Every finding on record at Haymount Rehabilitation & Nursing Center, Inc.

Based on observations and staff interviews, the facility failed to ensure uncovered cooked food was not stored next to a partially closed trashcan with trash in it. The facility also failed to label and date a resident's personal food item and discard an expired food item stored in 1 of 2 nourishment refrigerators (Rehabilitation Unit refrigerator). These practices had the potential to affect food served to residents. Findings included:a. An observation of the kitchen with the Food Services Director on 6/30/26 at 1:50 PM revealed a pan of uncovered cooked rice, a pan of uncovered mashed potatoes and a pan of uncovered cooked spinach on a cart next to a partially closed large kitchen trashcan that had trash in it and was approximately 1/3 full. No flies were observed in the trashcan or around the trashcan. During this observation on 6/30/26 at 1:50 PM, the Food Services Director stated that the food items were left over from lunch and were supposed to be cooled down before being stored to be utilized within 3 days of storage. The Food Services Director inquired from the kitchen staff who had placed the food items next to the trashcan and [NAME] #1 reported he had placed it there. During an interview on 6/30/26 at 1:51 PM with [NAME] #1, he reported that he had moved the food approximately 5 minutes prior to the observation from the line tray area to the area where the food was observed (next to the trashcan) in preparation for cooling and storage. During an interview on 6/30/26 at 1:56 PM with the Food Services Director, he explained that the food should have been covered and placed in shallow pans for cooling prior to storage, away from an uncovered trashcan to prevent foodborne illnesses. b. Observation of the Rehabilitation Unit nourishment room refrigerator with the Food Services Director on 6/30/26 at 2:09 PM revealed the following: -A carton of milk with an expiration date of 6/21/26.-An unidentified greenish substance in a plastic container covered with a napkin with an unidentifiable date.The Food Services Director, who was present during the observation, placed the items in the trashcan. The Food Services Director explained that nursing staff were supposed to ensure the food items were labeled and dated before being placed in the refrigerator and dietary staff were responsible for checking the refrigerator daily and discarding any expired food items. An interview was conducted on 7/1/26 at 4:40 PM with the Administrator. She indicated that she expected staff to date and label all food items, check the refrigerator daily and discard expired food items. The Administrator also stated that she expected dietary staff to handle food under sanitary conditions and that she expected food to be kept in a designated area away from the trashcans.

Based on observations and staff interviews, the facility failed to protect private health information by leaving confidential medical information visible and accessible to the public on an unattended medication cart for 1 of 4 medication carts (Unit 6 hallway medication cart). (Resident #17 and Resident #54) Findings included: A continuous observation of an unattended medication cart on Unit 6 hallway was conducted on 07/02/2026 from 8:53 AM to 9:05 AM. Nurse #2 left Resident #17's medication bottle of Lactulose oral solution, on top of the cart. Resident #17's identifiable information included the residents' name, medication and why the medication was administered. Nurse #2 then left the cart, leaving the computer screen visible while she retrieved vital signs and administered medications to Resident #54 in the resident's room. Resident #54's face sheet (a summary sheet containing medical information) was visible on the computer screen. Visitors, residents, and staff were present in the hallway during this observation. During an interview conducted on 07/02/2026 at 9:05 AM, Nurse #2 stated she had left the computer screen unattended in the hallway while retrieving vital signs and administering medications to Resident #54. She acknowledged that she forgot to close the electronic medical record before leaving the cart and stated she should have locked the screen to prevent Resident #54's medical information from being visible to others. She also reported that she should not have left Resident #17's medication bottle with identifiable information on the cart. She explained she intended to reorder the medication and forgot to discard the bottle, which should have been emptied in the medication room and placed in the destroyer container after removing identifiers. Instead, she placed the bottle in the cart's trash can, stating she would discard it properly in the medication room.An observation on 07/02/2026 at 10:47 AM of the Unit 6 medication cart parked at the nurse's station revealed that Resident #17's medication bottle, still containing identifiable information, remained in the cart's trash can. The Director of Nursing (DON) was notified.An interview with the DON was conducted on 07/02/2026 at 10:56 AM. She stated Nurse #2 should not have left Resident #17's medication bottle with identifying information on the cart. She explained that the bottle should not have been disposed of in the cart's trash, and any remaining liquid should have been poured out, resident identifiers removed, and the bottle placed in the destroyer. She also stated Nurse #2 should not have left the computer screen visible when entering Resident #54's room, emphasizing that nurses are responsible for protecting residents' medical information from unauthorized visibility.During an interview on 07/02/2026 at 2:37 PM, the facility Administrator stated that private health information should never be left visible to the public.

Based on record review, observation, staff and physician interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 3 residents reviewed for respiratory care (Resident #36). The findings included:Resident #36 was admitted to the facility on [DATE]. Her diagnoses included chronic diastolic congestive heart failure, dependence on supplemental oxygen and chronic obstructive pulmonary disease (COPD). A physician order dated 6/30/25 indicated administer oxygen via nasal cannula at 2 liters per minute continuously for COPD.Resident #36's medication administration record (MAR) indicated check oxygen level every shift to maintain oxygen saturations above 92 %. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was moderately cognitively impaired and was dependent on staff for all activities of daily living (ADL) to include turning left and right in bed and transfers. Her diagnoses included COPD and dependence on supplemental oxygen. She was coded for shortness of breath or trouble breathing when lying flat. Resident #36's care plan last revised 6/22/26 had a care focus area that indicated Resident #36 required use of oxygen continuously via nasal cannula related to COPD. Interventions included ensuring oxygen was titrated to appropriate setting as ordered by physician. During an observation on 6/29/26 at 11:00 AM Resident #36 was observed with the oxygen nasal cannula in place. Resident #36's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. During an observation on 6/30/26 at 2:20 PM with Nurse #1 present, Resident #36 was observed with the oxygen nasal cannula in place. Resident #36's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. Resident #36's oxygen regulator was verified with Nurse #1 to be set at 3 liters per minute. During an interview on 6/30/26 at 2:22 PM with Nurse #1 who was assigned to care for Resident #36 during the day shift on 6/30/26 (7:00 AM - 7:00 PM) she revealed that she frequently cared for Resident #36 and that Resident #36 had a physician order for oxygen at 2 liters per minute via nasal cannula. She further explained she would normally check the setting on the oxygen concentrator when she went to Resident #36's room, but she had not checked it earlier that morning when she went to Resident #36's room to administer her morning medication. Nurse #1 reported that she had last checked Resident #36's oxygen during her pervious shift. Attempts to interview the nurse who was assigned to care for Resident #36 on night shift 6/29/26 at 7:00 PM to 6/30/26 at 7:00 AM were unsuccessful. An interview was conducted on 7/1/26 at 4:40 PM with the Director of nursing (DON). The DON explained Nurse #1 should have verified the oxygen concentrator upon entering Resident #36's room during morning medication administration and throughout her shift to ensure it was set per the doctor's orders. She stated nurses were to follow physician's orders and obtain another order if they needed to titrate the oxygen rate. An interview was conducted on 7/2/26 at 9:51 AM with the facility Physician. She stated Resident #36 was receiving oxygen for COPD. The Physician stated nursing staff were to follow physician orders as given and to call the physician if they needed to titrate the oxygen rate. During an interview on 7/2/26 at 3:02 PM with the Administrator, she stated she expected nurses to administer oxygen to residents according to physician orders.

Based on observations, staff interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5%, as evidenced by 2 medication errors out of 30 opportunities, resulting in a medication error rate of 6.67% for 1 of 4 residents observed during medication administration (Resident #54). Findings included:A review of Resident #54's physician orders revealed orders for Aspirin 81 milligrams (mg) delayed release tablet daily for atherosclerotic heart disease, and for estrogen 0.625 mg tablet daily.On 07/02/2026 at 8:44 AM, an observation of a medication pass was conducted for Nurse #2 while she was administering medications to Resident #54. Nurse #2 was observed removing one 81 mg chewable aspirin tablet from a stock bottle and placing it into a medication cup she was preparing for Resident #54. She then administered the chewable aspirin tablet to the resident that was not delayed release. During the same observation, Nurse #2 did not administer the estrogen tablet.At 8:50 AM on 07/02/2026, an interview was conducted with Nurse #2. She stated she did not realize the aspirin tablet was chewable rather than delayed release. She also stated she did not administer the conjugated estrogen tablet because it had not been ordered on time and that she would call the physician.An interview was conducted on 07/02/2026 at 11:49 AM with the Director of Nursing (DON). The DON stated she expected nurses to administer medications exactly as ordered by the physician. She reported that the physician was notified and the resident was assessed, with no issues resulting from the administration of the chewable aspirin. She also stated that staff are required to order medications according to the medication card to prevent missed doses.

Based on record review and staff interview, the facility failed to accurately code the discharge status for 1 of 3 residents (Resident #82) reviewed for discharge. The findings included: Resident #82 was admitted for the facility 2/18/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A social worker progress note dated 4/14/21 revealed plan for Resident #82 to discharge to home with his wife and home health services on 4/15/21. A discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #82 was discharged to acute hospital. A Social Worker progress note dated 4/16/21 indicated she spoke with the resident on the phone and things were going well at home. During an interview 7/14/21 at 9:45 AM, the MDS nurse #1 stated Resident #82 was discharged home. She revealed she filled out the discharge MDS and coded Acute Hospital by mistake. Resident #82's discharge status should have been home. During an interview on 7/14/21 at 10:15 AM, the Administrator stated other MDS coordinators should have reviewed the MDS before transmittal. She further stated she would work with corporate to prevent this in the future.

