Every finding on record at Fuquay-Varina Health and Rehabilitation Center

Based on record review and Resident Representative (RR) and staff interviews, the facility failed to provide written information about advance directive and/or an opportunity to formulate an advance directive and to an obtain advance directive and maintain the advance directives in the medical record for 2 of 4 residents reviewed for advance directives (Residents #52 and #7). The findings included: Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Review of the Care Plan dated 1/26/26 revealed Resident #52 had an advance directive of full code. Record reviews revealed there was no documentation in the record regarding providing information to the RR about the right to refuse medical or surgical treatment and formulate an advance directive for Resident #52. An interview with the Resident Representative (RR) on 3/31/26 at 9:30 AM revealed she had not had a representative from the facility discuss any information regarding an advance directive for Resident #52. An interview with the Social Worker was conducted on 3/31/26 at 9:40 AM, she stated she was out on leave during the time of Resident #52's admission and it would have been the previous Social Worker's responsibility to discuss advance directives with Resident #52's RR. An interview with the previous Social Worker was not obtained during this investigation process. An interview with the Administrator was held on 3/31/26 at 9:45 AM, she stated she would have expected the Social Worker to discuss advance directives with the resident or RRs within three days of admission into the facility. 2. Resident #7 was admitted to the facility on [DATE]. A care plan meeting note dated 12/5/25 revealed Social Worker #2 documented that a care plan meeting was held with Resident #7's Responsible Party by phone. During the meeting the Responsible Party confirmed Resident #7's full code status and stated he had guardianship paperwork he would bring in. A Discharge Planning Psychosocial assessment dated [DATE] signed by Social Worker #2 revealed the resident was assessed to have an advance directive per the Responsible Party. A care plan meeting note dated 12/18/25 revealed Social Worker #2 documented that a care plan meeting was held with Resident #7's Responsible Party by phone. The Social Worker documented there were no changes to code status or funeral arrangements and there was no documentation that the Social Worker requested the advance directive. A Discharge Planning Psychosocial assessment dated [DATE] signed by Social Worker #2 revealed the resident was assessed to have advance directives per the Responsible Party. There was no documentation that the Social Worker requested the Responsible Party provide Resident #7's advance directives. A Discharge Planning Psychosocial assessment dated [DATE] signed by Social Worker #2 revealed the resident was assessed to have an advance directive per the Responsible Party. A care plan meeting note dated 3/12/26 revealed Social Worker #2 documented that a care plan meeting was held and Resident #7's Responsible Party did not answer the phone call, and a voice message was left. A care plan meeting note dated 3/17/26 revealed Social Worker #2 documented that a care plan meeting was held and Resident #7's Responsible Party did not answer the phone call, and a voice message was left. Resident #7's medical record on 3/29/26 revealed no advance directives were in Resident #7's medical record. During an interview on 3/30/26 at 10:19 AM Social Worker #1 stated if a resident already had an advance directive in place upon admission, the social workers request the resident or responsible party to bring the advance directive to the facility so they can keep a copy in the resident's medical records. If the resident or responsible party does not provide the advance directives prior to the next time the social workers meet with the resident or responsible party during a care conference, they again request the advance directives. With Resident #7, her Responsible Party stated during a care plan meeting on 12/5/25 that he had an advance directive for Resident #7 and Social Worker #2 requested the advance directive be brought to the facility. Social Worker #1 further stated the Responsible Party had not brought Resident #7's advance directive to the facility. Social Worker #1 stated she did not follow up with the family to acquire Resident #7's advance directive, and there was no documentation that any other staff had followed up with Resident #7's Responsible Party to acquire Resident #7's advance directive. During an interview on 3/30/26 at 3:09 PM, Social Worker #2 stated when Resident #7 first admitted , she spoke on the phone with the resident's Responsible Party who indicated at that time Resident #7 had an advance directive and would provide a copy to the facility. She stated the Responsible Party had been present on the phone for one other care conference on 12/18/25 and she did not remember but believed she did not follow up with Resident #7's Responsible Party about providing Resident #7's advance directive. She concluded that the Responsible Party was difficult to get ahold of and she had not followed up to obtain a copy of Resident #7's advance directive. During an interview on 3/30/26 at 3:03 PM the Administrator stated upon admission, the Social Worker discusses advance directives with the resident or responsible party to identify if the resident had advance directive in place or if they would like to create an advance directive. If the resident does have an advance directive, the staff then request a copy of the advance directive. She concluded that if the resident or responsible party does not provide a copy of the advance directives prior to the next care conference, this should be followed up during the next care conference and a copy of the advance directives should be obtained and maintained in the resident's medical records.

Number of Residents Sampled - 6Number of Residents Cited - 1Based on record reviews, and staff, Guardian and physician interviews, the facility failed to ensure a resident was not prescribed a medication to which the resident had a documented allergy for 1 of 6 residents reviewed (Resident #115).Findings included: Record review of the hospital after-care summary dated 8/27/2025 through 8/30/2025 showed an allergy to Doxycycline causing shortness of breath. Record review of allergies listed on the resident banner in the electronic medical record (EMR) included Doxycycline.Review of nursing progress notes dated 1/19/2026, written by Nurse #3, stated Resident #115 tested positive for an infectious disease. The physician was made aware and a new order for Doxycycline 100 milligrams (mg) twice daily for seven days was received.Review of physician orders dated 1/19/2026 showed a telephone order for Doxycycline 100 mg twice daily written by Nurse #3. During an interview on 3/31/2026 at 2:05 PM, Nurse #3 stated she sent the physician a text message about the positive test results and did not have the EMR open to see the resident allergies. The physician texted message back the Doxycycline 100 milligrams order. Nurse #3 reported she did not recall any allergy alert appearing when she entered the Doxycycline order into the EMR. The medication had not yet been delivered, so none was administered.During an interview on 3/31/2026 at 6:15 AM, Nurse #4 stated allergies were listed in the EMR beneath the resident name. She stated an allergy alert appears when entering a contraindicated medication.During a telephone interview with the physician on 3/31/2026 at 9:30 AM, he stated he was unaware of the allergy to the Doxycycline and that the EMR was unavailable to him. He stated nursing staff normally informs him of allergies.During a telephone interview with the resident's Guardian on 3/31/2026 at 12:10 PM, she stated she went to the facility and requested medical records that included the medication administration record (MAR). Upon review of the MAR, the Guardian noted the order for Doxycycline and notified the facility of the allergy to Doxycycline. The Guardian stated Doxycycline should never have been ordered by the physician.During an interview with the Director of Nursing (DON) on 4/1/2026 at 10:00 AM, she stated nurses should have the resident EMR open when contacting physicians and that the EMR provided allergy alerts.During an interview with the Administrator on 4/1/2026 at 10:15 AM, she stated she was aware the physician prescribed a medication to which the resident was allergic and that Nurse #3 did not inform the physician when the physician prescribed the medication.

Based on record review, and staff and Medical Director interviews, the facility failed to provide tracheostomy (an opening into the neck through the windpipe) care consistent with professional standards of practice when Nurse #2 cleaned and reused a single use disposable tracheostomy inner cannula when she provided tracheostomy care. This was for 1 of 3 residents reviewed for respiratory care (Resident #109).Findings included:Resident #109 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (a state in which oxygen present in a tissue or the whole body is insufficient). A physician's order for Resident #109 dated 7/18/25 was for tracheostomy care every shift and as needed, clean or change inner cannula as applicable.Resident #109's comprehensive care plan revealed a focus area for her risk of complications related to tracheostomy. The goal dated as initiated on 7/22/25 was for Resident #109 to have no complications related to her tracheostomy. An intervention was tracheostomy care as ordered.Resident #109's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She received oxygen therapy and tracheostomy care while a resident.Resident #109's August 2025 Treatment Administration Record (TAR) revealed documentation on 8/11/25 that Nurse #2 had provided tracheostomy care to Resident #109 on the night shift.A nursing progress note for Resident #109 dated 8/11/25 at 1:11 AM written by Nurse #2 revealed Nurse #2 provided tracheostomy care to Resident #109. This care had been well tolerated.Resident #109's August 2025 TAR further revealed documentation on 8/12/25 that Nurse #2 provided tracheostomy care to Resident #109 on the night shift.A nursing progress note for Resident #109 dated 8/12/25 at 3:02 AM written by Nurse #2 revealed she had provided tracheostomy care to Resident #109. This care had been well tolerated.In a telephone interview on 3/31/26 at 1:55 PM Nurse #2 stated she recalled Resident #109. She reported Resident #109's tracheostomy inner cannulas had always been the disposable single use type. She indicated she recalled providing tracheostomy care to Resident #109 on 8/11/25 and 8/12/25 on the night shifts (7PM-7AM). Nurse #2 stated tracheostomy care included changing Resident #109's disposable tracheostomy inner cannula. She went on to say Resident #109 usually had extra disposable tracheostomy inner cannulas in her room. She reported on either 8/11/25 or 8/12/25, she could not recall which, there had been no extra inner cannulas in Resident #109's room. She indicated Resident #109 had needed tracheostomy care, and so she had used a tracheostomy care kit which included sterile (completely free from living microorganisms and bacteria) gloves, sterile water, and a sterile brush to clean Resident #109's disposable tracheostomy inner cannula. She reported she then re-inserted this back into Resident #109's tracheostomy rather than disposing of it and inserting a new one. Nurse #2 stated she had felt bad doing it at the time because she knew she was not supposed to. She reported reusing a disposable tracheostomy inner cannula could risk infection. Nurse #2 stated she had been very careful to use sterile technique. She indicated she had not looked anywhere other than Resident #109's room for additional disposable tracheostomy inner cannulas. She stated she did not have access to the supply room where there might have been some. She reported she had never done this before during tracheostomy care for Resident #109 or any other resident. She indicated she had never done it again. Nurse #2 stated she thought she had reported the incident to an administrative staff member, but she could not recall who. She stated since then, she made sure she had all the supplies she needed for tracheostomy care at the start of her shift.On 4/1/26 at 9:03 AM an interview with the Director of Nursing (DON) indicated she had not been aware that Nurse #2 had cleaned and reused a disposable tracheostomy inner cannula when she provided Resident #109 tracheostomy care. She stated the facility only used the disposable type of inner tracheostomy cannula. She reported disposable inner cannulas were for one time use and should not be cleaned and reused. The DON indicated although Nurse #2 should have ensured she had the supplies she needed to perform tracheostomy care, she thought Nurse #2 used her professional judgement because she didn't have another disposable inner cannula for Resident #109, and Resident #109 had needed tracheostomy care.On 3/31/26 at 2:57 PM an interview with the Administrator indicated she had not been aware that Nurse #2 had cleaned and reused a disposable tracheostomy inner cannula. She stated Resident #109's tracheostomy inner cannulas had been the disposable type. She reported these were for single use only and should not be cleaned and reused. She stated that while she did not think Nurse #2 cleaning and reusing Resident #109's disposable tracheostomy inner cannula was best practice she felt Nurse #2's goal had been to keep Resident #109 comfortable by providing the care.On 3/31/26 at 2:16 PM a telephone interview with the Medical Director indicated there would have been no risk to Resident #109 when Nurse #2 used sterile technique to clean and reuse a disposable tracheostomy inner cannula. He reported this single incident had not caused Resident #109 any harm.

Based on observations and staff interviews, the facility failed to secure medications and treatment supplies in a locked wound care cart for 1 of 2 wound care carts observed (Station 2 Wound Care Cart).Findings included:During continuous observation on 3/29/26 (Sunday) from 10:29 AM until 10:36 AM the Station 2 Wound Care Cart was observed unlocked and unattended at the nursing station. There were no staff, residents, or visitors observed in sight of the wound care cart at that time. At 10:30 AM a housekeeping staff member walked past the unlocked wound care cart followed by a nurse aide who also walked past the unlocked wound care cart. At 10:31 AM three visitors walked past the unlocked wound care cart. At 10:32 AM Nurse #1 went to the nursing station, retrieved an item from the nursing station, and left visual range of the Station 2 Wound Care Cart which remained unlocked. At 10:33 AM a nurse aide walked past the unlocked wound care cart. At 10:34 AM three visitors walked by the unlocked wound care cart. At 10:35 AM a visitor walked past the unlocked wound care cart. At 10:35 AM another visitor walked past the unlocked wound care cart and a resident wheeled past the unlocked wound care cart. At 10:36 AM Nurse #1 returned to the nursing station. During an interview on 3/29/26 at 10:36 AM Nurse #1 stated the nurses on the hall completed wound care on the weekends. She stated someone must have used the cart and left it unlocked but she did not know who last accessed the Station 2 Wound Care Cart. She stated all nurses were responsible for the Station 2 Wound Care Cart and it should be locked when left unattended because there were medications in the cart and many confused residents resided in the facility so an unlocked wound care cart could be a safety issue. On 3/29/26 at 10:39 AM an observation was completed of the Station 2 Wound Care Cart with Nurse #1. The Station 2 Wound Care Cart was observed to contain calcium alginate dressing, iodoform packing strips, collagen wound filler, xeroform medicated petrolatum dressing, zinc oxide paste, Silvasorb gel, diclofenac sodium topical gel 1%, 70% Isopropyl alcohol, lidocaine ointment USP 5%, carbamide Peroxide 6.5%, Ciclopirox olamine cream USP 0.77%, Nystatin cream USP 100,000, Gentamicin Sulfate Cream USP 0.1%, and nystatin topical powder. During an interview on 3/29/26 at 12:31 PM the Director of Nursing stated wound care carts should be locked at all times when not attended by a nurse due to safety concerns for confused residents.

Based on observation, record review, and staff interviews, the facility failed to post daily staffing information in an area of the facility visible to residents and visitors on 1 of 4 days of the survey (3/29/26). In addition, the facility failed to have an effective process in place to ensure staffing information data was posted daily, including on the weekend.The findings included:On 3/29/26 (Sunday) at 10:00 AM an initial tour was conducted in the facility. The posted daily staffing information sheet was observed on the counter at the reception desk in lobby and was dated 3/26/26 (Thursday).On 3/30/26 at 3:15 PM an interview with the Scheduler revealed she was responsible for posting daily staffing information sheets. She reported she had not been in the office on 3/27/26 and she didn't work on the weekends. She stated although she knew that staffing information sheets were required to be posted daily, the facility did not have a process for ensuring this happened when she was out of the office or on the weekends. She reported she had not completed and posted the daily staffing information sheets for 3/27/26, 3/28/26 or 3/29/26. The Scheduler stated she had not had a conversation with the Administrator regarding the implementation of a process to ensure daily staffing information sheets were posted as required.On 4/1/26 at 10:20 AM a review of facility's previous 30 days of daily staffing information sheets from 3/2/26 through 3/30/26 revealed them to be complete.In a follow up interview on 4/1/26 at 11:03 AM the Scheduler stated when she returned to the office, she would create the daily staff postings for the days she had been off, such as on weekends or when she was out of the office, based on the staffing schedules for those days to ensure the record of them was complete and accurate. She reported this is what she had done when she completed the daily staffing postings for 3/27/26, 3/28/26, and 3/29/26 when she returned to the facility on 3/30/26.On 3/31/26 at 2:57 PM an interview with the Administrator revealed the Scheduler was responsible for posting the daily staffing information sheets. She reported she was unaware that staffing information sheets were not being posted when the Scheduler was out of the office. The Administrator reported that anytime she reviewed the daily staffing information sheets, she found them to be complete. She stated the facility did not have a process in place to ensure staffing information sheets were posted when the Scheduler was out of the office or the weekends.

Based on observation, record review, and staff interview, the facility failed to ensure a resident was treated respectfully when a Nurse Aide was using her personal cell phone rather than responding to a resident's verbal yell for help and the activation of his call bell. This was for 1 of 15 sampled residents (Resident # 15).The findings included:Resident # 15 resided at the facility from 11/13/25 to 11/20/25. The resident was [AGE] years of age. Review of Resident # 15's 11/13/25 hospital discharge summary revealed the following information. Resident # 15 had undergone left hip surgery in February 2025 for a broken hip. He was admitted to the hospital again on 11/10/25 where he was identified to have a left acetabular fracture (a fracture in the socket in the left pelvis that forms the hip joint with the femur (leg bone) and also a sacral ala fracture (a fracture in the portion of the sacrum at the base of the spine and which can cause buttock and low back pain). Resident # 15 underwent conservative treatment and no surgery. Review of Resident # 15's 11/16/25 admission Minimum Data Set Assessment, dated 11/16/25, revealed the resident was moderately cognitively impaired. He required substantial to maximum assistance to turn in bed. He received pain medication. Review of Resident # 15's November 2025 Medication Administration record revealed Resident # 15 received a prescribed dose of Oxycodone on 11/16/26 at 9:30 AM by Medication Aide # 2 for a reported pain level of 6 on a pain scale of 1 to 10. Resident # 15's family member was interviewed on 12/4/25 at 10:05 AM and reported the following information. He had arrived on 11/16/25 and could hear Resident # 13 yelling for help 200 to 300 feet before he reached the room. He could hear Resident # 13 yelling before he even passed the nursing desk. When he passed the nursing desk there was a staff member sitting at the desk who was in some other world. She had her head down and was looking at her phone and ignoring Resident # 15's yelling. The staff member was so engrossed in her phone that she did not even see him (the family member) pass by. After arriving to Resident # 15's room, he (the family member) found that the resident needed to be made comfortable and use the bathroom. He thought if the staff member ignored the verbal yelling, then the staff member would respond to the call light. He (the family member) turned on the call light. The call light stayed on for about 13 to 14 minutes. He tried to calm Resident # 15 down. No one came to assist Resident # 15. He approached the nursing desk and the same staff member, who he had passed at the nursing desk, was still seated at the nursing desk on her personal phone. He called her out for not doing her job. Two other staff members arrived and one of them went to take care of Resident # 15's needs. One of the staff members whispered to him that, She does this all the time referring to the staff member who had been on her phone while Resident # 15 needed help. Nurse Aide # 2 (NA # 2) was interviewed on 12/4/25 at 9:05 AM and reported the following information. She had been working on another unit on 11/16/25 but she was passing by Resident # 15's Nursing Station when she saw the call light was on in Resident # 15's room. The resident was yelling, help me, help me, get me up. She saw a family member come out of the room and approach the nursing desk. At the time that the call light was on and Resident # 15 was yelling for help, NA # 4 had been at the nursing desk and using her personal phone. She had not attempted to go check on the resident. The family member started talking to NA # 4 and NA # 4 still did not go check on the resident. Instead NA # 4 cursed at the family member. Therefore, she (NA # 2) went to check on Resident # 15. She knew he had a fracture and seemed to be in pain and uncomfortable in the bed. She helped reposition him and meet his needs and then the resident stopped yelling. He was okay after care was rendered. Medication Aide # 2 was interviewed on 12/4/25 at 9:30 AM and reported the following information. She did not care for Resident # 15 a lot but she knew the resident would yell. She thought this was because of pain. On 11/15/25 she heard loud voices and was on the adjacent hall from Resident # 15's hall. She went to the desk and saw that Resident # 15's light was on. NA # 4 was at the desk and on her phone. The phone was a personal device and NA # 4 was not charting. Resident # 15's family member was there and reported that the call light had been on for awhile. Nurse Aide # (NA) # 4 was interviewed on 12/5/25 at 11:19 AM and reported the following information. Resident # 15 was experiencing pain on 11/16/25 before she got him dressed. She had told the Medication Aide. She did not recall the specific Medication Aide. She assisted Resident # 15 up to the chair that morning and he yelled his butt was hurting. She therefore put him back in bed. She went to lunch. She came back from lunch and was entering the nursing station when Resident # 15's family arrived at the nursing desk and wanted to know who she was and to which hall she was assigned. She was putting her personal phone down when she came into the nursing station. Resident # 15's family member reported Resident # 15's call light had been going off. She did not hear Resident # 15 yelling for help and she did hear the call light go off. She was not the one who went to care for Resident #15 that day. It was her intent to go and check on Resident # 15 but didn't because the family member called her a name. During an interview with the Director of Nursing on 12/4/25 at 2:24 PM the DON reported that Resident # 15's family member had reported Nurse Aide # 4 for failing to attend to Resident # 15 while she was on her personal phone. There were witnesses and Nurse Aide # 4 was terminated. During an interview with the Administrator on 12/8/25 at 12:38 PM the Administrator reported that the facility had taken correction action to ensure that all residents were treated in a dignified manner. The Administrator provided the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 11/16/2025 NA #4 was sitting at the nurse's station on her phone while resident #15 was yelling for help, and his call light was activated. NA #2 was on the hall, and she went into the resident's room to answer his call light. NA #2 took care of the residents' needs while she was in the room. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 11/17/2025, the Unit Managers talked to residents on each unit to determine if their needs were met. No concerns were noted. On 11/17/25 the department heads completed angel rounds and communicated any identified concerns during the stand-up meeting. Angel rounds are completed Monday through Friday. Each room has an assigned department head who visits the room daily. During the rounds the department head monitors call bell location and response and listens for interactions between staff. All nurses' notes, physician orders, vital signs, x-ray and lab results are reviewed for previous 24 hours. This will help identify any residents who are not able to say they have a problem. The angel rounds were used to identify other at-risk residents in the facility. The initial audits did not indicate that any other residents had not been treated respectfully. On 11/24/25 the Unit Manager began a call light audit, to ensure lights are answered timely and residents' needs are met. During the audit it was identified that the call light response time was greater than 10 minutes. Verbal re-education was completed with identified staff. In April 2025, staff were educated on the use of cell phones. Education continues to be ongoing. Any staff who continue to use cellphones in inappropriate areas will be re-educated, and disciplinary action may be initiated. Ongoing observations by nursing administration and department heads provide continued monitoring of staff use of personal cell phone devices at nurses' station and resident care areas. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The daily angel rounds (Monday-Friday) will be used to identify any resident at risk for being treated disrespectfully, any dignity concerns, and call light not being answered in a timely manner. Managers will bring the Angel rounds to Morning meeting to address concerns. Unit manager and ADON, will complete call light audit, to ensure lights are answered timely and residents' needs are met, and free from any dignity concerns. If there are concerns identified the Unit manager, and ADON, and the Director of Nursing will address each concern individually, using 1:1 education, and including disciplinary action. The QAPI (Quality Assurance Performance Improvement) team met on 11/19/2025 and initiated a corrective action plan on call bell response time and dignity. The following members of the committee were present: Administrator, Director of Nursing, Regional Director of Clinical Services, MDS Coordinator, Recreation Director, Director of Rehabilitation, Pharmacist, Medical Director, Business Office Manager, Assistant Business Office Manager, and Unit Manager. The Unit Manager and RN supervisor began in-service education on 11/18/2025. The following topics were covered in education: answer call bells in a timely manner, give respect, speak kindly to our residents, staff to follow through with resident requests, and give PRN (as needed) pain medication when requested per order frequency. Staff who have not completed the training by 11/26/2025 were not allowed to work until they completed the training. The DON and ADON are designated to keep up with ongoing training. A data collection audit tool will be used to monitor that call lights are being answered in a timely manner and residents are free of any dignity issues. The Unit Managers will complete audit for 10 random residents 5 times per week for 2 weeks, then 3 times per week for 2 weeks, then 2 times per week for 4 weeks beginning 11/24/25. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.A data collection audit tool will be used to monitor that call lights are being answered in a timely manner and that residents are free of any dignity issues. The Unit Managers will complete the audits for 10 random residents 5 times per week for 2 weeks, then 3 times per week for 2 weeks, then 2 times per week for 4 weeks 11/24/25. The QAPI team met on 11/19/25 and initiated a corrective action plan on call bell response time and dignity. The following members of the committee were present: Administrator, Director of Nursing, Regional Director of Clinical Services, MDS Coordinator, Recreation Director, Director of Rehabilitation, Pharmacist, Medical Director, Business Office Manager, Assistant Business Office Manager, and Unit Manager. A summary of audit results will be presented by the Director of Nursing monthly for three months to ensure continued compliance.Compliance date: 11/26/25. The facility's corrective action plan was validated by the following:On 12/3/25, beginning at 8:25 AM an initial tour of the facility was conducted during which multiple residents and a family member were interviewed. Residents and the family member reported no concerns with staff treating residents respectfully. Although not all inclusive of interviews one randomly interviewed resident reported, I am so thankful to the Lord to be in such a wonderful place. Staff members were observed during the survey, which began on 12/3/25, to interact with residents in a respectful manner and be responding to call bells and residents' requests for assistance. The facility provided documentation of their in-service and audits. Staff members were interviewed and reported they had received training regarding dignity, and they were knowledgeable that the facility's policy was that they were not to be on their personal phones when they were accountable for responding to residents' needs. One of the staff members, who was interviewed, was a staff member designated to make Angel Rounds. This staff member reported he checked on his assigned residents daily, talked to them about any concerns and observed staff interactions with his assigned residents' needs. The facility's corrective action plan compliance date of 11/26/25 was validated.

