Every finding on record at Graham Healthcare and Rehabilitation Center

Based on record review and staff, Visitor, Police Sergeant, and Nurse Practitioner interviews, the facility failed to protect a cognitively impaired resident's right to be free from staff to resident physical and verbal abuse when Agency Nurse #1 yelled at Resident #1 loudly in a common area of the facility utilizing language that was vulgar and demeaning in a volume that was loud enough for a visitor in a nearby room to hear. Agency Nurse #1 also pushed Resident #1 down into her wheelchair when she attempted to stand up, shook the wheelchair violently, propelled the resident down the hall in her wheelchair in an aggressive manner, and hit Resident #1 in the back with a closed fist multiple times. Resident #1 was crying following the incident and stated to staff that she was afraid. Agency Nurse #1 was charged with assault on a handicapped person. The language utilized by Agency Nurse #1 would have humiliated a reasonable person. This deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, right eye glaucoma (eye condition that damages the optic nerve and can cause vision loss or blindness) secondary to other eye disorders, right eye age-related cataract Morgagnian (advanced and severe type of a cataract that typically results in vision loss such as only being able to see hand movements or light), and left eye cortical age-related cataract (clouding of the eye's natural lens that typically causes increased glare, halos and blurred vision). The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severe cognitive impairment. Resident #1 required substantial/maximum assistance with sit-to-stand, chair/bed-to-chair transfers and was independent with wheelchair mobility. Resident #1 received anticoagulant medication and displayed no physical, verbal or other behaviors during the MDS assessment look-back period.Review of the facility's initial allegation report (24-hour report) completed by the Administrator revealed on [DATE] at 6:00 AM the facility became aware of an incident of staff-to-resident abuse involving Agency Nurse #1 and Resident #1 that occurred on [DATE]. Resident #1 had no injuries or signs of mental distress.A Nurse Practitioner (NP) progress note dated [DATE] revealed the NP was asked to come to the facility to evaluate Resident #1 urgently due to an incident of abuse. The NP noted the facility was informed by a witness that Agency Nurse #1 had struck Resident #1 in the back of the head the previous night ([DATE]), law enforcement was notified, and the abuser had been incarcerated per staff reports. The NP's exam revealed Resident #1 had normal range of motion to all extremities, no edema (swelling) or bony abnormalities, and no complaints of pain during palpation (use of hands or fingers to feel the surface of the body) to any bone, joint or muscle. Resident #1 had ecchymosis (bruising) to the lateral right fifth digit (pinky finger), right lateral wrist, right forearm, and right elbow. In addition, Resident #1 had a small one centimeter scratch to the left neck. Resident #1 complained of no pain during the exam but did report feeling swimmy headed. The NP noted that prior to the incident on [DATE], Resident #1 had a fall the evening of [DATE] and complained of right wrist pain. The on-call provider was notified and ordered a 2-view right wrist x-ray which resulted on [DATE] at 8:35 PM. The x-ray results showed demineralization and degenerative changes and suspicion of fracture with recommendations to consider a more complete assessment with Computed Tomography (CT, medical imaging test that combines a series of x-rays taken from different angles to create detailed images of internal structures, including bones, that standard x-rays cannot show) and Magnetic Resonance Imaging (MRI, medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in the body). Under Assessment and Plan, the NP noted a diagnosis of Victim of Elder Abuse with no apparent injuries; however, given Resident #1 reported feeling swimmy headed and received Pradaxa (anticoagulant), the decision was made to send Resident #1 to the Emergency Department (ED) for an evaluation. ED records dated [DATE] revealed Resident #1 was evaluated following a fall the day prior and x-rays obtained at the facility showed a possible fracture to the right wrist. The ED noted x-rays and imaging obtained at the hospital revealed no acute findings. Resident #1 was discharged back to the facility in stable condition on [DATE]. A police report dated [DATE] revealed the Police Sergeant arrived to the facility in reference to a report of abuse that occurred on [DATE] at 7:05 PM. The police report indicated Agency Nurse #2 was interviewed and reported that near shift change Resident #1 approached and entered the nurses' station to request water. Resident #1 suffers from dementia, she is also blind and in a wheelchair. Resident #1 was removed from the nurses' station by Agency Nurse Aide (NA) #1 and told to wait in the hallway for the water. Resident #1 entered the nurses station again. Agency Nurse #1 was at the end of her shift and made angry comments to and about Resident #1 as she violently removed Resident #1 and the wheelchair from the nurses' station. While removing Resident #1, Agency Nurse #1 exclaimed that she is sick of this b***h's s**t and pulled Resident #1 out of the nurses' station in an aggressive manner, shaking her wheelchair violently, while cursing at Resident #1. Agency Nurse #2 separated the two (Agency Nurse #1 and Resident #1) and finished the nurse report with Agency Nurse #1 while Agency NA #1 took Resident #1 to the courtyard. Agency Nurse #1 completed the nurse report then left to go home. Agency NA #1 was interviewed and reported she saw Resident #1 trying to get a cup of water from the medication cart and Agency Nurse #1 began to yell mean things at [Resident #1], so she wheeled Resident #1 back into the hallway and gave her some water. Agency NA #1 then went to a room to assist other residents, heard yelling and cursing and returned to see Agency Nurse #1 pushing Resident #1 in an aggressive manner in the wheelchair and yelling go to hell you ugly b***h. Agency NA #1 then saw Agency Nurse #1 hit [Resident #1] on the back. The only other witness to the incident was a visitor who reported she did not see the incident but she heard a loud commotion while she was at the facility visiting a family member. The visitor reported she heard Resident #1 arguing with someone and that person was being very ugly to [Resident #1] with the language that she was using.Continued review of the police report (dated [DATE]) revealed Agency Nurse #1 was interviewed by the Police Sergeant at her place of residence. Agency Nurse #1 reported Resident #1 had been involved in a fight with another resident because Resident #1 couldn't see and she goes along the side of the hallway and kicks at any one that gets in her way. Agency Nurse #1 did put Resident #1 back into her wheelchair when she tried to stand up because she did not want Resident #1 to fall. A follow-up call was made to the facility to validate Agency Nurse #1's claim of breaking up a fight and it was reported by the facility that there was no fight. The Police Sergeant noted that based on the statements from Agency Nurse #1, Agency NA #1, and the Visitor, there was sufficient evidence to charge Agency Nurse #1 with assault on a handicapped person, she was advised of her [NAME] Rights and transported to the County Detention Center. Agency Nurse #1 was no longer employed at the facility. A phone interview was attempted with Agency Nurse #1 on [DATE] at 11:55 AM. Agency Nurse #1 refused to discuss the incident involving Resident #1 and abruptly disconnected the phone call.An undated witness statement from Agency Nurse #2 revealed, on [DATE] at 7:05 PM during shift change, Agency Nurse #1 was giving report to Agency Nurse #2 when Resident #1 came behind the nurses' station in her wheelchair asking for water. Agency NA #1 removed Resident #1 from behind the nurses' station and told Resident #1 to wait in the hallway while she got her some water. While waiting for Agency NA #1 to bring her some water, Resident #1 went back behind the nurses' station again asking for water. Agency Nurse #1 walked toward Resident #1 stating, I'm so tired of this b***h's s**t and pulled Resident #1 in her wheelchair out from behind the nurses' station into the hallway in a backwards motion with Agency Nurse #2 following them. Agency Nurse #1 continued to curse at Resident #1 while pulling her wheelchair backwards aggressively in a zig-zag pattern from the right to left causing Resident #1 to almost fall out of the wheelchair. Resident #1 yelled at Agency Nurse #1 to stop and tried to stand up from the wheelchair. Agency Nurse #1 placed her right hand around the right side of Resident #1's throat, pushed Resident #1 back down in the wheelchair and told Resident #1 don't f---in fall out. Agency Nurse #1 then started punching Resident #1 in the back with her left hand in a closed fist while Resident #1 was leaning forward in the wheelchair scratching at Agency Nurse #1's forearms and yelling for Agency Nurse #1 to let her go. Agency Nurse #1 then told Resident #1 go to hell you f***in b***h and started walking back toward the nurses' station telling Agency Nurse #2 that she wanted to give report so that she (Agency Nurse #1) could leave. Agency Nurse #2 went to assess Resident #1 but Resident #1 cursed at Agency Nurse #2 and told her to leave her alone. Agency Nurse #2 asked Agency NA #1 to take Resident #1 outside and stay with her. Agency Nurse #1 was angry in her demeanor while trying to give Agency Nurse #2 report, stated she (Agency Nurse #1) was sick of this place and her ass too. Agency Nurse #2 told Agency Nurse #1 to just leave and go home because she (Agency Nurse #2) did not want her around anyone else. Agency Nurse #1 grabbed her belongings and exited the facility. Agency Nurse #2 looked out the door into the courtyard and Agency NA #1 was sitting with Resident #1. Approximately, two hours later, Agency NA #1 brought Resident #1 back into the facility and told Agency Nurse #2 that Resident #1 had been crying while out in the courtyard and was scared to return back inside the facility. When Resident #1 came back into the facility, she was no longer crying and Agency NA #1 assisted Resident #1 to bed for assessment. Upon assessment, Agency Nurse #2 noted Resident #1 had a scratch on the right side of her neck approximately 1 to 2 centimeters in length, two bruises near the inside bend of the right forearm each approximately the size of a quarter, four smaller areas that were scattered down the forearm toward the hand and bruising around both the right pinky and middle fingers. Resident #1 complained of pain all over but refused pain medication and slept throughout the remainder of the shift. Agency Nurse #2 notified the Director of Nursing (DON) of the incident on [DATE] at approximately 6:00 AM. Agency Nurse #2 was no longer employed at the facility. Telephone attempts made on [DATE] at 11:25 AM, [DATE] at 8:52 AM, and [DATE] at 10:21 AM for an interview with Agency Nurse #2 were unsuccessful.A witness statement from Agency NA #1 dated [DATE] revealed that she went to the nurses' station after arriving to work on [DATE] at approximately 7:03 PM. Resident #1 was behind the nurses' station at the medication cart, trying to stand up from the wheelchair and get some water. Agency NA #1 assisted Resident #1 with getting water from the medication cart. Agency Nurse #1 was giving report to Agency Nurse #2 at the time and Agency Nurse #1 yelled at Resident #1 stating, I am not dealing with this s**t, I've dealt with this all day. Sit your g**damn ass down. I hate dealing with her. Resident #1 told Agency Nurse #1 that she just wanted some water and stated, I know, I know, I am sitting down. Agency NA #1 assisted Resident #1 out into the hallway and Resident #1 calmed down. Agency NA #1 then went down the hall and into another resident's room to provide care. Approximately 2 to 4 minutes later, Agency NA #1 heard Agency Nurse #1 yelling, screaming and cussing. Agency NA #1 heard Agency Nurse #1 state get off me, go to hell you ugly old b***h as she was coming out into the hall to see what was going on. As she walked up the hall, Resident #1 was seated in her wheelchair with her back toward Agency NA #1 and Agency Nurse #1 was standing on the left side of Resident #1's wheelchair. Agency Nurse #1 was shaking Resident #1's wheelchair trying to get Resident #1 turned around and used both her hands to grab Resident #1's shirt. Agency Nurse #1 then held Resident #1's left hand with her left hand while hitting Resident #1 on the right side of her back with a closed fist at least three times very fast and heard Resident #1 tell Agency Nurse #1 you are ringing my neck. Agency NA #1 ran to Resident #1 and heard Agency Nurse #2 tell Agency Nurse #1 to leave. Agency NA #1 moved Resident #1 to the dayroom and sat with Resident #1 because she was crying. Agency NA #1 observed that Resident #1 had a red mark on the right side of her neck approximately 2-3 inches long. Agency NA #1 took Resident #1 out into the courtyard and stayed with her for approximately 2 hours because Resident #1 stated she was afraid to go back inside. Agency NA #1 told Resident #1 she would be taking care of her and assured Resident #1 she would be safe. At approximately 9:30 PM, Agency NA #1 brought Resident #1 back inside the facility and assisted her to bed. Agency NA #1 was no longer employed at the facility. Telephone attempts made on [DATE] at 11:27 AM, [DATE] at 8:53 AM, and [DATE] at 10:21 AM for an interview with Agency NA #1 were unsuccessful.During a phone interview on [DATE] at 4:23 PM, a Visitor reported that on the evening of [DATE] she was visiting her family member who was a resident at the facility. The Visitor stated she and her family member were in the resident's room with the door of the room partially opened when around 7:00 PM, the Visitor heard a heated discussion out in the hall. The Visitor stated she did not go out into the hall and only heard bits and pieces of the conversation. She recognized Resident #1's voice but did not recognize the other person's voice who was speaking to Resident #1 loudly. The Visitor reported the other person called Resident #1 a b***h and that she was a mean old lady. The Visitor expressed there was no way of her knowing who the other person was that was speaking to Resident #1 but what was said by the other person was not a proper way to speak to anyone.During a phone interview on [DATE] at 10:31 AM, the Police Sergeant confirmed he responded to the facility on [DATE] to investigate the incident involving Resident #1 and Agency Nurse #1. The Police Sergeant stated he interviewed Agency Nurse #1, Agency Nurse #2, Agency NA #1, and a Visitor and the documentation of their interviews included in his police report was an accurate account of their statements. When he spoke to the Visitor, she reported she did not witness anything but did hear the commotion out in the hall and recognized Resident #1's voice. She expressed not recognizing the voice of the other person but stated the other person was speaking to Resident #1 in a very bad manner. He did not interview Resident #1 due to her dementia but stated when he saw her at the facility, she did have a scratch on her neck. He stated he drove to Agency Nurse #1's home to talk with her about the incident. When he asked her what had happened at the facility and gave her some of the details of what was alleged, she denied the allegation and stated she did not assault Resident #1. He recalled Agency Nurse #1 reported to him that Resident #1 was fighting with another resident, she separated the two residents and when Resident #1 tried to stand, she pushed her back down in the wheelchair. The Police Sergeant stated Agency Nurse #1's statements of the events did not coincide with other witnesses statements. The Police Sergeant expressed that based on the statements he received from Agency Nurse #2, Agency NA #1 and the Visitor, he took what information he had to the Magistrate's office and the decision was made to charge Agency Nurse #1 and she was placed under arrest.During an interview on [DATE] at 5:54 PM, the DON stated she received a call from Agency Nurse #2 on [DATE] at approximately 6:00 AM to let her know that Agency Nurse #1 had called out of work for the 7:00 AM to 7:00 PM shift for [DATE]. Agency Nurse #2 then proceeded to inform the DON of the incident related to Agency Nurse #1 and Resident #1 that occurred during shift change (7:00 PM) on [DATE]. The DON stated she was with the Police Sergeant when they assessed Resident #1 the morning of [DATE] and she had a slight red mark on her neck, bruising around the pinky finger of her left hand and bruising approximately the size of a dime at the palm of the thumb of her right hand with no bruising noted to her back. The DON stated she felt all over Resident #1's head with no lumps or bumps noted and Resident #1 complained of no pain. Resident #1 was also evaluated by the NP on [DATE] who sent Resident #1 to the hospital for evaluation and x-rays obtained at the hospital were negative for fractures. The DON stated that prior to the incident on [DATE], she had not received any reports about Agency Nurse #1's interactions with residents at the facility and was not sure what prompted her to act the way she did toward Resident #1. Following the incident, the DON stated she has had no further communication with Agency Nurse #1.During an interview on [DATE] at 5:26 PM, the Administrator revealed Agency Nurse #1 had only worked at the facility since [DATE] and prior to the incident on [DATE], she had received no reports of any issues with Agency Nurse #1's interactions with residents. The Administrator stated at approximately 6:00 AM on [DATE], she received a call from the DON informing her of the incident involving Resident #1 and Agency Nurse #1 and she came straight to the facility to start an investigation. When the Administrator talked to Resident #1 the morning of [DATE], Resident #1 appeared to be her normal self, sweet and talkative but not making a lot of sense, and when the Administrator asked if she could look at her neck, Resident #1 stated she whopped me good but could not recall the name of the staff member or further details. The Administrator stated she observed a small, red scratch on the right side of Resident #1's neck that was very faint in color and there was no bruising on her back but she did have some bruising on her hands/arms that could have been from the fall she had on [DATE]. The Administrator stated the contracts for Agency Nurse #1, Agency Nurse #2 and Agency NA #1 were terminated as of [DATE] and they were not allowed to return to the facility. She stated a QA meeting was held to discuss the incident and they immediately started implementing a corrective action plan that included in-service education with quizzes and scenarios to ensure staff understood the education provided and conducted observations of staff interactions with residents during care. During a phone interview on [DATE] at 9:00 AM, the NP revealed she received a call from the facility on [DATE] informing her of the incident involving Resident #1 the evening prior ([DATE]) and was asked if she could come to the facility to evaluate Resident #1. The NP stated when she arrived to the facility, Resident #1 was sitting up in her wheelchair finishing lunch. She was her at her normal baseline, not tearful or distressed, and unable to recall the incident on [DATE] due to her advanced dementia. The NP stated she conducted a complete head-to-toe assessment of Resident #1 and from what she could recall, Resident #1 had bruising to the right wrist, elbow and forearm and a small scratch to the neck with no injuries or bruising to her back or other areas. She stated Resident #1 had hurt her wrist when she fell on [DATE] and the facility x-rays showed suspicion for a fracture with recommendation to obtain additional imaging. Resident #1 denied pain until the NP started palpating the back of her head and she then reported having a swimmy head. The NP stated that given Resident #1's report of having a swimmy head along with the initial x-ray results, the decision was made to send Resident #1 to the hospital for an evaluation and x-rays obtained at the hospital showed no acute findings or fractures. The NP stated she re-evaluated Resident #1 on [DATE], completed another head-to-toe examination and there were no latent injuries identified. The NP stated she had seen Resident #1 several times following the incident and had she had been at her normal baseline, pleasantly confused with no memory of the incident. The NP stated she felt the facility acted quickly and appropriately to address the issue once the facility was made aware of the incident involving Agency Nurse #1 and Resident #1. The facility provided the following corrective action plan with a completion date of [DATE]:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #1 had diagnoses including dementia, hypertensive heart disease with heart failure, atrial fibrillation, type 2 diabetes mellitus, hyperlipidemia, major depressive order, and congestive heart failure.On [DATE] at approximately 7:00 PM, Resident #1 entered the area behind the nurses station requesting water. During this encounter, Agency Nurse #1 spoke to Resident #1 in an inappropriate and unprofessional manner. Agency Nurse Aide (NA) #1 redirected Resident #1 away from the nurses station; however, Resident #1 later returned to the area. The interaction between Agency Nurse #1 and Resident #1 then escalated. As Agency Nurse #1 removed Resident #1 from behind the nurses station, Agency Nurse #1 continued speaking in an inappropriate manner and transported Resident #1 down the hallway in the wheelchair in an erratic and aggressive manner. The oncoming nurse, Agency Nurse #2, who was witnessing the interaction, was walking behind them. Agency NA #1 heard the commotion and came out of a room to inquire what was going on. Both Agency Nurse #2 and Agency NA #1 reported that they witnessed the interaction escalating further. According to Agency Nurse #2, she observed Agency Nurse #1 place her right hand around the right side of Resident #1's throat and pushed the resident back toward the wheelchair while the resident was attempting to stand. Agency Nurse #2 further reported that Agency Nurse #1 then struck Resident #1 in the back multiple times with her left hand clinched in a closed fist. Agency NA #1 stated that she observed Agency Nurse #1 grab the top of Resident #1's shirt. She further stated that Agency Nurse #1 held Resident #1's left hand with her left hand and struck the upper right side of the resident's back with a closed fist at least three times.Agency Nurse #2 informed Agency Nurse #1 to leave the premises and observed Agency Nurse #1 exit the premises. Simultaneously, Resident #1 was then removed from the day room and taken outside to the courtyard by Agency NA #1 for approximately 2 hours to provide emotional support, reassurance, and psychosocial comfort following the incident. Resident #1 initially refused an assessment. After returning inside the facility, Resident #1 allowed Agency Nurse #2 to complete an assessment. The assessment revealed a small scratch to the right side of the neck, discoloration to the right forearm, the 5th digit of the right hand and middle finger of the right hand, bruising to the right anterior wrist, along with complaints of generalized pain. Resident #1 refused pain medication and repositioning. Staff continued to monitor Resident #1 throughout the night.On [DATE] at approximately 5:55 AM, Agency Nurse #2 notified the Director of Nursing (DON) of the incident. At approximately 6:00 AM the DON notified the Administrator of the incident and the Administrator immediately initiated an investigation. Agency Nurse #1 was immediately removed from the schedule pending investigation. At approximately 6:51 AM, the Administrator notified the police. Notifications were made to Adult Protective Services (APS), Health Care Personnel Investigations/Registry (HCPI/HCPR), Board of Nursing, and Resident #1's representative regarding the allegation and inappropriate staff to resident interaction. Law enforcement and APS responded to the facility and initiated an investigation. The facility was later informed that Agency Nurse #1 had been arrested and charged in relation to the incident. Agency Nurse #1 refused to give a statement to the facility. Per law enforcement, Agency Nurse #1 denied the incident and stated that following an interaction with another resident and Resident #1 attempted to stand and Agency Nurse #1 assisted her back into her wheelchair because she did not want Resident #1 to fall.At approximately 10:15 AM on [DATE], the Administrator implemented 1:1 with Resident #1 for psychosocial support and well-being. Resident #1 remains on 1:1 observation.On [DATE], the Nurse Practitioner was notified and assessed Resident #1. While being assessed by the Nurse Practitioner, Resident #1 reported feeling swimmy headed. This complaint was determined to be related to low blood pressure and not this incident. On [DATE], Resident #1 was transferred to the emergency department for further evaluation with agreement from Resident #1's representative. On [DATE], hospital evaluation included diagnostic imaging consisting of CT scans of the brain and cervical spine, as well as a right wrist x-ray, with no fractures or acute abnormalities identified. Resident #1 returned to the facility with no new treatment orders or recommendations.Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On [DATE], 100% skin checks were initiated on all residents with a Brief Interview of Mental Status (BIMS) score of 12 or less (including Resident #1) who are unable to report signs/symptoms of abuse, by Facility Floor Nurses. A skin check assessment tool will be utilized with documentation in the electronic medical record. The skin checks were completed by [DATE]. There were no concerns related to abuse identified during the audit.On [DATE],100% of all alert and oriented residents with a BIMS score of 13 and above were interviewed by a sister facility ADON regarding: Do you know what it means to be abused? Are there any instances that you felt you were abused that has not been reported and/or addressed? Are there any instances that you witnessed abuse that has not been reported and/or addressed? Do you feel safe in the facility? There were no concerns regarding abuse verbalized during the interviews. During the interviews, education was completed regarding abuse to include the definitions, resident rights, what to do in an abusive situation, and how to report abuse. The education was completed by [DATE].On [DATE], all abuse allegations for the last three months were reviewed for trends and patterns by the Administrator. There were no trends and patterns identified during this timeframe.On [DATE], all employee files were audited by the sister facility Administrator to ensure the files had background checks, reference checks, Health Care Personnel Registry (HCPR) checks and abuse education on hire, with no concerns noted.On [DATE], an audit of incident reports from the previous three months was conducted by the Facility Consultant to identify any incidents that may have involved concerns related to staff-to-resident interactions or potential abuse. Any identified concerns will be reviewed and addressed promptly through the facility's investigation and abuse process, as appropriate. No concerns were identified.Address what measures will be put into place or systemic changes made to ensure that deficient practice will not recur:On [DATE], an in-service was initiated, in person, by the sister facility DON with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, DON, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding (1) abuse, including policy and definition, (2) burnout, including signs and symptoms, (3) dementia and de-escalation/communication for residents with dementia, and (4) the abuse allegation action checklist. The education emphasized (A) the importance of immediately intervening during inappropriate staff-to-resident interactions, (B) immediately reporting all allegations, concerns, observations, involving possible abuse, mistreatment or inappropriate conduct to the Administrator, DON or supervisor, (C) timely documentation of incidents, observations, actions taken, and notifications completed, (D) expectations related to maintaining resident dignity and safety, (E) appropriate dementia communication techniques and use of de-escalation strategies during resident care, and (F) the potential disciplinary action associated with failure to appropriately intervene, report, or respond to allegations involving resident abuse or mistreatment. The in-services were completed by [DATE] for all staff who worked. After [DATE], any staff that has not worked and not received the in-service will complete it before the start of their next scheduled shift. The DON and ADON will monitor the staff's completion. All newly hired staff, including agency staff, will be in-serviced by the Staff Development Coordinator (SDC) during orientation regarding (1) abuse, (2) burn out, (3) dementia and de-escalation, and (4) the abuse allegation action checklist.On [DATE], Abuse/Burn out Quizzes were initiated, in person, by the sister facility DON with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, DON, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist. The purpose of the quizzes is to ensure that all staff successfully validate knowledge and understanding of the abuse/burn out in-services. Any employee who does not successfully pass the quiz will be required to retake the quiz unital a successful passing score is achieved. The quizzes were completed by [DATE] for all staff who worked. After [DATE], any staff that has not worked and completed the quiz will complete it before the start of their next scheduled shift. The DON and ADON will monitor the staff's completion. The DON and ADON were notified of this responsibility by the Administrator on [DATE].Effective [DATE], all newly hired staff, including agency, will receive an abuse\burnout quiz by the Staff Development Coordinator to validate knowledge and understanding. Newly hired staff and agency staff will not be permitted to independently assume resident care assignments until successful completion of the required quiz. The ADON who is also the Staff Development Coordinator was notified of this responsibility by the Administrator on [DATE].On [DATE], local law enforcement and the Long-Term Care Ombudsman were contacted by the Administrator to coordinate and schedule abuse education for staff related to resident protection, immediate reporting, intervention expectations, and potential criminal implications. Training is scheduled for [DATE].Effective [DATE], the Social Worker will discuss resident rights including abuse during the monthly resident council meeting to ensure understanding of the definition of abuse and importance of immediately reporting. During the discussion, residents will be encouraged to discuss any concerns of potential abuse that may not have previously been reported. The Social W[TRUNCATED]

