Every finding on record at Liberty Commons Nursing & Rehab Center of Southpor

Based on record review and staff interviews, the facility failed to implement an effective water management program to minimize the risk of Legionella (a bacterium that grows in warm water (77-113 F) and can multiply in building water systems). The facility established hot water control limits between 100-116 F, a range that supports Legionella growth, but failed to document corrective actions when hot water temperatures measured within this range. The facility also established a cold water control limit of 68 F but failed to monitor or document cold water temperatures. Although a written water management plan was provided, the facility did not demonstrate implementation of required monitoring or corrective actions. This failure had the potential to affect 82 of 82 residents, placing residents, staff, and visitors at risk for exposure to waterborne pathogens, including Legionella. Findings included: The facility's Water Management Policy (revised 7/2026) states in part; that the purpose of the water safety program was to monitor, control, and disinfect the facility's water to reduce the risk of Legionella and other opportunistic pathogens. Legionella can cause Legionnaires' disease, a type of pneumonia that can be fatal in susceptible individuals. The policy requires monitoring and documenting hot and cold water temperatures and implementing and documenting any corrective actions taken in TELS (the facility's electronic maintenance and work order management system). The policy identified temperature management as a control measure and stated that corrective actions must be taken and documented to reduce the risk for Legionella growth and spread. Hot water validation limits were set at 100-116 F, and the cold water validation limit was set at 68 F. The policy stated if hot water temperatures were out of range to adjust the temperature set points and flush with 150 degree plus water if necessary. If cold water was out of temperature range to flush less frequently used fixtures/piping to assure fresh chlorinated water was introduced. Review of hot water temperatures recorded by the Maintenance Director from 4/1/26 through 7/30/26 showed temperatures were documented weekly and ranged from 109-111 F. There was no evidence that cold water temperatures were monitored or recorded. There was no documentation showing any corrective actions or flushing protocols in areas at risk for water stagnation, including when these activities occurred, how often they were conducted, or which fixtures such as sinks, showers, toilets, were monitored. During an interview on 8/13/26 at 2:00 PM, the Maintenance Director stated that he checked the hot water temperatures in the facility weekly. He stated he selected 3 rooms per hall and conducted water testing and recorded the temperatures on a paper notepad. He reported that he also checked pH and chlorine levels (pH and chlorine levels show whether disinfectant levels are adequate to help control bacterial growth) monthly which measured within the required limits. He stated the hot water temperatures in the facility ranged around 110 degrees F. The Maintenance Director stated he thought the hot water temperatures had to be less than 116 degrees and indicated he was not clear on what water temperature range increased the risk of Legionella growth. The Maintenance Director stated he would flush toilets in empty rooms and would run shower heads but indicated he had no set schedule for flushing or running water and was unable to provide documentation of any corrective actions taken or any documentation of cold-water temperature checks. During an interview on 8/13/26 at 11:00 AM, the Infection Preventionist Nurse stated that the Maintenance Director was fully in charge of the Legionella program. She stated she was responsible for infection surveillance and there had been no Legionella outbreaks in the facility. During an interview on 8/13/26 at 3:00 PM, the Administrator stated the facility had a water management program that was updated annually. She reported the facility's policy established hot water limits between 100-116 F and cold water limits at 68 F and included corrective actions to be taken to reduce legionella growth. The Administrator indicated she was not aware that the maintenance department was not implementing the protocol for water temperature checks or implementing and documenting corrective actions taken to prevent Legionella growth.

Based on record review and staff interviews, the facility failed to ensure the arbitration agreement clearly communicated that the right to rescind within 30 days could be requested verbally or in writing. Additionally, the facility failed to ensure the arbitration agreement stated that, with each new admission more than 30 days after discharge, a new arbitration agreement would be offered. The deficient practice has the potential to affect all residents admitted to the facility. The census was 82.Findings included: Record review of the facility Arbitration Agreement revealed the following bullet: 9. The Resident understands and acknowledges that: .(b) he/she has the right to revoke this Arbitration Agreement by written notice delivered and received by the Facility within thirty (30) days of signing this Arbitration Agreement. The Admissions Director provided a facility census that documented each resident (or Responsible Party) currently residing at the facility had been offered the arbitration agreement. An interview was conducted with the Admissions Director on 8/13/26 at 11:30 AM. She stated she reviewed the Arbitration Agreement with each new admission. The Admissions Director acknowledged the facility did not have an arbitration policy but did have an arbitration agreement. She provided the Arbitration Agreement which she explained she reviewed with each new admission. Included in the document was the right to rescind the agreement in writing within 30 days of signing. The Admissions Director explained that according to the arbitration agreement, the request to rescind the arbitration agreement had to be in writing. She was not aware that a resident could rescind the agreement verbally. The Admissions Director noted that any resident who was readmitted to the facility after 30 days signed all the admission paperwork again, including the Arbitration Agreement, but this was not specifically explained in the written arbitration agreement.An interview was conducted with the Administrator on 8/13/26 @ 12:05 PM. She stated the facility had an arbitration agreement not a policy. She noted the agreement clearly stated that a written request was required within 30 days of signing the agreement to rescind the agreement. The Administrator confirmed the facility allowed residents to resign the arbitration agreement upon each new admission when the resident had been out of the facility for more than 30 days. However, this practice was not clearly supported by or reflected in the written arbitration agreement itself.

Based on observations, record review, and resident, staff, and Nurse Practitioner interviews, the facility failed to remove a dressing from a resident's dialysis shunt (a surgical connection that allows blood to flow between the body and dialysis machine in the forearm or upper arm created to provide reliable access for dialysis) as ordered by the physician and failed to observe the site for signs of infection per the care plan for 1 of 2 residents reviewed for dialysis (Resident # 85). Findings included:Resident #85 was admitted on [DATE] with diagnosis which included chronic kidney disease, end stage renal disease and dialysis. Resident #85's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was receiving dialysis.Resident #85's physician orders dated 5/18/26, revealed an order to remove the pressure dressing over the shunt site 6-8 hours after returning from dialysis at bedtime on night of dialysis in the evening at bedtime every Monday, Wednesday, and Friday. Report any bleeding to the physician.The Care Plan for Resident #85 dated 7/24/25 and updated on 7/2/26 revealed a plan of care for dialysis. Interventions included checking and removing the dressing to the dialysis access site as ordered and observing the site for signs and symptoms of infection. The care plan also indicated to monitor the shunt site for thrill (a distinct, rhythmic buzzing sensation felt over the shunt site which confirms healthy blood flow) and bruit (an audible whooshing or swishing sound heard using a stethoscope indicating a healthy dialysis shunt site).An observation and interview with Resident #85 were completed on 8/11/2026 at 11:08 AM. Resident #85 was observed to have a gauze dressing secured with tape to the right upper arm dialysis shunt. Resident #85 stated the dressing was applied to her right upper arm shunt yesterday by the dialysis nurse after she completed treatment. Resident #85 stated that one of the nurses would probably take the dressing off before she went for her next dialysis treatment.An interview was conducted with Nurse #1 on 8/11/26 at 6:33 PM. Nurse #1 stated he was the nurse assigned to care for Resident #85 on 8/10/2026 during the 7:00 PM to 7:00 AM on 8/11/26. He stated he was supposed to remove the dressing from Resident #85's right arm shunt after she returned from dialysis but he forgot. He acknowledged that he knew he was required to remove the dressing when the resident returned from dialysis and assess the site for complications.An interview with the Nurse Practitioner occurred on 8/13/26 at 10:50 AM. The Nurse Practitioner stated that it was important for Resident #85 to have her dressing removed and the shunt assessed by the nursing staff after dialysis. The Nurse Practitioner indicated that she expected the staff to follow the physician order to remove the dressing after dialysis. An interview with the Director of Nursing (DON) was completed on 8/13/26 at 3:21 PM. The DON stated that nursing staff usually removed the dressing and assessed the shunt site after Resident #85 returned from dialysis. She stated she expected the nursing staff to follow the physician orders, remove the dressing, and assess the site for signs and symptoms of infection or bleeding.

