Every finding on record at Liberty Commons Nsg and Rehab Ctr of Rowan County

Based on observations and staff interviews, the facility failed to: label and date leftover food stored for use in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer and discard food showing signs of spoilage or past its use-by date in the walk-in cooler; monitor dish machine temperatures; and maintain a clean kitchen ice machine. These practices had the potential to affect food served to residents. The findings included:a. During an initial observation of the facility's kitchen with the Assistant Dietary Manager on 9/22/2025 at 10:36 AM, the walk-in cooler was noted to have the following concerns: -An opened and unlabeled 5-pound (lb.) bag of fancy shredded cheese.-An opened and unlabeled 5-pound (lb.) bag of romaine lettuce with signs of spoilage (brownish/ blackish in color lettuce leaves with thickened clear fluid).-A bag of diced strawberries with an open date of 9/10/2025 and a discard date of 9/10/2025 available for use.-Three (3) of 7 bell peppers showing signs of spoilage (black/ grayish looking spots, mushy texture with clear liquid). b. During an initial observation of the facility's kitchen with the Assistant Dietary Manager on 9/22/2025 at 10:45 AM the walk-in freezer was noted to have the following concerns:-An open, unlabeled package of chicken strips with signs of dehydrated spots, discolored patches, leathery spots.-An open, unlabeled package of hot dogs with signs of dehydrated spots, discolored patches, leathery spots.-One (1) box of open, unlabeled package of sausage patties with signs of dehydrated spots, discolored patches, leathery spots.-Two (2) boxes of open, unlabeled chocolate chip cookies with signs of dehydrated spots, discolored patches, leathery spots; and -One (1) box of open, unlabeled sugar cookies with signs of dehydrated spots, discolored patches, leathery spots. An interview with the Assistant Dietary Manager on 9/22/2025 at 10:43 AM revealed that she understood that items were not stored correctly. The Assistant Dietary Manager disposed of food items. The Assistant Dietary Manager stated that labels and dates on open food items should be checked weekly. She further stated the items in the walk-in freezer should not be open and needed to be discarded. An interview with the Administrator on 9/25/2025 at 1:22 PM revealed all food and beverage items should be dated when they are opened, food with signs of spoilage should be discarded, and food items should be used or discarded according to use-by policies. He further stated the dietary department was responsible for food storage and safety daily. c. During an observation of the facility's kitchen with the Dietary Manager on 9/25/2025 at 10:07 AM the dish machine was noted to have the following concerns:-1st wash cycle had 9 dome lids and 4 bottoms. The dish machine washing thermostat gauge froze to 120 degrees and did not move up or down. -2nd wash cycle at 10:10 AM had 6 trays and 5 dinner plates. The dish machine washing thermostat gauge froze to 120 degrees and did not move up or down. -3rd wash cycle at 10:11 AM had 9 plates and 11 small dishes. The dish machine washing thermostat gauge froze to 120 degrees and did not move up or down. An interview was conducted with Dietary Aide (DA) #1 on 9/25/2025 at 10:12 AM. DA #1 stated she was responsible for the clean side of the dish machine when the dishes come through and were being cleaned. She further stated that the temperatures for the dish machine were not working like it was supposed to. The DA revealed the dish machine washing thermostat gauge had not been working since last Tuesday, 9/16/25, and the Dietary Manager was aware. She further stated there was no other alternative method of checking the dishwashing temperatures. An interview with the Dietary Manager on 9/25/2025 at 10:25 AM revealed the dish machine was not functioning properly. The Dietary Manager stated the dish machine was a rental from an outside vendor and there had been issues with the dish machine for some time. The Dietary Manager stated since the dish machine was a rental from an outside vendor, the Maintenance department could not complete repairs. The Dietary Manager explained the outside vendor did not have an assigned representative assigned to the facility and would send a representative to the facility when available. The Dietary Manager immediately notified the outside vendor of the washing gauge on the dish machine and the gauge not capturing the temperatures of the washing cycles. The Dietary Manager advised the dietary staff not to utilize the dish machine. An interview was conducted with the Administrator on 9/25/2025 at 1:22 PM. The Administrator stated the dish machine was checked on 9/24/2025 and he was unaware of any issues remaining with the dish machine and the washing thermostat gauge not working. The Administrator stated dietary staff should monitor the wash/ rinse cycle temperatures while the dish machine was in use. The Administrator further stated if the in-house maintenance staff cannot fix the dish machine, then the vendor would be called. d. During an observation of the facility's kitchen with the Dietary Manager on 9/25/2025 at 10:20 AM in the kitchen, the white interior cover of the ice machine was covered with blackish film-like matter. An interview was conducted with the Dietary Manager and the Assistant Dietary Manager on 9/25/2025 at 10:20AM revealing the ice machine just recently received service. The Dietary Manager stated the white piece in the ice machine was stained and needed replacement. The Dietary Manager used her finger to show the staining, and the black film type matter was removed with her finger. The Dietary Manager and Assistant Dietary Manager stated they would not use the ice machine until it was serviced. An interview with the Administrator on 9/25/2025 at 1:22 PM revealed he expected the ice machine to be clean. The Administrator further revealed the ice machine was no longer going to be used until cleaned.

Based on record reviews, observations, staff and resident interviews, the facility failed to provide access to the call bell, telephone, and water cup to accommodate a visually impaired resident. This resulted in Resident #6 yelling for assistance or asking his roommate to turn on the call bell, missing phone calls, and prevented access to the water cup as he wanted. This was for 1 of 1 resident reviewed for accommodation of needs (Resident #6).The findings included:Resident #6 was readmitted on [DATE] with diagnoses including heart failure, kidney disease, gastro-esophageal reflux disease, dysphagia (trouble swallowing), Barrett's esophagus (inflammation of the esophagus), macular degeneration, legal blindness, and history of falling. The most recent quarterly Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #6 was cognitively intact. He was dependent with mobility, used a wheelchair, needed extensive assistance with toileting and transferring, and required supervision with set up with eating. Coding for vision showed highly impaired-object identification in question, but eyes appear to follow objects. The Care Plan revised on 10/5/2023 for Resident #6, showed the focus area of impaired vision related to macular degeneration and legal blindness. The goal was no decline of visual function with target date of 11/14/2025. Interventions included - to advise Resident #6 where personal items were placed, and to be consistent with the location of the items. Further interventions were to keep the call bell within reach and encourage the resident to call for assistance with transfers. The Care Plan revised on 6/02/2025 for Resident #6, showed the focus area of increased risk for falls related to a history of falls and gait/balance problems. The goal was to minimize the risk for falls and be free of injury using current interventions. Interventions included - to anticipate and meet Resident #6's needs as much as possible and keep frequently used objects within resident's reach as much as possible. An observation and interview with Resident #6 on 09/22/2025 at 12:40 PM revealed resident sitting up in his wheelchair with his lunch tray on the overbed table in front of him. The call bell was observed laying across the seat of the recliner chair behind him. When asked if he had trouble reaching his call bell, Resident #6 turned in his wheelchair and reached his arm toward the recliner behind him but couldn't locate or reach the bell. The resident then said, Here lately it seems to get away from me a lot. I holler for them if I can't find it. During an observation and interview on 09/22/2025 at 3:17 PM, Resident #6 was sitting up in his wheelchair, the call bell was lying in the recliner behind resident, out of reach. During this observation the resident's phone rang along with an electronic voice announcing he had a call. He was unable to reach the phone that was ringing which was on the charger on top of his dresser. Observation further revealed a second cordless phone on Resident #6's bedside table which he also had been unable to reach and a third cordless phone sitting on his roommate's bed. His roommate, Resident #41, assessed on 07/14/2025 with intact cognition, was asked about why Resident #6's phone was on his bed. Resident #41 stated he had the phone on his bed to answer it for Resident #6's when he couldn't get to it. An observation on 09/23/2025 at 8:22 AM, showed Resident #6 sitting in his wheelchair with the overbed table in front of him. The call bell was lying across his bed out of his reach. On 09/23/2025 at 12:54 PM an observation of Resident #6 showed him sitting up in his wheelchair for lunch. The call bell was observed to be lying across the recliner behind him, out of his reach. During an observation and interview on 09/24/2025 at 8:30 AM, Resident #6 was observed sitting in the wheelchair. His call bell was not within reach. It was observed lying in recliner behind him. When asked where the call bell was, he patted around on his table and reached over to the bed with his hands but couldn't locate it. Asked what he would do if he needed help, he stated, He would ring, while pointing to his roommate, Resident #41. When asked what he would do if his roommate wasn't there, Resident #6 replied that he would holler. During an interview on 09/24/2025 at 8:40 AM, Resident #6's roommate, who was Resident #41, stated that he had pushed the call bell and answered the phone for Resident #6 when he wasn't able to get to them, maybe several days of a week. On 09/24/2025 at 11:54 AM, Resident #6 was observed sitting up in wheelchair in front of his recliner, in the room by himself. His call bell was lying on recliner chair arm behind Resident #6. During the observation one of the residents' three cordless telephones rang. All three cordless phones were out of his reach and Resident #6 was unable to get to the telephone to answer it. An observation of the cordless phone screen showed 34 missed calls. When asked about how often he could not reach his phone, he said he often had trouble answering the phone and thought it probably had fallen on the floor. Further observation revealed Resident #6 was unable to reach his water cup which was on the bedside table in the space between the foot of the bed and bathroom door out of his reach. He had bumped into the table when propelling around the room and was unable to turn the wheelchair around to reach the call bell or water. During an interview with Nurse #2 on 09/24/2025 at 11:58 AM, she confirmed she was Resident #6's assigned nurse that day shift. Nurse #2 stated Resident #6 could propel himself in the wheelchair to move about his room. She further stated he didn't move around much because he was blind, so he preferred staff to move him, so he didn't bump into things. During an interview in Resident #6's room on 09/24/2025 at 12:29 PM, Nurse Aide (NA) #6 confirmed she was assigned to Resident #6 that day during day shift. When asked about the resident's call bell, she looked at the call bell in the recliner chair and indicated that's where she put it there when he's up in his wheelchair. When asked about him reaching the call bell, she said she had seen him move around in the wheelchair in his room. An observation and interview on 09/24/2025 at 3:51 PM revealed Resident #6 was sitting in his wheelchair in his room by himself. The call bell was on the recliner chair arm behind him. The overbed table with water cup was in the space between the foot of the bed and bathroom door. Resident #6 was observed reaching out with his hands to his left toward the bed but couldn't reach his water on the table and said he wanted to be able to get his water. Further observation revealed that two cordless phones were out of Resident #6's reach. One was on the dresser, and the other was lying on his roommate's bed. When asked if he wanted to be able to use the phone himself, Resident #6 indicated he wished he could reach the phone so he could answer it himself. An interview and observation were done on 09/25/2025 at 3:57 PM with NA #4 who was currently assigned to Resident #6 and cared for him often. Resident #6 was not in the room at the time of the observation. The call bell was observed to be tucked into the pocket of the recliner chair. When asked how Resident #6 used the call bell, she stated that when he was in the recliner or bed as he usually was on her evening shift, she put call bell in the pocket on the side of his recliner. She stated he sometimes had his roommate turn his call light on for him when he can't use his call bell. She further explained that when the overbed table was in front of him in the wheelchair, he had bumped into the table trying to propel himself and didn't wheel around if the table was in front of him. The interview further revealed when she brought him his tray, she would make sure to put his hand to the food bowl, hand him his spoon, open his cartons, and make sure he got going with feeding himself before leaving his room. An interview was done on 09/25/2025 at 4:04 PM with Nurse #3, who was currently assigned to Resident #6. She indicated Resident #6 had been able to push the overbed table, but because of his blindness he was not able to move around the table without bumping into the bed, preventing him from propelling around room to reach items. She further said he answered the phone, and he had made calls out. When asked about how she knew how to care for visually impaired residents, she said that during facility orientation she was instructed to look at the care plan to know how to provide specific care for residents with visual impairments. An interview was conducted with the Director of Nursing (DON) with the Nurse Consultant present on 09/25/2025 at 4:21 PM. The DON explained that any resident specific needs related to blindness or low vision would be in the resident's care plan. The DON further explained when she went into Resident #6's room she made sure his water and call bell were in reach and expected all staff to make sure the resident could reach his call bell, phone, and water.

Based on observation and staff interviews, the facility failed to provide a clean homelike environment when they failed to maintain a sink drain that leaked in 1 of 4 shared bathrooms used only by Resident #50.The findings included:An observation on 9/22/25 at 1:55 PM of the bathroom in Resident #50's room revealed an approximate twelve-inch diameter puddle of clear liquid substance that resembled water on the bathroom floor. The liquid substance was located under and in front of the bathroom sink. The sink was a wall mounted unit and had two water feed lines from the wall to the bottom of the sink. The lines did not have leak protection covers. The sink had a center drain extending down to the p-trap (a plumbing device that prevents sewer gases from entering the facility by maintaining a water seal. P-traps are commonly found under sinks, bathtubs and showers), then a pipe from the p-trap that terminated at the wall of the bathroom. The bathroom floor was a solid surface linoleum type floor mostly beige/tan in color with blue/green accents. An observation on 9/23/25 at 10:24 AM of the bathroom in Resident #50's room revealed an approximate twenty-four-inch diameter puddle of clear liquid substance that resembled water on the floor of the bathroom between the sink and the toilet. There were no wet floor signs displayed in the bathroom. An observation on 9/24/25 at 11:54 AM of the bathroom in Resident #50's room revealed a puddle of clear liquid substance that resembled water on the floor of the bathroom. A clear liquid was observed dripping from the sinks p-trap drain, about one drip every two to three seconds, creating a puddle under the sink. The puddle was about two feet in diameter extending out from under the sink. There were no wet floor signs displayed in the bathroom. An interview was conducted with the Director of Maintenance on 9/24/25 at 12:07 PM. He observed the puddle of liquid on the floor in Resident #50's bathroom and stated the puddle on the floor was water that leaked from the p-trap of the bathroom sink. He confirmed the p-trap had a crack possibly from the fitting being overtightened, which caused water to leak out of the p-trap onto the bathroom floor. The Maintenance Director stated he was not aware of the leak until this observation. He stated the facility used a work order system to inform maintenance about repair issues. He continued that the process was for staff, which included housekeeping staff, nurse aides and nurses, to fill out a work order that was located at the nurse's station and place it in the box attached to the maintenance office door. The facility Maintenance Worker would check the work order box every morning, prioritize issues, then complete the repairs. He also stated if repairs needed immediate attention from maintenance that staff could verbally inform the Maintenance Worker. An interview conducted on 9/24/25 at 12:27 PM with the facility Maintenance Worker revealed he had not been informed of any issues in Resident #50's room until 9/24/25 when he was informed by the Director of Maintenance. An interview conducted with Housekeeper #1 on 9/24/25 at 12:24 PM revealed Housekeeper #1 cleaned Resident # 50's room and the bathroom on 9/23/25. She stated she did not notice water on the bathroom floor or a leaking pipe in the bathroom when she cleaned. She also stated had she noticed water on the floor or a leaking pipe she would have informed the Maintenance Worker or her supervisor. An interview conducted on 9/24/25 at 2:51 PM with Nurse Aide (NA #3) revealed NA #3 provided care for Resident #50 on 9/24/25, which included taking Resident #50 to the bathroom around 8:15 AM. She stated she did not notice water on the bathroom floor or a leaking pipe in the bathroom when she provided care for Resident #50. She also stated, due to Resident #50's impaired cognition, Resident #50 would use the bathroom on her own. NA #3 stated she did not go back into the room until around 1:00 PM at which point maintenance had fixed the leaking drain. She stated if she had seen the water on the floor she would have cleaned up the water then notified the Maintenance Worker verbally or filled out a work order. An interview conducted on 9/24/25 at 3:39 PM with Nurse #3 revealed she worked with Resident #50 around lunch time on 9/24/25. She did not notice any water on the floor in the bathroom. Nurse #3 stated if she had noticed water on the floor she would have informed the Maintenance Worker or the Director of Maintenance. An interview was conducted with the Nursing Home Administrator (NHA) on 9/25/25 at 10:38 AM. The NHA stated the severity of a water leak would determine the staff response and first staff should make the area safe for residents. Then place wet floor signs in the area and notify maintenance with a work order or, if immediate attention was needed, verbally so maintenance can address the issue right away.

Based on observations, record review, and staff interviews, the facility failed to provide a pureed diet (a smooth, creamy consistency/ texture) to a resident on an ordered therapeutic diet. Resident #24 was observed eating a moist to minced (food that can be easily mashed with little pressure from metal dinner fork, not sticky, no larger than 4 millimeters) breakfast meal. This deficient practice affected 1 of 8 residents reviewed for food form (Resident #24). The findings included:Resident #24 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), vascular dementia, and decreased appetite. Resident #24 had a physician's order dated 2/15/2024 for a regular diet, pureed texture, thick liquids consistency. Resident #24's Care Plan, last revised on 3/20/2025, indicated the following interventions: 1) observe for/document/report to MD as needed (PRN) for signs and symptoms of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals, 2) provide, serve diet as ordered; and 3) Registered Dietician (RD) to evaluate and make diet change recommendations PRN. Resident #24's quarterly Minimum Data Set (MDS) dated [DATE], revealed she was severely cognitively impaired. She had range of motion impairment in her upper extremities and required setup and supervision assistance when eating. The MDS indicated Resident #24 had a swallowing disorder and was on a therapeutic mechanically altered diet. The MDS further revealed Resident #24 demonstrated coughing or choking during meals or when swallowing medications. An observation of Resident #24 was conducted on 9/23/2025 at 8:41 AM. She was observed lying in her bed sitting upright with breakfast in front of her on her overbed table. Consumption of her breakfast meal revealed 75% consumed. The breakfast plate revealed a serving of square piece of formed eggs with a baked cheese topping, a small bowl of regular consistency oatmeal with visible oats, and pureed toast. The meal ticket for Resident #24 revealed pureed diet, thick fluids-mildly thick. An interview and observation conducted with Nurse #1 on 9/23/2025 at 9:04 AM revealed that she delivered and assisted Resident #24 with her breakfast meal. She identified Resident #24 as consuming a pureed meal for breakfast. She further stated that the eggs identified on the plate always looked like this, and the oatmeal always looked regular with visible oats. She further stated sometimes the consistency of the meals will appear different depending on who was working in the kitchen. Nurse #1 stated the breakfast meal was appropriate for Resident #24. During an interview with the Dietary [NAME] #1 on 9/23/2025 at 9:15 AM, she stated she did not puree the eggs because it would make them too runny. She further revealed the oatmeal was never pureed. She stated the eggs may have seemed hard because they sat on top of the steam table for a long time. She stated she provided a cheese bake on top of the eggs for the pureed meal so they would have more flavor. Dietary [NAME] #1 stated pureed consistency was very thick and smooth. The Dietary [NAME] #1 revealed she did not follow the recipe for pureed breakfast meals, and she did not state a reason for not following the recipes. Dietary [NAME] #1 further stated cream of wheat, oatmeal, and grits were already pureed and come in a pureed form. An interview was conducted with Dietary [NAME] #2 on 9/25/2025 at 9:23 AM. Dietary [NAME] #2 was able to explain the difference in altered diets when preparing meals for the residents. Dietary [NAME] #2 stated there was a difference between the different types of textures of the foods, explaining moist to minced chopped food was ground-up food that had a bumpy texture while pureed food looked smooth, like baby food. He stated he was unaware Resident #24 had received a moist to minced breakfast on the morning of 9/23/2025. Dietary [NAME] #2 worked as a diet aide on the morning of 9/23/2025. Dietary [NAME] #2 stated a resident who received the wrong texture diet could choke or aspirate. The recipe instructions for pureeing the eggs and oatmeal specified placing the ingredients in a food processor until a smooth consistency was achieved, with liquid added as needed. An interview and observation were conducted with the Dietary Manager on 9/23/2025 at 9:30 AM. The Dietary Manager observed the breakfast plate and stated the food items were pureed. She stated the oatmeal was not normally pureed and further revealed the breakfast tray was right in its consistency. The Dietary Manager verified Resident #24 was to receive a pureed therapeutic diet order for meals. The Dietary Manager stated a resident diet order was entered into their computer system and tray tickets that contain the order were printed out for each meal. She explained at mealtimes one staff member would call out the diet order from the ticket and the cook would plate the correct diet and consistency of foods items. The Dietary Manager verified the dietary department had recipes for hot cereal puree and egg and sausage strata puree. The Dietary Manager verbalized the recipe was not followed on 9/23/2025 by Dietary [NAME] #1. An interview and observation were conducted with the Director of Nursing (DON) on 9/23/2025 at 11:29 AM of Resident #24's breakfast meal. The DON stated a puree meal should be creamy, separated, and with no lumps. She further stated the oatmeal was already mushy. She did verify the eggs were not of puree consistency. The DON verbalized the dietary department should deliver the correct meal to the residents and the nurse aides were to verify the correct meal was being delivered to the residents. The DON stated if there were discrepancies with any meals she should be notified. The DON stated she was not notified of Resident #24 receiving the incorrect therapeutic meal at breakfast on 9/23/2025. An interview was conducted with the Administrator on 9/25/2025 at 1:05 PM. The Administrator stated that residents must receive the physician-prescribed diet and consistency.

Based on record reviews, resident and staff interviews, and observations, the facility failed to provide resident meals in bowls along with preferred foods as ordered, for 1 of 1 resident with visual impairment (Resident #6), which resulted in Resident #6 having difficulty feeding himself and missing preferred foods.The findings included:Resident #6 was readmitted [DATE] with diagnoses including heart failure, kidney disease, gastro-esophageal reflux disease, dysphagia (trouble swallowing), Barrett's esophagus (inflammation of the esophagus), macular degeneration and legal blindness. The most recent quarterly Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #6 was cognitively intact. He required supervision for set up with eating. The Care Plan revised on 10/5/2023 for Resident #6, showed for the focus area of impaired vision related to macular degeneration and legal blindness revised on 10/05/2023, the goal was no decline of visual function with a target of 11/14/2025. Interventions included to tell Resident #6 where items were being placed and to be consistent with placement of items. The Care Plan revised on 12/28/2023, with a target date of 8/28/2025, showed for the focus area of ADL Self Care Performance, the goal was that Resident #6 will maintain his current level of functioning for eating. Intervention was for him to feed himself with set up and assistance as needed. The Care Plan dated 8/12/2025 showed with the focus area of potential nutritional problems and fluctuations in weight, included the goal for Resident #6 to maintain weight. The intervention included him to receive all food in separate bowls to distinguish foods, due to poor vision. The current diet order dated 04/28/2025, revealed: No Added Salt (NAS) diet, soft & bite-sized texture, thin consistency, all food in bowls, two milks with lunch. Family requests no sandwiches (all other breads are OK). On 9/22/2025 at 1:10 PM an observation of a sign posted above Resident #6's bed stated: Resident is visually impaired. Caregivers Must: 1) Announce tray arrival, 2) Describe food in bowls, 3) Open condiment packets, 4) Ask how else you can help, 5) Ask if patient is finished before removing tray. Resident #6's Tray Card showed- Diet Order: Soft/Bite Sized, NAS; Adaptive Equipment: All Food in Bowls; Notes: Vanilla Cream, Always Send Bowl of Peanut Butter Crackers, Send Milk, Mashed Potatoes No Gravy; Standing Orders: 8 ounces (oz.) of Whole Milk and 8 oz. of Water. On 09/22/2025 at 1:00 PM during an interview, Resident #6 stated it's easier to eat with food in bowls so he can scoop around with the spoon on the sides of the bowl, and the food doesn't run away from him. During an observation and interview with Resident #6 on 9/24/2025 at 6:00 PM, the meal consisted of an uncut, whole cheese sandwich which was served on a plate, and soft-cooked squash pieces in bowl. Resident #6 stated he doesn't eat whole sandwiches because they are too hard to pick up. On 09/25/2025 at 12:42 PM an observation of Resident #6's lunch revealed Nurse #7 delivered Resident #6's tray. The meal was in bowls except for a piece of cake on a plate, and there was one carton of milk. Nurse #7 didn't offer to open the condiments. Resident was observed to have taken a few bites of cake from plate with a spoon and had difficulty getting the cake on the spoon because it would fall off. The resident then ate part of the cake with his fingers. An interview with Nurse #7 on 09/25/2025 at 12:45 PM revealed she hadn't delivered a tray to Resident #6 before and wasn't aware specifically of his need for food in bowls. In an interview with the Dietary Manager on 09/25/2025 at 3:36 PM she stated that when an order read for all food items to be in a bowl, that means everything and that sandwiches were cut and placed in a bowl. She further said that when asked why Resident #6 did not get all the items in bowls as ordered, she said that her staff were nervous and made mistakes. When asked why he did not get 2 milks with his lunch tray as ordered, she looked at his meal ticket and said it was not on the Tray Card. She looked more closely at the Tray Card and admitted it was written in a confusing way on the card with send milk in notes section and whole milk in the standing orders section. During an interview with Nurse #3 on 09/25/2025 at 4:04 PM, she stated that she has brought Resident #6 his tray at all three mealtimes and he had gotten 1 carton of milk at each meal. During an interview with the Director of Nursing (DON) on 9/25/2025 PM at 4:21 PM, when questioned what the staff should do if Resident #6's food wasn't in bowls, she indicated staff should take the tray back to the kitchen and get it in bowls to make sure he can access the food. She elaborated that if a tray ticket has something listed that was missing, they were expected to retrieve it from the kitchen.