Based on record review and staff interviews, the facility failed to ensure staff implemented their abuse policy in the areas of protecting and reporting for 1 of 3 residents reviewed (Resident #1) for abuse. On [DATE] at approximately 7:05 PM, Agency Nurse #2 and Agency Nurse Aide #1 witnessed Agency Nurse #1 use inappropriate language to speak to Resident #1, aggressively push Resident #1 down the hall in her wheelchair in an erratic and aggressive manner, hit Resident #1 in the back with a closed fist multiple times, and did not effectively intervene and immediately report the incident to the Administrator. On [DATE] at approximately 6:00 AM, Agency Nurse #2 reported the incident to the Director of Nursing. This failure resulted in a delay in implementing protection for a resident being abused, reporting the allegation to the State Agency, law enforcement and the Adult Protective Services, and the facility investigating the allegation.Findings included:The facility's policy titled, Abuse, Neglect or Misappropriation of Resident Property last revised on [DATE] revealed in part, any employee who witnesses or suspects that abuse, neglect, exploitation, or misappropriation of property has occurred will immediately report the alleged incident to their supervisor who will immediately report the incident to the Administrator. The facility shall take whatever steps are necessary to prevent further acts of abuse, neglect, misappropriation while the investigation is in progress.the employee(s) accused of being directly involved will be suspended immediately pending the outcome of the investigation. The resident will be examined for any sign of injury as appropriate and emotional support will be provided as needed.Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia and major depressive disorder.The facility's initial allegation report (24-hour report) completed by the Administrator revealed on [DATE] at 6:00 AM the facility became aware of an incident of staff-to-resident abuse involving Agency Nurse #1 and Resident #1 that occurred on [DATE]. Resident #1 had no injuries or signs of mental distress.An undated witness statement from Agency Nurse #2 revealed in part, on [DATE] at 7:05 PM during shift change, Agency Nurse #1 was giving report to Agency Nurse #2 when Resident #1 came behind the nurses' station in her wheelchair asking for water. Agency Nurse Aide (NA) #1 removed Resident #1 from behind the nurses' station and told Resident #1 to wait in the hallway while she got her some water. While waiting for NA #1 to bring her some water, Resident #1 went back behind the nurses' station again asking for water. Agency Nurse #1 walked toward Resident #1 stating I'm so tired of this b***h's s**t and pulled Resident #1 in her wheelchair out from behind the nurses' station into the hallway in a backwards motion with Agency Nurse #2 following them. Agency Nurse #1 continued to curse at Resident #1 while pulling her wheelchair backwards aggressively in a zig-zag pattern from the right to left causing Resident #1 to almost fall out of the wheelchair. Resident #1 yelled at Agency Nurse #1 to stop and tried to stand up from the wheelchair. Agency Nurse #1 placed her right hand around the right side of Resident #1's throat, pushed Resident #1 back down in the wheelchair and told Resident #1 don't f---in fall out. Agency Nurse #1 then started punching Resident #1 in the back with her left hand in a closed fist while Resident #1 was leaning forward in the wheelchair scratching at Agency Nurse #1 forearms and yelling for Agency Nurse #1 to let her go. Agency Nurse #1 then told Resident #1 go to hell you f***in b***h and started walking back toward the nurses' station telling Agency Nurse #2 that she wanted to give report so that she (Agency Nurse #1) could leave. Agency Nurse #2 went to assess Resident #1 but Resident #1 cursed at Agency Nurse #2 and told her to leave her alone. Agency Nurse #2 asked Agency NA #1 to take Resident #1 outside and stay with her. Agency Nurse #1 was angry in her demeanor while trying to give Agency Nurse #2 report and stated she (Agency Nurse #1) was sick of this place and her ass too. Agency Nurse #2 told Agency Nurse #1 to just leave and go home because she (Agency Nurse #2) did not want her around anyone else. Agency Nurse #1 grabbed her belongings and exited the facility. Agency Nurse #2 notified the Director of Nursing (DON) of the incident on [DATE] at approximately 6:00 AM. A witness statement from Agency NA #1 dated [DATE] revealed in part, she went to the nurses' station after arriving to work on [DATE] at approximately 7:03 PM. Resident #1 was behind the nurses' station at the medication cart, trying to stand up from the wheelchair and get some water. Agency NA #1 assisted Resident #1 with getting water from the medication cart. Agency Nurse #1 was giving report to Agency Nurse #2 at the time and Agency Nurse #1 yelled at Resident #2 stating I am not dealing with this s**t, I've dealt with this all day. Sit your g**damn ass down. I hate dealing with her. Resident #1 told Agency Nurse #1 that she just wanted some water and stated, I know, I know, I am sitting down. Agency NA #1 assisted Resident #1 out into the hallway and Resident #1 calmed down. Agency NA #1 then went down the hall and into another resident's room to provide care. Approximately 2-4 minutes later, Agency NA #1 heard Agency Nurse #1 yelling, screaming and cussing. Agency NA #1 heard Agency Nurse #1 state get off me, go to hell you ugly old b***h as she was coming out into the hall to see what was going on. As she walked up the hall, Resident #1 was seated in her wheelchair with her back toward Agency NA #1 and Agency Nurse #1 was standing on the left side of Resident #1's wheelchair. Agency Nurse #1 was shaking Resident #1's wheelchair trying to get Resident #1 turned around and used both her hands to grab Resident #1's shirt. Agency Nurse #1 then held Resident #1's left hand with her left hand while hitting Resident #1 on the right side of her back with a closed fist at least three times very fast and heard Resident #1 tell Agency Nurse #1 you are ringing my neck. Agency NA #1 ran to Resident #1 and heard Agency Nurse #2 tell Agency Nurse #1 to leave. Agency NA #1 moved Resident #1 to the dayroom and sat with Resident #1 because she was crying. Agency NA #1 did not notify anyone of the incident because she thought Agency Nurse #2 had.The facility's investigation report completed by the Administrator on [DATE] revealed Resident #1 had skin alteration to the neck, discoloration to the right forearm, the fifth digit (pinky finger) of the right hand, middle finger of the right hand, and complaints of generalized pain. Resident #1 had no signs of mental distress. The allegation of staff-to-resident abuse was substantiated and Agency Nurse #1's employment was terminated effective [DATE].Agency Nurse #1 was no longer employed at the facility. A phone interview was attempted with Agency Nurse #1 on [DATE] at 11:55 AM. Agency Nurse #1 refused to discuss the incident involving Resident #1 and abruptly disconnected the phone call.Agency Nurse #2 was no longer employed at the facility. Telephone attempts made on [DATE] at 11:25 AM, [DATE] at 8:52 AM, and [DATE] at 10:21 AM for an interview with Agency Nurse #2 were unsuccessful.Agency NA #1 was no longer employed at the facility. Telephone attempts made on [DATE] at 11:27 AM, [DATE] at 8:53 AM, and [DATE] at 10:21 AM for an interview with Agency NA #1 were unsuccessful.During an interview on [DATE] at 5:54 PM, the DON stated she received a call from Agency Nurse #2 on [DATE] at approximately 6:00 AM to let her know that Agency Nurse #1 had called out of work for the 7:00 AM to 7:00 PM shift for [DATE]. Agency Nurse #2 then proceeded to inform the DON that during shift change (7:00 PM) on [DATE], Agency Nurse #1 was giving report to Agency Nurse #2 when Resident #1 entered the nurses' station for water. She stated Agency NA #1 gave Resident #1 some water and then assisted her back out into the hallway. Shortly after being assisted back out into the hall, Resident #1 came back behind the nurses' station while Agency Nurse #1 was still giving report which upset Agency Nurse #1 and Agency Nurse #2 took Resident #1 back out into the hall with Agency Nurse #1 following behind them. Agency Nurse #1 grabbed Resident #1's wheelchair and aggressively pushed her down the hall, describing it as moving the wheelchair rapidly left-to-right in a zig-zag pattern, and using foul language to Resident #1 as she pushed her down the hall. Agency Nurse #2 told the DON that Agency Nurse #1 appeared to choak Resident #1 and hit her in the back with a closed fist but did not say how many times. Agency Nurse #2 stated she immediately intervened and told Agency Nurse #1 to leave. The DON stated she asked Agency Nurse #2 if Resident #1 was safe and if Agency Nurse #1 was gone and she reported yes; however, the DON stated once she arrived to the facility she found out that Agency Nurse #1 had stayed to finish shift report with Agency Nurse #2 after the incident and then left the facility. During the phone conversation with Agency Nurse #2, the DON stated she reviewed the abuse policy with Agency Nurse #2 and reminded her that staff had been instructed to report abuse immediately. When asked why she didn't report the incident sooner, Agency Nurse #2 stated it was a busy night and she felt that she and Agency NA #1 had handled the situation. The DON stated when Agency NA #2 was asked why she didn't report the incident, Agency NA #1 stated she thought that Agency Nurse #2 had.During an interview on [DATE] at 5:26 PM, The Administrator stated at approximately 6:00 AM on [DATE], she received a call from the DON informing her of the incident involving Resident #1 and Agency Nurse #1 and she came straight to the facility to start an investigation. She immediately started interviewing the staff, students and instructor who were at the facility during the evening shift (7:00 PM to 7:00 AM) and no one reported witnessing the incident or overhearing any commotion except for Agency Nurse #2 and Agency NA #1. She stated Agency Nurse #2 reported she was getting shift report from Agency Nurse #1 when Resident #1 came behind the nurses' station wanting water, which was her normal behavior, Agency NA #1 gave Resident #1 some water and assisted her back out into the hall. Agency Nurse #1 and Agency Nurse #2 continued on with shift report and at some point, Resident #1 came back behind the nurses' station asking for more water which upset Agency Nurse #1. Agency Nurse #2 stated when she started pushing Resident #1 back out into the hall, Agency Nurse #1 grabbed Resident #1's wheelchair, said a few unchoice words and pushed Resident #1 aggressively down the hall. Agency Nurse #2 reported observing Agency Nurse #1 hitting Resident #1 in the lower mid-back with a closed fist and at some point, when Resident #1 started to stand up from the wheelchair, Agency Nurse #1 placed her hands on Resident #1's shoulders next to her neck and roughly pushed Resident #1 back down into the wheelchair which was how they determined Resident #1 likely sustained the scratch to her neck. Agency Nurse #2 reported she then intervened, told Agency NA #1 to take Resident #1 out into the courtyard and told Agency Nurse #1 to leave but Agency Nurse #1 stated she wasn't leaving until they finished shift report and once that was done, Agency Nurse #1 left the building. She stated Agency NA #1 also reported witnessing Agency Nurse #1 hit Resident #1 in the back. The Administrator stated all staff had received abuse education and instructed to report any abuse concerns to her immediately. When she asked Agency Nurse #2 why she didn't call her when the incident happened or report the incident sooner, Agency Nurse #2 stated she thought that she and Agency NA #1 had handled the situation which was why she felt she didn't need to report it right away. When Agency NA #1 was asked why she didn't report the incident to her (Administrator), she stated she thought Agency Nurse #2 had. The Administrator stated the contracts for Agency Nurse #1, Agency Nurse #2 and Agency NA #1 were terminated as of [DATE] and they were not allowed to return to the facility. She stated a QA meeting was held to discuss the incident and they immediately started implementing a corrective action plan that included in-service education with quizzes and scenarios to ensure staff understood the education provided and conducted observations of staff interactions with residents during care. The facility provided the following corrective action plan with a completion date of [DATE]:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:Resident #1 is a [AGE] year old with diagnoses including dementia, hypertensive heart disease with heart failure, atrial fibrillation, type 2 diabetes mellitus, hyperlipidemia, major depressive order, and congestive heart failure.On [DATE] at approximately 7:00 PM, Resident #1 entered the area behind the nurses station requesting water. During this encounter, Agency Nurse #1 spoke to Resident #1 in an inappropriate and unprofessional manner. Agency Nurse Aide (NA) #1 redirected Resident #1 away from the nurses station and Agency NA #1 did not report the initial inappropriate exchange to Agency Nurse #2. Resident #1 later returned to the area and the interaction between Agency Nurse #1 and Resident #1 then escalated. As Agency Nurse #1 removed Resident #1 from behind the nurses station, Agency Nurse #1 continued speaking in an inappropriate manner and transported Resident #1 down the hallway in the wheelchair in an erratic and aggressive manner and became physically aggressive toward Resident #1 by striking Resident #1 in the back with a closed fist. This interaction was observed by Agency NA #1 and Agency Nurse #2. Agency NA #1 did not report the inappropriate verbal exchange to the Director of Nursing (DON) or Administrator as she thought Agency Nurse #2 had reported it. Agency Nurse #2 did not immediately intervene and/or report the continued inappropriate verbal exchange, erratic movements of the resident in her wheelchair or the physical abuse to the DON or Administrator as she believed Resident #1 was protected due to Agency Nurse #1 removing herself from the situation as Agency Nurse #2 informed Agency Nurse #1 to leave the premises and observed Agency Nurse #1 exit the premises. Simultaneously, Resident #1 was then removed from the dayroom and taken outside to the courtyard by Agency NA #1. Staff continued to monitor Resident #1 throughout the night. On [DATE] at approximately 5:55 AM, Nurse #2 notified the DON of the incident. At approximately 6:00 AM the DON notified the Administrator of the incident and the Administrator immediately initiated an investigation. Agency Nurse #1 was immediately removed from the schedule pending investigation. Approximately at 6:51 AM, the Administrator notified the police. Notifications were made to Adult Protective Services (APS), Health Care Personnel Investigations/Registry (HCPI/HCPR), Board of Nursing, and Resident #1's representative regarding the allegation and inappropriate staff-to-resident interaction. Law enforcement and APS responded to the facility and initiated an investigation. The facility was later informed that Agency Nurse #1 had been arrested and charged in relation to the incident. Agency Nurse #1 refused to give a statement to the facility. Per law enforcement, Agency Nurse #1 denied the incident and stated that following an interaction with another resident and Resident #1 attempted to stand and Agency Nurse #1 assisted her back into her wheelchair because she did not want Resident #1 to fall.Approximately at 10:15 AM on [DATE], the Administrator implemented a 1:1 with Resident #1 for psychosocial support and wellbeing. Resident #1 remains on 1:1 observation.Effective [DATE], employment contracts for Agency Nurse #1, Agency Nurse #2 and Agency NA #1 were terminated.Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On [DATE], reportable investigation folders from the past 30 days were reviewed by the Administrator to ensure all previous allegations or concerns involving potential abuse were appropriately reported, investigated, and addressed. There were no other reportable allegations identified.On [DATE], local law enforcement and the Long-Term Care Ombudsman were contacted by the Administrator to coordinate and schedule abuse education for staff related to resident protection, immediate reporting, intervention expectations, and potential criminal implications. Training is scheduled for [DATE].Address what measures will be put into place or systemic changes made to ensure that deficient practice will not recur:On [DATE], the Administrator developed and posted an Abuse Allegation Action Checklist on brightly colored paper at the nurses station, time clock, and break room to serve as a readily accessible reference for staff regarding intervening, responding, and immediately reporting to the Administrator and DON for allegations or concerns involving potential abuse. This action checklist steps to be taken in the case of any allegations of abuse. The checklist includes that staff are to immediately ensure the resident is removed from harm, immediate removal of the perpetrator, immediate notification of the Administrator and DON.On [DATE], the Administrator made the decision to implement a badge buddy (laminated card worn behind an employee's ID badge) to provide staff with a simple, consistent, and easily accessible reference to reinforce expectations related to abuse recognition, intervention, immediately reporting, and response responsibilities. On [DATE], the badge buddies were ordered by the Administrator. The badge buddies indicate that staff are to tell nurse, supervisor, DON and/or Administrator immediately related to any potential allegation of abuse. The badge buddies were distributed to staff upon receipt prior to the start of their next scheduled shift.On [DATE], an in-service was initiated, in person, by the sister facility DON with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, DON, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding abuse, including policy and definition. The education emphasized immediately reporting all allegations, concerns, observations, involving possible abuse, mistreatment, or inappropriate conduct to the Administrator, DON or supervisor. The in-services were completed by [DATE] for all staff who worked. After [DATE], any staff that has not worked and not received the in-service will complete it before the start of their next scheduled shift. The DON and ADON will monitor the staff's completion. The DON and ADON were notified of this responsibility by the Administrator on [DATE]. All newly hired staff, including agencies, will be in-serviced by the Staff Development Coordinator during orientation regarding abuse and the abuse allegation action checklist.On [DATE], Abuse Quizzes was initiated, in person, by the sister facility DON with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, DON, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist. The purpose of the quizzes is to ensure that all staff successfully validate knowledge and understanding of when to report abuse and the importance of reporting abuse. Any employee who does not successfully pass the quiz will be required to retake the quiz until a successful passing score is achieved. The quizzes were completed by [DATE] for all staff who worked. After [DATE], any staff that has not worked and completed the quiz will complete it before the start of their next scheduled shift. The DON and ADON will monitor the staff's completion. The DON and ADON were notified of this responsibility by the Administrator on [DATE].Effective [DATE], the facility implemented an Abuse Response Competency Validation Program requiring all staff, including agency, to demonstrate competency related to abuse recognition, intervention, immediate reporting, and resident protection measures upon hire. All newly hired staff, including agency, will receive an abuse\burnout quiz and complete the abuse scenario by the Staff Development Coordinator to validate knowledge and understanding of how to respond to staff inappropriate interactions with residents, including immediately intervening. Newly hired staff and agency staff will not be permitted to independently assume resident care assignments until successful completion of the required quiz and abuse response serious scenario competency validation. The ADON who is also the Staff Development Coordinator was notified of this responsibility are the administrator on [DATE].Effective [DATE], the Social Worker will discuss resident rights including abuse during the monthly resident council meeting to ensure understanding of the definition of abuse and importance of immediately reporting. During the discussion, residents will be encouraged to discuss any concerns of potential abuse that may not have previously been reported. The Social Worker will immediately notify the Administrator of all potential abuse concerns voiced and document on the resident concern form. The Administrator will ensure timely reporting and investigation of concerns of potential abuse per protocol. The Administrator will notify newly hired Social Workers of this responsibility during orientation.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:10 Abuse Quizzes will be completed by the DON, ADON, SDC, or supervisor with staff weekly x 4 weeks then monthly x 1 month. The quizzes are to ensure staff maintain knowledge and understanding of immediately reporting abuse. These quizzes will be conducted on all shifts and weekends. Staff will be immediately retrained during the quiz for any identified areas of concern. The DON will review and initial the abuse quizzes weekly x 4 weeks then monthly x 1 month for completion and to ensure all areas of concerns are addressed. The Director of Nursing was notified of this responsibility by the Administrator on [DATE].Progress notes and incident reports will be reviewed by the DON, ADON, SDC, or Supervisor 5 x per week x 4 weeks then monthly x 1 month for all residents to include Resident #1. This audit is to identify any events of potential abuse to ensure it was immediately reported and investigated per facility protocol. All newly identified potential abuse allegations will be documented on the (Interdisciplinary) IDT meeting minutes form. All identified areas of concerns will be immediately addressed by the Administrator to include reporting and retraining of staff as necessary.A Quality Assurance Meeting was held to include the Administrator, DON, admission Coordinator, Medical Records, Minimum Data Set Nurse, Accounts Payable, Nurse Practitioner, and Maintenance Director on [DATE] to discuss the action items related to abuse reporting. The committee made the decision to implement the action plan with monitoring on [DATE].Date corrective actions completed: [DATE].On [DATE] and [DATE], the facility's corrective action plan was validated by the following: Staff interviews revealed they had received education related to abuse which included immediately intervening and removing the resident from the situation and immediately reporting any concerns of abuse to their immediate supervisor, DON, and/or Administrator, signs/symptoms of burnout, and communication/deescalation for residents with dementia. In addition, staff also reported taking quizzes to ensure they understood the education and receiving a buddy badge to remind them of what to do if they had concerns or witnessed abuse. Alert and oriented residents were interviewed who all reported they felt safe at the facility, had no concerns of abuse and verified they knew how/who to report any concerns. Review of the attendance sign-in sheets and quizzes completed by staff revealed in-service education was initiated for all staff/departments on [DATE]. Skin assessments were completed on all cognitively impaired residents and interviews were conducted with all alert and oriented residents on [DATE] with no concerns reported or identified. Staff interviews were conducted with staff in all departments on [DATE] with no concerns of abuse reported. Audits and Monitoring tools were reviewed for the period [DATE] through [DATE] with no identified concerns noted and were completed as outlined in the facility's corrective action plan. The corrective action plan's completion date of [DATE] was validated.

