Every finding on record at Lenoir Health and Rehabilitation Center

Based on observation, record review, staff, resident, Nurse Practitioner, Medical Director, Pharmacist, and Regional Pharmacy Consultant interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer the medication Gabapentin for diabetic polyneuropathy (a chronic nerve disorder caused by long-term high blood sugar in diabetes, leading to damage of multiple peripheral nerves, especially in the feet and legs) for 1 of 3 residents reviewed for medication errors (Resident #1). Resident #1 missed a total of 8 doses of Gabapentin over a 4-day period. Resident #1 stated the pain in his legs was extremely bad and rated his pain at a 10 on a 0-10 scale (0 is no pain 10 is worst pain). Resident #1 also stated he experienced twitching in his legs that kept him from sleeping for 3 nights.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with diabetic polyneuropathy.A Physician order dated 10/24/25 revealed an order for Gabapentin (used to treat neuropathy) oral tablet 800 milligrams (mg), give one tablet by mouth three times a day related to diabetes mellitus.Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. He was assessed as having frequent pain present during the assessment period that occasionally interfered with therapy activities and frequently interfered with day-to-day activities. Resident #1's pain intensity was assessed at a level 6 on a 0-10 scale.Review of a physician order dated 12/18/25 read; Oxycodone-Acetaminophen 10-325 mg 1 tablet by mouth 4 times a day. Additionally, the order read, Oxycodone-Acetaminophen 10-325 mg 1 tablet by mouth every 8 hours as needed and the resident may have it 2 hours before or 2 hours after scheduled dose. Further review of Resident #1's MAR for January 2026 revealed an order for Gabapentin oral tablet 800 mg, one tablet by mouth three times a day for diabetes mellitus. The medication was marked as not administered on 1/26/26 for the 8:00 AM dose (Medication Aide #2) and 8:00 PM dose (Nurse #1); on 1/27/26 for the 8:00 PM dose (Nurse #1); on 1/28/26 for the 8:00 AM (Nurse #2), 12:00 PM (Nurse #2), and 8:00 PM (Nurse #3) doses; and on 1/29/26 for the 8:00 AM and 12:00 PM doses (Medication Aide #1).On 1/29/25 at 12:46 PM an interview was attempted with Nurse #3 with no return phone call received.On 2/04/26 at 2:15 PM, an interview was conducted with Medication Aide #2. During the interview, she stated on 1/26/26 at 8:00 AM Resident #1's Gabapentin was not in the medication cart to administer. The interview revealed she reordered Resident #1's medication in the electronic charting system but did not recall who she let know the resident did not receive his medication.Review of Resident #1's MAR for January 2026 revealed the medication Gabapentin was scheduled to be administered on 1/26/26 at 8:00 PM and 1/27/26 at 8:00 PM and was coded with a (9) as not administered by Nurse #1.On 1/29/26 at 2:00 PM, an interview was conducted with Nurse #1. During the interview, she stated Resident #1's medication was not in the medication cart on the two-night shifts she had worked on 1/26/26 and 1/27/26. She stated the facility had a medication dispensing machine; however, she knew the machine did not have enough Gabapentin to cover Resident #1's prescribed dosage. She explained she had not reordered the medication from the pharmacy because it had also been missed on day shift, and they would typically be the ones who would reorder a medication from the pharmacy. Nurse #1 stated Resident #1 would typically come to her if he were in pain and request his as needed medication. Nurse #1 did not recall Resident #1 stating he had a pain level of 10 or experiencing twitching in his legs.Review of Resident #1's MAR for January 2026 revealed the medication was scheduled to be administered on 1/28/26 and was coded with a (9) as not administered by Nurse #2 for the 8:00 AM dose and coded with a (2) as the resident refused for the 12:00 PM dose.On 1/29/26 at 1:03 PM, an interview was conducted with Nurse #2. During the interview, she stated on 1/28/26 the 8:00 AM dose of Gabapentin 800 mg was not in the medication cart for Resident #1. She stated it was hard to remember but felt like they were trying to piece his medication together using the medication dispensing machine, and he eventually refused his 12:00 PM dose so she didn't attempt to get it from the medication dispensing machine. Nurse #2 stated the facility was experiencing issues with the Pharmacy obtaining medication. She explained the nursing staff would reorder a medication, they wouldn't hear back from pharmacy, and then the medication would not be delivered. Nurse #2 stated she was unaware Resident #2 had missed several doses of the medication and had not personally contacted the pharmacy to check on Resident #1's medication status. Resident #1 did not report a pain level of 10 or experiencing twitching in his legs during her shift. An observation conducted on 1/29/26 at 11:52 AM with Medication Aide (MA) #1 revealed MA #1 preparing Resident #1's 12:00 PM medication. During the observation, MA #1 stated Resident #1's medication Gabapentin 800 mg had been missing from the medication cart for at least 3 days. She explained that she had reordered the medication on 1/29/26 and let the Nurse on duty know (Nurse #2). MA #1 stated, he's alert so he knows he isn't getting it. MA #1 explained on 1/29/26 Resident #1 had missed his 8:00 AM dose and 12:00 PM dose because the medication was unavailable.Review of the Medication Administration Record (MAR) for January 2026 revealed an order for Oxycodone- Acetaminophen tablet 10-325 mg give one (1) tablet by mouth every 8 hours for pain as needed (PRN) and the resident may have it 2 hours before or 2 hours after scheduled dose. The Oxycodone- Acetaminophen was initialed as administered on 1/26/26 at 5:20 AM and 3:35 PM with a pain rating of a 9 on a 0-10 scale. The order was initialed as administered on 1/27/26 at 6:50 PM with a pain rating of 2 on a 0-10 scale. Resident #1 also received Oxycodone-Acetaminophen tablet 10-325 mg one (1) tablet by mouth four times a day for pain scheduled. The pain assessment using a 0-10 scale or non-verbal scoring every shift revealed on 1/26/26 during day shift Resident #1's pain level was rated at a 2 and during night shift rated at a 2. On 1/27/26 Resident #1's pain level was rated as a 2 for day shift and a 0 for night shift. Resident #1's pain level was rated at 0 during day and night shift on 1/28/26 and 1/29/26.On 1/29/26 at 5:19 PM, an observation and interview were conducted with Nurse #2 of the medication dispensing machine located in the medication storage room at the nurse's station. The machine had no 100 mg Gabapentin in stock and only (2) 300 mg Gabapentin in stock. Nurse #2 confirmed that the in-stock medication wouldn't have covered one of Resident #1's scheduled doses of Gabapentin.On 1/29/26 at 5:20 PM, an interview was conducted with Resident #1. Resident #1 stated he had been having issues not receiving his medication Gabapentin in the facility and had not received it for a week. He explained he was taking the medication for nerve pain because he had neuropathy. Resident #1 stated, the pain in my legs is extremely bad, I would rate it as a 10 on a 0-10 scale during the day and at night. He stated he was up all night due to twitching pain and had not slept in at least 3 nights. Resident #1 stated he didn't understand how someone could be in a facility and not receive their medication and that he had never refused his medication. He stated he would ask staff members about his medication, and they told him they would check on it; however, they never returned to the room.On 1/29/26 at 2:35 PM, an interview was conducted with Unit Manager #1. During the interview, she stated she worked 5 to 6 days each week during first shift. Unit Manager #1 stated no staff member had come to her to let her know Resident #1 was missing medication. She explained she could pull the medication from the medication dispensing machine if it was unavailable on the medication cart. Unit Manager #1 stated she would have also called the Nurse Practitioner or Medical Director to let them know Resident #1's medication was not in the facility and would have followed up with the Pharmacy.On 1/29/26 at 1:33 PM, an interview conducted with the Pharmacist revealed the Pharmacy sent a 30-day supply of Gabapentin (90 tablets) to the facility on 1/09/26. He explained that supply was enough Gabapentin medication for Resident #1 until 2/09/26. The Pharmacist stated the facility had attempted to re-order the medication on 1/26/26; however, it was too soon to refill the medication because insurance would only allow the medication to be reordered 7 days prior to the 30-day period (02/02/26). The Pharmacist explained the facility could have called and requested the medication and billed it to the facility, as other facilities often did; however, based on his records, no staff member from the facility had called to check on the status of Resident #1's medication. The Pharmacy delivered to the facility twice a day and could have sent the medication to the facility the same day. The Pharmacist indicated the Pharmacy was closed on 1/26/26 but could have filled the prescription the following day on 1/27/26.On 1/30/26 at 12:47 PM, an interview was conducted with the Regional Pharmacy Consultant. During the interview, she stated if Resident #1 took the medication Gabapentin for diabetic nerve pain and did not receive the medication for several doses, Resident #1 would experience the reoccurrence of the pain sensation. She stated he may have psychological dependence on the medication because it can have sedating effects, making it difficult to sleep without it, especially if taking a large dosage such as 800 mg three times a day. The interview revealed Gabapentin was also prescribed for mood disorders and had a calming effect on patients. She stated that without the medication, mood, behaviors, and sleep may be disrupted.On 1/29/26 at 5:10 PM, an interview was conducted with the Nurse Practitioner. During the interview she stated she was unaware Resident #1 had missed doses of the medication Gabapentin. She explained he was taking the medication because he had a wound on his foot and could have adverse effects from not taking it, such as pain. The Nurse Practitioner stated missed doses of the medication would be significant for Resident #1's pain control. The Nurse Practitioner stated Resident #1 received scheduled and as needed Oxycodone and it would have helped with his pain control however, the medications focus on different nerve receptors and the Oxycodone may or may not have resolved the missed doses of the residents Gabapentin but possibly could have helped.On 1/30/26 at 2:20 PM, an interview was conducted with the Medical Director. During the interview, he stated missing doses of the medication Gabapentin would have affected Resident #1's pain level. The Medical Director stated Resident #1 had other options for pain management. On 1/30/26 at 11:10 AM, an interview was conducted with the Director of Nursing (DON). The DON stated it was the nurse's responsibility to reorder the medication from the pharmacy, which could be done through the electronic charting system. She explained on 1/26/26 the medication was reordered by the facility; however, the pharmacy was closed due to weather conditions and reopened on 1/27/26 at lunchtime. The DON stated the medication should have been delivered to the facility on the night of 1/27/26, and if it did not arrive, the nursing staff should have called the Pharmacy on 1/28/26 to check on the status of the medication. She stated she was unaware Resident #1 did not have his medication until 1/29/26 and they were able to get him the Gabapentin for the 8:00 PM dose on 1/29/26. The DON stated the Pharmacy was good about stocking the medication dispensing machine and had done so prior to the week of 1/26/26. The DON indicated the Pharmacy had not come back to restock the medication dispensing machine yet for the week but would expect them to come soon.On 1/30/26 at 12:49 PM, an interview was conducted with the Administrator. During the interview she stated nursing staff should have called Pharmacy the next day after not receiving Resident #1's medication. She stated he was prescribed a high dose of Gabapentin and the back-up medication dispensing machine would not cover his dosage; it had to come from Pharmacy. The Administrator stated Resident #1 should not be missing doses of his medication and expected staff members to follow up when medication was not in the facility.

Based on observation, record review, and staff and Nurse Practitioner interviews, the facility failed to notify the Physician/Nurse Practitioner when a resident did not receive his prescribed medication, Gabapentin, for diabetic polyneuropathy (a chronic nerve disorder caused by long-term high blood sugar in diabetes, leading to damage of multiple peripheral nerves, especially in the feet and legs) for 1 of 3 residents reviewed for notification (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with diabetic polyneuropathy.A Physician order dated 10/24/25 revealed an order for Gabapentin (used to treat neuropathy), oral tablet 800 milligrams (mg), give one tablet by mouth three times a day related to diabetes mellitus.Review of Resident #1's Medication Administration Record (MAR) for January 2026 revealed an order for Gabapentin oral tablet 800 mg, one tablet by mouth three times a day for diabetes mellitus. The medication was marked as not administered on 1/26/26 for the 8:00 AM dose (Medication Aide #2) and the 8:00 PM dose (Nurse #1); on 1/27/26 for the 8:00 PM dose (Nurse #1); on 1/28/26 for the 8:00 AM (Nurse #2), 12:00 PM (Nurse #2), and 8:00 PM doses; and on 1/29/26 for the 8:00 AM and 12:00 PM doses (Medication Aide #1).On 2/04/26 at 2:15 PM, an interview was conducted with Medication Aide #2. During the interview, she stated on 1/26/26 at 8:00 AM Resident #1's Gabapentin was not in the medication cart to administer. The interview revealed she reordered Resident #1's medication in the electronic charting system but did not recall who she let know the resident did not receive his medication.On 1/29/26 at 2:00 PM, an interview was conducted with Nurse #1. During the interview, she stated Resident #1's medication was not in the medication cart on the two night shifts she had worked on 1/26/26 and 1/27/26. The interview revealed she documented on Resident #1's MAR that the medication was not administered and did not notify a provider that Resident #1 had missed doses of his prescribed medication, but she did not notify the provider because it had also been missed during the first shift and she thought the provider was aware.An observation conducted on 1/29/26 at 11:52 AM with Medication Aide (MA) #1 revealed MA #1 preparing Resident #1's 12:00 PM medication. During the observation, MA #1 stated Resident #1's medication, Gabapentin 800 mg, had been missing from the medication cart for at least three days. She explained that she had reordered the medication on 1/29/26 and let the Nurse on duty know (Nurse #2); however, it still was not in the medication cart, and she did not know why. The interview revealed as a Medication Aide, she would not notify a provider if a resident had missed a medication and she stated she told Nurse #2.On 1/29/26 at 1:03 PM, an interview was conducted with Nurse #2. During the interview, she stated on 1/28/26 the 8:00 AM dose of Gabapentin 800 mg was not in the medication cart for Resident #1. Nurse #2 stated that she did not notify the Nurse Practitioner or medical provider that Resident #1 had missed his medication because she thought it was just a pharmacy delay and the medication would be back in stock soon.On 1/29/26 at 2:35 PM, an interview was conducted with Unit Manager #1. During the interview, she stated she worked five to six days each week during first shift. Unit Manager #1 stated no staff member had come to her to let her know Resident #1 was missing medication. Unit Manager #1 stated she would have also called the Nurse Practitioner or Medical Director to let them know Resident #1's medication was not in the facility and would have followed up with the Pharmacy.On 1/29/26 at 5:10 PM, an interview was conducted with the Nurse Practitioner. During the interview, she stated she was unaware Resident #1 had missed doses of the medication Gabapentin. She explained he was taking the medication because he had a wound on his foot and could have adverse effects from not taking it, such as pain. The Nurse Practitioner stated missed doses of the medication would be significant for Resident #1's pain control. The Nurse Practitioner stated the facility should have notified her, and she would have called the Pharmacy and found out what the issue was with delivering his medication or ordered a substitute medication.On 2/04/26 at 3:14 PM, an interview was conducted with the Director of Nursing and Administrator. During the interview, the Director of Nursing stated the protocol for staff was to notify the Nurse Practitioner first, up until 5:00 PM daily, and if it were after 5:00 PM, to notify the on-call provider. The Director of Nursing stated nursing staff should have notified the Nurse Practitioner when Resident #19 missed his first dosage of the medication. The Administrator stated she also expected the nursing staff to notify the Nurse Practitioner immediately if a resident had not received their prescribed medication.

Based on observation, record review, and staff and Pharmacist interviews, the facility failed to follow up with the pharmacy to ensure the availability and delivery of a resident's prescribed medication. The facility did not contact the pharmacy to verify the status of the resident's medication when it was unavailable in the medication cart, resulting in total of 8 missed doses of Gabapentin over a 4-day period. The deficient practice occurred for 1 of 3 residents reviewed for medication errors (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with diabetic polyneuropathy (a chronic nerve disorder caused by long-term high blood sugar in diabetes, leading to damage of multiple peripheral nerves, especially in the feet and legs). A Physician order dated 10/24/25 revealed an order for Gabapentin (used to treat neuropathy) oral tablet 800 milligrams (mg), give one tablet by mouth three times a day related to diabetes mellitus.Review of Resident #1's MAR for January 2026 revealed an order for Gabapentin oral tablet 800 mg, one tablet by mouth three times a day for diabetes mellitus. The medication was marked as not administered on 1/26/26 for the 8:00 AM dose (Medication Aide #2) and 8:00 PM dose (Nurse #1); on 1/27/26 for the 8:00 PM dose (Nurse #1); on 1/28/26 for the 8:00 AM (Nurse #2), 12:00 PM (Nurse #2), and 8:00 PM doses; and on 1/29/26 for the 8:00 AM and 12:00 PM doses (Medication Aide #1).On 2/04/26 at 2:15 PM, an interview was conducted with Medication Aide #2. During the interview, she stated on 1/26/26 at 8:00 AM Resident #1's Gabapentin was not in the medication cart to administer. The interview revealed she reordered Resident #1's medication in the electronic charting system but did not recall who she let know the resident did not receive his medication.On 1/29/26 at 2:00 PM, an interview was conducted with Nurse #1. During the interview, she stated Resident #1's medication was not in the medication cart on the two-night shifts she had worked on 1/26/26 and 1/27/26. She stated the facility had a medication dispensing machine; however, she knew the machine did not have enough Gabapentin to cover Resident #1's prescribed dosage. Nurse #1 explained she had not reordered the medication from the pharmacy because it had also been missed on day shift, and they would typically be the ones who would reorder a medication from the pharmacy and she had not contacted the pharmacy to check on the resident's medication.On 1/29/26 at 1:03 PM, an interview was conducted with Nurse #2. During the interview, she stated on 1/28/26 the 8:00 AM dose of Gabapentin 800 mg was not in the medication cart for Resident #1. She explained that Medication Aides were typically on the cart and could not pull medication from the dispensing machine located in the medication storage room. She stated it was hard to remember but felt like they were trying to piece his medication together using the medication dispensing machine, and he eventually refused his 12:00 PM dose so she didn't attempt to get it from the medication dispensing machine. Nurse #2 stated the facility was experiencing issues with the Pharmacy obtaining medication. She explained the nursing staff would reorder medication, they wouldn't hear back from pharmacy, and then the medication would not be delivered. Nurse #2 stated she was unaware Resident #2 had missed several doses of the medication and had not personally contacted the pharmacy to check on Resident #1's medication status.An observation conducted on 1/29/26 at 11:52 AM with Medication Aide (MA) #1 revealed MA #1 preparing Resident #1's 12:00 PM medication. During the observation, MA #1 stated Resident #1's medication Gabapentin 800 mg had been missing from the medication cart for at least 3 days. She explained that she had reordered the medication that day (1/29/26) and let the Nurse on duty know (Nurse #2). MA #1 stated, he's alert so he knows he isn't getting it. MA #1 explained on 1/29/26 Resident #1 had missed his 8:00 AM dose and 12:00 PM dose because the medication was unavailable.On 1/29/26 at 5:19 PM, an observation and interview were conducted with Nurse #2 of the medication dispensing machine located in the medication storage room at the nurse's station. The machine had no 100 mg Gabapentin in stock and only (2) 300 mg Gabapentin in stock. Nurse #2 confirmed that the in-stock medication wouldn't have covered one of Resident #1's scheduled doses of Gabapentin.On 1/29/26 at 2:35 PM, an interview was conducted with Unit Manager #1. During the interview, she stated she worked 5 to 6 days each week during first shift. Unit Manager #1 stated no staff member had come to her to let her know Resident #1 was missing medication. She explained she could pull the medication from the medication dispensing machine if it was unavailable on the medication cart. Unit Manager #1 stated she would have also called the Nurse Practitioner or Medical Director to let them know Resident #1's medication was not in the facility and would have followed up with the Pharmacy.On 1/29/26 at 1:33 PM, an interview conducted with the Pharmacist revealed the Pharmacy sent a 30-day supply of Gabapentin (90 tablets) to the facility on 1/09/26. He explained that supply was enough Gabapentin medication for Resident #1 until 2/09/26. The Pharmacist stated the facility had attempted to re-order the medication on 1/26/26; however, it was too soon to refill the medication because insurance would only allow the medication to be reordered 7 days prior to the 30-day period (02/02/26). The Pharmacist explained the facility could have called and requested the medication and billed it to the facility, as other facilities often did; however, based on his records, no staff member from the facility had called to check on the status of Resident #1's medication. The Pharmacy delivered to the facility twice a day and could have sent the medication to the facility the same day. The Pharmacist indicated the Pharmacy was closed on 1/26/26 but could have filled the prescription the following day on 1/27/26.On 1/30/26 at 11:10 AM, an interview was conducted with the Director of Nursing (DON). The DON stated it was the nurse's responsibility to reorder the medication from the pharmacy, which could be done through the electronic charting system. She explained on 1/26/26 the medication was reordered by the facility; however, the pharmacy was closed due to weather conditions and reopened on 1/27/26 at lunchtime. The DON stated the medication could have been delivered to the facility on the night of 1/27/26 if the nursing staff had called the Pharmacy to check on the medication. The DON stated she could have provided the pharmacy with an override for the medication so it would have been filled, billing it to the facility. She stated she was unaware Resident #1 did not have his medication until 1/29/26. The DON stated the Pharmacy was good about stocking the medication dispensing machine and had done so prior to the week of 1/26/26. The DON indicated the Pharmacy had not come back to restock the medication dispensing machine yet for the week but would expect them to come soon.On 2/04/26 at 3:14 PM, an interview was conducted with the Administrator. During the interview she stated nursing staff should have called Pharmacy the next day after not receiving Resident #1's medication. She stated he was prescribed a high dose of Gabapentin and the back-up medication dispensing machine would not cover his dosage; it had to come from Pharmacy. The Administrator stated Resident #1 should not be missing doses of his medication and expected staff members to follow up when medication was not in the facility.