Based on record review and resident and staff interviews, the facility failed to implement trauma-informed care approaches (an approach to delivering care that involves understanding, recognizing and responding to the effects of trauma) that utilized a comprehensive trauma assessment to identify the resident's history of trauma and potential triggers that may be stressors for the resident in order to incorporate that information into a resident's care plan by developing individualized interventions that minimized or eliminated the effects of trauma triggers, ensured that staff understood a resident's trauma history, and directed staff on how to care for and respond to the resident to avoid re-traumatization for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), a mental health condition that can occur after exposure to traumatic events and may involve distressing memories, heightened anxiety, or strong reactions to triggers. This deficient practice affected 1 of 1 resident reviewed for trauma informed care (Resident #22). Findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses including PTSD.Review of the electronic medical record noted that Resident #22 previously served in the United States Air Force and held the rank of Master Sergeant indicating prolonged exposure to military environments that may be associated with traumatic experiences relevant to his PTSD diagnosis.Review of the care plan initiated on 2/4/25, with interventions last revised on 4/28/25, revealed Resident #22 was care planned for potential effects on psychosocial well being related to PTSD. The care plan listed three general interventions: allow time for the resident to answer questions and verbalize feelings and fears, monitor and document unusual responses to problems, and provide opportunities for resident and family participation in care. No individualized or trauma specific interventions were included.Review of Resident #22's progress notes from 5/1/25 through 8/12/26 revealed no documented behavioral symptoms or PTSD related symptoms such as heightened anxiety, startle responses, or hypervigilance. He was not followed by psychiatric services. Additionally, review of the Medication Administration Record (MAR) and physician's orders confirmed Resident #22 did not receive psychotropic medications.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #22 was cognitively intact, had no behavioral symptoms, and did not reject care. He received no psychotropic medications and required substantial staff assistance with activities of daily living (ADLs).During an interview on 8/12/26 at 12:15 PM, Resident #22 was pleasant and engaged in conversation. Resident #22 stated that he was in the Air Force for many years but indicated he had no fear or anxiety, he was satisfied with his care, and voiced no concerns. He did not recall participating in a care plan meeting to discuss care needs. During an interview on 8/12/26 at 1:00 PM, Nurse #3 stated she routinely provided care to Resident #22 and was not aware of his PTSD diagnosis. She stated that knowledge of the diagnosis would explain some things, including the resident becoming anxious or startled at times when his belongings were moved. Nurse #3 indicated she had not been informed of any PTSD related care approaches or interventions in the resident's care plan. During an interview on 8/12/26 at 2:00 PM, the MDS nurse stated she was new to the role and was not the nurse who developed Resident #22's PTSD care plan. She stated Resident #22 had not had any documented behaviors, he was not followed by psychiatry and did not receive psychotropic medications, so she did not make revisions to the care plan. She acknowledged the care plan lacked sufficient trauma informed interventions and indicated it should have included individualized guidance, identification of triggers, monitoring needs, and patterns staff should be aware of. During an interview on 8/13/26 at 4:00 PM, the Director of Nursing (DON) stated Resident #22's care plan should have included individualized, person centered interventions addressing his PTSD diagnosis, including identification of triggers and direction for staff response. She acknowledged the care plan lacked PTSD specific guidance. The DON stated that earlier that day, the team spoke with Resident #22, and he denied having any triggers, and this information was added to the care plan; however, she did not indicate which staff were present for that discussion.

Based on record review and staff interviews, the facility failed to revise a resident's care plan in the areas of a). range of motion and b). hearing loss and communication for 1of 27 residents reviewed for care plans (Resident # 26).Findings included: Resident #26 was admitted on [DATE] with diagnosis which included dementia and transient ischemic attack. a). Review of an Occupational Therapy functional maintenance program form dated 5/15/26 indicated that Resident #26 had left upper extremity impaired range of motion and required contracture management of the left-hand digits. The program indicated that Resident #26 was to receive active range of motion to the upper extremity with 1 set of 10 of the following exercises daily: left elbow flexion and extension, left hand supination and pronation (rotating the forearm so the palm faces upward or downward), left wrist flexion and extension and flexion and extension of the digits on the left hand. Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident was cognitively intact and had impaired range of motion of the upper extremity on one side. A review of Resident #26's care plan initiated on 2/10/25 and revised on 5/24/26 revealed that impaired range of motion of the upper extremity and the functional maintenance exercise program were not included. An interview was conducted with the Rehabilitation (Rehab.) Manager on 8/11/26 at 4:00 PM. The Rehab Manager stated that Resident #26 received Occupational Therapy from 4/9/26 through 5/18/26. The Rehab. Manager indicated that Resident #26 was placed on a functional maintenance program for range of motion of the hand when occupational therapy services ended on 5/18/26. An interview was conducted with the Unit Manager on 8/13/26 at 1:50 PM. The Unit Manager stated that she was not aware of a functional maintenance program for Resident #26. The Unit Manager stated that it should be in the care plan so that it can be coordinated and to ensure that it was completed. The Unit Manager stated that she did not know why Resident #26's functional maintenance program was not in the care plan. An interview was conducted with the MDS Coordinator on 8/13/26 at 2:15 PM. The MDS Coordinator stated that she was in the position for a few months and was still learning. The MDS Coordinator indicated that she was aware that the care plans were to be updated and range of motion exercises should be included. The MDS Coordinator stated that she must have missed updating Resident #26's care plan to include impaired range of motion and the exercises. An interview was conducted with the Director of Nursing (DON) on 8/13/26 at 3:20 PM. The DON stated that she expected that the interdisciplinary team reviewed and updated the resident care plans so that the information was communicated to staff as the resident's condition and care changed. The DON stated that range of motion exercises should be included in the care plan. She further stated that the information from the care plan flowed into the tasks that were assigned to the Nurse Aides to complete daily. b). Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident was cognitively intact and had minimal difficulty hearing and did not have hearing aids. A review of Resident #26's care plan initiated on 2/10/25 and revised on 5/24/26 revealed that hearing difficulty was not included. A review of an audiology consult dated 6/11/26 indicated that Resident #26 had bilateral hearing difficulty with mild to moderate sensorineural hearing loss and hearing aids were ordered. During an observation and interview with Resident #26 on 8/10/26 at 12:15 PM the resident revealed that she had mild difficulty hearing, and hearing aids were observed in a case on the resident's nightstand. An interview was conducted with the MDS Coordinator on 8/12/26 at 2:45 PM. The MDS Coordinator confirmed Resident #26 received hearing aids and had a hearing impairment so a care plan should have been initiated to reflect this. The MDS Coordinator stated she must have just missed it. The MDS Coordinator stated that she was new to the role of MDS Coordinator and was still learning. The MDS Coordinator indicated that she was aware that the care plans were to be updated as the resident's condition and care changed and that hearing aids should be included. An interview was conducted with the Director of Nursing (DON) on 8/13/26 at 3:20 PM. The DON stated that she expected that the interdisciplinary team reviewed and updated the resident care plans as the resident's condition and care changed. The DON stated that hearing aids should be included in the care plans.

Based on record review and resident and staff interviews, the facility failed to provide bathing, including the resident's designated shower, on the assigned shower day. This deficient practice affected 1 of 3 residents reviewed for activities of daily living (ADL) care (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF). The care plan initiated on 11/13/25 noted Resident #29 had an ADL self-care performance deficit related to a recent hospitalization.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact and had no behaviors or rejection of care. He had functional limitations in range of motion in his bilateral lower extremities and was dependent on staff assistance for showers and bathing. Review of the Nurse Aide task documentation in the electronic medical record on 8/11/26 identified Resident #29's bathing schedule as follows: showers on day shift every Tuesday and Friday, with bed baths provided on Monday, Wednesday, Thursday, Saturday, and Sunday.During an interview on 08/11/26 at 9:17 AM, Resident #29 stated he had not had many showers since admission and wanted to receive showers. He indicated that he did not know his shower schedule and was unaware of which days he was supposed to be showered. Resident #29 reported he received daily bed baths on most days.During an interview on 8/12/26 at 12:30 PM, Resident #29 stated he did not receive his scheduled shower or a bed bath the previous day (Tuesday). He reported he did not refuse a shower or bath and had not been asked if he wanted one. He expressed that he would like to receive showers on his scheduled shower days. During a phone interview on 8/12/26 at 2:56 PM, Nurse Aide #2 stated she was assigned to Resident #29 on Tuesday (8/11/26, day shift) and was responsible for providing his scheduled shower. She stated she dropped the ball, she did not ask Resident #29 if he wanted a shower and she did not provide a bed bath. Nurse Aide #2 stated Resident #29 required two person assistance with care and that she did not realize it was his scheduled shower day. She reported she became busy during the shift and overlooked providing both the shower and the bed bath. Nurse Aide #2 stated the process was to review the shower book at the start of the shift, complete scheduled showers, fill out the shower sheets, and give the completed sheets to the nurse. She indicated she reviewed the shower book daily but missed seeing Resident #29 listed for a shower that day. During an interview on 8/11/26 at 5:00 PM, Nurse #4, Resident #29's assigned nurse, stated she was an agency nurse and indicated she was not familiar with the individual ADL care needs of the residents.During an interview on 8/12/26 at 3:30 PM, the Assistant Director of Nursing (ADON) stated the shower process was outlined in the shower book that was located at the nurses station and that Nurse Aides were aware of the process. The ADON stated she would ensure Resident #29 received his shower that day (8/12/26). She provided a copy of the shower process, which showed that shower sheets were to be completed for each resident on their assigned shower day and that the nurse must sign to verify the shower was given or refused. The ADON stated bed baths were to be given each day when it was not the resident's shower day. During an interview on 8/12/26 at 3:45 PM, the Director of Nursing (DON) stated the facility's process required Nurse Aides to follow the shower schedule outlined in the shower book and ensure scheduled showers and bed baths were offered and completed. She stated Nurse Aides were expected to document completed showers on the shower sheets and notify the nurse if a shower was refused. The DON stated she expected Resident #29's scheduled shower on Tuesday to have been provided and documented, or a bed bath given.

