Every finding on record at Forrest Oakes Healthcare

Based on record review and interviews with the Nurse Practitioner and staff, the facility failed to accurately transcribe and carry out physician orders for protective skin care for 1 of 3 residents reviewed with pressure ulcers (Resident #48).The findings included: Resident #48 was originally admitted to the facility on [DATE]. Her diagnoses included contractures of both knees and protein calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #48 had severely impaired cognition and limited range of motion to both lower extremities. She was coded with one unstageable pressure ulcer. A review of Resident #48's care plan, last reviewed 6/23/25, included a focus area for impaired mobility, thin/fragile skin, poor oral intake. She is under hospice care due to terminal prognosis of vascular dementia. She has actual impairment to skin integrity related to deep tissue injury wound of the right hip and blisters to right inner ankle and left posterior thigh. The interventions included administer treatments as ordered and monitor for effectiveness. Review of Resident #48's physician orders included the following orders:- An order dated 6/26/25 for Skin Prep to the left great toe twice a day. This order was created by the Wound Nurse.- An order dated 6/26/25 for Skin Prep to the right lateral foot twice a day. This order was created by the Wound Nurse. Review of the June 2025 Treatment Administration Record (TAR) revealed:- Skin Prep to the left great toe daily starting on 6/26/25. The TAR was initialed by a nurse as being completed once a day.- Skin Prep to the right lateral foot daily starting on 6/26/25. The TAR was initialed by a nurse as being completed once a day. A review of Resident #48's medical record indicated that as of 5/26/26, she was without any skin breakdown. An interview occurred with the Wound Nurse on 5/28/26 at 10:52 AM. She reviewed the orders for skin prep to the left great toe and right lateral foot dated 6/26/25 to be applied twice a day. She verified she had transcribed the order incorrectly to the TAR as daily instead of twice a day. The Wound Nurse stated Resident #48 had discoloration to those areas and the Skin Prep was used to toughen up the skin to prevent breakdown. The Wound Nurse confirmed that Resident #48 was without any skin breakdown. The Nurse Practitioner (NP) was interviewed on 5/28/26 at 9:52 AM and stated she would have expected the order to be transcribed and carried out correctly. An interview was completed with the Director of Nursing (DON) on 5/29/26 at 9:50 AM and stated it was her expectation for the skin protective orders to be transcribed and carried out correctly to prevent any further breakdown.

Based on manufacturer recommendations, observations, record reviews, and staff interviews, the facility failed to date multi use medications upon opening and failed to refrigerate unopened medication per manufacturer instructions on 1 of 3 medication carts reviewed (D Hall Cart).The findings included: Review of the manufacturer's guidelines for Rhopressa eye drops instructed to refrigerate unopened bottles.Review of the manufacturer's guidelines for Brimonidine Tartrate required discarding the medication 28 to 30 days after opening.Review of the manufacturer's guidelines for Erythromycin ophthalmic ointment read to discard the ointment within 28 days of opening.Review of the manufacturer's guidelines for Latanoprost eye drops read it must be discarded four to six weeks after opening.An observation was conducted on 5/28/26 at 10:00 AM of the D Hall medication cart in the presence of Medication Aide (MA) #1. The observation revealed the following medications stored in the medication cart:One (1) bottle of Rhopressa eye drops (a prescription eye drop used to lower high pressure inside the eye) that were unopened and not refrigerated. The manufacturer seal was intact and a sticker on the package read, Refrigerate until opened.One (1) bottle of Brimonidine Tartrate (a prescription eye drop used to lower eye pressure associated with glaucoma) eye drops that were opened and undated.One (1) tube of Erythromycin ophthalmic ointment (an antibiotic used to treat and prevent bacterial infections of the eye) that was opened and undated.Two (2) bottles of Latanoprost (a prescription eye drop used lower eye pressure) eye drops that were opened and undated.An interview with MA #1 on 5/28/26 at 10:10 AM revealed she was unaware that the eye drops were not dated when opened. She stated that prescription eye drops should be dated upon opening and discarded 30 days after being opened. MA #1 also stated she was unaware that the Rhopressa eye drops on the medication cart had not been opened but confirmed that unopened eye drops should have been stored in the refrigerator per the manufacturer's directions written on the medication label, until opened. MA #1 explained that the nurses and medication aides who opened the eye drops were responsible for labeling the medication with the date opened and ensuring that medications requiring refrigeration were stored as directed. MA #1 removed the unopened and undated medications from the medication cart and requested replacement refills from the pharmacy.During an interview with the Director of Nursing (DON) on 5/28/26 at 3:10 PM, she stated that it was her expectation that nurses and MA's follow manufacturer directions for medication storage and expiration dates. She explained that the nurse or MA who opened a medication was responsible for labeling it with the date opened and ensuring the medication was discarded in accordance with manufacturer guidelines.

Based on observations, record reviews, staff, and Nurse Practitioner interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #46).The findings included:Resident #46 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (when tissues and cells do not receive enough oxygen to function properly), asthma, alveolar hypoventilation (breathing is too shallow or slow to meet the body's metabolic needs), and acute and chronic respiratory failure with hypercapnia (an abnormally elevated level of carbon dioxide).A review of Resident #46's care plan revealed a focus area revised on 11/29/23 that read Resident #46 had potential for altered respiratory status/difficulty breathing. An intervention initiated on 1/21/26 indicated the resident would receive oxygen at 3 liters per minute (lpm) continuously via nasal cannula.A review of Resident #46's active orders included an order dated 12/12/25 for continuous oxygen at 3 lpm via nasal cannula. Review of Resident #46's annual Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact. Resident #46 was coded as receiving oxygen therapy.An observation of Resident #46's oxygen concentrator was conducted on 5/26/26 at 10:24 AM. The oxygen flow rate was noted to be set at 2.5 lpm when viewed at eye level. Resident #46 was lying in bed wearing his nasal cannula. He denied any shortness of breath or respiratory distress.On 5/27/26 at 9:56 AM an observation of Resident #46's oxygen concentrator revealed the flow rate was set at 2.5 lpm when viewed at eye level. Resident #46 was lying in bed wearing his nasal cannula. He denied any shortness of breath or respiratory distress.On 5/28/26 at 9:53 AM an observation and interview were conducted with Nurse #1 who was assigned to Resident #46 from 7:00 AM through 7:00 PM on 5/26/26 and 5/28/26. Nurse #1 accompanied the surveyor to Resident #46's room and viewed the oxygen concentrator setting at eye level. Nurse #1 verified the flow rate was set at 2.5 lpm upon viewing and stated the flow rate should have been set at 3 lpm. Nurse #1 explained she had completed rounds on Resident #46 at 7:30 AM the morning of 5/28/26 and checked his oxygen flow rate at that time. She stated the concentrator was set at 3lpm during her rounds and that someone must have bumped the concentrator afterwards and caused the flow rate to be lower than 3 lpm.Nurse #2 who was assigned to Resident #46 on 5/27/26 from 7:00 AM to 7:00 PM could not be reached for an interview.A review of the May 2026 Medication Administration Record (MAR) revealed an entry for oxygen at 3 liters per minute continuously every 12 hours for COPD. The MAR had a daily check mark and staff initials on all shifts on 5/26/26, 5/27/26, and the morning of 5/28/26. The MAR was initialed by Nurse #1 on 5/26/26 and 5/28/26, and the MAR was initialed by Nurse #2 on 5/27/26.The Nurse Practitioner (NP) was interviewed on 5/28/26 at 10:42 AM and stated she thought the staff did not know how to read the oxygen concentrator regulator correctly. She stated the staff should verify the bottom of the ball in the flow meter was sitting on the correct flow rate. The NP reviewed Resident #46's oxygen saturation levels and stated he did not show any adverse effects related to the lower flow rate and Resident #46 had maintained a good oxygen saturation level.The Director of Nursing (DON) was interviewed on 5/29/26 at 10:15 AM and stated staff should check an oxygen concentrator at eye level and verify the rate on the Medication Administration Record (MAR) matched the setting.The Administrator was interviewed on 5/29/26 at 11:47 AM and stated staff should verify the oxygen concentrator was set at the ordered flow rate.

Based on record review and staff interviews, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was completed prior to admission for 1 of 2 residents reviewed for PASRR (Resident #7).The findings included:The North Carolina Department of Health and Human Services (NCDHHS) PASRR determination letter dated 5/11/2023 for Resident #7 indicated a Level I screen and provided a PASRR number that remained valid for the duration of the individual's stay (this Level I screen was not requested by or for the current facility). The letter stated that no additional PASRR screening was required unless a significant change in the individual's condition occurred, which could suggest a diagnosis related to mental illness.Resident #7 was admitted from home to the facility on 3/30/2026 with a diagnosis of post traumatic stress disorder.The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #7 was cognitively intact and was not currently considered by the state Level II PASRR process to have serious a mental illness. The MDS further revealed that Resident #7 was identified as having a serious mental illness with a diagnosis of PTSD, had not exhibited any behaviors or rejection of care during the assessment period, and had received antipsychotic medications. In an interview on 5/28/26 at 2:58 PM, the Social Services Director stated she was responsible for ensuring that a PASRR was completed prior to admission when required. She reported she did not know that Resident #7 needed a new PASRR evaluation prior to his admission on [DATE] because he had a PASRR evaluation provided by hospice dated 5/11/23 that had no expiration date. The Social Services Director stated she did not realize the notice indicated it was valid for the length of his stay in a different facility.In an interview on 5/28/26 at 3:55 PM, the Administrator stated that Resident #7's Level I PASRR screen was provided by hospice on admission that indicated no further screening was required unless a significant change occurred with his status that suggested a diagnosis of mental illness or a change in treatment needs for the conditions. The Administrator reported that Resident #7 did not have a new mental health diagnosis and had no changes in treatment needs for his PTSD. The Administrator stated he was unaware that a new evaluation was required and confirmed that the Social Services Director was responsible for submitting requests for PASRR screenings and evaluations. The Administrator stated it was his expectation that PASRR screenings and evaluations be completed in accordance with regulations and that he would notify the Social Services Director that Resident #7 required a new PASRR.

Based on record review and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of personal funds when the Medical Records Manager accepted money from the resident for cleaning his personal apartment. The Medical Records Manager was alleged to have accepted $280.00 from Resident #60 on 4/17/26. This deficient practice occurred for 1 of 1 resident reviewed for misappropriation of resident property (Resident #60).The findings included:A review of the facility's policy entitled Abuse, Neglect and Exploitation revised on 10/14/25 read in part: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent, use of a resident's belongings or money without the resident's consent.A review of the facility's undated code of ethics read in part: Accepting any gift or gratuity from a patient or family member is strictly prohibited. Resident #60 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, unspecified and cognitive communication deficit (difficulty with speech, listening, reading, or writing caused by impaired underlying brain functions like attention, memory, and executive function). A quarterly Minimum Data Set (MDS) assessment date 3/11/26 indicated Resident #60 was cognitively intact. An initial allegation report was submitted to the State Agency by the Director of Nursing (DON) on 4/22/26 at 1:30 PM. The report read that the DON was made aware of an allegation involving the Medical Records Manager and the Activity Director who reportedly accepted monetary compensation from Resident #60 on 4/17/26 to perform cleaning services at his personal residence outside of the facility. Local police were notified on 4/23/26 at 12:09 PM, and the facility investigation was initiated. On 5/28/26 at 12:37 PM the Activities Director (AD) was interviewed and stated the Administrator had asked her and the former Medical Records Manager to clean Resident #60's apartment since he was scheduled to discharge home soon. The AD explained that the Administrator instructed her and the Medical Records Manager to clock in at the facility each day then leave to clean the apartment for Resident #60. The AD stated at the end of the second day of cleaning on 4/17/26, the Medical Records Manager told her that the Administrator had called to ask if Resident #60 had offered to give them any money to clean his apartment. According to the AD, the Medical Records Manager told the Administrator Resident #60 had not offered them any money. The AD stated later that day on 4/17/26, the Medical Records Manager talked to her and informed her Resident #60 had given her money to split between them for cleaning his apartment. The AD indicated she did not know the amount of money Resident #60 had given to the Medical Records Manager. According to the AD, the Medical Records Manager told her Resident #60 handed the money to the Transportation Assistant who handed the money to the Medical Records Manager. The AD explained that the Medical Records Manager told her she had planned to return the money to the Administrator when she returned to work the following Thursday 4/23/26. According to the AD, she had received training and knew she was not to accept money from residents. The AD stated she did not receive any money from Resident #60 for cleaning his apartment.The former Medical Records Manager was interviewed by phone on 5/28/26 at 2:25 PM. She stated on 4/14/26 the Administrator pulled her and the Activities Director (AD) aside and asked if they would clean Resident #60's apartment before he discharged home. The Medical Records Manager stated that as she and the AD were leaving the facility the Transportation Director and Transportation Assistant asked if they were getting paid by Resident #60 to clean his apartment. The Medical Records Manager explained she told the Transportation Assistant they were on the clock while they cleaned Resident #60's apartment, and that if the resident wanted to do more then he could purchase more cleaning supplies. According to the Medical Records Manager, the Transportation Assistant and Transportation Director brought Resident #60 to the Medical Records Manager's home on 4/17/26. The Medical Records Manager explained she did not know why Resident #60 was taken to her home, and when she walked to the van she was told by the Transportation Assistant that the resident wanted to give her something for cleaning his apartment. The Medical Records Manager stated she felt Resident #60 was giving her money out of the goodness of his heart, and she did not feel it was her place to say anything to him or refuse to take the money. According to the Medical Records Manager, she did not attempt to give Resident #60 his money back and instead just stuck the money in her work bag and finished handling her day. The Medical Records Manager stated the AD called her, and she informed her what had happened. According to the Medical Records Manager, she told the AD she was not going to spend Resident #60's money and was going to give it back to the Administrator when she returned to work the following week. The Medical Records Manager stated the facility had provided in-services about not accepting gifts or money from residents.On 5/28/26 at 3:15 PM the Administrator was interviewed and stated he had gone to Resident #60's apartment with one of the physical therapists to see his living arrangements before the resident's discharge from the facility because he had heard Resident #60 was living in poor conditions. The Administrator stated he wanted to make sure Resident #60 had a safe discharge. The Administrator explained he had asked the Activities Director and Medical Records Manager if they would assist him with getting Resident #60's apartment cleaned before his discharge. According to the Administrator, he had spoken with Resident #60, who had agreed to let the AD and Medical Records Manager clean his house before his discharge. The Administrator stated he explained to the resident that the facility would pay the AD and Medical Records Manager for cleaning his apartment, and Resident #60 would not have anything out of pocket. The Administrator further explained he had gotten approval from the corporate office to pay the AD and Medical Records Manager to clean the apartment. The Administrator stated the apartment complex management had planned to repaint Resident #60's apartment once the cleaning was completed. He stated the facility never asked Resident #60 for any monetary compensation for the cleaning. The Administrator stated he had received a phone call on an unknown date from an unnamed source that informed him Resident #60 was going to pay the AD and Medical Records Manager for working on his apartment. The Administrator stated he spoke with the AD, Medical Records Manager, and Resident #60 to remind them there would be no monetary exchange. The Administrator stated the AD and Medical Records Manager affirmed to him that they were aware they could not accept payment from the resident. According to the Administrator, he was informed on 4/22/26 by the Director of Nursing that the Medical Records Manager had accepted money from Resident #60 and investigation began on 4/22/26. He stated he was informed by the DON that the Transportation Director and Transportation Assistant took Resident #60 to the Medical Records Manager's home on 4/17/26 and saw he gave the Medical Records Manager money for cleaning his apartment. He stated the Transportation Director and Transportation Assistant had reportedly taken Resident #60 to withdraw money from his bank to pay the deposit on his apartment that day. The Administrator stated he did not recall having received a phone call from the Transportation Assistant about the money exchange on 4/17/26. According to the Administrator, he never got a clear explanation as to why the Transportation Director and Transportation Assistant took Resident #60 to the Medical Records Manager's home. The Administrator stated on 4/22/26 he called the Medical Records Manager to ask if she accepted money from Resident #60 and was told she had accepted the money. The Medical Records Manager informed the Administrator she had an emergency, but she was going to return the money to the facility when she returned to work on 4/23/26. According to the Administrator, he, the Activities Director, and the Medical Records Manager were suspended while the Director of Nursing completed the investigation into the incident.On 5/28/26 at 7:27 PM the Transportation Assistant was interviewed by phone and stated when she returned to work on 4/15/26 she asked the Transportation Director where the Activities Director and Medical Records Manager were and was informed that they were cleaning Resident #60's apartment before he discharged home. The Transportation Assistant stated on 4/17/26 she and the Transportation Director had driven Resident #60 to a local store to get a money order to pay his rent and deposit on his apartment. She explained while they were at the store the Medical Records Manager called and asked if they would pick up more cleaning supplies. According to the Transportation Assistant, when they took Resident #60 to the apartment complex to pay his rent, the Medical Records Manager was no longer at the apartment. The Transportation Assistant indicated she called the Medical Records Manager who asked if they would drop the cleaning supplies off at her home instead. The Transportation Assistant explained when they arrived at the Medical Records Manager's home, the Medical Records Manager got on the van and unloaded the cleaning supplies. The Transportation Assistant stated Resident #60 reached into his pocket and handed the Medical Records Manager some money. According to the Transportation Assistant, when the Medical Records Manager got out of the van, she asked Resident #60 why he gave her money and he replied because they were going to paint his apartment. The Transportation Assistant stated she called the Administrator immediately on 4/17/26 to report the exchange of money between Resident #60 and the Medical Records Manager. The Transportation Assistant stated she did not ask the Medical Records Manager why she accepted money from Resident #60, and she did not ask the Medical Records Manager to return the money to the resident.On 5/28/26 at 7:37 PM an interview was conducted with the Transportation Director who stated sometime in April 2026 he drove the Administrator and one of the physical therapists to Resident #60's apartment to view it before he discharged from the facility. The Transportation Director stated when they entered the apartment it was extremely dirty, and the landlord said they would have to charge Resident #60 an extra $100.00 each month if the landlord had to clean the apartment prior to him moving back. He stated on 4/17/26 he and the Transportation Assistant drove Resident #60 to a local store to get a money order to pay his rent and deposit. Once at the store, he said the Medical Records Manager called and requested they pick up more cleaning supplies. The Transportation Director stated they drove Resident #60 to the apartment complex to pay his rent and deposit and noted the Medical Records Manager was not there. He further explained after paying the deposit at the apartment complex he drove Resident #60 to the Medical Records Manager's home to drop off the cleaning supplies. The Transportation Director stated while they were at the Medical Records Manager's home Resident #60 handed her some money. He stated he asked Resident #60 why he gave the Medical Records Manager money, and the resident told him they were supposed to paint his apartment. The Transportation Director stated the Transportation Assistant was already on the phone with the Administrator to report on the money exchange, so he did not call himself. The Transportation Director stated he was not sure what was going on, and he did not ask the Medical Records Manager to return Resident #60's money.On 5/29/26 at 11:34 AM the Director of Nursing (DON) was interviewed and stated on 4/22/26 she was alerted by an unnamed source that the Activities Director and Medical Records Manager had accepted money from Resident #60 to clean his apartment. The DON stated she reported the information to the Administrator immediately and then suspended all parties involved and began an investigation of the incident. According to the DON, she sent an initial allegation report to the State, notified the local police, reported it to Adult Protective Services, and called the Ombudsman to notify them about the incident. The DON explained she met with Resident #60 who told her he was not asked to give money to anyone. Per the DON, Resident #60 stated on 4/17/26 transportation took him to get a money order to pay his rent then took him to the Medical Records Manager's home to drop off cleaning supplies. The DON stated while Resident #60 was at the Medical Records Manager's home Resident #60 gave her money. According to the DON, when the Medical Records Manager was asked why she did not refuse the money, she stated she was grieving the anniversary of her son's death, and she also did not want to hurt Resident #60's feelings by refusing his money. The DON indicated the Medical Records Manager should not have accepted the money at all. According to the DON, she called the Medical Records Manager on 4/22/26 when she became aware of the incident, and the Medical Records Manager informed her she had planned to return the money to Resident #60 when she returned to work later that week. The DON stated she asked the Medical Records Manager to return the money to the facility on 4/22/26 and met the Medical Records Manager in the parking lot on the afternoon of 4/23/26 where she received $280.00 from her. The DON stated she and the Business Office Manager met with Resident #60 immediately afterwards and counted his $280.00 back to him and obtained a signed receipt from him. The DON stated she educated the resident he should never pay any staff for services.A review was completed of a receipt for the return of $280.00 to Resident #60 dated 4/23/26 and was signed by Resident #60 and the DON.Multiple attempts were made to contact Resident #60 by phone calls and text messages but were unsuccessful.The facility submitted a plan of correction that was not accepted for past non-compliance as it did not address measures to prevent misappropriation from recurring.

