Every finding on record at Lexington Health Care Center

Based on record review, staff, resident and law enforcement interviews, the facility failed to honor a resident's right to refuse treatment when the resident declined five hemodialysis (a life-sustaining procedure for kidney failure that uses a machine to filter waste, toxins, and excess fluids from the blood) treatments and the facility proceeded to file an involuntary commitment which deemed the resident a danger to herself. The resident reported once the local law enforcement officer had walked her out to the front entrance of the facility, the resident was asked to put her hands out and the officer placed handcuffs on both wrists in the front of her body and had her sit in the backseat of the police car. The resident stated she did not know what was happening as she had no previous experience with law enforcement. The resident expressed she was upset and aggravated but tried to remain calm and was cooperative and compliant with the officer's instructions. The resident stated she now felt she no longer had the right to refuse hemodialysis and was afraid local law enforcement would again be contacted by the facility if she did so. This deficient practice affected 1 of 3 residents reviewed for the resident's right to refuse treatment (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) with dependence on hemodialysis (a brand new diagnosis and treatment process for Resident #101) and a history of anoxic brain injury. Resident #101 was her own Responsible Party (RP). Resident #101 was [AGE] years old.Resident #101's care plan dated 3/9/2026 had a focus area for Resident #101 having an increased risk of complications due to the need for community hemodialysis for ESRD. Goals included Resident #101 would be free of complications from hemodialysis through the review period. Interventions included Resident #101 would receive community hemodialysis three times weekly, perform labs and diagnostics as ordered, and monitor for the signs and symptoms of complications related to ESRD including but not limited to fluid overload, hemorrhage, infection at the access site, hypotension, respiratory and/or cardiac distress and notify the provider as indicated. Resident #101's care plan had a focus area added on 6/10/2026 related to Resident #101 having behaviors of refusing medications and hemodialysis treatment due to denial of health conditions. Goals included Resident #101's behaviors would not cause her or other resident's distress through the next review period. Interventions included staff would administer medications as ordered, and assign staff members that are familiar or preferred by Resident #101 when possible. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #101 was moderately cognitively impaired. Resident #101 required minimum assistance with Activities of Daily Living (ADL). Resident #101 ambulated independently and self-propel independently in a wheelchair. Resident #101 was admitted to the facility after a hospital admission from 1/11/2026 to 3/8/2026 at which time hemodialysis was initiated due to an acute kidney injury/ESRD and Resident #101 required rehabilitation.A telephone interview with the community dialysis center Clinic Manager on 6/25/2026 at 10:55 AM indicated that prior to 6/10/2026, Resident #101 had refused hemodialysis on 5/30/2026, 6/2/2026, 6/4/2026, 6/6/2026 and 6/9/2026. A Nurse Practitioner (NP) note dated 6/10/2026 at 1:00 PM created by Nurse Practitioner #1 stated that Resident #101 continued to be noncompliant with her hemodialysis treatments and was scheduled to go on Tuesday, Thursday, and Saturday. Resident #101 was reminded that the hemodialysis access dressing needed to be changed and flushed as well. Resident #101 acknowledged understanding and stated she would attend the hemodialysis session on 6/11/2026 but then stated that after she had the dressing changed and access flushed she may not return for further hemodialysis treatments. Resident #101 was seen in the dining area coloring and was in no distress. Resident #101 did not make urine. Resident #101 denied fever, chills, chest pain and abdominal pain. Resident #101 displayed poor safety awareness. Nursing reported Resident #101 was provided with her medical records as requested which stated that Resident #101 had chronic renal failure but Resident #101 was still not convinced. Resident #101 had not displayed any nausea, vomiting or diarrhea. The NP note stated Resident #101 may require Involuntary Commitment (IVC) due to the inability to make sound choices regarding her health. An interview with the Nurse Practitioner (NP) on 6/25/2026 at 9:00 AM revealed the NP was very familiar with Resident #101 and stated the facility had experienced a lot of issues with Resident #101 as she refused her hemodialysis treatments. The NP stated she felt that Resident #101 could not make her own decisions despite not being deemed incompetent by a court hearing. The NP stated that Resident #101 had refused several hemodialysis treatments and the facility was unsure what Resident #101's current blood work values were on 6/10/2026. The NP reported she wanted to send Resident #101 out to the hospital on 6/10/2026 for an evaluation but Resident #101 declined to go with EMS. The NP indicated the nursing team discussed IVC and the DON went to the Magistrate's office and filed the petition as Resident #101 was unable to make her own decisions. The NP stated she was not aware that local law enforcement had transported Resident #101 to the hospital and thought Resident #101 had travelled by ambulance. The NP stated a resident had the right to declined medication/treatment but only if he or she was competent. The NP shared she thought Resident #101's refusal of lifesaving hemodialysis treatments was a form of suicide.A local Emergency Medical Services (EMS) report dated 6/10/2026 at 4:19 PM indicated a call from the facility had been received for a sick person with the primary symptom listed as patient's [Resident #101] noncompliance with renal hemodialysis. EMS arrived on scene at the facility to find Resident #101 lying in bed. Resident #101 was fully alert and oriented. Nursing staff reported that Resident #101 missed a week of hemodialysis due to her not wanting to go and needed to be sent out. Resident #101 denied any complaints. Resident #101 stated that she did not understand why she needed hemodialysis and requested documentation explaining why she was initially placed on hemodialysis. Resident #101 was adamant that her kidney's worked due to normal urination. EMS attempted to explain the concerns of missing hemodialysis to Resident #101 with no success. EMS expressed concern for hypertension and tachycardia which indicated possible toxicity from missing hemodialysis. Resident #101 remained adamant that she did not want to be transported. Resident #101 showed no indication to be an active threat to herself or others at this time. Nursing staff stated that Resident #101 was unable to make decisions on her own due to an anoxic brain injury, however they were unable to produce court mandated paperwork confirming same. Paperwork was produced with a written paragraph under the patient's medical history which stated, cognitive decision making may be questionable. EMS explained to the facility that documentation expressing guardianship or equal authority was needed. They were unable to produce such paperwork. EMS offered to request a law enforcement officer in reference to explaining the IVC process. EMS expressed the risks of refusing transport being worsening of Resident #101's condition and/or death. A nursing note created by Nurse #1 on 6/10/2026 at 4:51 PM revealed Resident #101 had refused to go with EMS for chronic kidney failure. Resident #101 stated that she did not have kidney failure. The Director of Nursing (DON) spoke with EMS and the nurse. Resident #101 would require an IVC as not competent enough to make her own decisions.An interview on 6/25/2026 at 10:32 AM with Nurse #1 revealed Resident #101 had been refusing hemodialysis and medications for 2 weeks. Nurse #1 indicated Resident #101 was not competent as she had been denying her medical diagnoses and refusing hemodialysis. Nurse #1 reported she had printed out Resident #101's diagnosis list and medications several times and reviewed these with Resident #101. Nurse #1 stated that on 6/10/2026 Resident #101 refused to go to the hospital with EMS and EMS stated Resident #101 could not be transported against her will. Nurse #1 recalled the decision for IVC was made by the Administrator, NP and DON. The Nurse stated Resident #101 was at no time violent, aggressive, suicidal or homicidal on 6/10/2026. Nurse #1 stated on 6/11/2026 she learned Resident #101 had attended her scheduled hemodialysis appointment and Nurse #1 reported she had not spoken to anyone further including Resident #101 about the events on 6/10/2026.An Affidavit and Petition for Involuntary Commitment dated 6/10/2026 at 6:50 PM indicated that the petition was completed by the DON. The DON checked the box on the Affidavit and Petition for Involuntary Commitment for the prewritten choice indicating that Resident #101 had a mental illness and was dangerous to self or others or has a mental illness and is in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. The DON's sworn, handwritten statement stated on the petition that Resident #101 had an anoxic brain injury that rendered her to be incompetent of her decisions regarding her health. Resident #101 was refusing her hemodialysis and had for the last two weeks. Resident #101 believed she no longer needed hemodialysis and wanted bloodwork done. Resident #101 had a history of depression and was refusing lifesaving medications, hemodialysis and care. An interview with the Director of Nursing (DON) on 6/25/2026 at 9:51 AM indicated she initiated the IVC on 6/10/2026 as Resident #101 had an anoxic brain injury, had refused to go to hemodialysis and was denying her medical diagnosis of renal disease. The DON stated the decision to IVC Resident #101 was made by the Administrator, DON, NP and also the facility Nurse Consultant as Resident #101 had refused to go to the hospital with EMS for a medical evaluation. The DON revealed the facility was concerned that toxins had built up as Resident #101 had refused hemodialysis for about 2 weeks. The DON stated she left a message for Resident #101's emergency contact on 6/10/2026 to advise that Resident #101 was recommended to go to the hospital with EMS but refused so the facility had pursued IVC. The DON indicated she spoke with the emergency contact later to report the IVC had been completed. The DON stated that a resident's right to refuse treatment really depended on the resident and if that resident could make their own decisions. The DON revealed that at no time was Resident #101 considered to be suicidal, homicidal and displayed a calm demeanor throughout the day. The DON stated the facility did not reach out to the Regional Ombudsman regarding Resident #101 and the refusals of hemodialysis.A nursing note dated 6/10/2026 at 8:45 PM created by Nurse #2 indicated Resident #101 was picked up by the police and transferred to the emergency room. A telephone interview on 6/24/2026 at 5:28 PM with a local law enforcement Supervisor revealed the Magistrate's office contacted local law enforcement when IVC papers were filed to assist with transportation of the individual named in the petition. The Supervisor indicated the individual was usually behaviorally unstable, suicidal and/or homicidal. The law enforcement officer would only transport an individual in the police car if deemed medically stable and would call for EMS transport if the individual required medical attention/monitoring. The Supervisor reported law enforcement policy/procedure required the individual to be searched and handcuffed usually with hands in the front unless the person showed dangerous behavior which would require the hands to be handcuffed behind the individual's back. The Supervisor stated the individual would then ride in the cage in the back seat of the police car. The Supervisor went on to say that this procedure was followed to ensure the safety of the individual and the officer as the person had been deemed a danger to themselves or others by the Magistrate. The Supervisor indicated that the responding officer would not discuss the IVC with the individual named in the petition as the officer was not part of the assessment process and just present for safe transportation of the individual. The Supervisor stated they would not transport an individual who refused medical treatment as the person had a right to refuse. The Supervisor indicated IVC would not be the appropriate procedure if medical personnel believed an individual could not make his or her own decisions. The Supervisor stated filing a petition for guardianship would be the appropriate process in that situation.A telephone interview on 6/25/2026 at 5:24 PM with the local law enforcement officer who responded to the IVC transportation request on 6/10/2026 revealed he rarely pushed back on the IVCs he was involved with but did so in this case. The officer stated that the facility nurse (did not recall her name) indicated the IVC had been completed as Resident #101 was refusing hemodialysis treatments. The officer indicated he provided education to the nurse that Resident #101 could refuse treatment and the IVC was not appropriate but the facility staff had the IVC papers and wanted to follow through with the IVC. The officer went on to say that Resident #101 was alert, oriented, cooperative, clearly not a danger to herself or others and did not appear to be in any medical distress when he arrived at her room. The officer revealed he tried to make the interaction as calm and dignified as possible for Resident #101 and walked out to the front of the building with her. The officer indicated Resident #101 sat down on the bench in the front and started to cry and became nervous. Initially, the officer stated he was going to have Resident #101 ride in the front seat but when she became upset, he chose to follow procedure and handcuffed her hands in the front of her body and had her ride in the backseat of the police car. Once at the hospital, the officer reported Resident #101 had become less upset and spent most the time at the hospital texting her cousin while lying on a stretcher. The officer reported that the hospital physician examined Resident #101 and ordered blood work. The officer stated Resident #101's blood work showed hemodialysis would be beneficial but Resident #101 was not in crisis. Had Resident #101 been in an unstable medical state, the officer revealed he would not have transported her in the police car and would have called for EMS support. The officer stated he returned Resident #101 to the facility as the hospital physician indicated Resident #101 had the capacity to make her own treatment decisions. The officer revealed the Administrator had contacted him by telephone and the officer stated he had told the Administrator that the IVC was not needed and had been completely inappropriate for Resident #101.A hospital emergency room physician note dated 6/10/2026 at 10:22 PM reported Resident #101 was seen due to a concern for a possible behavior problem. Resident #101 was brought in under IVC with the police. Per the IVC paperwork, the petitioner stated that Resident #101 was refusing hemodialysis and the petitioner was concerned that Resident #101 may not have capacity to refuse this. Resident #101 stated she just did not want to do hemodialysis and reported she urinated well and believed her kidneys were functioning okay at this time. Resident #101 denied any other complaints including fevers, chills, chest pain, shortness of breath, nausea/vomiting or abdominal pain. Resident #101 denied suicidal ideation, homicidal ideation, auditory/visual hallucinations and stated that this was not an attempt to end her life by refusing hemodialysis. The case was discussed with police. Resident #101 had been calm and cooperative for police. Also discussed the case with Resident #101's emergency contact and relayed the discussion with Resident #101. Resident #101's emergency contact stated that Resident #101's denial of her diagnoses had been an ongoing issue but did state that Resident #101 was able to currently make her own decisions. Resident #101 was not showing any signs of incapacitation. Resident #101 did not have a guardian and was not a ward of the state. Hospitalization was considered; however, labs were reassuring and Resident #101 wanted to leave. Resident #101 had the capacity to make this decision. Evaluation and diagnostic testing in the emergency department did not suggest an emergent condition requiring admission or immediate intervention beyond what had been performed at this time. Resident #101 was safe for discharge and had been instructed to return immediately for worsening symptoms, change in symptoms or any other concerns.A nursing note dated 6/10/2026 at 11:00 PM created by Nurse #2 stated Resident #101 returned, walking into the facility. ER paperwork was obtained. Resident #101 was in stable condition. An interview on 6/24/2026 at 4:15 PM with Resident #101 revealed she had refused hemodialysis treatments since the end of May 2026 until June 11, 2026. Resident #101 stated she had refused as she did not understand why she needed hemodialysis as she urinated normally. Resident #101 indicated she had requested the original hospital documents to review to better understand her medical condition as she had only been told by a hospital physician that hemodialysis was required or she would die. Resident #101 reported she had been attending hemodialysis since admission to the facility but began to have painful stomach cramping during treatments and felt like her throat was closing up. Resident #101 stated she was not sure that she had any kidney issues. Resident #101 stated she did not recall anyone discussing with her what she really wanted regarding her future care and treatment especially in the area of hemodialysis. Resident #101 revealed nursing staff seemed to become upset with her when she declined going to hemodialysis treatments. On 6/10/2026 in the evening, Resident #101 recalled a local law enforcement officer came to her room and asked her to walk out with him. Resident #101 indicated she complied and when she reached the front of the building she sat down on the bench at the front of the building. Resident #101 stated the police car was parked at the front of the building and initially the officer opened the front passenger door but then told her to stand up and hold out her hands. Resident #101 stated the officer handcuffed her hands in the front and told her to sit in the back of the police car. Resident #101 indicated she had asked the officer what was happening and where they were going but the officer did not answer her. Resident #101 recalled arriving at a building with a large emergency sign so she thought she was at the hospital. Resident #101 stated she waited in a room and a physician and nurse came into the room and her vital signs were taken. Resident #101 indicated she could not remember if the handcuffs were removed while she was in the room but knew the handcuffs had been taken off when she was moved to a stretcher in the hallway. Resident #101 revealed she thought blood work was taken and she stayed on the stretcher until it was time to return to the facility. Resident #101 recalled she saw the officer and physician talking and the physician came over to her and stated, All I can tell you is to please go to dialysis. At that point Resident #101 stated she left with the officer and returned to the facility. Resident #101 reported she did not recall speaking with staff when she returned until the next morning when breakfast was served and she got up to go to hemodialysis. Resident #101 stated during the interaction with the officer, she was upset and aggravated but tried to stay calm and cooperative. Resident #101 revealed that she had never had any interaction with law enforcement in the past but knew she had not been arrested that evening. Resident #101 indicated she now felt that she did not have the right to refuse her hemodialysis treatments as she was afraid the facility would contact local law enforcement again. Resident #101 stated she recalled a nurse had asked her to meet with staff regarding her care but could not remember the specific date. Resident #101 knew the request was after 6/10/2026. Resident #101 stated she did not want to talk with the facility staff about her care or condition as she did not trust them after the facility called local law enforcement on her.An interview on 6/25/2026 at 12:26 PM with the facility Discharge Planner #1 indicated psychology services were ordered on 3/8/2026 but Resident #101 declined the services. Discharge Planner #1 stated she was not part of the decision making process for the IVC for Resident #101. Discharge Planner #1 stated she had left one voice mail message for Resident #101's emergency contact regarding a discussion about guardianship but had never received a return call. Discharge Planner #1 indicated she could not recall the exact date of the call but knew it was before 6/10/2026. Discharge Planner #1 stated she met with Resident #101 once she learned about the IVC. Discharge Planner #1 recalled Resident #101 expressed she was upset about the IVC as Resident #101 felt she should be able to decline hemodialysis, and make her own decisions. Discharge Planner #1 stated Resident #101 appeared to feel better after having the opportunity to verbalize her feelings with Discharge Planner #1.A telephone interview on 6/25/2026 at 1:35 PM with Resident #101's emergency contact revealed Resident #101 had, in the past, denied other medical diagnoses. The emergency contact reported she had received a voicemail from the facility on 6/10/2026 and had called back. The emergency contact indicated she knew Resident #101 had been sent to the hospital and the IVC had been done due to Resident #101 refusing hemodialysis and concerns that toxins were building up. The emergency contact indicated that she believed Resident #101 could make some decisions but was unsure if Resident #101 could make medical decisions. The emergency contact reported she had discussed the importance of hemodialysis and medications with Resident #101 while Resident #101 was hospitalized and more recently when Resident #101 began refusing hemodialysis in June 2026. The emergency contact stated that guardianship had not been discussed with her. The emergency contact indicated she had been invited to a care team meeting but she was working and could not be on her phone while at work.A telephone interview with the Medical Director on 6/25/2026 at 11:45 AM revealed he had not been advised that an IVC had been initiated for Resident #101 until the surveyor told him during the telephone interview. The Medical Director reported he was not included in the decision process for the IVC. The Medical Director stated the NP saw Resident #101 on a regular basis but did recall the last time he assessed Resident #101 on 6/9/2026, he believed Resident #101 demonstrated some cognitive impairment. The Medical Director reported he knew Resident #101 had refused some hemodialysis treatments but also knew that Resident #101 had not been legally declared incompetent. The Medical Director indicated he had no comment on Resident #101's current decision making capability but felt residents who were competent could refuse treatment. The Medical Director stated he thought the IVC was an attempt by the facility to address Resident 101's poor choices. The Medical Director stated the facility should have pursued guardianship with Resident #101's family.An interview with the Administrator on 6/25/2026 at 3:15 PM indicated the facility felt that Resident #101's refusal of hemodialysis and medications was becoming an emergent situation on 6/10/2026 due to the buildup of toxins. The Administrator revealed he had personally met with Resident #101 and explained the importance of hemodialysis but could not provide a specific date this was done. The Administrator stated he did not feel Resident #101 could make her own decisions due to the buildup of toxins from not receiving hemodialysis. The Administrator reported he did believe Resident #101 was a danger to herself when she refused hemodialysis treatments and had completed the IVC as Resident #101 refused to go to the hospital with EMS and they could not take her against her will. The Administrator stated that he was aware Resident #101 had travelled to and from the hospital in the police car and had talked with the responding law enforcement officer via telephone. The Administrator stated the officer had told him the IVC had been completely unnecessary for Resident #101. The Administrator stated that the facility did not reach out to the Regional Ombudsman prior to initiating the IVC. The Administrator stated Resident #101's cognition seemed better now that she had resumed hemodialysis treatments. The Administrator stated the facility attempted to have a care team meeting on 6/18/2026 but Resident #101 and the emergency contact did not attend.

Based on record review and interviews with resident, family, Medical Director, and staff, the facility failed to treat a resident in a dignified manner when staff filed legal guardianship of the resident without communicating with the resident or the resident's family and without having the resident evaluated or assessed to be deemed incompetent. Resident #1, with visible tears in her eyes, stated she felt the facility was trying to control her and take her rights away. This affected 1 of 1 resident reviewed for dignity and respect (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, hypertension, anoxic brain damage, dependence of renal dialysis, cognitive communication deficit, and muscle weakness.Review of Resident #1's face sheet revealed the resident was her own responsible party (RP). The face sheet further revealed the resident had Family Member #1 and Family Member #2 listed as emergency contacts.A physician note completed by the Medical Director dated 07/26/26 noted Resident #1 had historically refused dialysis and medication but had shown variable willingness to reconsider when educated about their purpose. The note further revealed Resident #1's cognitive impairment rendered comprehension of her decisions doubtful, but Resident #1 had not been declared incompetent and family were not willing to force the issue.Resident #1's significant change Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and had no behavior or rejection of care. The MDS further revealed the resident was coded for dialysis.Review of Resident #1's active care plan (revised on 06/12/26) revealed the resident had behaviors of refusing medications and dialysis treatments due to denial of health conditions. The goal was that Resident #1's behaviors would not cause the resident distress. Interventions included administering medications as ordered and assign staff to the resident that were familiar or preferred.Review of Resident #1's active care plan (revised on 06/18/26) revealed the resident was expected to be at the facility on a short-term basis and return to the community. The goal was that Resident #1 would return to the community successfully when ready. Interventions included to coordinate with the physician regarding discharge plans as indicated, refer to community resources as indicated per resident and resident representative preference, and update discharge plans with the resident when needed.A physician note completed by the Medical Director dated 08/14/26 noted Family Member #1 had been involved in the resident's care and had been notified of the resident's refusal of hemodialysis treatments. Resident #1 believed she did not have chronic kidney disease and education had been provided. Resident #1 reported she wanted to speak with Family Member #2 (ex-husband) before making any decisions.Review of a court petition filed for guardianship of Resident #1 on 08/14/26 by the Social Worker revealed there was a pending court date for 09/23/26.An interview with the Social Worker (SW) on 08/17/26 at 1:00 PM indicated Resident #1 had some days that she was confused, but she was still able to make her own decisions. She revealed that on 08/14/26 the facility filed for legal guardianship at the courthouse due to Family Member #1 and Family Member #2 not being able to be contacted. The SW indicated on 08/14/26 it was reported to her by the Administrator that Resident #1 had a letter of competency that deemed her to be incompetent; however the SW had not reviewed the letter. The SW stated she was not included in the decision making to file paperwork but was directed by the Administrator on 08/14/26 to go to the courthouse and file the same day for legal guardianship of Resident #1. The SW revealed the guardianship had not been obtained and was set to be heard in court in September. The SW stated she knew Resident #1 had been her own RP prior to 08/14/26.Phone interview with Family Member #1, Resident #1's daughter, on 08/17/26 at 1:45 PM revealed she had not been notified by the facility that they were trying to obtain legal guardianship of Resident #1. Family Member #1 further revealed the resident was her own RP but the facility had notified her when Resident #1 had gone to the hospital on [DATE]. She explained that she had not spoken to facility staff since that time. Family Member #1 stated the facility had her phone number and email address. Family Member #1 indicated that if Resident #1 needed a guardian that she would have wanted to be the guardian for Resident #1. Family Member #1 revealed she stayed in touch with Resident #1 and the resident had not mentioned anything about guardianship.Interview with Resident #1 on 08/17/26 at 2:00 PM revealed she had not been notified that the facility had filed legal guardianship paperwork. Resident #1 further revealed she did not understand why they would want to obtain guardianship. Resident #1 stated she would not want the facility to oversee her decision making. Resident #1 stated she had family that would step in and make decisions for her if she needed them to do so. Resident #1 indicated she was her own RP. Resident #1, with visible tears in her eyes, a tense facial expression, and a shaking voice, stated, The facility is trying to control my life and take my rights away because I do not want to go to dialysis. Interview with the facility's Receptionist on 08/17/26 at 3:00 PM revealed she was assigned to send care plan invitations for care plan meetings. It was further revealed she sent care plan invitations to Family Member #1 via email. The Receptionist indicated the email invites had been kicking back (not going through) since March 2026. The Receptionist also indicated that she had attempted to call Family Member #1 a couple times but had no documentation when the attempts were made. The Receptionist stated she had not taken any other measures to contact Family Member #1 or Family Member #2.Phone interview with the Medical Director on 08/17/26 at 3:15 PM revealed he believed Resident #1 to not be able to make financial, social, and health decisions due to her ongoing non-compliance with dialysis treatments. The Medical Director further revealed he was unable to determine if Resident #1 was incompetent because no formal assessment had been completed.Interview with the Administrator on 08/17/26 at 3:40 PM revealed Resident #1 had denied she had kidney failure, certain diagnoses, and was non-compliant with dialysis. She stated that she felt that the resident was unable to make appropriate medical decisions. The Administrator further revealed that the SW and Receptionist attempted to contact Family Member #1 by phone and email but was unsuccessful. The Administrator indicated he thought the facility needed to file for guardianship so that somebody could make appropriate decisions for the resident. The Administrator stated he was aware Resident #1 was her own RP and had two family members, Family Member #1 and Family Member #2, on the resident's emergency contact list. The Administrator indicated he did not have a conversation with Resident #1 about filing for guardianship. The Administrator revealed the facility had made no efforts other than phone calls and a care plan invite via email to contact Resident #1's family members. She further revealed that no formal assessment or evaluation had been completed to deem the resident incompetent.Interview with the Director of Nursing (DON) on 08/17/26 at 4:00 PM revealed she was aware there had been no documentation of efforts made to contact Resident #1's Family Member #1 or Family Member #2. The DON further revealed no formal assessment or evaluation had been completed on Resident #1 to deem her unable to make her own health care decisions. The DON indicated she was not involved in the decision making to file for guardianship of Resident #1.

Based on observations and staff interviews, the facility failed to label and date food items stored for use, reseal dry goods that were left open to air, keep a gas range and oven clean of grime (ingrained dirt or filth accumulated on a surface) and grease build-up, and maintain a clean food preparation area. These practices occurred in 1 of 3 reach-in coolers (cooler #2), 1 of 1 dry goods storage room and had the potential to affect food served to residents. The findings included:An initial tour of the main kitchen occurred on 6/22/26 at 10:20 AM with the Dietary Manager. The following concerns were identified:a. Undated food items found in the reach-in cooler #2 included: - A large, prepared container of sliced fresh tomatoes,- A large, prepared container of sliced fresh onions. b. Leftover food items found in the dry storage area on 6/22/26 at 10:25 AM that were not resealed and left open to air and/or undated included:- A 35 ounce (oz.) bag of crisped rice cereal,- A 35 oz. bag of corn flakes cereal,- One 24 oz. open-to-air bag of strawberry gelatin in the original container without a date.c. Observations of the cooking equipment and the food preparation area on 6/22/26 at 10:35 AM included:-Visible grime and grease build-up present on four burners of the gas cooking range in the food preparation area, -Visible grease build-up and food particles present on the glass oven doors in the food preparation area,- Grease build-up and food crumbs were present in the tile grout in front of the cooking and food preparations areas.An interview with the Dietary Manager on 6/22/26 at 10:35 AM revealed she had just started as the Dietary Manager a few weeks ago and she stated kitchen staff were expected to clean the food preparation areas daily. She stated she was unsure of the deep cleaning schedule, but she had degreasing products which she planned to use on the grease build up in the food preparation areas.A second interview with the Dietary Manager occurred on 6/25/26 at 3:11 PM. She stated kitchen staff started using resealable storage bags for the opened cereal. An interview with the Administrator on 6/25/26 at 3:46 PM revealed he had the expectation that the kitchen would not have any grease build-up in the food preparation area and that staff would keep the equipment clean. He stated he had received a quote for repairing and replacing some of the tile and grout areas in the food cooking and preparation areas. The Administrator also stated he had the expectation that all food stored in the kitchen would be correctly stored and labeled.