Based on observations, record reviews, staff, and resident interviews the facility failed to maintain resident areas and equipment in a safe and sanitary manner for 2 of 3 shower (Shower room [ROOM NUMBER] on the 200 hall, Shower room [ROOM NUMBER] on the 300 hall), clean wheelchairs for 4 of 7 Resident's wheelchairs (Resident #24, Resident #132, Resident # 64, and Resident #3), and repair a wall behind the bed (room [ROOM NUMBER] bed A) for 1 of 10 rooms reviewed for environmental concerns. The findings included: 1a. On 09/09/24 at 3:38 PM the entrance door of the 200 hall shower room [ROOM NUMBER] was propped open. Upon entering the shower room, a rancid odor permeated the entire shower room causing the surveyor to feel nauseous until the morning of 09/10/24. On the left side wall of the shower room where the sink was located a white ceramic toothbrush holder on the right side of the sink was loosely attached to the tile wall. The round floor drain cover located in the center of the shower room floor was observed with unidentified debris and hair covering more than half of the floor drain cover. An observation of the tiled wall dividing the shower stall and bathtub area revealed the lower right side of the divider wall had 5 cracked, jagged edged tiles. The plastic corner guard, which would have covered the cracked, jagged edged tiles, was observed on the floor at the back of the shower stall. Observation of the tiles and grout on the surrounding walls and floor of the shower stall revealed thick dark-brownish black dirt and debris at the joints of the wall and floor tiles. Upon closer inspection it was revealed there were 2 missing tiles on the shower room floor that measured 1 inch x 1 inch. The round drain cover located on the floor of the shower stall was covered with thick gray debris and visible hair. b. On 09/09/24 at 4:08 PM an observation of the shower room [ROOM NUMBER] on the 300 hall revealed there was no trash can liner in the trash can, and trash was observed on the floor around the trash can. A white ceramic toothbrush holder to the left of the sink was observed loosely fastened to the wall. The left faucet handle of the sink was observed without the top cover and the exposed inside screw was covered with rust. The shower stall area next to the bathtub revealed a silver nail clipper and soiled washcloth on the floor. The inside tiles and grout on the surrounding walls and floor of the shower stall revealed thick dark-brownish black dirt and debris at the joints of the wall and floor tiles. 2a. On 09/09/24 at 4:16 PM an observation of the wheelchair of Resident #24 revealed crumbs of dried food debris on the seat cushion, and dried spill marks were observed in the wheelchair arm side pieces. The wheelchair frame and wheel spokes were observed covered with a layer of thick gray dust. b. The wheelchair that belonged to Resident #132 was observed on 09/09/24 at 4:16 PM and revealed the frame and wheel spokes covered with a layer of thick gray dust. c. On 09/09/24 at 4:18 PM an observation of the wheelchairs that belonged to Resident # 64 and Resident #3 revealed food crumbs on both wheelchair seats and the frames and wheel spokes of both wheelchairs were covered with a layer of thick gray dust. On 09/10/24 at 1:42 PM an environmental tour was conducted with the Administrator and included an observation of shower room [ROOM NUMBER] on the 300 hall, and shower room [ROOM NUMBER] on the 200 hall. There was a faint, rancid smell detected from shower room [ROOM NUMBER] on the 200 hall. The Administrator revealed during the tour, the shower rooms needed repair and cleaning. The Administrator observed the wheelchairs of Resident #64 and Resident #3 and revealed the nurse staff on the night (11:00 PM - 7:00 AM) Monday through Friday. On 09/10/24 at 2:14 PM the wheelchair cleaning schedule was reviewed and revealed each room with a wheelchair, including the wheelchairs of Resident #24, Resident #132, Resident #64, and Resident #3, were to be cleaned monthly on night shift. Review of work orders revealed no concerns reported related to shower room cleanliness or wheelchair cleaning. Wheelchairs that were assigned to be cleaned were observed in the assignment book. There was no documentation to confirm if wheelchairs were cleaned or not. On 09/11/24 at 7:29 AM Nurse #2 was interviewed. Nurse #2 revealed that she worked the night shift when the Nursing Assistants (NAs) were scheduled to clean wheelchairs as scheduled posted in the assignment books. Nurse #2 revealed 4 wheelchairs were scheduled to be cleaned every night and there was no place to document if they were cleaned or not, but she had never received a report that wheelchairs had been cleaned or not cleaned. On 09/11/24 at 7:45 AM an interview with Housekeeper #1 was conducted and revealed she was assigned to clean the 200 hall shower room, shower room [ROOM NUMBER] and sometimes left the door propped open to dry the floor after it was mopped. Housekeeper #1 revealed she did smell an odor in the shower room [ROOM NUMBER] on the 200-hall and believed the odor was from the trash and the soiled linen bins. Housekeeper #1 revealed if she had any concerns about any room, she was assigned to clean she would have notified her manager. Housekeeper #2 interviewed at 7:52 AM on 09/11/24 revealed she was assigned the 200 hall and 300 hall shower rooms, shower rooms, #2 and #3, she had not smelled any strong odors in either of them and had not noticed the cracked tiles or concerns with the privacy curtains because she would have verbally reported any concerns to her manager. An interview with Nurse Assistant (NA) #1 who worked the night shift was conducted on 09/10/24 09:25 AM. NA #1 revealed she knew there was a wheelchair cleaning schedule in the daily assignment book. She reported the staff tried to clean as many wheelchairs as scheduled but were not always able to get to them all and there was nowhere to document if they had been cleaned or not. An observation and interview conducted with the Maintenance Director on 09/11/24 at 10:43 AM of the 200 hall shower room revealed he did not check the shower room frequently for maintenance concerns or housekeeping concerns. The Maintenance Director revealed he knew the shower room needed repairs and multiple items needed to be replaced. He also revealed he did notice a foul odor from shower room [ROOM NUMBER] on the 200 hall shower room at times and believed the odor came from either stagnant water in the drain system or dirty water clogged the drains. There was a faint odor of the rancid smell detected on the observation on 09/09/24, in shower room [ROOM NUMBER]. The Maintenance Director revealed he had previously smelled an odor that was stronger than it was during our tour. The physical structural and cleanliness issues identified on 09/09/24 at 3:38 PM were also found during the observation with the Maintenance Director . On 09/11/24 at 1:40 PM a follow up interview with the Administrator was conducted and he revealed all shower rooms were expected to be clean, neat, and orderly, and wheelchairs were to be cleaned as per the schedule. 37281 3. room [ROOM NUMBER] bed A was observed on 9/8/24 at 3:53 PM. Resident #1 was in bed and her family members were at the bedside. Behind the bed, the wall had streaks of dried adhesive, and the drywall had gouges, and the paint appeared to be rubbed off in spots. Resident #1's family members were interviewed during the observation, and they reported the plastic wall protector had fallen off the wall a while ago and that they had placed the sheet of plastic beside the bed A closet. The sheet of wall protector was brittle and discolored yellow. The family members explained they had reported the plastic wall protector sheet had come off the wall to a staff member. The family members were unable to recall the name of the staff member. The family members said they had been told room [ROOM NUMBER] was scheduled to be repainted over a year ago. Nursing assistant (NA) #1 was interviewed on 9/10/24 at 9:25 AM and she reported if she noticed repairs needed completed, she filled out a work order and put in in the maintenance department mailbox. NA #1 explained she had not noticed the wall behind 309 bed A needed repaired. NA #2 was interviewed on 9/10/24 at 9:38 AM. NA #2 reported she filled out a work order for repairs, or she verbally notified the maintenance department. An interview was conducted with Nurse #1 on 9/10/24 at 10:01 AM. Nurse #1 reported she was usually assigned to the 300 hall, but she had not noticed the wall behind bed A in room [ROOM NUMBER]. The nurse explained if repairs need to be made, she filled out a work order and placed it in the maintenance department mailbox. An observation of room [ROOM NUMBER] with the maintenance director occurred on 9/11/24 at 10:46 AM. The maintenance director reported he was not aware of the condition of room [ROOM NUMBER] bed A's wall, and he reported his assistant was responsible for completing work orders on resident rooms. The maintenance assistant was interviewed on 9/11/24 at 11:02 AM during an observation of room [ROOM NUMBER]. The maintenance assistant reported he was not aware of the condition of the wall behind bed A, and he had not received a work order for repairs. The maintenance assistant explained he would have replaced the plastic wall protector sheet and repaired the walls behind bed A. Work orders for the facility were reviewed and there were no work orders for room [ROOM NUMBER] bed A. The Administrator was interviewed on 9/11/24 at 2:07 PM and he reported he expected the resident rooms to be clean and in good repair with maintenance completing repairs as quickly as possible. The Administrator reported he expected nursing staff to use a work order form to report repairs to the maintenance department.

Based on staff interviews and record review the facility failed to complete a comprehensive significant change in status Minimum Data Set (MDS) assessment for 1 of 7 residents (Resident #11) reviewed for significant change in condition. The findings included: Resident #11 was readmitted to the facility on [DATE] with diagnoses that included urine retention and chronic kidney disease. A review of hospital discharge note dated 08/26/24 revealed in part Resident #11 had a urinary tract infection and a wound to her sacrum. Review of a readmission skin assessment dated [DATE] revealed in part that Resident #11 had a stage 3 pressure ulcer of the sacrum. A review of a nurse progress note dated 8/27/24 at 10:24 AM revealed in part that Resident #11 had a urinary catheter. A weight loss note dated 08/28/24 at 12:20 PM revealed that Resident #11 had a weight loss of 10% or greater in the last 180 days. A quarterly MDS assessment dated [DATE] included in part that Resident #11 had severe cognitive impairment, she was always incontinent of bladder and bowel, had no weight loss or weight gain and was at risk to develop pressure ulcers. The MDS Coordinator was interviewed on 09/11/24 10:46 AM she revealed she missed coding those areas and should have completed a significant change in status MDS assessment for Resident #11 upon her readmission. On 09/11/24 at 1:40 PM an interview with the Administrator revealed he expected significant change MDS assessments be completed in a timely manner.

Based on observations, record review, and staff interviews, the facility failed to provide care according to professional standards when Unit Manager #1 failed to ensure Resident #50 swallowed her medications prior to leaving her room and was observed with a pill lying on her chest, and Resident #13 was observed to have a medicine cup with pills left unattended on her bedside table. The deficient practice occurred for 2 of 2 residents reviewed for professional standards (Resident #50 and Resident #13). The findings included: 1. Resident #50 was admitted to the facility 4/23/24 with diagnoses that included cerebral infarction (stroke) and gastrostomy. A review of Resident #50's physician orders revealed an order dated 5/20/24 for Tramadol 50 milligrams (mg) one tablet by mouth every 8 hours. The physician orders further revealed Resident #50 was able to swallow medications whole and all her pills were ordered to be administered by mouth. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #50 had severe cognitive impairment. An observation conducted on 9/8/24 at 5:48 PM revealed Resident #50 was lying in bed talking but her speech was unclear and there was no one else in her room. Resident #50 was further observed to have a white oblong pill lying on the right side of her chest that was dry and intact. An interview conducted with Unit Manager #1 on 9/8/24 at 6:00 PM indicated Resident #50 was able to swallow her medications whole and they were ordered to be administered by mouth. Unit Manager #1 revealed she gave Resident #50 one tablet of Tramadol 50mg at 4:42 PM. She stated she placed the pill in Resident #50's mouth and watched her swallow 5 to 6 sips of water indicating to her she also swallowed the pill. Unit Manager #1 revealed she could not explain why the pill was found on Resident #50's chest but she must have spit it out after she left her room. An interview was conducted with the Director of Nursing (DON) on 9/9/24 at 9:41 AM. She stated Resident #50 was able to take her medications by mouth and she was not aware of any concerns related to her pocketing or spitting out pills. The DON further stated Unit Manager #1 should have confirmed Resident #50 swallowed her medication before leaving her room. 2. Resident #13 was admitted to the facility 4/27/21 with diagnoses that included type 2 diabetes and chronic kidney disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact. A review of Resident #13's 9/9/24 active physician orders revealed orders for citalopram hydrobromide 20 milligrams (mg) one tablet by mouth once daily, potassium chloride extended release 20 milliequivalent two tablets by mouth once daily, amlodipine besylate 5mg one tablet by mouth once daily, bupropion hydrochloric acid (HCL) 75mg one tablet by mouth once daily, acetaminophen extra strength 500mg two tablets by mouth twice daily, metoclopramide HCL 5mg one tablet by mouth twice daily, torsemide10mg one tablet by mouth twice daily and lorazepam 0.5mg one half tablet by mouth twice daily. An observation conducted on 9/9/24 at 9:48 AM revealed Resident #13 was in her bathroom with the door closed. Further observation of Resident #13's room revealed a medicine cup was left unattended on her bedside table which contained two large oblong white pills, one round dark orange pill, four round white pills, one round orange pill, one small oblong white pill, and half of a round white pill. An interview conducted with Nurse #3 on 9/9/24 at 10:06 AM revealed she went to Resident #13's room to administer her morning medications but Resident #13 had to use the bathroom. She indicated she placed Resident #13's medications on the bedside table and then left the room. Nurse #3 stated she should have waited for Resident #13 to return from the bathroom to administer the medications and they should not have been left unattended on the bedside table. An interview was conducted with the Director of Nursing (DON) on 9/9/24 at 9:41 AM. She stated nurses should ensure a resident takes their medications prior to leaving the room and medications should not be left unattended at the bedside.

Based on record reviews and staff interviews, the facility failed to use the services of a Registered Nurse (RN) for 8 consecutive hours per day for 10 of 10 dates reviewed (7/8/23, 7/15/23, 7/22/23, 7/23/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, and 9/9/23). The findings included: The Payroll Based Journal (PBJ) data report for fiscal year 2023, the quarter from 7/1/23 to 9/30/23 was reviewed. The report indicated the facility had the following days within the quarter with no Registered Nurse (RN) hours: 7/8/23, 7/15/23, 7/22/23, 7/23/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, and 9/9/23. The nursing schedules for 7/8/23, 7/15/23, 7/22/23, 7/23/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, and 9//9/23 were reviewed. No RN was scheduled to work on the reviewed dates. The time sheets for 7/8/23, 7/15/23, 7/22/23, 7/23/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, and 9//9/23 were reviewed and no RN were documented to have had worked any shifts for the reviewed dates. During an interview with the Director of Nursing (DON) on 12/13/23 at 12:40 PM she reported she had started her position in May 2023, and she was not aware a RN was to be scheduled to work every day for 8 consecutive hours until September 2023. The DON reported the scheduler had told her there were no RNs available to work those dates, but the DON did not understand the importance of having an RN on the schedule. The DON explained a corrective action plan had been put in place and she was conducting daily audits of the schedule for RN coverage. An interview was conducted with the Scheduler on 12/14/23 at 11:11 AM. The Scheduler explained the facility used staffing agencies to fill in blank spots in the schedule and on the dates listed above, when she knew there was no RN to work, she had reported to the DON about the lack of RN coverage. The Scheduler explained the schedule was discussed by nursing managers and her every morning. The Scheduler concluded she had received education regarding RN coverage on 11/10/2023 by the Quality Assurance nurse. The Administrator was interviewed on 12/14/23 at 3:06 PM. The Administrator reported the dates without an RN scheduled to work were before he started his position as Administrator, and when he took the position, he received the PBJ report of no RN hours for Quarter 4 of 2023. The Administrator explained a Performance Improvement Plan was developed to prevent a recurrence of no RNs scheduled for 8 consecutive hours per day. The facility plan of correction was reviewed and it read: On 11/10/23 the facility identified there were occurrences when there was no RN coverage scheduled. The facility conducted audits and identified 10 days where there was no RN coverage: 7/8/23, 7/15/23, 7/22/23, 7/23/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, and 9/9/23. The Quality Assurance (QA) Nurse Consultant in-serviced the Administrator, DON, Assistant DON, and the Scheduler on 11/10/23 regarding RN coverage. The Administrator and QA Nurse will monitor staffing to ensure the facility has RN coverage daily using the Quality Assurance tool for staffing. This would be completed daily for 5 days per week for 4 weeks, and then weekly for 8 weeks. The reports will be presented to the weekly Quality Assurance committee by the Administrator or the DON to ensure corrective action that was initiated was appropriate. Compliance will be monitored and ongoing auditing program at the weekly Quality Assurance meeting, attended by the Administrator, the DON, and other management leaders. The date of compliance was 11/11/23. The plan of correction was validated by review of the education provided, review of the audits completed by the facility and interviews with the DON, Scheduler, and the Administrator. The facility date of compliance of 11/11/23 was validated.

Based on record reviews, observations, resident and staff interviews, the facility failed to resolve repeat grievances related to dietary issues that were reported during the Resident Council meetings for 8 of 11 months reviewed (January 2023, February 2023, March 2023, April 2023, May 2023, September 2023, October 2023, and November 2023). The findings included: Resident Council meeting minutes for 2023 were reviewed and revealed issues the Resident Council had identified: a. The Resident Council meeting minutes dated 1/12/2023 indicated that the food served for meals was cold, and no spoons were available. The Dietary Manager's written response to the resident council dated 1/13/2023 read: We temp [check the temperature] of all food before it leaves dietary [department for meal delivery]. We have spoons. b. The Resident Council meeting minutes dated 2/9/2023 indicated that the facility was always out of jelly, the eggs and grits were cold, and the menus were repeated without variety. The Dietary Manager's written response to the resident council dated 2/9/2023 read: We do have jelly; it's ordered once a month. I notified nursing about getting the food out faster, and sorry we go by a set menu. c. The Resident Council meeting minutes dated 3/9/2023 indicated that the food was always cold by the time the residents received their trays and the beverages were always hot (no ice). There was no response to the complaints. d. The Resident Council meeting minutes dated 4/25/2023 indicated that residents were receiving iced tea without ice in the drinks, the coffee was cold when delivered to the residents, the grits were lumpy, and one resident received out of date milk. The interventions dated 4/26/2023 read: Activity Director will talk with dietary manager to resolve these issues; and on 4/27/2023 the Dietary Manager's written response, All issues [were] resolved. I talked to my [kitchen] employees to make sure we were all on the same page. e. The Resident Council meeting minutes dated 5/11/2023 indicated that the residents did not want Mexican food and were requesting more potatoes and onions. The minutes documented the resident council wanted more Southern food, as well as steak, and fish. The Dietary Manager's written response to the resident council dated 5/12/2023 read: Sorry, the food comes off a menu that's already put together and sent to me. f. The Resident Council meeting minutes dated 9/12/2023 indicated the food was delivered cold to the residents, and they were not receiving flatware or condiments. There was no response to the complaints. g. The Resident Council meeting minutes dated 10/10/2023 indicated the residents wanted a more versatile variety of menu items for breakfast and dinner. There was no response to the complaints from the dietary department. h. The Resident Council meeting minutes dated 11/20/2023 indicated the residents were requesting more snacks, and the food was not hot. The Dietary Manager's response to the resident council dated 11/20/2023 documented a response: Residents discussed concerns with the kitchen manager during today's resident council meeting. The Resident Council meeting was observed on 12/12/2023 at 2:30 pm and 14 residents were in attendance. During resident interviews, Resident #47 indicated the food was cold when delivered to her room, and Resident #19, Resident #4, and Resident #58 agreed. The Resident Council President, Resident #58, reported the Resident Council brought up the same dietary department issues every month, but the facility did not resolve the issues. An in-person interview was conducted with the former Administrator on 12/13/2023 at 3:21 PM. The former Administrator reported he left the facility for a sister facility in June 2023, and he did not recall the any grievances from the Resident Council. The former Administrator reported he did not recall hearing that the food was cold when it was delivered to the residents. The Dietary Manager (DM) was interviewed on 12/14/2023 at 8:47 AM. The DM reported she had been in her position for 1 year and she was aware of the Resident Council issues with the food temperature, and she had been checking the dish warmer to make certain it was heating the plates. The DM explained she was not aware she could make changes to the menu until recently, and the Registered Dietician made a list of substitutions. The DM reported test trays were tested by the Corporate Dietary Manager. The DM reported she wanted the residents to have a good variety of food that was served at the right temperature and tasted good. The Activity Director was interviewed on 12/14/2023 at 9:38 AM. The Activity Director reported she had been in her position for 3 months and when a resident expressed a concern or complaint during the Resident Council meetings, she went to the department head to discuss the issue. The Activities Director reported she had invited department heads to attend the resident council meetings to address any questions or concerns. During an interview with the current Administrator on 12/14/2023 at 3:06 PM, he reported he had been in the position since mid-September 2023, and he was not aware of the multiple issues the Resident Council had with the food and dietary department. The Administrator reported the Resident Council provided the residents an opportunity to express concerns and have those concerns addressed. The Administrator explained that the facility should provide actions to resolve issues and if the response by the individual departments required revision, he should direct the revision and response.

Based on a test tray observation, record review, and resident and staff interviews the facility failed to serve food warm that should be served warm to 1 of 4 halls (300 hall). This practice had the potential to impact other residents. The findings included: 1)Resident #30 was admitted to the facility 3/8/2019. A review of the quarterly Minimum Data Set (MDS) revealed Resident #30 was cognitively intact and had not experienced weight loss. An interview was conducted with Resident #30 on 12/12/2023 at 9:45 a.m. and he revealed the food frequently arrives cold. An observation of the meal tray line service in the kitchen was conducted on 12/13/2023 at 12:31 p.m. The temperatures of the food items of regular and puree consistency were greater than 135-degree Fahrenheit. The food items were placed on heated plates from a plate [NAME]. The plated meals were covered with insulated, dome shaped lids with bottoms. The dome shaped lids did not close completely due to a bowl, containing brussel sprouts that prevented the closer. The Dietary Manager (DM) was observed to provide instructions to the dietary staff to ensure the lids closed. A total of nine plates were observed to be placed on the 300-hall meal cart with the lids opened on the sides. The meals were placed in a four-sided, stainless-steel delivery cart and transported to the 300-hall at 12:52 p.m. where the nursing staff immediately began serving the residents on the 300-hall. A test meal tray of regular and puree textured foods were included in the meal delivery cart. On 12/13/2023 at 1:02 p.m., after the residents of the 300-hall were served, the DM and this surveyor observed the test meal tray for palatability. The lasagna was cool to taste on both test trays and the brussel sprouts were cool on the puree test tray. The DM participated in the testing of the two meal trays and acknowledged these findings. An interview was conducted with Resident #30 on 12/13/2023 at 4:50 p.m. and he revealed his lunch on 12/13/2023 tasted good but it was cold. He added he did not ask anyone to warm up his food because this happens a lot and the Nursing Assistants would be spending all their time warming up meal trays. He stated he had informed staff on many occasions the food arrives cold. 2)Resident #47 was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE] revealed Resident #47 was cognitively intact and had not experienced weight loss. An observation of the meal tray line service in the kitchen was conducted on 12/13/2023 at 12:31 p.m. The temperatures of the food items of regular and puree consistency were greater than 135-degree Fahrenheit. The food items were placed on heated plates from a plate [NAME]. The plated meals were covered with insulated, dome shaped lids with bottoms. The dome shaped lids did not close completely due to a bowl, containing brussel sprouts that prevented the closer. The Dietary Manager (DM) was observed to provide instructions to the dietary staff to ensure the lids closed. A total of nine plates were observed to be placed on the 300-hall meal cart with the lids opened on the sides. The meals were placed in a four-sided, stainless-steel delivery cart and transported to the 300-hall at 12:52 p.m. where the nursing staff immediately began serving the residents on the 300-hall. A test meal tray of regular and puree textured foods were included in the meal delivery cart. An interview was conducted with Resident #47 on 12/13/2023 at 3:34 p.m. and she revealed the lunch tray on 12/13/2023 was cool to the touch and if she could have reheated it, she would have. 3) Resident #19 was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE] revealed the Resident was cognitively intact and had not experienced any weight loss. An observation of the meal tray line service in the kitchen was conducted on 12/13/2023 at 12:31 p.m. The temperatures of the food items of regular and puree consistency were greater than 135-degree Fahrenheit. The food items were placed on heated plates from a plate [NAME]. The plated meals were covered with insulated, dome shaped lids with bottoms. The dome shaped lids did not close completely due to a bowl containing brussel sprouts that prevented the closer. The Dietary Manager (DM) was observed to provide instructions to the dietary staff to ensure the lids closed. A total of nine plates were observed to be placed on the 300-hall meal cart with the lids opened on the sides. The meals were placed in a four-sided, stainless-steel delivery cart and transported to the 300-hall at 12:52 p.m. where the nursing staff immediately began serving the residents on the 300-hall. A test meal tray of regular and puree textured foods were included in the meal delivery cart. An interview was conducted with Resident #19 on 12/13/2023 at 3:34 p.m. and the Resident stated at lunch the brussel sprouts were cold.

Based on observations and staff interviews the facility failed to date and label opened food in 1 of 1 walk in cooler. The findings included: On 12/11/2023 at 10:52 a.m. observations were made of the facility's walk-in cooler with the Dietary Manager (DM). Upon entrance there were the following items without a label or date: A. Sliced ham opened and wrapped in a plastic wrap. B. Two containers of sliced turkey wrapped in a plastic wrap. C. A freezer storage bag with a white chunk of food. This item also did not have an expiration date. During the observation of the walk-in cooler, an interview was conducted with the DM on 12/11/2023 at 10:52 a.m. and she revealed the sliced ham should contain a label and date. She added the two containers of sliced turkey should also contain a label and date. She stated the white substance stored in the freezer bag was cream cheese that had been removed from the original packaging. She stated it was her expectation that every item in the walk in cooler have a label and date when it has been opened. An interview was conducted with the Administrator on 12/14/2023 at 11:01 a.m. and he revealed it was his expectation that all foods in the kitchen be labeled and dated once opened.

Based on observation, record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions the committee had previously put into place following the 5/12/2022 recertification and complaint investigation survey. The deficiencies were in the areas of (F636) Comprehensive Assessments; (F638) Quarterly Assessments at least every three months; (F641) Accuracy of Assessments; and (F812) Food Procurement and Store, Prepare, and Serve Food in a Sanitary Manner. These deficiencies were subsequently recited on the current recertification and complaint survey on 12/15/23. The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: The tag is cross-referenced to: F636-Based on record reviews and staff interviews, the facility failed to complete 1 of 4 admission comprehensive Minimum Data Set (MDS) assessments within 14 days of an admission and failed to complete comprehensive MDS assessments within 14 days of the Assessment Reference Date (ARD) [the last day of the assessment period] for 5 of 26 sampled residents. The facility failed to complete an admission Minimum Data Set (MDS) comprehensive assessment within 14 days of the assessment reference date for 2 of 7 residents during a recertification and complaint investigation survey conducted 5/12/2022. F638-Based on record reviews and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) [the last day of the assessment period] for 6 of 21 sampled residents. The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the assessment reference date for 1 of 9 residents reviewed for timeliness completion of quarterly MDS assessments during a recertification and complaint investigation survey conducted 5/12/2022. F641-Based on record reviews and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 3 of 26 sampled residents. The facility failed to accurately complete the quarterly minimum data set (MDS) for 1 of 2 sampled residents reviewed for range of motion during a recertification and complaint investigation survey conducted 5/12/2022. F812-Based on observations and staff interviews the facility failed to date and label opened food in 1 of 1 walk in cooler. The facility failed to maintain sanitary conditions in the kitchen and in 1 of 2 nourishment rooms by not ensuring food items were not stored on the floor; by not ensuring resealed food items were dated/labeled; by not ensuring food service equipment remained free from debris; and by not ensuring dietary staff wore hair covering while preparing meal trays on the meal tray line during a recertification and complaint investigation survey conducted 5/12/2022. During an interview with Administrator #1 on 12/14/2023 at 3:50 pm he stated he was not the administrator during the 5/12/2022 recertification and complaint investigation survey but the facility had put a plan of correction into place and had worked to improve the areas identified for the Minimum Data Set assessments to be completed timely and accurately since he was hired as the Administrator. The Administrator also stated the storage of food would be addressed by the facility's Quality Assessment and Assurance Committee and the facility would work to improve in that area. The Administrator indicated the facility's Quality Assessment and Assurance Committee was meeting monthly and would continue to improve in the areas of concern.