Based on record review, observations, and staff and Nurse Practitioner interviews, the facility failed to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 3 residents (Resident #33) reviewed. Findings included: Resident #33 was admitted to the facility on [DATE]. A Physician's Order dated 10/11/2024 indicated Resident #33 required an indwelling urinary catheter. A quarterly Minimum Data Set assessment dated [DATE] indicated he was cognitively intact and had an indwelling urinary catheter. Resident #33's Care Plan dated 3/8/2025 indicated he had an indwelling suprapubic urinary catheter. During an observation of Resident #33 on 3/12/2025 at 9:45 am he was found to be in bed and his urinary catheter drainage bag was lying on the floor beside his bed. There was no hook on the urinary catheter bag to attach it to the bed frame. Nurse Aide #1 came to the room and emptied Resident #33's urinary catheter bag and stated she would get the Unit Manager to replace the urinary catheter bag so that she could secure it to the bed and off of the floor. During an interview conducted on 3/12/2025 at 1:03 pm with the Unit Manager, who was the nurse assigned to Resident #33. She stated Resident #33 was seen by the Urologist on 3/6/2025 and his catheter, catheter tubing and urinary catheter bag were changed at the appointment. The Unit Manager stated she went to the room this morning after Nurse Aide #1 told her the bag was on the floor and changed the urinary catheter bag. The Unit Manager stated the staff should have changed his urinary catheter bag to ensure it could be hung from his bed instead of resting on the floor. An interview was conducted by phone with the Nurse Practitioner on 3/12/2025 at 5:40 pm and she stated Resident #33's urinary catheter bag should not have been on the floor. The Nurse Practitioner stated Resident #33 was verbal and was cognitively intact and could let staff know if he was having any abdominal pain or urgency. She stated since he did not have any complaints related to his catheter, she did not feel Resident #33 was harmed. The Director of Nursing was interviewed on 3/12/2025 at 4:57 pm and she stated Resident #33's urinary catheter should not have been on the floor to prevent the increased risk of infection. During an interview with the Administrator on 3/12/2025 at 5:06 pm she stated Resident #33's urinary catheter bag should not have been on the floor.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a safe environment as evidenced by exposed wires to the bed control cord (room [ROOM NUMBER]) and to clean the vents of the Packaged Terminal Air Conditioner (PTAC-room [ROOM NUMBER]). The facility also failed to ensure resident rooms were clean and in good repair (Rooms #112, 128, 144, 120, 122, 126, and 129). This was for 8 of 18 resident rooms reviewed for comfortable, clean and homelike environment. The findings included: 1a. On 2/3/25 at 11:33 AM, room [ROOM NUMBER]'s bed control was observed lying on the mattress to the right of the resident's pillow. The bed control cord was noted with approximately 1 inch of yellow electrical tape below the control box. Beyond the yellow electrical tape was approximately 1/4 inch of exposed wires showing. On 2/5/25 at 9:00 AM, the Maintenance Director observed the bed control unit for room [ROOM NUMBER]. He explained that the outer casing protecting the wires tore very easily. He acknowledged that he had wrapped the yellow electrical tape to the bed control cord when exposed wires were first seen but was unable to state when that was. He went onto say the bed control used low voltage so wouldn't hurt a resident if wires were exposed and he would need to rewrap the bed control cord for the exposed wires. When asked if the bed controls could be replaced, he stated yes, but I try to tape them first. The Maintenance Director stated he tried to do frequent checks of the controls for any exposed wires on the cords but had lost his assistant in December 2024 and was doing the best he could. The Administrator was interviewed on 2/6/25 at 9:25 AM and stated that she expected bed control units not to have exposed wires. b. On 2/2/25 at 11:10 AM, room [ROOM NUMBER]'s PTAC vent had a large amount of grey dust particles and dried white material throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. The Housekeeping Manager was interviewed on 2/4/25 at 2:53 PM and explained that the housekeepers cleaned the outside of the PTAC units but anything inside the vents would be taken care of by the Maintenance department. On 2/5/25 at 9:00 AM, an observation of room [ROOM NUMBER] was conducted with the Maintenance Director. He explained that housekeeping cleaned the outside of the PTAC and anything inside the vents would be cleaned by the Maintenance department. The Maintenance Director added that PTAC's were to be cleaned monthly and confirmed the vents to room [ROOM NUMBER]'s PTAC was dirty with various particles in it and required cleaning. The Administrator was interviewed on 2/6/25 at 9:25 AM and stated that she would expect the PTAC's to be clean. 2. On 2/2/25 at 12:38 PM, in room [ROOM NUMBER], there were multiple areas of the wall under both of the overbed lights with exposed dry wall. This room was occupied by a resident. The Maintenance Director was interviewed on 2/5/25 at 10:15 AM and observed the walls of room [ROOM NUMBER] with exposed sheetrock under both of the overbed lights. He explained that as a room became unoccupied, he was fixing walls and installing back splashes to these areas. He was unable to state if this room was scheduled to be repaired. On 2/6/25 at 9:21 AM, the Administrator was interviewed and stated it was important for the environment to be well maintained and homelike. 46095 3a. On 02/03/25 at 8:35 AM, in room [ROOM NUMBER], there were multiple areas of the wall on the right side of the headboard and on the wall to the right when entering the room with exposed dry wall. This room was occupied by a resident. An interview was conducted on 02/05/25 at 03:07 PM with the Maintenance Director. He indicated that he observed the walls of room [ROOM NUMBER] with exposed dry wall on the right side of the headboard and on the wall to the right when entering the room. He explained that as a room became unoccupied, he would fix the walls and install back splashes into these areas. He then stated this room was not scheduled to be repaired. On 2/6/25 at 9:21 AM, the Administrator was interviewed and stated it was important for the environment to be well maintained and homelike. b. On 02/03/25 at 8:35 AM, in room [ROOM NUMBER], there were multiple areas of the wall on the right side of the PTAC with exposed dry wall. This room was occupied by a resident. An interview was conducted on 02/05/25 at 03:07 PM with the Maintenance Director. He indicated that he observed the walls of room [ROOM NUMBER] with areas of the wall on the right side of the PTAC with exposed dry wall. He explained that as a room became unoccupied, he would fix the walls and install back splashes into these areas. He then stated this room was not scheduled to be repaired. On 2/6/25 at 9:21 AM, the Administrator was interviewed and stated it was important for the environment to be well maintained and homelike. 4. On 02/03/25 at 8:35 AM, in room [ROOM NUMBER], the floor under the bed had a brown coffee cup, food crumbs, 3 pencils, and a clear plastic cup on it. The floor beside the bed had a brownish dried liquid (like water was spilled on dirty floor) spot. This room was occupied by a resident. An observation and interview were conducted on 02/03/25 at 12:15 PM with the Housekeeping Manager in room [ROOM NUMBER]. The floor appeared to have been mopped, the food crumbs, brownish dried liquid (like water was spilled on dirty floor, and water cup were removed from floor. However, the brown coffee cup and pencils were still located on the floor under the bed but were pushed up towards the headboard. The Housekeeping Manager stated that the housekeepers don't touch the residents' personal belongings due to residents accusing them of taking their items, but the coffee cup and other trash should have been removed. She expected the rooms to be neat, clean, and free of debris. She removed the coffee cup and other items from under the bed. An interview was conducted on 02/03/25 at 3:15 PM with the Housekeeping District Manager. He stated he was not aware the housekeeping staff were not touching the residents' belongings when cleaning the rooms. He stated he expected the rooms to be clean, neat, and free of trash and debris. The items should be removed and/or swept up prior to mopping. An interview was conducted on 02/05/25 at 11:52 AM Housekeeper #2. She verified she worked 02/03/25 and was assigned room [ROOM NUMBER]. She stated she did clean room [ROOM NUMBER] and that she thought she got all the stuff from under bed A. She explained that she had a bad back and she didn't bend all the way over to see under the beds, she just took the mop and tried to blindly sweep under the bed. She verified there was trash and a brown coffee cup under the bed that she did not get out because she could not reach it. 50415 5. On 2/2/25 at 11:46 AM room [ROOM NUMBER] was observed to have multiple areas of black scuff marks on the window wall as well as the wall at the head of the bed. This room was occupied by a resident. The Maintenance Director was interviewed on 2/5/25 at 10:15 AM. He indicated that as rooms became vacant, he repaired the walls and installed backsplashes at the head of the beds. He was unable to state if room [ROOM NUMBER] was scheduled to be repaired. Housekeeping staff #1 was interviewed on 2/6/25 at 9:01 AM. She stated housekeeping was responsible for wiping down the walls from visible dirt when the rooms were cleaned. At 9:08 AM on 2/6/25 the Housekeeping Manager was interviewed. She stated that housekeeping had a list of areas to be cleaned every day. She stated staff was supposed to wipe down visibly dirty areas in the residents' rooms, but that it was the responsibility of maintenance to repair damaged walls. The District Manager for housekeeping was interviewed on 2/6/25 at 9:23 AM. He stated that housekeeping was responsible for cleaning walls if they were visibly dirty. He also indicated that maintenance was responsible for repairing damaged walls. On 2/6/25 at 9:21 AM, the Administrator was interviewed. She stated that it was important for the environment to be well maintained and homelike for the residents. 6. On 02/02/25 at11:53 AM room [ROOM NUMBER] was noted to have black scuffs and a partially painted wall by the closet where the television was placed. Paint streaks were also noted on the 3 walls that surrounded the bed. Blue paint was streaked on the white wall at the head of the resident's bed, and white paint streaks were noted on the blue wall on the door wall. The white ceiling also had blue paint streaks on it over the blue wall. The Maintenance Director was interviewed on 2/5/25 at 10:15 AM. He indicated that as rooms became vacant, he repaired the walls and installed backsplashes at the head of the beds. The Maintenance Director stated room [ROOM NUMBER] was due to be painted as the walls were partially painted from a prior repair. He presented a piece of paper with multiple rooms highlighted for repairs, but room [ROOM NUMBER] was not on the list. He was unable to state if room [ROOM NUMBER] was scheduled to be repaired. Housekeeping staff #1 was interviewed on 2/6/25 at 9:01 AM. She stated housekeeping was responsible for wiping down the walls from visible dirt when the rooms were cleaned. At 9:08 AM on 2/6/25 the Housekeeping Manager was interviewed. She stated that housekeeping has a list of areas to be cleaned every day. She stated they're supposed to wipe down visibly dirty areas in the residents' rooms, but that it was the responsibility of maintenance to repair damaged walls. The District Manager for housekeeping was interviewed on 2/6/25 at 9:23 AM. He stated that housekeeping was responsible for cleaning walls if they were visibly dirty. He also indicated that maintenance was responsible for repairing damaged walls as this was beyond the scope of housekeeping. On 2/6/25 at 9:21 AM, the Administrator was interviewed. She stated that it was important for the residents' rooms to be clean, well maintained, and homelike for the residents. 7. On 02/02/25 at 12:11 PM room [ROOM NUMBER] was noted to have black scuff marks on the walls at the right and head of the resident's bed. This room was occupied by a resident. The Maintenance Director was interviewed on 2/5/25 at 10:15 AM. He indicated that as rooms became vacant, he repaired the walls and installed backsplashes at the head of the beds. room [ROOM NUMBER] was not on the highlighted list of rooms to be repaired at the time of the interview. He was unable to state when the room would be scheduled for repair. He stated that he lost his assistant in December 2024 and was doing the best that he could. Housekeeping staff #1 was interviewed on 2/6/25 at 9:01 AM. She stated housekeeping was responsible for wiping down the walls from visible dirt when the rooms were cleaned, but that housekeeping was not responsible for fixing scuff marks or damaged walls. At 9:08 AM on 2/6/25 the Housekeeping Manager was interviewed. She stated that housekeeping had a list of areas to be cleaned every day. She stated they're supposed to wipe down visibly dirty areas in the residents' rooms, but that it was the responsibility of maintenance to repair damaged walls. The District Manager for housekeeping was interviewed on 2/6/25 at 9:23 AM. He stated that housekeeping was responsible for cleaning walls if they were visibly dirty. He stated that housekeeping is responsible for cleaning vertical and horizontal surfaces, removing trash, and dust mopping followed by wet mopping of the residents' rooms. He also indicated that maintenance was responsible for repairing damaged walls since this was beyond the scope of housekeeping. On 2/6/25 at 9:21 AM, the Administrator was interviewed. She stated that it was important for the residents' rooms to be well maintained and homelike for the residents. 8. On 02/03/25 09:07 AM room [ROOM NUMBER] was observed to have peeling paint on the wall by the window. The wall also had brown marks beside the resident's bed. The Maintenance Director was interviewed on 2/5/25 at 10:15 AM. He indicated that as rooms became vacant, he repaired the walls, painted walls as needed, and installed backsplashes at the head of the beds to reduce damage from beds and wheelchairs hitting the walls. The Maintenance Director stated that he checked the condition of the rooms as he walked the halls and kept a paper of what rooms needed repairing. He was unable to state if room [ROOM NUMBER] was on the list as scheduled to be repaired. Housekeeping staff #1 was interviewed on 2/6/25 at 9:01 AM. She stated housekeeping was responsible for wiping down the walls from visible dirt when the rooms were cleaned. She stated that housekeeping could wipe the brown marks off the wall, but the peeling paint was the responsibility of maintenance to repair. At 9:08 AM on 2/6/25 the Housekeeping Manager was interviewed. She stated that housekeeping has a list of areas to be cleaned every day. She stated they're supposed to wipe down visibly dirty areas in the residents' rooms, but that it was the responsibility of maintenance to repair damaged walls. She stated that she would have housekeeping staff #1 wash the brown marks off the wall in room [ROOM NUMBER]. The Housekeeping Manager stated once the staff turned in their completed task sheets for the day that she inspected the rooms for the areas reported to have been cleaned. The District Manager for housekeeping was interviewed on 2/6/25 at 9:23 AM. He stated that housekeeping was responsible for cleaning walls if they were visibly dirty such as the brown marks on Resident #129's wall. He stated that housekeeping is responsible for cleaning vertical and horizontal surfaces, removing trash, and dust mopping followed by wet mopping of the residents' rooms. He also indicated that maintenance was responsible for repairing damaged walls since this was beyond the scope of housekeeping. On 2/6/25 at 9:21 AM, the Administrator was interviewed. She stated that it was important for the environment to be well maintained and homelike for the residents.

Based on record reviews, observations, and staff interviews, the facility failed to review and revise a care plan following the most recent Minimum Data Set (MDS) assessment in the area of falls (Resident #6) and failed to revise the care plan in the area of side rails (Resident #31). In addition, the facility failed to develop an individualized and comprehensive care plan in the area of Activities of Daily Living (Residents #51 and #205) This was for 4 of 18 resident records reviewed. The findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included history of a stroke and chronic obstructive pulmonary disease (COPD). The active care plan was last reviewed and revised on 10/3/24. There was a focus area for risk for falls related to history of falls, impaired gait/balance problems related to stroke with weakness, potential side effects related to use of psychoactive medications, poor safety awareness and impulsive behaviors. One of the interventions included a fall mat to the right side of the bed. A review of the physician orders included an order for a fall mat to the right side of the bed that was discontinued on 11/13/24. A quarterly MDS assessment was completed on 12/10/24 and indicated that Resident #6 was cognitively intact, displayed no behaviors and required maximum assistance from staff for activities of daily living (ADL). The active care plan did not indicate it had been reviewed or revised after the 12/10/24 MDS assessment. On 2/4/25 at 6:14 AM, Resident #6 was observed lying in bed with the bed covers over his head. There was no fall mat to the right side of the bed. The MDS Nurse was interviewed on 2/5/25 at 3:17 PM and stated she had been employed by the facility for four weeks. She reviewed Resident #6's care plan and confirmed it had been reviewed and revised on 10/3/24. The MDS Nurse explained that the care plan should have been reviewed and revised following the MDS assessment that was completed on 12/10/24, in which the fall mat to the right side of the bed would have been removed. She was unable to state why the prior MDS Nurse did complete this task. The Director of Nursing (DON) was interviewed on 2/6/25 at 9:32 AM and stated she would expect the care plan to be reviewed and revised as needed following the most recent MDS assessment. 2. Resident #31 was admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness and osteoarthritis. A review of Resident #31's physician orders included an order 8/20/23 for the use of quarter side rails. This order was noted to be discontinued on 2/26/24 by the Unit Manager. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #31 had severe cognitive impairment and required maximum assistance from staff for bed mobility. She was not coded for any restraint usage. Resident #31's active care plan, last reviewed 11/25/24, included a focus area for potential limited physical mobility and required use of quarter side rails. On 2/2/25 at 12:38 PM, an observation occurred of Resident #31 who was lying in bed. There were no quarter inch side rails present to the bed. The Unit Manager was interviewed on 2/5/25 at 11:49 AM and stated that the quarter inch side rails were discontinued to Resident #31's bed on 2/26/24 as she no longer used them to aide in bed mobility. She felt it was an oversight not to have discontinued the care plan for the side rail use. On 2/5/25 at 3:17 PM, the MDS Nurse was interviewed and explained that she had been employed at the facility for four weeks. She reviewed Resident #31's care plan and verified that a focus area was present for the use of quarter inch side rails. She also reviewed the discontinued physician order for quarter inch side rails on 2/26/24 and stated the focus area should have been resolved from the care plan. She was unable to state why this had not been done by the prior MDS Nurse. The Director of Nursing was interviewed on 2/6/25 at 9:32 AM and stated she would expect the care plan to be accurate reflection of Resident #31. 46095 3. Resident #51 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis (weakness or paralysis on one side of the body), and aphasia (loss of ability to understand or speak). Resident #51 ' s active care plan, initiated on 01/13/25, did not include a focus area for activities of daily living. Baseline care plan, dated 01/13/25, revealed Resident #51 required assistance with activities of daily living. He was dependent on staff for incontinence care, toileting hygiene, personal hygiene, shower/bath, and transfers. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51's cognition was severely impaired. He had no behavior and no rejection of care. He was dependent on staff for personal hygiene, toileting hygiene, transfers, and shower/baths. An interview was conducted on 02/05/25 at 3:16 PM with Minimum Data Set (MDS) Nurse. She verified there were no areas on Resident #51 ' s care plan for ADL care and there should have been a focus added. She explained that by the time the MDS assessment was completed the care plan should also be completed. She stated it was an oversight that this intervention was not added on Resident #51 ' s care plan. An interview was conducted on 02/06/25 at 9:33 AM with the Director of Nursing (DON). She stated a focus or intervention area for ADL care should have been part of Resident #51 ' s care plan. 4. Resident #205 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, stage 4 pressure ulcer to the sacrum, unstageable pressure ulcer to the left heel and type 2 diabetes mellitus. Resident #205's active care plan, initiated on 01/20/25, did not include a focus area for activities of daily living. Baseline care plan, dated 01/20/25, revealed Resident #205 required assistance with activities of daily living. He was dependent on staff for toileting hygiene, shower/bath, and transfers and required moderate assistance with personal hygiene. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #205's cognition was intact. He had no behavior and no rejection of care. He was dependent on staff for shower/baths, toilet hygiene, dressing, transfers, and bed mobility. He also required moderate assistance with personal hygiene. Resident #205 was always incontinent with bowel and bladder and had range of motion limitations to both sides of his upper extremities. Resident 205's care area triggered for ADL care. An interview was conducted on 02/05/25 at 3:16 PM with Minimum Data Set (MDS) Nurse. She verified there were no areas on Resident #205's care plan for ADL care and there should have been a focus added. She explained that by the time the MDS assessment was completed the care plan should also be completed. She stated it was an oversight that this intervention was not added on Resident #205's care plan. An interview was conducted on 02/06/25 at 9:33 AM with the Director of Nursing (DON). She stated a focus or intervention area for ADL care should have been part of Resident #205 ' s care plan.

Based on record reviews, observations, and family, resident, and staff interviews, the facility failed to provide nail care and/or incontinence care for 8 of 13 residents dependent on staff for activities of daily living (ADL) (Residents #9, #32, #35, #51, #205, #1, #206, and #33). The findings included: 1a. Resident #9 was admitted to the facility on [DATE] with diagnoses that included a history of a fractured right femur, history of a stroke, Alzheimer's disease, and diabetes. The care plan updated 7/18/24 indicated Resident #9 required one person staff assist for bathing and personal hygiene. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #9 was cognitively intact. There were no mood concerns, but it was noted that the resident was coded for rejection of care. Resident #9 was dependent on staff for toileting, bathing, and personal care and was incontinent of bowel and bladder. A review of the shower sheets for Resident #9 indicated that on 2/3/25 the resident was given a shower, but nail care was marked as not done. An observation on 2/3/25 at 9:07 AM revealed that Resident #9 had jagged fingernails on both hands that extended beyond the fingertips. The fingernails had a yellow-brown substance underneath all of them. Resident #9 stated at the time of the observation she was not offered nail cleaning during her shower that day. Subsequent observations on 2/4/25 at 11:40 AM and on 2/5/25 at 9:30 AM revealed the resident had jagged fingernails with a yellow-brown substance underneath. On 2/6/25 at 8:50 AM NA #4 was interviewed and confirmed she was the NA assigned to Resident #9 that day. NA #4 stated she was regularly assigned to the E hall where Resident #9 lived. She stated that nail care was completed during showers unless the resident refused. She indicated that Resident #9 had a nail care pouch that sat on her table, and she would try to do her own nail care. She stated Resident #9 refused nail care on her shower day on 2/3/25. She further stated that Resident #9 refused showers and nail care a lot. On 2/3/25 at 12:59 PM the Treatment Nurse was interviewed. She stated at the end of the day she brought the Nurse's Aides (NA) to her office to review if the residents received their shower and if nail care was completed at that time. She stated that she knew the residents were getting their showers because she saw the NAs taking the residents to the shower room. The Infection Control (IC) nurse was interviewed on 2/4/25 at 10:33 AM. She stated that she randomly went through the facility checking the residents' fingernails. She stated that the NAs were ultimately responsible for nail care, but that it was lacking lately. The Director of Nursing (DON) was interviewed on 2/6/25 at 10:01 and stated the Nurse Aides normally do nail care during showers and morning care. She indicated that the Infection Control nurse would assist with nail care sometimes as well. She stated that nail care should be done on shower days and residents should be checked daily for as needed care. 1b. An observation and interview with Resident #9 occurred on 2/3/25 at 9:07 AM. The room had a strong odor of urine. Resident #9 reported that she was a heavy wetter and had been wearing a wet brief for a long time last night. She stated that she had pushed her call light, but it was turned off. Resident #9 stated she had to wait an extended period before staff helped change her undergarment after the light was turned off. She stated it was about 5:00 AM when the NA helped her. There was a clock noted on the wall located at the end of the resident's bed within her line of vision. On 2/3/25 at 6:11 AM NA #1 was interviewed. She stated that she was the only NA who worked 7:00 PM to 7:00 AM on the night shift that day and that she was assigned all the halls in the facility. She stated that it was difficult to get to each resident to check on them throughout the shift. She stated the last time she changed Resident #9 was around 5:00 AM when she did rounds on the E hall. The Director of Nursing was interviewed on 2/6/25 at 10:01 AM and stated that NAs were supposed to round on residents every two hours to assist with toileting and as needed to provide personal care. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbances, diabetes type II, and major depressive disorder. A review of the care plan revised on 9/13/24 revealed Resident #32 required two person staff assistance with bathing/showering. Staff were to check nail length and trim and clean on bath day and as necessary. The care plan also indicated the resident had a history of refusing showers and should be offered a sponge bath if she refused. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #32 was cognitively intact without mood or behavioral concerns. She was coded as requiring substantial/maximal assistance with bathing/showering and setup assistance for personal hygiene. An observation and interview was conducted with Resident #32 on 2/2/25 at 12:54 PM. The resident was noted to have long jagged fingernails that extended beyond the fingertips on both hands. She had chipped nail polish on the nails and there was a black substance noted underneath. Resident #32 stated that she liked having her nails long and pretty. She stated that the Activities Director would paint her nails for her sometimes as part of activities. Resident #32 stated she had never refused to have her fingernails cleaned when she was given a shower because the NA never asked her if she wanted to have the care done. Subsequent observations were completed on 2/3/25 at 3:10 PM and 2/4/25 at 10:18 and continued to reveal the fingernails were long and jagged with a black substance underneath the nails. The shower sheets were reviewed and indicated on 2/3/25 Resident #32 refused a shower but received a bed bath. The shower sheet also indicated she refused nail care. On 2/5/25 at 9:49 AM NA #2 was interviewed. She stated she gave Resident #32 a shower on 2/3/25. She stated that she usually took a washcloth underneath the resident's nails to clean them, but she missed doing that for Resident #32 on her shower day due to so much going on and being pulled to do different things for other residents. NA #2 stated she could only clean Resident #32's nails since she had diabetes, and the nurses had to cut her fingernails. She further stated that Resident #32 liked having long fingernails and would refuse nail care at times. The Infection Control (IC) nurse was interviewed on 2/4/25 at 10:33 AM. She stated that she randomly went through the facility checking the residents' fingernails. She stated that she would cut the nails of the residents who had diabetes if the NAs informed her it needed to be done. She stated that the NAs were ultimately responsible for nail care, but that it was lacking lately. On 2/4/25 at 2:34 PM the Activities Director was interviewed. She stated pretty nails were offered to residents weekly. The activity included painting nails and occasionally filing them. She stated she did not clip fingernails, and she would let the nurse know if any resident needed their fingernails clipped. She could not recall the last time Resident #32 was at the pretty nails activity. The Director of Nursing was interviewed on 2/6/25 at 10:01 AM stated the Nurse Aides normally do nail care during showers and morning care. She indicated that the IC nurse would assist with nail care sometimes as well for those residents diagnosed with diabetes. She stated that nail care should be done on shower days, and the residents should be checked daily for as needed care. The DON stated that Resident #32 did receive care and seemed happy to her. 3. Resident #35 was admitted to the facility on [DATE] with diagnoses including a displaced fracture of the left femur and acute weakness. A review of the care plan updated 11/4/24 revealed Resident #35 needed assistance of 1 staff person for bathing and personal hygiene. The care plan also indicated Resident #35 had a history of refusing her showers and bed baths. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #35 was severely cognitively impaired without mood or behavioral concerns. The resident was coded as dependent on staff for bathing/showering and personal hygiene care. On 2/2/25 at 6:09 PM Family Member #1 was interviewed. She stated the family visited Resident #35 daily and they had noted the NAs rarely cleaned or cut the resident's nails. Family member #1 stated that she had to cut the resident's fingernails herself in the past and needed to cut them again that week. She stated that the facility was often short staffed, and if the NAs saw her with the resident, they would often skip her care. On 2/2/25 at 11:37 AM Resident #35 was observed with long fingernails that extended beyond the tips of her fingers. There was a black substance underneath the nails. Subsequent observations conducted on 2/3/25 at 12:38 PM and 2/4/25 at 10:18 AM revealed the resident had long fingernails with a black substance underneath them. The shower sheets were reviewed for Resident #35 on 2/3/25. She was scheduled for a shower every Monday and Thursday. The shower sheets were signed for 1/27/25, 1/30/25, and 2/3/25, but the contents indicating what type of care was provided was incomplete. On 2/6/25 at 8:50 AM, NA #4 was interviewed. She stated that nail care was completed during showers unless the resident refused. She indicated that Resident #35 refused her shower on 2/3/25 and said she did not want to be touched. NA #4 stated Resident #35 would often refuse showers and request not to be touched. She stated the family would assist her at times when they visited. On 2/3/25 at 12:59 PM the Treatment Nurse was interviewed. She stated that at the end of the day she brought the NAs to her office to review the care provided to the residents during showers. She stated that she was unsure why the shower sheets for Resident #35 were left blank, but she stated that she knew the residents were getting their showers because she saw the NAs taking the residents to the shower room. The Infection Control nurse was interviewed on 2/4/25 at 10:33 AM and stated that she randomly went through the facility checking the residents' fingernails. She also stated that she would cut the nails of the residents who had diabetes if it was reported to her that it was needed since NAs could not cut their nails. She stated that the NAs were ultimately responsible for nail care, but that it was lacking lately. The Director of Nursing was interviewed on 2/6/25 at 10:01 AM and stated the Nurse Aides normally do nail care during showers and AM care. She indicated that the IC nurse would assist with nail care sometimes as well for those residents diagnosed with diabetes. She stated that nail care should be done on shower days, and the residents should be checked daily for as needed care. She stated the NAs should report refusals of showers to the floor nurse. 46095 4. Resident #51 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis (weakness or paralysis on one side of the body), and aphasia (loss of ability to understand or speak). Baseline care plan, dated 01/13/25, revealed Resident #51 required assistance with activities of daily living. He was dependent on staff for incontinence care, toileting hygiene, personal hygiene, shower/bath, and transfers. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51's cognition was severely impaired. He had no behavior and no rejection of care. He was dependent on staff for personal hygiene and shower/baths. A review of Resident #51's nursing progress notes from 01/13/23 to 02/04/23 did not reveal refusals for showers or nail care. An observation of Resident #51 was conducted on 02/02/25 at 11:20 AM. The observation revealed Resident #51's fingernails on his left and right hands extended approximately 1/4 to 1/2 of an inch beyond his fingertips and were jagged. Under the fingernails on the left and right hands was a brown/black substance. An observation of Resident #51 was conducted on 02/03/25 at 11:08 AM. He was observed on a shower stretcher being taken to the shower room. The observation revealed Resident #51's fingernails were still long, jagged, and dirty. An observation of Resident #51 was conducted on 02/03/25 at 12:08 PM. Resident #51 was observed sitting in his wheelchair with his family member rubbing his legs. The Resident's fingernails were still long, jagged, and dirty. An observation and interview were conducted on 02/03/25 at 12:09 PM with Resident #51's family member. She stated she tried to keep Resident #51's nails clean and cut because they were long, and he had been scratching himself. She stated the staff had not cut or cleaned them since he was admitted to the facility, and she did not realize that was their responsibility. An observation of Resident #51 was conducted on 02/04/25 at 9:14 AM. Resident #51's fingernails were still long, jagged, and dirty. A phone interview was conducted on 02/04/25 at 1:12 PM with Nursing Assistant (NA) #7 which stated she provided showers to the residents that were scheduled for 02/03/25. She verified she gave Resident #51's shower on 02/03/25. She stated she did clean Resident #51's nails on 02/03/25 after his shower, however she did not cut or file them. She indicated she did not know why she did not cut or filed his nails. An interview was conducted on 02/05/25 at 11:22 AM with Nursing Assistant (NA) #2. She verified she was the direct care NA for Resident #51 on 02/03/25. She stated she did not perform nail care to the residents on F Hall because she did not know the residents and did not know if they were diabetic. She also stated she did not think to ask the nurse. She explained that she normally performed nail care when she gave showers. An observation and interview were conducted on 02/04/25 at 10:00 AM with the Director of Nursing (DON). She stated nail care was to be done any time it was needed. The Nursing Assistants normally did nail care during showers, morning care, and as needed. She observed Resident #51's nails and stated his nails needed to be cut and cleaned. She then stated there was no reason his nails had not been tended to. An interview was conducted on 02/04/25 at 10:33 AM with the Infection Control (IC) Nurse. She stated that she randomly went through the facility checking fingernails. She also stated that Nursing Assistants were ultimately responsible for nail care, but it's been lacking lately. 5. Resident #205 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra and type 2 diabetes mellitus. Baseline care plan, dated 01/20/25, revealed Resident #205 required assistance with activities of daily living. He was dependent on staff for toileting hygiene, shower/bath, and transfers and required moderate assistance with personal hygiene. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #205's cognition was intact. He had no behavior and no rejection of care. He was dependent on staff for shower/baths and required moderate assistance with personal hygiene. A review of Resident #205's nursing progress notes from 01/20/23 to 02/04/23 did not reveal refusals for showers or nail care. An observation of Resident #205 was conducted on 02/02/25 at 11:30 AM. The observation revealed Resident #205's fingernails on his left and right hands extended approximately 1/4 of an inch beyond his fingertips and were jagged. Under the fingernails on the left and right hands was a brown/black substance. An observation of Resident #205 was conducted on 02/03/25 at 2:19 PM. His fingernails were still noted to be long, jagged, and dirty. An observation and interview were conducted on 02/04/25 at 9:40 AM with Resident #205. He was observed lying in bed watching television. Resident #205's fingernails were observed to still be long, jagged, and dirty. He stated he asked a staff member to cut and clean his fingernail a week ago, the staff member said they would be back to do them but never returned. An interview was conducted on 02/05/25 at 11:22 AM with Nursing Assistant (NA) #2. She verified she was the direct care NA for Resident #205 on 02/03/25. She stated she did not perform nail care to the residents on F Hall because she did not know the residents and did not know if they were diabetic. She also stated she did not think to ask the nurse. She explained that she normally performed nail care when she gave showers. An interview was conducted on 02/05/25 at 12:48 PM Nurse #1/Wound Nurse. She verified she was Resident 205's direct care nurse on day shift for 02/02/25 and 02/03/25. She stated the Nursing Assistants should be performing nail care when they did showers and when they performed morning care. She stated she had not noticed that Resident 205's fingernails needed to be cut or cleaned, and NA #2 did not report to her that the nails were long and needed to be cut. An observation and interview were conducted on 02/04/25 at 9:55 AM with the Director of Nursing (DON). She stated nail care was to be done any time it was needed. The Nursing Assistants (NAs) normally did nail care during showers, morning care, and as needed unless they were diabetic. If the resident was diabetic the NAs could clean the nails, but the nurse would have to cut the nails. She observed Resident #205's nails and stated his nails needed to be cut and cleaned. She then stated there was no reason his nails had not been tended to. An interview was conducted on 02/04/25 at 10:33 AM with the Infection Control (IC) Nurse. She stated that she randomly went through the facility checking fingernails. She also stated that Nursing Assistants were ultimately responsible for nail care, but it's been lacking lately. 6. Resident #1 was admitted to the facility on [DATE]. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] indicated her cognition was moderately impaired. She required moderate assistance with toileting hygiene, shower/bath, and dressing. She was occasionally incontinent with bowel and bladder. An observation was conducted on 02/02/25 at 10:54 AM of Resident #1 sitting on the side of her bed with the bedside table in front of her. The surveyor observed her sheet with a very large wet area with a brown ring around it in the center. Resident #1 stated the staff did not put a pull-up on her or check on her last night and she saturated her clothes and bed. She explained that she wore pull-ups at night time and she needed assistance with incontinence care. The surveyor observed a note taped to the closet door that read, I am incontinent and need help going to bathroom!!! (Even at night). She indicated a nurse put the note on the door a while back because the NAs didn't assist her at night. Resident #1 also stated the note on the door did help some but there were still times that night shift didn't come in her room. She further explained that she did use her call bell for assistance, but the night staff would come in and turn it off without assisting her. An interview was conducted on 02/04/25 at 6:10 AM with Nursing Assistant (NA) #1. She verified she did work the night of 02/01/25 and that she was Resident #1's direct care NA. She indicated she checked on Resident #1 at 6:00 AM on the morning of 02/02/25 and she was not soaked. She explained she put a pullup on Resident #1 and checked on her at 3:00 AM and about 6:00 AM. An interview was conducted on 02/02/25 at 11:50 AM with Nursing Assistant (NA) #4. She verified she was the direct care NA for Resident #1. NA #4 stated Resident #1 and her bed were saturated this morning (02/02/25) when she entered the room. She explained she did not have a pull-up or brief on, so she provided incontinent care and removed the linens from her bed. An observation was conducted on 02/03/25 at 8:35 AM of Resident #1's room. A strong smell of urine was present, the bed was without sheets, and the mattress appeared wet. Resident #1 was not in her room. An interview was conducted on 02/03/25 at 8:50 AM with Nursing Assistant (NA) #4. She verified she worked full time on day shift and was normally the direct care NA for Resident #1. She stated Resident #1 did have a pullup on this morning (02/03/25) however, she and her bed were saturated with urine. She explained that she gave Resident #1 a shower and removed the linen from the bed. She then explained this was a reoccurring problem. A follow-up interview was conducted on 02/04/25 at 12:35 PM with Resident #1. She stated that the staff on night shift do not assist her with putting on a pullup or incontinent care throughout the night. She explained she sometimes she reminds them, but they don't listen to her. She had not filed a grievance regarding the concern because she forgot to do it. An interview was conducted on 02/06/25 at 9:33 AM with the Director of Nursing. She stated she was unaware Resident #1 had not received incontinent care consistently on night shift. She also stated she expected all residents to be provided with incontinent care timely. 7. Resident #206 was admitted to the facility on [DATE]. Baseline care plan, dated 01/30/25, revealed Resident #206 required assistance with activities of daily living. Resident #206's Minimum Data Set (MDS) assessment was in progress. Admission/Readmission Data Collection, dated 01/30/25, revealed Resident #206 was alert and oriented to person, place, and time. She was frequently incontinent with bowel and bladder and wore briefs. She also required assistance from one staff member with activities of daily living. An interview was conducted on 02/02/25 at 6:21 PM with Resident #206's and her family member. The family member stated on 02/01/25 at 5:10 PM when dinner trays were being served, he told the Nursing Assistant (NA) (did not know the NAs name) that the resident needed incontinence care to be provided because Resident #206 was wet. He also stated the NA told him she would be back, however, no one returned to change her. He indicated he turned the call bell on at 5:20 PM and at 5:40 PM a nurse and an NA (did not know their names) were in the hallway, he stopped them and told them Resident #206 needed incontinence care to be provided but they did not come into the room to assist. The family member stated he then put the call bell on again at 5:45 PM but no one responded. He explained that he walked up the hall, looked at the nurses' station and down all the halls but he did not see anyone at all. He stated by this time his mom and the bed were saturated with urine. At 6:30 PM a different NA came by the room, and he stopped her and asked if she could provide incontinent care to Resident #206, which she did. Resident #206 stated that what her son had stated was correct, they didn't come after being asked several times. An interview was conducted on 02/04/25 at 2:20 PM with Resident #206. She stated the Nursing Assistant (NA) was good today and had provided incontinent care like she should. She then stated on 01/31/25 she waited 1 hour and 30 minutes for the NA to come and change her and on 02/01/25 she waited 1 hour and 20 minutes to be changed. She explained that her family member timed the occurrences because no one would answer her call bell or respond to her family member's request for assistance needed. She also explained that she did not know the NAs name that assisted her, only that it was an African American female. Multiple unsuccessful attempts were made to contact the Nursing Assistant that worked from 4:00 PM until 7:00 PM on 01/31/25 and from 3:00 PM until 7:00 PM on 02/01/25. 40197 8. Resident #33 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, and diabetes type 2. The active care plan, last reviewed 9/6/24, included a focus area for Activities of Daily Living (ADLs) self-care performance deficit related to activity intolerance, impaired balance and is at risk for further decline. The interventions included one person assistance for bathing/showering and personal hygiene. The care plan did not include any refusals of nail care. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact and was dependent on staff for bathing and personal hygiene. A review of Resident #33's nursing progress notes from 2/1/24 to 2/2/25 revealed no refusals of nail care documented. A review of the Nurse Aide (NA) shower sheets for December 2024 to February 2025 revealed that nails were cleaned but not cut. A shower sheet dated 2/1/25 indicated that Resident #33's nails were cleaned. On 2/2/25 at 11:10 AM, an interview and observation were conducted with Resident #33. A dark substance was present under the nails to both hands and jagged nails were observed to the third and fourth finger on the right hand. Resident #33 explained that he was not able to see very well and relied on others to care for his fingernails. He stated that occasionally a nurse came by to cut his fingernails. An observation occurred on 2/3/25 at 11:33 AM while Resident #33 was lying in bed. A dark substance was present under the nails to both hands and jagged nails were observed on the third and fourth fingers of the right hand. A phone interview occurred on 2/4/25 at 1:02 PM with NA #7. She was assigned to care for Resident #33 on 2/1/25 and had indicated on the shower sheet that she had cleaned his fingernails. NA #7 explained that she provided Resident #33 with his scheduled shower on 2/1/25 and had used the stick to clean under his nails. She stated she observed the jagged nails and indicated she could have filed them but didn't stating, Maybe I'll try that next time I see they are jagged. She was unsure if she had let the nurse know of the jagged fingernails. A phone interview with a family member for Resident #33 was completed on 2/4/25 at 4:23 PM. She indicated that nail care was a concern when she visited, and she would often let staff know when she identified a dark substance under his fingernails or if they needed to be trimmed. On 2/5/25 at 9:49 AM, NA #2 was interviewed and indicated when she provided personal care to Resident #33, she would use a washcloth to clean his fingernails but didn't cut them. She could not recall if she had noticed the jagged nails to his right hand when she had cared for him on 2/3/25. Attempts were made to contact NA #3 on 2/4/25 and 2/5/25, who was assigned to care for Resident #33 on 2/2/25 during the 7:00 AM to 7:00 PM shift but were unsuccessful. The Director of Nursing (DON) was interviewed on 2/4/25 at 10:00 AM and explained the NAs were to complete nail care during showers/baths, personal care and as needed. For diabetic residents, the NAs were able to clean and file fingernails and if they needed to be trimmed would need to let the nurse know. On 2/4/25 at 10:33 AM, an interview occurred with the Infection Control nurse who explained that she randomly went throughout the facility checking fingernails and would clean, file and trim as needed at times. The Infection Control nurse stated that ultimately it was the responsibility of the NAs to perform nail care during personal care and baths. On 2/4/25 at 10:39 AM, an observation was conducted of Resident #33's fingernails with the Infection Control Nurse. She confirmed they had a dark substance under the nails to both hands and there were 2 fingernails that were jagged on the right hand. Resident #33 agreed to let the nurse care for his fingernails. Nurse #1 was interviewed on 2/4/25 at 12:50 PM. She worked in the facility as both the wound care nurse and a floor nurse when needed. She explained that nail care should be completed by the NAs during personal care and baths. They are to clean under the fingernails and file if uneven. If the resident was diabetic and needed their nails cut the NA would let the nurse know. She had not been made aware that Resident #33 had jagged fingernails on his right hand. Another interview was completed with the DON on 2/6/25 at 9:32 AM and stated Resident #33's jagged fingernails should have been reported to the nurse so they could have trimmed them. She added that she would expect fingernails to be observed on shower days and during personal care with nail care rendered as needed.