Based on record review and interviews with staff and the physician, the facility failed to monitor and document a resident's pulse and blood pressure for a resident who had physician ordered hold parameters for digoxin (a cardiac glycoside used to strengthen heart contractions) and losartan (antihypertensive medication) for 1 of 5 residents reviewed for unnecessary medications (Resident #52).Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, congestive heart failure, and hypertension. a. The physician's orders dated 10/16/25 revealed Resident #52 had an order for digoxin 125 micrograms (mcg) by mouth in the evening with a hold parameter if the pulse was below 60. The Medication Administration Record (MAR) for October 2025, November 2025, December 2025, January 2026, and February 2026 revealed digoxin 125 mcg was documented as administered every day except for 11/27/25 and 12/24/25 when documentation indicated that Resident #52 was absent from the facility. There was no hold parameter transcribed on the MARs and no pulse documentation on the MARs. Review of the electronic health record documentation for Resident #52's pulse for October 2025, November 2025, December 2025, January 2026 and February 2026 revealed no pulse documented for the following dates:October - 30, 31 November - 1, 2, 3, 4, 6, 7, 8, 9, 10, 13, 14, 15, 16, 17, 18, 20, 23, 24, 25, 28, 29, 30December - 2, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 26, 28, 29, 30January - 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 28, 29, 30, 31February - 1, 2, 3, 5, 6, 7, 8, 9, 10 ,11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28 b. The physician's orders dated 2/07/25 revealed Resident #52 had an order for losartan 100 milligrams (mg) by mouth daily with a hold parameter if the systolic blood pressure was less than 110. The Medication Administration Record (MAR) for February 2026 revealed losartan 100 mg was documented as administered daily beginning 2/08/26. There was no hold parameter transcribed on the MAR and no blood pressure documentation on the MAR. Review of the electronic health record for Resident #52 revealed blood pressures documented for 2/19/26 and 2/21/26. The facility was unable to produce any further documentation for Resident #52's blood pressures during the month of February 2026. An interview on 3/04/26 at 12:51 PM with Nurse #3 revealed when the physician's order was clarified, the nurse should have added the parameters in the supplemental documentation section. The supplemental documentation flagged the parameters on the MAR for the nurse to enter the pulse or blood pressure. Nurse #3 stated she should have identified that the order had not been entered correctly without the hold parameters in the supplemental documentation but did not. She also stated that the orders were reviewed in the morning meetings, and the error should have been caught there and did not know why it had not been identified. An interview on 3/04/26 at 1:28 PM with Nurse #4 revealed if she hovered over the medication on the electronic MAR, it would display the hold parameters. She stated she was aware of Resident #52's hold parameters for her digoxin and losartan but was unable to locate documentation of the blood pressure or pulse from prior administration of the resident's medication. Nurse #4 stated she administered Resident #52's medications infrequently and could not recall if she had been aware of the need to monitor and document her pulse and blood pressure. An interview on 3/05/26 at 9:28 AM with Nurse #2 revealed she frequently administered Resident #52's medications. She stated she always checked the pulse and blood pressure but did not document them. Nurse #2 was unable to state why she did not document the pulse and blood pressure. An interview on 3/05/26 at 9:44 AM with Nurse #1 revealed she was responsible for entering and confirming all resident orders. She explained when an order had parameters, there should be supplemental documentation which flagged the nurse to check the pulse or blood pressure. She stated the orders were not always entered in the electronic health record correctly due to lack of staff knowledge. The nurse who confirmed the order was supposed to double-check the orders to ensure accuracy but sometimes the same nurse who entered the order was the one who confirmed it. Nurse #1 stated she had not administered Resident #52's medications but stated orders should be entered accurately on the MAR. An interview on 3/05/26 at 8:38 AM with the Physician revealed she expected the facility nurses to follow her orders for medication hold parameters. The Physician stated the resident could have adverse effects such as low blood pressure, increased risk of falls, exacerbation of heart failure, or low heart rate. An interview on 3/05/26 at 9:08 AM with the Director of Nursing (DON) revealed she was not aware of the lack of parameter monitoring. She stated pulse and blood pressure monitoring and documentation was just missed due to human error and she would educate the staff. The DON indicated she expected the staff to follow the physician's orders and to monitor and document as necessary. An interview on 3/05/26 at 10:26 AM with the Administrator revealed she was not aware of medication orders with hold parameters were not being followed and was unable to say why this was occurring.

