinator, and IDT team audited all residents charts to ensure that residents were correctly identified for wandering and exit seeking behaviors. ? 01/27/11 Photos of those residents identified as exhibiting exit seeking and wandering behaviors were placed on the MAR by the admissions director. ? 1/27/11 The care plans and care cards of residents, who were identified as having with wandering and exit seeking behaviors, were audited by the MDS Coordinator, Dietary Manager, Act. Dir, and SW, DON and ADON to ensure that they correctly addressed these behaviors. ? 1-28-11 additional signage discouraging visitors to allow residents to exit the facility without first speaking with a staff member posted on all exit doors. ? 1-28-11 inservices on How to Identify Wanderers and those at Risk for Elopement presented to all staff by DON/ADON/Dietary Manager/ Rehab Director/Housekeeping Director. Staff members will not be permitted to return to work until they have received the inservice. ? 1-28-11 the security codes of entrance doors were changed in the facility by the maintenance director such that only staff know the codes and visitors must ring for assistance to be let into the facility during non-business hours. All staff inserviced as to the importance of not sharing the codes by their Dept. Managers. ? 1-28-11 Responsible Parties of the residents will be contacted by phone by the medical records clerk and central supply clerk to inform them of this change and will also be informed in writing, ? 1-28-11 The facility (Administrator, DON, Interdisciplinary Team (IDT) has reviewed the policy regarding Residents at Risk for Elopement and have developed and implemented a new policy for residents at risk for elopement. The new policy has been taken through the QA process on 1-28-11. ? 1-28-11, the visitor access to the facility will be the Front Entrance during normal business hours (8:30 a.m. To 5:00 p.m, Monday through Friday) which is monitored by the receptionist or another designated staff member. During non-business hours the visitor entrance will be the Facility's Canopy Entrance in which they will be required to gain assistance from a staff member to enter or exit the facility. ? 1-28-11 the maintenance installed an observational mirror in the front lobby area such that the front entrance can be observed by staff when the receptionist steps away from the main desk. Immediate Jeopardy was removed on 01/28/11 at 5:30 p.m. Observations of Resident #7 confirmed that he was on the facility's secured unit on the 400 hallway. Review of the Medication Administration Reviews (MARs) for residents assessed as having exit seeking behaviors contained updated photos of these residents. A review of resident elopement risk assessments were verified as being complete. All facility exit doors were checked and found to be either secured by magnetic locks or under direct staff supervision and to have signs posted instructing visitors to not allow residents out of the facility. Observations of the facility front lobby revealed that an observational mirror was installed. Interviews conducted with staff in all departments and who worked on all three shifts confirmed that they had received inservice training on "How to Identify Wanderers and those at Risk for Elopement" and that the security codes for all facility exit doors were changed.

Based on observations, record review, staff interviews and family interview the facility failed to prevent one (1) of two (2) sampled cognitively impaired residents, who were assessed as being at risk for elopement, from exiting the facility. Resident #7 eloped from the facility on 01/21/11 while unsupervised and was found by staff walking next to a roadway approximately 0.2 miles away from the facility. (Resident #7) Immediate Jeopardy began on 01/21/11 when Resident #7 eloped from the facility without staff's knowledge that he was outside without supervision. Immediate jeopardy was removed on 01/28/11 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 (an isolated deficiency, no actual arm with 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 findings are: Resident #7 was admitted to the facility from a hospital setting on 12/16/10 with a [DIAGNOSES REDACTED]. Review of Resident #7's hospital notes, from the facility that he was discharged from on 12/16/10, revealed the following: 12/14/10 2:00 p.m.: "Pt (patient) attempted to go off floor multiple times states "I have got to go home", combative at times; constant redirection and distraction performed. Dr. (physician's Name) notified; nurses are advised to distract pt. Will continue to monitor closely." 12/14/10 2:30 p.m.: "Dr. (physician's name) on the floor, will order 1:1 observation." 