Based on observations, record reviews, staff interviews, resident interviews, and resident family interviews, the facility failed to provide sufficient nursing staff to provide incontinence care in a manner to maintain the residents' dignity (Resident #1, #206, and #9) and failed to provide assistance with Activities of Daily Living (ADL) to residents who required extensive to total care with nail care and incontinence care (Residents #9, #32, #35, #51, #205, #1, #206, and #33). This affected 8 of 18 sampled residents reviewed for sufficient staffing. The findings included: This tag is cross-referred to: 1. F550: Based on record review, observations, resident, resident family, and staff interviews, the facility failed to provide incontinence care in a manner to maintain the residents' dignity for 3 of 5 residents reviewed for dignity (Residents #1, #206 ,and #9). 2. F677: Based on record reviews, observations, and family, resident, and staff interviews, the facility failed to provide nail care and/or incontinence care for 8 of 13 residents dependent on staff for activities of daily living (ADL) (Residents #9, #32, #35, #51, #205, #1, #206, and #33). Review of staff posting, assignment sheets, and the time cards revealed: On 01/12/25 there was 1 Nursing Assistant (NA) providing resident care from 3:40 PM until 7:00 PM for a census of 50 residents. On 01/27/25 there was 1 NA providing resident care from 4:00 PM until 7:00 PM for a census of 52 residents. On 01/30/25 there was no NA working the floor from 4:00 PM until 7:00 PM and 1 NA providing resident care from 7:00 PM until 11:00 PM for a census of 54 residents. On 01/31/25 there was 1 NA providing resident care from 4:00 PM until 11:00 PM and from 11:00 PM until 7:00 AM for a census of 54 residents. On 02/01/25 there was 1 NA providing resident care from 3:00 PM until 7:00 PM for a census of 54 residents. On 02/02/25 there was 1 NA providing resident care from 3:00 PM until 7:00 PM for a census of 54 residents. A phone interview was conducted on 02/05/25 at 10:40am with Nurse #2. She stated she hadn't been at the facility working for about a month. She explained when she started working at the facility it was on day shift however, about a month later she went to night shift because she was overwhelmed on day shift due to not having enough Nursing Assistants (NA) working. She further explained she was no longer a full-time employee, she only worked as needed because of her concerns with staffing. She went on to say when she worked 7:00 PM-7:00 AM there were nights, and could not recall how many, she would come in and there wouldn't be an NA until 11:00 PM. She indicated she would be over a medication aide, have her own medication cart to pass out medications, do blood sugars, and there were times the residents received incontinent care and/or were assisted to bed later than they should have. She went on to say she felt like there needed to be a plan in place when an NA wasn't coming to work, but the facility didn't have a plan when an NA was not going to come to work. She then stated the nurses assisted as much as they could, but they were trying to pass out medications. A phone interview was conducted on 02/05/25 at 06:09 PM Nursing Assistant (NA) #8. She stated she normally worked 7:00 PM-7:00 AM and she had to work the whole building by herself two to three times a week. She also stated it was not possible to keep every person dry when working by herself or conduct routine rounds and provide incontinent care at least every two hours. She further explained some nurses would assist, and some wouldn't. She concluded the interview by stating, you just can't operate a building like that. An interview was conducted on 02/06/25 at 9:01 AM with Nursing Assistant (NA) #6. She stated she had worked at the facility for 9 years and she had never seen staffing as bad as it was over the past three to four months. She explained she worked all shifts but at times when she would come in at 11:00 PM there would not be any NAs in the building, and she would normally have to work by herself on the night shift. She indicated there was one nurse, a med aide and herself on night shift. She further explained there was no way to keep all of the residents dry and do all of the required tasks when there were only 2 NAs on first shift or 1 NA at any time. She went on to say the census was normally above 50 residents. An interview was conducted on 02/06/25 at 9:33 AM with the Director of Nursing (DON). She stated staffing was hard, she had requested to use an agency, and to give bonuses to the staff that did come in and work extra. However, she explained both requests had to be approved by corporate and they had not approved the facility to use agency. She explained qualified department heads would assist the NAs when they were short staffed to ensure the residents were fed and provided with incontinent care. She also stated she expected all residents to be fed and provided incontinent care timely. She explained on the day shifts when there were 2 NAs scheduled it was not possible to complete all showers and tasks. She verified the staffing numbers on 01/12/25, 01/27/25, 01/30/25, 01/31/25, 02/01/25, and 02/02/25 were correct.

Based on observations and staff interviews, the facility failed to label, date and remove expired food items stored for use and remove food with signs of spoilage from 1 of 1 walk-in refrigerator and failed to ensure frozen food items were dated and not stored open to air with signs of freezer burn in 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents. The findings included: Accompanied by Dietary Aide #1, an observation was made of the walk-in refrigerator on [DATE] at 10:46 AM. The following items were stored in the refrigerator: -One undated box of butter that was open and partially used -One undated bag of mozzarella cheese that was open and partially used -One undated box of mozzarella cheese that was open and partially used -One open and partially used container of sour cream dated [DATE] -One box of parmesan cheese opened and dated [DATE] -One undated metal baking pan of gelatin dessert covered with aluminum foil with a frozen white substance on top of the foil -One box of 12 cucumbers with white fuzzy spots -One plastic container of honey opened and undated -One bottle of lemon juice opened and undated An observation of the walk-in freezer revealed the following stored items: -One box of frozen carrots opened and undated -One bag of shrimp undated -One bag of toast undated -One box western style beef patties unwrapped and open to air with ice crystals on them On [DATE] at 10:46 AM Dietary Aide #1 was interviewed. She stated that the former Dietary Manager (DM) walked out without notice this past Friday, [DATE]. She indicated that the DM was the one responsible for dating food and disposing of outdated food kept in storage. Dietary Aide #1 stated a new DM would begin working on [DATE]. Cook #1 was also interviewed on [DATE] at 11:15 AM. He stated that the dietary department was short staffed that day due to a call out. He stated that the Dietary Manager usually made sure the food was dated and stored correctly. The District Dietary Manager was interviewed on [DATE] at 12:45 PM. He stated that the former Dietary Manager had walked out this past Friday, [DATE]. He indicated that he had spoken with the dietary staff this past Friday, [DATE], regarding the need to date food.

Based on observation, and staff, and family interviews and record review, the facility failed to serve the lunch meal at the posted time on 2/2/25 as well as failed to serve the breakfast meal at the posted time on 2/3/25 for 2 of 5 meal observations. This practice had the potential to affect other residents for meal delivery. The findings included: An observation was completed on 2/2/25 at 11:30 AM of the area outside of the main dining room. A meal schedule was posted as follows: -Breakfast 7:15 AM to 8:10 AM -Lunch 12:00 PM to 12:45 PM -Dinner 5:15 PM to 6:10 PM 1. On 2/2/25 at 12:30 PM four residents were observed waiting in the dining room for their lunch to be served. The Administrator was noted to be walking around the area assuring the residents their meals were due out soon. Lunch trays were served to the residents in the dining room beginning at 1:28 PM. On 2/2/25 at 12:45 PM the Regional Dietary Manager provided a copy of the facility's meal delivery log. The meal delivery log indicated that lunch was scheduled to be served in the dining room at 12:00 PM. a. Resident #206 was admitted to the facility on [DATE]. The quarterly Minimum Data Set was in progress. Family member #1 was interviewed on 2/2/25 at 12:50 PM, and he stated that one of Resident #206's family members was always at the facility for mealtimes. He stated supper was served 1.5 hours late on 1/31/25 and lunch was served late on 2/2/25. He stated it was hard to encourage Resident #206 to eat without knowing when meals would be delivered. On 2/2/25 at 1:00 PM Resident #206's Family Member #1 was heard in the hallway asking staff why the resident's lunch tray had not been delivered yet. He stated Resident #206 had waited a long time for her meal, and she was hungry. Staff stated that trays were due to come out soon. The first cart to leave the kitchen for lunch service on 2/2/25 was 1:28 PM. The meal cart was observed to be delivered to the F hall where Resident #206 resided at 2:00 PM. Lunch was scheduled to be delivered to the F hall by 12:45 PM. The Regional Dietary Manager was interviewed on 2/2/25 at 2:35 PM. He indicated that a staff member called out that day without letting the manager know. He further stated that one of the meals got dropped during lunch service and had to be redone causing a delay. According to Dietary Aide #1 who was interviewed on 2/2/25 at 2:43 PM, the dietary staff was not usually behind with meal delivery. She indicated that lunch trays were typically out by 11:30 AM. She stated that the State surveyors being in the kitchen delayed them that day. Dietary Aide #1 stated the kitchen was short staffed due to a call out that morning. She stated that they typically have three staff members in the mornings to help with meal service. She further stated that a tray had been dropped causing the staff to prepare a new entree for lunch. On 2/2/25 at 2:47 PM the new Dietary Manager was interviewed. She stated that the dietary staff called her that morning to let her know she needed to buy bread. She stated that when she arrived at the facility, she then had to redo the meal tickets, and that threw the kitchen off on meal delivery. 2. An observation of the breakfast meal service on 2/3/25 beginning at 7:15 AM revealed the Dietary Manager (DM) was recording the temperature of food items. The pureed eggs and ground sausage were below the holding temperature, and the DM had to place the food back in the oven to bring to up to serving temperature. The plating of food by dietary staff did not begin until 7:40 AM. The first meal cart left the kitchen at 7:50 AM. Breakfast trays were scheduled to be delivered beginning at 7:15 AM. An interview was completed on 2/3/25 at 8:35 AM with the Dietary Manager. She stated that breakfast service was late that morning in part because of training a new cook as well as having one staff member call out. She indicated that due to some foods not being at the proper temperature for serving, the ground sausage and pureed eggs, she had to put them back in the warming oven to get the food to the correct temperature causing a further delay in serving breakfast. The Dietary Manager stated staff will say they will work then fail to show up for work. An interview was completed on 2/3/25 at 2:46 PM with the District Dietary Manager. He stated that due to the former Dietary Manager walking out on 1/31/25 and staff calling out that mealtimes were delayed on 2/2/25 and 2/3/25. He stated that the new Dietary Manager began working on 2/3/25 as well as a new dietary staff member, and he felt the service would improve with additional staff on board. The Director of Nursing was interviewed on 2/6/25 at 10:01 AM. She stated that dietary had hired new staff, and she expected mealtimes to get better.

Based on record review, observations, resident, resident family, and staff interviews, the facility failed to provide incontinence care in a manner to maintain the residents' dignity for 3 of 5 residents reviewed for dignity (Residents #1, #206 ,and #9). Findings included: 1. Resident #1 was admitted to the facility on [DATE]. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] indicated her cognition was moderately impaired. She required moderate assistance with toileting hygiene, shower/bath, and dressing. She was occasionally incontinent with bowel and bladder. An observation was conducted on 02/02/25 at 10:54 AM of Resident #1 sitting on the side of her bed with the bedside table in front of her. The surveyor observed her sheet with a very large wet area with a brown ring around it in the center. Resident #1 stated the staff did not put a pull-up on her or check on her last night and she saturated her clothes and bed. She explained that she wore pull-ups at night time and she needed assistance with incontinence care. The surveyor observed a note taped to the closet door that read, I am incontinent and need help going to bathroom!!! (Even at night). She indicated a nurse put the note on the door a while back because the NAs didn't assist her at night. Resident #1 also stated the note on the door did help some but there were still times that night shift didn't come in her room. She further explained that she did use her call bell for assistance, but the night staff would come in and turn it off without assisting her. An interview was conducted on 02/04/25 at 6:10 AM with Nursing Assistant (NA) #1. She verified she did work the night of 02/01/25 and that she was Resident #1's direct care NA. She indicated she checked on Resident #1 at 6:00 AM on the morning of 02/02/25 and she was not soaked. She explained she put a pullup on Resident #1 and checked on her at 3:00 AM and about 6:00 AM. An interview was conducted on 02/02/25 at 11:50 AM with Nursing Assistant (NA) #4. She verified she was the direct care NA for Resident #1. NA #4 stated Resident #1 and her bed were saturated this morning (02/02/25) when she entered the room. She explained she did not have a pull-up or brief on, so she provided incontinence care and removed the linens from her bed. An observation was conducted on 02/03/25 at 8:35 AM of Resident #1's room. A strong smell of urine was present, the bed was without sheets, and the mattress appeared wet. Resident #1 was not in her room. An interview was conducted on 02/03/25 at 8:50 AM with Nursing Assistant (NA) #4. She verified she worked full time on day shift and was normally the direct care NA for Resident #1. She stated Resident #1 did have a pullup on this morning (02/03/25) however, she and her bed were saturated with urine. She explained that she gave Resident #1 a shower and removed the linen from the bed. She then explained this was a reoccurring problem. A follow-up interview was conducted on 02/04/25 at 12:35 PM with Resident #1. She stated she was very embarrassed when her room smelled like urine and to have wet clothes on. She explained that it was not right for the staff on night shift not to assist her. She explained she sometimes reminds them, but they don't listen to her. She had not filed a grievance regarding the concern because she forgot to do it. An interview was conducted on 02/06/25 at 9:33 AM with the Director of Nursing. She stated she was unaware Resident #1 had not received incontinence care consistently on night shift. She also stated she expected all residents to be provided with incontinence care timely. 2. Resident #206 was admitted to the facility on [DATE]. Baseline care plan, dated 01/30/25, revealed Resident #206 required assistance with activities of daily living. Resident #206's Minimum Data Set (MDS) assessment was in progress. Admission/Readmission Data Collection, dated 01/30/25, revealed Resident #206 was alert and oriented to person, place, and time. She was frequently incontinent with bowel and bladder and wore briefs. She also required assistance from one staff member with activities of daily living. An interview was conducted on 02/02/25 at 6:21 PM with Resident #206's and her family member. The family member stated on 02/01/25 at 5:10 PM when dinner trays were being served, he told the Nursing Assistant (NA) (did not know the NAs name) that the resident needed incontinence care to be provided because Resident #206 was wet. He also stated the NA told him she would be back, however, no one returned to change her. He indicated he turned the call bell on at 5:20 PM and at 5:40 PM a nurse and an NA (did not know their names) were in the hallway, he stopped them and told them Resident #206 needed incontinence care to be provided but they did not come into the room to assist. The family member stated he then put the call bell on again at 5:45 PM but no one responded. He explained that he walked up the hall, looked at the nurses' station and down all the halls but he did not see anyone at all. He stated by this time his mom and the bed were saturated with urine. At 6:30 PM a different NA came by the room, and he stopped her and asked if she could provide incontinent care to Resident #206, which she did. Resident #206 stated that what her son had stated was correct, they didn't come after being asked several times. An interview was conducted on 02/04/25 at 2:20 PM with Resident #206. She stated the Nursing Assistant (NA) was good today and had provided incontinence care like she should. She then stated on 01/31/25 she waited 1 hour and 30 minutes for the NA to come and change her and on 02/01/25 she waited 1 hour and 20 minutes to be changed. She explained that her family member timed the occurrences because no one would answer her call bell or respond to her family member's request for assistance needed. Resident #206 further stated she did not like to be left soaking wet like she was on these two occurrences, even her bed and sheets were wet. She then stated, it felt yucky, and I stunk. She also explained that she did not know the NAs name that assisted her, only that it was an African American female. Multiple unsuccessful attempts were made to contact the Nursing Assistant that worked from 4:00 PM until 7:00 PM on 01/31/25 and from 3:00 PM until 7:00 PM on 02/01/25. 50415 3. Resident #9 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #9 was cognitively intact and her vision was assessed as adequate. During an interview and observation with Resident #9 in her room on 2/3/25 at 9:07 AM she reported that she was a heavy wetter and had been wearing a wet brief. She stated that she had to wait for an extended period during the night of 2/2/25 before staff would help change her undergarment. She stated she had pressed her call light, but it was turned off and the staff did not assist her for at least an hour afterward. A clock was observed in the resident's room on the wall in front of her bed. She indicated that she felt ignored when she needed help and had to wait. Resident #9 further stated having to wait so long for help to arrive caused her to feel aggravated. She indicated she was uncomfortable having to wear wet briefs. On 2/3/25 at 6:11 AM Nurse Aide (NA) #1 was interviewed. She stated that she was the only NA who worked 7:00 PM to 7:00 AM on the night shift that day. She stated that it was difficult to get to each resident to provide toileting care throughout the shift. She stated that when she worked alone, she tried to round on everyone at least every 2 hours. She indicated that she had checked on Resident #9 around 5:00 AM, and she didn't need any assistance at that time. NA #1 stated staff calling out was often an issue, leaving the night shift shorthanded. She stated it was difficult to respond to the call lights when multiple residents needed help. The Director of Nursing (DON) was interviewed on 2/6/25 at 10:01 AM. She stated that NAs were supposed to round on residents every two hours and as needed to provide personal care and that Resident #9 should have received incontinence care. The DON stated that an NA had called out the night of 2/3/25 causing the facility to be short staffed.