Based on record review, staff, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to complete a Medical Orders for Scope of Treatment (MOST) form with a required signature for 1 of 3 residents reviewed for advance directive (Resident #26).The findings included:Resident #26 was admitted to the facility on [DATE]. Her diagnoses included dementia.Review of Resident #26's face sheet revealed she had a Resident Representative.A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #26 was rarely/ never understood. The MDS indicated she had short term memory problems, long term memory problems, and her cognitive skills for daily decision making were severely impaired.A MOST form dated 10/6/25 for Resident #26 was reviewed. The MOST form indicated Do Not Resuscitate (DNR), comfort measures, antibiotics if indicated, intravenous (IV) fluids for defined trial period, and no feeding tube. The form indicated it had been discussed with and agreed to by an individual with an established relationship with the patient who is acting in good faith and can reliably convey the wishes of the patient. The form was signed by NP #1. The form did not include the name of the individual the form was discussed with. The patient or representative signature section at the bottom of the form was not completed and was blank. A telephone interview was attempted on 3/3/26 at 9:21 AM with Resident #26's Resident Representative but was not successful.An interview was conducted with Medical Records on 3/4/26 at 11:04 AM. She stated after the provider completed a MOST form it was returned to her box. She reported she reviewed the forms to ensure they were completed entirely with dates and all signatures, before she scanned them into the electronic medical record. She then placed the hard copy of the MOST form into the code book at the nursing station. Medical Records stated if the MOST form was missing the Resident Representative signature, she called the Resident Representative and asked them to come to the facility to sign the form. Medical Records stated the form was not valid unless it was signed by the resident and/or their Resident Representative. She stated she missed that Resident #26's MOST form was not signed by her Resident Representative.An interview was conducted on 3/4/26 at 1:59 PM with the Social Worker (SW). She was not sure if the MOST form would be valid if it was not signed by the resident and/or Resident Representative. She stated she conducted audits of MOST forms, but her audit was mainly taking note of who had a MOST form. An interview was conducted with The Medical Director on 3/5/26 at 8:24 AM. She said the form needed to be signed by the resident and/or Resident Representative to be considered a valid form. She reported NP #1 completed Resident #26's MOST form and she was not sure if NP #1 was aware the form had to be signed by the resident and/or representative. She reported that if the form was reviewed by telephone, then there should be documentation on the form of who it was reviewed with and a witness signature.An interview was conducted with NP #1 on 3/5/26 at 8:50 AM. She reported she was not aware the MOST form had to be signed by the resident and/or Resident Representative to be a valid form. She thought the signature box for resident and/or Resident Representative was optional because it stated above the signature box you are not required to sign this form to receive treatment. She reported she had missed that the section under the bold print signature of patient or personal representative stated signature is required.An interview was conducted with the Director of Nursing (DON) on 3/4/26 at 1:00 PM. She reported the MOST form needed to be signed by the resident and/or their Resident Representative to be considered a valid form. She stated Resident #26's MOST form would not be considered a valid MOST form because it was not signed by her Resident Representative. The DON said Medical Records was responsible for reviewing the MOST form and ensuring all signatures and dates were present before scanning the form into the electronic record.An interview was conducted with the Administrator on 3/5/26 at 9:08AM. She stated the MOST form had to be signed by the resident and/or Resident Representative to be considered valid. She said Resident #26's form would not be considered a valid form because it was not signed by her Resident Representative. She explained Resident #26's form needed to be signed by her Resident Representative because she was not cognitive enough to sign the form. The Administrator reported that if the MOST form was reviewed and completed with the Resident Representative by telephone then there should be a witness. She stated the name of the individual the form was reviewed with should be documented in the Representative Name box, the form should indicate it was reviewed by telephone, and then two people should sign the form as witnesses. The Administrator stated she had become aware yesterday about the MOST form missing signatures and had completed an audit. She reported during the audit that the facility had found 7 MOST forms that had not been signed by the resident and/or Resident Representative.

Based on record review, staff and Medical Director interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident diagnosed with intellectual disability for 1 of 2 residents reviewed for PASRR (Resident #15). The findings included:Resident #15 had a Level I PASRR screening completed on 8/16/24 by a physician at the hospital emergency room. The diagnosis listed were diabetes and history of Guillain- Barre Syndrome (autoimmune disorder where the immune system damages peripheral nerves causing muscle weakness).Resident #15 was admitted to the facility from a local hospital's emergency room on 8/20/24 with diagnoses including diabetes and Guillain-Barre Syndrome.The Medical Director's history and physical note dated 8/20/24 indicated a new diagnosis of intellectual disability was added by the Medical Director and added to Resident #15's diagnosis sheet.Review of Resident #15's current diagnosis list in the medical record included the diagnosis of intellectual disability.There was no evidence in the medical record that a request for a Level II PASRR evaluation was submitted.The 2/20/26 quarterly Minimum Data Set (MDS) showed that Resident #15 was cognitively intact.On 3/3/26 at 2:25 PM an interview was conducted with the Social Worker. She stated that she had worked at the facility for numerous years and she knew Resident #15. The Social Worker stated she did not know when Resident #15 was diagnosed with an intellectual disability. She stated that she did know Resident #15 did not take any antipsychotic medications. The Social Worker stated that when a new admission came from the hospital, the hospital completed the PASRR, and if a resident came from home the Social Worker completed the PASRR. The Social Worker could not state her method of keeping track of PASRRs for residents or how she would know about a new diagnosis being added. The Social Worker stated that today she had done an audit and noticed that Resident #15 was diagnosed with an intellectual disability on 8/22/24 and a Level II PASRR should have been submitted within a day or two of a new diagnosis being added. On 3/4/26 at 1:45 PM an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident was admitted to the facility from the hospital, they came with a diagnosis sheet, and if a resident came from home the resident's primary doctor provided the diagnosis sheet. The MDS nurse would then enter the diagnoses at admission. If a resident had a new diagnosis added after admission, then the MDS nurse would notify the staff at the morning meeting. The Social Worker would then be alerted to start a new PASRR if needed. The DON stated that Resident #15 had a diagnosis of intellectual disability and that a request for a Level II PASRR evaluation should have been completed. The DON could not state why this did not happen. On 3/5/26 at 8:34 AM a telephone interview was conducted with the Medical Director. She stated that Resident #15 was not admitted with a diagnosis of intellectual disability. The Medical Director stated on 8/20/24 she reviewed Resident #15's past medical history with his family representative and the family representative informed the Medical Director that Resident #15 had an intellectual disability. The Medical Director stated she had also reviewed Resident #15's past medical records, which revealed he had an intellectual disability diagnosis. On 8/20/24 the diagnosis of intellectual disability was added. The Medical Director stated that back in 2024 the facility had a different method of sharing information. The Medical Director stated that in 2024 she had to inform numerous staff about the details of a new admission and whether the new admission had an additional diagnosis. The Medical Director could not state exactly which staff she had to notify. Presently, after she saw a new admission, she only notified the DON and medical records. The Medical Director stated she did not have anything to do with PASRR. The Medical Director did know that if a resident had a diagnosis of intellectual disability, a Level II PASRR should be completed. She stated she was unaware that the Level II PASRR was not completed.On 3/5/26 at 8:52 AM an interview was held with the Administrator. The Administrator agreed that a Level II PASRR evaluation should have been submitted once the intellectual disability diagnosis was added.

Based on record review and staff, Consultant Pharmacist, Supervisor Consultant Pharmacist, and Physician interviews, the Consultant Pharmacist failed to identify and report the lack of documented monitoring for a resident who had hold parameters for digoxin (a cardiac glycoside used to strengthen heart contractions) and losartan (an antihypertensive medication). This failure affected 1 of 5 residents reviewed for unnecessary medications (Resident #52). Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, congestive heart failure, and hypertension. a. The physician's orders dated 10/16/25 revealed Resident #52 had an order for Digoxin 125 micrograms (mcg) by mouth in the evening with a hold parameter if the pulse was below 60. Review of the Medication Administration Record (MAR) for October 2025, November 2025, December 2025, January 2026, and February 2026 revealed Digoxin 125 mcg was documented as administered every day except for 11/27/25 and 12/24/25 when documentation indicated that Resident #52 was absent from the facility. Review of documentation of Resident #52's pulse in the electronic health record for October 2025, November 2025, December 2025, January 2026 and February 2026 revealed no pulse documented for:October - 30, 31November - 1, 2, 3, 4, 6, 7, 8, 9, 10, 13, 14, 15, 16, 17, 18, 20, 23, 24, 25, 28, 29, 30December - 2, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 26, 28, 29, 30January - 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 28, 29, 30, 31February - 1, 2, 3, 5, 6, 7, 8, 9, 10 ,11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28 Review of the Consultant Pharmacist medication review for Resident #52 dated 11/06/25 revealed no recommendations related to Digoxin. Review of the Consultant Pharmacist medication review for Resident #52 dated 12/12/25 revealed no recommendations related to Digoxin. Review of the Consultant Pharmacist medication review for Resident #52 dated 1/07/26 revealed no recommendations related to Digoxin. Review of the Consultant Pharmacist medication review for Resident #52 dated 2/12/26 revealed no recommendations related to Digoxin. b. The physician's orders dated 2/07/25 revealed Resident #52 had an order for Losartan 100 milligrams (mg) by mouth daily with a hold parameter if the systolic blood pressure was less than 110. Review of the Medication Administration Record (MAR) for February 2026 revealed Losartan 100 mg was documented as administered daily beginning 2/08/26. Review of documentation for Resident #52 revealed blood pressures documented for 2/19/26 and 2/21/26. The facility was unable to produce any further documentation for Resident #52's blood pressures during the month of February 2026. An interview on 3/05/26 at 8:52 AM with the Consultant Pharmacist and Supervisor Consultant Pharmacist revealed the facility had not entered the supplementary order for the nurse to enter the pulse for the digoxin medication or blood pressure when administering the losartan medication. The Supervisor Consultant Pharmacist stated the Consultant Pharmacist was fairly new to their company and was unaware of how to look in the system to check. The Supervisor Consultant Pharmacist stated the Consultant Pharmacist did not identify this lack of documentation during the monthly medication review but should have. The Consultant Pharmacist had no comment during this interview. An interview on 3/05/26 at 8:38 AM with the Physician revealed she expected the Consultant Pharmacist to review the residents' medications and to notify the facility when hold parameters were not monitored. An interview on 3/05/26 at 10:26 AM with the Administrator revealed she was not aware the Consultant Pharmacist had not known how to review hold parameter documentation.