Based on observations, record review and Medical Director, Nurse Practitioner, staff and resident interviews the facility failed to provide the necessary assistance to obtain dental services for 1 of 2 residents reviewed for dental services (Resident #57).The findings included:Resident #57 was admitted to the facility on [DATE] with diagnoses that included dysphagia oral phase (difficulty chewing or moving food from the mouth to the throat) and protein calorie malnutrition.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was cognitively intact and received a mechanically altered diet. Resident #57 was not coded for a swallowing disorder or any dental/oral concerns.Resident #45's physician orders revealed an order dated 3/18/26 for a regular pureed diet with thin liquids. The Medical Director note dated 6/09/26 revealed Resident #57 was seen for a routine visit and was monitored closely for weight loss due to a diagnosis of severe protein-calorie malnutrition. Resident #57 reported during the visit that she was receiving a pureed diet but did not like most of the meals and stated she could eat better if her teeth were better. A dental consult was ordered for Resident #57 to be evaluated for dentures.Resident #57's physician orders revealed an order dated 6/09/26 for a dental consult for dentures due to poor dentition and the order end date was 6/23/26. The quarterly MDS assessment dated [DATE] indicated Resident #57 did not have a weight loss of 5 percent or more in one month or 10 percent or more in six months.The Nurse Practitioner (NP) note dated 6/17/26 revealed monitoring continued of Resident #57's nutritional status due to a diagnosis of severe protein-calorie malnutrition and dental consult was pending. Resident #57 continued with a pureed diet and nutritional supplements three times a day, however, was refusing the supplements. Resident #57 was observed during visit with snack/drink at beside and her condition was stable. No new orders at this time.During an observation and interview with Resident #57 on 6/22/26 at 11:19 AM she was observed to have several missing teeth. Resident #57 indicated she was receiving a pureed diet due to difficulty chewing but did not like most of the pureed food and wanted to be evaluated for dentures. Resident #57 stated I would not need a pureed diet if I had teeth and could chew. Resident #57 indicated she did not recall their names, but since her admission to the facility she had notified several staff members she wanted a dental appointment, however nothing had been done. A phone interview conducted with the Medical Director on 6/26/26 at 10:09 AM revealed Resident #57 had poor dentition, difficulty chewing and was receiving a pureed diet. He stated Resident #57 reported she did not like most of the pureed food and requested a dental consultation for dentures. The Medical Director indicated he entered a dental consultation order for Resident #57 into the electronic medical record (EMR), but he did not recall the date or duration of the order. He revealed he usually set the duration of a consultation order for 7 to 14 days to give the nurses time to schedule the appointment and would expect the appointment to be scheduled before the order end date. During an interview with the NP on 6/24/26 at 10:15 AM she stated Resident #57 was admitted with a diagnosis of protein-calorie malnutrition and had difficulty maintaining her weight, but this was expected. The NP indicated Resident #57 had nutritional interventions in place and no significant weight loss at this time. The NP revealed there was a dental consult pending for Resident #57 but she was unsure as to why the consult was ordered. The NP revealed Resident #57 had not reported any concerns to her related to not liking the pureed diet or that she wanted to be evaluated for dentures. An interview with Nurse Aide (NA) #1 on 6/25/26 at 8:40 AM revealed she was the primary NA assigned to Resident #57 from 7:00 AM to 7:00 PM. NA #1 stated she did not recall the date but approximately 2 or 3 weeks ago Resident #57 requested to see the dentist because she did not like the pureed diet and wanted to get dentures. NA #1 revealed she notified Nurse #1 that Resident #57 requested to see the dentist. An interview conducted with Nurse #1 on 6/25/26 at 8:45 PM revealed she was the primary nurse assigned to Resident #57 from 7:00 AM to 7:00 PM but she did not recall NA #1 notifying her that Resident #57 requested to see the dental provider. Nurse #1 stated she would observe a new order for a resident in the EMR when she pulled up their order list to administer medications, but she did not recall seeing a new order for a dental consult for Resident #57's on her order list. Nurse #1 revealed if she was notified that resident requested to see the dental provider or they had a new order for a dental consult she would notify the Unit Manager or Discharge Planner #1. During a phone interview with the Unit Manager on 6/26/26 at 8:34 AM she revealed she was not aware that Resident #57 had a physician order for a dental consult. She indicated Nurse #1 should have notified her or Discharge Planner #1 that Resident #57 had an order for a dental consult. The Unit Manager revealed the dental provider was at the facility on 6/18/26 however Resident #57 was not seen during their visit. An interview was conducted with Discharge Planner #1 on 6/24/26 at 1:35 PM which indicated the facility had a dentist that visited the facility quarterly to provide dental services for the residents. Discharge Planner #1 revealed she was unaware that Resident #57 had requested to see the dental provider or that she had a physician order for a dental consult. Discharge Planner #1 stated the dental provider's last visit was on 6/18/26 however Resident #57 was not seen during their visit.An interview with the Administrator on 6/25/26 at 4:27 PM revealed when a resident requested dental services or the physician ordered a dental consult, Discharge Planner #1 should be notified by the nurse or Unit Manager to ensure the resident was placed on the dental providers list to receive services during their next scheduled visit at the facility.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening Resident Review (PASRR) was completed prior to admission to the facility for a resident with a diagnosis of a serious mental illness for 1 of 1 resident reviewed for PASRR (Resident #45).The findings included: A review of the medical record revealed a PASRR Level I was completed for Resident #45 on 9/15/22. The hospital Discharge summary dated [DATE] indicated Resident #45 was transferred to the emergency department (ED) from his home on [DATE] by law enforcement to be evaluated for involuntary commitment (IVC) due to suicidal ideations and aggressive behaviors. A psychiatric evaluation completed in the ED on 12/23/25 indicated Resident #45 had diagnoses including post-traumatic stress disorder (PTSD) and stroke with right sided weakness and was living with a family member. Resident #45 reported his living situation was stressful and he verbalized suicidal ideations in frustration during an argument with a family member which led to the IVC. Resident #45 denied wanting to hurt himself or others and had exhibited no acute psychiatric concerns or behaviors while being evaluated in the ED. Resident #45 was determined not to meet criteria for IVC but was admitted to the hospital on [DATE] for assistance with finding facility placement due to his uncertain housing situation. Resident #45's condition remained stable during the hospitalization, and he was discharged to the facility on [DATE] with orders to follow up with outpatient psychiatry services as needed. Resident #45 was admitted to the facility on [DATE] with diagnoses that included PTSD and adjustment disorder with mixed disturbance of emotions/conduct. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact, exhibited no behaviors or rejections of care, had active diagnoses including PTSD and adjustment disorder with mixed disturbance of emotions/conduct, and he was not receiving any psychotropic medications. The MDS indicated Resident #45 was not currently considered by the state Level II PASRR authority to have a serious mental illness or intellectual disability. During an interview with Discharge Planner #1 on 6/24/26 at 1:36 PM she revealed she assumed the responsibilities of the Former Social Worker at the end of February 2026 after Resident #45 was admitted to the facility. Discharge Planner #1 stated the hospital case managers usually completed a Level I PASRR for a resident prior to admission to the facility however she was responsible for reviewing the Level I PASRR screen in the North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) to ensure the hospital submitted it during the most recent hospitalization and included the resident's active diagnoses of mental illness. She stated if she observed the Level I PASRR screen was not submitted recently or did not include the resident's active diagnoses of mental illness then she would complete a new Level I PASRR screen and submit it for review. She explained that but she was unsure if the Former Social Worker followed this procedure when Resident #45 was admitted to the facility. Discharge Planner #1 revealed if a Level I PASRR had not been completed for Resident #45 since 2022 then a new Level I PASRR screen including his active diagnoses of mental illness should have been completed and submitted for review. A phone interview conducted with the Former Social Worker on 6/25/26 at 2:07 PM revealed when a resident was admitted to the facility, she was responsible for reviewing the admission paperwork to ensure the resident had a PASRR number. The Former Social Worker indicated she did not complete or review the Level I PASSRs for newly admitted residents to ensure it was completed on a recent date prior to admission and included the resident's active diagnoses of mental illness. The Former Social Worker stated that Resident #45 had a PASRR number when he was admitted to the facility on [DATE] but she was unsure when the Level I PASRR screen was completed or if it in included Resident #45's active diagnoses of mental illness. An interview conducted with the Administrator on 6/25/26 at 4:22 PM indicated the Former Social Worker was responsible for ensuring a Level I PASRR was completed for all residents prior to admission to the facility. He stated the hospital case managers typically completed the Level I PASRR however the facility was responsible for reviewing the Level I PASRR screen to ensure it included resident's active diagnoses of mental illness and was completed during their most recent hospitalization.

Based on observations, record review, and Responsible Party (RP), continuous radar-monitoring system representatives, and staff interviews, the facility failed to obtain written consent and educate the resident or Responsible Party for the use of a continuous radar-monitoring system mounted on the wall above the resident's bed for 1 of 2 sampled residents with a monitoring system (Resident #35). Findings included: Resident #35 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was moderately cognitively impaired. An observation on 6/22/26 at 12:00 PM revealed Resident #35 had a small, white device with no lens or light mounted above her bed which was pointed directly at her bed. A review of the continuous radar-monitoring system's website revealed the mounted device continuously monitored vital signs and activity through clothing and bedding using radar-based sensors. Subtle skin movements from the patient's heartbeat were detected, measured, and tracked around the clock. The data was sent to a centralized dashboard, giving facility staff access to patient insights, analysis, and alerts. A telephone interview with continuous radar-monitoring company Representative #2 occurred on 7/1/26 at 11:12 AM. He stated the continuous radar-monitoring device in any resident's room would continuously collect data and was never physically turned off, but the data would not be monitored until the consent was signed. When asked by the State Surveyor how the monitoring company would know if a resident had moved in or out of a room, he replied that the monitoring service would rely on nursing documentation of a discharge, room change, etc. and as soon as that update was loaded, the data would be received. An interview with Resident #35 was attempted on 6/22/26 at 12:00 PM but was unsuccessful. An interview with Resident #35's Responsible Party (RP) on 6/22/26 at 12:00 PM revealed he was not aware of what the small, white device mounted to the wall was and noted it had been there since Resident #35 was admitted . He stated he thought it might be a camera and was not sure how he felt about a camera or other monitoring device being used in Resident #35's room. The RP stated he was not made aware of the device and did not recall receiving any education on the device or signing a consent form for its use when he signed Resident #35's admission paperwork. He stated he could not decide if he was ok with the use of the device as he was not aware of what it was monitoring. The RP noted he had not asked facility staff about the device. A request was made by the State Surveyor on 6/25/26 for the continuous radar-monitoring system written consent forms. On 6/26/26 the signed consent forms were reviewed and there were none present for Resident #35. A telephone interview with the Director of Nursing (DON) on 7/1/26 at 10:01 AM revealed she and the admission Director went through the consent forms requested by the State Surveyor on 6/25/26 and 6/26/26 and realized a consent form for Resident #35 was missing. A combined telephone interview with the Admissions Director and the Administrator on 7/1/26 at 10:44 AM revealed the Admissions Director did the admissions paperwork for Resident #35 when she moved into the facility. She stated the admission Assistant typically did the admission paperwork, but she was out on vacation, so she went through the paperwork with Resident #35's RP. She stated she missed the consent form and the education that accompanied the form when speaking to Resident #35's RP. The Administrator stated the continuous radar-monitoring device would not have been turned on in Resident #35's room until a consent had been signed for her. A telephone interview with continuous radar-monitoring device Representative #1 occurred on 6/29/26 at 1:20 PM. He stated the device in Resident #35's room used continuous radar technology and would monitor metrics such as heart rate and respirations on all residents. He indicated a team of clinicians offsite monitored the information tracked from the device. Representative #1 stated the system interfaced with the facility's EMR and the offsite clinicians monitoring the data could view the EMR and would look for an action of the facility's nursing staff and if there was not a current action, it would send an alert through the system to the nursing staff to alert them to a problem with a resident. He stated the continuous radar-monitoring device did not use a receiver on any resident being monitored but instead took the data from the person in the bed. Representative #1 stated if someone else stepped in front of the monitor, the continuous radar-monitoring system would shut down and reestablish on the correct resident. He stated a daily risk report was formulated and sent to the administrative staff in the building every morning. The report is formulated by Artificial Intelligence (AI) algorithms as it started to pick up on and resident's habits such as getting up out of bed, turning, etc. Representative #1 stated education should occur when the consent forms were signed, and the company representatives did a lot of education with admissions staff so they could relay the information to the families and inform them the system is covered by Medicare and Medicaid in most states. Representative #1 stated if there was no consent, the company would not monitor that resident. A combined interview with the Nurse Consultant and the Administrator on 6/25/26 at 2:45 PM revealed all the company's facilities had the continuous radar-monitoring system in resident rooms and the device tracked things like respirations and resident movement. The Nurse Consultant stated the facility received a report each morning which included a list of residents who were most at risk. She was unable to explain what metrics were used or how the list was formulated. The Administrator stated all new residents or their RP's signed a consent form during the admission process with the Admissions Director or Admissions Assistant and were given education on the device. He stated all previous residents in the building were educated and consents were signed when the devices were installed.

Based on record review, and resident and staff interviews, the facility failed to complete smoking assessments when a resident was identified as a smoker and to provide supervision and retain smoking materials in accordance with the smoking policy for a resident assessed as a supervised smoker for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Review of the policy titled Patient Smoking dated 01/29/24 indicated if supervision was deemed necessary, the resident would be supervised by staff or other appropriate person (i.e., family member). Residents who wished to smoke would be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine need for supervision. The facility would maintain all smoking paraphernalia for residents who required supervision with smoking. Resident #1 was admitted to the facility on [DATE] with diagnoses of tobacco use. Resident #1's care plan with a date of 04/12/25 revealed the resident preferred to smoke. Interventions included educating Resident #1 on facility smoking policy, assessing smoking as needed, and being supervised while smoking.Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had no functional impairments with range of motion. The MDS further revealed Resident #1 used a wheelchair and walker for mobility. Resident #1's smoking assessments revealed an assessment was completed by Nurse #1 on 08/11/25 that deemed the resident was a supervised smoker. There was no evidence that a smoking assessment was completed prior to 08/11/25 for Resident #1. An interview with Nurse #1 on 12/31/25 at 11:45 AM revealed she completed Resident #1's initial smoking assessment on 08/11/25. Nurse #1 revealed a staff member (she was unable to recall which staff member) had brought it to her attention during a staff meeting that Resident #1 did not have a smoking assessment completed. She explained that she believed the resident did not smoke when he was admitted to the facility. She indicated she recalled Resident #1 not wanting to smoke cigarettes until later in his stay at the facility but could not recall the date. Nurse #1 indicated Resident #1 was deemed to be a supervised smoker on 08/11/25 due to his dexterity issues. Nurse #1 could not recall why Resident #1's care plan indicated that the resident was a smoker since admission [DATE]). An interview and observation of Resident #1 on 12/30/25 at 11:50 AM revealed he had never been supervised while smoking at the facility and went out to smoke whenever he wanted to. Resident #1 indicated he had smoked cigarettes since admission and kept his lighter and cigarettes in his possession. Resident #1 did not have any burn holes on his clothing or his wheelchair seat cushion at the time of the observation.A phone interview with Nurse Aide (NA) #1 on 12/31/25 at 12:25 PM was conducted. NA #1 indicated Resident #1 was an unsupervised/independent smoker and kept his smoking materials on him. NA #1 stated he was not aware Resident #1 was assessed as requiring supervision to smoke. NA #1 revealed he had not been educated on which residents required supervision for smoking. NA #1 added that he normally worked the 7:00 PM to 7:00 AM shift when supervised smokers did not have scheduled smoking times. NA #1 stated he had observed Resident #1 going out to smoke unsupervised throughout the night when he worked. He explained that the assigned nurses never said anything about the resident requiring supervision to smoke, so he thought it was okay. NA #1 revealed unsupervised smokers were allowed to keep their smoking materials in their possession and supervised smokers had their smoking materials kept at the nurse's desk.A phone interview with Nurse #2 on 12/31/25 at 3:20 PM was conducted. Nurse #2 revealed she did not recall Resident #1 ever being supervised for smoking during his (the resident's) time at the facility. Nurse #2 stated a few months ago there had been a smoking list posted at the nurse's desk that indicated which residents required supervision to smoke. Nurse #2 revealed she did not recall Resident #1 being on the supervised smoker list. He indicated he had not seen a smoking list recently. She explained that Unit Manager (UM) #1 also sometimes communicated to her (Nurse #2) when she came on shift if a resident's smoking status changed. She further explained that UM #1 did not communicate any information about Resident #1's smoking status. Nurse #2 indicated Resident #1 went in and out throughout the night (the shift Nurse #2 worked) to smoke independently and kept his smoking materials on him. Nurse #2 revealed supervised smokers had smoking materials secured and unsupervised smokers were able to keep their smoking materials in their possession. An interview with UM #1 on 12/30/25 at 12:20 PM revealed Resident #1 had been an independent (unsupervised) smoker since admission. It was further revealed she was not aware that Resident #1 had been care planned at admission for being a supervised smoker and had been assessed to be a supervised smoker on 08/11/25. UM #1 revealed smokers were discussed in staff meetings and there was a list with supervised and unsupervised smokers. UM #1 revealed independent smokers were able to have their smoking materials in their possession and supervised smokers had their smoking materials stored at the nurse's desk. UM #1 recalled that Resident #1 always had his own smoking materials. UM #1 did not recall why a smoking assessment was not completed at admission for Resident #1. UM #1 stated a smoking assessment should have been completed at admission on Resident #1 by the assigned nurse.An interview with the Administrator on 12/30/25 at 1:00 PM revealed he was not aware Resident #1 had no smoking assessment completed prior to 08/11/25. The Administrator further revealed he expected smoking assessments to be conducted on admission and quarterly for residents who smoked. The Administrator indicated that per nursing staff he understood that Resident #1 had not started smoking until 08/11/25. The Administrator did not indicate which nursing staff informed him of this information or when he was informed. He did not explain why Resident #1 had a care plan for smoking that was initiated on admission [DATE]). The Administrator stated unsupervised smokers kept their own smoking materials and supervised smokers had their smoking materials secured by nursing staff. The Administrator revealed staff should have been aware of smokers' assessed status through communication between nursing staff, discussions from staff meetings, reviewing the care plans, and reviewing the residents' charts for orders and progress notes.

Based on record review, and resident and staff interviews, the facility failed to report reasonable suspicion of a crime to law enforcement when Resident #1 was identified with an odor of marijuana after he returned inside the facility from the smoking area. A subsequent drug screen was completed and the resident tested positive for Tetrahydrocannabinol (THC [the main psychoactive ingredient in marijuana] ). This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1). The findings included:Review of the facility policy and procedure titled Substance Use with a date of 01/29/24, states to protect the health and safety of resident, the center prohibits unprescribed use of drugs and alcohol. The policy indicated if items were found that posed a health and safety risk they were to be confiscated if in plain sight and law enforcement was to be contacted. Resident #1 was admitted to the facility on [DATE].Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.A phone interview with Nurse Aide (NA) #1 on 12/31/25 at 12:25 PM revealed on 11/13/25 around 11:00 PM when Resident #1 came back inside the facility from the smoking area the resident smelled of marijuana. NA #1 further revealed he immediately reported the odor of marijuana to Nurse #2 who was assigned to the resident. A phone interview with Nurse #2 on 12/31/25 at 3:20 PM revealed on 11/13/25 during the second shift (7:00 PM to 7:00 AM) NA #1 reported an odor of marijuana coming from Resident #1. Nurse #2 stated Resident #1 agreed to drug screen but denied smoking marijuana/THC.A 10-panel urine drug screen (tests for 10 common drug classes) was completed for Resident #1 on 11/14/25. Results of the screen (dated 11/15/25) indicated Resident #1 tested positive for cannabinoids (marijuana/THC). An interview with Resident #1 on 12/30/25 at 11:50 AM revealed in November 2025 he had smoked a THC vape that he obtained from another resident.During an interview with the Director of Nursing (DON) on 12/30/25 at 12:45 PM she confirmed that staff identified that Resident #1 had an odor of marijuana, a drug screen was completed, and Resident #1 tested positive for cannabinoids. The DON revealed Resident #1 allowed the facility to search his room and nothing was found. The DON stated that she felt law enforcement did not need to be contacted because no hard evidence was found during the room search. An interview with the Administrator on 12/30/25 at 1:00 PM revealed an investigation was completed after he was notified in November 2025 that staff suspected Resident #1 utilized marijuana. The Administrator indicated Resident #1 allowed the facility to drug screen him and search his room. The facility was unable to find any signs of illegal substances when they searched Resident #1's room and he (the Administrator) was unable to determine where the THC had come from. The Administrator revealed that even though the facility did an investigation and the resident tested positive for an illegal substance, he did not feel that he needed to report the incident to law enforcement because he did not think they would have been able to do anything more than the facility had done.

Based on record review, and staff interview the facility failed to ensure a resident's medical record was complete regarding medication orders given by a Nurse Practitioner and documentation of the administration of medications. This was for 1 of 3 of three sampled residents whose medications were reviewed (Resident # 1).The findings included: Resident # 1 was admitted to the facility on [DATE] with a diagnosis of metastatic lung cancer disease.Review of a Nurse Practitioner's (NP) progress note for the date of 10/3/25 revealed the NP had ordered some medications when the resident was not responding. According to the NP's note she ordered two doses of Narcan and one dose of Lasix which were administered to the resident.Review of Resident # 1's orders revealed these orders were never entered into the resident's electronic record. Review of Resident # 1's MAR (Medication Administration Record) revealed no documentation when these medications were given. They did not appear on the MAR. Review of the facility's emergency medication supply sign out records revealed Narcan was removed from the supply on 10/3/25 at 9:32 AM and 12:16 PM for Resident # 1. Lasix was removed from the emergency supply for Resident # 1 on 10/3/25 at 9:37 AM.Nurse # 5 was interviewed on 10/13/25 at 1:06 PM and reported the following information. There had been multiple nurses in the room with the Nurse Practitioner on 10/3/25 when the NP gave orders for the first dose of Narcan and the Lasix. This included Nurse Manager # 1, Nurse # 3, Nurse # 4, and herself (Nurse #5). The NP did not direct the order to any particular nurse, and it was not clear that she (the NP) did not enter the order in herself. Nurse # 4 had removed the Narcan and the Lasix from the backup supply and she (Nurse # 5) had administered Narcan and Lasix at the time these had been removed from the emergency supply. She had not documented the administration on the MAR.Nurse # 3 was interviewed on 10/13/25 at 1:10 PM and reported the following information. The NP had given the order for a second dose of Narcan on 10/3/25 around 12:30 PM. She had removed the Narcan from the backup supply and administered it per the verbal order. She had not documented the order on the MAR. When entering orders into the electronic medical record system, the system had choices of different medications and different forms in which the medications were supplied. She had tried to enter the order in the facility's electronic medical record system, but she could not find the correct form of Narcan in the electronic record as a choice. Therefore, the order was not entered into the resident's electronic record, and it never appeared on the MAR. Therefore, she had not documented the administration, but she did administer it.According to interviews with the Administrator on 10/10/25 at 5:00 PM and again on 10/13/25 at 12:59 PM the Resident's record should have reflected the orders and administration times of the Narcan and Lasix.

Based on observation, record review, and interviews with staff, Nurse Practitioner, Pharmacist, and Physician the facility failed to ensure a nurse accurately measured a liquid narcotic medication per professional standards of practice resulting in a wrong administration dose. This was for 1 of 3 residents whose medications were reviewed (Resident #1). The findings included:Resident # 1 was admitted to the facility on [DATE]. Review of a hospital discharge summary revealed that prior to Resident # 1's facility residency he had been hospitalized from [DATE] to 9/2/25. The resident was diagnosed with pulmonary nodules, a large chest mass with evidence of metastatic disease to multiple areas in his bones along with enlarged lymph nodes. Additionally, Resident # 1 had diagnoses of heart failure with a decreased ejection fraction (percent of blood flow the heart pumps with each heart beat), chronic obstructive pulmonary disease, anxiety disorder, schizophrenia, hypertension, and seizure disorder. Resident # 1's admission weight on 9/2/25 registered 256.6 pounds.Resident # 1's admission Minimum Data Set assessment, dated 9/9/25, coded Resident # 1 as cognitively intact with occasional pain.Review of Nurse Practitioner (NP) # 1's progress note, dated 9/17/25, revealed the following information. The resident had chosen not to receive any treatment for his metastatic lung cancer. He had chosen not to be hospitalized or to be resuscitated. He was becoming more lethargic and more hypoxic, and there had been a decline in his meal intake.Review of physician orders revealed an order, dated 9/24/25 at 11:42 AM, for Morphine Sulfate (concentrate) solution 20 mg (milligrams)/ML (Milliliter) Give 5 mg by mouth every 2 hours as needed for end of life care/restlessness, labored breathing for 10 days comfort measures.Review of Resident # 1's Medication Administration Record (MAR) revealed the 9/24/25 Morphine order was transcribed onto the MAR without any directions that .25 ml would equate to the ordered 5 mg.Nurse Manager # 1 and Nurse # 2 were interviewed together on 10/10/25 at 3:12 PM. Nurse # 2 routinely cared for Resident # 1 and Nurse Manager # 1 was the resident's care manager. Nurse # 2 reported the following information. Resident # 1 was ordered to have oxygen and nebulizer treatments. He was noncompliant and would take the oxygen off or remove the nebulizer treatments. After being at the facility for approximately three weeks he began to decline, and they had trouble keeping his oxygen levels up because he would remove his oxygen. Nurse Manager # 1 reported that the resident, who had mental illness and anxiety, would take his oxygen off and then he would not be able to get his breath. This further increased his anxiety, which in turn made it harder for him to breathe. He would then cry out he could not breathe as if panicking. He had been prescribed Morphine which helped him become calmer, slow his respirations, and raise his oxygen saturations as part of his comfort care in the end of life. Nurse # 2 further reported that after three weeks of being at the facility, Resident # 1 would sleep almost the entire shift at times, and this was not correlated to the morphine. At times he would do this even when the morphine was not administered.On 10/1/25 a significant change MDS assessment was completed. Resident # 1 was coded on this assessment as being moderately cognitively impaired and as having frequent pain during the assessment period.Review of Resident # 1's Controlled Substance Receipt/Count Sheet revealed on 10/3/25 at 2:30 AM Nurse # 1 signed out 1 milliliter of Morphine from Resident # 1's supply. According to the Controlled Substance Receipt/Count Sheet, there were 20 milligrams of Morphine per one milliliter. This indicated that Nurse # 1 signed out 20 milligrams of Morphine rather than the prescribed 5 mg of Morphine. On 10/3/25 at 3:03 AM Nurse # 1 documented on Resident # 1's MAR (Medication Administration Record) the administration of the Morphine beside of the order which noted the dosage should have been 5 milligrams.On 10/10/25 at 1:39 PM an attempt was made to interview Nurse # 1 and she could not be reached for interview.Nurse Aide (NA) # 1 was assigned to care for Resident # 1 on the night shift which began on 10/2/25. NA # 1 was interviewed on 10/13/25 at 1:23 PM and reported the following information. Nurse # 1 had informed her that she had made a medication error and given the resident too much morphine. Nurse # 1 went to call the physician. Nurse # 1 had instructed her (NA # 1) to take the resident's respirations and oxygen saturation every ten minutes, and she had done so and checked on him throughout the night. She also did full vitals every four hours. Nurse # 1 also checked on him. Resident # 1 was still alert after the error until around 5:00 AM. He had not slept in a long time prior to the error being made and then around 5:00 AM he started to rest and seemed really relaxed at that point. His respirations were at his baseline at the end of her shift.Review of nursing notes revealed an entry on 10/3/25 at 6:00 AM noting Resident # 1 was sleeping and was responsive to tactile stimuli. His vitals were 101/67, heart rate 115, oxygen saturation 93%, and his respirations were easy and unlabored.Interview with the DON (Director of Nursing) on 10/10/25 at 12:42 PM revealed the following information. Nurse # 1 had made a medication error and administered 20 mg of Morphine to Resident # 1 rather than 5 mg. Nurse # 1 had recognized after she had given the wrong dosage that there had been more in the syringe than was supposed to be in the syringe and had called the provider right after the error. The provider instructed that the resident be monitored which was done. The nurse had reported to the DON that she had been in and out of the room through the night and checking the resident. She (the DON) had spoken to Nurse # 1, and the nurse did not say what had contributed to the problem.Nurse # 3 cared for Resident # 1 from 7:00 AM to 7:00 PM on 10/3/25. Nurse # 3 was interviewed on 10/10/25 at 3:34 PM and reported the following information. She had received report from Nurse # 1 on 10/3/25 at 7:00 AM. Nurse # 1 had reported she had given Resident # 1 one ml instead of .25 ml of Morphine. That morning when she (Nurse # 3) arrived the resident appeared stable, was not having apnea, and was sleeping. His oxygen saturations were in the 90s which was an improvement for him because they usually struggled to keep his saturations up.Nurse Practitioner (NP) # 1 signed a progress note on 10/5/25 at 7:46 AM in which she had noted she had seen the resident on 10/3/25. She documented the occurrences of 10/3/25 within the progress note. NP # 1 noted the following information. She followed up on Resident # 1's comfort care and that the resident had received the wrong dose of Morphine earlier on 10/3/25. At the time she saw the resident his respirations were 12 with some apnea and he was not responding. She ordered IM (intramuscular) Narcan to be given and then to reassess. (Narcan is a medication to reverse the effects of opioid medications) After 15 minutes following the Narcan, the resident became somewhat responsive and made contact with the provider and nurses. He continued to be lethargic. The resident's brief was dry, and Intravenous fluids and Lasix were also ordered. They attempted to get the resident to drink and he refused fluids. Later during the 10/3/25 shift the resident became unresponsive again and he was again given Narcan. The resident remained on oxygen from 2 to 5 liters to maintain his saturations at 90 % and his saturations had ranged from 88 % to 96 %. Later during the 10/3/25 shift, the resident became more alert with behavioral problems and anxiety.Oxygen saturation readings and respirations were documented as follows on the 7 AM to 7 PM shift on 10/3/25 under Resident # 1's vital sign records within the electronic record:7:18 AM- 95% oxygen level and 12 respirations 5:00 PM-97 % oxygen level and 18 respirations NP # 1 was interviewed on 10/10/15 at 1:19 PM and reported the following information. Resident # 1 was actively dying. He had metastatic lung cancer with numerous metastatic sites. She had been notified by the night shift nurse that the wrong dose of Morphine had been administered during the early morning hours of 10/3/25. She had been informed that the resident was stable even though the wrong dose had been given. She had instructed the nurse to monitor the resident. She then saw Resident # 1 on the morning of 10/3/25 when she came to the facility. She felt as if he was transitioning despite the Morphine being administered in the wrong dose. He was not arousable, it was his pattern to be less alert on some days and more arousable on other days. He had been waxing and waning prior to the wrong dose of Morphine. Given that he did have the wrong dose of Morphine, she had prescribed the Narcan, and she had ordered that he receive some fluids and Lasix that day also to see how he would do and if he would perk up. She did not think the resident had been harmed by receiving 20 mg of Morphine rather than the 5 mg. Resident # 1 was a large man and at times dosages of 15 to 20 mg of Morphine were prescribed when being aggressive with pain management. Morphine usually acts within a few hours of administration and if Morphine causes any problems, it will typically occur within a few hours of the administration.The facility's Pharmacy Consultant was interviewed on 10/10/25 at 2:38 PM and reported the following information. She had been made aware that Resident # 1 had been given 20 mg of Morphine rather than 5 mg. The Pharmacist was interviewed regarding acceptable dosages of Morphine, the effect it has, and the effects of Narcan. The Pharmacist reported the following information. Although 20 mg was not prescribed for Resident # 1, for some residents with cancer a 20 mg dose of Morphine is an acceptable and prescribed dosage. If she saw that amount prescribed for a cancer resident while doing a routine monthly review, she would not question the dosage because it was considered acceptable. If a resident does have an adverse reaction to Morphine, it will usually happen within 30 minutes of oral administration. The effect of Morphine peaks around 30 minutes to an hour and Morphine can be given every two hours orally. Given the way the Morphine usually acts, she did not see how any sedation on dayshift could be attributed to the extra Morphine. Giving Narcan does not harm individuals. Narcan is a binding agent for the Morphine so that the effects are reduced in the body and therefore the Morphine is reversed.The facility Medical Director was interviewed on 10/10/25 at 4:18 PM and reported the following information. He was aware the resident had received 20 mg of Morphine rather than 5 mg. Although the wrong dose was administered, he (the Medical Director) did not think the error was significant or caused the resident harm in any way. Resident # 1's last labs had shown normal kidney function, and the morphine should have been out of his body at six hours tops after administration. Given Resident # 1's order of 5 mg as needed every two hours, the resident could have had up to 60 mg of Morphine per day if he had been needing and receiving the prescribed 5 mg dosage every two hours. Resident # 1 was not morphine naive. (Morphine naive references someone who has not been receiving Morphine and not developed a tolerance to the effects.) Resident # 1 was already on comfort measures, had been receiving the Morphine, and he (the Medical Director) felt that the additional dosage given in error had minimal effect on him. It might have sedated him a little more. At times, individuals can be prescribed doses that exceed 20 mg to treat a medical condition. Resident # 1 also had multiple diagnoses which could affect his respiratory status. These included chronic obstructive pulmonary disease, lung cancer, and heart failure. Each of these individually or in combination could have been the causative factor in any decreased respirations or apnea on 10/3/25.Interview with the DON and Administrator on 10/10/25 at 3:00 PM revealed the following information. The 9/24/25 Morphine order had not specified that the dosage was to be .25 ml. Therefore, the nurse would have had to calculate the dosage based on the concentration and this could have led to the error. They had made sure all other Morphine orders clearly depicted the actual milliliters to administer based on the concentration, and all other orders had the orders written clearly. They had also met on the day of the error (10/3/25) with their quality assurance team and placed a corrective action plan in place.The Administrator provided the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Upon review of Resident # 1's chart, it is noted that resident has diagnoses of COPD, neoplasm of trachea, bronchus, and lung, obstructive sleep apnea, heart failure, and epilepsy. Resident #1 was made Do Not Resuscitate on 9/2/2025This facility failed to follow standards of professional care in medication administration when Resident #1 received 1mL (milliliter) of Morphine Sulfate 20milligrams/mL versus his prescribed dose of 5mg (0.25mL) PRN (as needed) every two hours. The error occurred on 10/3/25 at 2:30 AM when Nurse #1 signed out medication on the controlled substance receipt sheet. Nurse # 1 immediately realized that the dose she had given was not right and called the provider. She received instructions at 2:30 AM for close monitoring for any sudden changes in condition. Nurse # 1 monitored resident's health status and obtained a full set of vital signs every hour for 4 hours. Nurse Aide # 1 assessed oxygen saturation and respiratory rate every 10-15 minutes for four hours. No changes were noticed in Resident # 1's vital signs and they remained within normal limits for his baseline throughout the night shift.Vital signs were taken on 10/3/2025 at 6:00 AM and his blood pressure was 107/67, heart rate 115, and oxygen saturation was 93%. Respirations were noted to be easy and unlabored. At approximately 9:30 AM Nurse Manager # 1 noted Resident # 1's respirations to be decreased and notified the Nurse Practitioner of change in condition. The Nurse Practitioner assessed Resident # 1 and consulted the medical director for the facility. Orders received for Narcan. Orders also received for saline and fluid bolus due to Resident #1's dryness. Nurse practitioner notified Resident # 1's emergency contact # 2 and confirmed Resident # 1's do not resuscitate and not hospitalize status. Was he notified or they attempted to notify?The guardian was notified multiple times on 10/3/20205. Messages were left until she was reached. The Guardian expressed her understanding and had no further questions or concerns. Resident # 1 became more responsive and vital signs remained stable throughout that day.Nurse # 1 received one on one education about medication administration rights due to it being her planned (resignation given prior) last shift at this facility. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. IDT (Interdisciplinary) team met on 10/3/25 to discuss incident and root cause analysis and a corrective action plan was put in place. An audit of all residents in the facility receiving Morphine sulfate was completed by the Director of Nursing. Resident # 1 had Morphine Sulfate order, and it had 5mg PRN every 2 hours. The other residents (total of 2) receiving the same medication had the order listed in mL to be given vs mg. Based on investigation, clarity of order was identified as root cause, therefore Resident # 1's order was changed to reflect mL (0.25mL) q 2 hours PRN. The decision was made to implement this plan of correction in QAPI. Address measures that will be put into place and systemic changes made to ensure that deficient practice will not reoccur.On 10/3/2025 immediate one on one education was provided to Nurse # 1. Liquid medications and measurements of medications were reviewed throughout the facility to determine clarity of medication orders including units per dosage. Medication education started on 10/3/2025. A skills fair was completed on 10/7/25 and 10/8/25. The following topics were covered in the inservice: right drug, right patient, right dose, right route, time and frequency, documentation, history and assessment, drug approach and right to refuse, drug-drug interaction and evaluation, and education and information. All regular staff Nurses and Medication Aides attended. All staff who do not work on a regular basis will be inserviced prior to starting their next shift. Training is included for new hires in orientation completed by the Staff Development Coordinator.On 10/3/25 the consultant pharmacist was contacted and included in the facility's corrective action plan. The Consultant Pharmacist provided additional information to be used in training for the Nursing Staff and Medications Aides. This was incorporated into the skills fair on 10/7/26 and 10/8/25. Indicate how the facility will monitor its performance to make sure solutions are sustained.On 10/3/25 a plan was formulated by the facility's Quality Assurance Improvement team to implement the corrective action plan and monitor the plan through the facility's quality assurance program.An individual med pass audit for all nurses and certified medication aides will be completed by the Director of Nursing or designee. This will be conducted on both the 7:00 AM to 7:00 PM shift and the 7:00 PM to 7:00 AM shift. This was initiated on 10/8/25. Each nurse or medication aide will be observed doing a complete medication pass. Audits will continue until all medication aides and nurses have been audited performing a complete medication pass.In addition to the above, medication observations will be completed by the Director of nursing or designee on 5 licensed nurses and/or certified medication aides for 12 weeks following the initial audits.The Consultant Pharmacist will monitor all Morphine orders for clarity during her monthly review.On 10/9/2025 during monthly Quality Assurance Performance Improvement (QAPI) meeting with the IDT team, the Administrator or Director of Nursing will begin reviewing the plan above. Any changes will be made to the plan as necessary to maintain compliance with resident safety.Alleged date of compliance: 10/9/25 The facility's corrective action plan was validated by the following.On 10/10/25 nurses were observed administering medications. This included controlled substance medications and different forms of medications. Nurses were observed to administer medications correctly. Medications, which were observed administered, were reconciled to be correct with orders. Two residents, who were observed as nurses administered medications, voluntarily spoke up when they observed that a surveyor was observing the nurses and made positive remarks about the nurse's abilities.Review of Resident # 1's Medication Administration MAR revealed a new order was obtained on 10/3/25 which was clear and transcribed to the MAR to denote that .25 ml of Morphine equated to the prescribed 5 mg.The facility provided documentation of inservice records per their plan of correction.Nurses from different shifts were interviewed and validated they had attended the education/skills fair and were able to speak of topics covered.Interview with the DON on 10/10/25 at 12:42 PM revealed that the audits were being conducted with every nurse and medication aide for an entire medication pass. The DON provided the audit tool and evidence of completion of multiple nurses who had been audited thus far. A review of the audit tool revealed nurses were being checked off on 29 different itemsInterview with a Nurse on 10/10/25 validated he had been one of the nurses who had completed an observation audit thus far.The facility's corrective action plan compliance date of 10/9/25 was validated.