Based on record review and staff interviews, the facility failed to make a referral for re-evaluation after a change in mental health status for 4 of 4 sampled residents reviewed for Preadmission Screening and Resident Review (PASRR). (Resident #31, Resident #73, Resident #50, and Resident#13) Findings included: 1. Resident #31 was admitted to the facility on [DATE]. Resident #31 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the level I determination notification letter revealed it was completed on 09/25/2020. It indicated The level I screening and PASRR number remains valid for the individuals stay. A copy of this notice should be transferred with the individual if he/she relocates to another Nursing facility. No further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31's cognition was severely impaired. The MDS did not indicated any psychiatric diagnoses/mood disorder. The quarterly MDS dated [DATE] indicated a psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident # 31 medical record revealed a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Social Worker (SW) on 07/14/2021 at 11:40 AM. SW confirmed that Resident # 31 had a level I PASRR. Resident # 31's 05/27/2021 MDS assessment that indicated the active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She added the Admission coordinator was responsible for referring the residents to PASRR authority. SW added moving forward she will make sure residents with new psychiatric/ mood disorders were referred to State agency for level II PASRR referral. An interview was conducted with the MDS nurse on 07/14 /19 at 1:44 PM. She stated it was a learning experience that when a resident was newly diagnosed with a serious mental illness that was not present on admission that the resident needed to be referred for evaluation for level II PASRR. The MDS added that SW will be responsible for making this referral. An interview was conducted with the Director of Nursing on 07/14/19 at 2:00 PM. she indicated her expectation was for the regulations to be followed in reference to completing a PASRR for a newly identified mental illness diagnosis. An interview was conducted with the Administrator on 07/14/19 at 2:10 PM. She indicated her expectation was for a referral to be made to PASRR State agency as soon as a resident was diagnosed with a new mental illness 2. Resident #73 was admitted to the facility on [DATE]. Resident # 73 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the level I determination notification letter revealed it was completed on 02/08.2021. It indicated The level I screening and PASRR number remains valid for the individuals stay. A copy of this notice should be transferred with the individual if he/she relocates to another Nursing facility. No further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73's cognition was severely impaired. The MDS indicated psychiatric diagnoses/mood disorder which included anxiety, depression and psychotic disorder. Review of Resident # 73 medical record revealed a new psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Social Worker (SW) on 07/14/2021 at 11:40 AM. SW confirmed that Resident # 73 had a level I PASRR completed on 02/08/2021. SW confirmed Resident # 73 had new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . SW revealed she had not referred Resident # 73 to the PASRR authority for a re-evaluation related to these new diagnoses. SW added moving forward she will make sure residents with new psychiatric/ mood disorders were referred to State agency for level II PASRR referral. An interview was conducted with the MDS nurse on 07/14 /19 at 1:44 PM. She stated it was a learning experience that when a resident was newly diagnosed with a serious mental illness that was not present on admission that the resident needed to be referred for evaluation for level II PASRR. The MDS added that SW was responsible for making this referral. An interview was conducted with the Director of Nursing on 07/14/19 at 2:00 PM. she indicated her expectation was for the regulations to be followed in reference to completing a PASRR for a newly identified mental illness diagnosis. An interview was conducted with the Administrator on 07/14/19 at 2:10 PM. She indicated her expectation was for a referral to be made to PASRR State agency as soon as a resident was diagnosed with a new mental illness 3. Resident #50 was admitted [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] had her coded as cognitively impaired and totally dependent on staff for activities of daily living (ADL). The NC uniform screening tool read in part . effective date 06/10/2008 and there was no new PASRR level II submitted. An interview with the Administrator on 07/13/2021 at 1:21 PM, the Administrator stated the screening tool is all the documentation the facility had available. The Administrator also stated all residents should be reviewed and screened for any needed Level II PASRR assessments when there is a new mental health diagnosis. An interview was conducted with the MDS nurse on 07/13/2021 at 3:29 PM. She stated a new level II PASRR is supposed to be submitted after a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Social Worker (SW) on 07/13/2021 at 3:17 PM. The SW stated when a resident was newly diagnosed with a mental illness the resident needed to be evaluated for a Level II PASRR. The SW stated she was not responsible for the PASRR information and Admissions is the person who does the applications. An interview was conducted with Admissions on 07/13/2021 at 3:40 PM. She stated she did not know she was supposed to put in the application for PASRR, but she will check with MDS to make sure they are submitted. 4. Resident #13 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual minimum data set (MDS) dated [DATE]had resident coded as cognitively intact and needed total dependency on staff for activities of daily living (ADL). The determination letter dated 06/30/2015 read in part .The level I screening and PASRR number remains valid for the individuals stay. A copy of this notice should be transferred with the individual if he/she relocates to another Nursing facility. No further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Administrator on 07/13/2021 at 1:21 PM. The Administrator stated all residents should be reviewed and screened for any needed Level II PASRR assessments when there is a new mental health diagnosis. An interview was conducted with the MDS nurse on 07/13/2021 at 3:29 PM. She stated a new level II PASRR is supposed to be submitted after a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 07/13/2021 at 3:17 PM with the Social Worker (SW). The SW stated when a resident was newly diagnosed with a mental illness the resident needed to be evaluated for a Level II PASRR. The SW stated she was not responsible for the PASRR information and Admissions is the person who does the applications. An interview was conducted with Admissions on 07/13/2021 at 3:40 PM. She stated she did not know she was supposed to put in the application for PASRR, but she will check with MDS to make sure they are submitted.