Based on observations and staff interviews, the facility failed to clean 1 of 2 ice machines (the dining room ice machine). This practice had the potential to affect beverages served to residents.The findings included:During the initial tour of the kitchen on 11/16/2025 at 9:40 AM an observation of the dining room ice machine was conducted with the Dietary Manager (DM). The observation revealed a black substance located on the plastic splash guard above the ice. The substance was not in contact with the ice in the ice machine.During an interview with the DM on 11/16/2025 at 10:15 AM, the DM stated the ice machine was less than six months old was still under warranty and the first full deep clean was scheduled for 12/01/2025 and then would be completed every 6 months. The DM stated maintenance was responsible for completing a wipe down cleaning of the ice machines monthly, but a new Maintenance Supervisor just recently started at the facility. The DM stated she expected the ice machine to be free of any black substances. The Maintenance Supervisor was in training and not available for interview.During an interview on 11/20/2025 at 6:45 AM the Administrator stated a new Maintenance Supervisor had been recently hired and the ice machines may not have been cleaned on schedule prior to the recent hire. The Administrator stated she expected the ice machine to be cleaned routinely.

Based on observations, record review, and Nurse Practitioner (NP), Local Health Department Nurse, State Health Department, staff and resident interviews, the facility failed to implement their infection control policy and procedures for enhanced barrier precaution (EBP) for a resident who was positive for Carbapenem Resistant Enterobacterial (CRE) (bacteria resistant to one or more antibiotics and could cause serious infection). In addition, the facility failed to immediately implement health department recommendations to initiate the process to test other residents for CRE. This deficient practice was identified for 1 of 6 residents observed for infection control practices and had the potential to affect other residents (Resident #105). The findings included: Review of revised facility enhanced barrier precautions (EBP) policy dated 3/26/24 revealed this policy might be indicated for residents known to be colonized or infected with bacterial organisms to include carbapenem resistant enterobacterial (CRE) (bacteria resistant to one or more antibiotics and could cause serious infection), surgical wounds, and indwelling medical devices. The policy also revealed the EBP policy required the use of personal protective equipment (PPE), hand hygiene, and EBP signage to be placed on the wall or door outside of resident's room. Resident #105 was admitted to the facility on [DATE]. Review of Resident #105's preliminary lab results for right foot wound culture dated 10/31/25 revealed the culture obtained on 10/27/25 was positive for carbapenem resistant enterobacterial (CRE). Review of NP order dated 10/31/25 received by the Director of Nursing (DON) for Resident #105 to be placed on enhanced barrier precautions for wound infection. Review of Resident 105's final lab results received from the local county health department dated 11/13/25 revealed Resident #105's right foot wound culture obtained on 10/27/25 was positive for CRE. Recommendations included immediate placement of resident on enhanced barrier precautions and further screening of residents to ensure no colonization. Review of nursing note dated 11/13/25 written by Nurse #3 indicated a return phone call was made to the communicable disease nurse from the local county health department and was informed Resident #105's right foot wound sample came back positive for CRE. NP was made aware. An interview was conducted with Nurse #3 on 11/18/25 at 4:00 PM. Nurse # revealed that she was working first shift on Thursday 11/13/25 and had received a telephone call from the nurse at the local health department stating Resident #105's final wound culture was available and had been faxed over to the facility and that he was positive for CRE. She stated she made a note in Resident #105's electronic medical record, retrieved the paper copy of the results off the fax, made copies of the results, and placed the copies of the results in the DON and the NP's box for review. Nurse #3 stated she did not review the results herself and was not aware of the recommendations. She revealed she had not been made aware of Resident #105's precautions status and that typically nursing staff were not notified of a resident's precautions status unless they had received the order for the resident to be placed on precaution or happened to see the order in the chart. She stated typically the only way staff are made aware of when a resident was placed on precautions for whatever reason was by the precaution signage placed on their door and if a resident did not have precautions signage on their door, then it was assumed they were not on any type of precautions. An interview and observation were conducted with Resident #105 inside of his room on 11/16/25 at 11:11 AM. He revealed that he recently had all his toes on his right foot surgically removed, his wound was currently draining and required daily wound care and was positive for a bacterial infection from his wound. Observation of Resident #105's wound dressing on his right foot revealed the top and bottom of the dressing covering the surgical wound to be soaked through with a wet brown discharge and areas of dried brown discharge. There was no barrier precaution signage located on or outside of Resident #105 door and no PPE present. An interview was conducted with Unit Manager #1 on 11/16/25 at 11:25 AM. Unit Manager #1 stated Resident #105 should have already been placed on enhanced barrier precautions, he was admitted with a surgical wound that required wound care, had an order for enhanced precautions from the NP, and was also positive for a bacterial wound infection. She revealed she was on her way to place the enhanced precautions on Resident #105 door and that it was nursing staff responsibility to make sure all residents' orders were followed, residents were placed on the correct precautions, and that all staff were informed of resident's precaution status. An interview was conducted with Wound Nurse on 11/17/25 at 10:45 AM. The Wound Nurse stated that to her knowledge all residents requiring wound care were on enhanced barrier precautions to help prevent the spread of any bacteria and reduce infections. She revealed she was not aware and had not even noticed that Resident #105 was not on enhanced barrier precaution or that he did not have any precautions posted on his door. The Wound Nurse stated that she practices enhanced barrier precautions automatically with all her residents. She revealed the decision on whether a resident was placed on transmission based or enhanced barrier precautions was decided by the physician or the NP and they were responsible for writing the order for the precaution and nursing staff were responsible for making sure the order was being followed, precaution signage was placed on the door, and all staff were alerted to resident's precautions status. An interview on 11/19/25 at 9:31 AM with the Director of Nursing (DON). The DON stated she was not aware Resident #105 was not on enhanced barrier precaution, and no precaution signage had been placed on his door to alert staff of his precaution status. She revealed that per facility policy all residents requiring wound care should be placed on enhanced barrier precautions and their precaution signage placed on their door to inform staff of what type of precautions and protective equipment they should be using when providing care. She stated in reviewing Resident #105's electronic medical record she saw that she had signed off as receiving the verbal order from the NP on 10/31/25 for enhanced barrier precautions but did not recall why Resident #105 was not placed on enhanced barrier precautions at that time or why no precautions signage was placed on his door. The DON revealed that she had been out of the facility the previous week on vacation, had not checked her emails while on vacation, and did not have anyone designated to cover for her while she was gone so she did not receive Resident #105's final wound culture results dated 11/13/25 until she returned to work on Monday 11/17/25. She stated that she had also received what appeared to be some kind of infection control kit she believed was from the local health department, telephone messages and emails from both the local health department nurse and the state health department regarding the final wound culture results for Resident #105 but had not had the time to review the toolkit, return their calls, or respond to their emails. She revealed that as far as the testing of other residents for CRE she would have to speak with the Administrator to see how testing needed to be handled. The DON stated enhanced barrier precautions should be followed as ordered for all residents, precautions signage should be placed on doors to identify precautions status, and all staff should be made aware of any resident placed on barrier precautions to help in preventing the spread of infections. A telephone interview was conducted with the local health department nurse on 11/19/25 at 11:41 AM. The local health department nurse stated that on 11/13/25 he received the final results from the right foot wound culture obtained on 10/27/25 for Resident #105. He revealed once he received the final results, he contacted the facility and spoke with Nurse #3 to notify Resident #105 was positive for CRE, they would be receiving a copy of the results by fax, and that he would be dropping off a toolkit on 11/14/25 to assist the facility with making sure precautions were in place and explaining the testing of other residents to prevent the spread of the bacteria. He stated he also left a telephone message and sent an email to the DON explaining the final results and requested a return call to discuss the recommendations to prevent the spread of the bacteria. The local health department nurse revealed he dropped off the toolkit on the morning of Friday 11/14/25 to what he assumed was a facility nurse although he did not receive the nurse's name who stated they would leave the toolkit for the DON. He stated he had left a message and emailed the DON again on 11/16/25 requesting a return call to discuss the positive results for Resident #105 and at this time he had not received a returned telephone call or email response back from the DON or the facility. He revealed the state health department had also been trying to contact the DON regarding Resident #105's positive results for CRE and had also not received a response back. The local health department nurse stated it was highly important for someone from the facility to either return his or the state health department's telephone call so they could discuss Resident #105's results, importance of making sure enhanced barrier precautions were being followed, provide instruction and assistance with the testing of other residents at the facility, and assist with the ordering of the testing kits. He revealed this type of organism could easily be spread to other residents especially those with wounds and that was why it is so important for the facility to be educated on the bacteria, how the bacteria can be spread, precautions needed in place, and actions the facility needs to take to ensure all residents are safe and prevent the bacteria from spreading. A telephone interview was conducted with the state health department on 11/19/25 at 4:05 PM. The state health department stated they were notified on 11/13/25 of the final results from Resident #105's right foot wound culture showing positive for CRE. He revealed he contacted the local health department nurse on 11/13/25 and notified them of the results. He stated that he also left a telephone message and sent an email for the facility DON on 11/14/25 and 11/16/25 requesting a return call to discuss Resident #105's positive results and the recommendations on how the facility should proceed moving forward to prevent further spread of the bacteria to include the importance of Resident #105 being placed on enhanced barrier precaution and the testing of other residents in the facility to ensure the bacteria had not spread. He stated he had not received a return telephone call or an email response from the facility at this time. He revealed it was of high importance that someone from the facility reach out to him so they could discuss Resident #105's results, receive education on this particular bacterium and how it can be spread, importance of barrier precautions especially since can easily spread through wound care, identifying residents and obtaining sample size for further testing, and assist with ordering test kits. An interview was conducted with the Nurse Practitioner (NP) on 11/18/25 at 1:29 PM. The NP stated Resident #105 was admitted to the facility on [DATE] with a surgical wound to his right foot that required wound care treatment. She revealed during her first encounter with Resident #105 on 10/27/25 she noticed that his wound had a smell and could possibly be infected, so she ordered his wound treatments and a wound culture to be completed. She stated she received the preliminary results back from the culture on 10/31/25, gave a verbal order for Resident #105's antibiotic and for him to be placed on enhanced barrier precautions. The NP revealed she felt that enhanced barrier precautions were appropriate for Resident #105 and did not realize that he had not been placed on enhanced barrier precautions at that time. She stated she received a copy from the local county health department of Resident #105's final results from his wound culture on 11/14/25 which included recommendations for enhanced barrier precautions and testing of other residents to ensure the bacteria had not spread. She stated since she had already written an order for enhanced barrier precautions on 10/31/25 she did not write another order for precautions and that she did not have any input on the testing of other residents that would be a decision made by the DON and the Administrator. She revealed she assumed Resident #105 had been placed on enhanced barrier precautions from her order on 10/31/25 and was not aware that he had not been placed on barrier precautions or that all staff had not been made aware of his precaution status. The NP stated that she herself used barrier precautions with all of her residents and that it was of high importance that the facility followed precaution orders for all residents, all staff were made aware of residents' precaution status and were implementing the correct precautions to prevent the spread of infections. An interview was conducted with the Administrator on 11/20/25 at 11:01 AM. The Administrator revealed that she was not aware that Resident #105 had not been placed on enhanced barrier precautions prior to Sunday 11/16/25. She stated according to facility policy, any resident requiring wound care should have been placed on enhanced barrier precautions upon their admission. She revealed once Resident #105 received an order from the NP for enhanced barrier precautions on 10/31/25 the nursing staff including the DON should have made sure Resident #105 had been placed on enhanced barrier precautions, precautions signage was placed on door, and all staff were made aware of precaution status. The Administrator stated that she was not made aware until yesterday 11/19/25 of Resident #105's final results showing he was positive for CRE, that the local and state health department had left telephone messages and emails for the DON regarding the positive test results and those had gone unreturned, or of the recommendations for further resident testing. She revealed they had spoken with state health department this morning regarding Resident #105's positive results, had identified a sample size of 48 residents that would require further testing, and the state health department would be mailing them the test kits.

Based on record review and Nurse Practitioner, Psychiatric Nurse Practitioner, and staff interviews, the facility failed to obtain consent and inform the resident in advance of the risks and benefits of psychotropic medications prior to the initiation of the antianxiety medication clonazepam and the antidepressant medication venlafaxine for 1 of 5 residents reviewed for unnecessary medications (Resident #45).The findings included:Resident # 45 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), bipolar disorder, and depressive disorder. A Psychiatric Nurse Practitioner progress note dated 07/28/2025 indicated Resident #45 had experienced panic attacks 3 to 4 times weekly with symptoms that felt like he was having a heart attack. The plan indicated to start clonazepam twice a day. Resident #45's physician orders revealed an order dated 07/28/2025 for clonazepam 0.5 milligrams (mg) by mouth twice a day for anxiety. Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed intact cognition and indicated Resident #45 received antianxiety and antidepressant medications on a routine basis during the 7-day look back period. Resident #45's physician orders revealed an order dated 08/12/2025 for the venlafaxine 75 mg by mouth daily for depression. A review of Resident # 45's medical record revealed no information whether Resident #45 was informed in advance of the risks and benefits of initiating clonazepam or venlafaxine and consented to the treatment. The Medication Administration Record (MAR) from 07/28/2025 to 11/18/2025 indicated Resident #45 was administered clonazepam and venlafaxine as ordered by the physician. An interview with Resident #45 on 11/17/2025 at 10:05 AM revealed Resident #45 was in good spirits, and he stated his anxiety and his depression were well controlled. An interview with the Nurse Practitioner on 11/19/2025 at 10:30 AM revealed she deferred Resident #45's psychotropic medication management to the Psychiatric Nurse Practitioner (NP) and she did not obtain consents for these medications. An interview with the Director of Nursing (DON) on 11/19/2025 at 2:00 PM revealed that the facility had not consistently been obtaining consents for psychotropic medications. The DON stated she thought that sometimes the psychiatric Nurse Practitioner obtained consents prior to starting the psychotropic medication. An interview with the Psychiatric Nurse Practitioner on 11/20/2025 at 9:00 AM indicated the nursing staff were supposed to notify the resident or the responsible party to discuss the treatment and the possible side effects when a psychotropic medication was initiated or the dosage had been increased. The Psychiatric Nurse Practitioner indicated that her discussion with Resident #45 consisted of asking the resident about mood fluctuations, anxiety episodes, and his degree of depression. An interview with Administrator on 11/20/2025 at 9:42 AM revealed that she was aware there was opportunity for improvement related to the use of psychotropics and informed consents. She stated that she expected informed consents including a discussion of the risks and benefits would be obtained prior to starting or changing a psychotropic medication.

Based on record reviews, staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to notify the physician immediately of abdominal bruising on a resident receiving Plavix and aspirin (antiplatelet medications) for 1 of 5 residents reviewed for unnecessary medications (Resident #23). The facility also failed to notify the physician before turning off a continuous enteral feeding (tube feeding) when a resident's blood sugar was elevated for 1 of 3 residents reviewed for tube feeding (Resident #63).The findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses which included type-2 diabetes mellitus with chronic kidney disease, peripheral vascular disease (a condition of decreased blood flow in the lower extremities), and atherosclerotic heart disease (a heart condition caused by plaque buildup in the walls of arteries blocking blood flow to the heart). A review of Resident #23's physician orders revealed the following: Plavix 75 milligrams by mouth daily for peripheral vascular disease Aspirin 81 milligrams by mouth daily for atherosclerotic heart disease Insulin Glargine (long-acting insulin) Pen-Injector (100 Unit/Milliliter) inject 15 unit subcutaneously (under skin) every 12 hours for type-2 diabetes NovoLOG (Regular insulin) Solution Pen-Injector (100 Unit/Milliliter) inject subcutaneously before meals and at bedtime per sliding scale: if blood sugar 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-450 give 10 units; above 450 notify provider A progress note written by Nurse #1 dated 11/15/25 at 7:30 PM revealed the following: A large bruise was noted on the left lower quadrant of abdomen. Bruise purple/blue in appearance. An interview with Nurse #1 was conducted on 11/17/25 at 10:33 AM. Nurse #1 revealed that on the morning of 11/15/25 at 6:00 AM, a skin assessment was performed on Resident #23 which revealed no injury. Nurse #1 further revealed when she arrived for her next shift on the evening of 11/15/25 at 7:30 PM, Resident #23 reported pain to abdominal area. Nurse #1 visualized the abdominal area and noted a purple bruise to Resident #23's left lower quadrant of abdomen. Nurse #1 stated she did not notify the provider. An interview with Unit Manager #1 was conducted on 11/16/25 at 1:42 PM. Unit Manager #1 revealed that she had come in at 3:00 PM on 11/15/25. Unit Manager #1 stated she assessed Resident #23 and noted a large bruise to the left lower quadrant of Resident #23's abdomen. Unit Manager #1 indicated that she did not notify the provider at that time. An interview of Resident #23 was performed on 11/16/25 at 11:16 AM. Resident #23 revealed a large bruise to left abdomen during the interview. A telephone interview with Unit Manager #2 was conducted on 11/17/25 at 6:16 PM. Unit Manager #2 reported on the night of 11/16/25, Resident #23 stopped to show her the bruising on her abdomen. Unit Manager #2 stated that she did not report it to the provider. An interview with the NP was conducted on 11/18/25 at 3:01 PM. The NP stated that she was not notified of the bruised area to Resident #23 until the AM of 11/17/25. The NP stated that when she became aware of the bruising, Resident #23 was seen by her in clinic. The NP stated the Plavix and aspirin are antiplatelet medication that Resident #23 received daily and could have contributed to bruising and Resident #23 received insulin injections which are commonly administered in the abdominal area. The NP indicated the provider should have been notified when the bruising was first assessed. 2. Resident #63 was admitted to the facility on [DATE]. Resident #63 had diagnoses that included diabetes mellitus (DM) type 2, encounter for attention to gastrostomy. Resident #63 had a physician's order dated 6/29/2024 for enteral feeding (method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) for Nutren 2.0 (feeding formula) at 46 milliliters (ml)/hour (hr) administered continuously from 9:00 PM to 9:00 AM daily. Resident #63 had a physician's order dated 6/29/2024 for blood sugar checks four times daily before meals and at bedtime for DM. An order dated 2/26/2025 for Lantus inject 20 units subcutaneously at bedtime for diabetes mellitus if CBG less than 65 only give 10 units. Notify provider if CBG is less than 60 or greater than 450. A progress note dated 8/1/2025 written by Nurse #3 revealed Resident #63's blood glucose was 335 milligram/deciliter mg/dl, tube feeding stopped early to help blood glucose stabilize. During a telephone interview on 11/17/2025 at 4:56 PM Nurse #3 revealed she worked at the facility on the 7:00 PM to 7:00 AM shift and was familiar with Resident #63. Nurse #3 confirmed she had turned off Resident #63's tube feeding early due to high blood sugar on the morning of 8/1/2025. Nurse #3 stated she didn't think she needed to get a doctor's order to turn off a tube feeding early and stated she thought it was nursing judgement. Nurse #3 stated she thought it was better to turn the tube feeding off early instead of calling a provider to try and get coverage orders when it would take a couple hours to hear back from the provider. Nurse #3 confirmed she did not notify the provider when she turned the tube feeding off early. An order for enteral feeding dated 10/4/2025 for Nutren 2.0 administer 65ml/hr continuously at 9:00 PM and off at 9:00 AM. During a telephone interview on 11/19/2025 at 8:20 AM Nurse #1 stated she worked at the facility since September 2025 and currently worked the 7:00 PM to 7:00 AM shift at the facility and was familiar with Resident #63. Nurse #1 stated one night in October 2025, she did not recall the specific date, she was worried about Resident #63 having a high blood sugar over 400, and no orders for sliding scale insulin coverage at that time. Nurse #1 stated she asked another nurse, she could not remember which one, what to do and the nurse told her to turn off the tube feeding. Nurse #1 stated she thought they had been turning off the tube feeding early due to high blood sugars, so Nurse #1 turned off Resident #63's tube feeding and did not notify the provider. During a telephone interview on 11/18/2025 at 7:05 AM Unit Manager #4 stated sometime around mid-October Nurse #1 reported to Unit Manager #4 that Resident #63's tube feeding had been held due to high blood sugar, that other nurses had done it since Resident #63 had no sliding scale insulin coverage for elevated blood sugars. Unit Manager #4 stated she told Nurse #1 that a tube feeding was not supposed to be turned off for elevated blood sugars, and a provider should have been notified. Unit Manager #4 stated she reported the information the NP #2 who gave new sliding scale insulin coverage orders, and to the Director of Nursing (DON). Review of a progress note from the NP #2 dated 10/13/2025 revealed in part, NP #2 had seen Resident #63 on 10/13/2025 regarding weight loss, with an additional note that revealed NP #2 had a telephone encounter 10/15/2025 and spoke with bedside nurse who stated that Resident #63 received before meals and a bedtime blood glucose checks without any sliding scale insulin coverage in place. Per nurse- tube feeding was stopped by night shift nurse due to blood sugar of 446. Per nursing reports tube feeding gets turned off frequently due to elevated blood sugars. Reviewed blood sugars and added sliding scale insulin coverage and would continue to monitor and adjust plan of care as needed. During a telephone interview on 11/17/2025 at 4:29 PM the Nurse Practitioner (NP) #2 stated she was notified by the facility that Resident #63's had weight loss in early October 2025 and Resident #63's tube feeding rate was reviewed by the RD and the tube feeding rate was increased. The NP #2 stated near the middle of October, Unit Manager #4 reported that when Resident #63 had elevated blood sugars the nurses had turned off Resident #63's tube feeding instead of calling the provider to get orders for insulin. NP #2 stated she expected nurses to administer tube feedings as ordered and should contact a provider to get an order for a tube feeding to be turned off early. During an interview on 11/19/2025 at 4:50 PM the Medical Director stated he expected tube feedings to be administered as ordered and to be contacted by the nurse to receive orders to turn a tube feeding off early, and for a provider to be notified for blood sugars over 400, if a resident did not have an order for coverage. During an interview on 11/18/2025 at 8:45 AM the DON stated a physician ordered tube feeding should not be turned off early unless the nurse contacted the provider and received orders to turn the feeding off early. During an interview on 11/20/2025 at 7:10 AM the Administrator stated she expected nurses to administer tube feedings as ordered, and to contact a provider for an order to turn a tube feeding off early.

