Every finding on record at Kindred Hospital East Greensboro

Based on observations, record review and staff interviews, the facility failed to implement infection control policy and procedures when Nurse #3 failed to perform wound cleansing and treatments for several wounds separately and failed to remove gloves and perform hand hygiene between cleansing each wound and providing the treatment for each wound. Nurse #3 also touched a new wound observed on the resident's right leg wearing a soiled glove (Resident #14). In addition, Nurse #2 failed to wear a gown when entering the room for a resident on contact precautions (Resident #13). The deficient practice occurred for 2 of 2 staff members observed for infection control practices (Nurse #3 and Nurse #2).The findings included: 1. The facility's Hand Hygiene policy last released in November 2022, stated to practice good hygiene to prevent the spread of disease or cross-contamination between patients, staff and food. The policy indicated hand hygiene should be performed: before having direct contact with patient/patients, before a clean/aseptic procedure, after touching a patient, after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled, after touching a patient's surroundings/environment, with additional opportunities being: before donning and after removal of gloves. The facility's Clean Dressing Change policy last released in October 2022, stated to perform clean aseptic technique while performing dressing changes to open wounds to protect from contamination and absorb drainage. The policy indicated to place plastic bag near foot of bed to receive soiled dressing, perform hand hygiene, create clean field with paper towels or drape, put on first pair of gloves, remove old adhesive, remove soiled dressing and discard one layer at a time, remove gloves and dispose, perform hand hygiene and put on second pair of gloves, clean wound with prescribed solution, remove gloves and perform hand hygiene, open dressing pack, and put on gloves. The Clean Dressing Change policy further noted if patient has multiple wounds to wash hands in between wounds and cleanse the least contaminated to the most contaminated wound. During an observation of wound care on 12/17/25 at 8:46am Nurse #3 was observed with supplies placed on a drape on top of Resident #14's overbed table. Nurse Aide #2 was also present to help position Resident #14 during wound care. Once Resident #14's was placed on his right side Nurse #3 loosened the edges of the dressings dated 12/16/25 from a wound to the sacrum (triangular bone at the base of the spine), a wound to the right ischium (curved bone that forms the lower and back portion of the pelvis), and wound to the left buttock. Nurse #3 performed hand hygiene and applied a clean pair of gloves. Nurse #3 was then observed removing the old dressing from the wound to the sacrum and rolling the old dressing down to the right ischial wound and rolling both old dressings from both wounds together and discarded both old dressings into a wastebasket at the bedside. Nurse #3 then removed the old dressing from the wound to the left buttock and discarded the old dressing into the wastebasket at the beside. Nurse #3 performed hand hygiene and applied a clean pair of gloves. Nurse #3 then began cleaning the wound to the sacrum, the wound at the right ischium and the wound at the left buttock. He used multiple gauze to clean all three wounds. Nurse #3 did not perform hand hygiene or apply clean gloves between each wound. While wearing the same pair of gloves Nurse #3 began packing an absorbent dressing in the wound to the sacrum, the wound to the right ischium and the wound to the left buttock. Nurse #3 did not perform hand hygiene or apply clean gloves between packing each wound or after she had packed the wounds. Nurse #3 opened three separate dressings onto the overbed table and proceeded to apply clean dressings to the wound to the sacrum, right ischium, and the left buttock. Nurse #3 was then observed performing hand hygiene and applying clean gloves before starting treatment to Resident #14's left heel. Nurse #3 applied the wipe that forms a protective barrier to the left heel. Nurse #3 then cut the soiled bandage from the right foot and placed the scissors onto the overbed table and applied the wipe that forms a protective barrier to Resident #14's right heel. Nurse #3 did not perform hand hygiene or apply clean gloves between performing the treatment between the wound on the left heel and the right heel. While still wearing the same pair of gloves Nurse #3 wrapped the right heel with a clean bandage. During the observation Nurse Aide #2 identified a new wound on Resident #14's outer right leg and Nurse #3 touched the new wound with his right index finger wearing the soiled gloves. Resident #14 was repositioned by Nurse #3 and Nurse #3 removed his gloves and performed hand hygiene. Nurse #3 did not remove his gloves or perform hand hygiene before repositioning Resident #14. Nurse #3 then discarded his supplies, removed his gloves and performed hand hygiene. Nurse #3 did not clean the overbed table that was used during Resident #14's treatment before leaving the room. During an interview on 12/17/25 at 1:51pm Nurse #3 stated he was not aware that he had touched the newly identified wound on Resident #14's outer right lower leg with soiled gloves he wore during the treatment for the left and right heel. Nurse #3 confirmed he did not perform hand hygiene or apply clean gloves between each wound. He confirmed he did not follow the dressing change policy, nor did he complete the dressing changes as he was trained. Nurse #3 stated he felt like he could have done better. An interview was conducted on 12/18/25 at 3:30pm with the Infection Preventionist (IP) who revealed she was responsible for training Nurse #3. The IP stated that the policy for dressing change does indicate staff should change gloves in between wounds during a dressing change. She then stated the expectation for staff would be to not cross contaminate between wounds and perform wound care for one wound before moving on to the next wound. When the IP was asked what the outcome could have been from Nurse #3's actions, the IP stated Resident #14 could have been put at risk for cross contamination if there was infection in any of the wounds. She also indicated she did not believe any of Resident 14's wounds were infected at that time. An interview was conducted on 12/18/25 at 2:55pm with the Director of Nursing (DON) revealed she would expect staff to perform hand hygiene and apply cleans gloves in between dressing changes for each wound. The DON also stated she would expect staff to clean the work surface before and after performing a treatment. When the DON was asked if she thought the actions of Nurse #3 could have had a negative impact on Resident #14, she stated it was possible. An interview was conducted on 12/19/25 at 3:00pm with Physician #2 who revealed he would expect staff to perform hand hygiene and apply clean gloves between wounds. Physician #2 stated that the actions of Nurse #3 were not appropriate and could have moved microbes (microorganism) from one area to another. 2. The facility's Personal Protective Equipment (PPE) policy last released in October 2022 revealed that PPE will be utilized to reduce the risk of transmission and prevent the transmission of pathogenic organisms from patient to health care worker and from health care worker to patient. The policy further noted that contact precautions were intended to prevent the transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient's environment. The policy stated that contact precautions required the use of gown and gloves on every entry into a patient's room or the patient's environment. On 12/17/25 at 9:33 am Resident #13 had signage posted at the entrance of the room that alerted staff that Resident #13 was on contact precautions. The signage noted that all healthcare personnel must wear gloves and gown when entering the room. A supply holder was observed hung on the door and was stocked with PPE, which included disposable gowns and disposable gloves. A continuous observation was conducted on 12/17/25 at 9:33 am through 9:35 am of Nurse #2 who was observed in Resident #13's room without a gown in place. Nurse #2 was observed to pick up enteral feeding supplies from the overbed table and walk towards the sink before returning the supplies to the overbed table. Nurse #2 was then observed to remove the disposable gloves, perform hand hygiene and exit the room. An immediate interview was conducted with Nurse #2 on 12/17/25 at 9:35 am. Nurse #2 confirmed that Resident #13 was on contact isolation for multiple drug-resistant organism (MDRO) related to pneumonia and she should have donned a disposable gown before entering the room, but it slipped her mind. An interview was conducted with the Infection Preventionist on 12/18/25 at 3:27 pm who revealed Nurse #2 was required to wear PPE, which included a disposable gown, for the entire time she was in a resident room that was on contact precaution isolation.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for level II Preadmission Screening and Resident Review (PASRR) determination for a resident with serious mental health diagnoses. This deficient practice was for 1 of 1 resident reviewed for PASRR (Resident #6).The findings included:The PASRR history detail reported dated 5/16/11, provided by the facility, revealed Resident #6 had a PASRR Level 1 review only completed on 5/16/11 and the review did not meet level II criteria. The PASRR review revealed Resident #6 was noted to have no mental health diagnosis at the time of the review.Resident #6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. A review of the active diagnosis list revealed Resident #6 had a diagnosis of bipolar disorder unspecified noted as active on 4/18/19 and a diagnosis of schizophrenia unspecified noted as active on 7/20/24. Review of Resident #6's electronic and paper medical record revealed no evidence a request was submitted for an evaluation for level II PASRR determination. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #6 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.A telephone interview was conducted with Social Worker #2 on 12/18/25 12:44 pm who confirmed she was responsible for requests for PASRR evaluations for the facility at the time of Resident #6's new serious mental health diagnoses. Social Worker #2 stated that she typically would only review a PASRR for new admissions or those residents that had an expiration date on a PASSR level I. Social Worker #2 confirmed that Resident #6's new serious mental health diagnoses of bipolar disorder and schizophrenia would be a significant change in her mental health but it was not her normal practice to submit a request for evaluation of PASRR level II. Social Worker #2 stated she understood the process of PASRR evaluations, but it was not something that was normally needed for the resident population at the facility and not part of her normal practice. An interview was conducted with the Administrator on 12/19/25 at 3:38 pm who revealed the facility received Resident #6's PASRR level I information from the hospital and she was unsure who was responsible to resubmit when new mental health diagnoses were identified at the facility. The Administrator stated it was not the facility's normal practice to resubmit PASRR information after a resident was admitted to the facility and it was not something the facility was doing.