Based on record review, staff interviews, and detective interview the facility failed to protect a resident's right to be free of sexual abuse for one of three residents (Resident #2). Resident # 1 was observed by staff to touch Resident # 2 in her perineal area and confessed to police that he had touched Resident # 2, who was a severely cognitively impaired resident. Resident # 1 was deemed by police to be sufficiently oriented to the extent that his confession was credible evidence he had assaulted Resident # 2. The findings included: Record review revealed Resident # 1 was admitted to the skilled part of the facility on 6/26/18 after previously residing in the facility's assisted living unit. The resident had [DIAGNOSES REDACTED]. Review of Resident # 1's admission minimum data set (MDS) assessment, dated 7/5/18, revealed the resident was assessed to have a BIMs (brief interview for mental status) score of 11 which indicated moderately impaired cognition. The resident was also assessed to have no mood or behavior problems, to need extensive assistance with transfers, and to use a wheelchair for mobility. Review of Resident # 1's admission care plan, dated 7/6/18, revealed staff noted the resident had a problem with social isolation. Review of NA (Nurse Aide) documentation revealed from 6/26/18 to 8/22/18, the resident had no wandering or any other behaviors. Review of nursing notes revealed the following information. Prior to the date of 8/21/18, there were no nursing entries noting inappropriate sexual behavior since the resident's initial admission to the skilled facility on 06/26/18. On 8/21/18 at 6:57 AM Nurse # 1 entered a nursing entry which read, CNA (certified nurse aide) reported she observed resident standing in doorway being sexually inappropriate X2 (two times) this shift. Further review of nursing notes revealed from 8/21/18 to 8/23/18 at 7:00 AM, there were no further documented episodes of sexually inappropriate behaviors noted. Nurse # 1 was interviewed on 1/10/19 at 12:30 PM and again on 1/11/19 at 7:00 AM. According to Nurse # 1, Resident # 1 was in his room on 8/21/18. Resident # 1's room was diagonally across the hall from Resident # 2's room. Nurse # 1 stated on 8/21/18 Resident # 2 had a full time facility staff member sitting with her because she had recently sustained a fall and was confused. Nurse # 1 stated that Resident # 2's sitter had reported to Nurse # 1 that she had observed Resident # 1 looking across the hall into Resident # 2's room while masturbating in his room. Nurse # 1 stated she recalled the sitter stating that Resident # 1's vision was directed at her (the sitter), and not at the resident while engaging in this activity. According to Nurse # 1, the resident did not wander and typically stayed in or around his room. According to Nurse # 1, Resident 2 had multiple staff members sitting with her and she did not recall which sitter had reported this. Record review revealed documented evidence of 15 minute checks on Resident # 1 starting 8/21/18 at 4:30 AM. There was no notation who initiated the checks. For every 15 minute increments, yes was circled that the resident had a safety check through the date of 8/23/18 at 1:00 PM. Review of the resident's care plan revealed on 8/21/18 the following problem was added to the care plan: (Resident) displays socially inappropriate/sexual behavior in public. Beneath this care plan problem the following notations were written by the facility social worker (SW). On 8/21/18 the SW noted, Resident was seen masturbating on the hall looking at a female resident. This happened at night 8/20-21/18. On 8/22/18 the SW noted, Resident repeated the same behavior the night of 8/21-22/18. Care plan interventions included the following: Activities staff to visit with resident and provide diversional activities; observe and document resident behavior; Do not argue with resident; Elicit family input for best approaches to resident; Praise resident for demonstrating desired behavior; Talk with resident in calm voice when behavior is disruptive; Remove resident from public area when behavior is disruptive and unacceptable; Encourage family/responsible party to visit with resident; Every 15 minute checks; Care plan meeting with IDT (interdisciplinary team) to discuss behaviors. Review of the resident's record revealed no nursing entry documenting the incident which the SW had noted occurred on the night from 7:00 PM on 8/21/18 to 7:00 AM on 8/22/18. Nurse # 3 made an entry on 8/22/18 at 1:44 AM noting the resident had no behaviors on her shift. Nurse # 3 was interviewed on 1/11/19 at 8:35 AM and confirmed she was the nurse who had cared for the resident on the night shift from 7:00 PM on 8/21/18 to 7:00 AM on 8/22/18. She reported she did not ever witness Resident # 1 to have any inappropriate sexual behaviors towards other residents. The resident generally was in his room and she had only noted him in his doorway on a couple of occasions. She had not observed or was not aware of any wandering behaviors by Resident # 1. Nurse # 3 also stated she had heard the resident would masturbate in his room, but not in front of others. She had not witnessed this herself, and no nurse aide had reported inappropriate behaviors to her. Interview with the facility SW on 1/10/19 at 1:48 PM revealed Resident # 1 had no previous history of sexually inappropriate behavior before 8/21/18 and she had not been aware of any sexually inappropriate behavior prior to 8/21/18. She did not recall being told that the resident was directing his vision or attentions across the hall to any particular resident/visitor while masturbating in his doorway. It was the SW's understanding that the resident had masturbated within public view on two nights although the nurses had documented it had occurred on one night. The SW explained she met with the resident and his family on 8/22/18 and informed the resident that he needed to close his door if engaging in sexual behavior. The SW stated Resident # 1 voiced understanding and agreement. According to the SW the resident did not exhibit any behavior which would indicate he would assault another resident. The SW noted a referral was made for psychiatric evaluation on 8/22/18 for a future date. Record review revealed on 8/23/18 at 9:43 AM Nurse # 1 made another nursing entry into Resident # 1's record. The entry read, Late entry for 8/23/18 at 7 am. CNA came and reported resident (Resident #1) was in female resident (Resident #2) room with his hand touching female private areas. This nurse went to female residents room and removed (Resident # 1) from area and returned him to his room. Administrator notified and CNA was placed by resident door for 1:1. According to the facility's five day investigative report to the state agency, dated 8/29/18, a care conference was held with Resident # 1's responsible party (RP); the administrator, the SVU (Special Victim's Unit) detective, and a registered nurse at approximately 10:45 AM on 8/23/18. The SVU detective informed the RP that Resident # 1 had confessed to molestation and it had been determined that he was competent to have given the confession. The SVU detective provided Resident # 1's RP with two options: they could take the resident home, or the resident would be taken to jail. According to the report, the RP was unable to care for Resident # 1, and at 1:00 PM Resident # 1 was discharged to jail. Detective # 1 was interviewed on 1/11/19 at 9:25 AM and reported the following. She talked to Resident # 1 on the morning of the incident, 8/23/18, within his room and asked, Do you know why I am here? Resident # 1 responded, Yes, and Detective # 1 asked, Why? Resident # 1 then responded, Because I molested someone. Detective # 1 then inquired, Who? Resident # 1 then pointed across the hall to Resident # 2's room. Detective # 1 then asked Resident #1 what happened, and Resident # 1 said that Resident #2 had her door open, was naked, and was asking for him to come over. He confessed to going over and touching the resident on her stomach and her back. Detective # 1 reported that the resident appeared to be cognizant to what he was confessing, and his confession in conjunction with the witnessing NA's account (NA # 1) gave her reason to take him to the police station. At the police station, Detective # 1 reported she questioned him again and Resident # 1 was consistent in the details of his confession. Review of Resident # 2's record revealed she had a history of [REDACTED]. According to the record the resident was undergoing a fourteen day MDS readmission assessment when the incident occurred on 8/23/18. This assessment was finalized on 8/29/18 and coded Resident # 1 with a BIMS score of 6; indicating the resident had severely impaired cognition. A review of Resident # 2's nursing notes revealed the resident was assessed by Nurse # 1 for injury following the 7:00 AM incident of 8/23/18. Nurse # 1 noted within the nursing entry that a male resident had been seen touching her (Resident # 1's) private areas. Nurse # 1 noted Resident # 2 had no bleeding, bruising, or injury. During an interview, which was conducted with NA # 8 on 1/11/19 at 10:07 AM, the NA reported the following. She had been a facility caregiver for Resident # 2 during August, (YEAR), and Resident # 2 would at times take off her gown due to confusion. NA # 8 would see that Resident # 1 was watching Resident # 2 from his room, which was diagonally across the hall, and therefore NA #8 would close Resident # 2's door for privacy and place the gown back on her. NA # 8 reported she never saw Resident # 1 enter Resident # 2's room. NA # 8 stated she did report this to a nurse, but did not recall a specific nurse to whom she had spoken. NA # 7 was interviewed on 1/11/19 at 9:03 AM. NA # 7 had been a one on one sitter on some of the evening shifts for Resident # 2 during the time period of 8/15/18 to 8/21/18 due to fall precaution measures the facility was taking with Resident # 2. NA # 7 reported as she sat with Resident # 2, there were never any times Resident # 1 tried to enter Resident # 2's room, and she never witnessed him to have any inappropriate behaviors. NA # 1 was interviewed on 1/10/19 at 11:30 AM. NA # 1 confirmed she had witnessed Resident # 1 touch Resident # 2 in a private area on 8/23/18. NA #1 stated she had been walking down the hall around 7:00 AM on 8/23/18 before shift change report when she glanced in Resident # 2's room and saw Resident # 1 was in Resident # 2's room. When she entered the room, she found Resident # 1 was seated in his wheelchair beside of Resident # 2. Resident # 1's gown was on and her disposable brief was pulled down to her thigh area. Resident # 1 had his hand in Resident #2's private area and was moving his hand back and forth. NA # 1 immediately said, No stop, don't do that, and pulled Resident # 1's wheelchair away from the resident and back to the doorway. She ran to get the nurse, who was at the desk. It took her about 4 seconds to get Nurse # 1. Nurse # 1 immediately came to the room, and informed Resident # 1 he was not to be in the room and should not be touching Resident # 2. Nurse # 1 directed staff that Resident # 1 be placed back in his room. Nurse # 1 placed a staff member outside of Resident # 1's door. According to NA # 1, Resident # 2 was taking deep breaths as if she was upset but did not verbalize anything. Following the incident, she was not bathed, but she was dressed. During the interview conducted with Nurse # 1 on 1/10/19 at 12:30 PM, Nurse # 1 reported the following details. Prior to the incident of 8/23/18 at 7:00 AM, she had just observed Resident # 1 in his room and in his bed approximately five to ten minutes earlier. NA # 1 alerted her at 7:00 AM on 8/23/18 that she needed to come right now with her. She immediately went to Resident # 2's room where Resident #1 was sitting in his wheelchair at the doorway. At that point Resident # 1 had been pulled away from the resident, and therefore she did not witness Resident # 1 touching Resident # 2. Nurse #1 noted she appointed a staff member to be 1 on 1 with Resident # 1 in his room. Resident # 2 was assessed and found to be nervous, but otherwise okay. Once she made sure Resident # 1 was being monitored full time, and Resident # 2 was without injury she immediately called the Administrator. When she assessed Resident # 2, she did not find any signs of physical injury. Nurse # 1 reported Resident # 2 appeared very nervous which was not like her normal status. According to Nurse # 1, Resident # 1 had gotten himself out of bed on the morning of 8/23/18 without staff assistance. NA # 6 was interviewed on 1/11/19 at 6:50 AM. NA # 6 routinely cared for Resident # 1 on the night shift. NA # 6 stated Resident # 6 would generally be asleep at the beginning of the shift, and would get himself up in the morning before she left at 7:00 AM. At times she would find him in the hallway outside his room and in front of the residents' rooms across from his or beside him. At times he would look in, but there would never be any times he would enter others rooms. NA # 6 reported he did not wander to other parts of the facility, and she never knew him to have any sexually inappropriate behaviors or any other type of inappropriate behaviors. When she saw him looking into others rooms, she redirected him back to his room and he went back to his room. NA # 3 was interviewed on 1/10/19 at 2:16 PM. NA # 3 routinely cared for Resident # 1 on the dayshift. NA # 3 reported Resident # 1 always acted like a gentleman and she had never known him to have sexually inappropriate behaviors, other types of behavior problems, or wandering behavior. MA (Medication Aide) # 3 was interviewed on 1/11/19 at 8:52 AM. MA # 3 stated she had cared for the resident while he resided on the assisted living unit of the facility and prior to his transfer to the skilled unit. MA # 3 stated the resident had no inappropriate behaviors or wandering, and was always appropriate. According to facility documentation after the incident occurred, the following transpired on the date of 8/23/18 at the following times: The Administrator was notified-approximately at 7:21 AM The Administrator arrived at the facility-7:30 AM Police notified-approximately 7:45 AM Resident # 1 and Resident # 2's responsible parties were notified-8:00 AM Police arrived at the facility to conduct an investigation-8:05 AM Resident # 2's responsible party (RP) arrived at the facility-8:30 AM Resident # 2 was assessed from head to toe with her RP present -9:10 AM by a facility nurse The special victims unit (SVU) detectives arrived at the facility-9:20 AM The residents' physicians were notified-8:50 AM Psychiatry services were notified of an immediate need for psychological assessment for Resident # 2-9:15 AM Regional Ombudsman notified at 10:30 AM A 24 hour report, noting that the facility was investigating an incident of suspected resident abuse, was submitted to the state agency on 8/23/18. Record review revealed on 8/29/18 a five day investigative report was completed and submitted to the state agency. The facility substantiated Resident # 2 had been sexually assaulted by Resident # 1. Interview with the Acting Administrator on 1/10/19 at 5:50 PM revealed the current Administrator was on extended leave at the present time. According to the Acting Administrator, who was a corporate employee, she had been aware of the incident when it had occurred on 8/23/18. According to the Acting Administrator, Resident # 1 had not displayed any signs of sexually inappropriate behavior towards residents prior to the 8/23/18 incident. The Acting Administrator stated the facility did their investigation and conducted their own internal plan of correction (P[NAME]) to assure no future occurrences. The Acting Administrator stated she would follow up with the Administrator, who was on leave, and locate the documentation of their P[NAME] (Plan of Correction). The Acting Administrator presented the documented evidence on 1/11/19 at 3:54 PM that following the incident of 8/23/18, the facility took corrective measures to assure there would be no further assault. The facility presented the following plan of correction that had been completed on 8/30/18 Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; 1) On 8/23/18 at approximately 7:05AM Resident 1 was witnessed to be in Resident 2's room by staff CNA1. CNA1 reported Resident 2 was lying on her bed on the left side with her brief pulled down and Resident 1 was in his wheelchair next to her bed with his left hand in between her legs. CNA immediately instructed him to stop and pulled him out of the room. CNA saw nurse standing at the nurse's station and yelled for her. Nurse came and the CNA reported what she saw. Nurse ensured Resident 2 was safe and Resident 1 was being supervised by CNA1. 2) On 8/23/18 at approx. 7:21am, nurse notified Administrator of the incident. Administrator on site at 7:30am and ensured that Resident 2 was safe and secure and both residents separated. Resident 1 was immediately placed on 1:1 supervision by the Administrator. Staff instructed not to remove any articles from the room; staff dressed resident for comfort but did not bathe until further instructed by detectives. Police immediately notified approx. 7:45am. Administrator notified both responsible parties at 8:00am and both parties expressed that they will be arriving to the facility ASAP. 3) On 8/23/18 at 8:05a Fayetteville police arrived to take report and investigate the allegation. RP of Resident 2 arrived to the facility at 8:30 to support her mother throughout the process. Detectives of SVU were notified by the Fayetteville police and arrived on the scene at 9:20a to conduct a full investigation. As part of the investigation, the detective interviewed employees, Resident 2 (along with RP present due to resident not interview able), and Resident 1. Detectives obtained the necessary materials needed such as clothing, swabs, and hand/fingernail inspection. Detectives were informed that Resident 2 has a BIMS score of 6/15 and Resident 1 with a BIMS of 11/15. 4) On 8/23/18 at approx. 9:10a, a full head to toe body assessment was completed on Resident 2 by MDS Coordinator (assessing RN) with no injuries present. MD notified of incident at 8:50a by unit nurse; administrator notified by medical director expressing his concern of incident and that Resident 1 is to be discharged due to the safety and wellbeing of individuals in the facility due to his inappropriate sexual behaviors. 5) On 8/23/18 at approx. 10:30a, Ombudsman notified of the incident by the Director of Operations and a 30 day discharge notice had been issued. Guidance provided regarding discharge options. Approx. 10:45a Care conference was held with the family of Resident 1. Administrator, SVU Detective, and assessing RN in attendance. The detective informed family that Resident 1 confessed to molestation, expressing he touched her breast, stomach, and vaginal area. Detective was able to determine that Resident 1 was fully competent of his actions, as he restated his inappropriate behavior. Detective offered family two options: take Resident 1 home or he would be obtained by law enforcement. Family unable to care for Resident 1 at home; no other options available. Copy of discharge notice provided to family. 6) On 8/23/18 approx. 11:30a, detective notified administrator via phone that an officer will be arriving to the facility within an hour to pick up Resident 1 to take him to Cumberland County jail. Family of Resident 1 at bedside. Resident discharged to law enforcement approx. 1:00p. Medications provided to officer. 7) On 8/23/18 at approx. 3:30p Psych arrived to evaluate Resident 2; resident had no recollection of the incident and displayed no signs of mental anguish. Resident 2 was placed on acute charting and monitoring for changes in mood and behavior. RP of Resident 2 cooperative and satisfied with facility interventions and appreciative of the quick responses and reporting. RP did not wish to press charges against Resident 1. 8) On 8/24/18, staff in serviced on abuse, how to respond the media, and residents/family questions regarding the incident. Inservices conducted by administrator and facility performance improvement nurse/staff development coordinator. Other resident's on that unit interviewed for any inappropriate behaviors. The two non-verbal residents on that unit were observed by the RN MDS Coordinator. No other concerns or issues noted. After interviews it has been concluded that this was an isolated incident. 9) An initial investigation report was sent to DHHS on 8/23/18. Final investigation report was sent to DHHS on 8/29/18. A. Address how the facility will identify other residents having the potential to be affected by the same deficient practice 1) On 8/23/18, 100% of active residents with behaviors as identified by the MDS (Section E) have been reassessed by the IDT including the Administrator, MDS Coordinator, DON, and Social Worker for the type of behaviors exhibited and for any resident with inappropriate sexual behaviors. Resident interventions to include but not limited to 15 minute Safety Checks and 1:1 monitoring; will be implemented based on individualized needs to protect the safety and well-being of the affected resident and all other residents. 2) From this audit it was determined one other male resident had the tendency towards inappropriate behavior. This resident was immediately placed on 24 hour one-on-one monitoring. That shall continue until the behavior is no longer exhibited or until the resident is no longer physically able to act upon the behavior. 3) Section E will be completed by the MDS Coordinator on all residents admitted after 8/24/18 to assess for any abnormal behaviors, sexually inappropriate behaviors, physically aggressive behaviors, etc. B. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur 1) Beginning on 8/24/18, all staff were in-serviced by the administrator or designee on CMS Phase 2 Regulations with re-education of staff duties to report immediately abnormal or disruptive behaviors, protecting the resident from abuse (Redirection is not an intervention), and monitoring the effectiveness of interventions. Abnormal or inappropriate behaviors should be documented by CNAs in the kiosk under the behavior section and the nurse will document in the nurses note. 2) Staff not in-serviced by 8/29/18 will be in serviced prior to the beginning of their next. 3) New staff will continue to be in-serviced on abuse prevention upon hire and at least annually. 4) During new admission conference, the Admission Coordinator will review the facility Abuse Prevention Program and inquire of any history of behaviors or abuse. Any history of abuse will communicated to the MDS Coordinator the same day. 5) Room Audit Rounds will be conducted by the QI nurse or designee to monitor for compliance with the Abuse Reporting requirements and to monitor for any abnormal behaviors. Findings will be immediately addressed by the IDT and appropriate follow-up care and monitoring will be implemented as deemed appropriate. C. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; 1) Beginning 8/24/18, outcomes of MDS audits (Section E) or other behavior with the potential to cause harm to residents were reviewed by the administrative team for alerts to inappropriate sexual behavior. Any resident who codes on the MDS as having the potential behavior will be discussed by the IDT to include administrator, DON, Social Work and MDS Coordinator during morning administrative meeting for development of actions or plan if needed. This will occur at a minimum of monthly X 3 months 2) Random Room Round audits will be conducted weekly x3, then monthly x2, then quarterly thereafter by performance improvement nurse/staff development nurse. Any abnormal behaviors or reports from staff of abnormal or inappropriate behaviors will be documented on the Room Round Audit form and sent to the ED/DNS for immediate intervention. D. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; 1) Beginning 8/24/18, outcomes of MDS audits (Section E) or other behavior with the potential to cause harm to residents were reviewed by the administrative team for alerts to inappropriate sexual behavior. Any resident who codes on the MDS as having the potential behavior will be discussed by the IDT to include administrator, DON, Social Work and MDS Coordinator during morning administrative meeting for development of actions or plan if needed. This will occur at a minimum of monthly X 3 months 2) Random Room Round audits will be conducted weekly x3, then monthly x2, then quarterly thereafter by performance improvement nurse/staff development nurse. Any abnormal behaviors or reports from staff of abnormal or inappropriate behaviors will be documented on the Room Round Audit form and sent to the ED/DNS for immediate intervention. 3) Results/outcomes of the above plan will brought to the facility QA meeting quarterly for review by committee members for compliance. Any revisions to the plan will require re-inservicing of appropriate personnel. 4) Any revision to the plan will require the monitoring process to begin again at D(1) Validation Information On 1/11/19 at 5:19 PM an interview was held with the Acting Administrator regarding their plan of correction. According to the Acting Administrator the facility identified no other resident who had experienced any mistreatment from Resident # 1. They did this through interviewing and observing other residents who resided on the unit, on which Resident # 1 reportedly contained his limited wheelchair movements to. The Acting Administrator presented documented evidence that the audit of all facility resident behaviors was completed on 8/23/18. According to the Acting Administrator, the facility's initial audit of 8/23/18 had revealed one cognitively impaired resident who made sexual comments but had no history of displaying physically sexual inappropriate behavior. Following 8/23/18, the facility had placed a 1 on 1 staff member with this cognitively impaired resident as an added assurance, and this intervention was to be continued long term. The Acting Administrator provided documentation of this. The Acting Administrator presented the facility abuse policy which noted there was zero tolerance for abuse. According to the Acting Administrator, this policy was discussed with all newly admitted residents and their families, and an inquiry was made of the family/resident upon admission of any previous abuse history. An online search was also conducted to assure all newly admitted residents were not listed on a published National Sex Offenders List. According to the Acting Administrator, the facility had no further newly admitted residents with sexually inappropriate behavior. Also according to the administrator, there were no residents who had been residing at the facility on 8/23/18 and who had developed sexually inappropriate behaviors since their initial audit. This was based on their continuing assessments and audits done per their P[NAME]. The Acting Administrator presented documented evidence of room audits which had been done per the schedule in their P[NAME], and reported the quality assurance nurse observed during the room audits for residents with behaviors which would indicate they were at risk of abusing others or had experienced abuse; talked to staff members about resident behaviors; and talked to staff members to assure they knew about reporting abuse during the audits. The administrator presented documented evidence of abuse training that was conducted with staff, and which was completed on 8/30/18. The Acting Administrator presented documented evidence that their plan of correction was discussed in their October, (YEAR) quarterly quality assurance meeting, and it was determined their plan was working and no new cases of resident abuse had been found. During the survey, on 1/10/19 beginning at 8:55 AM observations were made on all facility halls revealing there were multiple staff members in attendance and supervising residents. Multiple interviews were held with random residents on all halls of the facility, and no mistreatment or fear of mistreatment was reported by residents. There were no residents observed to be displaying inappropriate sexual behaviors or abusive behaviors. There were no residents who were observed to be exposing themselves to public view. Multiple staff members were interviewed and reported they had received training regarding abuse, and all were knowledgeable regarding actions they should take if they suspected abuse. Interview with staff members revealed they were not aware of any abuse or mistreatment which had occurred since 8/23/18. Other cases of alleged abuse were reviewed, and revealed 1) no evidence any residents had been abused and 2) the facility followed their policy in regards to keeping residents safe, investigating other alleged cases, and reporting other alleged cases. The facility's date of compliance was validated at 8/30/18.