Based on record review, staff and resident interviews, the facility failed to develop abuse policies and procedures that directed staff on how to immediately protect residents after an abuse allegation. The facility also failed to implement their abuse policy in the areas of reporting and training. An allegation of staff to resident physical abuse occurred on 11/15/25. The facility failed to immediately remove the alleged perpetrators from the facility, immediately notify the Administrator of the abuse allegation, and train staff on immediately reporting abuse allegations to administration. This deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #23). Findings included: Review of the facility's abuse policy titled Patient Protection dated 10/17/23 revealed all employees are responsible for immediately (no later than 2 hours after the allegation is made if the incident involves abuse or bodily injury, no later than 24 hours if the incident does not involve abuse of bodily injury) reporting to the Administrator, or in their absence, the Director of Nursing, or their immediate supervisor any and all suspected or witnessed incidents of patient abuse, neglect, theft, exploitation, and/or mistreatment of a patient as well as any reasonable suspicion of a crime against a patient. Any and all suspected or witnessed incidents of patient abuse, neglect brought to the attention of Administration will result in internal investigation, appropriate and timely reporting to the State Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. The abuse policy did not direct staff to immediately protect all residents after an abuse allegation by removing alleged perpetrators from access to residents. Review of the facility's abuse policy titled Prevention/Screening/Training dated 02/05/23 revealed all employees receive training in orientation and are routinely in-serviced regarding the definitions of abuse, neglect.and their responsibility for understanding and preserving patient rights, protecting patients from abuse and neglect, and their responsibility to immediately report any cases of suspected or witnessed abuse or neglect. Resident #23 was admitted to the facility on [DATE].A review of Resident #23's quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #23 was cognitively intact. A telephone interview with Nursing Assistant (NA) #2 was conducted on 11/16/25 at 3:48 PM. NA #2 reported that she was assigned to Resident #23 the night of 11/15/25. At around 5:40 AM, NA #2 entered Resident #23's room for rounds where NA #1 was present providing care to Resident #23's roommate. Resident #23 refused incontinence care three times and NA #2 stated that there was a planned refusal form for Resident #23 to sign if she refused care due to frequent refusals. When NA #2 got the form, Resident #23 became agitated and began cursing. NA #1 then asked Resident #23 if she wanted to be changed to which Resident #23 agreed for NA #2 to complete incontinence care at that time. NA #2 had Resident #23 roll to her right side facing the window, then tapped her to roll over to her back. NA #2 stated that when Resident #23 rolled back onto her back, she began yelling you are in my organs. NA #2 stated that she was not touching Resident #23 at the time she began yelling. NA #2 stated that there was no bruising on Resident #23's abdomen at that time. NA #2 reported the incident to Unit Manager #2. NA #2 indicated that Resident #23 was her last resident for rounds and she left at 7:00 AM. NA #2 reported that her assignment was not changed for the brief period left in her shift. NA #2 indicated she had been off since and had not returned due to previously scheduled time off. An interview with NA #1 was conducted on 11/16/25 at 3:19 PM. NA #1 revealed that she had arrived at work the 3:00 PM to 11:00 PM shift at the time of the interview. NA #1 stated that she was in Resident #23's room providing incontinence care for Resident #23's roommate on 11/15/25 at 5:40 AM. NA #2 entered the room to provide incontinence care for Resident #23. NA #1 stated she was not assigned to Resident #23 because she would not work with Resident #23. NA #1 stated that she would have another NA provide care to Resident #23. NA #2 worked with Resident #23 on the 11/15/25 7:00 PM to 7:00 AM shift. NA #1 observed NA #2 offer incontinence care to Resident #23 who refused 3 times. When NA #2 requested Resident #23 sign the planned refusal form, Resident #23 became upset and began cursing. NA #1 reported that she stated to Resident #23, are you going to let her change you? At that time, Resident #23 agreed to incontinence care by NA #2. NA #1 did not assist with care but observed Resident #23 had rolled to her right side facing the window when NA #2 tapped gently on Resident #23's left hip to get her to turn over (Resident #23 is hard of hearing so this is how they indicate to her to turn). NA #1 observed Resident #23 roll over onto her back and NA #2 was at the bedside not touching Resident #23 when Resident #23 began yelling you're hurting my organs. NA #1 reported that she told NA #2 to stop and told her to go get Nurse #1. NA #1 indicated that she left the room after completing care for the other resident. NA #1 stated that no one told her that she could not enter the room again or interviewed her about what happened. NA #1 stated her shift ended at 7:00 AM so Resident #23's room was the last round of the shift. A progress note written by Nurse #1 dated 11/15/25 at 6:09 AM revealed the following: Patient reported to this nurse that she feels she was being abused by nightshift aides. Patient stated that aides were speaking to her harshly and handling her in a manner she perceived as rough. Patient was calm but appeared upset while reporting concerns. No signs of physical injury noted at the time. An interview with Nurse #1 was conducted on 11/17/25 at 10:33 AM. Nurse #1 revealed that on the morning of 11/15/25 at 6:00 AM, Resident #23 reported to her she felt like she had been abused by the night shift NAs. Nurse #1 indicated that Resident #23 reported to her that the NAs had turned her roughly but did not report any specifics and could not name the NAs. Nurse #1 stated that she performed an assessment on Resident #23 at that time which was within normal limits. Nurse #1 reported that she told the two NAs on the floor that they needed to stay out of Resident #23's room but that was their last round of their shift and Nurse #1 believed they left at 7:00 AM. Nurse #1 indicated she was not aware of what the NA's names were as she was new. Nurse #1 stated she notified Unit Manager #2 but did not notify the Administrator and thought that Unit Manager #2 had. A telephone interview with Unit Manager #2 was conducted on 11/17/25 at 6:16 PM. Unit Manager #2 reported on the morning of 11/15/25 at 7:00 AM, Resident #23 approached her and reported that staff had scolded her during incontinence care at 5:45 AM that morning. Unit Manager #2 stated that Resident #23 did not report any physical abuse to her at that time, nor report any injury. Resident #23 could not name the NAs but described NA #1. Unit Manager #2 stated she did not instruct the NAs to leave the floor because she was unaware of the abuse allegation, and stated Nurse #1 did not report anything to her. Unit Manager #2 stated that she did not report the allegation to the Administrator. Unit Manager #2 stated she felt it was a minor incident and would discuss it with the Administrator on Monday. Unit Manager #2 stated that she was new to the role of Unit Manager and had not been educated in the supervisory reporting process of the Unit Manager role. Unit Manager #2 indicated she returned to work at 7:00 PM on 11/15/25 into 11/16/25. At 1:00 AM 11/16/25, Resident #23 approached Unit Manager #2 again and showed her a bruise to her left lower abdomen and reported it came from the NAs turning her the previous morning. Resident #23 did not report how the bruising occurred specifically and denied pain. Unit Manger #2 asked Resident #23 if she had reported it, and Resident #23 stated to her someone from administration had been there that day to see her. Unit Manager #2 indicated that Unit Manager #1 had come in the afternoon of 11/15/25 to assess Resident #23. And Resident #23 probably thought that was administration staff. An interview with Unit Manager #1 was conducted on 11/16/25 at 1:42 PM. Unit Manager #1 revealed that she had come in at 3:00 PM on 11/15/25 and Resident #23 reported to Unit Manager #1 that the night shift NAs were rough with her and dug their hand into her side during incontinence care. Unit Manager #1 revealed she did not know what NAs had worked with Resident #23 the night before. At that time, a bruise was noted to Resident #23's left lower quadrant of her abdomen. Unit Manager #1 stated she did not notify the Administrator and assumed Unit Manager #2 had. Unit Manager #1 stated that she was new to the role of Unit Manager and had not been educated in the supervisory reporting process of the Unit Manager role. A review of the initial allegation report revealed an abuse allegation in which NA #1 and NA #2 were allegedly rough with Resident #23 while providing incontinent care at 5:45 AM on 11/15/25. The Administrator was notified of the allegation on 11/16/25 at 1:40 PM. The Administrator notified law enforcement and Adult Protective Services on 11/16/25 at 2:18 PM. The completed initial allegation report was submitted to the State Agency on 11/16/25 at 2:38 PM. A review of staffing schedules revealed the following: NA #1 and NA #2 worked from 11:00 PM on 11/14/25 to 7:00 AM on 11/15/25. NA #1 was scheduled to work from 3:00 PM on 11/1625 until 7:00 AM on 11/17/25. NA #2 was not scheduled to work after 11/15/25 due to scheduled time off. A joint interview with the Regional Nurse Consultant and Administrator conducted on 11/16/25 at 3:32 PM revealed that the Administrator identified NA #3 (agency staff) as the alleged perpetrator of the staff to resident abuse. The agency had been contacted, and NA #3 had been terminated from the facility. This Surveyor revealed to the Administrator that NA #1 and NA #2 were the alleged perpetrators and worked with Resident #23 on 11/15/25 and not NA #3. The Administrator and Regional Nurse Consultant were notified by this Surveyor that NA #1 was in the building preparing to start her shift at that time. The Administrator stated they were not aware that NA #1 was one of the alleged perpetrators or that she was currently in the facility working and would be sent home immediately pending the investigation. The Administrator stated that NA #2 was not working due to scheduled time off and would remain out until the investigation was completed. A subsequent interview with the Administrator was conducted on 11/20/25 at 10:19 AM. The Administrator stated the staff did not inform her about the allegation of staff to resident abuse involving Resident #23 in a timely manner. The incident occurred on 11/15/25 at 5:45 AM and she was notified on 11/16/25 at 1:40 PM. The Administrator stated the staff should have notified her immediately of any suspected or witnessed allegation of abuse or neglect. The Administrator indicated that an investigation would have been immediately initiated had staff notified her when it occurred. The Administrator explained that abuse and neglect training were provided annually to all staff with additional training when needed. The Administrator further added one on one education was provided to staff who did not report the incident within the appropriate time frame. The Administrator indicated that NA #1 and NA #2 had been suspended during the investigation. NA #1 was an agency staff and was terminated from the facility. NA #2 was returning to work on her next scheduled day. The Administrator stated the allegation was unsubstantiated and investigation report had been submitted to the State Agency.

Based on observation, record reviews, and staff interviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within 14 days following hospice election for 1 of 1 resident reviewed for hospice (Resident #73).The findings included:Resident #73 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified dementia, and senile degeneration of the brain.A medical record review revealed Resident #73 was admitted to hospice on 09/19/25 with a primary hospice admission diagnoses of senile degeneration of the brain.A review of Resident #73's MDS assessments revealed a significant change in status MDS assessment was completed on 10/16/25 after the resident was admitted to hospice services. The MDS was coded for hospice care. An interview with the facility MDS Nurse was conducted on 11/20/25 at 10:04 AM. The MDS Nurse stated if a resident was admitted to hospice services, a significant change in status MDS assessment should be completed within 14 days. The MDS Nurse reported that no significant change in status MDS assessment was completed for Resident #73 within the required 14-day period. The MDS Nurse stated that several residents had been admitted to hospice services around the same time and she overlooked the significant change in status MDS for Resident #73. An interview was conducted with the Director of Nursing (DON) on 11/20/25 at 10:34 AM. The DON stated residents admitted to hospice services was considered a significant change and a significant change in status MDS assessment should have been completed within 14 days of hospice admission date.An interview with the Administrator was conducted on 11/20/25 at 11:19 AM. The Administrator stated that a significant change in status MDS should have been completed within 14 days after Resident #73 was admitted to hospice.

Based on observations, record reviews, and Medical Director, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to complete and document thorough assessments of abdominal bruising on a resident that received Plavix (antiplatelet medication) and aspirin daily. The facility also failed to follow physician orders for daily scheduled treatment of surgical wounds. These practices occurred for 2 of 4 residents reviewed for providing care to maintain wellbeing (Resident #23 and Resident #105). Findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses which included type-2 diabetes mellitus with chronic kidney disease, peripheral vascular disease (a condition of decreased blood flow in the lower extremities), and atherosclerotic heart disease (a heart condition caused by plaque buildup in the walls of arteries blocking blood flow to the heart). A review of Resident #23's physician orders revealed the following: Plavix 75 milligrams by mouth daily for peripheral vascular disease Aspirin 81 milligrams by mouth daily for atherosclerotic heart disease Insulin Glargine (long-acting insulin) Pen-Injector (100 Unit/Milliliter) inject 15 unit subcutaneously (under skin) every 12 hours for type-2 diabetes NovoLOG (Regular insulin) Solution Pen-Injector (100 Unit/Milliliter) inject subcutaneously before meals and at bedtime per sliding scale. A progress note dated 11/15/25 at 7:30 PM written by Nurse #1 revealed the following: A large bruise was noted on the left lower quadrant of abdomen. Bruise purple/blue in appearance. An interview with Nurse #1 was conducted on 11/17/25 at 10:33 AM. Nurse #1 revealed that on the morning of 11/15/25 at 6:00 AM, a skin assessment was performed on Resident #23 which revealed no bruising. Nurse #1 stated she did not document that skin assessment in the electronic medical record. Nurse #1 further revealed when she arrived for her next shift on the evening of 11/15/25 at 7:30 PM, Resident #23 reported pain to abdominal area. Nurse #1 visualized the abdominal area and noted a large purple bruise to Resident #23's left lower quadrant of abdomen. Nurse #1 stated she completed a progress note but did not complete measurements or documentation of the skin assessment in the electronic medical record. An interview with Unit Manager #1 was conducted on 11/16/25 at 1:42 PM. Unit Manager #1 revealed that she had come in at 3:00 PM on 11/15/25. Unit Manager #1 stated she assessed Resident #23 and noted a large bruise to the left lower quadrant of Resident #23's left lower abdomen. Unit Manager #1 indicated that she did not complete measurements or documentation of the skin assessment in the electronic medical record. Unit Manager #1 did not complete a progress note. A telephone interview with Unit Manager #2 was conducted on 11/17/25 at 6:16 PM. Unit Manager #2 reported on the night of 11/16/25, Resident #23 stopped to show her the bruising on her abdomen. Unit Manager #2 stated that she did not document completion of the skin assessment in the electronic medical record or complete a progress note. An observation and interview with Resident #23 was performed on 11/16/25 at 11:16 AM. Resident #23 revealed a large area of diffuse (no defined shape) bluish purple bruising to left lower abdomen during the interview. Resident #23 stated that the area was painful and rated her pain level at an 8 out of 10 at that time (zero (0) meaning no pain and 10 meaning the worst pain). An interview with the NP was conducted on 11/18/25 at 3:01 PM. The NP stated that she was notified of the bruised area to Resident #23 on the morning of 11/17/25 and saw Resident #23 in clinic. The NP indicated that she assessed a hematoma (a collection of blood under the skin) to Resident #23's left lower quadrant of abdomen. The NP reported that area was tender per Resident #23 and appeared slightly swollen. The NP stated that the Plavix and aspirin that Resident #23 received daily placed her at risk for bleeding and could have contributed to the bruising. The NP stated Resident #23 also received insulin injections which are commonly administered in the abdominal area and may cause bruising to injection site areas. The NP indicated she ordered an abdominal x-ray and blood work to be performed STAT (immediately) on 11/17/25. The NP reported that labs were received and were within normal limits with no concerns about active bleeding. The abdominal ultrasound was still pending due to the ultrasound company's schedule. A review of laboratory results performed 11/17/25 at 3:00 PM revealed the following: aPTT (activated partial thromboplastin time) (a blood test that measures how long it takes for blood to clot) within normal limits. PT (prothrombin time) (a blood test that measures how long it takes for blood to clot) within normal limits. INR (international normalized ratio) (a blood test that measures how long it takes for blood to clot) within normal limits. CBC (completed blood count) (a routine blood test that measures the number of red blood cells, white blood cells, platelets, and hemoglobin and hematocrit levels) within normal limits. A review of Resident #23's abdominal ultrasound performed 11/19/25 at 8:00 AM revealed no subcutaneous (under the skin) fluid collection to left lower quadrant. An interview with the Director of Nursing (DON) was conducted on 11/19/25 at 11:22 AM. The DON reported that Resident #23 was administered Plavix and aspirin daily. Resident #23 had a large area of bruising noted to her left lower quadrant of abdomen initially noted on 11/15/25 by Unit Manager #1. Unit Manager #1 did not document measurements or assessment of the bruised area in Resident #23's electronic medical record. The NP was notified of the bruising and assessed Resident #23 in clinic on the morning of 11/17/25. The NP ordered blood work and an abdominal x-ray to be performed STAT on 11/17/25. The blood work had been performed and was within normal limits. The abdominal x-ray was performed the morning of 11/19/25 and the results were still pending at time of the interview. The DON stated that nurses should complete documentation of skin assessments when performed and complete a progress note in the electronic medical record. 2. Resident #105 was admitted to the facility on [DATE] with diagnoses which included trans-metatarsal amputation (surgical procedure to remove the forefoot including the metatarsal bone to preserve function of the foot) of the right foot, carbapenem resistant enterobacterales (CRE) (bacteria resistant to one or more antibiotics and could cause serious infection), and type 2 diabetes. Review of surgical wound treatment order for Resident #105 written by the Nurse Practitioner (NP) dated 10/27/25 revealed clean open wound at right foot amputation site with Dakins 0.25% (solution used for cleaning infected and contaminated wounds), pack with Dakins 0.25% fluffed gauze (cotton roll used to cushion wound and secure dressing in place), cover with dry dressing (dry absorbent pad used to cover wound), abdominal pads (ABD)(pads used to absorb discharges from heavily draining wounds) and Kerlix (sterile bandage used to provide protection and manage wound drainage), perform daily and as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 was cognitively intact and required minimal assistance with activities of daily living. The assessment also revealed Resident #105 had surgical wound to the foot, nutrition, and hydration interventions to manage skin problems, surgical wound care, application of medications and dressings, no behaviors or refusals of care. Review of revised care plan dated 11/06/25 revealed Resident #105 had a surgical wound to the right foot and was at risk for infection and complications. Interventions included keeping skin clean and dry as possible, complete treatment as ordered, observing the site for any signs or symptoms of infection, and enhanced barrier precautions per order. Review of November 2025 nursing schedule and daily assignment sheet revealed Nurse #12 was assigned to Resident #105 during first shift (7:00 AM to 7:00 PM) on Saturday 11/01/25 and Saturday 11/08/25. Nurse #2 was assigned during first shift on Saturday 11/15/25. Review of the November 2025 Treatment Administration Record (TAR) revealed Resident #105's daily scheduled surgical wound care was not documented on Saturday 11/01/25, Saturday 11/08/25, and Saturday 11/15/25 as completed. Nurse #12 who was scheduled to work first shift on Saturday 11/01/25 and Saturday 11/08/25, assigned on both dates to Resident #105 was unable to be reached for an interview. An interview was conducted with Resident #105 on (Sunday) 11/16/25 at 11:11 AM. He revealed that he had all of his right toes surgically removed, his right foot wound dressing was supposed to be changed daily, and the dressing had not been changed since Friday 11/14/25. He stated his wound was draining through his bandage and he needed his dressing changed. He revealed earlier this morning he had notified Nurse #2 that his wound was draining and he needed his dressing to be changed, and Nurse #2 had stated that she was not doing wound care and for him to find another nurse to do it. Resident #105 revealed that he currently had a bacterial infection and was afraid that his wound would become infected if his dressings were not changed daily. He stated that since he was admitted to the facility on [DATE], there had been times during the weekends when his wound dressing had not been changed and when he asked the nurse assigned to him (could not recall nurse's name) about changing his dressing they refused. Observation of Resident #105's wound dressing on his right foot revealed the top and bottom of the dressing covering the surgical wound to be soaked through with a wet brown discharge, areas of dried brown discharge, dated Friday 11/14/25, and initialed by the Wound Nurse. An interview with Nurse #2 on 11/16/25 at 11:20 AM revealed she had been assigned to Resident #105 yesterday 11/15/25 and today 11/16/25. She stated Resident #105 had asked her yesterday (11/15/25) and today (11/16/25) about changing his wound dressing but she was a contract nurse who had been working at the facility for one week and did not know anything about resident wound care orders or being responsible for providing wound care, had no plans to perform resident wound care, and any further questions regarding resident wound care could be directed to the Unit Manager. An interview was conducted with Unit Manager #1 on 11/16/25 at 11:25 AM. She stated the facility Wound Nurse performed resident wound care Monday through Friday and nursing staff were responsible for performing wound care scheduled for the evenings and on weekends. She revealed she was not aware of nursing staff refusing to perform wound care or resident wound care not being performed as ordered. UM #1 stated she would investigate why Resident #105's wound care had not been performed as ordered on the weekends and would speak with nursing staff immediately to ensure Resident #105's wound dressing was changed as soon as possible. An interview was conducted with the Nurse Practitioner (NP) on 11/18/25 at 1:29 PM. The NP revealed that she expected the facility nursing staff to follow her wound care orders as written. She stated she also expected the nursing staff to notify her with any questions or concerns regarding any resident's wound care orders and to inform her of any issues involving resident's wounds. The NP revealed Resident #105's wound care should be provided daily and as needed especially if the wound was draining to keep the wound from becoming infected. An interview on 11/19/25 at 9:31 AM with the Director of Nursing (DON). The DON stated she expected the wound treatments to be done as ordered. She stated she also expected that if nursing staff were not able to complete a wound treatment that they notify their nursing supervisor immediately. The DON revealed Resident #105 should have received his wound treatments daily and as needed per his wound orders. An interview was conducted with the facility's Medical Director on 11/19/25 at 4:53 PM. The Medical Director stated that he expected the nursing staff to follow physician orders for dressing changes and wound care. An interview was conducted with the Administrator on 11/20/25 at 11:01 AM. The Administrator revealed that she expected nursing staff to follow all orders, procedures, and protocols for providing resident wound care and should have provided Resident # wound care as ordered. She stated if nursing staff had questions regarding wound care orders or were not able to provide a resident's wound care as ordered then she expected them to inform their supervisor immediately.