Based on record review, and resident, family member, neighbor and staff interviews, the facility failed to protect a resident's right to be free from exploitation. In [DATE], Nurse Aide (NA) #1 told Resident #1 that her landlord raised the rent at her apartment and she was going to be evicted. Resident #1 reported that NA #1 asked to live in his personal home and being a goodhearted trusting person, he was considering letting NA #1 and her friend house-sit his personal home while he was at the facility. NA #1 asked the resident if she could look at his house and he informed her where the keys were located. NA #1 went to the resident's home and due to being unable to find the keys she went to Resident #1's neighbor's home to request a key at which time the neighbor did not give her the key preventing NA #1 from entering the home and having access to all of Resident #1's personal belongings. The deficient practice occurred for 1 of 3 residents reviewed for abuse, neglect and/or misappropriation of property/exploitation (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included depression and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired and was receiving antidepressant medication and opioid medication (pain medication). Psychological Provider #1 notes dated [DATE] recorded Resident #1 had a major depressive disorder and anxiety with ongoing grief and a cognitive communication disorder but Resident #1 was able to express needs and communicate effectively.In an interview with Nurse Manager #1 on [DATE] at 2:58 pm, she recalled Resident #1's Family Member and a friend (Resident #1's neighbor) came to the facility in [DATE] and informed her that NA #1 had taken advantage of Resident #1 by asking Resident #1 if she (NA #1) could move into his personal house. She stated she escorted the family member and friend to the former Administrator's office. She stated although she never discussed the incident with Resident #1, she was able to obtain permission from Resident #1 to review his cellular phone and identified NA #1's phone number from a text that was sent to Resident #1. Nurse Manager #1 was unable to recall the date of the text and stated NA #1 was suspended and never worked at the facility after Resident #1's family member and neighbor came to the facility. An initial allegation report dated [DATE] at 2:13 pm was completed by the former Administrator and faxed to the State Agency alleging misappropriation of Resident #1's property on [DATE]. The initial report recorded the facility became aware of the incident on [DATE] at 10:45am. Details of the allegation stated NA #1 convinced Resident #1 to allow her to stay/live in his personal house while he was at the nursing facility. NA #1 went to Resident #1's neighbor's home to obtain a key to Resident #1's personal house who refused to give NA #1 a key to Resident #1's personal house. On [DATE], Resident #1's neighbor and family member reported NA #1 attempted to exploit Resident #1 to become a squatter in Resident #1's personal house. Resident #1's family member, who was financial proxy and health power of attorney for Resident #1, stated Resident #1 was easily manipulated and coerced into agreements of helping others. NA #1 was suspended pending investigation of the allegation on [DATE]. The facility notified the local law enforcement on [DATE] at 12:41 pm of the allegation.The facility's investigation report signed by the former Administrator on [DATE] was faxed to the State Agency on [DATE]. The investigation report recorded that Resident #1 agreed initially and then changed his mind and denied allowing NA #1 to stay/live in his personal house. The investigation report further stated Resident #1 was not mentally able to discern the ramifications of the action of NA #1 living in his personal house and family reported Resident #1 was easily manipulated and coerced into agreements to help others. NA #1 was suspended pending investigation and terminated on [DATE]. The termination was noted to not be related to the allegation. The allegation was not substantiated.In an interview with Resident #1 on [DATE] at 3:12 pm, he explained he had not seen his personal home in the last eight months due to repeated hospitalizations and rehabilitation at the facility. He stated NA #1 worked part-time at the facility and had been assigned to his hall. He explained it was in the mid of [DATE] when he and NA #1 were in the dining room talking at a table and NA #1 mentioned how her landlord had raised the rent and she was being evicted out of her living quarters. Resident #1 stated NA #1 asked to go live at his personal home and being the goodhearted trusting person that he was, he was considering letting NA #1 and her friend house-sit his personal home while he was at the facility. He stated NA #1 asked to go look at his house and he told her where the key was kept to his personal house. Resident #1 stated he had a love for people and a big house, and his wife had died while he and his wife were both hospitalized . Resident #1 stated he changed his mind after talking to other employees and learning that NA #1 had a rough boyfriend who he did not want in his personal house. He explained NA #1 went to his house but was unable to find the key to his personal home and she (NA #1) then went to Resident #1's neighbor's home to get the key to enter Resident #1's personal home. The neighbor would not give NA #1 the key to his (the resident's) house and the neighbor called one of his (the resident's) family members who told him (the neighbor) not to give NA #1 a key. Resident #1 stated he did not feel pressured when talking with NA #1 and admitted he had not gotten a chance to inform NA #1 before she went to enter his personal home that he wasn't considering having anyone house-sit his personal home anymore. During the interview, Resident #1 asked if he was in trouble and was explained he was not in trouble, and the interview was to gather information.In a phone interview with NA #1 on [DATE] at 11:16 pm, NA #1 stated in [DATE] while talking with Resident #1, he (the resident) asked her (NA #1) if she would provide private care to help him when he was discharged to his personal house. NA #1 was unable to recall the exact date. NA #1 admitted going to Resident #1's personal house to check out the living quarters to see if his personal home was conducive to caring for Resident #1. NA #1 stated she went to the house on a professional level only and did not plan to live in Resident #1's house. She explained she never went there to live as a permanent home; only to live in the house to care for Resident #1 and stay when housework was needed to be performed. NA #1 stated Resident #1 asked her to go to his personal house and told her the key was in the garage. NA #1 explained when she went to Resident #1's personal house in [DATE] she informed Resident #1 by phone that there was no key in the garage and Resident #1 told her to go to the neighbor's house for the key to enter his (Resident #1's) personal house. NA #1 stated the neighbor called Resident #1's family member and she (NA #1) was not given a key to enter Resident #1's personal house. She stated she did not pursue this any further and left the situation alone. NA #1 stated she never entered or lived in Resident #1's personal house and stated she never asked to go live in Resident #1's personal house. She explained she was placed on suspension when she reported to work on [DATE] for attendance issues and was fired three days later on [DATE] for attendance issues. NA #1 stated the Administration never discussed the situation with Resident #1 with her.In a phone interview with Resident #1's Neighbor on [DATE] at 9:24 am, he stated NA #1 came to his house requesting a key to Resident #1's personal house and stated she was going to stay in Resident #1's personal house for a while. He was unable to recall the specific date this occurred but knew it was in July of 2025. Resident #1's Neighbor stated he did not give NA #1 the key to Resident #1's personal house. He stated he called Resident #1's family member, who headed to his (Resident #1's Neighbor) house, to speak with NA #1, but NA #1 left prior to the family member arriving. Resident #1's Neighbor stated when he talked to Resident #1 on the phone after NA #1 left the his (Resident #1's Neighbor) home, Resident #1 told him not to give NA #1 a key to his personal house. Resident #1's Neighbor stated NA #1 did not display a temper but NA #1 was not happy about not receiving the key to Resident #1's personal house. He stated Resident #1 was a friendly and helpful individual.In a phone interview with Resident #1's Family Member on [DATE] at 8:51 am, he stated NA #1 tried to go live in Resident #1's personal house. The Family Member stated he could not recall the exact date of the incident. He explained he found out about the situation late in the evening hours of a day in [DATE] and went to the facility the next day to report the incident. The family member explained Resident #1's Neighbor called him explaining NA #1 was at his home requesting a key to Resident #1's personal house and no one had called him (the neighbor) about giving NA #1 a key to Resident #1's personal house. He stated NA #1 got upset when the neighbor would not give her a key to Resident #1's personal house and when he (the Family Member) arrived at the neighbor's home approximately 8-9 minutes later, NA #1 had already left. He stated when he called Resident #1 on that same evening in [DATE] to ask about the situation, he (Resident #1) stated not to give NA #1 a key to his personal house. He stated Resident #1 told him (the Family Member) NA #1 had told Resident #1 she wanted to stay in his personal house for a few weeks until she found somewhere else to live and Resident #1 felt sorry for NA #1. He stated Resident #1 explained to him (the Family Member) NA #1 and Resident #1 were having a general conversation (date unknown) when NA #1 was assigned to Resident #1. The Family Member stated Resident #1 told him NA #1 informed Resident #1 about her current living situation, rent increase and lease agreement expiration. Resident #1's family member stated Resident #1 was easy prey because he was a kind person and thought he was doing good. The family member reported Resident #1 had been receiving a lot of pain medications due to post surgical care and felt Resident #1 would have not made the decision to let NA #1 into his personal home to live if Resident #1 was thinking clearly. In a phone interview with NA #2 on [DATE] at 4:57pm, she stated when Resident #1 told her in [DATE] NA #1 was going to live in his personal house, she advised Resident #1 against allowing NA #1 to live in his personal house because she (NA #2) would not allow NA #1 to stay/live at her house. NA #2 stated she was unable to recall the date of the day she told the resident not to let NA #1 live in his personal house. NA #2 stated she was aware that Resident #1 and NA #1 had exchanged phone numbers in [DATE] but was unable to recall a specific date. NA #2 couldn't recall observing or overhearing Resident #1 and NA #1 talk about her staying/living in Resident #1's personal house. NA #2 stated she informed a couple nurses about the situation (NA #1 staying/living in Resident #1 personal house) and was unable to recall when in [DATE] she informed the other nurses of this, and which nurses she informed. NA #2 stated she felt Resident #1 was taken advantage of in the situation by NA #1 telling Resident #1 of her (NA #1's) problems and NA #1 needing someone to help her with her living situation.In an interview with the Director of Nursing on [DATE] at 3:46 pm, she stated when Resident #1's Family Member learned NA #1 was trying to go stay/live in Resident #1's personal house, the family member brought it to Administration's attention. She stated although Resident #1 said it was okay for NA #1 to stay/live in his personal house, it was inappropriate for NA #1 to think she could go stay/live in Resident #1's personal house because employees cannot access goods or property from residents. The DON stated NA #1 was suspended during the investigation and then terminated for attendance issues. She stated NA #1 did not work after the facility was aware of the allegation.A phone interview on [DATE] at 9:38am with the local law enforcement officer whose name was listed on the initial allegation report dated [DATE]. He stated he was unable to recall responding to the call or any circumstances regarding the allegation. He stated he did not complete a report, and he was unable to review notes that may have been written on the call sheet (the call sheet is documentation recorded by the local 911 call center that is provided to local law enforcement to respond to a 911 call).A request was made during the survey for a copy of the law enforcement call sheet related to the [DATE] allegation involving Resident #1 and NA #1. This was not received. In a phone interview with the former Administrator on [DATE] at 4:44pm, she explained she was not aware of conversations between Resident #1 and NA #1 until Resident #1's family member and neighbor came to the facility on [DATE] and reported NA #1 had attempted to obtain a key to enter Resident #1's personal house. She explained Resident #1's wife had recently died, and she learned from Resident #1 that he felt sorry for NA #1 when he (the resident) learned from NA #1 that she would have nowhere to live at the first of the month. She stated the resident admitted giving NA #1 permission to stay at his personal house and when he learned about NA #1's boyfriend, Resident #1 was concerned and changed his mind. She stated the facility identified NA #1 through matching the phone number on the text messages observed on Resident #1's cellular phone after learning NA #1 had attempted to obtain a key to Resident's #1 personal house from Resident #1's neighbor. She stated the allegation for misappropriation of property and resident abuse was not substantiated because Resident #1 was not harmed and NA #1 did not access Resident #1's personal house or obtain any of Resident #1's property. The former Administrator stated she had not thought about exploitation for Resident #1 because NA #1 had not benefited from the situation. She indicated looking back, she should have substantiated the allegation for exploitation because after NA #1 discussed staying/ living at Resident #1's personal house with Resident #1, she attempted to enter Resident #1's personal house without the resident being present.In an interview with the Administrator, Regional Clinical Consultant and Director of Nursing present on [DATE] at 5:30 pm, they stated the facility had not completed a plan of correction for misappropriation of property/exploitation.

Based on record review and staff interviews, the facility failed to report an allegation misappropriation of property/exploitation to Adult Protective Services (APS) for 1 of 3 residents reviewed for abuse, misappropriation of property and/or exploitation (Resident #1).Findings included:The Facility's Reporting Requirements/Investigations policy statement dated effective 2/5/2023 indicated the Administrator will immediately notify the adult protective services agency for any incident of patient abuse, mistreatment, neglect or misappropriation of personal property or other reasonable suspicion of a crime. Resident #1 was admitted to the facility on [DATE].An initial allegation report dated 7/10/2025 at 2:13 pm was completed by the former Administrator and faxed to the State Agency alleging misappropriation of Resident #1's property on 7/9/2025. The initial report recorded the facility became aware of the incident on 7/10/2025 at 10:45am. Details of the allegation stated NA #1 convinced Resident #1 to allow her to stay/live in his personal house while he was at the nursing facility. NA #1 went to Resident #1's neighbor's home to obtain a key to Resident #1's personal house who refused to give NA #1 a key to Resident #1's personal house. On 7/10/2025, Resident #1's neighbor and family member reported NA #1 attempted to exploit Resident #1 to become a squatter in Resident #1's personal house. Resident #1's family member, who was financial proxy and health power of attorney for Resident #1, stated Resident #1 was easily manipulated and coerced into agreements of helping others. NA #1 was suspended pending investigation of the allegation on 7/10/2025. The facility report indicated notification of the allegation was made to local law enforcement on 7/10/2025 at 12:41 pm. There was no documentation that APS was notified of the allegation of misappropriation of property and/or exploitation.The facility's investigation report signed by the former Administrator on 7/16/2025 was faxed to the State Agency on 7/17/2025. There was no documentation that APS was notified of the allegation of misappropriation of property and/or exploitation.In a phone interview with the former Administrator on 8/27/2025 at 4:44pm, she stated she could not recall if APS was notified of the allegation related to misappropriation of property/exploitation for Resident #1. She explained that usually the Social Worker electronically notified APS of abuse, misappropriation or property and/or exploitation allegations.In an interview with the Social Worker on 8/28/2025 at 5:47 pm, she explained since starting at the facility in May 2025, she was responsible for notifying APS for incidents of residents leaving against medical advice and exploitation of funds. She stated the former Administrator would have to let her know when there were allegations of misappropriation of property and/or exploitation to report to APS. She stated she was not informed by the former Administrator of the allegation of misappropriation of property and/or exploitation for Resident #1 and therefore, she had not notified APS of the allegation.In a follow up phone interview with the former Administrator on 9/4/2025 at 12:00 pm, she stated per the facility's policy, the local adult protective agency should be notified of allegations of misappropriation of property and/or exploitation. She explained she had no recall of informing the Social Worker of the allegation of misappropriation of property and/or exploitation for Resident #1 and the local adult protective agency was not notified. In an interview with the Administrator, Regional Clinical Consultant and Director of Nursing on 8/28/2025 at 5:50 pm, they stated the facility did not have a plan of correction that was completed for reporting an allegation of misappropriation of property and/or exploitation for Resident #1.

Based on record review, observations, and interviews with staff, resident and Nurse Practitioner, the facility failed to: 1) provide oxygen at the rate ordered by the physician: provide clean air intake filters on oxygen concentrators for 1 of 5 residents (Resident #79); 2) post oxygen signs for 3 of 5 residents (Resident #10, Resident #13, and Resident #33); 3) change oxygen tubing for 2 of 5 residents (Resident #10 and Resident #33); and 4) obtain physician's order for oxygen delivery for 1 of 5 residents (Resident #250) reviewed for respiratory care. Findings included: 1. Resident #79 was admitted to the facility on [DATE] with diagnoses of respiratory failure, pneumonia, and stroke. A Physician's Order dated 3/24/2025 indicated Resident #79 should receive 2 liters per minute oxygen by nasal cannula. An admission Minimum Data Set assessment dated [DATE] indicated Resident #79 was cognitively intact and required oxygen therapy. The 10-liter Oxygen Concentrator Guide stated the air filter should be cleaned at least once a week with warm water and dishwashing detergent, rinsed thoroughly with warm tap water and towel dried. The filter should be completely dry before reinstalling. The guide also stated the exterior cabinet of the oxygen concentrator should be cleaned with a damp cloth or sponge with mild household cleaner and wiped dry weekly. On 4/13/2025 at 11:05 am Resident #79 was observed in her room with the head of her bed elevated. Resident #79 had a tracheostomy with an inner cannula and tracheostomy collar and dressing in place. The tracheostomy, tracheostomy collar, and tracheostomy dressing were clean with no stain or sputum noted. Resident #79's oxygen concentrator had approximately 1/2 inch of dust covering the air intake filter. During an observation on 04/15/25 at 12:44 PM of Nurse #1 providing Resident #79's tracheostomy tie and dressing change the oxygen was set at 4 liters per minute by tracheostomy collar. Nurse #1 stated the resident was ordered 2 liters per minute by her tracheostomy collar and the order was written 3/24/2025 but her oxygen was set at 4 liters per minute. Nurse #1 stated she did not know why Resident #79's oxygen was set higher than what was ordered. On 4/14/2025 at 1:05 pm an interview was conducted with Nurse #1, and she stated she thought the nurse that worked from 7:00 pm to 7:00 am should clean the oxygen machines but she was not sure how often the machine should be cleaned. Nurse #1 stated there was a 1/8-inch film of grey dust on the oxygen concentrator filter. During an interview with the Central Supply Technician on 4/15/2025 at 12:58 pm she stated she cleaned the oxygen concentrator before she assigns the machine to a resident when they are admitted , and she checks them once a month and either dusts them out or cleans them with an air gun. The Central Supply Technician stated she was not aware of the manufacturer's instructions. Unit Manager #1 was interviewed on 4/15/2025 at 1:10 pm and she stated she was not aware of a schedule for cleaning the oxygen concentrators on a regular basis, but they should be checked daily by the nurse. During an interview with the Nurse Practitioner #1 on 4/15/2025 at 3:06 pm she stated the nursing staff should have followed the order that was written for oxygen at 2 liters per minute for Resident #79's oxygen and notified her if the oxygen needed to be increased for any reason. Nurse Practitioner #1 stated she changed Resident #79's oxygen order to 2 to 4 liters per minute to keep her oxygen saturation above 90%. Nurse Practitioner #1 stated she did not know the protocol for cleaning the oxygen concentrators. The Director of Nursing was interviewed on 4/16/2025 at 12:30 pm and stated the oxygen concentrators should be cleaned at least every two weeks and the nurse should clean them when they change the oxygen tubing. She stated the facility's policy stated the oxygen concentrator should be cleaned according to the manufacturer's guidelines. On 4/16/2024 at 12:42 pm the Administrator was interviewed and stated Resident #79's oxygen should have been set at the level that was ordered by the Physician, and the concentrator should have been cleaned as needed and periodically per the manufacturer's guidelines for the oxygen concentrator. 43643 2. a. Resident #10 was admitted on [DATE] with diagnoses of asthma, respiratory failure, and muscle weakness. A physician order for Resident #10 dated 03/21/25 read oxygen at 3 liters per minute via nasal canula every shift. Review of Resident #10's admission Minimum Data Set (MDS) 03/28/25 revealed the resident was cognitively intact and was coded for the use of oxygen. An observation conducted on 04/13/25 at 11:55 AM revealed there was no signage for oxygen use found anywhere near the entrance of Resident # 10's room. Resident #10 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 10's room. An observation conducted on 04/14/24 at 12:50 PM revealed there was no signage for oxygen use found anywhere near the entrance of Resident # 10's room. Resident #10 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 10's room. b. Resident #13 was admitted on [DATE] with diagnoses of asthma, respiratory failure, and muscle weakness. A physician order for Resident #13 dated 04/01/25 read oxygen at 3 liters per minute via nasal canula every shift. Review of Resident #13's significant change MDS revealed the resident was cognitively intact and was coded for the use of oxygen. An observation conducted on 04/13/25 at 11:55 AM revealed there was no signage for oxygen use found anywhere near the entrance of Resident #13's room. Resident #13 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 13's room. An observation conducted on 04/14/24 at 12:50 PM revealed there was no signage for oxygen use found anywhere near the entrance of Resident # 13's room. Resident #13 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 13's room. c. Resident #33 was admitted on [DATE] with diagnoses of asthma, hypertension, respiratory failure, and muscle weakness. A physician order for Resident #33 dated 02/28/25 read oxygen at 2 liters per minute via nasal canula every shift. Review of Resident #33's admission MDS dated [DATE] revealed the resident was cognitively intact and was coded for the use of oxygen. An observation conducted on 04/13/25 at 11:45 AM revealed there was no signage for oxygen use found anywhere near the entrance of Resident #33's room. Resident #33 was observed wearing oxygen via nasal cannula at 2 liters per minute (LPM). The oxygen concentrator was observed in Resident # 33's room. An observation conducted on 04/14/24 at 1:15 PM revealed there was no signage for oxygen use found anywhere near the entrance of Resident # 33's room. Resident #33 was observed wearing oxygen via nasal cannula at 2 liters per minute (LPM). The oxygen concentrator was observed in Resident # 33's room. An interview conducted with Unit Manager (UM) #1 on 04/15/25 at 11:20 AM revealed she was aware Resident #10, Resident #13, and Resident #33 had continuous oxygen but was not aware the residents did not have oxygen signs posted outside or inside their rooms. UM #1 indicated she was not aware rooms had to have signage. An interview conducted with the Director of Nursing (DON) on 05/15/25 at 3:45 PM revealed unit managers, housekeeping supervisors, and admissions were responsible for hanging signage when a resident was on oxygen. The DON stated she was not aware signage had not been posted but should have been because it was facility policy. 3.a. Resident #10 was admitted on [DATE] with diagnoses of asthma, respiratory failure, and muscle weakness. Review of Resident #10's admission Minimum Data Set (MDS) 03/28/25 revealed the resident was cognitively intact and was coded for the use of oxygen. A physician order for Resident #10 dated 03/21/25 read oxygen at 3 liters per minute via nasal canula every shift. A physician order for Resident #10 dated 3/22/25 read oxygen tubing change weekly every Saturday during night shift. An observation and interview on 04/13/25 at 11:55 AM revealed Resident #10's tubing was dated 03/30/25. Resident #10 stated nursing staff had not recently changed her tubing and felt like her nasal canula was dirty. Observation indicated the nasal canula to be cloudy and with a crust like substance. b. Resident #33 was admitted on [DATE] with diagnoses of asthma, hypertension, respiratory failure, and muscle weakness. Review of Resident #33's admission MDS dated [DATE] revealed the resident was cognitively intact and was coded for the use of oxygen. A physician order for Resident #33 dated 02/28/25 read oxygen at 2 liters per minute via nasal canula every shift. A physician order for Resident #33 dated 3/21/25 read oxygen tubing change weekly every Saturday during night shift. An interview and observation conducted with Nurse #5 on 04/14/25 at 1:15 PM revealed Resident #33's and Resident #10 oxygen tubing was dated 03/30/25 and had not been changed in two weeks. Nurse #5 indicated oxygen tubing should have been changed and needed to be changed. A phone interview conducted with Nurse #6 on 04/16/25 at 10:30 AM revealed on 04/05/25 she worked evening shift and was assigned Resident #33 and Resident #10. It was further revealed she did not change oxygen tubing due to not having enough supplies. Nurse #6 indicated she had voiced concerns of lack of supplies to upper management before she left her shift on 04/06/25. A phone interview with Nurse #7 on 04/15/25 at 11:30 AM revealed they were assigned Resident #10 and Resident #33 on 04/12/25. Nurse #7 stated he had not changed tubing due to lack of supplies or the shift being chaotic. Nurse #7 indicated night shift can be hectic and there are other priorities. An interview conducted with the Director of Nursing (DON) on 04/15/25 at 3:50 PM revealed Resident #10 and Resident #33 were on continuous oxygen. The DON stated she was not aware the residents' oxygen tubing had not been changed as ordered but should have been changed on 04/05/15 and 04/12/25. 4. Resident #250 was admitted the facility on 03/26/25 with diagnoses which included muscle weakness and hypertension. Review of Resident #250's admission MDS dated [DATE] revealed the resident was moderately cognitively impaired and was not coded for oxygen use. Review of Resident #250's care plan revealed no plan or interventions for oxygen use. Review of Resident #250's physician orders revealed no orders in place for continuous oxygen use. An observation was conducted on 04/13/25 at 12:00 PM revealed Resident #250 sitting up in her wheelchair with oxygen running at 2 liters per minute. An observation was conducted on 04/14/25 at 1:45 PM revealed Resident #250 sitting up in her wheelchair with oxygen running at 2 liters per minute. An interview conducted with UM #1 on 04/15/25 at 2:15 PM revealed she did not recall when Resident #250 had started on oxygen but indicated she had been on continuous oxygen for at least a week. UM #1 stated nursing staff had been educated to ensure orders were initiated when residents started oxygen. UM #1 indicated Resident #250 was seen by a Nurse Practitioner on 04/07/25 due to respiratory concerns and believed the order got missed. A phone interview conducted with Nurse Practitioner (NP) #2 on 04/15/25 at 11:20 AM revealed she had filled in on 04/07/25 to assist the facility and recalled assessing Resident #250. NP #2 saw the resident due to shortness of breath and wheezing. The NP stated she did not order oxygen because the resident was already on oxygen when she arrived and thought it was already ordered. The NP indicated Resident #250 should have had an order put in for oxygen due to the resident having continuous oxygen for several days. An interview with the DON on 04/15/25 at 3:50 PM revealed NP #2 had assessed Resident #250 on 04/07/25 due to respiratory concerns. The DON further revealed she was not aware there had been no oxygen order put in for Resident #250. The DON indicated she was unable to determine when Resident #250 had started using oxygen, but nursing staff should have completed an order if the NP failed to enter one.

