Every finding on record at Greenhaven Health and Rehabilitation Center

Based on observations, record review, and staff, physician, family and law enforcement interviews, the facility failed to supervise a severely cognitively impaired resident from exiting the facility without supervision. On 08/05/25 at approximately 8:30 pm Resident #1 followed Dietary Aide #1 out of the employee exit door and exited the facility. Resident #1 did have a wanderguard bracelet (component of a wander management system) on his left ankle; however, the door Resident #1 exited did not have a transmitter sensor and the magnetic lock was released when Dietary Aide #1 entered a code on the door keypad. Dietary Aide #1 believed Resident #1 to be a visitor (because he was wearing street clothes, had a hat on, and was walking unassisted) and had directed him to exit through the front door and did not realize Resident #1 had followed him out the door until he saw him walking outside the building toward the front as he was driving away. On 08/05/25 Resident #1 was located by local law enforcement at 10:37 pm (approximately 1.0 mile away from the facility.) He was found lying in the road on a five-lane main street where the I-40 interstate east and west on and off ramps are located at the intersection of [NAME] Road and [NAME] Street. When law enforcement arrived, a bystander was trying to help Resident #1 get out of the street. It appeared to law enforcement that Resident #1 had fallen over the median and was lying face down on the pavement in the middle of the busy road. It was raining and he was shaking, cold, and wet. He was returned to the facility by the Director of Nursing and Medication Aide #1 in Medication Aide #1's private vehicle. Emergency Medical Services (EMS) personnel assessed Resident #1 at 11:41 pm on 08/05/25 at the facility. Resident #1's mental status was oriented to person only and EMS presumed Resident #1 had fallen. EMS left the resident with his family to transport him to the hospital at the family's request. The family took him directly to a regional hospital where he was diagnosed with a left 1 cm (centimeter) subdural hematoma (brain bleed), a right 7 mm (millimeter) subdural hematoma (brain bleed), a 3 mm midline shift of the ventricle (when the brain moves past it's center line) due to the subdural hematoma (brain bleed), a right maxillary sinus fracture (beside the nose/beneath the eye), a right orbit fracture (bone around the eye), and a right zygomatic arch fracture (cheek). He was transferred to a higher-level trauma hospital for treatment. The Trauma Medical Center Physician stated Resident #1 had been transferred to their trauma unit from an affiliated regional medical center because the size of his brain bleed was too large for the other hospital to manage in accordance with their hospital protocol and the injuries Resident #1 presented with were life threatening. This was for 1 of 3 residents reviewed for accidents (Resident #1). Findings included:A history and physical assessment completed by Physician #1 on 05/28/25 for Resident #1 (when Resident #1 was previously admitted to the facility for a 5-day respite stay) was reviewed. Resident #1 was assessed to have severe chronic dementia. He required assistance with bathing and was continent of bowel and bladder. He was without untoward behaviors or overt agitation. He had a subtle anxious affect, with a tendency toward wandering.Resident #1 was admitted to the facility on [DATE] for respite care (temporary institutional care of a sick, elderly, or disabled person, providing relief for their usual caregiver). He entered the facility from home. Diagnoses included Alzheimer's disease, low back pain, chronic kidney disease stage 1, Type 2 Diabetes Mellitus, major depressive disorder, hypothyroidism, and essential hypertension.A Nursing Admission/Re-entry Evaluation assessment completed by Nurse #2 on 08/04/25 was reviewed. Resident #1 needed setup or clean-up assistance with dressing and personal hygiene. He needed moderate assistance with showering. He was independent with eating. He was independent with mobility, transferring, and ambulation. He did not use any assistive devices for mobility. He could communicate with some difficulty. He wore glasses. He had no falls within the past 30 days of admission. He had a serious intellectual mental health diagnosis. His admission to the facility was for short-term placement.A Wandering Risk Evaluation completed by Nurse #2 on 08/04/25 was reviewed. Nurse #2 documented Resident #1 had no known history of attempts to leave home or facility or wander. His mood and behavior was complacent. He was ambulatory and/or self-mobile. He had a diagnosis of Alzheimer's dementia or severe cognitive impairment. He never or rarely made decisions. He rarely/never understood or was understood when communicating. He made verbal statements of a desire or intent to leave the facility. Resident #1 scored 13 on the assessment (a resident who scores greater than 5 is at risk for wandering.) A progress note written on 08/04/25 at 4:25 pm documented Resident #1 arrived at the facility on 08/04/25 at 12:00 noon from PACE (a program of all-inclusive care for the elderly) for Respite Care accompanied by family. He had a wanderguard on his left leg. Resident #1 was a participant in the PACE of the Triad program under the primary care of the PACE physician. In an interview with the Pace Program Physician on 08/11/25 at 9:49 am she stated Resident #1 had been a participant in the Pace program since 05/01/25. She explained he wandered and was often agitated. She stated he was not okay to be outside by himself. She noted PACE staff often calmed Resident #1 down by singing hymns to him. She reported that he acted out in non-violent ways and was resistant to care.Review of a skin assessment dated [DATE] at 6:07 pm by the Treatment Nurse was reviewed. Resident #1 had no abrasions or cuts on his body on admission.A progress note written on 08/04/25 Nurse #1 at 11:35 pm documented, in part, that on admission Resident #1's skin was dry and warm to touch with no lesions noted, that he was ambulatory, wandered around and needed frequent redirection.Review of the care plan for Resident #1 initiated on 08/04/25 revealed the following focus areas: Wandering and or at risk for unsupervised exits from facility related to cognitive impairment and at risk for falls characterized by a history of falls/actual falls, injury and multiple risk factors. The goals were: 1) The whereabouts will be known to staff as demonstrated by no events of leaving the facility unsupervised, 2) Will have no episodes of unsupervised exits from the facility, and 3) The resident will remain free of injury as evidenced by no falls or accidents through the next review. Interventions included to place familiar objects in resident surroundings, Wanderguard alarm bracelet to the resident's left ankle, have commonly used articles within easy reach, and keep the call light within reach and answer timely.The following physician orders were reviewed: WANDERGUARD-Verify location and expiration every day and night shift for Safety (start date 08/05/25); and Check Wander Device Transmitter to ensure proper functioning every day and night shift for Safety/Monitoring (start date 08/05/25).A telephone interview was conducted with Nurse Aide #1on 08/12/25 at 10:29 pm. She stated she had cared for Resident #1 on 08/04/25 and 08/05/25 on day shift. She recalled on 08/04/25 he had been looking for his mama and asked her where she was. She told him that his mama wasn't there. She remembered she had seen him walking up and down the hall several times but had not seen him pushing on any exit doors.An interview was conducted with Medication Aide #2 on 08/12/25 at 10:16 am. She started her shift at 5:00 pm on 08/05/25. She recalled Resident #1 was sitting in a chair on the 400 hall and did not appear to be upset and he was calm. He was still sitting in the chair when the dinner carts came to the hall at approximately 5:30 pm. She stated at approximately 6:30 pm she saw Resident #1 walking up and down the 300 and 400 halls. Medication Aide #2 recalled when she was providing care to another resident, Resident #1 approached her and asked her where the door was to get out. She stated she told him, No, and directed him to his room, but he replied, I already paid my money and I'm going to see my mother and father and he walked away.In a telephone interview with Nurse Aide #1 on 08/12/25 at 10:29 pm she stated on 08/05/25 Resident #1 ate his meals in the hallway because he did not want to be in his room. She noted that he had refused to allow her to take him to the bathroom during her shift.A telephone interview was conducted with Nurse Aide #3 on 08/12/25 at 11:25 am. She stated she worked at the facility through an agency. She reported that she had arrived at work around 3:00 pm on 08/05/25. She observed Resident #1 walking around the facility and wandering in and out of rooms. She recalled he would swing his arms at staff who approached him. He was difficult to redirect and continued wandering in and out of rooms and hallways during the shift. Around 6:30 pm she helped pass out meal trays on the hall. At that time Resident #1 was wandering in the hallway. She had attempted to redirect him to his room for his meal, but he refused. She recalled she had taken a break at 7:30 pm. She reported that during her break she had been sitting in her car that was parked in the front of the building, and she did not see any resident leave the building while she was on break.An interview was conducted with the Dietary Aide on 08/12/25 at 9:42 am by telephone. He stated that on the night Resident #1 exited the building without staff knowledge on 08/05/25 he had worked the evening shift in the kitchen. He stated he clocked out at approximately 8:17 pm. He reported that when he approached the first set of double doors that lead to the employee exit door, he noticed a man (Resident #1) behind him. He stated Resident #1 was dressed in street clothes, had a hat on, and was walking unassisted and looked like a visitor, so he told him that visitors exited the building in the front and directed Resident #1 to go to the front and sign out. He noted the man kept saying, I paid my money. My parents are coming to pick me up. He thought Resident #1 had walked away. He stated his ride arrived; he punched in the code for the employee exit door and left the building. He recalled he was almost to the car when he noticed the employee exit door was open and alarming, so he went back to the building and secured the door. He stated he did not see Resident #1 exit the building; however, when he was leaving the parking lot, he had seen Resident #1 outside of the building walking toward the front. He explained he believed Resident #1 to be a visitor who was going to the front of the building to catch a ride, so he did not intervene.An interview was conducted with Medication Aide #1 on 08/12/25 at 9:50 pm by telephone. She stated when she went to give Resident #1 his evening medications on 08/05/25, he was not in his room. She reported it was 8:17 pm when she noticed he was not in his room. She explained she instructed two Nurse Aides to look up and down the 300 and 400 hallways because he did wander. The Nurse Aides could not find him, so the 100 and 200 halls were searched. Medication Aide #1 stated she could not find the resident in the facility. The search exhausted all areas he might have been and when she realized the resident might have exited the building, she notified Nurse #1. She could not remember what time she told Nurse #1 that the resident was missing. She stated Nurse #1 called a Code Orange (missing person) as soon as she told her. Medication Aide #1 concluded she had locked her medication cart and participated in the search but did not find the resident.An interview was conducted with Nurse #1 on 08/12/25 at 1:55 pm by facetime. Stated she was told that Resident #1 could not be located at 8:45 pm by Medication Aide #1 on 08/05/25. She explained she immediately called a code orange (missing person). She stated she had kept notes and written down times regarding the three searches she conducted. She recorded the following times: the first search was at 8:50 pm; the Director of Nursing (DON) was called at 8:55 pm, the second search was at 9:13 pm, and the third search was at 9:20 pm. All searches included inside and outside the facility. She stated at 9:25 pm she got in her personal car to search the surrounding area. She stated she went to the left when she turned out of the parking lot because she thought he would have gone that way because there were more lights, but she couldn't find him. She noted she continued to search for him until the police arrived at the facility. She stated that when the resident returned to the facility she helped the family change his clothes and provided first aide to a laceration on his face and abrasions on both his legs above his knees. She noted that EMS came to the facility and were able to assess the resident. She stated she was never able to perform a head-to-toe assessment on the resident because the family wanted to take him home. She concluded that the last time she interacted with the resident he had been sitting in a chair with his family in the front lobby. During the interview she provided a copy of the notations she had made regarding the times mentioned above along with a screen shot of the phone record that indicated the time she reported to the DON that Resident #1 was missing.In an interview conducted with Medication Aide #2 on 08/12/25 at 10:16 am she recalled sometime around 9:00 pm on 08/05/25 an Agency Nurse Aide approached her and asked if she had seen Resident #1 and stated staff could not find him. She stated she began to look for him and had searched the salon, bathroom, and laundry room but was unable to find him. As she was looking for him another Nurse Aide told her she had seen him on the 300 hall pulling at the exit door, but she did not know the Nurse Aide's name. She explained she went to the 300 hall to search for him. She checked all the doors on the 300 hall, and they were all locked. She stated she had not heard any door alarms sound during her shift. The following written statement made by Nurse Aide #4 on 08/06/25 was reviewed. She had documented, in part, that she witnessed Resident #1 push the exit door handle on the 300 hall at approximately 8:00 pm on 08/05/25. She also documented that she had seen the resident around 8:45 pm. She had told him that the door was locked, and he walked back up the 300 hall towards the nursing station. She wrote that he stated he was looking for his mom and dad. An interview was conducted with Nurse Aide #4 on 8/12/25 at 3:11 pm. She stated that her written statement was not correct. She reported she thought her first interaction with the resident was at 8:00 pm on 08/05/25 but she had heard some other staff member say 8:45 so that's what she documented. She denied she had seen him push the door handle and had only heard him say he wanted to get out to see him mom and dad.In a telephone interview conducted with Nurse Aide #3 on 08/12/25 at 11:25 am she remembered that when she returned to the building after her break on 08/05/25 she was told that Resident #1 was missing. She stated she really wasn't sure what time she returned to the building. She noted she joined in the search for the resident and recalled some staff members used their personal cars to search in surroundings neighborhoods. She stated when she punched out around 11:05 pm the resident had not been found.The law enforcement Incident/Investigation Report was reviewed. The date and time of the report was 08/05/25 at10:37 pm. The location of the incident was 2501 [NAME] Road and [NAME] Street. The victim was Resident #1. A second police officer assisted the responding officer on the scene. The responding law enforcement officer documented: On 08/05/2025 at 2237 (10:37 pm) hours, I responded to [NAME] Rd. and [NAME] St. in reference to a suspicious activity. The investigation is ongoing at this time.A return telephone call from the responding Law Enforcement Officer was received on 08/12/25 at 10:20 pm. He explained he had responded to a call at the location of [NAME] Road and [NAME] Street on 08/05/25 for an incident of simple physical assault. He stated when he arrived a bystander was standing over the resident trying to get him up and out of the street. Two young ladies had pulled over after exiting the I-40 ramp and were yelling aggressively at the bystander who was trying to help Resident #1. He stated when he interviewed the 2 young ladies they told him they thought the bystander was assaulting the resident but had never seen him or anyone hit the resident. The bystander explained to him that he had been walking by with his girlfriend, saw the resident lying in the middle of the road and was trying to help him. The responding Law Enforcement Officer stated the traffic on [NAME] was heavy that night on the 5-lane road. He reiterated that no one was seen beating up the resident. He commented that it was a very busy area and if someone was getting beat up there would have been more than one call to 911. He concluded it appeared that Resident #1 had fallen over the median and was lying face down on the pavement in the middle of the busy road and the bystander was trying to help him get out of the road. The responding Law Enforcement Officer concluded that the investigation was ongoing.Weather conditions reported by customweather.com for the Greensboro area on 08/05/25 documented the outside temperature to be between 66 degrees Fahrenheit at 7:54 pm and 63 degrees Fahrenheit at 10:54 pm. The conditions were mostly cloudy with light rain and fog.A telephone interview was conducted with Nurse Aide #2 on 08/12/25 at 4:39 pm. She stated it was about 10:40 pm on 08/05/25 when she and the DON went in her personal car to pick up Resident #1 from where he had been found by the police. She recalled Resident #1 was shaking because he was cold and wet. She stated that it had been raining that night. When they arrived, she noticed Resident #1 had some blood on his face. She stated she checked to see if his wanderguard bracelet was on and she found it on his left foot. She recalled she talked to Resident #1 while they waited for EMS to arrive, and it calmed him. They were at the intersection of [NAME] Road and [NAME] Street. The resident was rambling on about his mom and dad. He told her, They fought me, but they didn't win. She stated when EMS arrived the resident would not let them assess him. Resident #1 eventually allowed EMS to take his blood pressure and oxygen saturation percentage because she held his arm for them. She stated EMS would not transport the resident because they could only take him to the hospital and the family wanted him returned to the facility, so she and the DON took Resident #1 back to the facility in her personal car.An interview was conducted with the DON on 08/11/25 at 1:26 pm. The Administrator was also present. The DON stated Nurse #1 had called her and reported that staff could not find Resident #1 on 08/05/25. She was told that Resident #1 had been seen 15 to 20 minutes earlier on the top of 400 hall. She stated that she told Nurse #1 to stop everything and look for the resident. She asked Nurse #1 if any doors were alarming, if there were any visitors in the building, and did anyone let anyone out of the front door. She noted she got the first call at 8:55 pm. She explained she then called the Administrator to let him know Resident #1 could not be found. She recalled the Administrator came to the building about 9:15 pm. She started another search high and low. She left the building in her personal car and went up and down the road in her car but did see anything. She recalled the Administrator came and started searching outside about 9:45 pm. Maintenance was called to the building to check the doors. She went back outside and searched the surrounding area to the left of the facility, then the Administrator called her back to the building. She recalled the Administrator had called the police and the family to explain the resident was missing. She stated when the police arrived at the facility, they spoke to her and the Administrator and searched the facility. She heard the police officer get a call that the resident had been found. The DON explained they wanted to be sure the person the police found was Resident #1, so she and Nurse Aide #2 went in Nurse Aide #2's personal car to the corner of [NAME] and [NAME] Street at 10:52 pm. Two officers were present, 2 bystanders were there, along with Resident #1. She put Resident #1 in the back of Nurse Aide #2's car and called the Administrator. She recalled Resident #1 was confused and the police lights were agitating him. The police officers had called EMS before she got there. Resident #1 would not go to the EMS truck, and he wouldn't allow EMS to assess him. She notified the Administrator and explained the resident would not go with EMS. The family had arrived at the facility and requested she come back to the facility with the resident. The family met them at the front door when they returned. The resident was asking for momma and daddy and was confused. The DON recalled he had dirt on his pants and was wet, but it was not raining at the time she picked him up, although it had been raining earlier in the evening. Nurse #1 took Resident #1 to his room, and she suggested to the family that EMS be called, and they agreed. EMS and the provider were called. She noted EMS did arrive and went to the resident's room where Nurse #1 was assessing the resident and providing first aid aide. The Administrator interjected that the family and EMS came to him and reported that the resident did not want to leave with EMS and the family member told the resident that he did not have to be at the facility and that they would take him home. The Administrator explained that the family left the facility with the resident. He noted that the resident had appeared to have fallen because he had dirt on his clothing. Resident #1 was wearing his glasses that did not appear to be damaged. The Administrator stated that the resident was fully dressed when he returned to the facility wearing black sweatpants, dark gray shoes, a black t-shirt, a dark blue zip up jacket and a black hat.An incident report by EMS dated 08/05/25 at 11:05 pm was reviewed. The report documented that the nursing home staff would not let EMS fully assess the patient at the scene of [NAME] Road and [NAME] Street because they wanted him to be taken back to the facility at the family's request.An EMS Incident report dated 08/05/25 at 11:41 pm documented that EMS was called back to the facility to assess the resident. EMS personnel assessed Resident #1 at 11:41 pm on 08/05/25 at the facility. The EMS report documented Resident #1 had a blood pressure of 136/100 millimeters of mercury, a heart rate of 100 beats per minute, a respiratory rate of 18, and an oxygen saturation reading of 96% on room air. He had a right facial cheek laceration approximately 2.5 inches long with controlled bleeding. He had band aids on his knees placed by Nurse #1 during first aid care. Resident #1's mental status was oriented to person only. EMS presumed Resident #1 had fallen and they informed the family of the risks of an intracranial hemorrhage after a fall and the risks of transporting the resident themselves. EMS left the resident with his family to transport him to the hospital at their request and advised the family to call 911 for any changes.In an interview with a family member on 08/11/25 at 4:08 pm she stated the family took Resident #1 straight to the regional hospital after removing him from the facility. The regional hospital then sent him to the trauma center in [NAME]-Salem for treatment of a brain bleed. She stated Resident #1 was doing better but that the hospital was keeping him for a couple extra days in a regular room to keep an eye on the brain bleed to make sure there were no further complications.An interview was conducted with the Maintenance Director on 08/13/25 at 12:30 pm. He stated on the night of 08/05/24 he was called back to the facility to check the doors after Resident #1 had exited the building without staff supervision. He explained that only the front exit was alarmed for the wanderguard system, and all other doors had a keypad. Each door that had a keypad had its own unique key sequence to unlock the door. He stated all doors at the facility including keypads and the front entrance were checked daily and logged in the maintenance electronic computer system.An observation of the employee exit door was made on 08/12/25 at 10:10 am. The door was equipped with a keypad to enter a specifically assigned code for that door. When left ajar, the door did sound a faint alarm. The door was not equipped with a wanderguard alarm.An observation of the routes Resident #1 may have taken was conducted by the survey team by driving both routes on 08/12/25 beginning at 8:15 pm. Whether the resident turned left or right when leaving the facility driveway, the location where he was found by police was measured by driving the routes as 1.0 miles either way. The road where the resident was found (the intersection of [NAME] Road and [NAME] Street) had 5 lanes and was the hub for the on and off ramps for Interstate 40. Traffic was steady during the observation. There were streetlights that came on if the resident had turned right (Creek Ridge) but to the left the street was a dark industrial side road ([NAME] Street). Both routes were observed to be heavily wooded. A 35 mile per hour speed limit sign was observed on [NAME] road where Resident #1 was found.Hospital records dated 08/06/25 at 1:01 am were reviewed. Resident #1 was diagnosed with a left 1 cm (centimeter) subdural hematoma (brain bleed), a right 7 mm (millimeter) subdural hematoma (brain bleed), a 3 mm midline shift of the ventricle (when the brain moves past it's center line) due to the subdural hematoma (brain bleed), a right maxillary sinus fracture (beside the nose/beneath the eye),a right orbit fracture (bone around the eye), and a right zygomatic arch fracture (cheek). He was transferred to a higher level trauma medical center for treatment. A telephone interview with the Hospital physician was conducted on 08/15/25 at 4:09 pm. He stated Resident #1 was not able to tell him what had happened due to his advanced dementia but that the injuries he had to his face were caused from blunt force trauma and could have been the result of a fall. He reported that he thought the subdural hematomas he currently had could be a mix of an old subarachnoid brain bleed from January 2025 but that two of the subdural hematomas were acute meaning they had occurred within the last 24 hours. He explained he did not have anything else to offer, that Resident #1 had been transferred to a trauma hospital and the family was happy with the care Resident #1 had received at the Regional Medical Center.A telephone interview was conducted with the Trauma Medical Center Physician on 08/21/25 at 10:30 am. He stated Resident #1 had been transferred to their trauma unit from an affiliated regional medical center because the size of his brain bleed on 08/06/25 was too large for the other hospital to manage in accordance with their hospital protocol. He stated the injuries Resident #1 presented with were life threatening and very reasonably were caused from a fall. He stated he examined the brain scan results and noted both the subdural hematomas were new and had occurred within the previous 12 hours. The Trauma Center physician explained that Resident #1 had a previous brain bleed in January 2025 which he reviewed and noted that the previous brain bleed was a very different type of bleed than the current subdural hematomas. The comparison showed the January 2025 brain bleed was from a different area of the brain and only had trace bleeding-unlike the current subdural hematomas that had a large amount of bleeding. He also noted that the January 2025 test results showed no facial fractures. He stated all of the facial fractures were also from this episode. He stated that Resident #1 was fortunate to be in stable condition. He noted it was a shame this had happened when the family had only placed Resident #1 for respite care to free up their time to hold a birthday party for Resident #1's wife. At the end of the interview the Trauma Center Physician reported that the resident had returned home with his family.The Administrator was notified of Immediate Jeopardy on 08/12/25 at 5:35 pm.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is alert but not oriented, with a Brief Interview for Mental Status (BIMS) of 3. Diagnoses included Alzheimer's dementia and major depressive disorder. He was admitted to the facility on [DATE] for respite care. On August 5, 2025, at approximately 8:15 pm, Dietary Employee #1 observed an unknown gentleman (Resident #1), presumed to be a visitor, walking down the service hallway of the facility. The employee redirected the individual toward the front entrance, assuming he was unfamiliar with the building layout and attempting to exit. Upon the dietary employee exiting the facility via the service hall door, the gentleman followed behind him and proceeded to walk around to the front of the building. The dietary employee ensured the service hall door was secured and then proceeded to leave the facility with his transportation, believing the gentleman who came out behind him was walking around the front to meet his own ride.At approximately 8:30 pm, Medication Aide #1 attempted to administer Resident #1's, evening medications but was unable to locate him. Medication Aide #1 notified Nurse #1 that Resident #1 could not be located. A facility-wide search was immediately initiated, and a code orange (code used to notify all staff of a missing resident) was announced by Nurse #1. The Director of Nursing (DON) and Administrator were notified that resident #1 could not be located. Staff continued to search for resident #1 inside the facility and in the surrounding areas in their vehicles. At approximately 9:49 pm, the Administrator notified law enforcement that Resident #1 could not be located. At approximately 10:00 pm, local law enforcement arrived onsite to begin searching for Resident #1. At approximately 10:36 pm, the Administrator notified the Resident Representative (resident's daughter) that resident #1 could not be located. At approximately 10:45 pm, the police department notified the Administrator that the resident was located 0.9 miles away from the facility. The Director of Nursing and a Nursing Assistant #1 went to the location of the resident. The resident was uncooperative with EMS, so the family was contacted by the DON and made the decision for the resident to be brought back to the facility. Resident #1 was brought back to the facility via the staff's private vehicle, where the family was onsite at arrival. The Director of Nursing discussed with the resident's family the need for the resident to be sent to the emergency room (ER). The family agreed, and EMS was notified. An assessment was completed by the assigned hall nurse and revealed a laceration approximately one inch to the right cheek and a 3/4 inch abrasion above both knees. Treatment was provided to the areas along with resident care. EMS arrived to evaluate the resident and found the resident to be stable. The family decided to discharge the resident Against Medical Advice (AMA) and take the resident to the ER via their private vehicle. At approximately 11:32 pm, the physician services were notified by the DON of the incident and the family's decision to discharge the resident AMA. At approximately 12:00 pm, the resident left AMA with family.On 8/6/25, the Administrator completed a root cause analysis for Resident #1's unsupervised exit. The investigation identified the root cause to be that Resident #1 walked out behind a dietary aide, and the dietary aide did not intervene to prevent an unsupervised exit, thinking he was a visitor. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 8/5/25, t[TRUNCATE

Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to lock the brakes on a resident's wheelchair before leaving her unattended on the facility's front patio. Nurse Aide (NA) #5 positioned Resident #102 on the front patio and then walked away from the resident without securing the wheelchair brakes. Due to the brakes not being locked, and the resident's inability to stop the wheelchair when it began to roll due to weakness in all of her extremities, Resident #102 rolled approximately 10 feet across a circle drive and then struck her head on a brick wall which resulted in two lacerations to Resident #102's forehead that required sutures to repair. In addition, the facility also failed to provide care in a safe manner when Resident #310 rolled off the bed while NA #6 was providing a bed bath. This deficient practice occurred for 2 of 10 residents reviewed for accidents (Resident #102 and Resident #310). The findings included:1. Resident #102 was admitted to the facility on [DATE] with diagnoses including quadriparesis (weakness in all four limbs) and chronic dislocation of right shoulder. Resident #102 was discharged from the facility on 4/24/25.Resident #102's most recent quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #102 was cognitively intact, used a manual wheelchair, and was dependent on staff for all activities of daily living.The care plan last reviewed on 3/18/25 showed Resident #102 was care planned for falls and required assistance with activities of daily living due to chronic health conditions and weakness in extremities. The interventions included the use of a manual wheelchair for mobility. Review of physician orders showed Resident #102 was not on any blood thinners.An incident report dated 3/28/25 at 3:30 PM completed by the Director of Nursing (DON) revealed NA #5 transported Resident #102 out to the front patio of the facility. The report read that Resident #102 had lost control of her wheelchair and had rolled into the wall. The report further read that staff assisted immediately to complete a head-to-toe assessment, including vital signs, and applied pressure to stop bleeding. The emergency contact and the Nurse Practitioner were notified. Resident #102 was sent to the hospital for evaluation and treatment. During an interview with NA #5 on 7/1/25 at 2:17 PM, she stated she had pushed Resident #102 outside to the front patio in the afternoon of 3/28/25. NA #5 stated Resident #102 liked to sit in the sun, so she had pushed to her usual spot which was all the way across the patio and beside the circular drive. NA #5 also reported Resident #102 naturally leaned slightly forward in her wheelchair and did not have the strength to propel or stop herself in a wheelchair. NA #5 indicated she always locked the brakes on the wheelchair and couldn't explain why she didn't that day other than she just forgot. NA #5 stated she had just walked back into the building when she turned and saw Resident #102 slowly rolling across the circular drive. NA #5 reported she didn't reach her fast enough and Resident #102 struck her forehead on the brick retaining wall. NA#5 stated Resident #102 did not fall out of her chair and she didn't lose consciousness. NA #5 further stated that Resident #102 told her she was trying to get into the sun more and couldn't stop the wheelchair from rolling. NA #5 stated she didn't remember calling for any assistance, but other staff members then appeared to assist with getting Resident #102 back into the building to assess her and address her wound on her head that was bleeding.During an interview with the DON on 7/1/25 at 3:34 PM, she stated that she was up front on 3/28/25 when the incident with Resident #102 occurred. The DON stated she heard a staff member (unable to recall whom) say a resident just had an accident outside. The DON stated she responded immediately and performed an assessment on Resident #102. The DON reported Resident #102 did not fall out of her wheelchair, did not lose consciousness, and was complaining of minimal to moderate pain around the wound on her forehead. The DON stated Resident #102 told her she was trying to move further into the sun and couldn't stop the chair from rolling. The DON stated she contacted the emergency contact and NP #1 who provided the order to send Resident #102 to the hospital to assess her wound. The DON stated her vital signs were normal and Resident #102 was verbally responding in her normal manner.Review of the Emergency Medical Service note showed they arrived on 3/28/25 at 3:31 PM to the facility and found Resident #102 sitting upright in her wheelchair in the lobby. The note further read Resident had free rolled several feet across the drive into a brick wall. The resident had two small lacerations on her forehead. Bleeding was controlled, the area was cleaned and bandaged by staff .Resident is not on blood thinners and did not lose consciousness. Resident requested transport to a specific hospital for treatment. Alert and oriented, vital signs normal. No complaints of dizziness, only some pain around laceration. Resident is a non-emergency transport today.Review of the emergency department note dated 3/28/25 at 4:09 PM showed Resident #102 sustained two lacerations- a 4.2-centimeter laceration over the middle of the forehead and a 1.0 centimeter laceration to the right of the other. There was a small amount of bleeding with no visible bone. Both wounds were closed with a total of 6 non-absorbable simple sutures. All lab work and diagnostic scans, including computed tomography of Resident #102's cervical spine and head were negative, and Resident #102 was transported back to the facility on 3/28/25.An observation of the facility main entrance front patio on 7/1/25 at 3:15 PM showed an approximate 10 foot by 20-foot concrete slab directly adjacent to a circular drive that was approximately 10 feet wide. The drive adjacent to the patio appeared slightly sloped away from the front patio and sloped down toward the wall on the opposite side of the drive. There was an approximately 4-foot-high brick retaining wall on the other side of the circular drive.During a follow-up interview with the DON on 7/2/25 at 9:24 AM, she stated after investigating the incident, they found that NA #5 inadvertently forgot to lock the wheelchair brakes on Resident #102's chair and they had addressed that with NA #5. Resident #102 stated she attempted to move herself further into the sun, began slowly rolling and was unable to stop due to the limited amount of strength in her extremities. The DON also stated the resident should not have been left alone with the brakes unlocked, was not safe to be left unsupervised with the wheelchair brakes unlocked, and that the facility continued doing neurological checks after Resident #102 returned for an additional 3 days.During an interview with the NP #1 on 7/3/25 at 2:08 PM, she stated she saw Resident #102 after she returned from the hospital and removed her stitches from her forehead. NP #1 stated the two wounds healed well, Resident #102 voiced no complaints of pain to her, and she had no other injuries related to the incident.2. Resident #310 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, and weakness.Review of physician orders showed Resident #310 was not on any blood thinners.Resident #310's admission MDS dated [DATE] showed Resident #310 was cognitively intact and was dependent on staff for all activities of daily living including bed mobility. The MDS showed Resident #310 weighed 275 pounds.The care plan last reviewed on 5/2/25 showed Resident #310 was care planned as totally dependent on staff for activities of daily living due to chronic health conditions and weakness.The care guide dated 5/2/25 being used by nurse aides to determine how much care Resident #310 needed with her activities of daily living showed the resident was totally dependent on staff for bed mobility and bathing.Review of the incident report by Nurse #6 dated 6/17/25 stated during morning care with NA #6, Resident #310 became weak and had a witnessed fall. Resident verbalized no pain. While still lying on the floor, during the nursing assessment, Resident #310 had a syncopal (fainting) episode and became unresponsive. Oxygen was immediately applied by Nurse #6, and 911 was called. Resident #310 never stopped breathing, regained consciousness in less than a minute, and left the facility with oxygen level of 93%.During an interview with NA #6 on 7/1/25 at 10:36 AM, she stated she was giving Resident #310 a bed bath sometime after breakfast on 6/17/25 and had raised the bed up to her waist height. NA#6 stated she was aware Resident #310's care guide showed she required two staff members, but she stated everyone was usually busy helping other residents so sometimes she just did it herself. NA#6 reported Resident #310 was on her left side facing away from NA #6, NA #6 was on the right side of the bed, and the NA was talking with the resident while she was washing the resident's back when Resident #310 stopped responding to her and slowly rolled away from her off the left side of the bed onto the floor, landing on her right side facing the bed. NA #6 stated she called for help and Nurse #6 responded quickly. NA#6 reported Resident #310 was alert at that time, rolled over to her back and asked how she got on the floor.During an interview with Nurse #6 on 7/1/25 at 2:20 PM, she stated she responded to Resident #310's room when NA#6 called for her (unsure of time) on 6/17/25 and found Resident #310 lying on her back beside her bed. Nurse #6 reported NA #6 told her she was giving Resident #310 a bath and NA#6 had the resident on her side washing her back when Resident #310 talking to her and then rolled forward off the bed onto the floor. Nurse #6 stated Resident #310 was alert but confused about how she ended up on the floor and was not complaining of any pain. Nurse #6 stated Resident #310's blood pressure was slightly low for her at 114/52 but was still within normal range. Nurse #6 reported Resident #310 was responding appropriately to questions and then became unresponsive. Nurse #6 stated another staff member (unable to recall whom) called 911, brought in oxygen, and it was applied. Nurse #6 reported Resident #310 regained consciousness quickly and was able to say her name and responded appropriately to questions. EMS arrived and transported the resident to the emergency room for evaluation. Nurse #6 reported that cardiopulmonary resuscitation was not needed nor provided, and Resident #310 never stopped breathing.Review of the Emergency Medical Service note showed they arrived on 6/17/25 at 10:55 AM to the facility and found Resident #310 lying on the floor. The report further stated Resident fell presumably due to weakness and possibly hit her head. No blood thinners taken. Resident is hypotensive (low blood pressure) but responsive to stimulation. Intravenous fluids started . Resident became more responsive to verbal stimuli and spoke her name clearly upon leaving the facility . Resident transported to the hospital for evaluation.Review of the emergency department note dated 6/17/25 at 11:25 AM showed Resident #310 was alert and oriented upon arrival and had no complaints of pain. Lab work and diagnostic tests showed possible pneumonia and a high creatinine indicating the need for possible dialysis. Resident #310 was admitted for further testing and did not return to the facility.During an interview with the DON on 7/2/25 at 10:49 AM, she stated she was made aware of the incident on 6/17/25 when Resident #310 rolled off the bed during a bed bath. The DON stated the facility did in-service training regarding bed mobility and the importance of following the care guide for each resident which is what NA#6 should have done which would have prevented Resident #310 from rolling off the bed. The DON also stated Resident #310 was diagnosed with pneumonia at the hospital and was found to be in need of dialysis based on her labs compared to her previous labs done prior to admission to the facility which likely contributed to her fainting episode.

Based on interviews with staff and record reviews, the facility failed to clarify the dosage of aspirin to administer to 1 of 5 residents reviewed for unnecessary medications (Resident #66). The findings included: Resident #66 admitted to the facility on [DATE] with diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease. Resident #66's quarterly Minimum Data Set (MDS) dated [DATE] documented she had severe cognitive impairment. The MDS noted she had a history of a stroke and she received antiplatelet medications (prevents the accumulation of platelets to prevent blood clots). Resident #66's Medication Administration Records (MAR) from January 2025-July 2025 were reviewed and included an order for staff to administer aspirin once every other day. The MAR did not have a dosage listed on the entry. In an interview on 7/03/25 at 3:30 PM, Nurse #12 stated she was the regular nurse on Resident #66's hallway and routinely gave her the aspirin. She stated she gave Resident #66 an 81 milligram (mg) every other day out of the facility stock of over-the-counter medications because she thought that was what was ordered. She stated she was not aware there was no dosage in the original order but stated she believed there was a standing order for aspirin for all residents of aspirin 81 mg if needed. Resident #66's standing physician's orders did not include an order for aspirin. In an interview on 7/03/25 at 9:27 AM, the Director of Nurses (DON) stated she had been at the facility since the end of 2024 and stated she was not aware there was no dosage listed for the aspirin until surveyor intervention. She stated all medications orders should have the strength of the medication to be given. She stated there were two dosages of aspirin in the over-the-counter facility stock, 81 mg and 325 mg. She stated Resident #66 should have received 81 mg of aspirin which was the usual dosage for residents with a history of stroke and the order should have been clarified. Resident #66's physician was unable to be interviewed during the survey.

Based on staff interviews and record reviews, the facility failed to offer the opportunity to be vaccinated with the Pneumococcal 20-valent Conjugate Vaccine (PCV20) for 3 of 5 residents reviewed for pneumococcal immunizations (Resident #52, #74, and #66).Findings include:The Center for Disease Control and the Advisory Committee on Immunization Practices (ACIP), last reviewed on 10/26/24, recommends routine vaccination against pneumococcal infection for all adults aged 65 years or older and 19-64 with certain underlying medical conditions. Beginning June 8, 2021, for persons aged 65 years and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown, they should receive 1 dose of PCV15 [Pneumococcal 15-valent Conjugate Vaccine] or 1 dose of PCV20.Review of the facility's immunization policy last reviewed 3/4/2024 stated that all residents would be offered a pneumococcal vaccine PCV13 (Pneumococcal 13-valent Conjugate Vaccine) or PPSV23 (pneumococcal polysaccharide vaccine) upon admission.A. Record review revealed Resident #52 was admitted to the facility on [DATE].Review of the pneumococcal immunization records for the residents, provided by the facility, indicated Resident #52 declined a pneumococcal vaccine on 8/11/21. There was no documentation on the declination form that the resident had specifically been offered a pneumococcal 20-valent conjugate vaccine. There was no documentation the resident was offered or received a pneumococcal 20-valent conjugate vaccine since the last recertification on 3/14/24. There was no documentation the resident declined or received pneumococcal 20-valent conjugate vaccine prior to admission to the facility.B. Record review revealed Resident #74 was admitted to the facility on [DATE].Review of the pneumococcal immunization records for the residents, provided by the facility, indicated Resident #74 declined to receive a pneumococcal polysaccharide 23 vaccine and a pneumococcal conjugate 13 vaccine on 7/14/23. There was no documentation on the declination form that the resident had specifically been offered a pneumococcal 20-valent conjugate vaccine since 7/14/23. There was no documentation that the resident received a pneumococcal 20-valent conjugate vaccine prior to admission or since the last recertification on 3/14/24. There was no documentation that the resident declined or received pneumococcal 20-valent conjugate vaccine prior to admission to the facility.C. Record review revealed Resident #56 was admitted to the facility on [DATE]. Review of the pneumococcal immunization records for the residents, provided by the facility, indicated Resident #56 declined to receive a pneumococcal polysaccharide 23 vaccine and a pneumococcal conjugate 13 vaccine on 3/18/24. There was no documentation on the declination form that the resident had specifically been offered a pneumococcal 20-valent conjugate vaccine since the last recertification on 3/14/24. There was no documentation that the resident declined or received pneumococcal 20-valent conjugate vaccine prior to admission to the facility.During an interview with the Director of Nursing (DON)/Infection Preventionist (IP) on 7/2/25 at 8:52 AM, she stated this was her first DON position and she had been with the facility since April 2025. The DON reported she was aware the facility offered pneumococcal polysaccharide 23 vaccine and to all pneumococcal conjugate 13 residents and was unaware they needed to also offer pneumococcal 20-valent conjugate vaccine. The DON indicated she would be setting up a vaccine clinic as soon as possible with an outside vendor who would be offering and providing the necessary vaccines, including pneumococcal 20-valent conjugate vaccine.

Based on record review, staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council, resolve repeat grievances, and communicate the facility's efforts to address grievances voiced during Resident Council meetings for 4 of 4 consecutive months: March 2025, April 2025, May 2025, and June 2025.The findings included:A review of the grievance policy that was revised on 10/12/2020 indicated that Resident Council concerns that are voiced through Resident Council are recorded on the Facility Concern/ Grievance Form and are handled in a similar manner to individually voiced concerns., complaints and grievances. The Administrator is informed that the concern is referred to a department head, investigated and resolved, and the Resident Council is informed of the progress of the resolution. a. A review of the Resident Council minutes completed on 3/19/25 had no stated author and revealed the following grievances were expressed: Shower room floor needs to be cleaned more, want better access to the phone, call bells are not being answered for 45 minutes, and staffing at night and weekends were not available. A review of the grievances for the month of March 2025 revealed no Resident Council grievances were submitted. b. A review of the Resident Council minutes completed by the Activities Director dated 4/8/25 revealed the following grievances were expressed: resident food had been stolen from the nutritional room, cigarettes and lighters are getting missing, call bells not answered for 30 minutes, laundry is getting missing, nursing assistants have attitudes when residents ask for assistance after 6 pm, sandwiches are hard. There was no documented discussion or resolution of the previous month's grievances. A review of the grievances for the month of April 2025 revealed no Resident Council grievances were submitted. c. A review of the Resident Council minutes completed by the Activities Director dated 5/6/25 revealed the following grievances were expressed: third shift staff are not assisting residents, call lights are not answered for 30 minutes, lack of sheets, staff are asleep at 4:00 AM, residents did not get baths and staff made racist comments during 2nd shift. There was no documented discussion or resolution of the previous month's grievances. A review of the grievances for the month of May 2025 revealed a Resident Council grievance was submitted on 5/6/25. The grievance indicated resident concerns regarding 3rd shift call light response times, sheets, staff on phones/sleeping. The only noted action taken was that nursing will follow up with 3rd shift staff. d. A review of the Resident Council minutes completed by the Activities Director dated 6/4/25 revealed no new grievances for this month. There was no documented discussion or resolution of the previous month's grievances noted in the minutes. A Resident Council meeting was held on 7/2/25 at 3:3P PM with Residents #2, # 8, 28, #53 and #55. During the meeting, Resident #8, the resident council president, expressed that the Resident Council has made repeated grievances month after month which had not been fully addressed or resolved. Resident #53 stated the resident council's complaints were not resolved and the residents were never provided follow up to their stated grievances. An interview with the Activities Director on 7/3/25 at 10:12M revealed that she completes the resident council minutes and then provides a copy of the minutes to the Administrator. She further indicated that she did not fill out grievance forms for Resident Council grievances nor did she provide follow-up to the Resident Council members at the next meeting because she did not know that she needed to do it. An interview with the Administrator on 7/3/25 at 1:35 PM revealed that Resident Council grievances were reviewed in morning meetings by the Administrator but neither he nor the Activities Director documented any actions taken to address the grievances and did not communicate the facility's efforts to address the grievances. He further indicated that these actions should have been taken and felt this was an oversight.

Based on record review, observations, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of a narcotic medication (oxycodone-acetaminophen) prescribed to treat pain for 1 of 1 resident reviewed for misappropriation of property (Resident #56). The findings included:Resident #56 was admitted to the facility on [DATE].A review of Resident #56's quarterly Minimum Data Set assessment, dated 04/26/25, indicated his cognition was intact.Resident #56 had an order dated 5/25/23 for oxycodone-acetaminophen 5-325 milligrams (mg) two times a day every Tuesday, Thursday, Saturday, Sunday, for pain. The second oxycodone-acetaminophen 5-325 mg order dated 6/25/25 for oxycodone-acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain on hemodialysis days on Monday, Wednesday, and Friday.a. A review of Resident #56's June 2024 Medication Administration Record (MAR) revealed the resident received oxycodone -acetaminophen 5-325 mg administered as ordered.A review of the investigative report dated 6/25/24 read in part, a narcotic card of oxycodone-acetaminophen with 30 pills was missing from the medication cart. On 6/20/24 during shift change the narcotic card count sheet indicated 21 cards (a card is a bubble pack used for storage of medications) total during shift change at 07:00 PM. On 06/24/24 on the morning of shift change the unit coordinator (Director of Nursing) counted and took keys from the night shift nurse (Nurse #8) due to first shift nurse (Nurse #3) running late and the narcotic card count resulted in 23 total cards, which included 2 additional cards delivered on 06/21/24. At about 7:30 AM the first shift nurse (Nurse #3) came in and the unit coordinator (Director of Nursing) handed over the keys to the medication cart to the first shift nurse without counting the narcotics, including the number of cards, due to the unit coordinator (Director of Nursing) just holding the keys and not opening the cart after she counted with the night shift nurse (Nurse #8). The first shift nurse worked the cart until 3:00 PM when another nurse (Nurse #9) came in to relieve her. During the count the incoming nurse (Nurse #9) counted 22 narcotic cards, and the first shift nurse (Nurse #3) brought it to her attention there were supposed to be 23 cards based on what was written. The incoming nurse (Nurse #9) recounted again while the first shift nurse (Nurse #3) flipped the sheets to confirm, and there were 22 cards. The first shift nurse (Nurse #3) assumed it was probably a miscount. On 06/25/24 at approximately 7:00 AM the outgoing nurse counted off 22 cards and sheets with oncoming nurse. Resident #1 requested a pain pill, and the oncoming nurse administered the medication. The oncoming nurse mentioned to Resident #56 there was only 1 oxycodone-acetaminophen left, and she would have to notify the hospice physician to receive a script to order a refill. Resident #56 informed the oncoming nurse (Nurse #3) he was told on the day before that he had another full card of the medication. The oncoming nurse (Nurse #3) called hospice to get a script and was informed they had sent 44 tablets of the oxycodone-acetaminophen on 06/21/24. The oncoming nurse (Nurse #3) informed management of her findings, and an investigation was initiated into the missing medication.A review of the Pharmacy delivery manifest sheet dated 06/21/24 revealed 44 oxycodone-acetaminophen tablets delivered to the facility.A review of the controlled substance count sheet record dated 06/21/24 indicated 1 of 2 cards for 30 of 44 tablets revealed 14 oxycodone-acetaminophen tablets signed for on the record. There were 14 tablets signed out from 06/22/24 through 06/25/24.An interview was conducted on 07/02/25 at 11:30 am with the Director of Nursing (DON) (who was the Unit Manager during the timeframe of the missing medications that counted narcotics with Nurse #8 at 07:00 AM. The DON indicated she counted the narcotic sheets with Nurse #8 and the narcotic cards and sheets they counted matched. She stated she did not open the medication cart again until Nurse #3 came in at approximately 7:30 AM on 06/24/24 and she didn't recall if they counted the cards and the sheets, but she did know she did not go back in the cart after counting with Nurse #8.On 07/02/25 at 4:05 PM an interview was conducted with Nurse # 3, and she indicated she was called in to work on her day off due to a call out on 06/24/24. She stated when she arrived at work she counted the narcotic cards with the Unit Manager, however she did not count the narcotic cards. She indicated at 3:00 PM at the end of her shift Nurse #9 counted the cards and she was counting the pages, and they noticed the cards and the narcotic sheets were not matching. Nurse #3 indicated she thought it was a mistake and she and Nurse #9 corrected the narcotic count sheet with the narcotic cards. She stated she thought someone forgot to put the right number of cards on the sheet. Nurse #3 indicated she received a call at home the following day about the missing narcotics, and she was informed she had been suspended pending an investigation. She stated when the investigation was complete, she was able to return to work and receive education training on counting the narcotic sheets and cards.On 07/03/25 at 9:38 AM an interview was conducted with Nurse #8, and she indicated she counted the narcotic sheets and cards on 06/24/24 after working the night shift, and the count was correct. She indicated she did not recall the number of narcotic sheets and cards but there was no discrepancy that she was aware of. Nurse #8 indicated she was contacted by the facility, they informed her they were doing an investigation of the missing narcotics, and she informed them the count was correct when she left. She stated prior to working again she received education on counting the narcotic sheets and cardsb. A review of Resident #56's August 2024 Medication Administration Record (MAR) revealed the Resident received oxycodone-acetaminophen 5-325 mg as ordered.A review of the Pharmacy delivery manifest sheet dated 08/12/24 revealed 28 oxycodone-acetaminophen tablets delivered to the facility.A review of the controlled substance count record dated 08/21/24 indicated 1 of 1 card for 28 tables revealed 28 oxycodone-acetaminophen tablets signed for on the record. There were 28 tablets signed out from 08/13/24 through 08/19/24. The record noted to have dates illegibly documented over with unrecognizable times and signatures on 08/17/24.An interview was conducted on 07/03/25 at 9:55 AM with the previous Assistant Director of Nursing (ADON) and she indicated the previous DON investigated the missing narcotics in June 2024 and she had investigated the discrepancies with the narcotic sheets in August 2024. The previous ADON indicated she was reviewing the narcotic sheets and recognized some discrepancies with the signatures. She indicated she started an investigation and identified Nurse #9 was signing medications out and changed some of the dates by writing over the numbers and it appeared medications could have been diverted but it was hard to tell due to the number changes. The previous ADON reported Nurse #9 was suspended pending the investigation and she did not cooperate with the investigation, so she was terminated. She indicated Resident # 56 did not complain of any increased pain and he was very vocal and if he thought he was not getting his medication he would have voiced it. She indicated Resident #56 acted unaware that anything was going on with his medication.On 07/03/25 at 10:26 AM an interview was conducted with the previous Director of Nursing (DON), and she indicated the previous ADON was doing an audit, and she found discrepancies with Resident #56's oxycodone-acetaminophen narcotic sheets. She indicated it was signed out on 8/17/24 by Nurse #9 and she did not work on that day. The previous DON stated, I was out of the country and the ADON and Administrator did most of the investigation and by the time I returned the investigation was completed. She indicated she made multiple attempts to contact Nurse #9 to follow up with the investigation, however she was unable to contact her. The previous DON stated the contact attempts included phone texts, phone calls, and certified mail. The previous DON stated Nurse #9 was terminated due to not complying with the investigation. She reported they did not substantiate the investigation because the Resident stated he had no issue with getting his medications and the other alert and oriented residents interviewed also did not have any concerns with receiving their pain medications.On 07/03/25 at 11:08 AM an interview was conducted with the previous administrator, Administrator #3, and he indicated there were concerns with missing medications and documentation with the count sheets. He reported they put processes in place to ensure the Nurses understood the importance of counting the narcotic sheets and cards. Administrator #3 stated there was no evidence that a specific person had taken the medications and they were unable to determine where the narcotics went. He also indicated they interviewed all the nurses, did audits and put process in place through the quality assurance and performance improvement (QAPI) process.An interview was conducted with Resident #56 on 07/03/25 at 9:20 AM and he indicated he did not have any problems currently getting his pain medication and he did not remember having any problems getting pain medications in June or August of 2024.Attempts to interview Nurse #9 were unsuccessful. The facility provided the following corrective action plan with a completion date of 09/03/24:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 06/24/24, the facility identified Resident #56 was missing 1 card of 30 oxycodone-acetaminophen 5-325 milligrams (mg). A pain assessment of Resident #56 was completed by the licensed nurse on 06/24/24 with no pain identified by Nurse #12. The medication administration record was reviewed by the Director of Nursing (DON) on 06/25/24 with no missed doses identified and the pharmacy was notified to replace the identified missing medications at the expense of the facility on 06/25/24. On 6/25/25 the pharmacy delivered the missing card that was paid for by the facility.8/23/24, the Assisted Director of Nursing (ADON) identified a discrepancy in the controlled substance declining count sheet of 2 Percocet 5-325mg related to Resident #56.On 08/27/24, the pain assessment was completed by the licensed nurse with no pain notes.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All the current residents are at risk for this deficient practice. On 06/26/24, the ADON/DON reviewed the electronic medical record (EMAR) of the current residents and compared it to the declining count sheets for all current narcotics and narcotics dispensed in the last 30 days to ensure the narcotic medications cards are accounted for and present on the medication carts. On 06/26/24, the ADON/DON reviewed the shift change controlled count check form of the current residents for the last 30 days to ensure medication cards that were delivered from the pharmacy were added to the count and their declining count sheet was present with no concerns identified. On 06/26/24, the ADON completed an audit of the current residents for the last 30 days of the ordered narcotic medications to ensure that medication cards in the medication cart matched the total number of counts sheets on the shift change controlled substance count check form with no concerns identified.On 06/26/24, Pain assessments were completed on the current residents with no concerns identified. On 08/26/24, the ADON/ Unit Managers completed a 100% audit of the current residents' medication administration record (MAR) starting from 8/1/24 to 8/26/24 to ensure that the medication cards and the declining counts sheets reflect that medications had been given as ordered. No concerns were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 06/25/24, the Staff Development Coordinator (SDC) initiated in-service training with all the licensed nurses and medication aides regarding the Controlled Substance Diversion to include: the definition, implications, and the process for counting medications cards and ensuring medication cards and declining count sheets match and are accounted for. If discrepancies are noted the Director of Nursing and the Administrator should be notified immediately. by 09/02/24.On 08/27/24, the SDC initiated training with 100% of the licensed nurses and the medication aides related to the 6 rights of Medication Administration to include reading the MAR, accurately administering medications per the physician order, and what to do with medications which cannot be administered. This training was to be completed by 09/02/24. Licensed nurses and medication aides will be required to complete the education prior to working. Newly hired staff will complete the education during orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.The DON/SDC will audit of a medication carts weekly x 4 weeks then monthly x 2 months to ensure medications cards and declining count sheets continue match and medication cards are accounted for. Any areas of concern medication cards will be immediately addressed during the observation including staff retraining. The Administrator or DON will review and initial the audits weekly x 4 weeks then monthly x 2 months to ensure all areas of concern are addressed appropriately. The Administrator or DON will present the findings of the Audit Tools to the QAPI committee monthly for 3 months. The QAPI committee will meet monthly for 3 months and review the Audit Tools to determine trends and/or issues that may need further interventions and the need for additional monitoring.Date of Compliance 09/03/24Validation of the corrective action plan was completed on 07/03/25:The corrective action plan was validated by reviewing the education provided to the staff, reviewing the interviews with staff and residents, and reviewing the daily Quality Monitoring documentation. Residents were interviewed during the survey, and none reported untreated pain. Nursing staff were interviewed and indicated they had all received education on narcotic diversion. No evidence of drug diversion was discovered during the validation.The facility completion date of 09/03/24 was validated on 07/03/25.