Based on record review, and Guardian, staff, Registered Dietician, Nurse Practitioner and Medical Director interviews, the facility failed to provide enteral feedings (method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) per the physician orders for 1 of 3 residents reviewed for nutrition (Resident #63).The findings included: Resident #63 was admitted to the facility on [DATE]. Resident #63 had diagnoses that included diabetes mellitus (DM) type 2, anxiety, major depressive disorder, encounter for attention to gastrostomy (artificial opening in the stomach). Resident #63 had a physician's order dated 6/29/2024 for enteral feeding (method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) for nutren 2.0 (feeding formula) at 46 milliliters (ml)/hour (hr) administered continuously from 9:00 PM to 9:00 AM daily. Resident #63 had a physician's order dated 6/29/2024 for blood sugar checks four times daily before meals and at bedtime for DM. Resident #63 had a physician order dated 2/26/2025 for Lantus (long-acting insulin) inject 20 units subcutaneously at bedtime for diabetes mellitus if Capillary Blood Glucose (CBG) less than 65 only give 10 units. Notify provider if Capillary Blood Glucose (CBG) is less than 60 or greater than 450. This order was discontinued on 10/15/2025 and a new order was written. Review of Resident #63's care plans last revised on 2/27/2025 revealed:Resident was at risk for complications related to the need for an enteral tube feeding secondary to dysphagia and poor po intake with interventions that included check for residual prior to feeding administration, if greater than 120 milliliters (ml) hold feeding for 1 hour and recheck. If residual amount remains over 120ml call provider for further instruction. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had severe cognitive impairment, indicated Resident #63 had a feeding tube, and received a mechanically altered and therapeutic diet and received 51% or more of diet and 501 cubic centimeters (cc)/day or more of fluid through a feeding tube, and weighed 95 lbs. A progress note dated 8/1/2025 written by Nurse #3 revealed Resident #63's blood glucose was 335 milligram/deciliter (mg/dl), tube feeding stopped early to help blood glucose stabilize. During a telephone interview on 11/17/2025 at 4:56 PM Nurse #3 revealed she worked at the facility on the 7:00 PM to 7:00 AM shift and was familiar with Resident #63. Nurse #3 confirmed she had turned off Resident #63's tube feeding early due to high blood sugar on the morning of 8/1/2025. Nurse #3 stated she thought it was nursing judgement. Nurse #3 stated she thought it would be better for the resident to have the tube feeding stopped than have an elevated blood sugar. Nurse #3 would not verify if this was the only time she turned Resident #63's tube feeding off early. On 10/3/2025 Resident #63's had a new physicians order for enteral feeding nutren to increase flow rate by 10ml every 24 hours to a goal rate of 65ml/hr from 9:00 PM to 9:00 AM. During an interview on 11/19/2025 at 8:20 AM Nurse #1 stated she had worked at the facility since September 2025 and currently worked the 7:00 PM to 7:00 AM shift and was familiar with Resident #63. Nurse #1 stated one night in October 2025, she did not recall the specific date, she was concerned about Resident #63 having a high blood sugar over 400, and that it would continue to get higher, and no orders for insulin sliding scale coverage. Nurse #1 stated she asked another nurse, she could not remember which one, what to do and the nurse told her to turn off the tube feeding. Nurse #1 stated she thought the nurse that had told her to turn off the tube feeding, had been turning off the tube feeding early due to high blood sugars, so Nurse #1 turned off Resident #63's tube feeding. Nurse #1 stated she did not document in the electronic medical record or on the MAR that Resident #63's tube feeding had been turned off early. Nurse #1 stated she had reported it to Unit Manager #4 who told her not to turn a resident's tube feeding off early, and no one else talked to her about it. Nurse #1 stated at the time she was more worried that the elevated blood sugar could cause a seizure. During a telephone interview on 11/17/2025 at 10:00 AM, Resident #63's Guardian stated she had concerns that Resident #63's tube feeding was not running the full length of time it was ordered and discussed weight loss Resident #63 experienced. Resident #63's Guardian stated on several visits to Resident #63 around 9:00 AM in morning, the tube feeding was not running. Resident #63's Guardian stated she spoke to the Director of Nursing (DON), a unit manager and the Nurse Practitioner (NP #2) regarding her concerns and did not feel Resident #63's tube feeding had been monitored until she spoke to the facility after Resident #63 experienced weight loss. During a telephone interview on 11/18/2025 at 7:05 AM Unit Manager #4 stated sometime around mid-October Nurse #1 reported to Unit Manager #4 that Resident #63's tube feeding had been held due to high blood sugar, and that other nurses had done it since Resident #63 had no insulin orders for sliding scale coverage for elevated blood sugars. Unit Manager #4 stated she told Nurse #1 that a tube feeding was not supposed to be turned off for elevated blood sugars. Unit Manager #4 stated she reported the information to NP #2 who gave new insulin orders, and she reported the information to the Director of Nursing (DON). Review of Resident #63 clinical note written by NP #2 dated 10/15/2025 read in part: the NP #2 spoke with the DON regarding weight loss concerns from Resident #63's guardian. NP #2 noted it was unclear if tube feeding was not actually running for full 12 hours and that staff would be educated on appropriate administration of tube feeding. The NP #2's clinical note also read in part: Telephone encounter 10/15: Per nurse- TF (tube feeding) was stopped by night shift nurse due to BS 446. Per nursing reports TF gets turned off frequently due to hyperglycemia. Reviewed blood sugars and added SSI. Will continue to monitor blood sugars and adjust plan of care based on changing condition. Will update guardian on new orders. During a telephone interview on 11/17/2025 at 4:29 PM NP #2 stated around the middle of October 2025 the Unit Manager #4 reported that when Resident #63 had elevated blood sugars the nurses had turned off Resident #63's tube feeding instead of calling the provider to get orders for insulin. NP #2 stated she had discussed Resident #63's weight loss with the DON and concerns regarding tube feeding being administered as ordered, and NP #2 thought the nurses had been educated by the DON. NP #2 stated she expected nurses to administer tube feedings as ordered and to notify the provider if a resident had elevated blood sugars. During a telephone interview on 11/17/2025 at 4:13 PM the Registered Dietician (RD) stated she was not made aware Resident #63's tube feeding had been turned off early by nurses but could not say for sure if that alone could contribute to the weight loss. The RD stated if Resident #63's tube feeding was turned off early she would not have received her minimal nutritional needs. The RD stated due to Resident #63's inconsistent intake of pleasure foods and supplements, her nightly tube feeding was determined to provide the minimal nutrition Resident #63 required. During an interview on 11/19/2025 at 4:50 PM the Medical Director (MD) stated having tube feeding cut off early for a short period of time could cause weight loss. The MD stated if the tube feeding had been turned off early long term it had the possibility to cause malnutrition and further damage. During an interview on 11/18/2025 at 8:45 AM the DON stated, she did not recall the specific day that Unit Manager #4 reported that Nurse #1 had turned off Resident #63's tube feeding at 6:00 AM because there were no orders for insulin coverage. The DON stated she went to the NP #2 and the RD when she was made aware and asked why Resident #63 was not on a diabetic tube feeding and got orders for insulin coverage, at this time the amount of nondiabetic tube feeding had been increased due to weight loss. The DON stated she educated Nurse #1 that Resident #63's tube feeding needed to run for the full 12 hours as it was ordered. The DON stated Nurse #1 was a new nurse and the DON was not sure that Nurse #1 knew you can't turn off the feeding early without an order. The DON stated she did not talk to any other nurses regarding tube feeding running the complete time it was ordered because she thought it was only Nurse #1 that had turned it off early. The DON stated she had not been told other nurses had also turned off Resident #63's tube feeding early. The DON was not aware of the progress note from 8/1/2025 that documented Resident #63's tube feeding was turned off early. The DON stated she expected nurses to follow orders and administer tube feedings as ordered. During an interview on 11/20/2025 at 7:10 AM the Administrator stated she expected the nurses to follow orders and administer tube feeding to residents as ordered.

Based on observations, record reviews, and Nurse Practitioner and staff interviews, the facility failed to obtain a physician's order for a resident who was admitted from the hospital on continuous oxygen (Resident #126). The facility also failed to post cautionary signage outside of resident rooms that indicated the use of oxygen for 1 of 5 residents reviewed for respiratory care (Resident #126).Findings included: Resident #126 was admitted on [DATE] with diagnoses that included pneumonia.A review of Resident #126's admission orders revealed that Unit Manager #2 completed the admission.Resident #126's physician orders revealed no order for oxygen use. Resident #126's admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #126 was admitted [DATE] and MDS was in progress at time of review. No oxygen or respiratory information was complete. A review of Resident #126's care plan updated on 11/14/25 revealed a plan for risk of respiratory complications. The stated goal was that Resident #126 would be free from respiratory complications. Interventions included administer oxygen as ordered, monitor for signs of respiratory distress, and check vital signs as needed. a. An observation of Resident #126 in her room on 11/16/25 at 12:41 PM revealed oxygen concentrator in use via nasal cannula at 2 liters per minute. A second observation of Resident #126 in her room on 11/17/25 7:54 AM revealed oxygen concentrator in use via nasal cannula at 2 liters per minute. A third observation of Resident #126 in her room on 11/18/25 7:42 AM revealed the oxygen concentrator in use via nasal cannula at 2 liters per minute. b. An observation of Resident #126 in her room on 11/16/25 at 12:41 PM revealed no cautionary oxygen in use signage was noted outside of Resident #126's room indicating oxygen was in use.A second observation of Resident #126 in her room on 11/17/25 7:54 AM revealed no cautionary oxygen in use signage outside of Resident #126's room indicating oxygen was in use.A third observation of Resident #126 in her room on 11/18/25 7:42 AM revealed no cautionary oxygen in use signage outside of Resident #126's room indicating oxygen was in use.An interview with Medication Aide #1 was conducted on 11/18/25 at 1:08 PM. Medication Aide #1 stated Resident #126 received oxygen continuously. Medication Aide #1 indicated, she did not see an order for oxygen on the medication administration record and indicated she did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms. Medication Aide #1 verbalized she had not noticed that Resident #126 did not have an oxygen in use sign on door.An interview was completed with Unit Manager #2 on 11/20/25 at 7:47 AM. Unit Manager #2 revealed that she could not recall if she completed the admission orders for Resident #126. Unit Manger #2 stated that orders were received from the hospital via discharge paperwork and entered into facility electronic medical record. Unit Manger #2 stated there were many admissions that day, and she could not remember if she initiated Resident #126's oxygen or not. Unit Manager #2 stated whoever initiated the oxygen should have placed the cautionary signage on Resident #126's door. An interview with the Nurse Practitioner (NP) was completed on 11/18/25 at 2:28 PM. The NP stated that Resident #126 was admitted from the hospital, and any orders on discharge paperwork would be entered by the nurse admitting the resident. The NP stated that she assessed Resident #126 on Monday 11/17/25 and stated that she was on oxygen via nasal cannula at time of assessment. The NP stated that Resident #126 had no respiratory difficulty or shortness of breath on assessment. The NP stated she did not know how the order for oxygen got overlooked. An interview was conducted with the Director of Nursing (DON) on 11/20/25 at 10:19 AM. The DON stated that oxygen orders should have been in place for oxygen use for Resident #126 prior to initiating oxygen. The DON further stated that oxygen-in-use cautionary signage should be posted outside the doors of all residents' rooms who used continuous oxygen.

Based on record reviews, observations, Consultant Pharmacist, and staff interviews, the facility failed to discard expired medications in 1 of 1 medication room, failed to store influenza vaccine per manufacturer recommendations, and failed to maintain a refrigerator temperature log for 2 of 2 refrigerators housing medications that required refrigeration.The findings included:1. An observation of the medication room was conducted on 11/19/2025 at 1:45 PM with the Director of Nursing (DON). The observation revealed one medication room that contained 2 small refrigerators. One on the upper counter and one on the lower counter. The observation revealed 8 unopened, expired bottles of magnesium citrate. The expired bottles of magnesium citrate were located on the bottom shelf in the medication storage room. A review of the manufacture's label affixed to the bottles of Magnesium Citrate indicated the expiration date was 10/9/2025 on all 8 bottles. During the observation the DON confirmed the expiration date and stated there should be no expired medications in the medication storage room or in the medication carts. She also stated the bottles of magnesium citrate should have been discarded. The DON further explained that all nursing staff were responsible for checking the medication rooms weekly for expired medications and the bottles of Magnesium Citrate should have been discarded. An interview was conducted with the Administrator on 11/19/2025 at 3:30 PM. The Administrator stated that she expected all expired medications to be discarded and not available for use. 2. Review of the manufacture's storage recommendations that were undated for Seqirus Influenza vaccines (the brand in both refrigerators) indicated that vaccines should be refrigerated between 36-46 degrees Fahrenheit and should not be frozen, any vaccine that is frozen should be discarded immediately. It was recommended that temperatures be checked and recorded in the storage units twice a day. An observation of the upper refrigerator and temperature logs for September 2025 was conducted on 11/19/25 at 1:45 PM revealed a temperature was recorded once daily for 10 out of 30 days, temperatures ranged from 38-42 degrees Fahrenheit. No temperatures were recorded for 20 out of 30 days. The refrigerator contained Seqirus influenza vaccines. These temperatures were within manufacturers' recommendations, but temperatures were not recorded twice daily as recommended. Further observation of the lower refrigerator and review of the logs for September 2025 revealed a temperature was recorded once daily for 10 out of 30 days, temperatures ranged from 38-42 degrees Fahrenheit. No temperatures were recorded for 20 out of 30 days. The refrigerator contained Seqirus influenza vaccines. These temperatures were within manufacturers' recommendations, but temperatures were not recorded twice daily as recommended. An observation of the upper refrigerator and temperature logs for October 2025 on 11/19/25 at 1:45 PM revealed a temperature was recorded once daily for 18 out of 31 days, temperatures ranged from 38-42 degrees Fahrenheit. No temperatures were recorded for 13 out of 31 days. The refrigerator contained Seqirus influenza vaccines. These temperatures were within manufacturers' recommendations, but temperatures were not recorded twice daily as recommended. Further observation of the lower refrigerator and review of logs for October 2025 revealed a temperature was recorded once daily for 18 out of 31 days, temperatures ranged from 38-42 degrees Fahrenheit. No temperatures were recorded for 13 out of 31 days. The refrigerator contained Seqirus influenza vaccines. These temperatures were within manufacturers' recommendations, but temperatures were not recorded twice daily as recommended. An observation of the upper refrigerator and temperature logs for November 2025 on 11/19/25 at 1:45 PM revealed temperatures had been recorded once a day for 2 out of 19 days on 11/10/25 and 11/11/25 and was at 32 degrees Fahrenheit on both days. No temperatures were recorded for 17 out of 19 days. The refrigerator contained Seqirus influenza vaccines. These temperature readings were outside of the manufacture's recommendations for storing these medications. Recommended temperature recordings of twice daily were also not being followed for the month of November. Further observation of the lower refrigerator and review of November 2025 logs revealed temperatures had been recorded once a day for 2 out of 19 days on 11/10/25 and 11/11/25 and was at 32 degrees Fahrenheit on both days. No temperatures were recorded for 17 of 19 days. The refrigerator contained Seqirus influenza vaccines. These temperature readings were outside of the manufacture's recommendations for storing these medications. Recommended temperature recordings of twice daily were also not being followed for the month of November. Observation of the Seqirus influenza vaccine vials revealed vials with clear liquid that had no free-floating particles and no evidence that the liquid had been frozen. An interview was conducted with the Director of Nursing (DON) 11/19/25 at 1:45 PM that indicated she expected staff to record temperatures twice a day, for both refrigerators and report to her or the administrator if temperatures were out of range. She reported all nursing staff were responsible for doing this and she was not aware of the temperature log having holes or temperatures being out of range. An interview with the Administrator on 11/19/25 at 3:30 PM indicated she expected staff to record temperatures for both refrigerators and report any out-of-range temperatures. She reported she was unsure why this was not being done correctly. An interview with facility Consultant pharmacist on 11/20/25 at 10:25 AM. He reported that vaccines were only good for 12 days when not being stored between 36-46 degrees Fahrenheit. He stated that a temperature reading of 32 degrees Fahrenheit would only be a concern if any of the medication had frozen. He reported that the pharmacy expected the facility to keep logs of temperature recordings of all refrigerators twice a day and any temperature outside of the 36-46 degrees Fahrenheit should be reported to pharmacy. He reported that if the vaccine did not freeze during the days the temperature was recorded to be 32 degrees Fahrenheit, then it would still be ok to administer for another four days, since the last known temperature was on 11/11/25.

Based on record review and staff interviews, the facility failed to post accurate Registered Nurse (RN) staffing information for 10 of 79 days reviewed for posted nurse staffing (09/08/2025, 09/09/2025, 09/15/2025, 09/17/2025, 09/19/2025, 10/27/2025, 11/07/2025, 11/14/2025, 11/17/2025, and 11/18/2025).The findings included:The daily posted nurse staffing sheets were reviewed for the period of 09/01/2025 through 11/18/2025 and revealed the following:September 2025 did not have any RN documented as working for all 3 shifts on the following days: 09/08/2025, 09/09/2025, 09/15/2025, 09/17/2025, and 09/19/2025.October 2025 did not have an RN documented as working for all 3 shifts on the following day: 10/27/2025. November 2025 did not have any RN documented as working for all 3 shifts on the following days: 11/07/2025, 11/14/2025, 11/17/2025, and 11/18/2025.Review of employee timecard punches provided by the Administrator verified there had been RN coverage in the building for all the above dates and the RN staffing information posted was incorrect.During an interview on 11/19/2025 at 8:40 AM with the Scheduler, she stated she was responsible for the staff posting and she was unaware of the requirement to adjust the posted staffing information to reflect the actual staff present. She stated she completed the posted staffing sheets ahead of time based on the staff work schedule. She stated when she was off on the weekend or vacation, she completed the posted staffing sheets ahead of time and they were not adjusted to accurately reflect the actual staffing. During an interview on 11/19/2025 at 9:52 AM with the Administrator, she stated she was aware of the requirement to adjust the posted staffing to accurately reflect the actual staff present. She also stated she was unaware this was not being done, and the Scheduler did not know the posted staffing information should be updated with the actual staff on each shift.

Based on record review, and Nurse Practitioner, and staff interviews, the facility failed to provide supervision to prevent accidents when a resident (Resident #1) with left sided weakness, muscle wasting, vascular dementia and at risk for falls fell from the bed in low position on 5/25/2025 and the facility failed to implement a new intervention for fall prevention. The resident had another fall from bed that was not in the low position on 6/1/2025 and was found face down on the floor. Resident #1 was transferred to the hospital for emergency medical treatment where it was discovered Resident #1 had sustained a large scalp laceration with significant bleeding that was cleaned and repaired with staples and a cervical spine (one of the vertebrae of the neck) fracture that required wearing a cervical collar at all times. This deficient practice occurred for 1 of 3 residents reviewed for falls (Resident #1).