Based on record review, family and staff interviews the facility failed to notify the resident's responsible party (RP) of a change in roommate for 1 of 3 residents reviewed for notification of change (Resident #13). Findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses of dementia and kidney disease. An annual Minimum Data Set assessment dated [DATE] indicated Resident #13 was severely cognitively impaired. On 12/11/2023 at 3:55 pm the RP was interviewed by phone and stated he was not notified Resident #13 would be getting a new roommate on 9/4/2023. He stated when he visited after 9/4/2023 the roommate was cussing, and he was concerned the cussing would upset Resident #13. During an interview with Nurse #1 by phone on 12/14/2023 at 10:53 am she stated she remembered Resident #13 having a change of roommate when she resided on the 100-hall, and the RP was upset because the roommate would cuss. Nurse #1 stated the roommate had not cussed at Resident #13, but she would talk to herself and say cuss words. Nurse #1 stated she thought the Social Worker notified the Responsible Parties of the resident when they are moved to a different room, but she was not sure if they notified the Responsible Parties of the resident that received a new roommate. The Social Worker was interviewed on 12/14/2023 at 3:12 pm and she stated she was on vacation when Resident #13 received the new roommate and she did not know who called the RP but Administrator #2, who was the interim administrator at that time, was responsible for managing the room changes while she was on vacation. On 12/14/2023 at 3:47 pm Administrator #1, the current administrator was interviewed, and he stated he was not the administrator in the building on 9/4/2023 when Resident #13 received a new roommate. Administrator #2, the previous administrator, was interviewed on 12/15/2023 at 12:24 pm and stated she did not remember Resident #13 and did not remember notifying the RP Resident #13 would be getting a new roommate. She also stated she would have asked the Nurse who had Resident #13 to call the RP if the Social Worker was not available. The Director of Nursing stated on 12/14/2023 at 12:35 pm that Nurse #2 worked on 9/2/2023 on the day shift and she asked her if she remembered Resident #13 receiving a new room ate that day. The Director of Nursing stated Nurse #2 said she did not remember if she called the RP to notify them Resident #13 received a new roommate.

Based on record reviews and staff interviews, the facility failed to complete 1 of 4 admission comprehensive Minimum Data Set (MDS) assessments within 14 days of an admission (Resident #233) and failed to complete comprehensive MDS assessments within 14 days of the Assessment Reference Date (ARD) [the last day of the assessment period] for 5 of 26 sampled residents (Resident #7, Resident #19, Resident #30, Resident #239, Resident #27). The findings included: 1. a. Resident #233 was admitted to the facility on [DATE]. A review of Resident #233's admission MDS assessment with an ARD of 8/4/2023 was signed as completed on 8/16/2023. 2. a. Resident #7 was readmitted to the facility 7/30/2023. A review of Resident #7's annual MDS with an ARD of 5/11/2023 was signed as completed on 5/28/2023. b. Resident #7 was admitted to the facility 10/22/2019. A review of the annual MDS with an ARD of 4/18/2023 was signed as completed on 5/8/2023. c. Resident #30 was admitted to the facility 3/8/2019. A review of the annual MDS with an ARD of 5/2/2023 was signed as completed on 5/18/2023. 38904 d. Resident #239 was admitted to the facility on [DATE]. A Significant Change Assessment with an assessment reference date (ARD) of 10/10/2023 was completed on 10/26/2023. 42900 e. Resident #27 was admitted to the facility on [DATE]. A review of Resident #27's Admission Minimum Data Set (MDS) assessment had an assessment reference date (ARD) scheduled for 8/4/2023. The MDS assessment was signed and completed on 8/16/2023. The facility MDS nurse was not available for interview during the survey. An interview was conducted with the Clinical Reimbursement Consultant on 12/14/2023 at 2:09 PM. The Clinical Reimbursement Consultant revealed she became aware of the late admission and comprehensive MDS assessments after running a report in 9/14/2023 and a Performance Improvement Plan (PIP) was developed at that time. The Clinical Reimbursement Consultant explained the MDS nurse was unable to meet the expectations of the PIP and the PIP was modified on 11/30/2023, to include hiring additional MDS nurses to assist with completing the admission and the comprehensive MDS assessments in a timely manner. The Regional Nurse Consultant was interviewed on 12/14/2023 at 2:54 pm and she reported the facility had received the report from the Clinical Reimbursement Consultant in September 2023 and the facility developed a PIP and the goals were not being met by the MDS nurse, so they modified the plan on 11/30/2023. The Regional Nurse Consultant explained the facility had hired additional MDS nurses to help with the completion of MDS assessments. During an interview with the Administrator on 12/14/2023 at 3:06 PM, he reported he started his position on 9/14/2023 and received the late MDS report from the Clinical Reimbursement Consultant. The Administrator explained the facility had an ad hoc Quality Improvement Meeting and developed a PIP, but upon review on 11/30/2023, discovered that the goals were not being met, and the Quality Improvement team developed another PIP. Nurse #4 was interviewed on 12/14/2023 at 3:41 PM. Nurse #4 reported she was newly hired to assist with the completion of MDS assessments for the facility and she had received education regarding the timeliness of MDS completion for admission and comprehensive assessments. The facility plan of correction was reviewed and it read: On 11/29/2023 the facility identified past due admission and comprehensive MDS assessments were not being completed and submitted. The Clinical Reimbursement Consultant identified residents who were impacted by the late completion of the admission or comprehensive MDS assessments and discovered 46 late assessments during an audit of the past 60 days for all current and discharged residents. Education was provided by the Administrator to the MDS nurses on MDS completion on 12/1/2023. The Administrator or designated manager will monitor MDS assessments weekly for 4 weeks and monthly for 2 months using the Quality Assurance tools to ensure assessments were completed timely. The reports will be presented to the weekly Quality Assurance meeting by the Administrator or the Director of Nursing. Compliance will be monitored, and an ongoing auditing program will be reviewed at the weekly Quality Assurance meeting. The date of compliance was 12/2/2023. The plan of correction was validated by review of the education provided, review of the audits completed by the facility, and interview with the newly hired MDS nurse regarding education received and monitoring in place. Admission and comprehensive MDS completed after 12/2/2023 were were reviewed and no issues were identified. The facility date of compliance of 12/2/2023 was validated.

Based on record reviews and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) [the last day of the assessment period] for 6 of 21 sampled residents (Resident #30, Resident #6, Resident #7, Resident #19, Resident # 236, and Resident #50). The findings included: A. Resident #30 was admitted to the facility on [DATE]. A review of Resident #30's quarterly MDS assessment with an ARD of 8/1/2023 was signed as complete on 8/17/2023. B. Resident #6 was admitted to the facility on [DATE]. A review of Resident #6's quarterly MDS assessment with an ARD of 11/10/2022 was signed as completed on 12/1/2022. C. Resident #7 was readmitted to the facility on [DATE]. A review of Resident #7's quarterly MDS assessment with an ARD of 11/2/2023 was signed as completed on 11/28/2023. D. Resident #19 was admitted to the facility on [DATE]. A review of Resident #19's quarterly MDS assessment with an ARD of 1/19/2023 was signed as completed on 2/14/2023. 38904 E. Resident #236 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment for Resident #236 with an assessment reference date (ADR) of 5/17/2023 was signed as completed on 6/7/2023. F. Resident #50 was admitted to the facility on [DATE]. A quarterly MDS assessment with an assessment reference date (ADR) of 11/3/2023 was signed as completed on 11/29/2023. The facility MDS nurse was not available for interview during the survey. An interview was conducted with the Clinical Reimbursement Consultant on 12/14/2023 at 2:09 PM. The Clinical Reimbursement Consultant revealed she became aware of the late quarterly MDS assessments after running a report in 9/14/2023 and a Performance Improvement Plan (PIP) was developed at that time. The Clinical Reimbursement Consultant explained the MDS nurse was unable to meet the expectations of the PIP and the PIP was modified on 11/30/2023, to include hiring additional MDS nurses to assist with completing the quarterly MDS assessments in a timely manner. The Regional Nurse Consultant was interviewed on 12/14/2023 at 2:54 pm and she reported the facility had received the report from the Clinical Reimbursement Consultant in September 2023 and the facility developed a PIP and the goals were not being met by the MDS nurse, so they modified the plan on 11/30/2023. The Regional Nurse Consultant explained the facility had hired additional MDS nurses to help with the completion of MDS assessments. The Administrator was interviewed on 12/14/2023 at 3:06 PM, he reported he started his position on 9/14/2023 and received the late MDS report from the Clinical Reimbursement Consultant. The Administrator explained the facility had an ad hoc Quality Improvement Meeting and developed a PIP, but upon review on 11/30/2023, discovered that the goals were not being met, and the Quality Improvement team developed another PIP. Nurse #4 was interviewed on 12/14/2023 at 3:41 PM. Nurse #4 reported she was newly hired to assist with the completion of MDS assessments for the facility and she had received education regarding the timeliness of MDS completion for quarterly assessments. The facility plan of correction was reviewed and it read: On 11/29/2023 the facility identified past due quarterly MDS assessments were not being completed and submitted. The Clinical Reimbursement Consultant identified residents who were impacted by the late completion of the quarterly MDS assessments and discovered 46 late assessments during an audit of the past 60 days for all current and discharged residents. Education was provided by the Administrator to the MDS nurses on MDS completion on 12/1/2023. The Administrator or designated manager will monitor MDS assessments weekly for 4 weeks and monthly for 2 months using the Quality Assurance tools to ensure assessments were completed timely. The reports will be presented to the weekly Quality Assurance meeting by the Administrator or the Director of Nursing. Compliance will be monitored, and an ongoing auditing program will be reviewed at the weekly Quality Assurance meeting. The date of compliance was 12/2/2023. The plan of correction was validated by review of the education provided, review of the audits completed by the facility, and interview with the newly hired MDS nurse regarding education received and monitoring in place. Quarterly MDS assessments completed after 12/2/2023 were reviewed and no issues were noted with late assessments. The facility date of compliance of 12/2/2023 was validated.

Based on record reviews and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 3 of 26 sampled residents (Resident #30, Resident #6, and Resident #19). The findings included: A. Resident #30 was admitted to the facility on [DATE]. A review of medication orders for Resident #30 revealed he was not prescribed antipsychotic medications. A review of the Quarterly MDS dated [DATE] documented yes that Resident #30 was taking antipsychotic medications. B. Resident #6 was admitted to the facility on [DATE]. A review of physician orders for Resident #6 revealed no orders for enteral feedings. A review of the quarterly MDS dated [DATE] documented no Resident #6 had not received enteral feedings. The MDS assessment documented Resident #6 received 500 milliliters or less and 25% of calories or less from enteral feedings. C. Resident #19 was admitted to the facility on [DATE]. A review of physician orders for Resident #19 revealed no orders for enteral feedings. A review of the quarterly MDS dated [DATE] revealed documentation that Resident #19 received parenteral feeding and enteral feeding, and she received 500 or more milliliters and 51% of her calories via enteral feeding. The facility MDS nurse was not available for interview during the survey. An interview was conducted with the Clinical Reimbursement Consultant on 12/14/2023 at 2:09 PM. The Clinical Reimbursement Consultant revealed she became aware of the inaccurate MDS assessments after running a report on 9/14/2023 and a Performance Improvement Plan (PIP) was developed at that time. The Clinical Reimbursement Consultant explained the MDS nurse was unable to meet the expectations of the PIP and the PIP was modified on 11/30/2023, to include hiring additional MDS nurses to assist with MDS assessments in a timely manner. The Regional Nurse Consultant was interviewed on 12/14/2023 at 2:54 pm and she reported the facility had received the report from the Clinical Reimbursement Consultant in September 2023 and the facility developed a PIP and the goals were not being met by the MDS nurse, so they modified the plan on 11/30/2023. The Regional Nurse Consultant explained the facility had hired additional MDS nurses to help with the completion of MDS assessments. The Regional Nurse Consultant reported that MDS accuracy was an important factor in resident care. During an interview with the Administrator on 12/14/2023 at 3:06 PM, he reported he started his position on 9/14/2023 and received the late MDS report from the Clinical Reimbursement Consultant. The Administrator explained the facility had an ad hoc Quality Improvement Meeting and developed a PIP, but upon review on 11/30/2023, discovered that the goals were not being met, and the Quality Improvement team developed another PIP. Nurse #4 was interviewed on 12/14/2023 at 3:41 PM. Nurse #4 reported she was newly hired to assist with the completion of MDS assessments for the facility and she had received education regarding the accuracy of MDS assessments. The facility plan of correction was reviewed and it read: On 11/29/2023 the facility identified inaccurately coded MDS assessments. Education was provided by the Administrator to the MDS nurses on MDS accuracy on 12/1/2023. The Administrator or designated manager will monitor MDS assessments weekly for 4 weeks and monthly for 2 months using the Quality Assurance tools to ensure assessments were coded correctly. The reports will be presented to the weekly Quality Assurance meeting by the Administrator or the Director of Nursing. Compliance will be monitored, and an ongoing auditing program will be reviewed at the weekly Quality Assurance meeting. The date of compliance was 12/2/2023. The plan of correction was validated by review of the education provided, review of the audits completed by the facility, and interview with the newly hired MDS nurse regarding education received and monitoring in place. MDS assessments completed after 12/2/2023 were reviewed for accuracy and no issues were identified. The facility date of compliance of 12/2/2023 was validated.

Based on observations, record review and staff, resident, Nurse Practitioner, and Law Enforcement Detective interviews the facility failed to protect Resident #1 right to be free from sexual abuse by Resident #2, who was his roommate. Resident #1 was severely cognitively impaired and did not have the capacity to consent to sexual activity. Resident #2 had intact cognition. On 3/30/23 Resident #2 was observed by two Nurse Aides (NA #1 and NA #2) at Resident #1's bedside. Resident #1's brief was opened, and Resident #2 was rubbing Resident #1's penis with his hand. Using the reasonable person concept, all residents would expect to be free from sexual abuse in their home and could experience anger, anxiety, fear, and depression. This was for 1 of 3 residents reviewed for resident abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy, epilepsy, and major depressive disorder and developmental delay. A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 was severely cognitively impaired, had unclear speech (slurred or mumbled words) and usually understood others. The MDS showed that Resident #1 required extensive assistance from one to two staff members for activities of daily living (ADL). Resident #1 was assessed as being always incontinent of bowel and bladder. Resident #1's care plan revised on 1/30/23 revealed a focus area which stated, Resident #1 has impaired cognition function with impaired thought processes related to disease process of cerebral palsy and being developmentally delayed. Interventions included: Ask yes/no questions in order to determine needs, approach resident from the front in a calm an unhurried manner, identify yourself at each interaction, face me when speaking and make eye contact, reduce distractions with communication by turning off the television, radio, resident understands simple, directive sentences. provide the resident with necessary cues and stop and return if agitated. Resident #2 was admitted to the facility on [DATE] with a diagnosis of Type II diabetes, history of falling, and major depressive disorder. A comprehensive Minimum Data Set assessment dated [DATE] coded Resident #2 as being cognitively intact and needing extensive assistance with the support of 2 persons in the areas of transfer and extensive assistance with the support of one person for dressing, toilet use and personal hygiene. Resident #2 used a wheelchair for mobility and was coded as not steady, only able to stabilize with staff assistance for surface-to-surface transfers. Resident #2 was assessed to not display any behaviors such as physical or verbal symptoms directed towards others. A review of a facility reported incident dated 3/30/23 revealed staff witnessed Resident #2 masturbating. Resident #1 while Resident #1 was lying in bed. A review of the facility investigation dated April 6, 2023, read in part; Resident #1 and Resident #2 were roommates. Two Nurse Aides reported they saw Resident #2 hands down Resident #1 pants as they were walking by his room and had his hands around Resident #1's penis. The Nurse Aides immediately stopped the action and Resident #2 was separated from Resident #1 immediately and Resident #2 was put on one-to-one care. A room move was completed, and Resident #2 was moved into a room with alert and oriented resident while still being on one-to-one care. Resident #1 was assessed and did not present any frightened or withdrawn behaviors and had no change in his normal daily activities. Resident #1's responsible party was notified. The local police department was notified and has forwarded the investigation to the detective section of the police department, and it was an on-going investigation. Adult protective services were notified .in conclusion, based on interviews and witness statements, our facility has decided to substantiate the allegation of sexual abuse. A review of an undated signed statement from Nurse Aide #1 read; I saw on the morning of 3/30/23, at (name of nursing home) me and another CNA was taking the trash out that morning, was at the end of the 300 hall, walked by 315, which is Resident #1 and Resident #2's room. Saw Resident #2 by Resident #1's bedside, cover was pulled down, Resident #1's gown was pulled up, diaper was undone, Resident #2 had his hand on Resident #1's private area, using an up and down motion on his privates, we asked at that time Resident #2 what are you doing he jumped and moved his wheelchair to his side of the room, then we asked Resident #1 what was he doing to you, he had a scared look on his face, also asked Resident #1 why his diaper was open, Resident #2 responded he likes it that way, me and the other CNA reported this to the nurse as soon as it happened, Resident #2 was removed from Resident #1 and replaced in another room. An interview was completed with NA #1 on 4/25/23 at 1:32 PM. NA #1 witnessed the incident on 3/30/23 between Resident #1 and Resident #2. NA #1 stated that she had been with NA #2 to take out the trash on 3/30/23 before her shift was ending at 7:00 AM and observed Resident #2 in his wheelchair leaning over Resident #1's bed and had his hand on Resident #1's penis and his hand was going up and down. NA #1 asked Resident #2 what he had been doing and why Resident #1's brief was undone. Resident #2 told NA #1 that Resident #1 liked it that way and wheeled back to his side of the room immediately. NA #1 reported Resident #1 did have an erection. NA #1 stated that to her knowledge, Resident #1 had never undone his brief or tried to take it off. NA #1 stated Resident #1 had a confused look on his face when they (NA #1 and NA #2) entered the room and reported after the sexual encounter Resident #1 seemed a little down and had his head was down looking sad. NA #1 reported there was no evidence this happened before. NA #1 stated she was shocked by the sexual encounter between Resident #1 and Resident #2. NA #1 reported sometimes the door would be closed but staff would open it as Resident #1 had a seizure disorder and staff liked to have the door open in case Resident #1 would have a seizure. NA #1 stated sometimes Resident #2 would try and help Resident #1 by pulling the covers over him but never had witnessed anything that would cause concern. NA #1 reported that Resident #1 would refuse ADL care and really had to get to know the staff before allowing the NA to assist. NA #1 stated Resident #2 required transfer assistance by staff and used a stand up to lift transfer method so he would not be able to go over to Resident #1's bed independently unless he was up in his wheelchair. NA #1 reported that since the incident Resident #1 seems happy and will wave and smile when NA #1 walked by. A review of an undated signed statement from Nurse Aide #2 read; On Thursday March 30, 2023 around 6:30 AM I (name) and another CNA were walking down the 300 hallway to attempt to take the trash out upon doing so walking up towards room [ROOM NUMBER], which the door was opened, me and CNA observed Resident #2 with his right hand moving up and down very fast while holding Resident #1's penis in his hand. The brief was torn open. Resident #1 was asked by myself what was he doing. Resident #1 stated he wasn't doing anything but then stated that Resident #1 asked Resident #2 to change his brief. Resident #2 then tried to hurry up and fix the brief and stated Resident #1 no longer wanted to be changed. I, myself had just left room [ROOM NUMBER] before this occurred after getting Resident #2 up, I proceeded to try and do cares for bed A which Resident #1 refused to be cleaned up. Resident #1 had a very distraught look on his face. An interview was completed with NA #2 on 4/25/23 at 3:14 PM. NA #2 stated she had witnessed the incident on 3/30/23 between Resident #1 and Resident #2. NA #2 stated that on 3/30/23 she and NA #1 had been taking the garbage out around 6:40 AM and walked by Resident #1 & Resident #2's room and observed Resident #2 had his right hand on Resident #1's penis. NA #2 stated Resident #1's penis was erect, and Resident #1 was just lying in his bed with a distraught look on his face. NA #2 stated we (NA #1 & NA#2) asked Resident #2 what he was doing, and he said to NA #1 and NA #2 Resident #1 asked Resident #2 to change him. NA #2 reported she told Resident #2 that Resident #1 could not talk and would not be able to verbalize he needed to be changed. NA #2 reported Resident #2 tried to cover Resident #1 back up and replied, Yes, he did ask me to change him and wheeled back over to his side of room. NA #2 stated Resident #1 could be difficult (refusing care) about his personal hygiene and would not signal anyone to change him. NA #2 reported Resident #1 was willing to have her (NA#2) complete his ADL, but when she first started working with him, he would not let her. NA #2 reported Resident #1 needed to get to know a person first before he would allow them to provide care. NA#2 confirmed she was assigned to Resident #1 and Resident #2 on 3/29/23 from 11:00 PM to 7:00 AM and Resident #2 was the last resident she had gotten up out of bed during her shift around 6:00-6:30 AM. NA#2 had not witnessed any sexual encounter previously with Resident #1 and Resident #2 and was surprised when she witnessed it. NA #2 stated that she had reported the sexual encounter to the Nurse on duty. An interview was completed with NA #3 on 4/25/23 at 2:07 PM who stated she had worked on 3/30/23 and at 7:05 AM provided care ADL care for Resident #1 which included changing his brief. NA #3 reported Resident #1 was happy to see NA #3 and appeared no different than previous days she had cared for him. NA #3 explained Resident #1 had not refused his care on the morning of 3/30/23 and had always been cooperative when NA #3 would provide his care but knew Resident #1 would refuse care from other NAs. NA #3 explained she had not witnessed any type of sexual inappropriateness between Resident #1 and Resident #2 and was surprised to learn of the sexual encounter. A risk assessment note written by the Director of Nursing dated 3/30/23 read in part; staff separated roommate from resident, 1:1 Initiated with roommate and roommate moved to a room with an alert and oriented roommate. Resident (Resident #1) assessed by nursing staff, no complaints of pain or visible injury noted. No acute distress noted. Incontinent care provided by staff. An interview was completed with the Director of Nursing (DON) on 4/25/23 at 4:20 PM who stated the report to her was two staff were walking down the hallway and observed inappropriate movement of Resident #2 on Resident #1's private area. The DON explained they quickly got Resident #2 away from Resident #1 and had Resident #2 with 1:1 care. Resident #2 was moved to a room with a resident who was alert and oriented as it was believed it could reduce the risks of sexual abuse to reoccur as the resident could verbalize and understand if something bad like an unwanted sexual encounter would occur. DON reported that when she arrived at the facility on 3/30/23 she saw Resident #1 approximately between 8:00 AM and 8:30 AM and he appeared fine and was not scared. The DON reported that Resident #2 and Resident #1 had been roommates for over a year, and they gotten along good, and Resident #2 would look out for Resident #1 and would try to help Resident #1 by offering to shave him, however the staff did not let that occur. The DON stated that the facility had maintained 1:1 care with Resident #2 every shift and the Social Worker (SW) completed daily rounds on both Resident #1 and Resident #2 to ensure Resident #1 did not have any psychosocial (changes in how a person would think, their feelings, moods, or ways of coping) effects from the incident. DON stated that once Resident #2 could not go back to his old room with Resident #1 he wanted to go to a different facility where he had a friend. The DON reported that full body audits were completed on all residents that were not alert and oriented and interviews with residents that were alert and oriented revealed no concerns related to sexual abuse. An interview was completed with Resident #1 on 4/25/23 at 1:00 PM who was sitting in his chair next to his bed with numerous toys in front of him. Resident #1 was receptive to conversation by shaking his head, smiling and grunting but was unable to answer any specific questions regarding the incident with Resident #2 nor did he change his facial expressions when asked about the incident. Resident #1 appeared happy and was pointing to his walls which were adorned with cartoon characters. An undated signed statement from Resident #2 was reviewed. It read; I Resident #2, was trying to help Resident #1 change his brief because I saw that his brief was soiled. When I asked him if he wanted me to change it, he nodded his head showing that he did. When the CNAs (certified nursing assistants) walked in, they saw what I was doing. I know that I should not have touched him or tried to change his brief, I knew that it was wrong from the beginning, but I wanted to help him. I would never do anything to hurt him. I care about Resident #1. The statement was signed by Resident #2. A telephone interview was completed on 4/26/23 at 12:57 PM with Resident #2. The DON at the facility he had transferred to was present during the phone call to assist Resident #2 with any difficulties with the phone. Resident #2 stated the only thing that happened on 3/30/23 was that Resident #1 wanted help to change his diaper. Resident #2 was asked how he knew that, and Resident #2 stated he pointed to his middle part. Resident #2 stated then Resident #1 asked him to stop and repeated he was trying to change Resident #2's wet diaper. Resident #2 was asked if he had his hands on Resident #1's penis and he replied No. Resident #2 stated that two staff asked him what he was doing, and he (Resident #2) had stopped changing Resident #1. Resident #2 stated he had never changed Resident #1's diaper before. An interview was completed with Nurse #1 on 4/25/23 at 3:01 PM and she stated she had never witnessed any sexual abuse between Resident #1 and Resident #2, and she was surprised to learn of the incident. Nurse #1 explained Resident #2 spent time knitting in his room or would like to roam the hallways talking to other people. Nurse #1 reported when Resident #1 was in a different room (3/30/23 to 4/4/23 unable to recall exact date of conversation) Resident #2 was adamant about going back to his room with Resident #1 and stated to Nurse #1 if he could not go back to his room he wanted to move to a different facility. Nurse #1 reported that Resident #1 had been more friendly and interacted more with Nurse #1 since the incident and seemed happier and had not refused his medications. A telephone interview was completed with Resident #1's responsible party (RP) on 4/25/23 at 7:00 PM. The RP explained that she went to see Resident #1 on 3/31/23 and Resident #1 was in good spirits and appeared to be his usual self. RP had never known Resident #1 to have any sort of sexual encounter like what happened on 3/30/23 and was certain he did not understand what was being done to him. RP said that she was aware of Resident #1 refusing care and first had to get to know his NA before he would cooperate. RP had small conversations with Resident #2 when she would visit Resident #1 and had no concerns with Resident #2. A review of a Nurse Practitioner progress note dated 4/3/23 at 4:00 PM read in part; The DON and Social Worker (SW) asked me to see patient (Resident #1) regarding an incident that occurred with another patient (Resident #2) involving a sexual encounter. Staff states that this patient can't consent to any sexual encounters due to cerebral palsy. DON stated police were notified of the incident as well as State and other protocols were followed. Patient was asked about the encounter, but he makes incomprehensible sounds at baseline. A physical exam was attempted, but the patient refused holding his pants tightly. An exam attempt will be tried again later this week. The Nurse Practitioner noted Resident #1 seemed withdrawn during interaction. An interview was completed with the Nurse Practitioner (NP) on 4/26/23 at 11:28 AM. NP saw Resident #1 for an examination on 4/3/23 and he would not allow the NP to pull his pants down to do an examination of his peri area. The NP explained Resident #1 had communicated by gestures of arms and facial expressions that he did not want the NP to touch him. NP was able to listen to his heart and lungs. NP explained that was the first time on 4/3/23 she had met Resident #1. NP saw Resident # 1 on 4/26/23 at 11:15 AM and reported Resident #1 was very cooperative, and she was able to examine Resident #1's peri area. NP stated there were no bruises and no redness to his peri area. NP confirmed if Resident #1 was bruised, bruises could be observed up to 6-8 weeks after an injury. NP reported she did not have any other concerns for Resident #1. An interview was completed with the Administrator on 4/25/23 at 10:43 AM who stated Resident #2 and Resident #1 had been roommates for 18 months. The Administrator stated Resident #2 had always been kind to Resident #1 and did not believe this sexual incident had happened previously. Resident #1 never showed any kind of behavior towards Resident #2. The Administrator believed that Resident #2 did not think he had done anything wrong. The Administrator stated Resident #2 was asked if he touched Resident #1 and Resident #2 replied no, he did not and then admitted yes, he did touch him. Resident #2 was then asked did you touch his brief and Resident #2 stated no, well yes, I did touch his brief, Resident #2 was asked did you touch his penis, Resident #2 replied no, well yes I did touch his penis The Administrator asked Resident #2 why he did it, and Resident #2 told the Administrator that Resident #1's brief was soiled and Resident #2 was going to help change him. The Administrator stated that Resident #2 was separated from Resident #1 in another room with an alert and oriented male resident and Resident #2 did not like the new room and wanted to go back with Resident #1, the Administrator told Resident #2 he could not. The Administrator stated he offered Resident #2 a different room and Resident #2 stated if he could not go back to being roommates with Resident #1, he wanted to go to another facility. The Administrator had reported that when Law Enforcement came to the facility to take a report on 3/30/23 they had referred the case to the detective due to the nature of the sexual encounter. The Administrator reported the Detective visited the facility the week of April 3, 2023, and interviewed Resident #1 and the NAs who witnessed the incident. The Administrator indicated Resident #2 had been discharged at the time of the Detective's visit. An interview was completed on 4/26/23 at 9:00 AM at the local law enforcement agency with the detective assigned to the case for Resident #1 and #2. The Detective stated he had interviewed Resident #2 at his new facility (date unknown) and stated during the interview with Resident #2 he felt Resident #2 was trying to use his age, being in a nursing home as a method to minimize his sexual behavior and told the Detective he (Resident #2) had not done anything wrong. The Detective stated Resident #2 never admitted to doing anything wrong to Resident #1 and reported he (Resident #2) was changing Resident #1's diaper. The Detective stated that he did inform Resident #2 he could go to jail and stated Resident #2 appeared a little more nervous when hearing this but never admitted to any wrongdoing. The Detective reported he was waiting for medical information from the facility Resident #2 is at and once that is received, he will present the case to the District Attorney regarding pressing any charges. The Detective reported he attempted to interview Resident #1 the week of April 4th (no specific date given) at Resident #1's facility but due to his impaired cognition he was not able to answer any questions the detective asked. The Administrator was notified of the Immediate Jeopardy on 4/26/23 at 5:12 P.M. The facility provided the following corrective action plan with a compliance date of 4/5/23: Corrective action for resident involved: On March 30, 2023, at approximately 8:00am, two certified nursing assistants reported to charge nurse that they witnessed Resident #2 with his hand in Resident #1's brief around his penis as they were walking past room [ROOM NUMBER] to take out trash. Nurse aide #1 immediately removed resident#1's roommate, Resident #2, from room and notified charge nurse and remained with resident #2, who was cognitively intact, while nurse aide #2 stayed with resident#1. On 3/30/2023, upon notification by phone of incident, the Director of Nursing drove to the facility to meet with Resident #1, who was severely cognitively impaired, with a diagnosis of Cerebral Palsy and was assessed by the Director of Nursing for any injury on the resident's body as a result of the alleged abuse and incontinent care was provided for resident #1. The assessment revealed that resident #1 had no obvious bruising or redness on his body or genitals. On 3/30/2023, the Director of Nurses notified Resident #1's responsible party and the Medical Director of the alleged abuse. On 3/30/2023, once determined that there was suspected abuse the Administrator notified police and Adult Protective Services and submitted initial allegation report to State Survey Agency. On 3/30/2023, the Administrator and Director of Nursing interviewed resident #2 regarding alleged abuse. Resident stated he was attempting to change resident #1's brief. Immediately following the incident, resident #2 was transferred to room [ROOM NUMBER]B and placed on 1:1 supervision in which he remained until his discharge on 4/4/2023. On 3/30/2023, the Director of Nursing and Administrator interviewed each of the two nurse aides separately to get details of the alleged abuse. During the interviews, each nurse aide also completed a reenactment of the event. On 4/5/2023, the Administrator concluded alleged abuse and based on investigation findings substantiated alleged abuse of resident #1. On 4/6/2023, the Administrator submitted an investigation report to the State Survey Agency with findings. Corrective action for potentially impacted residents: On 3/30/2023, the Director of Nursing identified residents that were potentially impacted by this practice by completing head to toe body audits on all residents with a BIMS below 13 on all current residents. The results included: 47 of 47 residents had no areas of concern identified related to skin integrity or potential injuries. On 4/3/2023, all current residents with a BIMS of 13 or above were interviewed by the Administrator and were asked if they had any concerns related to sexual abuse or been approached by anyone about having sex or been touched inappropriately. The results included: 34 of 34 residents denied any alleged abuse occurred. On 3/31/2023, the Administrator audited grievances for the last 30 days and Resident Council Minutes for any concerns related to abuse. The results included: There were no grievances or Resident Council Minutes that included any abuse. On 3/31/2023, the Administrator audited resident#2 chart to assure that sex offender registry was reviewed as part of the new admission process. The results included: sex offender registry checked prior to resident admitting to facility and resident #2 was not on the sex offender registry. On 4/3/2023, the Director of Nursing (DON) interviewed all full-time, part-time, and PRN (as needed) direct care staff including agency (licensed nurses, certified nursing assistants, and medication aides) to determine if staff had observed any sexual abuse or inappropriate touching of residents by anyone including resident #2. The findings of the audit were: No staff were aware of any other incidents involving sexual abuse or inappropriate touching. On 3/30/2023, after gathering more details, the Quality Assurance Committee convened to discuss the alleged abuse incident and the status of the investigation. On 4/4/2023, there was an additional Quality Assurance meeting attended by the Director of Nursing, Administrator, Interdisciplinary Team and the Quality Assurance Consultant to review the Abuse policy and status of the investigation. There were no additional findings at that time. Measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 3/30/2023 the Director of Nursing/Staff Development Coordinator began in-service of all full-time, part-time, and PRN (as needed) staff, administration, housekeeping, dietary, nursing, therapy and maintenance (including agency) on the abuse prohibition/reporting policy. This training will include all current staff including the agency. This training included: Abuse Types, reporting abuse allegations immediately to nurse/DON/Administrator, what to do if abuse observed or suspected, assuring resident safety, zero tolerance of retaliation of reporting allegations of abuse, addressing challenging behaviors and catastrophic reactions, along with notification of local law enforcement, Adult Protective Services, and State Survey Agency. Staff were also asked if they were aware of any abuse occurring to any resident in the facility and what to do if observed or suspected. No staff were aware of any other abuse occurring in the facility. The Director of Nursing will ensure that any of the above-identified staff (all staff including agency) who do not complete the in-service training by 4/3/2023 will not be allowed to work until the training is completed. This training will be included in the new hire orientation for any newly hired staff. On 4/3/2023, the Administrator completed re-education related to resident's rights policy with all current residents with BIMS of 13 or higher and provided a copy of policy to residents. How the facility plans to monitor its performance to make sure that solutions are sustained: Beginning the week of 4/3/2023, The Administrator or designee will monitor the abuse process to ensure residents are free from abuse and any abuse identified reported and addressed according to facility policy using the QA Tool for Abuse. The Administrator or designee will interview 3 staff members to monitor if staff know the procedure for reporting alleged abuse and when and who to report to. Also, the Administrator or designee will interview 5 residents related to Abuse and how and when to report allegations of abuse. As a part of the interviews, the Administrator or designee will include questions pertaining to whether the interviewed staff observed or were they aware of any abuse. The monitoring will be completed weekly for 4 weeks and then monthly for 2 months or until resolved. Reports will be presented to the weekly Quality Assurance Committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and an ongoing auditing program reviewed at the weekly Quality Assurance Meeting. The weekly Quality Assurance Meeting is attended by the Administrator, Director of Nursing, Staff Development Coordinator, Minimum Data Set Coordinator, Therapy Director, Health Information Manager, and the Dietary Manager. The facilities corrective action plan with a compliance date of 4/5/23 was validated during the on-site review of 4/25/23 through 4/27/23 by the following: A review of completed audit logs was reviewed which included interviews with residents who were alert and oriented regarding if they (residents) had been approached by anyone relating to having a sexual encounter; audit logs related to body checks for any injuries which were conducted on residents who were not alert and oriented. An audit of staff abuse interview questions was reviewed regarding if staff had witnessed any sexual abuse, inappropriate touching to a resident in the facility, if so, did they provide safety to the resident, if yes, did the resident display any emotional response and if abuse was observed who it would get reported to. A review was completed of the resident rights training and review of the in-service sign-in sheet for alert and oriented residents. Audit logs that included the educational information provided to staff during the in-service and a review of in-service staff sign-in logs was reviewed. Randomly selected staff on all shifts were interviewed to verify if they have received training on sexual abuse as well as an interview with the staff educator who verified a follow-up training related to the sexual abuse incident on 3/30/23 had been planned. A review of the Quality Assurance Monitoring tool - Recognizing and Reporting Abuse/Neglect which began on 4/4/23 which included ongoing interviews with 3 staff weekly and 5 residents related to abuse allegations and reporting abuse verified the monitoring was being completed. Additional interviews with the Corporate Quality Assurance Nurse Consultant, the Administrator, Director of Nursing and the former Social Worker related to the monitoring plan were completed during the on-site review.