Based on observations, record reviews, resident and staff interviews, the facility failed to place a resident's call light within reach for 2 of 2 residents reviewed for accommodation of needs (Residents #6 and #14). The findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included history of stroke, chronic pain, and chronic obstructive pulmonary disease (COPD). Resident #6's active care plan, last reviewed 10/3/24, included the following focus areas: - Activities of Daily Living (ADL) self-care performance deficit related to COPD, chronic pain syndrome and left-sided weakness. One of the interventions was to encourage the resident to use the call light for assistance. - Risk for falls related to history of falls, impaired gait/balance problems related to history of a stroke with weakness, potential side effects related to use of psychoactive drug use, poor safety awareness and impulsive behaviors. One of the interventions included to encourage the resident to use the call light for assistance with transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was cognitively intact, displayed no behaviors and required maximum assistance from staff to complete ADLs. On 2/2/25 at 11:30 AM, an observation and interview occurred with Resident #6 while he was lying in bed listening to his radio. The call light was lying on the floor to the left side of the bed out of reach. Resident #6 stated he didn't know how long the call light had been on the floor and couldn't recall it sliding off the bed. He went on to say that normally the call light was fastened to his bed covers so that he could use it, but there were times he would have to ask staff who passed by his room to put the call light where he could reach it. He stated he would have to yell out if he needed something as he was unable to get out of bed on his own to reach it. Another observation was made on 2/2/25 at 12:40 PM. Resident #6 was lying in bed listening to his radio. The call light remained on the floor to the left side of the bed out of reach. When asked how he would request assistance, he stated he would use the call light when he could reach it, otherwise he let staff know when they entered the room, were passing by or yelling out for assistance. Resident #6 stated the nurse had been in to give him his medications that morning but left out of his room before making sure his call light was pinned to him. He recalled asking for it and was told they would be right back. On 2/2/25 at 1:15 PM, an interview occurred with Nurse Aide (NA) #3. She was scheduled to care for Resident #6 from 7:00 AM to 7:00 PM on 2/2/25. She explained she was working with one other NA for the entire building (the census on the day of the interview was 54) and had three other hallways to care for. This was the first time she had been over to Resident #6's hall, she was unaware the call light was not within reach and would fix it immediately. On 2/2/25 at 2:45 PM, an interview was completed with Medication Aide (MA) #1 who was assigned to care for Resident #6 on the 7:00 AM to 7:00 PM shift for the day of the interview. She couldn't recall if his call light was within reach when she provided him with his morning medications. On 2/5/25 at 9:12 AM, Resident #6 was observed lying in his bed listening to the radio. The head of the bed was elevated, and the call light was noted to be hanging between the headboard and the wall behind Resident #6, out of his reach. NA #6 was interviewed on 2/5/25 at 10:00 AM. She observed Resident #6's call light hanging on the back of headboard out of reach. NA #6 explained she was assigned to care for Resident #6 from 7:00 AM to 3:00 PM and thought she had clipped it to his covers after personal care had been rendered that morning. She retrieved the call light and hooked it to Resident #6's blankets within reach. The Director of Nursing was interviewed on 2/6/25 at 9:32 AM and stated Resident #6's call light could have fallen off the bed if he reached for a snack, but staff should be ensuring the call lights are clipped within reach, so they don't fall off the bed. 46095 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc degeneration and repeated falls. Resident #14's active care plan, dated 01/16/25, indicated she was at risk for falls related to intervertebral disc degeneration and repeated falls. The interventions included ensuring her call light was within reach and encouraging Resident #14 to use it for assistance as needed. Resident #14's admission Minimum Data Set (MDS) dated [DATE] indicated her cognition was intact. Resident #14 required maximal assistance with toileting hygiene, shower/bathe self, dressing, bed mobility, transfers, and personal hygiene. She was occasionally incontinent with bladder and always incontinent with bowels. An observation was conducted on 02/02/25 at 11:00 AM of Resident #14. She was observed asleep lying on her bed. Her call light was on the floor under the left side of her bed. An observation was conducted on 02/02/25 at 12:10 PM of Resident #14. She was sitting in her wheelchair about an arm's length from the left side of the bed. Her call light remained out of reach on the floor under the left side of her bed. An observation and interview were conducted on 02/02/25 at 1:01 PM with Resident #14. She was sitting in her wheelchair on the left side of the bed. Her call light was on top and in the center of her bed. She indicated that after the Nursing Assistant (NA) got her out of bed she made the bed and put the call bell in the center of it before exiting the room. Resident #14 propelled herself to the left side of her bed and stated if she attempted to reach for the call bell, she would fall face first out of her wheelchair. She then stated she would have to yell for assistance if she needed anything and hope that someone would hear her. She explained when the NA was in a hurry, they didn't pay attention to where they put the call bell and whether it was in her reach. She then indicated it was frustrating if she couldn't reach the call bell because she could not get the staff's attention. An observation and interview were conducted with Nursing Assistant (NA) #3 on 02/02/25 at 1:15 PM. She verified she was the direct care NA for Resident #14. She verified she did put Resident #3's call bell in the center of her bed and that Resident #3 could not reach the call bell from where the wheelchair was positioned. She indicated that Resident #3 would propel herself in the wheelchair and she figured if she needed it, she would move over to get it. An interview was conducted on 02/04/23 at 10:00 AM with the Director of Nursing (DON), she stated the call light device should always be in the resident's reach.

Based on record review and staff interviews, the facility failed to develop an individualized and comprehensive care plan in the areas of pain and opioid medications (Resident #21), and the facility failed to implement a care plan area for safety (Resident #25). This was for 2 of 18 residents whose care plans were reviewed. 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included unspecified abnormalities of gait, osteoarthritis, and chronic pain syndrome. A review of the medication orders for Resident #21 for December 2024 revealed an order for oxycodone 5 milligrams, give 2 capsules by mouth every 4 hours as needed for pain that was active from 11/7/24 until 12/16/24. The order was changed to oxycodone 5 milligrams, give 1 capsule by mouth every 4 hours as needed for pain with a start date of 12/19/24 and end date of 12/31/24. The order was renewed 12/31/24 with a discontinued date of 1/2/25. A review of the December MAR revealed Resident #21 reported pain levels to nursing that ranged from 2 to 6 each day and was administered oxycodone 5 mg every 4 hours as needed for pain. The 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 was cognitively intact with a depressed mood without behavioral concerns. She was coded as having pain occasionally and for receiving an opioid. Active orders reviewed for January 2025 revealed Resident #21 had an order for oxycodone 5 milligrams, give 2 tablets by mouth every 6 hours as needed for pain. The order was active from 1/2/25 until 1/28/25. The medication orders for February 2025 revealed Resident #21 had an order for morphine sulfate, give 20 milligrams by mouth every six hours as needed for pain. A review of the MAR for January 2025 revealed the resident reported pain levels to nursing that ranged from 3 to 10 daily and received oxycodone 5 milligrams every 6 hours as needed for pain. The care plan updated 1/9/25 did not have a focus for pain management. A review of the medication administration record (MAR) for February 1-3, 2025, revealed that Resident #21 reported pain levels to nursing that ranged from 4 to 5 each day and was administered morphine sulphate 20 milligrams every 6 hours as needed for pain. On 2/5/25 at 3:00 PM the MDS nurse was interviewed. She verified the care plan for Resident #21 did not include a focus for pain. She stated that it should have been added at the time the MDS was completed. The Director of Nursing (DON) was interviewed on 2/6/25 at 10:01 AM. She stated that a focus for pain should have been added to Resident #21's care plan. 40197 2. Resident #25 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness and Alzheimer's disease. A review of Resident #25's physician orders included an order dated 8/14/23 for a fall mat to the left side of the bed when in bed. Resident #25's active care plan, last reviewed 9/26/24, included a focus area for risk for falls related to dementia, muscle weakness, lack of coordination, cognitive impairment, impaired mobility, poor safety awareness , impulsive behaviors and history of falls. One of the interventions was to place a fall mat to the left side of the bed when in bed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #25 had moderately impaired cognition and required moderate assistance for bed mobility and transfers. He was not coded with any falls. On 2/2/25 at 11:00 AM, Resident #25 was observed lying in bed. There was no fall mat to either side of the bed. On 2/3/25 at 2:14 PM, Resident #25 was observed lying in bed with his eyes closed. There was no fall mat present to the left side of the bed. There was no fall mats observed in Resident #25's room or bathroom. On 2/4/25 at 6:11 AM, Resident #25 was observed lying in bed. There was no fall mat to the left side of the bed. Nurse Aide (NA) #1 was interviewed on 2/4/25 at 6:18 AM and stated she had been assigned to care for Resident #25 during the 7:00 PM to 7:00 AM shift on the day of the interview. She stated she had been employed at the facility for two months, had never seen a fall mat in Resident #25's room nor was she aware he needed to have one at bedside. NA #6 was interviewed on 2/5/25 at 10:00 AM. She was assigned to care for Resident #25 from the 7:00 AM to 3:00 PM on 2/5/25. She explained that she hadn't seen Resident #25 with a fall mat next to his bed until it was in his room on 2/4/25. She added that items such as fall mats needed would be on Resident #25's Kardex, but because they worked with a limited number of staff it was hard to review the Kardex each day. She stated she relied on report from the off going shift. The Unit Manager was interviewed on 2/5/25 at 11:33 AM and stated that she couldn't explain why there was no fall mat next to Resident #25's bed or located in his room until 2/4/25. She felt like he still needed the fall mat for safety as he did attempt to get himself up unassisted at times. The Director of Nursing (DON) was interviewed on 2/6/25 at 9:32 AM and stated she was unsure why Resident #25 did not have a fall mat next to his bed or located in his room or bathroom on 2/2/25, 2/3/25 or 2/4/25. She stated that the NAs should be reviewing resident care guides daily to ensure items such as fall mats were in place as ordered.

Based on observations, record review and staff interviews, the facility failed to maintain a safe environment as evidenced by a housekeeping staff member mopping the entire width of the F hallway (Rooms 135-146) which would have required residents, staff, and visitors to walk on the wet floor. This was for 1 out of 5 resident hallways. Findings included: A continuous observation was conducted on 02/03/25 from 10:30 AM until 10:35 AM of the Housekeeping Manager mopping the floor at the top of the F Hall and the hall area in front of the nurse's station. The Housekeeper Manager was actively mopping the area to the left then middle of hall. When asked if the floor was wet all the way across the hall, she stopped to let the surveyor walk through to the right side of the hall where there was a 2 foot area of dry floor. As soon as the surveyor walked through the area the Housekeeper Manager mopped the only dry area left. The total area was 4 foot (ft) x 10 ft. The floor was wet completely across the hall with the wet sign located in middle of walkway. An interview was conducted with the Housekeeping Manager on 02/03/25 at 10:40 AM. She stated she mops and assists with other housekeeping duties daily. She then stated she did mop completely across the hall/walk area but did not give a reason why. She explained that she normally mops half of the hall area at a time and will wait for that half to dry prior to mopping the other side. She further stated that waiting for the floor to completely dry before starting the other side prevents residents and staff from accidentally falling. An interview was conducted with Nurse #1 on 02/03/25 at 10:48 AM. She stated some housekeepers mop completely across the hall area and some only mop one side at a time. She verified the floor at the top of the F Hall and the hall area in front of the nurse's station were wet completely across. She explained that was why she walked around the other side of the nurse's station because she did not want to fall. An interview was conducted with the Housekeeping District Manager on 02/03/25 at 3:15 PM. He explained when housekeepers were mopping the halls they should be mopping half of the hall at a time. After one side was completely dry, they were to mop the opposite side. He stated this was to prevent anyone from falling. He then stated all housekeeping staff have been educated and trained to mop the floors in that manner.

Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 2 residents reviewed for respiratory care (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure. Resident #33's active care plan, last reviewed 9/6/24, included a focus area for potential for altered respiratory status/difficulty breathing related to acute on chronic respiratory failure, COPD, history of bronchopneumonia and pleural effusion. One of the interventions included oxygen continuous at 4 liters per minute via nasal cannula. Resident #33 was hospitalized from 10/3/24 to 10/11/24 for pneumonia. A review of the physician orders included an order dated 10/11/24 for oxygen continuously at 4 liters per minute for COPD. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact, displayed shortness of breath when lying flat and was coded with oxygen use. On 2/2/25 at 11:10 AM, Resident #33 was observed lying in bed with oxygen flowing via nasal cannula. The oxygen regulator on the concentrator was set at 3.5 liters flow when viewed horizontally at eye level. Resident #33 indicated he had very poor bad sight and relied on the nursing staff to ensure his oxygen was set at the correct amount. Resident #33 was observed lying in bed on 2/3/25 at 11:33 AM. The oxygen regulator on the concentrator was set at 3.5 liters flow by nasal cannula when viewed horizontally, eye level. The February 2025 Medication Administration Record (MAR) was reviewed and included Oxygen continuous at 4 liters per minutes every 12 hours to be checked at 9:00 AM and 9:00 PM. Staff had initialed Resident #33 as receiving oxygen as ordered on 2/2/25 and 2/3/25. An observation occurred of Resident #33 on 2/4/25 at 6:14 AM, which revealed the oxygen regulator on the concentrator was set at 3.5 liters flow by nasal cannula when viewed horizontally at eye level. An observation was made with Nurse #1 of Resident #33's oxygen concentrator on 2/4/25 at 12:20 PM, who stated the oxygen regulator on the concentrator was set at 3.5 liters when viewed horizontally at eye level and looked to be set on 4 liters when standing over the concentrator. Nurse #1 adjusted the flow to administer 4 liters of oxygen. On 2/5/25 at 8:45 AM, Resident #33 was observed lying in his bed. The oxygen regulator on the concentrator was set at 3.5 liters flow by nasal cannula when viewed horizontally at eye level. The oxygen concentrator was not within reach of Resident #33. An observation was made with the Unit Manager on 2/5/25 at 11:33 AM of Resident #33's oxygen concentrator. She indicated that the oxygen regulator on the concentrator was set at 3.5 liters when viewed horizontally at eye level and looked to be set on 4 liters when standing over the concentrator. The Unit Manager adjusted the flow to administer 4 liters of oxygen and stated that staff should be setting the oxygen concentrators and ensuring they were on the ordered flow rate by looking at the oxygen regulator at eye level rather than standing over the concentrator. During an interview with the Director of Nursing on 2/6/25 at 9:32 AM, she indicated it was her expectation for oxygen to be delivered at the ordered rate.

Based on record review, resident council members and staff interviews, the facility failed to resolve repeated grievances regarding cold food for 2 of the last 4 months, not answering call bells timely for 3 of the last 4 months and late medications for 4 of the last 4 resident council meetings. The findings included: Review of the resident council meeting minutes for 7/26/23 read new business was call bells not being answered, cold food and late medications. Grievances were completed regarding late medications and cold food. There were no grievances regarding the call bells. Review of the resident council meeting minutes dated 8/22/23 read old and new business reviewed was late medications, aides answering call bells timely and cold food and remained unresolved. A grievance was completed regarding late medications but not for cold food or answering call bells timely. Review of the resident council meeting minutes dated 9/20/23 read old and new business of late medications and aides not answering call bells timely. A grievance was completed regarding late medications and call bells. Review of the resident council meeting minutes dated 10/24/23 read old and new business of late medications and aides not answering call bells timely. New business included cold food. Grievances were completed regarding late medications and the call bells but not for cold food. A resident council meeting was held on 11/1/23 at 1:30 PM with 12 residents that regularly attend the meetings. Five of the 12 stated they felt like their concerns 'fell on deaf ears and voiced a lot of frustration with issues remaining unresolved. Residents voiced continued unresolved issues regarding cold food and call bells. They also voiced frustration regarding call bells, the ice machine in the dining room being broken since they mentioned it in their August resident council meeting. The only answer ever provided by the facility was that the part was on back order. Residents voiced the kitchen did not offer an alternate except for a peanut butter and jelly sandwich and did not serve what on the menu. An interview was completed on 11/1/23 at 2:53 PM with the Director of Nursing (DON). She stated she started her position late September and began working on call bell audits in October and was ongoing. She also stated the issue of late medications was partially resolved due to hiring and training more staff. An interview was completed on 11/2/23 at 10:45 AM with the Administrator. She stated the facility replaced the food serve carts in an effort to resolve the cold food issues and had been completing audits of the call bells. She stated she was unaware of the ongoing concerns regarding the ice machine in the dining room but she would follow up with the Maintenance Director. The Administrator stated resident council grievances should be resolved timely but there were concerns that required more time to fix. When that happens, the facility should follow up with the resident council to explain why an issues remained unresolved.

Based on observations, resident and staff interviews, the facility failed to ensure residents over the bed lights were in working order. This was for 2 (Resident #30 and Resident #40) of 5 residents reviewed for pressure ulcers. The facility also failed to ensure the walls in resident rooms were in good repair. This was for 4 (room #'s 117, #118, #123 and #127) of 19 rooms reviewed for homelike environment. The findings included: a) During a wound care observation of Resident #30 on 10/31/23 at 11:00 AM, the Wound Nurse attempted to turn the over the bed light on, but it did not come on. The Wound Nurse stated it was difficult to see what she was doing because there were no ceiling lights in any of the resident rooms. Resident #30 stated the Maintenance Director came in and stated he would replace the bulb in his over the bed light. b) During an observation of wound care on 10/30/2023 at 10:19AM, the Wound Nurse could not get Resident #40's overhead light to function. The wound bed could not be visualized. After completing wound care, the Wound Nurse used her cell phone light to check the alternating air mattress settings. The Wound Nurse stated she would get the Maintenance Director to fix the over the bed light. c) Observations completed from 10/30/23 to 11/2/23, of rooms 117, 118, 123 and 127 revealed the wall behind residents' beds were in disrepair with dents and exposed sheetrock. During an observation and interview on 11/1/23 at 11:10 AM, the Maintenance Director provided a notebook outside his office where staff wrote down issues and repairs for him to address. He attempted to turn on the light over Resident #30's bed, but it did not turn on. He stated there was nothing in his notebook about Resident #30's or Resident #40's bulb needing to be changed. The Maintenance Director stated someone likely just told him about a burnt-out light bulb yesterday, but he didn't recall which room it was. He toured rooms 117, 118, 123 and 127 and noted the condition of the resident's walls. The Maintenance Director stated he knew there were a lot of walls in need of repair, but he was doing his best and could only do so much. An interview was completed on 11/2/23 at 10:45 AM with the Administrator. She stated there was no specific plan for repairing the walls in the resident rooms and the Maintenance Director had trouble prioritizing his work.

Based on observation, resident, and staff interviews the facility failed to provide the residents with meals served at regularly scheduled times for 1 of 1 meal observation of the F-Hall. This practice had the potential to affect meals served to other residents. The findings included: A meal schedule was provided on 10/30/23. Meal delivery times were recorded as follows: Breakfast - 7:30 AM - 8:15 AM Lunch - 12:00 AM - 12:45 PM Dinner - 5:30 PM - 6:15 PM On 10/30/23 at 09:05 AM, staff were observed removing the last 2 breakfast trays from the tray cart and taking them into rooms at the end of F-Hall. a. The admission Minimum Data Set (MDS) dated [DATE] had Resident #262 coded as cognitively intact and was independent with eating after set-up. During an interview with Resident #262 on 10/30/23 at 9:22 AM, Resident #262 stated the breakfast trays had just got served and that meal trays were often late and cold. He further stated he has only been at the facility for 6 days. He indicated he looked at his clock when the trays are delivered. He also indicated it was important to him to eat his meals at consistant times due to him being a diabetic. b. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #43 coded as cognitively intact and was independent with eating after set-up. During an interview with Resident #43 on 11/02/23 at 9:30 AM, he stated breakfast normally comes out daily between 9:00 AM and 10:00 AM, late and cold all the time. He also stated lunch is normally no later than 1:00 PM and dinner between 5:30-6:30 PM. Resident #43 pointed at the clock and indicated he looked at it when the meals are brought to the room. During an interview with NA #2 on 10/31/23 at 1:08 PM, she stated meals come out late all the time. The latest time she had seen breakfast served was 10:00 AM, lunch at 2 PM, and dinner at 7 PM. She also stated the kitchen had recently hired more staff and that hopefully the meal trays would start coming out daily on time. During an interview with NA #5 on 10/31/23 at 1:13 PM, she stated meals come out late all the time. She further stated breakfast was normally served between 9:00 AM and 10:00 AM. She indicated that the breakfast meal was the only one that she observed coming out late. She further indicated the kitchen had hired new dietary aides so the time of the breakfast trays being brought to the halls should improve. During an interview with the Dietary Manager (DM) on 11/01/23 at 2:35 PM, he stated a new relief cook called out on 10/30/23 approximately 45 mins prior to his shift which caused breakfast to be served late. He then stated the meals have come out late at times due to staff not showing up or calling out. If it's a no call, no show he sometimes finds out right before he gets to the facility or when after he arrives. He indicated the kitchen was short staffed but he had recently hired new dietary aides that were still learning how the kitchen functions. He further indicated he still needed a relief cook. During an interview with the Dietary District Manager on 11/02/23 at 9:45 AM, she stated she was aware breakfast was late at times due to staffing issues. She then stated they had recently hired new dietary aides but the kitchen was short a relief cook at this time. During an interview with the Administrator on 11/02/23 at 10:05 AM, she stated the kitchen staff are contracted out and were not [NAME] employee's. She indicated they had been working with the Dietary Manager and trying to get staff hired, but they had not had much luck for a relief cook. She was aware the kitchen was short staffed, and that staff had called out late or didn't call out at all, which interfered with the meal being served at scheduled times. She then stated she expected meals to be served on time and expected enough kitchen staff to carry out the functions of food and nutrition services.