Based on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for 1 of 1 resident reviewed for communication (Resident #57). The findings included:Resident #57 was admitted to the facility on [DATE] with a diagnosis of cardiac arrythmia, dementia, and essential hypertension. A review of Resident #57's electronic medical record (EMR) included an ophthalmology consultation note dated 11/19/24. The assessment revealed a medical condition of cataracts in both eyes and related blurred vision. The consultation note further indicated that cataract surgery was recommended and had been scheduled on 3/26/25 for the left eye and 4/30/35 for the right eye. A review of Resident # 57's Significant Change in Status MDS assessment dated [DATE] was completed by MDS Nurse #2 and revealed the resident had severely impaired cognition , adequate vision and had corrective lenses. Resident #57's most recent Minimum Data Set (MDS) assessment dated [DATE] was completed by MDS Nurse #1 and revealed the resident had severely impaired cognition ,adequate vision, and had corrective lenses. Resident #57's care plan revised on 5/15/25 by MDS Nurse #1 did not include any identified problems or interventions related to visual impairment. An interview and observation was conducted with Resident #57 on 6/30/25 at 10:21 AM. Resident #57 indicated that she was waiting for cataract surgery for her eyes and that she had difficulty seeing her food. An interview was conducted with the scheduler for appointments and transportation on 7/1/25 at 3:01 PM. She indicated that Resident #57's cataract surgeries were delayed due to a hospital stay in March of 2025 prior to her scheduled surgery. She further revealed that a follow-up appointment was scheduled for 7/24/25. An interview was conducted with MDS Nurse #1 on 7/1/25 at 3:05 PM. She revealed that she completed the quarterly assessment of 5/15/25, and she was not aware of any blurred vision or that Resident #57 had bilateral cataracts. MDS Nurse #1 then indicated that Resident #57 should have been coded for visual impairment. An interview was conducted with MDS #2 on 7/2/25 at 11:22 AM. She indicated she was the interim MDS nurse and completed Resident #57's Significant Change in Status Assessment of 3/19/25. She further revealed that she was not aware of an ophthalmology consultation note that indicated bilateral cataracts and blurred vision and if she had seen the report, she would have coded Resident #57 to have visual impairment and cataracts. An interview on 7/3/25 at 1:38 PM with the Administrator revealed that Resident #57's MDS assessments should have been coded to accurately reflect the resident's medical condition.

Based on record review and resident and staff interviews, the facility failed to provide a copy of the baseline care plan to the responsible party for 1 of 23 residents reviewed for baseline care plans (Resident #57).Findings included:Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, in part, non-traumatic intracerebral hemorrhage in the hemisphere (bleeding within the brain tissue of one cerebral hemisphere, occurring without any known trauma or injury). A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired.A review of the medical record revealed a baseline care plan was completed by Unit Manager #1 3/13/25.A review of the medical record revealed Resident #57 listed a family member as her own responsible party. A review of the medical record revealed no documented evidence that a copy of the baseline care plan was given to the resident or the responsible party. Multiple attempts were made to interview the responsible party, but attempts were not successful. An interview was conducted with Resident #57's admitting Nurse, Nurse # 7. She indicated she did not complete the baseline care plan and did not provide a summary of the baseline care plan. Multiple attempts were made to interview Unit Manager #1, but attempts were not successful. On 7/2/25 at 11:03 AM an interview was completed with Unit Manager #2. He stated that typically the unit managers develop the baseline care plan for new or readmitted residents and reviewed it with the resident and/or responsible party within 48 hours of admission.On 7/2/25 at 11:03 AM an interview was completed with the Director of Nursing (DON). She stated the baseline care plan was initiated and completed 3/13/25 by Unit Manager #1. She said she expected the baseline care plan to be developed within 48 hours of admission, and a copy provided to the resident or resident representative. The DON further stated she could not confirm that Resident #57's t baseline care plan summary was ever provided to the resident or responsible party. An interview was conducted with the Administrator on 7/3/25 at 1:30 PM and he indicated that he expected the resident and/ or the responsible party to receive a written summary of the baseline care plan within 48 hours of their admission.

Based on observation, record review, resident and staff interviews, the facility failed to arrange or coordinate podiatry care for 1 of 5 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #31). The findings included:Resident #31 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb, chronic kidney disease and congestive heart failure.Resident #31's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was dependent on staff for personal hygiene. The MDS further revealed the resident was coded for not being ambulatory. Resident #31 s care plan, revised 6/6/25, revealed the resident had a focus area of activities of daily living/personal care. The goal was for Resident #31 to have staff complete activities of daily living as appropriate to maintain the highest practical level of functioning through the next review. There was no documentation in the medical record the resident had been seen by podiatry. An interview and observation with Resident #31 on 6/30/25 at 10:30 AM revealed the resident's great toenails on both feet to be extending beyond the end of her toes, and were thick, and yellow in color. Resident #31 indicated that she felt the nursing staff would not be able to cut her toenails and has not been offered a podiatry consult and would like to have a podiatry visit from the facility onsite provider. Resident #31 stated she was not in pain from the length of her toenails as she did not walk or wear shoes.An interview was conducted with Nursing Assistant (NA) #7 on 7/1/25 at 2:15 PM. She indicated that she was assigned to Resident #31 on 7/1/25 and that she completed personal hygiene care which included nail care. NA #7 indicated that she observed Resident # 31's toenails to be long, hard and overgrown and did not feel she was able to trim the toenails therefore she notified Nurse #7 of the status of her toenails and that she was in need of a podiatry consult. An interview conducted with Nurse #7 on 7/1/25 at 2:31 PM revealed she was not aware Resident #31 needed a podiatry consult and that NA #7 did not report this issue to her. An interview was conducted with the Director of Nursing (DON) on 7/1/25 at 3:05 PM. She indicated toenail care was to be provided by the nursing staff and if the nurses were not successful with trimming a resident's toenails, then the resident was offered a podiatry consult to the resident's toenails needs. The DON indicated the in-house podiatrist visited the facility quarterly. The DON reported the facility attempted to trim Resident #31's toenails in May of 2025, but she declined. The DON further revealed Resident #31 was not offered a podiatry consult at that time and should have been referred to the podiatrist for services in May when she declined to let staff trim her toenails.

Based on interviews with staff and record reviews, the facility failed to address discrepancies identified by the facility consultant pharmacist when a recommendation was made to clarify the dosage of aspirin ordered for 1 of 5 residents (Resident #66) reviewed for unnecessary medications. The findings included: Resident #66 admitted to the facility on [DATE] with diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease. Resident #66's quarterly Minimum Data Set (MDS) dated [DATE] documented she had severe cognitive impairment and had no behaviors or refusals of care. The MDS noted she had a history of a stroke and she received antiplatelet medications (prevents the accumulation of platelets to prevent blood clots). Resident #66's Medication Administration Records (MAR)s from January 2025-July 2025 were reviewed and included an order for aspirin once every other day. The MAR did not have a strength listed on the entries. Resident #66's monthly consultant pharmacist reviews dated 2/27/25, 4/30/25, and 6/27/25 noted she had an order for aspirin but there was no strength in the order, either 81 milligrams (mg) or 325 mg. There was no documentation of the facility addressing the recommendations. In an interview on 7/03/25 at 3:30 PM, Nurse #12 stated she was the regular nurse on Resident #66's hallway. She stated she gave Resident #66 aspirin 81 mg every other day out of the facility stock of over-the-counter medications because she thought that's what was ordered. She stated she believed there was a standing order for aspirin for all residents. Resident #66's standing physician's orders did not include an order for aspirin. In an interview on 7/03/25 at 9:27 AM, the Director of Nurses (DON) stated she had been at the facility since the end of 2024 and stated when she looked for the recommendations at the surveyor's request, she found there were several pharmacy recommendations that were not completed by the former DON and former Assistant Director of Nursing (ADON). She stated she was not aware of the missing dosage until surveyor intervention. She stated the recommendations should have been reviewed and the order clarified within a few days of receiving the recommendation.

Based on observation, record review and interviews with staff and family member, the facility failed to protect a resident's right to be free from sexual abuse (Resident #2). Resident #1 sexually abused Resident #2 while he was sleeping in his bed. The resident's family member believed the resident would have rejected a male's sexual advance, would have been angry, and was unable to protect himself. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being sexually abused by a resident in their home environment making them feel angry, dehumanized, and powerless. This deficient practice affected 1 of 2 residents reviewed for abuse. Findings included: Resident #2 was admitted to the facility on [DATE] with the diagnosis of dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented he was severely cognitively impaired. The resident was dependent for all his activities of daily living except for meals. There were no behaviors during the MDS assessment period. The resident's diagnoses included non-Alzheimer's dementia, anxiety, psychotic disorder, and cognitive communication deficit. The care plan for Resident #2 dated 4/16/25 documented he had a cognitive deficit and was physically and verbally aggressive at times. The resident had an intervention to assure he was aware before touching or speaking to him. Resident #1 was admitted to the facility on [DATE] with diagnoses that included depression and dementia with other behavioral disturbance. The quarterly MDS assessment dated [DATE] documented he was severely cognitively impaired, he was feeling down nearly every day, and there were no behaviors or psychosis during the assessment period. The resident required partial to moderate assistance for upper body and maximal assistance for lower body bathing and dressing. The resident was always incontinent and dependent on staff for personal care. The resident's diagnoses included non-Alzheimer's dementia and intellectual disability. The resident received antipsychotic medication daily. The care plan for Resident #1 dated 3/12/25 included behaviors of taking other's food. There was no behavioral issue of touching others identified in the care plan. On 4/23/25 at 2:12 pm an interview was conducted with the Director of Nursing (DON). The DON stated she was aware of an incident with Resident #1 and Resident #2 and she provided staff statements. A review of the staff's written statement by NA #2 dated 4/20/25 provided by the DON documented that NA #2 was assigned to Resident #2 on 4/19/25 evening shift from 3:00 pm to 7:00 pm. During rounds at 3:30 pm NA #2 observed Resident #2 in his bed and he had his brief open and no one else was in the room. NA #2 again observed Resident #2 had his brief open at 5:30 pm and no one was in the room. This was reported to NA #3 at shift change. On 4/23/25 at 2:40 pm NA #2 was interviewed. NA #2 stated that Resident #2 was known to open his undergarment and staff provided privacy or closed the undergarment. The open undergarment was reported during shift change. A review of the staff's written statement by NA #3 dated 4/20/25 provided by the DON documented NA #3 was assigned to Resident #2 on night shift 4/19/25 7:00 pm to 7:00 am (ending 4/20/25). NA #3 observed Resident #1 in his wheelchair and put him to bed at 9:00 pm. Resident #2 was in his bed and appeared to be sleeping (Resident #1 and Resident #2 were roommates). Rounds were completed at approximately 11:30 pm, 2:30 am, and 4:00 am. Resident #1 was sitting on the fall mat watching TV and there was no touching observed during these rounding times. Resident #1 was asked to get back into bed during each time and he did. During rounds at 5:45 am Resident #1 was on Resident #2's fall mat and had his hand inside of Resident #2's brief moving back and forth. Resident #1 was asked to stop and did not. NA #3 ran out of the room to obtain help. Medication aide (MA) #1 was at the nurses' station and returned to the room with NA #3. Both staff informed Resident #1 to get away from Resident #2 and he did. MA #1 called Nurse #1 on the phone to assist and she arrived. Resident #2 appeared to be sleeping during this incident. Both residents were assessed and separated. Resident #2 was known to open or remove his own brief. NA #3 was interviewed on 4/23/25 at 12:43 pm. NA #3 was assigned to Residents #1 and #2 on night shift 4/19/25 7:00 pm to 7:00 am (ending 4/20/25). NA #3 stated she completed rounds by walking into the residents' room on her shift every 2 hours until 4:00 am and there was no touching observed at those times. NA #3 stated during rounds at approximately 6:00 am, Resident #1 was sitting on Resident #2's fall mat and Resident #1's back was to her. Resident #1 was observed touching Resident #2's penis with an open hand. Resident #1 was told to stop but he did not stop. NA #3 stated she ran out of the room to go get help. MA #1 was in the hall and came back to the room and assisted Resident #1 to stop touching Resident #2. Resident #2 was sleeping and his undergarment was completely off. Resident #2 had been known to take his undergarment off and be exposed. NA #3 stated Resident #1 had no prior history of touching anyone and that this was new behavior. NA #3 stated it had taken her about 10 seconds to get assistance. She left the room for assistance because she could not get Resident #1 to stop touching Resident #2's genitals. A review of a staff's written statement by MA #1 dated 4/20/25 provided by the DON documented that MA #1 was requested by NA #3 to assist with an incident between Residents #1 and #2 (roommates). Resident #1 was lying on Resident #2's fall mat next to the bed. Resident #2 was facing the window and only his back was visible. As the MA entered the room, Resident #1 had his hand over Resident #2's genitals and was rubbing his penis and scrotum. Resident #2 had his brief open. Resident #1 was asked, what are you doing and he replied nothing. Resident #1 stopped touching Resident #2 and sat back up on the mat with his back to Resident #2. Resident #2 appeared to be asleep. Resident #1 was asked several times to go back to his bed and he did. The charge nurse was called and MA #1 remained in the room until the nurse entered the room. On 4/24/25 at 10:40 am MA #1 was interviewed. MA #1 stated she was assigned to the hall where the incident happened on 4/19/25 during the night shift but she was not assigned to the residents involved. NA #3 came to the nurses' station where MA #1 was standing and summoned her to Residents #2's room on 4/20/25 sometime after 6:00 am. Resident #1 was lying on the fall mat of Resident #2 watching TV. Resident #1 had his hand over Resident #2's genitals and was rubbing the genitals. Resident #2's brief was open. MA #1 reported that Resident #2 was sleeping, he had his back to the door, and her (MA #1) view of the incident was limited. Resident #1 was informed to stop, and he had stopped and scooted back to his side of the room. Resident #1 responded that he was doing nothing. MA #1 stated she called for Nurse #1 by phone and the nurse arrived immediately. MA #1 stated she had not left the room until the residents were separated. Resident #2's genitals were assessed and no injuries were observed. Resident #1 was taken out of the room by wheelchair. Resident #2 had to wake up and was then undressed and assessed all over by Nurse #1. No injury was observed. Resident #2 appeared to be sleeping during the incident. He was not moving or talking when spoken to. Resident #1 was placed on a one to one (1:1) supervision. Resident #1's had a bariatric bed and needed to be dismantled to be moved to another room. After multiple attempts it was decided that Resident #2 would be moved to another room for safety. Nurse #1 informed Nurse #4 who was the supervisor for the shift. A review of a staff's written statement by Nurse #1 dated 4/20/25 provided by the DON documented Nurse #1 had begun her shift at 7:00 pm on 4/19/25 and Resident #1 was observed moving around the unit in his wheelchair. Resident #1 received his medication at 9:00 pm and remained in his wheelchair. Shortly after 5:50 am (4/20/25) Nurse #1 received a call from MA #1 that she was needed in Resident #2's room. I arrived within a couple of minutes. Resident #1 was sitting on Resident #2's fall mat and Resident #2 was lying in his bed with his undergarment open and his penis exposed. Nurse #1 had not observed the incident and had not observed nor been informed that Resident #1 inappropriately touched anyone before. Resident #2 appeared to be sleeping. The residents were separated. On 4/23/25 at 11:59 am an interview was completed with Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 4/19/25 night shift (7:00 pm to 7:00 am the following day). Nurse #1 stated MA #1 alerted her that Resident #1 was inappropriately touching Resident #2. Upon entering the residents' room, Resident #1 was sitting on Resident #2's fall mat close to his bed. Resident #2's brief was open. Resident #1 was assisted back to his bed. NA #3 was present. Resident #2 was assessed for injury and none was found. Resident #2 was then moved to another room. Nurse #4 was the supervisor for the shift and was informed. Resident #1 was placed on 1:1 supervision. Nurse #1 stated the only behavior she was aware of for Resident #1 was eating other residents' food. There was no observation or information that Resident #1 was touching staff or residents prior to this incident. This was a new behavior. Resident #1's nurse's note dated 4/20/25 written by Nurse #4 documented at about 6:10 am she was notified by Nurse #1 that Resident #1 sexually assaulted Resident #2. Nurse #4 went into the room to assess the situation and found Resident #1 sitting on Resident #2's fall mat. Resident #2 had his brief open. Nurse #4 directed Medication Aide #1 to remain with Resident #2 until a room was identified. Resident #1 was placed on 1:1 supervision. The Administrator was called, and he responded that he would be in the building later. Witness statements were obtained from staff. On 4/23/25 at 12:28 pm an interview was completed with Nurse #4. Nurse #4 stated she was the supervisor on 4/19/25 on night shift 7:00 pm to 7:00 am the following day. Towards the end of the shift (early am 4/20/25) Nurse #4 was informed by Nurse #1 there was inappropriate touching by Resident #1 toward Resident #2. Nurse #4 stated she entered the residents' room and Resident #1 was back in his bed and Resident #2 was in his bed and his brief was all the way open. Nurse #1 had completed an assessment of Resident #2's genitals and there was no injury. Resident #1 was immediately removed from the room and was placed on 1:1 supervision. Resident #1 was interviewed by Nurse #4 and the resident could not remember what happened. Resident #2 was undressed, his entire body was assessed, and no injury was found. The incident was reported to the Administrator after the residents were assessed, separated, and safe. Nurse #4 stated she had rounded earlier during her shift 3 times and Resident #1 was always in his bed. Resident #2 had a psychiatry progress note dated 4/22/25. The resident was evaluated after staff had reported he was sexually assaulted by another resident. The resident had a recent room change and a new roommate. Staff reported no new mood or behavioral concerns. The past history included dementia with behavioral disturbances and delusional disorder. The resident was in no acute distress and had cognitive decline. The resident was observed to be in his wheelchair in the dining room sleeping and not easily aroused. The staff was to monitor mood and behaviors. Resident #2 had a psychiatry progress note addendum to the 4/22/25 note dated 4/25/25 that documented after the staff and administration completed a further review of the incident, it appeared that the resident was not actually a victim of a sexual assault, and that Resident #2 may have disrobed himself. On 4/23/25 at 9:35 am an interview was conducted with the DON and Administrator. The resident-to-resident incident on 4/20/25 was still under investigation. Resident #1 was observed by NA #3 to be fondling the penis of Resident #2 (roommates). Resident #1 was known to be kind of touchy feely per the DON. The resident had never inappropriately touched another resident and was not aggressive. The facility had immediately initiated an investigation and staff education on 4/20/25. On 4/23/25 at 10:40 am an observation was completed of Resident #2. The resident was sleeping in a low bed with a fall mat on one side. He was dressed and clean. The resident was not easily awakened. Nurse #3 was interviewed on 4/23/25 at 1:56 pm. Nurse #3 stated she was assigned to Resident #2 today (4/23/25 day shift) and was familiar with the resident. The resident had no behaviors and could barely follow directions. He was sleeping more and his dementia was advanced. Nurse #3 stated she was aware of the resident-to-resident incident and believed Resident #2 had not remembered what occurred due to a poor memory. Nurse #3 stated Resident #1 was not known to inappropriately touch staff or residents prior to the 4/20/25 incident. On 4/23/25 at 2:10 pm an observation was completed of Resident #2. He was up in his wheelchair slowly self-propelling in the hallway. He was alert and oriented to self, had a flat affect, and was hunched over. An attempt was made to interview the resident but it was unsuccessful. The resident was unable to state anything about the prior incident (on 4/20/25) or what happened earlier that morning (4/23/25). On 4/23/25 at 3:30 pm Nurse #2 was interviewed. Nurse #2 stated she was frequently assigned to Resident #2 on day shift. She stated his vision had declined, his dementia was advanced, and he was sleeping more. The resident had a history of verbal and physical behavior but there had been none recently. He was accepting of care and not combative. On 4/24/25 at 12:05 pm an interview was completed with Resident #2's family member. The family member stated the resident would not accept sexual advances from a male and would be very upset if that happened. The resident had dementia and would not be able to defend himself. He was sleeping more. The resident was not able to remember the incident when asked. Resident #1 had a psychiatry progress note dated 4/22/25. The resident was evaluated after staff had reported he had sexually assaulted another resident. The resident had a recent room change and a roommate added. The past medical history included major depression with psychotic symptoms and moderate intellectual deficits. The history also included resident-reported sexual abuse. The plan was to continue with current medication and the resident had failed a dose reduction. Paroxetine (antidepressant) was added for decreased libido and staff was to continue to monitor mood and behaviors. Resident #1 had a psychiatry progress note addendum to the 4/22/25 note dated 4/25/25 that documented the resident (Resident #1) had significant cognitive decline and intellectual deficit, therefore, had no awareness of participating in a sexual assault and was not aware of inappropriate sexual behaviors. On 4/23/25 at 10:40 am an observation and interview was conducted with Resident #1 in his room. He had no roommate and was sitting in his wheelchair. He appeared clean and was dressed. There was a sitter in the room with him supervising (NA #1). An interview was attempted with the resident which was unsuccessful due to poor memory. The resident had not remembered his previous roommate or any daily occurrence. Almost all his answers to questions were yes, no or don't know. The resident had a flat affect and low tone in his voice. The resident could not state what he was watching on television or which family member came to visit him. NA #1 was present and was aware of the incident (on 4/20/25) but had not provided care to Resident #1 previously. On 4/23/25 at 11:59 am an interview was completed with Nurse #1. Nurse #1 stated Resident #1 had a room change about a month ago and had a new roommate (Resident #2) for about 2 weeks. Staff had not reported any concerns after the room change and Resident #1 had no prior history of inappropriately touching other residents. The incident on 4/19/25 night shift (that occurred on 4/20/25) of Resident #2 touching Resident #1's penis was a new behavior. Both residents had dementia and were unable to remember anything. NA #3 was interviewed on 4/23/25 at 12:43 pm. NA #3 stated Resident #1 was alert to self and able to make his needs known. He was cooperative and had no behavior when care was provided. The resident had no instances of inappropriate touching of staff or residents prior to the 4/20/25 incident that the NA was aware of. On 4/23/25 at 3:30 pm Nurse #2 was interviewed. Nurse #2 stated she was frequently assigned to Resident #1 on day shift from 7:00 am to 7:00 pm. The resident had dementia and a poor memory. He was calm, allowed care, and was cooperative. The resident was not known to touch residents or staff inappropriately. The facility provided the following corrective action plan with a completion date of 4/22/25: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. - Resident #1 is alert but not oriented to person and place with a Brief Interview for Mental Status (BIMs) of 3. Diagnoses include Intellectual Disabilities, Dementia, Major Depression, and unspecified lack of Physiological Development in Childhood. Resident # 2 is alert but not oriented to person and place with BIMs of 0. Diagnoses include dementia and cognitive-communication deficits. On 4/20/25, at approximately 5:45 am, Nurse Aide (NA) #3, entered the room and observed Resident #1 on the fall mat on the right side of Resident #2's bed. Resident #1 was positioned sideways on the mat, with his back facing the door. Resident #2 had repositioned himself in the bed, in a reverse position with his head towards the foot of the bed and his feet toward the head of the bed, and his brief was noted to be open. Resident #1 was rubbing his hands back and forth on Resident #2 genitals. NA #3 left the room to obtain assistance from the Medication Aide (MA) #1. When MA #1 and NA #3 walked into the room, they ensured that Resident #1 had stopped physically contacting Resident #2. MA #1 called Nurse #1 via phone for assistance. Resident #2 was assessed by Nurse #1, and no injuries were noted. When Resident #1 was asked what he was doing, he replied, Nothing. Resident #2 could not verbalize what happened during the incident due to impaired cognition. Resident #2 was moved to a private room and Resident #1 was placed on 1:1 observation by the weekend supervisor with a staff member remaining in close proximity to the resident at all times to prevent the resident from physical contact with another resident. The weekend supervisor ensured the initial assigned staff member was informed of the rationale behind the intervention. The weekend supervisor notified the Director of Nursing (DON) regarding the incident and the initiation of the one-on-one supervision. Subsequently, the DON informed the scheduler of the need to assign one-on-one coverage until further notified and to communicate the purpose of the intervention to staff at the time of assignment. Nurse #4 notified the physician, Administrator, and Resident #1's Resident Representative of the incident. The Director of Nursing notified Resident #2's resident representative of the incident. On 4/20/25, the Nursing Home Administrator notified the police, Adult Protective Service, and faxed the Health Care Personnel Investigation and Registry regarding the incident. On 4/21/25, the Social Worker completed a wellness visit with Residents #1 and #2 with no negative findings. On 4/21/25, Resident #1 was seen by the Nurse Practitioner. On 4/22/25, the psychiatric provider conducted an onsite visit with Resident #1 and Resident #2. Per the psychiatric provider, due to Resident #1's cognitive deficits, Resident #1 did not have the mental capacity to be aware of being sexually inappropriate. Resident #2 had no known effects from the incident. Resident #1 was moved to a private room on 4/24/25 and remained on 1:1 services until clear by the primary physician on 4/29/25. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. - On 4/20/25, skin assessments were completed on all non-alert and oriented residents, including Resident #2, for signs or symptoms of abuse by the treatment nurse/charge nurse with a Brief Interview of Mental Status (BIMS) of 12 or below with no negative findings. - On 4/20/25, resident interviews regarding inappropriate touching were completed for alert and oriented residents, with a BIMS of 13 or above by the Nursing Supervisor and Treatment Nurse. There was no concern of abuse reported during the interviews. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur - On 4/22/25, the Director of Nursing initiated a 100% audit of all residents' progress notes and Nurse Aide documentation of behaviors in the last 14 days to identify residents with sexually inappropriate behaviors. The purpose of the audit is to ensure the physician and family were notified of the behaviors, interventions in place including a psych consult, and behaviors are care planned to prevent resident to resident abuse. There were no identified areas of concern noted during the audit. - On 4/22/25, education was completed with all alert and oriented residents with a BIMS of 13 and higher, by the Nursing Supervisor and Staff Development Coordinator about abuse, including the definitions, resident rights, what to do in an abusive situation, and how to report abuse. - On 4/22/25, an in-service was conducted, in person, by the Nursing Supervisor and Staff Development Coordinator, with 100% of all staff (Administrator, Director of Nursing, and Department Managers, nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, admission, and agency staff) regarding Abuse. The in-service included the definition, policy, and prevention of Abuse. On 4/22/25, an in-service was initiated by the Nursing Supervisor with all staff regarding residents with behaviors. The education covered proper procedures for reporting, intervening, and documentation including updating the care plan. In-services were completed by 4/22/25. After 4/22/25, Nursing Supervisor and the RN Staff Development Coordinator will continue to monitor staff completion of the in-services, including agency. If a staff member has not worked and attended the initial in-service, they will be required to complete the in-service before starting their assignments on their next scheduled shift. The Staff Development Coordinator will ensure all newly hired facility staff and agency staff receive the inservice during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. - On 4/22/25, the decision was made by the Administrator to monitor the plan for prevention of resident to resident abuse including identifying residents with sexually inappropriate behaviors and presented to the QAPI Committee on 4/22/25. - On 4/22/25, the Administrator made the decision for the Nursing Supervisors to review progress notes and nurse aide documentation of behaviors including Resident #1, 5 times per week x 4 weeks, then monthly x 1 month to identify behaviors including sexually inappropriate behaviors. This audit is to ensure the physician and family were notified of the behaviors, interventions in place including a psych consult, behaviors are care planned, and early identification of behaviors to prevent resident to resident abuse. The Nursing Supervisor ensure all identified concerns are addressed. - The Administrator or Director of Nursing will present the findings of the behavior audit Tools to the Quality Assurance Performance Improvement (QAPI) committee monthly for 2 months to review and to determine trends and/or issues that may need further interventions and the need for additional monitoring. Compliance Date: 4/23/25 Validation of the corrective action plan was completed on 4/25/25. Review of documentation/staff roster of education that was completed with nursing and all non-nursing staff. The education took place between 4/20/25 through 4/22/25. The facility used a staff abuse questionnaire to determine if there was additional resident abuse observed or reported to the staff member and whether it was immediately reported to the Administrator. The facility used a behavior and abuse quiz to evaluate staff education. Each resident's record for progress notes and behaviors was reviewed by the DON and documented for dates 4/8/25 through 4/22/25. No negative findings were identified. On 4/23/25 interviews were conducted individually with Nurses #1, #2, #3, and #4 and NAs #1, #2, #3, and #4. On 4/24/25 an interview was conducted with MA #1. The staff stated they participated in education for resident abuse, reporting, and to remain with the residents until they were separated and safe. Monitoring was in place as indicated in the corrective action plan. The compliance date of 4/23/25 was validated.