Based on observations, record review, and interviews with staff and the Nurse Practitioner, the facility failed to obtain a physician's order for the continuation of oxygen therapy, including an order specifying the flow rate, for 1 of 1 residents reviewed for respiratory services (Resident #22). Findings included:Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), a lung disease that makes it difficult to breathe and causes airflow limitations and can lead to shortness of breath, coughing, and increased oxygen needs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact, exhibited shortness of breath, and was not receiving oxygen therapy at the time of the assessment. Record review revealed that Resident #22 was transferred to the hospital on 8/4/26 for evaluation of respiratory symptoms and returned to the facility later that same day. The hospital Discharge summary dated [DATE] indicated that no order for nasal cannula oxygen was provided upon Resident #22's return. Review of the admission nursing assessment dated [DATE], completed by Nurse #2, indicated that no information was documented regarding nasal cannula oxygen for Resident #22.During a phone interview on 8/12/26 at 2:10 PM Nurse #2, the admission nurse on 8/4/26 the day Resident #22 returned from the hospital, stated he thought Resident #22 was on oxygen prior to going to the hospital and assumed the oxygen upon return was not a new order. He stated he recalled Resident #22 was on 2 liters per minute the day he returned from the hospital and therefore had not verified or obtained a new physician's order. During an observation on 8/10/26 at 1:00 PM Resident #22 was observed in his room wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at 3.5 liters per minute. Resident #22 was resting in bed and showed no signs of acute distress.During an observation and interview on 8/12/26 at 12:15 PM, Resident #22 was observed wearing a nasal cannula connected to an oxygen concentrator delivering 3.5 liters per minute. Resident #22 stated he was not on oxygen before going to the hospital, was placed on oxygen while hospitalized , and had been on oxygen since returning to the facility over a week ago. He reported the oxygen was helping him and showed no signs of acute distress. Further review of Resident #22's electronic medical record on 8/12/26 revealed that there was no current physician's order for supplemental oxygen. Additionally, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July and August 2026 confirmed that no order for oxygen therapy was present. Review of Resident #22's electronic medical record on 8/12/26 revealed that no care plan had been developed to address oxygen therapy.During an interview on 8/12/26 at 12:45 PM, Nurse #3 stated Resident #22 had been receiving nasal cannula oxygen since returning from the hospital over a week ago. Nurse #3 stated she needed to check the medical record for the correct flow rate. After reviewing the electronic medical record, she stated she could not find an oxygen order for Resident #22.During an interview on 8/12/26 at 1:00 PM, the Nurse Practitioner stated she was not aware that Resident #22 had no oxygen order in place and indicated she would evaluate him and write an order if continued oxygen therapy was needed. She indicated oxygen orders should have been verified by nursing staff upon Resident #22's return from the hospital, including the type of order (continuous or as needed) and the correct flow rate. She stated no concerns had been reported to her regarding Resident #22. During an interview on 8/12/26 at 1:15 PM, the Director of Nursing (DON) stated the admission nurse was responsible for verifying hospital orders upon the resident's return to the facility. She explained the process included the admission nurse verifying the orders, followed by the Unit Manager conducting a second check to ensure the orders were verified and accurate. During an interview on 8/12/26 at 1:20 PM the Unit Manager stated she was responsible for verifying hospital orders after the admission nurse entered the orders, but she was off work on 8/4/26 when Resident #22 returned from the hospital. The Unit Manager indicated there was no other second check system in place when she was not working.