Based on record review and staff interviews, the facility failed to protect a resident's right to be free from misappropriation. This was for 1 of 1 sampled resident who was reported to have possible diversion of her pain medication (Resident #2). The findings included:Record review revealed Resident # 2 resided at the facility from 9/11/25 until 9/23/25. According to Resident # 2's hospital discharge summary Resident # 2 had undergone surgical repair of a fractured femur on 9/4/25 and was transferred to the facility for rehabilitation. The resident also had a diagnosis of dementia according to the discharge summary.Facility admission orders included Oxycodone 5 mg (milligrams) every six hours as needed for pain. Additionally, Resident # 2 was ordered to receive Acetaminophen 500 mg (milligrams) on a scheduled basis every eight hours for 10 days.Review of pharmacy delivery records revealed on 9/12/25 at 4:20 AM 28 tablets of Oxycodone 5 mg were delivered and received by the facility.Review of Resident # 2's September 2025 MAR (Medication Administration Record) revealed Nurse # 13 signed she administered Oxycodone 5 mg to Resident # 2 on 9/11/25 at 9:44 PM and again on 9/12/25 at 3:46 AM.Resident # 2's controlled drug receipt record was reviewed. (A controlled drug receipt record contains documentation of all controlled medication pills that are removed from storage. Nurses are required to sign the date and time when controlled medications are removed from storage, the amount of controlled pills removed, and sign their name on the controlled drug receipt sheet. The number of pills on the drug receipt record is then reconciled at the end of each shift when another nurse becomes accountable for the controlled medications by counting and reviewing the sheets with the actual number of pills in locked storage). A review of Resident # 2's Oxycodone controlled drug receipt record revealed the number of tablets that were labeled by the pharmacy had been marked through. Nurse # 13 had signed at the top of the controlled drug receipt record that the initial count of pills was 26 rather than the 28 that had been delivered from the pharmacy. On 9/11/25 Nurse # 13 signed that she removed 2 tablets at 9:30 PM from Resident # 2's Oxycodone supply which then left 24 tablets. On 9/12/25 at 3:50 AM, Nurse # 13 signed that she removed two tablets from Resident # 2's supply which then left 22 tablets. Therefore, the accounting sheet showed that during Nurse # 13's shift six tablets from Resident # 2's 28 dose supply had been removed while Nurse # 13 worked with Resident # 2 and four of these tablets which were removed were at a documented time on the accounting sheet prior to the Oxycodone being delivered to the facility (which was at 4:20 AM).Nurse # 10 was interviewed on 12/4/25 at 9:50 AM and reported the following information. She had relieved Nurse # 13 on 9/12/25 at 7:00 AM. Nurse # 13 was counting fast as they reconciled controlled medications. The count was correct. (The number of pills on the controlled drug receipt record matched the number in the resident's supply.) Resident # 2's Oxycodone was in a bubble pack card, and each dose was individually in its own bubble storage. Later in the day she noticed that the punches on the card seemed odd and that Nurse # 13 had signed out for two each time when the order was for only one. The resident also tended to ask for only acetaminophen. She also noticed that the number of pills which the pharmacy had put on a label when they filled the medication had been crossed out. Therefore, she reported the issue to the supervisor.The MDS (Minimum Data Set) assessment Nurse was interviewed on 12/4/25 at 5:00 PM and reported the following. She was acting DON (Director of Nursing) on 9/12/25 when Nurse # 10 reported a problem with the accounting of Resident # 2's Oxycodone. She had taken a picture of the card. The number of tablets that Nurse # 13 noted at the top of the drug receipt record by her signature was 26. The number on the label was marked through. She verified with the pharmacy that they had sent 28. The MDS Nurse also saw there had been four doses documented as removed from the supply at a time when the Oxycodone had not even been delivered to the facility. She also saw on the times that the medication was removed that Nurse # 13 had removed two tablets rather than one as ordered. She talked to Nurse # 13 and Nurse # 13 reported she had gotten the Oxycodone tablets from the facility's back up medication supply. There was no record of any Oxycodone being removed from the back up supply for Resident # 2. Nurse # 13 was questioned why she would have documented the removal of the Oxycodone in an amount more than prescribed and documented a time on the removal when the Oxycodone had not been available to administer. According to the MDS Nurse, Nurse # 13 did not have an explanation which would reconcile and account for the missing Oxycodone. She was suspended and then terminated and the Department of Drug Enforcement, North Carolina Division of Health and Human Services, and the North Carolina Board of Nursing (NCBON) were notified.At attempt was made to Interview Nurse # 13 on 12/5/25 at 10:45 AM and Nurse # 13 could not be reached for interview.Interview with the facility's Pharmacy Director on 12/5/25 at 3:16 PM revealed the following information. The pharmacy had sent 28 tablets of Oxycodone 5 mg for Resident # 2 on 9/12/25 and their records showed it was received by the facility at 4:20 AM. The pharmacy records showed there were no Oxycodone tablets signed out from the facility's back up supply on 9/11/25 and 9/12/25 for Resident # 2.Interview on 12/8/25 at 10:49 AM with the NCBON's assigned investigator to Nurse # 13's case revealed the investigator was still awaiting paperwork and had not interviewed Nurse # 13 yet to obtain a statement from her.Interview with the Administrator on 12/8/25 at 12:38 PM revealed she had been out on leave during the time period when Resident # 2's Oxycodone had been unaccounted for. A report had been filed with all the required entities. The facility had completed a corrective action plan.The Administrator provided the facility's corrective action plan. The facility's alleged corrective action plan was reviewed and found unacceptable.

Based on record review and interviews with staff and staff members at the North Carolina Board of Nursing, the facility failed to ensure it did not employ a nurse who currently had disciplinary action in effect against her professional license secondary to a history of drug diversion. This was for 1 of 2 staff members whose personnel information was reviewed (Nurse # 13). The findings included:Record review revealed Resident # 2 resided at the facility from 9/11/25 until 9/23/25. On 9/12/25 the facility reported an incident of suspected controlled pain medication diversion by Nurse # 13 to the state agency when multiple Oxycodone tablets could not be accounted for while Resident # 2 was under the care of Nurse # 13.The facility's MDS (Minimum Data Set) assessment Nurse was interviewed on 12/4/25 at 5:00 PM and reported the following. She was acting DON (Director of Nursing) on 9/12/25 and had completed the investigation while the Administrator was on a leave of absence. There had been problems with the following: 1) the number of tablets, which were filled and delivered by the pharmacy, was marked through on a pharmacy label located on the Oxycodone drug receipt record 2) Nurse # 13 had signed on the drug receipt record she had received 26 tablets which was less than the 28 tablets the pharmacy had records of sending 3) Nurse # 13 could not account for the extra tablets the pharmacy showed as sending 4) Nurse # 13 signed out more tablets at a time than Resident # 2 was ordered to receive 5) Nurse # 13 had no explanation which could reconcile the issues that had been found.Interview with the facility's Human Resources Director on 12/5/25 at 4:00 PM revealed the following information. Nurse # 13 had been hired on 8/12/25 and had restrictions on her license per the North Carolina Board of Nursing (NCBON). The facility had screened Nurse # 13 prior to hiring her and found that she had worked at two other skilled nursing facilities earlier in 2025 and was eligible for rehire at both of the facilities where she worked in 2025. They had obtained the restrictions from the NCBON for her employment at their facility (Facility # 1) when they hired her on 8/12/25.The facility provided Nurse # 13's license restrictions which had been given to them (the facility) when Nurse # 13 was hired. A review of the information which the facility (Facility #1) was given by the North Carolina Board of Nursing (NCBON) on 8/12/25 revealed Nurse # 13 had been disciplined for diverting Oxycodone while employed at a facility (Facility # 2) in 2021. Facility # 2 and Facility #1 were under the same corporation. A review of the information and orders from the NC Board of Nursing, dated 1/11/22, revealed the following information. The NCBON found that Nurse # 13's conduct constituted grounds for discipline based on their investigation into the case of diversion of Oxycodone in 2021 at Facility # 2. The NC Board of Nursing interviewed Nurse # 13 on 12/21/21. At that time Nurse # 13 admitted to the NC Board of Nursing that she had diverted 90 Oxycodone 10 mg pills from Skilled Nursing Facility # 2 and that she had begun diverting Oxycodone in the summer of 2021. Nurse # 13 also admitted she had a substance abuse disorder. The NCBON document included the following statements: 1. This matter is properly before the Board and the Board has jurisdiction overLicensee and the subject matter of this case.2. Licensee's conduct, as set out in the findings of fact above, constitutes groundsfor discipline pursuant to N.C. Gen. Stat. S90-171.37 as follows:(6) Engages in conduct that deceives, defrauds, or harms the public in thecourse of professional activities or services;(7) Has violated any provision of this Article or any provision of the rulesadopted by the Board under this Article; and 21 N.C. Admin. Code 36 .0217(a)(3) illegally obtaining, possessing, or distributing drugs or alcohol forpersonal or other use, or other violations of the North Carolina ControlledSubstances Act, G.S. S90-86 et seq.3. Grounds exist pursuant to N.C. Gen. Stat. S90-171.37 for the Board to revoke orsuspend a license to practice nursing and invoke other such disciplinary measures, such as censure or probative terms, against a Licensee as it deems fit and proper. One of the orders by the NC Board of Nursing was that Nurse # 13 enter the Alternative Program for Chemical Dependency. The order also noted Nurse # 13's license would have restrictions. The restrictions were categorized based on the number of years Nurse # 13 was employed in an approved nursing position.On 12/5/25 at 2:50 PM a member of the NC Board of Nursing, who was serving as the compliance case analyst and overseeing Nurse # 13's participation in the Alternative Program, was interviewed and reported the following. There were different encumbrances (restrictions) on a nurse's license based on the number of years within the program. Stricter encumbrances were during the first year of being in the program. This meant that a nurse had to complete a full year of employment while under the one year's restrictions set forth by the NCBON. Nurse # 13 had spotty employment from 2021 through 2023 and therefore did not meet the full one-year employment history to drop the one-year restrictions set forth by the NC Board of Nursing until December 2023. At that point (in December 2023) her license was restricted with certain requirements for 2 years. It had been permissible for her to be working at night following December 2023 and be accountable for controlled medications. On 9/12/25 Facility # 1 had reported the nurse was suspended and then terminated on 9/18/25. A formal complaint intake was received from the facility on 10/27/25 and the NC Board of Nursing had not completed their investigation.A review of the documented license restrictions set forth by the NCBON and provided to Facility # 1 when the nurse was hired at Facility # 1 included that the nurse still had restrictions on her license when hired by Facility # 1. The restrictions as of Nurse # 1's hire date on 8/12/25 mandated that she should not work for a staffing agency, as a traveler nurse, be employed at a home health agency or hospice home care provider. The nurse was also not to work in a supervisory capacity. These restrictions were part of the two year encumbrances on her license which had begun in December 2023.Interview with the current DON (Director of Nursing) on 12/4/25 at 6:10 PM revealed she had not been the DON when Nurse # 13 was hired or when she was suspended and terminated for suspected drug diversion. She was not familiar with why the nurse had been hired.

Based on record review and interviews with resident and staff, the facility failed to implement their abuse policy when they 1) failed to suspend a staff member who was accused of slapping a resident and 2) ensure the incident was reported to the Administrator in order that regulatory reporting timeframes to other agencies were met and an investigation was initiated on the day of the allegation. This was for 1 of 3 sampled residents who alleged abuse had occurred (Resident # 1).The findings included:Review of the facility's policy entitled Abuse, Neglect, Misappropriation, Crime which was dated 10/17/23, revealed the following information. All employees were responsible for immediately (no later than two hours after the allegation is made if the incident involves abuse or bodily injury) to report to the Administrator, or in their absence, the Director of Nursing, or their immediate supervisor any and all suspected or witnessed incidents of patient abuse. Allegations of abuse would result in staff suspension, and an investigation would take place. Also, the policy directed that after notification to the Administrator of alleged abuse, the Administrator would immediately report to the state agency, but not later than two hours after the allegation is made, regarding the events that caused the abuse allegation. Adult protective services, the local ombudsman, and the appropriate local law enforcement authorities would be notified of resident abuse also. Record review revealed Resident #1 was admitted to the facility on [DATE].Review of a facility investigation report into alleged abuse for Resident # 1 revealed the alleged incident occurred on 11/18/25 and the facility Administrator became aware of the incident the following day. According to the investigation report, Resident # 1 had alleged she was hit in the face by Nurse Aide (NA # 4).Resident # 1 was interviewed on 12/3/25 at 11:25 AM regarding whether anyone had ever mistreated her or abused her in anyway. Resident # 1 reported the following. Two people would whip her. Resident # 1 did not mention being hit in the face. She could not give a specific day. When directly asked if she had been hit in the face, Resident # 1 responded she believed she had been hit in the face. Resident # 1 did not report that she had been cursed or that derogatory language had been used towards her. According to Resident # 1, the police came and then everything stopped and she felt safe and without problems currently.Nurse # 1 was interviewed on 12/3/25 at 2:08 PM and reported the following information. On 11/18/25 Resident # 1 was yelling to the point that it was disruptive to other residents and could be heard in the hallway. She was yelling, Help. Get that b. out of here. Resident # 1 did not normally yell to the degree that she was doing. She (Nurse # 1) went to check on Resident # 1 and Resident # 1 reported she did not want that b.Nurse Aide in the room and that the Nurse Aide had slapped her in the face twice. The resident was assessed and found to have no injuries. There were no marks on her face. NA # # 4, who was assigned to Resident # 1, was in the next room with NA # 1 and another resident. She (Nurse # 1) called them out of the room and asked them what happened. NA # 4 reported that the resident had said that she did not want that b. in her room while referring to her (NA # 4) when she entered the room to care for Resident # 1. NA # 4 reported to her (Nurse # 1) that she then called her back out of her name, and this meant that NA # 4 had been derogatory and not used the resident's name when replying to the resident's remark about not wanting that b. in the room. She (Nurse # 1) had also talked to NA # 1 who had been in the room, and NA # 1 reported that NA # 4 had made racial slurs and called Resident # 1 a fat b. She (Nurse # 1) reported the situation to Unit Manager # 1 and she thought the DON (Director of Nursing) was made aware of the situation. She had followed the chain of command. Unit Manager # 1 reported that she had spoken to the DON and that sometimes Resident # 1 made up things. She (Nurse # 1) was directed by the Unit Manager that two staff members needed to be in the room when providing care to Resident # 1. She (Nurse # 1) thought this was an unusual situation because it had been her experience that if a resident alleged that they were hit, then the accused staff member would not be allowed to stay. On that date, she changed the assignment after the incident so that NA # 4 was no longer assigned to Resident # 1.NA # 1 was interviewed on 12/3/25 at 1:05 PM and reported the following about the incident on 11/18/25. She had gone in the room with NA # 4 to care for Resident # 1. NA # 4 had made derogatory comments before approaching the resident by saying, Let's get this fat white racist b. done. She (NA # 1) informed NA # 4 that they were not doing this which she (NA # 1) reported meant she wanted NA # 4 to stop using unkind remarks. Resident # 1 tried to swing at NA #4, but she did not see NA # 4 hit Resident # 1. NA # 4 stood back while she (NA # 1) cared and provided care for Resident # 1 in a calm manner. After completion of care, she (NA # 1) was gathering used care items and headed out the door. NA # 4 was still behind her and had not exited the room. As she (NA #1) headed out the door she heard Resident # 1 say to stop hitting her in the face. She said it twice. She (NA # 1) turned around but did not see or hear Resident # 1 being hit or slapped. The resident next door was needing immediate assistance, and they had to immediately go and check on him. While in the room, she was called out by Nurse # 1 and told her what had occurred.Unit Manager # 1 was interviewed on 12/3/25 at 12:30 PM and reported the following information. On 11/18/25, Nurse # 1 called her to come to the room because Resident # 1 was saying that she had been hit. Resident # 1 told her (Unit Manager # 1) that she had been slapped in the face by one of the Nurse Aides. She (Unit Manager # 1) saw no red marks. She talked to NA # 4 about the incident and NA # 4 reported the resident was not telling the truth and that she had not hit the resident. NA # 4 reported she had been trying to provide care and that the resident routinely had behaviors and would call her (NA # 4) names. On the day of the incident NA # 4 reported Resident # 1 was swinging the bed remote control and it had hit her (NA # 4), and therefore she had removed it from Resident # 1. NA # 4 further reported that when she removed the remote from Resident # 1's hand the resident reported that she was going to tell that she (NA # 4) would take things and that she (NA # 4) had hit her. She (Unit Manager # 1) had also talked to NA # 1, who had been in the room. NA # 1 had commented, I don't really know about [NA # 4] and then had made general negative remarks about NA # 4 that were unrelated to the incident and seemed vague and not specific. After the incident she (Unit Manager # 1) went to tell the DON about what had been reported. She was not sure why NA # 4 was allowed to stay and work following the incident.NA # 4 was interviewed on 12/3/25 at 12:07 PM and reported the following information. Resident # 1 was known for lying and she and NA # 1 had gone in together to care for her on 11/18/25. At first the resident did not want to be changed and hit her with a remote control. The resident needed to be checked and finally agreed to have care. She had not hit the resident. The resident would call staff derogatory names such as fat a. She had never said anything derogatory to the resident. The only thing she had said was that God did not like for her (the resident) to talk like she did. She and NA # 1 had left the room together at the same time. The DON (Director of Nursing) was interviewed on 12/4/25 at 2:24 PM and reported the following information. She had been helping on the medication cart where a Medication Aide was assigned on 11/18/25. There was a resident who was having chest pain and not doing well. She had been very busy getting orders and getting medications for administration. She did not recall Unit Manager # 1 telling her about the incident of alleged hitting on 11/18/25. The next day (11/19/25) she was making rounds and checking in with the nursing staff. At that time Nurse # 1 said to her, I just want you to know about an incident because I think you would have done something about this. Then Nurse # 1 told her about the incident that had occurred the previous day (11/18/25) when Resident # 1 alleged she was hit. At that point she (the DON) suspended NA # 4, notified the Administrator, and started an investigation. During the investigation Resident # 1 never brought up that any disrespectful words had been used towards her. She alleged she had been hit and there was no witness or evidence of that. The DON further reported that Unit Manager # 1 should have gone to the Administrator if she (the DON) was too busy to take care of the matter on 11/18/25 or did not understand there was an allegation of abuse.The Administrator was interviewed on 12/4/25 at 11:26 AM and reported the following information. She learned Resident # 1 alleged she was hit the day following the incident. She had been on her way to work, and the DON had called her on her cell phone. The DON was also just learning about the incident. Unit Manager # 1 had mentioned the incident to the DON the previous day, but Unit Manager # 1 did not make it seem significant and the DON had been busy at the time. According to the Administrator, this had resulted in the suspension of NA # 4 not being immediate and that the investigation and reporting of the incident in required regulatory timeframes was not started until the day following the incident. After the investigation was started the police were called and she had been present when they talked to the resident. At that time, the resident reported to the police that she had not been hit and was lonely and could not get out of her room. Regarding NA # 1's comments that NA # 4 had said in the presence of Resident # 1 before the alleged incident, Let's get this fat white racist b. done the Administrator reported NA # 4 and NA # 1 did not get along and she had in past times had to move them to separate halls. This statement had not come up in their investigation. They had identified a problem with abuse reporting through their quality assurance program and implemented a corrective action plan.The facility provided a corrective action plan which did not include the education of all facility staff members. During an interview with the Administrator via phone on 12/8/25 at 4:05 PM the Administrator reported that they had done in-service training about abuse with their nursing staff but had not included all facility staff.

Based on observation, record review, and interviews with staff, Registered Dietician (RD), and Nurse Practitioner (NP), the facility failed to discontinue a previous enteral feeding (tube feeding) order when a new order was initiated which resulted in the resident not receiving the enteral feeding as most recently ordered. This was for 1 of 3 sampled residents who received nutrition by an enteral feeding (Resident #12).The findings included:Record review revealed Resident # 12 was admitted to the facility on [DATE]. Resident # 12's diagnoses included stroke, dysphagia, cognitive communication problems, and renal disease. Resident # 12's admission Minimum Data Set assessment, dated 11/6/25, coded the resident as moderately cognitively impaired. Resident # 12 was also coded to receive part of his nutrition by an enteral feeding as well as receiving a mechanically altered diet. His height was 66 inches, and his weight was 134 pounds.Resident # 12's care plan, dated 11/1/25, included that the resident had an enteral feeding. The care plan directed to consult with the RD (Registered Dietician) as needed and to administer tube feedings as ordered.On 11/3/25 a physician's order was written for Novasource Renal (tube feeding formula) bolus 200 ml (milliliters) after each meal if the resident ate less than 50 percent of his meal and 200 ml at 8:00 PM. The resident was to have 50 ml of water flush before and after each bolus feeding. Resident # 12 was also ordered to receive a Renal Dysphagia diet on 11/3/25.On 11/27/25 the RD noted the following information in a progress note. The resident's current enteral feeding order was for bolus enteral feedings of 200 ml (milliliters) Novasouce Renal three times after meals and 200 ml at bedtime. She was seeing Resident # 12 because he had been refusing his bolus feedings. The resident also had some nausea. The resident had poor oral intake for the last seven days. Therefore, she recommended that the bolus feedings be discontinued and that the resident start on Novasource Renal at 60 ml/hour for fourteen hours to be infused between the hours of 8:00 PM to 10:00 AM. She also recommended Resident # 12 had a 150 ml flush every four hours.On 11/27/25 an order was entered into the electronic system for an Enteral Feeding order of Novasource Renal at 60 ml per hours times 14 hours to be infused from 8:00 PM to 10:00 AM. Resident # 12 was also ordered to have a 150 ml water flush every four hours. According to the electronic system the orders were per the physician and created in the electronic system by the RD.Review of Resident # 12's November and December 2025 MARs (Medication Administration Records) revealed beginning on 11/27/25 the MARs had both the 11/3/25 orders for bolus feedings which were contingent on his intake and the MARs also included the new 11/27/25 order for the continuous feeding to run from 8:00 PM to 10:00 AM. The 11/3/25 bolus feeding had not been discontinued off the MARs. There was no place on Resident # 12's November and December 2025 MARs for the 7:00 A and 7:00 PM nurses to document about the continuous enteral feeding order which was ordered on their shift to infuse from 7:00 AM to 10:00 AM. The specific documentation by the latest 11/27/25 enteral feeding order included a scheduled time to document at 8:00 PM by this order. The specific documentation with this order was as follows:On 11/27/25-initials for a nurse that did not correspond to a nurse's signature at the bottom of the MAR were entered.On 11/28/25 Nurse # 5 documented Resident # 12 refused.On 11/29/2 Nurse # 5 documented the enteral feeding was given.On 11/30/25 Nurse # 4 documented the enteral feeding was given.On 12/1/25 Nurse # 2 documented Resident # 12 refused.On 12/2/25 Medication Aide # 1 documented the enteral feeding was given.On 12/3/25 Nurse # 3 documented the enteral feed was given.Resident # 12 was observed on 12/4/25 at 8:07 AM. This observation time correlated to a time the resident was ordered to receive a continuous enteral feeding per the last order dated 11/27/25. It was observed at this time that there was no continuous enteral feeding infusing. Resident # 12 replied to simple questions and was able to say nurses gave him an enteral feeding but did not report if it was per bolus or continuous, and he was not able to give times.Nurse # 6 was observed to be assigned to Resident # 12 on 12/4/25. Nurse # 6 was interviewed on 12/4/25 at 8:09 AM and reported the following. Resident # 12 did not receive a continuous enteral feeding. He was ordered bolus enteral feedings and that was why there was no enteral feeding infusing.Nurse # 4, who had documented that the continuous enteral feeding was administered beginning at 8:00 PM on 11/30/25 was interviewed on 12/5/25 at 9:22 AM by phone and reported the following information. On 11/30/25 she had provided a bolus feeding at bedtime because that was what showed on the MAR to be administered. She did not recall the continuous enteral feeding order showing on the MAR to be started on 11/30/25 at 8:00 PM and therefore she had not administered the continuous feeding.Nurse # 7 had cared for Resident # 12 on 12/1/25 and 12/2/25 during the 7:00 AM to 7:00 PM shift. Nurse # 7 was interviewed on 12/5/25 at 11:40 AM by phone and reported the following information. She had given Resident # 12 a bolus feeding on 12/1/25 and 12/2/25 based on his meal intake parameters and per the 11/3/25 order. Also at times, the resident would refuse the bolus because he would say he was nauseated. She had not known anything about a continuous enteral feeding order that was supposed to be infusing on her shifts until 10:00 AM. She did not recall anything showing on the MAR that the resident was to have an enteral feeding infusing up until 10:00 AM or she would have questioned it. The order had not appeared on the MAR for her shift for her to question the order. The resident also ate food that his family brought and therefore he had not been going without nutrition.Nurse # 2, who had documented a refusal of the continuous enteral feeding on 12/1/25 at 8:00 PM, was interviewed on 12/5/25 at 2:09 PM and reported the following. The resident had refused an enteral feeding on the night of 12/1/25 because he said that it made him stay up at night going to the bathroom. She did see both the bolus enteral feeding and the continuous enteral feeding order populate on the MAR and should have sought clarification from the provider about the two orders but did not do so.Medication Aide # 1 was interviewed on 12/5/25 at 9:45 AM and reported the following. Resident # 12 had never received an enteral continuous feeding when she worked. She did not know why her initials were on the MAR signifying this had been given. The nurse who had been covering for her (Nurse # 3) had not given it.Nurse # 3, who had documented that the continuous enteral feeding was administered beginning at 8:00 PM on 12/3/25 and who had been responsible for doing nursing tasks that MA # 1 was not licensed to do on 12/2/25, was interviewed on 12/5/25 at 5:20 PM via phone and reported the following information. When she covered for MA # 1 on 12/2/25 the continuous enteral feeding was not mentioned to her and therefore she did not give it. On 12/3/25 she gave the bolus bedtime enteral feeding per the 11/3/25 order but did not start a continuous feeding at 8:00 PM per the new 11/27/25 order. She saw the new order and was going to clarify what to do but then had an emergency to deal with and did not get around to clarifying the orders.Unit Manager # 1 was interviewed on 12/5/25 at 1:00 PM and reported the following information. The RD wrote orders for the enteral feedings, and she had written a new order on 11/27/25 for the Enteral Feeding order of Novasource Renal at 60 ml per hours times 14 hours to be infused from 8:00 PM to 10:00. When the RD did that she forgot to discontinue the old bolus enteral feeding orders from 11/3/25. No one had brought it to anyone's attention until 12/4/25 and therefore the resident had continued to get bolus feedings and was not switched to the continuous feeding from 8:00 PM to 10:00 AM.The RD was interviewed on 12/5/25 at 10:50 AM and reported the following information. The order should be for the continuous Novasource Renal at 60 ml per hours times 14 hours to be infused from 8:00 PM to 10:00. The problem that the bolus enteral feeding had not been discontinued had not been recognized until 12/4/25. Resident # 12's intake varied over the last seven days but had picked up in the most recent last days. His weights had been stable.The DON (Director of Nursing) was interviewed on 12/5/25 at 5:00 PM and reported the following information. The RD had permission from the providers to write the orders based on her recommendations. There had been a mistake in that the bolus feeding order had not been discontinued but Resident # 12 ate in addition to having bolus feedings. Family members also brought him food in addition to his meals at the facility.NP # 2 was interviewed on 12/8/25 at 2:45 PM and reported the following. The providers had approved the RD to write orders for enteral feedings based on her assessment of the residents' needs. Then the nurse would confirm the order, and the physician would sign it. Resident # 12 had not lost weight and suffered any negative outcome from not having a continuous enteral feeding as ordered on 11/27/25. The bolus feedings had continued along with water flushes.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice (Resident #6), Hearing, Speech and Vision (Resident #13), Functional abilities and Goals (Resident #56) and Dialysis (Resident #350) for 4 of 21 residents reviewed for MDS accuracy. The findings included: Resident #6 was readmitted to the facility on [DATE] with diagnoses that included stroke, hypertension, and heart failure. Review of a hospice visit note dated 6/13/24 revealed that Resident #6 was seen by hospice services as a follow-up evaluation. Review of the quarterly MDS assessment dated [DATE] coded Resident #6 as not receiving hospice care services. MDS Nurse #1 was interviewed on 12/04/24 at 2:24 PM, and she revealed that the hospice services in section O of the 6/21/24 quarterly MDS assessment should have been coded as YES. MDS Nurse #1 stated she must have miscoded the hospice details by accident. Resident #6 had a hospice visit on 6/13/24, and she was still on hospice at that time. An interview was conducted with the Director of Nursing (DON) on 12/05/24 at 11:31 AM. She revealed that if MDS Nurse #1 had any question about any resident, she should have reviewed the chart or asked the DON directly. The DON stated that her expectation was for MDS to find out all correct information before miscoding anything. During an interview with the Administrator on 12/05/24 at 12:16 PM, she revealed that Resident #6's hospice details in the quarterly MDS assessment dated [DATE] should have been coded accurately. 49502 2.Resident #13 was admitted to the facility on [DATE] with diagnoses which included: absolute glaucoma bilateral, legal blindness, and diabetes mellitus. Review of optometrist note dated 12/1/23 revealed Resident #13 was legally blind and recommended access to audiobooks. Review of Resident #13's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had moderate cognitive impairment and was noted with adequate vision (sees fine detail, such as regular print in newspapers/books). Resident #13's care plan dated 8/23/24 revealed a focus area for blindness. Resident #13 was interviewed on 12/5/24 at 8:35 a.m. and she stated she was blind. During an interview on 12/5/24 at 8:38 a.m. with Nurse #9, she stated Resident #13 was unable to see. She was dependent upon staff for activities of daily living (ADL). In an interview on 12/5/24 at 8:45 a.m., CMA #1 stated Resident #13 was blind and could not see. CMA #1 further stated Resident #13 understood directions and made her needs known but was dependent on staff for her ADL. During an interview on 12/5/24 at 8:58 a.m. with the MDS Nurse #1, she stated Resident #13's vision assessment was coded incorrectly because of her diagnosis of absolute glaucoma and the optometrist documentation indicating blindness. In an interview on 12/5/24 at 9:01 a.m. with the Administrator, she indicated the MDS should be coded accurately. 48007 3. Resident #56 was admitted into the facility on [DATE] with a re-entry on 1/3/24 with diagnoses of a cerebrovascular accident. A review of Resident #56's physician orders revealed an order dated 7/1/24 for bilateral multi podus boots (a boot used to treat and prevent ankle and foot contractures) up to four hours daily for ankle stiffness. A review of Resident #56's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed he had functional limitations of his upper extremities. A review of Resident #56's most recent Annual MDS indicated that he had functional limitations of his upper and lower extremities. An observation on 12/3/24 at 1:10 PM of Resident #56 noted that he had difficulty raising the front part of both feet. An interview with Resident #56's family member was conducted on 12/3/2024 at 1:13 PM revealed that the podus boots were ordered to help with Resident #56's foot drop. An interview with the MDS Coordinator was conducted on 12/4/24 at 10:10 AM which revealed that she was aware of Resident #56's functional limitations of his lower extremities and that it was not marked accurately on the quarterly MDS dated [DATE]. She also acknowledged that it was her responsibility to ensure that the MDS was filled out accurately in all areas. An interview was conducted with the Administrator on 12/4/24 at 10:25 AM and she said that the MDS should be filled out accurately and that accuracy should be verified prior to submission. 38702 4. Resident #350 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #350 wascognitively intact but was not coded for end stage renal disease (ESRD) and dialysis. The diagnosis list revealed ESRD 01/25/2024 and was active. An interview with the Minimum Data Set (MDS) Nurse was conducted on 12/04/2024 at 10:23 AM. The Nurse stated another MDS nurse completed the MDS assessment for Resident #350 but was not available. He did have ESRD and was on dialysis. They were transitioning electronic systems, and it was an oversite. The MDS should have been coded correctly. An interview with the Administrator was conducted on 12/04/2024 at 11:25 AM. The Administrator stated Resident #350 had a diagnosis of ESRD and was on dialysis. She also stated that she expected the MDS nurses to code the assessments correctly.