Based on observations, and resident, staff, and pest control contractor supervisor interviews, the facility failed to maintain an environment free from of flies in 2 of 2 resident rooms (Resident #2 and #3) on 1 of 4 halls and the kitchen. In addition, the facility failed to notify the pest control contractor of the increased fly activity. Findings included:a. Resident #3 was admitted to the facility on [DATE].Review of Resident #3's Minimum Data Set (MDS) admission assessment dated 7/01/25 indicated he had moderately impaired cognition.An observation on 7/07/25 at 10:20 AM in Resident #3's room noted 6 flies at the same time on the bed and privacy curtain. Resident #3 stated he could not sleep due to flies crawling on him and thought it was an awful environment. He also stated he had reported his concerns about the flies to multiple staff members.b. Resident #2 was admitted to the facility on [DATE].Review of Resident #2's Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated he had moderately impaired cognition.An observation on 7/07/25 at 11:50 AM in room [ROOM NUMBER]'s room noted 3 flies at the same time on the bed and bedside table. Resident #2 stated he had trouble eating since he did not like eating food after he saw flies crawling on his food.c. An observation on 7/07/25 at 12:15 PM in the kitchen revealed 1 fly on a metal cart and 3 flies on the temperature logbook lying on the counter by the food preparation area where food was being plated for the lunch meal. The Dietary Manager stated the pest control service technician had been there recently to treat. She also stated they cleaned between meals and stored the food between meals.An interview on 7/07/25 at 7:33 PM with Nursing Assistant (NA) #1 revealed she had not reported seeing flies in the facility electronic software maintenance system. She stated the Administrator was already aware since it had been mentioned in the facility group chat text messaging. An interview on 7/07/25 at 8:36 PM with NA #2 revealed he knew there was a book at the nurses' station to write maintenance concerns. He had not reported the flies in the facility as it was a known issue.An interview on 7/07/2 at 2:22 PM with the Maintenance Director revealed they had a pest control service company who serviced the facility monthly and as needed for pest control. He also revealed they currently had a fly pest problem which had gotten worse in the last couple of weeks. He stated his first reported fly concern was on 6/20/25. He also stated he had not asked the pest control service technician about other treatment options available to treat the flies. He stated he had not notified his Regional Maintenance Director of the increased number of flies. The Maintenance Director stated he believed the increased presence of flies was a result of the new automatic doors which were installed to allow easier access to the outside courtyard and smoking area. He stated he had recently had them adjusted to close faster. He stated about a year ago, the facility started utilizing an electronic software program where staff reported maintenance concerns. He stated based on this electronic software program, the first reported flies were reported on 6/20/25, but the report did not provide any further details.An observation was conducted on 7/07/25 at 9:30 AM of the automatic doors exiting the facility into the smoking area and courtyard. The automated doors opened with a hand wave sensor. No air curtain was observed to engage when the door was opened.Observations conducted on 7/08/25 at 5:55 AM and at 6:15 AM both revealed the left side of the automatic door was not fully closed and there was an open area of approximately 3 inches between the door and the door frame.Review of the pest control summary sheets on 7/07/25 at 2:25 PM, was conducted in conjunction and in the presence of the Maintenance Director. The review of the summary sheets revealed the pest control service had been to the facility and provided pest control services most recently on 6/23/25, 6/20/25, 5/27/25, and 4/24/25. The pest control summary sheets all noted flies in multiple locations and had recommendations which read in part the insect light traps in multiple locations were not working properly and needed to be replaced. The Maintenance Director stated he thought the insect light traps were working properly. He also stated insect light traps had been ordered for the kitchen. An observation on 7/7/25 at 2:30 PM with the Maintenance Director of the 5 insect light traps. Each resident hall had an insect light trap mounted on the wall and 1 insect light trap was located at the nurses' station. Dead bugs were observed on the sticky trap sheets inside the machines. All the light traps had stickers which read the bulbs were replaced on the date of 3/25/24.An interview on 7/08/25 at 9:23 AM with the Pest Control Contractor Supervisor revealed he had not received any reports of increased fly activity from the facility. He stated this facility was noted to have fly activity on a regular basis. He also stated there were additional treatments which could have been done if they had been aware of the increased fly activity at the facility. An interview on 7/08/25 at 10:42 AM with the Administrator revealed she was aware of the fly problem and had requested the pest control service technician to come to the facility last week for fly treatment but did not know if he had come or not. She also revealed the facility had ordered an air curtain to be placed at the automatic door to help prevent pests from entering the facility through that door. She stated there should not be fly problems when residents were trying to sleep or eat.

Based on observation, record review, staff, pharmacist and Nurse Practitioner interviews, the facility failed to prevent a significant medication error when an ordered medication was not available to be administered and when Medication Aide (MA) #1 pulled an incorrect dose of a potassium supplement and crushed and administered the potassium supplement that was labelled as a do not crush medication for 1 of 3 residents reviewed for medication errors (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease on hemodialysis, other specified disorders of the brain, secondary hyperparathyroidism of renal origin, and dysphagia oral phase.Review of Resident #4's hospital records prior to admission revealed the following lab results:On 6/4/2025 a Potassium level of 3.8 (Normal range 3.5-5.2)On 5/30/2025 a Potassium level of 3.9, a Calcium level of 9.6 (normal range 8.5-10.2), Phosphorus 2.7 (Normal range 2.5-4.5)Review of Resident #4's care plan 6/6/2025 revealed resident was care planned at risk for cardiac complications secondary to chronic kidney disease with interventions that included administer medication as ordered. Review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact and indicated Resident #4 received hemodialysis.A. Review of a Physician's order dated 6/4/2025 stated Cinacalcet HCL (cinacalcet mimics the action of calcium in the body and is used to treat hyperparathyroidism with chronic kidney disease and also helps regulate calcium and phosphorus levels which reduce the risk of bone disease and cardiovascular issues) 60 milligrams (mg) tablet take one tablet by mouth once daily with food.Review of the Medication Administration Record (MAR) for June 2025 revealed cinacalcet HCL 60mg daily was coded as not available to be administered to Resident #4 as scheduled on 6/19/2025 and 6/23/2025.Review of the MAR for July 2025 revealed cinacalcet HCL 60mg daily was coded as not available to be administered to Resident #4 as scheduled on 7/3/2025 and 7/7/2025. On 7/7/2025 at 9:06 AM Medication Aide (MA) #1 was observed as she prepared Resident #4's medications. MA #1 noted that Resident's cinacalcet 60mg was not available and MA #1 was observed as she reported the unavailable medication to Nurse #3. MA #1 was asked prior to administering the medications if she had completed pulling Resident #4's medication. MA #1 confirmed she had all of Resident #4's medication and was ready to administer them.During an interview on 7/7/2025 at 9:15 AM MA #1 stated Resident #4's cinacalcet 60mg had been unavailable on other days as well and she had asked the nurses to reorder it.During an interview on 7/8/2025 at 11:54 AM Nurse #3 stated MA #1 had reported that Resident #4 did not have any cinacalcet available. Nurse #3 stated she called and reported the unavailable medication to the dialysis center.During an interview on 7/8/2025 at 9:03 AM the Pharmacist stated that seven tablets of cinacalcet 60 mg had been sent to the facility from the pharmacy on 6/5/2025, 6/11/2025 and 6/23/2025. The Pharmacist stated that medication (cinacalcet) was supposed to be supplied from the dialysis center, but they had sent a week supply when the facility requested to try to help the facility have a supply until it was received from dialysis center. The Pharmacist stated missing doses of cinacalcet may cause a difference in residents serum lab values. During an interview on 7/8/2025 at 10:24 AM the Dialysis Charge Nurse stated the facility had called the week prior for a refill of Resident #4's cinacalcet and it had been processed for refill. The Dialysis Charge Nurse stated the facility would receive the medication by mail and it was likely in transit.B. Review of a Physician's order dated 6/5/2025 stated Potassium Chloride Crys ER (extended release) (extended-release potassium chloride is used to treat or prevent low potassium levels. It is crucial for proper functioning of the heart, muscles, kidneys and nervous and digestive systems) 20 milliequivalents (MEQ) tablet extended release take two tablets by mouth once daily for supplement.On 7/7/25 at 9:06 AM MA #1 was observed as she pulled one tab of potassium chloride 20 MEQ and placed it in a medication cup for Resident #4. MA #1 completed preparing Resident #4's medications and put several medications in a plastic sleeve to crush them. MA #1 was asked prior to crushing the medications if she had completed pulling Resident #4's medication. MA #1 confirmed she had all of Resident #4's medication and was ready to administer them. The MA #1 and surveyor reviewed Resident #4's order for potassium chloride and verified the order read to administer two tablets of potassium chloride 20 MEQ. MA 1 stated she had missed that and only pulled one tablet and verified she would have administered an incorrect dose. MA#1 pulled a second potassium chloride 20 MEQ tablet, placed it into a plastic sleeve and crushed the two potassium tablets along with several other medications and administered Resident #4 the medications that had been prepared.During an interview on 7/7/2025 at 9:15 AM MA #1 verified she had prepared an incorrect dose of potassium chloride for Resident #4. During a follow up interview on 7/8/2025 at 9:45 AM MA #1 verified she had crushed the potassium chloride tablets and administered them to Resident #4. MA #1 verified that the card that contained Resident #4's potassium chloride had a sticker that read DO NOT CRUSH and she stated she should not have crushed the potassium chloride tablets. Review of Resident # 4's physicians orders revealed there was not instructions that read DO NOT CRUSH in the medication profile in the electronic record.During an interview on 7/7/2025 at 4:50 PM the Clinical Nurse Consultant stated medications that were not supposed to be crushed would have DO NOT CRUSH prepopulated into the medication instructions through the computer system. The Clinical Nurse Consultant stated, potassium can't be crushed so it will automatically show on the MAR. The Pharmacist stated only certain formulations of Potassium could be crushed. The Pharmacist stated the formulation used by Resident #4 was not supposed to be crushed. The Pharmacist stated they do not prepopulate DO NOT CRUSH instructions into medication instructions in the electronic medication profile but the cards of medications would have a sticker that read DO NOT CRUSH for any medication that was not supposed to be crushed. The Pharmacist stated receiving a lower dose of potassium chloride had the potential to cause a change in serum blood levels.During an interview on 7/8/2025 at 11:00 AM the Nurse Practitioner (NP) stated it was significant for a dialysis resident to miss doses of cinacalcet and to receive an incorrect dose of potassium chloride. The NP stated that medications were ordered for a reason and should be administered as ordered. The NP stated cinacalcet was prescribed to help control calcium levels and missing doses could affect those levels. The NP stated if a resident received an incorrect dosage of potassium, it could alter the levels in the blood, and it should not be crushed because it affected the absorption rate.During an interview on 7/8/2025 at 11:45 the Unit Manager #1 stated she was not aware Resident #4 did not have her cinacalcet available to administer. The unit manager stated she knew it was provided by the dialysis center. The Unit Manager #1 stated medication instructions could be entered into the medication profile under instructions. The Unit Manager #1 verified medications that were not supposed to be crushed would have a sticker on the packaging that read DO NOT CRUSH. During an interview on 7/8/2025 at 12:40 PM Director of Nursing (DON) stated she expected that a pill labeled DO NOT CRUSH would not be crushed, and that if a resident was unable to swallow a pill that could not be crushed a different form of the medication should be ordered. The DON stated she expected residents to receive medications as ordered and if two tablets were ordered, two tablets should be administered. The DON stated she expected medication ordered for the resident to be available to be administered as ordered.During a joint interview on 7/8/2025 at 12:45 PM the Clinical Nurse Consultant and Administrator stated they expected the correct dosage of medication to be administered as ordered and that medications that were not supposed to be crushed would not be administered crushed. The Administrator and Clinical Nurse Consultant stated they expected medications ordered for the resident to be available to be administered to the resident but knew there was some adjustment since some medications were now being provided by the dialysis center and not the facility pharmacy.