12/14/10 3:30 p.m.: "Maintain close observation and constant redirection with minimal result." 12/14/2010 11:50 p.m.: "Patient is alert but seems confused from the start of this tour. Insisted of (sic) going home and to speak with MD (Physician). PRN (As needed) medication for agitation was given, calmed down around 1800 (6:00 p.m.) and advised (sic) to go back to bed. PEG (percutaneous endoscopic gastrostomy) tube remains intact and patent and received feeding 2x from this tour. Remains on 1:1. will continue to monitor." 12/15/10 1:38 p.m.: "Patient needed 1:1 yesterday since he was constantly trying to get out of ward." Review of Resident #7's Admission "Interdisciplinary Assessment" of 12/16/10 revealed he was identified as being at risk for elopement. This assessment specified that staff should initiated a care plan for potential elopement because Resident #7 was assessed as being a new admission, was ambulatory, had a history of [REDACTED]. Review of Resident #7's "Interim/Admission Care Plan", developed on 12/16/10 specified that he was an elopement risk. A nursing note written by Nurse #1 on 12/22/10 for the 3:00 p.m. to 11:00 p.m. shift specified that Resident #7 tried to get out of exit door under canopy two times. Review of the facility's Nursing twenty four (24) hour report for 12/22/10 specified that Resident #7 was "exit seeking". On 01/27/11 at 3:00 p.m. an interview was conducted with Nurse #1 who documented on 12/22/10 that Resident #7 tried twice to get out an exit door. Nurse #1 stated that Resident #7 would go to the facility's canopy door, which is locked, to look out and say he was ready to go. Nurse #1 further explained that the resident would also come to nurse's desk and a lot of times say that he was ready to go home. Nurse #1 stated that she would redirect Resident #7 back to his room which she felt was effective to keep him from eloping. Further interview with Nurse #1 on 01/27/11 at 4:15 p.m. revealed that she documented the Resident #7's behavior on 12/22/10 as "exit seeking" because she observed him going to the facility's canopy door twice on this date. Review of Resident #7's Minimum Data Set (MDS) of 12/29/10 assessed him as being independent with walking in room and in corridor, having moderately impaired cognitive skills for daily decision making, exhibiting wandering behaviors which occurred every one (1) to three (3) days and was at risk of getting (wandering) to dangerous place. Resident #7's Behavioral Symptoms assessment dated [DATE] specified: "Resident does have dx (diagnosis) of severe dementia. Resident attempted to exit the facility door x (times) 1 (NN 12/22/10). Resident was easily redirected. Resident's daughter brought in a television for his room, which has kept him more satisfied in his room." Review of Resident #7's current plan of care, which was reviewed by staff on 12/29/10, revealed that on 12/23/10 staff developed a "Problem/Need" which addressed his [DIAGNOSES REDACTED]. lost." Further review of the resident's plan of care revealed that staff did not develop a plan to address the resident's risk of elopement until after he successfully eloped from the facility on 01/21/11. A nurse's note written by Nurse #2 on 12/30/10 at 11:00 p.m. specified that Resident #7 was "exit seeking" two times. Review of the 12/30/10 twenty four (24) hour nursing report revealed no exit seeking behaviors were documented for Resident #7. On 01/27/11 at 3:07 p.m. an interview was conducted with Nurse #2 who documented that Resident #7 was "exit seeking" on 12/30/10. Nurse #2 stated that Resident #7 would always talk of wanting to leave the facility and would stand by doors and windows looking outside. Nurse #2 explained that she documented Resident #7's actions on 12/30/10 as "exit seeking" because she observed him standing at an exit door on two (2) occasions, but did not recall him touch the door or the door's handle. Nurse #2 stated that she redirected Resident #7 when he was going toward an exit door. A nurse's note written on 01/19/11 at 10 p.m. by Nurse #2 specified: "After daughter left res. (resident) was exit seeking. Wanting to go home & see his wife. Wanted to go out and check on his car. We called his daughter and he talked to her. But that still did not calm res (resident) down. Ativan given that did seem to help some. Is in bed now awake (with) peg tube feeding being administered." Review of the Nursing twenty-four (24) hour report for 01/19/11 specified that Resident #7 was "exit seeking". On 01/27/11 at 3:07 p.m. an interview was conducted with Nurse #2 who documented that Resident #7 was "exit seeking" on 01/19/11. Nurse #2 stated that she documented Resident #7's actions on 01/19/11 as "exit seeking" because she observed him coming out of his room wearing his hat and coat and walking