Based on record review and interviews with staff, the facility failed to follow their abuse policy in the area of protection when Nursing Assistant (NA) #3 observed a resident-to-resident sexual assault between Resident #1 and Resident #2 and left the room during the incident to find staff assistance. This deficient practice affected 1 of 2 residents reviewed for abuse (Resident #2). Findings included: The facility abuse policy, last revised on 3/10/2017, documented, in part, The facility believes that our residents have the right to be free from abuse, neglect . Training of Employees: Orientation to the facility's policies and procedures regarding abuse, neglect, exploitation, and misappropriation of resident property will be provided to newly hired employees. Retraining programs for employees will be conducted on a regular basis. Training programs may include Indicators of resident vulnerability to abuse and related interventions. Protection: The facility shall take whatever steps are necessary to prevent further acts of abuse . A review of the staff's written statement by NA #3 dated 4/20/25 documented NA #3 was assigned to Resident #2 on night shift 4/19/25 7:00 pm to 7:00 am (ending 4/20/25). NA #3 observed Resident #1 in his wheelchair and put him to bed at 9:00 pm. Resident #2 was in his bed and appeared to be sleeping. Rounds were completed at approximately 11:30 pm, 2:30 am, and 4:00 am. Resident #1 was sitting on the fall mat watching TV and there was no touching observed during these rounding times. (Resident #1 and Resident #2 were roommates) Resident #1 was asked to get back into bed during each time and he did. During rounds at 5:45 am Resident #1 was on Resident #2's fall mat and had his hand inside Resident #2's brief moving back and forth. Resident #1 was asked to stop and did not. NA #3 ran out of the room to obtain help. Medication Aide (MA) #1 was at the nurses' station and returned to the room with NA #3. Both staff informed Resident #1 to get away from Resident #2 and he did. MA #1 called Nurse #1 on the phone to assist and she arrived. Resident #2 appeared to be sleeping during this incident. Both residents were assessed and separated. Resident #2 was known to open or remove his own brief. NA #3 was interviewed on 4/23/25 at 12:43 pm. NA #3 explained she was assigned to Residents #1 and #2 on night shift 4/19/25 7:00 pm to 7:00 am (ending 4/20/25). NA #3 stated she completed rounds by walking into the residents' room on her shift every 2 hours until 4:00 am and there was no touching observed during those rounds. NA #3 stated during rounds at approximately 6:00 am, Resident #1 was sitting on Resident #2's fall mat and Resident #1's back was to her. The NA indicated Resident #1 was observed touching Resident #2's penis with an open hand and Resident #1 was told to stop but did not stop. The NA explained she left the room to get assistance because she could not get Resident #1 to stop touching Resident #2's genitals. NA #3 further stated she ran out of the room to go get help and MA #1 was in the hall at the nurses' station. The NA stated she and the MA came back to the room and assisted Resident #1 to stop touching Resident #2. NA #3 communicated that Resident #2 was sleeping and his undergarment was completely off, but Resident #2 had been known to take his undergarment off and be exposed. NA #3 stated Resident #1 had no prior history of touching anyone and that this was new behavior. NA #3 stated it had taken her about 10 seconds to get assistance after she left the room and then returned with the MA. NA #3 commented that she was not allowed to use her personal phone and left the room to find help. She stated she did not use the call light because she wanted to get help faster than pressing the call light button and waiting for someone to respond. NA #3 stated she participated in education that included abuse, reporting, and to remain with the resident and not leave the room in the event she discovered abuse. The NA explained staff were asked to use the call light, yell out for staff, or use their personal phone for help. On 4/24/25 at 10:40 am MA #1 was interviewed. MA #1 stated she was working on 4/19/25 on night shift (7:00 pm to 7:00 am) and she was assigned to the hall where the abuse happened. The MA stated NA #3 came to the nurses' station where MA #1 was standing and summoned her to Residents #2's room on 4/20/25 sometime after 6:00 am. The MA explained that NA #3 told her she (NA #3) was unable to redirect Resident #1 from touching Resident #2's penis and requested MA #1 to assist. MA #1 stated she called for Nurse #1 by phone while in the resident's room and the nurse arrived immediately. MA #1 stated she was able to intervene and stop the sexual abuse and waited for Nurse #1 to arrive. MA #1 stated NA #3 should not have left the room until the residents were separated and safe. On 4/23/25 at 12:28 pm an interview was completed with Nurse #4. Nurse #4 stated she was the supervisor on 4/19/25 night shift (7:00 pm to 7:00 am [shift ends on 4/20/25]) and she was aware of the incident between Resident #1 and Resident #2. NA #3 observed sexual abuse by Resident #1 and could not redirect the resident. The nurse explained NA #3 left the room to find help from staff. The nurse further stated the NA should not have left the room while there was an act of abuse occurring and the NA was expected to remain with Resident #2 to keep him safe. On 4/24/25 at 10:21 am an interview was conducted with the Administrator. The Administrator stated he was aware of the sexual abuse incident in the early morning of 4/20/25 where Resident #1 sexually abused Resident #2 and this was observed by NA #3. The Administrator explained Resident #1 was rubbing the genitals of Resident #2 and it was discovered by NA #3. The Administrator further stated NA #3 left the room briefly during the assault to obtain staff assistance and the NA should not have left the resident room. The Administrator indicated the NA left the room because she could not redirect Resident #1 from touching Resident #2, but the NA should not have left the room and should have called out into the hall for staff assistance. The facility provided the following corrective action plan with a completion date of 4/22/25: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is alert but not oriented to person and place with a Brief Interview for Mental Status (BIMs) of 3. Diagnoses include Intellectual Disabilities, Dementia, Major Depression, and unspecified lack of Physiological Development in Childhood. Resident # 2 is alert but not oriented to person and place with BIMs of 0. Diagnoses include dementia and cognitive-communication deficits. On 4/20/25, at approximately 5:45 am, Nurse Aide (NA) #3, entered the room and observed Resident #1 on the floor mat on the right side of Resident #2's bed. Resident #1 was positioned sideways on the mat, with his back facing the door. Resident #2 had repositioned himself in the bed, in a reverse position with his head towards the foot of the bed and his feet toward the head of the bed, and his brief was noted to be open. Resident #1 was rubbing his hands back and forth on Resident #2 genitals. NA #3 left the room to obtain assistance from the Medication Aide (MA) #1. When MA #1 and NA #3 walked into the room, they ensured that Resident #1 had stopped physically contacting Resident #2. MA #1 called Nurse #1 via phone for assistance. Resident #2 was assessed by Nurse #1, and no injuries were noted. When Resident #1 was asked what he was doing, he replied, Nothing. Resident #2 could not verbalize what happened during the incident due to impaired cognition. Resident #2 was moved to a private room and Resident #1 was placed on 1:1 observation. Nurse #1 made the Nursing Supervisor, Nurse #4, aware of the incident. Nurse #4 notified the physician, Administrator, and Resident #1's Resident Representative of the incident. The Director of Nursing notified Resident #2's resident representative of the incident. On 4/20/25, the Nursing Home Administrator notified the police, Adult Protective Service, and faxed the Health Care Personnel Investigation and Registry regarding the incident. On 4/21/25, the Social Worker completed a wellness visit with Residents #1 and #2 with no negative findings. On 4/21/25, Resident #1 was seen by the Nurse Practitioner. On 4/22/25, the psychiatric provider conducted an onsite visit with Resident #1 and Resident #2. Per the psych provider, due to Resident #1's cognitive deficits, Resident #1 did not have the mental capacity to be aware of being sexually inappropriate. Resident #2 had no known effects from the incident. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 4/20/25, skin assessments were completed on all non-alert and oriented residents, including Resident #2, for signs or symptoms of abuse by the treatment nurse/charge nurse with a Brief Interview of Mental Status (BIMS) of 12 or below with no negative findings. On 4/20/25, resident interviews regarding inappropriate touching were completed for alert and oriented residents, with a BIMS of 13 or above by the Nursing Supervisor and Treatment Nurse. There was no concern of abuse reported during the interviews. On 4/22/25, the Nursing Supervisor initiated an abuse questionnaire with all employees. The questionnaire included: Do you know of any resident that you witnessed, or that has verbalized abuse to you that has not been reported and addressed? All identified areas of concern will be addressed through the resident concern and abuse process as necessary by the Administrator. Questionnaires were completed by 4/22/25 for all staff that worked. After 4/22/25, The Nursing Supervisors and the RN Staff Development Coordinator will continue to monitor staff completion of the questionnaires, including agency. If a staff member has not worked and completed the questionnaire, they will be required to complete it before starting their assignments on their next scheduled shift. On 4/22/25, the Nursing Home Administrator posted an abuse action checklist at each nurses' station on bright-colored paper for nurses to use as a reference during allegations of abuse. The checklist includes ensuring the resident is safe and out of harm's way and immediately reporting the incident. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 4/22/25, an in-service was initiated, in person, by the Nursing Supervisor and Staff Development Coordinator, with 100% of all staff , to include NA #3, (Administrator, Director of Nursing, Department Managers, nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, admission, and agency staff) regarding abuse. The in-service included the definition and prevention of abuse. Additionally, the in-service emphasized to always ensure the resident is out of harm's way first when abuse is suspected and to remain with the resident until the resident is safe, and calling for assistance if needed by yelling, utilizing the call bell, or utilizing a phone. In-services were completed by 4/22/25. After 4/22/25, The Nursing Supervisor and the RN Staff Development Coordinator will continue to monitor staff completion of the in-services, including agency. If a staff member has not worked and attended the initial in-service, they must complete it before starting their assignments on their next scheduled shift. The Staff Development Coordinator will ensure all newly hired facility and agency staff receive the in-service during orientation. On 4/22/25, quizzes were initiated, in person, with all staff, including NA #3 and agency, by the Nursing Supervisor and Staff Development Coordinator to ensure a successful understanding of the abuse education, including the first thing to do when abuse is suspected is to ensure the resident is out of harm's way. Any staff that does not pass the quiz after 3 attempts will not be allowed to work until they are re-educated and successfully pass. The quizzes will be completed on 4/22/25 for all staff that worked. After 4/22/25, The Nursing Supervisor and the RN Staff Development Coordinator will continue to monitor staff completion of the quiz including agency. If a staff member had not worked and received the initial quiz, they will be required to complete it before starting their assignments on their next scheduled shift. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. On 4/20/25, the decision was made to monitor the plan for abuse and presented to the QAPI Committee by the Administrator on 4/21/25. On 4/20/25, the decision was made by the Administrator, for the Nursing Supervisors to review progress notes, grievances, and reportable allegations including Residents #1 and #2, 5 times per week x 4 weeks, then monthly x 1 month to identify any allegations of abuse. This audit is to ensure all allegations of abuse have been appropriately addressed to include ensuring the safety of the residents by staff remaining with the resident until out of harm's way, calling for assistance if needed by yelling, utilizing the call bell, or utilizing a phone, and policy and procedures were followed. The Nursing Supervisor will immediately report all identified concerns to the Administrator and Director of Nursing. The Administrator or Director of Nursing will ensure all concerns are addressed including reeducation of staff as needed. The Nursing Supervisors and RN Staff Development Coordinator will complete 10 quizzes with staff including NA #3 and agency, weekly x 8 weeks. The purpose of the quizzes are to ensure staff remain knowledgeable of what to do when abuse is suspected, including ensuring the resident is out of harm's way first and remain with the resident until the resident is safe. The Nursing Supervisor will immediately reeducate staff as needed for all identified areas of concern. The Administrator or Director of Nursing will present the findings of the quizzes and audit of the progress notes, grievances, and reportable allegations to the Quality Assurance Performance Improvement (QAPI) committee monthly for 2 months to review and to determine trends and/or issues that may need further interventions and the need for additional monitoring. Date corrective actions completed: 4/22/25 Compliance Date: 4/23/25 Validation of the corrective action plan was completed on 4/24/25. Review of documentation/staff roster of education that was completed with nursing and all non-nursing staff. The education took place between 4/20/25 through 4/22/25. On 4/23/25 interviews were conducted individually with Nurses #1, #2, #3, and #4 and NAs #1, #2, #3, and #4. On 4/24/25 an interview was conducted with MA #1. The staff stated they participated in education for resident abuse, reporting, and to remain with the residents until they were separated and safe. Monitoring was in place as indicated in the corrective action plan. The compliance date of 4/23/25 was validated.

Based on observations, resident and staff interviews, and record reviews, the facility failed to allow residents assessed to be safe to smoke the ability to smoke independently at any time of his/her choice. This occurred for 3 of 3 residents (Resident #47, #8, and #69) who expressed a desire to smoke at times other than the supervised smoking times designated by the facility. This practice had the potential to affect other safe smokers in the facility. The findings included: A review of the facility's Smoking Policy (Revised on 10/15/22) was conducted. A section of the policy entitled Determination of Smoking Residents' Supervision Needs included the following Procedures, in part: #3 (of 6). After completion of each assessment, the interdisciplinary care plan (ICP) team will review and determine the smoking status (supervised/unsupervised) of the resident. a) When the Smoking Evaluation identifies a resident with any potential hazard risk, including but not limited to a cognitive deficit, the resident will be allowed to smoke only during this facility's designated smoking times with direct staff supervision. b) When the Smoking Evaluation identifies a resident without any potential hazard risk and who is safe to smoke independently, the resident will be allowed to smoke unsupervised, at any time of his/her choice. An observation was conducted on 3/12/24 at 3:13 PM of a sign placed on the door leading to the facility's designated smoking area. The sign read: Smoking Schedule 1st 11:00 AM - 11:30 AM 2nd 2:00 PM - 2:30 PM 3rd 5:00 PM - 5:30 PM a. Resident #47 was admitted to the facility on [DATE] with cumulative diagnoses which included diabetes and history of a stroke. The resident's most recent Minimum Data Set (MDS) was an annual assessment dated [DATE]. The MDS revealed Resident #45 had intact cognition. A review of Resident #47's electronic medical record (EMR) included a Smoking Evaluation dated 3/2/24. The Outcome section of the Smoking Evaluation reported the following: 1. Outcome: Resident is a safe smoker and may smoke independently at this time. 2. Resident Education: Education on Smoking Policy provided. In agreement to follow. 3. Care Plan reviewed and revised as necessary (Dated 3/2/24). An interview was conducted on 3/12/24 at 3:40 PM with Resident #47. During the interview, the resident confirmed she was a smoker. When asked, Resident #47 reported that although she was a safe smoker, she was only allowed to smoke during the scheduled smoking times of 11:00 AM, 2:00 PM and 5:00 PM. She stated that they (the smokers) didn't understand why they were only allowed to go out at these times if they were safe smokers. b. Resident #8 was admitted to the facility on [DATE] with cumulative diagnoses which included diabetes and cerebrovascular disease (a disorder where the blood flow to the brain is affected). The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #8 had intact cognition. A review of Resident #8's electronic medical record (EMR) included a Smoking Evaluation dated 3/2/24. The Outcome section of the Smoking Evaluation reported the following: 1. Outcome: Resident is a safe smoker and may smoke independently at this time. 2. Resident Education a. Education on Smoking Policy provided. In agreement to follow. 3. Care Plan reviewed and revised as necessary (Dated 3/2/24). An interview was conducted with Resident #8 on 3/12/24 at 4:20 PM. During the interview, Resident #8 confirmed she was a smoker. The resident reported she was only allowed to smoke during the supervised smoking times designated by the facility (11:00 AM, 2:00 PM, and 5:00 PM). When asked, the resident reported she was not happy she was limited to smoking during the facility's designated smoking times. c. Resident #69 was admitted to the facility on [DATE] with cumulative diagnoses which included non-traumatic spinal cord dysfunction. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #69 had moderately impaired cognition. A review of Resident #69's electronic medical record (EMR) included a Smoking Evaluation dated 3/2/24. The Outcome section of the Smoking Evaluation reported the following: 1. Outcome: Resident is a safe smoker and may smoke independently at this time. 2. Resident Education: Education on Smoking Policy provided. In agreement to follow. 3. Care Plan reviewed and revised as necessary (Dated 3/2/24). An interview was conducted on 3/12/24 at 4:25 PM with Resident #69. During the interview, the resident confirmed she was a smoker and was only allowed to smoke at 11:00 AM, 2:00 PM and 5:00 PM. When asked what her thoughts were about the designated smoking times, the resident emphatically stated she wanted More! An observation was conducted on 3/13/24 at 11:10 AM as an Activities Department Aide unlocked the coded door leading to the facility's designated smoking area. Residents wishing to smoke were observed to follow the Aide outdoors to the enclosed patio. An interview was conducted on 3/13/24 at 11:15 AM with the Activities Director as she approached the smoking area. When asked, the Activities Director reported the Activities Department assumed the primary responsibility to supervise all the smokers during the scheduled smoking times. An interview was conducted on 3/13/24 at 3:30 PM with the facility's Interim Administrator in the presence of the corporate Regional [NAME] President. During the interview, the concern related to the facility's mandated supervision and restriction of smoking times for residents assessed as safe smokers was discussed. The Interim Administrator reported the supervised smoking schedule was already in place when he came to the facility in mid-January. He confirmed the designated, supervised smoking times currently applied to all smokers. The Interim Administrator stated, It's an issue that needs to be addressed.

Based on record review, resident, and staff interviews the facility failed to investigate and resolve grievances for Residents #46 and #42 and maintain evidence demonstrating the result of the grievances for Residents #282, #29, #68. This was for 5 of 5 residents reviewed for grievances. The findings included: 1a. Resident #46 was admitted on [DATE]. A review of Resident #46's grievance dated 1/8/24 was conducted and revealed no documented investigation or follow up noted on the grievance form. An interview was conducted with Resident #46 on 12/1/2023 at 1:45 PM and she revealed she had shared a grievance regarding poor call light response times and never received a response. 1b. Resident #42 was admitted on [DATE]. A review of Resident #42's grievances dated 1/8/24 and 1/24/24 was conducted and revealed no documented investigation or follow up noted on the grievance form. The 1/8/24 grievance expressed by Resident #42 was related to the failure of the nursing staff to provide Activities of Daily Living (ADL) care in a timely manner. The grievance shared on 1/24/24 was regarding the resident's medications, incontinence care, and staff failing to be polite in their interactions with her. An interview was conducted with Resident #42 on 3/14/24 at 3:55 PM. During the interview, the resident was asked if she recalled whether the facility responded to the concerns/grievances she had shared on 1/8/24 and 1/24/24. Resident #42 was unable to recall what the concerns were at that time and therefore, she could not address whether she received a response from the facility or follow-up information on the resolution of these concerns. 2. A review of the facility grievance log was conducted from August 2023 to March 2024. The review revealed logged grievances for Resident 281 dated 10/9/23, a grievance for Resident # 282 dated 11/5/23 and a grievance for Resident #68 dated 9/29/23. No copies of these three grievances were provided by the facility. An interview was conducted on 3/14/24 at 9:57 AM with the Administrator. He revealed that he was not able to provide completed grievances forms for residents #46 and #42 but felt that the grievances had been investigated. He also revealed Residents #282, #68, and #281 had logged grievances but the facility did not maintain a copy of these grievances and was not sure why this occurred. A follow up interview was conducted on 3/14/24 at 8:02 AM and he revealed that he was not able to locate any of the missing information and that the facility should have a documented record of grievance resolution, complainant follow up and the records should have been maintained for three years.

Based on staff interviews and record reviews, the facility failed to review and revise a resident's care plan when indicated for 4 of 29 sampled residents (Resident #47, Resident #8, Resident #69, and Resident #46). The care plan for Residents #47, #8 and #69 were not revised to accurately reflect the results of their Smoking Evaluation. Resident #46's plan of care was not updated when there was a change in her Advance Directive. The findings included: 1-a. Resident #47 was admitted to the facility on [DATE] with cumulative diagnoses which included diabetes and history of a stroke. The resident's most recent Minimum Data Set (MDS) was an annual assessment dated [DATE]. The MDS revealed Resident #47 had intact cognition. A Smoking Evaluation was completed on 3/2/24. The Outcome section of the Smoking Evaluation reported the following: 1. Outcome: Resident is a safe smoker and may smoke independently at this time. 2. Resident Education: Education on Smoking Policy provided. In agreement to follow. 3. Care Plan reviewed and revised as necessary The resident's current Care Plan included the following area of focus, Resident is a supervised smoker / Problematic manner in which resident acts characterized by inappropriate smoking of tobacco related to: Cognitive impairment, Physical limitations (Revised on 4/21/23). Goal: Resident will smoke safely in designated areas with supervision thru next review. Interventions included, in part: Evaluate resident's ability to smoke safely on a consistent and regular basis. 1-b. Resident #8 was admitted to the facility on [DATE] with cumulative diagnoses which included diabetes and cerebrovascular disease (a disorder where the blood flow to the brain is affected). Review of the resident's EMR indicated her most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #8 had intact cognition. A review of Resident #8's EMR included her most recent Smoking Evaluation dated 3/2/24. The Outcome section of the Smoking Evaluation reported the following: 1. Outcome: Resident is a safe smoker and may smoke independently at this time. 2. Resident Education a. Education on Smoking Policy provided. In agreement to follow. 3. Care Plan reviewed and revised as necessary (Dated 3/2/24). The resident's current Care Plan was reviewed and included the following area of focus, Resident has been evaluated to be an unsafe smoker due to smoking in unauthorized areas. The care plan was last revised on 9/8/23. Goal: Resident will smoke safely in designated areas with supervision thru next review. Interventions included, in part: Assist resident to designated smoking areas during established facility smoking times and Do not leave resident unattended while smoking. 1-c. Resident #69 was admitted to the facility on [DATE] with cumulative diagnoses which included non-traumatic spinal cord dysfunction. Further review of the resident's EMR indicated her most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed Resident #69 had moderately impaired cognition. A review of Resident #69's electronic medical record (EMR) included her most recent Smoking Evaluation dated 3/2/24. The Outcome section of the Smoking Evaluation reported the following: 1. Outcome: Resident is a safe smoker and may smoke independently at this time. 2. Resident Education: Education on Smoking Policy provided. In agreement to follow. 3. Care Plan reviewed and revised as necessary (Dated 3/2/24). The resident's current Care Plan was reviewed and included the following area of focus, Resident is a supervised smoker. Goal: Resident's preference to use tobacco/tobacco substitute products of her choices will be honored thru next review. An interview was conducted with the facility's Director of Nursing (DON) in the presence of the Regional Nurse Consultant. Upon inquiry as to who was responsible to ensure a resident's care plan accurately reflected the results of a resident's Smoking Evaluation, the DON stated the MDS nurse assumed that responsibility. She stated both a resident's Smoking Evaluation and care plan should include the same information. An interview was conducted on 3/14/24 at 11:45 AM with the MDS nurse. During the interview, the MDS nurse reviewed the most recent Smoking Evaluations and care plans for Resident #47, Resident #8, and Resident #69. The nurse confirmed the care plans were not in agreement with each resident's most recent Smoking Evaluation and determination of being a safe, independent smoker. The MDS nurse reported she would need to modify each residents' plan of care to accurately reflect the conclusion of the residents' Smoking Evaluations. An interview was conducted on 3/14/24 at 3:30 PM with the facility's Interim Administrator. Concern regarding the residents' care plans not containing the same information as indicated by their Smoking Evaluations was discussed. The Interim Administrator stated he had been made aware of the issue and that it would need to be addressed. 46725 2. Resident #46 was admitted on [DATE]. The most recent Minimum Data Set (MDS) was a significant change in status assessment dated [DATE], which revealed Resident #46 had intact cognition. A review of Resident #46 electronic medical record (EMR) revealed a physician's order dated 1/4/24 to change the full code status to Do Not Resuscitate (DNR). A review of Resident #46's paper chart revealed a physician signed DNR form effective 1/4/24 with no expiration date. A review of Resident #46's care plan noted as revised on 1/25/24 revealed a care plan for full code status. An interview was conducted with MDS Nurse #2 on 03/13/24 at 10:20 AM. She confirmed that she revised the care plan on 1/25/24 to continue the full code directive and did not realize that there was a new order for DNR on 1/4/24. She further revealed the care plan should have been updated to reflect the change in code status to a Do Not Resuscitate but it was missed. An interview was conducted with the Administrator on 03/14/24 at 08:01 AM. He revealed that when a change in code status occurs the residents care plan should be updated to reflect the correct code status.