Based on record review, staff, Consultant Pharmacist, and Physician interviews the facility failed to have clinical documentation to support a diagnosis of schizophrenia for 1of 5 residents reviewed for unnecessary medications (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Resident #6 was readmitted to the facility from a short-term hospital stay on 7/20/24. The hospital Discharge summary dated [DATE] did not list a diagnosis of schizophrenia for Resident #6.The provider progress note dated 5/06/25 revealed Resident #6 was seen by Physician #2 related to reported visual hallucinations by the nursing staff. The provider's progress note did not list schizophrenia as a diagnosis for Resident #6. The assessment and plan for Resident #6, as noted by Physician #2, was to add haloperidol (an antipsychotic medication primary used to treat psychotic disorders like schizophrenia) one (1) milligram tablet by mouth every 6 hours as needed for the continued hallucinations.The active diagnosis list revealed Resident #6 had a diagnosis of schizophrenia, unspecified which was noted as an admitting diagnosis that was active as of 7/20/24 with no onset date listed, and with the clinical category of medical management. The diagnosis list further revealed Resident #6's schizophrenia diagnosis was added by Nurse #1 on 5/06/25.An interview was conducted with Nurse #1 on 12/19/25 at 11:11 am who added Resident #6's schizophrenia diagnosis to the medical record. Nurse #1 stated she recalled adding the schizophrenia diagnosis based on a medication that Resident #6 was taking that did not have a correct diagnosis. Nurse #1 stated she believed the diagnosis was given to her by a physician at the facility but she could not recall exactly who gave the information. Resident #6's care plan which was last revised on 11/04/25 revealed no care plan was in place for the diagnosis of schizophrenia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #6 was coded for the following psychiatric/mood disorders: anxiety, depression, and bipolar disorder. Resident #6 was not coded for a diagnosis of schizophrenia. Review of Resident #6's electronic and paper medical records revealed no clinical documentation supporting the schizophrenia diagnosis. Multiple attempts to conduct a telephone interview with the MDS Nurse on 12/19/25 were unsuccessful. A telephone interview was conducted on 12/19/25 at 11:16 am with the Consultant Pharmacist who revealed the pharmacy had not requested that the facility add a diagnosis of schizophrenia for Resident #6. A telephone interview was conducted on 12/19/25 at 3:09 pm with Physician #1 who revealed he had not written or given the facility a diagnosis of schizophrenia for Resident #6. Physician #1 stated to the best of his knowledge Resident #6 did not have a diagnosis of schizophrenia.An attempt to conduct a telephone interview with Physician #2 on 12/19/25 at 3:19 pm was unsuccessful. An interview was conducted with the Director of Nursing (DON) on 12/19/25 at 3:29 pm who revealed she was unable to locate documentation from either Physician #1 or Physician #2 that noted Resident #6 to have a schizophrenia diagnosis. The DON stated she believed Physician #2 had reported that Resident #6 had a significant history of schizophrenia but she was not able to say why there was no clinical documentation regarding the diagnosis. The Administrator was interviewed on 12/19/25 at 3:42 pm. The Administrator revealed she was unable to recall if Resident #6 had a schizophrenia diagnosis but she stated she would discuss the diagnosis with the clinical team to confirm the diagnosis was correct.

Based on observations, record review, and staff interviews, the facility failed to provide tracheostomy (a hole surgeons make through the front of the neck and into the wind pipe, also known as the trachea) care consistent with professional standards of practice for 1 of 1 resident observed for tracheostomy care (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy and respiratory failure.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was severely impaired cognitively. The MDS further revealed the Resident #2 was coded for oxygen therapy, suctioning, respiratory services, and tracheostomy care.Resident #2 had a care plan with effective date of 12/12/25 that indicated a goal he would have no abnormal drainage around his tracheostomy site through the next review date. The care plan had interventions that included instructing the resident/caregiver in providing tracheostomy care/suctioning and signs/symptoms to report. An observation was conducted of tracheostomy care on 12/17/25 at 9:15am with Respiratory Therapist (RT) #1. RT #1 was observed performing hand hygiene and applying two pairs of clean disposable gloves. RT #1 opened the tracheostomy care tray on Resident #2's overbed table. RT #1 did not clean the overbed table before opening and setting up tracheostomy care supplies. RT #1 was observed pouring normal saline into the tracheostomy care tray and removing a clean gauze saturated with normal saline from the tracheostomy care tray. She then cleaned around Resident #2's tracheostomy site and placed the dirty gauze on a dressing package on Resident #2's overbed table. RT #1 was then observed removing another clean gauze from the tracheostomy care tray and cleaning around Resident #2's tracheostomy site and placing the soiled gauze in the clean tracheostomy care tray on top of the remaining clean gauze. RT #1 removed two cotton tip applicators saturated with normal saline from the tracheostomy care tray and cleaned around Resident #2's tracheostomy site. RT #1 was observed removing a clean gauze from under a used gauze to clean around the resident's tracheostomy site and placing the used gauze in the tracheostomy care tray. RT #1 removed the top pair of disposable gloves before opening the dressing to apply around Resident #2's tracheostomy site. RT #1 did not perform hand hygiene before applying the clean dressing to Resident #2's tracheostomy site.During an interview on 12/17/25 at 2:40pm RT #1 stated she was trained to work from the tracheostomy care tray, and she was not aware she needed to clean her work surface before setting up supplies. RT #1 confirmed she doubled gloved during the procedure and stated a third shift supervisor instructed her to use double gloves during tracheostomy care the morning of the observation. The RT #1 stated she normally wears the same gloves throughout tracheostomy care. She stated she was not aware she place the dirty gauze on top of the clean gauze.An interview was conducted over the phone on 12/18/25 at 11:41am with the Third Shift Supervisor who revealed he did not instruct RT #1 to double glove during tracheotomy care. The Third Shift Supervisor stated there was a discussion RT #1 on how care was performed in the past. He stated RT #1 must have misunderstood the conversation, because he never gave any directives for double gloving during tracheostomy care. The Third Shift Supervisor stated if he were performing tracheotomy care, he would perform hand hygiene and apply a clean pair of disposable gloves before applying a clean dressing.An interview was conducted on 12/18/25 at 10:10am with the Director of Respiratory Therapy who revealed they follow Lippincott's (digital resource) guidance for hand hygiene, which included removing gloves and performing hand hygiene between touching clean and dirty items during tracheostomy care. She stated that the Respiratory Department did not have an actual policy for tracheostomy care and that was a policy that may need to be added. She stated tracheostomy care was taught at the beside once the trainee was on the floor. The Director of Respiratory Therapy stated staff were not trained to double glove during tracheostomy care. She stated dirty items used should be disposed of to prevent cross contamination during tracheostomy care. She also stated she would expect staff to clean the work surface before setup, place wastebasket close by for disposal of dirty items, and she would expect hand hygiene to be performed before and after the procedure. When asked could there have been a negative outcome to Resident #2, the Director of Respiratory Therapy's response was anything is possible.An interview was conducted on 12/18/25 at 3:30pm with the Infection Preventionist (IP) who revealed she was not responsible for training staff from the Respiratory Department. The IP stated tracheostomy care was taught by Respiratory Department. She also stated they follow Lippincott's guidance. When the IP was asked what the expectation of staff was working on the unit, she stated the expectation would be not to contaminate a clean area. When asked what the outcome could have been from Rt #1's actions, the IP stated it could have put Resident #2 at risk for infection. An interview was conducted on 12/18/25 at 2:55pm with the Director of Nursing (DON) who revealed she was not aware of any training for staff that involved wearing double gloves. The DON stated her expectation during tracheostomy care would be for staff to perform hand hygiene and apply clean gloves, before applying a clean dressing. She also stated she would not expect staff to go from dirty to clean when providing care and she would expect staff to clean their work surface before and after performing care. When the DON was asked if she thought RT #1's actions could have had a negative impact on Resident #2, she stated it was possible.An interview was conducted on 12/19/25 at 3:00pm with Physician #2 who revealed he would expect RT #1 to apply clean gloves between dirty and clean when providing care. He also stated double gloves were not the appropriate Personal Protective Equipment (PPE) and staff should not take short cuts with hand hygiene. When asked if the actions of RT #1 could have had an negative effect on Resident #2, he indicated it could have caused additional problems.