Based on record review, and staff interviews the facility failed to conduct a comprehensive nursing assessment and neurological assessments after a Nurse Aide (Nurse Aide #3) reported a newly identified injury on a residents (Resident #1) face to the nurse on duty (Nurse #5) following an unwitnessed injury that resulted in facial bruising around the right eye and above the right eye on the forehead. A nurse did not complete a comprehensive assessment of the resident until a few hours after the initial discovery of the facial bruising and the resident was observed to have bruising to the right shoulder, right lateral knee (outer side), left knee and left toe. A reddened area was also observed to the left neck area. This occurred for 1 of 1 resident reviewed for accidents (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including terminal cancer -multiple myeloma (a type pf blood cancer) without remission, history of malignant breast cancer, osteopenia (loss of bone density), vitamin D deficiency, dementia, and a history of a fall with a spinal fracture. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Falls occurred prior to admission with no falls since admission. Anticoagulant medication were administered. Resident #1 required extensive assistance with bed mobility, transfers, activities of daily living, and received Hospice services.A care plan dated 8/9/25 revealed Resident #1 had an increased risk of falls related to confusion, de-conditioning, history of falls, incontinence, psychoactive drug use, and being unaware of safety needs. The goal of care was the risk of falls or fall related injuries would be minimized with current interventions.During a phone interview on 10/16/25 at 8:30 AM Nurse #5 stated he worked on 10/1/25 from 7:00 PM through 7:00 AM and was Resident #1's assigned nurse. Nurse #5 stated he received report on 10/1/25 at 7:00 PM from Nurse #1 who did not report anything to him regarding Resident#1. Nurse #5 went into Resident#1's room between 9:00 to 9:30 PM on 10/1/25 to administer medications and noticed the right side of Resident #1's face at the temporal area had red marks. Nurse #5 stated Resident #1 typically laid on her right side with both hands under her face, like praying hands. Resident #1 took her medications without difficulty. Nurse #5 stated he asked Nurse Aide #1 who had been there since 3:00 PM if she knew about the red marks and Nurse Aide #1 stated she pushed her head against the mattress today, he didn't ask further questions but assumed the day shift nurse (Nurse #1) had addressed the marks. He stated the Nurse Aide #3 was in Resident#1's room during the night and did not report anything to him. Nurse #5 reported Resident #1 slept most of the night. When Nurse #5 went in the room around 3:00 AM Resident #1 was tangled in the sheets but the light was off, so he repositioned her in the bed and didn't notice anything on her face. Nurse #5 reported he went in Resident #1's room again around 4:00 AM to give scheduled lorazepam (an antianxiety medication) and Resident #1 was sleeping and he held the medication. Around 5:00 AM Nurse Aide #3 called out to him from down the hall saying what's with the marks on her face. Nurse #5 stated he thought Nurse Aide #3 was referring to the red marks Nurse #5 had observed at the 9:00 PM medication pass so he told Nurse Aide #3 that he knew about the marks. Nurse #5 stated he did not go down and assess Resident #1 at that time when Nurse Aide #3 reported marks. He stated Nurse Aide #3 did not say that he had observed bruising. Nurse #5 stated he went in Resident #1's room around 6:00 AM to give scheduled lorazepam, which Resident #1 took, but he did not turn the lights on, and he did not assess for marks, and stated he did not see bruising on Resident #1's face. Nurse #5 stated he left his shift at 7:00 AM and did not report anything to the oncoming day shift nurse (Nurse #1). Nurse #5 stated he should have gone to assess Resident #1 at 5:00AM when Nurse Aide #3 reported marks to him, but he did not. During an interview on 10/15/25 at 3:48 PM Nurse Aide #3 stated he worked the night shift on 10/1/25 from 11:00 PM until 7:00 AM and was assigned to Resident #1. He stated Resident #1 was sleeping when he came in for his shift and slept most of the night. He went into the room a couple of times during the night to check for incontinence and she was sleeping on her right side. He stated Resident #1 had dementia and agitation, so he did not want to wake her up while she was sleeping. Nurse Aide #3 reported that Resident #1 remained on her right side during the night, so he never saw any bruising. When he went in for the 5:00 AM check Resident #1 was awake and needed changing. Nurse Aide #3 stated he noticed right away the bruising on Resident #1's face when he turned her. Nurse Aide #3 stated he got a second nurse aide (Nurse Aide #4) who came in and witnessed the bruising. Nurse Aide #3 stated he reported the bruising to Nurse #5 at that time. Nurse Aide #3 stated Resident #1 was in bed the entire shift and had no falls or injuries during that time.A phone interview was conducted on 10/15/25 at 6:00 PM with Nurse Aide #4 who stated Nurse Aide #3 called her to come into Resident #1's room on 10/2/25 around 5:00 AM. Nurse Aide #4 stated she saw a large purple bruise on Resident #1's forehead. She stated the bruising was immediately reported to Nurse #5 by Nurse Aide #3.A nursing progress note dated 10/2/25 at 8:00 AM written by Nurse #1 revealed she was called to Resident #1's room to observe bruising. Upon entering the room Resident #1 was observed to be lying in bed. A large bruise was observed on the right side of her face (eye area) which was dark purple, and blue, in color. The ADON (Assistant Director of Nursing) was at the bedside. Resident #1 was also observed to have bruising to the right shoulder, right lateral knee, left knee, foot and left toe. A reddened area was also observed to the left neck area.A nursing note dated 10/2/25 at 9:07 AM written by the Director of Nursing (DON) revealed Resident #1 was observed this morning with bruising to the left forehead, left toe, right wrist, and an abrasion to the left knee. A skin assessment was completed with no further skin issues identified. The Physician was notified, and x-rays were ordered. Resident #1's Responsible Party (RP) and Hospice were notified.Review of Resident #1's electronic medical record on 10/2/25 following the 7:00 to 8:00 AM observation revealed the following neurological assessments recorded: 10/2/25 at 7:25 AM: level of consciousness, pupil response, motor function, and pain response were assessed however the vital signs recorded on this assessment were not taken until 6:18 PM on 10/2/25 and signed by the 10/2/25, 7:00 PM to 7:00 AM night shift nurse (Nurse #2). 10/2/25 at 10:02 AM: level of consciousness, pupil response, motor function, and pain response were assessed however the vital signs recorded on this assessment were dated 9/30/25 at 10:26 AM and signed by the Assistant Director of Nursing. 10/2/25 at 2:55 PM: level of consciousness, pupil response, motor function, and pain response were assessed and up to date vital signs were recorded on this assessment. The assessment was signed by Nurse #1. 10/2/25 at 6:03 PM: level of consciousness, pupil response, motor function, and pain response were assessed and up to date vital signs were recorded on this assessment. The assessment was signed by Nurse #1. Review of Resident #1's electronic medical record on 10/3/25 revealed neurological assessments were completed every shift. A hospice note dated 10/2/25 at 3:30 PM written by the Hospice Nurse revealed in part; Resident #1 with terminal diagnosis of multiple myeloma. The Hospice Aide reported that when she arrived to give Resident #1 her bath this morning (10/2/25), she was noted to have several bruises to her body, she was uncomfortable and had possible injury to her left leg. The injuries had been reported to facility staff. Upon arrival, Resident #1 was resting quietly in bed with her eyes closed, she aroused to voice and touch. She smiled and had nonsensical conversation and was cognitively at baseline. She was oriented to person only. Resident #1 was noted to have dark purple bruising to the right forehead, blue/red bruising to the right periorbital (eye) area. Slight redness noted to the left side of her neck. Slight bruising noted to right shoulder, and right knee. Redness and bruising to left knee and foot. Resident #1 was able to move her right leg. Her left leg was pulled up, and she did not want the nurse to touch her left leg. There was obvious injury to the left lower extremity. This nurse did not attempt to move or perform range of motion to left leg. Facility staff stated that x-rays have been ordered and will be done in house. Pain level was zero during visit. The facility nurse administered as needed Morphine concentrate (pain medication) with good effect at this time. Unsure of cause of injury at this time, presumed fall, facility staff stated they were investigating the injury, and all appropriate agencies had been notified of the injuries. Resident #1 was comfortable during visit. A phone interview was conducted on 10/15/25 at 2:45 PM with Nurse # 1, the assigned nurse on 10/1/25 and 10/2/25 from 7:00 AM through 7:00 PM. She indicated Resident #1 was at baseline with no bruising on 10/1/25, and no falls or injuries were reported to her on 10/1/25. Nurse #1 stated when she returned to work the following morning on 10/2/25 at 7:00 AM the Hospice Aide was in Resident #1's room early before 8:00 AM, and Nurse Aide #2 asked Nurse #1 to go look at Resident #1. Nurse #1 went in to evaluate Resident #1 at that time and saw the facial bruising and bruising to her shoulder, both knees, and one of her toes. Nurse #1 stated the night shift nurse (Nurse #5) did not report anything at all to her that morning during shift report regarding Resident #1. Resident #1 did not seem to be in pain, at that time. Nurse #1 assessed Resident #1, notified the Director of Nursing and the physician who ordered a mobile x-ray. During a follow up interview on 10/17/25 at 12:00 PM Nurse #1 stated she was an agency nurse and was not certain what the facility protocol was for checking neurological assessments following unwitnessed injuries. She stated the neurological assessments that she completed on 10/2/25 were only what was recorded in the electronic medical record. During a phone interview on 10/22/25 at 2:00 PM the Assistant Director of Nursing stated she recorded one of the neurological assessments on 10/2/25 and when she documented the assessment the electronic medical record pulled the most recent vital signs which were from 9/30/25. She stated that was done in error on her part and she should have ensured up to date vital signs were done and recorded in the medical record. During an interview on 10/17/25 at 11:00 AM the Director of Nursing (DON) stated a full investigation was initiated on 10/2/25 at 8:00 AM when unexplained bruising was observed on Resident #1 by the Hospice Nurse Aide who reported it to Nurse #1. The DON stated Resident #1 had no reported falls or trauma and was evaluated at the hospital and diagnosed with facial bruising and a tibia fibula fracture. The DON stated Nurse #5 should have gone to the room and checked Resident #1 and completed a full assessment at 5:00 AM on 10/2/25 when Nurse Aide #3 reported unexplained marks and bruising but Nurse #5 did not do that. The DON stated when the unexplained facial bruising was later observed by Nurse #1 at approximately 7:30 AM on 10/2/25 Nurse #1 should have initiated neurological assessments every hour for four hours, then every shift for a total of 48 hours. The DON stated up to date vital signs were part of the neurological assessments.

Based on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide #1 failed to apply all the required Personal Protective Equipment (PPE) before entering a room with a resident on special contact-droplet precautions. This occurred for 1 of 1 staff observed for infection control practices (Nurse Aide #1). The findings included: Review of the facility's contact precautions signage last revised 01/20/22 read in part: All healthcare personnel must: Clean hands before entering and when leaving room. Wear gloves when entering room and remove before leaving room. Wear a gown when entering room and remove before leaving. The facility's Infection Prevention and Control Program policy last revised on 08/2024 read in part: When a resident is infected or colonized with any Multidrug-Resistant Organism (MDRO) that has secretions or excretions that are unable to be covered or contained then contact precautions should be used. Review of Resident #111's April/2025 physician orders included: Admit to skilled level of care for Extended Spectrum Beta Lactamase (ESBL), Escherichia Coli (E. coli), Methicillin Resistant Staphylococcus Aureus (MRSA), and chronic kidney disease stage IV, Vancomycin, and contact precautions related to ESBL dated 04/29/25. An interview and observation were conducted on 04/30/25 at 8:05 AM with Nursing Assistant (NA#1). NA #1 was observed entering room [ROOM NUMBER] to deliver Resident #111's breakfast meal tray without first cleaning her hands or applying appropriate contact precaution personal protection equipment (PPE) of gown and gloves. She was observed leaning against the left side of resident's bed while setting up his meal tray. She then exited the resident's room without washing her hands. When NA #1 was asked in the hall why she did not clean hands, or apply PPE she said she did not have to if the resident was on enhanced barrier precautions. The NA then looked at the isolation sign hanging on the resident's door and realized the resident was on contact precautions and not on enhanced contact precautions. She said, after reading the sign, that she made a mistake, thinking the resident was on enhanced contact precautions and not contact precautions. She stated she should have washed her hands prior to entering and exciting resident's room and applied a gown and gloves while in the room. An interview was conducted on 04/30/25 at 8:10 AM with Nurse #2. Nurse #2 stated Resident #111 was on contact precautions for having multiple Multidrug-Resistant Organism (MDRO) with secretions or excretions so he was ordered by the Physcian to be on contact precautions, the only resident in the facility on contact precautions. Nurse #2 indicated staff were supposed to clean hands and put on the PPE prior to entering the room. An interview was conducted with NA #1 on 04/30/25 at 8:15 AM and she stated, it's confusing, I thought as long as I was not providing patient care it was ok since I was just taking the tray in the room. I did not realize there was a resident in the facility on contact precautions. She said she needed to pay closer attention to the isolation signs on residents' doors. An interview was conducted on 04/30/25 at 12:15 PM with the Physician Assistant (PA). The PA indicated he expected staff to read the contact isolation signage and put on the PPE prior to entering Resident #111's room. An interview was conducted on 04/30/25 at 12:20 PM with the Director of Nursing (DON). She stated, Sometimes her nursing staff were not reading the signs. The DON further stated, we haven't had a contact precaution isolation in a while. The DON indicated she expected NA #1 to have read the signage on the resident's door and put on the appropriate PPE that was listed on the signage, which the NA did not do. An interview was conducted on 05/01/25 at 10:45 AM with the Administrator. She indicated staff should read the isolation signs to understand the precautions before entering a room.