Based on record reviews and staff interviews, the facility failed to submit a request for an evaluation of updated Pre-Admission Screening and Resident Review (PASARR) determination for 1 of 3 residents reviewed (Resident #11). The findings included: Resident #11 was originally admitted to the facility on [DATE] with fibromyalgia, osteoarthritis, and Post Traumatic Stress Disorder (PTSD). On 04/10/2024, resident was diagnosed with Major Depressive Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. The MDS further revealed diagnoses on 04/10/2024 of major depressive disorder. Behaviors during the look back period included feeling down, depressed or sleepy. Care plan dated 04/28/2024 revealed Resident #11 had feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by ineffective coping, low self-esteem, tearfulness, motor agitation, withdrawal from care/activities. A review of the Psychiatric Periodic Evaluation revealed that Resident #11 was assessed for depression. Nurse Practitioner (NP) on 04/08/2024 included major depressive disorder. NP documented to continue duloxetine (for depression and anxiety) and Wellbutrin XL (for depression), and to utilize non-pharmacological interventions. Review of medical record revealed a new application for Level II PASARR had not been completed after the diagnosis of Major Depressive Disorder. Interview with Social Worker on 12/18/2024 at 10:59 AM revealed she was responsible for notifying State Mental Health Authority of resident's new mental health condition to establish a new PASARR level and a Level II PASARR had not been completed. Social Worker explained that she must be notified by nursing of any new mental health diagnoses to submit the evaluation for screening. On 12/18/2024 at 11:20 AM, the MDS Coordinator interview revealed the NP had not notified nursing of the additional diagnoses of major depressive disorder for Resident #11. During interview with Unit Manager on 12/19/204 at 8:05 AM, it was revealed that NP no longer came to the facility and the replacement Physician Assistant (PAs) first day was today. On 12/19/2024 upon interview with the PA at 10:50 AM, it was revealed this was his first day at the facility, and he was unfamiliar with the resident's case. Interview with Interim Administrator on 12/19/2024 at 2:50 PM disclosed that she expected a Level II PASARR to be completed for residents that were diagnosed with additional mental health diagnoses.

Based on observations and staff and Consultant Pharmacist interviews, the facility failed to discard expired medications from 2 of 2 medication rooms (North and South medication rooms), and 1 of 2 medication carts (South medication cart). The facility also failed to date an eye drop after opening in 1 of 2 medication carts (South medication cart). The findings included: 1.a. An observation of the North medication room refrigerator on 12/18/24 at 11:08 AM with Nurse #1 revealed five full bags of Normal Saline 250 milliliters labeled as containing Gentamicin Injection with Resident #4's name. Each bag had a sticker that indicated do not use after with the following dates: 12/9/24, 12/11/24, 12/13/24, 12/15/24, and 12/17/24. There was also another bag labeled the same way which was half full and the sticker date was to discard after 12/5/24. An interview with Nurse #1 on 12/18/24 at 11:10 AM revealed she was not sure why the bags of Normal Saline with Gentamicin were still available in the medication room refrigerator. Nurse #1 stated they were supposed to have been used to irrigate Resident #4's urinary catheter and this procedure had been scheduled for the evening shift. A phone interview with the Consultant Pharmacist on 12/18/24 at 4:14 PM revealed they had sent pre-mixed Gentamicin solution for Resident #4's urinary catheter irrigation, and the Normal Saline bags were only good for 48 hours because they had already been punctured by the pharmacy adding the Gentamicin medication into the bags of saline. She stated that any unused solution should have been discarded after two days. b. Further observation of the North medication room on 12/18/24 at 11:15 AM with Nurse #1 revealed two boxes of Bisacodyl suppositories marked with a manufacturer's expiration date of 8/31/24. One box contained 24 suppositories, and the other box contained 15 suppositories. There was also a 473 milliliter (ml) bottle of Guaifenesin marked with an expiration date of August 2024. Both medications were available for use in the North medication room. An interview with Nurse #1 on 12/18/24 at 11:18 AM revealed the nurses were responsible for checking the medication room for expired medications. Nurse #1 stated she thought they had one of the medication aides go through the medication rooms this week. An interview with the Nurse Supervisor on 12/19/24 at 11:24 AM revealed she usually checked the medication rooms at the beginning of each month, but she did not notice any of the expired medications that were observed. An interview with the Director of Nursing (DON) on 12/19/24 at 3:27 PM revealed she did not know why there were expired medications available for use in both medication rooms and the South medication cart. The DON stated she would have thought that the supervisors would have caught them sooner and addressed them. The DON further stated that she called pharmacy and verified that the Normal Saline bags expired in two days only if they were punctured, and she did not think any of them were punctured. The DON also said that the supervisors should check the stock medications in the medication rooms, while the nurses were responsible for checking the medication carts. 2. An observation of the South medication room with Nurse #2 on 12/18/24 at 12:03 PM revealed a 236 ml unopened bottle of Multi-Vite marked with an expiration date of November 2024. An interview with Nurse #2 on 12/18/24 at 12:05 PM revealed the night shift nurses were responsible for checking the medication room for expired medications and also which ever nurse put the stock medications into the cabinets. She did not know why the expired bottle of Multi-Vite was left available for use in the South medication room. An interview with the Nurse Supervisor on 12/19/24 at 11:24 AM revealed she usually checked the medication rooms at the beginning of each month, but she did not notice any of the expired medications that were observed. An interview with the Director of Nursing (DON) on 12/19/24 at 3:27 PM revealed she did not know why there were expired medications available for use in both medication rooms and the South medication cart. The DON stated she would have thought that the supervisors would have caught them sooner and addressed them. The DON also said that the supervisors should check the stock medications in the medication rooms, while the nurses were responsible for checking the medication carts. 3. An observation of the South medication cart with Nurse #2 on 12/18/24 at 12:13 PM revealed a box of twelve Hemorrhoidal suppositories marked with an expiration date of September 2024 available for use. There was also an opened bottle of Latanoprost eye drops with no open date. It was marked as sent by the pharmacy on 11/7/24. The bottle had a sticker that indicated it expired six weeks after opening. An interview with Nurse #2 on 12/18/24 at 12:15 PM revealed the nurses on the cart were responsible for going through it to check for expired medications. Nurse #2 stated she did not notice both medications because the Hemorrhoidal suppositories were no longer needed by the resident for whom it was ordered and the Latanoprost eye drops were only given at bedtime. Nurse #2 stated that whoever opened the Latanoprost eye drop bottle should have put a date on it due to the expiration date being six weeks after opening. An interview with the Director of Nursing (DON) on 12/19/24 at 3:27 PM revealed she did not know why there were expired medications available for use in both medication rooms and the South medication cart. The DON stated she would have thought that the supervisors would have caught them sooner and addressed them. The DON also said that the supervisors should check the stock medications in the medication rooms, while the nurses were responsible for checking the medication carts.

Based on record reviews, observations, and staff interviews, the facility failed to implement their infection control policy when 3 staff members (Nurse Aides #1, #2, and #3) failed to sanitize their hands in between resident contacts and contact with surfaces in the dining room during meal service. In addition, Nurse #1 failed to don Personal Protective Equipment (PPE) including a gown when providing urinary catheter care and failed to perform hand hygiene before applying gloves and after removing gloves during catheter care for Resident #4. This involved 4 of 5 staff members observed for infection control practices (Nurse Aides #1, #2, #3 and Nurse #1). The findings included: Review of the facility's policy for Handwashing dated 4/2023 indicated that the facility ensures that all employees wash hands using soap, running water, and friction in the following situations: immediately or as soon as feasible after removal of gloves or other personal protective equipment. 1.a. Nurse Aide (NA) #2 was observed on 12/16/24 at 11:51 AM touching the hands and hair of a resident in the dining room. NA #2 then walked to another resident in the dining room without washing or sanitizing her hands and then touched the resident on the hands. On 12/16/24 at 12:05 PM NA #2 was observed assisting a resident with meal set up while wearing gloves, then immediately assisted another resident with meal set up without removing the gloves. NA #2 then helped cut the resident's food and touched the resident's bread while wearing the same gloves. NA #2 was interviewed on 12/16/24 at 12:50 PM. She stated she would wash and sanitize her hands after delivering meals to each resident and after assisting a resident with eating before assisting another resident with a meal. NA #2 said her usual procedure was to wash her hands after removing gloves or replacing them and after touching hair or other areas of the body. NA #2 said she did not wash or sanitize her hands for every occasion needed when she assisted residents in the dining room. b. On 12/16/24 at 11:59 AM NA #1 was observed adjusting a residents clothing protector with his hands, then immediately serve another resident a meal tray without sanitizing or washing his hands. On 12/16/24 at 12:20 PM NA #1 was observed touching and readjusting a resident's clothing protector and then immediately assisted another resident with their meal. NA #1 did not wash or sanitize his hands before assisting the resident with their meal. NA #1 was interviewed on 12/26/24 at 12:56 PM. He stated he usually would wash or sanitize his hands after he helped set a resident up for a meal and after touching a resident. NA #1 stated he overlooked washing and sanitizing his hands between assisting residents with meals and after touching clothing protectors. c. On 12/16/24 at 12:10 PM NA #3 was observed placing gloves in her coat pocket and washing her hands. NA #3 then removed the gloves from her coat pocket, placed them on her hands and touched a resident's sandwich. NA #3 was interviewed 12/16/24 at 12:39 PM. NA #3 stated she would wash or sanitize her hands before and after she passed meals to each resident, after she touched clothing, and after she removed gloves. NA #3 said she did forget to sanitize and wash when she used gloves and after touching residents clothing before assisting another resident. The Director of Nursing (DON) stated on 12/19/24 at 3:39 PM the NAs and Nurses should have washed or sanitized their hands in-between assisting residents with meals. The DON stated hands should be washed or sanitized after touching their own clothing, residents clothing, hair, face, and after removing gloves. The Administrator was interviewed on 12/19/24 at 4:08 PM and stated Nurses and NAs should have sanitized hands in-between assisting residents with meals. She stated hands should have been sanitized after touching hair, clothing and before they assisted a resident with eating. 41069 2. Review of the facility's policy for Enhanced Barrier Precautions (EBP) revised on 6/13/24 indicated Enhanced Barrier Precautions will be utilized by staff for all residents with a known CDC (Centers for Disease Control and Prevention) targeted MDRO (multidrug-resistant organism) infection or colonization (when contact precautions are not indicated) and/or residents without known MDRO who have wounds and/or implanted medical devices. An observation on 12/18/24 at 10:29 AM revealed Resident #4 had signage for EBP posted on his door. The signage indicated all healthcare personnel must wear gloves and gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use to include urinary catheter, and wound care. Nurse #1 entered Resident #4's room to provide urinary catheter care without wearing a gown for the procedure. Nurse #1 put gloves on both hands without performing hand hygiene and obtained soapy water in a kidney basin from Resident #4's bathroom sink faucet. Nurse #1 placed the kidney basin on Resident #4's bedside table, uncovered Resident #4, and pulled open his brief. Nurse #1 wiped Resident #4's urinary catheter insertion site with a washcloth soaked in the soapy water from the kidney basin. She removed both gloves and without performing hand hygiene, she proceeded to put on a new set of gloves to both hands. She reached inside her shirt pocket and obtained a tube of antibiotic ointment. Nurse #1 squeezed the contents of the tube into a medicine cup and placed the cup on Resident #4's bedside table. Nurse #1 changed her gloves without doing hand hygiene. She applied the ointment onto Resident #4's urethral meatus (passage or opening leading to the interior of the body). Nurse #1 removed her gloves and put on a new pair of gloves to both hands. She wiped the rest of Resident #4's urinary catheter, discarded any unused supplies, removed her gloves and washed her hands. An interview with Nurse #1 on 12/18/24 at 10:36 AM revealed that she did not notice the sign for EBP on Resident #4's door and stated that the sign must have just been put up. Nurse #1 indicated she was supposed to have put on a gown when she provided catheter care to Resident #4. Nurse #1 stated that she had washed her hands prior to entering Resident #4's room, and she would normally wash her hands prior to putting gloves on but Resident #4 was agitated and wanted to get up, so she was trying to hurry. Nurse #1 further stated that she had not heard that she was supposed to sanitize her hands after removing gloves and before applying new ones. Nurse #1 stated that she had received education on hand hygiene and EPB, and that she knew what she was supposed to do, but she could not explain why she hadn't donned a gown or perform hand hygiene after removing her gloves. Nurse #1 stated that there was no excuse. An interview with Director of Nursing (DON) who also served as the facility's Infection Preventionist on 12/19/24 at 3:27 PM revealed staff was supposed to wash their hands and apply PPE when going into rooms on EBP. The DON stated Nurse #1 should have worn a gown and gloves while providing catheter care to Resident #4. The DON also stated that Nurse #1 should have done hand hygiene after removing her gloves. She shared that Nurse #1 had been educated on the facility's infection control policies and should have known what to do.