Based on record review, and resident, staff, and physician interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed for unnecessary medications (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE]. Resident #6 was noted with diagnoses which included major depressive disorder, bipolar disorder, general anxiety disorder, and schizophrenia.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that Resident #6 was cognitively intact and was not coded for hallucinations or behavioral symptoms during the assessment reference period. The MDS further indicated that Resident #6 reported feeling down, depressed, or hopeless for 2-6 days (several days) during the assessment reference period. The MDS quarterly assessment noted that Resident #6 was coded for the following psychiatric/mood disorders: anxiety, depression, and bipolar disorder. Resident #6 was coded for the use of antipsychotic and antidepressant medications. Review of the active physician orders dated December 2025 revealed that Resident #6 was prescribed the following medications: venlafaxine (antidepressant medication) 75 milligram (mg) capsule extended release 24-hour one capsule every day for bipolar disorder, unspecified; cariprazine (antipsychotic medication) 4.5 mg capsule daily for bipolar disorder unspecified; and fluoxetine (antidepressant medication) 20 mg capsule every day for major depressive disorder recurrent. The facility was unable to provide any documentation regarding mental health provider visits for Resident #6 since the last recertification survey of 9/18/24. The Facility Assessment that was last revised on 11/26/25, revealed the facility did not have behavioral or mental health providers which included psychiatrist, psychologist, or licensed counselors. The Facility Assessment further noted that the facility provided mental health and behavior services which were performed by the attending physician and the Social Worker. The Facility Matrix for Providers (a tool used to track resident's specific medical conditions and services needed) provided by the Administrator was reviewed and revealed that 16 of the 20 residents that resided at the facility were prescribed psychotropic (medications used to treat mental health conditions) medications which included antianxiety, antidepressants, and antipsychotic medications. An interview was conducted with Resident #6 on 12/19/25 at 11:16 am. Resident #6 reported that she was unable to recall the last time she was able to talk to a doctor about her mental health issues. The resident stated she used to see a mental health provider in the past before living at the facility. Resident #6 stated that she does talk to the staff, but she would like to be able to talk to a doctor when she begins to feel down. An interview was conducted with Nurse Aide (NA) #1 on 12/19/25 at 11:06 am who revealed she provided care to Resident #6 frequently. NA #1 reported that Resident #6 often had hallucinations which included seeing cats, dogs, rats, and people that were not there, as well as episodes of crying. NA #1 stated that when these things happened, she attempted to calm Resident #6 by trying to convince the resident that what she was seeing was not there. NA #1 stated she also would also spend time with Resident #6 until the resident was calm. During an interview on 12/19/25 at 11:11 am with Nurse #1 she revealed that Resident #6 had a history of hallucinations but reported the resident was easily settled by talking with the resident. The Social Worker was interviewed on 12/18/25 at 11:43 am who confirmed that the facility did not have a mental health provider that met with the residents. The Social Worker reported that Resident #6 had periods of hallucinations that were worsening and she was not sure how to engage with the resident when that happened. The Social Worker stated the nursing staff was very engaged with Resident #6 and talked with the resident often to help support Resident #6 when the hallucinations were occurring. The Social Worker stated she was able to provide Resident #6 with emotional and psychosocial support but stated that Resident #6 would benefit from talking to a mental health provider. The Social Worker reported that she had attempted to obtain a mental health provider for the facility by reaching out to providers and community organizations but she had not been successful. The Social Worker stated the need for a mental health provider had been discussed during the facility's IDT (interdisciplinary team) meetings but the facility was still without the services. A telephone interview was conducted with Physician #1 on 12/19/25 at 3:29 pm who was the provider for the residents of the facility along with Physician #2. Physician #1 stated that he and Physician #2 were Internists (physicians specialized in adult care) which afforded them the ability to manage all areas of care needed by the residents. Physician #1 reported that he and Physician #2 manage the mental health medications and immediate needs of the residents. He stated that the facility had a mental health provider in the past but they have not had anyone recently to provide those services. Physician #1 stated that the discussion regarding the need for a mental health provider in the facility has been discussed with Administration during the IDT meetings. An attempt to conduct a telephone interview with Physician #2 on 12/19/25 was unsuccessful.The Director of Nursing (DON) was interviewed on 12/18/25 at 2:57 pm who revealed the facility did not have a mental health provider but the facility relied on the physicians to mange the mental health care. The DON stated that Resident #6 did have periods of hallucinations but she was not able to say when she was last seen by a mental health provider.An interview was conducted on 12/19/25 at 3:09 pm with the Administrator who revealed the facility had a mental health provider that would come to the facility in the past, but they no longer came to see the residents. The Administrator stated the attending physicians were responsible for managing the mental health needs and medications of the residents. The Administrator confirmed the need for a mental health provider had been discussed during the quarterly IDT meetings but she had not been able to secure a mental health provider for the facility.

Based on record review, and staff, Consultant Pharmacist, and Physician interviews, the facility failed to monitor a TSH (thyroid stimulating hormone) level for a resident prescribed amiodarone (a medication used to treat life-threatening irregular heartbeats). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation (an irregular heartbeat). Resident #19 had a physician order dated 10/14/25 for amiodarone 200 milligram tablet once a day for paroxysmal atrial fibrillation.The Consultant Pharmacist Recommendation to Physician report dated 10/27/25 revealed Resident #19 received the medication amiodarone but did not have a TSH blood test documented in the medical record for the last six months. The Consultant Pharmacist recommendation was to please monitor TSH on the next convenient laboratory day and every six months thereafter.Resident #19 was noted to have a physician order dated 11/06/25 for a TSH level blood test. The order was discontinued on 11/07/25. Resident #19's electronic and paper medical records were reviewed and revealed no TSH laboratory results from the 11/06/25 physician order.A telephone interview was conducted on 12/18/25 at 2:13 pm with the Consultant Pharmacist who revealed he reviewed Resident #19's medications upon admission and identified that a TSH level was not in the record. The Consultant Pharmacist stated that it was important to monitor TSH when taking the medication amiodarone because the medication had large amounts of iodine which can interfere with the normal thyroid function. An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 3:00 pm who revealed the order for Resident #19's TSH level was entered as a one-time order (completed once) in the electronic record to be performed on 11/06/25 but it was not drawn by the lab. The DON stated that when an order was entered as a one-time order, the order automatically discontinued 24 hours after the order was entered because it was expected to be completed within the 24-hour period. The DON stated she did not know why the TSH lab was not obtained as ordered for Resident #19 and stated that when the TSH level was not drawn on 11/06/25 it should have been re-ordered to be drawn on the next day. The DON stated that she did not follow up to confirm that the TSH level was drawn as ordered on 11/06/25 and she was unable to locate any previous TSH results from the hospital discharge record. A telephone interview was conducted with the Physician on 12/19/25 at 3:09 pm who confirmed he was notified by the facility on 12/18/25 that Resident #19's TSH order was not completed as ordered. The Physician stated he did not have a concern that Resident #19's TSH level was not drawn when first ordered because it was just for monitoring purposes.

Based on observation, record review, and staff interviews, the facility failed to ensure the medical record was accurate related to pressure ulcer documentation and pressure ulcer treatment orders for 1 of 8 residents reviewed for accuracy of resident records (Resident #14).The findings included:Resident #14 was admitted to the facility on [DATE]. Review of Resident #14's Weekly Wound Assessments dated 11/03/25, 11/11/25, 11/18/25, and 11/25/25, and 12/02/25 revealed documentation of Resident #14's multiple wounds including a pressure ulcer to the right buttock, but there was no documentation for a wound to the left buttock. The assessments were completed by Nurse #3.Review of the December Treatment Administration Record (TAR) for Resident #14 revealed the following order for treatment to the right buttock wound, for the period of 12/2/25 through 12/10/25, to clean the right buttock wound with the wound cleanser, apply collagenase to the wound bed, pack the wound with saline soaked gauze, and apply foam dressing once daily and if soiled. This treatment was signed off as administered from 12/2/25 through 12/10/25. Nurse #3 signed off as administering the treatment on 12/9/25 and 12/10/25. For the period of 12/11/25 through 12/17/25 the treatment ordered was to clean the right buttock wound with wound cleanser, pack calcium alginate to wound bed, apply foam dressing once daily and as needed. Nurse #3 signed off the treatments as administered on 12/11/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, and 1217/25. There was no documentation for wound treatment provided to the left buttock.During an observation on 12/17/25 at 8:46 am Nurse #3 provided treatment to a wound on Resident #14's left buttock and there was no wound observed on the resident's right buttock.An interview was conducted on 12/17/25 at 1:51 pm with Nurse #3. During the interview Nurse #3 identified he had been documenting the location of Residents #14's left buttock wound incorrectly on his weekly wound assessments and Treatment Medication Record since the resident was admitted on [DATE]. He stated when Resident #14 was admitted to the facility he had conducted a wound assessment, then obtained an order for treatment for the wound from the physician and entered the order in the medical record. Nurse #3 stated he should have put the order in for the left buttock and not the right buttock. He also stated he should have documented the wound location as the left buttock not the right buttock on the weekly wound assessment sheet. Nurse #3 indicated he never noticed he was signing off the TAR for treatment to a right buttock wound after he provided the treatment to the left buttock.An interview was conducted on 12/17/25 at 2:55 pm with the Director of Nursing (DON). The DON stated Nurse #3 had informed her about Resident #14's wound documentation and wound orders being incorrect.During a follow up interview on 12/19/25 the DON stated she had not done rounds with Nurse #3, but a process needed to be put in place.