Based on record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey dated 4/12/21 and the recertification and complaint survey dated 1/13/23. This was for one deficiency in the area of Grievances (585) which was originally cited during the recertification and complaint investigation survey conducted on 4/12/21 and recited during the current recertification and complaint investigation conducted on 3/14/24. In addition, Care Plan timing/revision (657) and Medication Storage (761) here were originally cited during the recertification and complaint investigation survey conducted on 1/13/23 and recited during the current recertification and complaint investigation conducted on 3/14/24. The repeated citations during the three surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F 585: Based on record review, resident, and staff interviews the facility failed to investigate and resolve grievances for Residents #46 and #42 and maintain evidence demonstrating the result of the grievances for Residents #282, #29, #68. This was for 5 of 5 residents reviewed for grievances. During the recertification and complaint survey dated 4/12/21 the facility failed to initiate a written grievance summary for grievances verbally reported for one of one resident reviewed for grievances. F 657: Based on staff interviews and record reviews, the facility failed to review and revise a resident's care plan when indicated for 4 of 29 sampled residents (Resident #47, Resident #8, Resident #69, and Resident #46). The care plan for Residents #47, #8 and #69 were not revised to accurately reflect the results of their Smoking Evaluation. Resident #46's plan of care was not updated when there was a change in her Advance Directive. During the recertification and complaint survey dated 1/13/23 the facility failed to review and update a care plan and ensure the care plan was signed for 1 of 5 residents reviewed for weight loss. F 761: Based on observations and staff interviews, the facility failed to remove the expired medications from the refrigerator and expired supply kits from the medication storage room. During the recertification and complaint survey dated 1/13/23 the facility failed to label inhalers and multidose vials with the date open and date to expire, dispose of expired medications, keep a medication refrigerated per pharmacy instructions, and label inhalers with the minimum required labeling (including a resident's name and instructions for administration) in 1 of 2 medication carts (Hall 300) and 1 of 1 medication rooms observed. An interview with the Administrator was conducted on 03/14/24 at 5:10 pm. He indicated his expectation was for the team to work together to maintain an effective Quality Assurance Performance Improvement Committee to ensure the facility does not repeat a previous deficient practice.

Based on facility policy review, record review and staff interview the facility failed to monitor antibiotic usage in the facility for 6 of 13 months reviewed (August 2023, September 2023, October 2023, November 2023, December 2023, January 2024). Findings included: Review of the facility's policy titled Antibiotic Stewardship, revised on 03/04/24 revealed the following: As a component of this facility's IPCP (infection prevention control program), the antibiotic stewardship program supports the appropriate and safe use of antibiotics in the treatment of residents' infections with a focus on the development and reduction of antibiotic-resistant organisms. On 03/14/24 at 3:00 pm an interview was conducted with the Assistant Director of Nursing (ADON), and she indicated she was unable to locate 2023 antibiotic stewardship information initially then presented with January 2023 through July 2023 antibiotic stewardship information. A review of February 2023 through January 2024 antibiotic stewardship revealed no information for antibiotic monitoring for the months of August 2023 through December 2023 and January 2024. During an interview on 3/14/24 at 4:15 pm with the Regional Nurse Consultant she indicated the previous ADON was responsible for the antibiotic stewardship, and she was here until December 2023. She indicated they were trying to find the rest of the antibiotic information. Attempted to contact the previous ADON and was unsuccessful. On 03/14/24 at 4:21 pm an interview was conducted with the Director of Nursing (DON), and she indicated her expectation was to monitor the antibiotics and infections on day one of the start of antibiotic. She indicated when an antibiotic started, they would ensure it was needed, track and trend the infections and review specifics of particular issues of infection monitoring monthly.

Based on record review 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 5 of 5 residents (Resident #46, Resident #14, Resident #26, Resident #33, and Resident #54) and offer the COVID-19 vaccine for 3 of 5 residents (Resident #26, Resident # 33, and Resident #54) and maintain a resident's record of COVID-19 vaccine history for 3 of 5 residents (Resident #26, Resident #33, and Resident #54), the failures regarding education, offering the vaccine, and maintain records were found for 5 of 5 residents reviewed for infection control. The findings included: a. Resident #46 was admitted to the facility on [DATE]. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #46 was cognitively intact. Review of Resident #46's medical record revealed no information the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 immunization. b. Resident #14 was readmitted to the facility on [DATE]. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #14 was cognitively intact. Review of Resident #14's medical record revealed no information the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 immunization. c. Resident #26 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #26 had cognitive impairment. Review of Resident #26's medical record revealed no information the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 immunization and no information about Resident #26 being offered and/or received the COVID-19 vaccine. d. Resident #33 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #33 had cognitive impairment. Review of Resident #33's medical record revealed no information the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 immunization and no information about Resident #33 being offered and/or received the COVID-19 vaccine. e. Resident #54 was admitted to the facility on [DATE], discharged to the hospital on 01/29/24 and readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #54 was cognitively intact. Review of Resident #54's medical record revealed no information the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 immunization and no information about Resident #54 being offered and/or received the COVID-19 vaccine. An interview was conducted with the Infection Preventionist on 03/14/24 at 1:38 pm and she indicated she had been employed in the facility for 1 1/2 weeks and had researched in the North [NAME] (NC) Vaccine Registry the vaccines for the current residents and had checked the consents to see which Residents had consents had. She indicated some consents were in the computer and some were on paper, but now she was not able to locate the consents and or education regarding the COVID-19 vaccine for any residents and the Director of Nursing (DON) was trying to locate them. On 03/14/24 at 3:12 pm an interview was conducted with the DON, and she indicated she believed the consents were being done, however they were unable to locate them. The DON indicated the vaccine process was started on admission. She indicated they would check the record, and if a resident had been given the vaccine it was documented the computer, and if they have not received the vaccine, it was offered to them, and they received education about the vaccination. She stated the consents were obtained and the vaccine would be administered.

Based on record review and staff interviews, the facility failed to complete and submit an initial report within 2 hours to the state regulatory agency for an allegation of family provided sitter to resident abuse for 1 of 3 residents reviewed in facility reported incidents (Resident #68). Findings included: A review of the initial report on 1/13/24 at 11:30 pm revealed the facility was made aware Resident #68 alleged his family provided sitter hit him in the stomach. No injuries were reported. The initial report was faxed to the state regulatory agency on 1/14/24 at 4:52 pm. An interview was conducted with the Administrator on 3/14/24 at 1:48 pm which revealed he was made aware of the allegation of abuse on 1/13/24 around 11:30 pm and immediately started their investigation. Interview further revealed Administrator did not have access to a fax machine. The Administrator indicated all steps were taken within 2 hours except faxing in the initial report to the state regulatory agency.

Based on observations, staff interviews and record review, the facility failed to apply splints for 1 of 1 resident (Resident #33) reviewed for contractures. The findings included: Resident #33 was admitted on [DATE] with diagnoses of hypertension, diabetes, cerebral vascular accident, and left-hand contracture/hemiparesis. Review of admission Minimum Data Set(MDS), dated [DATE] , indicated Resident #33 was severely cognitively impaired and required total assistance with activities of daily living. The MDS coded Resident #33 with left hand contracture. Review of the occupational discharge summary dated 2/1/24, documented Resident #33 met the goal on 2/12/24. Resident #33 exhibited left upper extremity pain with passive range of motion and application of resting hand splint. Resident #33 tolerated up to 4 hours wearing once splint was applied. Review of the functional maintenance record restorative phase three for Resident #33 completed by occupational therapy on 2/9/24, range of motion task was to provide passive range of motion to left upper extremities daily with activities of daily living. The approach was to apply the resting hand splint for two hours daily. Review of the physician order dated 2/26/24, revealed an occupational therapy evaluation and treatment for contracture management, documented place left hand orthotic once daily. There was no documentation of when to remove splint. Review of the Medication Administration Records (MAR) for February 2024 and March 2024 for Resident #33 revealed documentation of the left-hand splint application was being done at 7:30 AM. An observation was conducted on 3/11/23 at 10:10 AM, Resident #33 was in bed and her left hand was contracted with no splint. There was no splint available in the room. An observation was conducted 03/11/24 11:34 AM, the left hand continued to be without a splint. There was no splint available in the room. An observation was conducted on 3/12/24 at 7:45 AM, the left hand had no splint in place. There was no splint available in the room. An observation was conducted on 3/12/24 at 8:20 AM, resident in bed with a splint in place. An observation was conducted on 3/12/24 at 10:00 AM, resident remain in bed without splint in place. There was no splint available in the room. An observation was conducted 3/12/24 at 12:26 PM, with the Director of Nursing, Resident #33 was in bed with no splint in place on her left hand. The Director of Nursing confirmed Resident #33's left hand was contracted and there was no splint in place. She further stated Resident #33's splint was not on the list of residents who had assistive devices provided by the rehabilitation therapy department. She stated she would follow-up with therapy regarding the use of a splint for Resident #33. The Director of Nursing stated she was unaware of the location of the splint. An interview was conducted on 3/12/24 at 12:36 PM, Nurse Aide #4 stated she was not sure Resident #33 wore a hand splint and could not recall when the resident had a left-hand splint . She did not apply the splint application because she did not know she wore one. An interview was conducted on 3/12/24 at 3:00 PM, in conjunction with a record review with Nurse#3, stating she was unaware the resident had an order for a splint. Nurse#3 reviewed the physician orders and confirmed there was order for a left hand orthotic to be worn every day. She stated orders for splint application would have been on the MAR. Review of the MAR revealed documentation the splint was applied but she could not recall when she had observed left-hand splint on the resident. The Nurse #3 searched for the splint in the room and the splint could not be located. An interview was conducted on 3/12/24 at 3:44 PM, in conjunction with an observation with Nurse Aide #5 stated she reviewed the resident care card and there was no information about the resident wearing any type of splint. The care card only stated the resident always wore a protective boot on left foot. Nurse Aide #5 confirmed there was no splint in place on the left hand. Nurse Aide #5 stated was she unaware the resident should be wearing a splint. An interview was conducted on 3/12/24 at 4:00 PM, the Nurse#4 stated she was unaware the resident had an order for a splint. She indicated she did not know where the splint was located. She further stated when residents wore splints, the information would be on the physician order and flagged on the medication administration record as a reminder to ensure the splints were applied. A follow-up interview was conducted 3/13/24 at 1:49 PM, in conjunction with a record review with the Director of Nursing reviewed the occupation therapy discharge summary dated 2/12/24, revealed the resident was to wear the splint for 4 hours a day and staff were trained on the application process. She confirmed the physician order dated 2/26/24 for the left-hand orthotic was to be worn every day. The Director of Nursing further stated the physician order would include frequency of donning/doffing and the care plan would be updated to reflect the addition of the splint. She further stated nursing would also document on the MAR when the splint was applied and removed. The Director of Nursing stated she was unaware of the location of the splint at this time and would place the splint order on hold until the resident could be re-evaluated, and all staff trained on the application of the splint. She stated she would follow-up with therapy regarding the use of a splint for Resident #33. The Director of Nursing stated she was unaware of the location of the splint An interview was conducted on 3/12/24 at 2:00PM, in conjunction with a record review with the Certified Occupational Therapist Assistant stated therapy was doing trial palm splints/hand rolls on the resident from 1/24/24-2/12/24, she stated the discharge summary documented the resident tolerated the splint application up to 4 hours once splint was applied. She reviewed the order dated 2/26/24 and confirmed the transcription of the order did not include what was in the discharge summary and staff knowledge or application of splint was not available. She also confirmed the location of the splint was also not available. An observation was conducted on 3/13/24 at 7:30 AM, Resident #33 was lying in bed without splint. A follow-up observation was conducted on 3/13/24 at 8:43 AM, in conjunction with record review, with the Director of Nursing, revealed Resident #33 did not have a splint on and there was no splint available for the resident. The Director of Nursing acknowledged that staff had been documenting on the medication administration record(MAR) for February 2024 and March 2024, the splint was being applied at 7:30 AM, 3/11/24-3/13/24 during the week of survey, however there was no splint in place or available.

Based on record review, resident and staff interviews the facility failed to maintain the dignity of residents by not providing assistance with Activities of Daily Living (ADLs) when requested for 2 of 5 residents (Resident #19 and Resident #11) reviewed dignity. Resident #19 indicated she waited over 1 hour for her call bell to be answered and this made her feel ignored, bad, and resulted in the resident being tearful, and Resident #11 stated it made them feel mad. Finding included: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis secondary to cerebral infarction, affecting right dominant side, chronic pain, and type 2 diabetes mellitus. A review of Resident #19's quarterly minimum data set (MDS) dated [DATE] identified Resident #19 as being cognitively intact. Resident #19's MDS also indicated that she needed extensive assistance with dressing. During an interview with Resident #19 on 01/09/23 at 1:28 pm she indicated the staff took a long time to help her with getting dressed. She indicated that she has waited over an hour just to get assistance with putting on her bra, pulling up her pants and to fastening her pants. Resident #19 indicated that because she can do a lot for herself, and when she asks for assistance from staff, they make her feel bad. During a second interview with Resident #19 on 01/13/23 at 2:38pm, Resident #19 revealed again on the morning of 01/13/23 she had the same problem waiting over an hour for staff to respond to her call bell to help her with getting dressed. She reported she had to use the phone to call another staff member. She explained that she got ahold of the Scheduler, who was not a Nursing Assistant, by phone to come and help her. Resident #19 stated, she also reported this information to that staff member this morning. Resident #19 indicated it made her feel bad and ignored. She stated, I try to do as much as I can for myself, I use my stick (adaptive equipment that aides with reaching items) to help me, but I still need some help from staff. Resident #19 stated I learned to do a lot for myself because I plan on getting out of here, I try not to get anyone in trouble, like today I did everything I could, and waited for someone to come help put my bra on and pull up my pants. Resident #19 indicated she normally activates her call bell and must wait over an hour. Resident #19 was observed to be very tearful when discussing having to wait on staff to assist her and stated, she just wanted to get better and go home. During an interview with the Scheduler on 01/13/23 at 2:08pm, it was indicated that she had received several phone calls from Resident #19 on different occasions, because of having to wait a long time for the nursing assistants to help her with getting dressed. The Scheduler stated she went to the Resident's room and provided assistance. She indicated she had reported these concerns related to call bell response time to the nursing staff (unable to recall specific staff members) on several occasions. During an interview with Nursing Assistant (NA) #9 on 01/13/23 at 4:00pm, she indicated she was assigned to Resident #19 on 01/13/23 from 7am to 7pm and has worked with her resident before. She stated she has helped Resident #19 get dressed before when she called for assistance, and she also helped her today put her bra on and pull up her pants. NA #9 stated she asked Resident #19 if she needed help with anything else and the resident said no. She revealed no knowledge of Resident #19's concerns of waiting over an hour for assistance with getting dressed. NA #9 indicated that she answered residents' call bells between 10 to 15 minutes of residents activating their bells. An interview was conducted with the Unit Manager on 01/13/23 at 4:15pm, and she indicated Resident #19 had reported concerns of not getting assistance from staff when needed. She was unable to remember when this was reported or how many times the resident had reported this but she indicated it was more than once. The Unit Manager indicated when it was reported to her, she had verbally counseled the staff but did not document it. During an interview with the Director of Nursing on 01/13/23 at 5:00 pm she indicated that her expectation was for staff to answer call bells within 3-5 minutes and treat all residents with respect and dignity, that no residents should be waiting long periods of time for assistance with Activities of Daily Living. She further indicated that she was a new DON at the facility and she was unaware of any concerns with call bell response time. 46725 2. Resident # 11 was admitted on [DATE]. A review of Resident #11's quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #11 as being cognitively intact. Resident #11's MDS also indicated that she needed total care with all activities of daily living. During an interview with Resident #11 on 1/9/23 at 10:50am she indicated the staff take (unable to recall specific staff) 45 minutes to an hour to answer her calls for assistance with needs such as getting her a drink or pulling her up in the bed. Resident #11 indicated that she was not able to do these things for herself and that it made her mad to have to wait for assistance. She further revealed that she has made nursing staff aware of this concern. An interview was conducted with Nursing Assistant #2 on 1/11/23 at 12:27pm. She revealed that she was assigned to Resident #11 frequently and she had previously made her aware of her concern regarding call light response. She explained that when the concerns were reported to her by Resident #11 the needs had already been addressed. NA #2 was unable to recall when Resident #11 informed her of this issue. She indicated she had not relayed this issue to anyone else. An interview was conducted with Nurse #2 on 1/13/23 at 2:00pm. She revealed she worked with Resident #11 frequently and that she had not been made aware of Resident #11's concern regarding poor call light response times. An interview was conducted with the Director of Nursing on 01/13/23 at 02:50 PM. She revealed that she has not been made aware of any call light response time concerns for Resident #11 and her expectation was that staff respond to call lights for assistance within 3-5 minutes.

Based on observation, staff and resident interviews, physician interviews and record review the facility neglected to provide incontinence care for 3 of 5 (Resident #24, Resident #26 and Resident #12) residents observed for incontinence care. Resident #24 expressed that he had to wait 2 and a half hours for incontinence care and felt embarrassed and angry about being left in a soiled brief. Resident #26 was not checked for incontinence for over two and a half hours and had a drying brown liquid covering just above his buttocks and down the back of his thighs. Resident #12 stated she had to wait over an hour for incontinence care and felt bad and neglected having to remain in a soiled brief. Findings included: 1. Resident #24 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 was cognitively intact and needed extensive assistance with one person for bed mobility, dressing and personal hygiene and total assistance with one person for toileting. Resident #24's care plan dated 11-11-19 revealed a goal that personal and activities of daily living care would be completed with staff support and Resident #24 would be neat, clean and odor free. The interventions listed for that goal were; staff to provide total care to include combing the hair, shaving and washing the face, hands and perineum (area below the pelvis and between the legs). During an interview and observation of Resident #24 on 12-17-19 at 8:55am, Resident #24 stated he was angry because he had informed Nurse #1 at 7:20am he needed to have incontinence care completed and was told there were no nursing assistants on the floor but when a nursing assistant arrived Nurse #1 would inform them he needed incontinence care. He also stated when he put his call light on around 8:00am a staff member came in and turned off the light telling me I would have to wait because the breakfast trays were coming out. The resident stated he had not received care and had to eat his breakfast lying in his own feces. Resident #24 was noted to have an odor of feces. The resident also stated this is an everyday occurrence. I usually have to wait up to 2 hours before they will clean me up. Nurse #1 was interviewed on 12-17-19 at 9:05am. Nurse #1 stated she had been informed at 7:20am by Resident #24 that he needed incontinence care completed but she was the only staff member on the hall and did not feel she could perform incontinence care by herself due to Resident #24 having [MEDICAL CONDITION] on his left side. She also stated there were nursing assistants on the hall and she had informed them of Resident #24's need for incontinence care at 7:45am. Nurse #1 stated she was unaware Resident #24 had not received incontinence care and she would remind staff. Resident #24 was interviewed on 12-17-19 at 9:25am. Resident #24 stated no one had come to provide incontinence care and he was still lying in his urine and feces I'm sorry if I smell but I can't help it when they won't come and clean me up. On 12-17-19 at 9:26am, Nurse #1 was observed to attempt to locate the nursing assistants but was unable to find them on the hall. Nurse #1 was noted to request the medication nurse to provide incontinence care to Resident #24. Incontinence care was observed on 12-17-19 at 9:30am. Resident #24 was noted to have crusted dried feces on his buttocks and his brief was noted to have a dried dark yellow ring. The resident's skin was intact with no redness noted. Nursing assistant #2 was interviewed on 12-17-19 at 10:00am. The nursing assistant stated she was the assigned nursing assistant for Resident #24 and had not been informed Resident #24 needed incontinence care when she arrived to work at 7:40am. She stated Resident #24 had put his call light on for incontinence care around 8:00am but stated she could not perform care at that time due to the arrival of the breakfast trays. Nursing assistant #2 stated she had planned to attend to Resident #24 after breakfast but there were only 2 nursing assistants on the hall, and she had been requested to help the other nursing assistant first. During an interview with the facility's physician on 12-18-19 at 12:55pm, the physician stated Resident #24 could not perform most of his activities of daily living care by himself due to his [MEDICAL CONDITION] but that the resident was cognitively intact. The physician stated she expected staff to respond to any resident's needs within minutes and allowing feces or urine to dry on the resident's skin could cause infection and skin breakdown. An interview on 12/20/19 at 4:07 pm with the Administrator revealed he felt the primary reason the residents did not receive care in a timely manner was related to the need to improve the quality of care the staff provided and recruit additional staff for the facility. 2. Resident #26 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #26 was moderately cognitively impaired and needed extensive assistance with one person for toileting and personal hygiene. Resident #26's care plan dated 11-11-19 revealed a goal of activities of daily living and personal care would be completed with the support of staff. The interventions listed for the goal were; assist with frequent incontinence and provide supervision and physical assistance. An observation and interview were conducted with Resident #26 on 12-16-19 at 1:30pm. Resident #26 was noted to be laying on his left side covered with a white sheet that was noted to have a brown liquid substance covering the sheet from the back of Resident #26's thighs to just above his buttocks. The brown liquid was noted to be drying around the edges and there was a foul odor in the resident's room. The resident stated he last received incontinence care before lunch but was not able to provide an exact time. It was also noted Resident #26 did not have his call light in reach. The call light was noted to be wrapped around the right bed rail which was down below the mattress. The resident attempted to reach his call light but was unable. Once the call light was handed to Resident #26, he was able to turn it on for assistance. An observation made on 12-16-19 at 1:35pm revealed Resident #26 was in bed laying on his left side covered by a white sheet with his call light turned on. A large area of the resident's white sheet was observed to be soiled with a brown liquid substance that was easily visible to anyone who entered the resident's room. The activities director (AD) was observed to enter Resident #26's room, turned off his call light and asked the resident what he needed but then quickly stated oh you're ok. The AD was observed to leave the residents room without giving the resident a chance to respond to why his call light was activated. During an interview with the AD on 12-16-19 at 1:36pm, the AD stated she did not notice Resident #26 was soiled or the foul odor in the resident's room. The AD stated, I was just looking at his face. The AD stated she would have a nursing assistant check on the resident. Incontinence care was observed with Resident #26 on 12-16-19 at 1:50pm. Nursing assistant #2 was observed providing the care and when NA #2 removed the sheet covering Resident #26, it was noted the brown liquid was partially dry on the back of his thighs and above his buttocks. The resident's skin was noted to be intact with no redness. During an interview with nursing assistant (NA) #2 on 12-16-19 at 2:05pm, the nursing assistant stated she could not remember the last time she provided Resident #26 with incontinence care but believed it was before lunch between 10:30am and 11:00am. She also stated the resident ate in the dining room, so she did not know if Resident #26 had been soiled during lunch and was unaware he was back in his room. The NA stated residents should have their call bell within reach and whoever put him in the bed should have checked to make sure he could reach it. She also stated she tried to check on her residents every 2 hours for incontinence but sometimes there is not enough help and it takes a little longer. NA #2 stated she had not checked Resident #26 for incontinence for over 2 hours and stated she felt it was neglectful because we are supposed to do our rounds at least every 2 hours. During an interview with the facility physician on 12-18-19 at 12:55pm, the physician stated she expected staff to respond to any resident's needs within minutes and allowing feces or urine to dry on the resident's skin could cause infection and skin breakdown. An interview on 12/20/19 at 4:07 pm with the Administrator revealed he felt the primary reason the residents did not receive care in a timely manner was related to the need to improve the quality of care the staff provided and recruit additional staff for the facility. 3. Resident #12 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. An annual minimum data set ((MDS) dated [DATE] for Resident #12 identified she was always incontinent of bowel / bladder and required extensive two-person assist with toilet use. She required extensive one-person assist with personal hygiene, her cognition was intact, and no behaviors were identified for the look-back period. A care plan for Resident #12 with a revision date of 11/19/19 stated activities of daily living and personal care would be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning. An additional care plan, also with a revision date of 11/19/19 stated problematic manner in which resident acts characterized by inappropriate behavior, resistive to treatment / care by certain staff members which resulted in missed treatments. An interview with Resident #12 on 12/18/19 at 9:30 am revealed her primary concern was she had to sit in stool and urine for an hour or more before being changed. She stated this made her feel bad and neglected by the staff. Resident #12 stated this was an ongoing problem and she had gone an entire shift without being changed. She explained she had not reported this directly to the facility staff, but she had submitted 2 complaints to the state. Resident #12 expressed she didn ' t know if she had to wait so long to be changed because of a lack of staff or that the staff just didn ' t bother to check on her. Resident #12 stated she had a cell phone and that was how she know how long it took to respond to her call bell. She added frequently the staff would come in and turn her call light off and tell her they would be right back and not return. An interview with Resident #12 on 12/19/19 at 9:15 am revealed she had urinated in her brief, but it had not been very long, and she hadn ' t called for assistance yet. An observation on 12/19/19 of the 300-hall revealed Resident #12 ' s call light came on at 9:35 am. A continuous observation revealed a staff member entered Resident #12 ' s room and the call light went off at 9:40 am. An interview on 12/19/19 at 9:41 am with the Activity Director (AD), who answered Resident #12 ' s call light, revealed the resident needed to be changed. She stated she had turned the residents call light off and notified Resident #12 ' s nurse (Nurse #5) the resident needed to be changed. An interview on 12/19/19 at 9:42 am with Nurse #5 revealed the AD had notified her that Resident #12 needed to be changed and she would let a Nursing Assistant (NA) know. A follow-up interview with Resident #12 on 12/19/19 at 10:05 am revealed she had not been changed yet and she had urine in her brief. A follow-up interview with Resident #12 on 12/19/19 at 10:44 am revealed no staff had come in to clean her up yet. She stated her brief was wet and her gown was soaked. She added she had not put her call light back on since the AD had turned it off. During an interview with Nurse #5 on 12/19/19 at 10:45 am she stated she was going to get someone to change Resident #12 and she would get right on it after she gave the medications she had already pulled out. An observation on 12/19/19 at 10:47am identified Resident #12 ' s call light was on. NA #3 entered Resident #12 ' s room at 10:48 am and the call light went off. NA #3 left the room and was observed entering another residents room. At 10:49 am NA #3 was observed speaking to Nurse #5 in the hallway. At 10:53 am NA #3 was observed entering Resident #12 ' s room with wash clothes and left the room again. An interview and observation of Resident #12 on 12/19/19 at 10:56 am revealed she was tearful upon entering the room. The resident stated she was okay and didn ' t want to talk about it. An observation on 12/19/19 at 11:00 am of Resident #12 during incontinence care revealed the bottom of her gown was wet and her brief was soaked with urine that had leaked onto the incontinence pad. An interview on 12/20/19 at 4:07 pm with the Administrator revealed he felt the primary reason the residents did not receive care in a timely manner was related to the need to improve the quality of care the staff provided and recruit additional staff for the facility.