toward an exit door. Nurse #2 stated she redirected him when she observed him going toward the door and felt that redirection was effective in keeping him from going outside the facility. Nurse #2 stated that she did not actually see Resident #7 touching an exit door on 01/19/11. A nurse's notes written by Nurse #3 on 01/21/11 at 2:30 p.m. specified that Resident #7 was up and about on hallway and stated; "I'm going home." Staff spoke with him and he went to lie down on his bed. Another nurse's note written by Nurse #3 on 01/21/11 at 3:00 p.m. specified that; This nurse came out of another resident's room and staff was saying that Resident #7 had been found outside of the facility. An interview was conducted with Nurse #3 on 01/27/11 at 8:05 a.m. Nurse #3 stated that on 01/21/11 at approximately 2:30 p.m. Resident #7 told her that he was going home. She redirected him back to his room and a little later observed him laying on his bed watching television. Nurse #3 stated that approximately twenty (20) minutes later she was informed by staff that Resident #7 was found outside of the facility and had been safely returned to the building. Nurse #3 stated that Resident #7's behaviors exhibited on 01/21/11 including making comments about going home were normal for him. Nurse #3 stated that she believed that everyone was aware to keep an eye on Resident #7 because of his risk for elopement. Nurse #3 explained that she would redirect him when he exhibited this behavior. Observations of Resident #7 on 01/25/11 at 3:30 p.m. revealed he was going from door to door trying to open them while on the facility's secured unit (the 400 hallway). He then asked how to get out of the building. Interview with Resident #7's Responsible Party on 1/27/11 at 10:55 A.M. revealed that Resident #7 had a history of [REDACTED]. The family member stated that when the staff discovered that Resident #7 had eloped from the facility on 01/21/11 they notified her immediately. The facility's incident report of Resident #7's elopement from the facility on 01/21/11 was reviewed. The investigation specified that on 01/21/11 at 2:30 p.m. nursing staff observed Resident #7 lying in bed being content. The investigation revealed that on 01/21/11 Resident #7 wandered from the facility's "canopy door" and was observed outside of the facility by an employee. After staff returned Resident #7 to the facility the resident informed staff that "I waited for someone to open door & I went out of it ". The investigation specified that the actions taken by the facility on 01/21/11 included; moving Resident #7 to the facility's secured unit (400 hallway) for safety measures. The outside temperatures on 01/21/11 in Fletcher, NC (the facility's location) per the Weather Channel Internet service, was a low temperature of 22 degrees Fahrenheit and a high temperature of 33 degrees Fahrenheit. Nursing Assistant (NA) #4 who observed Resident #7 outside of the facility on 01/21/11, was interviewed on 01/27/11 at 5:15 p.m. NA #4 stated that on 01/21/11 at around 3:00 p.m. she was driving to work when she thought she saw Resident #7 walking down the road in front of the facility. NA #4 stated that she continued to drive into work, quickly entered the facility to see if Resident #7 was in his room and found that he was not there. NA #4 stated she then alerted NA #5 and a nurse about possibly seeing Resident #7 walking down the road in front of the facility as she drove into work. NA #4 stated that she and two other staff members immediately left the facility to search for Resident #7 and found him walking beside the roadway. NA #4 stated that when Resident #7 was found he appeared uninjured and was cooperative with staff. Resident #7 stated to the staff who found him that he was going to Fletcher and that "Locked doors are meant to get out of." The facility's Social Worker (SW) was interviewed on 01/26/11 at 5:05 p.m. and at 6:10 p.m. The SW stated that it was her responsibility for developing the care plans for residents with behavior issues including elopement risks. The SW confirmed that Resident #7's care plan did not address that he was an elopement risk until after he had eloped from the facility on 01/21/11. Nursing Assistant (NA) #1, who worked with Resident #7, was interviewed on 01/27/11 at 8:00 a.m. NA #1 stated that Resident #7 would act like he was going to therapy, but he was looking for a way to get out of the facility. Resident #7 would also tell her that he was waiting for his ride. NA #1 stated that she would attempt to redirect Resident #7 by taking him to watch the television. Nursing Assistant (NA) #2, who regularly worked with Resident #7, was interviewed on 01/27/11 at 8:27 a.m. NA #2 stated that Resident #7 would often tell her, "I have