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 25 of 61 days reviewed for sufficient staffing. Findings included: Review of the daily assignment schedules from April 01, 2024, to May 28, 2024, revealed the facility failed to provide 8 hours of Registered Nurse (RN) coverage on the following dates: 04/01/24, 04/03/24, 04/05/24, 04/06/24, 04/07/24, 04/13/24, 04/20/24, 04/21/24, 04/22/24, 04/26/24, 04/27/24, 04/30/24, 05/04/24, 05/06/24, 05/09/24, 05/10/24, 05/11/24, 05/14/24, 05/18/24, 05/19/24, 05/20/24, 05/21/24, 05/24/24, 05/25/24, and 05/28/24. An interview was conducted with the facility Scheduler on 12/04/2024 at 9:30 AM. During the interview the Scheduler reported she was not aware that she needed to schedule an RN for at least 8 consecutive hours every day. The Scheduler explained that there had been a large amount of staff turnover, including RNs, since the facility changed ownership in June-July 2024. She further explained the facility had been using staffing agencies but at times could not get 8 hours of RN coverage when it was needed, however the facility was in the process of hiring RNs. During the interview the above schedules were reviewed with the facility Scheduler to verify there had been at least 8 consecutive hours of RNs scheduled to work on those days. An interview was conducted on12/04/24 at 12:15 PM with the Director of Nursing (DON). She had been the DON since 11/25/24. During the interview the DON reported she was aware there had been issues related to RN staffing, including the lack of RNs in supervisory roles. She explained the facility was in the process of hiring RNs, including an Assistant Director of Nursing (ADON). An interview was conducted on12/04/24 at 12:20 PM with the Administrator. She revealed she was aware RN coverage had been an issue at the building before and after it changed ownership. The Administrator reported that many nurses, including RNs, had left or changed roles and the facility was utilizing agency staff including Medication Aides. The Administrator explained she was not aware the Scheduler had difficulty filling the 8-hour RN spots, and the facility was in the process of hiring additional RNs.

Based on interviews with Resident Council members and staff and review of Resident Council minutes, the facility failed to resolve concerns voiced by the Resident Council members for 1 of 6 months reviewed (July 2024). The findings included: Resident Council Meeting minutes from January 2024, February 2024, March 2024, July 2024, August 2024, and September 2024 were reviewed. A review of Resident Council minutes dated 7/9/24 indicated residents voiced concerns regarding not being able to get out of bed or get showers on their scheduled shower days due to staffing. Two administrative responses to the Resident Council form were reviewed dated 7/9/24. One stated the residents were being told they could not get out of bed due to staffing. There was no resolution listed. A second form revealed residents were concerned about not being able to get showers on their scheduled shower days due to staffing. There was no resolution listed. Review of Resident Council minutes dated 8/13/24 revealed there were no administrative resolutions from the July 2024 meeting. An interview was conducted on 12/4/24 at 2:00 PM with the facility's Resident Council. There were 12 residents present. During the meeting residents expressed concern with the resolution of grievances. The residents in the meeting reported not all grievances were acted on promptly by the facility and there was no explanation as to why the grievances were not resolved. The residents stated at each meeting they discussed the same concerns. Residents stated the Activities Director was present at the Resident Council meetings and communicated their concerns to the Administration. Residents stated they continued to have concerns about getting out of bed and receiving showers on their scheduled shower days. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:54 AM. She stated she was never advised of any concerns from the Resident Council for July 2024. The DON stated it was her responsibility to resolve Resident Council concerns related to nursing. Attempts to contact the former Activities Director were not successful. An interview was conducted with the Administrator on 12/5/24 at 12:05 PM who stated resolution of Resident Council concerns should be forwarded by the Activities Director to the appropriate department head and resolutions should be shared at the next Resident Council meeting. She stated the Activities Director resigned on 11/11/24.

Based on record review and staff interviews, the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 2 of 21 residents reviewed for advance directive (Residents #14 and Resident #17). The findings included: a. Resident #14 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, dysphagia, and end stage renal disease. There was no documentation in Resident #14's medical record for education regarding the formulation of an advanced directive and/or an opportunity to formulate an advance directive was offered. An interview was conducted with the Director of Social Services on 12/04/2024 at 3:51 PM. She revealed that during care plan meetings or as needed, code status was discussed. However, the conversation never went further into detail to include advance directive. During an interview with the Admissions Director on 12/05/24 at 8:22 AM, she revealed that prior to the change of ownership in June 2024, residents/families were only educated on code status. This was included in the admissions packet at the time. Beginning June 2024, the new company moved the advance directive discussion responsibility to Social Services. An interview was conducted on 12/05/2024 at 11:15 AM with the Director of Nursing (DON). The DON revealed it was her expectation for the resident's advanced directives to be discussed with the residents or resident responsible party during admission. She indicated Resident #14's advanced directive should have been filed in the residents' medical records. On 12/05/2024 at 2:12 PM an interview was conducted with the Administrator who stated she expected all residents to have an advanced directive indicated in their electronic medical record when admitted or readmitted to the facility. 43222 b. Review of Resident #17's medical record revealed the Resident was readmitted to the facility on [DATE] with diagnoses that included dementia, stroke, and diabetes. The review revealed a do not resuscitate (DNR) order was placed on 8/5/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview was conducted with the Director of Social Services #1 on 12/04/24 at 3:51 PM. She revealed that during care plan meetings or as needed, code status was discussed. However, the conversation never went further into detail to include advance directive. During an interview with the Admissions Director on 12/05/24 at 8:22 AM, she revealed that prior to the change of ownership in June 2024, residents/families were only educated on code status. This was included in the admissions packet at the time. Beginning June 2024, the new company moved the advance directive discussion responsibility to Social Services. An interview was conducted with the Regional Director of Clinical Services on 12/05/24 at 8:26 AM. She revealed that the conversation about advance directive was not being done but rather only code status. The Regional Director of Clinical Services stated that the advance directives discussion/education needed to be completed upon admission, and the responsibility was now assigned to the Director of Social Services #1. She stated there was now a statement about advance directive included in the current admissions packet.

Based on record review and staff interview, the facility failed to protect residents' right to be free from misappropriation of resident property for 2 of 21 residents reviewed for misappropriation of resident property (Resident #152 and Resident # 97). Findings included: a. Resident #152 was admitted to the facility on [DATE] with diagnoses that included hypertension, respiratory failure and fracture of facial bone. The resident was discharged from the facility on 11/01/2024. An admission Minimum Date Set (MDS) dated [DATE] revealed that Resident #152 was cognitively intact. A review of the initial facility report dated 10/28/24 at 11:45 AM documented that a resident (Resident #152) reported that his air pods (wireless Bluetooth earbuds designed by apple) had been removed from his room. The resident reported he left the facility at approximately 4:30 PM on Friday 10/25/2024 and returned at 12:00 AM on 10/26/2024. Resident #152 reported he left the air pods charging on his bedside table. The air pods were tracked to an address in another town. The address was linked to Nurse #14. The report indicated that the corrective actions following the incident was the resident was given a new nightstand which can be locked to secure his valuables. All staff received education on misappropriation of resident property. The Police Department Incident Report dated 12/28/2024 by Officer #1 was reviewed. On Monday, October 28,2024, approximately 11:43 AM, Officer #1 was dispatched to Resident #152 room in reference to a larceny. Officer #1 spoke with the Administrator at the facility who stated that Resident # 152 had his air pods missing at the facility. The report revealed the air pods had been entered into the National Crime Information Center (NCIC) and the case was inactive pending the recovery of the items and charges for suspected larceny. On 12/04/2024 at 1:05 PM a phone interview was attempted with the alleged perpetrator, Nurse #14, but the attempt was unsuccessful On 12/04/2024 at 2:35 PM a phone interview was attempted with Resident #152, but the attempt was unsuccessful. On 12/05/2024 at 11:05 AM a phone interview was attempted with the police, but the attempt was unsuccessful. An interview was conducted with the Administrator on 12/05/2024 at 1:14 PM and revealed She investigated the incident that was reported on October 28, 2024, that involved misappropriation of property with Resident #152. The police were notified about Resident# 152's air pods missing in his room. The police were able to track the air pods to an address in another town. (air pods can be tracked by going to Find My app on an iPhone or iPad that was previously paired with the Air Pods.). The address belonged to Nurse #14 who was assigned to Resident #152 on 10/25/2024. The Administrator added that Nurse #14 was found to be in possession of Resident # 152's air pod by the police. The Administrator indicated that Nurse #14 was agency staff, and she had been terminated. The administrator also revealed they completed 24-hour and 5-day reports and faxed the information to the state agency. The Administrator stated that all staff were trained in resident abuse and misappropriation of property at the facility. She reported a background check was completed for Nurse #14 prior to hire and the facility had no concerns related to any criminal activity. The Administrator also revealed that Nurse #14 should not have taken the air pod from Resident #152 and the nurse failed to follow the policy of misappropriation of property. 39731 b. Resident #97's medical record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and hypertension. The resident was discharged from the facility on 10/31/24. An admission Minimum Date Set (MDS) dated [DATE] revealed that Resident #97 was assessed as having moderate cognitive impairment. A review of the initial facility report dated 10/28/24 at 1:00 PM documented that Resident #97's family member reported Resident #97's debit card had been removed from his wallet. Resident #97 kept his wallet in his front shirt pocket. When she came to visit his wallet was lying on his bed. The family member discovered two transactions totaling approximately $29 were made. The debit card transactions were used to pinpoint times to review video surveillance at a local gas station. A photo was shared to determine if the employee on the staffing sheets matched the photo. The report indicated that the corrective actions following the incident was Resident #97's wallet was sent with family and locked boxes will be used to secure valuables when requested. All staff received education on misappropriation of resident property. The Police Department Incident Report dated 10/28/24 by Officer #1 was reviewed. On Monday, 10/28/24, at approximately 1:03 PM, Officer #1 was dispatched to Resident #97's room in reference to a larceny. Officer #1 spoke with the Administrator at the facility who stated that Resident # 97 had his debit card missing at the facility and charges were made. The report revealed the case was inactive pending charges for suspected larceny. On 12/04/2024 at 1:05 PM a phone interview was attempted with the alleged perpetrator, Nurse #14, but the attempt was unsuccessful. On 12/05/2024 at 11:05 AM a phone interview was attempted with the police, but the attempt was unsuccessful. On 12/4/24 at 12:15 PM a phone interview was conducted with Resident #97's family member who stated she discovered the bank card was missing and the charges made on the bank card. She stated she notified the facility and met with Police Officer #1. The family member stated she was satisfied with the facility's response to the incident by immediately notifying the police. and initiating an investigation. She reported the next court date for Nurse #14 was in January 2024. An interview was conducted with the Administrator on 12/05/2024 at 1:14 PM and revealed she investigated the incident that was reported on 10/28/24 that involved misappropriation of property with Resident #97. The police were notified about Resident# 97's debit card missing in his room. After speaking with Resident #97's family member and being informed of transactions at a local gas station the police officer was able to track the use of the debit card to a local gas station and review video footage of Nurse #14 in the gas station. The Administrator indicated that Nurse #14 was agency staff, and she had been terminated. The Aministrator also revealed they completed 24-hour and 5-day reports and faxed the information to the state agency. The Administrator stated that all staff were trained in resident abuse and misappropriation of property at the facility. She reported a background check was completed for Nurse #14 prior to hire and the facility had no concerns related to any criminal activity. The Administrator also revealed that Nurse #14 should not have taken the debit card from Resident #97 and the nurse failed to follow the policy of misappropriation of property.

Based on staff interviews and record review the facility failed to develop a comprehensive care plan to include application of splints or multi podus boots for 1 of 32 residents (Resident #56) reviewed for comprehensive care planning. Findings included: Resident #56 was admitted into the facility on [DATE] with a re-entry on 6/24/2024. A review of Resident #56's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #56 was severely cognitively impaired. A review of Resident #56's physician orders indicated on 7/1/2024 an order for bilateral multi podus boots up to four hours daily and on 10/8/24 an order for apply left hand splint when sitting up in wheelchair daily, remove when going back to bed. Resident #56's was to wear bilateral elbow extension splints daily, applied with afternoon care once back in bed and removed at PM care for effective contracture management. A review of Resident #56's comprehensive care plan revised on 10/22/2024 did not have a care plan related to the application of splints or multi podus boots. An interview was conducted on 12/4/2024 at 10:10 AM with the MDS Coordinator who stated that Resident #56's current comprehensive care plan interventions did not include the application of splints or multi podus boots. The MDS Coordinator further stated that when the computer system was switched from one system to another the care plan related to the application of splints and multi podus boots had not carried over for some reason. The MDS Coordinator was able to provide the care plan from the prior system which had the application of splints and the multi podus boots as interventions. An interview was conducted with the Administrator on 12/4/2024 at 10:25 AM during the interview she stated that Resident #56's current comprehensive care plan should have included the use of splints and multi podus boots as an intervention.

Based on record review, observations, and staff interviews, the facility failed to apply left hand splint, elbow extender splints and multi podus boots as ordered for 1 of 3 sampled residents with limited range of motion/contractures (Resident #56). The findings included: Resident #56 was admitted into the facility on [DATE] and readmitted on [DATE]. A review of Resident #56's quarterly Minimum Data Set (MDS) dated [DATE] indicated that he was severely cognitively impaired. A review of Resident #56's physician orders indicated on 7/1/2024 an order for bilateral multi podus boots (an orthotic to treat and prevent ankle and foot contractures) up to four hours daily and on 10/8/24 an order to apply left hand splint when sitting up in wheelchair daily, remove when going back to bed. Resident #56's was to wear bilateral elbow extension splints daily (an orthotic to help increase elbow extension in patients with non-fixed contractures), applied with afternoon care once back in bed and removed at PM care for effective contracture management. Observations for the application of the left-hand splint when he was in his wheelchair and for elbow extender splints when he was in bed were conducted on 12/3/24 at 9:00 AM, 11:00 AM, 1:00 PM and 3:00 PM and it was noted that the splints and multi podus boots had not been applied. An interview Resident #56's Family Member on 12/3/24 at 3:00 PM indicated that the multi podus boots and the hand and elbow splints had not been applied to Resident #56 during the time she had been in the room from 9:15 AM until now. The Family Member also indicated that the splints were not put on most days and that she visited every day from about 9:00 AM until usually around 6:00 PM. Observations for the application of a left-hand splint when he was in his wheelchair and for multi podus boots and elbow extender splints when he was in bed were conducted on 12/3/24 at 9:00 AM, 11:00 AM and 1:00 PM and it was noted the splints had not been applied. An interview with Resident #56's Family Member revealed that there had been no splints or multi podus boots put on Resident #56 since she had been in the room around 9:30 AM and the splints or multi podus boots had not been applied by the time she left yesterday around 5:30-6:00 PM Observations for the application of a left-hand splint when he was in his wheelchair and for multi podus boots and elbow extender splints when he was in bed were conducted on 12/4/24 at 8:30 AM, 10:00 AM and 12:30 PM and it was noted the splints had not been applied. An interview conducted with Nursing Assistant #30 on 12/3/24 at 10:10 AM revealed that either licensed nursing staff or nursing assistants put on any splints that were ordered. Nurse Assistant #30 indicated that the application of splints was on a resident's information sheet and listed as a daily task on the nursing assistant required charting in the electronic medical record. Nurse Assistant #30 further indicated that she had not been aware Resident #56 required the application of any splints. An interview with Licensed Nurse #31 on 12/3/24 at 10:30 AM indicated that either nursing assistants, licensed nursing staff, or physical therapy applied splints to the residents who had orders. She stated that it was on the resident's information sheet which residents had splints applied and if the licensed nursing staff were to apply the splints, they would show up on the medication administration sheet. She further stated that she was unaware Resident #56 required the application of splints but was aware he had an order for multi podus boots. An interview with COTA (Certified Occupational Therapy Assistant) #1 on 12/3/24 at 11:00 AM revealed that Resident #56 was not currently on the therapy caseload and the nursing staff was responsible for applying and taking off any ordered splints. He stated that the therapy department had trained the unit supervisors on the application of splints and/or braces so that they would be able to instruct any new nursing staff on their unit. An interview with the MDS (Minimum Data Set) Coordinator on 12/4/24 at 10:10 AM indicated that the splints and multi podus boots and not been care planned for Resident # 56 so the task had not been linked to the resident information sheet or the nursing assistants' task which was the only way the nursing assistants and licensed nursing staff would be aware of Resident #56's need for splint application. An interview with the Administrator on 12/4/24 at 10:25 AM indicated that by not having the left-hand splint, elbow extender splint and multi podus boot care planned it caused a system failure which resulted in no documentation of them being applied or of the nursing staff being made aware of the needed application.

Based on record review, resident and staff interviews, the facility failed to ensure Resident #64 was scheduled for a neurology appointment for 1 of 1 resident reviewed for medical appointments (Resident # 64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, hypothyroidism and failure to thrive. Resident #64's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. An interview was conducted with Resident #64 on 12/2/24 at 12:21 PM. She reported she had a referral to a neurologist and an appointment was never made. Resident #64 stated she questioned her diagnosis of Parkinson's disease and wanted a neurology appointment to confirm the diagnoses. Record review revealed a referral was made to neurology on 3/1/24 by the facility scheduler. A letter written to the facility by the Referral Coordinator at the local neurology office addressed to the Scheduler at the facility dated 3/26/24 read in part, notes did not provide sufficient information about the Parkinson's disease. There was no appointment made. A facility progress note dated 4/20/24 stated Resident #64 contacted 911 and stated she wanted to see a neurologist. The resident was transferred to a local hospital. Review of discharge instructions from Resident #64's hospital visit on 4/20/24 dated 4/20/24 stated for Resident #64 to schedule an appointment with a Neurology provider as soon as possible. An interview was conducted with the Scheduler on 12/4/24 at 1:30 PM who stated she let the doctor know about the notice dated 3/26/24. She stated she did not send a referral to the Neurology provider after Resident #64's hospital visit on 4/20/24 because she was advised by Nurse #9, she had already been referred to neurology. She reported she received a handwritten note from Nurse #9 which was left on her desk. Review of a handwritten note written by Nurse #9, dated 4/20/24 read, the doctor called to inform the facility he has a referral for Resident #64 already. Nurse #9 was unavailable for interview. An interview was conducted with the Director of Nursing on 12/5/24 at 11:55 AM who stated the Scheduler, or the Nurse #9 should have ensured Resident #64 had a neurology appointment scheduled.

Based on observation and staff interviews, the facility failed to dispose/discard expired medications in 1 of 3 medication carts (Rehab Medication Cart) observed. The findings included: During an observation of the Rehab Medication Cart on 12/04/24 at 9:34 A.M., one bottle of aspirin 325 milligrams (mg) tablets with an expiration date of 09/2024 and one bottle of Allergy Relief tablets with an expiration date of 04/2024 were observed in the top drawer of the cart. During an interview with Certified Medication Aide (CMA) #1 on 12/04/24 at 9:36 A.M., CMA #1 confirmed she had been working the Rehab Medication Cart that day. She stated it was the responsibility of the nurses to check the medication carts for expired medications. During an interview with Nurse #8 on 12/04/24 at 9:45 A.M., Nurse #8 stated it was his responsibility to check the Rehab Med Cart for expired medications. When asked if he was sole person responsible for checking the medication carts for expired medications, Nurse #8 clarified and stated that it was the responsibility of all nurses to check their medication carts for expired medications. An interview was conducted with the Administrator on 12/04/24 at 1:50 P.M. The Administrator stated it is her expectation that nursing staff check the medication carts and medication storage rooms for expired medications and to discard them.

Based on record review and staff interviews, the facility failed to have a complete and accurate medication and administration record for 2 of 5 residents reviewed for medical record accuracy (Resident #250 and Resident #350). Findings included: 1. Resident #250 was admitted to the facility 07/19/24. Review of Resident #250's Emergency Department (ED) Note revealed she was sent to the hospital on 08/09/24 for evaluation and transferred to the hospital. Review of Resident #250's medical record revealed there was no entry to indicate the resident was transferred to the hospital on 08/09/24 or the resident's condition at the time of transfer. The only documentation in the medical record was a nurse blood pressure vital sign 120/70 dated 08/09/24 at 10:04 AM written by Nurse #2 regarding Resident #150's hospital transfer. An interview was conducted on 12/04/24 at 1:45 PM with Nurse #2 revealed she was working as a floor nurse on the 700-hall on 08/08/24 and 08/09/24. Nurse #2 said Resident #250 told her that she had just called her family member and told her to call 911 because she was mad and did not want to stay there anymore. Nurse #2 said she took the resident's vital signs, which were all within normal ranges. Nurse #2 stated emergency medical services (EMS) soon arrived, and took their own vital signs, also within normal ranges. Nurse #2 explained the resident and family member were still demanding that the resident go to the ED due to being tired and short of breath (SOB). Nurse #2 said she called the MD and documented her notes in the electronic chart. She said later, when she checked her charting, the resident's information had already been removed from the electronic system. Nurse #2 stated she did not know why resident's discharge information was not available in their electronic medical record system, thinking once she was discharged to the hospital, her discharge notes and information were lost due to a computer glitch, after the resident was changed from an active resident to a discharged resident. Nurse #2 stated she had been trained to write a nurse's note any time a resident was transferred to the hospital which included what time the resident left the facility, why the resident needed to be transferred to the hospital, how they were transported, and their condition at the time of the transfer. She stated Resident #250 not having a progress note regarding her transfer to the hospital on 08/09/24 was due to miscommunication or computer error, she did not really know. An interview was conducted on 12/04/24 at 11:40 AM with Nurse #4. She stated Nurse #2 was new to the facility, and on 08/09/24 she should have asked a charge nurse for assistance with getting Resident #250 sent to the hospital on 08/09/24 and that they would assist her by gathering the required paperwork and arranging for transportation to the hospital. Nurse #4 stated that she was not Resident #250's assigned nurse on 08/09/24 and it was the responsibility of the assigned nurse to complete documentation detailing why the resident was transferred. An interview was conducted on 12/04/24 at 12:15 PM with the Director of Nursing (DON). She revealed that any time a resident was transferred to the hospital the nurse caring for the resident was responsible for writing a note which included when and how the resident left, their condition when they left the facility, and any other information relevant to the situation. She stated she was unsure why there was no note in Resident #250's medical record regarding his transfer to the hospital on 08/09/24. The DON reviewed the physician's orders for Resident #4 and confirmed there was no transfer order documented. An interview was conducted with the Administrator on 12/04/24 at 3:22 PM. The Administrator stated the nurse should have documented an order for Resident #250 to be transferred to the emergency department once she received the verbal order for transfer. 38702 2. Resident #350 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] had Resident #350 coded as cognitively intact. A review of the Physicians order dated 02/12/2024 revealed an order for sevelamer (A medication used to treat high phosphate levels in the blood for patients with chronic kidney disease who are on dialysis) 800 milligrams (mg) by mouth three times daily and was discontinued on 03/15/2024. The February 2024 Medication Administration Record (MAR) revealed an order for sevelamer 800 MG tablet by mouth three times daily. The medication was not signed as administered on 02/02/2024 times 2 (x2), 02/05/2024, 02/07/2024, 02/08/2024 x2, 02/09/2024, 2/10/2024, and 02/17/2024. The March 2024 MAR revealed sevelamer 800 mg tablet by mouth three times a day. The medication was not signed as administrated on 03/01/2024, 03/02/2024, 03/06/2024 x2, and 03/15/2024. An interview with Nurse #5 was conducted on 12/04/2024 at 02:51 PM. The Nurse stated Resident #350s sevelamer 800 mg was taken with food and was administered as ordered but was not documented at times and is now checking to make sure all medications are documented as administered when given. An interview with Nurse # 7 was conducted on 12/05/2024 at 09:48 AM. The Nurse stated Resident #350 would want the sevelamer 800 mg without meals, but he got it with meals as ordered. The Nurse also stated he had missed documentation that the medication was administered but Resident #350 received his medications. An interview with the Director of Nursing (DON) was conducted on 12/04/2024 at 09:44 AM. The DON stated she had noticed some of the nurses have missed some of their documentation. She was checking the charts but some days the documentation was missing but the medications were administered.