Based on observation, resident and staff interviews and physician interviews the facility failed to provide sufficient nursing staff to prevent resident neglect and provide incontinence care for 3 of 5 sampled residents (Resident #24, Resident #26 and Resident #12) reviewed for activities of daily living. The residents had to lay in urine and feces while waiting for staff to provide incontinence care. Findings included: This tag was crossed referenced to: 1. F600: Based on observation, staff and resident interviews, physician interviews and record review the facility neglected to provide incontinence care for 3 of 5 (Resident #24, Resident #26 and Resident #12) residents observed for incontinence care. Resident #24 expressed that he had to wait 2 and a half hours for incontinence care and felt embarrassed and angry about being left in a soiled brief. Resident #26 was not checked for incontinence for over two and a half hours and had a drying brown liquid covering just above his buttocks and down the back of his thighs. Resident #12 stated she had to wait over an hour for incontinence care and felt bad and neglected having to remain in a soiled brief. During an interview with nurse #1 on 12-17-19 at 9:00am, the nurse stated she was the only employee working on hall 300 on 12-17-19 from 7:00am until about 7:40am because the nursing assistants were late coming to work. She also stated she had been aware residents' needed incontinence care, but she was not able to perform the care on her own due to the acuity of the residents so they just had to wait until more staff arrived. Nurse #1 stated on hall 300 there were 2 nursing assistants scheduled on 12-17-19 for the 7:00am to 3:00pm shift and there were 24 residents on hall 300. The Assistant Director of Nursing (ADON) was interviewed on 12-19-19 at 3:00pm. The ADON was made aware on 12-17-19 around 7:15am that there were no nursing assistants present on hall 300. She stated she informed the Director of Nursing (DON) and they checked the schedule to see who was supposed to be working and then the ADON stated she returned to the dining room to help feed residents. She stated she was aware the 11:00pm to 7:00am nursing assistants had left and there were no nursing assistants working on hall 300. An interview with the DON occurred on 12-19-19 at 3:10pm. The DON stated he arrived at the facility at 6:59am on 12-17-19, checked the schedule to see who was supposed to be working and about 15 minutes later he heard the call lights on hall 300 that were not being answered. So he went to see what was happening and that was when he was made aware the two nursing assistants who were scheduled to work the 7:00am to 3:00pm shift, had not reported to work. The DON stated he had expected the ADON to call the staff that was scheduled and the scheduler to find out what was going on but I guess she did not do that. He also stated he saw the staffing issue as a safety factor for the residents. During an interview with nurse #2 on 12-19-19 at 7:58am, the nurse stated on 12-19-19 there were no nursing assistants working on hall 300 except NA #8. Nurse #2 also stated she was agency and was asked to work that morning (12-19-19). Nurse #2 stated it was not safe for the residents to have one nursing assistant on the hall. Nurse #2 also stated we need some help down here. The facility's scheduler was interviewed on 12-19-19 at 8:20am regarding the lack of staff on hall 300 for the 7:00am to 3:00pm shift on 12-19-19. The scheduler stated there were normally 2-3 nursing assistants assigned to hall 300 and was not made aware there were no nursing assistants on hall 300 until I walked in the door 5 minutes ago. She stated it was the facility's policy that the previous shift (11:00pm to 7:00am) could leave as long as there was one person on the hall. The scheduler stated there were usually just two nursing assistants assigned to hall 300. The scheduler also stated she was not sure how the residents would be cared for if there was an emergency I guess we would ask for help from the other halls. An interview with nurse #2 occurred on 12-19-19 at 8:15am. Nurse #2 stated she felt frustrated when she worked at the facility because she was not able to provide the best care due to the lack of staff I have to stop giving medications which makes medication pass late or rush a resident taking the medication because I have to answer call lights. She also stated there were 2 nursing assistants for hall 300 and she would often have to help the nursing assistants with activities of daily living care and answering call lights which takes away from me spending quality time with the residents. NA #8 was interviewed on 12-19-19 at 8:15am. The NA stated she was frustrated that she could not provide high quality care for the residents because there were not enough staff. She also stated she had been the only nursing assistant on hall 300 for the last hour for 24 residents I can't get to all the call lights or provide the incontinence care they need when they need it. During an interview with NA #9 on 12-19-19 at 2:50pm, the NA stated she felt she could not provide timely incontinence care to the residents due to having only 2 nursing assistants working on hall 300. She also stated there were only 2 nursing assistance working on hall 300 the majority of the time like every day. NA #5 was interviewed on 12-19-19 at 3:32pm: The NA stated she resigned in (MONTH) 2019 because the work load was to much. She stated she worked hall 300 and would typically have 14 to 15 residents to care for and there were days I was the only nursing assistant. The NA stated she could not provide quality care to the residents with 2 nursing assistants because the residents on hall 300 required total care. NA #5 further stated all I could do was apologize to the residents for having to wait so long to answer their call bell or change them. A phone interview was conducted on 12/20/19 at 8:42 am with NA #6. She stated she worked at the facility for a year and usually was assigned to the hall 300. NA #6 revealed there were typically 2 NAs scheduled for the 300 hall and it was difficult to provide activities of daily living or incontinence care when the residents requested the care to be done because the residents on that hall were heavy care. She added they really needed 3 NAs on hall 300 to provide the care the residents needed. During a phone interview with NA #7 on 12/20/19 at 10:59 am she stated she had worked at the facility for about a year and was scheduled for both first and third shifts. NA #7 revealed she typically had 15 residents when she worked on third shift. She added she felt hall 300 required more staff than scheduled because there were residents that had behaviors and that could take up a lot of your time if they were acting out. NA #7 stated, because there was not enough staff working on hall 300, she was not able to provide the residents incontinence care when it was needed or answer the residents call lights timely. The Administrator was interviewed on 12-19-19 at 11:55am. The Administrator stated the facility had a shortage of staff and the facility was trying to hire more staff by advertising and offering sign on bonuses. He also stated until more staff could be hired, the facility was using agency nurses. The Administrator was interviewed on 12-20-19 at 3:55pm. The Administrator stated the system failure was due to the change in leadership and staff making changes to when they arrive to work without informing management. He also stated he expected staff to remain at work until their relief arrived and he had started the process to correct the situation by verbal counseling with staff members.

Based on record review, facility staff and resident interviews, and observation, the facility ' s administration failed to remove 1 of 6 electric beds (bed #1) from service following an occurrence of sparking. The bed remained in the room and was observed plugged into the wall socket. Routine maintenance was not being performed according to manufacturer ' s instructions. The facility administrator was not aware of a bed remote (bed #1) which had sparked while a resident (Resident #58) occupied bed #1 in Room 115B, was not aware the maintenance director was not providing preventative maintenance on the beds and remotes within the facility, and was not aware the bed manufacturer ' s recommendations for repairs and preventative maintenance were not being followed. Immediate Jeopardy (IJ) began on 5/30/2015 when a nurse aide (NA#1) informed a nurse (Nurse #1) that bed #1 had sparked while Resident #58 was in bed #1 in Room 115B. The bed was not removed from service and was observed plugged into an electrical socket. The IJ was abated on 6/15/15 at 7:42 PM when the facility provided an acceptable allegation of compliance. The facility remains out of compliance at a lower scope and severity at a D (an isolated deficiency at no actual harm with a potential for more than minimal harm, that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: A review of the quarterly minimum (MDS) data set [DATE] for Resident #41 revealed Resident #41 had a brief interview for mental status score (BIMS) of 14 which indicated no cognitive impairment A resident interview was conducted on 6/9/15 at 8:50 AM with a resident (Resident #41) in her room (Room 115A). During the interview, the resident was asked about having a roommate and stated there is usually a resident (Resident #58) in the other bed (bed #1) but, She was moved because something happened to her bed. They told me it sparked or something. The resident also stated bed #1 had not been removed from the room yet and no one had used the bed since Resident #58 was moved to another room. Bed #1 was observed to be plugged into an electrical outlet with a remote control lying on top of the bed linens. Resident #58 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE] revealed Resident #58 was unable to complete a BIMS assessment related to cognitive impairment, speech which was always unclear or garbled, and signs and symptoms if delirium which included disorganized thinking and inattention. An interview was conducted on 6/9/15 at 9:25 AM with Nurse #1 who was typically assigned to the 100 Hall and revealed Nurse #1 was on duty on 5/30/15 and assigned to the 100 Hall when there was a problem with bed #1. Nurse #1 stated NA #1 had told her she had been providing care to a resident and bed #1 had sparked. Nurse #1 stated she went to the resident ' s room and removed the resident from bed #1, moved the resident to an empty room on the same hall, and unplugged bed #1. Nurse #1 further stated she filled out a facility work order and informed the manager on duty the next day (5/31/15). An interview was conducted on 6/11/15 at 2:44 PM with NA #1 who was present at bed #1 when the spark occurred and had notified Nurse #1 of the problem. The NA stated she raised bed #1 with the remote and when she pushed the button on the remote the wires popped. She stated, I noticed the wires to the remote had black tape wrapped around them where they tried to fix the remote before. That ' s where the sparks came from. NA #1 also stated she reported it to Nurse #1. An additional interview was conducted on 6/11/15 at 1:30 PM with Nurse #1. She stated after NA#1 informed her of the problem with bed #1 she entered Resident #58 ' s room and smelled an electrical like smell. You know, like when something is melting. She also stated she did not call anyone, but told the manager on duty #1 on Sunday, 5/31/15 about bed #1. An interview was conducted on 6/11/15 at 2:05 PM with manager on duty #1 and she stated she did not remember anything about a problem with a bed or remote sparking. She stated she filled out manager on duty observation reports for anything that happens and the observation sheet for 5/31/15 had no entry related to bed #1. A review of a facility work order dated 5/30/15 and signed by Nurse #1 read repair needed-remote sparked. The action taken section of the work order read need to change out bed (bed #1) and was signed by the maintenance director. An observation was made on 6/9/15 at 9:25 AM in Room 115B of bed #1 plugged in to an electrical outlet and had a remote lying on top of the bed linens. An interview was conducted on 6/9/15 at 9:27 AM with the maintenance director and revealed a work order was filled out on 5/30/15 for bed #1 on the 100 Hall. The maintenance director stated, The bed (bed #1) doesn ' t have any power. The outlet works, but the bed doesn't. The work order has a job description that says the bed (bed #1) sparked. The bed (bed #1) should be unplugged because it could be a fire hazard. He stated his usual procedure for beds which had malfunctioned was to check the electrical outlet to ensure it was working, and check the remote for any exposed wires. The maintenance director also stated the wires on the remote for the bed (bed #1) were exposed so he exchanged the remote, plugged the bed (bed #1) back in and observed the bed (bed #1) did not work. An interview was conducted on 6/9/15 at 9:42 AM with the facility administrator and maintenance director. She stated her expectation was to remove a malfunctioning bed from the room and replace it with a functioning bed. The administrator also stated she expected a bed which had sparked to be unplugged and removed from resident care areas. The maintenance director stated he had not removed bed #1 from Room 115B related to not having time that day. An observation was made on 6/9/15 at 10:00AM of bed #1, in Room 115B, plugged in to an electrical outlet with a remote lying on top of bed linens. An additional interview was conducted on 6/9/15 at 10:25 AM with the maintenance director. The maintenance director stated, I usually do all the maintenance on the beds. If I can't find the problem, I ' ll call the home office and request a new bed or parts to fix the broken one. I did not do that for this bed (bed #1) because I thought it was the remote. I was going to look at the motor for the bed (bed #1) because changing the remote didn't help but I haven ' t had time to take the bed (bed #1) out of the room. He also said, I'm not sure if the bed (bed #1) is unplugged because I didn't unplug it before I left the room. I just forgot to unplug it. An observation was made on 6/9/15 at 11:15 AM in Room 115B of bed #1 plugged into an electrical outlet with a remote control lying on top of the bed linens. An additional interview with the maintenance director was conducted on 6/9/15 at 12:09 PM and revealed the facility did not have a service contract with anyone to repair the bed. He stated he did all the bed repairs when something was reported to him. He was not aware of any manuals in the facility from the manufacturer, but would request one at the conclusion of the interview. The instructions for the same type of bed as bed #1 read in part: NEVER operate the bed if a cord or plug is damaged, or if it is not working properly; contact Qualified Service Personnel for examination and repair. · Assembly Inspection-Electrical Inspect-6 months 1. Check pendant cord for chaffing cuts or wear 2. Check all pendant functions o Head raises and lowers properly o Foot raises and lowers properly o Bed raises and lowers properly On 6/15/15 at 12:05 PM, an interview was conducted with the maintenance director. He stated the facility administrator was his supervisor, and conducted in-services for him on 6/12/15 through 6/14/15. He stated prior to 6/12/15 he had not received any in-services, training classes, or certifications. He stated he was not an electrician and had no electrical experience. He also stated prior to 6/11/15 the facility had no instruction manual for bed #1. The maintenance director stated he had no recollection of wrapping tape around the wires of the remote for bed #1 and did not know who placed the tape there. On 6/15/15 at 2:50 PM, an interview was conducted with the administrator. She revealed she supervised the maintenance director and did not believe he had completed any competencies or in-services related to maintenance. She also stated there was no preventative maintenance policy for beds, and no cleaning/maintenance schedule in place prior to 6/12/15. The administrator also stated the maintenance director had no training prior to being hired as maintenance director. The administrator was notified of the IJ on 6/12/15 at 4:48 PM A credible allegation of compliance was accepted on 6/15/15 at 4:30 PM. The submitted credible allegation of compliance revealed: · On 5/30/2015 Resident #58 agreed to be moved from defective bed #1 by the nursing staff and placed on a properly working bed, bed #2, in a different room. On 5/30/2015 Resident # 58 was assessed with [REDACTED].#1, was not operated by any staff or used by any resident. On 5/30/2015 a work order was completed for bed #1. On 6/1/2015 the remote on bed #1 was replaced by the maintenance director. On 6/1/2015 through 6/9/2015 the nursing assistants and nurses communicated to each other bed #1 was not to be used and bed #1 was not used. On 6/9/2015 bed #1 was unplugged and removed from the room by the maintenance director and taken out of the resident living areas. On 6/9/2015 the Director of Nursing (DON) verified Resident #58's bed #2 was in proper working order. On 6/13/2015 the maintenance director and administrator examined Resident # 58's bed #2 to ensure the preventative maintenance and proper working order of the bed. On 6/13/2015 a licensed electrician was contracted to test and make necessary repairs to beds and electrical outlets used by beds. The electrician completed testing of beds and electrical outlets on 6/14/2015. · On 6/9/2015 an audit of all beds in use was completed by the maintenance director in order to determine functionality. The audit determined that all beds being used by residents were functioning properly. The audit was documented on a census sheet. On 6/9/2015 all beds that were not being used by residents and/or not functioning properly were unplugged and removed from resident living areas by the maintenance director. 6/9/2015 the corporate facility consultants verified all beds not being used by residents were unplugged from an electrical outlet. Starting on 6/9/2015 and completed on 6/13/2015 all beds not in good repair or not functioning properly were not in resident living areas and were tagged with an Out of Order, Do NOT Use sign. On 6/9/2015 a 100% in-service for all staff was initiated by the DON on reporting faulty equipment with focus on immediately reporting faulty electrical equipment. The administrator, DON, staff development coordinator, and/or maintenance director will continue in-servicing 100% of staff on reporting faulty equipment 6/9/2015 through 100% completion by 6/14/2015. No current staff will complete a work shift until trained on reporting faulty equipment. All newly hired staff will be in- serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding immediately reporting any faulty equipment to include faulty electrical equipment. On 6/11/2015 the maintenance director was in-serviced by the administrator on immediately reporting faulty equipment to the administrator. On 6/11/2015 the administrator reviewed with the maintenance direct the manufacturer's instruction manual for bed #1. At that time, on 6/11/2015, the administrator in-serviced the maintenance director of the expectation for preventative maintenance on beds is done according to manufacture guidelines and documented properly. On 6/14/15 the administrator in-serviced the maintenance director on how to use the Preventative Maintenance - Beds tool and the schedule during which the maintenance director will use the Preventative Maintenance - Beds tool to perform preventative maintenance on beds. On 6/13/2015 a licensed electrician was contracted to test beds and electrical outlets used by beds. On 6/14/2015 the contracted electrician completed testing of beds and electrical outlets. · On 6/15/15 the administrator will review at Resident Council the topic of resident safety and request the residents to report malfunctioning and/or unsafe equipment. · On 6/9/2015 an audit of all beds in use was completed by the maintenance director in order to determine functionality. On 6/13/2015 the maintenance director and the administrator again reviewed the manufacturer instruction manual for bed #1 and manufacturer instruction manuals for all other beds in use for the purpose of establishing a preventative maintenance schedule for beds. On 6/13/2015 a bed functionality audit schedule and a bed preventative maintenance schedule was established by the maintenance director and approved by the administrator. On 6/13/2015 all beds were assigned an individual identification number by the maintenance director and administrator. · On 6/12/2015 the administrator consulted with the corporate facility consultant and regional vice president and determined to implement a Red Tag faulty equipment safety system. On 6/13/2015 the administrator ordered red tags from the corporate office print shop. On 6/13/15 the administrator, DON, staff facilitator, and/or maintenance director began in-servicing 100% of staff regarding the Red Tag faulty equipment safety system. The Red Tag process includes immediately removing faulty equipment away from residents, placing a red tag on the equipment, and completing a work order which goes to the maintenance director. No current staff will complete a work shift until trained on the Red Tag faulty equipment safety system. All newly hired staff will be in-serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding the Red Tag faulty equipment safety system, to include faulty bed remotes. · On 6/13/2015 a 100% in-service for all staff was initiated by the administrator on properly completing and processing work orders. The administrator, DON, staff development coordinator, and/or maintenance director will continue in-servicing 100% of staff on properly completing and processing work orders 6/13/2015 through 100% completion by 6/14/2015. No current staff will complete a work shift until trained on properly completing and processing a work order. All newly hired staff will be in- serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding properly completing and processing a work order. On 6/15/2015 at 6:0 1PM through 6/15/2015 at 7:38 PM validation of the credible allegation of compliance was conducted: · An audit of all beds dated 6/9/15 had been completed. · Staff, including the maintenance man, were in-serviced on 6/12/15. · An interview on 6/15/2015 at 6:15 PM with the staff development coordinator (SDC) revealed she currently has 3 new staff members in orientation who were currently in day 2 of training. She stated the training related to faulty beds will occur on 6/16/15. · Red bed tags, which indicated the bed was out of service, were observed to be posted at the nurses station at 6:55 PM on 6/15/15. · A review of the policy and procedures and in-services performed was reviewed on 6/15/15. · An interview on 6/15/2015 at 6:21 PM with Nurse #2 was held and Nurse #2 was able to express the training and new protocol. · An interview on 6/15/2015 at 6:22 PM with NA #3 was held and revealed NA #3 was able to describe the training and new protocol · An interview on 6/15/2015 at 6:25 PM with NA #4 was held and revealed NA #4 was able to describe the training and new protocol. · An interview on 6/15/2015 at 6:30 PM with NA #5 revealed NA #5 was able to describe the training and new protocol. · An interview on 6/15/2015 at 6:35 PM with a physical therapist (PT #1) revealed she was able to describe the training that had been provided. · An interview on 6/15/2015 at 6:45 PM with the social worker revealed she had training and was able to express the process. · Observations were made of the bed remotes on 6/15/2015 at 7:00 PM and on 6/15/2015 at 7:38 PM in rooms 403,411,418, 406b, 114 and 115 with the vice president of operations revealed all the bed remotes and beds were functioning properly. · All the maintenance logs and audit tools were reviewed. All in-service trainings were reviewed. No concerns were identified.