Based on observations, record reviews and staff and Psychiatric Nurse Practitioner interviews, the facility failed to provide the necessary supervision to prevent a resident with known wandering behaviors from entering the room of another resident and attempting to take the other resident's (Resident #94's) belongings during the night for 1 of 3 residents reviewed for accidents (Resident #91). The findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by imbalances in the body's metabolism, often due to underlying systemic illnesses), alcohol-induced persisting dementia, major depressive disorder, and anxiety disorder. A physician's order for Resident #91 dated 3/11/25 indicated Olanzapine (an antipsychotic medication) 5 milligrams (mg) every 8 hours for severe alcohol abuse disorder with unspecified mood disorder. A care plan developed on 3/11/25 addressed behaviors for Resident #91, including safety concerns regarding ambulating independently, spitting out medications, sitting on the floor, and not following directions. Interventions included consulting psychiatric services and redirection of Resident #91 when she exhibited behaviors. A Nurse Practitioner (NP) note dated 3/15/25 documented that Resident #91 had agitation, was disoriented to place, date, and situation. Resident #91 was observed to be self-propelling in a wheelchair. The plan described in the note indicated medication adjustments to be made based on Resident #91's behavior, and staff continued to monitor her behavior and report changes. A physician's order for Resident #91 dated 3/15/25 indicated Divalproex Sodium (an antiseizure medication that is also used for mood disorders) 250 mg every 12 hours for agitation. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #91 to be severely cognitively impaired with hallucinations, delusions, and physical behaviors that impacted her care, activities, and social interactions. The MDS documented Resident #91 did not reject care at the time of the assessment. The MDS documented Resident #91 required substantial assistance of staff for transfers, partial to moderate assistance for mobility, and was dependent on staff for ambulation. The MDS documented Resident #91 used a walker and wheelchair for mobility. Antipsychotic medications were documented as received on a routine basis. The Care Area Assessment for the admission MDS dated [DATE] documented Resident #91 had behaviors of aggression towards staff with spitting out medications and not following directions. A psychiatry NP initial consult note dated 3/19/25 documented that Resident #91 had intermittent confusion during the assessment, and she had been experiencing anxiety. The note documented anti-anxiety medication to be increased to three times per day, and staff to continue to monitor Resident #91 for changes in behavior. A physician note dated 3/19/25 documented marked cognitive impairment, with wandering and repeating questions. A physician's order for Resident #91 dated 3/19/25 indicated Diazepam 5 mg 3 times per day for anxiety. A nursing note dated 3/21/25 documented that Resident #91 was exhibiting behaviors: itching, picking at skin, restlessness, agitation, hitting, biting, kicking, spitting, cussing, racial slurs, stealing, delusions, hallucinations, and refusing care. The note documented Resident #91 was wandering into other resident rooms, touching residents, and attempting to leave the facility. The note documented 2 nurses, and 1 nursing assistant (NA) were attempting to redirect Resident #91. A NP note dated 3/21/25 documented Resident #91 was observed pacing up and down the hallway, wandering in and out of resident's rooms, and following visitors and staff members. The note documented Resident #91 was not easily redirected. A NP note dated 3/22/25 documented Resident #91 was observed walking up and down the hallway, attempting to walk in and out of other residents' rooms. The note documented Resident #91 had a 1:1 sitter and she was not easily redirected. The note documented that staff reported that Resident #91 was refusing medications and had been resistant to care. Lab work was ordered, and results were pending. The note documented Resident #91's symptoms were difficult to control due to metabolic encephalopathy and Resident #91 had poor safety awareness. The care plan that addressed Resident #91's behaviors was modified on 3/26/25 to add 1:1 sitter and noted the family was assisting with supervision. Unit Manager #1 was interviewed on 4/16/25 at 11:48 AM and she reported the facility initiated a 1:1 sitter assigned to Resident #91 on 3/26/25 from 7:00 AM to 11:00 PM, but there had been no assigned sitter on 11:00 PM to 7:00 AM shift. Unit Manger #1 explained that all staff were responsible for supervising Resident #91. A NP note dated 3/29/25 documented Resident #91 was observed ambulating in the hall with a sitter present. The note documented Resident #91 was confused and restless. A NP note dated 3/30/25 documented nursing report that Resident #91 had an increase in restlessness and going into other resident rooms. The note documented Resident #91 was wandering with poor sleep at night. The note documented a one-time dose of haloperidol (antipsychotic medication used to treat nervous, emotional, and mental conditions) for restlessness and requested a psychiatric NP evaluation. The note documented to continue the 1:1 sitter and to notify the NP of any changes in behavior. A nursing note dated 3/30/25 documented the administration of haloperidol without any effect on behavior for Resident #91. The note documented Resident #91 continued to roam the halls and attempted to enter other resident rooms, and she was aggressive with staff when staff attempted to redirect her. A NP note dated 3/31/25 documented Resident #91 remained restless and wandered the halls. The note documented Resident #91 had poor sleep, poor attention span, and poor safety awareness. A nursing note written by Nurse #1 and dated 3/31/25 documented Resident #91 continued to have poor safety awareness and was taking other resident's personal items. A NP note dated 4/1/25 documented Resident #91 was in the hallway, confused, and difficult to redirect. The note documented Resident #91 continued to wander in and out of other resident rooms. A Psychiatric NP note dated 4/2/25 documented Resident #91 had been experiencing increased confusion and behavioral changes, including attempts to elope and sleep disturbances. The note documented medication adjustments and continued monitoring. On 4/2/25 Resident #91's physician orders indicated her Divalproex Sodium 250 mg twice daily was increased to 250 mg 3 times per day and Olanzapine was changed from 5 mg in the morning to 10 mg at bedtime. A NP note dated 4/3/25 documented Resident #91 was ambulating in the hall with a 1:1 sitter. The note documented staff reported Resident #91 was attempting to bite staff and slapping at their hands when they attempted to redirect her. A nursing note dated 4/3/25 documented Resident #91 was aggressive and combative towards staff. A nursing note in Resident #91's medical record written by Nurse #1 and dated 4/4/25 at 3:40 AM documented Resident #91 entered Resident #94's room and attempted to take his cell phone and glasses. The nurse was alerted to this by Resident #94 yelling out, stop, put that down. The note documented the items were returned to Resident #94 and Resident #91 was redirected to exit the room. A nursing note in Resident #94's medical record written by Nurse #1 and dated 4/4/25 at 3:40 AM documented Resident #94 was heard to be yelling stop, stop, put that down. The note documented when staff entered the room, Resident #91 was noted to be standing beside Resident 94's bed with his cell phone and glasses in her hands. The note documented after Resident #91 was removed from the room. Upon assessment, small indentations on the back of Resident #94's right hand were noted, without bruising. The skin was intact and Resident #94 denied pain. An interview was conducted with Nurse #1 on 4/15/25 at 10:34 AM. Nurse #1 reported she was working 11:00 PM to 7:00 AM shift on 4/4/25 when Resident #91 wandered into Resident #94's room and tried to take his cell phone and glasses. Nurse #1 described NA #4 had been assigned to supervise Resident #91, but she was not assigned to be a 1:1 sitter for the resident. Nurse #1 explained another resident called out for assistance and NA #4 went into the room and asked Nurse #1 to help her with the resident. During the care, Nurse #1 reported she heard yelling and when she went out into the hall, followed the yelling to Resident #94's room where she observed Resident #91 standing beside Resident #94's bed with his (Resident #94's) cell phone and glasses in her (Resident #91's) hands. Nurse #1 reported she did not see Resident #91 grab Resident #94, and she was able to redirect Resident #91 to leave the cell phone and glasses and leave the room. NA #4 was interviewed by phone on 4/16/25 at 12:28 PM. NA #4 reported she was not assigned to provide 1:1 care for Resident #91 on 4/4/25, but she was told to keep an eye on her. NA #4 reported she worked a split assignment between halls and during the time Resident #91 wandered into Resident #94's room, she was providing care to another resident. Resident #94 was interviewed by phone on 4/15/25 at 8:57 AM. Resident #94 was alert and oriented person, place, time, situation and reported he very clearly remembered the incident on 4/4/25 with Resident #91. Resident #94 explained he was woken up by someone at the side of his bed on 4/4/25 about 3:00 AM, and when he fully awoke, he realized it was Resident #91, and she had his cell phone and glasses. Resident #94 explained he knew Resident #91 was confused and he grabbed to get his phone and glasses away from her. Resident #94 reported Resident #91 grabbed at him and one of her fingernails pressed into his skin. Resident #94 described an indentation of Resident #91's fingernail on the back of his right hand that did not leave a mark or bruise his skin afterwards. Resident #91 was observed on 4/14/25 at 9:47 AM. She was walking in the hall with NA #3 and she was observed standing at the door and pointing at the conference table. NA #4 attempted to redirect Resident #91 away from the conference room, but Resident #91 pushed her aside, came into the conference room and sat down at the table and spoke nonsensically for several minutes. NA #3 attempted to redirect Resident #91 to leave the conference room, but she would not leave with NA #3. An attempt was made to interview Resident #91, but she was unable to answer questions. An interview was conducted with NA #3 on 4/14/25 at 9:47 AM. NA #3 reported she was assigned to provide 1:1 care to Resident #91 during the day shift (7:00 AM to 3:00 PM) on 4/14/25. NA #3 explained Resident #91 had been up walking the halls for 4 hours at that point, and she was very difficult to redirect. NA #3 explained that Resident #91 would become very focused on something and would not stop until she was able to see and pick up whatever got her attention. NA #3 explained she would attempt to redirect Resident #91 from taking other resident's belongings, but if she tried to take the object away from Resident #91, that caused her to become agitated. The Psychiatric NP (NP #3) was interviewed on 4/16/25 at 9:28 AM. NP #3 explained she visited the facility every month and had last assessed Resident #91 on 4/2/25, before the incident with Resident #94. NP #3 explained Resident #91's behaviors were difficult to control due to the metabolic encephalopathy and multiple medication adjustments had been made, as well has a 1:1 sitter during the day. NP #3 explained that she was adding a medication to start on 4/16/25 that would hopefully help Resident #91 sleep at night and reduce her wandering behaviors. The NP reported she was notified of the incident on 4/4/25 this morning (4/16/25) when she arrived at the facility to perform her rounds. On 4/16/25 Resident #91's Divalproex Sodium medication order was changed to 500 mg at bedtime only. The Director of Nursing (DON) was interviewed on 4/16/25 at 12:53 PM. The DON explained that the facility had been attempting to place Resident #91 in a locked dementia facility that could better supervise her, but until that time, they had assigned sitters from 7:00 AM until 11:00 PM, and the depending on staffing, a sitter could be assigned on the 11:00 PM to 7:00 AM shift, but that was not the case on 4/4/25. The DON explained that all staff were responsible for supervising Resident #91, as well as other residents, and she did not know if the incident could have been prevented because of Resident 91's persistent behaviors and difficulty with being redirected. The Administrator was interviewed on 4/16/25 at 1:32 PM. The Administrator explained that the facility was attempting to find placement for Resident #91 in a facility better suited to provide her with 24 hours of supervision. The Administrator explained that the facility had 1:1 sitter during the day and staffing was being adjusted to provide that 1:1 supervision during the night shift from 11:00 PM to 7:00 AM.

Based on record review and staff interviews, the facility failed to completely fill out the Do Not Resuscitate (DNR) form for 1 of 2 residents reviewed and Advanced Directives (Resident # 30). The findings included: Resident # 30 was admitted to the facility on [DATE]. Resident # 30's diagnosis included hypertension, and cognitive impairment. Review of Resident # 30's paper medical record revealed Resident # 30's DNR form signed by the Nurse Practitioner (NP) # 1 was not dated. Review of Resident # 30's Electronic Medical Record (EMR) revealed a physician's order dated 1/21/2025 for code status DNR. An interview was conducted on 4/14/2025 at 1:05 PM with Unit Manager # 2. Unit Manager # 2 revealed upon admission, the nurse would complete the DNR. Unit Manager # 2 continued by stating the form would then go to the Nurse Practitioner (NP) to be signed, dated, and then scanned into the EMR. The hard copy would be kept at the nurse's station in a binder. Unit Manager # 2 further stated the DNR form should correspond with a matching date and should also match what was documented in the EMR. Upon review of the form Unit Manager # 2 indicated the date was missing from the DNR form. The Nurse Practitioner (NP) # 1 was interviewed on 4/16/2025 at 11:29 AM. She stated DNR forms are usually dated before they are given to her to sign. NP # 1 further stated she usually received a stack of forms to sign with the date already on them. An interview was conducted with the Director of Nursing (DON) on 4/14/2025 at 1:13 PM. The DON revealed the admissions nurse would be responsible for completing the DNR form. The DON indicated information on the form should be checked during the twenty-four-hour chart check after admission. The DNR form should have an effective date. An interview was completed with the Administrator on 4/16/2025 at 11:44 AM. The Administrator revealed NP # 1 was responsible for signing and dating the DNR form. The Administrator further stated NP # 1 was new and may need additional training or retraining of the process.

Based on record review and Nurse Practitioner and staff interviews, the facility failed to notify the Nurse Practitioner (NP) after an International Normalized Ratio (INR) test (monitors the effectiveness of blood-thinning medications) was not completed as ordered for 1 of 1 resident (Resident # 255) reviewed for monitoring anticoagulant medicine. The findings included: Resident #255 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation. Resident #255's physician order dated 01/30/25 revealed the resident was ordered to receive a warfarin sodium (anticoagulant/blood thinner) oral tablet 2 milligram (mg), give 1 tablet by mouth at bedtime related to unspecified atrial fibrillation. A progress note dated 03/05/25 completed by Nurse Practitioner (NP) #1 revealed Resident #225's INR was recently checked, and it was at 4.0 that morning (normal range 2-3). It was further noted Resident #255's warfarin was to be held until 3/7/25. The note indicated Resident #255's INR was to be rechecked on 03/07/25 and to notify NP #1 of any bleeding or changes. Resident #255's physician orders revealed an order dated 03/07/25 to check Resident #255's INR on 03/07/25 and hold Warfarin until further notice. Resident #255's MAR revealed from 03/05/25 through 03/12/25 warfarin was not administered to Resident #255. Further review revealed Nurse #1 signed off on 03/07/25 that an INR was completed on the resident but there was no documented INR result. Resident #255's labs and progress notes indicated no results for an INR lab for Resident #255 for the 03/07/25 ordered INR. A phone interview conducted with Nurse #1 on 04/24/25 at 8:00 pm revealed on 03/07/25 she was assigned Resident #255. Nurse #1 could not recall if she had completed Resident #255's INR on that date but explained if she had completed the resident's INR it would have been in the resident's chart. Nurse #1 stated if the INR result was not in the residents' chart, then she did not complete it. A phone interview conducted with NP #1 on 04/24/25 at 1:10 PM revealed Resident #255's INR was being followed closely due to the resident's INR numbers fluctuating. NP #1 revealed on 03/05/25 Resident #255 had an INR rate of 4.0 and she wanted the resident's warfarin held and the INR to be rechecked on 03/07/25. The NP indicated Resident #255 was checked on 03/12/25 and Resident #255 had an INR result of 1.3. The NP stated there was no harm or negative outcome as a result of the resident's INR was not checked on 03/07/25 but expected nursing staff to follow through with orders given and notification of any changes. The NP indicated she was not notified the lab was not completed and would expect staff to notify her if it was not completed as ordered. An interview conducted with the Director of Nursing (DON) on 04/24/25 at 3:00 PM revealed Resident #255 had ongoing issues with her INR not being consistent. The DON further revealed it was being followed closely by the medical providers. The DON stated she was not aware it was not checked on 03/07/25 but expected nursing staff to follow orders. The DON revealed she was not aware the lab had been missed, but the NP should have been notified for Resident #255's lab not being completed as ordered on 03/07/25. An interview conducted on 04/28/25 at 1:00 PM the Administrator revealed she had reviewed Resident #255's chart and could not find any documentation Resident #255 received an INR check on 03/07/25. The Administrator further revealed she expected orders to be followed through with and believed Resident #255's order from 03/07/25 to have her INR checked was missed and the NP was not notified.

Based on observations, record review, and resident and staff interviews, the facility failed to allow residents who were assessed to be safe smokers to smoke independently per their individual preference for 2 of 3 residents (Resident #8 and #249) reviewed for smoking. The findings included: Review of the Facility Smoking Acknowledgement read, in part: patients who wish to smoke will be evaluated using the smoking safety screen upon admission and as needed to determine need for supervision. The patient must also agree to the policy and sign the Patient Smoking Acknowledgement form . based on the Smoking Safety Screen, a patient may smoke in designated smoking area either independently or with supervision . The smoking schedule for the facility dated 3/18/25 was reviewed. Times for smoking were listed as 8:30 AM, 11:00 AM, 1:30 PM, 3:30 PM, 5:30 PM, and 8:00 PM. The form read Staff members go with residents out back to designated smoking areas. Ensure the resident is in proper clothing and has shoes or foot pedals in place. No adjustments will be made to these times. a. Resident #8 was admitted to the facility 11/27/24. A Patient Smoking Acknowledgement form dated 12/2/24 was signed by Resident #8. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #8 was cognitively intact, and she did not use tobacco. Review of Resident #8's medical record revealed a smoking assessment dated [DATE] that determined Resident #8 was a safe smoker and she could smoke unsupervised. A care plan initiated on 12/9/24 and the most recent revised date on 3/13/25 documented Resident #8 preferred to smoke cigarettes, and included the goal Resident #8 would smoke safely through the review period. The interventions included educating Resident #8 on the facility smoking policy and conducting smoking assessments as needed. Resident #8 was interviewed on 4/15/25 at 1:39 PM. Resident #8 reported while she was glad she was able to smoke at the facility, she wanted to be able to go out to smoke any time she wanted. She explained she was not allowed to go out to smoke after 8:00 PM and this made her feel anxious. During an interview with Nursing Assistant (NA) #2 on 4/16/25 at 9:52 AM, she reported Resident #8 would ask to go outside to smoke frequently. An interview was conducted with NA #1 on 4/16/25 at 10:06 AM and she reported Resident #8 became upset if she was not able to go out to smoke. Nurse #5 was interviewed on 4/16/25 at 10:44 AM and she reported Resident #8 became anxious if she was unable to go out to smoke. b. Resident #249 was admitted to the facility 4/7/25. A Patient Smoking Acknowledgement form dated 4/7/25 was signed by Resident #249. Review of the medical record for Resident #249 revealed the smoking assessment dated [DATE] documented Resident #249 was a safe smoker and could smoke unsupervised. A care plan initiated 4/7/25 documented Resident #249 preferred to smoke cigarettes and included a goal he would smoke safely through the review period. The interventions included educating him on the facility smoking policy and conducting a smoking assessment as needed. The admission MDS dated [DATE] documented Resident #249 was cognitively intact. The admission MDS was in progress and not completed for tobacco use. Resident #249 was interviewed on 4/16/25 at 8:25 AM. Resident #249 reported he was looking for someone to open the door so he could go out to the smoking area. He reported he was frustrated he had to wait for certain times to smoke and had to wait for a staff member to take him out to the smoking area. Resident #249 reported he had been smoking for 50+ years, he was able to determine when he wanted to have a cigarette and waiting for the smoking times was upsetting to him. The Director of Nursing (DON) was interviewed on 4/16/25 at 1:04 PM. The DON reported the facility had been non-smoking in the past, but residents who wanted to smoke were going outside and smoking on the porch, down the steep hill of the driveway that led to the street, and back by the dumpsters, to name a few places. The DON reported the facility felt that those smoking behaviors were unsafe and decided to allow smoking in a designated area at the rear of the building at certain times and with staff supervision. The DON explained that the smoking times had become a social activity for residents, and they seemed to enjoy it. The DON reported she was aware Resident #8 wanted to go outside to smoke whenever she wanted but reported Resident #249 had not expressed frustration over not being able to choose his own smoking times. The Administrator was interviewed on 4/16/25 at 1:32 PM. The Administrator explained the facility was previously smoke-free, but they had several residents who refused a nicotine patch and were going outside to smoke, at various places. The Administrator explained that the interdisciplinary team did not feel this was safe for the residents and they decided to implement supervised smoking for all residents, and determined the times they would offer smoking. The Administrator explained that the facility decided to develop a system that provided residents with the opportunity to smoke if they wished, while providing them with safety through supervision. The Administrator was unable to explain why the residents who were assessed as independent smokers were required to smoke at the designated times with supervision.

Based on record review and staff and resident interviews, the facility failed to resolve grievances that were reported in the Resident Council meetings for 4 of 6 months (11/19/2024, 12/18/2024, 1/29/2025 and 2/26/2025). Findings included: A review of the Resident Council Minutes indicated the residents had complained on 11/19/2024, 12/18/2024, 1/29/2025, and 2/26/2025, during the Resident Council meeting, that they received potatoes and green beans several times during the same week. A Departmental Response/Resolution dated 11/26/2024 indicated the facility's menu was provided by the corporate office and the Dietary Manager stated the menu could not be changed. The Department Response/Resolution also stated green beans were served three times a week and mashed potatoes were served two times a week per the facility's menu. On 12/18/2024 the Departmental Response/Resolution form updated by the Administrator stated they continued to report the residents' concerns to the Dietary Manager to see if any substitutions could be made. On 1/29/2025 the Departmental Response/Resolution form was updated and stated the Dietary Manager would contact the corporate office to ask about substitutions and at your request options for residents. On 2/27/2025 the Departmental Response/Resolution form was updated by the Administrator and stated she emailed the Senior Regional Director of Operations regarding the resident's concerns and asked about the availability of alternate options. On 3/26/2025 the Departmental Response/Resolution form was updated and stated the menu would change for the season in May or June of 2025. An interview was conducted with the Resident Council on 4/15/2025 at 3:20 pm during which the council members indicated they had brought up concerns that the same foods were being served repeatedly. Resident #15 stated they shared multiple times in the past six months that they were being served the same food items for lunch and dinner several times a week, but they continued to be served the same things, and it continued to be an issue. Resident #15 stated residents were served potatoes and green beans multiple times a week and the facility did not respond to the concern and correct the issue. On 4/15/2025 at 3:49 pm the Activity Director was interviewed, and she stated the concerns were written in the Resident Council Minutes and a Departmental Response/Resolution form was sent to the Department Manager of the area of concern. The Activity Director stated the complaint about being served the same food items had been a consistent problem and the Administrator was notified of the concern, and the Administrator had contacted the contracted dietary company and there was a plan to change the menus in either May 2025 or June 2025. The Activity Director stated she did not know why it had taken so long for something to be done about the mashed potatoes and green beans being served so frequently. She indicated the response form for the complaint was dated 11/26/2024 and green beans had been served three times a week and potatoes two times a week. The Administrator was interviewed on 4/16/2025 at 12:46 pm and stated she was aware of the grievances during the Resident Council Meetings on 11/19/2024, 12/18/2024, 1/29/2025 and 2/26/2025. She stated she talked with the Dietary Manager to replace the potatoes and green beans to make sure the residents were happy with their meals. She stated she thought the reason the issue had taken so long was because the Dietary Manager had not been comfortable with substituting what was on the menu.

Based on record review, observations, and staff interviews, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for 1 of 3 residents (Resident #79) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination. Findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses of stroke and difficulty swallowing. A Physician's order dated 3/24/2025 stated Resident #79 should have placement checked to her gastrotomy tube before each feeding and medication administration every shift; her residual should be checked each shift; a 20 to 30 milliliter flush of water should be given before and after administration of medication; she should receive a flush of 150 milliliters of water four times a day, and she should receive 50 milliliters an hour of enteral feeding. An admission Minimum Data Set assessment dated [DATE] indicated Resident #79 was cognitively intact and received 51% or more of her total calories and more than 501 milliliters of fluids per day by enteral feedings. A review of Resident #79's Medication Administration Record for 4/13/2025 revealed she received medications, a 20 to 30 milliliter flush, 150 milliliters of water, and her residual feeding was checked at 9:00 am on 4/13/2025. During an observation of Resident #79 on 4/13/2025 at 11:03 am the plastic syringe used to check the residual amount of feeding in her stomach and flush her gastrotomy tube was stored in a plastic bag hanging from her feeding pump pole. The plastic syringe had a cream-colored liquid in the tip of the syringe and the plunger was engaged in the barrel of the syringe. The syringe was stored in a plastic bag hanging from the feeding pump pole. On 4/13/2025 at 2:41 pm the plastic syringe continued to have a cream-colored liquid in the tip and the plunger was engaged in the barrel of the syringe. The syringe was stored in a plastic bag hanging from the feeding pump pole. Nurse #2 was interviewed on 4/13/2025 at 2:52 pm and she stated she was training Nurse #3 and Nurse #3 had checked the residual and gave Resident #79 her medications this morning at 9:00 am. She stated she did not go into the room with Nurse #3 when the residual was checked and when Nurse #3 gave Resident #79 her medications around 9:00 am. Nurse #2 stated she was not aware the plunger should be removed from the barrel of the syringe to allow the syringe to dry completely after it was rinsed when it was used to give Resident #79 her medications. Nurse #2 stated she was aware the syringe should be rinsed after each use and the feeding should not have been left in the syringe. Nurse #3 stated she was in training and was not aware she should have separated the plunger from the barrel of the syringe, rinsed the syringe and the plunger, and allowed them to dry before placing them in the plastic bag after she checked Resident #79's enteral feeding residual and gave her medications through her gastrostomy tube this morning at 9:00 am. During an interview with Nurse Practitioner #1 on 4/15/2025 at 3:06 pm she stated the enteral feeding Resident #79 received had sugar in it and the product sitting in the plastic syringe with the plunger engaged would have caused bacteria to grow. She stated Resident #79 had not had any issues that would indicate the enteral feeding syringe being left with feeding in the tip had caused her any harm. The Director of Nursing was interviewed on 4/16/2025 at 12:30 pm and she stated the enteral feeding syringe should have had the plunger removed, rinsed out and placed so that it could air dry, and then stored with the plunger not engaged. The Director of Nursing stated she planned to re-educate all the nursing staff. On 4/16/2025 at 12:42 pm the Administrator was interviewed and stated the enteral feeding syringe should have been taken apart and cleaned, allowed to dry and then stored in the bag with the plunger separate from the syringe.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a resident swallowed medications during medication administration when Nurse #5 left medications at the bedside for 1 of 5 residents observed for medication administration (Resident #2). The findings included: Resident #2 was admitted to the facility 12/19/24 with diagnoses including diabetes and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #2 to be moderately cognitively impaired. Review of the physician orders for Resident #2 revealed the following medications to be administered: - Digoxin 125 micrograms 1 tablet daily for atrial fibrillation at 9:00 AM - Furosemide 20 milligrams (mg) 1 tablet daily for blood pressure at 8:00 AM - Nadolol 40 mg 1 tablet daily for blood pressure at 9:00 AM - Oxybutynin chloride 5 mg 1 tablet daily for bladder spasm at 8:00 AM - Sennosides-docusate sodium 8.6 mg/50 mg 2 tablets daily for constipation at 9:00 AM - Divalproex Sodium 125 mg 1 tablet daily for anxiety at 9:00 AM - Metformin 500 mg 1 tablet twice daily for diabetes at 9:00 AM - Methenamine Hippurate 1 gram 1 tablet for urinary tract at 9:00 AM Resident #2 was observed on 4/13/25 at 11:50 AM. A medication cup with 9 pills was on her overbed table. Resident #2 was asked about the medications, and she reported she did not know what they were or why they were on her table. Nurse #5 was asked to come to Resident #2's room and she arrived at 12:00 PM. When shown the medication on the overbed table, Nurse #5 exclaimed, Oh, you didn't take your medication! Resident #2 shook her head 'no' and refused to take the medications. During the observation on 4/13/25 at 12:00 PM, Nurse #5 was asked why the medications were left on the overbed table and Nurse #5 reported that Resident #2 had put the pills in her mouth and must have spit them out. Nurse #5 explained she had an urgent need to use the bathroom and had left the medications with Resident #2 and had not watched her swallow the medications. The medication administration record was reviewed with Nurse #5 and the medications had been administered to Resident #2 at 10:11 AM. The Director of Nursing (DON) was interviewed on 4/13/25 at 12:40 PM. The DON reported that the medications should not have been left on the overbed table and Nurse #5 should have watched her swallow the medications. The DON was interviewed again on 4/16/25 at 12:53 PM and she reported she expected all nurses to ensure the residents were taking their medications by watching them swallow the medications and not leaving pills at the bedside. The DON reported Nurse #5 notified the physician of Resident #2's refusal to take the medications on 4/13/25. The Administrator was interviewed on 4/16/25 at 1:32 PM and she reported that Nurse #5 had to urgently use the bathroom during the medication administration to Resident #2, and she left the pills for Resident #2 to take. The Administrator reported she expected all nurses to follow the 6 rights of medication administration and to watch the residents swallow the medications.