Based on observations, record review, and staff, police dispatch, physician, and responsible party (RP) interviews the facility failed to prevent a severely cognitively impaired resident (Resident #71) with known wandering behaviors and poor safety awareness from becoming trapped alone in a locked administrative staff's office with the lights off without staff's knowledge. The facility also failed to provide evidence that a thorough investigation of the incident was conducted and to put corrective measures in place after the incident to prevent a potential recurrence. This deficient practice had a high likelihood of causing Resident #71 serious physical and psychosocial harm. Resident #71 did not have the cognitive capacity to express an adverse outcome. A reasonable person would have suffered feelings of fear, anxiety, and/or helplessness from the incident. This was for 1 of 11 residents reviewed for the provision of supervision to prevent accidents. Immediate Jeopardy began on 7/26/23 when Resident #71 became trapped alone in a staff office. Immediate Jeopardy was removed on 10/15/23 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses including dementia, generalized muscle weakness and unsteadiness on feet. A review of the Physical Therapy discharge summary for Resident #71 dated 6/21/22 completed by Physical Therapist (PT) #1 revealed the discharge recommendation was for staff to continuously monitor Resident #71 and to keep Resident #71 in line of sight of staff due to her high fall risk. A review of a nursing progress note for Resident #71 dated 11/21/22 at 6:36 PM revealed in part she was found on the floor in the hallway. She had no injuries. A review of a nursing progress note for Resident #71 dated 11/27/22 at 12:59 PM revealed in part she was found on the floor in a kneeling position. She had no injuries. A review of a nursing progress note for Resident #71 dated 12/2/22 at 6:56 PM revealed in part she was found sitting on the floor in the dining room. She had no injuries. A review of a nursing progress note for Resident #71 dated 4/13/23 at 6:23 PM revealed in part Resident #71 was found on the floor in the dining room. She had no injuries. A Fall Risk Assessment for Resident #71 dated 4/14/23 revealed in part she had a history of falls. It further revealed she overestimated her abilities and forgot her limitations. It concluded Resident #71 was at high risk for falls. Resident #71's comprehensive care plan revealed in part a focus area last updated on 4/22/23 of at risk for further falls and injury related to weakness, impaired mobility, potential side effects of medication, poor safety awareness and history of falls. It further revealed Resident #71 had actual falls with no injury on 7/29/22, 8/12/22, 8/17/22, 8/19/22, 11/21/22, 11/27/22, 12/2/22 and 4/13/23. The goal was for Resident #71 to remain free from falls with injury through the next review. Interventions included the following: 8/12/22 referral to Occupational Therapy for wheelchair positioning, 8/17/22 a non-slip mat to seat of wheelchair, 8/19/22 staff education to ensure resident is wearing non skin {sic} footwear when OOB (out of bed), 12/2/22 anti-tippers to wheelchair, and 4/13/23 frequent monitoring during mealtimes. There was no care plan focus area in place for wandering. A review of Resident #71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She displayed inattention and disorganized thinking continuously. She displayed no behavioral symptoms, rejection of care or wandering behavior. Resident #71 required the extensive assistance of 2 people for transfers and set-up assistance for locomotion on and off her unit. She did not walk. She was not steady when moving from a seated to standing position and was only able to stabilize with human assistance. She was not steady during transfers from surface to surface (between bed to chair or wheelchair) and was only able to stabilize with human assistance. She had no functional impairment of range of motion in her upper or lower extremities. She used a wheelchair for mobility. She had one fall with no injury since her prior MDS assessment. She did not use a wander/elopement alarm. A review of an Elopement Risk Tool for Resident #71 dated 7/15/23 completed by the Director of Nursing (DON) revealed Resident #71 was found to be at risk for elopement. It further revealed her wandering behavior affected her safety and well-being. On 10/10/23 a review of the physician's orders for Resident #71 revealed an order dated 7/15/23 for a wanderguard (a type of elopement alarm) to be placed to her right ankle. A nursing progress note dated 7/27/23 at 7:58 AM written by Nurse #2 revealed in part Resident #71 was reported missing around 9:00 PM to 11:00 PM (7/26/23). All open doors were searched multiple times including outside in the courtyard and around the facility and she was not found. Management and law enforcement were notified, and law enforcement came to the facility. Resident #71's family was notified. She was found in the MDS (Minimum Data Set) office in the dark seated on the sofa facing the door. The door was locked and needed a code to enter. She was assessed for injury at that time with none noted. Her family was notified that she had been found safe. On 10/10/23 at 11:19 AM a telephone interview with Nurse #2 indicated she was familiar with Resident #71. She stated Resident #71 often self-propelled herself round in the facility by wheelchair. She stated she was assigned to care for Resident #71 from 7:00 PM to 7:00 AM on 7/26/23. She went on to say about 7:30 PM to 8:00 PM on 7/26/23 she had some residents including Resident #71 gathered around her medication cart in the hallway. She further indicated around 8:20 PM Resident #71 refused her medications and her vital signs, and she told Resident #71 she would try again later. Nurse #2 stated this was the last time she had seen Resident #71 herself prior to her being identified as missing. Nurse #2 stated around 9:20 PM she went to find Resident #71 in her room, but she wasn't there. She went on to say she found Nurse Aide (NA) #4 to ask her where Resident #71 was. She stated NA #4 had not known and NA #4 went to look for Resident #71. Nurse #2 stated when NA #4 reported back to her that NA #4 was not able to locate Resident #71 after looking on all the halls Nurse #2 let all staff know to begin looking for her. She went on to say they searched everywhere inside the facility and outside that they could access for about 30 minutes but could not locate Resident #71. She further indicated at that point she knew it was time to notify her chain of command and the police. She stated when she spoke with the Administrator by telephone, the Administrator told her to call the police, so she did. She went on to say the Director of Nursing, the Admissions Director, and the police had all arrived at the facility about the same time Nurse #2 further indicated the police asked for the codes to the locked doors in the facility. She went on to say the Admissions Director then went to the MDS office door, entered the code, opened the door, and Resident #71 was there alone in the dark seated on a couch with her wheelchair facing the door and the brakes to her wheelchair locked. She stated Resident #71 was smiling and asked if the police were going to arrest her. She further indicated when she arrived to work on 7/26/23 at 7:00 PM she walked past the MDS office and recalled the office door being closed like it usually was in the evening. Nurse #2 stated there was no way Resident #71 could have gotten out of there by herself due to the heavy door, and the codes that were needed. She stated Resident #71 was thin, not very strong, and could not walk. She further indicated she had assessed Resident #71 for injuries and there had been none. On 10/11/23 at 2:43 PM an interview with Police Dispatch #1 indicated the [NAME] Varina Police Dispatch first received the call for a missing resident at the facility on 7/26/23 at 10:23 PM. A review of the local Police Department Call for Service report dated 7/26/23 for a missing person verified the call was initially received from the facility at 10:23 PM. On 10/10/23 12:00 PM an observation of the MDS office was conducted with MDS Nurse #2. She stated she had been working in this MDS office for over a year. She went on to say she was not working on 7/26/23. She stated the current arrangement of the MDS office was the same as it had always been. On entrance to the office there was observed to be one desk to the right of the door facing towards the back of the room. There was a second desk on left of the office which faced the door. There was a short, narrow Z shaped path between the opposing corners of desks leading to the back wall of the office. There were 2 chairs at the front of the desk on the right which were pushed together and facing the desk on the left. The door to the office did not atomically shut and had to be manually pushed to close. On 10/10/23 at 5:21 PM an observation was conducted with the Director of Nursing (DON) of the MDS office including the key code door locking mechanism. The MDS office was observed to be at the end of the 400 Hall past where resident rooms were located. A numerical push button keypad was located on the outside of the door below the door handle which required entering the correct numerical code to open the door if it were locked. There was also a keyhole. The interior aspect of the locking mechanism on the inside of the office door was observed to have a knob. If this knob was turned one way, it disabled the need to enter a numerical code to unlock the door if the door were closed. When this knob was turned the opposite way it enabled the keypad lock which locked the door requiring the correct keypad code be entered to unlock the door if it were closed. On 10/11/23 at 11:04 AM a telephone interview with NA #4 indicated she was familiar with Resident #71 and had been assigned to care for her at the time of the incident on 7/26/23. She stated Resident #71 was at baseline that night and did not have any behaviors. She stated Resident #71 liked to propel herself around the facility in her wheelchair and everyone kept an eye on her for safety reasons. NA #4 went onto say around 8:30 PM on 7/26/23 she had gone to look for Resident #71 to help her get ready for bed and could not find her. She stated she notified Nurse #7 who was the Supervisor that night. NA #4 stated Nurse #7 said she had seen Resident #71 earlier and Nurse #7 instructed everyone to keep looking. NA #4 stated when Resident #71 could not be found, the DON, Administrator and police were notified. She stated the police arrived and wanted all the locked doors opened. She went on to say the Admissions Director arrived at the facility and had gone straight to the MDS office and opened the door. She went on to say she had no idea how Resident #71 could have gotten locked in the MDS office by herself. A review of a written statement from Nurse #7 dated 7/26/23 (provided by the facility on 10/11/23) revealed in part she last saw Resident #71 at around 8:30 PM in the facility. Around 9:00 PM NA #4 reported to her she could not find Resident #71 after she looked everywhere in the facility. All staff were notified of the situation, and they began to look for Resident #71. On 10/10/23 at 8:36 PM a telephone interview with Nurse #7 indicated she was very familiar with Resident #71. She stated Resident #71 liked to self-propel herself around the facility in her wheelchair and so everyone kept an eye on her for safety. Nurse #7 stated the last time she saw Resident #71 on 7/26/23 was around 8:30 PM near the nurse's station. She reported she told Resident #71 to head back towards her hall which she usually did when you told her to. She stated around 9:00 PM that night NA #4 came to her and told her they had been looking for Resident #71 and could not find her. Nurse #7 went on to say she had become very concerned and immediately got all the staff together to begin looking for Resident #71. She stated Resident #71 was not steady enough to transfer herself without falling. She went on to say Resident #71 had a wanderguard and there were no alarms going off so everyone really felt she must still be in the building. Nurse #7 stated she was fuzzy about the time, but she thought it was about 10:00 PM when she called the DON. She stated she did not think the DON had known yet about Resident #71 being missing. She went on to say she was fuzzy about who called the police or when but the reason the police were not notified sooner was everyone thought Resident #71 would not have been able to get out of the building unless someone let her out and there were no alarms going off, so she had wanted to be sure Resident #71 was not in the building before the police were called. She went on to say it took time to look everywhere. Nurse #7 stated she got in her car and began driving around to look for Resident #71. She went on to say when she got back to the facility the Admissions Director was there getting out of her car. She stated she followed the Admissions Director into the building and the Admissions Director went straight to the MDS Office. Nurse #7 stated the Admissions Director, the DON, and the police were all there at the same time, the Admissions Director put the key code in and opened the MDS office door and found the resident. She further indicated that door had been checked during the search earlier and it had been locked. She went on to say when the door was opened initially, the room was dark. She stated Resident #71 had been sitting in a chair and her wheelchair was in the back of the room facing the door. In an interview on 10/10/23 at 12:06 PM MDS Nurse #1 stated she left for the day on 7/26/23 between 3:00 PM and 4:00 PM. She went on to say she had locked the office door when she left like she always did and checked to make sure it was locked. She stated the last thing she did every day was make sure the lights in the office were off and the door was locked. MDS Nurse #1 stated she had never shared the door code with anyone. On 10/12/23 at 8:28 AM MDS Nurse #1 stated the only thing in the MDS office at the time of the incident she could think of that would have posed any risk to Resident #71 would have been a bottle of hand sanitizer. A review of a written statement dated 7/31/23 from NA #5 (provided by the facility on 10/11/23) revealed in part she spoke with the Admissions Director by phone and told her Resident #71 had been missing for over an hour and a half and neither the Administrator nor the DON had been notified. It further revealed NA #5 told the Admissions Director Nurse #7 had said she was going to drive around the block to look for Resident #71 and if she didn't see her, she would come back and call the Administrator, DON, and the police. On 10/10/23 at 1:23 PM a telephone interview with NA #5 indicated she was familiar with Resident #71. She stated Resident #71 was confused and did not walk. She went on to say Resident #71 required 1 person to assist her with standing and transferring to the wheelchair. NA #5 stated Resident #71 liked to self-propel herself throughout the facility in her wheelchair. She went on to say everyone knew this and kept an eye on her to ensure Resident #71 stayed safe. She further indicated Resident #71 had a couple of favorite places she liked to sit which included the glass door at the end of the 400 Hall where Resident #71 liked to look out. NA #5 stated she had been working on the 400 Hall on 7/26/23 from 3:00 PM until 11:00 PM. She further indicated Resident #71 had been at baseline that evening with no unusual behaviors. She stated she had last seen Resident #71 about 7:00 PM looking out the 400 Hall exit door with another resident when she was picking up supper trays. She went on to say she recalled the MDS office door being shut during her shift that evening. NA #5 stated about 8:30 PM she came in from her break and NA #4 told her they couldn't find Resident #71. She went on to say she participated in looking for Resident #71 from about 8:30 until 10:00 PM. She further indicated she had been present when the police arrived about 10:00 PM. NA #5 stated when she had been on her break that evening, the Admissions Director called her about an issue with another resident in the facility. She went on to say when she called the Admissions Director back that evening, she told her she couldn't talk because Resident #71 was missing, and they were looking for her. She stated she had no idea how Resident #71 could have gotten locked into the MDS office. A review of the written statement provided by the Admissions Director dated 7/31/23 (provided by the facility on 10/11/23) revealed in part that at 9:52 PM she received a call from NA #5 who told her Resident #71 had been missing for about 2 hours. NA #5 told her that the nurse had not called to notify the DON or the Administrator. NA #5 reported staff had been looking for Resident #71 all over the building, in the parking lots, out behind the dumpster and near the woods. NA #5 told her the nurse had said she was going to get in her car and look around the neighborhood and if she still couldn't find Resident #71, she was going to notify the Administrator and DON. The Admissions Director told NA #5 she would call the Administrator herself immediately. At approximately 10:35 PM the Admissions Director arrived at the facility. There were 3 police cars at the facility. The DON provided her with the code to unlock the MDS office door. Initially she entered the wrong code and was unable to open the door. When she opened the door, the lights were off, and it was totally dark in the office. She flipped on the lights due to not being able to see clearly without the lights on and saw Resident #71 sitting on the edge sofa chair. To prevent Resident #71 from being scared or upset, the Admissions Director spoke with her. Resident #71 noticed the police officers in the hallway and muttered something about being arrested and going to jail. The Admissions Director sat down beside Resident #71 and told her the police had not come because of her. Resident #71's wheelchair was not extended all the way out (the seat was pulled up in the middle). The wheelchair was beside Resident #71 facing the door. The Admissions Director assisted with getting Resident #71's wheelchair out of the very small office space between the desks. She noticed Resident #71 had her bedroom shoes under a file cart near the door. At 10:43 PM she sent the Administrator a text to let her know the resident had been located. On 10/10/23 at 12:13 PM an interview with the Admissions Director indicated she had been made aware by telephone that Resident #71 was missing at the facility on 7/26/23 around 10:00 PM when NA #5 called her. She went on to say NA #5 told her the nurse had tried to give Resident #71 her medication but Resident #71 had refused. She went on to say NA #5 reported that the nurse had gone back to try again, and they couldn't find Resident #71. The Admissions Director stated she immediately went to the facility to assist with the search. She went on to say when she arrived at the facility, the police were there. She further indicated the Director of Nursing (DON) gave her the code for the MDS office and she went there while the DON went to open the beauty shop door. She stated she initially entered the wrong code to the MDS office, and the door wouldn't open but she tried again and was able to open the door. She went on to say the lights were off in the office and when she flipped on the lights, she saw Resident #71 seated in a chair. The Admissions Director further indicated when Resident #71 saw the police standing in the open doorway Resident #71 asked her if the police were there to arrest her. She stated she reassured Resident #71 the police were not. On 10/10/23 at 2:04 PM an interview with the DON indicated she received a telephone call about 10:00 PM on 7/26/23 from the facility saying that Resident #71 was missing, staff had looked in all the rooms in the facility and outside and still couldn't find her. She stated she told staff to keep looking. She went on to say the police had already been called. She further indicated she had the code to the office doors, and she immediately went to the facility. The DON stated when she arrived at the facility, she checked the beauty salon and then opened the door to the MDS office. She went on to say when she opened the MDS office door the lights were off. She further indicated she flipped on the lights and saw Resident #71 seated on a chair in the office. She stated Resident #71 was calm, kind of laughed because she could see the police and said, Y'all call the police on me?. The DON went on to say Resident #71 was assessed for injury and none was found. On 10/10/23 at 5:22 PM a follow-up interview with the DON she stated other staff had already tried to open the MDS office door earlier when looking for the resident on 7/26/23 and found it to be locked. She further indicated the door had been locked when she first tried it. In an interview on 10/10/23 at 2:41 PM the Regional Nurse Consultant #1 stated there were no cameras and there was no video footage or any pictures from the incident on 7/26/23 to be reviewed. On 10/10/23 at 5:51 PM an interview with the Maintenance Director indicated he received a call in the evening on 7/26/23 regarding a missing resident. He stated he could not recall who called him or the exact time. He further indicated he thought it was from the DON. He went on to say by the time he arrived at the facility the resident had been found. The Maintenance Director stated it was reported to him that Resident #71's wheelchair had been backed into the MDS office. He stated he was familiar with Resident #71 because he often saw her in the halls. He went on to say at times he would see Resident #71 with her wheelchair brakes locked but she wouldn't realize it and she would be just rocking the wheelchair back and forth trying to get it to move and he would have to go over and help her unlock them. He went on to say he immediately changed all the door codes that night. He stated he felt like if that was the issue, he would fix that. The keypad code locking mechanism on the MDS office door was discussed with the Maintenance Director. He confirmed if the door's inner knob was turned one way when the office door was closed, the door would not be locked and no keycode would be required to open the closed door. He further confirmed if the inner knob was turned the opposite way when the door was closed, the entry of the correct code on the keypad would be required to open the door. He stated there was no physical key for the keyhole in the MDS office door. On 10/11/23 at 8:33 AM an additional interview with the DON indicated an investigation of the incident had been conducted which included interviews with the staff present in the facility at the time of the incident. She went on to say the investigation was inconclusive regarding how it could have occurred. She further indicated education had been provided to staff that they were to immediately notify administration when a resident was missing. She stated if administration had been immediately notified, staff would have been instructed to call the police then. She went on to say she did not consider an hour to be immediately and felt staff should have notified administration and the police sooner than they did. She went on to say staff had been educated on the missing resident policy and all the door codes had been changed to ensure only certain people had access. On 10/11/23 Regional Nurse Consultant #1 provided the investigation information of the 7/26/23 event which did not include written statements from Nurse #2, MDS Nurse #1, or therapy staff. On 10/13/23 at 10:22 AM a follow-up interview with the Regional Nurse Consultant #1 indicated she was not aware of any written statement from MDS Nurse #1 or therapy staff. As of this survey's exit (10/18/23) the facility provided no written statements from Nurse #2, MDS Nurse #1, or therapy staff. On 10/11/23 at 8:47 AM an interview with the Administrator indicated she received a phone call from the Admissions Director between 9:30 PM and 10:00 PM on 7/26/23 letting her know that Resident #71 was missing. She stated she immediately called Nurse #2 who told her they were looking for Resident #71. She went on to say she immediately called the DON who went to the facility and found Resident #71 in the locked MDS office. The Administrator stated when she came to the facility the next day (7/27/23), they did an investigation by talking to the people familiar with the incident to see if they could determine how Resident #71 was able to get into the office. She went on to say their investigation had been inconclusive. She further indicated because Resident #71 could have a conversation with her some days and somedays not she felt that maybe the door to the MDS office had been unlocked and Resident #71 had been able to get herself in there. On 10/12/23 at 10:27 AM an interview with Physical Therapist (PT) #1 indicated he was familiar with Resident #71 from treating her in PT. He stated Resident #71 was a high fall risk due to her impaired safety awareness. He went on to say being unsupervised in a locked office alone would place Resident #71 at high risk for a fall and injury. On 10/12/23 at 2:57 PM an interview with the Therapy Manager indicated she was familiar with Resident #71 from treating her in speech therapy. She stated Resident #71 was severely cognitively impaired as the result of her dementia. She went on to say while there had been a telephone in the administrative office, she would not think Resident #71 would have the cognitive ability to use the phone to call for help. The Therapy Manager stated she had never seen Resident #71 use a telephone. She went on to say based on what she knew of Resident #71, one of her biggest concerns was the simple fact that Resident #71 did not have the cognitive ability to move about in the space and she would just be sitting there. On 10/13/23 at 10:03 AM the Corporate MDS Consultant discussed reviewing the event of 7/26/23 involving Resident #71 this week. She stated in thinking about things, she recalled Resident #71 visited the MDS office at times before the event. She stated she felt this made it very plausible Resident #71 entered the MDS office herself on 7/26/23. On 10/13/23 at 10:31 AM in an interview Occupational Therapist (OT) #1 stated she was familiar with Resident #71. She went on to say residents with dementia had fluctuating cognition and while on one day they might not be able to do something, another day they could. She further indicated for residents with dementia, while their short-term memory might be impaired their long-term memory could be intact. OT #1 stated she felt that given enough time Resident #71 could have wiggled herself into the MDS office and done a squat pivot transfer. She stated she felt Resident #71 would have the cognition to try to move something that was in her way. On 10/12/23 at 3:15 PM a telephone interview with the Medical Director indicated he was familiar with Resident #71 and had been notified of her being missing on 7/26/23. He stated for residents with advanced dementia like Resident #71 it was common for them to go in and out of rooms. He stated the same way that these residents did not recognize family members anymore he did not think Resident #71 knew which room was hers and which room was not. He stated because Resident #71 would not have known the difference regarding whether she was in an office or her room, he did not feel it would have been psychologically upsetting for her. He stated his biggest concern was that staff had been unaware of where Resident #71 was. He stated this would not have been safe for Resident #71. The Medical Director further indicated because staff had been unaware of Resident #71's location, anything could have happened to Resident #71 including falls and other injuries. On 10/16/23 at 8:43 AM a telephone interview with Resident #71's Responsible Party (RP) indicated the facility had notified her on 7/26/23 that Resident #71 was missing. She stated they called her back later that evening to let her know Resident #71 had been found safe. She further indicated it was very upsetting for her to find out that Resident #71 had been locked in an office. She stated Resident #1 did not have the ability to lock or unlock doors and would not have been able to get out. The RP went on to say this would not have been safe for Resident #71 to be trapped alone where staff were not monitoring her. The Administrator was notified of Immediate Jeopardy (IJ) on 10/13/23 at 12:40 PM. The facility provided the following credible allegation of IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: Resident #71 was found in the MDS office on 400 hall behind a locked door at 10:45 PM on 7/26/23 by the DON and local police. The facility administrator and Director of Nursing (DON) began an investigation into this incident on 7/26/23. Upon review by the Regional Clinical Nurse on October 11, 2023, this investigation was missing statements from MDS Nurse and Physical Therapist, Occupational Therapist, and Therapy Manager. These statements were obtained on 10/13/23. The results of this re-investigation concluded that the MDS door was not secured, and the resident did have the physical ability to enter the unlocked office. The resident was immediately assessed for physical injuries by the Director of Nursing. There were no identified injuries. Resident was laughing when the door was opened. Her psychosocial well-being was assessed by the in-house mental health provider, on 8/14/23. The facility social worker completed a trauma informed assessment on 8/9/23. The resident's psychosocial well-being was not affected and is still at baseline. The Regional Clinical Nurse and DON completed a review of facility investigations to ensure that the investigation was thorough on 10/13/23. This included a review of the incident logs and state reportables for the past 30 days. The facility administrator re-opened 1 investigation, 10/13/23 related to a reportable, as a result of the review. No other issues were identified. The Regional MDS Nurse reviewed Brief Interview of Mental Status (BIMS) scores for all current residents to determine who was classified as cognitively impaired. Of those residents, the facility therapy manager identified residents who are able to locomote independently. These residents have been identified as at risk of being behind an unlocked office door to include conference room, therapy gyms, kitchen, and other common storage rooms. This was completed on 10/13/2023. The facility licensed nurses, Nurse Aides, including agency, and administrative staff were educated on 10/13/23 by the Staff Development Coordinator and the DON that all office doors must be closed, locked, and secured when not occupied, in order to keep residents who are cognitively impaired safe. They were also educated on residents who are cognitively impaired and move independently about the facility are at increased risk of entering into unsupervised, unsecured areas. When a resident is identified in one of these areas, the resident will be encouraged to go to a more common, higher trafficked area for increased supervision. A review of the incident log for the last 30 days on 10/13/2923 by the Regional Clinical Nurse revealed no similar incidents in the facility. Specify action the facility will [NAME] [TRUNCATED]