Based on record review, facility staff and resident interviews, and observation, the facility failed to conduct routine maintenance for 1 of 6 electrical beds per the manufacturer instructions. The facility failed to maintain the electrical bed in Room 115B (bed #1) in a safe operating condition. The bed ' s remote control (Bed #1) sparked while a resident (Resident #58) occupied the bed. Immediate Jeopardy (IJ) began on 5/30/2015 when a nurse aide (NA#1) informed a nurse (Nurse #1) that bed #1 had sparked while Resident #58 was in bed #1 in Room 115B. The bed was not removed from service and was observed plugged into an electrical socket. The IJ was abated on 6/15/15 at 7:42 PM when the facility provided an acceptable allegation of compliance. The facility remains out of compliance at a lower scope and severity at a D (an isolated deficiency at no actual harm with a potential for more than minimal harm, that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: A review of the quarterly minimum (MDS) data set [DATE] for Resident #41 revealed Resident #41 had a brief interview for mental status score (BIMS) of 14 which indicated no cognitive impairment A resident interview was conducted on 6/9/15 at 8:50 AM with a resident (Resident #41) in her room (Room 115A). During the interview, the resident was asked about having a roommate and stated there is usually a resident (Resident #58) in the other bed (bed #1) but, She was moved because something happened to her bed. They told me it sparked or something. The resident also stated bed #1 had not been removed from the room yet and no one had used the bed since Resident #58 was moved to another room. Bed #1 was observed to be plugged into an electrical outlet with a remote control lying on top of the bed linens. Resident #58 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE] revealed Resident #58 was unable to complete a BIMS assessment related to cognitive impairment, speech which was always unclear or garbled, and signs and symptoms if [MEDICAL CONDITION] which included disorganized thinking and inattention. An interview was conducted on 6/9/15 at 9:25 AM with Nurse #1 who was typically assigned to the 100 Hall and revealed Nurse #1 was on duty on 5/30/15 and assigned to the 100 Hall when there was a problem with bed #1. Nurse #1 stated NA #1 had told her she had been providing care to a resident and bed #1 had sparked. Nurse #1 stated she went to the resident ' s room and removed the resident from bed #1, moved the resident to an empty room on the same hall, and unplugged bed #1. Nurse #1 further stated she filled out a facility work order and informed the manager on duty the next day (5/31/15). An interview was conducted on 6/11/15 at 2:44 PM with NA #1 who was present at bed #1 when the spark occurred and had notified Nurse #1 of the problem. The NA stated she raised bed #1 with the remote and when she pushed the button on the remote the wires popped. She stated, That ' s when the fire started. I noticed the wires to the remote had black tape wrapped around them where they tried to fix the remote before. That ' s where the sparks came from. NA #1 also stated she reported it to Nurse #1. An additional interview was conducted on 6/11/15 at 1:30 PM with Nurse #1. She stated after NA#1 informed her of the problem with bed #1 she entered Resident #58 ' s room and smelled an electrical like smell. You know, like when something is melting. She also stated she did not call anyone, but told the manager on duty #1 on Sunday, 5/31/15 about bed #1. An interview was conducted on 6/11/15 at 2:05 PM with manager on duty #1 and she stated she did not remember anything about a problem with a bed or remote sparking. She stated she filled out manager on duty observation reports for anything that happens and the observation sheet for 5/31/15 had no entry related to bed #1. A review of a facility work order dated 5/30/15 and signed by Nurse #1 read repair needed-remote sparked. The action taken section of the work order read need to change out bed (bed #1) and was signed by the maintenance director. An observation was made on 6/9/15 at 9:25 AM in Room 115B of bed #1 plugged in to an electrical outlet and had a remote lying on top of the bed linens. An interview was conducted on 6/9/15 at 9:27 AM with the maintenance director and revealed a work order was filled out on 5/30/15 for bed #1 on the 100 Hall. The maintenance director stated, The bed (bed #1) doesn ' t have any power. The outlet works, but the bed doesn't. The work order has a job description that says the bed (bed #1) sparked. The bed (bed #1) should be unplugged because it could be a fire hazard. He stated his usual procedure for beds which had malfunctioned was to check the electrical outlet to ensure it was working, and check the remote for any exposed wires. The maintenance director also stated the wires on the remote for the bed (bed #1) were exposed so he exchanged the remote, plugged the bed (bed #1) back in and observed the bed (bed #1) did not work. An interview was conducted on 6/9/15 at 9:42 AM with the facility administrator and maintenance director. She stated her expectation was to remove a malfunctioning bed from the room and replace it with a functioning bed. The administrator also stated she expected a bed which had sparked to be unplugged and removed from resident care areas. The maintenance director stated he had not removed bed #1 from Room 115B related to not having time that day. An observation was made on 6/9/15 at 10:00AM of bed #1, in Room 115B, plugged in to an electrical outlet with a remote lying on top of bed linens. An additional interview was conducted on 6/9/15 at 10:25 AM with the maintenance director. The maintenance director stated, I usually do all the maintenance on the beds. If I can't find the problem, I ' ll call the home office and request a new bed or parts to fix the broken one. I did not do that for this bed (bed #1) because I thought it was the remote. I was going to look at the motor for the bed (bed #1) because changing the remote didn't help but I haven ' t had time to take the bed (bed #1) out of the room. He also said, I'm not sure if the bed (bed #1) is unplugged because I didn't unplug it before I left the room. I just forgot to unplug it. An observation was made on 6/9/15 at 11:15 AM in Room 115B of bed #1 plugged into an electrical outlet with a remote control lying on top of the bed linens. An additional interview with the maintenance director was conducted on 6/9/15 at 12:09 PM and revealed the facility did not have a service contract with anyone to repair the bed. He stated he did all the bed repairs when something was reported to him. He was not aware of any manuals in the facility from the manufacturer, but would request one at the conclusion of the interview. The instructions for the same type of bed as bed #1 read in part: NEVER operate the bed if a cord or plug is damaged, or if it is not working properly; contact Qualified Service Personnel for examination and repair. · Assembly Inspection-Electrical Inspect-6 months 1. Check pendant cord for chaffing cuts or wear 2. Check all pendant functions o Head raises and lowers properly o Foot raises and lowers properly o Bed raises and lowers properly On 6/15/15 at 12:05 PM, an interview was conducted with the maintenance director. He stated the facility administrator was his supervisor, and conducted in-services for him on 6/12/15 through 6/14/15. He stated prior to 6/12/15 he had not received any in-services or training classes. He stated he was not an electrician and had no electrical experience. He also stated prior to 6/11/15 the facility had no instruction manual for bed #1. The maintenance director stated he had no recollection of wrapping tape around the wires of the remote for bed #1 and did not know who placed the tape there. On 6/15/15 at 2:50 PM, an interview was conducted with the administrator. She revealed she supervised the maintenance director and did not believe he had completed any competencies or in-services related to maintenance. She also stated there was no preventative maintenance policy for beds, and no cleaning/maintenance schedule in place prior to 6/12/15. The administrator also stated the maintenance director had no training prior to being hired as maintenance director. The administrator was notified of the IJ via telephone on 6/12/15 at 4:48 PM A credible allegation of compliance was accepted on 6/15/15 at 4:30 PM. The submitted credible allegation of compliance revealed: · On 5/30/2015 Resident #58 agreed to be moved from defective bed #1 by the nursing staff and placed on a properly working bed, bed #2, in a different room. On 5/30/2015 Resident # 58 was assessed with [REDACTED].#1, was not operated by any staff or used by any resident. On 5/30/2015 a work order was completed for bed #1. On 6/1/2015 the remote on bed #1 was replaced by the maintenance director. On 6/1/2015 through 6/9/2015 the nursing assistants and nurses communicated to each other bed #1 was not to be used and bed #1 was not used. On 6/9/2015 bed #1 was unplugged and removed from the room by the maintenance director and taken out of the resident living areas. On 6/9/2015 the Director of Nursing (DON) verified Resident #58's bed #2 was in proper working order. On 6/13/2015 the maintenance director and administrator examined Resident # 58's bed #2 to ensure the preventative maintenance and proper working order of the bed. On 6/13/2015 a licensed electrician was contracted to test and make necessary repairs to beds and electrical outlets used by beds. The electrician completed testing of beds and electrical outlets on 6/14/2015. · On 6/9/2015 an audit of all beds in use was completed by the maintenance director in order to determine functionality. The audit determined that all beds being used by residents were functioning properly. The audit was documented on a census sheet. On 6/9/2015 all beds that were not being used by residents and/or not functioning properly were unplugged and removed from resident living areas by the maintenance director. 6/9/2015 the corporate facility consultants verified all beds not being used by residents were unplugged from an electrical outlet. Starting on 6/9/2015 and completed on 6/13/2015 all beds not in good repair or not functioning properly were not in resident living areas and were tagged with an Out of Order, Do NOT Use sign. On 6/9/2015 a 100% in-service for all staff was initiated by the DON on reporting faulty equipment with focus on immediately reporting faulty electrical equipment. The administrator, DON, staff development coordinator, and/or maintenance director will continue in-servicing 100% of staff on reporting faulty equipment 6/9/2015 through 100% completion by 6/14/2015. No current staff will complete a work shift until trained on reporting faulty equipment. All newly hired staff will be in- serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding immediately reporting any faulty equipment to include faulty electrical equipment. On 6/11/2015 the maintenance director was in-serviced by the administrator on immediately reporting faulty equipment to the administrator. On 6/11/2015 the administrator reviewed with the maintenance direct the manufacturer's instruction manual for bed #1. At that time, on 6/11/2015, the administrator in-serviced the maintenance director of the expectation for preventative maintenance on beds is done according to manufacture guidelines and documented properly. On 6/14/15 the administrator in-serviced the maintenance director on how to use the Preventative Maintenance - Beds tool and the schedule during which the maintenance director will use the Preventative Maintenance - Beds tool to perform preventative maintenance on beds. On 6/13/2015 a licensed electrician was contracted to test beds and electrical outlets used by beds. On 6/14/2015 the contracted electrician completed testing of beds and electrical outlets. · On 6/15/15 the administrator will review at Resident Council the topic of resident safety and request the residents to report malfunctioning and/or unsafe equipment. · On 6/9/2015 an audit of all beds in use was completed by the maintenance director in order to determine functionality. On 6/13/2015 the maintenance director and the administrator again reviewed the manufacturer instruction manual for bed #1 and manufacturer instruction manuals for all other beds in use for the purpose of establishing a preventative maintenance schedule for beds. On 6/13/2015 a bed functionality audit schedule and a bed preventative maintenance schedule was established by the maintenance director and approved by the administrator. On 6/13/2015 all beds were assigned an individual identification number by the maintenance director and administrator. · On 6/12/2015 the administrator consulted with the corporate facility consultant and regional vice president and determined to implement a Red Tag faulty equipment safety system. On 6/13/2015 the administrator ordered red tags from the corporate office print shop. On 6/13/15 the administrator, DON, staff facilitator, and/or maintenance director began in-servicing 100% of staff regarding the Red Tag faulty equipment safety system. The Red Tag process includes immediately removing faulty equipment away from residents, placing a red tag on the equipment, and completing a work order which goes to the maintenance director. No current staff will complete a work shift until trained on the Red Tag faulty equipment safety system. All newly hired staff will be in-serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding the Red Tag faulty equipment safety system, to include faulty bed remotes. · On 6/13/2015 a 100% in-service for all staff was initiated by the administrator on properly completing and processing work orders. The administrator, DON, staff development coordinator, and/or maintenance director will continue in-servicing 100% of staff on properly completing and processing work orders 6/13/2015 through 100% completion by 6/14/2015. No current staff will complete a work shift until trained on properly completing and processing a work order. All newly hired staff will be in- serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding properly completing and processing a work order. On 6/15/2015 at 6:0 1PM through 6/15/2015 at 7:38 PM validation of the credible allegation of compliance was conducted: · An audit of all beds dated 6/9/15 had been completed. · Staff, including the maintenance man, were in-serviced on 6/12/15. · An interview on 6/15/2015 at 6:15 PM with the staff development coordinator (SDC) revealed she currently has 3 new staff members in orientation who were currently in day 2 of training. She stated the training related to faulty beds will occur on 6/16/15. · Red bed tags, which indicated the bed was out of service, were observed to be posted at the nurses station at 6:55 PM on 6/15/15. · A review of the policy and procedures and in-services performed was reviewed on 6/15/15. · An interview on 6/15/2015 at 6:21 PM with Nurse #2 was held and Nurse #2 was able to express the training and new protocol. · An interview on 6/15/2015 at 6:22 PM with NA #3 was held and revealed NA #3 was able to describe the training and new protocol · An interview on 6/15/2015 at 6:25 PM with NA #4 was held and revealed NA #4 was able to describe the training and new protocol. · An interview on 6/15/2015 at 6:30 PM with NA #5 revealed NA #5 was able to describe the training and new protocol. · An interview on 6/15/2015 at 6:35 PM with a physical therapist (PT #1) revealed she was able to describe the training that had been provided. · An interview on 6/15/2015 at 6:45 PM with the social worker revealed she had training and was able to express the process. · Observations were made of the bed remotes on 6/15/2015 at 7:00 PM and on 6/15/2015 at 7:38 PM in rooms 403,411,418, 406b, 114 and 115 with the vice president of operations revealed all the bed remotes and beds were functioning properly. · All the maintenance logs and audit tools were reviewed. All in-service trainings were reviewed. No concerns were identified

Based on record review, facility staff interviews, and observation, the facility ' s administration failed to implement policies and procedures related to preventative maintenance of electrical equipment (specifically remote controls) for 1 of 6 resident beds, provide supervision to the maintenance director, provide training to the maintenance director, and monitor ongoing competencies for the maintenance director. Immediate Jeopardy (IJ) began on 5/30/2015 when a nurse aide (NA #1) informed a nurse (Nurse #1) that bed #1 had sparked while a resident (Resident #58) was in bed #1 in room [ROOM NUMBER]B. The IJ was removed on 6/15/15 at 7:42PM. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective and all staff were in-serviced. This tag is cross referenced to F323 and F456. Findings included: 1a) Based on record review, facility staff and resident interviews, and observation, the facility's administration failed to remove 1 of 6 electric beds (bed #1) from service following an occurrence of sparking. The bed remained in the room and was observed plugged into the wall socket. Routine maintenance was not being performed according to manufacturer ' s instructions. The facility administrator was not aware of a bed remote (bed #1) which had sparked while a resident (Resident #58) occupied bed #1 in room [ROOM NUMBER]B, was not aware the maintenance director was not providing preventative maintenance on the beds and remotes within the facility, and was not aware the bed manufacturer ' s recommendations for repairs and preventative maintenance were not being followed. Immediate Jeopardy (IJ) began on 5/30/2015 when a nurse aide (NA#1) informed a nurse (Nurse #1) that bed #1 had sparked while Resident #58 was in bed #1 in room [ROOM NUMBER]B. The bed was not removed from service and was observed plugged into an electrical socket. The IJ was abated on 6/15/15 at 7:42 PM when the facility provided an acceptable allegation of compliance. The facility remains out of compliance at a lower scope and severity at a D (an isolated deficiency at no actual harm with a potential for more than minimal harm, that is not immediate jeopardy) to ensure monitoring systems put into place are effective. 1b) Based on record review, facility staff and resident interviews, and observation, the facility failed to conduct routine maintenance for 1 of 6 electrical beds per the manufacturer instructions. The facility failed to maintain the electrical bed in room [ROOM NUMBER]B (bed #1) in a safe operating condition. The bed ' s remote control (Bed #1) sparked while a resident (Resident #58) occupied the bed. Immediate Jeopardy (IJ) began on 5/30/2015 when a nurse aide (NA#1) informed a nurse (Nurse #1) that bed #1 had sparked while Resident #58 was in bed #1 in room [ROOM NUMBER]B. The bed was not removed from service and was observed plugged into an electrical socket. The IJ was abated on 6/15/15 at 7:42 PM when the facility provided an acceptable allegation of compliance. The facility remains out of compliance at a lower scope and severity at a D (an isolated deficiency at no actual harm with a potential for more than minimal harm, that is not immediate jeopardy) to ensure monitoring systems put into place are effective. An interview was conducted on 6/9/15 at 9:42 AM with the facility administrator and maintenance director. The administrator stated she had not been made aware bed #1 had sparked, and was not aware bed #1 remained in a resident care area. The facility administrator also stated she was not aware the maintenance director was not providing preventative maintenance on the beds and remotes within the facility, and was not aware the bed manufacturer ' s recommendations for repairs and preventative maintenance were not being followed. On 6/15/15 at 12:05 PM, an interview was conducted with the maintenance director. He stated the facility administrator was his supervisor, and conducted in-services for him on 6/12/15 through 6/14/15. He stated prior to 6/12/15 he had not received any in-services or training classes. On 6/15/15 at 2:50 PM, an interview was conducted with the administrator. She revealed she supervised the maintenance director and did not believe she had provided any competencies or in-services to maintenance director. She also stated there was no preventative maintenance policy for beds, and no cleaning/maintenance schedule in place prior to 6/12/15. The ADM also stated the maintenance director had no training prior to being hired as maintenance director, and was not certified in any area of maintenance. An interview was conducted on 6/15/15 at 12:05PM with the maintenance director and revealed: All non-functioning beds were removed from the facility and brought to an off-site area for storage. He also stated the administrator was his supervisor and conducted his in-services. He was in-serviced on lock out/tag out (placing a red tag on broken equipment which indicated it was out of service). This in-service took place 6/12/15 through 6/14/15, and was conducted by the facility administrator. An interview with the maintenance director was conducted on 6/15/15 at 6:57 PM. The maintenance director stated, My current role here is housekeeping manager. My responsibilities include: making sure the staff cleans the rooms, dining room, and sweep and mop floors. I also help out with room changes. I was told not to do any maintenance until further notice. When I was hired I was hired as a housekeeping manager, and became maintenance supervisor in July 2013. The administrator was notified via telephone of the IJ on 6/12/15 at 4:48PM. A credible allegation of compliance was accepted on 6/15/15 at 4:30 PM. The submitted credible allegation of compliance revealed: ¿ On 5/30/2015 Resident #58 agreed to be moved from defective bed #1 by the nursing staff and placed on a properly working bed, bed #2, in a different room. On 5/30/2015 Resident # 58 was assessed with [REDACTED].#1, was not operated by any staff or used by any resident. On 5/30/2015 a work order was completed for bed #1. On 6/1/2015 the remote on bed #1 was replaced by the maintenance director. On 6/1/2015 through 6/9/2015 the nursing assistants and nurses communicated to each other bed #1 was not to be used and bed #1 was not used. On 6/9/2015 bed #1 was unplugged and removed from the room by the maintenance director and taken out of the resident living areas. On 6/9/2015 the Director of Nursing (DON) verified Resident #58's bed #2 was in proper working order. On 6/13/2015 the maintenance director and administrator examined Resident # 58's bed #2 to ensure the preventative maintenance and proper working order of the bed. On 6/13/2015 a licensed electrician was contracted to test and make necessary repairs to beds and electrical outlets used by beds. The electrician completed testing of beds and electrical outlets on 6/14/2015. ¿ On 6/9/2015 an audit of all beds in use was completed by the maintenance director in order to determine functionality. The audit determined that all beds being used by residents were functioning properly. The audit was documented on a census sheet. On 6/9/2015 all beds that were not being used by residents and/or not functioning properly were unplugged and removed from resident living areas by the maintenance director. 6/9/2015 the corporate facility consultants verified all beds not being used by residents were unplugged from an electrical outlet. Starting on 6/9/2015 and completed on 6/13/2015 all beds not in good repair or not functioning properly were not in resident living areas and were tagged with an Out of Order, Do NOT Use sign. On 6/9/2015 a 100% in-service for all staff was initiated by the DON on reporting faulty equipment with focus on immediately reporting faulty electrical equipment. The administrator, DON, staff development coordinator, and/or maintenance director will continue in-servicing 100% of staff on reporting faulty equipment 6/9/2015 through 100% completion by 6/14/2015. No current staff will complete a work shift until trained on reporting faulty equipment. All newly hired staff will be in- serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding immediately reporting any faulty equipment to include faulty electrical equipment. On 6/11/2015 the maintenance director was in-serviced by the administrator on immediately reporting faulty equipment to the administrator. On 6/11/2015 the administrator reviewed with the maintenance direct the manufacturer's instruction manual for bed #1. At that time, on 6/11/2015, the administrator in-serviced the maintenance director of the expectation for preventative maintenance on beds is done according to manufacture guidelines and documented properly. On 6/14/15 the administrator in-serviced the maintenance director on how to use the Preventative Maintenance - Beds tool and the schedule during which the maintenance director will use the Preventative Maintenance - Beds tool to perform preventative maintenance on beds. On 6/13/2015 a licensed electrician was contracted to test beds and electrical outlets used by beds. On 6/14/2015 the contracted electrician completed testing of beds and electrical outlets. ¿ On 6/15/15 the administrator will review at Resident Council the topic of resident safety and request the residents to report malfunctioning and/or unsafe equipment. ¿ On 6/9/2015 an audit of all beds in use was completed by the maintenance director in order to determine functionality. On 6/13/2015 the maintenance director and the administrator again reviewed the manufacturer instruction manual for bed #1 and manufacturer instruction manuals for all other beds in use for the purpose of establishing a preventative maintenance schedule for beds. On 6/13/2015 a bed functionality audit schedule and a bed preventative maintenance schedule was established by the maintenance director and approved by the administrator. On 6/13/2015 all beds were assigned an individual identification number by the maintenance director and administrator. ¿ On 6/12/2015 the administrator consulted with the corporate facility consultant and regional vice president and determined to implement a Red Tag faulty equipment safety system. On 6/13/2015 the administrator ordered red tags from the corporate office print shop. On 6/13/15 the administrator, DON, staff facilitator, and/or maintenance director began in-servicing 100% of staff regarding the Red Tag faulty equipment safety system. The Red Tag process includes immediately removing faulty equipment away from residents, placing a red tag on the equipment, and completing a work order which goes to the maintenance director. No current staff will complete a work shift until trained on the Red Tag faulty equipment safety system. All newly hired staff will be in-serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding the Red Tag faulty equipment safety system, to include faulty bed remotes. ¿ On 6/13/2015 a 100% in-service for all staff was initiated by the administrator on properly completing and processing work orders. The administrator, DON, staff development coordinator, and/or maintenance director will continue in-servicing 100% of staff on properly completing and processing work orders 6/13/2015 through 100% completion by 6/14/2015. No current staff will complete a work shift until trained on properly completing and processing a work order. All newly hired staff will be in- serviced by the administrator, DON, staff development coordinator, and/or maintenance director during orientation regarding properly completing and processing a work order. On 6/15/2015 at 6:0 1PM through 6/15/2015 at 7:38 PM validation of the credible allegation of compliance was conducted: ¿ An audit of all beds dated 6/9/15 had been completed. ¿ Staff, including the maintenance man, were in-serviced on 6/12/15. ¿ An interview on 6/15/2015 at 6:15 PM with the staff development coordinator (SDC) revealed she currently has 3 new staff members in orientation who were currently in day 2 of training. She stated the training related to faulty beds will occur on 6/16/15. ¿ Red bed tags, which indicated the bed was out of service, were observed to be posted at the nurses station at 6:55 PM on 6/15/15. ¿ A review of the policy and procedures and in-services performed was reviewed on 6/15/15. ¿ An interview on 6/15/2015 at 6:21 PM with Nurse #2 was held and Nurse #2 was able to express the training and new protocol. ¿ An interview on 6/15/2015 at 6:22 PM with NA #3 was held and revealed NA #3 was able to describe the training and new protocol ¿ An interview on 6/15/2015 at 6:25 PM with NA #4 was held and revealed NA #4 was able to describe the training and new protocol. ¿ An interview on 6/15/2015 at 6:30 PM with NA #5 revealed NA #5 was able to describe the training and new protocol. ¿ An interview on 6/15/2015 at 6:35 PM with a physical therapist (PT #1) revealed she was able to describe the training that had been provided. ¿ An interview on 6/15/2015 at 6:45 PM with the social worker revealed she had training and was able to express the process. ¿ Observations were made of the bed remotes on 6/15/2015 at 7:00 PM and on 6/15/2015 at 7:38 PM in rooms 403,411,418, 406b, 114 and 115 with the vice president of operations revealed all the bed remotes and beds were functioning properly. ¿ All the maintenance logs and audit tools were reviewed. All in-service trainings were reviewed. No concerns were identified.

Based on document review, staff interview, pharmacy interview and interview with staff at the discharge location the facility failed to provide a supply of medications to a resident at discharge, failed to ensure a resident had a provider and initial post discharge follow-up appointment, failed to provide patient education regarding discharge medications, including insulin, and to provide patient teaching regarding diabetic care and management for 1 (Resident #2) of 1 residents discharged to a homeless shelter. The findings included: The Hospital Discharge Summary dated 1/29/13 revealed Resident #2 had not previously been on any diabetic medications prior to his hospitalization . In the hospital he was started on [MEDICATION NAME] (injected subcutaneously). He was discharged from the hospital to the facility on [MEDICATION NAME] 16 units daily. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set indicated Resident #2 was cognitively intact. Review of the Admission Record dated 2/7/13 revealed Resident #2 was his own Responsible Party (RP) he also had a family member listed as his emergency contact person. Review of the Care Plan - Return to Community note dated 7/5/13 revealed that at 10:30 AM on 7/5/13, a meeting was held with Resident #2 regarding discharge due to non payment for his stay. According to the note, Resident #2 indicated he had no plans to pay the bill and could be discharged to his family member ' s home or to a Boarding House he had been at before. Review of the Care Plan - Return to Community note dated 7/5/13 revealed that at 11:40 AM on 7/5/13, the Social Worker spoke with Resident #2 ' s family member, on the telephone, to see if Resident #2 could be discharged to the family member ' s home. The family member indicated that having Resident #2 discharged to her home was not feasible at that time. According to the note the Social Worker then told the family member that Resident #2 could potentially be discharged to another location which was not specified in the documentation of this conversation. The Social Worker also documented that the family member stated that she could transport Resident #2 to the discharge location and that once plans were in place she (the family member) would be contacted. Interview with the Social Worker on 11/22/13 at 11:20 AM revealed that Resident #2 was on Medicaid at the time of discharge but did not want to sign over his social security check to the facility as he had bills to pay. She stated that it was not possible to discharge Resident #2 to the Boarding House he mentioned because he needed a wheelchair and that made him ineligible. The Social Worker said an Assisted Living facility also came to assess the resident for transfer there but he refused to pay anything from his social security check so they would not take him. She added that the Homeless Shelter was wheelchair accessible and said they had a bed for him on the day of discharge. Further review of the Care Plan - Return to Community note dated 7/5/13 revealed " once D/C (Discharge) is in place resident will require orders to D/C with medications, prescriptions for medications that he will need to obtain after being D/C and orders for a W/C. He will follow up with (name and address of clinic), apt (appointment) will need to be obtained prior to D/C. " The Social Worker also documented that at 11:55 AM on 7/5/13 she informed Resident #2 that he would not be able to live with his family member on discharge as there was no space available in her home. Interview with the Social Worker on 11/22/13 at 11:20 AM indicated she had not made the follow-up appointment with the clinic mentioned in the above note when Resident #2 was discharged . The reason for not making this appointment was because the family member said she would do it. The Social Worker acknowledged that she had not documented this. The Care Plan revised on 8/22/13 revealed Resident #2 required little or no help with hygiene and intermittent supervision and assistance with dressing to ensure clothing and footwear was clean and appropriate, was independent for toileting and used a urinal to void, had a barrel quad cane assistive device that was to be within reach, used a wheelchair for distances and ate independently with assistance for meal set up. Review of the physician's order [REDACTED].#2 was on the following scheduled medications: [REDACTED] [MEDICATION NAME] 100 mg (milligrams) tab po qd (tablet by mouth daily) for depression. [MEDICATION NAME] 15 mg tab po qd for left shoulder pain, to be taken with food. [MEDICATION NAME] 1 cap (capsule) 25-200 mg bid (twice a day) po for stroke ([MEDICAL CONDITION]). [MEDICATION NAME] tab 150 mg po bid for [MEDICAL CONDITION] reflux disease. Doculace cap 100 mg po bid for constipation, hold for diarrhea (this was a stock medicine - stock medicines do not require a prescription). [MEDICATION NAME] tab 40 mg po qd for [MEDICAL CONDITION] (high cholesterol) Gabepentin cap 300 mg po every 8 hours (an associated [DIAGNOSES REDACTED]. [MEDICATION NAME] inject 20 units subcutaneously every night at bedtime for diabetes. Review of the physician's order [REDACTED].#2 has orders for some the following narcotic and other controlled medication on an as needed basis: [MEDICATION NAME] ([MEDICATION NAME] - Acetominophen) tab 5-325 mg 1 po every 4 hours as needed for moderate pain and 2 every 4 hours for severe pain. [MEDICATION NAME] ([MEDICATION NAME]) tab 1 mg po every night as needed for anxiety. The 10/1/13 - 10/1/31 physician's order [REDACTED]. Resident #2 was also on a regular diet with no added salt and no added sugar. Review of the 10/7/13 Social Narrative Progress Note revealed Resident #2 ' s family member was verbally informed on 10/3/13 that Resident #2 was issued a 30 day discharge notice (Nursing Home Transfer/Discharge form dated 9/6/13) the previous month. It also indicated that she was informed on this date that assistive living was not a possibility as Resident #2 refused to pay so Resident #2 might need to be discharged to a homeless shelter. Review of the Medical Progress Note dated 10/7/13 (electronically signed by Nurse Practitioner #1 on 10/18/11) revealed this was a discharge note. Resident #2 ' s [DIAGNOSES REDACTED]. There were no further [DIAGNOSES REDACTED]. " Under Assessment/Plan on page 3 of the document it was indicated that the prescriptions were written. Under the Medication Review section the document indicated " Patient ' s medication list has been reviewed. " There were no negative findings on the systems review or physical examination other than " left sided weakness, especially left upper extremity. " The review also noted that Resident #2 was " oriented to person, place, and time. Mood and affect appropriate. " Review of the 10/8/13 Social Narrative Progress Note revealed " a wheelchair will allow patient to safely perform daily activities. Patient can safely propel the wheelchair. Patient can walk 200 ft (feet) with assistance helping him. Patient will be discharged to (name of Homeless Shelter) and will not have assistance to walk, need wheelchair for safety. " Review of the 10/10/13 Social Narrative Progress Note revealed " spoke with the resident ' s (family member) and informed her that the resident stated she was picking him up to find an apartment. She stated she would not be picking him up because she is having health problems herself. " Review of the Progress Notes from 10/1/13 - through 10/11/13 (Resident #2 ' s date of discharge) revealed no nursing notes regarding the resident ' s health status or discharge. Interview with Nurse #2 on 11/22/13 at 5:45 PM revealed that she was informed on the morning of 10/11/13, during her morning medication pass, that Resident #2 was being discharged . She said then she went to the resident ' s room at that time and he was not yet packed to leave. Nurse #2 said she then went to fill out his discharge paperwork with the list of all his medications, with dosages, times of administration and the number of tablets he was being discharged with on it. Nurse #2 added that there were two copies of this form, one for the resident and one for the chart. Nurse #2 indicated she was unaware that the facility had been unable to locate the chart copy of this document. After filling out the form Nurse #2 said she packed up the residents medications and took them with the form to him in his room. She said no one saw her hand the medications or the discharge instructions to Resident #2. She said she reviewed the medications with Resident #2 by reading the list on thee form and telling him when to take then and what they were for. When asked she stated that she did not give Resident #2 any syringes for his insulin, or any blood sugar testing supplies. She also said that she did not review how to self inject insulin and did not review diabetic care and management with Resident #2 because she believed he had the [DIAGNOSES REDACTED]. She was not aware that he started insulin while in the hospital just prior to admission at the facility. Nurse #2 stated that she then resume her medication pass and when she got to his room which was the last one Resident #2 was already packed and gone. During an interview on 12/12/13 at 6 PM with a staff member of the Pharmacy that supplies medications to the facility (Pharmacy Staff #1) provided information on the medications for Resident #2 that had been sent to the facility since 9/1/13 and the number of tablets that were sent back to the Pharmacy when Resident #2 was discharged : 10/6/13 [MEDICATION NAME] 1 vial - 0 returned 10/5/13 [MEDICATION NAME] 30 tablets sent to the facility - 19 returned 9/28/13 [MEDICATION NAME] 60 tablets sent to the facility - 41 returned 9/25/13 [MEDICATION NAME] 60 tablets sent to the facility - number returned not available at the time the of interview 9/24/13 [MEDICATION NAME] 60 tablets sent to the facility - 50 returned 9/21/13 [MEDICATION NAME] 30 tablets sent to the facility - 17 returned 9/18/13 [MEDICATION NAME] 90 day supply sent to facility - 28 returned 9/8/13 [MEDICATION NAME] 30 tablets sent to facility - 0 returned (restocked 10/5/13) 9/8/13 [MEDICATION NAME] 30 tablets (30 day supply) - 0 returned 9/4/13 [MEDICATION NAME] 1 vial - 0 returned In addition, Pharmacy Staff #1 stated that the [MEDICATION NAME] for Resident #2 was last sent to the facility on [DATE] and that 20 tablets were sent at that time; the number returned to the facility was not available at the time of the interview. Review of a Return of Drugs form (specific to Narcotic and other controlled medications) revealed that on 10/21/13 the following medications for Resident #2 were returned to from the facility to the pharthe pharmacy from the facility: [MEDICATION NAME] 5-325 mg 47 tablets [MEDICATION NAME] 1 mg 18 tablets An undated written statement signed by the Social Worker indicated, in part, that on the day of discharge " I also gave him his prescriptions and informed him that (name of Nurse #2) the nurse on his hall would bring him his medicine. " Her written statement also indicated that while at the Homeless Shelter that day she helped Resident #2 fill out the paperwork and " I asked if he had his medicine and everything he needed in the bags. " " (Resident #2) stated yes he did. " Review of the Social Work Note dated 10/26/13 indicated Resident #2 was discharged to a Homeless Shelter, on 10/11/13. The note also indicated that the Social Worker went back to the Homeless Shelter with the facility van Driver on 10/26/13. According to the note, while at the Shelter the Social Worker spoke with Resident #2 about returning to the facility, for a week, to learn to use his medications but Resident #2 refused. She also spoke with an employee of the Homeless Shelter (Homeless Shelter Employee #1) on 10/26/13 and asked her if the Homeless Shelter had someone that could instruct Resident #2 on how to use his medications, if the facility were to provide the medications and deliver them to the Homeless Shelter. The note indicated that the Social Worker was informed that Nurses from another organization called IRC (Interactive Resource Center) came to the Shelter and sometimes brought over medications but whether they could assist Resident #2 was not specified in the note. During interview on 11/22/13 at 11:20, the Social Worker stated she gave Resident #2 his prescriptions on the morning of discharge (10/11/13) and that she remembered that Nurse #2 gave Resident #2 his medication. The Social Worker also revealed that on 10/26/13 the Administrator told her that Resident #2 did not receive any medications to take with him at discharge. She said that she believed that Resident #2 had medications as well as his prescriptions at discharge but that she did not know how many days supply of medications he had. The Social Worker said that on 10/26/13 she asked Resident #2 to come back to the facility to get his medications but he didn ' t want to and told her it had been taken care of. The Social Worker was also interviewed on 12/12/13 at 10 AM with the Administrator present and said that she told Resident #2 that his nurse (Nurse #2) would give him his discharge medications. She further indicated that she did not see the discharge medications being handed to Resident #2. The Social Worker was not asked why she had previously stated she remembered Resident #2 received discharge medications to take to the Homeless Shelter. An undated written statement signed by facility van Driver indicated, in part, that on the day of discharge Resident #2 " was given all of his meds (medications and prescriptions). I was at the nurses station and seen it in person. " " I also loaded all his belongings including a bag with all his meds in it. " " We asked them if they could show him how to take his meds. They said no but somebody from IRC would come and show him how to do it. " " They wouldn ' t keep his meds, because they normally don ' t give out meds, so they made him keep his meds. " On 12/1213 at 6 AM the facility van Driver was interviewed. He stated that he had not seen Resident #2 receive any medications to take with him to the Homeless Shelter but he believed Resident #2 had them in his possession, because they could not leave the facility until the resident had everything he needed. Interview with the Administrator on 12/12/13 at 6 :30 PM revealed that she expected residents to be discharged with sufficient discharge medications available as indicated and expected any necessary patient education to be completed prior to discharge. Interview with Homeless Shelter Staff #1 on, 12/11/13 at 1:30 PM, revealed that she was present on the day Resident #2 arrived at the homeless shelter. She stated that she found out from Resident #2 that day that he did not have any medications with him but that he had some prescriptions he needed assistance filling. She stated that she called Resident #2 ' s family member, with his permission, and the family member said she would help. Homeless Shelter Staff #1 said that when she returned to the facility seven days later Resident #2 had most of his medications, although she did not know how long it took to get them, but some of them were not due to be filled yet; she could not recall which ones were not due to be filled but thought the [MEDICATION NAME] was one of them. She said Resident # 2 also did not have the caps he needed for the insulin pen he had. Homeless Shelter Staff #1 said she obtained the necessary pen needles with caps (supplied separately and a new one is required for each injection) from a Pharmacy and also had Resident #2 show her that he could self inject his insulin. Homeless Shelter Staff # 1 added that she assisted Resident #2 to get signed up for a transportation service and in getting a medical provider and follow-up visit. Interview with Homeless Shelter Staff #2 on 1/3/14 revealed that Resident #2 had been at this homeless shelter previously. He stated that the shelter could accommodate the resident ' s wheelchair and that there had been no concerns regarding Resident #2 ' s ability to carry out activities of daily living. He added that the shelter provided 3 meals a day. Homeless Shelter Staff #2 indicated that the issue was that the facility had discharged Resident #2 without any medications and Resident #2 was without mediations for a day or more. Since the Homeless Shelter staff did not look after the medications of the people there he was uncertain how long it took to get the medications but that medical intervention had not been required. Homeless Shelter Staff #2 stated that when he became aware Resident #2 still did not have all his medications he contacted the facility. He added that the facility wanted to bring Resident #2 back to the facility to get his medications but Resident #2 refused to go.