Based on record review, staff interviews, Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to determine the accuracy of a weekly weight for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) when the resident's weight indicated a 27 pound weight gain in one week for 1 of 4 residents reviewed for nutrition. (Resident #108) Findings included: Resident #108 was admitted on [DATE]. His medical diagnoses included Congestive Heart Failure (CHF), coronary artery disease (CAD), and pulmonary hypertension. An admission physician order written to start on 04/18/25 revealed weekly weight times four weeks then monthly, and Demadex (used to reduce swelling). Resident #108's admission Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired, had CHF, CAD, and needed total assistance with activities for daily living (ADLs). Review of Resident #108's weekly weights revealed: 04/18/24 hospital weight was 148.6 pounds (lbs.) 04/18/25 was 126.6 lbs. 04/19/25 was 126 lbs. 04/26/25 was 153.2 lbs., a weight gain of 27.2 lbs. in 7 days. 04/28/25 was 156 lbs. Further review of Resident #108's medical record revealed there were no additional weights. An interview was conducted on 04/29/25 at 1:15 PM with Resident #108. The resident was alert, resting in bed, with feet elevated. He stated he was breathing fine, was not on any oxygen, had swollen ankles and feet, ate very little breakfast, but ate a normal lunch. He said he did not know if he had any weight gain or loss since his admission. An interview was conducted on 04/30/25 at 10:05 AM with Nurse #1. He stated he helped the NA on 04/26/25 to weigh Resident #108 since two nursing staff were needed to do resident's weight using a mechanical lift. He said he noticed the resident's weight was 27 lbs. greater than his last weight, but since there was no order do a re-weight for weights greater or less than 5 pounds, he did not need to do a re-weight. Nurse #1 could not recall the NA that weighed Resident #108. An interview on 04/30/25 at 10:15 AM with the Director of Nursing (DON) revealed it was her expectation that Resident #108 should have been reweighed immediately after noting a possible 27 lb. weight gain on 04/26/25. The DON stated any weights with a 5-pound discrepancy from the last weight should be re-weighed, especially since the resident had a history of CHF. She said she did not know why Nurse #1 did not get the NA to re-weigh Resident #108 but should have. An interview was conducted on 04/30/25 at 10:25 AM with the Physician Assistant (PA). The PA stated this was the first time he heard of Resident #108's one week weight gain of 27 pounds since admission on [DATE]. The PA stated if Resident #108's weekly weight was greater than 5-lbs. from the previous weight, and had a history of CHF, that a re-re-wight should have been done. The PA said Resident #108's weight 27 gain had no health outcome but could have. An interview was conducted on 05/01/25 at 9:45 AM with the Medical Director (MD). The MD stated this was the first time she had heard of Resident #108's weight gain of 27 pounds from 04/19/25 to 04/26/25. The MD stated it was expected that if any resident had a weight loss or gain greater than 5 pounds from the previous weight, to have a re-weight confirming the second weight, which was not done, and was important in this case due to the resident having a diagnosis of CHF. The MD said Resident #108's weight gain of 27 lbs. could not have been accurate, since the resident had no respiratory health outcome, and that the weight was not close to the hospital's discharge weight.

Based on record review, staff, the Nurse Practitioner, and Physician interviews the facility failed to obtain an ordered Pro BNP (pro-B-type natriuretic peptide) a blood test that measures the levels of Pro BNP, a protein produced by the heart and used to help diagnose and monitor heart failure. This occurred for 1 of 1 resident (Resident #23) reviewed for laboratory services. Findings included. Resident #23 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease and Stage 5 chronic kidney disease with heart failure. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #23 was cognitively intact. A physician's order dated 4/3/25 for Resident #23 entered by Nurse #3 revealed to obtain a Pro BNP level. Review of Resident #23's electronic medical record from 4/3/25 through 5/1/25 revealed no documentation of the Pro BNP lab result. Review of the progress notes from 4/3/25 through 5/1/25 revealed no documentation that Resident #23 had experienced any acute symptoms of heart failure such as shortness of breath, swelling in the abdomen or lower extremities, chest pain, or fatigue. Her blood pressure was stable. During an interview on 4/30/25 at 12:00 PM the Nurse Practitioner stated the Pro BNP was ordered for Resident #23 to monitor heart failure. He stated he reviewed the electronic medical record and could not find the lab result. He indicated Resident #23 was not symptomatic, and the lab would be reordered. During an interview on 05/01/25 at 10:30 AM the Physician stated the Pro BNP lab was ordered for Resident #23 to evaluate her cardiovascular status due to heart failure and chronic kidney disease. She stated Resident #23 received hemodialysis three days a week which pulled fluid off to keep her at dry weight (the weight after excess fluid is removed) and therefore had no significant outcome from not obtaining the ordered lab and she had not been symptomatic of acute heart failure or fluid overload. She stated she expected labs to be obtained according to the physician orders. During an interview on 5/1/25 at 2:00 PM Resident #23 was observed sitting up in a bedside chair in her room. She was alert and oriented to person, place, and time. She was smiling and talkative and was not aware of the ordered lab. She stated she received hemodialysis three days a week, she felt fine, and stated she had no complaints at this facility. An attempt was made on 5/1/25 at 2:19 PM to contact Nurse #3 who entered the order for the Pro BNP on 4/3/25. There was no response. During an interview on 05/01/25 at 2:00 PM the Director of Nursing stated she completed a record review and could not find the Pro BNP lab result for Resident #23. She stated she determined that the Physician entered the order into the electronic medical record but then the nurse who completed the new order failed to edit the order so that it would trigger on the Medication Administration Record (MAR) which was why it continued to be missed. She stated the process included that the physician entered the orders into the residents electronic medical record, then the nurse would go in and edit the order so that it would flow to the Medication Administration Record (MAR). The nurse was supposed to print the residents face sheet (this provides the residents identifying information) and fill out the lab requisition form (informs the lab of what tests to perform) and then records the order in the lab book located at the nurses station. She stated Nurse #3 who was responsible for the error no longer worked at this facility. She stated labs were reviewed daily in clinical meetings to ensure they were done and to ensure that the physician had reviewed the results. She stated they missed the lab in clinical meetings because of the order not being edited and completed by Nurse #3 therefore it did not show on her lab reports. She stated she planned to review the process for ordered labs and education would be provided to staff.

Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 1 of 419 days reviewed for staffing (08/11/24). Findings included: The PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 4, 2024 (July 1 - September 30) documented the facility had no RN Coverage on 08/11/24. Review of the daily assignment sheets from 03/8/24 through 04/30/25 revealed the RN who was originally scheduled to work 7:00 PM - 7:00 AM beginning on 08/11/24 had called off. The staff member who replaced the RN on the schedule was a Medication Aide. In an interview with the Director of Nursing (DON) and the Administrator on 05/01/25 at 11:49 AM the DON stated she had been the nurse on call and had taken the call when the RN called off work on 08/11/24. She noted it was her responsibility to find RN coverage for the shift and she had not. The Administrator stated she expected the on call staff member who had the on call phone to find coverage for the assignment. The Administrator explained that the process when there was a call off was that the on call staff member or nurse who had the call off phone was responsible for filling the assignment on the schedule. On 8/11/24 the on call nurse was notified of the call off but she did not find a replacement and no RN coverage was in the building on 8/11/24.