Based on observations, record review, resident, staff, Physician, and pest control technician interviews the facility failed to control the presence of ants in the facility, maintain an effective pest control program, and to protect a vulnerable resident from having ants crawling on him while in bed. The resident sustained multiple ant bites/stings to his arms, torso, and upper back which resulted in the resident experiencing the discomfort of stinging and itching. Furthermore, the resident stated having ants in his bed, on him, and having been stung/bitten made him feel upset and like No one cared. The facility also failed to implement effective pest reduction measures when the ants were first observed on the resident by staff on 10-6-23. This occurred for 1 of 4 residents (Resident #1) observed for pest control. Immediate Jeopardy began on 10-6-23 when NA #1 first discovered red colored ants crawling on Resident #1's bed and person but had not reported the incident. Immediate Jeopardy was removed on 10-13-23 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included paraplegia (which included numbness below the waist), bilateral above the knee amputation, and diabetes. The quarterly Minimum Data Set (MDS) revealed Resident #1 was cognitively intact and required total assistance with two people for bed mobility, total assistance with one person for dressing, toileting, and personal hygiene. Resident #1 was interviewed in conjunction with an observation on 10-9-23 at 12:13pm. The resident stated, I would be doing good if they would get these ants out of my room, so they quit crawling on me. Resident #1 discussed since last Monday (10-2-23) he had been reporting to staff ant activity in his room and told them the ants had been crawling on him and the bed. The resident stated no one had done anything except for one NA (NA #2) who, he stated, placed hot sauce in an area of the wall by the bathroom where the NA thought the ants maybe coming from and then placed a washcloth over the hot sauce to try and kill the ants. He explained he could not feel anything below his waist but had seen the ants crawling on his torso and arms. The resident also stated the ants had bit/stung him several times you can see the one on my arm and I have felt the stinging when they bite my back. Resident #1 stated he had also told the nurses (could not remember any names) since Sunday (10-8-23) he was itchy but said he had not received any medication to relieve his itching. Resident #1 voiced being frustrated and feeling like no one cares. During an observation of the resident, there was a small round reddened area on his upper left arm. There were no ants observed in the resident's room at the time of the observation and interview. A telephone interview was conducted with NA #1 on 10-10-23 at 3:15pm. NA #1 confirmed she had been assigned to Resident #1 on 10-6-23 during the 7:00pm to 7:00am shift. The NA discussed when she had gone into Resident #1's room to provide him care she had observed red ants crawling on the resident's bed and on the resident's torso and arms. She stated she wiped' the ants off the resident onto the floor and changed his linens. The NA stated she had seen ants a few weeks ago in the living room area and said she had reported it to the nurse on duty (could not remember which nurse). NA #1 said she had not seen any ant bites/stings on Resident #1 and stated she had reported the ants to the nurse (Nurse #2). NA #2 was interviewed by telephone on 10-10-23 at 3:19pm. NA #2 confirmed he had been assigned to Resident #1 on 10-7-23 and the evening of 10-9-23 from 7:00pm to 7:00am. The NA discussed Resident #1 informing him of having ants in his room and stated on 10-7-23 while in Resident #1's room providing care he saw red ants crawling on the resident's bed and body. NA #2 stated he cleaned the ants off Resident #1 by wiping them onto the floor with a washcloth and changed his linens. He also explained he thought the ants were coming from an area of the wall by the bathroom, so he stated he placed some hot sauce and a washcloth on the area of the wall in hopes to kill the ants. The NA stated it was after hours and he did not have access to any sprays to try and kill the ants. The NA stated on 10-9-23 he again saw ants on Resident #1's bed and body. NA #2 explained he washed Resident #1 and changed his linens. NA #2 said he did not observe any ant bites/stings on the resident and that he had reported the ant sighting on 10-7-23 to the nurse (Nurse #2). During a telephone interview with Nurse #2 on 10-10-23 at 3:33pm, the nurse confirmed she had been working the 7:00pm to 7:00am shift on 10-6-23 and 10-7-23. Nurse #2 also confirmed she had been made aware and saw the red ants on Resident #1's bed, torso, and arms both days. The nurse discussed assisting NA #1 in wiping the ants off the resident's bed, torso, and arms onto the floor. She said she had not seen any ant bites/stings on the resident's arms or torso, so she did not inform the Physician or provide any medical care. Nurse #2 stated she had not completed a full skin assessment but had just assessed Resident #1's arms and torso. The nurse stated she also had not informed anyone in management or maintenance of the presence of ants in Resident #1's room because I did not know who I was supposed to report to. Observation of wound care for Resident #1 occurred on 10-10-23 at 1:17pm with Nurse #4 and NA #3. Upon pulling back Resident #1's sheet, several red ants, too many ants to count, were seen crawling on the resident's bed and the resident's body. The red ants were crawling on Resident #1's arms, torso and into and out of his brief. Nurse #4 left the room to get the Maintenance Director and NA #3 left the room to get the Director of Nursing (DON). Upon return of the DON, Resident #1 was assessed for ant bites/stings and revealed a bite/sting to his left arm that was round, bright red approximately a centimeter in diameter and 4-5 ant bites/stings to the resident's upper back that were red and raised. Resident #1 stated he had felt the ants stinging/biting his back but that he was not currently itchy or in pain. Staff were observed to place the resident in his wheelchair and remove him from his room. The Maintenance Director was interviewed on 10-10-23 at 1:26pm. The Maintenance Director explained there was a maintenance logbook at each nursing station to record any pest concerns and/or maintenance issues. He stated he checked the logbook two times a day and said there had not been any reports of ants in Resident #1's room. The Maintenance Director discussed there were ants found over the summer in a resident room on the other side of the building and in the living room area a few weeks ago. He stated he had called the pest control company both times and they came and treated the areas. The Maintenance Director discussed the pest control company coming every 2 weeks to treat pests (not just ants) however he explained he did not have any invoices to confirm the treatments. Review of the maintenance logbook from August 2023 through October 2023 revealed no reports of ants in Resident #1's room however there had been reports of ants on 8-29-23 and 10-8-23 in other areas of the building. A follow up interview was conducted with the Maintenance Director on 10-10-23 at 1:45pm. The Maintenance Director discussed calling the pest control company and said they were on their way to treat Resident #1's room. Observation/interview of Resident #1 occurred on 10-10-23 at 5:23pm. Resident #1 was observed back in his room sitting in his wheelchair. Resident #1 stated he had not been back in his room long and that he had not seen any ants. He stated he had wheeled himself back into his room after activities and stated he was unaware he was supposed to go to another room until his room was treated. The resident also stated he was concerned about staying in the room because he did not know if the ants would return. Observation of the facility's center courtyard occurred on 10-10-23 at 5:27pm. There were 5 active ant mounds observed. There were 2 located by the door to the courtyard and 3 along the walkways in the courtyard. The ant mounds were not located near Resident #1's room. The Maintenance Director was interviewed on 10-10-23 at 5:37pm. The Maintenance Director stated the pest control company was not coming to treat Resident #1's room until 10-11-23. He stated he was not aware Resident #1 was back in his room and confirmed other than cleaning the room there had not been any treatment provided. During an interview with the DON, Assistant Director of Nursing (ADON) and the Corporate Nurse Consultant and Administrator on 10-10-23 at 5:43pm, the DON, ADON and the Corporate Nurse Consultant all stated they did not know who placed Resident #1 back into an un-treated room. The Administrator explained Resident #1 was supposed to be moved to another room. Nurse #3 was interviewed on 10-10-23 at 5:51pm. Nurse #3 stated she saw Resident #1 wheel himself back into his room. She said she had been told by maintenance or housekeeping (could not remember who) that the room had been treated so she allowed the resident to stay in his room. Review of Resident #1's medical record revealed a late entry note for 10-10-23 by Nurse #5. The nurse documented she had contacted the Physician regarding Resident #1's ant bites. She wrote there were no new orders, and the resident did not have any discomfort. The Maintenance Director and the pest control Account Manager were interviewed on 10-11-23 at 12:00pm. Upon observing Resident #1's room, where the ants had been seen, there were no ants present. The Maintenance Director stated he had treated the room on 10-10-23 with an over-the-counter ant killer. He clarified he had treated the room after he had been informed Resident #1 had returned to the room and stated he had not treated it beforehand because he knew the pest control company was coming to treat. The pest control Account Manager explained he could not know for certain what kind of ants were in Resident #1's room as there were no ants currently present. He did clarify that fire ants were the only ants that would bite without provocation. The pest control Account Manager discussed plans on treating the room on 10-11-23 and speaking with the facility on expanding their contract to cover the several active ant hills on the property. He stated he had observed the exterior of the building and had found 5 active ant hills in the courtyard and 7 active ant hills around the facility's perimeter. A nursing note written by Nurse #5 dated 10-11-23 at 6:48pm documented Resident #1 was itching a little and she observed 2 circular scabbed areas to the resident's upper chest. Nurse #5 wrote that she called the Physician and obtained new orders. Review of the Physician orders for Resident #1 revealed an order for Hydroxyzine (antihistamine medication) 25 milligrams by mouth every 8 hours as needed for itching. During a telephone interview with the Medical Director on 10-12-23 at 7:50am, the Medical Director discussed being informed by the facility on 10-10-23 of the ants and the ant bites on Resident #1. He explained when he spoke with staff on 10-10-23 Resident #1 was not having any itching or reaction to the ant bites, so he had not ordered any medication at that time. The Medical Director said on 10-11-23, staff had contacted him regarding Resident #1 complaining of itching and discomfort which was unrelated to the ant bites/stings, so he stated he ordered medication. The Medical Director said he would have expected staff to report the ant issue as soon they were aware and that there was a possibility of harm if Resident #1 had been allergic to the ant bites. The DON was interviewed on 10-13-23 at 10:03am. The DON discussed feeling there was a lack of education with staff on knowing who to report issues to and where the maintenance communication book was located. She stated if staff saw an infestation of ants in Resident #1's room on 10-6-23 and 10-7-23, staff should have contacted her and moved Resident #1 to another room. The DON said she expected staff to ensure residents safety and notify her of any situation involving the safety of residents if they do not know who to report to. On 10-10-23 at 7:15pm the Administrator was informed of the Immediate Jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 10-13-23. The allegation of Immediate Jeopardy removal indicated: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: On October 10, 2023, at approximately 2:30pm, it was reported by the survey team that an observation was made that resident #1 had ants in his bed. Resident #1 stated he reported the ants on 10/6/2023 and 10/7/2023 to a nursing assistant. CNA #1 (10/6) said last Friday she observed ants in his bed and on the floor. She said she changed the sheets, provided Activities of Daily Living (ADL) care, cleaned the floor, and did not notice any reddened areas on the resident. She indicated that she reported it to Nurse #1. CNA #2 stated on 10/7/23, she alerted Nurse #2 of the sighting of ants. Nurse #2 assisted CNA #2 in providing care and changing the sheets. Nurse #2 stated she was alerted to the ants by CNA #2 on 10/7/23. On exam, neither Nurse #1 nor Nurse #2 found reddened areas on Resident #1 that could be interpreted as a bite and the resident had no complaints of itching or discomfort on his upper extremities or lower torso. Nurse #1 nor Nurse #2 reported the sighting of ants to the Maintenance Director or facility Administrator after the incidents. Complete skin assessments were completed on all current residents on 10/10/2023 by the Director of Nursing and administrative nurses. No other abnormalities were found. Interviews were conducted by the facility Social Worker on 10/11/2023 with the alert and oriented residents and no further pest sightings were reported. Resident #1 was relocated from his room to another room on 10/10/23 by his assigned nursing staff. The Maintenance Director completed a treatment for Resident #1's original room with an approved pesticide for indoor insect elimination on 10/10/23 in late afternoon. Any resident had the potential to be affected by this alleged deficient practice. Specify action the facility will take to alter the process or system failure to prevent a serious outcome from occurring or recurring and when the action will be completed: A facility notification was mailed to each resident representative on 10/11/2023 to alert them to make sure all food brought in the facility to residents will need to be placed in a sealed container to prevent further sightings. Corporate Contractor completed a reeducation with the facility maintenance director on timely follow up of work orders, including pest control sighting logbook, on 10/12/23. The facility administrator will be completing a weekly review of maintenance work orders & pest control sighting logbook to confirm that all work orders and pest treatments have been completed in a timely manner. This will include at the time of a pest sighting the facility nursing staff will contact the maintenance director and/or assistant maintenance director; they will also add the pest/ant sighting in the pest control log located at each nursing station. The Director of Nursing (DON) and Maintenance Director met with the current facility staff, including clinical agency and contract (HK/Laundry/Rehabilitation) staff on 10/10/2023 to discuss reporting pest sightings and no other sightings were reported by staff. Current facility staff, including clinical agency and contract (HK/Laundry/Rehabilitation) staff will receive this training prior to being able to work on their next assignment. The Director of Nursing and Administrative Nurses ensures this education is being completed prior to employees being able to work at the facility. The Maintenance Director and the contracted pest control provider inspected the perimeter of the building on 10/11/23 for signs of active ant mounds, and any areas identified were treated with approved pesticides. On 10/11/23, the contract pest control company provided an inspection of the facility and was not able to identify the type of ant. This was evident in their report on 10/11/23. The Corporate Contractor and Maintenance Director completed an observation inspection of the interior and exterior of the facility on 10/12/23 and identified 5 active ant mounds in the courtyard and 7 on the exterior of the facility. The Corporate Contractor and Maintenance Director completed treatment of these areas. Also, the contracted pest control company provided additional treatment. The Maintenance Director developed Pest Sighting Logbooks on 10/10/2023 for each nurse's station so the staff can document any sighting. If there were any sightings noted on residents or in rooms, the Director of Nursing and Administrator will be notified immediately by the staff member upon discovery and the resident will be removed from the identified area. The Pest Sighting Logbook will be reviewed by the Maintenance Supervisor to assure the area where the sighting occurred has been treated. The DON and Maintenance Supervisor educated all staff beginning 10/10/23 on the pest sighting logbooks. All staff can document in the logbooks as they are available at each nurse's station. Current facility staff, including clinical agency and contract (HK/Laundry/Rehabilitation) staff will receive this training prior to being able to work on their next assignment. The Director of Nursing and Administrative Nurses are monitoring that this education is being completed prior to employees being about to work at the facility. The Maintenance Director and/or the Assistant Maintenance Supervisor initiated weekly pest control rounds on 10/10/2023 to include room, bed, bath and building perimeter. There were no other sights inside the building on 10/10/23. The facility has a contract with a pest control company. The pest control company will be providing weekly observations to ensure there are no further ant or pest issues. The pest control company was onsite 10/11/2023 to complete interior and exterior treatments. The pest control company found no further live ant activity in the facility in their report that was provided by the Maintenance Director on 10/11/23. They treated the facility for pests to include acrobat ants, American cockroaches, ants, [NAME] ants, Black widow spiders, brown banded cockroaches, cockroaches, German cockroaches, odorous house ants, oriental cockroaches, pavement ants, Pharoah ants and smoky brown cockroaches. The Director of Nursing and Maintenance Director provided education on 10/10/2023, for all staff, including agency, regarding reporting ant sightings immediately to facility supervisors and assessing residents for bites. If bites are found, the resident will be immediately relocated, and the identified room treated for infestation by the Maintenance Director or Assistant Maintenance Director. Employees will not be able to work until they receive this education from the director of nursing, administrative nurse and/or maintenance director. Any employee who does not receive this education will not be able to work until education is completed by DON, Administrative Nurse and/or Maintenance Director. The DON and/or administrative nurses will be responsible for ensuring that the employees receive this required education prior to working. Allegation of Immediate Jeopardy removal date: 10/13/23 On 10-13-23 the facility's plan for Immediate Jeopardy removal was validated by the following. Multiple residents had been interviewed and confirmed they had not seen ant activity in their rooms. Observation of resident rooms revealed no current ant activity. There were pest sighting logbooks located at each nursing station. Upon interviewing staff, staff stated they had received education on the pest sighting logbooks and reporting any pest sightings immediately. Verification of completed skin assessments on all residents were completed. The pest control company was observed on 10-11-23 and 10-12-23 as explained by the exterminator, to be treating ants in the building and on the facility grounds outside. The facility's Immediate Jeopardy removal date of 10-13-23 was validated.

Based on record review, observation, resident and staff interviews the facility failed to provide incontinence care and showers for 2 of 2 dependent residents (Resident #20 and Resident #8) reviewed for Activities of Daily Living (ADL) care. Resident #20 voiced feeling awful and that staff did not care about her. Resident #8's scrotum and buttocks were bright red and Resident #8 voiced pain when his scrotum and buttocks was cleaned. The Nursing Assistant (NA) #9 applied protective barrier cream to Resident #8's scrotum and buttocks. Findings included: 1.Resident #20 was admitted to the facility on [DATE] Resident #20's care plan dated 3-28-22 revealed a goal that she would maintain her level of care needs. The interventions for the goal were in part resident requires assistance from staff for bathing, grooming and incontinence care. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact requiring assistance with 2 people for bed mobility, transfers, toileting, personal hygiene and bathing, one persona assist for dressing. There were no behaviors coded on the MDS. Review of Resident #20's ADL care documentation revealed no documentation that she had received a shower/bed bath for the following dates: -April 2022: 4-1-22 through 4-5-22, 4-8-22 through 4-11-22, 4-13-22 through 4-17-22, 4-19-22 through 4-27-22, 4-29-22 and 4-30-22. -May 2022: 5-1-22 through 5-4-22, 5-6-22 through 5-13-22, 5-15-22 through 5-18-22, 5-20-22 through 5-25-22, 5-27-22 through 5-30-22. -June 2022: 6-1-22 through 6-5-22, 6-9-22 through 6-11-22 and 6-13-22. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20 was interviewed on 6-13-22 at 10:15am. The resident discussed not receiving a bath daily. She stated the staff tell her they were short staffed and did not have time to provide a bath. Resident #20 also discussed issues with having to wait to receive incontinence care and specified she had looked at her clock on her over the bed table and had to wait over 2 hours. The resident said this made her feel like no one cared about her and that she felt awful. Observation of ADL care for Resident #20 occurred on 6-15-22 at 9:50am with Nursing Assistant (NA) #1. Resident #20's brief was observed to be saturated with urine that had soaked through to the under pad on the bed and her sheet. Resident #20's skin was noted to be intact. During an interview with NA #1 on 6-15-22 at 10:00am, NA #1 stated Resident #20's brief was saturated and said she had not been able to check or provide incontinence care to Resident #20 prior to 9:50am and did not know when night shift had last provided incontinence care to Resident #20. She explained she was the only NA for hall 400 (part of station 2 with approximately 14 residents) and could not check or provide incontinence care every 2 hours to her assigned residents. NA #1 also stated she would not be providing a bed bath or shower to all her assigned residents today (6-15-22). A telephone interview occurred with NA #7 on 6-16-22 at 10:47am. NA #7 confirmed she had worked with Resident #20 on the 11:00pm to 7:00am shift the night of 6-14-22. The NA stated she had last provided incontinence care to Resident #20 between 6:00am and 6:30am. An interview with NA #8 occurred on 6-16-22 at 12:34pm. NA #8 discussed working with Resident #20 on 5-21-22. She recalled being the only NA on hall 400 that day and assigned to approximately 14 residents. She explained on 5-21-22 Resident #20 had refused a bed bath when the NA was available to provide a bed bath. NA #8 stated she did not have time to go back and provide a bed bath when the resident requested so she said Resident #20 did not receive a bed bath on 5-21-22. NA #9 was interviewed on 6-16-22 at 1:43pm. NA #9 stated she had been assigned to Resident #20 on 6-5-22 but could not remember if she had provided a bed bath to the resident. She explained it was a weekend and she was the only NA assigned to hall 400 and said, so I might not have. A telephone interview occurred with NA #10 on 6-16-22 at 3:25pm. NA #10 discussed being assigned to Resident #20 on 4-10-22. She discussed 4-10-22 being a weekend and stated the facility had been short staffed so she was not able to provide a bed bath to Resident #20. The Administrator was interviewed on 6-17-22 at 4:58pm. The Administrator stated she expected staff to check on their assigned residents at least every 2 hours and stated the staff should be checking their assigned residents at the start of their shift for incontinence. She also added the facility had not been short staffed. 2. Resident #8 was admitted to the facility on [DATE] Resident #8's care plan dated 3-6-22 revealed a goal that he would be clean, dry, appropriately dressed and maintain his level of care. The interventions for the goal were in part resident requires assistance of staff with bathing, dressing, grooming, oral care and incontinence care. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was severely cognitively impaired with no mood or behaviors. He was coded as needing total assistance with 2 people for bed mobility and transfers, total assistance with one person for toileting, personal hygiene and bathing. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .). Observation of Activities of Daily Living (ADL) care for Resident #8 occurred on 6-16-22 at 9:30am with Nursing Assistant (NA) #9. Resident #8's brief was noted to be saturated with urine through to the under pad on the bed. The resident's scrotum was noted to be bright red and when the NA wiped the scrotum area Resident #8 said ow. Further observation of Resident #8's skin revealed his buttocks was also bright red. No open skin areas were observed, and NA #9 was observed to apply protective barrier cream to Resident #8's scrotum and buttocks. During an interview with NA #9 on 6-16-22 at 9:45am, the NA commented how saturated Resident #8's brief was and the redness to his scrotum and buttocks. She stated she would inform the nurse of the redness. NA #9 discussed not checking the resident prior to 9:30am for incontinence care and stated she did not have time before the breakfast trays were delivered because she was the only NA for hall 400 (part of station 2 with approximately 14 residents). She also said she was not aware when the last time Resident #8 had incontinence care provided. A telephone interview occurred with NA #11 on 6-16-22 at 3:32pm. NA #11 confirmed she had been assigned to Resident #8 from 7:00pm to 7:00am on 6-15-22. She stated she had last provided incontinence care to Resident #8 at approximately 5:30am on 6-16-22. The Administrator was interviewed on 6-17-22 at 4:58pm. The Administrator stated she expected staff to check on their assigned residents at least every 2 hours and stated the staff should be checking their assigned residents at the start of their shift for incontinence.

Based on record review, observation, resident and staff interviews the facility failed to provide sufficient staffing to assist with Activities of Daily Living (ADL) care for residents (Resident #20 and Resident #8) who were dependent on facility staff for ADL care. Resident #20 voiced feeling awful and that staff did not care about her. Resident #8's scrotum and buttocks were bright red and voiced he had pain when they were cleaned. The NA was observed to apply protective barrier cream to Resident #8's scrotum and buttocks. This affected 2 of 5 residents reviewed for staffing. Findings included: This citation is cross-referenced to: F677 Based on record review, observation, resident and staff interviews the facility failed to provide incontinence care and showers for 2 of 2 dependent residents (Resident #20 and Resident #8) reviewed for Activities of Daily Living (ADL) care. Resident #20 voiced feeling awful and that staff did not care about her. Resident #8's scrotum and buttocks were bright red and Resident #8 voiced pain when his scrotum and buttocks was cleaned. The Nursing Assistant (NA) #9 applied protective barrier cream to Resident #8's scrotum and buttocks. Review of the facility's daily staffing schedule for June 2022 revealed the following: -6/9/22 there were 3 Nursing Assistants (NA) for approximately 36 residents on the 7:00am to 7:00pm shift for station 2. -6/11/22 there were 3 Nursing Assistants (NA) for approximately 36 residents on the 7:00am to 7:00pm shift for station 2. -6/12/22 there were 2 Nursing Assistants (NA) for approximately 36 residents on the 7:00am to 7:00pm shift for station 2. -6/13/22 there were 3 Nursing Assistants (NA) for approximately 36 residents on the 7:00am to 7:00pm shift for station 2. During an interview with the facility's scheduler on 6-17-22 at 11:48am, the scheduler stated she began her position in March 2022 and was educated by the Director of Nursing and Administrator to schedule per census. She explained she was not taught to take acuity, resident care plans or resident needs into account when she was developing the schedule. The scheduler discussed trying to keep 4 NAs on station 2 during the 7:00am to 7:00pm shift but said most of the time there were only 3 NAs. She discussed the facility using agency staff to try and cover shifts and when there were call offs, she first attempted to have the facility staff cover and then she would contact the agency. The Administrator was interviewed on 6-17-22 at 4:58pm. The Administrator stated she was unaware the scheduler was scheduling by census. She explained the schedule should reflect the number of staff needed by the acuity of the residents.