Based on record review, interviews with staff, Nurse Practitioner (NP), Medical Director, Drug Enforcement Administration (DEA) agent, Adult Protective Services (APS) Supervisor, and hospital Social Worker the facility failed to protect Resident #1's right to be free an injury of unknown source; and abuse/neglect. During the investigation the source of injury to Resident #1 was not observed by anyone, the source of injury could not be explained by the resident, and the injury was suspicious due to the unexplained rapid change in condition that was later identified as dehydration, therefore no perpetrator was identified. Resident # 1 was dependent on staff. On 01/27/2025, Resident #1's family member was visiting with the resident. The family member came out in the hallway and yelled that Resident #1 had a seizure. Nurse Practitioner (NP) and Nurse #1 responded immediately. Resident #1 was assessed and found to be leaning towards the right side of the bed. Resident #1 had vital signs which were within normal limits. The resident was transferred to the hospital via Emergency Medical Services (EMS) who noted the resident to have pinpoint pupils, a sign of an opioid overdose. At the hospital Resident #1 had a positive urine drug screen for Fentanyl (an opioid pain medication that can be lethal) and Methylenedioxymethamphetamine (MDMA) (an illegal stimulant commonly known as ecstasy). Resident #1 did not have a physician's order for Fentanyl. The resident was admitted to the hospital with severe dehydration, a side effect of MDMA. Resident #1 was hospitalized for 4 days. This deficient practice affected 1 of 3 residents reviewed for resident abuse/injury of unknown origin. Immediate jeopardy began on 01/27/2025 when the facility failed to protect Resident #1's right to be free from an injury of unknown source; and abuse/neglect. Immediate jeopardy was removed on 02/08/2025 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident, dementia, seizure disorder, and hypertension. Review of Resident #1's baseline care plan dated 01/20/2025 revealed Resident #1 was care planned for being at risk for complications related to severe cognitive impairment with interventions to observe for changes in cognition. Resident #1's care plan also indicated she was receiving tube feedings and had a history of seizures. Review of Resident #1's physician's orders dated 01/20/2025 revealed Resident #1 had orders for: 1. NPO (nothing by mouth) 2. Keppra 1000 milligrams (mgs.) twice a day for seizures via feeding tube. 3. Acetaminophen 650 mgs. every 6 hours as needed for pain via feeding tube. There was no physician's order for Fentanyl. Review of the NP's visit note date 01/20/2025 revealed Resident #1 was receiving Osmolite (a nutritional formula use for tube feeding) 1.5 calories/milliliters (cal./mls.) four times day and Resident #1 was tolerating the tube feedings without any gastrointestinal distress. The NP's note also revealed Resident #1 was very pleasant, alert and able to follow simple commands. Resident #1 kept her eyes closed during the conversation. Review of the nutritional assessment dated [DATE] revealed Resident #1 was 66 inches tall and weighed 142.0 pounds (lbs.). Resident #1 was alert and received nothing by mouth. Resident #1 was receiving bolus (large volume of formula given at once, several times a day) tube feedings of 275 ml. of Osmolite 1.5 cal./mls. four times a day. Resident #1 was also receiving 75 ml. of water flushes before and after each bolus feeding. The assessment also indicated Resident #1 was receiving her estimated daily nutritional and water needs for calories, protein, and free water via from her tube feedings. Review of the facility physician's admission visit note dated 1/22/2025 revealed Resident #1 was sitting up in chair and in no acute distress. Resident #1's abdomen was soft, non-distended, and non-tender with a percutaneous endoscopic gastrostomy (PEG) (feeding tube) present in the left upper quadrant of her abdomen. No tremors or deficits were noted. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severely impaired cognition with no behaviors. Resident #1 was dependent with all Activities of Daily Living (ADL). The MDS also indicated Resident #1 was receiving tube feedings. The MDS also indicated that Resident #1did not receive an opioid during the assessment reference period. Review of Resident #1's Medication Administration Record (MAR) for January 2025 revealed Resident #1 received her bolus tube feedings and water flushes as ordered by the physician each day while present in the facility. The MAR also indicated Resident #1's tube feeding residuals (amount of tube feeding remaining in the stomach after a tube feeding) were checked every shift and no residual feedings were obtained. Review of Resident #1's electronic medical record (EMR) revealed Resident #1 did not go out of the facility on a leave of absence from 01/20/2025 to 01/27/2025. There was no evidence in Resident #1's medical record of a social history of drug abuse. Review of a nursing note dated 01/27/2025 at 3:36 PM revealed Resident #1's family was in her room and called for the nurse and NP. The family member stated Resident #1 had a seizure. Resident #1 was difficult to arouse. The NP gave orders to transfer Resident #1 to the emergency room (ER). Resident #1 was transferred via Emergency Medical Services (EMS) to theER on [DATE] 12:23 PM. Review of the facility's initial allegation report completed by the Administrator on 01/29/2025 revealed the facility became aware of an incident involving Resident #1 when local law enforcement, the DEA Agent, and APS came to the facility to report that Resident #1's family member alleged the staff of the facility provided Resident #1 with Fentanyl and MDMA. Review of the facility's investigation report completed and signed by the Administrator on 02/06/25 read in part, on 1/29/25 local law enforcement detectives (law enforcement and DEA detective) informed the facility of the allegations and began an investigation with cooperation of the facility An interview was conducted with NA #1 on 02/05/2025 at 11:15 AM. NA #1 was not aware of any incident concerning Resident #1. NA #1 stated that she only did vital signs on Resident #1 before starting her assigned rounds on 01/27/2025 around 8:00 AM. NA #1 revealed that she spoke to Resident #1 and asked to get Resident #1's blood pressure (BP). Resident #1 looked at NA#1 and extended her arm for Resident #1's BP to be taken, then Resident #1 closed her eyes like she was going back to sleep. NA#1 took her vital signs, turned the lights out and left Resident #1's room. An interview was conducted with NA #2 on 02/05/2025 at 11:34 AM. NA #2 stated that on the morning of 01/27/2025 around 10:00 AM, she went into Resident #1's room to provide resident care and Resident #1 was asleep. NA #2 stated that she woke Resident #1, and Resident #1 smiled at her. NA #2 stated that she bathed, dressed, and provided mouth care for Resident #1. NA#2 also stated that shortly after that, she saw Resident #1's nurse go into Resident #1's room to give Resident #1 her medications and tube feeding. NA #2 further revealed that around 11:15 AM, she saw Resident #1's family members go into Resident #1 room. NA #2 stated that she went to lunch about 11:30 AM and when she came back from lunch around 12:00 PM, she was told that Resident #1 was sent to the hospital. An interview was conducted with Nurse #1 on 02/05/2025 at 11:54 AM. Nurse #1 stated that on 01/27/2025 at approximately 11:00 AM she entered Resident #1's room and administered her medications and tube feeding. Nurse #1 stated that Resident #1 was lying in bed with her eye closed and Resident #1 was moving her sheets up closer to her face. Nurse #1 stated that Resident #1 tolerated her medications and tube feeding and voiced no complaints. Nurse #1 further stated that no family members were present during the medication administration or tube feeding. Nurse #1 stated that around 12:00 PM she was standing in the 100 hallway with the NP and a family member came out of Resident #1's room and yelled that Resident #1 was having a seizure. Nurse #1 stated she and the NP ran to Resident #1's room and found Resident #1 lying in bed and leaning towards her right side. The NP asked Resident #1 if she was in any pain and Resident #1 pointed to her head. Nurse #1 also stated she did not observe any facial drooping. Nurse #1 stated that the NP instructed her to call 911 and have Resident #1 sent to the ER. Nurse #1 stated she called EMS and then Nurse #1 and the NP lifted Resident #1 up in bed. Nurse #1 explained that EMS arrived, and they asked if Resident #1 was taking any narcotics and Nurse #1 said No, Resident #1 only takes Tylenol for discomfort. An interview was conducted with the NP on 02/06/2025 at 8:00 AM. The NP stated that she was very familiar with Resident #1. The NP stated that during her first encounter with the family member on 01/21/25 the family member requested that Resident #1 be put back on Prozac (anti-depressant) and Hydroxyzine (anti-anxiety medication) for her behaviors. The NP stated that she researched Resident #1's hospital records, contacted Resident #1's previous Home Health Agency, and also reviewed Resident #1's discharge summary from another long-term care facility to find out more information about Resident #1's medications including the Prozac and Hydroxyzine. The NP stated that there was no documentation or records which indicated Resident #1 was ever ordered Prozac or Hydroxyzine. The NP also explained that during her 2nd conversation 01/23/25 with Resident #1's family member, the family member stated that Resident #1 had been taking Oxycodone (pain medication) but later in the same conversation, the family member stated that Resident #1 did not take strong pain medications. The NP stated that she visited Resident #1 on 01/24/2025 and Resident #1 was sitting up in the chair in the hallway. The NP explained that Resident #1's hair was beautiful, her eyes were open, she was pleasantly confused and followed all commands. The NP stated Resident #1 was having a very good day. The NP also stated that Resident #1 had no visitors on 01/24/2025 at the time the NP was in Resident #1's room. The NP explained that on the following Monday on 01/27/2025 at about 11:50 AM Resident #1's family member came out into the hallway and yelled that Resident #1 had just had a seizure. The NP further explained that she and Nurse #1 went into Resident #1's room and found Resident #1 leaning toward the right side of the bed away from the family members. The NP further stated that the family member stated that Resident #1 did something funny with her left hand. The NP asked the family member if Resident #1 lost consciousness and the family member replied, No. The NP assessed Resident #1 and found Resident #1 to be alert and able to follow commands. The NP asked Resident #1 if she was having pain and Resident #1 held her chest with her hand but said that her head was hurting. The NP also revealed that Resident #1's vital signs were taken, and the vital signs were normal. The NP also stated that her assessment revealed Resident #1 was afebrile and had no facial drooping. The NP stated that she asked Nurse #1 to call EMS and have Resident #1 sent to the ER for evaluation of a possible stroke. The NP stated that she did not think Resident #1 had a seizure as Resident #1 did not have any signs or symptoms of seizure activity. The NP explained that EMS arrived, and they asked if Resident #1 was taking any narcotics and Nurse #1 said No, Resident #1 only takes Tylenol for discomfort. The NP stated that Resident #1's medication list was given to EMS personnel. Review of the ER physician's note dated 01/27/2025 at 1:39 PM revealed Resident #1 presented to the ER for evaluation of altered mental status (AMS) and possible seizure activity. Resident #1's family member was present and provided Resident #1's health information. The family member also revealed that when she arrived at the long term care facility today, Resident #1 was unresponsive, and her left arm had episodes of shaking which the family member thought was a seizure. The family member also stated that EMS personnel arrived at the facility and was concerned that Resident #1 had been given opioids (pain medication) because her pupils were pinpoint. The family member further explained that EMS administered Narcan (medication used to reverse an opioid overdose) and there were no changes to Resident #1's mental status. The family member also stated that Resident #1 should not be on any narcotic pain medications. Review of the ER physician's physical examination dated 01/27/2025 at 1:39 PM revealed Resident #1 had decreased responsiveness and an altered mental state with chronic right-sided weakness from a previous stroke. Resident #1 had pin-point pupils, dry mucous membranes, and was moving extremities without difficulty. There was no abnormal tone or obvious gross motor or sensory deficits. Review of the Comprehensive Metabolic Panel (a blood test that measure different substances in the blood) dated 01/27/2025 at 1:50 PM revealed Resident #1 had the following abnormal values which are indicators of severe dehydration: 1. Serum Sodium level of 168 milliequivalents per liter (mEq/l). Normal serum Sodium levels range from 135 to 145 mEq/l). 2. Blood Urea Nitrogen level of 67 milligrams/deciliter (mg/dl). Normal serum BUN levels range from 7-20 mg/dl. 3. Serum Creatinine level of 2.30 mg/dl/ Normal serum creatinine levels range from 0.6-1.1 mg/dl. Review of Resident#1's urine drug screen dated 01/27/2025 at 1:51 PM revealed Resident #1 was positive for Fentanyl and MDMA. Review of the ER physician's progress noted dated 01/27/2025 at 4:34 PM revealed Resident #1 was hypernatremic (elevated serum sodium level) raising concerns for severe dehydration and Resident #1's urine drug screen was positive for Fentanyl and MDMA. The ER physician contacted the hospital case manager and Adult Protective Services (APS) due to concerns with Resident #1's severe dehydration and positive urine drug screen. A telephone interview was conducted with the hospital SW on 02/06/2025 at 9:25 AM. The SW confirmed Resident #1 had a positive urine drug screen for Fentanyl and MDMA while in theER on [DATE]. The SW stated that the local police department, the DEA, and APS were notified. The SW stated that Resident #1 stayed in the hospital for 4 days and was discharged home with a family member. The SW also stated that Resident #1's family member did not want Resident #1 sent back to the nursing home. An additional interview was conducted with the NP on 02/06/2025 at 10:00 AM. The NP stated that MDMA would cause severe dehydration, confusion, depression, anxiety and paranoia. The NP also stated that Fentanyl would cause sedation. The NP further added that these drugs could be fatal for anyone and just touching Fentanyl could be deadly. The NP also explained that these drugs would induce dehydration very rapidly; especially in the elder population and abnormal hand/arm movements could also be a result of taking these drugs. A telephone interview was conducted on 02/06/2025 at 10:20 AM with the DEA agent who was investigating the report. The DEA agent stated that he and local law enforcement went to the facility and conducted recorded interviews with all staff at the facility who were working on 01/27/2025. He also stated that he had no concerns with the staff at the facility but had concerns with a family member who had a criminal history and who was currently under investigation. He further stated that all investigation efforts were directed toward the family member. The DEA agent further revealed that there was a street drug circulating in the community which was in powder form and contained a mixture of Fentanyl and MDMA. The DEA agent also stated that his interviews with the staff included asking about the presence of a powder near or around Resident #1's nose, mouth, or gums. The DEA agent stated that no staff member observed a powder near or around Resident #1's nose, mouth, or gums. The DEA agent also explained that MDMA would make an individual dehydrate rapidly. A telephone interview was conducted with the APS supervisor on 02/06/2025 at 11:05 AM. The APS supervisor stated that APS received two referrals on 01/27/2025 regarding Resident #1. The first referral was in reference to Resident #1 being severely dehydrated and the second referral was in reference to Resident #1 having had a positive urine drug screen for Fentanyl and MDMA while being treated in the ER. The supervisor also stated that APS had conducted a facility visit at the nursing home as well as a hospital visit on 01/28/2025. The visits included document reviews of Resident #1 health records and multiple staff interviews. An interview was conducted with the Administrator on 02/06/2025 at 2:30 PM. The Administrator stated that she had no knowledge of the incident occurring with Resident #1 until local law enforcement, the DEA agent, and APS arrived at the facility and told her that Resident #1 had a urine drug screen at the hospital which was positive for Fentanyl and MDMA. The Administrator stated that the facility worked in cooperation with all agencies investigating the incident. The Administrator stated that Resident #1 was admitted to the facility on Monday 01/20/2025. The Administrator explained that Resident #1's family member randomly told her on 01/21/25 that Resident #1 was not on Oxycodone and that Resident #1 normally did not take Oxycodone, but another hospital had ordered it, and the family member stated that she had discussed Resident #1's medications with the NP. Resident #1's family member told the Administrator on 01/21/25 that she and the NP both agreed that Tylenol would be used for Resident #1's pain. The Administrator further stated that 2 days later on 01/23/25 an admission meeting was held with the family member and during the meeting the family member had several concerns about Resident #1's medications (Prozac, Hydroxyzine, and Oxycodone) not being ordered. The Administrator stated that later that afternoon on 01/23/25 she received a call from the NP regarding Resident #1. The NP told the Administrator on 01/23/25 the family member wanted Resident #1 placed back on Prozac and Hydroxyzine and that Resident #1 had not taken these medications in a very long time and the NP stated that she did not think Resident #1 needed them. The Administrator told the NP that she did not have to order the medications unless they were medically necessary. The Administrator further explained that the NP also told her that two days after the family member asked her not to give Resident #1 Oxycodone; the family member approached her again and asked her to order it. The Administrator revealed that the NP stated that she did not know what was going on with Resident #1's family member but she was not comfortable ordering any of these medications. The Administrator stated that the NP did not order the medications. The Administrator was notified of immediate jeopardy on 02/06/2025 at 2:40 PM. The facility provided the following credible allegation of immediate jeopardy removal plan. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to protect Resident #1's right to be free from abuse/neglect/injury of unknown source. On 01/27/2025, Resident #1 was being visited by a family member. The family member alerted the staff that Resident #1 was having a seizure. The Nurse Practitioner was in the facility. The NP and Nurse #1 went to access Resident #1. The NP gave orders to transfer Resident #1 to the emergency room for evaluation. Resident #1 was admitted to the hospital with a diagnosis of possible new stroke and dehydration. Review of Resident #1's hospital records revealed a positive urine drug screen. Law enforcement and Adult Protective Services were notified by the hospital emergency room . Local law enforcement and local adult protective services (APS) notified the facility of the findings. The facility initiated an investigation when receiving this information. Resident #1 was transferred from the facility to the hospital on 01/27/2025. Current residents that have visitors are at risk. A review of current resident progress notes of the last 7 days was conducted by the nursing leadership team and reviewed for changes in condition and abnormal behaviors that have not been addressed. This review was completed on 02/06/2025. The kiosk will be audited on 02/07/2025 for the last seven days of visitors and the residents identified were audited for signs and symptoms of acute episodes. This is completed by the Administrator and Director of Nursing. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Education was started by the Director of Nursing on 02/06/2025 to current staff including all departments on monitoring for behaviors of any visitors outside of the normal expected behaviors both physical and mental. This education will be completed on 02/06/2025. Employees not receiving this education will not be allowed to work until the education is received. The Staff Development Coordinator will track the education to ensure that current staff have received. Education was started by the Director of Nursing on 02/06/2025 to current staff including the abuse policy that included injury of unknown source, of what is considered abuse and who to report suspected abuse to and that there will be no tolerance for illegal substances. This education will be completed on 02/06/2025. Employees not receiving this education will not be allowed to work until education is received. The Staff Development Coordinator will track the education to ensure that current staff have received. Education to agency staff will be completed when they enter for their shift by the charge nurse on duty. A statement is being added to the kiosk that visitors sign in on when they enter the building that states that I acknowledge the statement: No firearms or illegal substances while on premises. This statement was added to the kiosk that visitors use to sign in on 02/06/2025 by the Striv360 company. The Striv360 company is who is responsible for making changes to the kiosk. A member of corporate leadership team communicates the changes that are needed for the Striv360 kiosk. All visitors are required to sign in at the front door. This is the only entrance that visitors are allowed to access. The Administrator of the facility gets a notice of all kiosk sign ins by email and monitors to ensure the acknowledgement has been checked. The Administrator can login to the kiosk system and ensure that the acknowledgement was checked by all visitors that sign in. A sign is being placed in the front entrance that states no firearms and no illegal substances while on the premises. This sign was placed on 02/06/2025 by the maintenance director. The signage placed was created and laminated. This signage was placed on all doors that someone could enter the facility from. This sign was placed on doors by the maintenance director on 02/07/2025. Alert and oriented residents will be notified by the Administrator or designate on 02/07/2025 that there is no tolerance for abuse including illegal substances. This will be done verbally. Resident that are not alert and oriented, the responsible parties will be notified by telephone by the Administrator or designee on 02/07/2025. Staff members will be notified via mass message that is sent to the employee's cell phone via the payroll system regarding there will be no tolerance for abuse including illegal substances. This will be completed 02/07/2025 by the Human Resource Manager. Alleged Date Of IJ Removal: 02/08/2025 On 02/10/2025 the credible allegation for the immediate jeopardy removal was validated and the IJ removal date of 02/08/2025 was confirmed. A review of the audit tool of current resident's progress notes was conducted on 02/10/2025. This review included changes in resident condition and any abnormal behaviors. No new changes in condition or abnormal behaviors were found. A review of the audit tool of the kiosk visitor log was conducted on 02/10/2025. The audit revealed that all residents who had visitors were monitored for signs and symptoms of acute episodes. No residents were identified as having acute episode. A review of the in-service education records was conducted on 02/10/2025. The education was provided to all staff in the facility on monitoring for behaviors of any visitors outside of the normal expected behaviors both mental and physical. The education also included the facility's abuse/neglect/injury of unknown source policy and what is considered to be abuse and who to report suspected abuse/neglect/injury of unknown source to. The education also included that the facility has no tolerance for illegal substances. The education was provided by the Director of Nursing. Employees who had not received this education were not allowed to work until the education was completed. The Staff Development Coordinator has been responsible for tracking the education to ensure compliance. Agency staff completed the education when they entered the facility for their shift by the charge nurse. A review of the kiosk acknowledgement statement was conducted on 02/10/2025 and revealed when visitors sign in on the kiosk upon entry into the facility they acknowledge the following statement on the kiosk. No firearms or illegal substances while on premises. A review of the front entrance door was conducted on 02/10/2025 and revealed an 8 inch by 10 inch laminated sign which read, No firearms and no illegal substances while on the premises. Interviews with alert and oriented residents revealed they received education regarding there is no tolerance for abuse in the facility including the use of illegal substances. Interviews with responsible parties revealed they had received education regarding no tolerance for abuse in the facility including the use of illegal substances. Interviews with nursing staff, therapy staff, housekeeping staff, dietary staff, and the administrative staff revealed they had received email notification from the facility regarding no tolerance for abuse and the use of illegal substances. The staff also stated they had received education on monitoring residents and visitors behaviors and to report any suspicious behaviors immediately to Administration. Staff also reported that they had received education on the abuse policy including what is considered to be abuse and who to report suspected abuse to.

Based on record review and interviews with staff and residents, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of three residents (Resident (R) 1) reviewed for abuse. R2, who had severe cognitive impairment, hit R1 in the back of the head with his fist after a dispute over a TV channel. Findings included: Review of R1's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R1 admitted to the facility on [DATE] with diagnoses including other speech and language deficit, abnormalities of gait and balance, and intellectual disabilities. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/24, revealed a Brief Interview for Mental Status (BIMS) could not be completed due to the resident rarely being understood. Review of R2's Admission Record, located in the Profile tab of the EMR, revealed R2 admitted to the facility on [DATE] with diagnoses including major depressive disorder and cognitive communication deficit. Review of R2's quarterly MDS, with an ARD of 10/01/24, revealed a BIMS score of five out of 15, which indicated severe cognitive impairment. Review of R2's Care Plan, located under the Care Plan tab of the EMR and dated 07/31/24, revealed the resident did not have a care plan related to aggressive behaviors. Review of ''Nurse's Notes, located in the EMR under the ''Notes'' tab, revealed no documentation related to the incident that occurred on 10/12/24 between R2 and R1. Review of an Investigation Summary and Conclusion, completed by the Administrator and dated 10/15/24, revealed R2 admitted to hitting R1 on the head and calling him a derogatory name on 10/12/24 due to R1 changing the TV channel. R1 was assessed to have no injuries; however, there was no documentation of a skin assessment. The investigation concluded the incident did occur; however, the facility did not substantiate abuse due to R2's mental status. During an interview on 10/28/24 at 3:20 PM, R1 was asked what happened between him and R2 on 10/12/24. R1 pointed outside, said he (meaning R2) was there, always walked, and then R1 took a closed fist and put it up against the side of his head. R1 was unable to provide any specifics, but said they know what it is. He said it's the next room, the tv right there, and R1 pointed to the TV room. He said he sees him, referring to R2, walking in hallway, said he was a nice fell ow, and this was the first time this had happened. During an interview on 10/29/24 at 1:20 PM, R2 said that on 10/12/24, a male came into the dining room while he was in there watching tv and went over to the TV to change the channel. He said he told the man he was watching TV. R2 stated he then got up out of his wheelchair and punched the man in the head. R2 said R1 started screaming, and R2 told him to leave the [f****ing] channel alone, and then the nurses came into the TV room and told R1 to leave. R2 stated the police came and spoke with him but did not write him any tickets and left. During an interview on 10/29/24 at 3:49 PM, Certified Nurse Aide (CNA) 5 stated on the evening of 10/12/24, after she started her 11 PM shift, she did an initial check to see which residents were still awake. She stated sometime between 1 AM and 3 AM, she observed R1 and R2 in the TV room and R1 stepped out of the room. CNA5 stated when R1 returned to the TV, he noticed that R2 had changed the channel, and they started arguing. She said she did not actually see R2 hit R1, but she reported it to Licensed Practical Nurse (LPN) 3 who told R1 to go back to his room. CNA5 stated this was the first time she was aware of an incident between these two residents. During an interview on 10/30/24 at 2:50 PM, the Administrator stated the incident was reported to her at 7:15 AM on 10/12/24, and that R2 had admitted to hitting R1 with his closed fist. The Administrator stated she did not substantiate the abuse allegation due to the resident's mental capacity.

Based on record review and staff interview, the facility failed to report an incident of resident-to-resident abuse immediately to the Administrator and within two hours to the state survey agency for one of three residents (Resident (R) 1) reviewed for abuse. R2, who was severely cognitively impaired, hit R1 on the back of the head with his fist after a dispute over a TV channel. The incident was not reported to the state survey agency for more than 4 hours. Findings included: Review of the facility's policy titled, Abuse/Neglect/Misappropriation, dated 01/23/20, revealed, . All employees are responsible for immediately (no later than two hours after the allegation is made if the incident involves abuse or bodily injury, no later than 24 hours if the incident does not involve abuse or bodily injury) reporting to the Administrator, or in their absence, the Director of Nursing, or their immediate supervisor any and all suspected or witnessed incidents of patient abuse, neglect, theft, exploitation and/or mistreatment of a patient as well as any reasonable suspicion of a crime against a patient . The Administrator will provide to the State Agency an initial report for occurrences of alleged or reasonably suspected abuse, neglect, exploitation, mistreatment, or crime against a patient of the Center. immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury . Review of R1's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R1 admitted to the facility on [DATE] with diagnoses including other speech and language deficit, abnormalities of gait and balance, and intellectual disabilities. Review of R1's quarterly ''Minimum Data Set (MDS),'' with an Assessment Reference Date (ARD) of 07/09/24, revealed a BIMS could not be completed due to the resident rarely being understood. Review of R2's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed R2 admitted to the facility on [DATE] with diagnoses including major depressive disorder, and cognitive communication deficit. Review of R2's quarterly MDS, with an ARD of 10/01/24, revealed a BIMS score of five out of 15, which indicated severe cognitive impairment. Review of R2's Care Plan, located under the ''Care Plan'' tab of the EMR and dated 07/31/24, revealed no care plan related to aggressive behaviors. During an interview on 10/29/24 at 3:49 PM, Certified Nurse Aide (CNA)5 stated on the evening of 10/12/24, after she started her 11 PM shift, she did an initial check to see which residents were still awake. She stated sometime between 1 AM and 3 AM, she observed R1 and R2 were in the TV room, and R1 stepped out of the room. CNA5 stated when R1 returned to the TV, he noticed that R2 had changed the channel, and they started arguing. She said she did not actually see R2 hit R1, but she reported it to Licensed Practical Nurse (LPN) 3 who told R1 to go back to his room. CNA5 stated it was reported to the unit manager (UM)1 around 7 AM after she arrived. It was reported to the surveyor that LPN3 had walked out of the facility during a shift; therefore, the LPN could not be interviewed. During an interview on 10/29/24 at 2:40 PM, UM1 said she came in on the morning of 10/12/24 around 7 AM, and CNA5 told her there was an incident between the two residents in the dining room/tv room. She said CNA5 said there were some words exchanged and one hit the other. UM1 stated she could not remember who hit who because it had been a few weeks. UM1 said she was unsure if she was the first person that staff reported it to, and she thought it may have been reported to the third shift nurses. She stated she thought she was the first person in management the incident was reported to. She said she did not ask CNA5 what time it happened, but she said the night shift nurses did not call her to report it to her, and when she called the Administrator, she became aware that she was the first staff to report it. She said any allegations of abuse should be reported immediately to a supervisor. During an interview on 10/30/24 at 2:30 PM, the Director of Nursing (DON) said the incident between R1 and R2 should have been reported immediately to a supervisor so that the incident could be reported to the state survey agency within two hours. During an interview on 10/30/24 at 2:50 PM, the Administrator stated she thought the incident occurred at 7:00 am when it was first reported to her. She said she was unaware it had occurred earlier during the night shift. She said staff should have reported it to her immediately so that it could have been reported to the state survey agency within two hours. Review of an Investigation Summary and Conclusion, provided by the facility and dated 10/12/24, revealed the Administrator became aware that R2 hit R1 on the head and called him a derogatory name due to R1 changing the TV channel at 7:15 AM on 10/12/24. Review of the facsimile (fax) report of the incident to the state survey agency revealed it was reported at 7:22 AM on 10/12/24. This was more than four hours after the incident occurred.