Based on record review, staff interviews, Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to notify the provider of significant weight gain greater than 5-pound discrepancy from the last weight for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) when the resident's weight indicated a 27 pound weight gain in one week. This deficient practice occurred for 1 of 1 sampled resident reviewed for notification of change. (Resident #108) Findings included: Resident #108 was admitted on [DATE]. His medical diagnoses included Congestive Heart Failure (CHF), coronary artery disease (CAD), and pulmonary hypertension. An admission physician order written to start on 04/18/25 revealed weekly weight times four weeks than monthly, and Demadex (used to reduce swelling). Review of Resident #108's weekly weights revealed: 04/18/24 hospital weight was 148.6 pounds (lbs.) 04/18/25 was 126.6 lbs. 04/19/25 was 126 lbs. 04/26/25 was 153.2 lbs., a weight gain of 27.2 lbs. in 7 days 04/28/25 was 156 lbs. Further review of Resident #108's medical record revealed there were no additional weights. Further review of the medical record for Resident #108 revealed there was no evidence the physician was notified of weight changes. An interview was conducted on 04/30/25 at 10:05 AM with Nurse #1. He stated he helped the NA on 04/26/25 to weigh Resident #108 since two nursing staff were needed to do resident's weight using a mechanical lift. He said he noticed the resident's weight was more than 20 lbs. greater than his last weight, but since there was not a specific physician order telling him to notify the MD if resident's weight was greater or less than 5 lbs., he did not need to, even if the resident had a history of CHF. He said he just went by what he saw on the physician orders, and since it did not say to contact the MD with significant weight change, he did not need to. An interview on 04/30/25 at 10:15 AM with the Director of Nursing (DON) revealed it was her expectation that Resident #108's physician should have been notified by his nurse of the resident's greater than 5-lb. weight gain in a week, given the residents' history of CHF, even if there was no physician order. An interview was conducted on 04/30/25 at 10:25 AM with the Physician Assistant (PA). The PA stated this was the first time he heard of Resident #108's one week weight gain of 27 pounds since admission on 04/18/25. He stated no staff had reported to him any weight concerns. The PA expected he or the MD to be notified if Resident #108's weekly weights were greater than 5-lbs. from the previous weight, especially if the resident had a diagnosis of CHF. The PA said he expected the MD to have been notified, in order to treat the weight gain and to determine if related to CHF, and if additional medication was to be ordered or a change in treatment needed. An interview was conducted on 05/01/25 at 9:45 AM with the Medical Director (MD). The MD stated this was the first time she had heard of Resident #108's weight gain of 27 pounds from 04/26/25. The MD said she expected to be notified if residents' weights were greater than 5 pounds after a re-weight, which would include any resident having a diagnosis of CHF. The MD said she was not made aware or notified by nursing staff of resident's weight gain and should have. The MD said Resident #108's weight gains had no health outcome, and she expected the PA, MD, or on-call physician to have been notified, so they could treat the weight gain, and determine if it was related to CHF.

Based on observations, record review, and resident and staff interviews the facility failed to administer medications on time as prescribed by the physician for 1 of 1 residents reviewed. (Resident #7) Findings included: Resident #7 was admitted to the facility on [DATE]. Diagnoses included, in part, schizophrenia, anxiety, dementia with behavioral disturbance, and constipation. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact and received antipsychotics and antianxiety medications. An interview was conducted with Resident #7 on 03/04/24 at 1:00 PM. Resident #7 reported she did not receive her medications on time and at times the nursing staff would wake her up after 10:00 PM to administer her medications that were due at 8:00 PM. Resident #7 stated she had told the nursing staff she wanted her medications at 8:00 PM so she could go to bed and not be woken up. Resident #7 stated she had received her 8:00 PM medications as late as 2:00 in the morning. Resident #7 stated she did not have any increased anxiety, delayed bowel movements or increased behaviors as a result of receiving the medications late, but added, she wanted them when they were scheduled. Review of the physicians' orders revealed an order written on 10/03/20 for Senna Plus 8.6-50 milligrams (mg) give 2 tablets one time a day for constipation, an order written on 10/14/21 for Risperidone (an antipsychotic) tablet 0.5 mg give one tablet at bedtime, and an order written on 07/31/23 for Klonopin (an antianxiety) 0.5 mg give one tablet two times a day for anxiety. Review of the Medication Administration Record for February 2024 revealed the medications (Senna Plus, Risperidone, and Klonopin) were all scheduled to be given at 8:00 PM. Review of the Medication Administration Audit Report for February 1 through February 29, 2024, revealed the bowel medication, the antipsychotic medication, and the antianxiety medication were administered later than 8:00 PM. The audit report indicated the scheduled time which was 8:00 PM and the administration time. The following included the dates the medications were administered late per the actual administration time: 02/01/24 medications administered at 11:41 PM by Medication Aide (MA) #5 02/03/24 medications administered at 10:30 PM by MA #1 02/04/24 medications administered at 10:04 PM by MA #1 02/06/24 medications administered at 10:04 PM by MA #1 02/07/24 medications administered at 10:15 PM by MA #5 02/09/24 medications administered at 12:30 AM by MA #1 02/13/24 medications administered at 10:40 PM by MA #1 02/14/24 medications administered at 12:56 AM by MA #5 02/15/24 medications administered at 1:39 AM by Nurse #4 02/17/24 medications administered at 1:46 AM by MA #1 02/19/24 medications administered at 10:27 PM by MA #1 02/20/24 medications administered at 10:50 PM by MA #1 02/22/24 medications administered at 10:58 PM by MA #1 02/24/24 medications administered at 10:32 PM by MA #1 02/27/24 medications administered at 10:49 PM by MA #1 Review of the Medication Administration Record for March 2024 revealed the medications (Senna Plus, Risperidone, and Klonopin) were all scheduled to be given at 8:00 PM. Review of the Medication Administration Audit Report for March 1 through March 6, 2024, revealed the bowel medication, the antipsychotic medication, and the antianxiety medication were administered later than 8:00 PM. The audit report indicated the scheduled time which was 8:00 PM and the administration time. The following included the dates the medications were administered late per the actual administration time: 03/03/24 medications administered at 10:20 PM by MA #1 03/04/24 medications administered at 10:15 PM by MA #1 An interview was conducted with MA #1 via phone on 03/06/24 at 3:15 PM. MA#1 revealed she worked on the 500 hall where Resident #7 resided and the 300 hall from 7:00 PM to 7:00 AM. She stated she could not remember why she was late administering the medications to Resident #7. MA #1 added, things happen and she would fall behind. She stated she did not ask her nurse to help her when she was getting behind because she did not want to bother the nurse. MA #1 stated the medication time was 8:00 PM and the nursing staff had the flexibility to give the medications one hour before or one hour after the medications were due. MA #1 confirmed the times she gave the medications were much later than the prescribed allowable time. MA #1 stated she did not recall Resident #7 expressing to her that she wanted her medications at 8:00 PM. An interview was conducted with MA #5 via phone on 03/07/24 at 3:00 PM. MA #5 reported her routine when she came on shift was to read through the progress notes and she would start her medication pass about 8:00 - 8:30 PM. She stated she started on the 500 hall were Resident #7 resided and would usually finish about 10:00 - 10:30 PM. MA #5 stated she did not know why the medications were passed so late to Resident #7 on 02/01, 02/07 and 02/14/24. MA #5 stated Resident #7 had expressed to her to that she wanted her medications before she went to bed and not at 1:00 AM. MA #5 stated she did not reach out to the nurse on those nights to let her know she was behind on passing medications and she should have. An interview was attempted with Nurse #4 via phone on 03/07/24 at 11:00 AM. There was no response. An interview was conducted with the Physician on 03/07/24 at 12:10 PM. The Physician stated she would expect the nursing staff to administer the medications when they were due or within the hour before the medication was due or the hour after. An interview was conducted with the Director of Nursing (DON) on 03/07/24 at 2:30 PM. The DON reported she felt the medications aides needed to work on their time management and that the medication pass had been significantly decreased when the new physician had done an audit and discontinued several medications for several residents to decrease the medication pass time and unnecessary medications. The DON stated the medication aides were expected to start on the 500 hall and then finish on the 300 hall. She stated there were about 29 residents between the two halls and the medications aides should have been able to administer the medications at the prescribed time or no later than an hour after the prescribed time.