Based on record review, staff, nurse practitioner (NP), and Physician interviews, the facility failed to notify the physician or the nurse practitioner that an anti-[CONDITION(S)] medication ([MEDICATION(S)]) was not available for administration for 1 of 1 resident reviewed for notification of change (Resident #244). The facility failed to notify the NP or the Physician that [MEDICATION(S)] was not available for administration on 4/30/2022, 5/1/2022, 5/4/2022, 5/8/2022, 5/24/2022, and 5/26/2022. Resident #244 was hospitalized with cardiac issues on 5/11/2022 and with [CONDITION(S)] activity on 5/27/2022. Findings included: Resident #244 was admitted to the facility 4/27/2022 at 11:45 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #244 to be severely cognitively impaired. The MDS documented Resident #244 had a percutaneous endoscopic gastrostomy (PEG) tube for feeding and medications. The MDS documented Resident #244 had [CONDITION(S)] disorder. The medical record for Resident #244 was reviewed and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 4/30/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #13 for 4/30/2022 documented at 10:07 AM on hold from pharmacy without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. 5/1/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #12 for 5/1//2022 documented at 10:32 AM ([MEDICATION(S)])10 mg on order from pharmacy, not available. There was no documentation indicating the NP had been notified the medication was not available. 5/1/2022 9:00 PM dose, 9 (other, see progress notes). Nursing progress notes dated 5/1/2022 at 10:47 PM documented medication not available without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. 5/4/2022 9:00 PM dose 5. Nursing progress notes written by Nurse #13 dated 5/4/2022 at 9:50 PM documented, ([MEDICATION(S)])10 mg on order from pharmacy, not available. There was no documentation indicating the NP had been notified the medication was not available. 5/8/2022 9:00 PM dose 9. Nursing progress notes dated 5/8/2022 at 11:06 PM documented medication not available without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. Documentation from 5/9-5/11/2022 included NP notification. Resident #244 was readmitted from the hospital 5/23/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for May 2022 was reviewed and the documentation for [MEDICATION(S)] were as follows: 5/24/2022 9:00 AM dose 9. Nursing progress notes dated 5/24/2022 at 1:45 PM documented not in stock, without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. 5/26/2022 9:00 PM dose 5. No nursing progress note was documented. Nurse #11 was assigned to Resident #244 on this date. There was no documentation indicating the NP had been notified the medication was not available. Documentation 5/25/2022 included NP notification. An interview was conducted with Nurse #10 on 10/12/2022 at 3:51 PM. Nurse #10 reported that he had provided care to Resident #244 and had administered medications to him. Nurse #10 reported that he did not specifically remember [MEDICATION(S)] for Resident #244 and he could not remember if he talked to the DON or the NP regarding the availability of doses. An interview was conducted with Nurse #12 on 10/12/2022 at 4:38 PM. Nurse #12 reported she vaguely remembered Resident #244 but did not remember the medication administration. Nurse #12 reported that if her documentation did not say she contacted the NP, she had not called the NP to notify the [MEDICATION(S)] was not available. Nurse #11 was interviewed on 10/12/2022 at 5:02 PM. Nurse #11 reported that he was an agency nurse and he had provided care to Resident #244. Nurse #11 reported he told the DON Resident #244 did not have [MEDICATION(S)] available for administration but was not certain of the date. An interview was conducted with Nurse #13 on 10/13/2022 at 9:38 AM. Nurse #13 reported that [MEDICATION(S)] was not available and she notified the NP the medication was not available. Nurse #13 reported she had not reported the medication was not available to the DON. Nurse #13 reported she was unable to remember which NP she had contacted and on what date she had notified the NP the [MEDICATION(S)] was not available. Nurse #13 reported she must have forgotten to document she contacted the NP on 4/30/2022 and 5/4/2022. Nurse #9 was interviewed on 10/12/2022 at 12:36 PM. Nurse #9 reported she had provided care to Resident #244, and she had not been able to administer [MEDICATION(S)] to Resident #244 because the medication was not in the facility. Nurse #9 reported she had notified a NP, but she was not certain of the date she contacted the NP, or if she spoke to the facility NP or the on-call NP. Nurse #9 reported that she had not notified the Director of Nursing (DON) that [MEDICATION(S)] was not available for administration to Resident #244. Nurse #9 initials were on the MAR for Resident #244 on 4/28/2022, 4/29/2022, 5/7/2022, and 5/8/2022. An interview was conducted with the NP on 10/12/2022 at 1:53 PM. The NP reported that she was not notified by any nursing staff that the facility had not administered [MEDICATION(S)] to Resident #244 until 5/27/2022. The NP explained that [MEDICATION(S)] was a controlled medication and prescription had to be handwritten and submitted to the pharmacy for the medication to be filled. The NP reported on 4/23/2022 she had written a handwritten prescription and it was faxed to the pharmacy and she believed that Resident #244 was receiving the [MEDICATION(S)] for seizures because she was not notified [MEDICATION(S)] had not been delivered by the pharmacy. The NP reported she was notified on 5/27/2022 that Resident #244 had not received [MEDICATION(S)] for 3 days. The NP reported it was not until later (uncertain of date) she was notified that Resident #244 had not received any [MEDICATION(S)] in the facility from admission until 5/28/2022. The NP stated missing the [MEDICATION(S)] was a significant medication error that could have resulted in [CONDITION(S)] related to uncontrolled [CONDITION(S)] activity. The NP was interviewed again 10/12/2022 at 3:06 PM. the NP reported that abruptly stopping [MEDICATION(S)] could also cause significant cardiac issues. The NP reported if she had been notified of the issues with obtaining the medication, then she could have had discussions with the family, the facility, and the physician about changing or modifying medications. The facility physician (MD) was interviewed on 10/12/2022 at 3:13 PM. The MD reported he was not aware Resident #244 had not received [MEDICATION(S)] as ordered until today (10/12/2022). The MD reported that not administering the [MEDICATION(S)] for Resident #244 was a significant and serious error that could have impacted his cardiac health and his neurological health. The MD explained that after a stroke, some patients have [CONDITION(S)] activity, and that was why Resident #244 required the medication [MEDICATION(S)]. The DON was interviewed on 10/12/2022 at 6:01 PM. The DON explained that when Resident #244 was admitted from the hospital on 4/23/2022 he did not have a handwritten prescription for [MEDICATION(S)], and the NP wrote a prescription for the medication. The DON reported that the NP had written for tablets to be administered and Resident #244 required the liquid form for administration through the PEG tube. The DON reported there were complications from the pharmacy with the dosage of the medication that required clarification by the NP. The DON reported that she was not aware Resident #244 had not received [MEDICATION(S)] until 5/27/2022, 3 days after Resident #244 was readmitted to the facility from the hospital. The DON reported that Resident #244 was sent to the hospital for [CONDITION(S)] activity and sent back to the facility. The DON reported that on 5/27/2022 the NP wrote another handwritten prescription for [MEDICATION(S)], and it was sent to the pharmacy, and the medication was delivered on 5/28/2022. The DON reported that she notified Resident #244's family member about the medication error on 5/27/2022 and she started a plan of correction for the medication error. The Administrator was notified of the immediate jeopardy on 10/12/22 at 6:30 PM. The facility provided a plan of correction with a correction date of 6/15/2022. The plan of correction included F580: # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. ([MEDICATION(S)]) was not available for resident upon admission. The patient missed his medication upon admit 4/27/2022 to 5/11/2022. The patient discharged to hospital on 5/11/2022 and returned from hospital on 5/23/2022. Patient had a delay in ([MEDICATION(S)]) again from 5/23/2022 until 5/27/2022. On 5/27/2022, the patient received his medication. Nursing administration self-identified this ongoing issue of medication availability, and put together a 4-step plan POC for both: 1. Notification to physician and/or nurse practitioner (NP) when medications are unavailable at med pass for follow-up 2. Medication availability in general The root cause of this issue upon the first admission, was that upon missing medications, the physician and/or NP was not notified of the need for the hard script related to the ([MEDICATION(S)]). The hospital did not send the patient with the hard script upon admit. The information was passed from shift to shift by nurses, and not to nursing administration for intervention and resolution. Upon readmission on 5/23, the root cause was that the discharging hospital did not send the hard script again (for [MEDICATION(S)]). The NP was notified and did provide a script; however, it was for tablets, versus a liquid format given that the patient has a PEG tube for medications. The NP was notified, then re-wrote the script for liquid dosing; however, pharmacy could not accept this prescription related to the dosage. (The prescription could not be split as it was a scheduled medication) The NP again was notified and re-wrote the prescription for([MEDICATION(S)]) with the appropriate dosage which could be filled by the pharmacy. The pharmacy provided the medication in liquid form and the patient received the medication moving forward. The patient discharged on [DATE]. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All medications were reviewed by the Director of Nursing (DON) for [MEDICATION(S)]. No other residents in the facility were found to be ordered [MEDICATION(S)]. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education given to all current nurses (fulltime, part time and agency staff) on process of obtaining medication ([MEDICATION(S)]) and/or generic when not available. Moving forward nurses on hire will also receive this education. This will include notifying the physician and/or non-physician practitioner (PA, NP) with any and each missed dose of ([MEDICATION(S)]), for follow-up. The protocol is as follows: 1. Notify MD or NP/PA of missed ([MEDICATION(S)]) at time of med pass if unavailable. 2. Ask for hold order, alternate order and/or determine what next steps are via the MD/NP/etc. 3. If physician and/or NP does not offer a hold/alternate order for ([MEDICATION(S)]), notify DON for further intervention and follow-up, up and including administrator, attending physician, medical director and/or pharmacy consultant until resolution. 4. Notify pharmacy of missed medication to determine root cause and resolution. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. DON will audit all patients who receive ([MEDICATION(S)]) to ensure adequate supply three times weekly x 4 weeks, then weekly x 4 weeks and monthly ongoing. If/when a ([MEDICATION(S)]) medication is missed, audit will be performed to determine if the proper and timely notification was done to MD/NP for hold order, alternate order and/or next steps. Any issues found will be corrected immediately, and any nurse found not to be in compliance with protocol for medication availability and notification will be re-educated and/or disciplined up to and including termination as needed. The results will be reported to the monthly Quality Committee for review and discussion to ensure compliance. Once the QA Committee determines the problem no longer exits, then review will be completed on a random basis. Date of compliance as of 6/15/22. The plan of correction was reviewed and validated 10/13/2022 and 10/14/2022 by interviews with nursing staff, including Nurse #1, Nurse #2, Nurse #3, and Nurse #4. Included in the validation was a review of the educational in-services, review of the monitoring and audits, and medication administration observations. F580 was in compliance on 6/15/2022.

Based on record review, staff, Nurse Practitioner (NP), and Physician interviews, the facility failed to administer an anti-[CONDITION(S)] medication ([MEDICATION(S)]) as ordered by the physician for 1 of 1 resident reviewed for significant medication errors (Resident #244). Resident #244 missed 34 doses of [MEDICATION(S)]. The facility failed to administer [MEDICATION(S)] on 4/28/2022 to 4/30/2022, 5/1 to 5/11/2022; 5/23 to 5/27/2022. Resident #244 was sent to the emergency room from a physician appointment on 5//11/2022 with cardiac issues (and admitted for treatment) and was sent to the emergency room for evaluation after [CONDITION(S)] activity on 5/27/2022. Findings included: Resident #244 was admitted to the facility 4/27/2022 at 11:45 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #244 to be severely cognitively impaired. The MDS documented Resident #244 had a percutaneous endoscopic gastrostomy (PEG) tube for feeding and medications. The MDS documented Resident #244 had [CONDITION(S)] disorder. The medical record for Resident #244 was reviewed and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation for [MEDICATION(S)] was as follows: 4/28/2022 9:00 AM dose, 5 (hold/see progress note). Progress notes for 4/28/2022 revealed that all morning medications were on hold and the NP was aware. This note was written by Nurse #9. 4/28/2022 9:00 PM dose was documented as administered. 4/29/2022 9:00 AM dose, 6 (hospitalized ). Nursing progress notes written by Nurse #9 dated 4/29/2022 documented that Resident #244 was sent to the hospital because he pulled out his PEG tube. The note documented Resident #244 returned to the facility at 11:00 AM, the morning medications were not administered at that time, and the provider (NP) was notified. 4/29/2022 9:00 PM dose was documented as administered by Nurse #11. 4/30/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #13 dated 4/30/2022 documented at 10:07 AM on hold from pharmacy without specific medication identified. 4/30/2022 9:00 PM dose was documented as administered. 5/1/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #12 dated 5/1//2022 documented at 10:32 AM ([MEDICATION(S)])10 mg on order from pharmacy, not available. 5/1/2022 9:00 PM dose, 9 (other, see progress notes). Nursing progress notes dated 5/1/2022 at 10:47 PM documented medication not available without specific medication identified. 5/2/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/2/2022 at 12:59 PM documented hold, NP aware, without specific medication identified. 5/2/2022 9:00 PM dose 5. Nursing progress notes dated 5/2/2022 at 10:17 PM documented hold, NP aware, without specific medication identified. 5/3/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/3/2022 at 10:23 AM documented hold, NP aware, without specific medication identified. 5/3/2022 9:00 PM dose 5. Nursing progress notes dated 5/3/2022 at 9:46 PM documented hold, NP aware, without specific medication identified. 5/4/2022 9:00 AM dose was documented as administered by Nurse #13. 5/4/2022 9:00 PM dose 5. Nursing progress notes dated 5/4/2022 at 9:50 PM documented, ([MEDICATION(S)])10 mg on order from pharmacy, not available. 5/5/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/5/2022 at 10:31 AM documented hold, NP aware, without specific medication identified. 5/5/2022 9:00 PM dose 5. Nursing progress notes dated 5/5/2022 at 9:16 PM documented hold, NP aware, without specific medication identified. 5/6/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/6/2022 at 1:18 PM documented hold, NP aware, without specific medication identified. 5/6/2022 9:00 PM dose 5. Nursing progress notes dated 5/6/2022 at 6:57 PM documented hold, NP aware, without specific medication identified. 5/7/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #4 dated 5/7/2022 at 1:25 PM documented hold, NP aware, without specific medication identified. 5/7/2022 9:00 PM dose was documented as administered. 5/8/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/8/2022 at 12:56 PM documented hold, NP aware, without specific medication identified. 5/8/2022 9:00 PM dose 9. Nursing progress notes dated 5/8/2022 at 11:06 PM documented medication not available without specific medication identified. 5/9/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/9/2022 at 10:01 AM documented hold, NP aware, without specific medication identified. 5/9/2022 9:00 AM dose 5. Nursing progress notes dated 5/9/2022 at 9:13 PM documented Med held, NP notified, without specific medication identified. 5/10/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/10/2022 at 1:42 PM documented hold, NP aware, without specific medication identified. 5/10/2022 9:00 PM dose 5. Nursing progress notes dated 5/10/2022 at 9:48 PM documented NP aware, hold, without specific medication identified. 5/11/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/11/2022 at 10:37 AM documented on hold, NP aware, without specific medication identified. Nursing progress notes dated 5/12/2022 at 1:49 AM documented Resident #244 had been admitted to the hospital. The hospital discharge summary dated 5/23/2022 documented Resident #244 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #244 was seen in the cardiologist office on 5/11/2022 and referred to the hospital emergency department after that appointment. During transport to the hospital, it was noted Resident #244 had apnea (stopped breathing for several seconds). During the hospital stay, it was noted Resident #244 had second-degree heart block (electrical signals in the heart are disrupted, which can cause cardiac arrhythmias). The discharge note documented Resident #244 would continue to follow up with cardiology after discharge. Resident #244 was readmitted to the facility from the hospital 5/23/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . New orders for Resident #244 were entered into the electronic documentation system at 2:38 PM. A nursing progress note dated 5/23/2022 at 10:00 PM documented the NP was aware of Resident #244 readmission to the facility. The May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 5/24/2022 9:00 AM dose 9. Nursing progress notes dated 5/24/2022 at 1:45 PM documented not in stock, without specific medication identified. 5/24/2022 9:00 PM 5. A nursing note dated 5/25/2022 at 12:16 AM documented ([MEDICATION(S)]) 15 ml np aware, hold. 5/25/2022 9:00 AM dose 5. A nursing note written by dated 5/25/2022 written by Nurse #13 at 10:47 AM documented on hold NP aware without specific medication identified. 5/25/2022 9:00 PM dose was documented as administered by Nurse #10. 5/26/2022 9:00 AM dose 5. Nursing progress note dated 5/26/2022 at 1:25 PM written by Nurse #13 documented on hold, NP aware without specific medication identified. 5/26/2022 9:00 PM dose 5. Nurse progress note written by Nurse #11, dated 5/26/2022 at 11:27 PM documented med on hold np aware without specific medication identified. 5/27/2022 9:00 AM no documentation for missed dose of medication. A Nursing progress note dated 5/27/2022 at 4:37 PM documented Resident #244 was having a [CONDITION(S)] during physical therapy, and he was sent to the hospital. An emergency department discharge note dated 5/27/2022 documented Resident #244 had been sent to the hospital for evaluation after an apparent [CONDITION(S)]. The note documented when the medics arrived at the facility, Resident #244 was no longer having [CONDITION(S)] activity. The note documented that Resident #244 had not received [MEDICATION(S)] for 3 days. [MEDICATION(S)] was documented as administered on 4/28/2022 9:00 PM, 4/29/2022 9:00 PM by Nurse #11, 4/30/2022 at 9:00 PM, 5/4/2022 at 9:00 AM by Nurse #13, 5/7/2022 at 9:00 PM, and 5/25/2022 at 9:00 PM by Nurse #10. An interview was conducted with Nurse #10 on 10/12/2022 at 3:51 PM. Nurse #10 reported that he had provided care to Resident #244 and had administered medications to him. Nurse #10 was asked about dose of [MEDICATION(S)] that were documented as given on 5/25/2022 at 9:00 PM. Nurse #10 reported he did not specifically remember 5/25/2022, and he said that if the medication was not in the building, he may have mistakenly clicked that he gave the medication. Nurse #10 reported that he did not specifically remember [MEDICATION(S)] for Resident #244 and he could not remember if he talked to the DON or the NP regarding the availability of doses. Nurse #11 was interviewed on 10/12/2022 at 5:02 PM. Nurse #11 reported that he was an agency nurse and he had provided care to Resident #244. Nurse #11 reported when he attempted to administer the [MEDICATION(S)] to Resident #244, he discovered there was no [MEDICATION(S)] in the facility. Nurse #11 reported he did not know why he documented administering [MEDICATION(S)] to Resident #244 on 4/29/2022 because the medication was not in the building. Nurse #11 reported he told the DON Resident #244 did not have [MEDICATION(S)] available for administration, but he was not certain of the date he made the report. An interview was conducted with Nurse #13 on 10/13/2022 at 9:38 AM. Nurse #13 reported that she had provided care to Resident #244. Nurse #13 reported that [MEDICATION(S)] was not available and she notified the NP the medication was not available. Nurse #13 reported she had not reported the medication was not available to the DON. Nurse #13 reported she was unable to remember which NP she had contacted and on what date she had notified the NP the [MEDICATION(S)] was not available. Nurse #13 reported she was not certain why she documented she administered [MEDICATION(S)] on 5/4/2022 and reported she may have clicked off the medication on accident. Nurse #9 was interviewed on 10/12/2022 at 12:36 PM and she reported she had provided care to Resident #244, and she had not been able to administer [MEDICATION(S)] to Resident #244 because the medication was not in the facility. Nurse #9 reported she had notified a NP, but she was not certain of the date she contacted the NP, or if she spoke to the facility NP or the on-call NP. Nurse #9 reported that she had not notified the Director of Nursing (DON) that [MEDICATION(S)] was not available for administration to Resident #244. An interview was conducted with the NP on 10/12/2022 at 1:53 PM. The NP reported that she was not notified that the facility had not administered [MEDICATION(S)] to Resident #244 until 5/27/2022. The NP explained that [MEDICATION(S)] was a controlled medication and prescription had to be handwritten and submitted to the pharmacy for the medication to be filled. The NP reported on 4/23/2022 she had written a handwritten prescription and it was faxed to the pharmacy and she believed that Resident #244 was receiving the [MEDICATION(S)] for seizures because she was not notified [MEDICATION(S)] had not been delivered by the pharmacy. The NP reported she was notified on 5/27/2022 that Resident #244 had not received [MEDICATION(S)] for 3 days. The NP reported it was not until later (uncertain of date) she was notified that Resident #244 had not received any [MEDICATION(S)] in the facility from admission until 5/28/2022. The NP stated missing the [MEDICATION(S)] was a significant medication error that could have resulted in [CONDITION(S)] related to uncontrolled [CONDITION(S)] activity. The NP was interviewed again 10/12/2022 at 3:06 PM. the NP reported that abruptly stopping [MEDICATION(S)] could also cause significant cardiac issues. The NP reported if she had been notified of the issues with obtaining the medication, then she could have had discussions with the family, the facility, and the physician about changing or modifying medications. The facility physician (MD) was interviewed on 10/12/2022 at 3:13 PM. The MD reported he was not aware Resident #244 had not received [MEDICATION(S)] as ordered until today (10/12/2022). The MD reported that not administering the [MEDICATION(S)] for Resident #244 was a significant and serious error that could have impacted his cardiac health and his neurological health. The MD explained that after a stroke, some patients have [CONDITION(S)] activity, and that was why Resident #244 required the medication [MEDICATION(S)]. The DON was interviewed on 10/12/2022 at 6:01 PM. The DON explained that when Resident #244 was admitted from the hospital on 4/23/2022 he did not have a handwritten prescription for [MEDICATION(S)], and the NP wrote a prescription for the medication. The DON reported that the NP had written for tablets to be administered and Resident #244 required the liquid form for administration through the PEG tube. The DON reported there were complications from the pharmacy with the dosage of the medication that required clarification by the NP. The DON reported that she was not aware Resident #244 had not received [MEDICATION(S)] until 5/27/2022, 3 days after Resident #244 was readmitted to the facility from the hospital. The DON reported that Resident #244 was sent to the hospital for [CONDITION(S)] activity and sent back to the facility. The DON reported that on 5/27/2022 the NP wrote another handwritten prescription for [MEDICATION(S)], and it was sent to the pharmacy, and the medication was delivered on 5/28/2022. The DON reported she started a plan of correction for the medication error. The Administrator was notified of the immediate jeopardy on 10/12/22 at 6:30 PM. The facility provided a plan of correction with a correction date of 6/15/2022. The plan of correction included F760: # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. ([MEDICATION(S)]) was not available for resident upon admission. The patient missed his medication upon admit 4/27/2022 to 5/11/2022. The patient discharged to hospital on 5/11/2022 and returned from hospital on 5/23/2022. Patient had a delay in ([MEDICATION(S)]) again from 5/23/2022 until 5/27/2022. On 5/27/2022, the patient received his medication. Nursing administration self-identified this ongoing issue of medication availability, and put together a 4-step plan POC for both: 1. Notification to physician and/or nurse practitioner (NP) when medications are unavailable at med pass for follow-up 2. Medication availability in general The root cause of this issue upon the first admission, was that upon missing medications, the physician and/or NP was not notified of the need for the hard script related to the ([MEDICATION(S)]). The hospital did not send the patient with the hard script upon admit. The information was passed from shift to shift by nurses, and not to nursing administration for intervention and resolution. Upon readmission on 5/23, the root cause was that the discharging hospital did not send the hard script again (for [MEDICATION(S)]). The NP was notified and did provide a script; however, it was for tablets, versus a liquid format given that the patient has a PEG tube for medications. The NP was notified, then re-wrote the script for liquid dosing; however, pharmacy could not accept this prescription related to the dosage. (The prescription could not be split as it was a scheduled medication) The NP again was notified and re-wrote the prescription for([MEDICATION(S)]) with the appropriate dosage which could be filled by the pharmacy. The pharmacy provided the medication in liquid form and the patient received the medication moving forward. The patient discharged on [DATE]. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All medications were reviewed by the Director of Nursing (DON) for [MEDICATION(S)]. No other residents in the facility were found to be ordered [MEDICATION(S)]. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education given to all current nurses (fulltime, part time and agency staff) on process of obtaining medication ([MEDICATION(S)]) and/or generic when not available. Moving forward nurses on hire will also receive this education. This will include notifying the physician and/or non-physician practitioner (PA, NP) with any and each missed dose of ([MEDICATION(S)]), for follow-up. The protocol is as follows: 1. Notify MD or NP/PA of missed ([MEDICATION(S)]) at time of med pass if unavailable. 2. Ask for hold order, alternate order and/or determine what next steps are via the MD/NP/etc. 3. If physician and/or NP does not offer a hold/alternate order for ([MEDICATION(S)]), notify DON for further intervention and follow-up, up and including administrator, attending physician, medical director and/or pharmacy consultant until resolution. 4. Notify pharmacy of missed medication to determine root cause and resolution. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. DON will audit all patients who receive ([MEDICATION(S)]) to ensure adequate supply three times weekly x 4 weeks, then weekly x 4 weeks and monthly ongoing. If/when a ([MEDICATION(S)]) medication is missed, audit will be performed to determine if the proper and timely notification was done to MD/NP for hold order, alternate order and/or next steps. Any issues found will be corrected immediately, and any nurse found not to be in compliance with protocol for medication availability and notification will be re-educated and/or disciplined up to and including termination as needed. The results will be reported to the monthly Quality Committee for review and discussion to ensure compliance. Once the QA Committee determines the problem no longer exits, then review will be completed on a random basis. Date of compliance as of 6/15/22. The plan of correction was reviewed and validated 10/13/2022 and 10/14/2022 by interviews with nursing staff, review of the educational in-services, review of the monitoring and audits, and medication administration observations. F760 was in compliance on 6/15/2022.