Based on observation, staff and resident interviews and record review, the facility failed to provide a privacy cover for the urinary catheter drainage bag for 1 of 3 sampled residents with an indwelling urinary catheter (Resident #184). The findings included: Resident #184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #184 was cognitively intact and required extensive assistance with her Activities of Daily Living (ADLs). The MDS indicated Resident #184 had an indwelling urinary catheter and a [DIAGNOSES REDACTED]. A review of Resident #184's Care Plan, last revised 07/19/18, revealed Resident #184 had the potential for a urinary tract infection [MEDICAL CONDITION] related to the presence of an indwelling urinary catheter for [MEDICAL CONDITION] secondary to her [DIAGNOSES REDACTED]. A review of the Admission Nursing Assessment revealed Resident #184 had been admitted with an indwelling urinary catheter. During an observation of Resident #184 on 07/24/18 at 11:58 a.m., Resident #184 was noted to have an indwelling urinary catheter with the urinary catheter drainage bag attached to the side of the bed. The urinary catheter drainage bag did not have a privacy cover and could be seen from the hall. During an interview with Nurse #1 on 07/24/18 at 12:10 p.m., Nurse #1 stated it had been brought to her attention the urinary catheter drainage bag did not have a privacy cover while she had passed her morning medications. Nurse #1 stated Resident #184 had been admitted to the facility from the hospital with the indwelling urinary catheter. Nurse #1 stated upon assessment of the indwelling urinary catheter she had been unfamiliar with the tubing associated with the indwelling urinary catheter Resident #184 had and had planned to talk with her Director of Nursing (DON) for instruction. During an observation of Resident #184 on 07/25/18 at 9:10 a.m., Resident #184 had been sitting up on the side of her bed, feet touching the floor and facing the door to her room. Resident #184's urinary catheter drainage bag was connected to the side of the bed. The urinary catheter drainage bag did not have a privacy cover and could be seen from the hall. During an and observation and interview with Resident #184 on 07/26/18 at 10:15 a.m., Resident #184's urinary catheter bag was noted to have a privacy cover in place. Resident #184 stated she had felt embarrassed the urine in her urinary catheter drainage bag had been visible to others and felt better now that the urinary drainage bag had a privacy cover. During an interview with the DON on 07/26/18 at 10:20 a.m., the DON stated it was her expectation nursing staff use a privacy cover for urinary collection bags or replace the urinary collection bag with one with a privacy flap (fig-leaf design). During an interview with the Administrator on 07/26/18 at 10:30 a.m., the Administrator stated it was her expectation nursing staff use a privacy cover for urinary collection bags for new residents upon admission to the facility or when an indwelling urinary catheter had been placed on an established resident.