Based on record review and staff interviews the facility failed to report an allegation of sexual abuse to the State Agency, Law Enforcement and Adult Protective Services within two hours of becoming aware of the allegation for 1 of 2 abuse allegation reports reviewed for reporting alleged violations. (Resident #1). The findings included: Review of the facility policy revised on 9/2022 titled Abuse Prohibition, read in part: Definitions: e. Crime is defined by law of the applicable political subdivision where the facility is located. Examples of commonly accepted crimes include , sexual abuse . f. Criminal sexual abuse: serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conduct Serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or other sexual act involving a child. M. Sexual Abuse - is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. This is any non-consensual sexual conduct of any type. Covered Individuals Annual Abuse Reporting Guidelines: The timeframe requirements for reporting reasonable suspicion of crimes: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the Covered Individual must report the suspicion immediately, but not later than 2 hours after forming the suspicion. A review of an undated signed statement from Nurse Aide #2 read in part; On Thursday March 30, 2023 around 6:30 AM I (name) and another CNA (certified nursing assistant) were walking down the 300 hallway to attempt to take the trash out upon doing so walking up towards (Resident #1 and Resident #2's room), which the door was opened, me and CNA observed Resident #2 with his right hand moving up and down very fast while holding Resident #1's penis in his hand. An interview was completed with NA #2 on 4/25/23 at 3:14 PM who had witnessed the incident on 3/30/23 approximately 6:40 AM between Resident #1 and Resident #2. NA #2 stated that she had reported the incident to Nurse #2 who had worked the 11:00 PM -7:00 AM shift on 3/29/23. An interview was completed with the Support Nurse (Nurse #3) who stated that she had received a text message from Nurse #2 around 6:40 AM however Nurse #3 explained she had been sleeping and normally would not work on Thursdays (3/30/23). Nurse #3 stated she immediately contacted DON via phone at approximately 7:45 AM. An interview was completed with the Director of Nursing on 4/27/23 at 3:15 PM who stated that she learned of the incident from her support nurse (Nurse #3) who called her on the phone 7:30 - 7:50 AM. The DON explained that she was in her vehicle on her way to work and arrived at work around 8:00 AM and met with the Administrator when she arrived. A review of a Complaint Intake and Health Care Investigations Initial Allegation Report dated 3/30/23, revealed the Time the Facility Became Aware of Incident was documented as 11:30 AM. The date reported to Law Enforcement was 3/30/23 and the time was documented as 12:00 PM. The Allegation details read: Staff witnessed Resident #2 masturbating Resident #1 while Resident #1 was lying in bed. An email received from the Administrator dated 4/28/23 revealed that Adult Protective Services was notified at 11:45 AM on 3/30/23. An interview was conducted with the Administrator on 4/26/23 at 12:41 PM who was asked why the initial allegation report dated 3/30/23 indicated the facility learned of the incident at 11:30 AM documented on the report. The Administrator stated, As the Abuse Coordinator I found out at 11:30 AM.

Based on observations and staff interview, the facility failed to maintain sanitary conditions in the kitchen and in 1 of 2 nourishment rooms by not ensuring food items were not stored on the floor; by not ensuring resealed food items were dated/labeled; by not ensuring food service equipment remained free from debris; and by not ensuring dietary staff wore hair covering while preparing meal trays on the meal trayline. Findings included: 1. During the initial tour of the kitchen on 5/9/22 at 11:15 a.m., there were 2-cases labeled dinner napkins stored on the floor of the dry storage room and 2-cases (chicken and ground beef) stored on a large sheet tray beneath a storage rack in the walk-in freezer. On 5/12/22 at 5:30 p.m., there was 1-opened case of canned foods and 1-opened case of small porcelain plates stored on the floor in the dry storage room. 2. During the tour of the kitchen on 5/9/22 at 11:15 a.m., 5-resealed bags of noodles that were not dated were stored on the storage racks in the dry storage room. On 5/12/22 at 1:09 p.m., during an observation of 1 of 2 nourishment room refrigerators there were 2-(8 ounce) cartons of milks that were not dated and 1-opened box of single serve teabags that was not labeled with a resident's name, room number and date. In the dry storage room of the kitchen there were 2-resealed bags of noodles that were not dated. 3. The initial tour of the kitchen on 5/9/22 at 11:15 a.m. fine white particles were observed on the top of the lids of the flour and breadcrumb bins, and brown particles on the lid and handles of the cornmeal bin in the dry storage room of the kitchen. The filters in the vents of the hood over the stove contained thick, dark gray lint. When questioned, the Dietary Manager stated the hood was professionally cleaned every six months, but she was unable to recall when the dietary staff last cleaned the filters. The outer sides of the deep fryer and the floor surrounding the fryer consisted of thick brown/black grease build-up. On 5/12/22 at 1:09 p.m., the observation of 1 of 2 nourishment room refrigerators revealed a spilled brown liquid had frozen in the freezer compartment. The filters in the vents of the hood over the stove continued to be covered in thick, dark gray lint. The outer sides of the deep fryer and the floor surrounding the fryer remained dirty with thick brown/black grease build-up. 4. During the meal trayline service observation in the kitchen on 5/12/22 at 5:25 p.m., the two dietary aides were not wearing hair coverings while assisting the cooking with the meal tray preparation at the steamtable.

Based on observation, record review, family and staff interviews, and interviews with the physician and the orthopedic surgeon, the facility failed to have an effective plan in place to prevent recurrent falls of a cognitively impaired resident who had a fall with injury before admission. The resident fell three times in the facility within 2 weeks after admission and had a dislocated hip after the second fall. This is evident in 1 of 3 residents reviewed for falls. (Resident #1) Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Care Plan dated 1/22/19 for Resident #1 stated she had an actual fall before admission with risk for further falls due to communication and comprehension and unsteady gait. The goal of the care plan stated the resident would resume usual activities without further incident. Interventions in place were fall mats beside of bed, nonskid socks on resident, frequently used objects in reach, keep call light in reach, and anticipate needs. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and required extensive assistance with all activities of daily living, such as, moving about in bed, transferring to and from the bed, toileting, and eating. The assessment also revealed Resident #1 required extensive assistance of two staff members to walk. A review of a Falls Incident Report completed by Nurse #1 dated 1/22/19 at 7:25 am revealed Resident #1 had a fall and was found sitting in the doorway of her room on her buttocks. The report stated Resident #1 stated, I fell , but was unable to give details of the fall. She was assessed for injuries and none were found; and was assisted to her wheelchair and placed at the nurse's station for closer observation. The report also revealed the Responsible Party and the physician were notified of the fall. A review of Nurse's Note, written by Nurse #1, dated 1/22/19 at 7:34 am revealed Nurse Aide (NA) #2 walked past Resident #1's room door and found her sitting on the floor on her buttocks with bilateral legs drawn up. Resident #1 stated I fell on the floor but was not able to give any details. Resident #1 was assessed and no injuries were found. The note also revealed Nurse #1 notified the Family Member and the Physician of the incident. An interview with Nurse #1 on 2/18/19 at 2:20 pm revealed she was called to Resident #1's room on 1/22/19 by NA #2 when Resident #1 fell on [DATE] at 7:34 am. She stated the fall was unwitnessed and Resident #1 was in the bed before the fall and the fall mats were in place at the time of the fall. Resident #1 was not able to tell them what had happened. She stated she assessed her for injuries and then put her in the wheelchair, so she could watch her. She stated she did a lot of one on one with Resident #1 to keep her from falling. Nurse #1 stated Resident #1 did not have any safety awareness. An interview on 2/18/19 at 2:42 pm with NA #2 revealed she was the Nurse Aide that found Resident #1 sitting on the floor in her room on 1/22/19 at 7:34 am. She stated Resident #1 did not appear to be in pain and Nurse #1 assessed her for injuries before they moved her to the wheelchair. She stated the resident did not have non-skid socks on because she had taken them off but her fall mats were in place. Nurse Aide #2 stated the resident was moved to the nurse's station in her wheelchair. She also stated they did not have enough staff to sit with Resident #1, she stated they were usually only 3 Nurse Aides on the Skilled Unit. NA #2 stated she found Resident #1 on the floor shortly after she came on duty and she was making her first round. A review of the Falls Incident Report completed by Nurse #2 for a fall on 1/24/19 at 5:40 am. The report stated Resident #1 was heard yelling at the nurse's station and was observed lying on her left side on the floor. Nurse #2 wrote she observed the right knee was turned in and right hip was swollen. Nurse #2 wrote Resident #1 started screaming when she touched her right leg and she did not attempt range of motion on the leg or move Resident #1. Nurse #2 called the Nurse Practitioner and received orders to sent Resident #1 to the hospital for evaluation. Interventions added to Resident #1's Care Plan were sent to emergency room for evaluation; reinforce safety reminders; observe for possible side effects of medication; and physician to review medications. A review of the nurse's note written by Nurse #2 on 1/24/19 at 5:40 am revealed she heard Resident #1 yelling at the nurse's station, when she arrived at the nurse's station Resident #1 was lying on her left side on the floor. The note further revealed Resident #1's right knee was turned inward, and her right hip was swollen. Nurse #2 documented she did not move Resident #1 and called the physician on call for orders to send to the hospital for evaluation. The note also revealed she notified the Family Member of what had happened and Resident #1 was being sent to the hospital for evaluation. During an interview with Nurse #2 on 2/20/19 at 5:15 pm she stated she was Resident #1's nurse on 1/24/19 when she fell at 5:40 am. Nurse #2 stated Resident #1 was brought to the nurse's station that night in a reclining wheelchair to watch her more closely. Nurse #2 stated she had the 200 hall and the 400 Hall on 1/24/19 and she was on the 400 Hall on the other side of the facility when Resident #1 fell from the reclining wheelchair. She stated she had gone to the 400 Hall to pass meds and Resident #1 was asleep in her reclining wheelchair when she left, she stated she had left her a few minutes before. Nurse #2 stated she was the last staff to see Resident #1 before she fell . She stated they had only 3 Nurse Aides for the whole building that night, there should have been 4, and they could not monitor Resident #1 closely enough to keep her safe from falls. She stated at the time of the fall the Nurse Aides were all in rooms assisting other residents and the other nurse was on the 300 Hall. Nurse #2 stated she heard Resident #1 yelling and came back to the Nurse's Station and found her on the floor. Nurse #2 stated she did not move Resident #1 because her leg was turned in and she was in a lot of pain. She stated she called the physician on call and received orders to send her to the hospital, and then she called the Family Member to report what had happened. A review of the hospital Discharge Summary dated 1/25/19 revealed Resident #1 was taken to the Operating Room after reduction of the right hip hemiarthroplasty was unsuccessful in the emergency room . Resident #1 was taken to the Operating Room and underwent a closed reduction and the right hip was aligned. After recovering the anesthesia Resident #1 was transferred back to the facility on [DATE]. A review of the Fall Incident Report, written by Nurse #3, dated 2/6/19 at 7:45 am revealed Resident #1 was found sitting on the fall mat beside her bed, leaning on her left side with her immobilizer in place to her right leg. Resident #1 was assessed for injuries and assisted back to bed and her bed was in lowest position. Resident #1 was not able to state what had happened. Nurse #3 stated in the report she notified the physician on call and obtained an x-ray of the right hip to ensure the hip did not dislocate. A Nurse's Note dated 2/6/19 at 2:06 pm revealed Nurse #3 had notified the physician on-call and the Family Member of the fall and obtained new orders for an x-ray of Resident #1's right hip. An interview with Nurse #3 on 2/19/19 at 9:00 am revealed she was working when Resident #1 fell on [DATE] at 7:45 am. Nurse #3 stated she was on the 300 hall and a Medication Aide was working on Resident #1's hall when she fell . Nurse #3 stated when she got to the 200 hall Resident #1 was lying on her left side on the floor and her immobilizer was in place to her right leg. She stated she spoke with the Family Member when she came to the facility that morning and told her how Resident #1 was found and she obtained an order for [REDACTED].#3 stated the right hip x-ray was negative for new fracture or dislocation. Nurse #3 stated about a week later she was working on the 300 hall and a Medication Aide was on the 200 Hall, and the Family Member came to her and told her Resident #1 needed to be sent out to the hospital because her right hip was dislocated. Nurse #3 stated no one had told her Resident #1 needed to be assessed. Nurse #3 stated with a Medication Aide on the 200 hall and her having the 300 Hall, she could not take care of that many residents. She stated she had spoken with the Director of Nursing last week and told her she could not manage that many residents. An interview with Nurse Aide #2 on 2/18/19 at 2:42 pm indicated she had been getting residents up for breakfast when she walked by Resident #1's room and saw her sitting on the floor mat beside her bed. She stated her immobilizer was in place but she did not have nonskid socks on, she stated Resident #1 would take her nonskid socks off. Nurse Aide #2 stated Resident #1's bed was in the lowest position. Nurse Aide #2 further revealed Resident #1 did not appear to be in any pain. During an interview with the Medication Aide on 2/18/19 at 3:14 pm she stated she worked the 200 Hall when Resident #1 fell on [DATE] at 7:45 am. She stated Resident #1 did not appear to be in pain when she was found on the floor in her room on the fall mat beside her bed. She stated Nurse #3 assessed Resident #1 for injuries and they assisted Resident #1 back to bed. She stated Resident #1 did not grimace or cry out when they moved her back to the bed. She stated she had not been to Resident #1's room that morning and she had arrived at 7:00 am. Review of Nurse's Note dated 2/13/19 at 12:56 pm revealed the Family Member reported to Nurse #4 that Resident #1's right foot looked like it was turned in and requested an x-ray. Nurse #4 obtained an order for [REDACTED].>A review of Nurse's Note dated 2/14/19 at 12:25 am revealed Nurse #5 received an x-ray report which stated Resident #1 had a dislocated right hip prosthesis. Review of Nurse's Note dated 2/14/19 at 2:15 am revealed Nurse #5 spoke with the Physician and reported the right hip x-ray showed the right hip was dislocated. Orders were received to call the surgeon in the morning since Resident #1 was resting quietly and had no signs of pain. A Nurse's Note dated 2/14/19 at 6:11 am revealed Nurse #5 spoke with Resident #1's Family Member and reported the results of the right hip x-ray, the right hip was dislocated. The Family Member told Nurse #5 that she would call the Orthopedic Surgeon and see if they can do surgery to repair today. Review of a Nurse's Note dated 2/18/19 at 8:43 am revealed Resident #1 was sent to the hospital by ambulance on 2/15/19 and she was admitted . Review of the Discharge Summary from the hospital dated 2/18/19 revealed Resident #1 had a removal of the right hip prosthesis on 2/17/19 and she was discharged from the hospital to the facility on [DATE]. An observation of Resident #1 on 2/19/19 at 6:20 am revealed she was resting quietly in bed with a sitter at the bedside. An observation of Resident #1 on 2/20/19 at 12:15 pm revealed she was resting quietly in bed with a sitter at bedside. An interview with Resident #1's Family Member on 2/19/19 at 8:48 am revealed two family members were staying with Resident #1 from 8:00 am until 7:00 pm and she hired a sitter to sit with her from 7:00 pm until 12:00 am to keep Resident #1 from falling. The Family Member stated they had been sitting with her since the first fall on 1/22/19. The Family Member stated all she expected was for someone to check on Resident #1. The Family Member stated she felt the facility was very understaffed with Nurse Aides and that had been the reason her mother fell on [DATE] and dislocated her hip the first time. She stated there had only been three Nurse Aides that night to care for all the residents. During a phone interview with the Physician on 2/19/19 at 3:15 pm she stated Resident #1's right hip dislocated because of her age and co-morbidities. She stated due to her age her tendons would likely be looser around the joints and it would cause her to dislocate. She stated she felt Resident #1 should have had a hip replacement when she fell before coming to the facility and she would have had a better outcome. The Physician stated it was not necessarily the falls that cause Resident #1's dislocation, and she could have dislocated by just being turned in the bed. The Physician stated she would not be surprised if Resident #1's right hip dislocated again because of her cognition and behaviors. A phone interview with the Orthopedic Surgeon on 2/20/19 at 9:00 am revealed he felt it would be difficult to say that Resident #1's right hip dislocated because of a fall because she had so many other co-morbidities. He stated he did know when she had surgery before coming to the facility that Resident #1's hip was in place because he had checked her range of motion to the hip before she left the operating room and the hip was in place. He stated if it had not been in place it would have dislocated with the examination. The Orthopedic Surgeon stated Resident #1's right hip should not have dislocated with her being combative, he stated she would have to be extremely strong to dislocate her hip. During an interview with the Director of Nursing (DON) on 2/19/19 at 2:02 pm she indicated the staffing for Nurse Aides had been very low because she was not getting any applications until recently. She stated she had hired several Nurse Aides but they were still in orientation. She stated on 1/24/19 at 5:40 am when Resident #1 fell there were 3 Nurse Aides on duty on 11:00pm to 7:00am shift, and she indicated there should be 4 Nurse Aides. She further indicated on 2/6/19 at 7:45 am when the resident fell there were 7 Nurse Aides working on the 7:00am to 3:00pm shift and there should have been 9. The DON stated the facility had a clinical meeting each morning and the falls were discussed at the meeting. She stated the MDS Coordinator updates the care plans for each resident with falls. The DON stated Resident #1 had poor cognition and poor safety awareness. She also stated Resident #1 had behaviors of resisting care when she was bathed and provided incontinence care; and she hit, fought, and cursed staff. She stated they had put interventions, such as, anticipating her needs, encouraging her to wear nonskid socks, and observing for possible side effects of medication that may affect balance on admission. She further stated they had added fall mats and bed in lowest position after the fall on 1/24/19. After the fall on 2/6/19 the DON indicated the facility had obtained orders for a right hip x-ray to ensure the hip was not dislocated. On 2/20/19 at 5:00 pm with the MDS Coordinator she stated the facility meets every morning for a clinical meeting and falls are discussed in that meeting. She stated she updated the care plans with the interventions that are put into place from any falls and if the interventions in place are working. The MDS Coordinator indicated they had discussed Resident #1 after each fall. She further indicated on 1/22/19 the facility had put an interim care plan into place and interventions were anticipate needs as much as possible; educated resident about safety reminders; encourage to wear non-skid socks when not wearing shoes; keep frequently used objects within reach; and observe for side effects of medications. The MDS Coordinator stated on 1/24/19 the facility added fall mats; keep call light in reach; reinforce safety reminders frequently; and sent to the emergency room for evaluation. The MDS Coordinator stated on the 2/6/19 the intervention was the x-ray to determine if Resident #1's hip had dislocated. On 2/20/19 at 6:10 pm an interview with the Administrator revealed he expected staff to take measures to ensure residents were safe from falls and accidents.