Based on staff interview, Nurse Practitioner Interview and document review the facility failed to assess a resident after an episode of elevated fever and yellow secretions from a [MEDICAL CONDITION] and failed to evaluate and treat a resident with laboratory results indicating potential signs of infection and dehydration for 1 (Resident #1) of 2 residents with a [MEDICAL CONDITION]. The findings included: Blood Chemistry laboratory (lab) results indicating potential signs of dehydration include: Sodium levels higher than the reference range Chloride levels higher than the reference range Calcium levels higher than the reference range Blood Urea Nirtogen (BUN) levels higher than the reference range - BUN is an indicator of kidney function and high levels might indicate kidney disease or dehydration (Source: Pantex Occupational Nedicine, Understanding Your Blood Chemistry, Issue #3). Complete Blood Count and Differential lab results indicating potential signs of infection: Elevated White Blood Cells Elevated Granulocutes Elevated Lymphocytes (Source: Nurses Manual of Laboratory and Diagnostic Tests Third Edition) Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 1 also had a tube feeding and a [MEDICAL CONDITION] (trach). A Minimum Data Assessment was not yet required for Resident #1 at the time of his discharge from the facility. There was no care plan for the resident ' s [MEDICAL CONDITION] but there was an admission order dated 10/28/13 for [MEDICAL CONDITION]. The 10/29/13 4:57 AM Nursing note revealed Resident #5 was yelling out at night and almost pulled [MEDICAL CONDITION] out. He was given Tylenol for a temperature of 100 degrees Fahrenheit with effect. The Physician ' s History and Physical dated 10/29/13 revealed in part that Resident #1 ' s [MEDICAL CONDITION] site looked fine, he did not look dehydrates, his respirations were shallow but he had clear air entry and his lungs sounded fairly clear. Under neurological the following was included " He has purposeless movement with his left hand, often rubbing his head, his face and his [MEDICAL CONDITION] site. " " At other times, he will have jerking movements with a flexion of his trunk, flexion of his knees and hips. This almost looks like mild clonus (rhythmic jerking movements). " Review of the physician's order [REDACTED]. The nurses notes revealed that on 10/30/13 at 3:35 AM Resident #1 was confused and pulling at [MEDICAL CONDITION] " moderate yellow sputum noted coming [MEDICAL CONDITION] mouth suctioned several times. Will continue to monitor. " Telephone interview with Nurse #5 on 12/11/13 at 4:40 PM revealed that Nurse #5 worked with Resident #2 on 10/30/13 and 10/28/13. She stated he was highly agitated. She said that she usually only suctioned him once on her shift and that he was not that congested. She did not recall yellow secretions or a temperature. Review of the Comprehensive Metabolic Pannels (CMP) collected at 5:35 on 10/30/13 AM and collected at 5:30 PM 0n 11/1/13 revealed the following results (mEq/L (miliequavelents per liter), mg/dL (milligrams per decileter), U/L (units per liter), g/dL (grams per decileter), H (high), RR (Reference Rang/Normal Valuese)) : 10/30/13 Reference Range Sodium 142 RR 135-145 mEq/L Potassium 4.1 RR 3.5-5.3 mEq/L Chloride 107 RR 96-112 mEq/L CO2 (Carbon [MEDICATION NAME]) 21 RR 19-32 mEq/L Glucose 117 (H) RR 70-99 mg/dL BUN (Blood Urea Nitrogen) 35 (H) RR 6-23 mg/dL Creatinine 0.76 (H) RR 0.5 - 1.35 mg/dL Biliruben, Total 0.5 RR0.3 - 1.2 mg/dL 1/1/13 Reference Range Sodium 150 (H) RR 135-145 mEq/L Potassium 4.2 RR 3.5-5.3 mEq/L Chloride 117 (H) RR 96-112 mEq/L CO2 (Carbon [MEDICATION NAME]) 19 RR 19-32 mEq/L Glucose 112 (H) RR 70-99 mg/dL BUN (Blood Urea Nitrogen) 46 (H) RR 6-23 mg/dL Creatinine 0.86 RR 0.5 - 1.35 mg/dL Biliruben, Total 0.5 RR 0.3 - 1.2 mg/dL Alkaline [MEDICATION NAME] 84 RR 39-117 U/L AST/SGOT 45 (H) RR 0-37 U/L ALT/SGPT 34 RR 0-53 U/L Total Protein 9.1 (H) 6.8-8.3 g/dL [MEDICATION NAME] 4.5 RR 8.4-10.5 mg/dL Calcium 1.2 (H) 1.5-2.5 mg/dL There was a hand written note on the 11/1/13 CMP lab results indicating NP #1 was informed of the results on 11/1/13 or 11/2/13 (both a 1 and a 2 were written on top of each other). Both the 10/30/13 and 11/1/13 lab results had illegible initials on them with a date of 11/4/13 (after the resident ' s discharge). The 11/1/13 result also had a hand written note that said " not optimal. " Review of the Complete Blood Count with differential (CBC & diff) collected at 5:35 Am on 10/30/13 revealed (K/uL (thousands per cubic millimeter), H (high), RR (Reference Range/Normal Values) ) : White Blood Cells 13.2 K/uL (H ) RR 4.0 - 10.5 K/uL Absolute Granulocytes 8.8 K/uL (H) RR 1.7 - 7.7 K/uL Absolute Monocytes 1.2 K/uL (H) RR 0.1 - 1,1 K/uL The CBC & diff had illegible initials on them with a date of 11/4 and a hand written note that said " not optimal. " Review of the physician's order [REDACTED]. Review of the Nursing Note dated 11/2/13 at 1:17 AM revealed " resident thrashing limbs this shift and clawing at self, cursing. (Family member) concerned and this writer called (name of Nurse Practioner #1). NO (new order) STAT (without delay/immediately) CMP (comprehensive metabolic panel), mg (magnesium) and phosphorous (blood work laboratory tests). Labs received slightly abnormal and notified (family member). [MEDICAL CONDITION]. O2 sats (oxygen saturation) 95%. PRN (as needed) [MEDICATION NAME] given q6h (every 6 hours). Will continue to monitor. " 11/2/13 Review of the physician's order [REDACTED]. Interview with Nurse #4 on 12/11/13 at 2:56 PM revealed she worked with the resident on 11/1/13 second shift (3 PM- 11 PM) however she was still at the facility doing her documentation on 11/2/13 at 1:17 AM. She clarified that the above charting was for the time frame 11/1/13 3 - 11 PM. Nurse #4 stated Resident #1 ' s family member said she thought Resident #1 was acting differently with jerking and twitching so Nurse #4 contacted NP #1 about this. Nurse #4 indicated that NP #1 said Resident #1 could either be sent to the hospital, if the family member wanted, or they could do laboratory blood work and await the results. She then stated the family member agreed to await lab results. Nurse #4 said that when the results were received at the facility on 1/1/13 she notified NP#1 of the magnesium and phosphorus results but they were normal. She added that because of the jerking and twitching NP #1 had been concerned about these two results. When asked she stated that she also told the NP about the abnormal values but there were no new orders. Nurse #4 was not aware of any previous laboratory blood work so only told NP #1 about the 1/1/13 STAT results. She said that non STAT labs were not called to the physician immediately unless there were abnormal results. Nurse #4 said it was up to the floor Nurse to check for labs from the fax machine on first shift and to call the physician if needed. She added that labs were put in the physicians box for their review on their next visit to the facility and not put on the chart untiol reviewed by the physician. Nurse #4 also said that Resident #1 did not have many secretions from [MEDICAL CONDITION] that when she suctioned him the secretions were clear. The 11/2/13 Nursing Note at 5:33 PM revealed the resident was hard to arouse on one occasion complained of being hot and hungry. The note said the hall nurse reported that the resident ' s vital signs were stable. Nurse Practitioner #2 was notified and orders were received to hold the [MEDICATION NAME] until awake and lower the dose to 0.25 mg (milligrams) every 8 hours. A written statement from the Director of Nursing (DON) dated 11/2/13 revealed she was called to the resident ' s room and discussed the family members concern regarding the [MEDICATION NAME] medication order. The statement of the DON also revealed " I visualized [MEDICAL CONDITION] the dressing was clean as was the outer canual. There was no visible mucous or secretions. ' On 12/11/13 at 12:15 PM Nurse Practitioner #1 (NP #1) was interviewed. She stated that she had not seen Resident #1 in the facility but she recalled getting a call on Saturday 11/2/13 from Nurse #4 in regards to Resident #1 (she did not think the call came on 1/1/13). NP #1 stated that when she has not seen a resident before her process was to ask for previous labs. She said she asked Nurse #4 to check the hospital records for previous labs since the resident was new and Nurse #4 said she would check and call her back. NP #1 was not sure if she ordered any lab work at that time but said that Resident #1 ' s Physician likely ordered the 10/30/13 labs when he was in to see Resident #1 on 10/29/13. NP #1 was also not sure which lab results Nurse #4 shared with her when Nurse #4 called back, or who ordered the labs dated 11/1/13 and indicated that possibly Nurse #4 just have filled out the requisition without an order. NP #1 stated that she would not expect to be called about a BUN result of 35 (like the result dated 10/30/13) as this was above the reference range but not significant. However, she revealed that she did expect to be notified of BUN results that were at least 10 points greater than the previous BUN result (like the 11/1/13 BUN compared to the 10/30/13 BUN). For the creatinine result she said she would only expect to be called if the creatinine increased by 1 point. In addition NP #1 said that if she had been informed of a BUN of 46 she would have asked if he was getting water flushes and likely would have increased the amount of the water flushes as increased BUN can indicate dehydration. NP#2 said she would have reviewed Resident #1 the next time she was in the facility but he has already been discharged . She added that Resident #3 may have already been septic from his stay in the hospital but not showing signs of it yet. She indicated she was not aware of any signs of infection for Resident #1. The 11/3/13 Nursing Note at 7:41 PM revealed " CNA (Nursing Assistant) reported (family member) was holding suction catheter in hand. Called to room to suction resident. Unable to get cap off trach. Called supervisor to room and she removed cap and suctioned resident. No secretions noticed but did notice skin cool and clammy..checked BP (blood pressure) 90/60 , p (pulse) 98, r (respirations) 22, temp (temperature) 98.7 ) O2 sats (oxygen saturation) 70 % on ra (room air). O2 applied by hall nurse.. (Name of doctor) called order received to send out to hospital for eval (evaluation) and tx (treatment). EMS (Emergency Medical Service) call arrived at 7:40 PM to transport. " Nurse #6 who wrote this note was unavailable for interview. The Hospital History dated 11/3/13 revealed on EMS arrival patient was hypoxic with oxygen saturation in the 60 ' s. In the emergency department Resident #1 ' s white blood cell (WBC) result was elevated to 28.1 (reference range 4.0 - 10.5). The History and Physical dated 11/4/13 revealed scattered diminished air entry and scattered bilateral crackles. The discharge summary dated 11/8/13 revealed Resident #1 had respiratory distress in the emergency room department and mechanical ventilation was initiated. " At that time he was noted to have purulent secretions suctioned fro his [MEDICAL CONDITION] and was admitted to critical care and quickly weaned off the ventilator. Respiratory cultures were positive for [MEDICAL CONDITION] sensitive staph aures (bacterial infection). Antibiotics were initiated and Resident #1 ' s WBC stabilized. Discharge [DIAGNOSES REDACTED].

Based on resident and staff interviews, observations and a review of medical records the facility failed to administer oral and intravenous antibiotics, as ordered by the primary physician, to 1 of 8 sampled newly admitted residents, (Resident #2). The incident occurred on 6/29/12 and was identified and resolved on 7/2/12. The immediate jeopardy (IJ) for Resident #2 began on June 29, 2012 when the resident's antibiotics were not initiated. The administrator was notified of the immediate jeopardy (IJ) on July 31, 2012. The IJ was removed on July 18, 2012 when the facility completed inservicing all nursing staff. The facility was left out of compliance at no actual harm with the potential for more than minimal harm that is not IJ (D) to allow monitoring of the implementation of the corrective action. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had no cognitive deficits and required extensive assistance with some activities of daily living. Care Plans dated 7/3/12 included interventions to address the resident ' s Oste[DIAGNOSES REDACTED] including the administration of antibiotics as ordered. A hospital discharge summary dated 6/29/12 found in the resident ' s facility medical record indicated his hospital course included a right long finger partial amputation with incision and drainage of the right hand due to an infection on 6/26/12. The discharge instructions included that Resident #2 should continue his antibiotics [MEDICATION NAME] administered through the PICC (Percutaneous Intravenous Central Catheter) line daily and [MEDICATION NAME] orally daily, both for 4 weeks with follow up with Infection Diseases physician. A Discharge Med Reconciliation record, from the referring hospital, dated 6/29/12 indicated on page 3 of 4 pages that Resident #2 was to receive [MEDICATION NAME] 720 milligrams (mg) intravenously daily times 4 weeks and [MEDICATION NAME] 750mg orally daily times 4 weeks. A review of Resident #2 ' s Physician order [REDACTED]. A review of the resident ' s Medication Administration Record (MAR)s for June 2012 and July 2012 revealed that the [MEDICATION NAME] was first administered on 7/2/12 and the [MEDICATION NAME] was first administered on 7/3/12. All other medications were accurately reconciled and administered as ordered. Resident #2 ' s History and Physical dated 7/3/12 included " medication list reviewed. This is very complicated. Note, he has missed his antibiotics over the weekend. " On 7/18/12 at 1:40 pm Resident #2 was observed out of bed. His right arm was in a splint with dressings visible under the splint. There was erythmea (inflammation) and swelling of the right hand and forearm but the resident denied pain. He stated that he was admitted late on Friday (6/29/12) and that he hadn ' t received his intravenous antibiotics until Tuesday (7/3/12). He stated that he does have some pain at night up to a level of 7 on a scale of 1 to 10. He indicated that oral pain medication resolves the pain to a level of 0. The nurse who admitted Resident #2 (LPN #1) was interviewed on 7/19/12 at 8:40 am. She stated that Resident #2 was admitted late in the evening on 6/29/12. She stated that she did a head to toe assessment and saw the PICC line in the resident ' s left arm. She stated that she had written the physician orders [REDACTED]. She indicated that when she reported on duty on 6/29/12 at 3pm the Nurse Practitioner was reviewing the information on Resident #2 provided by the referring hospital. She stated she was given the Discharge Med Reconciliation record which she agreed were the same 4 pages provided to her during this interview. She then indicated that this type of discharge record was unfamiliar to her and that she missed the listing of [MEDICATION NAME] and [MEDICATION NAME] included at the bottom of page 3. She stated that there was an emergency with another resident and that she failed to document the presence of the PICC Line on her admission assessment and failed to follow up on why a resident with a PICC line had no orders for intravenous medications. She stated that a second nurse had also reviewed the admission orders [REDACTED]. On 7/19/12 at 10:00 am the Nurse Practitioner (NP) who had reviewed Resident #2 ' s hospital information was interviewed. She indicated that she had read the resident discharge summary and reviewed the Discharge Med Reconciliation record. She indicated that she had made any necessary changes on this Med Reconciliation record pointing out the areas where she had crossed out medications she did not want continued. She stated that her expectation was that the [MEDICATION NAME] and [MEDICATION NAME] would be administered once they were received from the pharmacy. She stated that she was notified on 7/2/12 of the error in not administering either of the antibiotics. She indicated that the [MEDICATION NAME] was started on 7/2/12 and that the [MEDICATION NAME] was started on 7/3/12. She stated that the resident had no indications [MEDICAL CONDITION] that he had remained afebrile. She stated that there was no change in the resident ' s erythmea or swelling of the right hand and forearm from her initial assessment on 7/3/12 to present. The resident ' s Infectious Disease physician was interviewed on 7/19/12 at 10:30 am. He indicated that he was unaware of the medication errors and that the resident had told him he had received the antibiotics. He stated that there had been some improvement in the resident ' s right hand and forearm which he documented for his consultation on 7/10/12. He indicated that Resident had a serious infection of the right hand and forearm due to a delay in the resident seeking medical evaluation prior to the hospitalization and that although this medication error was concerning it would not result in a change in the outcome for the resident. The 2nd nurse (RN#1) who reviewed the admission orders [REDACTED]. She stated that it was the facility ' s practice to have a 2nd nurse review the discharge information and compare it to the transcribed physician orders. She indicated that she had reviewed Resident #2 ' s discharge information and physician orders [REDACTED]. When supplied with the 4 page Discharge Med Reconciliation record for Resident #2 she indicated that she could not explain why the orders for antibiotics on page 3 had been missed. She stated that this form was unfamiliar to her and that might be the cause of the error. On 7/19/12 at 11:20 am the Director of Nursing (DON) on interview described the facility admission procedure. She stated that the discharge information provided by the referring hospital was reviewed by the admitting nurse. Any discrepancies were clarified with the referring hospital. The staff then calls the physician or NP and orders were verified. The physician orders [REDACTED]. She stated that the medication error regarding Resident #2 ' s antibiotics was identified by the facility educator (SDC) and herself the morning of 7/2/12. The NP was notified and orders to resume the antibiotics were obtained. Incident reports were completed and the Administrator was notified. Inservice education was provided to the admitting nurse and the RN who reviewed the orders. The DON stated that it was her expectation that the nurse would have looked through all the pages of the Discharge Med Reconciliation record and if she had questions she should have gotten help. She indicated that the unfamiliar form was a contributing factor but that she expected medications to be administered as ordered. The DON indicated the nurses involved were inserviced on proper medication reconciliation policies for new admissions. She stated that the she, the facility educator or the MDS nurse reviewed the orders of all new admissions 5 days a week Monday through Friday. She stated that this review had been increased from Monday to Friday to seven days a week. The weekend supervisor was trained in this audit process. Documentation of admission audits was provided and found to be up to date and no further errors had been found. She stated that this incident and the corrective measures instituted had been reviewed in the Quality Assurance meeting on 7/3/12. On 7/19/12 at 12:00 pm Resident #2 ' s primary physician who was also the facility Medical Director stated during an interview that he had been made aware of this medication error. He indicated that it was a significant error but would have no " morbid " effect on the resident. He stated that he was present at the QA meeting on 7/3/12 when this was reviewed. On 7/19/12 at 2:00 pm the Medical Records clerk provided documentation which on review confirmed that the medication error and the implementation of the facility plan of correction had been reviewed during the Quality Assurance Meeting on 7/3/12. The facility was notified of the immediate jeopardy on July 31, 2012. The facility provided an acceptable plan of correction August 1, 2012. When the resident was accepted to the facility the initial admission paperwork did not include the IV [MEDICATION NAME] Antibiotic. When resident was admitted , at 9:27pm per Point Click Care documentation, on Friday evening, June 29, 2012, (Hospital Name) Discharge Med Reconciliation accompanied the resident that added New Medication Orders on page 3 of the orders which did include the IV [MEDICATION NAME] 720 mg daily x 4 weeks order. During the Monday morning July 2, 2012 routine audit of the Friday evening June 29, 2012 admission paperwork, the Staff Facilitator identified the ABT IV [MEDICATION NAME] was not on the MAR and had not been administered to Resident #1. The assigned RN assessed the resident and spoke to the nurse practitioner on July 2, 2012 who gave orders to start the antibiotics as ordered. The resident, who is his own RP, was notified. The resident received (oral antibiotic) medication at 5pm, July 2, 2012 and IV ABT [MEDICATION NAME] at 9pm on July 2, 2012. On July 3, 2012 the medical director assessed the resident with no negative findings. July 3, 2012 the medication error was discussed at the QI committee meeting with the medical director and the consulting pharmacist present. July 4, 2012 labs were drawn and results reviewed by the physician with no new orders. On July 2, 2012 a 100 percent audit was completed by the DON, Staff Facilitator, and MDS Nurse on all new and all re-admissions occurring over the weekend, of June 29 - July 1, 2012 to identify any missed orders with no negative findings. The Admission QI Tool lists resident name, admitted , MD orders verified, orders transcribed correctly, pharmacy faxed, meds available/given timely, admit summary done, 2nd check. July 2, 2012 Director of Nursing initiated use of the Admission QI Tool used to verify physician orders [REDACTED]. The DON and administrative nurses are using the QI tool to complete the audit. Validation of the facility ' s credible allegation was completed on 7/31/2012. During the investigation, the facility provided documentation of interventions put into place as a result of the incident of 6/29/12: Resident #2 ' s antibiotics were initiated; LPN #1 and RN#1 were inserviced on the reconciliation of admission orders [REDACTED]. Documentation was provided for review that confirmed that the medication error identified on 7/2/12 was reviewed by the Quality Assurance Committee on 7/3/12. Members at the meeting included the Administrator, Medical Director and the DON. The facility has conducted daily audits of IV antibiotics since7/2/2012.