Based on record reviews, Pharmacy Nurse Consultant and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of narcotic medications (Hydrocodone and Oxycodone) prescribed to treat pain and an antianxiety medication (Lorazepam) prescribed to treat anxiety. This affected 6 of 6 residents reviewed for misappropriation of resident property (Residents #5, #17, #223, #224, #225 and #226). The findings included: A. Resident #5 was admitted to the facility on [DATE] with diagnoses of spinal stenosis and chronic pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact. A review of Resident #5's physician orders included the following: - An order dated [DATE] through [DATE] for Oxycodone 10 milligrams (mg) one tablet by mouth every six hours as needed for pain. - An order dated [DATE] for Oxycodone 10 mg one tablet by G-tube every six hours as needed for pain. A review of the Controlled Medication Utilization Record revealed Resident #5 was signed out as receiving Oxycodone 10 mg on [DATE], [DATE], [DATE], [DATE] and [DATE] by Nurse #1. A review of the Medication Administration Record (MAR) for [DATE], [DATE] and [DATE] did not reveal Resident #5 was signed out as receiving Oxycodone by Nurse #1 on [DATE], [DATE], [DATE], [DATE] or [DATE]. A review of Resident #5's medical record did not reveal any evidence of uncontrolled pain. B. Resident #17 was admitted to the facility on [DATE] with diagnoses that included spastic hemiplegia affecting the right dominant side and acute and chronic respiratory failure. A review of Resident #17's physician orders included an order dated [DATE] for Oxycodone 5 mg one tablet by G-tube every eight hours as needed for pain. A quarterly MDS assessment dated [DATE] indicated Resident #17 had severely impaired cognition. A review of the Controlled Medication Utilization Record revealed Resident #17 was signed out as receiving Oxycodone 5 mg on [DATE] at 5:00 AM and [DATE] at 12:00 PM by Nurse #1. A review of the [DATE] MAR did not reveal Resident #17 was signed out as receiving Oxycodone on [DATE] at 5:00 AM or 12:00 PM by Nurse #1. A review of a time punch record for Nurse #1 on [DATE] showed she did not clock into work until 7:06 AM. A review of Resident #17's medical record did not reveal any evidence of uncontrolled pain. C. Resident #223 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure and muscle spasm. A review of Resident #223's physician orders included an order dated [DATE] for Oxycodone 5 mg one tablet via G-tube every six hours as needed for moderate pain manifested by grimacing/restlessness. A quarterly MDS assessment dated [DATE] indicated Resident #223 had severe cognitive impairment. A review of the Controlled Medication Utilization Record revealed Resident #223 was signed out as receiving Oxycodone 5 mg on [DATE] at 8:40 AM and [DATE] at 12:00 PM by Nurse #1. A review of the [DATE] MAR revealed Resident #223 was signed out as receiving Oxycodone 5 mg on [DATE] at 8:40 AM but not [DATE] at 12:00 PM by Nurse #1. A review of Resident #223's medical record did not reveal any evidence of uncontrolled pain. D. Resident #224 was admitted to the facility on [DATE] with diagnoses that included chronic pain and a stage 4 pressure ulcer of the sacral region. He was discharged to the hospital on [DATE]. A review of Resident #224's physician orders included an order dated [DATE] for Hydrocodone-Acetaminophen 5 mg-325 mg one tablet by G-tube every six hours as needed for pain. A review of the Controlled Medication Utilization Record revealed the following regarding Resident #224's Hydrocodone: - The medication was marked as popped out by accident by Nurse #1 and wasted on [DATE], [DATE] and [DATE]. The witness signature was marked as Nurse #2. - The medication was signed out as given to Resident #224 on [DATE], [DATE] at 9:00 AM, [DATE] at 2:00 PM, ,d+[DATE]//24 at 2:00 PM, [DATE] at 3:00 PM and [DATE] at 2:00 PM by Nurse #1. A review of the [DATE] MAR revealed Resident #224 was not signed out as receiving Hydrocodone by Nurse #1 on [DATE], [DATE] at 9:00 AM, [DATE] at 2:00 PM, ,d+[DATE]//24 at 2:00 PM, [DATE] at 3:00 PM and [DATE] at 2:00 PM. A review of the Master Signature Log for staff revealed the initials for Nurse #2 did not match the Controlled Medication Utilization Record for the witnessed wastes on [DATE], [DATE] and [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #224 had severely impaired cognition. A review of Resident #224's medical record did not reveal any evidence of uncontrolled pain. E. Resident #225 was admitted to the facility [DATE] with diagnoses that included chronic respiratory failure, ankylosing spondylitis and chronic pain. He expired on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #225 had severe cognitive impairment. A review of Resident #225's physician orders included the following: - An order dated [DATE] through [DATE] for Lorazepam 2 mg per milliliter (ml). Inject 0.25 ml intravenous every three hours as needed for anxiety/agitation/shortness of breath. - An order dated [DATE] for Lorazepam 2 mg per ml. Give 0.25 ml intravenously every two hours as needed for anxiety/agitation/shortness of breath. A review of the Controlled Medication Utilization Record revealed the automatic waste of 0.75 ml of Lorazepam was signed out by Nurse #1 on [DATE] at 11:00 AM, [DATE] at 6:20 PM, [DATE] at 10:25 AM and the waste of the 0.75 ml was witnessed by Nurse #2. In addition, Nurse #1 signed out Lorazepam on [DATE] at 8:00 AM, [DATE] at 2:00 PM, [DATE] at 5:30 PM and [DATE] at 6:34 PM and the waste of the 0.75 ml was witnessed by Nurse #3. A review of the Master Signature Log for staff revealed the initials for Nurses #2 and #3, did not match the Controlled Medication Utilization Record for the witnessed wastes of Lorazepam 0.75 ml. Review of an employee timecard for Nurse #3 indicated she clocked in to work on [DATE] at 7:00 PM. F. Resident #226 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure and chronic pain. He expired [DATE]. A review of Resident #226's physician orders included an order dated [DATE] for Hydrocodone-Acetaminophen 5 mg- 325 mg one tablet via G-tube every six hours as needed for pain. A quarterly MDS assessment dated [DATE] indicated Resident #226 had severe cognitive impairment. A review of the Controlled Medication Utilization Record revealed Nurse #1 had the following Hydrocodone-Acetaminophen 5 mg-325 mg marked as wasted by Nurse #1: - An entry on [DATE] as an error and waste witnessed by Nurse #2. - An entry on [DATE] as an error and waste witnessed by Nurse #4. - An entry on [DATE] at 5:37 PM with no reason for waste and witness signature unreadable. - An entry on [DATE] at 10:00 AM with no reason for waste and witness signature unreadable. - An entry on [DATE] with no time and waste witness signature Nurse #2. - An entry on [DATE] at 7:00 PM with no reason for waste and waste witness signature Nurse #5. - An entry on [DATE] at 9:00 PM with reason as dropped and no waste witness signature. - An entry on [DATE] at 7:16 AM with no reason for waste and waste witness signature Nurse #2. - An entry on [DATE] at 12:00 PM with reason as dropped and waste witness signature Nurse #4 - An entry on [DATE] at 1:00 PM with no reason for the waste and waste witness signature Nurse #2. - An entry on [DATE] at 12:00 PM with reason as dropped for the waste and waste witness signature #2. A review of the Master Signature Log for staff revealed the initials for Nurses #2, #4 and #5 did not match the Controlled Medication Utilization Record. An initial report was submitted to the North Carolina Department of Health Human Services Division of Health Service Regulation on [DATE] by the Administrator. The allegation of misappropriation of property was made on [DATE] when narcotic discrepancies were found on five residents narcotic records involving Nurse #1. A witness statement dated [DATE] from Nurse #2 read that the signatures for wastes with Nurse #1 were not hers. Review of the facility investigation completed by the Director of Nursing on [DATE] revealed on [DATE] she was informed by the Unit Manager that there was a discrepancy on two Controlled Medication Utilization Records dated [DATE] by Nurse #1. Nurse #1 had signed out Oxycodone 5 mg for Resident #17 at 5:00 AM and 12:00 PM. Both administrations were not captured on the MAR and Nurse #1 did not clock into the facility to begin work on [DATE] until 7:06 AM. Therefore, she was not present in the facility at 5:00 AM. Nurse #1 also signed out Oxycodone 5 mg for Resident #223 at 12:00 PM on [DATE]. There was no documentation of this on the MAR. The previous administration was documented as 8:40 AM and the medication was ordered every six hours as needed for pain, thus it would have been too soon for the resident to have received the medication. A more thorough investigation began with all narcotic records being reviewed. It was found during the investigation that Nurse #1 signed out on the narcotic record providing Resident #5 with Oxycodone 10 mg five times with no record of the medication given on the MAR. Resident #226 had Hydrocodone-Acetaminophen ,d+[DATE] mg wasted seven times by Nurse #1 from [DATE] to [DATE] with signatures for witnessed wastes that did not match the Master Signature Log. Resident #225 was ordered Lorazepam 0.25 ml as needed with an automatic waste of 0.75 ml. There were eight witnessed wastes for this medication with questionable witness signatures. One that stood out the most was on [DATE] for a signature from Nurse #3 witnessed at 8:00 AM, 2:00 PM, 5:30 PM and 6:34 PM. Nurse #3 did not clock in for work on [DATE] until 7:00 PM. A witness statement dated [DATE] from Nurse #4 read that she had not witnessed the wasting of narcotics with Nurse #1 on [DATE] or [DATE]. The statement further read the initials that were present were not hers. On [DATE] at 8:07 AM, an interview occurred with the Unit Manager who stated that on the morning of [DATE] she was approached by Nurse #6 to look at the Controlled Medication Utilization Record for Resident #223, because the administration times for his Hydrocodone didn't look right. The medication was to be given every six hours as needed but the times of administration were to close together and weren't marked out as given on the MAR. It was also noted that Resident #17's Oxycodone 5 mg was signed out on the Controlled Medication Utilization Record as given by Nurse #1 at 5:00 AM and 12:00 PM. This was odd since Nurse #1 worked 7:00 AM to 7:00 PM that day. This was reported to the DON, who began an investigation of all the narcotic records. An interview occurred with Nurse #4 on [DATE] at 2:11 PM. She reviewed the narcotic record for Resident #226's Hydrocodone and stated that the witnessed waste signature for [DATE] and [DATE] were not hers. I didn't witness any wastes of medications with Nurse #1. Nurse #6 was interviewed on [DATE] at 2:13 PM and stated she notified the Unit Manager on [DATE] that something didn't look right on Resident #223's Controlled Medication Utilization Record. She explained she noticed his medications were signed out by Nurse #1 as being given to close together and weren't captured on the MAR and for Resident #17 the Oxycodone was signed out by Nurse #1 at a time she wasn't at the facility. A phone interview occurred with Nurse #3 on [DATE] at 9:40AM. She had a witness signature for a waste of Lorazepam 0.75 ml for Resident #225 on [DATE] at 8:00 AM, 2:00 PM, 5:30 PM and 6:34 PM on the Controlled Medication Utilization Record. Nurse #3 stated she worked 7:00 PM to 7:00 AM shift and wasn't present at the facility during those times on [DATE]. An interview occurred with Nurse #2 on [DATE] at 11:02 AM. After reviewing the narcotic records, she stated the following: - For Resident #224's Hydrocodone, that was not her signature for the witnessed wastes on [DATE], [DATE] and [DATE]. - For Resident #225's Lorazepam it was not her signature for the witnessed wastes on [DATE] and [DATE]. - For Resident #226's Hydrocodone it was not her signature for the witnessed wastes on [DATE], [DATE], [DATE], [DATE] or [DATE]. Nurse #2 further stated that she did not work on [DATE]. A phone interview occurred with the Pharmacy Nurse Consultant on [DATE] at 11:17 AM. She stated the facility had identified the misappropriation of narcotics by Nurse #1 and asked for her to come and audit narcotic records to ensure they had not missed anything. She stated the facility had captured all the concerns during her review and she provided education to all the nursing staff regarding procedure for wasting medications, and misappropriation of narcotics on [DATE]. The Director of Nursing (DON) was interviewed on [DATE] at 11:27 AM and explained that during a morning meeting on [DATE] she was notified by the Unit Manager there was a discrepancy found for two residents controlled medications by Nurse #1 on [DATE]. It was noted that Nurse #1 had signed the Controlled Medication Utilization Record as giving Resident #17 his Oxycodone on [DATE] at 5:00 AM and 12:00 PM. These were not captured on the MAR and Nurse #1 didn't arrive to work until 7:06 AM on [DATE], therefore she couldn't have administered the 5:00 AM dose. Resident #223's Oxycodone was signed out on the Controlled Medication Utilization Record by Nurse #1 on [DATE] at 12:00 PM but was not captured on the MAR. This prompted the DON to do a more thorough investigation that revealed a lot of wastes with questionable signatures for the nurses that were to witness the wasting of the narcotic or no witness signatures, as well as entries on the Controlled Medication Utilization Record that were not captured on the MAR. The specific narcotic records were reviewed with the DON and revealed the following: - Resident #5 had Oxycodone signed out on the Controlled Medication Utilization Record by Nurse #1 that was not captured on the MAR. - Resident #17 had Oxycodone signed out on the Controlled Medication Utilization Record by Nurse #1 on [DATE] at 5:00 AM when she didn't clock in for work on that day until 7:06 AM. - Resident #223 had Oxycodone signed out on the Controlled Medication Utilization Record by Nurse #1 on [DATE] at 12:00 PM and was not captured on the MAR. - Resident #224 had a waste of Hydrocodone on [DATE] where the witness signature did not match the master signature log and nurse denied the handwriting was hers. The July Controlled Medication Utilization Record had multiple times Hydrocodone was signed out by Nurse #1 and not captured on the MAR. - Resident #225 had multiple wastes of Lorazepam from Nurse #1. The witness signatures did not match the master signature log and nurses denied the handwriting was theirs. Nurse #3 wasn't at work during the times that indicated she witnessed a waste. - Resident #226 had wastes of Hydrocodone by Nurse #1 where there were no witness or incorrect witness signatures as well as the medication was signed out on the Controlled Medication Utilization Record and not captured on the MAR. The Administrator was interviewed on [DATE] at 2:01 PM and stated once the suspicion of misappropriation of narcotics was found the nurse was suspended pending the investigation. The police department, corporate, pharmacy, Drug Enforcement Agency and North Carolina Board of Nursing were notified. The investigation began with all the narcotic records being audited. The investigation showed that Nurse #1 was the nurse that marked waste for narcotics the most and most entries weren't reflected on the resident MAR's as being given to them. We never suspected her of taking medication prior to [DATE] as she was never visibly impaired. Once the investigation was completed Nurse #1 was terminated. Multiple unsuccessful attempts were made to contact Nurse #1. The facility provided the following corrective action plan: Corrective action for the involved residents: Resident records were reviewed as well as medications/narcotics for the residents affected. Interviews were conducted with the residents. Resident Council was completed. Pain assessments were completed. Pharmacy performed an audit of the narcotics on [DATE]. The nurse was suspended pending the investigation. On [DATE] the police department was notified. On [DATE] the Drug Enforcement Agency was notified. On [DATE] a 24 hour report was submitted, and the North Carolina Board of Nursing was notified. Corrective action for other potentially affected residents: All narcotic records as well as Medication Administration records were reviewed. A pharmacy audit was performed on [DATE] with no other concerns identified. Pain assessments were completed by the DON. Measures that were put in place or systemic changes: The Staff Development Coordinator (SDC) initiated education on [DATE] to all nurses on Controlled Substance Diversion Training and Drug Diversion Policy. How the facility plans to monitor: The DON and Unit Manager will continue their audits of the MAR, Narcotic Sheets and Medications weekly for six months then monthly for one year. The SDC will educate all new and active staff on a continued basis on Abuse, Neglect and Misappropriation. All nurses will continue, on a regular basis, to be educated by the SDC/DON on medication administration and drug diversion. The plan alleged compliance on [DATE]. As part of the validation process, the plan of correction was reviewed and verified through review of audit sheets, education records and staff interviews. Review of the facility plan of correction revealed evidence of 100% auditing of medication concerns or misappropriation, including pain assessments. The facility provided evidence of 100% staff education on Controlled Substance Diversion Training and Drug Diversion Policy completed on [DATE]. The facility reported Nurse #1 to the North Carolina Board of Nursing on [DATE]. Reports were presented to the Quality Assurance committee by the DON to ensure corrective action was appropriate. Ongoing audits were reviewed. The validation process verified the facility's date of compliance of [DATE].