Based on observations, record review, resident, staff, Wound Care Physician and Medical Director (MD) interviews, the facility failed to provide pain management prior to surgical debridement of Resident #1's pressure ulcers. Surgical debridement is a procedure to remove debris or infected/dead tissue from a wound. The procedure lasted forty-five minutes. Resident #1 expressed pain, cried, grimaced, cringed, became nauseated and requested cessation of the procedure. Resident #1 experienced pain at a level of 9 on a scale of 0 to 10 and was not provided pain management consistent with her comprehensive person-centered care plan or her goals and preferences. This deficient practice affected 1 of 1 resident reviewed for pressure ulcers. Immediate Jeopardy began on 4/26/2022 when the facility failed to pre-medicate Resident #1 prior to a painful procedure and continued the procedure when she expressed pain, verbally, to the Wound Care Nurse and the Wound Care Physician. Immediate Jeopardy was removed 4/28/2022 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and new certified wound physician training. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE] revealed Resident #1 was cognitively intact. The assessment indicated the Resident had pain during the lookback period that was a 6 on a scale of 0 to 10 with 10 being the worst pain ever and 0 being no pain. No behaviors were exhibited during the lookback period. The assessment identified one stage 3 pressure ulcer and two stage 4 pressure ulcers present on admission with treatments that included the application of nonsurgical dressings, ointments and medications, a pressure reducing device to the bed and nutritional support. Resident #1's care plan, dated 1/21/2022, revealed a focused area that read, the Resident was at risk for pain with a goal to have minimal interruption in normal activities due to pain through the review date. The intervention was to anticipate the Resident's need for pain relief and respond immediately to a complaint of pain. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)]-Acetaminophen (an opioid pain medication) 5 mg/325 mg give two tablets by mouth every 4 hours as needed for severe pain, initiated 1/5/2022 and discontinued on 4/23/2022. - [MEDICATION(S)]-Acetaminophen (an opioid pain medication) 5mg/325 mg give two tablets by mouth every 6 hours as needed for pain, written on 4/23/2022 by the Primary care physician. - 75 mcg/hour [MEDICATION(S)] Patch (a potent, long-acting opioid medication) to be applied to the skin every 72 hours, date initiated 3/26/2022. - 325 mg Acetaminophen (an analgesic pain medication) give 2 tablets by mouth as needed every 4 hours for pain or increased temperature, date initiated 2/26/2022. The Wound Care Physician notes, dated 4/19/2022, revealed Resident #1 had the following identified wounds: Site 1. Stage 4 pressure wound of the left ischium Site 2. Stage 4 pressure wound of the sacrum Site 3. Stage 4 pressure wound of the left lateral calf. Site 4. A full thickness shear wound of the right buttock. Site 5. A full thickness shear wound of the left buttock. Site 6. A full thickness shear wound of the right upper thigh. Site 7. An unstageable deep tissue injury of the right calf with partial thickness. The Resident's electronic Medication Administration Record for April 2022 revealed documentation that Resident #1 received [MEDICATION(S)]-Acetaminophen 5 milligrams (mg)/325 mg on 4/25/2022 at 11:06 p.m. and was not documented as administered on 4/26/2022 prior to the procedure. The documentation revealed the [MEDICATION(S)] 75 mg transdermal patch was changed and reapplied on 4/25/2022. A review of the narcotics log for Resident #1, for the [MEDICATION(S)]-Acetaminophen 5 mg/325 mg, 2 tablets every 6 hours as needed for pain, revealed the medication was signed out on 4/26/2022 at 6:00 a.m. by the night shift nurse, Nurse # 3. This medication was administered and not documented on the Medication administration record. On 4/26/2022 at 12:42 p.m. Resident #1 was observed lying in the bed on her right-side crying tears, with her face lying on the bedside table, grimacing, and clenching the bed linens in her fist. The Wound Care Physician and the Treatment Nurse were present at the bedside. The Resident had wound dressings removed, that included wound packing (a dressing used to treat large, open or deep wounds with material to absorb drainage and protect the area), from 7 wounds. At this time, the physician was observed to step outside of the Resident room to gather additional supplies. Upon discovering Resident #1 crying tears and grimacing on 4/26/2022 at 12:45 p.m., an interview was conducted while the Wound Care Nurse was standing at the doorway of the room. Resident #1 revealed she had informed the Wound Care Nurse when she came to her room to begin the dressing changes that she had not received her pain medication. Resident #1 was not sure if they were due yet, or if the next administration was closer to 2:00 p.m. when she could have them again. Resident #1 revealed she had received her last dose of pain medication from the night shift nurse (Nurse #3) prior to her leaving in the morning. She added that she requested to wait for the treatments but was told the physician had to go somewhere else. The Resident stated the Physician stated he had no other residents to provide care for and had another facility to go to. She revealed her as needed pain medications had been adjusted this past week and she was not sure why, but she now received less pain medication. The Wound Care Physician re-entered the room at 12:47 p.m. and an ongoing observation was conducted at this time. Upon discovering that pain medication had not been provided prior to the treatment, the Wound Care Nurse and the Wound Care Physician were asked if pain medication was provided. The Wound Care Nurse stated the Resident received a scheduled medication, via [MEDICATION(S)] patch and was not due any medication at the time. The Wound Care Physician stated he was providing the [MEDICATION(S)] spray (a topical anesthetic pain reliever) for local anesthetic. The Wound Care Physician was standing on the window side of the bed. He began cleansing the wound and removing a previous dressing, calcium alginate (a natural fiber dressing designed to absorb wound secretions and form a gel like covering over the wound), and the Wound Care Physician was told by the Resident that it hurt, and she was nervous. The Wound Care Physician replied, It's alright, you will do well. The Wound Care Physician asked the Resident if the pain resolved last time (referring to another day of treatment). The Resident responded, awhile later after you stopped and he replied, Good, then you will do fine. The Resident let out a cry and the Wound Care Physician stated, You are doing fine, and we need to get a little more goop out. The Resident then asked, Can we please wait for next week? The Wound Care Physician replied, We can't. The resident then requested additional [MEDICATION(S)] spray and the Wound Care Physician stated, you have been sprayed. The Wound Care Physician then looked at everyone in the room and provided the additional spray. When asked if the Resident's pain was assessed using a pain scale prior to beginning the treatment, the Wound Care Nurse stated the Resident's pain medication timing was not considered because she received scheduled pain medication that was extended release via a [MEDICATION(S)] patch. The Wound Care Physician stated the Resident had scheduled pain medication and was doing good (while she was observed to continue crying tears). The Wound Care Physician began to debride the right buttock with a sharp instrument used to remove tissue. He then began to cut tissue from the wound with scissors. The Resident was observed to cringe, grimace, and cry tears. At 1:12 p.m. the Resident stated she wanted it to be done. She did not ask them to stop when she stated she wanted to be done. The Wound Care Nurse provided a touch on the Resident's arm. The Resident was then rolled onto her back for the Wound Care Physician to view the right calf wound. The Resident gripped the bed and bedside table and was told by the Wound Care Physician, you must let go now. The Resident informed the Wound Care Nurse and the Wound Care Physician that she felt sick to her stomach at 1:15 p.m. At this time, the Surveyor had to request if someone could pause to see if the Resident required something for pain and a basin. The Wound Care Physician then stated, please get her a basin, but no one asked her if she desired pain medication. The Wound Care Physician asked if someone could get the Resident a [MEDICATION(S)], a nausea prevention medication, but did not stop to allow anyone to administer a [MEDICATION(S)] prior to continuing the treatment. The nurse did not go for [MEDICATION(S)] or a basin and the Resident finally stated to just forget it. The Wound Care Physician informed the Resident if the pain became too much for her, then he would stop. He sprayed the right calf wound with [MEDICATION(S)] spray. When the Wound Care Physician began to debride the wound, the Resident stated, Ouch, aww and stop. The Wound Care Physician stopped without the debridement of the wound. The wound care procedure ended at 1:28 p.m. An interview was conducted with the Wound Care Physician on 4/26/2022 at 1:41 p.m. and he revealed he felt the Resident was putting on a little because additional people were in the room during the procedure. He added that he had stronger topical pain medications he could have used, and he would have used the pain medication if he felt she needed it. He was referring to a stronger concentration of topical [MEDICATION(S)] ointment. He stated she did exhibit more anxiety than usual today, 4/26/2022. When asked if he was aware she had a change to her pain medication on 4/23/2022 and that she no longer received her as needed pain medication every 4 hours, he stated he was unaware, and this was important information that he would like to have known prior to the procedure. An interview was conducted on 4/26/2022 at 3:02 p.m. with Nurse #2, the hall nurse for Resident #1. Nurse #2 revealed she began her shift on 4/26/2022 at 7:00 a.m. and had not been asked by the Wound Care Nurse or the Wound Care Physician to provide a pre-procedure pain medication prior to the wound care being started. She added Resident #1 had not received an as needed (PRN) pain medication on her shift and was able to have [MEDICATION(S)]-acetaminophen 5 mg/325 mg, two tablets, prior to the procedure taking place because her last dose was at 6:00 a.m. by Nurse # 3. She revealed she entered the room, after the wound care had taken place, (she was unsure of the time) to answer a call light for Resident #1's roommate and observed Resident #1 required something for nausea and pain. The Resident rated her pain a 6 on a scale of 0 to 10. On 4/26/2022 at 3:20 p.m. an interview was conducted with the Wound Care Nurse, and she revealed it was her standard nursing practice to request the hall nurse to provide pain medication, if needed, prior to a procedure for wound care. She stated she would ask the Resident their pain level on a scale of 0 to 10 or do an assessment scale. The Wound Care Nurse reviewed the Medication Administration Record for Resident #1 and the narcotic signature log sheet and revealed the Resident could have pain medication prior to the procedure that took place on 4/26/2022. She stated she did not request Nurse #2 to provide pain medication prior to the procedure because she did not know the Resident had pain medication available and was not sure if the Wound Care Physician could wait. She added that based on the visual nursing assessment (she did not provide a pain scale number) during the wound care treatment on 4/26/2022 the Resident had an increase in pain and anxiety compared to the wound care treatment she performed on 4/25/2022 when she had received pain medication before the procedure. She stated Resident #1 informed her she had pain during the procedure on 4/26/2022. The Wound Care Nurse stated she did not assess Resident #1's pain scale prior to the treatment because the Resident told her she could not have pain medication until 2:00 p.m. She stated the Resident was usually aware of her orders and when she can receive medication. An interview was conducted with Resident #1 on 4/26/2022 at 4:08 p.m. and she revealed the pain level during the wound care treatment on 4/26/2022 had been a 9 on a scale of 0 to 10, with 10 being the worst pain she had ever felt and 0 being no pain. She added the Wound Care Physician told her he could not wait for her to receive her pain medication. She added this made her feel like she would just need to bear it and made her nervous causing her anxiety to get worse. She revealed when the nurses and doctors refuse to get her pain medication before her treatment it makes her feel like they do not understand the pain she endures during a treatment. She added that her pain medication had been changed on 4/23/2022 from every 4 hours as needed to every 6 hours as needed and she did not receive notification from the staff until she requested the medication. The Resident revealed she had not been told she could request medication prior to treatment and had gone without pretreatment on a few occasions with the Wound Care Physician only. An interview was conducted on 4/26/2022 at 5:18 p.m. with the Director of Nursing and she revealed it was her expectation that a resident be treated prior to wound care if there was pain reported and an order in place for an as needed medication. An interview was conducted with the facility Medical Director on 4/28/2022 at 10:43 a.m. and he revealed Resident #1 had been on prescription narcotics for chronic pain for an extended amount of time with 7 wounds. He indicated a sign of a resident experiencing pain would be movement during care, grimacing, crying, and taking deep breaths. He added that when he conducts a pain assessment of a resident, he uses the verbal statement from a resident combined with the visual cues from the body. He stated a Resident stating they have pain combined with grimacing, crying, and clenching the bed linens would indicate the resident was having the pain they revealed of a 9 out of 10 and he would take that at the face value. He stated a resident with multiple deep pressure ulcers has a reason to have significant pain during manipulation of the wound bed. He revealed if during the wound care, a resident indicated pain, he would expect a physician to stop, provide pain medication and then make another effort to try again. The Administrator was notified of immediate jeopardy on 4/27/2022 at 5:09 p.m. The facility provided a credible allegation of immediate jeopardy removal dated 4/28/2022. * Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Based on observations, record reviews, and State Surveyor and staff interviews, the facility failed to assess a resident's pain prior to, during and after wound care treatment provided, failed to verify and administer pain medication prior to wound care treatment (Resident 1). * Resident #1 has been assessed by the Wound Care nurse on 4-26-22 and pain medication was administered. Wound Care Nurse notified Resident #1's Physician concerning pain management, new orders received and transcribe to the Medication Administration Record, Resident #1 was notified of current medication changes made. Resident #1's Plan of Care has been updated on 4-26-22 by the Director of Nursing to reflect resident's problem, goal, and interventions. Resident #1 was notified of the current medication changes that were made to her plan of care. * Current Facility Residents with wounds have the potential to be affected. a. Current Residents with wounds (13) had Pain Assessments completed by a Licensed Nurse on 4-26-22 using a Pain Assessment to determine those that are at risk for pain. a.i. Current residents with wounds (13) were reviewed to ensure current orders included pain management. These Residents had interventions put into place by a Licensed Nurse and their Plans of care were updated on 4-27-22. b. Current Residents with wounds (13) had orders for pain management received for wound care prior to treatment. Pain Evaluations performed by a Licensed Nurse on 4-26-22 to ensure that resident with wounds have been addressed and appropriate interventions are in place. b.i. These affected Residents had interventions put into place by a Licensed Nurse and their Plans of care were updated, accordingly on 4-27-22. The residents and/or Responsible Party was notified of changes made with current orders to include pain medications and plan of care. b.ii. The Facility has a contract with a Certified Wound Company with Physicians who makes rounds weekly for consultation, assessment, and treatment orders. The Certified Wound Physician is available by phone and via telehealth for consultation, assessment and treatment orders. Previous Certified Wound Physician was terminated on 4/26/2022. A new Certified Wound Physician will be starting on 5/2/2022 and will be educated during orientation to center related to assessing pain before, during and after wound care is provided. Physician will be included in updating resident's plan of care to include pharmacological and non-pharmacological pain interventions are being offered prior to wound care management. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. * On 4-26-2022, the Director of Nursing conducted education with the Nurse Manager/Wound Care Nurse to ensure the following; assess pain before, during and after wound care is provided, to stop providing wound care if the resident says to stop as related to pain or discomfort, to verify that pharmacological pain interventions are offered prior to wound care management, will communicate with wound care provider of any pain management changes, pain medications are to be administered as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care education will be provided by the Nurse Manager during orientation for newly hired nurses and ongoing. * On 4-27-2022, the Director of Nursing conducted education with the Nurse Manager/Wound Care Nurse to ensure Nurse Aides were provided education related to reporting pain to the nurse based on the request or observation of the patient according to the plan of care. * On 4-26-2022, the Director of Nursing and/or Nurse Manager conducted re-education with Licensed Nursing Staff to ensure the following: a. Licensed Nursing Staff - assess pain before, during and after wound care is provided. b. Licensed Nursing Staff -- to stop providing wound care if the resident says to stop as related to pain or discomfort. c. Licensed Nursing staff - education provided to verify that pharmacological pain interventions are offered prior to wound care management. d. Licensed Nursing staff - will communicate with wound care provider of any pain management changes. Wound care education will be provided by the Nurse Manager during orientation for newly hired nurses and ongoing e. Licensed Nursing Staff- pain medications are to be administered as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . f. Starting on 4/27/2022 Nurse Aides were provided education related to reporting pain to the nurse based on the request or observation of the patient according to the plan of care. g. Staff not educated prior to 4/27/2022 will be educated prior to working their next shift. The Executive Director will validate the staff education was completed prior to the staff member working their next shift. The Executive Director was notified of the responsibility of validating staff education on 4/27/2022. h. Newly hired nursing staff will be educated by the Nurse Manager during the orientation period going forward. The Executive Director is responsible for the implementation of this credible allegation F-697. Alleged IJ removal date is 04/28/2022 Onsite validation was completed on 4/28/2022 through staff and resident interviews, observation, and record review. Staff were interviewed to validate in-service completion on pain management before, during and after wound care. Staff development education signature logs were reviewed. Resident #1 was interviewed to see if pain was assessed prior to wound care being provided if pain medication was offered and if time was allowed for the medication to take effect. Observations were conducted of wound care with pain assessments conducted. A review of the medical record for 13 residents with identified wounds revealed pain management orders were in place if identified pain was assessed and a review of Resident #1's medical record revealed a pain management order was provided to be given prior to wound care, as needed. The facility's Immediate jeopardy removal was validated to be completed as of 4/28/2022.

Based on record reviews and staff interviews, the facility failed to obtain and administer an intermediate acting insulin (NPH) and a rapid-acting insulin ([MEDICATION(S)]) for 1 of 3 newly admitted insulin dependent residents (Resident #2) resulting in hospitalization for six days with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital's discharge medication list included orders which read: 1. NPH 20 units subcutaneous daily before breakfast. 2. NPH 8 units subcutaneous each night at bedtime. 3. [MEDICATION(S)] subcutaneous 3 times a day before meals (number of units not specified). Review of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for NPH 20 units subcutaneous daily before breakfast or [MEDICATION(S)] subcutaneous 3 times a day before meals. A review of the facility's Admission Medication Reconciliation form dated 11/7/20 indicated there were no medication issues identified and no medications listed as needing clarification. The form was not signed or dated. Review of an undated Baseline Care Plan revealed under section titled Metabolic\Diabetic a check mark beside the resident's goal stating, will have no complications related to diabetes. None of the interventions were checked. Review of the nurse's note dated 11/7/20 at 8:20 p.m., written by Nurse #1 indicated Resident #2's medications were ordered but had not arrived. There was no documentation indicating the pharmacy, the physician, the DON (Director of Nursing) or the Executive Director were notified. The nurse's note dated 11/8/20 at 9:17 p.m., written by Nurse #1 indicated the facility continued to await the resident's medications to arrive from the pharmacy. There was no documentation indicating the pharmacy, the physician, the DON (Director of Nursing) or the Executive Director were notified. The November 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weights and Vitals Summary Record for the month of November 2020 revealed the first blood sugar value for Resident #2 was documented by Nurse #3 on 11/9/20 at 12:30 p.m. which was 379. There was no documentation of any blood sugar monitoring for the resident on 11/7/20 and 11/8/20. The nurse's note dated 11/11/20 as a late entry for 11/9/20 at 9:30 a.m. and written by Nurse #3 revealed the pharmacy was telephoned regarding Resident #2's medications not received at by the facility. The request was made for the pharmacy to immediately deliver all of the resident's medications along with the resident's other admission medications from the weekend. The pharmacy agreed to send the medications on the first run that would be delivered early that evening. The progress noted by Nurse #3 dated 11/10/20 documented that at approximately 9:15 a.m. Resident #2 became listless and was having trouble breathing during therapy exercises in his room. During the nurse's assessment, the resident's blood sugar read HI. The Nurse Practitioner was notified and ordered STAT (immediate) laboratory tests, IV (intravenous) fluids and STAT insulin (12 units [MEDICATION(S)]) was ordered and administered. The resident's family was notified. On 11/10/20 at 1:05 p.m., the laboratory notified the facility of the resident's critical blood glucose of 1452. The nurse practitioner was notified and ordered the resident sent to the emergency room . The resident's family was notified. Emergency Medical Services (EMS) arrived at the facility at 1:00 p.m. and transported Resident #2 to the hospital. During a telephone interview on 3/5/20 at 12:57 p.m., Nurse #3 stated she did not work during the weekend Resident #2 was admitted to the facility; but worked with the resident beginning the following Monday, 11/9/20 during first shift. She stated during the morning medication administrations to the residents on the F-hall she observed no medications in the medication cart for Resident #2. She revealed that during report, the third shift nurse did not inform her the resident's medications had not been delivered to the facility. Also, the resident was to receive NPH insulin, but there was no NPH in the facility. Nurse #3 stated she immediately notified the interim DON concerning the unavailable medications. She stated she also telephoned the pharmacy at approximately 9:30 a.m. and requested a STAT delivery of the ordered medications; the pharmacy agreed to the request. She revealed she was informed the next day the medications arrived during second shift on 11/9/20. Nurse #3 stated on the morning of 11/10/20 she observed the resident while administering his medications with no complaints or problems. But later that morning during room therapy, the therapist noticed resident was off balance while standing. Nurse #3 stated when she checked the resident's blood sugar level, it read HI (glucometer's maximum was 600). The NP was in the building and was notified and ordered BMP, IV fluids and a chest x-ray. She stated the NP also instructed her to give the resident a fast-acting insulin. She revealed when she informed the NP there was no order for the resident to receive a fast-acting insulin. the NP gave the order. Nurse #3 stated she obtained a spare fast-acting insulin pen from the refrigerator in the medication room and administered the insulin to the resident. The resident's blood sugar was rechecked but still read HI. The results of the BMP were called in from the laboratory showing the resident's blood sugar was at a critical level. Nurse #3 stated the NP ordered Resident #2 sent immediately to the emergency room . The review of the hospital discharge summary dated 11/16/20 revealed Resident #2 was admitted to the hospital on 11/10/20 due to blood glucose levels in the 1400s as the result of not receiving insulin since the weekend (11/7/20). The resident was quite lethargic but able to answer yes/no questions and did not refuse insulin. The resident was discharged from the hospital with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/25/20 at 4:35 p.m., the Executive Director stated while receiving in-room therapy on the morning of 11/10/20, the therapist noticed a change in Resident #2's interactions and called for the nurse who took his vital signs. The resident's blood sugars read HI (glucometer maximum was 600). The nurse informed the nurse practitioner who ordered STAT laboratory work up. The laboratory notified the facility of the resident's blood sugars were at the critical high value of 1452. The physician was notified and the resident was sent to the hospital. She stated because the resident's blood sugars were at such a critical high value, she and the acting Director of Nursing (DON) made the decision to investigate what caused the resident's blood sugars to rise so high and if the facility could have prevented the occurrence. Their findings included: the resident was admitted to the facility on [DATE] (Saturday); unless notified, the pharmacy did not make weekend deliveries; and the facility did not have the resident's type of insulin in-house. She stated there were two nurses on duty on 11/7/20 and 11/8/20. Nurse #1 worked first and second shifts and Nurse #2 worked third shift both days. The Executive Director stated the nurses on duty failed to follow facility policy and call the back-up pharmacy to obtain the needed insulin. The nurses also failed to make the supervising nurse on duty, the DON, or the Executive Director aware the resident did not have any of his insulin. Both nurses were aware of the facility's policy/protocol. She stated both nurses were terminated and reported to the Board of Nursing. The Executive Director also revealed the current DON was not employed at the facility at the time of the incident. During a telephone interview on 3/2/21 at 4:31 p.m., the Executive Director revealed Resident #2 did not receive four doses of NPH insulin as a result of the unavailability of the medication. She stated the resident's medications were delivered to the facility by the pharmacy on 11/9/20 between 8:00 p.m. and 9:00 p.m. During a telephone interview on 3/3/21 at 11:02 a.m., Nurse #1 revealed she admitted Resident #2 to the facility on Saturday, 11/7/20 and faxed his medication list to the pharmacy. The pharmacy did not delivery the resident's medications anytime throughout the weekend of 11/7/20 through 11/8/20 and the facility did not have any NPH insulin in stock. Nurse #1 stated she did not notify the physician, the Director of Nursing, or the Executive Director about the pharmacy not delivering the medication and the resident not receiving his medications. She revealed she was aware the resident had brittle diabetes and closely monitored his blood sugars. During a telephone interview on 3/3/21 at 11:42 a.m., Nurse #2 stated that on 11/8/20 and 11/9/20 she marked on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she forgot to erase/delete those markings During a telephone interview on 3/3/21 at 2:30 p.m., the Nurse Practitioner (NP) stated she was notified early morning of 11/10/20 via telephone that Resident #2's blood sugar reading was HI. She ordered STAT laboratory tests. The NP stated upon her arrival to the facility, she conducted an admission visit with the resident. The resident was awake, alert, calm, able to answer questions, skin temperature was normal, and blood pressure was 91/55. She stated during the exam the resident became lethargic but answered questions appropriately. She stated when the results of the basic metabolic panel with the reading greater than 1500 blood sugar level, she ordered the resident sent to the emergency room . The NP stated that in her professional opinion not receiving four doses of insulin would contribute to Resident #2's blood sugar reaching a high critical level. She revealed the facility was aware if there was ever a question about any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/4/21 at 1:55 p.m., the facility's Medical Director stated he did not receive any communication from the facility about not having Resident #2's medications available. He revealed he was made aware of the incident on 11/10/20 when the NP was at the facility. He stated the nursing staff should have contacted the pharmacy. He indicated if there was a delay with the pharmacy sending the medication, the expectation was for nursing staff to notify the provider within a 24-hour period. The Medical Director stated that in his opinion, Resident #2 not receiving his insulin over three days contributed to his critical blood sugar value. The Executive Director presented a completed POC with the date of compliance as 11/12/20. The POC included: On 11/11/20 at 4:40 p.m., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting was held as the result of the resident not receiving medication on the weekend. The QAPI team concluded there was a process failure for medication delivery. Medications were not received for 72 hours due to weekend cutoff being missed. The Root Cause Analysis (RCA) was the nurses were unaware of the need to call the pharmacy after weekend cutoff time. The Plan included: Pharmacy will do delivery on Saturdays and Sundays. Nurses re-educated on pharmacy process. Also re-educated all licensed nurses on 11/11/20 through 11/13/20 to contact physician when medications not available. The Administrator (Executive Director) and the DON were responsible for implementing the Plan. A quality review/observation was completed on 11/11/2020 by the regional Director of Clinical Services and Registered Nurse Manager to ensure currently diabetic residents' medication orders were accurate and up to date as prescribed by the physician to include, but not limited to insulin. An additional quality review/observation was completed on 11/11/2020 by the Director of Nursing to ensure current diabetic residents' medications were being administered by the nurse as ordered. Additionally, current residents with orders for blood glucose level monitoring were being monitored as ordered. All licensed nurses who care for the resident were interviewed on 11/11/20 about the resident not receiving his insulin throughout the weekend of 11/7/20 through 11/8/20. Education was initiated on 11/11/20 and completed on 11/13/20 by the Regional Director of Clinical Services and the Divisional Director of Clinical Services with all licensed nurses on the facility's policy on medication availability, notification, admission process and pharmacy process which included procuring medications on weekends. The weekend admissions process was evaluated, and the policies and procedures were reviewed with re-education provided to licensed nurses. Pharmacy delivery procedure changed to include Sunday delivery on 11/11/20. Pharmacy processes reviewed with attention to weekend deliveries as needed. Insulin would be added to the house medication stock in back-up for immediate availability on 11/11/20. As a result of the investigation, it was determined the licensed nurses who were assigned to the resident's care on 11/7/20 and 11/8/20 did not follow the policies and procedures regarding follow-up on medications from the pharmacy. Medication orders were entered upon admission after cut-off time for same-day pharmacy delivery. The nurses were unaware that the medications would not be delivered on 11/7/20 and 11/8/2020 unless pharmacy was called. Therefore, medications were not delivered until the next delivery day. The nurses failed to notify the Executive Director, Director of Nursing, or the physician when the medications were not available. Going forward, the facility would continue to review 5 different residents at for the next 3 months regarding all medications being available and administered to the residents as the physician ordered, use of the facility's back up (pyxis). Medications being administered on time, physician notification of missing medications, and blood glucose and insulin checks and administration. Any negative findings will be addressed immediately including notifying the physician, Executive Director, DON, and resident's responsible party. Any negative findings will be brought to the monthly QAPI meetings for review and discussion for 3 months and as long as needed. The two staff members were suspended on 11/10/20 and were terminated from the facility on 11/16/20 and 11/17/20. Both nurses involved in the incident were also reported to the NC Board of Nursing on 11/25/20. On 3/5/21 evidence of the implementation of the corrective action plan was validated through record review and staff interviews. -The quality review/observations (audits) of all medications for each diabetic resident completed by the Regional Director of Clinical Services and the facility Divisional Director of Clinical Services on 11/11/20 were reviewed and no concerns were identified with the initial audit. -The facility's signed attendance records and the agenda of the education in-service presented by the Regional Director of Clinical Services (RDCS) on 11/11/20 through 11/13/20 were reviewed. -All education listed in the corrective active plan was reviewed and there were no concerns. -Pharmacy deliveries days updated to include weekends, when needed -Weekly audit/monitoring tools were reviewed and there were no concerns. -The QAPI minutes were reviewed and diabetic/insulin/pharmacy procedures were included. -The corrective actions were completed by 11/13/20.