Based on record review and resident and staff interviews the facility failed to treat a resident in a dignified manner by not providing assistance and care when requested. Resident #1 contacted law enforcement and the responding officer had to request assistance from staff twice before care was provided. This deficient practice occurred for 1 of 3 residents reviewed for dignity (Resident #1). Resident #1 stated he was asking for assistance to the bathroom and then was incontinent of bowel movement due to the long wait which made him feel angry, disrespected, and embarrassed. The Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of hemiplegia and seizure disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact, required extensive assistance with toileting and transfers, and was always continent of bladder and bowel. Resident #1 was assessed as requiring wheelchair for mobility. No refusal of care and no skin breakdown was noted during the assessment reference period. Resident #1 was interviewed in his room on 10/03/23 at 12:20 PM. During the interview he stated he often had to wait at least 30 minutes or longer on staff to answer his call light when he needed assistance with using the bathroom. Resident #1 revealed on 08/05/23 at 10:15 AM he had put on his call light for assistance with transferring out of his bed and using the bathroom. He stated at 10:30 AM staff still had not responded to his call light, so he used his sliding board to transfer himself out of the bed into his wheelchair and went to the nurse station to ask staff for assistance with using the bathroom. He revealed staff were at the nurse station talking to themselves and ignoring his request, so he went back to his room and then called his sister asking her to call the facility and have someone come to his room to assist him in the bathroom. Resident #1 stated after speaking with his sister around 10:35 AM and continuing to wait on staff to assist him with going to the bathroom he had a bowel movement on himself. He revealed his sister called him back at 10:45 AM and told him she was not able to speak with any staff about assisting him with care and told him to contact local law enforcement. He stated he contacted law enforcement around 10:50 AM about staff not assisting him with using the bathroom causing him to have a bowel movement on himself and then went to the front lobby to wait for law enforcement to arrive. Resident #1 revealed once law enforcement arrived around 11:00 AM, he informed them of what had happened with him trying to receive staff assistance with using the bathroom and that he had a bowel movement on himself while waiting. He stated law enforcement asked the receptionist to have staff come to the lobby to assist him with care and two staff members came and said he would need to be in his room to receive care. He revealed the law enforcement officer assisted him back to his room and after waiting for 45 minutes for staff to come and assist him with care the law enforcement officer had to ask one of the staff again to assist him with care and at 12:00 PM Nurse Aide (NA) #1 and NA #2 assisted him with his care. Resident #1 also revealed he was able to know the time frame and how long he had to wait for care due to being able to read the clock in his room and on his cell phone. Resident #1 stated he felt mad, embarrassed, and disrespected because of the incident. A telephone interview conducted on 10/03/23 at 1:22 PM with Nursing Assistant (NA) #1 revealed she was familiar with Resident #1 and the incident that occurred on 08/05/23. She stated Resident #1's call light had gone off earlier that morning and she did not respond to the call due to not knowing he had been assigned to her. She stated the previous schedule had Resident #1 assigned to another staff member and due to Resident #1 requesting that staff member not work with him, the schedule had been changed and she had not checked the schedule prior to her shift. She revealed after Resident #1's call light had been going off for at least 30 minutes he did come to the nurse station and was cursing at staff about needing assistance with using the bathroom, but she was still not aware that he had been assigned to her and she assumed someone else would provide his care, so she continued not to respond to his call light. She also revealed that each staff person has an assigned group of residents they are responsible for providing care to and if a resident is not in their assigned group they do not provide for their care. NA #1 stated after law enforcement arrived at the facility, she was told by Nurse #1 that Resident #1 had been assigned to her and she and NA #2 went into Resident #1's room and provided him with personal care to include cleaning stool off his bottom and assisted with changing his pants due to him having a bowel movement on himself. She did not recall Resident #1 having dried stool on his bottom or having any signs of redness or skin breakdown. She stated after the incident, she did receive a write-up from administration due to not providing care to Resident #1 in a timely manner. Attempted to contact NA #2 on 10/03/23 and she did not return telephone calls. On 10/03/23 at 2:07 PM an interview was conducted with the Receptionist. She stated she was working on 08/05/23 and had received a call earlier that morning from a resident asking for staff assistance with care but the resident hung up before she had been able to get the resident name or room number. She revealed later that day, Resident #1 met with a law enforcement officer in the lobby about not receiving assistance with his care and the law enforcement officer requested for her to call staff to the lobby to assist Resident #1 with care and so she did and then the law enforcement officer assisted Resident #1 to his room. She stated she only worked weekends and was not familiar with all the staff or their names and could not recall which staff came to speak with Resident #1 and the law enforcement officer in the lobby and did not know why staff did not assist Resident #1 back to his room. On 10/04/23 at 12:34 PM an interview was conducted with the Law Enforcement Officer. He stated he had received a telephone call on 08/05/23 from Resident #1 around 10:45 AM stating he had been requesting assistance with using the bathroom from facility staff since 10:15 AM and no one would assist him causing him to have a bowel movement on himself. He revealed he responded to the facility at 11:00 AM and Resident #1 met with him in the lobby to discuss his concerns with staff not assisting him with using the bathroom when asked and causing him to have a bowel movement on himself. He stated he asked the receptionist at the facility to contact staff to come and assist Resident #1 with personal care and when staff arrived in the lobby, they stated Resident #1 would need to be inside his room to receive assistance with care. The officer stated he assisted Resident #1 back to his room and continued to wait for staff to come into the room and assist Resident #1 with personal care and no staff came. He revealed he left Resident #1 room and spoke with Nurse #1 and informed her of how long Resident #1 had been requesting assistance with using the bathroom causing him to have a bowel movement on himself and she stated she would find staff to assist as soon as possible. He stated staff did not arrive at Resident #1 room to provide him with assistance with using the bathroom until 12:00 PM and Resident #1 had been requesting assistance for at least an hour and forty-five minutes and had been sitting in his own bowel movement for at least an hour and a half. An interview was conducted with Nurse #1 on 10/03/23 at 3:03 PM. She stated she had been working on 08/05/23 but had not been made of any issues with Resident #1 not receiving assistance with his care until she had spoken with the law enforcement officer who was requesting staff to assist Resident #1 with his care. She revealed she asked NA #1 to go into Resident #1's room to provide for his care and the Administrator was notified about the incident and she made sure Resident #1 received assistance with his care in a timely manner for the rest of her shift. On 10/03/23 at 1:33 PM an interview was conducted with the Social Worker (SW). During the interview she stated she had received a telephone call on 08/05/23 from the Administrator informing her of the incident with Resident #1 and was asked to go to the facility and speak with Resident #1 about the incident. She revealed Resident #1 informed her that he had put on his call light early that morning for assistance with using the bathroom and no staff responded so he went to the nurse station and tried to ask for assistance but no would help so he called law enforcement, and they came to the facility and had to ask staff to assist him. She stated Resident #1 informed her that he did not receive assistance with using the bathroom for at least an hour and a half and during that time had soiled himself. SW revealed Resident #1 was very upset about the incident and she informed the Administrator of his concerns. An interview was conducted with the Director of Nursing (DON) on 10/03/23 at 1:54 PM revealed she was not at the facility when the incident with Resident #1 occurred and was told of the incident by the Administrator. She stated she had spoken with NA #1 about the incident and provided her with a written disciplinary action for not providing Resident #1 toileting care in a timely manner. She revealed she expected nursing staff to answer call lights and provide care to all residents in a timely manner. On 10/03/23 at 2:52 PM an interview was conducted with the Administrator. She revealed she had received a telephone call on 08/05/23 from Nurse #1 about the incident with Resident #1 and had asked the SW to take his statement about the incident. She stated NA #1 should have provided incontinence care for Resident #1 and answered call light within a timely manner. She also stated Resident #1 should not have had to call law enforcement or wait over an hour on incontinence care.

Based on observations, record review, and resident, staff, Legal Guardian, [CONDITION(S)] Nurse and Nurse Practitioner interviews the facility failed to prevent Resident #49's unauthorized and unsupervised exit from the facility. Resident #49 was ruled incompetent, had a legal guardian and had verbalized the desire to leave to several staff members. This affected 1 of 3 residents (Resident #49) reviewed for supervision to prevent accidents. Resident #49 was unsupervised and eloped from the facility's fenced in patio/smoking area the night of 6/17/21. The facility failed to communicate the 6/17/21 elopement to the [CONDITION(S)] center and Resident #49 was left unsupervised outside the [CONDITION(S)] center waiting on transportation on 6/25/21. As a result, Resident #49 eloped from the [CONDITION(S)] center and propelled himself two businesses down on a busy two-lane road. Resident #49 was found at a store by a [CONDITION(S)] center staff member and was taken back to the [CONDITION(S)] center. Immediate jeopardy began on 6/17/21 when Resident #49 exited the facility's fenced in smoking area unsupervised. The immediate jeopardy was removed on 7/4/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Review of Resident #49's court orders revealed on 02/25/21 Counseling Center received legal guardianship of Resident #49 and he was ruled incompetent by the courts. Guardianship included Resident #49 needed assistance taking prescribed medications, communicate regarding health decisions, seek medical help for serious problems, keeping a sanitary living environment, to identify and void life-threatening behaviors, recognize and avoid hazards in home, seek help in emergencies, and capacity to make decisions without undue influence from others. Resident #49 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)] with [CONDITION(S)], muscle weakness, and vision impairment due to loss of right eye. A review of the Elopement Risk Evaluation for Resident #49 dated 5/14/21 revealed Resident #49 was marked for no concerns of elopement. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was assessed for being cognitively intact and requiring extensive assistance with one person staff for activities of daily living (ADL). The MDS further revealed Resident #49 mobilized with a wheelchair and was not coded for delusions or hallucinations. Resident #49 did not have a care plan for wandering or elopement behaviors. An interview with Resident #49 on 6/27/21 at 10:23 AM revealed a week half ago he escaped the facility and made it to the fence line while smoking unsupervised in attempt to go home to another state and a staff member spotted him and brought him back inside the facility gate. Resident #49 revealed he also escaped again during [CONDITION(S)] recently while waiting on transport and made it down the road and a staff member stopped him. A further interview with Resident #49 on 6/29/21 at 4:15 PM stated his plan was to panhandle from one state to another to live with friends that he has not spoken to in [AGE] years. Resident #49 stated he had no plans to seek medical treatment, continue [CONDITION(S)], or where he would live or what he would eat during his attempt to travel. An interview with Nurse Aide (NA) #7 on 6/28/21 at 4:15 PM revealed on 6/17/21 at 11:30 PM Resident #49 was outside unsupervised smoking and another resident notified the NA that Resident #49 was outside of the fence. The NA #7 stated Resident #49 was sitting in his wheelchair outside the fence on the bank which sloped down to a wooded area. The NA further revealed she could barely see the resident due to the darkness and she ran and jumped the fence because she was scared the resident was going to flip off the bank. NA #7 stated Resident #49 plan was to travel to a store to buy cigarettes and go to another state. NA #7 stated a staff member contacted the Administrator and a note was put up at the nurse's desk instructing the staff if the resident attempted to elope to contact the administrator and the police. The NA revealed no interventions or precautions were put into place during 2nd shift on 06/17/21. NA #7 recalled seeing the posted note during her 2nd shift for only two shifts. NA #7 stated that she was not made aware Resident #49 had spoken to staff about leaving the facility on 6/17/21. NA #7 further revealed Resident #49 had discussed leaving the facility to go to another state since his admission (5/13/21). An interview with Nurse #3 on 6/30/21 at 12:15 PM revealed on 6/17/21 during 2nd and 3rd shift change another resident reported to staff Resident #49 had left the facility fenced in Nurse #3 stated when she got to Resident #49, he indicated he was going to the store to buy cigarettes but was aware he had no money. He further revealed to Nurse #3 and NA #7 that he was going to the store to make money and travel to another state. Nurse #3 revealed the Administrator was contacted and a staff member posted a note at the desk if Resident #49 attempted to leave again to contact the Administrator and the police. Nurse #3 further revealed Resident #49 had never voiced leaving the facility prior to 6/17/21 and was not made aware of Resident #49 wanting to leave the day of 6/17/21. No interventions or precautions were put into place during Nurse #3's shift. Review of incident reports revealed there were no incidents documented for Resident #49 on 6/17/21. In addition, there was nothing documented in the nurses notes and an Elopement Risk Evaluation was not completed after he eloped on 6/17/21. A review of the weather conditions per Weather Channel website revealed the following data for [NAME], North [NAME]. On 6/17/21 the website indicated it was partly cloudy with the low of 59 degrees Fahrenheit at 11:30 PM. An observation of the fenced in patio area was conducted on 6/28/21 at 4:55 PM and revealed residents entering and exiting the patio without having to use a code. The cement patio had covered area with one picnic table and was surrounded by a grass area. It was further observed the patio gate that Resident #49 exited out of had a metal latch and was closed with a yellow bungee cord. Outside of the gate a cement path wrapped around the left side of the building but to the right it was observed to be a small dirt path between the fence and the tree line which sloped down to a bank. An interview with the Maintenance Director on 6/29/21 at 10:40 AM revealed a request was completed by nursing staff dated 6/17/21 for a better gate mechanism. The Maintenance Director stated he was told to leave the bungee cord in place by the Administrator because it slows down residents trying to elope. An interview with [CONDITION(S)] Nurse on 6/28/21 at 2:00 PM revealed Resident #49 was left unsupervised waiting on transportation at the front of the [CONDITION(S)] building on 6/25/21. Resident #49 left the parking lot and propelled himself down the side of a two-lane highway traveling past a restaurant and turning into a gas station that is at the intersection of a major highway. Resident #1 was spotted by a [CONDITION(S)] employee who revealed cars passing were having to go around the resident and the employee was able to get the resident back to the facility. The [CONDITION(S)] Nurse revealed she told the facility transporter about what had happened. The [CONDITION(S)] Nurse stated they had no knowledge of Resident #1 to elope from the facility, and if they have known they would have not allowed him to go outside unsupervised. The [CONDITION(S)] Nurse further stated Resident #1 would no longer be allowed to sit outside to wait on transportation. An interview with the facility transporter on 06/28/21 at 1:00 PM revealed on 6/25/21 at 3:45 PM she picked up Resident #49 from the [CONDITION(S)] center on 6/25/21 and it was reported Resident #49 had left the facility unsupervised. The facility transporter further revealed Resident #49 made it two buildings down on a busy two-lane road. The Facility Transporter indicated Resident #49 had discussed multiple times escaping and leaving the facility and she had relayed the information to the Administrator. Review of incident reports revealed there were no incidents documented for Resident #49 on 6/25/21. In addition, there was nothing documented in the nurses notes and an Elopement Risk Evaluation was not completed after he eloped on 6/25/21. A review of the weather conditions per Weather Channel website revealed the following data for [NAME], North [NAME] on 6/25/21. The website indicated it was partly cloudy and 83 degrees Fahrenheit. An interview with the legal guardian on 6/28/21 at 8:20 PM revealed on 6/18/21 the guardian was contacted by the facility Social Worker (SW) and informed Resident #49 was making threats to leave the facility, and the facility could not stop the resident. The guardian reported she was not informed he had eloped from the facility on the night of 6/17/21 and stated Resident #49 was incompetent and could not make safe decisions for himself. An interview with the Social Worker (SW) on 06/29/21 at 11:35 AM revealed on 6/17/21 the Administrator reported to the SW Resident #49 was wanting to leave the facility through the front door that morning and go to a store to panhandle money to be able to hitch [NAME] to another state to get his money. The SW further revealed the SW had a conversation with the Legal Guardian on 6/18/21 but did not reveal the resident had eloped the night of 6/17/21. The SW indicated she told the guardian the resident was having behaviors of possible elopement stating he was going to leave the facility. The SW indicated no interventions were put in place to prevent the resident from eloping again after Resident #49 left the facility through the patio gate on 6/17/21. The Social Worker (SW) revealed she was not made aware of his elopement from the [CONDITION(S)] center on 6/25/21 and was never notified to contact the guardian. The SW stated no interventions were put in place to prevent the resident from eloping after leaving the [CONDITION(S)] center. The SW recalled conversations with the resident, and he did not understand why he had to be in the facility. A further interview with the SW on 7/1/21 at 8:15 AM revealed Resident #49 would not be able to be discharged to the community because the resident was unable to make safe decisions and was deemed incompetent. An interview with the Nurse Practitioner (NP) on 6/29/21 at 8:50 AM revealed Resident #49 was deemed incompetent before being admitted into the facility. The NP further revealed Resident #49 was incompetent, unable to make any kind of sound medical decisions, and had threatened to leave since 5/13/21. The NP further revealed she was made aware of Resident #49's first elopement on 6/18/21 but had not examined the resident. The NP revealed she was not made aware of Resident #49 leaving the [CONDITION(S)] center unsupervised on 6/25/21. An interview with the Director of Nursing (DON) on 6/29/21 at 9:25 AM revealed Resident #49 had stated to the Administrator on 6/17/21 that he was going to leave the facility because he was unhappy. The DON stated she did not recall if any interventions to prevent elopement were put in place for Resident #49. An interview with the Director of Nursing (DON) on 7/01/21 at 9:15 AM revealed Resident #49 was extremely delusional and had been since admission. The DON indicated she was not informed by the [CONDITION(S)] center or Administrator of Resident #49 leaving the [CONDITION(S)] center on 6/25/21 and did not recall any interventions put into place to address his elopement. The DON stated Resident #49 should not be discharged to the community because he was unable to make safe decisions for himself. An interview with the Administrator on 6/28/21 at 1:27 PM revealed on 6/17/21 during first shift Resident #49 was unhappy and continued to state he was going to leave the facility and go to another state. The Administrator revealed she had not put any interventions or precautions in place for Resident #49 at that time. She explained on 6/17/21 at 11:30 PM Resident #49 did exit out of the smoking area through the gate with plans of going to one state then to another. The Administrator stated she did not consider it an elopement because the resident was alert and had intact cognition. The Administrator further revealed if a resident with intact cognition left the facility and was alert it was not considered an elopement. The Administrator stated she had written a note and placed it at the nurses' desk for 24 hours on 6/18/21 for staff to keep an eye on Resident #49 and contact the Administrator and police if Resident #1 was to elope. The Administrator further revealed she did not discuss the resident's behaviors on 6/17/21 face to face with staff after he had discussed leaving the facility that day prior to the elopement. The Administrator stated no interventions or precautions were put in place. An interview with the Administrator on 06/29/21 at 12:15 PM revealed she was notified by the facility transporter on 6/25/21 of Resident #49 eloping from [CONDITION(S)] center but felt that it was the [CONDITION(S)] center's responsibility the resident eloped from their facility. The Administrator stated his elopement on 6/25/21 was discussed during their morning meeting on 06/28/21 and no safety interventions were put in place for Resident #49 to prevent further elopement. The Administrator revealed the facility should have made the [CONDITION(S)] center aware of Resident #49's behaviors of elopement but failed to do so. The Administrator further revealed she was aware Resident #49 was incompetent at admission and given the resident history of [CONDITION(S)] depression, and elopement, she should have sent Resident #49 to the hospital and put safety interventions in place after the first elopement on 6/17/21. The Administrator was informed of immediate jeopardy on 07/01/21 at 1:55 PM. The facility provided the following acceptable IJ removal Plan with the correction date of 7/4/21: The facility failed to supervise a cognitively impaired resident with wandering behaviors from exiting the facility and the [CONDITION(S)] center unsupervised. What corrective action will be accomplished for the residents found to have been affected by the deficient practice? 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #49 was admitted to the facility on [DATE] with diagnosis of [CONDITION(S)], [CONDITION(S)] with [CONDITION(S)], unspecified symptoms and signs with cognitive functions and awareness, muscle weakness, and vision impairment due to loss of right eye. Resident #49 was ruled incompetent on 2/25/2021 by the courts and was appointed a Legal Guardian with Phoenix Counseling Center at that time. On 6/17/2021, Resident #49 attempted to exit the facility front door stating that he was going back to West Virginia, facility Administrator was present. Later, 6/17/2021 at approximately 11:00 pm, Resident #49 propelled himself through a gate in the fenced in smoking area. When Resident #49 exited the gate, the resident propelled himself behind the fence where the ground is unlevel and slopes to a drop off next to a wooded area. Another resident that was in the smoking area at the time of exit notified staff and staff went and returned Resident #49 back onto the facility. Facility did not complete an elopement assessment after either incident, implement safety interventions to address elopement or notify the Physician or Guardian. Additionally, resident receives [CONDITION(S)] services on Monday, Wednesday, and Friday. The facility did not communicate elopement risk to the [CONDITION(S)] center to ensure coordination of care for safety. On 6/ 25/21, [CONDITION(S)] notified the Van Driver when picking up Resident #49 that Resident #49 left the premises unassisted and propelled out of the parking lot down a busy side street to a gas station. A [CONDITION(S)] employee noted resident at the gas station and returned him to the [CONDITION(S)] center. The facility Van Driver communicated this information to the facility Administrator. The facility did not ensure safety interventions were initiated post incident on 6/25/2021 and did not notify the Physician or Guardian of the incident. On 6/29/2021 Resident #49 was assessed by Physician. Physician advised periodic safety checks, placement of a wander guard related to elopement risk, and a Psychological Evaluation. Wanderguard placed on resident by Licensed Nurse on 6/29/2021 and every 15-minute safety checks initiated. Smoking Assessment was completed on 6/29/2021 and Resident #49 was made a supervised smoker and with placement of wander guard the door to the smoking area will alarm to alert staff of his proximity to the exit door. Elopement Assessment and care plan was updated by Director of Nursing on 6/29/2021 to reflect risk of elopement. All information was added to the Elopement Risk Binder and Careguide by the Administrator and Director of Nursing. Social Worker immediately contacted Community Mobile Crisis Unit for evaluation. Community mobile crisis completed an evaluation of Resident#1 on 6/29/2021 and recommends a higher level of care (i.e., secure unit). Social worker began referral process on 6/29/2021. On 6/30/2021, Social Worker, Minimum Data Set Nurse (MDS), Senior Clinical Consultant, and Regional Clinical Consultant conducted a care conference with resident #49's legal guardian. Discussions included interventions for elopement risk, wanderguard and safety checks (15-minute checks), she agrees with plan of care as stated above. On 6/30/2021, the Administrator discussed with the [CONDITION(S)] Center Social Worker the plan of care for Resident #49's elopement risk which included interventions of calling facility when [CONDITION(S)] is completed, and Resident #49 will remain in the [CONDITION(S)] center until facility transportation arrives. [CONDITION(S)] Social Worker confirmed understanding of the plan of care. All residents that are at risk for elopement have the potential to be affected when policies and procedures for elopements are not followed. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 6/29/2021, residents with Wanderguards were assessed to validate placement and function of the Wanderguards by Maintenance Director. Completion date of 6/29/2021. Effective 6/29/2021, elopement assessments and care plans were reviewed and validated for all current residents assessed at risk for elopement by the Director of Nursing and MDS Nurse. Elopement risk binders were reviewed and updated as needed by the Administrator. Completion date of 6/29/2021. Effective 7/1/2021, Licensed Nurses were re-educated by the Administrator and Director of Nursing on Elopement assessments and completion. They are completed on admission, then quarterly and/or as needed by the Licensed Nurse. Any newly identified residents noted at risk will be communicated by the licensed nurse during shift huddle at the change of each shift. Effective 7/1/2021, the Interdisciplinary Team (IDT) to include but not limited to Administrator, Director of Nursing, Charge Nurse, Activities Director, Social Worker, and Dietary Manager was re-educated by the Regional Clinical Consultant and Senior Clinical Consultant on Elopement Policy to include ensuring residents who are assessed at risk for elopement are supervised by facility staff and signs of elopement risk are recognized which included: resident packing belongings, resident stays near or searching for exit doors, and/or resident verbalizes/comments of wanting to go home. Additionally, they will be educated on their role in developing plans/interventions in response to any elopement risk. This should include a written careplan with elopement risk interventions formulated in conjunction with Physician/ Responsible Party (RP) and communicated with staff. Effective 7/1/2021 - Administrator, Director of Nursing, and/or Regional Clinical Consultant initiated education with all staff in all departments including contracted employees on the facility elopement policy including ensuring residents who are assessed at risk for elopement are supervised by facility staff. Facility ensures that residents that exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Facility will establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including assessment and identification of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Education also to include signs of elopement risk: resident begins packing belongings, resident stays near or searching for exit doors, and/or resident verbalizes/comments of wanting to go home. When the above behaviors are noted, the nurse must be notified immediately and the charge nurse. Notification to Physician/RP/Administrator and DON should occur immediately if resident displays these behaviors. Documentation of the behaviors should be documented in the Electronic Health Record as well as recorded on the 24-hour shift report. An elopement assessment should be completed by the Licensed Nurse immediately following these behaviors. Elopement assessment will be reviewed, and appropriate intervention applied as needed. Interventions for elopement attempt: Redirect, diversional activities and notify Physician/RP and DON for further interventions. Residents identified at risk for elopement will be added to the Elopement Risk Binder, there are 2 Elopement Risk Binders in the facility (reception desk, nursing station). All staff re-educated on the location of the Elopement Binders. Each book contains current wander guard resident list and individual identification forms with pictures of these residents. Each hall nurse is responsible for checking placement of the wander guard each shift and ensuring it is documented in the medical record. Maintenance, Licensed Nurse or/designee will check function of all residents with wanderguards daily. Maintenance or designee will continue routine daily door and alarm checks to ensure alarms are functioning properly (ie sounds when activated). Additionally, Director of Nursing, Social Worker, Admissions Coordinator, Business Office Manager, Maintenance Director, Dietary Manager, Therapy Director and Licensed Nurses educated on the process of reviewing Resident Profile in the Electronic Health Record to determine who has a legal guardian due to competency status, this information will be entered by the Admissions Coordinator. Resident Profile will be printed off and placed in a binder at the nurse's station for review by all staff as appropriate. The education will be communicated verbally and telephonically by the Administrator and the Director of Nursing. Written education will be available for review prior to the staff member working their assigned shift. Administrator will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. This education will be included in orientation for New Hires. Effective 7/1/2021, the Regional Nurse Consultant will review all electronic nursing notes and 24-hour log sheets for current residents for the last 14 days to ensure there are no unaddressed elopement risk behaviors. No other residents were noted to have elopement risks which were not addressed. This review will be completed by 7/1/2021. Effective 7/1/2021, Residents at risk for elopement that need to go out of the facility for an appointment will have elopement risk communicated with the receiving entity and have an appointment escort provided (i.e., family, facility staff). Nursing staff and Van Driver will be educated by Administrator. Effective 7/1/2021 Nursing Management to include Charge Nurse and/or Director of Nursing will review 24-hour report sheets and previous day nurses notes to identify any change in condition i.e., exit seeking behavior for appropriate follow up and notification to Physician review will be completed daily. Any newly identified residents noted at risk will be communicated by the licensed nurse during shift huddle. Administrator will educate the Nursing Management team to include Charge Nurse, Licensed Nurses, Director of Nursing and Social Worker on the new process of monitoring and responsibilities of this plan by 7/1/2021. Effective 7/1/2021 the Interdisciplinary Team (Nurse Managers, Social Work) will review residents at risk for elopement weekly in the Standards of Care Meeting to ensure continued appropriate interventions are in place to include Psych referral as indicated, with collaboration from the Physician/RP. Administrator will educate the Interdisciplinary Team on the new process of monitoring and responsibilities of this plan by 7/1/2021. Effective 7/2/2021, the Administrator, Regional Nurse Consultant, Rehab Manager, and the Environmental Services Manager began conducting interviews with all staff (to include contract staff) to determine if there were any other resident exhibiting behaviors for risk for elopement (i.e. stating they are wanting or going to leave, packing belongings, wandering, or exit seeking) to ensure there are no unaddressed elopement risk behaviors. Interviews to be completed by 7/3/2021. Effective 7/1/2021, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. The facility alleged immediate jeopardy removal effective date 7/4/2021. The credible allegation of compliance with an immediate jeopardy removal date of 7/4/21 was validated on 7/9/21. Elopement books were observed at the nurses' station and at the front reception desk. The elopement books included pictures and descriptions of residents currently identified at risk for elopement. Staff in-services conducted from 7/2/21 through 7/8/21 were reviewed. No staff were allowed to work until they had received the in-service education. In-services included the following: review of resident elopement risk profile, elopement policy review (missing resident/patient), an elopement drill, use of a post-elopement follow-up report, and an elopement drill or post-elopement checklist. Staff were further in-serviced on how to identify a resident at new risk for elopement. A review of the signature sheets for the in-services revealed all staff were educated. Interviews with staff on 7/9/21 from 3:42 PM through 5:24 PM revealed staff indicated they were required to complete on-line education regarding wandering / elopement. Staff were able to describe location of elopement books, how to identify elopement behaviors, responses to wander-guard alarms, identity of the 4 current residents at risk for elopement, strict observation of resident smokers in outdoor patio. Nursing staff were able to verbalize timing of elopement risk assessments as being on admission, with any indication that a resident was planning to elope and following any elopement. The administrator and DON verbalized a daily check of 24-hour reports was completed at the morning meeting. The Maintenance Director provided a daily audit of magnetic door locks. The audit was reviewed with no concerns identified.