Based on record review; staff, resident, and family member; and physician interviews the facility failed to provide enough nursing staff to ensure assistance with activities of daily living, such as, incontinence care for 1 of 4 residents reviewed; failed to honor resident requests when they wanted to get out of bed for 1 of 4 residents reviewed for preferences; and failed to protect 1 of 4 residents, Resident #1, from accidents. Resident #1 fell on [DATE] and was sent to the hospital for evaluation and treatment. Resident #1 was diagnosed with [REDACTED]. The findings included: This tag is cross-referenced to: 1a. F-677: Based on record review, staff and resident interview the facility failed to provide assistance with toileting for 1 of 4 residents, Resident #2, reviewed for assistance with activities of daily living. 1b. F-561: Based on record review and staff and resident interviews the facility failed to get a resident out of bed when requested for 1 of 4 sampled residents, Resident # 6, reviewed for preferences. 1c. F-689 Based on record review, staff interviews, interviews with the physician and the orthopedic surgeon the facility failed to provide adequate supervision to prevent falls that resulted in a hip dislocation in 1 of 3 residents, Resident #1, reviewed for accidents. Resident #1 had a right hip hemiarthroplasty on 1/17/19 before she admitted to the facility. She fell on [DATE] and sustained a right hip dislocation and was sent back to the hospital for a closed right hip reduction. Resident #1 had a third dislocation without a fall on 2/15/19 and was discharged to the hospital and on 2/17/19 she had surgery to remove her right hip prothesis. An interview on 2/18/19 at 3:40 pm with Nurse Aide #3 revealed it was not possible for her to provide care rounds every 2 hours and assist residents to the bathroom because she had too many residents due to low staffing. During an interview on 2/18/19 at 3:20 pm with Nurse Aide #7 she stated she usually worked 7:00 am to 3:00 pm shift but she did work overtime on 3:00 pm to 11:00 pm shift. She stated they were very short of staff and the residents suffered. She stated they usually only get two rounds in a shift. She stated she tried to get back to the residents that were more incontinent between rounds. She stated they worked with 4 Nurse Aides for the whole building 5 out of 7 days a week. She stated the staff were exhausted and they called out. An interview on 2/18/19 at 3:40 pm with Nurse Aide #8 revealed she worked the 3:00 pm to 11:00 pm shift. She stated they were so short on staff she can assist with incontinence care like they should be, she stated she usually only got two rounds done a shift. She stated the residents also waited a long time for their lights to be answered. Nurse Aide #3 was interviewed on 2/18/19 at 3:42 pm and she stated she usually worked the 7:00 am to 3:00 pm. She stated it was not possible to get more than one round and answer call lights with the low staffing. She stated the incontinent residents were wet longer than they should be and the residents that were not incontinent were waiting at least 30 minutes on staff to assist them. An interview with Nurse #5 on 2/19/19 at 7:25 am revealed the staffing on the 11:00 pm to 7:00 am shift was inadequate. She stated they were usually only able to get two care rounds complete and the care rounds should be every 2 hours or 4 times a shift. During an interview with Nurse #6 on 2/19/19 at 7:37 am she stated the staffing of Nurse Aides was insufficient. She stated they usually got two care rounds done each shift because there were so many residents to each Nurse Aide. She stated there were usually only two Nurse Aides on the Skilled Unit on 11:00 pm to 7:00 am shift. During an interview with Nurse #1 on 2/19/19 at 2:20 pm she stated the facility was so understaffed with Nurse Aides that it made it hard for the nurses to complete their work because they tried to help the Nurse Aides. She indicated there were usually 3 Nurse Aides for the skilled unit (100 Hall, 200 Hall, and 300 Hall) for the 7:00 am to 3:00 pm shift and there should be 5. During an interview with the Director of Nursing (DON) on 2/19/19 at 2:02 pm she stated she was not aware the staff were not able to complete personal care, including toileting, as they should. She stated they had been understaffed, mostly on 3:00 pm to 11:00 pm and 11:00 pm to 7:00 am shifts. The DON stated she was aware the Nurse Aides were giving residents bed baths instead of showers, but she was not aware residents had waited 30 minutes to an hour to use the toilet. The DON stated she had recently hired several Nurse Aides and they would be through orientation soon and the facility would be staffed on all shifts. The DON stated when she was fully staffed there were 9 Nurse Aides on 7:00 am to 3:00 pm shift; 6-7 Nurse Aides on the 3:00 pm to 11:00 pm shift; and 4 Nurse Aides on the 11:00 pm to 7:00 am shift. An interview with the Administrator on 2/20/19 at 6:10 pm revealed he expected the staff to assist with toileting and answer call lights timely. He stated he expected the nursing department to be staffed to provide man power to ensure all residents needs were met.

Based on observations, record review and staff interviews, the facility failed to provide supervision to prevent a cognitively impaired resident from exiting the facility for one of one resident reviewed for supervision. Resident #18 who was cognitively impaired exited the facility and was found approximately 50 feet away from the entrance door in 32 degree Fahrenheit weather. Immediate jeopardy began on 12/9/17 when the facility failed to maintain a safe environment as evidenced by a resident who had been identified as a wandering risk who had cognitive loss to have eloped from the facility and was discovered approximately 50 feet from the facility front entrance, on the sidewalk, at the covered drop off/pick area unaccompanied and without supervision. The facility failed to provide supervision which resulted in Resident #18 and other residents to be at risk for elopement at risk for a repeat incident. The Immediate Jeopardy was removed on 1/6/17 at 12:16 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Resident #18 was admitted to the facility 7/5/16 with [DIAGNOSES REDACTED]. A review of Resident #18 ' s Minimum Data Set (MDS) revealed the most recent completed assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 10/5/17. The MDS assessment indicated Resident #18 was severely cognitively impaired. The resident was coded as having had exhibited wandering type behavior for 1-3 days during the seven day look back period of the assessment. The resident was coded as requiring supervision for walking in his room, in the corridor and for moving between locations both on and off of corridor. Review of Resident #18 ' s care plan, dated 10/8/17, revealed the resident had a focus area for being an elopement risk/wanderer as evidenced by the resident wandered aimlessly, had impaired safety awareness, was disoriented to place, and had a history of [REDACTED]. The care plan goal specified the resident would not leave the facility unattended. Listed interventions included: Distract resident from wandering, identify pattern of wandering, monitor location, and use of a wander alert anklet transmitter. A review of the medical record for Resident #18 revealed a nurses ' note written by Nurse #6, dated 12/9/17, which read in part: This nurse was alerted of elopement of resident. Resident was wearing an anklet transmitter at the time of elopement. The alarm only sounded when he entered the building. The elopement was documented as having occurred at 12:32 PM. An interview with the physical therapy assistant (PTA) on 1/4/18 at 3:31 PM revealed she was working in the therapy gym on 12/9/17. The PTA stated she was working with a former resident who pointed out to her that Resident #18 was outside, on the sidewalk, and was at the point where the sidewalk met with the covered drop off/pick up area. The PTA stated the alarm on the front door was not sounding. The PTA said she went outside to assist the resident back inside. The PTA stated the resident did say what he was doing outside, but he said he was cold and was ready to go back inside the facility. She stated the resident was standing outside by himself, there were no other residents or visitors with the resident while he was outside. She stated the alarm did not sound until she was assisting him back through the door. The PTA walked with the resident to the 100/200/300 nurses ' station, the alarm continued to sound, and she informed the nursing staff the resident had been discovered to be outside. According to the PTA the alarm was still sounding when she reached the nurses ' station and a member of the nursing staff went and turned off the alarm at the front entrance. The PTA stated the nursing staff had commented the battery had been messed up on the transmitter and replaced the transmitter. An interview conducted with Nurse #6 on 1/4/18 at 6:52 PM revealed she was the nurse who completed the incident report for the elopement of Resident #18 and had spoken on the phone to the DON on 12/9/17. The nurse stated the PTA had brought Resident #18 to the 100/200/300 Hall nurses ' and informed the nursing staff the resident had been discovered outside under the awning at the pick up/drop off area. The nurse stated she had the PTA write a statement and she called the DON and informed her about the elopement. The nurse stated they attempted to discover how the resident had gotten outside. The nurse stated they started by testing the transmitters on the residents, including Resident #18, by taking them to the front door and the door did not lock. Resident #18 ' s transmitter was the only transmitter which was replaced. The nurse stated the maintenance director (MD) called a contracted service company who repaired the front door on 12/09/17. Prior to the service man coming to service the front door the nursing staff were making rounds to make sure another elopement would not occur. The nurse stated she remembered the service man coming to the facility standing at the front door and when he left he had stated the front door was in working order. She stated she checked the other residents ' transmitters ' function with the device from the manufacturer and found each one to be in working order. The nurse stated prior to the therapist bringing Resident #18 to the door she had not heard an alarm from the front door. In addition the nurse stated none of the other staff members she interviewed had heard an alarm when the resident exited the facility. The nurse was not aware of the last time someone had seen Resident #18 in the facility so she was unable to determine the length of time he was outside. She stated she assessed the resident when he came back into the facility and did not observe or discover any negative outcome from having been outside. The nurse also stated she called the resident ' s family and had notified them of the incident. An interview conducted with NA #3 on 1/4/18 at 2:17 PM revealed she was the NA assigned to Resident #18 during the time of the elopement on 12/9/17. The NA stated on 12/9/17 she was providing care for another resident on the 100 hall and had heard the alarm sound twice. She stated she did not see the resident exit or enter the facility. It was not till after the resident came back in the facility she was aware the resident had left the facility. The NA was unable to provide a time when she had last seen the resident prior to the elopement. A phone interview conducted with Nurse #7 on 1/4/18 at 6:29 PM revealed she was working on 12/9/17 at the time when Resident #18 eloped. The nurse stated she had not heard a door alarm when the resident had eloped. She stated when the MD was called he had instructed the nurses at the facility to call the contracted service company for the elopement security system. The service person arrived at the facility around 3:15 PM to service the alarm. An interview conducted with NA #1 on 1/4/18 at 5:09 PM revealed she had been working on 12/9/17 when Resident #18 was discovered outside and had not heard a door alarm sound. The NA further stated they did not have enough staff to have a staff member assigned to provide continuous monitoring of the front door. The NA stated as an additional preventive measure they closed the secondary doors to the front lobby as an extra barrier. A review of Resident # 18 ' s Treatment Administration Record (TAR) from 12/1/17 through 1/3/18 revealed a line item labeled, transmitter battery check every night by the night shift. Nightly checks were documented for all nights except for 12/6/17. There was an additional line item labeled, check the placement of the transmitter anklet to the right ankle every shift. There was documentation for each shift except for day shift 12/4/17, night shift 12/6/17, day shift 12/15/17, day shift 12/22/17, and day shift 12/28/17. A review of the weather conditions per Weather Underground web site revealed the following data for Salisbury, North Carolina (NC) on 12/9/17 at 12:05 PM were 32.0 degrees Fahrenheit (F) with no wind and overcast. The conditions at 12:25 PM were 32.2 degrees F, with a wind chill temperature of 28.9 degrees F. There was a North wind at 3.5 miles per hour (MPH). There was 0.02 inches of snow and the weather conditions were light snow. The conditions at 12:45 PM were 32.4 degrees F, with a wind chill of 29.1 degrees F. There was a Northwest wind at 3.5 MPH. There was 0.03 inches of snow and the conditions were light snow. The area where Resident #18 was initially observed to have been outside on 12/9/17 was approximately 50 feet 6 inches from the front entrance. The area was a covered and paved walkway which extended from the front entrance of the facility and connected to a covered pick up/drop off area connected to the parking lot. The reported site the resident was initially observed outside has a direct line of vision from the therapy gym. An observation of Resident #18 on 1/3/18 at 9:30 AM revealed the resident to be ambulating in his room without the assistance of a device or another individual. Resident appeared slightly unsteady but was able to ambulate to a chair located in his room and sit down unassisted. An interview conducted with Nursing Assistant (NA) #2 on 1/4/18 at 9:33 AM revealed Resident #18 was able to walk throughout the facility independently but had cognitive loss. The NA pointed out a transmitter anklet was on the resident ' s left ankle. The NA stated when the resident would get near a door which had a sensor, the sensor would pick up the signal from the transmitter and the door would automatically lock. An interview and observation was conducted with Nurse #5 on 1/4/18 at 9:46 AM in regards to how the automatically engaged magnetic lock worked on the front entrance door at the facility. Nurse #5 demonstrated the front door automatically locked when a resident with a transmitter anklet on her left ankle was wheeled toward the front door. When the resident was at the door, the magnetic lock on the door had engaged and the door was locked in a closed position and there was no audible alarm. When the resident was rolled away from the door, the magnetic lock disengaged and the door could be opened. The nurse further explained if the door happened to be open and there was a resident with a transmitter in the vicinity of the door, an audible alarm would sound. An interview and observation conducted with the Wound Treatment Nurse on 1/4/18 at 10:05 AM revealed she checked the transmitters on wandering residents. She stated she checked for placement, function, and the expiration date. She explained the function of the transmitters were checked with a device from the manufacturer of the transmitters. She demonstrated how she used the function testing device on Residents #18, #27, and #280. All transmitters were found to be in proper working order according to the Wound Treatment Nurse. In addition the nurse explained she checked the transmitters on the days she worked and it was the night nurses ' responsibility to check the transmitters for function nightly. The Wound Treatment Nurse stated she did not document her checks for the function of the transmitter anklets. An interview conducted with the Director of Nursing (DON) on 1/4/18 at 10:23 AM revealed Resident #18 had exited the facility on 12/9/17. The DON stated the resident was assisted back into the facility from an area near the front of the facility by a PTA. The DON stated she was unable to identify the exact length of time the resident was outside. The DON did not identify how the resident was dressed at the time he was discovered outside. The DON stated the nurses went and checked all of the residents with transmitters and Resident #18 ' s transmitter was discovered to be malfunctioning. The DON stated in addition to Resident #18 ' s transmitter malfunctioning there was a concern the front door magnetic lock for the elopement security system was not functioning properly. The DON stated there was not a specific individual assigned to provide continuous monitoring of the front door. The DON stated, she called the Maintenance Director (MD) on 12/9/17, after she was notified of Resident #18 exiting the facility, to inform him about the concern about the front door. The MD contacted the service company for the elopement security system and the company came out on 12/9/17 to service the door. The DON stated the transmitters located on the residents were checked for placement each shift by the nurses. The DON further stated the function of the transmitters were checked by the Wound Treatment Nurse when she worked and every night by third shift. The DON stated the doors were checked to make sure they were locked at the end of second shift every night by the second shift nurses. In regards to the function of the transmitter engaged electromagnetic lock located on the front door she stated it was checked periodically for function by the Maintenance Director. The DON stated she did not come to the facility on [DATE]. An interview conducted with the DON on 1/4/18 at 6:22 PM revealed she had not come in on 12/9/17. The DON stated she had spoken exclusively to Nurse #6 on the phone on 12/9/17. The DON stated she directed the nurse to check the transmitters and to change them if they were found to be out of date or out of order. The DON stated Resident #18 ' s transmitter was found to be malfunctioning and it was replaced. The malfunctioning transmitter was discarded. The DON stated the nurse documented the information about the resident elopement but had not documented the interviews. The DON stated the nurse had interviewed all of the staff at the facility during the time of the elopement and none of the interviewed staff had heard the alarm at the time of the elopement but it had sounded when the resident re-entered the facility. The DON told the nurse at the facility to call the MD and then she called the MD herself. She did not think the MD had come into the facility on [DATE], if he did, it was later in the evening. During an interview with the MD on 1/4/18 at 10:41 AM he stated he checked the function of the transmitter engaged electromagnetic locks once per week. The MD was able to provide documentation that each door in the facility which had the electromagnetic locks, including the front door, were tested , and found to be in proper working order on 12/4/17, 12/11/17, and 12/26/17. The MD also provided documentation from the second shift nurse for the date of 12/19/17 where the magnetic locks had been found to be working on all doors with magnetic locks. He stated he had contacted the service company for the electromagnetic locks and they had come out on 12/9/17. The MD provided a copy of the work order from the service call. The documented arrival time of the service technician on the work order for 12/9/17 was 3:15 PM and the departure time was 4:30 PM. The MD stated he had not come to the facility on [DATE]. During an interview conducted with the Administrator on 1/4/18 at 6:09 PM he stated all of the transmitters on the wandering residents were changed on 12/9/17. The sensor and the electromagnetic lock were found to be in working order by the contracted service company on 12/09/17. The Administrator stated there were only two ways the resident could have gotten out of the facility. The resident could have pushed on the door for 15-20 seconds and the electromagnetic lock would release or the resident could have followed another person out of the door when it was open. The Administrator stated in either case the alarm should have sounded. The Administrator stated Resident #18 was discovered outside near where the van loads and unloads residents (A distance measured to be approximately 50 feet 6 inches from the front door). The Administrator stated the DON interviewed staff members over the phone. Review of the work order from the contracted service company for the elopement security system from 12/9/17 revealed, under services rendered which read in part: Obtained transmitter from staff and tested the front door multiple times. Front door system picked up tag and locked door every time. An interview was conducted with the Service Manager (SM) from the contracted company for the elopement security system on 1/5/18 at 8:34 AM. The SM stated it was possible an individual had entered the code into the punch pad for the elopement security system which would have turned off the alarm. The SM reviewed the work order from 12/9/17 and stated from the documentation on the work order indicated that the service technician found the elopement system was in working order when he made the service call on 12/9/17. The SM stated the service technician tested the system at the front door with a transmitter he had obtained from the nurses ' station. The SM further stated there was no documentation the service technician made any repairs or any adjustments to the front door during the service call on 12/9/17. An interview was conducted with the Administrator on 1/6/18 at 12:45 PM. The Administrator stated it was his expectation for the elopement security system to function properly, for staff to respond to elopement alarms, and for residents not to elope. The Administrator was informed of Immediate Jeopardy on 1/5/18 at 9:32 AM. On 1/6/18 at 12:16 PM, the facility provided the following Credible Allegation of Compliance: Plan to correct specific deficiency and facts that led to the alleged deficient practice On 12-9-2017 at around 11:48am Resident #18 was observed by an outpatient resident in the therapy gym who then told the therapist about resident #18 being outside approximately 50 feet. Away. Resident #18 was immediately brought in by the therapy staff member who exited an alarmed door and the alarm to the front door went off at that time he was brought back in .The resident was returned to his room and examined by the nurse no injuries were noted. The (DON )Director of Nursing and Maintenance Director were notified by the LPN on the hallway that Resident #18 had been found outside the main entrance and no alarm had been heard by the nurses or aides in the building prior to him leaving . The responsible party (RP) and (MD) Medical Director were notified by the LPN and there were no new orders given. Resident #18 wander guard was checked at that time by his nurse .All other residents with wander guards in the facility were checked by their nurse .The maintenance supervisor and the Director of Nurses (DON) called the wand guard company who arrived around 3:15 pm and door was repaired by 4:30pm. The front door wander guard antenna was repaired on 12/9/17 by wander guard company. On 12-9-2017, the doors were all check and found functional by the wander guard company. On 12-11-2017 the QA team met in QOL meeting which included the Administrator, DON, RN supervisor, Unit manager, MDS coordinator, for a root cause investigation of the elopement .Their finding were that the resident walks around the facility frequently and looks out the windows. The front door alarm did not sound when he went out the door with a visitor. On 1/6/18 further review of the event revealed that a NA told the surveyors during the survey that she heard two alarms sound. On 1/6/18, the administrator interviewed the NA and she reports that she was in a closed room on 300 hall that is in the back of the facility and recalls hearing the alarm and stepping into the hallway. During the interview, the NA was unable to provide further clarification on hearing the alarm and is uncertain as to whether or not she heard a second alarm after further reflection. Because this NA was not part of the interviews conducted immediately after the event it is difficult to further clarify. The only explanation for her hearing two alarms is that the alarm went off when he exited the first time. The corrective action described below accounts for the fact that staff may not have responded to the first alarm when the patient exited the door. A sign was posted at the front door to alert visitors and on 1-5-2018. The administrator added to the visitor sign in book not to help any residents out the door on 12/11/7. Procedure for implementing a plan of correction for the alleged deficient practice All residents needing a wander guard device have the potential to be affected. On 12-9-2017, the nurses at the direction of the DON begin monitoring the patients by using the elopement book for identification of those at risk and using a wander guard transmitter. All residents were observed by the staff until the door was repaired by the alarm company on 12-9-2017 were completed. All doors with alarms were checked and found to be functional by nursing staff. All wander guards are checked for placement every shift by the nurse and function by night shift prior to the elopement and after 12-9-2017. The nurses use a checking device provided by the manufacturer to check for functioning. The maintenance director checks the doors daily with the code alert tags Monday through Friday and checked weekly through (TELS) system which is building maintenance management computerized program, this was done prior to and after 12-9-2017 elopement. On 1-4-2018 all residents with wander guards were checked the DON, Unit manager, support nurse and functioning. On 1-4-2018 all door alarms were checked maintenance and found to be functional. On 1-4-2018 the DON /UM begin education for FT , PT and PRN RN ' s, LPN ' s and CNA ' s , therapy, housekeeping laundry, dietary staff, social services, business office manager, heath information manager. This education will be completed by 1-5-2018. The DON will ensure that any staff member who did not receive the in-service training by 1-5-2018 will not be allowed to work until this is completed. As of 1-5-2018 12:00 noon 20 of nursing staff had not received this training. This training was incorporated into the general orientation program. All staff education: · Do not forget that frequent monitoring and supervision are needed in order to ensure resident safety. This means that you should be aware of the at risk for elopement resident ' s location. Do not accept the wander guard system as a substitution for resident supervision. Residents at risk for elopement are identified by this facility by placing a picture of the resident in an Elopement Risk notebook and it is located at front, nurses and receptionist desk. It is each employee ' s responsibility to review this notebook at the beginning of each shift so that you are familiar with residents who are at risk. · Any time an exit door alarm sounds or a squeal box alarms, then a staff member must immediately physically go to that door and check to see if a resident has exited or attempted to exit before resetting the alarm. · At no time can a staff member disable an exit door/wander guard system alarm without the knowledge and approval of the Administrator or DON. · If a resident begins to exhibit exit seeking behaviors such as sitting for long periods of time at the doors, trying to open exit doors, exhibits anxiousness about leaving or expecting a family member to arrive, and other activities that involve trying to leave the facility or verbalizing that they want to leave or are going to leave. Notify the Nurse immediately. Redirect the resident by encouraging them to participate in activities that they enjoy or meeting physical needs such as toileting or hunger/thirst. Assess for evidence of pain and address as indicated. The care plan/kardex is a good resource for additional interventions. · Once the resident starts exhibiting exit seeking behavior or any of the above behaviors, if the interventions are not effective in redirecting the behavior, then one-on-one should be initiated and you should call the Administrator or DON when this occurs. The MD, RP, DON, & Administrator should be notified of the exit seeking behavior for further interventions. · If new exit seeking behavior is noted, check the resident ' s vital signs and assess for a change in condition. Notify MD of the findings. · If the resident does not have a wander guard band on, then initiate one. Additional wander guard bands are located at the nurses stations. · The CNA ' s check placement of the wander bracelet q shift and this is documented on the electronic charting in P(NAME). If the bracelet is not found on the resident ankle or wrist immediately notify the nurse for a replacement. Placement and function of wander guards is completed by the shift nurse/ med tech every shift and all door checks completed weekly by maintenance director. · Procedure for this: Bracelets are deemed functional when red light is flashing and non-functional when light is off and all contain a battery that lasts at least 1 year when activated, and verified by the date with function and placement checks and by support nurse. · This placement and functional check is documented on the eMAR. · If an elopements occurs, complete an incident report with notification of MD and RP. You must also immediately notify the Administrator or Director of Nursing. Wander guard system We have a wander guard system that will alarm if a resident is trying to leave the facility. IF AN ALARM SOUNDS · Staff should quickly respond to the location and determine the cause of the alarm. · If it is possible that a resident has left the facility then implement the missing person procedure. · Complete an incident report for QA follow up. WHEN THE SYSTEM MAY NOT WORK · The system shuts down anytime the fire alarm is sounded. All doors should be checked to make sure that they lock back after the fire alarm is finished. The charge nurses responsible for that area should check. Exit doors and employee entrance should be checked by the hall nurse. · If a resident stands at the door for more than 20 seconds and applies pressure the door will release. If a resident is seen standing at the door they should be redirected. · Any time the system is not functioning properly the administrator and maintenance director should be immediately notified. Monitoring Procedure The Admin/DON will monitor for completion of the daily wander guards and daily door checks using a QA audit tool twice a week x 4 weeks, then monthly x 2 or until reviewed by the QA and team and resolved. The results of this audit will be reviewed at the weekly QOL Team Meeting. The administrator/DON will also conduct mock response drills by setting off the front door alarm and ensuring that staff respond to the door alarm promptly. This will be done weekly on all three shifts and the again on the weekend. This will be completed for 4 weeks, then monthly for at least 2 months until reviewed by the QA team and resolved. Corrective actions for these audits will be implemented to improve performance or correct issues. The QA/QOL Meeting is attended by Administrator, Director of Nursing, Unit Manager, Support Nurse Managers, Social Service, and Dietary Manager. Medical Director. Deficits that are identified during the monitoring process will be addressed through the facility QA process. Title of person responsible for implementing the acceptable plan of correction: Administrator Date of removal of immediate jeopardy 1/6/18 The credible allegation was verified on 1/6/18 at 2:00 PM as evidenced by staff interviews. Staff education was initiated on 1/4/18 regarding residents who have been identified to be at risk for wandering or may start to display behaviors which would place the resident at risk for wandering. All staff interviewed (nursing and non-nursing staff, administrative staff) stated they were to respond to respond to exit door alarms by immediately going to the door which triggered the alarm and investigate to see if a resident had exited or attempted to exit which would have triggered the alarm. Verification of education for staff regarding the education regarding wandering residents was completed on 1/6/18.