Based on record review and staff interview, the facility failed to prevent a dependent resident from rolling out of bed onto the floor, hitting her head on a nightstand, and becoming wedged between the bed and the nightstand during a bed bath. Resident #1 sustained a laceration to her head requiring staples as well as multiple skin tears to her left lower extremity. This was for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 ' s care plan with a review of date of 7/21/20 included the following focus areas: - The risk for falls related to decreased physical function (initiated on 7/15/19). The interventions included, in part, ensuring Resident #1 ' s call light was within reach and encouraging her to use it for assistance as needed (initiated on 7/15/19). A Transfer/Mobility Status Criteria assessment form dated 8/13/20 indicated Resident #1 required extensive assistance to total dependence. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact. She required extensive assistance of 1 for bed mobility, she was dependent of 1 for dressing and toileting, and dependent of 2 or more for transfers. Resident #1 had impaired range of motion on one side of her lower extremities. She had no falls noted. A hard copy form, Report of Resident Fall, dated 9/2/20 completed by Nurse #2 indicated Resident #1 had a fall with injury that was witnessed by Nursing Assistant (NA) #1 at 11:45 AM. Resident #1 rolled out of bed while staff (was) cleaning resident. The resident was on the floor on her left side wedged between her bed and nightstand. Resident #1 ' s side of her head was pressed against the nightstand with blood drainage noted. Her left lower leg was observed with skin tears. Nurse #2 indicated Resident #1 was alert and oriented and complained of back and head pain. Under the possible causative factors section of the form, Nurse #2 indicated bed remote in way. An SBAR (Situation Background Assessment Recommendation) change in condition electronic note dated 9/2/20 (was there a time) indicated Resident #1 had a witnessed fall from bed resulting in a laceration to left side of head and skin tears to left lower extremity. Resident #1 ' s left side of head was leaning on nightstand and blood was noted under the head on a blanket between the resident ' s head and the nightstand. During a pain assessment Resident #1 indicated an aching back and throbbing head pain at a rating of 8 on a scale of 1 to 10. The Nurse Practitioner (NP) was notified, and the resident was sent to the Emergency Department (ED) for evaluation and treatment. ED documentation dated 9/2/20 indicated Resident #1 rolled off bed while being cleaned up by staff, she hit her head on a dresser, and sustained wounds to her left leg. The physical exam showed a 2 centimeter (cm) linear scalp laceration to the head with minimal gaping as well as superficial scattered skin tears to lower extremity, and a large skin tear to the left lateral leg adjacent to the left knee approximately 8 cm x 8 cm. 2 staples were placed to Resident #1 ' s scalp laceration and her skin tears were cleansed, treated with antibiotic ointment, and dressed. The ED physician indicated that given the multiple scattered skin tears, Keflex (antibiotic medication) was ordered for outpatient therapy to prevent the development of bacterial infections. A nursing note dated 9/2/20 at 7:42 PM written by Nurse #1 indicated Resident #1 arrived back from hospital via Emergency Medical Services (EMS). She had 2 staples to the left upper forehead with some bleeding and skin tears to upper and lower outer leg. A review of the facility Nurse Aide Activity of Daily Living assistance documentation for Resident #1 from her most recent readmission on 8/13/20 to 9/2/20 revealed the following: - Bed Mobility: 3 total documented, 1 documented as dependent with 2+ assist (8/15/20 1st shift, 9/1/20 2nd shift), and 1 documented as dependent with 1 assist (9/2/20 2nd shift) The NA Care Guide, a guide that describes the resident ' s care needs, undated, indicated Resident #1 was incontinent of bowel and required 2 person assist with incontinence care, required total assistance of 2 staff members with mechanical lift for transfers, and required hands on assistance of one staff member to turn and reposition in bed. An interview was conducted with NA #1 on 9/29/20 at 1:00 PM. NA #1 reported she was familiar with Resident #1 and was working with her at the time of her 9/2/20 fall from bed that occurred during care. She indicated that Resident #1 required assistance with ADLs and that when she became sick from COVID (confirmed positive 7/30/20) she needed additional assistance as she was weaker. She stated that once on the COVID unit Resident #1 required the assistance of 2 staff for a bed bath due to the increased weakness as well as her physical size, and it was too much for 1 person to do on their own safely. NA #1 indicated that Resident #1 was on the COVID unit on 9/2/20 and she and Nurse #2 were the only staff members working on the COVID unit as there were about 10 residents total on the unit. She stated that on 9/2/20 she needed to give Resident #1 a bed bath which required 2 staff members for assistance. NA #1 revealed that at the time of the bed bath, Nurse #2 was completing her medication pass and she had not wanted to interrupt her, so she gave the bed bath to Resident #1 without anyone else ' s assistance. She explained that once staff entered the COVID unit, they were not able to re-enter any other areas of the facility. She further explained that this was why she was unable to ask a staff member who was not assigned to the COVID unit for help. NA #1 indicated that when she was finishing up Resident #1 ' s bed bath on 9/2/20, she rolled Resident #1 onto her side, away from the center of the bed, in order to change her linens. She reported that she was then positioned on the opposite side of the bed as the resident. She stated that Resident #1 must have accidentally hit the bed remote which tilted the head of the bed up and subsequently caused her to roll off the bed and onto the floor. NA #1 stated that she was unable to stop Resident #1 from rolling as she was on the opposite side of the bed. She indicated that Resident #1 hit her head on her nightstand and had several cuts on her leg. She stated that she immediately called for help and Nurse #1 came to assist her. NA #1 revealed that she should have waited for assistance from Nurse #2 to provide the bed bath. She explained that if Nurse #2 was with her, that she would have been positioned on the side of the bed the resident had rolled off of and could have prevented the fall. NA #1 was asked how she knew how much assistance Resident #1 required. She stated that she was familiar with the resident and that she talked to the other NAs who worked with her. An interview was conducted with NA #2 on 9/29/20 at 3:35 PM. She indicated that she was familiar with Resident #1 and that she required a 2 person assist for bed baths. She explained that this level of assistance was needed because of physical limitations and physical size. An interview was conducted with Nurse #1 on 9/29/20 at 3:40 PM. Nurse #1 indicated she was familiar with Resident #1. She reported that once Resident #1 was diagnosed with [REDACTED]. Nurse #1 explained this was because of physical limitations and physical size. A phone interview was conducted with Nurse #2 on 9/30/20 at 3:20 PM. She reported that she was familiar with Resident #1 and that she was working on the COVID unit at the time of her 9/2/20 fall from bed that occurred during care. She stated that on 9/2/20 she was in another resident ' s room when she heard NA #1 calling for help. She indicated that she stopped what she was doing and went into Resident #1 ' s room to assist NA #1. She stated she observed Resident #1 lying on the floor on the left side between the bed and the nightstand with her head against the nightstand. She reported that when she assessed the resident she had a laceration to the head, skin tears to her left leg, and the resident self-reported pain in her neck, back, and head. She stated that she wanted to transfer the resident from the floor to the bed, but was unable to secure a mechanical lift pad under the resident without additional staff assisting. She explained that she and NA #1 were not able to complete this task without help due to Resident #1 ' s bodyweight and her physical inability to bear weight at that time so the resident remained on the floor and EMS was called. Nurse #2 reiterated NA #1 ' s interview that once a staff member entered the COVID unit that they were unable to return to their previous assignment off of the COVID unit. She stated that she asked NA #1 what happened, and she said that she rolled Resident #1 onto her side and the resident must have either pressed the head tilt button on the remote or rolled on top of it, causing the head of the bed to raise up, and subsequently caused the resident to start rolling and she rolled right off the bed. Nurse #2 indicated that she was not sure what level of assistance Resident #1 normally required for bed baths, but that if NA #1 had asked her for help that she would have assisted when she was able. An interview was conducted with the DON on 9/29/20 at 1:40 PM. She stated that she began working at the facility in the beginning of August 2020. She indicated that she was familiar with Resident #1 and she completed an investigation into the 9/2/20 fall that occurred during care. The DON stated that she interviewed NA #1 and Nurse #2 in detail about the fall. During these interviews she determined that most often Resident #1 required 2+ assistance with ADL tasks of bed mobility, incontinent care, and bed baths. She stated that her investigation identified a twofold root cause for Resident #1 ' s 9/2/20 fall. The DON explained that 2 staff should have been used for Resident #1 ' s bed bath due to her care needs and that staff needed to ensure the bed control was positioned off of the bed to avoid any accidental pressing of the control. She reported that she began a PIP (Performance Improvement Plan) related to the 9/2/20 fall for Resident #1, but the plan had not been fully implemented as of 9/29/20. On 9/29/20 at 3:10 PM the DON provided a copy of the PIP and education inservices completed as of 9/29/20. A review of these documents revealed the PIP had not been fully implemented and education had not been completed.

Based on observations, record reviews, and interviews with resident, family, staff, psychologist, and mental health nurse practitioner, the facility failed to ensure a resident ' s safety when an immobile resident was improperly positioned in a geriatric (geri) chair when transferred by one staff using a mechanical lift. The improper positioning resulted in the geri chair tipping backward, the resident sliding out of the chair onto the floor and sustaining a golf ball sized hematoma to the back of her head for 1 of 4 residents (Resident #2) reviewed for accidents. The findings included: Resident #2 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 ' s cognition was severely impaired. She was assessed with [REDACTED]. Resident #2 was coded as dependent on two or more staff with transfers and dependent on one staff with locomotion on/off the unit, dressing, toileting, personal hygiene, and bathing. She was coded as requiring the extensive assistance of two or more staff with bed mobility. Resident #2 was not steady on her feet and was only able to stabilize with staff assistance for surface to surface transfers. The following activities were listed as not occurring for Resident #2 during the 7 day MDS look back period: moving from seated to standing position, walking, turning around, and moving on and off the toilet. Resident #2 had impairment on both sides of the upper and lower extremities and she utilized a wheelchair. She was indicated to always be incontinent of bowel and bladder. She had no falls noted. The Care Area Assessment (CAA) related to falls for the 7/21/17 annual MDS assessment indicated Resident #2 required extensive to dependent assistance with most Activities of Daily Living (ADLs). She was assessed as requiring (Brand Name) mechanical lift for transfers. Resident #2 had no recent falls, but was noted at an increased risk due to the assistance she needed. The fall risk evaluation dated 7/31/17 indicated Resident #2 was at risk for falls. She was assessed as disoriented, chair bound, poor vision status, and unable to stand. The plan of care for Resident #2 related to ADLs, initiated on 8/4/17, indicated she had an ADL self-care performance deficit, limited range of motion, limited mobility, and activity intolerance. The ADL interventions for Resident #2 included, in part, 1-2+ assistance with bed mobility, transfer assistance, and a mechanical lift for transfers. The plan of care for Resident #2 related to safety initiated on 8/4/17, indicated she had the potential for injury, poor safety awareness, poor communication, history of seizures, and decreased mobility. The safety interventions for Resident #2 included, in part, a mechanical lift for transfers. The SBAR (Situation, Background, Appearance, Review and notify) Communication Form dated 8/15/17 and completed by Nurse #1 indicated an unwitnessed fall occurred at 11:05 AM. A skin evaluation revealed Resident #2 sustained a golf ball sized hematoma to the back of her head. A pain evaluation indicated Resident #2 had chronic pain in her shoulders, arms, and hands. A neurological evaluation assessed Resident #2 with no changes. The Nurse Practitioner (NP) was notified on 8/15/17 at 11:14 AM. The NP recommendations were to monitor and notify of him of any neurological changes for Resident #2. The form indicated, (Nursing Assistant #1) reported to (Nurse #1) that Resident #2 was in a geri chair and geri chair fell back and (Resident #2) fell out. The daily skilled nurse ' s note dated 8/15/17 and written by Nurse #1 at 12:00 PM indicated Nursing Assistant (NA) #1 reported Resident #2 had a fall at 11:05 AM. The note indicated NA #1 stated the geri chair fell back and Resident #2 fell from the chair. Resident #2 sustained a hematoma to the back of her head. Neurological checks were initiated, the physician was notified, and the family was notified. Resident #2 was assessed for pain with no abnormal signs or symptoms of pain. The geri chair was checked for proper functioning and it was noted to be working properly. The Fall Root Cause Investigation Report dated 8/15/17 and completed by Nurse #1 indicated Resident #2 required two staff for assistance with transfers and a mechanical lift was to be utilized. The staff summary statement indicated Resident #2 was observed on the floor by Nurse #1. NA #2 reported Resident #2 was in her geri chair in the resident ' s room. NA #2 went into the resident ' s bathroom (located inside of the resident ' s room) and while inside of the bathroom she heard a noise. She re-entered Resident #2 ' s room and saw that Resident #2 had fallen from the geri chair. The resolution/intervention for minimizing future occurrences was staff re-education due to geri chair position/mechanical lift. A form titled, Five Whys Tool for Root Cause Analysis, not dated and not signed, indicated the following for Resident #2: - Problem Statement: Resident fell on floor - Why: She had unwitnessed fall - Why: She slid from geri chair - Why: Positioned improperly in geri chair - Why: Top or bottom too far up in chair - Why: Positioned in chair with use of lift - Root Cause: Geri chair positioning The Report of Resident Fall form dated 8/15/17 indicated Resident #2 fell at 11:05 AM. The description of the incident indicated, (Resident #2) found on floor behind geri chair. The report indicated Resident #2 slid out of the chair and was found on the floor in her room by NA #1. Resident #2 sustained a hematoma to the back of her head. New interventions that were indicated to be implemented as a result of the fall investigation were one on one re-education on geri chair/ (Brand Name mechanical) lift, group nursing re-education on proper placement of residents, and competency/skills checklists. An inservice training record with the subject of Mechanical Lift Competency and Skills Checklist was documented as provided by the Unit Manager (UM) to NA #1 on 8/15/17 at 3:00 PM. The daily skilled nurse ' s note dated 8/15/17 written for the 3:00 PM to 11:00 PM shift indicated Resident #2 ' s vitals were assessed with [REDACTED]. Neurological checks continued with no concerns identified. The physician was updated and no new orders were obtained for Resident #2. The note indicated a family member of Resident #2 arrived at the facility and requested for her to be sent to the emergency room (ER) for evaluation. The physician was notified and Emergency Medical Services (EMS) were contacted to transport Resident #2 to the ER. Resident #2 was noted to have been evaluated at the ER and returned to the facility with no new orders. An NP progress note dated 8/16/17 indicated Resident #2 was seen at the facility for a follow up to her ER visit from 8/15/17. Resident #2 was noted to have fallen backwards in her geri chair and hit her head on the floor. Neurological checks were done both prior to the ER visit and after the ER visit all of which were noted to be baseline for Resident #2. A Computed Tomography (CT) scan of Resident #2 ' s head was conducted at the ER and was reviewed with no acute abnormalities. Resident #2 ' s hematoma to the back of her head was assessed and was almost completely resolved within one day. The Fall Committee Minutes dated 8/16/17 indicated Resident #2 had a fall on 8/15/17. The plan of care changes related to Resident #2 ' s fall were indicated as staff education related to (Brand Name mechanical) lift policy/procedure and the geri chair. Resident #2 ' s plan of care related to safety was updated on 8/16/17. Resident #2 was noted with a fall on 8/15/17. The intervention added was staff re-education on proper use of a mechanical lift and geri chair. An inservice training record with the subject of (Brand Name) mechanical Lift was documented as provided by the UM to 18 staff (14 NAs and 4 nurses) on 8/16/17 at 7:00 AM. The training was noted to include reading materials and skills checklist. A list of the nursing staff (licensed and unlicensed) employed at the facility on 8/15/17 was reviewed. It indicated there were 37 nursing staff members (22 NAs and 15 nurses) employed at the facility on 8/15/17. An observation was conducted of Resident #2 on 9/11/17 at 12:05 PM. Resident #2 was seated in a geri chair in the dining room. Staff provided total assistance to Resident #2 with eating. Resident #2 was noted with no movement in the geri chair during this observation. A family interview was conducted for Resident #2 on 9/11/17 at 3:45 PM. The family member reported Resident #2 had fallen out of her geri chair about a month ago. She stated Resident #2 had hit her head on the floor and had a knot on her head. She reported she spoke with Nurse #1 on 8/15/17 and was informed Resident #2 had slipped and fell out of the geri chair when NA #1 had gone into the resident ' s bathroom. The family member reported the facility had not sent Resident #2 to the hospital so she had requested for her to be sent to the ER for evaluation on the afternoon of 8/15/17. She indicated Resident #2 was not admitted to the hospital and returned to the facility several hours after she had gone to the ER. Resident #2 ' s family member expressed concern about how the resident slipped out of the geri chair when she was immobile and was dependent on staff for assistance. An observation was conducted of Resident #2 on 9/12/17 at 7:50 AM. Resident #2 was lying in bed in her room. She was alert, but was unable to answer questions due to impaired cognition. Resident #2 was noted with no movement during this observation. An interview was conducted with Nurse #1 on 9/13/17 at 10:45 AM. She indicated she was familiar with Resident #2 and she worked with her regularly. She verified she was working on 8/15/17 when Resident #2 had a fall from her geri chair that resulted in a hematoma to the back of her head. Nurse #1 stated she was at the nurse ' s station when NA #1 came up to her and said Resident #2 had fallen. She revealed she was surprised Resident #2 had fallen because the resident was not mobile, she was dependent on 2 staff and a mechanical lift for transfers, and she had no recent falls. Nurse #1 stated she went to Resident #2 ' s room with the Director of Nursing (DON) and UM. She indicated when she got to the room she observed Resident #2 lying on the ground behind the geri chair. She reported Resident #2 ' s entire body was on the floor and the mechanical lift sling was on the ground beneath her. Nurse #1 indicated NA #1 said she had transferred Resident #2 from the mechanical lift to the geri chair without issue and she had then stepped into Resident #2 ' s bathroom when she heard the resident fall. Nurse #1 stated she thought Resident #2 had been positioned either too far forward or too far back in the geri chair which had caused the chair to tip. She reiterated that Resident #2 was immobile and was unable to move her body around in the chair independently. The interview with Nurse #1 continued. She stated Resident #2 had sustained a golf ball sized hematoma to the back of her head. She indicated the NP was contacted and neurological checks were initiated. She reported Resident #2 was alert, had no cognitive changes, and no abnormal pain. She clarified that Resident #2 had chronic pain issues and there were no signs or symptoms of worsened pain or distress. She stated the NP had not felt Resident #2 required evaluation at the ER as there were no acute changes with Resident #2 ' s status. The NP asked to be updated later that day on Resident #2 ' s condition. Nurse #1 reported Resident #2 remained at her baseline status throughout the day with no acute changes. She indicated the NP was updated on Resident #2 ' s status later that day (8/15/17) and no new orders were received. She reported Resident #2 ' s family member came to the facility sometime in the later afternoon or evening (8/15/17) and requested for Resident #2 to be sent to the ER for evaluation. She stated Resident #2 was evaluated at the ER and returned to the facility with no new orders. Nurse #1 stated she completed a nursing note, the SBAR, the Five Whys Tool, and the Fall Root Cause Investigation Report related to the 8/15/17 for Resident #2. An interview was conducted with the DON on 9/13/17 at 11:10 AM. She verified she was present at the facility on 8/15/17 when Resident #2 had a fall from her geri chair that resulted in a hematoma to the back of her head. She reported she was called to the room by NA #1 and when she got to the room she observed Resident #2 ' s entire body lying on the ground with the mechanical lift sling underneath her. The DON stated NA #1 said I put (Resident #2) in the wrong spot. She revealed NA #1 had utilized a mechanical lift independently to transfer Resident #2 from the bed to her geri chair. The DON confirmed NA #1 utilized the mechanical lift without another staff ' s assistance. She indicated this was the incorrect procedure as a mechanical lift transfer required two staff members. The DON reported she believed NA #1 had positioned Resident #2 too far forward or backward causing the geri chair to tip and the resident to slide out of the chair onto the floor. The DON indicated it was her expectation that staff followed the facility ' s procedure to have two staff members when using a mechanical lift. She additionally indicated she expected staff to ensure residents were positioned correctly when transferred. An interview was conducted with NA #1 on 9/13/17 at 3:55 PM. She stated she had worked at the facility for close to two years. She indicated she was familiar with Resident #2 and worked with her regularly. She reported Resident #2 was not mobile, she was dependent on staff for transfers, and a mechanical lift was utilized that required two staff members. She verified she was working with Resident #2 on 8/15/17 at the time of the fall that resulted in a hematoma to the back of Resident #2 ' s head. NA #1 described the events related to the 8/15/17 fall for Resident #2. She reported she needed to transfer Resident #2 from her bed to the geri chair for her go to lunch in the dining room. She stated she had briefly looked for a staff member to help her operate the mechanical lift, no one was readily available, and it was almost time for her own lunch break so she had decided to use the mechanical lift by herself. NA #1 stated she was aware she was not supposed to use the mechanical lift by herself. She revealed she had used the mechanical lift on her own approximately three other times prior to 8/15/17. She stated she had not used the mechanical lift on her own since the 8/15/17 incident with Resident #2. The interview with NA #1 continued. NA #1 stated she had used the mechanical lift on her own and transferred Resident #2 from her bed to her geri chair without issue. She indicated once Resident #2 was placed in the geri chair and the mechanical lift sling was unhooked, she had noticed there was more weight on the top end of the geri chair (the head of the chair) because Resident #2 was positioned too far back/up in the geri chair. NA #1 reported she scooted Resident #2 further down in the chair and into a more balanced position. She stated at that time she believed Resident #2 was in a safe position and she went into the resident ' s bathroom (located inside of the resident ' s room) to gather supplies. She reported she was in the bathroom with the door open, but with Resident #2 out of her eye sight for about one to two minutes when she heard a bang. NA #1 stated she immediately came out of the bathroom and saw that the geri chair had tipped backwards and Resident #2 had slid back and her head hit the ground. She reported she had yelled for assistance from Resident #2 ' s room and Nurse #1, the DON, and the UM all came to the room to assist Resident #2. NA #1 indicated following the incident she provided a verbal statement to Nurse #1 about the incident. She additionally stated the nursing staff had a meeting on mechanical lifts, geri chairs, and positioning. She reported the staff were instructed to never use the mechanical lift without 2 staff members. She indicated the staff had not been required to complete any demonstrations of how to properly use the mechanical lift to position a resident in the geri chair. NA #1 stated, I knew what to do I just didn ' t do it. A follow up interview was conducted with the DON on 9/13/17 at 4:30 PM. She indicated inservices on the mechanical lift, geri chair transfers, and positioning were conducted for NA #1 and other nursing staff on 8/15/17 and 8/16/17. The inservice staff sign in sheets dated 8/15/17 and 8/16/17 that indicated 18 nursing staff (22 NAs and 15 nurses) attended the inservice were reviewed with the DON. The nursing staff list that indicated there were 37 nursing staff members (22 NAs and 15 nurses) employed at the facility at the time of the incident (8/15/17) was reviewed with the DON. The DON verified all nursing staff were not re-education on the mechanical lift, geri chair, and positioning. She stated the nursing staff members who were in the facility working at the time of the inservices were the ones that were re-educated. She also verified no audits or ongoing monitoring was conducted related to the use of mechanical lifts, geri chairs, transfers, or proper positioning.