Based on record reviews and staff interview, the facility failed to submit an initial report to the state regulatory agency within 24 hours of a discovery of misappropriation of resident property. This was for 6 of 6 residents (Residents #5, #17. #223, #224, #225 and #226) reviewed. The findings included: A review of the facility's Reporting Reasonable Suspicion of Crime policy, last revised 10/2022, revealed the facility would report a 24-hour investigation for a reasonable suspicion of crime no later than 24 hours if the alleged violation does not result in serious bodily injury. An interview with the Director of Nursing (DON) was conducted on 9/17/24 at 11:27 AM and indicated she was notified on 8/9/24 by the Unit Manager that there was a discrepancy on the Controlled Medication Utilization Record for Residents #17 and #223 involving Nurse #1. The DON stated she notified the Administrator and began an audit of all resident Controlled Medication Utilization Records on 8/9/24 , finding the following: - Resident #5 had Oxycodone signed out on the Controlled Medication Utilization Record by Nurse #1 that was not captured on the MAR. - Resident #17 had Oxycodone signed out on the Controlled Medication Utilization Record by Nurse #1 on 8/7/24 at 5:00 AM when she didn't clock in for work on that day until 7:06 AM. - Resident #223 had Oxycodone signed out on the Controlled Medication Utilization Record by Nurse #1 on 8/7/24 at 12:00 PM and was not captured on the MAR. - Resident #224 had a waste of Hydrocodone on 6/6/24 where the witness signature did not match the master signature log and nurse denied the handwriting was hers. The July Controlled Medication Utilization Record had multiple times Hydrocodone was signed out by Nurse #1 and not captured on the MAR. - Resident #225 had multiple wastes of Lorazepam from Nurse #1. The witness signatures did not match the master signature log and nurses denied the handwriting was theirs. Nurse #3 wasn't at work during the times that indicated she witnessed a waste. - Resident #226 had wastes of Hydrocodone by Nurse #1 where there were no witness or incorrect witness signatures as well as the medication was signed out on the Controlled Medication Utilization Record and not captured on the MAR. On 9/17/24 at 2:01 PM, an interview occurred with the Administrator. She explained that she didn't send an initial report to the state regulatory agency within 24 hours because they were not sure if this was a misappropriation of resident medications issue or not on 8/9/24. The Administrator stated once they suspected the misappropriation of narcotic medications, the corporate agency, pharmacy, law enforcement, Drug Enforcement Agency and North Carolina Board of Nursing were notified. She acknowledged the 24 hour report was not sent to the State Agency until 8/19/24, stating we were doing the investigation and wanted to make sure the problem was corrected.