Based on record review, staff, physician, home health, resident, and resident family interviews, the facility failed to provide for a safe discharge to meet the needs of 1 of 3 residents who lived alone, was incontinent, had a pressure ulcer, was dependent on oxygen, and had physical limitations, (Resident #290). Immediate Jeopardy began on 12/13/2021 when Resident #290 was discharged to home to ascend 19 steps with oxygen to home where she lived alone, was incontinent, without home health services, without medical equipment, without instructions for wound care, without wound care supplies, and without a home assessment being completed. Immediate Jeopardy was removed on 1/7/2022 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: Resident #290 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #290 to be cognitively intact. The MDS assessed Resident #290 to require extensive assistance dressing, toileting, hygiene, and bathing. The MDS documented Resident #290 was frequently incontinent of bladder and bowels. The MDS documented Resident #290 had 2 Stage 3 pressure ulcers. The MDS documented Resident #290 received oxygen therapy and had dyspnea (shortness of breath with activity). Nursing assistant (NA) #3 was interviewed on 12/30/2021 at 9:36 AM. NA #3 reported she provided care to Resident #290 frequently during her stay at the facility. NA #3 reported Resident #290 became very short of breath with all activity, even with the oxygen on, and Resident #290 required rest breaks. NA #3 reported Resident #290 was able to transfer to the wheelchair from bed with 1-person assistance, required at least 1 person assistance to position in bed, and she needed 1-person assistance with all toileting tasks. An interview was conducted with NA #4 on 12/30/2021 at 9:57 AM. NA #4 reported Resident #290 was extremely short of breath with all activity, and she needed to stop to rest during any activity. NA #4 reported Resident #290 had been attempting to become more independent with toileting but required 1-person assistance to transfer and perform hygiene. NA #5 was interviewed on 12/30/2021 at 10:14 AM. NA #5 reported Resident #290 was very short of breath with all activity. NA #5 reported Resident #290 required assistance to transfer from the bed to the wheelchair and with all toileting tasks. A social work/discharge planning progress note dated 11/23/2021 was reviewed. The note documented a discussion with Resident #290 regarding her discharge planned for home. The note documented Resident #290 reported her family member assisted with shopping and was able to assist with household chores. The note documented Resident #290 lived on the 2nd floor of her building and her family member was working on getting her a ground-level apartment. Resident #290 reported it was her plan to return home and did not want to consider an alternative plan. The note documented Resident #290 had applied for Medicaid, but she did not qualify. The note documented Resident #290 had oxygen in her home but may need a wheelchair upon return to home. The wound care consult note dated 12/08/21 indicated Resident #290 ' s bilateral buttocks wound was a Stage 3 with scant serous (clear to light yellow) exudate (drainage) and measured 4 centimeters (cm) by 3.5cm by 0.5 cm. Review of the treatment orders for Resident #290 ' s pressure ulcer revealed an order dated 12/9/2021 to cleanse the wound to the buttocks with wound cleanser, apply honey fiber dressing to the wound bed (an absorbent gel dressing to promote healing) and cover with a non-stick transparent dressing and gauze. This wound care was to be performed daily. Review of the physician discharge summary for Resident #290 dated 12/13/2021 noted referrals for a home health nurse, Physical Therapy, and Occupational Therapy for strengthening and a Social Worker for community resources. The discharge summary did not include any information related to the pressure ulcer or wound care. A physical therapy discharge assessment completed on 12/13/2021 documented Resident #290 required partial to moderate assistance to ascend/descend 1 step, substantial to maximum assistant to ascend/descend 4 steps and was totally dependent for 12 or more steps. The physical therapy discharge note documented Resident #290 required substantial to maximum assistance for ambulation of 150 feet. The physical therapy discharge note recommended 24-hour care and an assistive device for safe and functional mobility for Resident #290 when she returned home. An interview was conducted with the physical therapist (PT) on 1/5/2022 at 9:50 AM. The PT reported Resident #290 was unable to ascend stairs due to shortness of breath and fatigue, and she was unable to lift her body weight from one stair to the next and required extensive to total assistance. The PT reported Resident #290 required assistance to lift approximately 50% of her body weight up when ascending stairs due to fatigue, dyspnea, and poor endurance. The PT reported Resident #290 required 1-2.5 minutes of recovery after activity related to shortness of breath. The PT reported Resident #290 required oxygen, and even with oxygen, her saturation levels were low. The PT reported a home visit had not been completed because Resident #290 was unable to perform stair climbing and she would have failed the home visit. The rehab therapy manager was interviewed at the same time and she reported it was the therapy department ' s opinion that Resident #290 was not safe to discharge, but they thought she was going to her family member ' s home without stairs, and she was going to receive home health therapy. The rehab therapy manager reported Resident #290 ' s limitations had been discussed with the interdisciplinary team in the daily morning meetings and the discharge planner/social worker (SW) had been a participant in those meetings. The discharge MDS dated [DATE] documented Resident #290 was cognitively intact, required extensive assistance with bed mobility, dressing, and toileting, and was frequently incontinent of bladder and bowels. The discharge MDS documented Resident #290 was short of breath with exertion, at rest, and when lying flat. The discharge MDS documented Resident #290 had 1 Stage 3 pressure ulcer. An occupation therapy discharge note dated 12/14/2021 documented Resident #290 required minimal assistance with toileting, dressing, bathing, and meal preparation from wheelchair level. The occupational therapy note documented Resident #290 required assistance due to fatigue and dyspnea, and oxygen saturation levels dropped with exertion. A certified occupational therapist aide (COTA) #2 was interviewed on 1/4/2022 at 3:59 PM. COTA #2 reported she provided therapy to Resident #290 and she had discussions with Resident #290 about what she needed in her home after discharge from the facility. COTA #2 explained Resident #290 had been given a reaching device and a sock aid by the facility, but she would need a wheelchair and a bedside commode to use as a toilet seat extender. COTA #2 reported Resident #290 was extremely short of breath with any activity and that home health was recommended to continue therapy. The Unit Manger (UM) was interviewed on 1/4/2022 at 12:25 PM. The UM reported that Resident #290 was discharged sometime after 4:00 PM on 12/13/2021. The UM reported when Resident #290 was discharged , the nursing staff, the resident and the family member were under the impression home health services would start on 12/14/2021. A follow-up interview was conducted with the UM on 1/5/2021 at 11:20 AM. The UM reported she and all the department heads had received an email from the SW on 12/13/2021 at 8:21 AM that reported Resident #290 was to be discharged home with the named home health agency that would provide nursing, PT and OT services to her. The UM reported that she did not receive any notification prior to the resident ' s discharge that the services would not be available. She noted that if they had, extensive education for her wound care would have been provided to the resident and the family member. The UM also stated they would have sent some supplies and found resources for her to get wound care supplies. The family member of Resident #290 was interviewed on 12/28/2021 at 12:12 PM. The family member reported Resident #290 was discharged from the facility on 12/13/2021 after 4:00 PM and when she returned to Resident #290 ' s home, she found no medical equipment had been delivered for Resident #290. The family member reported she had to purchase equipment for Resident #290, including a walker, bed rails, shower chair, hand-held shower device, and an elevated toilet seat. The family member reported 3 people assisted Resident #290 up the 19 stairs to her home on 12/13/2021. The family member reported Resident #290 was extremely short of breath and could take only one step at a time with 2 people holding onto her and assisting her to lift onto each step. The family member reported on 12/14/2021 she called the facility and spoke to the Social Worker (SW) to inquire when home health would arrive. The family member reported the SW told her that the home health agency could not provide services to Resident #290, but he was attempting to find a replacement home health agency. The SW was interviewed on 12/30/2021 at 11:59 AM. The SW explained he was responsible for ordering equipment for residents discharging to home, as well as setting home health services. The SW reported Resident #290 ' s insurance had issued a notice of non-coverage on 12/2/2021, and Resident #290 appealed that decision. The insurance company approved for a few more days of therapy. The SW reported when a second notice of non-coverage was issued, Resident #290 appealed, but the appeal was denied. The SW reported Resident #290 was unable to pay privately for services and had said she would go home. The SW reported he made the referral to home health on 12/13/2021 and he was contacted by the home health agency on 12/13/2021 to notify the facility that they were unable to provide care to Resident #290 due to staffing issues. The SW reported he attempted to find another home health agency to provide services to Resident #290 without success. The Home Health Agency Marketing Manager (HHA) was interviewed on 12/30/2021 at 3:39 PM. The HHA reported she had received the referral for Resident #290 on 12/13/2021 and she had contacted the local home health agency, but due to staffing issues, they were not able to provide services to Resident #290. The HHA reported she talked to several other home health offices within their organization, but no one was able to provide services. The HHA reported she notified the SW at the facility, but she was unable to recall the time of day she contacted him to notify him that her organization could not provide services to Resident #290. The SW was interviewed again on 1/4/2022 at 2:28 PM. the SW reported he had been notified by the home health agency at lunch time by phone that they were unable to accept Resident #290. The SW reported he did not notify Resident #290, her family, the physician, or the facility staff, and he instead attempted to find another home health agency to provide care to Resident #290, but he was unsuccessful. The SW reported he was not aware Resident #290 did not leave the building until after 4:00 PM. The SW reported he thought Resident #290 had discharged early in the morning on 12/13/2021 and he thought she was already at home when he was told the home health agency was unable to provide services to her. An interview was conducted with the SW on 1/5/2022 at 10:32 AM. The SW reported he was aware Resident #290 was going back to her home and she had 19 steps to get into the home. The SW reported he did not recall hearing that Resident #290 required total assistance to ascend more than 12 steps. The SW reported he had not notified Resident #290 or the facility staff about home health not being able to admit her to services because he felt he could find another home health agency to provide services to her. An interview was conducted with Resident #290 on 12/28/2021 at 2:47 PM. Resident #290 reported she was discharged from the facility on 12/13/2021 after 4:00 PM and she understood she was to have home health physical therapy and a nurse. Resident #290 was discharged to home without medical equipment to assist with bathing, grooming, hygiene, or toileting. Resident #290 reported she had 19 steps to ascend to get to her home and she required 3 people to assist her, one person carried her oxygen tank, and she had a person on each side of her to help her up the steps. Resident #290 explained she would take one step at a time and rest after each step and the effort was very taxing and fatiguing. Resident #290 reported on 12/14/2021 her family member called the facility to find out when home health was going to arrive, and her family member was told by the SW that the home health agency did not accept her, and the SW was attempting to find another home health agency. Resident #290 reported she had to rely on assistance from her family member to provide hygiene, grooming, toileting, transfers, and meal preparation. Resident #290 reported she lived alone in a 2nd story apartment without an elevator and her family member lived about 5 minutes away by car. Resident #290 reported no home assessment was completed by the facility, a wheelchair was ordered, but it was backordered and not delivered prior to her discharge home from the facility. Resident #290 reported her family member had to purchase equipment and wound care supplies for her use in the home. Resident #290 was incontinent of urine and feces and required an incontinence brief. Resident #290 stated she was not able to get to the bathroom or change her brief upon discharge and had terrible pain at the pressure ulcer site when she was incontinent. Resident #290 was interviewed again on 1/4/2022 at 3:31 PM. Resident #290 reported when she returned home, she reviewed her discharge instructions and saw there were no wound care orders. Resident #290 reported a home health agency was listed on the discharge instructions and she thought the home health agency would look at her pressure ulcer and get orders. Resident #290 reported her family member had purchased a walker to assist with transfers into the bathroom. Resident #290 reported she was able to stand for 1-2 minutes before she was fatigued and had to sit down. Resident #290 reported she needed to use incontinence briefs because she was not able to get to the bathroom in time, and her family member came to her house several times per day to help her perform hygiene after incontinence. Resident #290 said with help she would use the walker and she could walk to the toilet. She noted that it was tough, and she would have to go in her pants at times if she had no help. Resident #290 reported she had used a brief every day and night and when she was wet or soiled her pressure ulcer hurt. She stated, my sores looked terrible when I got home, and they hurt so bad. She said she would have to wait till her family member got there and got her cleaned up. Resident #290 reported because it was the holiday season, her family member was available to help her as often as she needed assistance. Resident #290 further reported her family member would get her food and drinks when the family member came to her home. Resident #290 reported if there was an emergency, she would call her family member, but Resident #290 did not have a plan to exit her home safely. Resident #290 reported she had a long cord for her oxygen, and she had to wear the oxygen all the time. Resident #290 explained when she performed activities, she had to increase the flow of oxygen, but that did not prevent her from having shortness of breath. Resident #290 reported she had a virtual visit with her personal physician, and he recommended a topical cream to apply to her pressure ulcer sites and made a referral to home health for her. Resident #290 did not receive home health services until 12/30/2021. Nurse #10 was interviewed on 1/4/2022 at 2:06 PM. Nurse #10 reported she discharged Resident #290 from the facility at 5:30 PM. The nurse reported Resident #290 ' s family member picked her up at the facility and the discharge instructions were reviewed with the family member and Resident #290. Nurse #10 reported she was not aware Resident #290 did not have home health services set up, or instructions for pressure ulcer care, that Resident #290 had to ascend 19 steps to her home, or that Resident #290 did not have medical equipment in the home, including the wheelchair. Nurse #10 reported if she knew Resident #290 did not have home health, she would have provided wound care teaching to Resident #290 and her family. The home health nursing admission completed 12/30/2021 documented Resident #290 was prescribed oxygen at 5 liters per minute and she was dyspneic with activity. The admission assessment documented Resident #290 was unable to ambulate on a level surface without assistive device, was unable to transfer self, unable to ambulate to and from the toilet, required moderate assistance to transfer on and off the toilet, and required moderate assistance to perform toileting hygiene. The home health nursing admission assessment documented Resident #290 required moderate assistance to dress lower body. The assessment documented Resident #290 had 4 (1-10 scale, with 10 being worst) pain at the pressure ulcer site daily. The nursing admission assessment documented Resident #290 reported feeling unsteady when standing or walking and she was afraid of falling. Home Health Nurse #1 was interviewed on 1/10/22 at 10:54 AM regarding Resident #290. She stated she had completed the resident ' s initial assessment for home health services on 12/30/2021. She noted the family member had been applying a protective cream and the pressure ulcer on her bottom had closed, however home health would continue to monitor it. She noted the resident had stated she had pain at the pressure ulcer site and the home health nurse had recommended a pressure relieving device for her chair. The Home Health Nurse #1 reported Resident #290 was able to get to her bathroom and her kitchen, if someone was there for assistance, but it was a taxing effort. The home health PT was interviewed 1/5/2022 at 1:03 PM. The home health PT reported there was concern for Resident #290 because she lived in a 2nd floor apartment without an elevator, was extremely weak, and she was unable to ascend or descend stairs. The home health PT reported Resident #290 ' s oxygen saturation level decreased to 77% (normal 90-100%) during ambulation and it took her approximately 2 minutes for her to recover from activity. The home health PT reported Resident #290 ' s family member had to purchase a walker, bed rails, shower chair, hand-held shower device, and an elevated toilet seat because those items were not ordered by the facility. The Nurse Practitioner (NP) was interviewed on 12/30/2021 at 12:09 PM. the NP reported she was not aware Resident #290 had been discharged home without home health services in place. A follow up interview was conducted on 1/04/2022 at 5:50 PM with the NP regarding Resident #290 ' s discharge. The NP stated she was not notified that home health would not be provided, and she would have expected to be notified if Resident #290 was not going to receive home health services. The NP was asked if the resident was negatively affected by not having orders for pressure ulcer care and having home health to follow her. The NP reported if no home health could see her, she would have expected to be called for wound care and other orders. The NP reported she would have expected her to see a physician sooner and the nursing staff should have done education on how to do the pressure ulcer wound dressing. Resident #290 ' s Physician (MD) was interviewed via phone on 1/5/2022 at 10:04 AM regarding her discharge. The MD stated he would have expected when the home health resources were not able to be provided for Resident #290 that this would be communicated, and he was not made aware of home health had not accepted Resident #290. The MD reported alternate resources should have been looked for by the facility prior to her leaving the facility and the family member and resident should have been provided education. The MD reported Resident #290 had a risk for harm related to her respiratory status and inability to ascend stairs, and she was fortunate that nothing negative happened to her. An interview was conducted on 1/4/2022 at 5:22 PM with the Administrator and the Director of Nursing (DON). The Administrator reported if home health was needed by a resident, it was arranged by the SW to the best of their ability and if home health could not be arranged, the facility should have notified the family. The Administrator reported that the discharge was not ideal, but Resident #290 was unable to pay for additional services at the facility. The DON reported Resident #290 should have gone home with home health services in place. The DON stated if home health was not in place, the facility should have provided education to the resident and the family member to manage her care. The DON reported Nurse #10 thought home health was set up and she discharged Resident #290 to home based on that information. The Administrator was interviewed again on 1/5/2022 at 5:17 PM. The Administrator reported she did not believe the facility, or the SW intended to unsafely discharge Resident #290 home without home health services or equipment. The Administrator reported Resident #290 ' s family member was insistent to take Resident #290 home, and if the family member reported she was unable to provide care for Resident #290, the facility would have allowed her to stay at the facility. The Administrator and DON were notified of Immediate Jeopardy on 1/5/2022 at 5:22 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 1/6/2022. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Deficient practice occurred on 12-13-21 when resident #290 was discharged home without a safe and appropriate discharge plan in place. All other discharges to home that occurred after 12-13-21 will be reviewed by 1-6-22 by the corporate discharge planning specialist to determine any potentially unsafe discharge plans. Immediate action will be taken if any deficient practice is identified, the Administrator and/or appropriate IDT member will contact the family and offer any assistance with services they may require. The Administrator and Corporate discharge planning specialist educated discharge planner on discharge planning role in skilled/ transitional care on 1-6-22. Future discharge planning will be discussed with administrator prior to discharge of resident. 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. Discharge planner will be educated on Discharge planning role in skilled/transitional care by the administrator and Corporate discharge planning specialist on 01/06/2021 to ensure a safe and appropriate discharge plan. The discharge planner specifically will be educated to complete the following tasks, as per policy: 1. Within 24 hours of admission or first business day if on weekend discharge planner will confirm patient/responsible party plans and support 2. Discharge Planner will identify post discharge needs with the interdisciplinary team daily in morning patient review meetings 3. Keep interdisciplinary team informed of discharge planning initiatives 4. Assist with, apply for, and/or secure needed services post discharge to include DME, Personal Care, and home health services. 5. Finalize and confirm services prior to discharge 6. Communicate all discharge plans with the patient, RP, and/or interested parties If at any time the discharge planner has any question of safety during the discharge process, discharge planner will discuss with the IDT team immediately to form a resolution in order to ensure a safe and appropriate discharge to home. If warranted, a home assessment will be completed. The Interdisciplinary team will be educated by VP of Operations and Corporate Discharge Planning Specialist on the policy on discharge planning, including the 6 areas above in skilled and transitional care. Education will also include to bring potential barriers to discharge to the attention of the discharge planner and other members of the team, in order to address these barriers prior to discharge. Examples are included but not limited to functional abilities, clinical needs, psychosocial needs, or an inability to access any recommended services upon discharge from the center. This education will be completed on 01/06/2021. The interdisciplinary team consist of Administrator, Director of Nursing, MD/Medical Provider, nurse manager, Director of Rehab, Discharge planner/social worker, and Dietary Manager. All discharges will be reviewed by the Interdisciplinary Care team and agreed upon by all relevant disciplines prior to the actual discharge. The administrator will be responsible for compliance. Date of immediate jeopardy removal 01/07/22. As part of the on-site validation process on 1/10/2022, the credible allegation was reviewed which included dates and content of the in-services that were conducted with the SW and the interdisciplinary team, including the Administrator, the DON, rehab therapy manager, the NP, and other department heads. Multiple staff were interviewed and verified they had received education on the facility discharge process. The facility ' s IJ removal date of 1/7/2022 was validated.

Based on record review and staff interview, the facility failed to ensure a staff member was educated on the symptoms of COVID-19 ([MEDICAL CONDITION] Disease of 2019) and when the staff member had symptoms of COVID-19 symptoms did not work with residents who were not diagnosed with [REDACTED]. This resulted in 5 of 17 Residents (Residents #3, #4, #5, #6, and #7) testing positive for [MEDICAL CONDITION] after receiving care from a staff member who tested positive for COVID-19. These failures occurred during the COVID-19 pandemic. As of 12/7/2020, 13 of 76 residents tested positive for COVID-19. Immediate Jeopardy began on 11/28/2020, when Nurse Aide #1 reported to work with a cough and body aches. Nurse Aide #1 failed to report symptoms of COVID-19 to the nurse supervisor. Nurse Aide #1 self-screened and indicated she did not have respiratory symptoms including cough on the Employee Screening Log. Nurse Aide #1 was assigned to a unit of residents who were not diagnosed with [REDACTED].#1 tested positive for [MEDICAL CONDITION] and within the week, five of the residents she worked with tested positive for [MEDICAL CONDITION]. The immediate jeopardy was removed on 12/10/2020 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure systems put into place were effective. Findings included: A review of the Infection Prevention and Control Policies and Procedures: COVID-19 policy dated 7/23/2020 revealed the policy stated, Any staff who develop signs and symptoms of COVID-19 while on the job should inform the Center's infection preventionist. The policy further stated if an employee has signs or symptoms of respiratory infection, such as fever, cough, sore throat, shortness of breath, headache, new loss of taste or smell, nausea, vomiting, diarrhea or myalgias then the staff should report to the Center's infection preventionist. Review of the in-service education provided 3/21/2020 for Symptoms of COVID-19 revealed symptoms listed were fever, cough, shortness of breath. Nurse Aide #1 had not signed the sign-in sheets for the education. An interview with the Infection Control Nurse on 12/7/2020 at 10:46 am revealed staff enter the facility from a staff entrance and screen themselves before their shift. She stated they are required to check their temperature and sign that they do not have symptoms on the Employee Log. She stated the staff had been educated on the symptoms of COVID-19. A follow up interview with the Infection Control Nurse on 12/7/2020 at 3:36 pm revealed Nurse Aide #1 was hired after the education was given to the staff regarding symptoms of COVID-19. She stated Nurse Aide #1 did not receive the education regarding the symptoms of COVID-19 in her orientation to the facility. She stated the information regarding the symptoms of COVID-19 was not added to the orientation packet until later in 6/2020. The Employee Log dated 11/28/2020 was reviewed and Nurse Aide #1 had signed the form which stated, I currently do not have respiratory symptoms (shortness of breath, new or change in cough, and sore throat) and recorded her temperature. A review of Employee Log dated 11/29/2020 revealed Nurse Aide #1 had signed the form which stated, I currently do not have respiratory symptoms (shortness of breath, new or change in cough, and sore throat) and recorded her temperature. On 12/7/2020 at 12:07 pm Nurse Aide #1 stated on 11/28/2020 she started having a cough and body aches, but she did not have a fever, so she did not report the symptoms to anyone. She stated she had not been told that a cough and body aches should be reported. She stated she worked on 11/28/2020 and 11/29/2020 and was given a rapid test by the facility on 11/30/2020 and was positive for COVID-19. A review of Nurse Aide #1's Resident Assignment for 11/28/2020 and 11/29/2020 revealed 5 of the 17 residents she cared for tested positive for COVID-19 after she cared for them. The following residents tested positive after Nurse Aide #1 cared for them: Resident #7 admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Nurse Aide #1's Resident Assignment Forms stated she cared for Resident #7 on 11/28/2020 and 11/29/2020. Review of the facility's Infection Control Surveillance Tracking Report revealed Resident #7 tested positive for COVID-19 on 12/3/2020. An interview with the Nurse Practitioner on 12/9/2020 at 4:15 pm revealed Resident #7 was very immunocompromised and was the first resident to test positive for COVID-19. She stated he was also at risk because of his [DIAGNOSES REDACTED]. The Nurse Practitioner stated she did not know how Resident #7 had contracted COVID-19. Resident #6 admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Nurse Aide #1's Resident Assignment Forms dated 11/28/2020 and 11/29/2020 revealed she cared for Resident #6 on both days. A Nurse's Progress Note dated 12/6/2020 at 7:15 am stated Resident #6 was tested and was positive for COVID-19. On 12/9/2020 at 4:15 pm an interview with the Nurse Practitioner was conducted and she stated Resident #6 had pneumonia due to COVID-19, but she was stable. She stated she did not know how Resident #6 had contracted COVID-19. Resident #3 admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Nurse Aide #1's Resident Assignment Forms dated 11/28/2020 and 11/29/2020 disclosed she cared for Resident #3 on both days. A Nurse's Progress Note dated 12/7/2020 at 10:44 am by the Director of Nursing revealed Resident #3 had a low-grade temperature, chills, and general weakness and was tested for COVID-19 and the test results were positive. During an interview with the Nurse Practitioner on 12/9/2020 at 4:15 pm she stated Resident #3 tested positive on 12/7/2020. She also stated Resident #3 had pneumonia and was being treated with antibiotics and steroids due to the COVID-19 virus. The Nurse Practitioner stated she could not be certain how Resident #3 contracted COVID-19. Resident #4 admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Nurse Aide #1's Resident Assignment Forms dated 11/28/2020 and 11/29/2020 revealed she had cared for Resident #4 on both days. A Nurse's Progress Note dated 12/7/2020 at 10:46 am stated Resident #4 had a low-grade temperature and malaise, and a COVID-19 test was performed with positive results. The Nurse Practitioner was interviewed on 12/9/2020 at 4:15 pm. She stated Resident #4 tested positive for COVID-19 on 12/7/2020 and had symptoms of a headache and cough. She states she could not be certain how Resident #4 contracted COVID-19. Resident #5 admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A Nurse's Progress Note dated 12/7/2020 at 10:30 am by the Director of Nursing revealed Resident #5 had fever, chills and malaise. A COVID-19 test was preformed, and Resident #5 was positive for COVID-19. An interview with the Nurse Practitioner on 12/9/2020 at 4:15 pm revealed Resident #5 had not exhibited any symptoms of COVID-19 but had tested positive for [MEDICAL CONDITION] on 12/7/2020. The Nurse Practitioner stated she could not say how Resident #5 had contracted COVID-19. An interview was conducted with the Administrator on 12/7/2020 at 4:27 pm. She stated the facility had included cough, body aches, and headache on the original Employee Log Form. She stated sometime in June 2020 the form had been altered and some of the symptoms had been removed from the form. She stated she would expect the staff to report any symptoms they were having to their supervisor before beginning work. She stated she would have expected all staff to receive the education regarding the symptoms of COVID-19 and did not know why Nurse Aide #1 had not received the education during orientation. The Administrator was notified of immediate jeopardy on 12/9/2020 at 12:35 pm. The facility provided the following credible allegation of immediate jeopardy removal. Credible Allegation: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Deficient practice occurred starting on 11/28/2020 when Nurse aide #1 on 11/28/2020 and 11/29/2020 cared for Resident # 3, Resident # 4, Resident #5, Resident # 6, and Resident # 7 with cough and body aches. Nurse aide #1 stated she did not have a fever, so she did not report the symptoms to anyone. Nurse aide # 1 signed Employee Screening log which stated, I currently do not have respiratory symptoms shortness of breath, new or change in cough, and sore throat and recorded her temperature. Nurse Aide # 1 had not been educated on signs and symptoms of COVID-19 upon hire 6/16/2020. Education to staff had been done on signs or symptoms of COVID-19 prior to her hire date on 3/22/2020. Resident # 3 was tested [DATE] and was positive for COVID-19; Resident # 4 was tested [DATE] and was positive for COVID-19; Resident # 5 was tested [DATE] and was positive for COVID-19; Resident # 6 was tested on [DATE] and was positive for COVID-19; Resident # 7was tested on [DATE] and was positive for COVID-19 12 of the 17 residents Nurse Aide # 1 cared for did not have a serious adverse outcome because of the non-compliance. Nurse Aide # 1 tested positive on 11/20/2020. Further non-compliance was identified on 12/07/2020 that employee screening log was dated 3/20 that only included signs and symptoms of COVID-19 (shortness of breath, new or change in cough and sore throat), not the updated 4/29/2020 current form that included signs and symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, chills, vomiting, diarrhea, muscle pain, headache, new loss of taste or smell). 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 Nurse aide #1 has been terminated effective 12/10/2020 for failure to notify facility of signs and symptoms of cough and body aches upon reporting to work on 11/28/2020 Employee Screening log was replaced by Administrator 12/7/2020 with current version dated 4/29/2020 with signs and symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, chills, vomiting, diarrhea, muscle pain, headache, new loss of taste or smell) on 12/7/2020. Administrator destroyed all copies of old Employee screening log 12/7/2020. Staff Development Nurse Posted CDC.Gov poster on each nursing hall, each nurses station, back door outside at employee screening entrance, at employee screening log stand, front door, closed doors at entrance at each unit, which identifies signs or symptoms of COVID-19; stating please notify Supervisor before coming in if have signs or symptoms of COVID-19 (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea); and Do not work with these symptoms. Completion date 12/9/2020. All Current employees have been trained by Staff Development Nurse or Department Head on 1) signs and symptoms of COVID-19 which includes fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea 2) Do not report to work with these symptoms, report to Supervisor immediately if have any symptoms, do not wait during shift to report signs or symptoms. Completion 12/9/2020. Any employee that has not received education by 12/9/2020 will not be allowed to work until they have received education. Effective 12/9/2020 Staff Development Nurse was informed by Administrator that all new hires will be educated By Staff Development Nurse on 1)signs and symptoms of COVID-19 which includes fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea 2) Do not report to work with these symptoms, report to Supervisor immediately if have any symptoms, do not wait during shift to report signs or symptoms, during orientation. Employee Screening log will be validated 2x weekly by Administrator or Director of nursing to validate current or any revised log is in place with all current signs and symptoms. Regional Nurse Consultant notified Administrator and Director of Nursing of this responsibility on 12/9/2020. Administrator initiated 12/10/2020 for all employees to be notified via mail on 12/10/2020, and notice will be place at time clock 12/10/2020 of the following: MFA no fault attendance policy based on a point system will be waived for an event of sickness and/or mandatory quarantine as a way to reinforce the importance of maintaining a healthy workforce and a germ free environment. Administrator initiated 12/10/2020 for all employees to be reminded/notified via mail on 12/10/2020, and notice will be place at time clock 12/10/2020 of the following: MFA has waived the requirement to first access your Paid time off before accessing Short Term Disability benefits with a specific focus on COVID-19 with at least one of the following criteria needing to be met: 1) The employee is working and is either symptomatic and or sent home for quarantine because of exposure or potential exposure to a COVID-19 positive person 2) The employee is experiencing symptoms of COVID-19 and seeking a medical diagnosis 3) If an employee meets one of the stated criteria but does not have Short Term Disability or Paid time off available to cover these absences, MFA will make available up to 80 hours of Short Term Disability time to the employee to be used solely to cover absences due to COVID-19. 4) All requests for Short Term Disability must be approved by the Administrator with input from the Vice President of Operations. Date of alleged Immediate Jeopardy removal 12/10/2020. Credible Allegation of IJ Removal: Validation of the Credible Allegation was conducted on 12/11/2020 to ensure deficient practice did not continue at jeopardy level. The Administrator stated the facility had terminated Nurse Aide #1 on 12/10/2020 because she had not reported the symptoms of cough and body aches before she reported to work on 11/28/2020. The Administrator also stated she had replaced the Employee Screening Log on 12/7/2020 with a form that reflected all the symptoms of COVID-19. The Employee Screening Logs were reviewed from 12/7/2020 to 12/11/2020 and the logs had been replaced with Employee Screening Logs with all the symptoms of COVID-19. The Administrator also provided an audit form that showed the Employee Screening Logs had been reviewed on 12/11/2020. The in-service education records for the facility were reviewed and all staff had received the education titled, Signs and symptoms of COVID-19 and Reporting/Testing Prior to Shift. The in-service education included the symptoms of COVID-19, staff should not report to work if they have any symptoms, staff should notify their supervisor immediately, and staff will be tested by the facility and instructions will be given to them if they are positive. The staff, including all shifts, were interviewed and were able to verbalize the symptoms of COVID-19 and they should report to their supervisor if they developed those symptoms. The Staff Development Nurse stated the in-service education for the symptoms of COVID-19 and what do if they develop symptoms was added to the new hire orientation education. The facility had also placed Centers for Disease Control (CDC) posters that listed the symptoms of COVID-19 at the employee time clock; on the main hallway; on the entrance to both units; on the dirty and clean utility room doors; and on the staff breakroom door. The immediate jeopardy was removed on 12/10/2020.