Based on staff interviews, pharmacy staff interviews and document review, the facility failed to have a system of reconciliation of controlled medications, failed to follow their procedures for reconciling missing medications including controlled schedule II drugs, and failed to follow their policies to control access to controlled medications on 1 of 3 medication carts (B/F hall medication cart). Immediate Jeopardy began on 12/13/13 and was identified on 2/21/14 at 4 PM. Immediate jeopardy was removed on 2/25/14 at 11 AM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and 100% of employee training. Findings included: Review of the facility Drug Diversion Policy dated 2012 indicated that in cases of potential drug diversion the DCS was to contact their Pharmacy Representative or the Board of Pharmacy for direction and the RDCS. If unable to reach pharmacy support the DCS was to contact local law enforcement for guidance. The policy also stated that " the facility will contact appropriate agencies (Board of Nursing etc) as appropriate " and that continued employment would be determined on a case by case basis. Review of the Pharmacy Consultant Agreement signed by the facility representative on 3/2/12 and by the Pharmacy representative on 3/30/12 revealed that the Consultant would provide the required serviced outlined in Schedule 1-A of the document. Review of Schedule 1-A revealed the required Consultant services including: " Consultant will establish a system of records of receipt and distribution of all controlled drugs in sufficient detail to enable accurate reconciliation " . " Consultant will determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled " . In collaboration with the facility and the facilities Medical Director, establish procedures to address the acquisition, dispensing, administering, disposing, labeling and storage of medications (including controlled substances) " . Under the heading of Labeling and Storage of Drugs the Consultant Agreement indicated the Consultant would work with the facility to ensure the safe and secure storage of medications in locked compartments; limit access to medications to authorized staff; and develop and implement safeguards and system control to account for and periodically reconcile controlled medications. In addition the agreement noted that Nurse Consultants and Pharmacy Assistants/Technicians could assist the Consultant in determining compliance with labeling and storage but that this assistance would be under the supervision of the Consultant Pharmacist. Review of the written statement from Nurse #2 dated 12/30/13 revealed that Nurse #1 (on-coming nurse) had said there was a missing blister package of controlled medications during the controlled drug count for the 11 PM shift change on 12/13/13. It went on to say that " This cart is a shared cart between two nurses. The keys to this cart (stays) on the cart either inside the black container or inside the MAR (Medication Administration Record) book. They are never on or in possession of any Nurse except during a med (medication) pass. Those keys are accessible to everyone at anytime " . Nurse #2 was not available for interview; she was terminated from employment at the facility on 2/9/14. Interview with Nurse #3 on 2/19 at 1:39 PM revealed that on 12/13/13 she worked the 3 PM - 11 PM shift and shared the medication cart for B and F hall with Nurse #2. She stated that the facility had three medication carts: one cart was for A and E halls, one cart were for C and D halls and the third cart was for B and F Halls. The B hall was assigned to the C/D hall nurse and the F hall was assigned to the A/E hall nurse, so the B/F medication cart became a shared medication cart. Both staff had access to the regular and controlled medications on the cart but shared one set of keys. According to Nurse #3, she always maintained the keys to the medication carts on her person until needed by the other nurse. She added that on occasion, when she would need to get the keys for B/F cart from the other nurse, she would find them inside the MAR book or in the black cooler (used for keeping drinks cool - not a lockable box) on top of the medication cart. During the interview with Nurse #3 on 2/19 at 1:39 PM she stated that on 12/13/13 after the 11PM shift change controlled medication count, Nurse #1 called the DCS, because they had been unable to locate a blister package/card of Klonopin that Nurse #1 identified as missing. Nurse #3 revealed that after the phone call to the DCS she (Nurse #3) and Nurse #2 were able to leave and that the DCS did not come to the facility to investigate. A written statement from Nurse #1 dated 12/31/13, revealed that on 12/13/13 she was counting the controlled medications on the medication cart for B and F hall cart with Nurse #2 (off going nurse) and noticed that one blister package/card of controlled medications for Resident #10 was missing. " I noticed this because I received the medication in and we had received 3 cards of Klonopin whole tabs (tablets). " Nurse #1 ' s statement also revealed that it looked to her as if someone had changed the numbers on the shift change controlled drug count sheet so they would match with the number of blister package/cards and declining inventory sheets remaining on the medication cart. According to the statement, Nurse #1 called the Director of Clinical Services (DCS) and reported to her that a blister package/card of 30 Klonopin tablets and 1 sheet (declining inventory sheet) were missing. Telephone interview with Nurse #1 on 2/20/14 at 8:15 AM revealed that as per her above statement Nurse #1 could tell one blister package of Klonopin for Resident #10 was missing because she had logged the medication in the day before (12/12/13). Nurse #1 indicated that she had logged in 3 cards of Klonopin with 3 declining inventory sheets so there should have been a total of 6 cards of Klonopin for Resident #10 with 6 declining inventory sheets. However on 12/13/13 during the 11 PM shift change count there were only 5 cards of Klonopin and 5 declining inventory sheets for Resident #10. Nurse #1 stated that she called the DCS to report that 1 card of Klonopin was missing and the DCS asked her how she knew and Nurse #1 told her she knew because she logged the medication cards into the inventory (count sheet) the day before. Nurse #1 said the DCS then talked to Nurse #2 who said she (Nurse #2) did not change the numbers on the controlled drug count sheet. When asked, Nurse #1 revealed that an investigation regarding the Klonopin that she had identified as missing was not conducted by the DCS or other management staff at that time. She stated that she was told to copy the sheets and the facilities receipt of what was delivered to the facility for Resident #10 and to put it under the door of the DCS which she did. She then carried on with her shift. During an interview with the DCS on 2/18/14 at 4:07 PM, she revealed that she had been on leave when she received a call on 12/13/13, around the time of the 11 PM shift change, from Nurse #1 about a missing blister package/card of Klonopin. The DCS also stated that when staff identify missing controlled medications, the facility policy required that they call the DCS and that the DCS was expected to go into the facility to investigate. The DCS reported that she called the Pharmacist on-call on that night (12/13/13) but was told the amount of Klonopin sent to the facility could not be researched until the Pharmacy opened again in the morning. She said she allowed the outgoing nurses for the B/F hall medication cart (Nurse #2 and Nurse #3) to go home and acknowledged that they were not suspended pending an investigation. The DCS said she investigated the incident when she returned from leave but said she did not know what day she returned from leave. The DCS indicated that she felt her investigation was immediate because she immediately called pharmacy to try and verify what had been delivered. She said the only evidence that something was missing was one nurse ' s statement that it was missing and the DCS thought it was a pharmacy error, so that ' s why she did not take additional action on 12/13/13. On 2/18/14 at 4:07 PM the DCS was interviewed and stated that she called Pharmacy on 12/27/13 and verified that one 30 tablet blister packet/card of Klonopon 0.5 mg was missing for Resident #10. She stated that since she was able to verify, on 12/27/13, that the Klonopin was actually delivered to the facility and could not be accounted for, that 12/27/13 was also the day that the loss actually occurred. She stated that she therefore did initiate an investigation immediately but that she needed to be sure how much Klonopin was sent to the facility and needed to get guidance from the Pharmacy General Manager, who was on vacation until 12/30/13. The DCS said that when she contacted the Pharmacy General Manager on 12/30/13 she was able to confirm that 1 blister package/card of Klonopin was missing. The DCS also stated that the Pharmacy General Manager instructed her to report the loss to the Drug Enforcement Agency, suspend the staff involved and obtain a drug test on the staff. The DCS indicated that she did everything she was instructed to do and reconciliation of controlled medications was not suggested. The DCS also said that because she did not know which staff member was responsible, and did not know exactly what happened to the Klonopon, that she could not determine that it was diverted. The DCS further stated that the Klonopon was just missing and that she completed a full investigation by contacting pharmacy and getting staff statements. She acknowledged that she did not inform the Consultant Pharmacist because she had contacted the Pharmacy General Manager and because there was not a diversion that she could prove. She also acknowledged a reconciliation of controlled medications was not done to identify other losses, and maintained that she did everything she was told to do, that she had completed a full investigation and that the Klonopin had not been diverted, it was just missing. During interview with the DCS on 2/25/14 at 8:19 AM she stated that she had considered terminating Nurse #2 after the Klonopin was verified as missing (12/27/13) because she had other concerns about this nurse as well. The DCS added that she ended up keeping Nurse #2 on staff because " the system was broken and the keys had been left out " and because the nurses had been sharing a cart, so there were two nurses (Nurse #2 and Nurse #3) involved (Nurse #2 was later terminated on 2/9/14). During interview on 2/19/14 at 11 AM the DCS said that by 12/31/13 she implemented the following changes: 1) removed the controlled medications from B/F hall cart and put B hall controlled medications on C/D hall cart and F hall controlled medications on A/E hall cart; the B/F hall cart was still used for non controlled medications on these halls, and 2) conducted an in-service regarding the above change and on proper procedures for the shift change controlled medication count and security of the medication keys. Review of the Narcotic Count in-service materials dated 12/31/13 revealed 11 of the facility ' s 21 licensed nurses signed that they received the in-service noted above. Telephone interview with the Consultant Pharmacist on 2/19/14 at 4:26 PM, revealed that he was only at the facility one day a month. He said that while at the facility he did the drug regimen review but did not do reconciliation of controlled medication. He added that as the Consultant Pharmacist it was not his responsibility to do reconciliation of controlled medications. In addition he stated that he had not been informed of a diversion of any controlled medication at the facility and had not been asked to do a reconciliation to determine if additional medication had been diverted. The Consultant Pharmacist indicated that there was also a Pharmacy Nurse Consultant who went to the facility quarterly to do medication pass observations. He thought she might do some audits to reconcile controlled medications at the facility but he did not know her name or have her contact information. The Consultant Pharmacist stated that he was also unaware that staff had been required to share access to the controlled medications on one of the medication carts and that they had not been maintaining the controlled medication and medication cart keys on their person. Telephone interview with the Pharmacy General Manager on 2/20/14 at 11:25 PM revealed that she did not do reconciliation of controlled medications at the facility, as her position was specific to the Pharmacy itself. She said she did not know what the Consultant Pharmacist contract stated about who was responsible for ensuring controlled medication was reconciled. Interview with the ED on 2/24/14 at 5:23 PM revealed that she was not aware that the Consultant Pharmacist was not doing controlled drug medication reconciliation or that controlled medications should be reconciled periodically. She also stated she had not been aware that the investigation of the missing Klonopon, conducted by the DCS, had not been immediate. The ED added that it had been her understanding that the incident of loss had occurred at the end of December 2013 and she did not know it occurred 12/13/13. In addition, the ED stated that she did not know that a diversion or misappropriation had taken place as she had been informed by the DCS that the controlled medication count was off, but two nurses had access to the controlled medications since they shared a medication cart, and as a result the DSC could not make a determination that the medication was stolen. The ED further indicated that she did not realize additional steps for investigating diversions, such as reconciliation, might be necessary since the DCS did contact Pharmacy and since it was not clear, at the time, that a diversion took place. During an interview with the Consultant Pharmacist on 2/20/14 at 2:25 PM he said that he was now aware that 1 blister package/card of 30 Klonopon 0.5 mg tablets had been diverted. The Consultant Pharmacist confirmed that following an identified diversion, a reconciliation of controlled medications should be done. He added that he would initiate a reconciliation of controlled medications in the facility to look for other diversions but maintained that doing this task on a routine basis, or having oversight for it, was not the responsibility of the Consultant Pharmacist. On 2/21/14 at 9 AM the Consultant Pharmacist stated that he had been trying to obtain documentation of any controlled drug medication reconciliation done at the facility by the Pharmacy Nurse Consultant or the Quality Assurance Technician. He indicated that he was unable to obtain any documentation and believed that reconciliation was not being done by any Pharmacy staff. Interview with the RDCS on 2/22/13 at 3 PM revealed that she recalled receiving a call about a missing Klonopin medication from the DCS but she was unsure of the date. She said that since the DCS said she had contacted Pharmacy, completed a DEA report and informed the ED of the missing medication the RDCS thought all the necessary investigation was being taken care of. The RCDS also indicated that she was now better aware of the scope of the problems in the facility regarding how controlled medications were managed including the lack of reconciliation; poor security of controlled drug medication keys; lack of comprehensive and timely investigation; lack of responsiveness to staff allegations of diversion and a pattern of messy documentation on the Controlled Drug shift change Count Sheets. During interview with the DCS on 2/25/13 at 8:19 AM the DCS indicated that the facility did not previously have a system in place for reconciling controlled medications and that after spending hours doing reconciliations during the survey, she has been able to identify the documents needed and planned to maintain these so both she and the Consultant Pharmacist could do a monthly reconciliation more easily. The Administrator was notified of the Immediate Jeopardy on 2/21/14 at 4 PM. The facility presented a credible allegation of compliance on 2/25/14 at 11 AM which included: Initial Corrective Actions: 1. On 12/13/13 at approximately 11:00pm, nurse 1 reported for duty and began her daily shift count with departing nurse 2. At approximately 11:30pm, nurse 1 reported to Director of Clinical Services (DCS), that a card and sheet of Klonopin was missing for resident 10. Immediately following the conversation on 12/13/13, the DCS contacted the on-call Consultant Pharmacist to report the event. The on-call pharmacy stated that they would verify the quantity sent to the facility on the next business day which would be Monday, 12/16/13. On 12/27/13, DCS followed up to the pharmacy with a phone call. The pharmacy technician checked the delivery records and stated that the Klonopin was showing as delivered to the facility, however, this would have to be verified by the Pharmacy General Manager when she returned from vacation on 12/30/13. On 12/30/13, the General Manager called the facility and spoke with DCS in regards to this issue. General Manager confirmed the delivery. DCS stated that the card could not be accounted for and that it was missing. DCS also asked what steps to take to address this concern. General Manager advised DCS to do a DEA Lost/Stolen Report and to drug test the suspected employee. The nurse was suspended on 12/30/13 and the DEA was notified electronically on 12/31/13. An investigation was initiated on 12/30/13 and 4 nurses (Nurse 2, Nurse 3, Nurse 4 and Nurse 1) were interviewed. The allegation was not substantiated at that time, and the nurse was returned to work on 1/1/14. Resident 10 was discharged on [DATE] and no longer resides in the facility. Changes made at this time was re-education to Licensed Nursing staff regarding existing policies by the DCS and Unit Manager 1 on 12/31/2013. There were 11 Licensed Nurses re-educated at this time. Changes made to address concerns for all other residents residing in facility: 2. The Consultant Pharmacist and DCS initiated a reconciliation of controlled substances for residents residing in the facility on 2/21/2014 for the months of January and February 2014 to ensure that drug records are in order and an account of controlled drugs is maintained. The reconciliation was completed on 2/22/2014. i. There were no additional findings. b. The Consultant Pharmacist and DCS completed a reconciliation of controlled substances for residents that received controlled medications into the facility from the pharmacy on 2/22/2014 for the month of December 2013 to ensure that drug records are in order and an account of controlled drugs is maintained. i. The previously identified card of Klonopin that went missing in December was the only noted finding. ii. There were no additional findings. c. Licensed nurses will maintain keys to the Medication/Treatment carts securely on their person as of 2/24/14 and will not leave them on the medication treatment cart or anywhere else. i. This was accomplished by Train the Trainer education provided on 2/21/14 by the Regional Director of Clinical Services to the Executive Director, the Director of Clinical Services, and the Unit Manager 1. ii. The Executive Director and Unit Manager 1 then provided education to Licensed Nursing staff regarding maintaining keys to the medication/treatment cart securely on their person effective 2/24/14. iii. 15 Licensed Nurses received the education on 2/21/2014. 1. There are 2 nurses remaining that will not work another shift until they have received the education, as well. iv. Observations documented on the QI Audit Tool of all nurses assigned to a cart on 7am-7pm and all nurses assigned to a cart on 7pm-7am have been made by the Director of Clinical Services on 2/22/2014 to ensure that these nurses are maintaining keys to the Medication/Treatment cart securely on their person and not on top of a medication cart. 1. There were no negative findings and these four nurses had their keys securely on their person during the observation. d. The facility removed the third medication cart that was previously shared by two nurses and consolidated the cart into the existing two medication carts on 2/21/2014. i. Only one Licensed Nurse will hold the keys to each cart at any given time effective 2/24/14. ii. There are 2 medication carts. iii. Cart 1 will include Halls A, E, and F. Cart 2 will include Halls B, C, and D. 1. The respective nurse assigned to each cart will maintain the keys for that cart throughout the scheduled shift effective 2/24/14. a. This was accomplished by eliminating the third, shared cart and consolidating its contents into Cart 1 and Cart 2. b. This was accomplished by Train the Trainer (on 2/21/14) education provided by the Regional Director of Clinical Services to the Executive Director, the Director of Clinical Services, and the Unit Manager 1 . c. The Executive Director and Unit Manager 1 provided education to Licensed Nursing staff regarding maintaining keys to the medication/treatment cart securely on their person and never leaving keys to the medication/treatment cart unsecured or in the medication cart or anywhere else at any time. d. 15 Licensed Nurses received the education on 2/21/2014. i. There are 2 nurses remaining that will not work another shift until they have received the education, as well. e. Medications are locked in the medication cart and controlled medications have been and continue to be secured under double locks. i. Observations documented on the QI Monitoring Tool were made by the DCS on 7am-7pm shift and 7pm-7am shift for all nurses assigned to a medication cart on 2/22/2014 to ensure that controlled medications are secured under double locks. There were no negative findings. f. Current medications for residents residing in the facility have had their Medication Administration Record [REDACTED]. i. Results of the review did not reveal additional medication errors. g. The Discontinued Controlled Medication Cards and corresponding declining inventory sheets will be removed from the cart on a weekly basis by the Director of Clinical Services and stored in an affixed cabinet secured behind 3 separate locks requiring 2 nurses to access at any given time until the date that the DCS removes and returns to the pharmacy for destruction. The licensed nurses have had to and must continue to co-sign the DCS on removal of drugs for returns. i. This was implemented on 2/21/2014. h. The DCS is the only person that has had authority and will continue to remove Controlled Medication Cards and declining inventory sheets from the medication cart. i. Should the DCS be out of work for an extended period of time, an interim DCS will be named and will function in this capacity. i. In order to validate cards and sheets that are removed, the nurse for the cart and the DCS will counter sign the controlled medication count cards and sheets. i. The controlled medication shift count records verifying removal of the controlled medication cards and sheets will be retained on the cart until they are full. ii. At that time, they will be removed from the cart. iii. Once removed from the cart, the controlled medication shift count sheets will be retained in the DCS office for minimum of one (1) year, on site for a minimum of seven (7) years and will then be stored in a secure location offsite for at minimum three (3) additional years based on the guidelines of the company record retention policy. j. Daily controlled drug counts at shift change will continue to be conducted by licensed nurses at the beginning and end of each shift to ensure that scheduled/controlled medications in the medication cart are accounted for. i. The daily controlled drug counts at shift change will include a review of current inventory of controlled medication cards and declining inventory sheets for controlled drugs. ii. The controlled medication declining inventory sheets will be reviewed for an accurate disposition of all controlled drugs and verification of drugs that are discontinued, removed and returned to the pharmacy for destruction or sent home with discharged residents. 1. The effectiveness of this process has been monitored by the Unit Manager 2 completing documented observations documented on a QI monitoring tool on 2/22/2014 on the 7am-7pm shift and the 7pm-7am shift to ensure that when the licensed nurses reconcile/count their controlled medications, that both nurses are counting both the controlled medication cards, the declining inventory sheets, and verify the number of doses remaining. a. There were no negative findings. Changes made to address Service Consultation Systems issues: 3. In relation to this issue, the following steps have been completed: Changes to sustain compliance made in process regarding drug storage, sharing of keys, and location of keys prior to the initiation of survey. Related to these specific areas, there were no additional resulting negative findings. a. The Consultant Pharmacist was informed by the DCS about the identified diversion on 2/19/2014. b. The Consultant Pharmacist and DCS completed a reconciliation of controlled substances for residents residing in the facility on 2/21/2014 for the months of January and February 2014 to ensure that drug records are in order and an account of controlled drugs is maintained. The Consultant Pharmacist and DCS completed a reconciliation of controlled substances for residents that received controlled medications into the facility from the pharmacy on 2/22/2014 for the month of December 2013 to ensure that drug records are in order and an account of controlled drugs is maintained. The previously identified card of Klonopin that went missing in December was the only noted finding. c. There were no additional findings from the December 2013 reconciliation. d. During the survey process, existing policies were amended to include immediate notification to the Consultant Pharmacist when there is a suspected drug diversion, Controlled Medication Count Sheet was amended to include a Reason Code/Key at the bottom of the page for clarification when controlled medication cards and sheets are added and/or subtracted from the existing numbers on the count sheet. e. Daily reconciliation will continue to be conducted by licensed nurses at the beginning and end of each shift to ensure that scheduled/controlled medications in the medication cart are accounted for. i. The reconciliation will include a review of current inventory of controlled medication cards and declining inventory sheets for controlled drugs. ii. The declining inventory sheet will be reviewed for an accurate disposition of all controlled drugs and verification of drugs that are discontinued, removed and returned to the pharmacy for destruction or sent home with discharged residents. 1. The effectiveness of this process has been monitored by the Unit Manager 1 completing observations on 2/22/2014 on the 7am-7pm shift and the 7pm-7am shift to ensure that when the licensed nurses reconcile/count their controlled medications, that both nurses are counting both the controlled medication cards, the declining inventory sheets, and verify the number of doses remaining. a. There were no negative findings. f. Consultant Pharmacist will be at the facility no less than monthly for chart reviews of residents along with Quality Assurance monitoring to include monthly reconciliation of facility controlled medications per guidance of F425 which will be monthly or more often as indicated. g. The steps in the reconciliation will include: i. a review that compares the delivery manifest for controlled medications delivered from the pharmacy to the facility ii. controlled medications returned to the pharmacy for destruction iii. controlled medications provided to resident or resident ' s responsible party upon discharge from facility iv. controlled medications that have been used up by the resident 1. Discrepancies in numbers will be immediately investigated for rationale in order to account for the disposition of the medication and the discrepancy. h. Consultant Pharmacist will immediately notify the ED (Executive Director) and/or DCS of any negative findings upon facility visit so that facility can initiate a plan to address any issues and/or follow up with the appropriate regulatory bodies if there is a suspected drug diversion. The Consultant Pharmacist will provide support and guidance as needed. In regards to education: i. The ED and DCS were re-educated on 2/21/14 regarding the duties of the Consultant Pharmacist, as dictated by the Consultant Pharmacist Agreement, and all required revisions to the Drug Diversion Policy by the Regional Director of Clinical Services (RDCS). j. The Pharmacy Manager re-educated the Consultant Pharmacist on 2/22/14 to ensure the Consultant Pharmacist knows that he is to visit the facility no less than monthly to complete chart reviews and a reconciliation of current residents controlled medications to ensure medications are appropriate and he is to make recommendations accordingly. k. The Consultant Pharmacist will conduct a controlled medication reconciliation. A New systemic change was implemented to include that a monthly reconciliation will be completed by the Director of Clinical Services and the Consultant Pharmacist or a pharmacy representative (RN/RPh) to ensure that scheduled/controlled medications sent from the pharmacy to the facility are reconciled and accounted for. The Consultant Pharmacist will verify this process for accuracy should anyone other than the Consultant Pharmacist complete this reconciliation. l. The Consultant Pharmacist will conduct a controlled medication reconciliation of the facility controlled medications in the instance that there is suspected drug diversion that will include comparing controlled medications that were delivered to ensure appropriate usage per physician's order [REDACTED]. An RPh or RN from the pharmacy will complete this reconciliation in the event that the Consultant Pharmacist is on vacation or leave. m. The Consultant Pharmacist will review controlled medication storage while at the facility to ensure that medications are stored appropriately to include narcotics and controlled medications are stored under double lock and key and that the nurses are maintaining Medication Cart keys and Narcotic Keys on their person. n. The Pharmacy Consultant understands that any negative findings will be immediately reported to the ED and/or DCS for further follow up. o. The ED and DCS understand that any negative findings will be investigated with written documentation and reported to the State of North Carolina if suspected diversion occurs. The ED has primary responsibility and the DCS is the back up for this procedure. p. The ED and DCS understand that identified pharmacy issues will require the development and implementation of an action plan to address issues and will require monitoring to determine if the action plan was effective or needs to be altered. The identified issue will be addressed through the QA process. q. The Consultant Pharmacist will bring findings from his monthly chart reviews, medication regimen reviews, reconciliation of controlled medications, medication storage concerns, med pass observations and any other pharmacy concerns as indicated. r. Should the facility identify any concerns regarding pharmacy issues, the Consultant Pharmacist will be notified immediately; and will meet with the ED and DCS within 24 hours to resolve and reconcile any concerns. s. Any controlled medications discrepancies will be documented and reported to the regulatory bodies and appropriately investigated immediately. Date of Completion: 2/25/14 Immediate Jeopardy was removed on 2/25/14 at 11 A