Based on observations, record review, staff, and Physician interviews the facility failed to clarify a medication order prescribed for hypotension (low blood pressure) to include hold parameters if the systolic blood pressure was greater than 120 mm/hg ( millimeters of mercury). This resulted in a resident (Resident #61) receiving 59 additional doses of the medication. There was no significant outcome from receiving the medication. This occurred for 1 of 3 residents reviewed for medication administration. Findings included. Resident #61 was admitted to the facility on [DATE] with diagnoses included in part; hypertensive chronic kidney disease with end stage renal disease, dependence on dialysis, and hypotension. A physicians order dated 05/03/23 for Resident #61 revealed Midodrine 10 milligrams (prescribed to treat hypotension which works by constricting the blood vessels causing increased blood pressure). Give 1 tablet by mouth three times a day for hypotension. Hold if systolic blood pressure is greater than 120 mm/hg. Review of the Medication Administration Record (MAR) for Resident #61 from 05/03/23 through 10/23/23 revealed Midodrine was administered as prescribed. Review of a hospital discharge summary dated 10/27/23 for Resident #61 revealed Midodrine oral tablets 10 mg (milligrams). Give 1 tablet by mouth three times a day for hypotension if systolic blood pressure is greater than 120 mm/hg. There was no hold parameter. Review of the Medication Administration Record (MAR) for Resident #61 dated November 2023 revealed Midodrine oral tablets 10 mgs. Give 1 tablet by mouth three times a day for hypotension if systolic blood pressure is greater than 120 mm/hg. There was no hold parameter included on the MAR. Further review of the Medication Administration Record (MAR) for Resident #61 dated November 2023 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 11/01/23 a blood pressure recorded at 09:00 AM revealed 142/76 (systolic/diastolic). 11/01/23 a blood pressure recorded at 02:00 PM revealed 142/76. 11/02/23 a blood pressure recorded at 06:00 AM revealed 142/84. 11/03/23 a blood pressure recorded at 09:00 AM revealed 170/65. 11/03/23 a blood pressure recorded at 02:00 PM revealed 176/89. 11/03/23 a blood pressure recorded at 09:00 PM revealed 176/89. 11/07/23 a blood pressure recorded at 09:00 AM revealed 133/72. 11/07/23 a blood pressure recorded at 02:00 PM revealed 122/64. 11/11/23 a blood pressure recorded at 06:00 AM revealed 122/58. 11/11/23 a blood pressure recorded at 02:00 PM revealed 122/58. 11/11/23 a blood pressure recorded at 09:00 PM revealed 130/79. 11/12/23 a blood pressure recorded at 02:00 PM revealed 172/95. 11/13/23 a blood pressure recorded at 06:00 AM revealed 152/97. 11/17/23 a blood pressure recorded at 02:00 PM revealed 139/66. 11/19/23 a blood pressure recorded at 02:00 PM revealed 167/105. 11/21/23 a blood pressure recorded at 02:00 PM revealed 152/78. 11/22/23 a blood pressure recorded at 06:00 AM revealed 144/72. 11/22/23 a blood pressure recorded at 04:00 PM revealed 148/78. 11/22/23 a blood pressure recorded at 09:00 PM revealed 148/78. 11/24/23 a blood pressure recorded at 04:00 PM revealed 128/70. 11/27/23 a blood pressure recorded at 06:00 AM revealed 147/84. 11/27/23 a blood pressure recorded at 04:00 PM revealed 129/78. 11/27/23 a blood pressure recorded at 09:00 PM revealed 132/86. 11/29/23 a blood pressure recorded at 06:00 AM revealed 138/78. Review of the Medication Administration Record (MAR) for Resident #61 dated December 2023 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 12/04/23 a blood pressure recorded at 04:00 PM revealed 141/76. 12/04/23 a blood pressure recorded at 09:00 PM revealed 141/76. 12/06/23 a blood pressure recorded at 06:00 AM revealed 141/76. 12/06/23 a blood pressure recorded at 04:00 PM revealed 128/98. 12/08/23 a blood pressure recorded at 06:00 AM revealed 132/64. 12/08/23 a blood pressure recorded at 04:00 PM revealed 130/68. 12/11/23 a blood pressure recorded at 06:00 AM revealed 142/60. 12/13/23 a blood pressure recorded at 04:00 PM revealed 127/79. 12/13/23 a blood pressure recorded at 09:00 PM revealed 127/79. 12/15/23 a blood pressure recorded at 06:00 AM revealed 130/70. 12/20/23 a blood pressure recorded at 06:00 AM revealed 122/64. 12/20/23 a blood pressure recorded at 04:00 PM revealed 122/64. 12/27/23 a blood pressure recorded at 04:00 PM revealed 126/79. Review of the Medication Administration Record (MAR) for Resident #61 dated January 2024 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 01/01/24 a blood pressure recorded at 09:00 PM revealed 167/87. 01/03/24 a blood pressure recorded at 06:00 AM revealed 167/87. 01/05/24 a blood pressure recorded at 04:00 PM revealed 136/72. 01/08/24 a blood pressure recorded at 06:00 AM revealed 157/79. 01/08/24 a blood pressure recorded at 04:00 PM revealed 158/80. 01/10/24 a blood pressure recorded at 09:00 PM revealed 131/74. 01/12/24 a blood pressure recorded at 04:00 PM revealed 140/85. 01/15/24 a blood pressure recorded at 04:00 PM revealed 165/84. 01/15/24 a blood pressure recorded at 09:00 PM revealed 165/84. 01/17/24 a blood pressure recorded at 06:00 AM revealed 165/84. 01/19/24 a blood pressure recorded at 06:00 AM revealed 123/68. 01/24/24 a blood pressure recorded at 06:00 AM revealed 134/73. 01/29/24 a blood pressure recorded at 04:00 PM revealed 148/89. 01/29/24 a blood pressure recorded at 09:00 PM revealed 148/89. Review of the Medication Administration Record (MAR) for Resident #61 dated February 2024 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 02/02/24 a blood pressure recorded at 06:00 AM revealed 141/82. 02/02/24 a blood pressure recorded at 09:00 PM revealed 147/77. 02/18/24 a blood pressure recorded at 06:00 AM revealed 140/80. 02/21/24 a blood pressure recorded at 06:00 AM revealed 152/95. 02/21/24 a blood pressure recorded at 09:00 PM revealed 146/68. 02/23/24 a blood pressure recorded at 09:00 PM revealed 155/77. 02/26/24 a blood pressure recorded at 06:00 AM revealed 155/77. Review of the Medication Administration Record (MAR) for Resident #61 dated March 2024 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 03/01/24 a blood pressure recorded at 4:00 PM revealed 146/87. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #61 was cognitively intact. She received Hemodialysis. During an interview with Resident #61 on 03/06/24 at 2:30 PM she indicated she was not aware of what times or dates the medication for low blood pressure was administered to her. She stated dialysis treatments took a lot out of her and she didn't feel well most days. She indicated she was not certain if receiving the Midodrine when it wasn't needed had any affect at all on her. During a phone interview on 03/06/24 at 02:53 PM Medication Aide #1 stated she routinely provided care to Resident #61. She stated she knew Midodrine was prescribed for low blood pressure. She stated she thought she held the medication if her blood pressure was over 120 but couldn't indicate what dates the medication was held. She stated she could have held the medication although documented she gave it. She indicated if it was signed that the medication was given, then she gave the medication in error. During an interview on 03/07/24 at 09:46 AM the Registered Nurse Supervisor stated Resident #61's order for Midodrine should have been clarified when it was transcribed from the hospital discharge summary on 10/27/23. She stated Resident #61 received dialysis and her medication times varied according to her dialysis schedule. She stated although her name was on the order entry following Resident #61's readmission she believed she only revised the order and was not the staff that entered the order. She could not determine who entered the initial order. She stated the Midodrine should have been clarified and hold parameters put in place but that was not done. During a phone interview on 03/07/24 at 12:00 PM Medication Aide #2 stated she routinely provided care to Resident #61. She stated she thought she held the medication at times. She indicated if the medication was administered when it wasn't needed then it was done in error. During a phone interview on 03/07/24 12:13 PM Medication Aide #8 stated she gave Midodrine to Resident #61 when her blood pressure was over 120 (mm/hg). She indicated that was how the order was written on the MAR. Attempts were made to contact Nurse #1 during the investigation. Nurse #1 was an agency nurse and was on duty during the dates and times the Midodrine was administered to Resident #61. There was no response. Attempts were made to contact agency Medication Aides #5 and #7 during the investigation. The Medication Aides were on duty during the dates and times the Midodrine was administered to Resident #61. There was no response. Medication Aide #6 who was on duty during the dates and times the Midodrine was administered to Resident #61 was no longer employed and no phone number was available. During an interview on 03/07/24 at 10:18 AM the Physician stated she was made aware of the Midodrine error this morning. She wrote a new order with hold parameters for blood pressures greater than 160/90. She indicated the medication was not needed if Resident #61's blood pressure was elevated. She stated the order should have been clarified and hold parameters accurate. She stated Resident #61 receiving Midodrine when it wasn't needed would have no significant effect on her and there had been no change in her condition. During an interview on 03/07/24 at 12:24 PM the Director of Nursing stated medications were reviewed in their morning meetings. She indicated she was not aware that hold parameters were not clarified on the order for Resident #61. She stated the order was corrected today. She stated the order should have been clarified on readmission and administered per order.