Based on record review, observations and resident and staff interviews, the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, Resident #66, Resident #36, and Resident #35) reviewed for incontinence. The residents expressed feelings of being upset, humiliated, being forgotten about and feeling like the staff members didn't care about them. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact, required extensive physical assistance with bed mobility, toilet use and personal hygiene. Resident #5 was always incontinent of both urine and bowel. Resident #5's care plan reviewed on 4/8/21 indicated Resident #5 required assistance for activities of daily living (ADL) related to chronic pain and generalized weakness. Interventions included to assist Resident #5 with ADL as needed and to assist with toileting or incontinence care routinely and as needed. An interview with Resident #5 on 6/27/21 at 9:49 AM revealed that she remembered having had to wait for hours before she was provided incontinence care. Resident #5 could not remember the dates when this had happened but said it had happened more than once on the day shift. On several occasions, she was changed at 6:00 AM prior to the night shift nurse aide (NA) leaving and then did not get checked again or changed until 2:30 PM. Resident #5 added there was one day when a NA entered her room to provide incontinence care to her roommate but when she requested to be changed as well, the NA told her that she was not assigned to her and that another NA was going to come and change her. But the NA that was assigned to her never did come to provide incontinence care to her until the end of the shift. Resident #5 reported that this incident upset her and made her feel like she was forgotten about. An interview with Nurse Aide (NA) #1 on 6/29/21 at 10:11 AM revealed she often had to work on day shift on the hall where Resident #5 resided by herself and that it was impossible to get all her assigned tasks done. NA #1 stated it was possible that she was not always able to provide incontinence care to Resident #5 until around 2:30 PM on the day shift because the hall was full of residents who required incontinence care and it was harder to work with residents who required two-staff assistance for transfers. NA #1 also stated another NA on the next hall was supposed to help her out when she was by herself, but they didn't always come to help her, and they were probably busy with their own residents on the other hall. An interview with NA #2 on 6/29/21 at 3:35 PM revealed she was a restorative nurse aide, but she often got pulled to work on the hall. NA #2 stated she often had to work by herself on day shift on the hall where Resident #5 resided. NA #2 said it was very hard to get everything done when she had to work on the hall by herself and that it was possible that she hadn't been able to get to Resident #5 to provide incontinence care to her until the end of the shift. An interview with NA #3 on 6/29/21 at 4:04 PM revealed she usually worked on a different hall on the day shift but sometimes got assigned to watch the call lights on the hall where Resident #5 resided. NA #3 confirmed that she often had to answer Resident #5's call light towards the end of the day shift and she sometimes found her wet with incontinence with her gown and bed sheet soaked with urine. NA #3 stated Resident #5 complained to her all the time that she didn't get changed for nearly eight hours. An interview with the Director of Nursing (DON) on 7/1/21 at 8:53 AM revealed she had not been aware of the instances when Resident #5 was not provided incontinence care until the end of the day shift. The DON stated the NA assigned to the hall should have told her so she could get an extra NA to help on the hall. The DON stated the Activities Assistant and the Social Worker were both nurse aides and should have been able to help on the hall if needed. The DON added that Resident #5 should have been provided incontinence care in the morning before and after breakfast, before and after lunch and before the day shift staff members left. She said incontinence care being provided at least every two hours would have been great but was impossible if there was only one NA assigned to the hall. The DON confirmed that it was possible that a NA had refused to provide incontinence care to Resident #5 because she was not assigned to her but she should have helped her instead of making her wait for the NA that was assigned to her. An interview with the Administrator on 7/1/21 at 12:50 PM revealed she had not been aware of any concerns related to Resident #5 not being provided incontinence care. The Administrator stated the restorative aides should have been available to help but if they got pulled to work on the hall, the NA on the next hall should have been helping the NA assigned to Resident #5. The Administrator stated incontinence care not being done timely was most likely due to not having enough staff to provide care to the residents in the facility. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact, exhibited no rejection of care behaviors and required extensive physical assistance with bed mobility, toilet use and personal hygiene. He was also occasionally incontinent of both urine and bowel. Resident #66's care plan dated 6/4/21 indicated Resident #66 required assistance for activities of daily living (ADL) related to generalized weakness and abnormalities of gait. Interventions included to assist with ADL as needed and to assist with toileting/incontinence care routinely and as needed. An interview with Resident #66 on 6/27/21 at 9:25 AM revealed he had sat for three hours before he got provided incontinence care. Resident #66 stated this happened all the time on the evening shift. Resident #66 said one time, two separate nurse aides (NA) came into his room to turn his call light off twice on the evening shift and told him that they would come back but they never did come back. Resident #66 said on that evening, he was provided incontinence care at 1:00 AM. Resident #66 stated this incident upset him and that it made him feel like they didn't care about him. Resident #66 added that he had given up on using the bed pan because it took them a while to get back to him to take him off and being on a bed pan for an extended period hurt his back. He stated he usually had to wait for two to three hours on the evening shift before his call light was answered. A second interview with Resident #66 on 6/30/21 at 9:29 AM revealed he was very frustrated and confused about the continued lack of response from the staff members especially on the evening shift. Resident #66 reported he had turned his call light on before 7:00 PM on 6/29/21 because he needed incontinence care, but nobody came into this room until 10:15 PM. Resident #66 stated Nurse Aide (NA) #4 went into his room at 10:15 PM and provided incontinence care to him but he never asked her why it took her a long time to come because he feared being retaliated on. Resident #66 stated he knew they were short-staffed. He further stated he felt like they had forgotten about him and that they didn't care about him. An interview with NA #1 on 6/30/21 at 11:56 AM revealed she usually took care of Resident #66 on the day shift and he told her all the time that they don't answer his call light on the evening shift until after two to three hours. An interview with NA #4 on 6/30/21 at 2:29 PM revealed she was usually assigned to Resident #66 on the evening shift but had to work by herself on the hall at least three times a week. NA #4 confirmed that she worked by herself on 6/29/21 on the evening shift and didn't get to Resident #66's call light until after 10:00 PM. NA #4 stated she could not remember seeing Resident #66's call light being on at 7:00 PM but said it was very busy during that time because the residents had just finished with supper and everyone was wanting either to go to the bathroom or to go to bed. NA #4 stated she usually started at the beginning of the hall and worked her way to the end of the hall so she could get everything done. She said that was why it took her so long to get to Resident #66's call light because he was one of the residents who were located all the way at the end of the hall. NA #4 further stated there was nobody to help her do her rounds because the other nurse aides had their own hall to take care of. An interview with the Director of Nursing (DON) on 7/1/21 at 8:53 AM revealed she had not been aware of the instances when Resident #66 was not provided incontinence care until the end of the evening shift. She said incontinence care being provided at least every two hours would have been great but was impossible if there was only one NA assigned to the hall. An interview with the Administrator on 7/1/21 at 12:50 PM revealed she had not been aware of any concerns related to Resident #66 not being provided incontinence care. The Administrator stated incontinence care not being done timely was most likely due to not having enough staff to provide care to the residents in the facility. 3. Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was severely cognitively impaired, required extensive physical assistance with bed mobility, toilet use and personal hygiene. Resident #36 was always incontinent of both urine and bowel. Resident #36's care plan reviewed on 4/21/21 indicated Resident #36 required assistance for activities of daily living (ADL) related to impaired mobility. Interventions included to assist Resident #36 with ADL as needed and to assist with toileting or incontinence care routinely and as needed. An observation conducted on 6/28/21 at 2:40 PM of NA #1 providing incontinence care to Resident #36. When NA #1 placed the resident in the bed and began to change her there was an odor noted in the room, Resident #36 ' s brief was heavy with brown substance and urine. NA #1 had to change Resident #36''s pants and brief due to incontinence. An interview with Nurse Aide (NA) #1 on 6/28/21 at 2:40 PM revealed she often had to work on day shift on the hall where Resident #36 resided by herself and that it was impossible to get all her assigned tasks done. NA #1 stated she had not provided incontinence care to Resident #36 during her 7:00 AM to 3:00 PM shift. She stated the last time Resident #36 had incontinence care was around 5:00 AM when third shift got the resident up from her bed. NA #1 stated the hall was full of residents who required incontinence care and it was harder to work with residents who required two-staff assistance for transfers. NA #1 also stated another NA on the next hall was supposed to help her out when she was by herself, but they didn't always come to help her, and they were probably busy with their own residents on the other hall. An interview with the Director of Nursing (DON) on 7/1/21 at 8:53 AM revealed she had not been aware of the instances when Resident #36 was not provided incontinence care. The DON stated the NA assigned to the hall should have told her so she could get an extra NA to help on the hall. The DON stated the Activities Assistant and the Social Worker were both nurse aides and should have been able to help on the hall if needed. The DON added that Resident #36 should have been provided incontinence care in the morning before and after breakfast, before and after lunch and before the day shift staff members left. She said incontinence care being provided at least every two hours would have been great but was impossible if there was only one NA assigned to the hall. An interview with the Administrator on 7/1/21 at 12:50 PM revealed she had not been aware of any concerns related to Resident #36 not being provided incontinence care. The Administrator stated the restorative aides should have been available to help but if they got pulled to work on the hall, the NA on the next hall should have been helping the NA assigned to Resident #36. The Administrator stated incontinence care not being done timely was most likely due to not having enough staff to provide care to the residents in the facility. 4. Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 was severely cognitively impaired, required extensive physical assistance with bed mobility, toilet use and personal hygiene. Resident #35 was always incontinent of both urine and bowel. Resident #35's care plan reviewed on 4/22/21 indicated Resident #35 required assistance for activities of daily living (ADL) related to impaired mobility. Interventions included to assist Resident #35 with ADL as needed and to assist with toileting or incontinence care routinely and as needed. An observation conducted on 6/28/21 at 2:05 PM revealed Resident #35 sitting in his wheelchair in the middle of the hall with his hands covering his groin area. Resident #35's pants were observed to be wet to his waist and mid thigh. He stated that he had been wet for a hour waiting on assistance from a staff member. An observation was conducted on 6/28/21 at 2:25 PM with NA #1 of her providing incontinence care to Resident #35. A strong urine odor was noted when she assisted the resident from his wheelchair. Resident #35's pants, shirt, brief and wheelchair pad was heavily saturated with urine. Urine was noted to be sitting in Resident #35's wheelchair on his slick covered foam pad. When NA #1 laid Resident #35 in the bed to change him she then had to change the sheet he laid on due to it being wet from the resident. An interview with Nurse Aide (NA) #1 on 6/28/21 at 2:30 PM revealed she often had to work on day shift on the hall where Resident #36 resided by herself and that it was impossible to get all her assigned tasks done. NA #1 stated she had provided incontinence care last to Resident #35 around 11:00 AM. The interview revealed she had noticed he was wet when she was picking up the lunch trays around 1:30 PM however had to assist another resident with incontinence care first due to them having an appointment. NA #1 stated the hall was full of residents who required incontinence care and it was harder to work with residents who required two-staff assistance for transfers. NA #1 also stated another NA on the next hall was supposed to help her out when she was by herself, but they didn't always come to help her, and they were probably busy with their own residents on the other hall. An interview with the Director of Nursing (DON) on 7/1/21 at 8:53 AM revealed she had not been aware of the instances when Resident #35 was not provided incontinence care. The DON stated the NA assigned to the hall should have told her so she could get an extra NA to help on the hall. The DON stated the Activities Assistant and the Social Worker were both nurse aides and should have been able to help on the hall if needed. The DON added that Resident #35 should have been provided incontinence care in the morning before and after breakfast, before and after lunch and before the day shift staff members left. She said incontinence care being provided at least every two hours would have been great but was impossible if there was only one NA assigned to the hall. An interview with the Administrator on 7/1/21 at 12:50 PM revealed she had not been aware of any concerns related to Resident #35 not being provided incontinence care. The Administrator stated the restorative aides should have been available to help but if they got pulled to work on the hall, the NA on the next hall should have been helping the NA assigned to Resident #35. The Administrator stated incontinence care not being done timely was most likely due to not having enough staff to provide care to the residents in the facility.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide sufficient nursing staff, resulting in missed showers for dependent residents (Resident #'s 238, 66, 48, 71, 30, 36, and 60), and incontinence care not being provided (Resident #'s 5, 66, 36 and 35) for 10 of 10 residents reviewed for staffing. The findings included: This tag is cross referred to: 1. F 550: Based on record review, observations and resident and staff interviews, the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, Resident #66, Resident #36, and Resident #35) reviewed for incontinence. The residents expressed feelings of being upset, humiliated, being forgotten about and feeling like the staff members didn't care about them. 2. F 677: Based on record review, observations, resident and staff interviews, the facility failed to provide showers as scheduled to 7 of 14 residents (Resident #238, Resident #66, Resident #48, Resident #71, Resident #30, Resident #36, and Resident #60) reviewed for assistance with activities of daily living. An interview was conducted on 06/29/21 at 5:56 AM with NA #4 who revealed staffing was poor. NA #4 stated she was frequently asked to come in early and work 12 hour shifts and to work double shifts to cover the schedule. NA #4 further stated it was all they could do to complete 2 incontinence rounds on the residents. NA #4 said they were only able to get a few residents up early due to no assistance. An interview was conducted on 06/29/21 at 3:16 PM with NA #7 who revealed she was not able to get all assigned showers done as scheduled. NA #7 stated they were usually able to get 2 incontinence rounds done but there was no way to do 4 rounds on the residents. NA #7 further stated there was not time to get everyone up out of bed. An interview was conducted on 06/29/21 at 3:35 PM with NA #2 who revealed she was a restorative aide but had been working the halls all the time recently due to staffing. NA #2 stated she was only able to get 2 incontinence rounds done on residents and stated it was not possible to get the showers done as scheduled. NA #2 further stated she had not done restorative for months. An interview was conducted with the Administrator on 06/30/21 at 4:10 PM. The Administrator stated staffing was a bit of a challenge. She further stated they had done several things to assist with recruiting. The Administrator indicated she was currently doing the schedule and was in the process of trying to hire a Staff Development Coordinator (SDC) who would be responsible for doing the schedule once her orientation was completed. She further indicated they had increased the base pay for Nurse Aides twice in one year - once in November 2020 and again in May of 2021. The Administrator also said they had increased the sign on bonuses for Nurses, Medication Aides and Nurse Aides. The sign on bonuses were described as: Nurses - $3500.00, Medication Aides $2000.00. and Nurse Aides $1000.00 and referral for NAs $1500.00 and for Nurses $2500.00. The Administrator stated they were hiring some Patient Care Aides (PCAs) and were working under a waiver and sponsoring NAs through college and paying their tuition, books and malpractice insurance and pay $100.00 towards their testing in return for the NA agreeing to contract to work at the facility for at least one year after graduation. She further stated she had met with the Regional Director of Operations and was now allowed to refresh ads with recruiters and currently used 3 different agencies to provide Nurses and NAs but was not always able to secure staffing through the agencies. The Administrator indicated the problem with agencies was they were not always able to send staff to assist with resident care. According to the Administrator, she had implemented administrative staff coming in on the weekends to assist with serving meals and feeding residents and for screeners to assist with the process also. The Administrator described the following open positions: Nurses: 1 PT 1st shift LPN Medication Aides (MAs): 1 part time 1st shift MA and 1 part time 2nd shift MA Nurse Aides: 3 full time 1st shift, 5 part time or Baylor 3 to 4 full time 2nd shift or 3-4 part time or Baylor 2 full time 3rd shift and 2 part time She further described their current shift bonuses for extra parts of shifts (4 hours) or whole shift (8 hours) as: NAs are offered $75.00 per shift up to $225.00 per shift and Nurses are offered $225.00 per shift. The Administrator said the hardest shift to cover for Nurses was the evening shift (3:00 PM to 11:00 PM) and for the NAs the hardest shift to cover was the night shift (11:00 PM to 7:00 AM). She further said the work ethic among young people was just not there anymore. The Administrator indicted she was currently offering a meal to staff when they had to work short and observed Nurses ' s week, Nurse Aide week and Nursing Home week, including a cook out and prizes. She further indicated they tried to find fun ways to honor the staff and boost their moral. A follow up interview was conducted on 07/01/21 at 1:22PM with the Administrator. She stated she didn ' t know how much more they could do other than what they were currently doing to improve staffing. The Administrator further stated she was working with the Regional Director of Operations on a weekly basis to try to resolve some of the staffing issues at the facility. She indicated the Regional Director of Operations was looking into other agencies to help with staffing and assisting with applications for employment.