Based on record review, contracted service interviews, and staff interviews, the administration failed to provide oversight and leadership to facility staff to maintain a safe environment and analyze an incident immediately for one of one resident reviewed for supervision. Resident #18 who was cognitively impaired exited the facility and was found approximately 50 feet away from the entrance door in 32 degree Fahrenheit weather. Immediate jeopardy began on 12/9/17 when the facility failed to maintain a safe environment as evidenced by a resident who had been identified as a wandering risk who had cognitive loss to have eloped from the facility and was discovered approximately 50 feet from the facility front entrance, on the sidewalk, at the covered drop off/pick area unaccompanied and without supervision. The facility administration failed to conduct a timely and thorough analysis to identify a causative factor that directly led to the incident which lead Resident #18 and other residents at risk for elopement at risk for a repeat incident. The Immediate Jeopardy was removed on 1/6/17 at 12:16 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Cross Refer to F689: Based on observations, record review and staff interviews, the facility failed to provide supervision to prevent a cognitively impaired resident from exiting the facility for one of one resident reviewed for supervision. Resident #18 who was cognitively impaired exited the facility and was found approximately 50 feet 6 inches away from the entrance door in 32 degree F weather. On 1/5/17 at 9:32 AM, the Administrator was informed of the Immediate Jeopardy for F835. On 1/6/18 at 12:16 PM, the facility provided the following Credible Allegation of Compliance: The statements made on this credible allegation are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all Federal and State Regulations the facility has taken or will take the actions set forth in this credible allegation. The credible allegation constitutes the facility ' s allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. Tag 835 Plan to correct specific deficiency and facts that led to the alleged deficient practice On 12/9/17, the facility began an investigation of the event that occurred; however a thorough investigation was not completed or documented. On 12-9-2017 immediately after the event the Director of Nursing told all nursing staff members to observe all patients with wandering risk until door checks could be completed. On 12-9-2017 all residents who were required to wear a transmitter due to an elopement risk where checked by the nurses in the building to ensure that the devices were on the patient and functioning properly. No concerns were identified. On 12/9/17, the alarm company checked all doors. On 12-9-2017 the director of nursing obtained witness statements from the nurses in the building, they were obtained but were not written. Not all staff working that day were interviewed. On 12-11-2017 the QA team met in QOL meeting which included the Administrator, DON, RN supervisor, Unit manager, MDS coordinator, for a root cause investigation of the elopement. Their finding were that the resident walks around the facility frequently and looks out the windows. A new sign was posted at the front door to alert visitors not to let resident out on 12/11/17. The team continued to do quality audits of all of the door alarms by taking a transmitter bracelet to the door to verify that the alarm sounded and the door locked as appropriate. This was an audit that was completed prior to the event as part of our quality program and it continued on 12/10/17 after the event. No new quality audits were initiated as a result of the event and/or investigation. On 1/6/18 further review of the event revealed that a NA told the surveyors during the survey that she heard two alarms sound. On 1/6/18, the administrator interviewed the NA and she reports that she was in a closed room on 300 hall that is in the back of the facility and recalls hearing the alarm and stepping into the hallway. During the interview, the NA was unable to provide further clarification on hearing the alarm and is uncertain as to whether or not she heard a second alarm after further reflection. Because this NA was not part of the interviews conducted immediately after the event it is difficult to further clarify. The only explanation for her hearing two alarms is that the alarm went off when he exited the first time. The corrective action described below accounts for the fact that staff may not have responded to the first alarm when the patient exited the door. Procedure for implementing a plan of correction for the alleged deficient practice On 1/5/18 the Vice President of Operations for the facility educated the Administrator and Director of nursing on the following items: 1. Any time a patient who is an elopement risk leaves the facility whether it is witnessed or not, immediate actions and a comprehensive investigation must be completed and documented immediately after the event. 2. Immediate actions should be initiated immediately by the Administrator or the Director of Nursing. These actions should include posting a door guard at the door that was exited and placing 1:1 supervision for the patient. These actions should be kept in place until it is determined that the doors and transmitters are functioning properly and that the patient is deemed to not be at risk for additional elopements. 3. All resident transmitter must be checked to ensure that they are properly functioning. All door must be checked to ensure that they are functioning properly. These duties should be assigned to appropriate staff members by the administrator or the Director of Nursing if the administrator is not available. 4. The investigation must include at a minimum witness statements from all staff who are on duty at the time of the event and a time line based on the interviews. A comprehensive chart review must also be conducted to identify if the elopement risk assessment was timely and accurate, whether the risk has been care planned, whether transmitter bracelets had been issued to the patient and if the bracelets were checked every shift for placement and daily for functioning. 5. Based on the investigation the quality assurance team must identify all the possible root causes. 6. Based on the root cause analysis, a corrective action plan must be developed and implemented. The action plan should address any and all failures or concerns identified in the investigation. Education to all staff must be provided based on failures or concerns that are identified. 7. The investigation and corrective action plan must be finished within 72 hours of the event. 8. Based on the corrective actions, quality assurance monitoring must be completed at least weekly for four weeks until resolved by the Quality Assurance Committee. 9. Immediate notification of the Vice President of Operations and the Nurse Consultant assigned to the facility must be made by the administrator. Monitoring Procedure On 1/5/2018, the vice president of operations and/or the nurse consultant will monitor incident reports weekly to identify any elopement activity that may have occurred. If elopement activity occurred the Vice President of Operations and/or the nurse consultant will review the facility investigation, root cause analysis and the corrective action plan to ensure that it is consistent with the education provided in this document. Reports will be presented to the administrator and Director of Nursing weekly that in turn will be shared with the weekly QA committee by the Director of Nursing to ensure corrective action for trends or ongoing concerns is initiated as appropriate. The weekly QA Meeting is attended by the DON, Wound Nurse, MDS Coordinator, Unit Manager, Support Nurse, Therapy, HIM, Dietary Manager Administrator and Medical Director. Title of person responsible for implementing the acceptable plan of correction: Administrator Date of removal of immediate jeopardy 1/6/18 The credible allegation was verified on 1/6/18 at 2:00 PM as evidenced by staff interviews. Staff education was initiated on 1/4/18 regarding residents who have been identified to be at risk for wandering or may start to display behaviors which would place the resident at risk for wandering. All staff interviewed (nursing and non-nursing staff, administrative staff) stated they were to respond to respond to exit door alarms by immediately going to the door which triggered the alarm and investigate to see if a resident had exited or attempted to exit which would have triggered the alarm. Verification of education for staff regarding the education regarding wandering residents was completed on 1/6/18.

Based on observations, staff interviews and record reviews the facility failed to provide restorative care according to physician orders [REDACTED]. Passive range of motion, positioning with a pillow and splint applications were not provided for Resident #125. A splint was not applied correctly and an alternating elbow brace was not applied for Resident # 27. The findings included: 1. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Occupational Therapy notes indicated Resident #125 received therapy from 6/19/13 until 7/24/13. Therapy included range of motion of the right side with application of a hand splint and a soft elbow splint. The splints were to be worn 6 to 7 hours a day. A palm guard would be applied to the right hand when the splint was not used. Resident #125 was discharged from occupational therapy to restorative nursing for application of the splints, palm guard and passive range of motion. The Physical Therapy notes indicated Resident #125 was treated 9/4/13 to 10/4/13 for passive range of motion and use of a soft leg splint to the right leg. Therapy treatment for [REDACTED]. Resident #125 was discharged from therapy on 10/4/13 to restorative nursing for continuation of the same therapy plan of care. Review of an order dated 10/4/13 indicated a right lower extremity splint was to be applied during the day. It would be donned and doffed (put on and taken off) by restorative aide. Occupational Therapy provided treatment to address splinting to the right upper extremity on 12/9/13. Review of the progress notes revealed the soft elbow splint was discontinued. The passive range of motion and application of the hand splint and palm guard were continued. Resident #125 was discharged from therapy to restorative nursing on 12/18/13 to continue the passive range of motion, hand splint and palm guard. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #125 required total care by staff for all of her care needs. This MDS indicated Resident #125 had memory impairment with short and long term memory. Resident #125 was assessed on this MDS as having limitations of both upper extremities and lower extremities. The care plan did not address limitation of movement, contractures or restorative nursing to treat the contractures. Review of a telephone order dated 12/18/13 revealed restorative was to provide treatment 6 times a week to the right upper extremity. Treatment included passive range of motion and a splint to be applied for 6-8 hours a day. The palm guard was to be used when the splint was not used. Review of the " Clinical - Assessment - Report - Restorative Nursing Review " for the months of October, November and December 2013 were as follows: - All three months had the same " Current Programs " that included " Passive Range of Motion and Splints/Braces with skin checks. " - All three months included documentation for " Evaluation. " The following was the documentation for the three months: * October 18, 2013 documented the resident was resistive to passive range of motion (PROM) and splinting. " ..pulls at the leg splint and cries out intermittently ...will continue current program. " * November 15, 2013 documented " Resident continues to cries (sic) when any care or tretment (sic) provided. PROM is difficult to do, she is resisting to all interventions by pushin (sic) our hands away or pulling her hand away. Continue with folded pillow to RLE (right lower extremity) ... will tolerate the palm protector. Position in bed with pillows ... " * December 20, 2013 documented " Resident cries when any care or tretment (sic) provided. PROM is difficult to do, she is resistive to all interventions by pushin (sic) our hands away or pulling her hand away. Continue with folded pillow to RLE .... Will tolerate palm protector. Position in bed with pillows ... " - All three months included " Plan " with the following options: " Select plan based on the evaluation of the current program. a. Continue current plan with existing goals. b. Continue current plan but with updated goals. Describe below. c. Discontinue specified programs (document details below). d. Initiate new program. " All three months the restorative nurse selected " a. Continue current program with existing goals. " No changes were made in November after the current program was altered. The most recent orders dated January 1 through 31, 2014 were the monthly recap orders. Review of the recap orders revealed an order for [REDACTED]. An interview was conducted on 01/27/2014 at 11:25 AM with nurse # 1. Resident #125 had contractures, wore splints and had range of motion to the upper and lower extremities. She reported Resident #125 " takes them (splints) off. " Observations on 1/27/14 at 11:35 AM and 3:30 PM revealed Resident #125 did not have splints on the right upper or lower extremities. The palm guard was not on the right hand. The right hand was in a closed fist. Observations on 1/28/14 at 9:00 AM revealed Resident #125 did not have splints on the upper or lower extremities. The palm guard was not on the right hand. The right hand was in a closed fist. Observations on 1/30/14 at 9:10 AM revealed Resident #125 did not have the splints on the upper or lower extremities and the palm guard was not on the right hand. The right hand was in a closed fist. Interview with aide #1 on 1/30/14 at 2:45 PM revealed she had removed the splint from the resident ' s hand that morning. It had been on through the night and her skin looked "red". She had spoken with therapy and was told it could be removed. Aide #1 explained the palm guard was not applied because it was not available. She did not know where the palm guard was and " had not seen it. " The resident had not had a leg splint on that day. She had not seen the leg splint. It was usually in the Geri chair, but not that day. The restorative aide was getting weights that day, and she did not know if restorative was being done. Interview with nurse #1 on 1/30/14 at 3:05 PM revealed the restorative aides were responsible for the range of motion and splinting. Resident #125 would sometimes refuse the splint applications. When the resident refused, a rolled washcloth was used in her hand. When resistant to use of the soft splint on the lower extremity, a folded pillow was used between her legs. Nurse #1 was asked where the palm guard was kept. Nurse #1 and the surveyor went to Resident #125 ' s room and she located the palm guard in the top drawer of the bedside stand. Observations were made on 1/30/14 at 3:46 PM of aide #7 providing passive range of motion and splint application. Resident #125 would not allow stretching of her bent fingers on the right hand. Her right hand was in a closed fist with the fingernails pressing into the palm. She allowed the palm guard to be applied. The lower extremities were bent at the knees and the heels were up to the buttocks. Aide #7 was not able to stretch out either lower extremity from the knee. Gentle stretching was provided with the back of the right knee opening enough to see the skin behind the knee. The skin behind the bend of the right knee was red with white substance. Nurse #1 was in attendance and stated she would come back later to assess the red area. Nurse #1 stated she was not aware of a red area prior to today. Interview on 1/30/14 at 4:03 PM with aide #7 revealed she had worked that day as an aide on the floor. This was first time working with this resident and she had not worked as a restorative aide before today. Aide #7 was asked if Resident #125 had a leg splint and she responded she was " not aware of any leg splint. " Interview with aide #6 on 1/30/14 at 4:08 PM revealed she did remember a leg splint, but had not seen one used on the resident for about 2 months. Aide #7 worked on the 3-11 shift and remembered therapy working with the resident. A leg splint was in place when she came on duty and would be removed around 4:00 PM. Interview on 1/30/14 at 4:18 PM with Occupational Therapist #1 (OT) revealed Resident #125 did have a splint for the right hand. OT #1 explained she thought a palm protector was added when the splint was removed, and a pillow was used for positioning for the upper arm. She was not able to answer questions regarding the leg splint. She explained physical therapy took care of splints to the leg. Interview on 1/30/14 at 4:35 PM with Physical Therapist #1 (PT) revealed they were trying a soft splint for the lower extremity. Resident #125 was placed on the restorative program. PT #1 explained she " believed they (restorative aides) became unable to apply it (soft leg splint). " She was not sure when it was stopped it. Resident #125 was very resistant and vocal during care. Therapy was able to apply the leg splint on the resident. Training by PT with restorative was provided upon the resident ' s discharge from therapy caseload. PT #1 explained communication between nursing and therapy included a written referral request for therapy to screen the resident for possible therapy services. At the time of discharge from PT in September, Resident #125 had contractures of the right knee and none on the left leg. Therapy had not received a referral to screen Resident #125 for contractures of both lower extremities. Interview on 1/30/14 at 4:45 PM with OT #2 revealed Resident #125 was on caseload from 6/19/13 to 7/24/13. At the time of discharge, the resident was positioned with a " T bar splint (type of hand splint) on the right hand for 6 to 7 hours per day " . OT #2 explained when the resident was not wearing the splint, she was to wear a palm guard. Resident #125 had an elbow soft extension splint and it was worn for 6 to 7 hours per day. When Resident #125 was discharged from therapy, education was provided to the restorative aides to continue the therapy program. OT#2 explained a screen was completed on 12/19/13 from staff due to the resident was not using the right T bar splint. She explained Resident #125 was provided therapy and positioning in a chair was reviewed. The resident sat in a wheelchair on her shower days and remained in bed most of the time. Therapy decided a Geri chair would be more comfortable for the resident. On 12/18/13 the resident was discharged from therapy and placed back with restorative. The elbow brace was discontinued due to skin issues. A pillow was used under the upper arm for positioning. The OT #2 was asked if restorative aides were informed about the use of a pillow and she responded no, it was not put on the communication form for restorative. Observations of Resident #125 on 1/31/14 at 12:55 PM revealed she did not have a pillow at the bend of her knee. A splint or palm guard was not applied to the right hand. The right hand was closed in a fist. There was no splint to the right lower extremity. Interview with aide #2, on 1/31/14 at 1:10 PM, revealed she worked Monday, 1/27/14 on 7-3 and was assigned to Resident #125. Resident #125 required staff to do all activities of daily living (ADLs), bathing, dressing, oral care, and positioning. She was trained by therapy on how to position the resident using pillows at hips, between legs and at the bend of the knees. She thought she put the pillow at the bend of her knees on Monday. Aide #2 had worked as a restorative aide in the facility. Resident #125 had two types of right hand splints. One was a wool soft type and the other was a blue splint. On Monday, 1/27/14 aide #2 explained she was working as an aide on the floor, with an assignment. She did not provide restorative treatment to Resident #125 on Monday. Interview with aide #3, on 1/31/14 at 1:15 PM, revealed she had provided care on 1/28/14 for Resident #125. She explained pillows were used for positioning at the knees. Aide #3 stated it was hard to get a pillow behind the right knee, since it is so contracted. Further interview revealed she may not have had a pillow behind her knees on Tuesday. Aide #3 did not think she had been told to put one behind the knees. Aide #3 was asked to explain the documentation by the aides and restorative in the computer. She stated restorative aides were to chart at end of the day if they provided restorative. If there had not been restorative charting for that day, she used the NA (not applicable) so the task closed in the computer. Aide #3 stated she saw a " crusty area behind her (Resident #125 ' s) knees on Tuesday 1/28/14. " The charge nurse was informed of the area. Interview with aide #5, on 1/31/14 at 1:23 PM, revealed the resident had a hand splint on when she came on duty that day. It was the "blue one" and was removed prior to giving her a shower. She was not aware if anything was to be placed in her hand after the splint was removed. She knew she did have an elbow splint and a leg splint. " Those (splints) have not been seen in use for a while." Aide #5 explained she would position Resident #125 with pillows under each buttock cheek. She usually placed a pillow in the bend of her knee. The resident did not leave the pillow in place behind her knees. Interview with aide #4 on 1/31/14 at 1:45 PM revealed she had been a restorative aide at times over the past 2 - 3 years. Aide #4 explained she was familiar with Resident #125 and had provided restorative care in the past. When asked to explain what restorative treatment she provided aide #4 explained "Moved her legs and arms, applied an elbow splint and arm splint. She had a leg splint, but don't know where it is. " Aide #4 did not know how long it had been since the resident had the leg splint. Aide #4 worked on 1/30/14, but was as an aide with an assignment. She did not do restorative that day with Resident #125. She further explained the restorative plan of care would be in the computer. When asked how she would position Resident #125, she stated she would use pillow under both legs, "longways" and at her back. The restorative plan of care and treatment was located in the wall computer for instructions and documentation by the aides. Review of this plan of care and treatment for [REDACTED]. Restorative treatment was documented as being done during this timeframe 16 days out of 31 days. Treatment was to be provided 6 days a week. The first week Resident #125 received treatment 4 times, the second week 3 times, the third week 5 times, the fourth week 5 times. On the days treatment was not provided the documentation indicated the resident " refused " one time, was " not available " one time and the rest " not applicable. " Interview with nurse #1 on 1/31/14 at 3:31 PM revealed she did not discontinue the leg splint. When reviewing the current monthly orders with nurse #1 she explained the orders would be considered current and in effect. She explained the leg splint was stopped and a folded pillow was used. The date of this change was unknown and no order was written. The orders for the right upper extremity range of motion, splint and palm guard application were not on the recap orders. Nurse #1 explained it must have been missed during the monthly order review. According to nurse #1, she and the restorative aide made the decision to use the pillow instead of the splint. When nurse #1 was asked if the contractures had changed, she explained the contractures remained the same since 10/13 when she was discharged from therapy. Nurse #1 was asked how changes were communicated to therapy. She explained the restorative aide would ask therapy for assistance if she was having problems with the splint or performing the restorative plan of care. The restorative aide had not come to her with any issues. This restorative aide was currently on medical leave and not available for interview. Nurse #1 stated she had not discussed the case with therapy. Review of the print out of restorative documentation with nurse #1 revealed the resident did not have restorative according to physician orders [REDACTED]. Therapy provided a book with pictures of Resident #125 used for a visual guideline for positioning of the resident. The pictures were not dated. Resident #125 was seated in a Geri chair with the left leg fully extended and straight. The right leg was in a leg splint and bent with the foot resting on the chair. The skin behind the right calf and knee were not touching the back of the thigh in this picture. Interview with the Director of Nursing (DON) on 1/31/14 at 4:15 PM revealed she expected the resident to be taken care of by the nursing staff. If there was an order for [REDACTED]. The restorative nurse was responsible for the restorative program. The DON stated she had not been updated by the restorative nurse supervisor of any changes in this resident's contractures or the need of any different type of restorative plan of care. 2. Resident # 27 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #27's most recent MDS assessment dated [DATE] indicated the resident was moderately impaired for daily decision making. Resident # 27 required extensive assistance with the use of two person physical assistance with all Activities of Daily living (ADL's). Resident #27 was assessed as having limitations of both the upper and lower extremities. Review of Resident #27's care plan updated 1/13/14 did not identify Resident #27's contracture or restorative nursing to treat contractures. Review of Resident #27 medical record revealed a physician order [REDACTED].#27's Occupational Therapy (OT) was discontinued. The physician order [REDACTED]." Review of Resident #27's OT discharge summary dated 10/17/13 indicated, "The patient tolerates right resting splint for 6-8 hours to address contractures. Elbow soft extender wrap brace wearing tolerance to 3 hours alternating between left and right elbow." Review of the facilities visual bedside Kardex report revealed a section "Mobility" the Kardex indicated, "Nursing Rehab: Assistance with splint or brace to right hand and right elbow for 4-6 hours as tolerated." Observation on 1/27/14 at 3:08 pm revealed Resident #27 in her bedroom seated in her wheelchair without splint to right hand or alternating left elbow brace. A family interview was conducted on 1/28/14 at 9:25 am in Resident #27's room. Resident #27 was observed seated in her wheelchair. Resident #27's family member revealed the facility did not correctly apply the resident's right hand splint for the prevention of contractures. The family member indicated that Resident #27 was to receive splinting to the right hand, soft extender wrap to elbow. Observation of Resident #27's right hand resting splint during the interview with family member revealed the resident's hand on top of finger separators. The finger separators were located on top of the palm rest of the splinting device. Resident #7's fingers separators were not observed to be between resident's individual fingers. The inside closet door revealed directions for the use and time frame for the adaptive devices. The directions for Resident #27's Wheelchair included; Elbow extension wrap, alternate left and right elbow for 6-8 hours; Right resting hand splint 6-8 hours. Observation on 1/28/14 at 2:30 pm revealed Resident #27 seated in her wheelchair in the facility TV lounge. Resident #27 was observed with right resting hand splint not applied correctly as evidenced by Resident #27 fingers resting on top of finger separators. The finger separators were located on top of the palm rest of the splinting device. Resident #7's fingers separators were not observed to be between resident's individual fingers. Observation on 1/30/14 at 10:35 am revealed Resident #27 seated in the facilities TV lounge with right resting hand splint applied incorrectly. As evidenced by Resident #27's hand being below the palm rest of the splinting device. Interview with Aide #7 on 1/30/14 at 3:26 pm revealed she was the aide assigned to Resident #27 for 1st shift on 1/30/14. Aide #7 continued that Resident #27 required extensive assistance with all ADL's. Aide #7 indicated she was unaware who provided the resident with splinting application although Aide #7 indicated she did take the residents splints off after dinner occasionally. Aide #7 continued that the direction for the use of Resident #27's splints and wedge cushion use was located in the resident's closet. Observation on 1/30/14 at 3:29 pm revealed Resident #27 lying in her bed with no right resting hand split. Interview with OT# 1 on 1/30/14 at 3:36 pm revealed resident #27 was referred by nursing due to increased risk of contracture of the resident's right hand. OT #1 indicated OT also worked on wheelchair positioning, contracture management, passive range of motion, splinting, and increasing Resident #27s tolerances of the splint and brace. Resident #27 received a resting hand splint and due to tightness in right elbow flexion a soft extension brace was used. OT #1 stated, Resident #27 increased her tolerance up to 6-8 hours a day for resting hand splint, and 3 hours for soft extension brace on right and 3 hours for left elbow. OT indicated the elbow brace was to be alternated from the left and the right elbow for 3 hours each. OT revealed Resident #27 should have her splinting on during times when she placed back into bed to ensure she is utilizing the devices for the ordered 6-8 hours. OT indicated it was her expectation that splinting and positioning devices as recommended. Observation on 1/31/14 at 8:02 am revealed Resident #27 sitting at the breakfast table in restorative dining. Resident #27 had no right resting hand splint and no elbow extension wrap. Interview with OT#1 on 1/31/14 at 8:45 am indicated the resident had finished eating breakfast and the Restorative aide may do her splinting later. OT#1 indicated that the order did not indicate a start time for Resident #27's splinting. Observation on 1/31/14 at 10:46 am Resident #27 was observed with resting hand splint applied. Resident #27 was not observed to be wearing an elbow extension wrap. Observation on 1/31/14 at 11:20 am Resident #27 was observed sitting in wheelchair in room with right resting hand splint applied. Resident #27's foam cushion and elbow extension wrap was located on the residents bed. Observation on 1/31/14 at 12:27 pm revealed resident in dining room with right hand splint. Interview with Aide # 8 on 1/31/14 at 3:03 pm revealed the restorative aid provided splinting for residents. Aide #8 revealed she had provided Resident #27 with care on 1/31/14. Aide #8 could not recall how many hours' Resident #27 splints were to be worn. Aide #8 indicated that although restorative staff were to do splinting she had been occasionally told by restorative to put splinting on or to take splitting off Resident #27. Aide #8 indicated she received training on how to correctly apply the splinting device by the restorative nurse and OT. Aide #8 stated she did not document any splinting for Resident #27. Aide #8 continued that the restorative nurse would document resident #27's splint usage. Interview with Aide #11 on 1/31/14 at 3:30 pm revealed she provided Resident #27 with restorative care on 1/31/14. Aide #11 indicated that due to a call out for personal reasons the scheduled restorative aide was not working. Aide #11 revealed Resident #27's restorative needs were documented in the facilities electronic information system. Aide #11 indicated that on Wednesday 1/29 /14 the facility did not have a restorative aide due to the inclement weather so an aide would have provided her with her splinting needs. Aide #11 revealed that when she initially viewed the facilities electronic information system, she only observed Resident #27's right hand splint. Aide #11 further indicated that when she went back into the electronic information system later during the day and viewed Resident #27 also required an elbow brace as well. Aide #11 indicated that the restorative aide's task needed to identify which extremity the splints were to be applied. Aide #11 stated the task section needed to be clearer so when the restorative aid was out other staff would be aware of which extremity requires the splint. Interview with the Director of Nursing (DON) on 1/31/14 at 4:15pm revealed the restorative nurse was responsible for the restorative program. The DON further revealed if there was an order for [REDACTED].