Based on record review, resident, family, staff, emergency medical services staff, and physician interviews, the facility failed to provide supervision to prevent a fall from bed for 1 of 3 sampled residents (Resident #1) reviewed for accidents. Resident #1 was sent to the hospital for evaluation and treatment of [REDACTED]. Resident #1 passed away eight days after she experienced the fall from bed. Immediate Jeopardy began on 1/20/19 when Resident # 1 fell from bed and was injured while not being supervised by Nursing Assistant (NA) #25. Immediate Jeopardy was removed on 2/6/19 when the facility provided and implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at the lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident # 1 was evaluated to be a high fall risk because she tried to stand, transfer, and walk alone unsafely. The assessment further revealed she was wheelchair bound and required assistance with toileting. Record review of Resident # 1's quarterly minimum data set (MDS) assessment dated for 12/26/18 revealed she was cognitively intact and was not coded for exhibiting any behaviors. She required one staff extensive assistance with bed mobility, dressing, bathing, and personal hygiene, and two staff extensive assistance with transfers. The resident was incontinent of bowel and bladder. Review of Resident # 1's care plan last reviewed on 1/11/19 revealed resident was at risk for falls and required extensive staff assistance with activities of daily living (ADL) Interventions included: make sure resident's call light is within reach and encourage her to use it when she needs assistance with toileting and ADL needs; constant supervision by staff with bathroom use; anticipate and meet resident's needs; fall mats at bedside; bed in low position; and do not leave resident in bathroom unattended. The resident had goals to not have any falls and to maintain current ADL functions. Review of Resident # 1's Kardex last updated on 1/11/19 revealed the resident required one staff assistance with bed mobility and had a low bed, fall mats at bedside, and assist bars to her bed. The Kardex was communication tool used by nursing assistants (NAs) how to care for the residents. Review of a progress note dated 1/20/19 at 1:50 am that was written by Nurse # 10 revealed at 1:35 am Nurse #10 went to Resident #1's room after NA # 25 had yelled for help. Nurse #10 observed Resident # 1 lying on the floor on her left side of her bed with a small pool of blood on the floor near the resident. Resident #1 was observed to have a raised hematoma to the left side of her forehead, and her left shoulder appeared discolored and disfigured. Nurse # 10 left a voicemail for resident's physician and called 911 for emergency medical services (EMS.) EMS arrived at the facility at 1:45 am and transported the resident to the emergency department (ED.) Review of an incident report completed by a revealed on 1/20/19 at 1:35 am a NA yelled for help and the nurse went to Resident #1's room. The resident was observed lying on her left side on the floor beside of her bed with a small pool of blood on the floor. Resident #1 was observed to have a raised hematoma to the left side of her head, and her left shoulder appeared discolored and disfigured. The Resident stated that she fell out of the bed, but she did not know why. The nurse attempted to notify physician and left a voicemail. The resident was sent to the ED for evaluation. The NA told nurse that while she was getting a brief the resident tried to get up out of bed unassisted and she had been unable to stop the resident from rolling herself off the side of the bed. The incident report further revealed that the resident had struck herself on the nightstand and the base of an intravenous (IV) pole when she rolled off the bed. An interview was conducted on 1/31/19 at 1:00PM with NA # 25 who revealed she worked at the facility on a as needed basis. NA # 25 said she had been assigned to care for Residents # 1 and # 2 on the night of 1/20/19 and on prior dates. On the night of 1/20/19 NA # 25 said she had provided incontinence care to Resident # 2 at around 1:00 am, and after she had finished Resident 2's care she had moved over to the other side of the room to provide care for Resident # 1. According to NA # 25, Resident # 1's bed had been in the low position before she started provided care, so she had raised the bed to waist height to provide resident's care. She said the resident's bed was three or four feet off the ground. NA # 25 stated Resident #1 became fidgety, so she moved the resident to the center of the bed. NA # 25 explained what she meant by fidgety was she observed the resident throw her legs over the side of the bed and try to get herself out of bed unassisted. She said that when she had cared for the resident prior to 1/20/19 the resident had not tried to move when she provided care for her. NA # 25 said she then turned to get the Resident # 1's brief that she had placed on a chair prior to providing care for Resident #1. She explained the chair was positioned against the wall that was across from the foot of the resident's bed. When NA # 25 turned back around after a few seconds she said Resident # 1 was again trying to get up out of bed unassisted and before she could stop her the resident had rolled herself off the left side of the bed striking her head on the nightstand and the bottom of the IV pole before she landed on the floor. She said she saw blood on the floor and yelled out for help. Nurse #10 came into the resident's room and not too long after that NA #26 came into the resident's room. Nurse #10 had supported Resident # 1's head and neck, and then the three of them rolled resident onto her back. She said next all three of them had moved the resident off the floor onto the resident's bed. The resident was in pain Nurse #10 applied a cool compress to a knot on resident's forehead and went to call EMS, and the EMS came and had taken the resident to the ED. She revealed Resident # 1 did not have any fall mats on the floor on either side of her bed on 1/20/19 and could not recall If she observed if the resident had any fall mats prior to the night of the fall. She said she had looked at the resident's Kardex before she had entered the room and said the resident needed one staff extensive assistance with ADLs, her bed in a low position, and fall mats at bedside. NA # 25 said she had received training prior to 1/20/19 concerning what to do if residents had behaviors or were being resistive with care. She said she should have asked another staff member for assistance with the resident's care when she observed the resident trying to throw her legs over the bed and was trying to get up out of bed unassisted instead of just moving her to the center of the bed. NA # 25 further revealed she should not have turned away from the resident to get the brief and should have also brought all of the needed supplies to provide care for the resident before she started. NA #25 denied she had rolled resident off the bed or had been rough with her care. An Interview was conducted with Resident # 2 on 1/30/19 at 1:30 pm who was Resident #1's roommate. Resident # 2's last completed MDS assessment of 12/20/19 revealed she was assessed as being cognitively intact. Resident # 2 said she and Resident # 1 had been roommates for several months. On the night of 1/20/19 at 1:00 am Resident # 2 stated NA # 25 had provided incontinence care to her. Resident # 2 said after NA # 25 had finished providing her care, NA # 25 had removed a brief out Resident # 1's closet and placed it on the end of Resident # 1's bed. She said NA # 25 had partially closed the privacy curtain between her bed and Resident #1's bed. Resident # 2 said she could not see what was happening on Resident # 1's side of the room, but she heard NA # 25 tell Resident # 1 to roll over two times. The next thing Resident # 2 heard was Resident # 1 hit the floor, and then NA # 25 yelled out for help. According to Resident # 2, Nurse # 10 and NA # 26 had come into the room to help Resident # 1. Resident # 2 said she heard the NA # 25 tell other staff that Resident #1 had tried to get up out of bed, she had moved Resident # 1 over to the middle of the bed, and when she had turned away to get a brief Resident # 1 had tried to get up from the bed unassisted and resident had rolled herself off the side of the bed before she could grab her. Resident # 2 also revealed NA # 25 had already placed a brief on the Resident 1's bed before she started providing care for Resident # 1. She said NA # 25 had taken care of both her and Resident # 1 before the night of 1/20/19. She denied that the NA # 25 had been rough with her care, and she denied that she heard NA # 25 being rough with Resident # 1. Resident # 2 also stated that there were no fall mats on the floor beside of Resident # 1's bed on 1/20/19. An interview was conducted with Nurse # 10 on 1/30/19 at 1:10 PM revealed she was the nurse assigned to Resident # 1 for 3rd third shift (11pm to 7am) on 1/20/19. At 1:35am NA #25 had yelled out that she needed Nurse #10's help. She went down to Resident # 1's room and observed the resident lying on the floor on her left side with a small pool of blood beside of her. NA #25 was the only staff present in the resident's room. She observed a raised hematoma on resident's left forehead and discoloring and disfigurement to resident's left shoulder. Nurse # 10 stated another NA had entered the room and that she had stabilized the resident's head and neck and that she along with the two NAs had rolled resident onto her back. She said the three of them then moved the resident from off the floor onto her bed. She attempted to call resident's physician but had to leave a voicemail. Resident # 1 was in so much pain according to Nurse #10 she had decided to call 911 and have resident transferred to the ED. She said that NA # 25 had told her that the resident had tried to get up unassisted when she was providing care, so she had moved the resident to the center of the bed. NA had said she had turned around to get a brief off the chair for the resident and the resident had tried to get up out of bed unassisted and she had been unable to keep her from rolling off the side of the bed. An interview was conducted at 1:27 pm on 1/31/19 with NA # 26 who revealed she heard NA # 25 yell out that she needed help at around 1:30 am. NA # 26 said she went into Resident # 1's room and saw the resident laying on the floor on her left side. According to NA # 26, the resident's head was bleeding, she was crying, and appeared to be in a lot of pain. She said that Nurse # 10 and NA # 26 were already in the room before she went in. NA # 26 revealed that the three of them rolled the resident onto her back and then moved her from the floor to the bed. Nurse # 10 had called EMS and resident was taken to the ED according to NA # 26. NA # 26 revealed NA # 25 had told her the resident had tried to get up out of bed unassisted and had rolled off the bed when she had turned around to get a brief off of a chair. She said she did not recall resident having fall mats on 1/20/19, or prior to that date. Review of an ED Hospital Summary dated 1/20/19 revealed Resident #1 had reported that she fell off of her bed while being changed by a NA that had been rough with her and shoved her. The ED physician had called the nursing facility. The ED physician stated, the facility reported that while the resident was being changed she had tried to get up and fell off the bed. The resident fell from a height of 3 to 5 feet. She landed on a hard floor with the point of impact being the head and shoulder. The pain is at a severity of 10/10. The pain is severe. The summary also revealed, Spinal x-ray results: 8th [MEDICATION NAME] vertebra compression fracture, kyphosis, and left arm fracture. Chest x-ray results: no rib fractures, osteopenia, and patchy opacities in both lungs. Computed tomography (CT) scan of head: no fracture or brain bleeds. Lab results: Complete Blood Count (CBC) revealed a white blood count of (WBC) 17.7. The summary went on to reveal Resident #1 had the following clinical impressions listed: fall, contusion of left the lung, closed [MEDICAL CONDITION] vertebra, closed displaced [MEDICAL CONDITION] surgical neck of the humerus, and an abrasion to left forehead. The resident was discharged to the hospice house on 1/20/19 per family and resident request. An interview was conducted on 2/11/19 with the EMS staff that had attended to Resident #1 on 1/20/19. According to the EMS staff person, when he entered the resident's room she was laying on her back in bed. Resident # 1 had a golf ball sized hematoma to her left forehead and her left shoulder was discolored and disfigured. He said he did not hear the resident say what had caused her injuries. The staff had reported to him the resident fell off the bed after she tried to get up unassisted from the bed. The resident had severe pain during her transfer to the ED and he said he had administered the resident a narcotic pain medication through her IV that he had inserted upon his arrival to the facility. He further revealed the resident should not have been moved by the staff. An interview was conducted on 2/5/19 with the ED physician that had examined Resident # 1 on 1/20/19. The physician revealed Resident # 1 had been seen due to a fall that occurred earlier that day. She said the resident had a golf ball size hematoma to the left side of her head, a compression fracture to a vertebra in the resident's spine, a fractured left shoulder, and discolorations. The physician further revealed Resident # 1 had told her that a NA had been rough with her when she was providing care and the NA had rolled her off the bed onto the floor. She said the resident described the NA. The physician then called the facility and a staff member had told her the resident fell off of a bed that was three to five feet off of the floor when the NA who had been providing care turned to get a brief, the resident tried to get up unassisted, and before the NA could prevent her from falling the resident had rolled off the side of the bed onto the floor. The physician said the resident had severe pain. The physician said it had decided by the resident and the resident's responsible party that due to the resident not being a surgical candidate the resident would be discharged to the local hospice house. An Interview was conducted with Resident # 1's facility physician on 1/31/19 at 1:40 pm. He stated that resident had been receiving hospice services related to [MEDICAL CONDITION] diagnosis. He had been made aware of resident's fall on 1/20/19. He said that the resident weighed 95 pounds and had osteopenia. The interview further revealed due to the resident's poor overall poor medical condition, hospice status, and diagnoses, she had been highly susceptible for continued decline, falls, behaviors, and cognitive loss. The physician said the fall could have caused the resident's death. An interview conducted with the MDS coordinator on 1/31/19 at 4:20 pm revealed Resident # 1 required one staff extensive hands on at all times assistance with ADLs and was communicated to the staff on the resident's Kardex and care plan. An interview was conducted with the Director of Nursing on 1/31/19 at 4:45 pm during which she revealed she had been made aware of Resident # 1's fall shortly after it had occurred on 1/20/19. She said Nurse # 10 had advised her that the resident had been trying to get up out of bed unassisted, and NA #25 had moved the resident to the center of the bed, NA # 25 had turned away to get a brief for the resident and when she turned away the resident had tried to get up unassisted and the resident had rolled herself onto the floor before the NA could stop her. She said she had not suspected abuse or neglect by NA #25 and had not reported the incident to the personnel registry. The interview further revealed the resident had a history or falls, had been receiving hospice services, needed one staff extensive care with ADL, received bolus tube feedings and pleasure foods, had her bed placed in the low position when she was not receiving care, and had floor mats at bedside when the resident was in bed. An interview was conducted with the Administrator on 1/31/19 at 4:55 pm. She stated she had been made aware of Resident # 1's fall on 1/20/19 and as a result of the fall on the facility had initiated a PIPs (Project Improvement Program) which had involved staff training on ADLs and safety-such as lowering the bed if they are moving away and taking all needed supplies with them before starting resident care. An interview was conducted on 2/1/19 at 9:10 am with Resident # 1's responsible party who revealed that the facility had called her on 1/20/19 around 1:40 am to report that the resident had rolled herself out of the bed and the facility was transferring the resident to the ED. She said at the ED the resident had described a NA at the facility that she said had been rough with her and had rolled her off of the bed. She said the resident was not a surgical candidate for the injuries she had received as a result of the fall, and it was decided to send the resident to the hospice house for comfort care. She said the resident had passed away on 1/28/19. Review of Resident # 1's death certificate dated 1/28/19 revealed resident's cause of death was complications from a fall. On 2/5/19 at 09:40 am the Administrator was informed of immediate jeopardy. The facility provided an acceptable Credible Allegation (CA) of Immediate Jeopardy removal on 2/5/19 at 5:45 pm. The facility provided credible allegation for immediate jeopardy removal as follows: This allegation of Immediate Jeopardy removal is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following allegation of Immediate Jeopardy removal. The following credible allegations constitutes the center's allegation of Immediate Jeopardy removal. All alleged deficiencies have been or will be completed by the dates indicated. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; Deficient practice - Resident #1 is an alert and oriented resident that required supervision to one person assist for ADL care. While providing care to Resident #1., certified nurse aide (CNA) turned around to grab a brief from a nearby chair. Bed was in a higher position to prevent CNA injury from bending. Resident moved which then caused her to fall to the floor. Mats were listed on the Kardex but are not used during care since they pose a trip hazard to the staff. She sustained the following injuries: left forehead hematoma and left arm fracture. The injuries were obtained when she fell on the nightstand and IV pole base that was at bedside. The nurse and 3 CNAs then stabilized her cervical area and lifted her back to the bed. Facility Actions o Vital signs obtained and visual assessment of resident body done by Nurse immediately following incident. Left forehead hematoma with no active bleeding, and discoloration to the left shoulder and upper arm area were noted. o Resident was taken by EMS to the hospital for further evaluation and treatment and never returned to facility. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; o The Director of Nursing (DON) and Staff Development Coordinator (SDC) completed one-on-one education to NA #25regarding care during ADLs, safety, and being prepared by having supplies readily available. NA # 25 instructed to ask for assistance if residents exhibit change of status from prior level of functioning. o The Director of Nursing (DON) completed one-on-one training with the nurse regarding stabilizing a patient and not moving them when there is a suspected head or neck injury. o Remaining nursing staff, which includes nurses and nursing assistants, began training on (MONTH) 21, 2019 by SDC. Staff education consisted of the following components: ADL care and safety, which includes - reminding them to place care items within reach, which would not require the loss of eye contact with the patient, ensuring the proper height of the bed for ADL care, and stabilizing the cervical area and not moving residents with suspected head or neck injuries. o Any employee that did not receive the education will be removed from the schedule until education is completed. o All new nursing employees will be educated on ADL care and safety such as: being prepared for ADL care, proper bed height, and not moving a resident with suspected head/neck injury during new hire orientation. o Residents with recent falls were reviewed by the DON to determine if there were any other residents that experienced accidents as a result of this same practice. No other issues were found. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or incompliance with the regulatory requirements; o Residents that have a fall will be reviewed by Nursing Administration the next day and any deficiencies noted will be corrected by Unit Manager or designee and new interventions put in place as required. Staff involved will be provided education or corrective action as necessary. o Falls will be reviewed weekly at the Risk Management meeting and any further recommendations from this meeting will be added to the individual residents care plan and Kardex. DON will audit falls from previous week to ensure interventions and Kardex are completed. o The SDC will observe 5 staff a week during care to ensure that staff have all supplies and are following Care plan for four weeks, and then 5 staff every two weeks for two months. o The findings will be reviewed at the quarterly QAPI meetings for one year (4 quarters). The Director of Nursing is responsible for implementing the acceptable plan of correction. The facility's credible allegation of IJ removal was verified on 2/6/19 at 10:08 am. A review of the medical records for a survey sample of residents that had noted falls revealed the residents had been accurately assessed for falls; had care plans that addressed the residents' risk for falls, updated interventions and goals; and the residents' Kardexs had updated fall interventions that were utilized by staff. A review of the in-service training for the nurses and all non-nursing employees were reviewed. The topics covered in the in-services were the areas identified in the facility's plan of correction. Interviews were conducted with various staff that included nurses and non-nursing employees. Interviews revealed the staff were knowledgeable of the information provided in the in-services regarding not leaving a bed in high position when a resident is unattended, bring all needed supplied to resident's area before care is started, not moving a resident that has a possible head injury or fracture, the placement of fall mats when a resident who has fall mats as an intervention is in bed, and seeking an additional staff member's assistance when a resident has behaviors.

Based on staff interview, resident interview, Nurse Practitioner interview, Physician interview, and record review, the facility failed to notify the physician and the responsible party of Resident #372 being lowered to the floor. The resident sustained [REDACTED].#36 of significant weight loss. This was evident in 2 of 4 residents reviewed for physician notification. Findings included: 1. Resident #372 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent Quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact and required extensive assistance with moving about in bed and toileting, and limited assistance for transferring from the bed and wheelchair. The assessment also revealed she had no falls since the previous assessment. An incident report dated 11/25/18 at 3:59 pm revealed Nurse #1 was called to Resident #372's bathroom by Nurse Aide #1. Nurse Aide #1 stated Resident #372 got weak during a transfer to the toilet and was slid down to the floor. Nurse #1 documented Resident #372 was on the floor in front of the toilet with her legs in front of her. An interview on 12/20/18 at 11:32 am with Nurse #1 revealed at approximately 9:00 am on 11/25/18 Nurse Aide #1 told her Resident #372 had been lowered to the floor in the bathroom. Nurse #1 stated the resident had no obvious deformities and she denied any pain. Nurse #1 stated she checked Resident #372's range of motion in her extremities, asked if she was having any pain, and got her vital signs. Nurse #1 stated Resident #372 sat up in her wheelchair after the incident and had not complained of pain when she checked on her two times before the end of the shift. Nurse #1 stated she forgot to document everything before she went home that day, but when Nurse #3 called her she came back to the facility and documented the incident. Nurse #1 stated she did not notify the physician or the family member of the incident. Nurses Progress Note dated 11/25/18 at 7:41 pm written by Nurse #3 revealed Resident #372's right knee was swollen and painful and the right knee was 7 centimeters larger than the left knee on assessment. Nurse #3 also documented Resident #372 complained of lower back pain. Nurse #3 notified the physician on call of her assessment and obtained orders for pain medication and x-rays. Her note further revealed the mobile imaging company arrived and an x-ray of the right knee revealed clear evidence of a fracture. Nurse #3 notified the provider on call and orders were obtained to send Resident #372 to the hospital. Resident #372 was transferred to the hospital at approximately 6:00 pm. An interview on 12/19/18 at 4:45 pm with Nurse #3 revealed she had reported to work on 2nd shift (2:00 pm to 10:00 pm) on 11/25/18 and stated shortly after she arrived for her shift Resident #372's family member came to the Nurse's Desk and asked her why she had not been notified that Resident #372 had fallen that morning. The family member told Nurse #3 that Resident #372 had told her she had fallen in the bathroom that morning. Nurse #3 stated the 1st shift (6:00 am to 2:00 pm) nurse, Nurse #1, had not notified her during report that Resident #372 had fallen. Nurse #3 stated she called Nurse #1 and asked her if Resident #372 had fallen that morning and Nurse #1 told her Resident #372 was lowered to the floor around 9:00 am and she had not called the family member or the physician. Nurse #3 stated she assessed Resident #372 and found her right knee was 7 centimeters larger than her left knee and the resident was complaining of right knee and lower back pain. Nurse #3 stated she called the physician on call and asked for an x-ray which showed a spiral [MEDICAL CONDITION] femur. A telephone interview with Nurse Aide #3 on 12/20/18 at 11:28 am revealed she and Nurse Aide #4 had worked 2nd shift (2:00 pm to 10:00 pm) on 11/25/18 and when she came in at 2:00 pm Resident #372 was in her wheelchair and Nurse Aide #4 transferred her to the bed. Nurse Aide #3 stated Resident #372 was in a lot of pain and was saying oh, oh, oh after Nurse Aide #4 transferred her to the bed. A telephone interview with Nurse Aide #4 on 12/20/18 at 11:30 am revealed he was asked by Resident #372's family member to transfer her to the bed when he first arrived for his shift on 11/25/18 at 2:00 pm. Nurse Aide #4 stated he noticed Resident #372 was rocking back and forth in her chair, but she did not say she was in pain or acted like she was in pain when he transferred her to the bed. Nurse Aide #4 stated he stood and pivoted Resident #372 to the bed. He stated after Resident #372 was in the bed she complained of pain in her right knee. Nurse Aide #4 stated he told the family member he would let the nurse know and reported the pain to Nurse #3. Nurse Aide #4 stated he got report from Nurse Aide #1 after the transfer and was told Resident #372 was lowered to the floor that morning. An interview with the Nurse Practitioner on 12/20/18 at 9:55 am revealed Resident #372 had a spiral fracture of her right femur which would not be treatable in a resident of Resident #372's age, [AGE] years old. She stated due to Resident #372's age and the need for narcotic pain medications to control her pain she was admitted to a hospice house. On 12/20/18 at 3:55 pm an interview with the Physician revealed he was notified by the Nurse Practitioner that Resident #372 had fallen on 11/25/18 in the morning and the staff had not reported the fall until later that day. He stated his expectation was the staff would report falls to the Responsible Party and the Physician or Nurse Practitioner as soon as they occur. 2. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS assessment dated [DATE] revealed Resident #36 was cognitively intact and required supervision and physical assist of one person for eating. The MDS further revealed Resident #36 required a mechanically altered diet, was 70 inches tall and weighed 148 pounds (lbs). A review of the care plan dated 5/22/2018 focused on nutritional risk related to impaired cognition, requiring assistance with by mouth intake. Goals for Resident #36 were to avoid significant weight change through next review of 11/20/2018. Approaches to meet the goal was to provide diet as ordered, monitor intake and record each meal, offer substitute when intake less than 50% and weights as ordered. A review of physicians orders dated 8/29/2018 revealed Resident #36 received a diabetic diet with level 6 soft and bite sized texture and regular liquids. There was also and ordered dated 9/5/2018 to give Med Plus 1.7 Nutritional Supplement 2 ounces three times a day for nutrition. A review of a progress note dated 9/4/2018 revealed Resident #36 had a 12.50% one-month comparison weight loss. A review of a progress note dated 10/15/2018 revealed Resident #36 had a 19.2% weight loss in comparison to baseline weight on 5/23/2018. A review of a progress note dated 11/4/2018 revealed Resident #36 had a 15.2% six-month comparison weight loss. A review of a malnutrition screening dated 5/28/2018 for Resident #36 revealed a score of zero, indicated no risk of malnutrition. A review of a weight warning note dated 11/4/2018 revealed a weight warning of 125.5 lbs. with 15.2 % loss. The note written by the Registered Dietitian (RD), further revealed Resident #36 was receiving a diabetic bite sized diet with supplemental shakes, staff would continue to encourage by mouth intake and supplements for weight stability/trend upward and that the physician (MD) was notified. A review of the last medical provider visit dated 10/17/2018 did not address weight loss or nutritional status. An interview on 12/18/2018 at 5:48 PM with NA #3 revealed Resident #36 only ate 25% of his meal. She revealed Resident #36 would request his supplement when he did not eat much and he usually ate 50% or more of all his meals. An interview on 12/20/2018 at 12:52 PM with Resident #36 revealed he was aware of his weight loss, had not experienced any difficulty eating or been seen by the MD for his weight loss. An interview on 12/19/2018 at 5:24 PM with the RD revealed she was aware of Resident #36's weight loss and added a house shake to his diet in August. She further revealed in (MONTH) Resident #36 continued to lose weight and another supplement was added. She noticed his weight began to trend back up in October. An interview on 12/20/2018 at 12:28 PM with the Unit Nurse Manager revealed Resident #36 was weighed monthly and she followed up with Resident #36's responsible party regarding his weight loss. The Unit Nurse manager further revealed she had not placed Resident #36 on the MD's book for evaluation of his weight loss. An interview on 12/20/2018 at 12L49 PM with NA #2 revealed Resident #36 needed cueing when eating and usually ate 75% of his meals. An interview on 12/20/2018 at 3:12 PM with the RD revealed that she printed off her notes monthly and left her notes for the MD but was unsure what was done about Resident #36 weight loss. The RD further revealed she had never received any recommendations or follow up communication from the MD regarding Resident #36's weight loss. An interview on 12/20/2018 at 4:59 PM with the Director of Nursing (DON) revealed Resident #36 weight loss was discussed at a meeting in September. The DON further revealed the MD and a nurse practitioner (NP) were present. An interview on 12/20/2018 at 3:44 PM with the MD revealed he was not aware and had not been notified of Resident #36's severe weight loss. The MD further revealed that if he had been notified he would have evaluated and assessed Resident #36. An interview on 12/20/2018 at 5:30 PM with the DON revealed she expected residents who experienced weight loss would be reviewed weekly with medical providers and the recommendations from the medical providers implemented.

Based on staff interview, Nurse Practitioner interview, and record review, the facility failed to provide ongoing assessment for injury for 1 of 2 residents who was lowered to the floor and did not receive care for a fractured right femur until a family member notified the next shift facility's staff of the incident. (Resident #372). Findings included: Resident #372 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent Quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact and required extensive assistance with moving about in bed and toileting, limited assistance for transferring from the bed and wheelchair. The assessment also revealed she had no falls since the previous assessment. An incident report dated 11/25/18 at 3:59 pm revealed Nurse #1 was called to Resident #372's bathroom by Nurse Aide #1. Nurse Aide #1 stated Resident #372 got weak during a transfer to the toilet and was slid down to the floor. Nurse #1 documented Resident #372 was on the floor in front of the toilet with her legs in front of her. She also documented Resident #372 stated, I don't know what happened, I just need someone to help me up. An interview on 12/20/18 at 11:32 am with Nurse #1 revealed at approximately 9:00 am on 11/25/18 Nurse Aide #1 had come to the Nurse's Station and told her Resident #372 had been lowered to the floor in the bathroom. She stated she went to Resident #372's bathroom and she was on the floor with her legs straight out in front of her. Nurse #1 stated the resident had no obvious deformities and she denied any pain. Nurse #1 stated she checked Resident #372's range of motion in her extremities, asked if she was having any pain, and got her vital signs. Nurse #1 stated Resident #372 sat up in her wheelchair after the incident and had not complained of pain when she checked on her two times before the end of the shift. Nurse #1 stated she forgot to document everything before she went home that day but when Nurse #3 called her she came back to the facility between 3:30 pm and 4:00 pm (on 11/25/18) and documented the incident. Nurse #1 stated when she returned to the facility she called the Supervisor on Call and told her what happened. Nurse #1 stated she did not notify the physician or the Family Member of the incident. On 12/20/18 at 12:09 pm an interview with Nurse Aide #1 revealed she was transferring Resident #372 to the toilet by herself when the resident's legs gave out and she yelled for help. She stated Nurse Aide #2 came to the bathroom and helped her lower Resident #372 to the floor. Nurse Aide #1 stated Nurse #1 assessed Resident #372 for injuries and took her vital signs before she and Nurse Aide #2 transferred the resident back to her wheelchair. Nurse Aide #1 stated Resident #372 stated she was not having any pain and had not acted like she was in pain throughout the rest of her shift. An interview with Nurse Aide #2 on 12/20/18 at 10:50 am revealed she was in the adjacent room that shared a bathroom with Resident #372's room when she heard Nurse Aide #1 calling out for help. She stated she entered the bathroom and assisted Nurse Aide #1 with lowering Resident #372 to the floor. She stated Resident #372 did not cry out in pain and stated she was not in pain. Nurse Aide #2 stated Nurse #1 was called to the room and she assessed Resident #372 before they moved her back to her wheel chair. Nurse Aide #2 stated Resident #372 did not call out in pain or act like she was in pain during the transfer back to her wheelchair. Nurses Progress Note dated 11/25/18 at 7:41 pm, written by Nurse #3, revealed Resident #372's right knee was swollen and painful and the right knee was 7 cm larger than the left knee on assessment. Nurse #3 also documented Resident #372 complained of lower back pain. Her note further revealed the mobile imaging company arrived and an x-ray of the right knee revealed clear evidence of a fracture. Nurse #3 notified the provider on call and orders were obtained to send Resident #372 to the hospital. Resident #372 was transferred to the hospital at approximately 6:00 pm (on 11/25/18). An interview on 12/19/18 at 4:45 pm with Nurse #3 revealed she had reported to work on 2nd shift (2:00 pm to 10:00 pm) on 11/25/18 and stated shortly after she arrived for her shift Resident #372's family member came to the Nurse's Desk and asked her why she had not been notified that Resident #372 had fallen that morning. The family member told Nurse #3 that Resident #372 had told her she had fallen in the bathroom that morning. Nurse #3 stated the 1st shift (6:00 am to 2:00 pm) nurse, Nurse #1, had not notified her during report of the fall or notified the family member of the fall. Nurse #3 stated she called Nurse #1 and asked her if Resident #372 had fallen that morning and Nurse #1 told her Resident #372 was lowered to the floor around 9:00 am and she had not called the family member or the physician. Nurse #3 stated she assessed Resident #372 and found her right knee was 7 centimeters larger than her left knee and the resident was complaining of right knee and lower back pain. Nurse #3 stated she called the physician on call and asked for an x-ray which showed a spiral [MEDICAL CONDITION] femur. An X-ray of the right knee dated 11/25/18 revealed Resident #372 had an acute spiral [MEDICAL CONDITION] femur with medial displacement. A telephone interview with Nurse Aide #3 on 12/20/18 at 11:28 am revealed she and Nurse Aide #4 had worked 2nd shift (2:00 pm to 10:00 pm) on 11/25/18 and when she came in at 2:00 pm Resident #372 was in her wheelchair. Nurse Aide #3 stated after Resident #372 was put to bed by Nurse Aide #4 she was in a lot of pain and was saying oh, oh, oh. A telephone interview with Nurse Aide #4 on 12/20/18 at 11:30 am revealed he was asked by Resident #372's family member to transfer her to the bed when he first arrived for his shift on 11/25/18 at 2:00 pm. Nurse Aide #4 stated he noticed Resident #372 was rocking back and forth in her chair, but she did not say she was in pain or act like she was in pain when he transferred her to the bed. Nurse Aide #4 stated he stood and pivoted Resident #372 to the bed. He stated after Resident #372 was in the bed she complained of pain in her right knee. Nurse Aide #4 stated he told the family member he would let the nurse know and reported the pain to Nurse #3. Nurse Aide #4 stated he got report from Nurse Aide #1 after the transfer and was told Resident #372 was lowered to the floor that morning. Review of the hospital record of 11/25/18 revealed Resident # 372 had a history of [REDACTED]. X-ray of the right thigh/femur showed acute oblique, mildly comminuted periprosthetic [MEDICAL CONDITION] right femur with total knee arthroplasty, about 2 cm posterior displacement, about 1.5 cm medial displacement and up to 2 cm override of the dominant distal fracture fragment. In view of the resident's advanced age and multiple comorbid conditions, it was decided to manage her non-surgically. The resident was admitted to the hospital for further management. An interview with the Nurse Practitioner on 12/20/18 at 9:55 am revealed Resident #372 had a spiral fracture of her right femur which would not be treatable in a resident of her age, [AGE] years old. She stated due to Resident's age and the need for narcotic pain meds to control her pain she was admitted to a hospice house and passed away.