Based on staff, physician, and Medical Examiner interviews, and record review, the facility neglected to provide assistance from two or more people for activities of daily living according to the most recent assessment dated [DATE] (Resident #7). This resulted in a fall from a raised bed onto the floor. Multiple administrations of Cardio-Pulmonary Resuscitation (CPR) were required to stabilize Resident #7 prior to being taken to the hospital. Resident #7 expired the following day. This was for one of one residents reviewed for neglect (Resident #7). The Immediate Jeopardy began on [DATE] when Nursing Assistant (NA) #4 gave a dependent resident (Resident #7) daily care alone when the resident required two person's assistance for care which resulted in a fall from his raised bed onto the floor. Resident #7 required CPR multiple times to be stabilized to be taken to the hospital. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Findings included: The care plan dated [DATE] stated Resident #7 needed total assistance for all care with ,d+[DATE] persons. This was the active care plan. Resident #7 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated [DATE] listed Behavior: Exhibits aggressive behavior at times. There were general interventions listed: talk in calm voice, refer to Social Services for evaluation, monitor and document target behaviors, place in area where frequent observation is possible. This care plan was reviewed [DATE]. On [DATE] at 11:00 AM, the MDS Nurse was interviewed and stated she did not know why the care plan was so general, and she would have put the number of staff needed for each care need. The MDS Nurse found a fall care plan from [DATE] with an intervention for fall mat indicated. The care plan was resolved on [DATE]. The MDS Nurse stated if a resident with a fall care plan does not have a fall for a period of time, the care plan for falls is sometimes resolved. The MDS Nurse stated the nurses fill out the Kardex. The Quarterly Minimum Data Set (MDS) dated [DATE] noted Resident #7 was severely impaired for cognition and required total assistance for all care needs with the assistance of two or more persons. The exceptions were eating and locomotion on and off unit which required one person ' s assist. The quarterly MDS did not indicate any behaviors or rejection of care. The Kardex (a care guide for NAs) indicated Resident #7 was dependent on total care for all ADLs and mobility was marked non-ambulatory, wheelchair, and transfers was checked with 2 assists with mechanical lift. Special care instructions were: Resident has episodes of agitation and behaviors, history of hitting/kicking at staff. The Kardex was undated. NA #6 was interviewed on [DATE] at 12:15 PM, and stated she was familiar with Resident #7 and his care needs required two staff. NA #6 stated Resident #7 was combative most days. NA #6 stated resident information for care was in the Kardex, which was in a binder in the nurse ' s station. On [DATE] at 12:33 PM NA #2 stated he worked for the facility through an agency. NA #2 knew where the Kardex was and stated if the Kardex said two staff were needed for a resident ' s care, he would always use two staff. NA #7 was interviewed on [DATE] at 3:15 PM and stated she was working at the facility through an agency. NA #7 stated she knew what the Kardex was and if she had any questions about care needs, she would ask the nurse in charge of the hall. On [DATE] at 3:25 PM, NA #8 was interviewed and stated she was an agency NA. NA #8 stated she would look for information about resident ' s needs in the Kardex but would ask the nurse on the hall if she was unsure about resident care needs. Nurse #3 was interviewed on [DATE] at 5:28 PM, and stated she reviewed the training packet with NA #4 on her first day of work in the facility. Nurse #3 stated she reviewed Kardex information and resident care needs for assistance information. NA #4 was interviewed on [DATE] at 1:30 PM, and stated she was working with Resident #7 on [DATE] at the time of his fall from the bed. NA #4 stated she had been in Resident #7 ' s room earlier to feed him breakfast, and the Resident was not combative, ate all his breakfast, and she began care with other residents. NA #4 said she had only been to the facility on e or two times prior to [DATE]. NA #4 indicated she was providing care to Resident #7 without any other staff ' s assistance. The NA noted she raised Resident #7 ' s bed and began to wash him and he started to swing his arms around and was trying to grab the washcloth. NA #4 indicated she changed Resident #7 ' s shirt, then took off his brief and washed his private area in the front and dried him. NA #4 said when she rolled the Resident to his side and started to wash his bottom, he was kicking his legs and he fell off the bed and onto the floor. When asked if she thought about stopping to get help when the Resident first became combative, NA #4 said No, I just thought I would go ahead and get it done. NA #4 stated she was not sure if she had worked with Resident #7 before or not. She explained that she was an agency NA and had worked with a lot of residents. When asked how she knew how much assistance Resident #7 required, NA #4 said she got information about feeding and patient care from someone on staff, she did not know if it was a nurse or another NA, but she was only told that Resident #7 was total care. NA #4 said she wanted to be clear that Resident #7 went from 20 % combative when she started his bath, to 150% combative when she started to wash his bottom. NA #4 stated she was not familiar with Kardex or Patient Care Guide, but other staff would give her a rundown on the residents she was assigned to. A nursing progress note dated [DATE] noted at 12:30 PM, Nurse #1 was notified by NA #4, who was assigned to Resident #7, of the fall. The note indicated the Resident became combative during care, kicking his legs and swinging his arms. NA #4 turned Resident #7 during care and the Resident slipped off the bed and fell to the floor and landed on his stomach on the fall mat which was in place. The note stated at 12:30 PM vital signs were taken and were blood pressure ,d+[DATE], pulse 52, oxygen saturation 80%. Nurse #1 cleaned the mid-forehead laceration with normal saline and applied a dry dressing. Nurse #1 was unable to assess blood on face due to not being able to move Resident #7 until Emergency Medical Services (EMS) arrived. EMS arrived 12:45PM, turned resident to lie on back while stabilizing neck, and Resident #7 became unresponsive and had no pulse. EMS began CPR, Nurse #1 assisted with chest compressions. More EMS personnel arrived to assist. Resident #7 left the facility via stretcher non-verbal, but responsive and stabilized at 1:35 PM to the hospital. Nurse #1 was interviewed on [DATE] at 10:45 AM and repeated the same facts written in the progress note dated [DATE]. Nurse #1 stated when Resident #7 became combative NA #4 should have gotten help. On [DATE] at 11:15 AM, Nurse #2 was interviewed and stated she was paged by Nurse #1 when Resident #7 fell . Nurse #2 stated she entered the room and saw Resident #7 face down on the floor, bleeding from his head. Nurse #2 indicated Resident #7 had good vital signs, and she left the room, called 911, called the front desk to anticipate EMS arrival, went back to the room and observed Resident #7 breathing. Nurse #2 noted she called the facility physician. Nurse #2 also stated Resident #7 quit breathing when EMS turned him over, CPR was performed three separate times and then was taken to the hospital. Resident #7 expired at the hospital on [DATE]. The Death Certificate signed [DATE] noted the cause of death as Multiple [MEDICATION(S)] force injuries. In an interview on [DATE] at 5:01 PM, the Medical Examiner (ME) stated there were neck fractures and facial fractures and some rib fractures. The ME confirmed the cause of death as multiple [MEDICATION(S)] force injuries that resulted from a fall from the bed. In an interview on [DATE] at 10:40 AM, the Director of Nursing (DON) stated when Resident #7 was combative, two staff were needed. The DON stated NA #4 should have lowered the bed and gone for help. On [DATE] at 9:32 AM, the facility Medical Director (MD) was interviewed and stated Resident #7 was totally dependent for his care. The MD was asked about a note he wrote on an [DATE] visit with Resident #7 indicating in his plan fall precautions and what did he mean. The MD stated it would be bed in low position, fall mat, and could progress to medications or medication changes. Regarding Resident #7s fall, the MD stated he got a call saying Resident #7 fell and coded. The facility Administrator was notified of the Immediate Jeopardy on [DATE] at 6:52 PM. The facility supplied the acceptable credible allegation on [DATE] at 2:45 PM. Identification of residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On [DATE] CNA #4 was providing ADL care alone to Resident #7 when Resident #7 required two-person assistance for that care. CNA #4 continued to provide care alone when the Resident #7 became combative. Resident #7 fell from his raised bed onto the floor. Resident #7 was transferred to the hospital where he expired the following day. Kardex and care plan reflected ,d+[DATE] person assist. Most recent MDS dated [DATE] is total dependence with two-person physical assist for bed mobility and bathing. Resident #7 was transferred to the hospital on [DATE]. Healthcare Personnel Registry notified of neglect allegation with CNA #4 via faxed initial Allegation Report on [DATE]. All residents with behaviors and that are dependent with care have the potential to be affected by the alleged deficient practice. 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 [DATE], a list of residents with behaviors were obtained through reviewing the most recent MDS assessments, discussions with staff and observations and a list of assistance needed based on the MDS coding was obtained. The Nursing Consultant, Director of Operations & MDS Coordinators reviewed the MDS Assessments, Care Plans & Kardex. The Nursing Consultant, Director of Operations, MDS updated the residents Kardex & Care Plan to reflect the needed assistance for care of each resident. All residents were reviewed by [DATE] by Nursing Consultant, Director of Operations, MDS with collaboration of CNAs to ensure the following areas have been appropriately addressed: 1) Numbers of staff members needed to provide care 2) Bed surface to ensure sufficient room for turning and repositioning 3) Whether or not the resident has a physical impairment of behaviors that need to be considered. 4) Any resident that cannot assist with turning or repositioning A Kardex will be completed by MDS or designee for each new admission, and they will be updated with the quarterly and significant change MDS and as indicated by nursing management for change in condition. All resident ' s care plans and Kardex that require updating were completed on [DATE] by MDS Coordinators. The Executive Director informed them of this responsibility. Effective [DATE], all direct care staff (including agency) will be educated on the locations of the resident Kardex, where on the Kardex to find the information needed to ensure appropriate care is provided to the resident, by ED or designee. Effective [DATE], all direct care staff (including agency) will be educated on handling residents with behaviors as well as halting care and /or seeking assistance when a resident becomes combative, by ED or designee. Effective [DATE], all direct care staff (including agency) will be educated on related to proper technique for turning and repositioning resident (+1/+2), by the ED or designee. Direct care staff (including agency) not in-serviced on above topics by [DATE] will be in-serviced prior to their next scheduled shift. Responsible person: ED or designee. Effective [DATE], the DON or designee will conduct direct observation of care audits to ensure that care is being provided according to the resident care plan and Kardex. The audits will be conducted 3 residents 3 x per week x 4 weeks, then 3 residents weekly for 8 weeks. In addition, audits of the Kardex and care plan will be conducted to ensure they complement each other. Any opportunities identified will be corrected. Effective [DATE], education was provided to all staff (including agency) on abuse and neglect, to include the definition of neglect with the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress along with consequences for not following the plan of care including potential negative outcome by DON or designee. Staff (including agency) not in-serviced on [DATE] will be in-serviced prior to their next scheduled shift. Responsible person. ED or designee. Effective [DATE], the ADON or designee will add to orientation specific education regarding what constitutes neglect and handling residents with behaviors, referring to and location of the Kardex & care plan in regards to the assistance needed for care of the residents. The facility alleges the removal of Immediate Jeopardy on [DATE]. On [DATE] beginning at 8:55 AM multiple staff members were interviewed. This included staff in multiple disciplines; including nursing, rehabilitation, maintenance, administration, and dietary. All interviewed staff members validated they had attended in-service training regarding abuse and neglect. Interviewed staff members were able to provide examples of what constituted abuse and neglect and to whom they were to report any incidents. Nursing staff members, who were interviewed, were able to report they would stop care if dealing with combative residents and obtain the assistance and direction of their supervisor. Nursing staff members were also able to locate or verbally report where they could locate residents ' kardexs. A random resident, who was identified by staff to be cognitively intact and in need of total care assistance by two staff members, was interviewed on [DATE] at 9:42 AM. This resident reported he felt safe and two staff members assisted in turning and repositioning him. A second random resident, who was identified by staff to be cognitively intact and in need of total care assistance by two staff members, was interviewed on [DATE] at 9:55 AM. This resident also reported he felt safe and that two staff members turned and repositioned him. On [DATE] at 10:15 AM facility documents were reviewed. The facility provided documented evidence of in-service training for their staff regarding abuse/ neglect. They also provided evidence of in-service training for their direct care staff for turning repositioning, location of the Kardex and where to find information, and dealing with residents with behaviors. They facility also had documented evidence of audits completed per their credible allegation of compliance. The facility ' s credible allegation of compliance is validated for the date of [DATE].

Based on staff, physician, Medical Examiner interviews and record review, the facility failed to provide supervision needed for one of three residents reviewed for falls (Resident #7), when a Nursing Assistant (NA) gave a dependent Resident (Resident #7) daily care alone when the Resident required two person ' s assistance for that care according to the most recent assessment dated [DATE]. This resulted in a fall from a raised bed onto the floor. Multiple administrations of Cardio-Pulmonary Resuscitation (CPR) were required to stabilize Resident #7 prior to being taken to the hospital. Resident #7 expired the following day. Findings included: The care plan dated [DATE] stated Resident #7 needed total assistance for all care with 1 - 2 persons. This was the active care plan. Resident #7 was readmitted to the facility on [DATE]. Diagnoses included dementia, history of falls, Alzheimer ' s Disease and [CONDITION(S)] (irregular and often rapid heart rate). The care plan dated [DATE] listed Behavior: Exhibits aggressive behavior at times. There were general interventions: talk in calm voice, refer to Social Services for evaluation, monitor and document target behaviors, place in area where frequent observation is possible. This was reviewed [DATE]. The MDS Nurse was interviewed on [DATE] at 11:00 AM and stated she did not know why the care plan was so general, and she would have included the number of staff needed for each care need. The MDS Nurse did find a falls care plan dated [DATE] with interventions of fall mat, bed in low position, etc. that had been resolved on [DATE]. The MDS Nurse stated if a resident had not had a fall for a period of time, the care plans are sometimes resolved. The MDS Nurse stated the nurses fill out the Kardex. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was severely impaired for cognition and needed total assistance with all daily care, with two person ' s physical assistance. The exceptions were eating and locomotion on and off unit which required one person ' s assistance. The quarterly MDS did not indicate any behaviors or rejection of care. The Kardex (a care guide for NAs) for Resident #7 indicated the Resident was dependent on total care for all Activities of Daily Living (ADLs). Mobility was marked non-ambulatory, wheelchair, and transfers was checked with 2 assists with mechanical lift. Special care instructions were: Resident has episodes of agitation and behaviors, history of hitting/kicking at staff. The Kardex was undated. Nurse #3 stated, in an interview on [DATE] at 5:28 PM, she had reviewed the training packet with NA #4 on her first day of work in the facility. Nurse #3 stated she had reviewed information on the Kardex and resident care needs for assistance information. NA #4 was interviewed on [DATE] at 1:30 PM and stated she was working with Resident #7 on [DATE] at the time of his fall from bed. NA #4 stated she had only been to the facility on e or two times prior to [DATE]. NA #4 indicated she was providing care to Resident #7 without any other staff ' s assistance. NA #4 stated she raised Resident #7 ' s bed and began to wash him, and he started to swing his arms around trying to grab the washcloth. NA #4 indicated she changed Resident #7 ' s shirt, then took off his brief and washed his private area in front and dried him. When she rolled him to his side and started to wash his bottom, he fell off the bed and onto the floor. When asked if she thought about stopping to get help when the Resident first became combative, NA #4 stated No, I just thought I would go ahead and get it done. NA #4 stated she was not sure if she had worked with Resident #7 before or not. She explained that she was an agency NA and had worked with a lot of residents. When asked how she knew how much assistance Resident #7 required, NA #4 said she got information about feeding and patient care from someone on staff, she stated she did not remember if it was a nurse or another NA but was only told that Resident #7 was total care. NA #4 stated she was not familiar with Kardex or the Patient Care Guide, but another staff member gave her a rundown on the residents she was assigned to. A nursing progress note dated [DATE] documented at 12:30 PM, Nurse #1 was notified by NA #4, who was assigned to Resident #7, of the fall. The note indicated the Resident became combative during care, kicking his legs and swinging his arms and began to slip off the bed, fell to the floor and landed on his stomach on the fall mat which was in place. The note stated vital signs were taken and were blood pressure ,d+[DATE], pulse 52, oxygen saturation 80%. Nurse #1 cleaned the mid-forehead laceration with normal saline and applied a dry dressing. Emergency Medical Services (EMS) arrived, turned the Resident over while stabilizing his neck, and Resident #7 became unresponsive with no pulse. EMS began CPR and Nurse #1 assisted with chest compressions. More EMS personnel arrived to assist. Resident #7 left the facility via stretcher non-verbal, but responsive and stabilized at 1:35 PM to the hospital. Nurse #1 was interviewed [DATE] at 10:45 AM and stated the same facts as she wrote in the [DATE] nurse progress note. Nurse #1 stated when Resident #7 became combative, NA #4 should have gotten help. Nurse #2 was interviewed on [DATE] at 11:15 AM and indicated she was paged by Nurse #1 when Resident #7 fell . Nurse #2 stated she entered the room, saw Resident #7 laying on his stomach with his head turned to the side and bleeding from his forehead. Nurse #2 indicated his vital signs were good, she left the room, called 911, called the front desk to anticipate EMS arrival, and called the facility Medical Director. Nurse #2 stated when EMS turned Resident #7 over, he quit breathing and CPR was performed three times and the Resident was taken to the hospital. Resident #7 expired at the hospital on [DATE]. The Death Certificate signed [DATE] noted the cause of death as multiple [MEDICATION(S)] force injuries. The Medical Examiner indicated on the death certificate the injuries occurred from a fall off the bed. The Medical Examiner (ME) was interviewed on [DATE] at 5:01 PM, and stated there were neck fractures, facial fractures, and some rib fractures. The ME confirmed the cause of death as multiple [MEDICATION(S)] force injuries that resulted from a fall from the bed. In an interview on [DATE] at 10:40 AM, the Director of Nursing (DON) stated when Resident #7 became combative, two staff were needed. The DON stated NA #4 should have lowered the bed and gone for help. On [DATE] at 9:32 AM, the Medical Director (MD) was interviewed and stated Resident #7 was totally dependent for his care. Regarding Resident #7 ' s fall, the MD stated he got a call saying Resident #7 fell and coded. Corrective Action Plan [DATE] Received [DATE] 12:30 PM PROCESSES THAT LEAD TO THE IDENTIFIED ISSUE On [DATE] CNA #4 was providing ADL-care to Resident #7 when Resident #7 became combative, swinging his arms and legs and when CNA #4 turned Resident #7 he rolled onto the floor, sustaining a laceration to his mid-forehead. Resident #7 was transferred to the hospital where he expired. Review of Resident #7 care plan states ,d+[DATE] person assist with ADL care and most recent MDS on [DATE] is total dependence with two-person physical assist for bed mobility and bathing. ADDRESS HOW CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR RESIDENT(S) FOUND TO HAVE BEEN AFFECTED BY THE IDENTIFIED ISSUE Resident #7 care plan, Kardex and MDS were reviewed on [DATE] regarding Resident #7 needs. Resident #7 was transferred to the Hospital. Unable to update due to resident d/c. ADDRESS HOW CORRECTIVE ACTION WILL BE ACCOMPLIISHED FOR RESIDENT(S) HAVING POTENTIAL TO BE AFFECTIED BY THE SAME ISSUE. All residents were reviewed by [DATE] by Nursing Consultant, Director of Operations, MDS with collaboration of CNAs to ensure the following areas have been appropriately addressed: 1) Numbers of staff members needed to provide care 2) Bed surface to ensure sufficient room for turning and repositioning 3) Whether or not the resident has a physical impairment or behaviors that need to be considered 4) Any resident that cannot assist with turning or repositioning The updated Kardex ' s and care plans were communicated verbally through training with all staff, including agency on [DATE]. ADDRESS WHAT MEASURES WILL BE PUT IN PLACE OR SYSTEMIC CHANGES MADE TO ENSURE THAT THE IDENTIFIED ISSUE DOES NOT OCCUR IN THE FUTURE. Effective [DATE], all direct care staff (including agency) will be educated by Interdisciplinary Team on the locations of the resident Kardex, where on the Kardex to find the information needed to ensure appropriate care is provided to the resident, by ED/Nursing Consultant. Effective [DATE], all direct care staff (including agency) will be educated by Interdisciplinary Team on handling residents with behaviors by ED/Nursing Consultant. Effective [DATE], all direct care staff (including agency) will be educated by Interdisciplinary Team related to proper technique for turning and repositioning residents (+1/+2). Direct care staff (including agency) not in-serviced by [DATE] will be in-serviced prior to their next scheduled shift. Responsible person: ADON or designee. Effective [DATE], the ADON or designee will add to orientation specific education regarding the Kardex to include the purpose of the Kardex and a detailed review of the information on the Kardex. As well as education on dealing with combative resident. Effective [DATE], the DON/designee will conduct direct observation of care audits to ensure that care is being provided according to the resident care plan and Kardex. The audits will be conducted 3 residents 3 x per week x 4 weeks, then 3 residents weekly for 8 weeks. These audits will be conducted on all shifts. In addition, audits of the Kardex and care plan will be conducted to ensure they complement each other. Any opportunities identified will be corrected. All resident ' s care plans and Kardex that require updating were completed on [DATE] by MDS Coordinators. The Executive Director informed them of this responsibility. MONITORING PROCESS QAPI meeting held on [DATE] and this plan was reviewed. Effective [DATE], DON or designee will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. The facility alleged full compliance with this plan of correction effective date [DATE]. On [DATE] beginning at 8:55 AM multiple direct care staff members were interviewed. These nursing staff members validated they had attended in-service training regarding resident safety and where to find information regarding care needs for residents. Nursing staff members, who were interviewed, were able to report they would stop care if dealing with combative residents and obtain the assistance and direction of their supervisor. Nursing staff members were also able to locate or verbally report where they could locate residents ' kardexs. A random resident, who was identified by staff to be cognitively intact and in need of total care dependence by two staff members, was interviewed on [DATE] at 9:42 AM. This resident reported he felt safe and two staff members assisted in turning and repositioning him. A second random resident, who was identified by staff to be cognitively intact and in need of total care assistance by two staff members, was interviewed on [DATE] at 9:55 AM. This resident also reported he felt safe and that two staff members turned and repositioned him. Both of these residents were observed to be in a safe position within their beds. On [DATE] at 10:15 AM facility documents were reviewed. The facility had documented evidence of audits completed per their credible allegation of compliance. The facility provided evidence of inservice training per their credible allegation of compliance. This included in-service training for their direct care staff regarding turning repositioning, location of the Kardex and where to find information, and dealing with residents with behaviors. Residents, who were documented to have behaviors, were verified to have this information on the kardex with instructions on how to deal with the behaviors. The facility also provided documentation that their quality assurance members met on [DATE] to assure continued compliance with their plan of correction. The facility ' s credible allegation of compliance is validated for the date of [DATE].

Based on record review, Nurse Practitioner (NP), Physician and staff interview, the facility failed to complete dressing changes as ordered by the physician for 1 of 1 resident which resulted in the resident being admitted to the hospital for a wound washout and application of a wound vac, (Resident #397). The findings included: Resident #397 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #397 was cognitively intact and required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. Resident #397 was independent for eating. A review of Resident #397's care plan revealed an Activities of Daily Living (ADL) self-care deficit related to weakness, pain, impaired balance and right Above the Knee Amputation (AKA). Resident #397 was also care planned for skin integrity for actual alterations as evidenced by a surgical wound right AKA and was at risk for further skin breakdown/pressure ulcer development due to weakness and impaired bed mobility. Interventions included treatment to right AKA as ordered. /Resident #397 was seen by the N/ of a vascular center on 08/07/2020 for follow-up regarding a right AKA. A review of the visit summary dated 08/07/2020 reveaeld no malodor or dark drainage present and a new dressing was dated and applied to her right AKA. A review of the after-visit orders provided to the facility indicated Resident #397's right AKA incision line was to be cleaned, dry-packed and covered with a wet-to-dry dressing every day. Resident #397 was given an appointment to return to the vascular clinic on 08/10/2020. A review of the facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order also included the dressing could be changed twice daily if excessive drainage was noted. A review of the Treatment Administration Record (TAR) for Resident #397 dated 08/08/2020 and 08/09/2020 revealed no staff signatures for either of these days. The TAR comment section for both 08/08/2020 and 08/09/2020 read as follows: · Right AKA dressing each day scheduled for 08/08/2020 was not administered. · Right AKA dressing each day scheduled for 08/09/2020 was not administered. On 08/10/2021, Resident #397 returned to the vascular clinic for the scheduled appointment. A review of the NP visit summary from the vascular center revealed dressings were not changed at the facility as ordered and the same dressing placed on 08/07/2021 was still on the resident's wound. The wound was dark and malodorous with drainage noted. The summary also indicated Resident #397 needed continuous wound care to the right AKA incision and was scheduled for an AKA wound washout with a possible wound vac placement to prevent further risk of infection. Resident #397 was sent to an emergency room (ER) from the vascular center and did not return to the facility. A review of the hospital ER records dated 08/10/2020 revealed Resident #397 presented with a non-healing wound to the right AKA with brown serosanguous drainage. Resident #397 was scheduled to undergo a wound washout and placment of a wound vac on 08/11/2020 and was admitted to the hospital on the evening of 08/10/2020. A review of the hospital records for visit dated 08/11/2020 revealed Resident #397 underwent right AKA washout and a wound vac was placed on 08/11/2020. Resident #397 was discharged to home with family on 08/13/2020 and was given follow up instructions and return appointment. A review of the hospital discharge summary dated 08/13/2020 revealed Resident #397's care involved complexity due to the comorbidities listed in the history and physical. A review of the facility's nursing assignment sheets for 08/08/2020 and 08/09/2020 revealed the nurses assigned to Resident #397 for each of these days were unavailable for interview. A review of Nurse #11's progress note dated 08/11/2020 labeled as late entry, revealed Nurse #11 received a call from the vascular clinic regarding Resident #397 to inform the facility the resident was being sent to the ER for surgery on her right AKA. An interview with Nurse #11 on 06/08/2021 at 11:17 am revealed she remembered Resident #397 but didn't remember the details of the phone conversation from the vascular office as to why the resident had to go to theER on [DATE]. She stated she had been off on both 08/08/2020 and 08/09/2020 and returned to work on 08/10/2020. An attempt was made to contact the resident for interview, but the phone number in the medical record for Resident #347 had been disconnected. In a phone interview with the vascular center NP on 06/07/2021 at 1:46 pm, the NP stated she provided care to Resident #397 for her right AKA on Friday, 08/07/2020, and ordered wet to dry dressing changes daily and as needed. During the visit, Resident #397 expressed concern that the facility would not change her dressing daily because she felt they may be short staffed. The NP stated she made Resident #397 an appointment to return to the vascular center on Monday, 08/10/2020 as a follow up just in case the facility did not change her dressing. The NP indicated Resident #397 returned to the vascular appointment on 08/10/2020 with the same dressing the NP had applied on Friday, 08/07/2020. She noted Resident #397 was scheduled for a debridement and possible wound vac placement for the next day, 08/11/2020 at a hospital. Resident #397 was sent to the ER from the vascular center. The NP stated Resident #397 had many comorbidities that could hinder the healing process of the right AKA and the NP could not say the lack of dressing changes caused the resident to need further treatment to her wound. An interview with a Corporate Nurse Consultant on 06/08/2021 at 10:53 am revealed there was a grievance filed by the vascular center on 08/07/2020 about Resident #397's dressing not being changed per the physician order. The Nurse Consultant stated she logged the grievance and further stated Resident #397 was discharged on [DATE]. The Consultant indicated she had no opportunity to interview the resident regarding the grievance. The Consultant stated the nursing staff did not change the resident's dressing on the dates of 08/08/2020 and 08/09/2020, and she had nothing to add but the nurses just didn't change the dressing as ordered. The interview with the Director of Nursing on 06/11/2021 at 11:43 pm revealed the nursing staff should follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with a physician on 06/11/2021 at 2:45 pm revealed he was aware Resident #397 did not receive dressing changes to her right AKA on the dates of 08/08/2020 and 08/09/2020. He stated the resident had complicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated Resident #397's wound debridement was unavoidable.