Based on observation, record review, resident interview, and staff interviews for one (Resident # 3) of three sampled residents, the facility failed to monitor for pain medication side effects when the resident had a documented history of side effects and allergies [REDACTED]. The findings included: Record review revealed Resident # 3 was admitted to the skilled section of the facility on 4/30/18 after undergoing a total left knee replacement secondary to [MEDICAL CONDITION]. Prior to the resident's surgery she had resided on the assisted living unit of the facility. Review of the resident's 4/30/18 hospital discharge summary revealed the following information. Following her surgery, the resident had initially been prescribed [MEDICATION NAME] for pain. On the second post-operative day, the resident had appeared lethargic. There was documentation the lethargy was likely secondary to pain medication. The [MEDICATION NAME] was stopped, and within approximately five hours the resident was noted to be more alert and oriented. The resident reported to the physician that she normally took [MEDICATION NAME] for pain, and therefore [MEDICATION NAME] was restarted. ([MEDICATION NAME] is a combination of [MEDICATION NAME] and [MEDICATION NAME]). At time of hospital discharge, the resident was documented as alert, oriented, emotionally appropriate, and cooperative. According to hospital discharge summary orders the resident was to receive [MEDICATION NAME]-[MEDICATION NAME] 5-300 mg (milligrams) every six hours as needed for pain. The hospital discharge summary also noted, scheduled Tylenol. According to the hospital discharge summary the resident had multiple documented allergies [REDACTED]. Review of the resident's facility record revealed on 5/1/18 the resident's pain medication orders were clarified through her facility physician to be [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one tab every six hours as needed for pain and Tylenol Extra Strength two 500 mg tabs every six hours as needed for pain. Also, it was noted upon the resident's facility admission orders [REDACTED]. This information appeared on her May, (YEAR) cumulative physician's orders [REDACTED]. Review of physician orders [REDACTED]. ([MEDICATION NAME] is a combination of [MEDICATION NAME] and [MEDICATION NAME]). At the time the PA wrote this order, the resident was not receiving [MEDICATION NAME]. The PA prescribed [MEDICATION NAME] 5 mg every six hours. When the 5/4/18 [MEDICATION NAME] order was written, there was still documentation on the record the resident had an allergy to [MEDICATION NAME]. According to the May, (YEAR) MAR indicated [REDACTED]. Excluding fourteen doses, the resident was documented as receiving the medication from 6 PM on 5/4/18 through 5/21/18 at 6 PM. This meant she received 55 doses of [MEDICATION NAME]. For fourteen of the doses, a N appeared on the digital MAR indicated [REDACTED]. These fourteen times were as follows: 5/14/18- at 12 PM and 6 PM 5/15/18 - at 12 AM; 6 AM; 12 PM; and 6 PM 5/16/18-at 12 AM; 6 AM; 12 PM 5/17/18 at 12 AM; and 6 AM 5/18/18 at 12 AM and 6 AM 5/21/18 at 12 PM. On 5/14/18 the resident's admission minimum data set assessment was completed. The resident was assessed to be cognitively intact. The resident scored a perfect score of 15 on her brief interview for mental status. Review of nursing notes revealed an entry on 5/15/18 at 2:17 AM by Nurse # 2. Nurse # 2 noted the resident stated the [MEDICATION NAME], makes me feel crazy. On 5/16/18 at 2:39 AM, Nurse # 3 documented the resident was not able to sleep at night. On 5/17/18 at 2:19 AM, Nurse # 3 documented the resident had been refusing her [MEDICATION NAME] and had spent more hours sleeping since she had refused it. According to the record, the resident went to the orthopedic on 5/15/18 for a follow up visit. The date of 5/15/18 coincided with a date on which the resident did not take the [MEDICATION NAME]. The orthopedic noted on his consultation report that he prescribed the resident to have one to two tablets of [MEDICATION NAME] 5/325 mg every one to two hours as needed for pain. ([MEDICATION NAME] is a combination of [MEDICATION NAME] and [MEDICATION NAME], which was originally prescribed for the resident after her surgery). According to the record, the resident was also seen by the attending physician on 5/15/18. The physician did not note anything regarding the resident's pain medications. Record review revealed on 5/17/18 the consultant pharmacist reviewed the resident's medication regimen during her monthly audit. The pharmacist noted the resident's [MEDICATION NAME] was discontinued on 5/4/18 and the resident was started on scheduled doses of [MEDICATION NAME]. The pharmacist did not question this order or make any recommendations regarding the [MEDICATION NAME] use. Two interviews were completed with the resident prior to the resident's full chart review being completed which revealed she had a documented history of an [MEDICATION NAME] allergy. These interviews were on 5/21/18 at 9:17 AM and 3:45 PM while the resident was still on [MEDICATION NAME]. On 5/21/18 at 9:17 AM the resident complained that she had not correctly received her pain medication. She had asked about it but was told by a staff member the medication nurse was hiding out somewhere and that was why she did not get it. The resident also reported at this time that she had recently had money stolen from her. She said she kept a key to her locked drawer around her wrist, and someone had removed the key while she slept. On 5/21/18 at 3:45 PM, the resident was interviewed again. The resident stated she had again not gotten her pain medication that day at 12 noon. She stated Nurse # 1 was supposed to have given it to her, and she had been in pain. When asked about details of not getting her pain medication, the resident seemed to have trouble recalling exactly all the details. She also reported Nurse # 1 had told her she was out of pain medication. The resident was worried about what she was going to do regarding her pain since there was no medication. The resident further reported the following. She had not wanted to be on [MEDICATION NAME] because she could not take the full strength of it. She had always taken [MEDICATION NAME] ([MEDICATION NAME]) for pain, which she was accustomed to taking without a problem. She had recently gone to her orthopedic and asked him to switch her back to the [MEDICATION NAME], and he wrote a prescription and order for it. She brought the order and prescription back to the facility following her orthopedic appointment and gave it to a staff member. She was still not getting the [MEDICATION NAME]. She had tried to talk to staff about it, and they had told her [MEDICATION NAME] and [MEDICATION NAME] were all the same thing. She was not clear regarding to whom she had had discussed this, but was consistent in that she did not like being on the [MEDICATION NAME] because she thought it made her feel different than when she was on the [MEDICATION NAME]. She also seemed unsure of what needed to be done since the staff had told her the [MEDICATION NAME] was the same thing as the [MEDICATION NAME] which she had always taken. Directly following the 3:45 PM interview on 5/21/18, Nurse # 1 was interviewed about the resident not receiving any pain medication and her claims that she was out of medication. According to the nurse, the resident had been asleep at 12 noon when the [MEDICATION NAME] was due to be administered. Therefore per nursing discretion the nurse held the pain medication and did not awaken the resident. The nurse stated she never told the resident she was out of pain medication, and the nurse stated she thought the resident might be confused. The nurse opened the narcotic medication cart to show there was pain medication still in stock for the resident. During the conversation with the nurse, the nurse did not mention that the resident had a documented allergy to [MEDICATION NAME] and the surveyor had not yet completed a chart review. While the surveyor was talking to Nurse # 1, the DON (Director of Nursing) approached. It was shared with the DON that the resident had concerns about her pain medication. The DON was asked if the orthopedic consult could be obtained for the surveyor's review the next day. The DON stated she would obtain it. On 5/22/18 at 9 AM the resident was observed in her room lying in bed. A nurse aide (NA) was taking away her breakfast tray at this time. The resident had not eaten. The resident stated she was dizzy and nauseous. Following this interview the review of the resident's chart was completed revealing the resident had the documented allergy to [MEDICATION NAME]. Also, the DON had made an entry on 5/21/18 at 5:39 PM noting she had spoken to the resident. The time of 5:39 PM was following the time the surveyor had spoken to the DON on 5/21/18 letting her know the resident had medication concerns. At 5:39 PM the DON documented the resident told her she did not want to be on [MEDICATION NAME] and wanted to be on the [MEDICATION NAME]. The DON noted the physician was called and an order was obtained to change the resident to [MEDICATION NAME] 5-325 mg every six hours for pain, and [MEDICATION NAME] 5-325 mg every six hours as need for breakthrough pain. The [MEDICATION NAME] was discontinued on the May, (YEAR) MAR indicated [REDACTED]. On 5/22/18 at 10:20 AM the DON and a corporate consultant were interviewed. They were asked about the 5/4/18 [MEDICATION NAME] discontinuation order which had been written when the resident was not on [MEDICATION NAME]. They did not know why the PA had written the order to discontinue a medication the resident was not receiving or why he had placed the resident on [MEDICATION NAME] when she had an allergy to [MEDICATION NAME]. The PA was interviewed on 5/22/18 at 12:15 PM and reported the following. On 5/4/18 he was trying to lessen the potential of liver damage by placing the resident on a pain medication that did not include [MEDICATION NAME]. In retrospect, he realized he should have written to discontinue [MEDICATION NAME] rather than discontinue [MEDICATION NAME]. The PA stated usually a resident, who could take [MEDICATION NAME], could also take [MEDICATION NAME]. For residents who have listed allergies [REDACTED]. Since Resident # 3 had been taking [MEDICATION NAME] without a problem, he had felt she could tolerate the [MEDICATION NAME]. A pharmacy manger was interviewed on 5/22/18 at 1:10 PM. The pharmacy manager stated they had not questioned the order for the [MEDICATION NAME] on 5/4/18 before filling it and dispensing it to the facility. According to the pharmacist both [MEDICATION NAME] and [MEDICATION NAME] are in the same drug class, and therefore if a resident was allergic to one then they should be allergic to the other. According to the pharmacist side effects could vary from one of these medications compared to the other, and were patient specific. Interviews were conducted with direct care staff who had cared for Resident # 3 while she was on the [MEDICATION NAME]. They are as follows. Medication Aide (MA) # 1 had been responsible for two of the fourteen [MEDICATION NAME] doses which had been held. MA # 1 was interviewed on 5/22/18 at 2:10 PM. The MA stated the resident had reported the [MEDICATION NAME] made her dizzy and she had told Nurse # 1. Nurse # 1 had been responsible for four of the fourteen [MEDICATION NAME] doses which had been held. Nurse # 1 was interviewed on 5/22/18 at 2:17 PM. Nurse # 1 reported sometimes the resident would be asleep and she did not awaken sleeping residents for pain medication. Nurse # 1 also stated MA # 1 had not told her the medication was making the resident dizzy or she would have talked to the physician about it. Nurse # 2 had been responsible for two of the fourteen [MEDICATION NAME] doses which had been held. These held doses were on 5/14/18. This date was before the resident discussed her medications with the orthopedic and returned to the facility to be told by staff that [MEDICATION NAME] and [MEDICATION NAME] were the same thing. Nurse # 2 was interviewed on 5/22/18 at 3:30 PM and reported the following. She had held the doses of [MEDICATION NAME] on the 14th because the resident had told her it made her feel loopy. The resident only wanted Tylenol. The doses she had held were on the same shift. She had placed the resident's concern on the 24 hour report and thought it would be addressed. She did not return to work until the night of 5/18/18 and was surprised when she saw the [MEDICATION NAME] was still ordered. She asked the resident about it, and the resident told her she would take it because she had decided it might be the Tylenol which was affecting her. Therefore, she gave the [MEDICATION NAME]. Nurse # 3 had been responsible for six of the fourteen [MEDICATION NAME] doses which had been held. Nurse # 3 was interviewed on 5/22/18 at 10:30 PM. Nurse # 3 reported the following. The resident had refused the [MEDICATION NAME] because she did not like the way it made her feel. She had said she did not want to take any more narcotics, and Tylenol helped her at night when the nurse worked. Therefore, she gave the resident Tylenol instead for pain. She had put the resident's concerns about [MEDICATION NAME] on the 24 hour report to be addressed. NA (Nurse Aide) # 1 was interviewed on 5/22/18 at 2:15 PM. NA # 1 reported the following. She took care of the resident approximately two days per week. The resident had complained of dizzy spells and feeling sick on her stomach at times when she cared for her. She told the medication aide on the hall when this occurred. NA # 2 was interviewed on 5/22/18 at 2:20 PM. NA # 2 stated she had cared for the resident on 5/20/18. The NA reported the following. The resident appeared confused on 5/20/18. The resident had claimed someone had stolen money from her and reported problems with the key to her personal locked storage. The NA reported the resident's story regarding the stolen money did not seem to make sense. Interview with the administrator on 5/23/18 at 4:43 PM revealed the consultant pharmacist would be available for interview on 5/29/18. The consultant pharmacist was interviewed on 5/29/18 at 12:18 PM and reported the following information. She had not questioned the 5/4/18 order to discontinue [MEDICATION NAME] and start [MEDICATION NAME]. Both [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME] derivatives and therefore typically an individual with an allergy to one would have an allergy to the other. The pharmacist had thought, since the resident had been taking the [MEDICATION NAME] without problems, there was no need to question the [MEDICATION NAME] order. During her 5/17/18 review, the pharmacist had identified the resident was starting to refuse a few doses of the [MEDICATION NAME], but thought it was attributed either to the resident not having pain or an effort to decrease her Opioid use. She had not talked to the resident, and staff had not alerted her that the resident could be having some side effects. According to the pharmacist, in general some residents tolerate one of the medications better than the other, and some residents report less side effects while taking one of the medications versus the other. The better tolerated medication varied between different individuals. It would have been her expectation that if the nurses knew the resident was complaining of dizziness, did not like how she felt on the [MEDICATION NAME], or felt it might be contributing to confusion that they would have reported this to the physician so it could be addressed. Interview with the physician on 5/22/18 at 1:45 PM revealed he had not been aware the resident was having any possible side effects to the [MEDICATION NAME]. The physician did not feel the resident had a true allergy to [MEDICATION NAME] or that she had been harmed by receiving it. The physician was not sure what the documented allergy to [MEDICATION NAME] entailed. According to the physician the resident might tolerate the [MEDICATION NAME] better and with less side effects than the [MEDICATION NAME], and it was his plan to discuss it with the resident.