Based on observations, record review, and interviews with the Registered Dietitian (RD) and staff, the facility failed to remove expired foods from refrigerated storage, store dented canned goods separate from foods available for use, store potentially hazardous foods in sealed containers with a label that recorded the date of storage and the use by date. This failure had the potential to affect food served to 7 of 21 residents. The findings included: 1a. An observation on [DATE] at 11:17 AM of the walk-in refrigerator occurred with the Kitchen Supervisor and revealed a sign posted on the exterior that recorded Food Storage Chart - Refrigerated Foods, Label when product is opened, the time listed is added to today's date. Deli Meats, + (plus) 3 days. Inside the walk-in refrigerator, a plastic bag of sliced turkey meat was observed open to air with a use by date recorded as [DATE]. During the observation, the Kitchen Supervisor stated that all foods stored in refrigeration should be stored in sealed containers and discarded by the use by date. 1b. An observation on [DATE] at 11:20 AM of the walk-in freezer revealed the following opened foods were stored on a rack in plastic bins, not in the original packaging, and open to air with no label to record the date opened or a use by date: - Diced potatoes were stored in a plastic bag that was open to air, with no label to record the date opened or the use by date. - Hash browns were stored in a plastic bag that was open to air, with no label to record the date opened or the use by date. The hash browns were covered with ice and had a dried, white appearance. During the observation, the Kitchen Supervisor discarded the hash browns and stated the hash browns appeared freezer burned. - Breakfast sausage was stored in a plastic bag that was open to air with no label to record the date opened or the use by date. - Diced chicken was stored in a plastic bag that was open to air, with no label to record the date opened or the use by date. The diced chicken was covered with ice and had a dried white appearance. During the observation, the Kitchen Supervisor discarded the diced chicken and stated the diced chicken appeared freezer burned. - Tater tots were stored in a plastic bag that was open to air with no label to record the date opened or the use by date. 1c. An observation of the dry storage room occurred with the Kitchen Supervisor on [DATE] at 11:30 AM. A canned product was observed with a dent along the seal and was stored with canned foods that were available for use. The Kitchen supervisor stated that I usually put the dented cans on the first row of the rack, but since that row is not labeled, for the storage of dented cans, that's why a dented can was stored with cans available for use. An interview on [DATE] at 11:24 AM with the Kitchen Supervisor revealed the facility received food delivery twice per week and on those days, staff monitored the storage of foods for proper packaging and labeling. He stated that foods should be stored in sealed containers to prevent freezer burn and include a label that recorded date opened/received and the use by or expiration date. The RD was interviewed on [DATE] at 3:23 PM. The RD stated that she conducted monthly sanitation rounds that included an observation of the dish room and cold, frozen and dry storage. The RD stated that when she identified concerns with food storage, she re-educated staff immediately. The RD stated that foods should be stored in sealed containers, with labels and discarded by the use by date. The Food Service Director stated in an interview on [DATE] at 12:02 PM that dietary services should be provided per regulatory requirements. The Administrator was interviewed on [DATE] at 11:00 AM. She stated that the dietary department should store foods per regulatory requirements.

Based on record review and staff interviews, the facility failed to include dementia management training and care for cognitively impaired residents as part of the required annual training for 3 of 6 nurse aide (NA)s reviewed for annual staff training (NA #4, NA #5 and NA #6). The findings included: 1a. NA #4 was hired on 9/14/20. Review of nursing assignment records revealed NA #4 worked the 7PM to 7AM shift on August 5, 6, 15, 22, and 29, 2024 and September 16, and 17, 2024. Attempts to interview NA #4 were unsuccessful. 1b. NA #5 was hired on 8/23/10. Review of nursing assignment records revealed NA #5 worked the 7PM to 7AM shift on August 10, 13, 19, and 23, 2024 and September 18, 2024. Attempts to interview NA #5 were unsuccessful. 1c. NA #6 was hired on 2/11/08. Review of nursing assignment records revealed NA #5 worked the 7PM to 7AM shift on August 2, 4, 9, 14, 24 and 31, 2024 and September 15, 2024. Attempts to interview NA #6 were unsuccessful. An interview with the Staff Development Coordinator (SDC) occurred on 9/17/24 at 2:00 PM. During the interview, a review of annual NA training revealed there was no documentation of annual dementia management training and care for cognitively impaired residents for NA #4, NA #5 or NA #6. The SDC stated that she was not aware that annual dementia management training and training to care for cognitively impaired residents was required. The SDC stated that the electronic training management system used by the facility allowed her to populate specific training for each NA to complete each month but stated I just have not populated the training yet, there is no specific reason why. The SDC further stated that NA #4, NA #5 and NA #6 each worked at the facility in the last 12 months. An interview with the Administrator occurred on 9/16/24 at 4:51 PM. The Administrator stated that she expected each NA to receive the required annual training. The Administrator stated she felt certain the required annual training for dementia management and care for cognitively impaired residents had been provided, but that she could not locate any documentation.

Based on observations, record review and interviews with the Registered Dietitian (RD) and staff, the facility failed to provide a four-ounce portion of pureed beef taco meat per the approved menu and prepare pureed foods per the recipe (beef taco meat, bean and corn salsa and cilantro lime rice). This failure occurred for 1 of 1 resident with a diet order for pureed textured foods (Resident #4). The findings included: A continuous observation of the lunch meal tray line occurred on 9/17/24 from 11:40 AM to 11:50 AM. Review of the tray card revealed Resident #4 had a diet order for pureed textured foods. During the observation, the following foods were plated for Resident #4: -Cook #1 used a #10 scoop to plate a 3 1/5-ounce portion of pureed beef taco meat that had an applesauce consistency instead of a four-ounce portion, per the menu. -Cook #1 used a #8 scoop to plate a four-ounce portion of pureed bean and corn salsa with a thick consistency. -Cook #1 used a #8 scoop to plate a four-ounce portion of pureed cilantro lime rice with an applesauce consistency. Review of the approved menus and recipes revealed the following instructions: -Bean and Corn Salsa, Pureed, serve a 1/2 cup or four-ounce portion. For texture modification, remove the number of portions required from the regular recipe, process bean and corn salsa and 3 tablespoons of thickener per 10 servings, to achieve a smooth textured product, final product should be smooth, pudding like consistency but not runny. -Cilantro Lime Rice, Pureed, serve a 1/2 cup or four-ounce portion. For texture modification, remove the number of portions required from the regular recipe, blend until smooth adding 1 teaspoon margarine, melted, plus 1 tablespoon hot water or hot low sodium vegetable broth per serving to achieve a smooth textured product. Final product should be smooth pudding like but not runny. -Beef Taco Bowl, Pureed. Serve a four-ounce portion. Prepare beef taco meat and puree according to the recipe. There was no recipe available for review for the beef taco meat, pureed. Cook #1 was interviewed on 9/17/24 at 11:50 AM and stated that he did not have a recipe to refer to when he prepared the pureed foods, so he used 2 servings of a #10 scoop (3 1/5 ounce) of each food item, beef taco meat, cilantro lime rice and bean and corn salsa, added some water and thickener, but that he did not measure how much water or thickener he added to puree these foods. He stated that this was his routine practice when he prepared pureed foods. The Patient Ambassador, Dietary Aide #1 (DA #1) was interviewed on 9/18/24 at 11:18 AM and stated that she worked in the kitchen as a DA since April 2024. DA #1 stated that she put together the recipe binder when she started, sometime in April 2024 or May 2024. DA #1 stated that when she put together the recipe binder, she printed the recipes for regular textured foods and some of those recipes included instructions to modify the texture to prepare pureed foods, but not all of recipes for regular textured foods included instruction for texture modifications. She stated that she did not print or include recipes for pureed foods in the recipe binder, but that she would do so going forward. The Kitchen Supervisor was interviewed on 9/17/24 at 11:55 AM and stated that he provided oversight of the lunch meal tray line three days per week. During the interview he reviewed the recipe binder and stated that the binder included recipe instructions for preparing foods for a regular textured diet and some of the recipes included instructions for modifying textures. After reviewing the recipe binder, he stated that the recipe binder did not have a recipe in the binder for pureed beef taco meat that was served for lunch on 9/17/24. He stated that the pureed taco meat should be served in a four-ounce portion. The Food Service Director was interviewed on 9/17/24 at 12:02 PM and stated that he provided tray line and food production oversight to the dietary staff. The Food Service Director stated that he was relatively new to his role in the dietary department and that he had not observed [NAME] #1 prepare pureed foods, but that he expected recipes to be followed. The RD was interviewed on 9/18/24 at 10:23 AM and stated that she reviewed/approved the recipes in the recipe binder. The RD stated that when she reviewed the recipe binder, she usually looked for the recipes for regular textured foods, and that she did not always review the recipe binder to ensure there were recipes included for all texture modifications. The RD stated that she expected recipes to be followed for texture modified foods and for foods to be served to residents in portions per the menu. During the interview, the RD provided recipes for pureed textured cilantro lime rice, pureed bean and corn salsa and pureed beef taco bowl. A recipe for pureed beef taco meat was requested, but not provided. The RD stated DA #1 was responsible to ensure the recipe binder was kept up to date. The Administrator was interviewed on 9/18/24 at 11:00 AM. She stated that menus and recipes should be available and followed to serve residents the correct portions and texture modifications.