Based on record reviews and resident and staff interviews, the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the COVID-19 immunization for 3 of 6 residents reviewed for infection control (Resident #2, Resident #11, and Resident #18). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #2's cognition was severely impaired. The electronic immunization record revealed that Resident #2 received the COVID-19 immunization on 10/16/2024. A review of Resident #2's medical record revealed there was no information documented in Resident #2's medical record that the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 vaccine. During an interview with the Interim Assistant Director of Nursing (ADON) on 12/18/2024 at 7:54 AM, she stated that she had been at this facility since the second week of November 2024. The ADON stated that she served as Staff Development Coordinator (SDC) and Quality Improvement (QI) nurse. She stated that she was responsible for resident and staff immunizations with consents and was catching up with the administration of the vaccines. At 1:00 PM on 12/19/2024, The Director of Nursing (DON) and the Regional Director were asked for documentation of the education provided for Resident #2 regarding the benefits and potential side effects of the COVID-19 immunization. The information was not received. The Director of Nursing (DON) who was interviewed on 12/19/2024 at 3:40 PM revealed that she was responsible for resident immunizations and acknowledged that she did not have documentation about providing education about benefits and potential side effects of COVID-19 immunization. The Interim Administrator was interviewed on 12/19/2024 at 4:25 PM and stated that she expected staff to educate and document education provided regarding benefits and potential side effects of COVID-19 immunizations. 2. Resident #11 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. A review of the electronic immunization record revealed that Resident #11 refused the COVID-19 immunization in 2024 without a documented date. On 09/25/2024, a note was authored by the Assistant Director of Nursing (ADON) who was no longer employed at the facility and stated that Resident and legal representative refused the COVID vaccine. During an interview with the Interim ADON on 12/18/2024 at 7:54 AM, she stated that she had been at this facility since the second week of November 2024. The ADON also that she served as Staff Development Coordinator (SDC) and Quality Improvement (QI) nurse. She stated was responsible for resident and staff immunizations with consents and was catching up with the administration of the vaccines. At 11:05 AM on 12/18/2024, Resident #11 was interviewed. She remembered refusing the COVID-19 vaccine this fall and stated that she did not recall being educated about the benefits and potential side effects of the vaccine. At 1:00 PM on 12/19/2024, The Director of Nursing (DON) and the Regional Director were asked for documentation of the education provided for Resident #11 regarding the benefits and potential side effects of the COVID-19 immunization. The information was not received. The DON who was interviewed on 12/19/2024 at 3:40 PM revealed that she was ultimately responsible for resident immunizations and acknowledged that she did not have documentation about providing education about benefits and potential side effects of COVID-19 immunization. The Interim Administrator was interviewed on 12/19/2024 at 4:25 PM and stated that she expected staff to educate and document education provided regarding benefits and potential side effects of COVID-19 immunizations. 3. Resident #18 was admitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had moderate cognitive impairment. A review of the electronic immunization record revealed that Resident #18 refused the COVID-19 immunization for 2024 without a documented date. On 09/25/2024, a note was authored by the former Assistant Director of Nursing (ADON) who was no longer employed at the facility and stated that Resident and legal representative refused the COVID vaccine. During an interview with the Interim ADON on 12/18/2024 at 7:54 AM, she declared that she had been at this facility since the second week of November 2024. The ADON also that she served as Staff Development Coordinator (SDC) and Quality Improvement (QI) nurse. She sated was responsible for resident and staff immunizations with consents and was catching up with the administration of the vaccines. At 11:05 AM on 12/18/2024, Resident #18 was interviewed. She remembered refusing the COVID-19 vaccine this fall and stated that she did not recall being taught about the benefits and potential side effects of the vaccine. At 1:00 PM on 12/19/2024, The Director of Nursing (DON) and the Regional Director were asked for documentation of the education provided for Resident #18 regarding the benefits and potential side effects of the COVID-19 immunization. The information was not received. The Director of Nursing (DON) was interviewed on 12/19/2024 at 3:40 PM, revealed that she was responsible for vaccine and acknowledged that she did not have documentation about providing education about benefits and potential side effects of COVID-19 immunization. The Interim Administrator was interviewed on 12/19/2024 at 4:25 PM and stated thatshe expected staff to educate and document education provided regarding benefits and potential side effects of COVID-19 immunizations.

Based on record review, staff and physician interviews, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 1 resident (Resident #1) reviewed for misappropriation of residents' property. Findings included: The facility's Abuse, Neglect, or Misappropriation of Resident Property policy last revised 3/10/17 read in part that the facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Resident #1 was admitted to the facility on [DATE] with diagnoses which included hip fracture and non-Alzheimer's dementia. A review of the initial allegation report dated 4/30/24 revealed the facility became aware of the incident on 4/30/24 at 6:00 AM when 2 staff members reported an allegation of misappropriation of Resident #1's morphine medication by a nurse. The 5-day investigation report dated 5/06/24 revealed the allegation of misappropriation of residents' property was substantiated. Nurse #1's urine drug screen tested positive for morphine on 5/06/24 and he was terminated. Resident #1's missing morphine medication was replaced at facility expense. An interview on 7/17/24 at 8:26 PM with Nursing Assistant (NA) #1 revealed she was working night shift on 4/30/24 on the same hall as Nurse #1. NA #1 stated around 4:00 AM she was sitting at the nurses' station, and she observed Nurse #1 take a brown bottle in a plastic bag out of the medication cart and place it on top of the medication cart. Nurse #1 then got another bottle of liquid out of the medication cart. NA #1 was unable to clearly see what Nurse #1 did with either medication bottle, but when he turned around, he had a medication syringe with clear liquid in it and stated he was going to give Resident #1 the mixture of both medications. NA #1 observed Nurse #1 walked down the hall toward Resident #1's room. NA #1 observed on top of the medication cart a medication cup which had liquid in it. Nurse #1 returned to the nurses' station and picked up his soda can. Nurse #1 filled the medication cup that had liquid already in it with soda and then went into the bathroom. NA #1 noted that on the medication cart, the medication cup of soda was bubbling. Nurse #1 came back to the medication cart and had his back to NA #1 and she observed Nurse #1's head tilted back like he had drunk something. When Nurse #1 moved and NA #1 could see the top of the medication cart, the medication cup of liquid and soda was gone. NA #1 was unable to observe what Nurse #1 did with the medication cup and was unable to clarify the color of the liquid in the cup. NA #1 was confused and unsure what to do and decided to contact the Director of Nursing (DON) around 6:00 AM. An interview on 7/17/24 at 10:13 AM with NA #2 revealed she was working night shift on 4/30/24 on the same hall as Nurse #1. Around 4:00 or 4:30 AM, while sitting at the nurses' station, NA #2 observed Nurse #1 take a medication bottle out of the medication cart and poured blue liquid into a medication cup. NA #2 observed the liquid in the medication cup to be blue, like 'mouthwash'. NA #2 stated she observed Nurse #1 take a medication syringe down to Resident #1's room and left the medication cup of blue liquid on top of the medication cart. When Nurse #1 returned to the nurses' station, he picked up his soda can, drank the blue liquid from the medication cup and went into the bathroom. NA #2 was with NA #1 when she called the DON around 5:00 or 6:00 AM to report the incident. An attempt to interview Nurse #1 on 7/17/24 at 11:24 AM was unsuccessful and he did not return the call. An interview on 7/17/24 at 1:33 PM with the Director of Nursing revealed that NA #1 had contacted her and reported her observations. When she arrived at the facility, she obtained a urine sample from Nurse #1 which was sent for drug testing. Nurse #1 was suspended and terminated on 5/06/24 when his urine drug test was positive for morphine, opiates, cannabinoids, and tetrahydrocannabinol (THC)(the main psychoactive part of marijuana). An interview on 7/17/24 at 2:47 PM with the Physician revealed Resident #1 was on scheduled and as needed pain medication and she did not believe the resident had as adverse effects from missing a dose of pain medication. The facility provided the following corrective action plan with a completion date of 5/06/24. Problem statement included: The administrator filed a report with the North Carolina Board of Nursing, notified DEA (drug enforcement agency) with Loss Report Letter on 5/06/24 and notified the facility Medical Director, [NAME] County DSS, [NAME] County Sherriff's Department, and Resident Representative of findings of investigation via telephone on5/06/24. An investigation report was sent to the local area Ombudsman and Health Care Personal Agency on 5/6/24. The resident was not billed for this medication. Address how the facility will identify other residents having the potential to be affected by the deficient practice: A medication count of all controlled drugs was conducted by the Registered Nurse supervisors on 4/30/24 to ensure all controlled medication counts were accurate and available as ordered by the physician. No concerns were identified during this audit. On 4/30/24 the consulting pharmacist was in the facility to perform a routine audit to include controlled substances and on 5/06/24 the pharmacist was notified of the incident and medications that were diverted were replaced by the pharmacy as appropriate. On 4/30/24, all residents who received controlled medications for pain were assessed by the Assistant Director of Nursing and the Registered Nurse supervisors for pain to include signs and symptoms of pain both verbal and non-verbal to ensure pain levels were being addressed appropriately. Any concerns were reported to the charge nurse, Director of Nursing or Assistant Director of Nursing and addressed immediately. The Medical Director was notified, and orders were given as appropriate. No concerns were identified. An in-service was initiated on 4/30/24 by the Director of Nursing and the Assistant Director of Nursing on Abuse Neglect, Misappropriation, Reporting, Reporting, Code of Ethics, and Diversion. An in-service was also initiated on 4/30/24 by the Administrator with all nurses and medication aides to include agency staff regarding Controlled Substance Diversion to include: the definition, implications, and the process for returning controlled medications. All education was completed by 5/03/24. Any nurse or medication aide to include agency staff that have not completed the education as stated above by the completion date will do so by their next scheduled shift. Any newly hired licensed nurse, medication aide or agency staff will receive the above stated in-service education during orientation prior to their first shift. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 4/30/24, the Administrator initiated an in-service with all nurses and medication aides regarding Controlled Substance Diversion to include: the definition, implications, and the process for returning narcotic medications. The in-service also included ensuring all nurses and medication aides are administering medications per the provider's order. All in services were completed by 5/03/24. After 5/03/24, all nurses or medication aides to include agency and newly hired nurses and medication aides that have not received the in-service training will complete prior to working their next scheduled shift. The pharmacy will conduct monthly cart and med-pass audits to ensure nurses and medication aides, including agency and newly hired nurses, are following policy and procedures related to medication administration. All residents who are receiving a controlled substance for pain management will be monitored every shift for signs and symptoms of pain both verbal and non-verbal to ensure pain levels are being addressed appropriately. Any concerns will be reported to the charge nurse, Director of Nursing or Assistant Director of Nursing and addressed immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: A 100 % audit of all ordered controlled medications will be reviewed by the Director of Nursing Assistant Director of Nursing weekly x4 weeks and compared to the Controlled Substance Count Sheets, medication administration record, and/or the return drug requisition slips to ensure all controlled substance medications are being administered or have been returned to pharmacy as required per policy and there are no signs of drug diversion. Medication pass audits were completed by the Director of Nursing or Assistant Director of Nursing 3x/week for 4 weeks. All areas of concern were addressed during the audits including re-educating nurses. The Director of Nursing reviewed the conducted audits weekly x 4 weeks then monthly x 1 month to ensure all areas of concern were addressed appropriately. Any concerns will be addressed and investigated immediately. The Medical Director and Responsible Party will be notified of any concerns and care-plans/care-guides will be updated as appropriate. The Administrator or Director of Nursing will present the findings of the audit tools to the Quality Assurance Performance Improvement Committee monthly for 2 months. The Quality Assurance Performance Improvement Committee will meet monthly for 2 months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. QAPI meetings were held on 5/30/24 and 6/27/24. Date of Compliance: 5/06/24 The facility's corrective action with a correction date of 5/06/24 was validated onsite by interviews with the DON and nursing staff. Nursing staff confirmed they had received in-service training regarding pharmacy policy on safeguarding of controlled medications in medication carts, signing of shift-to-shift count sheets, tracking total number of sheets of controlled medications in the locked medication cart with the count sheet and proper procedures for return of discontinued controlled medications to the pharmacy. Interview with the DON revealed after the incident she had immediately educated all nurses on pharmacy policy of controlled medications. She had audited the controlled medications and ensured a 100% pain audit of residents to include complaints of pain and signs and symptoms of pain. She stated the interventions were successful as the facility had not had any diversion incidents since then.

Based on record review and staff interviews the facility failed to provide completed Notice of Medicare Non-Coverage (NOMNC) and/or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) to 3 of 3 residents reviewed for Beneficiary Notification (Residents #102, #103, and #104). Findings included: A review of the Beneficiary Notice Worksheet provided by the Administrator on 07/17/23 revealed the following residents were discharged from Medicare Part A skilled services during the previous six months: a. Resident #102 was admitted to the facility on [DATE] and discharged to the community on 02/24/23. Review of Resident #102's medical record revealed no evidence a NOMNC or SNF-ABN was provided to Resident #102 when her Medicare Part A skilled services ended. b. Resident #103 was admitted to the facility on [DATE] and discharged to the community on 03/18/23. Review of Resident #103's medical record revealed no evidence a NOMNC or SNF-ABN was provided to Resident #103 when her Medicare Part A skilled services ended. c. Resident #104 was admitted to the facility on [DATE] and discharged to the community on 05/30/23. Review of Resident #104's medical record revealed no evidence a NOMNC or SNF-ABN was provided to Resident #104 when her Medicare Part A skilled services ended. During interviews on 07/18/23 at 5:20 PM and 07/20/23 at 2:00 PM, the Administrator revealed the previous Bookkeeper was responsible for completing the NOMNCs and/or SNF-ABN forms when a resident's Medicare Part A skilled services ended. The Administrator stated they had looked everywhere for the copies of the NOMNCs and SNF-ABNs that were completed; however, they were unable to locate any documentation for the resident's listed on the Beneficiary Notice worksheet she had provided. The Administrator explained when the previous Bookkeeper retired in July 2023, she had packed up her office and they had looked through the boxes she had placed in storage but were unable to find any documentation of the completed NOMNC or SNF-ABNs for Resident #102, Resident #103, or Resident #104. The Administrator stated the previous Bookkeeper came to the facility to try and locate the documents, even looking through the recycle bin in case she had accidentally thrown them away, but she was unable to locate the NOMNCs or SNF-ABNs she had completed. The Administrator stated the previous Bookkeeper informed her she had completed the NOMNCs and SNF-ABNs but since they were unable to locate any of the documents, she could not state for sure if they had been completed as they should have been.