Based on record review, staff and physician interviews, the facility failed to notify the physician of an abnormal lab value for one of one residents reviewed, which was a potential contributing factor in the Resident's decline in condition and subsequent hospitalization (Resident #154). Findings included: A review of medical records revealed Resident #154 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] noted Resident #154 to be severely impaired for cognition and needed extensive assistance for all Activities of Daily Living (ADLs) with the physical assistance of one person. A review of orders in the medical record revealed an order written [REDACTED]. The labs were a Complete Blood Count (CBC), a Complete Metabolic Panel (CMP) and a [MEDICAL CONDITION] Stimulating Hormone (TSH). The lab results were reviewed and the result sheet noted the labs were reported to the facility on [DATE] at 5:56 PM. The glucose value was 370 and the normal range listed on the lab sheet for a glucose was 70 - 105. The physician initials were on the lab sheet. There was no documentation of the lab result or the physician being notified. No new orders were noted. In an interview on 9/21/2017 at 12:15 PM, the Director of Nursing (DON) stated if there was a lab glucose reported of 300 +, the physician should be called. On 9/21/2017 at 3:15 PM, in an interview, Nurse #1 stated she did not remember Resident #154 or the abnormal lab, but if there was a lab value that high, she knew she would have notified the physician. There was no documentation in the medical record of the physician being notified. In a telephone interview on 9/21/2017 at 5:40 PM, the physician stated he had a stack of lab results to be signed each time he enters the facility, was unsure of who Resident #154 was, but did not remember being notified of a glucose of 370. The physician said if he had been notified of a glucose of 370 something would be done, you just can't let that go. Further medical record progress notes review revealed Resident #154 had a temperature of 101.5 F. The physician was notified and Resident #154 was started on an antibiotic and received a chest x-ray. Resident #154 was transported to the hospital on [DATE], according to the medical record.

Based on observation, family and staff interview and record review, the facility failed to inform a resident (Resident #116) and the Responsible Party of a room change and the reason for the room change. Findings included: A review of medical records revealed Resident #116 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE], noted Resident #116 to be severely impaired for cognition and needed limited to extensive assistance for all Activities of Daily Living (ADLs) with the physical assistance of one person. In an interview on 9/18/2017 at 12:15 PM, the Responsible Party (RP) for Resident #116 stated Resident #116 had been in a room on another hall and had been moved, but the RP stated she was not told and did not know why Resident #116 had been moved. On 9/21/2017 at 4:10 PM, in an interview, the Social Worker (SW) stated Resident #116 was in a room on another hall and shared a bathroom with a resident who had an infectious disease. That was the reason for the move. Documentation was reviewed in the SW note that the RP was notified. The SW stated the RP was not told why Resident #116 was moved because the facility did not want to alarm the RP. On 9/21/2017 at 4:30 PM, the Administrator, 2 corporate consultants and an Administrator in Training were interviewed. The Administrator stated the RP was not told because it would be a HIPPA violation. The corporate consultant stated the regulation did not require it.

Based on observation, record review, and staff interviews, the facility failed to comprehensively assess behaviors for 1 of 4 residents reviewed (Resident #14). Findings included: Record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive to total assist with all activities of daily living (ADLs). Section E of the MDS indicated the resident exhibited no physical or verbal behaviors, and did not reject care. An interview was conducted with the MDS Nurse on 9/21/2017 at 9:07 AM. The MDS Nurse indicated the information in the MDS assessment was gathered from the look back period of 7 days prior to the assessment date of 6/1/2017. The MDS Nurse indicated the documentation must not have revealed any behaviors during that time. Review of the nursing notes revealed Resident #14 displayed physical and verbal behaviors, and rejection of care during the period of 5/28/2017 through 6/1/2017. An interview was conducted on 9/21/2017 at 3:46 PM with the Cooperate Director of Clinical Operations who stated the facility expectation was for all assessments to be accurate.

Based on observation, record review, and staff interviews, the facility failed to maintain a hazard free environment for 1 of 1 residents (Resident #14) by leaving the resident unattended in bed while the bed was raised in the high position for over 30 minutes and failed to maintain acceptable and safe water temperatures for 2 of 6 halls (200 and 300) in the facility. Findings included: 1-Record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive to total assist with all activities of daily living (ADLs). The Care Area assessment dated [DATE] indicated Resident #14 was at a risk for falls and the area of falls was carried to the care plan. Record review of the care plan revealed the most recent update was 8/28/2017. The care plan indicated the resident was at a risk for falls due to impaired cognition, increased behaviors, poor safety awareness, and a history of falls. The interventions for the risk for falls included a completed fall risk assessment, provided assistance when needed, observation for unsafe activity with safety interventions. Record review revealed a completed falls risk assessment evaluation dated 5/18/2017 and indicated the resident scored a 14. The evaluation revealed a resident with a score of 10 or above should be considered a high risk for falls and a fall prevention protocol should be initiated. An observation of Resident #14 was conducted on 9/19/2017 at 12:10 PM. The resident was observed in bed, and the bed was raised in the high position. The resident removed the sheet, moved her legs from side to side, and attempted to pull the fitted sheet off the bed. The resident was observed continually from 12:10 PM to 12:40 PM. The bed remained in the high position. At 12:40 PM, NA #5 entered the room and spoke to Resident #14. NA #5 lowered the bed prior to exiting the room. An interview was conducted with the MDS Nurse on 9/21/2017 at 9:07 AM. The MDS Nurse indicated all residents' beds in the facility should be kept in the low position for safety. The MDS Nurse indicated it was a given for beds to be in the low position for safety, and all staff was aware the beds were to be in the low position for residents at risk for falls. An interview was conducted with NA #5 on 9/21/2017 at 3:40 PM. NA #5 reported she worked with Resident #14 on 9/19/2017 for the day shift. NA #5 indicated she must have forgotten to lower the resident's bed after lunch. NA #5 also indicated she was aware the resident was a fall risk and the bed needed to be lowered after care was provided for the resident's safety. An interview was conducted on 9/21/2017 at 3:46 PM with the Cooperate Director of Clinical Operations who stated the facility expectation was for residents who were identified a falls risk to have their beds in the lowest position. 2. On 9/19/2017 at 9:30 AM, the hot water was checked in the bathroom sink faucet in room 201. The hot water was very hot to touch. The remaining rooms on the 200 hall were also noted to have very hot water coming from the faucet. The 300 hall bathroom faucets were checked and also felt very hot. The 100 hall bathroom hot water did not feel as hot as the other halls. On 9/19/2017 at 10:30 AM, the Maintenance Director stated he checks the water temps in two rooms on each hall each week. He proceeded to check hot water temps in bathroom faucets on the 100, 200 and 300 halls. The hot water temperature in the sink in the bathroom shared by room 206 and 208 registered at 117.8 F. The temperature of the hot water in the sink in the bathroom shared by room 313 and 315 registered 119.6 F. The Maintenance Director stated his thermometer was an infrared gun which is aimed at the water and shows the temp. The Maintenance Director stated his thermometer is calibrated yearly by the manufacturer. At 11:45 AM, the Maintenance Director stated he was going to the mixing valve to adjust it. At 2:0 0 PM on 9/19/2017, the Maintenance Director checked the hot water temp in the sink of the bathroom between rooms 206 and 208. The temp was 111.0 F. The temperature of the hot water was also taken in the sink of the bathroom between room 313 and 315 and the temp was 111.0 F. The temperature logs were reviewed for August and September, 2017 and revealed all temps were within an acceptable range. On 9/22/2017 at 3:30 PM, the Administrator stated his expectation was the hot water temperatures would be within an acceptable range.

Based on observation, record review, and staff interviews, the facility staff failed to remove gloves following incontinence care and opened the room door, disposed of the uncontained soiled linen in the dirty linen bin, retrieved clean linen from the linen cart, reentered the room, and applied the clean linen to a resident's bed, which resulted in a risk of cross contamination for 1 of 1 residents reviewed for incontinence care (Resident #52). Findings included: Record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and required extensive to total assist with all activities of daily living. An observation of incontinent care by Nursing Assistant #5 (NA#5) was conducted on 9/20/2017 at 11:46 AM. NA #5 washed her hands, donned gloves, removed the resident's soiled brief and cleaned the resident. There was some stool observed on the linens and NA#5 removed the linens and placed the soiled linens and brief on top of the trash can which was lined with a plastic bag. NA #5 covered the resident and retrieved the soiled brief and linens from the top of the trash can, opened the room door by the door handle with her right hand and carried the soiled items un-bagged and placed in the soiled linen bin which was located in the hall directly outside of the room. NA#5 went to the clean linen cart which was also located in the hall outside of the room and obtained clean linen from the cart. The NA opened the door with the door handle and carried the clean linen into the room. NA #5 put the clean linens on the resident's bed, removed her gloves and exited the room. An interview was conducted with NA #5 on 9/20/2017 at 3:23 PM. NA #5 indicated she did not think about bagging dirty linen if the dirty linen cart is right outside the room. NA #5 reported she did not take her dirty gloves off when she exited the room of Resident #52 because she just didn't think about it. NA #5 indicated she didn't think about taking the dirty gloves off when she retrieved the clean linen. NA #5 stated she did not wash her hands after she took off the dirty gloves but she did wash them prior to working with another resident. NA #5 stated she always washed her hands before working with residents. NA #5 also indicated she was in-serviced on infection control in the last couple of weeks. An interview was conducted with the Director of Nursing (DON) on 9/20/2017 at 4:39 PM. The DON indicated all staff were educated on infection control during classroom orientation and were in-serviced throughout the year on infection control practices. The DON reported NA #5 was recently educated on infection control fundamentals and practices. The DON stated the expectation was for infection control practices to be followed by all staff which included the proper way to transport dirty linen, removal of dirty gloves prior to using a door handle or touching clean linen, and appropriate hand washing.