Based on record review, family, and staff interviews, the facility failed to provide the responsible party (RP) written notification of the reason for a hospital transfer for 1 of 1 resident reviewed for hospitalization (Resident #10). The findings included: Resident #10 was originally admitted to the facility on [DATE]. A review of Resident #10's medical record revealed the following transfers and discharges to the hospital: - Transferred to the hospital on 1/22/24 for hypotension and fever. He returned to the facility on [DATE]. - Transferred to the hospital on 2/6/24 for hypotension and returned to the facility on [DATE]. - Transferred to the hospital on 2/20/24 for altered mental status and returned to the facility on [DATE]. - Transferred to the hospital on 6/23/24 for altered mental status and returned to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the RP for any of the hospital transfers noted above. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 had severe cognitive impairment. During an interview with Resident #10's RP, he indicated he had not received anything in writing regarding Resident #10's hospital transfers but was notified by phone. The Administrator was interviewed on 9/17/24 at 9:00 AM and stated that when a resident was transferred to the hospital the RP was notified by phone. A transfer/discharge form was sent with the resident to the hospital, but nothing was mailed to the RP. The Administrator further stated it was her expectation for the resident and/or RP to be notified in writing for the reason of the hospital transfer per the regulation.

Based on observations, staff interviews and record review, the facility failed to post daily nurse staffing data at the beginning of two shifts, post accurate daily nurse staffing data for two shifts and maintain records of posted daily nurse staffing data for two shifts. This failure occurred for 6 of 45 days of daily nurse staffing data reviewed. The findings included: 1a. An observation of posted daily nurse staffing data occurred on 9/15/24 at 8:50 AM and 9/15/24 at 11:55 AM. Each observation revealed daily nurse staffing data was posted for the 7AM shift for 9/14/24. The daily nurse staffing data recorded the facility census of 21 residents, two registered nurses (RN) for a total of 24 hours worked, one licensed practical nurse (LPN) for a total of 12 hours worked and three nurse aides (NA) for a total of 36 hours worked. Actual staff observed for the 7AM shift on 9/15/24 included one RN, two LPNs and four NAs. 1b. A review of daily nurse staffing data records occurred with the Staffing Coordinator on 9/17/24 at 2:04 PM and revealed the following: - On Saturday, 8/3/24, there was no record of the daily nurse staffing data posting for the 7AM to 7PM shift. - On Monday, 8/12/24, the daily nurse staffing data posting for the 7AM shift did not record a RN who worked 8 hours. - On Saturday, 8/17/24, there was no record of the daily nurse staffing data posting for the 7AM to 7PM shift. - On Tuesday, 8/20/24 the daily nurse staffing data recorded two LPNs worked 12 hours on the 7PM to 7AM shift. The nursing assignment sheet recorded five LPNs, and one RN worked on 8/20/24, 7PM shift. An interview with the Staffing Coordinator occurred on 9/17/24 at 9:58 AM. The Staffing Coordinator stated she normally worked 9AM to 5:30PM Monday through Friday and weekends as needed. She stated that the nurse on each shift was responsible to post the daily nurse staffing data at the beginning of the shift, but that she checked when she arrived to work and if the correct daily nurse staffing data was not posted, she would post it. The Staffing Coordinator stated that she worked 9/14/24 7PM to 7AM and completed and posted the daily nurse staffing data for that shift but that she may have recorded the wrong shift on the posting. She stated she recorded that the data was for the 7AM to 7PM shift on 9/14/24, but that she meant to record that it was for 9/14/24, 7PM to 7AM shift. She stated that she always reminded the nurses that daily nurse staffing data should be posted at shift change, and currently the charge nurse was responsible to post daily nurse staffing data at the beginning of each shift. She stated she could not locate the daily nurse staffing postings for 8/3/24 or 8/17/24 and that the daily nurse staffing data postings on 8/12/24 and 8/20/24 did not include all the RNs or LPNs that worked in the facility on those dates. An interview with the charge nurse (Nurse #4) occurred on 9/18/24 at 9:32 AM. Nurse #4 stated that she worked the 7AM shift on 9/15/24 and that she trained a new nurse on that shift. Nurse #4 stated that when she arrived for work at 7AM on 9/15/24, she just forgot to post the daily nurse staffing data for the 9/15/24 7AM shift, but that she was aware of that responsibility. She stated, It was just an oversight. An interview with the Administrator occurred on 9/16/24 at 4:51 PM. The Administrator stated that she expected the nursing staff to work together to post the daily nurse staffing data at the beginning of each shift, ensure the records were accurate and that staffing data records should be maintained for 15 months.

Based on observation, staff interviews and review of facility menus, the facility failed to serve portions of foods planned on the facility's menu for 5 of 10 foods requiring scoops on the lunch meal tray line. The findings included: Review of the facility's planned lunch menu for 12/5/18 included the following portion sizes were to be served at lunch; 4 ounces of Chopped Chicken 4 ounces of Pureed Rice 4 and 2/3 ounces of Pureed Spinach 4 and 2/3 ounces of Pureed Squash 5 and 1/3 ounces of Sauteed Spinach On 12/5/18 at 11:45 AM, Dietary Staff (DS) #1 was observed in the kitchen plating foods for the resident lunch meal tray line service. At the same time the Dietary Manager (DM) and Director of Dietary Services (DDS) identified the amount of each scoop being used. The DM and DDS identified that DS #1 was plating one scoop each of the chicken, pureed rice, pureed spinach and pureed squash using green-handled scoops and a 3 ounce spoodle for the sautéed spinach. 3 and ¼ ounce scoop for the Chopped Chicken 3 and ¼ ounce scoop for the Pureed Rice 3 and ¼ ounce scoop for the Pureed Spinach 3 and ¼ ounce scoop for the Pureed Squash 3 ounce spoodle for the Sauteed Spinach During the same observation, the DM and DDS were asked to compare the menu portion sizes with the scoop sizes in use. The DDS stated there was confusion about the amount each scoop provided and the DM obtained a copy of the manufacturer's identified capacity for each color of scoop. The DM changed out the green-handled (3 and 1/4 ounce) scoop in the chopped chicken, with a white-handled scoop which she stated was a 4 ounce serving size, but didn't have enough white-handled (4 ounce) scoops for the rice, spinach and squash. On 12/5/18 at 12:31 PM, the DM and the DDS were interviewed about the serving sizes. They provided the correct scoop sizes and stated incorrect scoops had been used for some of the foods during lunch. The DM and DDS also indicated additional scoops would be ordered and education provided to staff. The Administrator was interviewed on 12/6/18 at 1:48 PM and stated that she had already been made aware of the incorrect portions of foods served during lunch on 12/5/18. The Administrator stated that she expected the dietary staff to follow the portions identified on the menu.