Based on observations and interviews with staff, the facility failed to secure a loose metal plate and place a cover over the telephone jack leaving the cutout in the wall and the metal plate exposed (room [ROOM NUMBER]-A), failed to repair areas of missing and discolored caulk and replace floor tiles with a buildup of a black colored substance around the base of the toilet in a shared bathroom (rooms [ROOM NUMBERS]) with odors resembling urine and failed to secure the light fixture located over the head of the bed (room [ROOM NUMBER]-B) for 4 of 4 rooms on 2 of 2 halls reviewed for environment. The findings included: 1. During an observation on 07/17/23 at 1:55 PM the cutout for the telephone jack located on the lower portion of the wall behind the head of the bed in room [ROOM NUMBER]-A had a loose-fitting metal plate with pointed edges and no cover to enclose the cut area of the sheetrock of the telephone jack. 2. During observations on 07/17/23 at 11:26 AM and 07/18/23 at 2:39 PM the shared bathroom of rooms [ROOM NUMBERS] had an odor resembling urine. At the base of the toilet there were areas with missing or black stained caulking. The floor tiles surrounding the base of the toilet had a buildup of a black colored substance. The bathroom appeared clean, and the floor was dry. An observation and interview were conducted with the Maintenance Director on 07/20/23 from 12:40 PM through 12:53 PM. Rooms 9-B, 33, 34, and 39-A were observed to be in the same condition with no sign repairs were being made. The Maintenance Director stated the lose metal plate exposing the telephone jack in room [ROOM NUMBER]-A was not connected to any electrical source but should be tightened and have a cover to prevent a resident from possible injury from the loose plate. The Maintenance Director revealed the light fixture over the bed in room [ROOM NUMBER]-B was not fully secured to the wall and should be tightened to prevent it from falling. The Maintenance Director observed the shared bathroom of rooms [ROOM NUMBERS] and stated both the floor tiles and caulk need replaced and should help prevent the urine like odors. The Maintenance Director revealed he checked resident rooms approximately once a month for environment concerns and staff use the computer system (TELS) to inform him of any environment concerns and stated he was not aware of the issues observed in rooms 9-B, 33, 34, and 39-A. An interview was conducted on 07/20/23 at 2:10 PM with the Administrator. The Administrator revealed staff report environment concerns to the Maintenance Director using the computer system (TELS). The Administrator revealed the loose metal plate and missing cover, and loose light fixture should be secure to prevent injury. The Administrator revealed staff should notice issues observed in rooms [ROOM NUMBER]-A and report and notify the Maintenance Director so they could be fixed. 37014 3. Observations of room [ROOM NUMBER]-B on 07/17/23 at 11:54 AM revealed the metal light fixture over the head of the bed was loose and not fully secured to the wall. Subsequent observations on 07/18/23 at 3:32 PM, 07/19/23 at 12:01 PM, and 07/20/23 at 9:36 AM revealed the condition of the light fixture over the head of the bed remained unchanged. An observation and interview were conducted with the Maintenance Director on 07/20/23 from 12:40 PM through 12:53 PM. The light fixture over the head of the bed in room [ROOM NUMBER]-B was observed to be in the same condition with no sign repairs were being made. The Maintenance Director stated the light fixture over the bed in room [ROOM NUMBER]-B was not fully secured to the wall and should be tightened to prevent it from falling. The Maintenance Director revealed he checked resident rooms approximately once a month for environment concerns and staff used the computer system (TELS) to inform him of any environment concerns. The Maintenance Director stated he was not aware of the issue with the light fixture being loose in room [ROOM NUMBER]-B. An interview was conducted on 07/20/23 at 2:10 PM with the Administrator. The Administrator explained staff reported environment concerns to the Maintenance Director using the computer system (TELS). The Administrator stated the loose metal light fixture in room [ROOM NUMBER]-B should be secured to the wall to prevent injury. The Administrator stated staff should have noticed the light fixture in room [ROOM NUMBER]-B and notified the Maintenance Director so it could be fixed.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of hospice and tobacco use for 2 of 3 sampled residents reviewed for hospice and smoking (Residents #47 and #22). Findings included: 1. Resident #47 was admitted to the facility on [DATE]. The Hospice Plan of Care, with an effective date of 06/29/23, revealed Resident #47 was certified to receive hospice services for end of life care. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had a life expectancy of 6 month or less; however, hospice care was not marked as received under special services and treatments. During an interview on 07/20/23 at 10:34 AM, MDS Nurse #1 confirmed Resident #47 was admitted to the facility under hospice care. She stated the MDS assessment dated [DATE] did not accurately reflect he received hospice care and it was an oversight. During an interview on 07/20/23 at 2:00 PM, the Administrator stated MDS assessments should be completed accurately per the Resident Assessment Instrument (RAI) guidelines (manual that explains how to code items on the MDS assessment). 2. Resident #22 was admitted to the facility on [DATE]. Review of Resident #22's comprehensive care plans, initiated 03/05/21 and last revised 07/17/23, revealed a plan that addressed a problem area of inappropriate smoking or use of tobacco/tobacco substitute products related to decreased safety awareness and risk for potential injury to self. Interventions included for staff to evaluate Resident #22's ability to smoke safely on a consistent and regular basis and supervise her smoking and monitor her extinguishing a cigarette. A Smoking assessment dated [DATE] revealed Resident #22 was assessed as a supervised smoker. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 revealed current tobacco use was marked as no. During an interview of 07/20/23 at 10:34 AM, MDS Nurse #1 confirmed Resident #22 was a supervised smoker. She stated the MDS assessment dated [DATE] did not accurately reflect she used tobacco and it was an oversight. During an interview on 07/20/23 at 2:00 PM, the Administrator stated MDS assessments should be completed accurately per the Resident Assessment Instrument (RAI) guidelines (manual that explains how to code items on the MDS assessment).

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed hospice care for 1 of 1 sampled resident reviewed for hospice (Resident #47). Findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and malignant neoplasm of colon. The Hospice Plan of Care, with an effective date of 06/29/23, revealed Resident #47 was certified to receive hospice services for end of life care. Review of Resident #47's medical record revealed a physician's order dated 06/30/23 for hospice services. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had a life expectancy of 6 month or less; however, hospice care was not marked as received under special services and treatments. Review of Resident #47's comprehensive care plans, last revised 07/17/23, revealed no care plan for hospice services. During an interview on 07/20/23 at 10:34 AM, MDS Nurse #1 confirmed Resident #47 was admitted to the facility under hospice care. She stated a hospice care plan should have been developed and was overlooked. During an interview on 07/20/23 at 2:00 PM, the Administrator stated Resident #47 was admitted to the facility under hospice care and a care plan should have been initiated upon his admission.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following a recertification and complaint investigation survey completed on 12/02/21. This failure was for one deficiency originally cited in the area of Develop/Implement Comprehensive Care Plan that was subsequently recited during a recertification and complaint investigation completed 07/20/23. This continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA Program. The findings included: This tag is cross referenced to: F656: Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed hospice care for 1 of 1 sampled resident reviewed for hospice (Resident #47). During the recertification and complaint investigation survey of 12/02/21, the facility failed to develop care plans that addressed a resident's diabetes and anticoagulant (blood thinner) medication use. During an interview on 07/20/23 at 2:19 PM, the Administrator revealed the concerns identified during the recertification survey of 2021 were reviewed by the QAPI committee and the processes that were put into place to ensure compliance had been effective at the time. The Administrator stated the previous Minimum Data Set (MDS) Coordinator resigned in August 2022 and the current MDS Coordinator was still new to the position. She explained there was a lot to learn related to the MDS assessment process and felt that the repeat concern related to care plans not being developed was just an oversight.

Based on observations, record review, staff interviews and the Centers for Disease Control (CDC) COVID-19 Tracker for [NAME] county transmission rate, the facility failed to follow CDC guidance regarding Personal Protective Equipment (PPE) for counties of high county transmission rates when 3 of 3 staff members (Infection Preventionist, Nurse #3 and Nurse Aide (NA) #3) failed to wear eye protection while providing care to 3 of 3 residents (Resident #3 Resident # 28 and Resident #51), the facility failed to implement their infection control policies and procedures when 2 of 2 staff members (Housekeeper #1 and NA #3) failed to wear the appropriate PPE for 1 of 1 resident (Resident #352) on enhanced droplet precautions and when 1 of 1 staff members (Wound care nurse) failed to perform hand hygiene in between glove changes while performing wound care for 1 of 1 resident (Resident # 49) reviewed for infection control. These practices had the potential to affect all residents who receive care from the facility staff. These failures occurred during a COVID-19 pandemic. The findings included: 1. On 11/29/2021 and 11/30/2021 the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker was reviewed. The CDC Covid-19 Data Tracker revealed that the county where the facility was located had a high level of community transmission for COVID-19. CDC guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 9/10/2021 indicated the following information under the section Implement Universal Use of Personal Protective Equipment for Healthcare Personnel (HCP): * If [CONDITION(S)]- CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), Healthcare Personnel (HCP) working in facilities working in counties with substantial or high transmission should also use PPE (Personal Protective Equipment) as described below including: Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. A facility policy entitled Guidelines on Latest Approach to PPE Use During COVID-19 Pandemic dated June 2021 read in part the following information under the section Eye Protection: * Staff working in the General Population should follow standard precautions with respect to eye protection UNLESS: -The facility is in a community with moderate to substantial COVID-19 transmission a. During an observation on 11/29/2021 at 11:42 AM, Nurse #3 was observed to administer medications to Resident #28 without eye protection in place. Nurse #3 was within 6 feet of Resident #28. An observation on 11/29/2021 at 11:45 AM revealed Nurse Aide (NA) #3 passing meal trays to Resident #3 and Resident #28 without eye protection in place. NA #3 was within 6 feet of both residents. An interview with NA #3 on 11/29/2021 at 3:05 PM revealed the NAs had attended a recent in-service regarding PPE but was not sure when the in-service was conducted. NA #3 further revealed she was not aware of what the Covid-19 community transmission rate was for the county the facility was in and had not recently been instructed to wear eye protection during patient care encounters. An interview with Nurse #3 on 11/29/2021 at 3:15 PM revealed Nurse #3 had attended a recent in-service regarding PPE but was not sure when the in-service was conducted. Nurse #3 further revealed she was not aware of what the Covid-19 community transmission rate was for the county the facility was in and there had been no recommendation to wear eye protection during patient care encounters. An interview with the Infection Preventionist on 11/29/2021 at 3:20 PM revealed the Infection Preventionist was not aware of the Covid-19 community transmission rate for the county in which the facility was located. The Infection Preventionist indicated she thought the staff were supposed to just wear surgical masks at that time. An observation on 11/30/2021 at 8:20 AM revealed the Infection Preventionist assisted Resident #51 to eat breakfast with no eye protection in place. The Infection Preventionist was within 6 feet of Resident #51. An interview with the Infection Preventionist on 11/30/2021 at 3:31 PM revealed the Infection Preventionist did not have eye protection in place during patient care encounters because she had asked the Administrator about it and reported she was told by the Administrator the community transmission rate was not what the facility used to decide if they wore eye protection during patient care encounters. The Infection Preventionist was not able to provide information on what policy or guidelines that were currently being followed. An interview with the Administrator on 11/30/2021 at 4:15 PM revealed she did look at the Covid-19 community transmission rate to determine whether the staff needed to wear eye protection. The Administrator further revealed she also looked at the case rate and it was suppressed. The Administrator indicated the facility policy dated June 2021 did state the staff should wear eye protection when their community transmission rate was high. The Administrator requested to research their facility policies at that time. A follow up interview with the Administrator on 11/30/2021 at 5:20 PM revealed per CDC guidelines and their facility policy dated June 2021, staff should have worn eye protection while the Covid-19 community transmission rate was high. b. A facility policy entitled Isolation Precautions dated 3/10/2020 read in part the following information: * Droplet precautions in addition to standard precautions should be used for residents known or suspected to be infected with microorganisms transmitted by droplets. Examples include Covid-19. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 11/29/2021 at 2:40 PM revealed NA #3 was in Resident #352's room making his bed with only a facemask in place. No other PPE was in place. Housekeeper #1 was also observed in Resident #352's room at the same time mopping the floor with only a facemask in place. No other PPE in place. Resident #352 was a new admission on enhanced droplet precautions due to unknown Covid status. Resident #352's door did have enhanced droplet precaution signage posted and PPE equipment was available for use. An interview with NA #3 on 11/29/2021 at 3:05 PM revealed she should have worn the appropriate PPE while in Resident #352's room. An interview with Housekeeper #1 on 12/1/2021 at 6:35 PM revealed Housekeeper #1 did not wear the appropriate PPE in Resident #352's room because she did not see the enhanced droplet precaution sign or the PPE equipment on Resident #352's door. Housekeeper #1 further revealed she would have worn the appropriate PPE if she had seen the signage and PPE equipment. During an interview with the Housekeeping Supervisor on 12/2/2021 at 8:16 AM, she indicated the part of the facility where Resident #352 resided was designated as quarantine rooms. The Housekeeping supervisor further indicated Housekeeper #1 should not have been in Resident #352's room without the appropriate PPE in place. An interview with the Director of Nursing (DON) on 12/1/2021 at 10:02 AM revealed Resident #352 was on enhanced droplet precautions at the time of the survey. The DON further revealed staff should wear the appropriate PPE when they enter an isolation/quarantine room. During an interview with the Administrator on 12/1/2021 at 10:08 AM, she indicated Resident #352 was on enhanced droplet precautions at the time of the survey. The Administrator further revealed staff should wear the appropriate PPE when they enter an isolation/quarantine room. An interview with the Administrator on 12/2/2021 at 8:56 AM revealed the part of the facility where Resident #352 resided was designated as quarantine rooms. The Administrator further revealed she expected staff to follow facility policies and procedures for isolation/quarantine rooms which included to wear the appropriate PPE according to the posted signage on the doors. 2. Review of the facility's handwashing policy, dated 3/10/20, stated in part, Wash hands before and after touching wounds, after touching blood, body fluids, secretions, excretions and contaminated items, whether gloves are worn or not. Wash hands immediately after gloves are removed .An alcohol-based hand sanitizer may be used for handwashing unless the hands are visibly soiled. On 12/01/21 at 1:34 PM, the Wound Nurse (WN) was observed performing wound care on Resident #49. The WN performed hand hygiene, put on clean gloves, cleaned Resident #49's buttocks of stool using wipes. The wipes were discarded as well as the dirty gloves. WN put on a clean pair of gloves without performing hand hygiene. She removed the soiled dressing and discarded. She removed her gloves but failed to perform hand hygiene. She put on a clean pair of gloves and cleaned with sacral pressure ulcer with normal saline, applied Santyl and silver alginate. She applied skin prep around the wound and applied a [MEDICATION(S)] dressing. She removed the gloves and failed to perform hand hygiene. She put on a clean pair of gloves and pulled Resident #49 up in the bed. On 12/01/21 at 2:01 PM, an interview was conducted with the Wound Nurse. She stated she should have used hand hygiene between glove changes. She stated she had hand sanitizer in her pocket but forgot to use it. On 12/01/21 at 2:10 PM, an interview was conducted with the Infection Control Nurse. She stated the wound nurse should have performed hand hygiene between each glove change while performing the wound care. On 12/2/21 at 9:30 AM, an interview was conducted with the Director of Nursing. She stated the wound nurse should have performed hand hygiene between each glove change.

Based on record review and staff interviews, the facility failed to develop an anticoagulant and diabetes care plan for 1 of 5 residents (Resident #28) reviewed for unnecessary medications. The findings included: Resident #28 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was severely cognitively impaired. Care plan review revealed there was no care plan in place for diabetes or for the anticoagulant medication. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] * [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]) -Give 1 tablet by mouth two times a day for DVT LLE q12hr. Order dated 11/25/2019 * [MEDICATION(S)] Solution 100 UNIT/ML -Inject 45 unit subcutaneously in the morning for diabetes. Order dated 1/17/2020 * NovoLog Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) -Inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 11; 401+ = 13 401 or Greater give 13u, subcutaneously four times a day for Diabetes Before meals and at bedtime. Call the provider if blood glucose is less than 70 or more than 350 two times in a row or at the same time each day for 3 days in a row. Order dated 5/13/2020 * [MEDICATION(S)] Solution 100 UNIT/ML -Inject 15 unit subcutaneously one time a day for diabetes. Order dated 11/25/2020 * NovoLog Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) -Inject 14 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) HOLD IF GLUCOSE IS < 90. Order dated 11/29/2020 During an interview with the MDS coordinator on 12/1/2021 at 9:50 AM, the MDS coordinator revealed she was the one responsible for ensuring the appropriate care plans were in place for the residents. The MDS coordinator further revealed there was no care plan in place for diabetes or the anticoagulant medication for Resident #28. The MDS coordinator indicated that Resident #28 should have a care plan in place for diabetes and the anticoagulant medication. An interview with the Director of Nursing (DON) on 12/1/2021 at 10:02 AM revealed Resident #28 should have had a care plan in place for diabetes and for the anticoagulant medication. An interview with the Administrator on 12/1/2021 at 10:08 AM revealed Resident #28 should have had a care plan in place for diabetes and for the anticoagulant medication.