Based on observation, staff and resident interviews, and record review the facility failed to act on grievances raised by the residents attending the monthly Resident Council Meetings for 5 out of 6 monthly Resident Council Minutes reviewed. Findings included: In an interview on 8/27/14 at 3:10 PM with Resident #59, who serves as the current Resident Council Vice President, it was stated that facility staff do not respond to the Resident Council group's concerns. Resident #59 stated that the facility staff do not "take our concerns seriously." She further stated "we never hear back from any staff concerning our complaints." Resident #59's most recent Minimum Data Set ((MDS) dated [DATE] specified she was cognitively intact without memory, mood, or behavior disorders. Record review of the Resident Council Meeting minutes dated 2/04/14 revealed resident concerns that stated "need to look at tables in dining room because some of them wobble." Additional concerns noted on the same minutes stated "need someone in charge to sit in dining room to watch nursing assistants (NAs) because they are still standing around and not passing out trays. Today a resident sat as the table for over an hour waiting on his tray while everyone else was eating." The minutes reflected the facility staff in attendance consisted of Activity Assistant #1 and Activity Assistant #2. The section of the minutes designated for facility response to previous issues stated "NAs answering call lights but not coming back. Just turning off lights" and "residents feel that certain NAs don't care about them just only care about the paycheck." The boxes indicating resolution of these problems were checked resolved. No explanation of what action was taken to resolve the issues was noted in the minutes. Record review of the Resident Council Meeting minutes dated 3/04/14 revealed no resident concerns under the section for new business. The minutes reflected the facility staff in attendance consisted of the Dietary Manager, Activity Assistant #1, Activity Assistant #2, and the Dietary Assistant. The section of the minutes designated as facility response to previous issues stated "dining room tables wobble", "tables need to be cleaned after breakfast, lunch, dinner!", "need new table cloths" and "Administrative needs to take turns supervising NAs." The boxes indicating resolution of the first two complaints related to tables were checked resolved. No explanation of what action was taken to resolve these two issues was noted in the minutes. The boxes indicating resolution of the issue concerning clean tables and administration supervision of NAs were checked no resolution. None of the other resident concerns from the 2/04/14 Resident Council meeting were documented as having been addressed in the 3/04/14 minutes. The Resident Council Minutes for April were not available for review. Record review of the Resident Council Meeting minutes dated 5/06/14 revealed resident concerns that stated "residents feel NAs spend too much time talking instead of bringing food trays", "one resident complained of rough handling when being put into bed", "residents would like tastier food and more food choices" and "a resident brought up that certain residents would like to be allowed access to the activities room bathroom to avoid accidents." The minutes reflected the facility staff in attendance consisted of the Social Worker, Activity Director, Activity Assistant #1 and Activity Assistant #2. The section of the minutes designated for facility response to previous issues stated " Still having problem with food being cold when residents who eat in their room get their trays. Also still noted that food tastes bland" and "NAs are not meeting in dining room at the proper time to pass out trays and assist residents." The boxes indicating resolution of these problems were checked no resolution. None of the other resident concerns from the 3/04/14 Resident Council meeting were documented as having been addressed in the 5/06/14 minutes. Record review of Resident Council Meeting minutes dated 6/03/14 revealed resident concerns that stated "residents are still getting cold food", "a resident complained of an NA smacking gum during patient care", "one resident complains about treatment during patient care indicating NAs were not answering call lights", "NAs are turning off call buttons without performing patient care (same CNA repeatedly)", and "CNAs are coming in rooms rude and angry with attitudes because residents need assistance."The minutes reflected that the facility staff in attendance consisted of Activity Assistant #3, the Activity Director, and the Social Worker. The section of the minutes designated for facility response to previous issues stated "Still having problems with food being cold." The box indicating resolution of the problem was checked no resolution. None of the other resident concerns from the 5/06/14 Resident Council minutes were documented as having been addressed in the 6/03/14 minutes. Record review of Resident Council Meeting minutes dated 7/01/14 revealed resident concerns that stated "a resident would like to go on a bowling outing" and "resident left alone while NAs go attend another residents." The minutes reflected that the facility staff in attendance consisted of the Activity Director and an activity assistant who was not named. The section of the minutes designated for facility response to previous issues stated "was happy with meal of the month", "not getting medicine on time", NAs talking and laughing in hallway while residents are trying to sleep " and " still having problems with call lights and NAs not answering." The boxes indicating resolution of these problems were left blank. None of the other resident concerns from the 6/03/14 Resident Council minutes were documented as having been addressed in the 7/01/14 minutes. Record review of Resident Council Meeting minutes dated 8/05/14 revealed resident concerns that stated "wants to go to Hamrick's to shop", residents not happy with NAs not answering call lights", 100 hall still not receiving anything on time" and "resident would like more church." The minutes reflected that the facility staff in attendance consisted of Activity Assistant #3 and Activity Assistant #4. The section of the minutes designated for facility response to previous issues stated "residents are still not happy with the NAs not answering call lights", "residents on 100 hall still not receiving anything on time", "churches cancelling on weekend" and "residents still not getting changed on time when needed." The boxes indicating resolution of these problems were left blank. None of the other resident concerns from the 7/01/14 Resident Council minutes were documented as having been addressed in the 8/05/14 minutes. In an interview on 8/28/14 at 2:10 PM with the Director of Food Service it was revealed that he sometimes attends the Resident Council Meetings. He stated he listens to the resident concerns and tries to accommodate resident needs as possible but he does not have a formal plan for acting on the resident grievances and recommendations brought out in the Resident Council meetings. He further stated that he does not report his response back to the resident council. In an interview on 8/28/14 at 2:15 PM with the Activity Director it was stated that she sometimes attends the council meetings. She stated that one of several activity assistants is responsible for recording the Resident Council Meeting minutes. She stated that it is not always the same activity assistant who records the minutes. The Activity Director further stated that she does not always read the minutes. When asked if she followed up on any of the complaints brought up in the meetings she stated "sometimes she did if she was aware of the problem." She further stated that she did not report back to the Resident Council with information concerning the resolution of a complaint or request. When asked if she was aware that residents had voiced a concern regarding the use of the bathroom in the activity room she stated that she was not present at that council meeting and was not aware of the request. In an interview on 8/28/14 at 2:30 PM with the Director of Nursing (DON) it was revealed that she did not have a system for addressing grievances brought forward by the Resident Council or a system for reporting back to the council in response to their concerns. She stated "I guess we need to give the residents an answer to their concerns. Currently we do not usually report back to the council regarding their concerns." She indicated that she did receive a copy of the Resident Council minutes but did not have a process for handling complaints or grievances brought out in the meetings. She stated that if a resident filed a formal grievance then she followed the facility policy for dealing with grievances. She further stated that she did not have a grievance policy for complaints identified in the Resident Council Meetings.

Based on observations, staff interviews and record review, the facility failed to ensure medications carts were securely locked when left unattended for 2 of 5 medications carts and failed to refrigerate unopened insulin on 2 of 5 medication carts reviewed for medication storage. The facility also failed to dispose of expired insulin in 2 of 5 medication carts and failed to date opened medications for 2 of 5 medication carts reviewed for medication storage. Findings included: 1. On [DATE] at 12:05 PM, nurse #2 was observed leaving his medication cart unlocked on 100 hallway during a medication pass to wheel a resident to the dining room. He returned at 12:08 PM and stated should have locked his medication cart. On [DATE] at 12:36 PM, the medication cart for 100 hallway was observed unlocked outside room [ROOM NUMBER]. Nurse #2 was inside room [ROOM NUMBER] with the door open assisting the resident. Nurse #2 stated he was unaware he had to lock the medication cart if the cart was outside the doorway in his line of vision. On [DATE] at 9:45 AM, the medication cart was observed on 300 hallway unlocked and unattended. Nurse #3 returned to the cart at 9:47 AM and stated she should never leave an open medication cart unattended. In an interview on [DATE] at 4:25 PM, the director of nursing stated all medication carts must be locked when unattended to secure resident's medications, prevent theft and for resident safety. 2. On [DATE] at 12:20 PM, a review of the 300 hallway medication cart revealed the following: *Unopened Humalog Lispro Flexpen for Resident #71 was inside the medication cart labeled as dispensed [DATE]. (Manufacture guidelines read unopened Humalog Lispro Flexpen should be stored in a refrigerator 36 degrees to 46 degrees F). In an interview on [DATE] at 1:39 PM nurse #3 stated she was unaware that unopened insulin was to be stored in the refrigerator. On [DATE] at 12:36 PM, a review of the 100 hallway medication cart revealed the following: * Unopened Levemir Insulin Flexpen for Resident #95 was inside the medication cart and labeled as dispensed [DATE]. (Manufacture guidelines read unopened Levemir should be stored in a refrigerator 36 degrees to 46 degrees F). *Unopened Lantus Insulin for Resident #17 was inside the medication cart and labeled as dispensed [DATE]. (Manufacture guidelines read unopened Lantus should be stored in a refrigerator 36 degrees to 46 degrees F). In an interview on [DATE] at 12:36 PM nurse #2 stated he was unaware unopened insulin was to be stored in the refrigerator. In an interview on [DATE] at 4:27 PM, the consultant pharmacist stated it was his expectation that unopened insulin be stored in the refrigerator prior to opening because if left un-refrigerated on the medication cart, the countdown to expiration begins once the insulin was placed on the medication cart whether it was opened or not. 3. On [DATE] at 12:20 PM, a review of the 300 hallway medication cart revealed the following: *One dated as opened on [DATE] Novolog Flexpen for Resident # 77. (Manufacture guidelines read once a cartridge or Novolog Flexpen is punctured, it should be kept at temperatures below 86 degrees F for up to 28 days). In an interview on [DATE] at 1:39 pm nurse #3 stated insulin over 30 days old should be discarded. On [DATE] at 12:36 PM, a review of the 100 hallway medication cart revealed the following: *One Novolog Flexpen for Resident #4 labeled as dispensed [DATE] and opened [DATE] and dated as expired [DATE]. (Manufacture guidelines state once a cartridge or Novolog Flexpen is punctured, it should be kept at temperatures below 86 degrees F for up to 28 days). In an interview on [DATE] at 12:36 PM nurse #2 stated insulin over ,[DATE] days should be discarded. In an interview on [DATE] at 11:45 AM, the consult pharmacist stated his expectation that the nurses date the insulin pens when opened to ensure the medications are not used beyond the "Beyond use date" to ensure the medications are still effective and not considered expired. 4. On [DATE] at 12:20 PM, a review of the 300 hallway medication cart revealed the following: *One dated as dispensed [DATE] and undated when opened Novolog Flexpen for Resident #77. (Manufacture guidelines state once a cartridge or Novolog Flexpen is punctured, it should be kept at temperatures below 86 degrees F for up to 28 days). *One bottle of Fluticasone nasal spray for Resident # 71 undated dispensed [DATE]. *Opened bottle of Polymixin eye drops for Resident #71 dispensed [DATE]. *Two Humalog Lispro Flexpen dispensed [DATE] opened but undated for Resident # 92. (Manufacture guidelines read opened Humalog Lispro Flexpen should be stored at room temperature below 86 degrees F and discarded after 28 days).*One bottle of opened Cipro eye drops for Resident # 127 dispensed [DATE] was undated. *One opened Levemir Flexpen for Resident #80 was undated no pharmacy label on the bag. (Manufacture guidelines state opened Levemir should be stored at room temperature below 86 degrees F and discarded after 42 days). In an interview on [DATE] at 1:39 pm nurse #3 stated when a medication was opened for use, it should be dated in order to determine when it would expired if the expiration date was not written on the label. On [DATE] at 12:36 PM, a review of the 100 hallway medication cart revealed the following: * One vial of Novolin Regular insulin dispensed [DATE] for Resident # 24 was not dated when opened. (Manufacture guidelines read opened vials of Novolin Regular insulin should be stored at room temperature below 86 degrees F and discarded after 28 days). * One Fluoromethol Suspension 0.1% dispensed [DATE] for Resident #93 was not dated when opened. *One Brimonidine eye drops dispensed [DATE] for Resident # 54 was not dated when opened. In an interview on [DATE] at 12:36 PM nurse #2 stated when a medication was opened for use, it should be dated in order to determine when it would expired if the expiration date was not written on the label. In an interview on [DATE] at 11:45 AM, the consult pharmacist stated his expectation that the nurses date the insulin pens when opened to ensure the medications are not used beyond the "Beyond use date" to ensure the medications are still effective and not considered expired. In an interview on [DATE] at 4:25 PM, the director of nursing stated her expectation that any eye drops, nasal sprays and inhalers should be dated when opened in order to know when the medications would be considered expired.