Based on record review, staff interviews, Nurse Practitioner interview, and Physician interview, the facility failed to prevent dehydration by addressing Resident #371's poor food and fluid intake resulting in increased sodium level, decline in condition and hospitalization . This was evident in 1 of 3 sampled residents reviewed for hydration status. Findings included: Resident #371 was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of Resident #371's Medical Orders for Scope of Treatment (MOST) form dated 12/19/17 revealed she requested limited additional interventions not comfort measures. The MOST form also noted Resident #371 had requested intravenous fluids if indicated for medical intervention. There was not an order for [REDACTED]. A review of Resident #371's laboratory results revealed she had a Sodium level of 146 on 4/5/18. The normal range for Sodium level is 135 to 145 milliequivalents per liter (mEq/L). A review of Resident #371's Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired. It also revealed she required extensive assistance of one staff member for eating. Review of the Communication Log for Nurse Practitioner #1 revealed there were no issues or concerns recorded from 10/7/18 to 10/29/18 for Resident #371. A Nurse's Progress Note dated 10/16/18 at 10:01 am revealed a Family Member expressed concerns related to Resident 371's condition. The note revealed Nurse Practitioner #1 was in the facility and ordered bloodwork to be drawn on 10/18/18. A Nurse's Progress Note dated 10/18/18 at 5:52 pm revealed Resident #371's Sodium level was 173, she was very slow to respond, and her extremities were mottling. The Family Member requested Resident #371 be sent to the hospital. A review of Resident #371's laboratory results revealed a Sodium level of 170 on 10/18/18. The normal range for Sodium level is 135 to 145 milliequivalents per liter (mEq/L). An interview with Nurse #1 on 12/19/18 at 10:35 am revealed she had talked to Resident #371's Family Member on 10/14/18 and they had requested bloodwork be drawn. Nurse #1 stated she had filled out the Communication Form and placed it in Nurse Practitioner #1's book. She stated 10/14/18 was a Sunday and the next day the laboratory would visit would be Thursday 10/18/18. She also stated Nurse Practitioner #1 should have visited the facility on Monday, 10/15/18. An interview with Nurse #2, the Unit Manager, on 12/19/18 at 11:10 am revealed she received orders on 10/16/18 for bloodwork for Resident #371. She stated the orders were not stat so they put the orders on the next lab day which was 10/18/18. Nurse #1 stated she looked at Resident #371 on 10/18/18 and she (the resident) was very confused and restless, and she was eating less. Nurse #2 stated she noticed a big decline in Resident #371 on 10/17/18 and 10/18/18, but she did not notify the Nurse Practitioner of the decline. An interview with Nurse Aide #6 on 12/19/18 at 4:12 pm revealed Resident #371 did not eat or drink anything for two days before she went out to the hospital. Nurse Aide #6 stated normally Resident #371 would drink all the fluids on her tray which would be three cups of liquid. She stated two days before she discharged to the hospital Resident #371's Family Member took her to the nurse's station from the dining room because she was sitting at the dining table and food and drink were sitting in her mouth and she wasn't swallowing it. Nurse Aide #6 stated she told the Nurse Resident #371 was not drinking but did not remember which nurse she told. Nurse Aide #7 was interviewed on 12/19/18 at 4:35 pm and stated she worked with Resident #371 on 10/16/18 and 10/17/18 and she did not drink or eat anything either day. She stated Resident #371 slept the whole shift she worked (2nd shift) on both days. Nurse Aide #7 stated Resident #371 became more confused on 10/16/18 and continued to decline. A Progress note dated 10/18/18 by Nurse Practitioner #1 stated, Member appears dehydrated nursing reports no intake in last 48 hours. On 12/19/18 at 11:55 am Nurse Practitioner #1 stated in a phone interview she did not see Resident #371 until 10/18/18. She stated she gave orders for bloodwork on 10/16/18 she was in the facility but did not assess Resident #371 because she was not told by staff she was not eating or drinking until 10/18/18 when the abnormal sodium level was reported to her. Nurse Practitioner #1 stated Resident #371 was severely dehydrated. She stated if she had known on 10/16/18 she was not eating or drinking she would have ordered intravenous fluids at that time. Nurse Practitioner #1 stated she spoke with the Family Member on 10/18/18 after she received the bloodwork results and the decision was made to make the resident comfort care but when the Family Member arrived at the facility she decided to send her to the hospital. An interview with the Physician on 12/20/18 at 3:50 pm revealed he was not aware Resident #371 was not eating or drinking prior to being sent to the hospital on [DATE]. He stated Nurse Practitioner #1 was following Resident #371 and the staff did not inform her Resident #371 was not eating and drinking until 10/18/18, he stated Nurse Practitioner #1 would have ordered intravenous fluids if she had known Resident #371 was not drinking. The History and Physical from the hospital dated 10/18/18 revealed Resident #371 had acute [MEDICAL CONDITION] related to [MEDICAL CONDITION], urinary tract infection, and stroke. The History and Physical also stated Resident #371 seemed very dehydrated.

Based on record review, staff and family member interviews, and observation the facility failed to develop abuse policies and procedures for protection of residents and failed to implement their abuse policies and procedures in prevention for 1 of 1 residents investigated for abuse, Resident #4. The facility failed to prevent family member abuse on 7/30/18 which resulted in Resident #4 having three bruised areas to his back and a red area to his face. Immediate jeopardy began on 7/30/18 when staff observed abuse of Resident #4 and did not intervene to protect the resident. The immediate jeopardy was removed on 8/16/18 when the facility provided an acceptable credible allegation of removal. The facility continues to remain out of compliance at a D (no harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to amend the abuse policy to include protection of residents from abuse, and to ensure monitoring systems put into place are effective. Findings included: A review of the facility's Abuse/Neglect/Misappropriation/Crime Policy with an effective date of 11/22/16 revealed the facility's procedure was Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse, corporal punishments, involuntary seclusion including abuse facilitated or enabled through the use of technology, and free from chemical and physical restraints except in an emergency and/or as authorized in writing by a physician and All employees are responsible for reporting to the Administrator any and all suspected or witnessed incidents of patient abuse, neglect, theft, exploitation and/or mistreatment of [REDACTED]. The policy did not include intervening or protection of the resident when abuse is observed. The Discharge Summary from the hospital dated 6/27/18 revealed the hospital had concerns for abuse and it was reported to Adult Protective Services. The Discharge Summary also noted the nursing staff had documented several witnessed episodes of Family Member #1 verbally and physically abusing Resident #4 including slapping his leg, poking at him, and throwing restraints at him. The Discharge Summary further revealed the hospital had initiated their abuse protocol and required Family Member #1 to be accompanied by security when she visited Resident #4. A telephone interview with Family Member #2 on 8/15/18 at 12:12 pm revealed she arrived at the facility on 6/27/18 before Resident #4 arrived at the facility to be admitted . Family Member #2 stated she arrived early to let the facility know the hospital had involved Adult Protective Services due to Family Member #2's abuse of Resident #4 during his hospital stay. Family Member #2 stated she had told the Admission Director that Family Member #1 needed to be watched closely when she visited Resident #4. An interview with the Admission Director on 8/15/18 at 2:10 pm revealed Family Member #2 came to the facility on [DATE] before Resident #4 was admitted to the facility and told her there were allegations of abuse against Family Member #1 at the hospital and an Adult Protective Services case was opened. The Admission Director stated the Case Manager from the hospital told her Family Member #1 had swatted Resident #4 while he was in the hospital. The Admission Director stated Resident #4 was put into a semiprivate room at admission, but no other interventions were put into place to protect Resident #4. She also stated the facility had not attempted to call Adult Protective Services to get details about the incident or provided supervised visits for Family Member #1. The Director of Nursing was interviewed on 8/15/18 at 1:35 pm. She stated she was told there was an open Adult Protective Services case open for Resident #4 when he was admitted . She also stated Family Member #2 told her she suspected Resident #4 had been abused by Family Member #1 during his hospital stay. The Director of Nursing stated Resident #4 was in a semiprivate room and that was the only intervention the facility put into place to protect Resident #4. The Director of Nursing stated the Family Member #1 had visited daily unsupervised until 7/30/18 when the incident occurred. The Director of Nursing stated they had discussed in morning meeting the morning after Resident #4 was admitted but she did not implement interventions regarding the risk of abuse. The facility's Discharge Planner stated during an interview on 8/15/18 at 1:45 pm that the Interdisciplinary Team discussed Family Member #1's abuse of Resident #4 while in the hospital during morning meeting the morning after Resident #4 was admitted but he did not implement interventions regarding the risk of abuse. An interview on 8/15/18 at 2:25 pm with the Social Worker revealed she learned about Family Member #1's history of abuse from the Activity Director. The Social Worker stated Family Member #1 came into the facility on [DATE] after Resident #4 was admitted . She stated Family Member #1 told her she had flicked him on the wrist with his restraints while in the hospital. The Social Worker stated she did not document the conversation with Family Member #1 or implement interventions to prevent abuse. A history and physical examination [REDACTED]. The History and Physical Exam also revealed there was concern for spouse abuse and Adult Protective Services was involved. Resident #4 was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. His comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired, he was able to understand others and was understood by others. He required extensive assistance of one staff member for moving about in the bed and extensive assistance of two staff members for transferring in and out of bed and was dependent on staff for eating. An Incident Report dated 7/30/18 at 11:18 am revealed Nurse #1 saw Resident #4's Family Member (Family Member #1) hit him on his right shoulder and then propelled him down the hall with her hand over his mouth. The report also revealed the Corporate Dietician also observed the Family Member (Family Member #1) with her hand over the resident's mouth and told him to shut up and then the Dietician witnessed Family Member #1 slap Resident #4 in the mouth and tell him to shut up again. The Incident Report stated Resident #4 told the Nurse Supervisor who completed the report that Family Member #1 hit him three times on the back, covered his mouth multiple times and slapped him in the mouth so that he could not speak and would not let him go to bed. The Payroll Representative was interviewed on 8/15/18 at 1:00 pm and stated she was at her desk on 7/30/18 and heard a man yelling save me. She stated she got up and went to see what was happening. The Payroll Representative revealed Resident #4 was at the end of the entrance hall, in his wheelchair with Family Member #1 behind him. She stated Family Member #1 reached around Resident #4 and hit him in his right upper arm. The Payroll Representative stated she went back to the office and told her supervisor, the Business Office Manager, what had happened. She stated she did not attempt to intervene when Family Member #1 hit Resident #4. The Payroll Representative stated she knew she should report abuse to her supervisor, but she was not aware she should intervene. The Business Office Manager was interviewed on 8/15/18 at 2:55 pm. She stated the Payroll Representative reported to her Family Member #1 had hit Resident #4 in the Entrance Hallway of the facility. She stated she went out into the hallway and followed Family Member #1 and Resident #4 into the Family Room. She stated she asked Family Member #1 if she hit Resident #4 and Family Member #1 stated she had and she could hit him whenever she wanted since she was his Power of Attorney. The Business Office Manager stated the Administrator arrived at that time and told Family Member #1 she should leave, and he was calling the Police. The Corporate Dietician was interviewed on 8/15/18 at 1:30 pm and stated she was sitting at her desk on 7/30/18 and heard a man screaming for someone to save him. She said she looked out her office door and saw Family Member #1 pushing Resident #4 towards the front of the building with her hand over his mouth and she slapped him in the neck/head area. The Corporate Dietician stated Family Member #1 turned the wheelchair around and headed back toward Resident #4's room and then hit him again in the same area. The Corporate Dietician stated she went to report the incident to the Administrator but did not attempt to intervene. She stated she was not aware she should intervene, but she stated she knew she should report the abuse to the Administrator. An interview with Nurse #1 on 8/15/18 at 2:00 pm revealed she saw Resident #4's family member (Family Member #1) hit him in his room from the room across the hall. She stated Family Member #1 hit him in his right upper arm/shoulder area and then immediately started down the hall toward the nurses' desk and then the front of the building. She stated she had her hand over his mouth as she was moving down the hall because he was yelling. She stated she did not intervene or call for help but did notify the RN Supervisor. On 8/15/18 at 2:40 pm the Nurse Supervisor was interviewed. She stated she did not witness the incident on 7/30/18 when Resident #4 was abused by Family Member #1. She stated she was told by the MDS Coordinator that the Administrator wanted her to obtain a skin assessment, incident report, and get statements from staff about the incident. The RN Supervisor stated she was getting statements from the staff when Nurse #1 told her she saw Family Member #1 hit Resident #4. The RN Supervisor stated when Nurse #1 reported she had seen Family Member #1 hit Resident #4 in his room it was after other staff had seen Resident #4 being hit at the entrance hall to the building. The RN Supervisor stated when she did the skin assessment for Resident #4 on 7/30/18 he had three red marks on his back and a red area on his face. The Incident/Investigation Report dated 7/30/18 from the police department revealed on 7/30/18 at 1:10 pm the Administrator reported a domestic assault regarding Resident #4. The report stated the Police Officer spoke with Resident #4 and he told the officer Family Member #1 had hit him on the back three times and covered his mouth. The Police Officer's report stated he took witness statements and a warrant was obtained for Family Member #1 for simple assault and assault on a handicapped person. Family Member #1 was later arrested and appeared before the Magistrate and released under a $2500.00 unsecured bond and is scheduled to appear in court on 8/31/18. An observation on 8/16/18 at 10:16 am with the Maintenance Director revealed the distance from room [ROOM NUMBER]A, where the resident resided, to the entrance hallway and then back to the family room was 221.5 feet. The Administrator was notified of Immediate Jeopardy of F607 on 8/15/18 at 5:30 pm. Lexington Health Care Credible Allegation of Compliance dated 8/15/18: This allegation of compliance is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following allegation of compliance. The following credible allegation constitutes the center's allegation of compliance. All alleged deficiencies have been or will be completed by the dates indicated. The plan of correcting the specific deficiency. The plan should address the process that lead to the deficiency cited: Deficient practice-the facility did not utilize the information contained in the hospital discharge summary or information from family member #2 to implement interventions to protect resident form spousal abuse during his stay. The reason why the facility did not implement any supervised visitation is because the interdisciplinary team did not recognize the concern with potential continued abuse. Family Member #2 was recently appointed Heathcare Power of Attorney (HPOA) due to hospital initiated Adult Protective Services (APS) involvement. The new family member #2/HPOA did not request supervised visitation to family member #1. Family member #2 was aware that Family member #1 would be visiting daily. Therefore, the facility did not implement any additional interventions to further protect the resident during his stay. While visiting on (MONTH) 30, (YEAR), family member #1 slapped resident on the back in his room. This incident was witnessed by nurse #1 who was across the hall in another resident's room. At the time, nurse #1 was administering a bolus tube feeding to a resident. Unfortunately, while knowing to rescue and report immediately, the reason why nurse #1 did not intervene immediately is because she did not think quickly enough to yell out for help, and made the decision to finish the bolus tube feeding. As soon as nurse #1 could safely finish she exited the room to immediately address the situation. By this time, a second incident between family member #1 and resident had occurred and staff were already intervening appropriately. Facility Action Visual assessment of resident body done by Nurse immediately following abuse, for any signs of bruising, redness, bleeding, agitation/anxiety-3 red areas noted on the mid back area and a slight red color to right cheek area. Family member #1 was arrested by local police on (MONTH) 30, (YEAR). There was a court order issued stating she was not to visit her husband at the facility. Therefore, she was not allowed visitation on facility property during resident's remainder of stay in the facility. Reception and nursing staff were made aware of court order restrictions prohibiting visitation to resident and facility. Resident is no longer in facility. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: The Director of Nursing (DON and the Regional Nurse Consultant completed one-on-one education to Admission Director regarding the review of all new admission paperwork to include previous abuse allegation history or APS involvement. Admission Director was also educated to provide these details to the nursing staff prior to admission so that an acceptable plan of care can be created for individuals with abuse potential or history. Education was completed on (MONTH) 16, (YEAR). MDS Coordinator reviewed discharge summaries of current residents on (MONTH) 16, (YEAR) for history of abuse or APS concerns. No other residents were identified as at risk for abuse or required protection due to history of abusive situations. The Director of Nursing (DON) and Regional Nurse Consultant completed education on (MONTH) 15, (YEAR) for department heads to include: Abuse/Neglect/Misappropriation/Crime-Initial Reporting Guidelines. On (MONTH) 15,2 018, education was completed with the following department heads: 1) Administrator 2) Director of Nursing 3) Business Office Manager 4) Human Resources 5) Dietary Manager 6) Receptionist 7) Discharge Planner/Social Worker 8) Environmental Services Manager 9) Rehab Director 10) Activity Director 11) Medical Records 12) Maintenance Director Remaining nursing staff, dietary staff, environmental staff and therapy staff began training on (MONTH) 15, (YEAR). Included in this training are the following components: what to do if abuse is suspected, who to notify for abuse allegations, timely reporting of abuse concerns, and protecting the resident from abuse by immediate intervention. In-services also included for staff to call out for help from other staff members if they are physically unable to stop any witnessed abuse. 145 out of 153 employees have completed the training. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or incompliance with the regulatory requirements: Once a referral is received for a new admission to the facility, the Admission Director was instructed on 8/16/18 to review the discharge summary for potential abuse allegations or concerns. Administrator will audit 50% of all new admission discharge summaries for abuse concerns and to ensure appropriate interventions have been implemented, if necessary, weekly x 1 month, every other week x 2 months, and monthly x 3 months. The DON was instructed on 8/16/18 that effective immediately, if abuse concerns are identified at admission, the Admission Director will notify the DON. The DON, or designee, will implement a care plan and protective interventions, such as supervised visitation, for any new admission identified with ongoing abuse investigation concerns. Date of compliance is (MONTH) 16, (YEAR). The Administrator is responsible for implementing the acceptable plan of correction. Validation Information: Validation of the facility's allegation of Immediate Jeopardy removal was completed on 8/17/18. Interviews with Nurse #1, RN Supervisor, Corporate Dietician, Director of Nursing, Discharge Planner, Admission Director, Payroll Representative, Business Office Manager, and multiple Nurses, Nurse Assistants, Housekeepers, Therapist, Maintenance Staff, and Dietary staff revealed the facility had educated the staff on what to do if abuse is suspected, who to notify for abuse allegations, timely reporting of abuse concerns, and protecting the resident from abuse by immediate intervention. The discharge summaries of all current residents were reviewed on 8/16/18 for any risk of abuse. To ensure no further incidents happened in the future the Admission Director will review all potential admissions for abuse allegations or concerns. The Administrator will audit 50% of all new admission discharge summaries for abuse concerns and ensure interventions have been implemented. The Admission Director will notify the Director of Nursing of any abuse concerns identified at admission and the Director of Nursing will implement the care plan and the interventions to protect the resident. The facility had no new admissions since the allegation of Immediate Jeopardy removal had been implemented.

Based on record review, staff and family member interviews, and observation the facility failed to provide an environment free of abuse for 1 of 1 residents investigated for abuse, Resident #4. The facility failed to utilize information in the hospital's discharge summary and information from a family member to develop and implement interventions to protect Resident #4 from being abused by a family member on 7/30/18. Resident #4 had three red marks on his back and a red area on his face as a result of this abuse. Immediate jeopardy began on 7/30/18 when Nurse #1 observed abuse of Resident #4 and did not intervene to protect the resident and was removed on 8/16/18 when the facility provided and implement an acceptable credible allegation of Immediate Jeopardy Removal. The facility continues to remain out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective Findings included: Review of Resident #4's Hospital Discharge Summary dated 6/27/18 revealed the hospital had concerns of Resident #4 being abused and it was reported to Adult Protective Services. The Discharge Summary also noted the nursing staff had documented several witnessed episodes of Family Member #1 verbally and physically abusing Resident #4 including slapping his leg, poking at him, and throwing restraints at him. The Discharge Summary further revealed the hospital had initiated their abuse protocol and required Family Member #1 to be accompanied by security when she visited Resident #4. A telephone interview with Family Member #2 on 8/15/18 at 12:12 pm revealed she arrived at the facility on 6/27/18 before Resident #4 arrived at the facility to be admitted . Family Member #2 stated she arrived early to let the facility know the hospital had involved Adult Protective Services due to Family Member #1's abuse of Resident #4 during his hospital stay. Family Member #2 stated she had told the Admission Director that Family Member #1 needed to be watched closely when she visited Resident #4. An interview with the Admission Director on 8/15/18 at 2:10 pm revealed Family Member #2 came to the facility on [DATE] before Resident #4 was admitted to the facility and told her there were allegations of abuse against Family Member #1 at the hospital and an Adult Protective Services case was opened. The Admission Director stated the Case Manager from the hospital told her Family Member #1 had swatted Resident #4 while he was in the hospital. The Admission Director stated Resident #4 was put into a semiprivate room at admission, but no other interventions were put into place to protect Resident #4. She also stated the facility had not attempted to call Adult Protective Services to get details about the incident. The facility's Discharge Planner stated during an interview on 8/15/18 at 1:45 pm that the Interdisciplinary Team discussed Family Member #1's abuse of Resident #4 while in the hospital during morning meeting the morning after Resident #4 was admitted but he did not implement a care plan or interventions regarding the risk of abuse. The facility's Discharge Planner stated Family Member #2 spoke with the Director of Nursing and the Admission Director regarding her concerns and he thought they should implement the interventions. Review of the Medical Record for Resident #4 revealed he was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of a history and physical examination [REDACTED]. The History and Physical Exam also revealed there was concern for spouse abuse and Adult Protective Services was involved. Review of Resident #4's Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired, he was able to understand others and was understood by others. He required extensive assistance of one staff member for moving about in the bed and extensive assistance of two staff members for transferring in and out of bed and was dependent on staff for eating. The Director of Nursing was interviewed on 8/15/18 at 1:35 pm. She stated she was told there was an open Adult Protective Services case open for Resident #4 when he was admitted on [DATE]. She also stated Family Member #2 told her she suspected Resident #4 had been abused by Family Member #1 during his hospital stay. The Director of Nursing stated Resident #4 was in a semiprivate room and that was the only intervention the facility put into place to protect Resident #4 from being abused. The Director of Nursing stated Family Member #1 visited Resident #4 daily unsupervised until 7/30/18 when the incident occurred. An Incident Report dated 7/30/18 at 11:18 am revealed Nurse #1 saw Resident #4's Family Member (Family Member #1) hit him on his right shoulder and then propelled him down the hall with her hand over his mouth. The report also revealed the Corporate Dietician also observed the Family Member (Family Member #1) with her hand over the resident's mouth and told him to shut up and then the Dietician witnessed Family Member #1 slap Resident #4 in the mouth and tell him to shut up again. The Incident Report stated Resident #4 told the Nurse Supervisor who completed the report that Family Member #1 hit him three times on the back, covered his mouth multiple times and slapped him in the mouth so that he could not speak and would not let him go to bed. The Payroll Representative was interviewed on 8/15/18 at 1:00 pm and stated she was at her desk on 7/30/18 and heard a man yelling save me. She stated she got up and went to see what was happening. The Payroll Representative revealed Resident #4 was at the end of the entrance hall, in his wheelchair with Family Member #1 behind him. She stated Family Member #1 reached around Resident #4 and hit him in his right upper arm. The Payroll Representative stated she went back to the office and told her supervisor, the Business Office Manager, what had happened. She stated she did not attempt to intervene when Family Member #1 hit Resident #4. The Corporate Dietician was interviewed on 8/15/18 at 1:30 pm and stated she was sitting at her desk on 7/30/18 and heard a man screaming for someone to save him. She said she looked out her office door and saw Family Member #1 pushing Resident #4 towards the front of the building with her hand over his mouth and she slapped him in the neck/head area. The Corporate Dietician stated Family Member #1 turned the wheelchair around and headed back toward Resident #4's room and then hit him again in the same area. The Corporate Dietician stated she went to report the incident to the Administrator but did not attempt to intervene. An interview with Nurse #1 on 8/15/18 at 2:00 pm revealed on 7/30/18 she saw Resident #4's family member (Family Member #1) hit him in his room from the room across the hall. She stated Family Member #1 hit him in his right upper arm/shoulder area and then immediately started down the hall toward the nurses' desk and then the front of the building. She stated she had her hand over his mouth as she was moving down the hall because he was yelling. She stated she did not intervene or call for help but did notify the RN Supervisor. On 8/15/18 at 2:40 pm the Nursing Supervisor was interviewed. She stated she did not witness the incident on 7/30/18 when Resident #4 was abused by Family Member #1. She stated she was told by the MDS Coordinator that the Administrator wanted her to obtain a skin assessment, incident report, and get statements from staff about the incident. The RN Supervisor stated she was getting statements from the staff when Nurse #1 told her she saw Family Member #1 hit Resident #4. The Nursing Supervisor stated when Nurse #1 reported she had seen Family Member #1 hit Resident #4 in his room it was after other staff had seen Resident #4 being hit at the entrance hall to the building. The Nursing Supervisor stated when she did the skin assessment for Resident #4 on 7/30/18 he had three red marks on his back and a red area on his face. The Business Office Manager was interviewed on 8/15/18 at 2:55 pm. She stated the Payroll Representative reported to her Family Member #1 had hit Resident #4 in the Entrance Hallway of the facility on 7/30/18. She stated she went out into the hallway and followed Family Member #1 and Resident #4 into the Family Room. She stated she asked Family Member #1 if she hit Resident #4 and Family Member #1 stated she had and she could hit him whenever she wanted since she was his Power of Attorney. The Business Office Manager stated the Administrator arrived at that time and told Family Member #1 she should leave, and he was calling the Police. The Incident/Investigation Report dated 7/30/18 from the police department revealed on 7/30/18 at 1:10 pm the Administrator reported a domestic assault regarding Resident #4. The report stated the Police Officer spoke with Resident #4 and he told the officer Family Member #1 had hit him on the back three times and covered his mouth. The Police Officer's report stated he took witness statements and a warrant was obtained for Family Member #1 for simple assault and assault on a handicapped person. A phone interview on 8/16/18 at 6:00 pm with the Police Officer revealed Resident #4 stated Family Member #1 had hit him multiple times in the head and had held her hand over his mouth so that he could not yell for help. An observation on 8/16/18 at 10:16 am with the Maintenance Director revealed the distance from room [ROOM NUMBER]A, where the resident resided, to the entrance hallway and then back to the family room was 221.5 feet. The Administrator was notified of Immediate Jeopardy on 8/15/18 at 5:30 pm On 8/17/18 the facility provided an acceptable credible allegation of immediate jeopardy removal dated 8/16/18 that included: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; Deficient practice - the facility did not utilize the information contained in the hospital discharge summary or information from family member #2 to implement interventions to protect resident from spousal abuse during his stay. The reason why the facility did not implement any supervised visitation is because the interdisciplinary team did not recognize the concern with potential continued abuse. Family member #2 was recently appointed Healthcare Power of Attorney (HPOA) due to hospital-initiated Adult Protective Services (APS) involvement. The new family member #2/HPOA did not request supervised visitation to family member #1. Family member #2 was aware that Family member #1 would be visiting daily. Therefore, the facility did not implement any additional interventions to further protect the resident during his stay. While visiting on (MONTH) 30, (YEAR), Family Member #1 slapped resident on the back in his room. This incident was witnessed by nurse #1 who was across the hall in another resident's room. At the time, nurse #1 was administering a bolus tube feeding to a resident. Unfortunately, while knowing to rescue and report immediately, the reason why nurse #1 did not intervene immediately is because she did not think quickly enough to yell out for help and made the decision to finish the bolus tube feeding. As soon as nurse #1 could safely finish she exited the room to immediately address the situation. By this time, a second incident between Family Member #1 and resident had occurred and staff were already intervening appropriately. Facility Action oVisual assessment of resident body done by Nurse immediately following abuse, for any signs of bruising, redness, bleeding, agitation/anxiety - 3 red areas noted on the mid-back area and a slight red color to right cheek area. oFamily member #1 was arrested by the local police on (MONTH) 30, (YEAR). There was a court order issued stating that she was not to visit her husband at the facility. Therefore, she was not allowed visitation on facility property during resident's remainder of stay in the facility. Reception and nursing staff were made aware of court order restrictions prohibiting visitation to resident and facility. Resident is no longer in facility. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; The Director of Nursing (DON) and Regional Nurse Consultant completed one-on-one education to Nurse #1 regarding prompt reporting of any type of resident abuse and providing a safe environment for the resident during abuse on (MONTH) 16, (YEAR). Included in this training was the following components: what to do if abuse is suspected, who to notify for abuse allegations, timely reporting of abuse concerns, and protecting the resident from abuse by immediate intervention. In-services also included calling out for help from other staff members if physically unable to stop any witnessed abuse. The Director of Nursing (DON) and Regional Nurse Consultant completed education on (MONTH) 15, (YEAR) for department heads to include: Abuse/Neglect/Misappropriation/Crime - Initial Reporting Guidelines. On (MONTH) 15, (YEAR), education was completed with the following department heads: o 1) Administrator o 2) Director of Nursing o 4) Business Office Manager o 5) Human Resources o 6) Dietary Manager o 7) Receptionist o 8) Discharge Planner/Social Services o 9) Environmental Services Manager o 10) Rehab Director o 12) Activity Director o 13) Medical Records o 14) Maintenance Director Remaining nursing staff, dietary staff, environmental staff, and therapy staff began training on (MONTH) 15, (YEAR). Included in this training are the following components: what to do if abuse is suspected, who to notify for abuse allegations, timely reporting of abuse concerns, and protecting the resident from abuse by immediate intervention. In-services also included for staff to call out for help from other staff members if they are physically unable to stop any witnessed abuse. 145 out of 153 employees have completed the training. Any employee that did not receive the education will be removed from the schedule until education is completed. MDS coordinator reviewed discharge summaries of current residents on (MONTH) 16, (YEAR) for history of abuse or APS concerns. No other residents were identified as at risk for abuse or require protection due to history of abusive situations. The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or incompliance with the regulatory requirements; Once a referral is received for a new admission to the facility, the Admission Director was instructed on 8/16/18 to review the discharge summary for potential abuse allegations or concerns. Administrator will audit 50% of all new admission discharge summaries for abuse concerns and to ensure appropriate interventions have been implemented, if necessary, weekly x 1 month, every other week x 2 months, and monthly x 3 months. The DON was instructed on 8/16/18 that effective immediately, if abuse concerns are identified at admission, the Admission Director will notify the DON. The DON, or designee, will implement a care plan and protective interventions, such as supervised visitation, for any new admission identified with ongoing abuse investigation concerns. Date of compliance is (MONTH) 16, (YEAR) The Administrator is responsible for implementing the acceptable plan of correction. Validation Information: The credible allegation for Immediate Jeopardy removal was validated on 8/17/18 at 4:00 pm, which removed the Immediate on 8/16/18. Validation of the facility's credible allegation of Immediate Jeopardy removal included; Interviews with Nurse #1, RN Supervisor, Corporate Dietician, Director of Nursing, Discharge Planner, Admission Director, Payroll Representative, Business Office Manager, and multiple Nurses, Nurse Assistants, Housekeepers, Therapist, Maintenance Staff, and Dietary staff revealed the facility had educated the staff on what to do if abuse is suspected, who to notify for abuse allegations, timely reporting of abuse concerns, and protecting the resident from abuse by immediate intervention. The discharge summaries of all current residents were reviewed on 8/16/18 for any risk of abuse. To ensure no further incidents happened in the future the Admission Director will review all potential admissions for abuse allegations or concerns. The Administrator will audit 50% of all new admission discharge summaries for abuse concerns and ensure interventions have been implemented. The Admission Director will notify the Director of Nursing of any abuse concerns identified at admission and the Director of Nursing will implement the care plan and the interventions to protect the resident. The facility had no new admissions since the credible allegation of Immediate Jeopardy removal had been implemented.