to go home." NA #2 stated that when Resident #7 would make statements about leaving or going home she would tell him that she needed to check with the doctor. NA #2 explained that she knew to closely watch Resident #7 and believed that other staff also knew to watch him very closely. NA #2 stated that if Resident #7 was not getting enough staff attention he would wander from his room into the hallways and would stand at exit doors looking outside with his arms crossed. NA #2 stated that she remembered two (2) to three (3) days before Resident #7 eloped from the facility (which occurred on 01/21/11) when he rang his call bell three (3) times within a fifteen (15) minute time period and said that he wanted to go home. NA #2 stated that she informed a nurse about these statements, but was unsure if any actions were taken. NA #2 stated that when possible she would try to check on Resident #7 every thirty (30) minutes, redirect him to his room when needed and converse with him to keep his mind off leaving the facility. NA #2 stated to her knowledge there was no information on Resident #7's ADL (Activity of Daily Living) book/flowsheet or on his care plan which addressed him as being at risk of elopement prior to his 01/21/11 elopement from the facility. Nursing Assistant (NA) #3, who worked with Resident #7, on 01/21/11 during the 7:00 a.m. to 3:00 p.m. shift, was interviewed on 01/27/11 at 8:55 a.m. NA #3 stated that on 01/21/11 Resident #7 asked all day if anyone was coming for him and she told him no. NA #3 further stated that on 01/21/11 at approximately 2:10 p.m. she last observed Resident #7 when she conducted her last resident checks. NA #3 stated that on 01/21/11 before 3:00 p.m. she was informed that Resident #7 had been found outside and was being brought back the facility. NA #3 stated that she did not recall Resident #7's care plan or his care card specifying that he was an elopement risk or being made aware of any planned interventions to be implemented to prevent him from eloping from the facility. NA #3 stated that she did recall NA #2 telling her to watch Resident #7 closely because he would leave his room and would try to get out of here. Nursing Assistant (NA) #5, who was one of the staff members that found Resident #7 walking outside of the facility by a roadway on 01/21/11, was interviewed on 01/27/11 at 9:15 a.m. NA #5 stated that on 01/21/11 NA #4 came to his office and informed him that she thought she had seen Resident #7 walking down the road in front of the facility. NA #5 stated that NA #4 and a nurse went to attempt to locate Resident #7 at around 3:00 p.m. and walking along the side the road which runs in front of the facility. NA #5 stated that when Resident #7 was found he was wearing his coat and hat. The resident said that he was not cold, was going to the house and had exited the facility by waiting for the door to open. On 01/27/11 at 9:30 a.m. NA #5 showed surveyors the location where staff found Resident #7 walking outside of the facility on 01/21/11. The location was approximately 0.2 miles away from the facility along a three lane roadway with a posted speed limit of thirty five (35) miles per hour. NA #5 stated that the distance from the facility's canopy exit, where staff believed Resident #7 exited the facility on 01/21/11, to where he was found by staff was a total of 410 steps. Observations of the facility's canopy exit with NA #5 revealed it's exit door was secured by magnetic locks and required a security code to enter and exit. The canopy exit door was also observed to have a walkway that lead from the door to the facility's parking lot. Interview on 01/27/11 at 1:50 p.m. with the Director of Nurses (DON) confirmed that Resident #7 eloped from the facility while unsupervised on 01/21/11 and was returned to the facility by staff uninjured. The DON explained that with the exception of the facility's front door which should be monitored by a staff member, residents were unable to get out of the facility without entering access/exit codes, but explained that a visitor probably let Resident #7 out one of the facility's secured doors. The DON stated that when Resident #7 was admitted to the facility she received the report from staff at his previous facility. The DON recalled being informed that Resident #7 would make attempts to exit the unit where he resided, but was not informed that he made attempts to exit the facility. The DON stated the facility did not utilize a Wanderguard system to prevent residents from eloping, but had exit doors equipped with automatic magnetic locks and had signs posted on each exit door instructing staff and visitors to not let residents out of the building. The DON further explained that staff were expected to monitor Resident #7's whereabouts and redirect him as needed. The DON stated that she did not observe Resident #7 and was not made aware of any exit seeking behaviors until 01/20/11. The DON specified that on 01/20/11 she observed Resident #7 bringing his clothes to the front of the facility and he told her that he was going to take his clothes out to his car. The DON explained that on 01/21/11 staff discussed moving Resident #7 to the facility's "secured 400 hallway" in response to her 01/20/11 observation and the resident's increased behaviors, but he eloped from the facility on 01/21/11 before this room change could be made. The DON explained that following Resident #7's elopement from the facility on 01/21/11 he was moved to the facility's secured unit (400 hallway) and the facility began assessing all residents for elopement risk. Nurse #4, who cared for Resident #7, was interviewed on 01/27/11 at 2:50 p.m. and at 3:30 p.m. Nurse #4 stated that a couple of times she observed Resident #7 turning door handles of exit doors. Nurse #4 stated that these observations of Resident #7 were not recent observations, but occurred sometime after he was taken off isolation (in January 2011). Nurse #4 stated that because Resident #7 had a tracheostomy she was more concerned about him drinking out of the water fountain than exiting the facility. Nurse #4 further explained that she did not document or report her observations of Resident #7 turning exit door handles. Interview with the facility's Administrator on 01/27/11 at 1:45 p.m. confirmed that on 01/21/11 Resident #7 eloped from the facility and was found by staff walking along side the roadway located in front of the facility. The Administrator stated the facility's investigation of this elopement concluded that Resident #7 probably exited the facility's "canopy door" when a visitor was either coming into or exiting from the facility. The Administrator stated that the facility had a policy entitled "Elopement Risk Review", to prevent resident elopements. However, the Administrator explained that this policy needed to be amended because it contained many planned measures which involved the use of a Wanderguard system and the facility was not equipped with a Wanderguard system. The Administrator stated that the facility's policy addressing a resident risk for elopement was currently being revised in order to address specific measures that were to be taken by staff to prevent a resident from eloping from the facility. Further interview with the facility's Administrator on 01/27/11 at 3:50 p.m. confirmed that the facility's elopement risk policy did specify that CNA (Certified Nursing Assistant) assignment sheets were to be updated to identify a resident who was assessed as an elopement risk, but Resident #7's information did not identify him as an elopement risk until after his elopement on 01/21/11. The Administrator explained that if a nurse observed a resident exhibiting exit seeking behaviors they were expected to document the behavior and to note it on the twenty-four hour nursing report, staff should then assess the resident's actual risk for elopement and when needed update the resident's care plan to address this behavior. On 01/27/11 at 12:50 p.m. a Nurse Practitioner (NP), who was familiar with Resident #7, was interviewed. The NP stated that on 01/20/11 she ordered Geodon for Resident #7 in order to relieve his restlessness and anxiety. The NP stated that she had discussed the resident's exit seeking behaviors with one of Resident #7's family members and the family wanted the resident placed on Geodon. The NP further explained that she thought the facility was utilizing a Wanderguard system to prevent residents from exiting the facility while unsupervised, but after Resident #7's elopement on 01/21/11 she was informed that that the facility did not have a Wanderguard system in place. The Administrator was notified of the immediate Jeopardy on 1/27/11 at 5:00 p.m. The facility provided a credible allegation of compliance on 1/28/11 at 3:45 p.m. The following interventions were put into place by the facility to remove the Immediate Jeopardy: During the afternoon of 1-21-11, Resident #7 left the facility and was brought back to the facility by the staffing coordinator and a certified nursing assistant. On 01/21/11 Resident #7 was assessed by the ADON and found to be uninjured. After the elopement of 01/21/11 Resident #7 was moved to the 400 hall, which is accessed by an additional magnetically locking door. This room change for Resident #7 occurred on 1/21/11 at 4:45pm. Prior to being moved to the facility's 400 hallway nursing staff performed 15 minute location checks on Resident #7 to ensure his safety until he was moved. The care plan for Resident #7 was updated by the social worker on 1-21-11 and his care card was updated by the ADON on 1-27-11 to include information regarding his potential risk for elopement. Additional Corrective actions taken by the facility included: ? 