Based on observation, record review, resident interviews, family interviews, staff interviews, and physician interviews, for one (Resident # 1) of two sampled residents with injuries, the facility failed to assure a resident did not sustain injuries which led to her death. Resident # 1 sustained three falls during her eleven day residency. Following an incident on the resident's last residency date, in which the resident was found on the floor, she was transferred to the hospital and identified to have multiple rib fractures, a hemopneumothorax, and a fracture in the wrist area. The resident expired on [DATE] from complications of her injuries. The findings included: 1. Record review revealed Resident # 1 resided in the facility from ,[DATE]/ 18 to [DATE]. Prior to her facility residency the resident had been hospitalized following a fall at home. The hospital physician noted the resident had a sudden significant decline in status and rapidly worsening dementia during her hospitalization . Additionally, the resident had [DIAGNOSES REDACTED]. Review of the resident's baseline care plan, initiated on [DATE], revealed the staff identified the resident had safety issues and a history of falls. Staff were directed to provide assistance with activities of daily living and keep commonly used items within the resident's reach. There was also a notation that the resident was not cooperative with care, was impulsive, and had poor safety awareness secondary to her dementia. Record review revealed the resident had a five day Minimum Data Set (MDS) assessment, completed on [DATE]. The resident was assessed to be severely cognitively impaired, and needed extensive assistance with her activities of daily living. The resident was also coded as having sustained falls prior to admission and since admission. Review of nursing notes revealed Resident # 1 sustained an unwitnessed fall on [DATE] at 3:39 PM. Nurse # 1 documented at this time that Resident # 1's family had stepped out from the resident's room to speak to him (the nurse), and as the family was speaking to the nurse they heard a scream for help. Resident # 1 was found on the floor on her left side, had a golf ball sized node to the back of her head, and complained of a headache and left hip pain. According to facility documentation, NA # 5 had been assigned to care for Resident # 1 on the 3:00 PM to 11:00 PM shift on [DATE]. NA # 5 was interviewed on [DATE] at 12:35 PM, and did not recall the resident or any events related to the resident. According to the nursing notes, Resident # 1 was sent to the hospital for evaluation directly following the [DATE] incident and returned at 10:30 PM on [DATE] following the hospital's determination that all x-rays were negative for injury. According to an interview with the DON (Director of Nursing) on [DATE] at 9:25 AM, Nurse # 1 was currently on an extended work leave and was not available for interview. Review of the facility's post incident actions form, dated [DATE] revealed under Immediate Post-Incident Action, it was noted the resident was assisted to the chair and the family and resident were re-educated to ask for assistance when there was a need for transfer. Review of nursing notes revealed Nurse # 2 made an entry on [DATE] at 12:21 AM noting that the resident's bed was in the lowest position, and fall mats were in place. On [DATE] at 6:59 AM, Nurse # 2 noted the resident was assessed again, found to have no injuries, and denied pain or discomfort. On [DATE] at 3:27 PM the NP (Nurse Practitioner) entered a progress note. The NP documented within the note that she saw the resident due to intermittent episodes of agitation. The NP noted she consulted with a psychiatrist regarding behavior management, and a change was made to the resident's medication regimen. The NP noted the plan was discussed with the resident's family and included the [MEDICAL CONDITION] medications [MEDICATION NAME], and [MEDICATION NAME]. On [DATE] at 7:29 PM, Nurse # 2 documented the following information in a nursing entry. Resident # 1 had sustained a second fall at 7:15 PM on [DATE]. The resident had been sitting outside the nursing station while Nurse # 2 was at the medication cart, which was about five feet away from the resident. Nurse # 2 heard a noise and saw the resident laying on her right side on the floor. The wheelchair was turned upside down and positioned beside of the resident. The resident was found to have a 7 cm (centimeter) in length by 1.5 cm in width skin tear to her right leg below the knee, and stated her right leg was hurting her. The resident's range of motion was assessed, and the resident did not complain of pain with movement of her extremities. The skin tear was cleansed, dressed, and the resident was offered to be assisted to bed. The resident stated she wanted to remain in the chair. The resident was kept in the common area, and the physician and responsible party were notified. Nurse # 2 was interviewed on [DATE] at 10:35 AM, and reported the following. She had been standing at the medication cart on [DATE] attending to her duties. The resident was close to her, but she did not see her fall. When she heard the noise, she turned to see the resident on the floor. The nurse did not recall that the resident had any other injury than the skin tear noted in her nursing entry. According to facility documentation, NA # 6 was assigned to care for Resident # 1 on the 3:00 to 11:00 PM shift of [DATE]. NA # 6 was interviewed on [DATE] at 11:31 AM and reported she did not recall the resident or events related to the resident. Review of the facility's post incident actions form, dated [DATE] revealed under Immediate Post-Incident Action, it was noted the resident was reminded to wait for assistance before ambulating, and there would be a medical evaluation for aggressive behaviors. Following Nurse # 2's entry of [DATE] at 7:29 PM, the next nursing entry was entered on [DATE] at 3:17 PM. At this time, a nurse noted the resident was confused, combative, and had multiple attempts to get out of her chair. The nurse noted the resident was placed at the nursing station for one on one monitoring. On [DATE] at 12:58 PM, the NP entered a progress note with the following information. She was seeing the resident due to the resident's fall the previous evening. The NP noted the resident had small ecchymoses (bruising) on her extremities and a larger ecchymosis to the right lower extremity with a skin tear. The NP noted the resident was in no acute distress, and was considered stable. On [DATE] at 4:37 PM, the NP made an addendum to her progress note. The NP documented the nurse reported the resident was combative, aggressive, and restless the previous night. The NP noted she would order [MEDICATION NAME] 1 mg (milligram) IM every day as needed for combative and agitated episodes for 14 days. Resident # 1's NP was interviewed on [DATE] at 12:45 PM, and reported the following. She recalled talking to both Nurse # 2 and Nurse # 3 while the resident was residing at the facility, and they had informed her the resident would become more agitated in the evening times. She had talked to a psychiatrist about managing the resident's behaviors, but at times the resident would be agitated and would refuse to take her medication by mouth. Therefore, she ordered the [MEDICATION NAME] IM for periods when the resident would not take her medication by mouth. According to the NP, she had not identified that the resident sustained [REDACTED]. The NP stated the resident always had some bruising on her extremities, and it was difficult to determine what was new and old. According to facility documentation, NA # 7 had been assigned to care for Resident # 1 on the shift which began on [DATE] at 11:00 PM and ended at 7:00 AM on [DATE]. NA # 7 was interviewed on [DATE] at 10:14 AM, and reported she did not recall the resident or events related to the resident. Review of the record revealed no nursing entries between the time of [DATE] at 3:17 PM and [DATE] at 4:31 PM. During this interim, in which there were no nursing notes, there was documentation on the Resident's August, (YEAR) MAR (medication administration record), that the resident received [MEDICATION NAME] 1 mg (milligram) intramuscularly on [DATE] at 8:28 AM by Nurse # 2. The reason noted on the MAR indicated [REDACTED]. Nurse # 2 was interviewed on [DATE] at 12:06 PM. According to Nurse # 2 the resident was restless, anxious, didn't want anyone near her, and couldn't calm herself down. According to facility documentation, NA # 1 had been assigned to care for Resident # 1 on the 7:00 AM to 3:00 PM shift of [DATE]. NA # 1 was interviewed on [DATE] at 9:30 AM and reported the following. She recalled that Resident # 1 would punch, kick and be combative with care. She did not recall the specific events of the last day she cared for Resident # 1 on [DATE] or if she was exhibiting behaviors on that day. On [DATE] at 3:47 PM, the NP documented in a progress note that she was seeing the resident for a fall, and the resident reported general pain. The NP noted the resident was alert, confused, restless, and agitated. The NP noted she ordered the resident to have an x-ray of her Lumbar spine, and x-ray of the hip. The NP also noted that she ordered the resident [MEDICATION NAME] for her pain. Following the nursing entry of [DATE] at 3:17 PM, the next nursing entry was entered on [DATE] at 4:31 PM by Nurse # 3. Nurse # 3 documented the following at this time. Resident # 1 had been found on the floor mattress at 4:03 PM on [DATE]. The resident was complaining of hip pain. The PA (physician's assistant) and responsible party were notified. The resident's vital signs were taken, and she was assessed for injury and none were seen. The resident was given an antianxiety medication. Also, although the nursing entry was made into the digital medical record by Nurse # 3 at 4:31 PM, Nurse # 3 documented within this entry that she gave [MEDICATION NAME] at 5:00 PM on [DATE]. Five o'clock had not transpired at the time of the digital entry. Nurse # 3 noted the resident was quiet after her pain medication. Nurse # 3 was interviewed on [DATE] at 8:05 AM and could not recall the resident or any details regarding the incident or events which had happened with the resident. According to facility documentation, NA # 4 had been assigned to care for Resident # 1 on [DATE] from 3:00 PM to 7:00 PM. NA # 4 was interviewed on [DATE] at 3:17 PM and could not recall the resident or any details or events which happened with the resident. The NP was interviewed on [DATE] at 12:45 PM, and reported the following. She was called to Resident # 1's room on [DATE] at 3:47 PM by the staff because the resident had fallen. The resident was still on the floor mat by the bed and was lying on her back. She asked the resident if she hurt and the resident said she hurt all over, but because of her confusion the resident could not describe if the pain was worse in any one area. When the NP checked the resident's back, it appeared tender, and she seemed to have limited range of motion in her left hip. She ordered the x-rays and some [MEDICATION NAME] for the resident's pain. The NP stated the resident had no other evident injuries. She stated her chest was symmetrical, and she was not experiencing any breathing problems. The NP thought the fall, which was documented by Nurse # 3 as occurring on [DATE] at 4:03 PM, was the fall that had actually occurred at 3:47 PM. It was her understanding that the resident only experienced one fall that day, and there had been no other incidents of which she was aware. The NP stated after the 3:47 PM fall, she thought the staff got the resident up to the wheelchair so they could watch her. The NP stated she left around 4:00 PM. The current DON and Administrator were interviewed on [DATE] at 4:45 PM. The Administrator was interviewed regarding whether there had been a fall at 3:47 PM and again at 4:03 PM. The Administrator stated he was not sure. According to the DON he had talked to Nurse # 3 on [DATE], and pointed out to her that she could not have charted at 4:31 PM that she gave the resident [MEDICATION NAME] at 5:00 PM since that reflected a time in the future. The DON stated Nurse # 3 had informed him that she charted at 4:31 PM what she intended to do at 5:00 PM. According to the DON, it was his expectation that the record should have reflected accurately what events had occurred after they had occurred, and nurses were not to chart what they planned to do. Following the nursing entry of [DATE] at 4:31 PM, the next nursing entry was entered on [DATE] at 2:03 AM by Nurse # 2. Nurse # 2 documented the following at this time. The resident had been received by her alert and awake, resting in bed asleep. At 9:00 PM the resident awakened and complained of back pain. The resident was given 5 mg (mg) of [MEDICATION NAME] at 9:10 PM. She had a hematoma to her right hand from top of her fingers to her wrist. The resident's right hand was noted to have increased swelling. The physician was notified, and orders were given to send the resident to the emergency room for evaluation and treatment. The resident was transferred to the hospital on [DATE] at 9:30 PM. Nurse # 2 was interviewed on [DATE] at 10:35 AM and reported the following. She had come into work on [DATE] at 8:00 PM. When she arrived, the previous nurse had told her that the resident had fallen. The x-ray technician did not arrive right away, and one of the resident's hands appeared to have increasing swelling. The resident was moaning and groaning when the nurse reported to work, and therefore because of the x-ray delay and the increased swelling she contacted the physician to have the resident sent out for evaluation. Nurse # 2 did not recall any other bruising or injury other than one of her hands. Review of hospital records revealed Resident # 1 underwent a CT scan while in the emergency room . She was identified to have fractures of the 2nd, 3rd, 4th, 5th, and 6th ribs. The 2nd, 5th, and 6th ribs were documented to be displaced. The hospital records noted it was the resident's left wrist which had sustained injury, and not her right wrist as reflected in the facility record. An X-ray, completed while in the ER, revealed the resident had a left non-displaced ulnar styloid fracture. (left wrist fracture). The resident was also identified to have a hemopneumothorax (air and blood were in the chest cavity) and [MEDICAL CONDITION] contusion (lung bruising). A chest tube was placed in the resident to drain the blood. The resident remained hospitalized until [DATE], and then was transitioned to hospice care. The resident expired on [DATE]. Review of her death certificate revealed cause of death was listed as complications of [MEDICATION NAME] force chest and arm trauma. The resident's responsible party (RP) was interviewed on [DATE] at 2:30 PM and reported the following. The RP stated she had visited with the resident during the morning of [DATE], and the resident seemed sleepy, but uncomfortable in her back. She was told by a nurse that was in charge that the resident had been combative, and they had given her medication. The RP stated she had left around lunch time that day. The RP stated after Resident # 1 passed away, she and other family members met with the administrator and informed him of all the injuries which were identified at the hospital. The RP stated the administrator maintained that the injuries were due to the resident's fall without giving an explanation of how this could have occurred. On [DATE] at 9:00 AM the other relative (Relative # 1), who had been with Resident # 1 on [DATE], was also interviewed. Relative # 1 reported the following. Relative # 1 received a phone call in the afternoon of [DATE] from the resident's RP. The RP informed Relative # 1 that the facility had called to let her (the RP) know the resident had fallen. Relative # 1 stated the RP could not go at that time, and she went to the facility around 4:15 PM. When she arrived to the resident's hallway, she could hear Resident # 1's screams into the hallway. She found the resident in bed. She found a nurse and inquired what had happened. The nurse told her she didn't know, and that she was just filling in. Around 5:00 PM a nurse gave the resident some [MEDICATION NAME] for pain, and told her they were going to do x-rays. The X-ray technician was delayed in getting to the facility, and the resident was sent out to the hospital for evaluation. Initially she was seen at one hospital, and transferred to a larger hospital due to trauma. The family was notified of the injuries at the hospital, and could not understand how they had occurred from a fall to a mat on the floor. Following the resident's death, Relative # 1 stated she looked through some photographs she had taken on the AM of [DATE], and realized the resident's left wrist was showing signs of swelling. Relative # 1 stated the picture indicated to her that something had been wrong with the resident's wrist before the resident fell on the afternoon of [DATE]. Relative # 1 stated a letter was sent on October, 9.2018 requesting to meet with the administrator, and conveying to him they had concerns about the resident's care. On [DATE], she, the resident's RP, and another relative met with the administrator, Nurse # 2, and the former DON. Relative # 1 stated she showed the administrator the picture of the resident's wrist which had been taken earlier in the day prior to the fall event the facility claimed caused her injury. Relative # 1 also said she had obtained copies of the resident's clinical record before the meeting and pointed out that there were discrepancies in the record to the administrator, such as when the resident had sustained her last fall. Relative # 1 stated she told the administrator that she did not think that the resident could have sustained her injuries from falling off a bed onto a soft floor mat. Relative # 1 stated the bed was only about 12 to 18 inches off the ground. Relative # 1 stated the administrator and his staff maintained that the resident had sustained the injuries from her fall, and the family received no further explanation or follow up regarding how this could have occurred. The facility Administrator was interviewed on [DATE] at 8:10 AM and again at [DATE] at 4:45 PM. The Administrator stated he recalled talking to the family about concerns they had regarding Resident # 1's falls, and the family was wanting to know more information in regards to what had happened. Per the Administrator, he did not recall what the family had said in regards to the extent of Resident # 1's injuries. The Administrator stated he had to step out of the meeting for a period and none of his staff had informed him of pictures. The emergency room physician, who saw Resident # 1 when she presented to the second hospital on [DATE], was interviewed on [DATE] at 2:35 PM. The physician stated the resident sustained [REDACTED]. According to the physician, the injury pattern could be consistent with a fall and the resident had been on a small dose of Aspirin which could have contributed to some of the bleeding. The resident's facility physician was interviewed on [DATE] at 2 PM. The physician stated he felt the resident's injuries had been sustained from her fall. According to the physician the resident was constantly trying to get up, and was confused. Review of the facility's Investigation into the Resident's fall which occurred on [DATE] revealed documentation was located on a Resident Incident Report. Nurse # 3 had noted on the form the resident had been seen on floor mattress at 4:03 PM. Nurse # 3 noted the resident was complaining of pain in her hip. Nurse # 3 noted, did not see any injury and did not see any skin break down. Attached to the Resident Incident Report form was a page entitled, Incident Investigation. It was signed by the former DON, and was not dated. Under narrative of investigation the narrative did not address what time the resident fell or if there had been two falls. It did not address where she fell , and what part of her body hit what object. It did not address if there were any witnesses to the fall. The narrative investigation included five sentences which read, On [DATE] resident was observed on the floor. Resident complained of pain her hip area and x-ray was ordered. Investigation of this fall conducted by the Director of Nursing concluded that resident attempted to transfer self lost balance and fell . Due to the fall impact resident sustained [REDACTED]. Resident was sent to the ER for evaluation and treatment. It was clarified with the Administrator on [DATE] at 4:45 PM that this was the only documentation that the facility had in regards to their investigation into the resident's injuries. There was no mention in the five sentence investigation narrative regarding the injury to the resident's wrist which was initially identified at the facility and later identified to be a fracture. There was no indication what events were reviewed and to whom the former DON had spoken in regards to the events of the resident's day on [DATE] to determine that the resident was trying to transfer when she sustained the rib fractures. There was no documentation to address the inconsistencies of the clinical record noting that the resident fell at 3:47 PM and at 4:03 PM. There was no documentation to show that the facility had identified that a nurse had documented future events into a digital record on the date and time the nurse recorded the resident's fall, and that they investigated why a nurse was documenting future events in the resident's clinical record at the same time she documented the fall. There was no documentation to show the facility had assessed their previous documentation on the Post Incident Actions Form, which noted staff reinforced to the resident that she needed to call and wait for assistance, and evaluated if this was a reasonable intervention for a cognitively impaired resident. There was no documentation so show the facility had evaluated the necessity of the resident's [DATE] morning administration of [MEDICATION NAME] and if it had contributed to an incident on [DATE] which may have led to the injuries via way of making the resident more unsteady and/or if she could have sustained injuries while being combative during the administration of the intramuscular [MEDICATION NAME] injection. The former DON was interviewed on [DATE] at 4:45 PM and reported the following. There was no witness to the fall of [DATE] at 3:47 PM. Prior to the incident, the former DON had been on the unit until around 3:00 PM on [DATE], and the resident had been in bed sleeping. The resident was found by Nurse # 3 on the floor mat, and Nurse # 3 had called the former DON when the resident was found. According to the former DON, Nurse # 3 had found the resident at 3:47 PM and not 4:03 PM as documented in the investigation and in the nursing entry. The resident was facing the door on the mat, and therefore the former DON concluded the resident was trying to get out of bed when she sustained the injuries. The former DON could not recall with certainty, but thought that the staff were going to get the resident up to the chair following her fall at 3:47 PM on [DATE]. The former DON left the unit after the 3:47 PM fall, and had not been told the resident had fallen again. At some point following the incident of 3:47 PM on [DATE], she had asked Nurse # 3 and NA # 4 if the resident had fallen again after 3:47 PM, and they had reported to the former DON that the resident had not done so. The facility submitted a credible allegation of compliance they had completed on [DATE]. Corrective action accomplished for those residents found to have been affected by the deficient practice. Resident #1 was admitted to the facility on [DATE] for long term care services. Review of facility most recent minimum data set, with Assessment reference date [DATE] section G indicated resident #1 requires extensive assistance with bed mobility with one assist, transfer with one assistance, and toileting with one assistance. Resident #1 coded in section J. to have a falls in the last month prior to admission, and also coded having a fall in the last ,[DATE] months prior to admission/entry or reentry. Review of fall incident log from [DATE] up to [DATE] indicated resident #1 had three falls dated [DATE], [DATE] and [DATE]. Review of resident's fall risk assessment completed on [DATE] indicated resident is at risk for fall due to resident's fall history, history of fracture, impaired vision, cognitive deficit, and being on ,[DATE] medications to include but not limited to, psychoactive medication such as [MEDICATION NAME] and [MEDICATION NAME], Anti-hypertensive medication such as [MEDICATION NAME] and [MEDICATION NAME] as well as [MEDICAL CONDITION] medication- [MEDICATION NAME]. Facility developed resident's baseline care plan within 48 hours of admission with intervention to prevent accidents and hazards. On [DATE] Resident was observed on the floor in her room, family had stepped out to speak to licensed nurse #1 and left the resident in the room unattended and that's when we heard the resident scream for help. Licensed nurse #1 walked in resident's room and observed resident #1 laying on floor on her left side. Licensed nurse #1 assessed the resident and noted a raised area on the back of resident #1 head. No other injuries noted. Resident family was re-educated not to leave a resident unattended in the room. On [DATE] resident #1 was sitting outside the nurses station, positioned at the door way. Resident attempted to ambulate and lost balance and fell . Resident was assessed by licensed nurse #2 and was able to move all extremities Medical evaluation was requested due to residents' aggressive behaviors. On [DATE] resident # was observed on the floor, no apparent injuries noted, however resident was complaining pain in her hip area. Resident Physician was notified, as well as resident's family (Daughter). Resident #1 received pain medication and antianxiety medication, medication was effective per documentation. X - Ray was ordered and scheduled for Left spine. Resident #1 was sent to the hospital on [DATE]. Resident #1 is no longer in the facility. No further actions warranted. Root cause analysis indicated resident #1 medical condition that resulted onto cognitive deficit, confusion and multiple falls were not identified and addressed after each fall. Facility failed to identify the relationship between resident's incidents/accidents and her overall medical condition, medication management specifically psychoactive medication. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. 100% audits of all current residents fall risk assessments was completed on [DATE] by the facility Director of nursing, and/or unit manager to ensure each resident medical risk factors are identified and addressed on each residents care plan. Three other residents identified with medical condition that was not addressed on the care plan. Facility Director of nursing updated the three residents' care plans identified on [DATE]. Interventions pertaining to nursing assistance were added on each resident's care card. Nursing assistants were notified of interventions added on residents' care cards through an in-service education provided by the facility Director of Nursing on [DATE]. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur Effective [DATE] licensed nurses will conduct fall risk assessments on admission, readmission, quarterly and with significant changes for each resident in the facility. Fall risk assessment will identify all factors to include medical, medicinal and historical and then ensure appropriate interventions are added on each resident's care plan to ensure resident's safety while in the facility. Effective [DATE] A license nurse who completes resident's incident report will conduct root cause analysis after each incident to identify all factors to include medical, medicinal and environmental. A license nurse will accomplish this task through answering questions in the incident report form that guide a licensed nurse to answer questions such as what, when, and how the incident occurs. Through answering those questions a licensed nurse will be able to determine the appropriate root cause for each incident. The licensed nurse will then ensure appropriate interventions are added on each resident's care plan to ensure resident's safety and prevent reoccurrences of incident/accidents. Any identified root cause will be addressed promptly on each resident's care plan before after each incident and intervention added on resident's care plans and care cards. Effective [DATE] licensed nurses will review resident's care plan before implementing new intervention to ensure the appropriateness of the intervention put in place. Effective [DATE] nursing assistance will review each resident's care card, maintained electronically and accessible to nursing assistants throughout the facility via the mounted kiosks, before providing care for any resident to ensure appropriate interventions are in place while on duty. Nursing assistants were notified of the requirement to review electronic care cards via in-service education conducted by the facility Director of Nursing on [DATE]. Any nursing aide who was not notified of this requirement not allowed to work until educated. Facility Director of Nursing and/or Unit manager #1 conducted re-education for current licensed nurses' onsite on [DATE]. This education included, importance of ensuring resident has a fall risk assessment on admission, readmission and quarterly as well as with significant changes, ensuring that the root cause analysis is completed after each fall and ensure all factors to include medical, medicinal, environmental and historical are considered to derive the appropriate intervention. This education will be completed by [DATE], any licensed nurse not educated by [DATE] will not be allowed to work until educated on this requirement. Effective [DATE] this education will be added on new hires orientation education for all new facility Licensed nurses. This education will also be provided annually for all facility licensed staff. Facility Director of Nursing and/or Unit manager #1 conducted re-education for current nursing assistants' onsite on [DATE]. This education included importance of following resident's interventions as indicated on the care cards, importance of reviewing care card before providing care and reporting any discrepancies to the licensed nurse promptly. The in-service education also emphasized on the importance of ensuring the resident environment remains as free of accident hazards as is possible; and also emphasized on importance of providing adequate supervision and assistance for each residents in order to prevent accidents. This education will be completed by [DATE], any nursing assistant not educated by [DATE] will not be allowed to work until educated on this requirement. Effective [DATE] this education will be added on new hires orientation education for all new facility nursing assistants. This education will also be provided annually for all facility nursing assistants. The facility plans to monitor its performance to make sure that solutions are sustained. Effective [DATE] the Director of Nursing, Assistant Director or Nursing, RN supervisors will review all new admits from prior day to ensure the fall risk assessment is complete, accurate, and ensure risk factors are identified and verify the appropriate interventions are added on each resident's plan of care and resident's care gu

Based on record review and staff interviews the facility failed to maintain an accurate Minimum Data Set (MDS) for a cognitively impaired wandering resident who had known exit-seeking behaviors for 1 of 2 sampled residents (Resident #147). Findings included: The immediate jeopardy began on 04/19/16 when Resident #147 eloped from the facility without staff knowledge. Immediate jeopardy was identified on 06/24/16 at 3:20 PM. Immediate jeopardy is present and ongoing. Findings included: Review of the Elopement/Wandering Risk Review dated 04/02/16 revealed Resident #147 had cognitive impairment with poor decision making. Resident #147 wandered aimlessly and ambulated independently. Resident #147's family had expressed concerns that indicated that Resident #147 had wandering tendencies or may try to leave the facility. Resident #147 was deemed to be at risk for wandering as evidenced by poor safety awareness, decreased memory retention, and verbalizations of desire to leave without supervision. Interventions to prevent elopement included frequent monitoring, medication review, wanderguard bracelet placement to the left lower extremity, and to make sure staff were aware of Resident #147's wandering risk. Review of the Physicians Telephone orders dated 04/02/16 showed an order for [REDACTED]. Review of the Elopement/Wandering Risk Review dated 04/05/16 revealed Resident #147 was cognitively impaired with poor decision making skills and wandered aimlessly while ambulating independently in the facility. Resident #147 had a history of [REDACTED]. Resident #147 had expressed the desire to go home and was not accepting of the situation. Resident #147 received medications that increased restlessness and/or agitation. Resident #147 expressed the desire to go home. Resident #147 was deemed to be at risk for elopement/wandering as evidenced by frequent wandering in the afternoons. No interventions were noted. Review of Resident #147's Annual Minimum Data Set ((MDS) dated [DATE] showed Resident #147 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #147 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The assessment showed resident #147 did not wander. Review of the 7:18 PM Nursing Departmental Notes dated 04/19/16 revealed Resident #147 was found out the front door across the parking lot in the grass with her walker, starting to climb the hill. The alarm was going off. Another resident's family called (on the telephone) and alerted the staff that Resident #147 was outside. The wanderguard bracelet was in place on the right ankle. Resident #147 stated the door opened and she walked through and she didn't do anything wrong. Resident #147 had been noticed 10 minutes before walking in the hall between the end door and the dining area. In an interview on 06/24/16 at 6:15 PM the Director of Nursing (DON) stated it was her expectation that the MDS nurses would update resident information during the assessment period. She indicated she expected assessments to be done accurately. In an interview on 06/24/16 at 7:40 PM the Administrator indicated she expected information to be disseminated appropriately, carried out correctly and documented. The Administrator was notified of the immediate jeopardy at 10:40 AM on 06/29/16.