Based on observations, staff interviews and record review, the facility failed to safeguard resident information on 2 of 5 medication carts. Findings included: A review of the facility policy dated revised December 2006 titled Confidentiality of Information in part read, " The facility will safeguard all residents records, whether medical, financial or social in nature, to protect the confidentiality of the information." On 8/25/14 at 12:20 PM, the 200 hallway the medication cart was observed unattended with a pharmacy reorder sheet on top of the medication cart for 13 minutes of continuous observation. The pharmacy reorder sheet listed resident names, room numbers and medication information. At 12:33 PM, nurse #1 returned to the medication cart and stated she should left the form face down on top of the medication cart because of confidentiality and Health Insurance Portability and Accountability Act (HIPPA) concerns. On 8/26/14 at 12:05 PM, nurse #2 was observed leaving his medication cart on 100 hallway during a medication pass to wheel a resident to the dining room. The 24 hour report/change of condition report was left face up uncovered on top of the medication cart. This form listed all his assigned resident's names, room numbers and any recent issues or items in need of follow up. He returned at 12:08 PM and stated should have covered clip board due to HIPPA and confidentiality concerns. At 12:12 PM, he left the medication cart and administered medications inside a resident ' s room leaving the report face up and uncovered. On return at 12:14 PM, he stated he forgot to cover up or turn the clipboard over due to confidentially and HIPPA concerns. On 8/26/14 at 12:36 PM, the medication cart for 100 hallway was observed outside room [ROOM NUMBER] unattended. The 24 hour report and change in condition report was again face up on top of the medication cart. Nurse #2 was inside room [ROOM NUMBER] and stated he forgot again to secure the resident information. In an interview on 8/27/14 at 4:25 PM, the director of nursing stated the no resident information should be left on top of the medication carts unless they are covered or turned over due to HIPPA regulations and confidentially concerns. In an interview on 8/28/14 at 2:10 PM, the administrator stated at a quarterly corporate meeting on 8/21/14, HIPPA was discussed. She provided a Plan of Action dated 8/23/14 (Saturday) which indicated the staff was to be in serviced by 8/27/14. The administrator provided in-service signature logs dated 8/26/14, 8/27/14 and 8/28/14 with numerous missing signatures. A copy of the flyer announcing the in-service read staff would be removed from the schedule until in-serviced. A review of the in-service logs revealed that NA #2 interviewed on 8/28/14 at 8:47 AM was working and her signature did not appear on any of the provided in-service logs.

Based on resident and staff interviews and record review, the facility failed to obtain a replacement social security card identified as missing on [DATE] for 1 (Resident # 93) of 1 residents reviewed for missing items. Findings included: Resident # 93 was admitted to the facility [DATE] with a [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] indicated Resident #93 was cognitively intact and required extensive assistance with activities of daily living (ADLs) and was non-ambulatory. In an interview on [DATE] at 10:45 AM, Resident #93 stated several months ago, a small purse was stolen from a handbag in her room. The purse contained what she recalled to be approximately $60.00, her social security card and some expired credit cards. The incident was immediately reported and the following Monday ([DATE]), the social worker (SW) and the director of nursing (DON) followed up regarding the circumstances involving the stolen purse. Resident #93 stated the social worker had not followed up with her about the status of the replacement social security card since April and she was concerned about the status of her card. A review of the facility reported investigations revealed a 24-Hour Initial Report completed, dated [DATE] and sent to the Healthcare Personnel Registry. The police were notified and completed an investigation at the facility on [DATE]. A review of the 5-Working Day Report indicated Resident #93 first noticed the items missing from her purse on [DATE]. A search of the room did not turn up the missing items. The SW in-serviced the staff on resident rights and she contacted the social security administration about having her social security card replaced. Environmental Services provided a lock box for Resident #93 and responsible party (RP) stated the items may have not been in Resident #93's possession. This report was dated [DATE] and also sent to the Healthcare Personnel Registry. A review of the social services notes from [DATE] to present did not contain any documentation regarding the lost items or any follow up on the social security card. In an interview on [DATE] at 1:00 PM, the SW stated she completed an online application for a replacement social security card but she had not followed up on the application until today. SW stated she learned today that Resident #93 would have to go to the social security administration office via stretch and the facility could not do that. In an interview on [DATE] at 5:10pm, the DON provided the grievance log for [DATE]. The intake was dated [DATE] and the log indicated the grievance was resolved. The DON provided a copy of a Lost/Stolen/Damaged Items Report and stated it was the form that was completed at the time the purse was discovered missing. The DON stated the SW indicated the grievance was resolved on the grievance log but she completed the missing items form on [DATE]. In an interview on [DATE] at 9:10 AM, the SW stated she had made numerous calls and left messages with the social security office but was unable to provide any evidence of any follow up. She stated she had downloaded a paper application for a replacement social security card and was in process of completing the application. She stated she spoke to the social security office and she was informed she could send a copy of the Medicaid card along with the application and they would mail the facility a replacement social security card. In an interview on [DATE] at 2:20 PM, the administrator stated she thought the issue was resolved and referenced a care plan meeting with a new RP where the social security card was discussed but no evidence provided that Resident #93 attended the meeting. The administrator stated new RP was satisified with the facility's attempts and understood the conintued process of getting a replacement card but she was not aware Resident #93 was concerned what she felt was a lack of follow through. The administrator stated her expectation was any unresolved grievances should be addressed timely and communication be conveyed to the person filing the grievance.

Based on observations, staff interviews and record review, the facility failed to provide the opportunity for a bedridden resident to attend music and church activities based on identified preferences for 1 (Resident #3) of 3 residents reviewed for activities. Findings included: Resident #3 was admitted on [DATE] with the [DIAGNOSES REDACTED]. A quarterly Minimum (MDS) data set [DATE] indicated Resident #3 had severe cognitive impairment, nonverbal, nonambulatory and required total assistance with all activities of daily living (ADLs). A Care Area assessment dated [DATE] indicated that Resident #3 was not an active participant in facility life/activities. Staff offer gentle touch and talk to resident during care. Resident #3 sits in common area and appears to enjoy church services and music. Staff was to bring her to various activities. A Care Area Assessment was dated 8/27/14 for Resident #3 ' s psychosocial wellbeing due to impaired cognition, non-verbal and total dependence of staff for all her ADLs. A review of Resident #3's care plan for activities was updated 7/15/14 to include a new goal of Resident #3 to attend 3 activities each week. Other interventions included staff to provide in room visits, wheel resident outside weather permitting, and include Resident #3 in music and church activities. The most recent care plan review dated was 8/22/14. Throughout the course of the survey starting 8/25/14 through 8/28/14 revealed no observations of Resident #3 involved in any in room or out of the room activities. In an observation on 8/25/14 at 12:33 PM, Resident #3 was lying in bed. The lights in the room were off and there was no music playing. Resident #3 was awake but non-verbal. In an observation on 8/26/14 at 9:15 AM, Resident #3 was lying in bed with the lights on over the bed. There was no music playing. Resident #3 was awake with her eyes open. In an interview on 8/27/14 at 12:00 PM, nurse #1 stated the family put the sign up over Resident #3 bed requesting her to be up in the reclining chair daily. Nurse #1 stated Resident #3 was up in the reclining chair sitting in the hallway yesterday. In an interview on 8/27/14 at 3:10 PM, the activity assistant (AA) provided the activity participation records from January 2014 to present. Everyday from 1/1/14 to present except for a hospitalization [DATE] to 1/28/14 and 5/1714 to 5/19/14 indicated Resident #3 was actively involved in walking/wheeling outdoors and visiting with family or friends daily. Monthly records indicated Resident #3 also participated in the following: 1. January: 1 music/spiritual activity and 2 visits to the beauty shop 2. February: 1 visit to the beauty shop, no in room visits 3. March: No activities in or out of room 4. April: Pretty Nails done in room by volunteer 5. May: No activities in or out of room 6. June: 1 in room reading, 1 music/spiritual activity and 1 visit to the beauty shop 7. July: 1 in room reading and 1 out of room activity called the " birthday bash" 8. August: Pretty nails and current eventsin the room on the same day A copy of the One on One Room Visits list updated 6/11/14 indicated Resident #3 was to have in room visits at least 1 to 2 times a week for sensory stimulation, spiritual reading, pretty nails, conversation, games, grooming or newspaper. It was during this same interview on 8/27/14 at 3:10 PM the AA confirmed Resident #3 had not attended an out of room activity since 7/15/14 for the " birthday bash." The AA explained the documented A's everyday for walking/wheeling outdoors on the activity participation records were documentation of what the Resident #3 was capable of performing and not necessarily what Resident #3 was performing. The AA stated Resident #3 was also one a 1:1 activity program but she neglected to document the visits. The AA confirmed the facility provided music and church activities during the week, evenings and also on weekends and stated she was aware Resident #3 enjoyed those types of activities. The AA stated the staff did not always have Resident #3 up in a reclining chair in order to attend the activities. The AA stated she had not discussed with her supervisor that there was an issue with Resident #3 not attending activities because the nursing staff were not getting her up out of bed. In an observation on 8/28/14 at 8:45 AM, Resident #3 was lying in bed. There was no music playing. The light in the room were off and she had her eyes open. In an interview on 8/28/14 at 8:47 AM, nursing assistant (NA) #2 stated Resident #3 had a supportative family and they wanted her up out of the bed everyday. NA #2 stated the family wanted Resident #3 to attend church activities but she had not seen Resident #3 in any activities in a very long time. NA #2 stated when she got Resident #3 up in the reclining chair, she placed Resident #3 in the common area and the AA assist Resident #3 to activities or ask the aides to assist in getting Resident #3 into the activity room. NA #2 stated Resident #3 may be attending an activity in the evenings she was not aware of. In an interview on 8/28/14 at 8:50 AM, nurse #1 stated she had seen the activity staff read to Resident #3 and sometimes she would sit up in the reclining chair in the hallway or nurses' station but nurse #1 was unsure when Resident #3 was last taken to the activity room. In an interview on 8/28/14 at 9:00 AM, the ward secretary stated she had not seen Resident #3 up in a reclining chair in over a week. She stated she was unsure about weekend activities, but she knew Resident #3's family wanted her to go to church and music services, especially the church services done on Thursday mornings. The ward secretary stated she did not think Resident #3 was in the church services last Thursday. In an interview on 8/28/14 at 11:40 AM, the Administrator stated the AA was documenting wrong on the activity logs. The activity director stated she was not aware that Resident #3 was not attending the music and church services or getting her in room visits as scheduled. The administrator stated her expectation was that the AA only document what she sees and Resident #3 be in religious activities as stated in a recent care plan meeting and received one on one visits as stated in her care plan.

Based on staff interviews and record review, the facility failed to revise a care plan for a resident who was upgraded from nothing by mouth (NPO) to a pureed diet with nectar thick liquids for 1 (Resident #127) of 24 residents reviewed for care planning. Findings included: Resident # 127 was admitted to the facility 5/23/14 with a [DIAGNOSES REDACTED].#127 was cognitively intact and required extensive assistance with activities of daily living (ADLs). This MDS also indicated Resident #127 was on a therapeutic diet. A review of the care plan dated 5/28/14 indicated Resident #127 was NPO. This care plan had not been discontinued as of last MDS review 7/18/14. A review of the speech therapist recommendations and physician orders [REDACTED].#127 was upgraded from NPO to a pureed diet and nectar thick liquids In an interview on 8/27/14 at 2:30 PM, the registered dietitian (RD) stated she completed a care plan dated 5/26/14 on Resident #127 because he was underweight and she used a broad care plan to address a variety of therapeutic diets. The RD stated the MDS nurse was responsible for discontinuing the NPO care plan in June when the order was written for Resident #127's diet changed to pureed diet with nectar thick liquids. In at interview on 8/27/14 at 3:20 PM, the MDS nurse stated that each person was responsible for their section of the MDS and each discipline should review, revised or discontinue their part of the care plan. In an interview on 8/28/14 at 10:00 AM, the MDS nurse stated she identified a problem with care planning in February but Resident #127's care plan must have been missed during the course of the audits completed 6/30/14. In an interview on 8/28/14 at 2:10 PM, the administrator stated her expectation was for the care plan to reflect the care to be provided to each resident and the MDS was responsible to ensure each care plans accuracy.