Based on record review, family and staff interviews, the facility failed to protect confidential medical information for 2 of 3 sampled residents (Resident #4 and Resident #5). Findings included: An interview with a family member (FM) of Resident #3 was conducted on 8/12/16 at 9:15 AM. The FM stated he had received the medical records, as requested, from the facility for Resident #3 and noticed the names of 2 residents (Resident #4 and Resident #5) on 2 separate pages within the medical record for Resident #3. He stated he had laboratory results for Resident #4 and a copy of a prescription for Resident #5. A review of the closed medical record for Resident #3 was conducted on 8/12/16 at 11:45 AM and revealed lab results for Resident #4 and a copy of a prescription for Resident #5 were included in the closed medical record of Resident #3. An interview was conducted on 8/12/16 at 12:10 PM with the Director of Nursing (DON). He stated if someone requested medical records they are entitled to see them. He stated the medical records coordinator handled those requests and anything requested, for example laboratory results, diagnostic tests and results, nursing notes, physician progress notes [REDACTED]. He also stated the facility staff just completed training related to the Health Insurance Portability and Accountability Act (HIPAA) to review patient privacy laws, and the staff was also in serviced annually on HIPAA. He stated, The medical records coordinator pulls information from the electronic medical record and the entire closed record (paper chart) for any information that was requested. An interview was conducted with the medical records coordinator on 8/12/16 at 12:50 PM. She stated, I get my information to send out to the family from the electronic medical record, and the paper chart. Laboratory results are typically on paper so I photocopy them and include them in the records I send out. A urinalysis and urine culture and sensitivity would get pulled from the paper record. Copies of physician written prescriptions are kept in the paper chart. A physician writes a prescription for a resident who is being discharged home, and the nurse makes a copy of it to put in the chart. This way, if a patient calls back and says they lost their prescription we can go back in the paper chart and look for it. I usually check each page of the medical record before I send it out to a family and make sure all the pages have the same name and identification number on all the pages. If someone gets the wrong chart, or pieces of a chart for someone else that would not be good. An interview was conducted on 8/12/16 at 1:30 PM with the facility Administrator. She stated, My expectations for HIPAA is that we protect the privacy rights of our residents. They are continually educated on HIPAA. I would not expect a family member to get the wrong medical information or information for another resident mixed in with their family member ' s medical record.

Based on record review and staff interviews, the facility failed to ensure the accuracy of 1 of 3 sampled residents (Resident #3) medical records by including the medical information of two other residents (Resident #4 and Resident #5) in Resident #3 ' s closed record. Findings included: A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Resident #3 was cognitively impaired, and required extensive assistance to complete all activities of daily living (ADLs). A review of the closed medical record for Resident #3 was conducted on 8/12/16 at 11:45 AM and revealed laboratory results (a urinalysis and urine culture and sensitivity) for Resident #4 and a copy of a medication prescription for Resident #5 included in the closed medical record of Resident #3. An interview was conducted on 8/12/16 at 12:10 PM with the Director of Nursing (DON). He stated the facility staff just completed training related to the Health Insurance Portability and Accountability Act (HIPAA) to review patient privacy laws, and the staff was also in serviced annually on HIPAA. The DON confirmed other resident ' s medical information was erroneously placed in Resident #3 ' s medical record. An interview was conducted with the medical records coordinator on 8/12/16 at 12:50 PM. She stated, I get my information to send out to the family from the electronic medical record, and the paper chart. Laboratory results are typically on paper so I photocopy them and include them in the records I send out. A urinalysis and urine culture and sensitivity would get pulled from the paper record. Copies of physician written prescriptions are kept in the paper chart. A physician writes a prescription for a resident who is being discharged home, and the nurse makes a copy of it to put in the chart. This way, if a patient calls back and says they lost their prescription we can go back in the paper chart and look for it. I usually check each page of the medical record before I send it out to a family and make sure all the pages have the same name and identification number on all the pages. If someone gets the wrong chart, or pieces of a chart for someone else are mixed in the wrong chart that would not be good. She also confirmed other resident ' s medical information was erroneously placed in Resident #3 ' s medical record which was provided to Resident #3 ' s family. An interview was conducted on 8/12/16 at 1:30 PM with the facility Administrator. She stated, My expectations for HIPAA is that we protect the privacy rights of our residents. They are continually educated on HIPAA. Medical records need to be accurate and not have medical information for someone else mixed up in it. She also confirmed other resident ' s medical information was erroneously placed in Resident #3 ' s medical record which was provided to Resident #3 ' s family.

Based on record review and interviews with residents, resident ' s family member, resident ' s sitter and staff, the facility failed to answer resident call bells in a timely manner and provide assistance, for residents needing assistance, to maintain dignity for 2 of 4 residents (Residents #15 and 11) reviewed for dignity. Findings included: 1.Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated the resident had adequate hearing, clear speech, made himself understood and understood others. He was cognitively intact, and had no behaviors or rejection of care. He required extensive assist of 2+ persons with activities of daily living, was occasionally incontinent of bladder and always continent of bowel. He was on a diuretic 6 of 7 days and required oxygen, suctioning,[MEDICAL CONDITION], and a ventilator. During an interview on 3/23/15 at 3:13 pm, when asked about being treated with dignity, Resident #15 stated, " There is one time you just don ' t (use the call bell) - that's at 7 at change of shift. (Sometimes I have called) and it seemed like it took forever. (Two of my family members) spoke with the (Director of Nursing (DON)) about it. My (family member) was here recently when I had to wait so long that I had a (bowel movement) in the bed. I was upset and so was my (family member). I know they are shorthanded. " Resident indicated that he frequently had to wait more than 30 minutes for his call bell to be answered. During an interview on 3/23/15 at 3:20 pm, Resident #15 ' s family member indicated she had been visiting the resident recently, the resident had a bowel movement " accident " and pushed the call bell at 3:00 pm for assistance. She stated, " We waited and waited until I went and got nurse in hallway. Someone came in, (indicated she would get someone to assist the resident), and turned off the call light. She came back about 15 minutes later and said ' No one has been in yet? ' It was about 50 minutes before he was finally cleaned up. I have talked to the DON about his call light not being answered. No grievance form was filled out and one said anything else about it. " The family member indicated the call bell wait times have not gotten better, even after speaking with the DON. During an interview on 3/25/15 at 1:11 pm with the Administrator she stated, " We have not had anything brought up recently about call bells. We have had in-services about call bells and it is my expectation that call lights are answered timely. " Record review revealed the nurse training record dated December 2014 included training about answering call lights. 2. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated the resident had adequate hearing, clear speech, made herself understood and understood others. She was cognitively intact, and had no behaviors or rejection of care. She required extensive assistance of 2+ people with toilet use, was always continent of bowel and bladder. She required oxygen, suctioning, [MEDICAL CONDITION]. During an interview on 3/23/15 at 11:58 am, when asked about being treated with dignity, Resident #11 stated, " Sometimes I wait for over an hour when I push my call bell. That is bad when you have to go to the bathroom. I have sometimes had to start pounding my call bell on the table to make noise to get someone to come in. I know the time on my clock and on my IPad. " The resident indicated she felt very frustrated about the amount of time she has to wait for her call bell to be answered and it caused her to worry. An observation of the resident ' s room on 3/23/15 at 11:58 am revealed a clock on the left wall beside her bed. The clock was working and indicated the correct time. The resident ' s IPad was sitting on her bedtable, directly in front of her and indicated the time. During an interview on 3/23/15 at 12:05 pm with Resident #11 ' s sitter, she stated, "(Staff) have turned off the call light and didn ' t even ask what she needed. No one came back in and she had to push the call bell again and wait over 30 minutes." She indicated a wait time of at least 20-30 minutes for the resident to receive assistance when she pushes her call bell was not uncommon. During an interview on 3/25/15 at 1:11 pm with the Administrator she stated, " We have not had anything brought up recently about call bells. We have had in-services about call bells and it is my expectation that call lights are answered timely. " Record review revealed the nurse training record dated December 2014 included training about answering call lights.

Based on observation, record review and interview, the facility failed to maintain a daily posting of nurse staffing and failed to maintain the staffing data for a minimum of 18 months. Finding included: During initial tour of the facility on 3/23/15 at 9:30 am, an observation revealed there was no nurse staffing posted of licensed and unlicensed staff. During an interview on 3/23/15 at 9:45 am with the Director of Nursing (DON) when asked about posted nurse staffing he stated, " We have the schedule posted. " He indicated a posting of the " Weekly Assignment " sheet and the " Daily Census/Resident Activity " sheet. There was no daily sheet that indicated the census, the total number and actual hours worked by licensed and unlicensed staff, or the facility name. The DON further stated, " What we have are the hours worked on the staffing schedule." During an interview on 3/23/15 at 12:30 pm with the DON he indicated the nurse staff posting had not been done for several months but the posting would be started on 3/23/15. During an interview with the Administrator on 3/25/15 at 1:11 pm she stated, " There is supposed to be a posting daily. That is my expectation. I don ' t remember when the last time was that it was posted. " She further indicated the posting was previously maintained and the daily posting sheets should be kept for 18 months. A request was made to the Administrator for the most recent posting of nurse staffing. No nurse staffing sheets were provided.

Based on observations and staff interview, the facility failed to dispose of garbage and refuse by ensuring one of three garbage dumpsters properly concealed the waste within, and by ensuring the area surrounding the three dumpsters was free from refuse and debris. Findings included: On 4/3/14 at 9:20am, observations of the three dumpsters revealed an opened door exposing refuse in one of the three dumpsters located outside of the facility behind the kitchen. The following items were observed on the ground directly behind the dumpsters: two large clear plastic bags containing plastic gowns and plastic gloves; one small clear bag containing a water bottle and a styrofoam cup; one small flattened cardboard box; one small disposable plastic tray; one plastic bottle labeled as cleaning solution; one used tube of body cream; and, a broom. During an interview on 4/3/14 at 9:25am, the Dietary Supervisor revealed the dumpsters were emptied by an outside service on Mondays, Wednesdays, and Thursdays. She indicated the items observed on the ground behind the dumpsters were transported from the facility by the housekeeping staff and that she would immediately inform their Supervisor of the current condition of the area.