Based on record review and staff interviews the facility failed to update an inaccurate care plan for a cognitively impaired wandering resident who had known exit-seeking behaviors for 1 of 2 sampled residents (Resident #147). Findings included: The immediate jeopardy began on 04/19/16 when Resident #147 eloped from the facility without staff knowledge. Immediate jeopardy was identified on 06/24/16 at 3:20 PM. Immediate jeopardy is present and ongoing. Findings included: Review of the Physician's Telephone orders dated 04/02/16 showed an order for [REDACTED]. Review of Resident #147's Annual Minimum Data Set ((MDS) dated [DATE] showed Resident #147 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #147 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The assessment showed resident #147 did not wander. Review of Resident #147's Care Plan (CP) with a problem onset date of 04/15/16 showed Resident #147 had a wanderguard bracelet due to exit seeking behaviors at times. The goal was to have no attempts to exit the building through the next review. Interventions included: Wanderguard bracelet in place, staff to monitor the function of the wanderguard bracelet and to change the batteries as needed, place resident in the elopement risk book, and educate staff on the risk for elopement. Review of the 7:18 PM Nursing Departmental Notes dated 04/19/16 revealed Resident #147 was found out the front door across the parking lot in the grass with her walker, starting to climb the hill. The alarm was going off. Another resident's family called (on the telephone) and alerted the staff that Resident #147 was outside. The wanderguard bracelet was in place on the right ankle. Resident #147 stated the door opened and she walked through and she didn't do anything wrong. Resident #147 had been noticed 10 minutes before walking in the hall between the end door and the dining area. In an interview on 06/23/16 at 7:19 PM the Environmental Services Manager stated when the wanderguard bracelets came within one month of the expiration date the bracelet was sent back to the manufacturer for replacement. He indicated battery changes were not performed by the facility. In a follow-up interview on 06/24/16 at 6:15 PM the DON stated the MDS/CP nurses should update a CP. The DON verified it was not the process in the facility to change batteries in the wanderguard bracelets. The bracelets were sent back to the manufacturer for battery changes. She indicated she expected a CP to be individualized and felt the intervention regarding the staff changing the batteries was a canned statement that had just not been removed. The Administrator was notified of the immediate jeopardy at 3:30 PM on 6/24/16.

Based on observation, record review and staff interviews the facility failed to follow the Care Plan for a cognitively impaired wandering resident who had known exit-seeking behaviors for 1 of 2 sampled residents (Resident #147). Findings included: The immediate jeopardy began on 04/19/16 when Resident #147 eloped from the facility without staff knowledge. Immediate jeopardy was identified on 06/24/16 at 3:20 PM. Immediate jeopardy is present and ongoing. Findings included: Review of the Physician's Telephone Orders dated 04/02/16 showed an order for [REDACTED]. Review of Resident #147's Treatment Administration Record (TAR) and for 04/02/16-04/22/16 revealed placement was being checked every shift. There was no documentation that the wanderguard bracelet's expiration date was being checked. Review of Resident #147's Annual Minimum Data Set ((MDS) dated [DATE] showed [DIAGNOSES REDACTED]. Resident #147 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The assessment showed resident #147 did not wander. Review of Resident #147's Care Plan (CP) with a problem onset date of 04/15/16 showed Resident #147 had a wanderguard bracelet due to exit seeking behaviors at times. The goal was to have no attempts to exit the building through the next review. Interventions included: Wanderguard bracelet in place, staff to monitor the function of the wanderguard bracelet and to change the batteries as needed, place resident in the elopement risk book, and educate staff on the risk for elopement. Review of the 04/20/16 Action Plan, designed in response to Resident #147's 04/19/16 elopement, revealed documentation that the transmitter in the resident's wanderguard bracelet had an expiration date of February 2016. In a telephone interview on 06/24/16 at 12:18 PM the wanderguard bracelet manufacturer stated that although the batteries should be good for 12-15 months, they should be returned by the eleventh month for refurbishment. He indicated a tester was available for the facility so they could monitor the functionality of the bracelets. Review of the 7:18 PM Nursing Departmental Notes dated 04/19/16 revealed Resident #147 was found out the front door across the parking lot in the grass with her walker, starting to climb the hill. The alarm was going off. Another resident's family called (on the telephone) and alerted the staff that Resident #147 was outside. The wanderguard bracelet was in place on the right ankle. Resident #147 stated the door opened and she walked through and she didn't do anything wrong. Resident #147 had been noticed 10 minutes before walking in the hall between the end door and the dining area. In an observation on 06/23/16 at 7:12 PM the Environmental Services Manager (ESM), who was not employed by the facility during April was able to show that the expiration date was inscribed on the wanderguard bracelet. The date was very difficult to visualize. In an interview on 06/23/16 at 7:15 PM Nurse #4 stated nurses checked the placement of the wanderguard bracelet every shift. She indicated they only checked that the bracelet was on the resident. They did not check for the expiration date or if the battery was working. In an interview on 06/23/16 at 7:19 PM the ESM stated when the wanderguard bracelets came within one month of the expiration date the bracelet was sent back to the manufacturer for replacement. He indicated battery changes were not performed by the facility. In an interview on 06/24/16 at 6:15 PM the DON stated she expected the nurses to follow the CP. In an interview on 06/24/16 at 7:40 PM the new Administrator stated any information regarding the residents should be carried out correctly and documented. The Administrator was notified of the immediate jeopardy at 3:30 PM on 06/24/16.

Based on observation, record review, service representative and manufacturer interviews, and staff interviews the facility failed to supervise a cognitively impaired wandering resident who had known exit-seeking behaviors. The facility also failed to monitor the expiration date of the wanderguard bracelet which had expired in February 2016 for 1 of 2 sampled residents (Resident #147). Findings included: The immediate jeopardy began on [DATE] when Resident #147 eloped from the facility without staff knowledge. Immediate jeopardy was identified on [DATE] at 3:20 PM. Immediate jeopardy is present and ongoing. Findings included: Review of the Elopement/Wandering Risk Review dated [DATE] revealed Resident #147 had cognitive impairment with poor decision making. Resident #147 wandered aimlessly and ambulated independently. Resident #147's family had expressed concerns that indicated that Resident #147 had wandering tendencies or may try to leave the facility. Resident #147 was deemed to be at risk for wandering as evidenced by poor safety awareness, decreased memory retention, and verbalizations of desire to leave without supervision. Interventions to prevent elopement included frequent monitoring, medication review, wanderguard bracelet placement to the left lower extremity, and to make sure staff were aware of Resident #147's wandering risk. Review of the Physician's Telephone Orders dated [DATE] showed an order for [REDACTED].#147 for the prevention of elopement. The wanderguard's function was to be checked every shift. Review of Resident #147's Treatment Administration Record (TAR) dated [DATE]- [DATE] revealed the times the wanderguard (bracelet) should be checked were 8:00 AM and 8:00 PM. For the 8:00 AM checks there was one box that was not initialed by the nurse. (Initials in the box signified the order was done.) For the 8:00 PM shift there were 10 boxes with missing initials. Review of the Daily Wanderguard Checklist (utilized by the former maintenance manager to document functionality of resident and front door wanderguard alarms) revealed documentation was missing for [DATE] through [DATE]. Review of the Elopement/Wandering Risk Review dated [DATE] revealed Resident #147 was cognitively impaired with poor decision making skills and wandered aimlessly while ambulating independently in the facility. Resident #147 had a history of [REDACTED]. Resident #147 had expressed the desire to go home and was not accepting of the situation. Resident #147 received medications that increased restlessness and/or agitation. Resident #147 expressed the desire to go home. Resident #147 was deemed to be at risk for elopement/wandering as evidenced by frequent wandering in the afternoons. No interventions were noted. Review of Resident #147's Annual Minimum Data Set ((MDS) dated [DATE] showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #147 had short and long term memory problems, and was severely impaired in cognitive skills for daily decision making. The assessment showed resident #147 did not wander. Review of the 12:49 PM Nursing Departmental Notes dated [DATE] revealed an interdisciplinary team (IDT) meeting was held, and it was decided to keep Resident #147's wanderguard bracelet in place. Review of the 5:49 PM Nursing Departmental Notes dated [DATE] revealed Resident #147 was wandering and looking for food and money. Review of the 8:02 PM Nursing Departmental Notes dated [DATE] showed Resident #147 met up with another resident earlier in the day, and began exit seeking with her. Review of Resident #147's Care Plan with a problem onset date of [DATE] showed Resident #147 had a wanderguard bracelet due to exit seeking behaviors at times. The goal was to have no attempts to exit the building through the next review. Interventions included: Wanderguard bracelet in place, staff to monitor the function of the wanderguard bracelet and to change the batteries as needed, place resident in the elopement risk book, and educate staff on the risk for elopement. In a telephone interview on [DATE] at 11:30 AM the service representative for the wanderguard alarm system stated on [DATE] the facility asked him to evaluate and assess the system because it was taking the front doors longer to lock and alarm when wanderguard residents approached and touched them. The service representative reported he found nothing wrong with the actual system or the front doors, but shared with the former administrator and former maintenance manager that the resident being used to check the system had a weak transmitter/battery in the wanderguard bracelet. Review of the 4:45 PM Nursing Departmental Notes dated [DATE] revealed Resident #147 was restless and looking for a way to go home. Review of the 7:18 PM Nursing Departmental Notes dated [DATE] revealed Resident #147 was found out the front door across the parking lot in the grass with her walker, starting to climb the hill. The alarm was going off. Another resident's family called (on the telephone) and alerted the staff that Resident #147 was outside. The wanderguard bracelet was in place on the right ankle. Resident #147 stated the door opened, she walked through, and she didn ' t do anything wrong. Resident #147 had been noticed 10 minutes before walking in the hall between the end door and the dining area. In an interview on [DATE] at 3:37 PM Nurse #1 who was Resident #147's nurse on [DATE] stated the resident had a wanderguard bracelet in place. She reported the transmitter in the bracelet was supposed to make the door lock so a resident could not exit. She commented if a resident did get out the door the alarm would sound. She indicated the front lobby doors did not lock, and Resident #147 was able to exit the building. Nurse #1 stated the nursing station doors were required to be kept closed and the alarms could not be heard inside the station. She indicated she had seen Resident #147 in the hall looking out the door by her room 10 minutes prior to finding out the resident was outside, and did not know she had left the unit. In a telephone interview on [DATE] at 5:19 PM Nursing Assistant (NA) #1 who assisted with bringing Resident #147 back inside after the elopement on [DATE], stated when she went to assist other staff with Resident #147 the alarm was not sounding. She indicated that normally she could hear the alarm because it was very loud. She indicated even if she were in a room with a closed door she would have been able to hear the alarm. She indicated she was not aware the resident was not on the unit. In a telephone interview on [DATE] at 5:23 PM NA #2 stated she was passing dinner trays on the hall on [DATE] when the telephone rang at the nursing station. She answered the telephone, and was told there was a resident outside the building. She reported she dropped the phone, and ran down the hall and out the door next to the Director of Nursing ' s (DON) office. NA #2 stated she was the first staff member outside. She indicated she did not remember an alarm sounding, but was focused on getting to the resident so she was not sure. She stated the lobby doors were supposed to lock so no one could open them, and if they were locked, it would have been impossible for Resident #147 to open them. In an interview on [DATE] at 6:00 PM the DON stated it was her expectation that residents did not get out of the building. She indicated the front doors should have locked, and if the front doors were touched the alarm should have sounded. She stated wanderguard bracelets had been checked and Resident #147's had been found to be weak. She stated a new wanderguard bracelet had been placed on Resident #147 after the elopement. In an observation on [DATE] at 2:30 PM the path out the front lobby doors was hard top to a six inch curb. On the other side of the curb was a hilly, grassy area. A busy road was on the other side of the grassy area. Resident 147's Care Plan was updated on [DATE], and documented Resident #147 had been found outside the building in the parking lot. The goal was to have no further attempts to exit the building through the next review. Added interventions included: 1:1 observation for 24 hours, wanderguard bracelet expiration date checks every shift, and to seek placement in a secure unit due to the resident ' s continuous exit-seeking behaviors. Review of the Action Plan dated [DATE] revealed all residents with wanderguard bracelets had their bracelets exposed to the front door, and none set off the locks on the doors. For the remainder of the night, the residents were kept in line of vision until they went to bed. They were checked frequently throughout the night. At 8:30 AM the next day the front desk was constantly manned to prevent any resident with a bracelet from walking through the door. The plan documented the wanderguard installer was contacted on [DATE] ([DATE]) to test and repair the system. The work was completed by 5:00 PM. The bracelet on resident #147 was noted to have an expiration date of February 2016. To prevent the incident from happening in the future the facility continued to check the wanderguard doors and bracelets daily for functionality. The expiration date was to be checked daily. The wanderguard testing documentation would be submitted to the Director of Nursing weekly for review. The DON was to monitor resident elopements and report to the Quality Assurance Committee monthly. The previous Administrator created the Action Plan and listed the date of repair of the system as [DATE] ([DATE]). (In interviews with current staff and the wanderguard alarm system service representative no one was aware of any problems/repairs of the actual front door alarm system). The DON revealed on [DATE] at 6:15 PM she had never seen the Action Plan and the QA book was missing. Review of the undated In-service for (Resident #147) which was also part of the action plan showed all wanderguard bracelets would be checked for placement daily by the nurse. The expiration dates would be placed on the wanderguard bracelets and the Medication Administration Record (MAR). Residents who appeared to be wander seeking needed to be reported to the nurses immediately. If a wanderguard bracelet was placed on a resident there needed to be an order, the MDS nurses should be made aware so it could be care planned and the wanderguard bracelet list should be updated. The wanderguard alarm was now wired at the nurse ' s station to alarm anytime a resident was near or trying to exit the front door. Response to the alarm was to be immediate if heard. In an interview on [DATE] at 7:00 PM the DON provided a list of current residents who wore wanderguard bracelets. There were two residents on the list. Review of the April, May and June TAR's for these residents revealed that one of the two did not have the expiration date of the wanderguard bracelet documented. Review of the Physician's Telephone Orders dated [DATE] revealed a new order to change the placement of Resident #147 ' s wanderguard bracelet to the right wrist. Review of the Nursing Departmental Notes dated [DATE] showed Resident #147 was discharged to a memory care unit in a nearby town. In an interview and observation on [DATE] at 4:20 PM the Environmental Services Manager (ESM) stated the front door was the only door on the wanderguard alarm system. The other doors leading outside were kept locked except for the courtyard doors which allowed residents to sit outside safely in an enclosed area. He reported he used a tester to check and make sure the wanderguard bracelets used by the residents were functioning. He stated he used a spare transmitter to test the functioning of the wanderguard alarm system at the front doors. He stated when a resident with a wanderguard bracelet got down the hallway to the foyer doors leading to the lobby the front doors would lock automatically. The EMS manager stated it would take a lot of continuous pressure on the push bars to open the front doors once locked. He indicated the alarm would sound when the front doors were opened and the threshold was crossed by a resident wearing a wanderguard. The ESM commented there was an alarm box in each nursing station, and the front door alarm sounded in each station. He indicated he did weekly rounds to check the wanderguard alarm in the lobby. The ESM provided a tour of the nursing stations to describe the alarm system. Station 1's alarm box was mounted high on the wall and 6 bulbs were seen. Each bulb was labeled unit 1 through unit 6. There was a sign posted below the alarm that indicated which light corresponded to which door. For example, unit 1= 100 hall door. Station 2 had the same alarm box labeled unit 1 through unit 6 and also had a sign posted below it. However, these alarms were for 6 different doors. For example, unit 1= front lobby. Station 3 had the same alarm system but no sign was noted telling which light corresponded with which door. A test was conducted by the ESM and it was discovered that the lobby door alarm did not ring in all the nursing stations. It only rang in Station 2. In an observation on [DATE] at 6:10 PM the DON escorted a resident wearing a wanderguard bracelet to the foyer doors and opened them. The front doors locked automatically. In an observation on [DATE] at 6:24 PM the front door alarm system was activated by the ESM. At 6:29 PM two nurses entered the lobby to check the alarm. Nurse #1 indicated Station 1 had received a telephone call from Station 2 that the unit 1 alarm was sounding. The nurses immediately came down to check the alarm because they knew that unit 1 in station 2 was the lobby alarm. In an interview on [DATE] at 6:32 PM Nurse #2 stated she was in a room and heard an alarm sounding but did not know where it was coming from (during the test that day). She looked at the alarm box and saw the unit 1 light was on so she called unit 1 (station 1) to let them know about the alarm. She stated she did not know unit 1 meant the front doors. In an interview on [DATE] at 6:35 PM Nursing Supervisor #1 stated it had been reported to her that Resident # 147 had eloped from the building. She indicated she was told all the residents who had wanderguard bracelets were checked for placement and functionality but she had not done this herself. The Nursing Supervisor commented that the front doors should lock down when activated by wanderguard transmitters and the alarm should sound if the door does got opened. She stated this might not happen if the wanderguard bracelet was expired or was weak. She indicated the alarm sounded when a resident was trying to get out of the building. When informed a test of the wanderguard alarm system had been performed by the ESM on [DATE] at 6:24 PM, and that it took staff five minutes to answer the wanderguard alarm, she expressed surprise and stated that was too long. She stated a lot could happen to a resident in five minutes including injury, death, or kidnapping. She stated there had been no further elopements from the lobby. In an interview on [DATE] at 8:15 PM Nurse #3 stated she did not hear the alarm sound during the test that day. She indicated she did not know if the lobby door alarm sounded in all three nursing stations. She indicated when an alarm sounded she looked at the alarm box to see where it was activated. Nurse #3 stated if the light for unit 1 was lit (front lobby alarm) that meant it was on station 1. In an interview on [DATE] at 8:18 PM NA #1 confirmed she had heard the alarm sounding earlier. She thought it was a room alarm and looked on her assignment to see which resident needed assistance. She did not see any room lights on, and did not do anything else about the alarm. In a follow-up interview on [DATE] at 11:01 AM the DON stated the activation distance for the wanderguard alarm was problematic. She indicated if a resident had the wanderguard bracelet on their leg they could get closer to the door before the locks engaged. If the wanderguard bracelet was on the arm the door locks would activate sooner. The DON stated when the lobby doors opened the alarm only sounded in Station 2, and there were no plans to make the alarm sound in all three nursing stations. The DON stated she expected the nurses to respond to alarms in a timely manner. She indicated the nurses in Station 2 should have known what the alarm was for and responded to it. In a follow-up interview on [DATE] at 7:19 PM the ESM stated when a wanderguard bracelet came close to the expiration date it was sent back to the manufacturer for replacement or refurbishment. He indicated the staff did not change the batteries on the wanderguard bracelets. In a telephone interview on [DATE] at 12:18 AM the wanderguard bracelet manufacturer stated that although the batteries should be good for ,[DATE] months, they should be returned by the eleventh month for refurbishment. He indicated a tester was available for the facility so they could monitor the functionality of the bracelets. The Administrator was notified of the immediate jeopardy at 3:30 PM on [DATE].

Based on record review and staff interviews the facility failed to develop and sustain an effective action plan following the elopement of a cognitively impaired wandering resident who had known exit-seeking behaviors for 1 of 2 sampled residents (Resident #147). Findings included: The immediate jeopardy began on 04/19/16 when Resident #147 eloped from the facility without staff knowledge. Immediate jeopardy was identified on 06/24/16 at 3:20 PM. Immediate jeopardy is present and ongoing. Findings included: Review of the 2016 Staff In-service Attendance Record provided by the Administrator and Maintenance Manager revealed an elopement in-service had been provided to 140 out of 201 listed staff members between 04/05/16 and 04/10/16. An undated Power Point In-service that had been used for the In-service was provided by the facility and reviewed. Titled: Elopement Code Green, it revealed staff were to be aware of where the residents were in the facility, that staff should know the difference in wandering and exit-seeking, and were to immediately report if an individual was exit-seeking. Routine door checks were to be done and any door that did not close was to be reported immediately. Review of the 7:18 PM Nursing Departmental Notes dated 04/19/16 revealed Resident #147 was found out the front door across the parking lot in the grass with her walker, starting to climb the hill. The alarm was going off. Another resident's family called (on the telephone) and alerted the staff that Resident #147 was outside. The wanderguard bracelet was in place on the right ankle. Resident #147 stated the door opened and she walked through and she didn't do anything wrong. Resident #147 had been noticed 10 minutes before walking in the hall between the end door and the dining area. Further review of the 2016 Staff In-service Attendance Record provided by the Administrator and the Maintenance Manager revealed on 04/22/16 an In-service had been held specifically regarding Resident #147 and was attended by 57 of the 201 listed staff members. The In-Service was provided by the facility and was reviewed. The In-service revealed all wanderguard bracelets would be checked for placement daily by the nurse. The expiration dates would be placed on the wanderguard bracelets and the Medication Administration Record [REDACTED]. If a wanderguard bracelet was placed on a resident there needed to be an order, the MDS nurses should be made aware so it could be care planned and the wanderguard bracelet list should be updated. The wanderguard alarm was now wired at the nurse's station to alarm anytime a resident was near or trying to exit the front door. Response to the alarm was to be immediate if heard. Review of Resident #147's Treatment Administration Record (TAR) dated 04/02/16- 4/21/16 revealed there was no expiration date for the wanderguard bracelet listed. Review of current Resident #124's TAR for April, May and June 2016 showed an order for [REDACTED]. Review of the Action Plan dated 04/20/16 revealed all residents with wanderguard bracelets had their bracelets exposed to the front door, and none set off the locks on the doors. For the remainder of the night, the residents were kept in line of vision until they went to bed. They were checked frequently throughout the night. At 8:30 AM the next day the front desk was constantly manned to prevent any resident with a bracelet from walking through the door. The wanderguard installer was contacted on 02/20/16 to test and repair the system. The work was completed by 5:00 PM. The bracelet on resident #147 was noted to have an expiration date of 02/16. To prevent the incident from happening in the future the facility would continue to check the wanderguard doors and bracelets daily for functionality. The plan did not specify who would do the monitoring but did specify that the manufacturers' testing device would be used. The expiration date was to be checked daily and changed as the date arrived. The wanderguard testing documentation would be submitted to the Director of Nursing weekly for review. The DON was to monitor resident elopements and report to the Quality Assurance Committee monthly. The previous Administrator created the Action Plan and listed the date of repair of the system as 02/20/16. The DON revealed on 06/24/16 at 6:15 PM she had never seen the Action Plan and the QA book was missing. In an interview on 06/23/16 at 3:37 Nurse #1 stated if she was in the nursing station with the doors closed as required by the facility, she was unable to hear the lobby door alarm sounding. In an observation on 06/23/16 at 6:24 PM the lobby door alarm system was activated by the Environmental Services Manager (ESM). At 6:29 PM two nurses entered the lobby to check the alarm. Nurse #1 indicated they had received a telephone call from Station 2 that the unit 1 alarm was sounding. They had immediately come down to check the alarm because they knew that unit 1 in station 2 was the lobby alarm. In an interview on 06/23/16 at 6:32 PM Nurse #2 stated she was in a room and heard an alarm sounding but did not know where it was coming from (during the test that day). She looked at the alarm box and saw the unit 1 light was on so she called unit 1 (station 1) to let them know about the alarm. She stated she did not know unit 1 meant the front lobby doors. In an interview on 06/23/16 at 8:15 PM Nurse #3 stated she did not hear the alarm sound during the test that day. She indicated she did not know if the lobby door alarm sounded in all three nursing stations. She indicated when an alarm sounded she looked at the alarm box to see where it was activated. Nurse #3 stated if the light for unit 1 was lit (front lobby alarm) that meant it was on station 1. In an interview on 06/23/16 at 8:18 PM NA #1 confirmed she had heard the alarm sounding earlier. She thought it was a room alarm and looked on her assignment to see which resident needed assistance. She did not see any room lights on and did not do anything else about the alarm. In an interview on 06/24/16 at 11:01 AM the DON stated when the lobby doors opened the alarm only sounded in Station 2 and there were no plans to make the alarm sound in all three nursing stations. The DON stated she expected the nurses to respond to alarms in a timely manner. She indicated the nurses in Station 2 should have known what the alarm was for and responded to it. In a follow-up interview on 06/24/15 at 6:15 PM the DON stated she expected the Quality Assurance (QA) recommendations to be followed. She indicated that if they were not aware of the recommendations they could not do them. The DON stated the previous Administrator did not let anyone know about the QA information. She indicated the facility had been unable to locate a large amount of records recently. In an interview on 06/24/16 at 7:02 PM the Minimum Data Set/Care Plan nurse indicated the 2016 Staff In-service Attendance Record had been used by the previous Administrator. She indicated the elopement In-services had been mandatory for all staff but the In-Service signature pages were missing. She indicated the previous Administrator shared some information at the time of In-services but not very much. In an interview on 06/24/16 at 7:40 PM the Administrator stated she expected any QA information to be disseminated properly, carried out correctly, and documented. She indicated she felt the QA action plan had not been successful because it lacked follow thru and follow-up. She stated there needed to be repercussions if things were not done. She acknowledged some things had not been done as they should have been. The Administrator was notified of the immediate jeopardy at 3:30 PM on 06/24/16.