Based on observations, staff interviews and review of the facility's infection control policies, the facility failed to implement their hand hygiene policy for 17 of 17 residents observed during meal tray delivery on the North hall when 2 nurse aides (NA) failed to remove gloves and perform hand hygiene after assisting the residents and before leaving the residents' rooms (Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and #17). These failures occurred during a COVID-19 pandemic. The findings included: Review of the facility's infection control policy, Handwashing version date 3/10/2020, revealed, Wash hands immediately after gloves are removed, between residents .and when otherwise necessary to avoid transfer of microorganisms to other residents .Good hand hygiene is essential Wash hands using soap and water. Waterless hand agents may be used if hands are not visibly soiled . On 9/29/20 at 8:45 am an interview with the Administrator identified the North hall as a non-Covid hall. The Administrator also stated that the health department has given a directive that all employees wear full personal protective equipment (PPE) at all times while in the facility. On 9/29/20 a continuous observation was conducted on the North hall from 11:30am until 11:55 am of NA #1 and NA #2 delivering meal trays. Each NA was wearing a face mask, a face shield, gloves and a gown. Both pushed the meal cart to the lower end of the hall where they began delivering meal trays, starting with Resident #1 and #2. NA #1 and NA #2 removed a meal tray and entered Resident #1 and #2's room. They failed to perform hand hygiene before entering the room. They delivered the meal trays and assisted with opening the disposable meal containers. After exiting the room, NA #1 and NA #2 proceeded to the meal cart, wearing the same gloves without performing hand hygiene. NA #1 and NA #2 continued delivering the meal trays to Residents #3, #4, and #5. NA #2 entered Resident #6's room, assisted the resident with removing the bed covers from over her arms and pulled the resident's sleeves down on both arms. She then proceeded to set up the meal tray. NA #2 left the resident's room, failed to perform hand hygiene and change gloves and proceeded to the meal cart, removed a meal tray for Resident #7. NA #2 entered Resident #7's room, placed the meal tray on the overbed table then assisted the resident with repositioning. NA #2 exited the room and proceeded to the meal cart without performing hand hygiene. NA#1 and NA #2 delivered meal trays to Residents # 8, #9, #10, #11, #12, #13, #14, #15, #16 and ended with Resident #17, wearing the same pair of gloves and failing to perform hand hygiene. The observation ended after all 17 residents on the North hall had been served a meal tray. An interview, conducted with NA #1 on 9/29/20 at 2:00 pm, revealed her main responsibility was to provide showers for the residents. She stated she has been pulled to work on the hall recently but not been passing meal trays to the residents. NA #1 revealed she had received recent COVID-19 pandemic training and was instructed to remove gloves and wash or sanitize her hands before exiting each resident's room after assisting residents and before they left the room. She stated there was access to a sink with soap and water from each room. She further stated she was confused about changing gloves since they were told they needed to wear gloves all the time, even when in the hallways. She stated the gloves were kept in the residents' bathrooms and were not easily accessible. An interview, conducted with NA #2 on 9/29/20 at 2:10 pm, revealed she was a NA whose responsibility was to provide showers for the residents. She stated she has been pulled to work on the hall recently and has not been passing meal trays to the residents. NA #2 revealed she had received recent COVID-19 pandemic training and was instructed to remove gloves and wash or sanitize her hands before entering and exiting each resident's room after assisting residents and before they left the room. She stated there was access to a sink with soap and water from each room. She further stated she thought she should be changing gloves but was confused about being told she needed to wear gloves all the time, even when in the hallways. She stated the gloves were kept in the residents' bathrooms and were not easily accessible. An interview, conducted with the Infection Preventionist (IF) on 9/30/20 at 9:00 am, revealed, at the end of August 2020, the health department instructed the facility that all employees should wear full PPE at all times. The IF stated she provided in-services to all staff on COVID-19 precautions which included all staff should perform hand hygiene when entering and exiting a resident's room. She stated that she, the DON, the Nursing Supervisor and the Administrator observed staff daily to ensure they were following basic infection control policy and procedures. If staff were found not to be following policy and procedure, they were immediately educated. The interview further revealed she expected the NAs to perform hand hygiene and put on a new pair of gloves between residents when delivering the meal trays. An interview with the DON on 9/30/20 at 9:20 am revealed she participated in surveillance of the staff daily to ensure staff were following basic infection control policy and procedures. If staff were found not to be following policy and procedure, they were immediately educated. The interview further revealed she expected the NAs to perform hand hygiene and put on a new pair of gloves between residents when delivering the meal trays.

Based on record review, observations and staff interviews the facility failed to provide supervision for a cognitively impaired resident who exited the facility while unsupervised for 1 of 3 sampled residents (Resident #6). Resident #6 was discovered outside of the facility 48 feet from the facility's front entrance without supervision and was assessed by a nurse to have no injuries upon his return to the facility. The findings included: Resident #6 was admitted to the facility 10/05/11 with [DIAGNOSES REDACTED]. Review of the notes of a Wandering Resident Meeting (WRM) on 05/24/18 revealed Resident #6 was discussed. The resident behavior documentation and Minimum Data Set (MDS) assessments were reviewed and no wandering behavior was noted. The determination was made that his alarm bracelet could be removed. The Interdisciplinary Team (IDT) progress notes gave no indication of any attempts by Resident #6 to exit the facility unsupervised. The annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had short and long term memory problems. The MDS further indicated Resident #6 had no wandering behavior during the 7 day assessment period. The MDS also indicated Resident #6 had severe cognitive impairment. There was no care plan addressing Resident #6 being at risk for wandering prior to exiting the facility on 07/09/18 unsupervised. Observations of Resident #6 throughout the survey revealed he was mobile in his wheelchair by using his legs only. He was observed going up and down the hallway and into his room slowly, but with little difficulty. Review of a nurse's note from Nurse #3 dated 07/09/18 revealed Resident #6 had an unwitnessed elopement from the building this AM and was found in the parking lot by the Maintenance Supervisor, returned to facility with no injuries and is currently on continuous supervisor watch with a staff member. During an interview with the Receptionist on 10/18/18 at 9:45 AM, she stated part of her job was to watch who comes in and leaves the facility. She also stated a Receptionist was available 7 days a week from 9:00 AM to 7:00 PM to observe who came in and left from the facility. She further stated whenever she took a break the front door was always monitored by another staff member, usually the Accounts Receivable (AR) Manager. During an interview with the Maintenance Director on 10/18/18 at 9:51 AM, he stated he had been outside the front of the building on 07/09/18 when he saw Resident #6 in his wheelchair propelling himself backwards with his legs. The Maintenance Director also stated he brought Resident #6 back into the building and stopped by the Administrator's office to let her know what happened before returning Resident #6 to the nurses' station on the hall where he resided and he was assessed by the nurse to have no injuries. During the interview the Maintenance Director showed where he found Resident #6 in the facility's parking lot on 07/09/18. The Maintenance Director utilized a measuring tape and measured the location where he saw Resident #6 in the parking lot and determined it was 48 feet from the front entrance and a total of 70.5 feet from where the parking lot began sloping down to the driveway. During an interview with the AR Manager on 10/18/18 at 10:00 AM, she stated on 07/09/18 the therapy manager came to her office and shut the door behind her. The AR Manager also stated the receptionist was not present that day and she was watching the front, so for about 20 minutes while she was completing the Medicare billing with the therapy manager, no one was watching the front door. She also stated she was educated by the Administrator that she could no longer close the door anymore and her first concern when she was watching the front was to see who was coming and going. She further stated when the receptionist took a break now, she actually went to the receptionist office and observed who came and went from the facility. During an interview with the Administrator on 10/18/18 at 10:28 AM, she stated she was always present for the monthly wandering resident meetings. She also stated she was present on the day Resident #6 was discussed back in (MONTH) (YEAR) and they had looked back over several months of notes and determined he had no exit seeking behaviors or periods of aimless wandering in his wheelchair. She further stated the determination was made to remove his alarm bracelet. The Administrator acknowledged a root cause analysis had been completed and it was determined that the Accounts Receivable Bookkeeper had not monitored the front door as assigned. The Administrator stated she did not believe Resident #6 was capable of opening the door independently. During an interview with the MDS Coordinator on 10/18/18 at 1:42 PM, she indicated she remembered when Resident #6 came to her door in his wheelchair on the morning of 07/09/18. She also stated he was attempting to speak to her, but then left and headed down the hallway in the opposite direction of the front door. She further stated about 10 minutes after this occurred, the medication nurse for Resident #6 came to her office to tell her he had been found outside by the Maintenance Director. The MDS Coordinator stated she then left her office to check on Resident #6 to make sure he was alright and found that he had already been assessed to be okay and had a one to one sitter with him. She then went to find the Maintenance Director and asked him what happened. She also stated she was very surprised to find out he had been outside the front of the facility because he had always been complacent and had never talked about leaving the facility or been observed pushing on exit doors. The facility provided a plan of correction with a correction date of 07/16/18. The plan of correction included the following: Root Cause: Accounts Receivable Bookkeeper did not monitor the door as assigned. What measures did the facility put in place for the resident affected? On 5/24/18 during wandering resident meeting, resident #6 was discussed, resident behavior documentation and MDS assessments were reviewed and no wandering behaviors were noted. It was determined to be safe to remove wander guard and resident #6 was care planned for this change. On 7/9/18 at approximately 10:30am resident #6, who is cognitively impaired, self-propelled out of facility in wheelchair without staff being aware. Was noted approximately 48ft from front door in the front parking lot of facility by maintenance director and was assisted back into facility. Resident #6 was outside for approximately 3-5 minutes. On 7/9/18 resident #6 was assessed by facility staff nurse with no injuries or concerns found. Physician and resident responsible party were notified on 7/9/18 by facility nurse. On 7/9/18 all exit doors were checked by facility staff, all doors were locked and alarming appropriately. On 7/9/18 a Wandering Risk Assessment, which includes questions regarding exit seeking behaviors, was completed for resident #6 and the care plan for the resident was updated to reflect at risk for wandering with interventions. On 7/9/18 a wander guard was placed on resident #6 by facility staff. On 7/9/18 resident #6 was placed on one on one supervision and wander guard was placed on resident #6. Care plan was updated to reflect interventions. On 7/16/18 one to one supervision was stopped when resident #6 was moved to room [ROOM NUMBER]B across from the nurse's station. On 7/16/18 resident #6 care plan was updated to reflect intervention change. Once resident #6 was moved across from nurses station one to one supervision was stopped because resident #6 was in a room that allowed for closer monitoring of location. What measures were put in place for residents having the potential to be affected? On 7/09/18 a 100% complete head count was completed for all residents by facility nurses. No residents were unaccounted for. On 7/09/2018 scheduling was changed so that a facility receptionist is assigned to monitor the facility front door 7 days per week from 9am to 7pm. The front is locked from 7PM until 9AM. The receptionist is scheduled and posted on a biweekly basis in the receptionist area on the phone list schedule and part of the receptionist duties are to watch the facility front door while doors are unlocked. On 7/09/2018 receptionists were notified of this responsibility by the Administrator and Director of Nursing. On 7/10/18, the facility nurses completed a wandering risk assessment on all current residents. Any resident assessed at risk, will be reviewed by the interdisciplinary (IDT) team to ensure the care plan, and interventions are in place and current. On 7/9/18 the facility consultant reviewed risk management reports for the past 90 days to identify any trends related to exit with no trends noted. An in-service was started on 7/9/18 by the Director of Nursing for all facility nurses on completion of the wandering risk assessment including implementation of interventions for residents at risk. No licensed nurse will be allowed to work after 7/9/18 until in-service is complete. The in-service was completed by 7/16/2018. An in-service was started on 7/9/18 by the Director of Nursing for all facility staff on monitoring of residents locations to include if assigned to watch the front door, you must physically be in line of sight of door at all times. No staff will be allowed to work after 7/9/18 until in-service is complete. The in-service was completed by 7/16/2018. Information regarding residents at risk for wandering will continue to be left in the receptionist area in the Wandering Residents Book, which is updated by the QI Nurse and Medical Records. Regardless of resident behavior, all staff are to contact the nurse on duty before a resident exits the front door, unless assisted by staff or Emergency Management Services. What systems were put in place to prevent the deficient practice from reoccurring? On admission, quarterly, and with significant change in condition a resident will have a wandering risk assessment completed. If resident is determined by assessment to be at risk, resident will be reviewed by the IDT team to ensure the care plan, and interventions are in place and current. The QI Nurse was in-serviced regarding this process on 7/09/18 by the Administrator and explained that she will oversee this process. How the facility will monitor systems put in place: The director of nursing (DON), administrator, social worker and/or staff facilitator will review risk management reports 5 x weekly x 4 weeks to ensure no exits occurred. If occurred actions taken were appropriate, including interventions. This audit will be documented on the Risk Management audit tool. The administrator and/or DON will present the findings and recommendations of the monthly (Quality Improvement) QI committee and to the quarterly executive Quality Assurance Performance Improvement (QAPI) committee for further recommendations and oversight. The Risk Management reports include a description in incident location which was reviewed to ensure no further incidents related to staff failure to monitor front door occurred. Ongoing monitoring of residents assessed to be at risk for wandering are reviewed monthly during Wandering at Risk QA meeting and reviewed during the Quarterly Quality Assurance Performance Improvement committee and there have been no additional negative findings related to staff monitoring of front door. Beginning 7/09/18, the Administrator is given a copy of the biweekly receptionist schedule. Staff were in-serviced beginning 7/09/18 by the Administrator and Director of Nursing that if the receptionist is unable to work her schedule, receptionist is to inform the Administrator. If the receptionist must leave the receptionist area, they must ensure that another staff member relieves them before they leave this area. In-service was completed on 7/16/2018. The QAPI Meeting was held on 8/23/2018 with Facility Department Heads and the Medical Director in which the incident and four point plan was reviewed. Validation: The facility's plan of correction and correction date of 07/16/18 was validated on 10/18/18 and 10/19/18. Validation of the facility's plan of correction included the following: Verification of wandering risk assessments completed for all residents, receptionist schedule verification of front door coverage from 9:00 AM to 7:00 PM daily, an in-service for all facility nurses of completing the wandering risk assessment and an in-service for all facility staff on the monitoring of residents location if assisted to watch the front door and an update of resident information for those at risk for wandering is updated with the information for Resident #6. The care plan updated for 07/09/18 indicated Resident #6 was at risk for wandering and/or at risk for unsupervised visits from facility related to attempts to leave unit/building. The goal for Resident #6 was to have no episodes of unsupervised exits from facility through next review. Some of the interventions included check daily to ensure resident has an alarm bracelet on and that it is functioning properly and document episodes of wandering. During an interview with Nurse #2 on 10/18/18 at 11:19 AM, she stated all residents with an alarm bracelet are visually inspected by the nurses at 6:00 AM and 6:00 PM and this is documented on the Medication Administration Record (MAR) daily. Nurse #2 also stated they have a nursing assistant (NA) who goes to all those residents with a mechanical device that checks the alarm bracelets to make sure they will alarm. During an interview with nursing assistant (NA) #4 on 10/18/18 at 11:29 AM, she stated she worked 6 days a week and uses a scanner tool to check all residents with wanderguards to ensure they are functioning correctly each morning. NA #4 further stated that the alarm bracelet for Resident #6 was on his left ankle and she had checked and signed off that it was working as of this morning.