Based on record review, physician, pharmacy, and staff interviews, the facility failed to ensure a resident was monitored for excessive sedation from medication and increased sedation was reported to the physician. They also failed to ensure the resident was free from unnecessary drugs by administering a medication beyond the end date of the medication for 1 of 4 sampled residents receiving medications with interactive sedating side effects (resident #2). Findings include: Resident #2 was admitted to the facility 2/4/2013 with multiple [DIAGNOSES REDACTED]. Review of the Medicare 5 day Minimum Data Set ((MDS) dated [DATE] noted that Resident #2 was cognitively intact, felt tired or had little energy over 2-6 of the last 7 days, and needed extensive assistance for activities of daily living. The MDS also indicated that Resident #2 had impairment of range of motion on one side of the upper extremities with occasional pain at level 8 that limited day to day activities. Scheduled and PRN (as needed) pain medications were given and antidepressants were given 7 out of 7 days of the review. Review of physician's orders [REDACTED]. 2/4/2013 [MEDICATION NAME] 50 mg (milligrams) tab take 6 tabs po (by mouth) q (every) hs (bedtime). [MEDICATION NAME] 600 mg tab po bid (twice a day), [MEDICATION NAME] 100 mg capsule poqhs, [MEDICATION NAME] 7.5/500 mg tab po tid (three times a day), no more that 3000mg [MEDICATION NAME] q day from all sources [MEDICATION NAME] 7.5/500 mg tab po q 4 hours for breakthrough pain no more that 3000 mg [MEDICATION NAME] q day from all sources. [MEDICATION NAME] 10 mg po q 8 hours PRN muscle pain 2/11/2013 [MEDICATION NAME] 60 mg cap po qd 3/26/2013 [MEDICATION NAME] 50 mcg (micrograms)/hr patch; apply 1 patch q 72 hours (every 3 days) rotate site Generic: [MEDICATION NAME] 5/21/2013 Increase [MEDICATION NAME] to 250 mg tabs q am and 250 mg tabs q pm and 6 50 mg tab qhs. 6/5/2013 at 9:00 pm [MEDICATION NAME] 25 mg po x 1 dose for itching or allergic reaction 6/7/2013 [MEDICATION NAME] 25 mg po q 6 hrs PRN itching x 7 days 6/13/2013 Increase [MEDICATION NAME] to 75 mcg/hr change patch q 72 hours DC (discontinue) [MEDICATION NAME], DC current [MEDICATION NAME] orders. [MEDICATION NAME] 600 mg po tid [MEDICATION NAME] ([MEDICATION NAME] sulfate instant release) 15 mg po q 4 hours PRN pain The 2013 Lippincott's Nursing Drug Guide read under drug to drug interactions of [MEDICATION NAME]: increased CNS (central nervous system) effects. One of the CNS effects listed for [MEDICATION NAME] was sedation, for [MEDICATION NAME] was somnolence (near sleep like state), for [MEDICATION NAME] potentiation (enhancement of one agent by another so that the combined effect is greater than the sum of the effects of each one alone) of effects when given with other CNS acting drugs, for [MEDICATION NAME] additive CNS effects with barbiturates and other CNS depressants, for [MEDICATION NAME] an adverse effect was somnolence, and for [MEDICATION NAME] increased sedation with other CNS depressants. A review of the June 1-June 30 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] From 6/1-6/12/2013 [MEDICATION NAME] 600 mg was given at 6:30 am, 2:00 pm, and 100 mg at 8:00 pm, [MEDICATION NAME] 60 mg was given at 8:00 am, [MEDICATION NAME] 100 mg was given at 8:00 am, 2:00 pm, and 300 mg at 8:00 pm, [MEDICATION NAME] 25 mg was given on 6/5 at 8:00 pm, 6/6 at 5:00 pm (? Time is not clear), 6/7 at 8:00 am, 6/8 at 1:45 pm, 6/9 at 3 pm, 6/10 at 4:30 pm, 6/11 at 7:40 am and 5:25 pm. (The [MEDICATION NAME] was given on 6/6 after order on 6/5 for a one time dose) [MEDICATION NAME] 10 mg on 6/4 at 12:00 ? (writing not clear) [MEDICATION NAME] 50 mcg/hr was placed at 8:00 am on 6/3, 6/6, 6/9, and 6/12. On 6/13-6/23/2013 the medications were given as shown below: 6/13/13 6:00 am [MEDICATION NAME] 600 mg 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 mg po, [MEDICATION NAME] 50 mcg/hr patch in place, 9:00 am [MEDICATION NAME] 25 mg, 11:30 am last dose of [MEDICATION NAME] 7.5/500 mg, 2:00 pm [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg, 6/14/13 at 8:00 am [MEDICATION NAME] 15 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, and [MEDICATION NAME] 60 mg, [MEDICATION NAME] 50 mcg/hr patch in place. 2:00 pm [MEDICATION NAME] 100 mg 600mg [MEDICATION NAME], 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg 6/15/13 at 8:00 am she had a new [MEDICATION NAME] at 75mcg/hr placed, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 mg 2:00 pm [MEDICATION NAME] 100 mg and [MEDICATION NAME] 600 mg 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg On 6/16/13 at 12:00 am [MEDICATION NAME] 15 mg 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] patch 75 mcg/hr in place 10:00 am [MEDICATION NAME] 15 mg 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME], 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg On 6/17/13 at 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 75 mcg/hr in place 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME], 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg On 6/18/13 at 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, new [MEDICATION NAME] 75 mcg/hr placed. 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME] 4:30 pm [MEDICATION NAME] 15 mg 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 25 mg (The order for x 7 days ended on 6/14/13) 8:30 pm [MEDICATION NAME] 15 mg On 6/19/13 at 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 75 mcg/hr in place. 10:00 am [MEDICATION NAME] 25 mg (The order for x 7 days ended on 6/14/13). 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME] 15 mg 6:30 pm [MEDICATION NAME] 15 mg 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg 9:00 pm [MEDICATION NAME] 10 mg 10:30 pm [MEDICATION NAME] 15 mg On 6/20/13 at 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 75 mcg/hr in place. 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME] 15 mg 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg 9:30 pm [MEDICATION NAME] 10 mg On 6/21/13 at 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, new [MEDICATION NAME] 75 mcg/hr placed. 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME], 4:45 pm [MEDICATION NAME] 15 mg 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg On 6/22/13 at 8:00 am received [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 75 mcg/hr in place. 9:00 am [MEDICATION NAME] 15 mg 2:00 pm 100 mg 600 mg [MEDICATION NAME], 8:00 pm [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg 9:45 pm [MEDICATION NAME] 10 mg On 6/23/13 at 8:00 am [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 75 mcg/hr in place. At 2:00 pm [MEDICATION NAME] 100 mg 600 mg [MEDICATION NAME] 15 mg. Nursing notes in review noted on 6/19/2013 that Resident #2 was given [MEDICATION NAME] 5 mg for a complaint of itching. On 6/20/2013 at 11:27 am Resident #2 was hard to awaken that morning, but was verbally stimulated for a moment and able to take her medications. On 6/21/2013 a note at 7:20 am indicated Resident #2 was sleeping each time the nurse went to visit on 6/20/2013. The note also revealed that Resident #2 was arousabl when spoken to and hand placed on the resident's arm, but did not open eyes when answering. Resident #2 was asked several times to get out of bed, but remained lethargic and sleepy. On 6/22/2013 at 2:07 am a note documented that Resident #2 was alert and verbal, but remained in bed with eyes closed. On 6/22/2013 at 12:12 pm the note detailed that Resident #2 was very sleepy and slow to respond to verbal stimulation, able to take meds, but was barely awake. On 6/22/2013 at 10:24 pm Resident #2 noted to be very lethargic that shift. She did awaken for family visit and [MEDICATION NAME] was given. On 6/23/2013 at 2:33 pm the note indicated that Resident #2 was resting in bed with eyes closed and no complaints of pain. At 6:34 pm Resident #2 was unable to be aroused, had thick frothy secretions coming out of mouth and nose, and was suctioned by the nurse at 5:56 pm for 60 ml (milliliters) returned. The physician was notified that Resident #2 had no gag reflex, no sternal arousal, and oxygen saturation was 64%. An order was received and 911 called to transport Resident #2 to the hospital. There was no indication in the notes that the physician had been notified of Resident #2 ' s lethargy prior to the call when she was non responsive. Record review found 2 24 hour Change of Condition Reports which were left for the physician to see on the next visit. The first report was dated 6/22/13 noted that Resident #2 was very lethargic, hard to wake on days and lethargic until family arrived on evenings. The second report dated 6/23/2013 indicated that Resident #2 was sent to the hospital at 6:23 pm 3 days post antibiotics. Hospital records were reviewed and noted that Resident #2 was admitted with a known overdose that was accidental. The record identified that Resident #2 had a [MEDICATION NAME], was given 15 mg of [MEDICATION NAME], and was found unresponsive. Resident #2 was given 2 mg of [MEDICATION NAME] (a medication to counter the effects of an opiate overdose) at the hospital and became more responsive. A hospital physician s note indicated that it appeared to be a case of opiate toxicity. The Discharge [DIAGNOSES REDACTED]. Laboratory blood test results noted that Resident #2 was positive for opiates and barbiturates. Urine tests confirmed a UTI. In an interview on 7/3/2013 at 9:09 am NA (nursing assistant) #1, who regularly cared for Resident #2, stated that for 2-3 days prior to being sent to the hospital Resident #2 was hard to wake up. She indicated that she reported this to the nurse. At 9:25 am on 7/3/2013 the Nursing Supervisor who wrote the above note on 6/21/2013, stated that right before Resident #2 went to the hospital, the resident had a good day and did get up. The next day Resident #2 was very groggy and didn't want to get up. The nursing supervisor added that Resident #2 had a lot of days when she slept a lot and she knew over the weekend got a lot sleepier. (weekend of 6/21-6/23) On 7/03/2013 at 12:26 pm Nurse #1, who gave the last dose of [MEDICATION NAME] on 6/23, stated in an interview that the family asked her throughout the day to give Resident #2 [MEDICATION NAME] for pain. The nurse indicated that she told the family that as long as the resident was sleeping without signs or symptoms of pain, she was not going to give the medication as it caused sedation. After a dressing change she indicated that Resident #2 was yelling and saying there was pain. At that time the nurse gave a PRN dose of the [MEDICATION NAME]. She included that she assessed Resident #2 later on and had no concerns. (The MAR indicated [REDACTED]. At 12:40 pm on 7/3/2013 Nurse #2 stated in a telephone interview that when she began her shift at 3:00 pm on 6/23/2013, Resident #2 was sleeping. She revealed that from the first time she cared for Resident #2, the resident was sleeping more. The nurse said usually if she had medications to give she would wake Resident #2, but didn't have any to give so did not wake the resident. She shared that the NA came to her because when she went to give care, she found Resident # 2 had secretions coming from the mouth. Nurse #2 went to the room cleaned the resident's mouth and checked the breathing and oxygen saturation. At that time Resident #2 was in a deep sleep with unlabored respirations and oxygen saturation of 92%. She stated that she was aware that Resident #2 had received pain medication around 2:00 pm. The NA gave care and went back to check on Resident #2. At that time the resident had more secretions and the NA notified the nurse. The nurse again suctioned the secretions, called her supervisor who put an oxygen mask on the resident and measured the oxygen saturation at 64%. At that time Nurse #2 called the physician and received an order to send Resident #2 to the hospital by 911. Nurse #2 added that she left a communication for the physician so he could assess Resident #2 and review her medications after the day nurse told her the resident had been sleeping all day. She said she didn't feel the resident sleeping a lot was urgent or she would have called the physician. On 7/3/2013 at 2:18 pm the pharmacy that provided medications for Resident #2 was called. A pharmacist stated in an interview that he was aware of an interaction between [MEDICATION NAME] and [MEDICATION NAME] causing increased sedation, but in his reference it was considered moderate. They notified the facility if the interaction was a level 1, but this was not so they assumed the staff would monitor the resident for over sedation. The Director of Nurses (DON) stated in an interview on 7/3/13 at 4:00 pm that Resident #2 started having more pain in the legs and shoulders. She indicated that the physician took the resident off [MEDICATION NAME] and put added [MEDICATION NAME] and the resident had a [MEDICATION NAME]. Resident#2 started refusing to get out of bed about the time the lethargy increased. However, the DON said whenever she went to visit the resident would wake and talk to her. She added that the physician came to the facility on Tuesdays and his nurse practitioner came on Mondays and Thursdays. The DON checked the communication book to the physician and indicated there was a message dated 6/22/2013 that Resident #2 was very lethargic. That was on Saturday and the nurse practitioner would not see it until Monday. The DON also stated that Resident #2 went to the hospital on Sunday 6/23/2013 unresponsive. The only explanation for the staff not calling a physician to report Resident #2's lethargy was that on call physicians on the weekend wouldn't change orders or write new orders. They said either wait until the regular physician could see the resident on Monday or send them to the hospital. The DON said they hesitated to do that as the state got on them for sending resident's to the hospital who could be treated in house. A telephone interview was conducted with Resident #2's physician on 7/3/2013 at 4:13 pm. He stated that he was very aware of the interaction between [MEDICATION NAME] and [MEDICATION NAME] and usually tried not to use that combination, but Resident #2 had such unrelieved pain. He had not received any reports of increased sedation and if he had known he would have changed her medications. He added that he did not write an order for [REDACTED].

Based on record review and staff interviews the facility failed to monitor and assess the bowel patterns of a resident who had a history of [REDACTED]. #1). Findings include: Review of the facility ' s Standing Orders/Constipation which were reviewed and revised 6/9/10, indicated the Bowel Protocol read: if no BM every 3 rd day, Resident may request as below oral medication, suppository or Fleet enema on as needed basis as follows: 1. Milk of Magnesia 30 milliliters by mouth every day for constipation and check bowel sounds every shift times 2 days. 2. Rectal check for hard stool, remove and continue with #3 and #4. 3. [MEDICATION NAME] Suppository 1 rectally every day as needed for constipation times 3 days or #4. 4. Fleet enema 1 rectally everyday as needed for constipation times three days. Notify MD if no response from protocol; if bowel sounds are absent or sluggish; if projective vomiting has occurred; or if resident has small loose stools as these may be symptoms of pending ileus or obstruction. Record review indicated Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident ' s medications included : [MEDICATION NAME] (an iron supplement) 325 milligrams, 1 tab by mouth every morning and [MEDICATION NAME](Generic for [MEDICATION NAME]) 10-325 milligram tablet, 1 tab by mouth three times per day as needed in April of 2012 and routinely beginning in May of 2012 for Arthritic Pain. Review of the current Significant Change Minimum Data Set (MDS) Assessment with Assessment Reference Date of 4/20/2012 indicated the resident had a significant change to include Hospice services. The Cognitive Patterns included Signs and Symptoms of [MEDICAL CONDITION] which were coded as Inattention and Disorganized Thinking. Functional Status: Extensive Assistance Required for Toilet use with two person physical assist. Pain was coded on the MDS as present, frequent, and severe. The Care Area Assessment (CAA) Summary dated 4/25/12 indicated the resident triggered for Cognitive Loss/Dementia and [MEDICAL CONDITION] Drug Use with the current care plan to be continued. Pain triggered and a New Care Plan was started. Review of the initial Care Plan of 2/07/12 and updated on 5/07/12 indicated Resident #1 was " At risk for side effects from antipsychotic drug use. The goal: Will have no adverse reactions related to medication usage/side effects. Approaches: Administer medication as ordered by physician. Monitor bowel elimination pattern and report any abnormalities to physician. Observe for side effects, document and report to physician. " Review of the documentation on the Medication Administration Record (MAR) indicated the resident received [MEDICATION NAME] for pain three times per day each day in April, May, and June of 2012. [MEDICATION NAME] was documented on the MAR daily in April, May, and June of 2012. Both the [MEDICATION NAME] and the [MEDICATION NAME] are medications that are known to increase the risk of constipation. The facility was unable to provide evidence of bowel movements or physician's order [REDACTED]. Review of the record of bowel movements on the Completed Care Tasks facility form from 4/6/12 - 4/12/12 indicated Resident #1 did not have a bowel movement (BM) for 7 days. The bowel protocol was not implemented. The resident had a BM on 4/13/12. The resident had no BM for 2 1/2 days (4/13/12 - through 4/15/12). The resident had no BM on 4/16/12. The resident had new Physician ' s telephone orders dated 4/17/12 at 2:00 PM for MOM (Milk of Magnesia ) 30 milliliters by mouth everyday as needed for constipation and Check Bowel Sounds every shift times 2 days. Review of the documentation on the Medication Administration Record (MAR) indicated the Nurse began the facility Standing Orders protocol for constipation on 4/17/12 for the resident. The MAR read, " MOM (Milk of Magnesia) 30 Milliliters as needed times 2 days. " The documentation on the MAR indicated the resident received 1 dose of Milk of Magnesia on 4/17/12 and none for 4/1812. The MAR also read, " Check Bowel sounds every shift x 2 days. " The documentation on the MAR indicated the bowel sounds were checked once on 7-3 shift on 4/17/12 and once on 11-7 shift on 4/18/12, instead of every shift according to the facility protocol. The resident had new Physician ' s telephone orders dated 4/17/12 at 3:30 PM for [MEDICATION NAME] 100 milligrams 2 = 200 milligrams by mouth at bedtime, and [MEDICATION NAME] 17 grams in 8 ounces of water daily for constipation. Review of the documentation on the MAR indicated there was no documentation to indicate the [MEDICATION NAME] was given on 4/17/12. [MEDICATION NAME] 100 milligrams 2= 200 milligrams was documented as given by mouth at Bedtime as ordered on [DATE]. The resident went 5 days from 4/18/12 to 4/23/12 without a BM. [MEDICATION NAME] was given on 4/18/12. Additional review of the Physician ' s telephone orders dated 4/17/12 indicated there was an order for [REDACTED]. According to the Nursing notes on 4/17/12 at 9:55 PM Nurse did a DRE (Digital Removal) of stool from the resident. The resident went 3 days from 4/26/12 to 4/28/12 without a BM. The bowel protocol was not implemented. The resident did not have a BM on 4/29/12 and 4/30/12. Review of the physician's order [REDACTED]. [REDACTED]. Nurses notes on 5/13/12 at 7:46 PM read, " NA (Nursing Assistant) reported that resident had a hard bowel which was stuck. Another nurse and I went, took resident in room to assess resident ' s stool. Resident began to get combative once we tried to put (the resident) on the toilet. I was able to digitally remove a lot of stool from the resident. " Review of the record of bowel movements on the Completed Care Tasks facility form indicated the resident went 2 days from 5/15/12 through 5/16/12 PM without a BM. For the next 3 days from 5/17/12 through 5/19/12 the resident did not have a BM. The bowel movement protocol was not implemented. The resident had a BM on 5/20/12, then no BM for 3 days from 5/20/12 to 5/22/12. The bowel movement protocol was not implemented. Review of the physician's order [REDACTED]. The [MEDICATION NAME] order was discontinued on 5/30/12. A new order for Senna S 2 by mouth two times per day for constipation was ordered 5/30/12. Review of the May and June 2012 MAR indicated the Senna S was documented given as ordered from 5/30/12 through June 26, 2012 when the survey started. A staff interview was conducted with the Director of Nurses (DON) on 6/26/12 at 4:50 PM regarding the concern the resident did not have regular bowel movements (BMS) from 4/01/12 - 4/17/12, and still had problems with BMS after 4/17/12 through 5/22/12. The DON indicated, " The protocol is started when the resident ' s name shows up on our No BM Report. (Resident #1) has not shown up on this list. " The DON indicated, " The No BM Report is generated if a resident does not have a BM for 3 days. The Nursing Assistants enter the information about no bowel movements in the computer, and the computer generates the No BM Report. I cannot explain why Resident #1 has not shown up on our No BM Report. I cannot explain the reason for her not having a BM or why nothing was ordered before 4/17/12. " Interview conducted on 6/27/12 at 10:30 AM with the first shift Nurse (Nurse #5) regarding an episode of bowel incontinence on 5/13/12 with the Nurse doing a DRE (Digital Removal) of stool from the resident. The Nurse indicated, " Basically a NA (Nursing Assistant) told me the resident couldn ' t get her stool out/have a bowel movement, so I went and got another Nurse (Nurse #6). Then we took the resident to the bathroom, and we sat the resident on the toilet. Once (Resident #1) sat on the toilet, (Resident #1) began getting combative and swatting/swinging at us while we were putting (Resident #1) on the toilet. There was some hard stool, and I tried to get the stool out digitally, and I was able to get out a large amount and then (Resident #1) was able to have a bowel movement on (Resident #1 ' s) own after that. (Resident#1) was not impacted. (Resident #1) was constipated. I cannot make the judgment whether (Resident #1) is impacted or not, because the Doctor makes the diagnosis. The (family member) tells me the resident has been having the problem of being constipated. " Interview with the DON on 6/27/12 at 11:20 AM indicated, " If the orders are for the bowel sounds to be checked every shift, it is supposed to be done every shift. " During an interview with Nurse #1 conducted on 6/27/12 at 11:50 AM, the Nurse could not explain why the medications ([MEDICATION NAME] and [MEDICATION NAME]) had not been given from May 1 - May 10, 2012. During an interview with Nurse #2 conducted on 6/27/12 at 12:10 PM regarding the reason the [MEDICATION NAME] and the [MEDICATION NAME] were not given from May 1 - May 10, 2012 , the Nurse could not explain why the [MEDICATION NAME] and [MEDICATION NAME] was not documented on the MAR and/or not given. A staff interview with Nurse #3 was conducted on 6/27/12 at 12:45 PM. The nurse was not able to explain why the medications ([MEDICATION NAME] and [MEDICATION NAME]) had not been given from May 1 - May 10, 2012. A staff interview was conducted with Nurse #4 on 6/27/12 at 1:00 PM. When asked the reason the [MEDICATION NAME] and the [MEDICATION NAME] had not been given to the resident from May 1 - May 10, 2012, and/or documented as given, Nurse #4 indicated the reason the [MEDICATION NAME] and [MEDICATION NAME] orders were not documented was, " When the Pharmacy had printed out the new Medication sheet for May, 2012, the medications were not on the sheet. I noticed it on 5/11/12 and started the medications on 5/11/12. I left a note for the Director of Nurses (DON) on 5/11/12 that it had not carried over from the April MAR. I talked with the resident ' s (family) about it on May 11, 2012, and I told the (family) the resident did not receive it from May 1 - 10th for that reason. " A staff interview with the DON was conducted on 6/2712 at 1:15 PM. When asked about her expectations for following the MD orders to give the [MEDICATION NAME] and [MEDICATION NAME] from May 1 through May 10, the DON indicated, " It ' s safe to say it ([MEDICATION NAME] and [MEDICATION NAME]) wasn ' t given, and should have been given. My expectation is that it should not have gone 10 days without somebody catching it on the MAR to MAR check from the last of the month (April 30th) to the beginning of the new month (May 1). The pharmacy didn't print it out on the MAR. On 5/11/12 the (family member) took out stool from (Resident #1 ' s) rectum. It was not hard and then on 5/13/12 the Nurse said it was hard stool, and was digitally removed by the Nurse. I don't think it was an impaction, because when it was removed, it was soft, and (Resident #1) was able to pass it. "

Based on record review and staff interview, the facility failed to develop a comprehensive care plan, including measureable goals and timetables, for 2 of 5 residents (Residents #4 and #1) receiving anticoagulation therapy. Immediate jeopardy began on 12/24/10. The facility was notified of the immediate jeopardy on 2/22/11 at 11:40 AM. The immediate jeopardy was removed on 2/23/11 at 2:00 PM. The facility remained out of compliance at a Scope and Severity level "D" (an isolated deficiency that constituted potential harm that is not Immediate Jeopardy) to ensure that policies and procedures implemented by the facility could be reviewed and evaluated by the Quality Assurance Committee. The facility was also in the process of ensuring the completion of employee training. The findings include: 1. Resident #4 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. admission orders [REDACTED]. Record review revealed an "Initial Care Plan" dated 10/8/10 for Resident #4 which listed a range of conditions that could be checked if applicable to the resident. Goals were pre-printed under all the conditions, and under the goals were pre-printed interventions which could be checked. The condition "Anticoagulant Therapy" was checked, the goal was "no complications". Interventions included a check for " abs/Meds as ordered". Handwritten below the pre-printed interventions was "ASA (aspirin) and [MEDICATION NAME]". Resident #4's comprehensive care plan, dated 10/11/10, did not mention anticoagulation therapy, nor did handwritten updates through 12/29/10 address anticoagulation. During an interview on 2/22/11 at 8:58 AM, administrative nurse #2 acknowledged that she did not develop a comprehensive care plan for Resident #4's anticoagulation therapy. Administrative nurse #2 indicated that all residents receiving anticoagulation therapy should have a care plan identifying the risks, measurable goals with timetable, and specific interventions. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. Resident #1's record included "Care Plan Meeting" sheets which indicated that his care plan was reviewed on 8/10/10, 10/19/10, and 1/18/11. The care plan revealed an entry dated 8/18/10 that read, "Risk of bleeding due to [MEDICATION NAME]. Monitor skin." No measureable goals or time tables were included. The care plan contained no other reference to anticoagulation therapy. During an interview on 2/22/11 at 8:58 AM, administrative nurse #2 acknowledged that she did not develop a comprehensive care plan for Resident #1's anticoagulation therapy. Administrative nurse #2 indicated that all residents receiving anticoagulation therapy should have a care plan identifying the risks, measurable goals with timetable, and specific interventions. Credible Allegation of Compliance F 279 Resident #1's care plan did not include problem statement, goals and interventions for [MEDICATION NAME]. The resident was discharged on [DATE] to an acute care hospital. Resident #4 had an interim care plan that included [MEDICATION NAME] but the comprehensive care plan did not. The interim care plan is created during the admission process as an initial plan of care. This is utilized by staff until the comprehensive care plan is created as a part of the resident assessment instrument process. [MEDICATION NAME] was discontinued for this resident during the hospitalization and has not been reordered. On 2/22/2011, all residents who currently receive [MEDICATION NAME] had their care plan updated by the corporate MDS nurse and the facility care plan nurse to ensure that [MEDICATION NAME] was listed as a problem. Appropriate goals and interventions were also care planned. These care plans include monitoring for side effects and symptoms of [MEDICATION NAME] toxicity as described below in the in-service training. On 2/22/2011, the corporate Minimum Data Assessment Coordinator educated the facility assessment nurse and care plan nurse on the importance of care planning [MEDICATION NAME] as a problem for all residents receiving [MEDICATION NAME]. The education session included that an appropriate care plan for [MEDICATION NAME] would include a problem statement, goals and interventions specific to the resident's needs. At a minimum, the care plan should include signs and symptoms of [MEDICATION NAME] toxicity and possible side effects as well as what staff should do if they identify any concerns. The Director of Nursing or Staff Development Coordinator will monitor the care plans for [MEDICATION NAME] usage using the "[MEDICATION NAME] Care Plan Audit Tool". The monitoring will include a review of all residents who currently receive [MEDICATION NAME] to verify that the care plans include a problem statement, goals and interventions related to the resident's needs regarding usage of [MEDICATION NAME]. This should include signs and symptoms of [MEDICATION NAME] toxicity and possible side effects of [MEDICATION NAME] and what staff should do if concerns are identified. This will be done daily (Monday thru Friday) for four weeks and then weekly times three months or until resolved by QOL/QA committee. Reports of the [MEDICATION NAME] Care Plan Audit Tool will be given to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality of Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Support Nurse and Health Information Management. On 2/23/11 at 11:05 AM, the care plan nurses (administrative staff #2 and Nurse #2) indicated during an interview that they had been educated on care planning residents who are on anticoagulation therapy. They presented the updated care plans of 10 residents on [MEDICATION NAME] who were currently residing in the facility. The care plans included signs and symptoms of [MEDICATION NAME] toxicity, possible side effects and what interventions to employ if problems were observed. The care plan nurses verbalized understanding of measurable goals and timetables.