Based on staff interviews, pharmacy staff interviews and document review, the facility failed to have systems in place to ensure that controlled medications were secure, failed to implement the policy for reconciliation of controlled medications, and failed to follow their policy for investigating a complaint of controlled drug diversion for 1 of 1 residents (Resident # 10). Immediate Jeopardy began on 12/13/13 and was identified on 2/21/14 at 4 PM. Immediate jeopardy was removed on 2/25/14 at 11 AM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and 100% of employee training. Findings included: The facility Controlled Drug Count Policy and Procedure dated 2012 revealed, in part: The two nurses will count the number of individual controlled drugs and see if it matches with the number on the declining inventory sheet. Also the two nurses will count the number of declining inventory sheets and the number of medication boxes/cards etc and verify these numbers match the numbers on the Controlled Drug Count Sheet. " If the numbers do not match, STOP 1. Do not sign the controlled drug count sheet 2. No one is to leave the unit 3. Determine why there is a discrepancy 4. Call the Director of Clinical Services (DCS) 5. When the DCS arrives he/she will begin an investigation to determine the reason for the discrepancy. 6. It is the responsibility of the off going nurse who has been the custodian of the medication cart keys for any missing medications 7. The DCS will determine the need for drug testing, notification of local police and notification of pharmacy 8. Any disciplinary action will be given to the nurse who is in charge of the keys 9. The DCS will notify the Executive Director and the Regional Director of Clinical Services (RDCS) " " Only the DCS can remove sheets and cards from the medication cart. It is the responsibility of the nurse to notify the DCS that a card is empty or the sheet is full. The DCS will note in the comment sheet the removal of cards/sheets and the number removed of each. " " The nurse is not to give the medication keys to anyone else during the shift if he/she is the one assigned to the medication cart and are responsible for the controlled drugs under their care. " Review of the facility Drug Diversion Policy dated 2012 indicated that in cases of potential drug diversion the DCS was to contact their Pharmacy Representative or the Board of Pharmacy for direction and the Regional Director Clinical Services RDCS. If unable to reach pharmacy support the DCS was to contact local law enforcement for guidance. The policy also stated that " the facility will contact appropriate agencies (Board of Nursing etc) as appropriate " and that continued employment would be determined on a case by case basis. The Inventory of Controlled Substances Policy and Procedure from the Pharmacy, revised 1/1/13, was available in the Pharmacy Manual within the facility. Review of this Policy and Procedure revealed, in part: " Facility should ensure that staff immediately reports suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up in accordance with Facility policy and Applicable Law " . Review of the Pharmacy Delivery Manifest for 12/11/13 revealed that 3 blister packages/cards of clonazepam (Klonopin) 0.5 mg tablets (30 tablets per card) were delivered to the facility for Resident #10 on 12/11/13 who had a physician's order [REDACTED]. Review of the Pharmacy Delivery Manifest for 12/12/13 revealed that 3 blister packages/cards of clonazepam (Klonopin) 0.5 mg half tablets (0.25 mg) were delivered to the facility for Resident #10 on 12/12/13 (30 half tablets per card). Nurse #1 signed this delivery into the facility. Review of the physician's order [REDACTED]. Review of the written statement from Nurse #2 dated 12/30/13 revealed " On Friday 13th, 2013 December I (Name of Nurse #2) came into work 3/11 shift. I will admit that I did not count the narcotic sheets or cards with the off going Nurse (Nurse #4). We did count the pills that (was) in the cards at the time. When the 11-7 shift Nurse (Nurse #1) came in we started to count the cart and when we got to the missing card she (Nurse #1) immediately stated one was missing and started to make a big deal of it. We looked for the card on all carts and notified our (DCS). This cart is a shared cart between two nurses. The keys to this cart (stays) on the cart either inside the black container or inside the MAR (Medication Administration Record) book. They are never on or in possession of any Nurse except during a med (medication) pass. Those keys are accessible to everyone at anytime. " Nurse #2 was not available for interview; she was terminated from employment at the facility on 2/9/14. Review of the written statement from Nurse #3 dated 12/30/13 revealed " On 12/13/13 thin nurse (name of nurse) worked the 3pm-11pm shift on A, E, and F halls. Medications (fro) F hall was on a shared cart between myself and another nurse who worked that evening on B, C, and D halls this nurse (name of nurse) meds (medications) was signed (outa) and accounted for. " Interview with Nurse #3 on 2/19 at 1:39 PM revealed that on 12/13/13 she worked the 3 PM - 11 PM shift and shared the medication cart for B and F hall with Nurse #2. She stated that the facility had three medication carts: one cart was for A and E halls, one cart was for C and D halls and the third cart was for B and F Halls. The B hall was assigned to the C/D hall nurse and the F hall was assigned to the A/E hall nurse, so the B/F medication cart was a shared medication cart. Both staff had access to the regular and controlled medications on the cart but shared one set of keys. According to Nurse #3, she always maintained the keys to the medication carts on her person until needed by the other nurse. She added that on occasion, when she would need to get the keys for B/F cart from the other nurse, she would find them inside the MAR book or in the black cooler (used for keeping drinks cool - not a lockable box) on top of the medication cart. During the interview with Nurse #3 on 2/19 at 1:39 PM she stated that she was assigned to A, E and F halls on 12/13/13 and Nurse #2 had B, C and D halls. Nurse #3 indicated that she was not involved in the shift change controlled medication count on the B/F hall cart when she came on shift at 3 PM because that task was normally the responsibility of the B/C/D hall nurse (Nurse #2). As a result, Nurse #3 said she did not know if there was a blister package missing when she overheard Nurse #1 (the oncoming nurse) talking about missing medication during the 11 PM shift change controlled medication count. Nurse #3 also said that she checked the computer system to confirm what had been sent for Resident #10 and a blister package/card was missing but then the question come up that someone might have sent that card back to pharmacy. She added however, that only the DCS could send controlled medications back to pharmacy. Nurse #3 stated that Nurse #1 called the DCS, because they had been unable to locate the missing medication. Nurse #3 revealed that after the phone call to the DCS she (Nurse #3) and Nurse #2 were able to leave. Nurse #3 said that management staff did not come in and she (Nurse #3) and Nurse #2 were not asked to write statements or do anything before they went off shift. A written statement from Nurse #1 dated 12/31/13, revealed that on 12/13/13 she was counting the controlled medications on the medication cart for B and F hall cart with Nurse #2 (off going nurse) and noticed that one blister package/card of controlled medications for Resident #10 was missing. " I noticed this because I received the medication in and we had received 3 cards of Klonopin whole tabs (tablets). " Nurse #1 then counted the total number of blister packages/cards and recalled that when she was going off shift after working the previous night, and counted with Nurse #4 (oncoming 7 AM - 3 PM Nurse) there had been 63 blister packages/cards of controlled medications on the medication cart. " I saw that someone had changed my +3 to a +2 and adjusted the page count " . Nurse #1 also wrote that she called Unit Manager #2 (UM #2) to see if she knew anything about why there was one less blister package/card but UM #2 did not. In addition, the statement indicated that Nurse #2 called Nurse #4 who said that there were 63 pages (declining inventory sheets) when she was going off shift at 3 PM and counted with Nurse #2. Nurse #1 then called the Director of Clinical Services (DCS) and reported to her that a blister package/card of 30 Klonopin and 1 sheet (declining inventory sheet) were missing. " I made a copy of the narcotic signature sheet (declining inventory sheet) and the pink narcotic slips and placed them under her (DCS) door. " Telephone interview with Nurse #1 on 2/20/14 at 8:15 AM revealed that as per her above statement Nurse #1 could tell one blister package of Klonopin for Resident #10 was missing because she had logged the medication in the day before (12/12/13). Nurse #1 indicated that she had logged in 3 cards of Klonopin with 3 declining inventory sheets so there should have been 6 cards of Klonopin for Resident #10 with 6 declining inventory sheets but there were only 5 cards of Klonopin and 5 declining inventory sheets for Resident #10 when she did the shift change count with Nurse #2 on 12/13/13. Nurse #1 added that on 12/12/13 she had written " +3 +3 " on the Controlled Drug Count sheet for B/F cart, to show that she had added 3 cards and 3 sheets to the inventory (count sheet) of controlled medications on that cart. She recalled that when she came on shift on 12/12/13 at 11 PM the inventory had been 60 cards and 60 sheets and when she went off shift on 12/13/13 at 7 AM the inventory was 63 cards and 63 sheets as she had added the additional 3 for Resident #10. Nurse #1 also said that it was sheet 2 of 3 and card 2 of 3, of the whole tablets of Klonopin 0.5 mg that were gone. Nurse #1 stated that she called the DCS to report that 1 card of Klonopin was missing and the DCS asked her how she knew and Nurse #1 told her she knew because she logged the medication cards into the inventory (count sheet) the day before. Nurse #1 said the DCS then talked to Nurse #2 who said she (Nurse #2) did not change the numbers on the controlled drug count sheet. When asked, Nurse #1 revealed that an investigation regarding the Klonopin that she had identified as missing was not conducted by the DCS or other management staff at that on 12/13/13. She stated that she was told to copy the sheets and the facilities receipt of what was delivered to the facility for Resident #10 and to put it under the door of the DCS which she did. She then carried on with her shift. Review of the Controlled Drug Count Sheet for 12/12/13 and 12/13/13 revealed that on 12/12/13 at the end of the 3 PM-11 PM shift there had been 60 controlled medication declining inventory sheets (sheets) and 60 controlled medication blister packages (cards) on the medication cart for halls B and F. The comment section for 11 PM - 7 AM shift had the numbers +2 and +2, however they were heavily written over and appeared to obscure another number underneath. On 12/13/13 at the end of the 11 PM (12/12/13) - 7 AM (12/13/13) shift the count of cards and sheets appeared to be 62 for both cards and sheets, but again was heavily written over and appeared to obscure another number underneath. On 12/13/13 at the end of the 7 AM - 3 PM shift the number of cards and sheets were again heavily written 62 ' s appearing to obscure another number underneath. At the end of the 3 PM - 11 PM shift on 12/13/13 the count of cards and sheets was a clearly written number 62 for each item. During an interview with the DCS on 2/18/14 at 4:07 PM, she revealed that she had been on leave when she received a call on 12/13/13 at approximately 11:30 PM from Nurse #1, about a missing blister package/card of Klonopin. The DCS also stated that when staff identify missing controlled medications, the facility policy required that they call the DCS and that the DCS was expected to go into the facility to investigate. She added that the report of missing Klonopin was just based on one nurse ' s statement that it was missing but there was no discrepancy between the number of cards present in the medication cart (62) and the number written on the shift change count sheet/inventory (62), although she acknowledged that she had not gone to the facility to review the count sheet on12/13/13 to verify if it had been altered. The DCS also acknowledged that that Nurse #1 told her she (Nurse #1) had signed a delivery receipt slip indicating she received 3 cards of Klonopin into the facility on [DATE], not just 2. However, the DCS indicated that she thought the Pharmacy may only have sent 2 blister packages/cards of Klonopin on 12/12/13 and not 3 like Nurse #1 signed for. She elaborated that there had been ongoing problems with the Pharmacy delivering less medication than what was actually written on the delivery slip and nurses had signed for it anyway. The DCS reported that she called the Pharmacist on-call on that night (12/13/13) but was told the amount of Klonopin sent to the facility could not be researched until the Pharmacy opened again in the morning. She said she allowed the outgoing nurses for the B/F hall medication cart (Nurse #2 and Nurse #3) to go home and acknowledged that a urine drug screen was not done at that time and they were not suspended pending an investigation. The DCS said she investigated the incident when she returned from leave but said she did not know what day she returned from leave. Documentation of the leave dates for the DCS was requested from the DCS, the Human Resources Manager (HRM) and the Regional Director of Clinical Services but there was no documentation of this available according to all 3 sources. Review of the Payroll time cards for Nurse #2 for the dates 12/14/23 - 12/26/13, revealed that she continued to work a regular schedule (December 14, 15, 20, 21, 22) following the allegation that a blister package/card of 30 Klonopin, and the declining inventory sheet that was matched with it, were missing from the medication cart (halls B & F cart) that she shared with Nurse #3, on 12/13/13, 3-11 PM shift. Review of the Payroll time cards for Nurse #3 for the dates 12/14/13 - 12/26/13, revealed that she continued to work a regular schedule (December 16, 17, 18, 19, 20, 22, 23, 25, 26) following the allegation that a blister package/card of 30 Klonopin, and the declining inventory sheet that was matched with it, were missing from the medication cart (halls B & F cart) that she shared with Nurse #2, on 12/13/13, 3-11 PM shift. The DCS worked in the facility on 12/26/13, according to documentation she signed on 12/26/13. It was unknown if this was her first day back from leave of absence. As noted previously, the facility did not have records of the DCS ' s leave of absence dates, however review of the Controlled Drug Count Sheet for B/F hall revealed that on 12/26/13, the DCS signed the form indicating that on 7 AM - 3 PM shift that day she removed 21 controlled drug declining inventory sheets and, 21 controlled drug blister packages/cards from the medication cart. DCS verified, during an interview on 2/21/13 at 4:30 PM, that she always signed the Controlled Drug Count Sheet on the actual date she removed items from the cart, as required, and indicated that she would have worked on 12/26/13, since she signed the form on that date. On 12/27/13 the DCS followed up with the Pharmacy and spoke to a Pharmacy Technician, according to the DCS ' s written statement dated 12/31/13. This statement revealed that on 12/27/13, the Pharmacy Technician " stated that it looked as though the medication had been delivered but the Pharmacy Manager would not be in until Monday " (12/30/13). The payroll timecards for Nurse #2, from 12/27/13 - 12/30 /13 revealed that she worked on both the 28th and 29th. The payroll timecards for Nurse #3, from 12/27/13 - 12/30 /13 revealed that she worked on the 30th from 3 PM - 11 PM. On 12/30/13 (time of day unknown) the DCS talked to the Pharmacy General Manager, according to the DCS ' s written statement dated 12/31/13. This statement revealed that on 12/30/13 the Pharmacy General Manager " verified that the medication had in fact delivered to the facility and began providing details on how to move forward with the investigation. " Interview with the DCS on 12/18/14 at 4:07 PM revealed that the instructions she received from the Pharmacy General Manager were to submit a report of the missing Klonopin to the Drug Enforcement Agency (DEA) and suspend the staff involved pending investigation and a drug screen. Interview with the Pharmacy General Manager on 2/20/14 at 11:25 AM revealed that she could not recall being informed about diverted Klonopin but that the DCS had called her on 2/19/14 to request information about the Klonopin for Resident #10. She stated that he she had been informed of a diversion she would have recommended that it be reported to the DEA and that the staff involved be drug tested . The time card for Nurse #2 revealed that she was suspended with pay on 12/30/13 and on 12/31/13. The time card for Nurse #3 revealed she was on PTO (Paid Time Off) on 12/31/13. A Report of Theft or Loss of Controlled Substances form, for reporting to the Drug Enforcement Administration, dated 12/31/13 at 8:59 AM, indicated that 30 tablets of clonazepam (Klonopin) 0.5 mg were lost or stolen and that the date of Theft/Loss was 12/27/13. Review of this form also revealed that the type of Theft/Loss was employee pilferage and that it was not reported to the police. The security measures taken to prevent future Theft/Loss was " Nurses will no longer share a cart with each other and have access to the same narcotic drawer. All narcotics will be on the cart assigned to the nurse and only the nurse responsible will have the key. " The form was completed by the Director of Clinical Services (DCS). Interview with the Ed on 2/20/14 at 9:30 AM revealed that she had been informed by the DCS about some missing controlled drugs but she could not recall when. She said that she was informed around the date that the report to the DEA was completed (12/31/13) and that it was her understanding that the medication went missing at that time, not on 12/13/13, and that immediate action had been taken. Interview with the DCS on 2/20 14 at 10:50 AM revealed that she put the date of the Theft/Loss of the Klonopin as 12/27/13 instead of 12/13/13 because 12/27/13 was when the loss was verified by confirming with the Pharmacy how much Klonopin was sent. Telephone interview with the Consultant Pharmacist on 2/19/14 at 4:26 PM, revealed that he was only at the facility one day a month. He said that while at the facility he did the drug regimen review but did not do reconciliation of controlled medication. He added that as the Consultant Pharmacist it was not his responsibility to do reconciliation of controlled medications. In addition he stated that he had not been informed of a diversion of any controlled medication at the facility and had not been asked to do a reconciliation to determine if additional medication had been diverted. The Consultant Pharmacist indicated that there was also a Pharmacy Nurse Consultant who went to the facility quarterly to do medication pass observations. He thought she might do some audits to reconcile controlled medications at the facility but he did not know her name or have her contact information, as he worked in 10 different facilities and there were 4 different Nurse Consultants. The Consultant Pharmacist stated that he was also unaware that staff had been required to share access to the controlled medications on one of the medication carts and that they had not been maintaining the controlled medication and medication cart keys on their person. Interview with the ED on 2/2014 at 9:30 AM revealed that she was not aware that the Consultant Pharmacist was not doing controlled drug medication reconciliation or that controlled medications should be reconciled. She also said she did not know what the Pharmacy Consultant ' s contractual obligations were as she had not reviewed the contract. Telephone interview with the Pharmacy General Manager on 2/20/14 at 11:25 PM revealed that she did not do reconciliation of controlled medications at the facility, as her position was specific to the Pharmacy itself. She said she did not know what the Consultant Pharmacist contract stated about who was responsible for ensuring controlled medication was reconciled. Review of the Pharmacy Controlled Substance Inventory Form (Receipt for Destruction), printed 2/20/14, revealed that all 3 of the Klonopin 0.5 mg half tablet blister package/cards delivered for Resident #10 were returned for destruction, less 1 dose which was accounted for on the declining inventory sheet. Only 2 of the 3 Klonopin 0.5 mg tablet blister packages/cards delivered for Resident #10 were returned for destruction. There was one blister package/card of 30 Klonopin 0.5 mg tablets unaccounted for. These 5 blister packages of Klonopin were sent back to the Pharmacy by the DCS were sent out on 12/31/13, and arrived in Pharmacy on 1/1/14, according to the Controlled Drug Count Sheet documentation for 12/31/13 and according to the Returns/Discards Report. During an interview with the Consultant Pharmacist on 2/20/14 at 2:15 PM he reviewed the above noted Delivery Manifests dated 12/11/13 and 12/12/13, as well as the Controlled Substance Inventory Form printed 2/20/14. Based on this review the Consultant Pharmacist confirmed that a total of 6 blister packages of Klonopin had been delivered for Resident #10 over 12/11/13 - 12/12/13 and only 5 of the 6 blister packages/cards were returned to pharmacy for destruction. He further confirmed that this documentation revealed that 1 blister package/card of 30 tablets of Klonopin 0.5 mg was missing, lost or diverted. The Consultant Pharmacist said that he had not been contacted by anyone at the facility about missing or diverted Klonopin and indicated that until reviewing the above documentation, at this time, he had not been aware that any controlled medications were unaccounted for. He also stated that the Pharmacy Nurse Consultant did not do medication reconciliation but there was a Pharmacy Quality Assurance Technician (QA Tech) who came to the facility every 2 months and who was responsible for controlled drug reconciliation. He did not know the name of the QA Tech or have the contact information and he was unsure if the QA Tech was licensed to have access to Controlled Medications. The Pharmacy Consultant added that he would initiate a reconciliation of controlled medications in the facility to look for other diversions but maintained that doing this task was not the responsibility of the Pharmacy Consultant. On 2/21 at 9 AM the Consultant Pharmacist stated that he had been trying to obtain documentation of any controlled drug medication reconciliation done at the facility by the Pharmacy Nurse Consultant or the QA Tech. He indicated that he was unable to obtain any documentation and believed that reconciliation was not being done by these staff. Interview with the ED on 2/22/14 at 1:15 PM, revealed that she still thought that the Klonopin went missing on 12/27/13 and was not aware that an actual diversion of medications had been identified. The staff statements from Nurse #1 and Nurse #2 were reviewed with her at this time and she stated that this was the first time she had seen these, as facility staff had not shared them with her. The apparent changes to the 12/12/13 and 12/13/13 numbers on the Controlled Drug shift change Count Sheet for B/F hall medication cart were shared with the ED as well and she acknowledge not having seen this before. Lastly, the documentation of the number of Klonopin blister packages/cards that were delivered for Resident #10 (6) and the number of blister packages/cards that had been returned (5) was also reviewed since she had not seen these previously either. The ED then acknowledged that there had been a diversion of a controlled medication (Klonopin) and that the diversion occurred 12/13/13. An amended Report of Theft or Loss of Controlled Substances form, for reporting to the Drug Enforcement Administration, dated 2/22/14 at 12:47 PM, indicated that the date of the Theft/Loss of 30 tablets of clonazepam (Klonopin) 0.5 mg was revised from 12/27/13 to 12/13/13. There were no additional changes on the amended form regarding the Theft/Loss incident. The form was completed by the Executive Director (ED). Interview with the RDCS on 2/22/13 at 3 PM revealed that despite hearing during the survey that 1 blister package/card of Klonopin was diverted on 12/13/13, she was unaware of any proof to support that. She indicated that she was under the impression that some Klonopin was missing and the date this occurred was 12/27/13 and furthermore that the loss had been investigated when it had actually occurred. Interview with the Regional Director of Human Resources on 2/22/14 at 4 PM revealed that Nurse #2 was terminated on 2/9/14 due to another incident involving controlled medications (2 tablets unaccounted for that were eventually located). She added that Nurse #3 was suspended starting 2/22/14, since she did have access to the controlled medications along with Nurse #2 when the Klonopin was diverted and no action had been taken previously to address this. The RDHR stated they would likely have Nurse # 3 go for a comprehensive drug toxicology screen outside the facility and reinstate her if it was negative. The Administrator was notified of the Immediate Jeopardy on 2/21/14 at 4 PM. The facility presented a credible allegation of compliance on 2/25/14 at 11 AM which included: Initial Corrective Actions: 1. On 12/13/13 at approximately 11:00pm, nurse 1 reported for duty and began her daily shift count with departing nurse 2. At approximately 11:30pm, nurse 1 reported to Director of Clinical Services (DCS), that a card and sheet of Klonopin was missing for resident 10. Immediately following the conversation on 12/13/13, the DCS contacted the on-call Consultant Pharmacist to report the event. The on-call pharmacy stated that they would verify the quantity sent to the facility on the next business day which would be Monday, 12/16/13. On 12/27/13, DCS followed up to the pharmacy with a phone call. The pharmacy technician checked the delivery records and stated that the Klonopin was showing as delivered to the facility, however, this would have to be verified by the Pharmacy General Manager when she returned from vacation on 12/30/13. On 12/30/13, the General Manager called the facility and spoke with DCS in regards to this issue. General Manager confirmed the delivery. DCS stated that the card could not be accounted for and that it was missing. DCS also asked what steps to take to address this concern. General Manager advised DCS to do a DEA Lost/Stolen Report and to drug test the suspected employee. Nurse 2 was suspended on 12/30/13 and the DEA was notified electronically on 12/31/13. An investigation was initiated on 12/30/13 and 4 nurses (Nurse 1, Nurse 2, Nurse 3 and Nurse 4) were interviewed. The allegation was incorrectly not substantiated at that time, and the nurse was returned to work on 1/1/14. Resident 10 was discharged on [DATE] and no longer resides in the facility. Changes made at this time was re-education to Licensed Nursing staff regarding existing policies by the DCS and Unit Manager 1 on 12/31/2013. There were 11 Licensed Nurses re-educated at this time. Changes made to address concerns for all other residents residing in facility: 2. An initial 24 Hour Report and final investigative 5 Day Report have been submitted to the State of North Carolina for the diverted Klonopin medication on 2/22/2014. a. An addendum to the initial 24 Hour Report and final investigative 5 Day Report were submitted to the State of North Carolina on 2/22/2014 to reflect that the facility has determined an identified drug diversion for the missing Klonopin. b. A revised report was sent to the DEA on 2/22/2014. c. The pharmacist and DCS initiated a reconciliation of controlled substances for residents residing in the facility on 2/21/2014 for the months of January and February 2014 to ensure that drug records are in order and an account of controlled drugs is maintained. The reconciliation was completed on 2/22/2014. i. There were no additional findings. d. The pharmacist and DCS completed a reconciliation of controlled substances for residents that received controlled medications into the facility from the pharmacy on 2/22/2014 for the month of December 2013 to ensure that drug records are in order and an account of controlled drugs is maintained. i. The identified diversion occurring in December was noted in December ' s findings. ii. There were no additional findings. e. Licensed nurses will maintain keys to the Medication/Treatment carts securely on their person as of 2/23/14 and will not leave them on the medication treatment cart or anywhere else. i. This was accomplished by Train the Trainer education provided on 2/21/14 by the Regional Director of Clinical Services to the Executive Director, the Director of Clinical Services, and the Unit Manager 1. ii. The Executive Director and Unit Manager 1 then provided education to Licensed Nursing staff regarding maintaining keys to the medication/treatment cart securely on their person effective 2/23/14. iii. 15 Licensed Nurses received the education on 2/21/2014. 1. There are 2 nurses remaining that will not work another shift until they have received the education, as well. iv. Observations documented on the QI Audit Tool of all nurses assigned to a cart on 7am-7pm and all nurses assigned to a cart on 7pm-7am have been made by the Director of Clinical Services on 2/22/2014 to ensure that these nurses are maintaining keys to the Medication/Treatment cart securely on their person and not on top of a medication cart. 1. There were no negative findings and these four nurses had their keys securely on their person during the observation. f. The facility removed the third medication cart that was previously shared by two nurses and consolidated the cart into the existing two medication carts on 2/21/2014. i. Only one Licensed Nurse will hold the keys to each cart at any given time effective 2/23/14. ii. There are 2 medication carts. iii. Cart 1 will include Halls A, E, and F. Cart 2 will include Halls B, C, and D. 1. The respective nurse assigned to each cart will maintain the keys for that cart throughout the scheduled shift effective 2/23/14. a. This was accomplished by eliminating the third, shared cart and consolidating its contents into Cart 1 and Cart 2. b. This was accomplished by Train the Trainer (on 2/21/14) education provided by the Regional Director of Clinical Services to the Executive Director, the Director of Clinical Services, and the Unit Manager 1 . c. The Executive Director and Unit Manager 1 provided education to Licensed Nursing staff regarding maintaining keys to the medication/treatment cart securely on their person and never leaving keys to the medication/treatment cart unsecured or in the medication cart or anywhere else at any time. d. 15 Licensed Nurses received the education on 2/21/2014. g. Medications are locked in the medication cart and controlled medications have been and continue to be secured under double locks. i. Documented observations on the QI tool were made by the DCS on 7am-7pm shift and 7pm-7am shift on 2/22/2014 to ensure that controlled medications are secured under double locks. h. Current medications for residents residing in the facility have had their Medication Administration Record [REDACTED]

Based on observation, resident and staff interview and record review, the facility failed to put interventions in place for pain and failed to provide skin care treatment as ordered for 1 of 2 residents (Resident #85). The findings included: 1a. Resident #85 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated that Resident #85 had moderate cognitive impairment, required extensive assistance of 2 persons for bed mobility, had an unstageable pressure ulcer (right heel) and denied having pain. Physician orders [REDACTED]. Nurse s notes dated 7/19/12 at 3:10 PM indicated the physician was faxed requesting something for pain for Resident #85. Review of Resident #85's physician orders [REDACTED]. During an interview on 7/23/12 at 4:39 AM, Resident #85 said that his feet hurt most of the time but his doctor did not want to write a prescription for a pain reliever. He added that he got some relief with repositioning his feet which he could do independently. On 7/25/12 at 2:35 PM, Nurse #1 was observed providing treatment to Resident # 85's right heel as ordered. At the beginning of the treatment, Nurse #1 asked the resident if he had any pain. The resident said that his right foot hurt. Nurse #1 proceeded with the treatment. During the treatment, Nurse #1 again asked if he was having pain. The resident said yes. Nurse #1 stated, "I apologize." Resident #85 replied, "You apologize every day." Immediately upon completion of the treatment Nurse #1 asked the resident about pain. The resident said he had no pain at this time but will have pain again. During a follow-up interview on 7/25/12 at 3:10 PM, Resident #85 said that he had pain in his right foot most of the time. He said sometimes the pain kept him awake at night, or if he did fall asleep, his foot was hurting when he awoke. During an interview on 7/25/12 at 3:15 PM, Nurse #1 stated that Resident #85's level of pain was hard to judge. "He does not pull back or flinch unless I actually touch the heel. He says he has pain in his right heel." Nurse's notes dated 7/25/12 at 3:25 PM indicated the physician was faxed again regarding pain medication. During an interview on 7/26/12 at 9:45 AM, Nurse #1 stated that the faxed request for pain medication on 7/19/12 should have been followed up by the nurse on 7/20/12. Nurse #1 stated that she did not pursue getting an order for [REDACTED]. During an interview on 7/25/12 at 10:03 AM, the Director of Nursing (DON) indicated that she expected pain assessments to be done before and during treatment. If the resident expressed pain, she would expect some type of pain relieving measures to be taken. 1b. Resident #85 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A Progress Note dated 7/17/12 revealed that Resident #85 was evaluated by a Wound Ostomy Clinician (WOC). The treatment plan included [MEDICATION NAME] cream to buttocks twice a day then cover completely with [MEDICATION NAME]. Physician orders [REDACTED]. On 7/25/12 at 2:35 PM, Nurse #1 was observed providing treatment to Resident #85. Nurse #1 applied the [MEDICATION NAME] first to two open areas on the buttocks, and then applied the [MEDICATION NAME] over the [MEDICATION NAME]. The buttocks were a deep red color. Nurse #1 indicated that they were much improved since starting the [MEDICATION NAME] cream. During an interview on 7/25/12 at 3:15 PM, Nurse #1 indicated that the WOC came to the facility every other Tuesday and she accompanied the WOC on rounds. Nurse #1 indicated that the WOC verbally communicated to her that the [MEDICATION NAME] was to be applied first, then the [MEDICATION NAME]. Nurse #1 acknowledged the discrepancy between the written orders and her understanding of the verbal communication. Nurse #1 indicated that clarification was needed.