1-21-11 The admissions director made sure that there were signs on the exit doors asking visitors not to assist resident with exiting the facility. ? 1-21-11 The Facility's magnetically locking doors were checked for proper function by the ADON with no malfunctioning doors identified. ? 1-21-11 A QA meeting was held at 4:45pm to review Resident #7's elopement and an action plan was developed. Administrator and ADON oversaw this process. ? Beginning on 01/21/11 Elopement Risk Assessments were completed on every resident in the facility. These Elopement Risk Assessments were completed by the Director of Nursing, the Assistant Director of Nursing, and RN Supervisor between 1-21-11 and 1-27-11. Based on these assessments an additional resident (#18) was identified as being at risk for elopement. The care plan for Resident # 18 was updated on 1-21-11 by social worker to address his potential for elopement. The care card for Resident #18 was updated to address potential for elopement on 1-21-11 by the ADON. ? 01/21/11 and 01/22/11 inservices were presented to staff regarding elopement and what to do in the event of an elopement by the ADON. ? 01/27/11 The DON, ADON, MDS coordinator, and IDT team audited all residents charts to ensure that residents were correctly identified for wandering and exit seeking behaviors. ? 01/27/11 Photos of those residents identified as exhibiting exit seeking and wandering behaviors were placed on the MAR by the admissions director. ? 1/27/11 The care plans and care cards of residents, who were identified as having with wandering and exit seeking behaviors, were audited by the MDS Coordinator, Dietary Manager, Act. Dir, and SW, DON and ADON to ensure that they correctly addressed these behaviors. ? 1-28-11 additional signage discouraging visitors to allow residents to exit the facility without first speaking with a staff member posted on all exit doors. ? 1-28-11 inservices on How to Identify Wanderers and those at Risk for Elopement presented to all staff by DON/ADON/Dietary Manager/ Rehab Director/Housekeeping Director. Staff members will not be permitted to return to work until they have received the inservice. ? 1-28-11 the security codes of entrance doors were changed in the facility by the maintenance director such that only staff know the codes and visitors must ring for assistance to be let into the facility during non-business hours. All staff inserviced as to the importance of not sharing the codes by their Dept. Managers. ? 1-28-11 Responsible Parties of the residents will be contacted by phone by the medical records clerk and central supply clerk to inform them of this change and will also be informed in writing, ? 1-28-11 The facility (Administrator, DON, Interdisciplinary Team (IDT) has reviewed the policy regarding Residents at Risk for Elopement and have developed and implemented a new policy for residents at risk for elopement. The new policy has been taken through the QA process on 1-28-11. ? 1-28-11, the visitor access to the facility will be the Front Entrance during normal business hours (8:30 a.m. To 5:00 p.m, Monday through Friday) which is monitored by the receptionist or another designated staff member. During non-business hours the visitor entrance will be the Facility's Canopy Entrance in which they will be required to gain assistance from a staff member to enter or exit the facility. ? 1-28-11 the maintenance installed an observational mirror in the front lobby area such that the front entrance can be observed by staff when the receptionist steps away from the main desk. Immediate Jeopardy was removed on 01/28/11 at 5:30 p.m. Observations of Resident #7 confirmed that he was on the facility's secured unit on the 400 hallway. Review of the Medication Administration Reviews (MARs) for residents assessed as having exit seeking behaviors contained updated photos of these residents. A review of resident elopement risk assessments were verified as being complete. All facility exit doors were checked and found to be either secured by magnetic locks or under direct staff supervision and to have signs posted instructing visitors to not allow residents out of the facility. Observations of the facility front lobby revealed that an observational mirror was installed. Interviews conducted with staff in all departments and who worked on all three shifts confirmed that they had received inservice training on "How to Identify Wanderers and those at Risk for Elopement" and that the security codes for all facility exit doors were changed.