Based on record review and staff interview, the facility failed to monitor PT ([MEDICATION NAME] time)/INR (International Normalizing Ratio) after a [MEDICATION NAME] (an anticoagulant) dose increase and failed to intervene when bruises were observed (Resident #4), and failed to monitor PT/INR as ordered (Resident #1) resulting in hospitalization for 2 of 5 residents receiving [MEDICATION NAME]. The facility also failed to accurately transcribe physician orders [REDACTED]. Immediate Jeopardy began on 12/24/10. The facility was notified of the immediate Jeopardy on 2/22/11 at 11:40 AM. The immediate Jeopardy was removed on 2/23/11 at 2:00 PM. The facility remained out of compliance at a Scope and Severity level "D" (an isolated deficiency that constituted potential harm that is not Immediate Jeopardy) to ensure that policies and procedures implemented by the facility could be reviewed and evaluated by the Quality Assurance Committee. The facility was also in the process of ensuring the completion of employee training. The findings include: 1. Resident #4 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. admission orders [REDACTED]. (PT is a blood test which measures the ability of the blood to clot, and INR is a blood test to monitor the effectiveness of [MEDICATION NAME].) Lexi-Comp's Geriatric Dosage Handbook, 14th edition, stated: [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant medication used in [MEDICATION NAME] and treatment of [REDACTED]." Under Adverse Reactions, the reference read, "Bleeding is the major adverse effect of [MEDICATION NAME] ([MEDICATION NAME]). Hemorrhage may occur at virtually any site." Under Monitoring Parameters/Reference Range, the reference read, "An INR greater than 4 does not generally add additional therapeutic benefit and is associated with increased risk of bleeding." The admission Minimum Data Set (MDS), dated [DATE], revealed that Resident #4's cognitive skills were intact, she understood others and was understood by others, she required limited assistance of 1 person for transfers and toileting, and was on [MEDICATION NAME]. Resident #4's comprehensive care plan, dated 10/11/10, did not identify a problem or need related to anticoagulation therapy. Physician orders [REDACTED]. On 11/12/10, the PT results were 16.4 sec (seconds) (normal range 11.5 - 14.7 sec) and INR was 1.3 (therapeutic range 2.0 - 3.5). On 11/17/10 the physician ordered to increase the [MEDICATION NAME] dose to 5 mg daily and recheck PT/INR in 1 week. On 11/24/10 the PT/INR results were 27.1 and 2.5. The physician was notified and no new orders were received. No follow-up PT/INR was ordered. Weekly skin reviews in December revealed that Resident #4 had no new skin areas of concern from 12/1/10 at 3:50 PM - 12/24/10 at 4:33 AM. Nurse's notes dated 12/24/10 at 12:50PM, written by Nurse #3, indicated that a new bruise was observed on the back of Resident #4's right arm and area under her arm measuring 11 centimeters (cm) from shoulder down, 5 cm in width across upper shoulder, and 5 cm in width under arm area. The notes indicated that Nurse #3 contacted the responsible party who said that the area was not bruised on the evening of 12/23/10. The notes further indicated that Resident #4 stated she bruises easily. The notes read, "Message left for MD". Neither nurse's notes, physician orders [REDACTED]. Nurse #3 could not be reached for interview. Nurse's notes from 12/25/10 through 12/28/10 revealed no documentation of bruises on Resident #4. The 12/29/10 weekly skin review note, written by Nurse #1, read, "New skin condition noted. See nurse's note." Nurse's notes dated 12/29/10 at 2:00 PM written by Nurse #1 indicated that the physician was notified of new bruising on Resident #4 and ordered a PT/INR. Nurse's notes 12/29/10 at 3:00 PM written by Nurse #1 read, "New bruising on right side flank (posterior shoulder region) 15 cm in length, 6 cm in width, bruising across upper back 30 cm in width and 6 cm in length. Bruise on right outer leg 5 cm width, 2 cm in length. Bruise noted on upper right leg ? cm in length and 3 cm in width and another bruise on left inner upper leg 1 cm width and 2 cm length. Bruise noted on left upper outer leg 4 cm length and 3 cm width. New hematoma on left hand from blood drawn today." The PT/INR report dated 12/29/10 at 3:08 PM revealed a PT of 117.1 seconds and INR of 15.5. Nurse's notes 12/29/10 at 3:30 PM written by Nurse #4 revealed the physician was notified of the high PT/INR and Resident #4 was transported to the Emergency Department at 3:55 PM. During an interview on 2/21/11 at 6:08 PM, Nurse #4 indicated that she took care of Resident #4 regularly, and worked the 3-11 shifts on 12/25/10, 12/27/10 - 12/29/10. Nurse #4 did not recall Resident #4 having large bruises until 12/29/10 as reported by the day shift. Nurse #4 recalled that she sent Resident #4 to the hospital on [DATE] with a high PT/INR. Nurse #4 indicated that the aides know to report bruises or bleeding to the nurse immediately for any resident, and that no special alerts are given to the aides for monitoring those residents on [MEDICATION NAME]. A hospital discharge summary dated 1/3/11 revealed that Resident #4 was admitted to the hospital 12/29/10 with cumulative [DIAGNOSES REDACTED]. Treatment included vitamin K 10 milligrams, 2 units of fresh frozen plasma and 1 unit of packed red blood cells. [MEDICATION NAME] was not restarted. Resident #4 returned to the facility on [DATE]. During an interview on 2/21/11 at 12:15 PM, administrative staff #1 indicated that when Resident #4 was admitted to the hospital, the facility had no system in place to ensure that follow up PT/INRs were ordered for residents receiving [MEDICATION NAME]. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. Lexi-Comp's Geriatric Dosage Handbook, 14th edition, stated: [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant medication used in [MEDICATION NAME] and treatment of [REDACTED]." Under Adverse Reactions, the reference read, "Bleeding is the major adverse effect of [MEDICATION NAME] ([MEDICATION NAME]). Hemorrhage may occur at virtually any site." Under Monitoring Parameters/Reference Range, the reference read, "An INR greater than 4 does not generally add additional therapeutic benefit and is associated with increased risk of bleeding." The quarterly Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 understood others and was understood by others, had moderate cognitive impairment, required extensive assistance of 1-2 people for bed mobility, transfers and toileting, and received an antidepressant daily. Resident #1's care plan revealed an entry dated 8/18/10 that read, "Risk of bleeding due to [MEDICATION NAME]. Monitor skin." On 12/28/10, physician orders [REDACTED]. On 12/30/10 laboratory results revealed [MEDICATION NAME] (PT) of 16.1 sec (seconds) (normal range 11.5-14.7 sec) and International Normalizing Ratio (INR) of 1.3 (therapeutic range 2.0-3.5). (PT is a blood test which measures the ability of the blood to clot, and INR is a blood test to monitor the effectiveness of [MEDICATION NAME].) No new orders were received. On 1/7/11 the PT was 16.4 and INR 1.3. On 1/11/11, the physician increased the [MEDICATION NAME] dose to 5 mg daily and ordered a PT/INR to be done on 1/18/11; the results were 20.7 and 1.8. On 1/21/11 a physician telephone order, taken by Nurse #2, read to increase Resident #1's [MEDICATION NAME] dose to 6 mg daily and recheck a PT/INR in 2 weeks. During an interview on 2/22/11 at 10:14 AM, Nurse #2 indicated that after she took the telephone order on 1/21/11 for Resident #1's follow-up PT/INR, she failed to put the request for the PT/INR in the computer. No further PT/INR results for Resident #1 were available on the medical record or from the laboratory. Nurse's notes dated 2/14/11 at 12:35 PM indicated that Resident #1 had a cut under his tongue on the right side that would not stop bleeding. The physician was in and applied pressure to the area but the bleeding did not stop. The resident stated he had sneezed and bit his tongue. The physician ordered the resident to be sent to the Emergency Department (ED). A copy of "Physician Documentation" dated 2/14/11 from the hospital ED revealed the physician observed a 0.5 millimeter laceration on the underside of Resident #1's tongue with moderate active bleeding. Plan was for hospital admission with [DIAGNOSES REDACTED]. In the ED, the PT/INR was 108.6/14.1. Vitamin K (Vitamin K is used as an antidote for [MEDICATION NAME]) 10 milligrams was given in the ED. Laboratory records from the hospital revealed that the resident also received 2 units of fresh plasma (the liquid component of blood which contains clotting factors) on 2/15/11. During an interview on 2/18/11 at 4:12 PM, Administrative Nurse #1 stated that a lab notebook was kept at the nurses' station which contained daily lab sheets on which the nurse who was processing a lab order was to record the name of the resident and the test ordered. The lab notebook had monthly dividers followed by daily dividers numbered 1-31. A daily lab sheet was to be placed behind the appropriate divider. The nurse processing the order was also responsible for entering the lab request in the computer, printing a copy of that request, then placing the request in the lab notebook behind the appropriate daily lab sheet. If the computer was down, the nurse was responsible for generating a paper requisition for the lab test and filing it in the lab notebook. The unit support nurse (Nurse #3) was responsible for checking the lab sheets against the lab request sheets to assure that all tests were ordered. Nurse #3 was could not be reached for interview. During an interview on 2/22/11 at 10:14 AM, Nurse #2 acknowledged that she failed to put the request for Resident #1's PT/INR ordered to be done on 2/4/11 in the computer. Nurse #2 indicated she remembered writing the request on a lab sheet in the lab notebook, but when the book was reviewed on 2/14/11 the request she wrote was not found. During an interview on 2/18/11 at 4:12 PM, Administrative Nurse #1 indicated that on 2/14/11 after Resident #1 left for the ED, she reviewed his record and realized the PT/INR ordered on [DATE] to be done on 2/4/11 was not obtained. Administrative Nurse #1 stated she reviewed the lab notebook and found no lab sheet or requisition for Resident #1. Administrative Nurse #1 said that she immediately audited records of all residents receiving [MEDICATION NAME] to determine when the last PT/INRs were obtained, what the results were, what the current dosage of [MEDICATION NAME] was, when the next PT/INR was scheduled, and that it was written in the lab notebook and entered into the computer. Credible Allegation of Compliance F 329 Resident # 1 had a [MEDICATION NAME] and international normalized ratio laboratory ordered on [DATE] to be drawn on 2/3/2011. The laboratory test was not drawn and on 2/14/2011 the resident had an episode of prolonged bleeding and was subsequently sent to the emergency room for bleeding. Resident was discharged on [DATE] to the hospital. Resident # 4 had [MEDICATION NAME] and international normalized ratio results on 11/24/2010. The [MEDICATION NAME] was noted to be 27.1 and international normalized ratio was 2.5 and the MD was notified via fax on 11/25/2010 by the facility and Physician Laboratory Services. No additional orders were noted. On 12/24/2010, a bruise to the back of the right under arm was noted to be 11 centimeters in length from shoulder down and 5 centimeters in width across the upper shoulder and 5 centimeters in the underarm area. A message was left for the MD related to this area. [MEDICATION NAME] and international normalized ratio was drawn 12/29/2010 because a new bruise was noted to right side, back and inner legs. Laboratory results were obtained on 12/29/2010 and the [MEDICATION NAME] was 117.1 and international normalized ratio was 15.5. Resident was sent to the emergency room and admitted to the hospital. Resident was readmitted to the facility on [DATE]. [MEDICATION NAME] was discontinued for this resident during the hospitalization and has not been reordered. All residents who receive [MEDICATION NAME] had a chart review completed on February 14 and 15, 2011 by the Director of Nurses to ensure that any order for a [MEDICATION NAME] and international normalized ratio was obtained and the results were followed up on using the [MEDICATION NAME] Protocol. There were 13 residents on [MEDICATION NAME] and all were reviewed. This was accomplished by reviewing the charts for orders and then verifying that the laboratory result was in the chart and had been appropriately addressed by the physician. Correction actions for any identified concerns were implemented as appropriate. The Director of Nursing processed orders for [MEDICATION NAME] and international normalized ratios for three residents identified during the audit. All three of these residents had an order for [REDACTED]. The physician was contacted about the results of the laboratory test and the [MEDICATION NAME] protocols were initiated. The director of nursing contacted the physician with the results of the laboratory test and director of nursing initiated orders as specified in the [MEDICATION NAME] protocol. Liberty Commons of Rowan County [MEDICATION NAME] Protocol -International Normalizing Ratio less than 2.0: Increase daily dose by 0.5mg and Recheck [MEDICATION NAME] and International Normalizing Ratio in 1 week -International Normalizing Ratio 2.0-3.4: No dose change; Recheck [MEDICATION NAME] and International Normalizing Ratio in 2 weeks. If stable for 2 months then recheck in 1 month -International Normalizing Ratio 3.5-5.0: HOLD [MEDICATION NAME] dose for 1 day; Decrease daily dose by 0.5mg; Recheck [MEDICATION NAME] and International Normalizing Ratio in 1 week -International Normalizing Ratio greater than 5.0 to 7.9: HOLD [MEDICATION NAME] dose for 2 days; Recheck [MEDICATION NAME] and International Normalizing Ratio in 2 days. Use the results of the repeat [MEDICATION NAME] and international normalizing ratio and reapply and follow the [MEDICATION NAME] protocol. -International Normalizing Ratio greater than or equal to 8.0: CALL PHYSCIAN for orders This protocol is to be followed on all residents taking [MEDICATION NAME], under DR. ____ care. Residents may be followed by the [MEDICATION NAME] clinic if it is so stated in the discharge summary. The original laboratory result forms are maintained in the physician notebook until they are reviewed by the physician or nurse practitioner during the next scheduled visits. The physician comes once a week, usually on Monday, and the nurse practitioner usually visits on Tuesday and Thursdays. Once reviewed, the physician or nurse practitioner signs the form and it is filed by the health information management clerk in the residents' chart. Additionally on 2/22/2011, the pharmacy consultant reviewed all 13 residents who are currently receiving [MEDICATION NAME]. Charts were checked to ensure that the [MEDICATION NAME] and international normalized ratio were current according to physician orders. Three residents had pending laboratory test results due 2/22/2011. Once results are available the [MEDICATION NAME] Protocol will be implemented by the hall nurse. No additional concerns were identified. On 2/22/2011, all 13 residents who currently receive [MEDICATION NAME] had skin checks completed by the wound nurse. Skin was checked for unusual or unexplained bruising. The results of this review are documented in the nursing notes. The physician was notified via phone immediately of any concerns. Four residents required complete blood counts due to bruises that were noted and these were drawn on 2/22/2011 and sent to the laboratory for results. Once results are received the wound nurse will notify the physician of the results and will implement any new orders. Additionally, all nurses (RN and LPNs) who currently work in the facility were in-serviced on 2/14/2011 and 2/15/2011 by Director of Nursing on the revised process for laboratory orders. Areas covered include: Processing the [MEDICATION NAME] and international normalized ratio order, ensuring the laboratory results are returned to the facility, that the staff should follow the laboratory protocol or call MD as appropriate. Laboratory Protocol and [MEDICATION NAME] Protocol: " COLLECTION OF [MEDICATION NAME] AND INTERNATIONAL NORMALIZED LABS & REPORTING Obtain order for needed lab unless it is a scheduled laboratory test and the order already exists The hall nurse should process order in entirety (write lab in lab book under appropriate day, enter lab into computer or write paper requisition, update Medication Administration and Treatment Administration Record with the name of the lab and date to be drawn, sign name that order has been processed) The hall nurse puts a copy of the laboratory requisition (either the hand written requisition or printed computer requisition) in the accordion file under the proper date Every night the 3rd shift nurse is to check all resident charts. If a physician order [REDACTED]. The 3rd shift nurse then takes all the laboratory sheets for the next day shift and verifies that lab requisition forms are in the accordion file. If not located they will complete the requisition form and file in the accordion file. Sunday, Monday, Wednesday, Friday and Saturday the day shift nurse is responsible for checking the accordion file for any laboratory requisitions due on any resident assigned to the nurse on that day. This nurse is then responsible for drawing the laboratory test and sending it to Physician Laboratory Services for processing. On Tuesdays and Thursdays, a phlebotomist comes to the facilities and checks the accordion file for any laboratory requisitions due on that day. The phlebotomist then obtains the laboratory studies. If the phlebotomist is unable to come to the facility the hall nurses would be notified by the Director of Nursing or Staff development Coordinator and they will then obtain any needed laboratory specimens for process by Physicians Laboratory Services. 1st shift Nurse to check lab book daily to ensure all labs have been drawn by verifying that the initials of the person who obtained the laboratory test are beside the resident's name & notify Director of Nursing or unit support nurse (who is a nurse position in this facility) if any lab not drawn that shift and corrective actions will be initiated as appropriate Lab tech/nurse is to obtain labs by verifying what laboratory test are identified in the laboratory book (that is kept at the main nurses station) & send to Physician Lab Services Lab & initial lab book that lab has been obtained Lab to fax results to facility usually by 3pm that day (critical labs to be called to MD). The second shift nurse checks the computer for laboratory results and calls the MD if indicated by the protocol. Labs to be called to MD or Implement the [MEDICATION NAME] protocol. The protocol would be initiated for all residents by the hall nurse. Residents with International Normalizing Ration greater than 8 would require physician notification via phone by the hall nurse as well as any resident experiencing signs and symptoms of toxicity or side effect. If the MD does not respond the hall nurse will notify the Director of Nursing who will immediately contact the physician using the other phones numbers available to her. Nurse receiving order to transcribe order on lab sheet Any new orders to be transcribed to physicians Telephone Order The hall nurse will make a copy of the laboratory results and place the copy in the resident's chart. The original is put in the physician book so that it can be reviewed and signed during the physician's or nurse practitioner's next visit. When the physician or nurse practitioner has signed and reviewed the laboratory results the original should be placed in the resident's chart. FYI: You will always have a follow up [MEDICATION NAME] and international normalized ratio even if you do not have a change in [MEDICATION NAME]. If a follow up [MEDICATION NAME] and international normalized ratio is not ordered by the physician the hall nurse is to immediately contact the director of nursing. The director of nursing will then contact the physician and determine why a follow up was not ordered. The director of nursing will then initiate any verbal orders that may be received as a result of this conversation. The director of nursing will also document the conversation in the nursing notes. Side Effects and Toxicity of [MEDICATION NAME] Bleeding gums, petechiae, bruising, black tarry stool, hematuria (blood in urine) fatal hemorrhage can occur) Any area with prolonged bleeding, Fever, Rash, hives Report any of the above conditions identified to the Nurse who will notify MD immediately by phone." Eighty five percent of RN and LPNs were in-serviced on 2/14/2011 and 2/15/2011. Additional staff was in-serviced 2/19/2011. The only staff that have not been trained are eight staff members that work very infrequently. Several attempts have been made to contact them by phone without success. The Director of Nursing will not allow these employees to work until in-service training has been completed. On 2/22/2011, additional in-services were completed by the Director of Nursing. All full time and part time RNs and LPNs, with the exception of 4 part time nurses were in-serviced on the collection of [MEDICATION NAME] and international normalized ratio Laboratory test. As of 2/23/2011 only four part time nurses have not yet been inserviced. Director of Nursing has contacted them by phone and left a message concerning the need to complete this inservice prior to returning to work in the facility. The Director of Nursing will ensure they do not work until they have been inserviced. This includes the steps for processing the order on the laboratory sheets, ensuring the results are received in the facility, and that either the laboratory protocol is implemented or that the MD is notified for follow up orders. The RNs and LPNs, were also educated by the Director of Nursing on 2/22/2011 to recognize the side effects and toxicity of [MEDICATION NAME]. This including reporting any bleeding gums, petechiae (small purple spotted discoloration under skin), bruising, black tarry stool, hematuria (blood in the urine) or any area with prolonged bleeding, fever, rash, hives. If any of these items are identified then the MD should be notified immediately by phone. Approximately fifty percent of all nursing staff has received this in-service. Phone in-servicing will continue until all staff has been in-serviced. If any staff member is not available to receive training via phone the Director of Nursing will not allow them to work until in-service training has been completed. Starting on 2/22/2011 the wound care nurse will conduct weekly skin checks on all residents receiving [MEDICATION NAME]. Documentation of these checks will include any petechiae, bruising or rash and will be documented in the nursing notes. The physician will be notified by the wound care nurse via phone immediately of any concerns and new interventions will be implemented as ordered. This has been communicated to the wound nurse by the Director of Nursing on 2/22/2011. On 2/22/2011, additional in-services were also conducted by the Director of Nursing. The nursing assistants were educated to recognize the side effects and toxicity of [MEDICATION NAME]. This including reporting any bleeding gums, petechiae (small purple spotted discoloration under skin), bruising, black tarry stool, hematuria (blood in urine) or any area with prolonged bleeding, fever, rash, hives. If any of these items are identified then the nurse should be notified immediately. Any staff member who does not receive training will not be allowed to work until in-service training has been completed. Approximately fifty percent of all nursing staff have received this in-service. Phone in-servicing will continue until all staff has been in-serviced. If any staff member is not available to receive training via phone the Director of Nursing will not allow them to work until in-service training has been completed. The Director of Nursing or Staff Development Coordinator will monitor the [MEDICATION NAME] and international normalized ratio using the "Laboratory Audit QA Tool". The Director of Nursing will print a [MEDICATION NAME] order list from the electronic health records prior to every daily audit Monday through Friday. This Order list is a report generated from the order entry section of the electronic health record and it will include all residents who have an order for [REDACTED]. This is will be an ongoing process. If an order is identified, the resident names will be added to the order list so they will be included in the audit. This list will then be used to audit the resident receiving [MEDICATION NAME]. This monitoring will include a review of all residents who currently receive [MEDICATION NAME] to verify that laboratory orders were transcribed into the laboratory book and entered into the computer. The audit will then continue to ensure that all laboratory tests were processed and results were received and appropriate follow up was initiated. Follow up will be deemed appropriate if the [MEDICATION NAME] protocol was initiated or if the physician was notified of the lab results. Staff will be expected to contact the physician by phone immediately when the international normalized index is greater than 8 or if there are signs and symptoms of [MEDICATION NAME] toxicity or side effects. This will be done daily (Monday thru Friday) for four weeks and then weekly times three months or until resolved by QOL/QA committee. Reports of the laboratory audit will be given by the director of nursing to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality of Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Support Nurse and Health Information Management. The Director of Nursing or Staff Development Coordinator will monitor the weekly skin checks using the "Weekly Skin Audit QA Tool". The monitoring will include a review of all residents who currently receive [MEDICATION NAME] to verify that skin checks were completed by the wound care nurse, documented in the nurses' notes, and the physician was notified of any concerns and orders were initiated as appropriate. This will be done weekly for at least three months or until resolved by QOL/QA committee. Reports of the weekly skin audit will be given to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. Additionally, every month during the Quality of Life-QA committee, the director of nursing will report on the laboratory errors identified during that month. Analysis will be conducted to identify trends/patterns and root causes of errors in order to implement systemic corrective action to reduce the number of laboratory errors. This monthly meeting is held in addition to the weekly meeting and focuses on trends and analysis of data versus individual residents. Completion Date: 2/23/2011 On 2/23/11 at 10:35 AM, interviews were completed with 3 nurses on different halls. The nurses were knowledgeable about the steps to process lab orders, were aware that the [MEDICATION NAME] Protocol was in the front of the lab book, and could state signs and symptoms of [MEDICATION NAME] toxicity and side effects. On 2/23/11 at 11:26 AM, interviews were completed with 5 nursing assistants on different halls and 1 therapy assistant. All stated that bruising and bleeding were the primary signs of [MEDICATION NAME] toxicity and would report them to the nurse immediately. The nursing assistants also named bloody stools or dark stools as signs of [MEDICATION NAME] toxicity. 3. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation. The 5 day Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had short term but no long term memory problems and had no problems with decision making. Review of the telephone order dated 08/16/10 revealed a doctor's order: "May use discharge summary for meds (medications)." The hospital discharge summary dated 08/16/10 was reviewed. The discharge summary had instructions for the resident's medications including "[MEDICATION NAME] (antianxiety medication) 0.25 mgs (milligram) by mouth daily as needed (PRN) for anxiety." Review of the facility's physician's orders [REDACTED]. Review of the telephone orders revealed no order to administer [MEDICATION NAME] 0.25 mgs daily. The MAR (Medication Administration Record) for August 2010 revealed that the [MEDICATION NAME] 0.25 mgs tablet was transcribed and was administered to the resident on a daily basis instead of PRN as ordered. The nurse's notes for August 2010 were reviewed. The notes did not have any documentation that the resident was anxious or agitated. On 02/21/11 at 2:30 PM, Nurse #1 was interviewed. Nurse #1 was the nurse who admitted the resident and transcribed the orders from the hospital discharge summary to the physician's orders [REDACTED]. She further stated that the facility system was to follow the orders from the hospital discharge summary and if there were changes in the medication order to write it on a telephone order. She revealed that it was not the physician who gave her an order to change it. On 02/22/11 at 2:02 PM, administrative staff #1 was interviewed. She stated that the facility's system was to follow the medications written on the hospital discharge summary. If the physician had changed the order written on the discharge summary, this new order should be written as a telephone order.