Based on observation, record review, staff, Nurse Practitioner, and Physician interviews the facility failed to follow the physicians order and provide sliding scale insulin at bedtime to a resident (Resident #18) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in the resident not receiving a total of 74 units of insulin from 01/12/24 through 03/04/24. There was no significant outcome. This occurred for 1 of 3 residents reviewed for medication administration. Findings included. Resident #18 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus. A care plan dated 08/23/23 revealed Resident #18 had diabetes with the risk for complications. The goal of care was to adequately manage her diabetes in order to minimize the risk for complications. Interventions included in part; to administer sliding scale insulin as ordered. The Minimum Data Set annual assessment dated [DATE] revealed Resident #18 was cognitively intact. She required limited assistance with activities of daily living. She received insulin. A physicians order dated 01/11/24 for Resident #18 revealed Novolog Injection Solution 100 units per milliliter: Inject as per sliding scale subcutaneously before meals for diabetes for blood glucose readings as follows: 000 - 199 administer 0 units; 200 - 250 administer 2 units; 251 - 300 administer 4 units; 301 - 350 administer 6 units; 351 - 400 administer 8 units; 401 - 450 administer 10 units; 451 - 1000 administer 10 units - recheck and notify the physician. A progress note dated 01/11/24 documented by the Nurse Practitioner revealed in part; plan to stabilize Resident #18's blood sugars which have been more elevated lately. Adding sliding scale insulin now four times a day in addition to her Lantus (long-acting insulin). A physicians order dated 01/12/24 revealed blood glucose checks before meals and at bedtime for diabetes please see sliding scale instructions. Review of the Medication Administration Record (MAR) for Resident #18 dated January 2024 revealed Novolog sliding scale insulin was administered as needed before meals. Novolog sliding scale insulin was not administered at bedtime as needed for blood glucose greater than 200 mg/dl for the following: 01/12/24 at 10:29 PM the blood glucose reading was 305 mg/dl no insulin administered. 01/13/24 at 08:41 PM the blood glucose reading was 253 mg/dl no insulin administered. 01/18/24 at 08:48 PM the blood glucose reading was 234 mg/dl no insulin administered. 01/19/24 at 09:03 PM the blood glucose reading was 259 mg/dl no insulin administered. Review of the Medication Administration Record (MAR) for Resident #18 dated February 2024 revealed Novolog sliding scale insulin was administered as needed before meals. Novolog sliding scale insulin was not administered at bedtime as needed for blood glucose greater than 200 mg/dl for the following: 02/03/24 at 10:42 PM the blood glucose reading was 248 mg/dl no insulin administered. 02/04/24 at 10:11 PM the blood glucose reading was 235 mg/dl no insulin administered. 02/06/24 at 10:11 PM the blood glucose reading was 215 mg/dl no insulin administered. 02/07/24 at 09:18 PM the blood glucose reading was 348 mg/dl no insulin administered. 02/08/24 at 08:34 PM the blood glucose reading was 274 mg/dl no insulin administered. 02/11/24 at 09:29 PM the blood glucose reading was 203 mg/dl no insulin administered. 02/12/24 at 09:20 PM the blood glucose reading was 204 mg/dl no insulin administered. 02/13/24 at 10:48 PM the blood glucose reading was 341 mg/dl no insulin administered. 02/15/24 at 08:44 PM the blood glucose reading was 207 mg/dl no insulin administered. 02/18/24 at 08:56 PM the blood glucose reading was 253 mg/dl no insulin administered. 02/19/24 at 10:18 PM the blood glucose reading was 204 mg/dl no insulin administered. 02/20/24 at 10:41 PM the blood glucose reading was 204 mg/dl no insulin administered. 02/25/24 at 10:51 PM the blood glucose reading was 225 mg/dl no insulin administered. 02/26/24 at 09:55 PM the blood glucose reading was 284 mg/dl no insulin administered. Review of the Medication Administration Record (MAR) for Resident #18 dated March 2024 revealed Novolog sliding scale insulin was administered as needed before meals. Novolog sliding scale insulin was not administered at bedtime as needed for blood glucose greater than 200 mg/dl for the following: 03/03/24 at 10:26 PM the blood glucose reading was 283 mg/dl no insulin administered. 03/04/24 at 10:32 PM the blood glucose reading was 220 mg/dl no insulin administered. During a phone interview on 03/06/24 at 02:53 PM Medication Aide #1 stated she worked night shift from 7:00 PM through 7:00 AM and routinely provided care to Resident #18. She stated she checked Resident #18's blood sugars two times during her shift, which were at bedtime and in the morning. She stated Resident #18 did not have orders for sliding scale coverage at bedtime and she only received insulin coverage before meals. She indicated Resident #18 was only given sliding scale insulin to cover her blood sugars when she checked her in the mornings. She stated she was not aware that sliding scale insulin was ordered at bedtime and indicated there was no space on the electronic medical record to document that insulin was to be administered at bedtime. She indicated she was not clear on the order if insulin was to be administered at bedtime. She stated as a Medication Aide she would not administer the insulin but would report it to the charge nurse anytime sliding scale insulin was ordered and the nurse would administer it. She reported that Resident #18 was not symptomatic at bedtime when her blood sugar levels were over 200 mg/dl. During a phone interview on 03/07/24 at 12:00 PM Medication Aide #2 stated she worked night shift from 7:00 PM through 7:00 AM and routinely provided care to Resident #18. She stated she checked blood sugars two times during her shift for Resident #18 which were at bedtime and in the morning. She stated Resident #18 did not have orders for sliding scale coverage at bedtime. She stated she would have reported blood sugar readings to the nurse in charge if insulin was scheduled and the nurse would administer the insulin, but no insulin was ordered at bedtime. She indicated she was not clear on the order if Resident #18 was supposed to be given insulin at bedtime. Attempts were made to contact Nurse #1 during the investigation. Nurse #1 was an agency nurse and was on duty during the dates and times the sliding scale insulin was not administered to Resident #18. There was no response. Attempts were made to contact Nurse #2 during the investigation. Nurse #2 was on duty during the dates and times the sliding scale insulin was not administered to Resident #18. Nurse #2 was no longer employed by the facility. There was no response. Attempts were made to contact agency Medication Aides #3, #4, and #5 during the investigation. The Medication Aides were on duty during the dates and times the sliding scale insulin was not administered to Resident #18. There was no response. During an interview on 03/07/24 at 10:18 AM the Physician indicated she was not aware Resident #18 was not getting sliding scale coverage at bedtime. She reported the Nurse Practitioner wrote the order for sliding scale insulin at bedtime. She stated she didn't typically like to prescribe nighttime insulin to residents due to the risk of hypoglycemia. She stated there would not be any significant outcome for Resident #18 not receiving insulin at bedtime and it was probably best that she didn't get the insulin at bedtime. During an interview on 03/07/24 at 11:12 AM the Nurse Practitioner stated she wrote the order for sliding scale insulin in January 2024 and had planned to discontinue the bedtime sliding scale insulin order after a few weeks which would be in February 2024, but she overlooked discontinuing the order. She stated it was fine that Resident #18 wasn't getting sliding scale insulin coverage for the bedtime blood sugar checks even though some of the blood sugar readings were greater than 200 mg/dl because of the risk of hypoglycemia. She stated she planned to change the order today and order blood sugar checks with sliding scale insulin three times a day before meals. During an interview on 03/07/24 at 11: 15 AM the Registered Nurse Supervisor stated that Novolog sliding scale was ordered before meals on 01/11/24, then on 01/12/24 an order was entered for blood sugar checks before meals and at bedtime and to see sliding scale instructions for coverage. She indicated what should have occurred when the order for blood sugars before meals and at bedtime was added the entire order for Novolog sliding scale before meals should have been discontinued and Novolog sliding scale four times a day before meals and at bedtime should have been entered and that was not how it was entered. She indicated this was likely the cause of the bedtime sliding scale insulin order not being followed. During an interview on 03/07/24 at 12:24 PM the Director of Nursing stated medications were reviewed daily in the morning meetings. She indicated she was not aware of the insulin order not being followed for Resident #18. She stated her expectation was for staff to follow the physicians orders and indicated the sliding scale insulin was an active order and should have been followed.

Based on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint survey of [DATE] and the recertification and complaint survey of [DATE]. This was for one deficiency that was originally cited in [DATE] in the area of significant medication errors and for two deficiencies originally cited in [DATE] for medication storage and unnecessary medications. These deficiencies were subsequently recited on the current recertification survey of [DATE]. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F757: Based on observations, record review, staff, and Physician interviews the facility failed to clarify a medication order prescribed for hypotension (low blood pressure) to include hold parameters if the systolic blood pressure was greater than 120 mm/hg (millimeters of mercury). This resulted in a resident (Resident #61) receiving 59 additional doses of the medication. There was no significant outcome from receiving the medication. This occurred for 1 of 3 residents reviewed for medication administration. During the recertification and complaint survey of [DATE] the facility administered a medication to a resident that was not medically justified. An interview was conducted with the Administrator on [DATE] at 3:30 PM. The Administrator stated she believed the QA process needed to be more focused on clarifying orders and reviewing all medications daily for accuracy and following the parameters. F760: Based on observation, record review, staff, Nurse Practitioner, and Physician interviews the facility failed to follow the physicians order and provide sliding scale insulin at bedtime to a resident (Resident #18) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in the resident not receiving a total of 74 units of insulin from [DATE] through [DATE]. There was no significant outcome. This occurred for 1 of 3 residents reviewed for medication administration. During the recertification and complain survey of [DATE], the facility failed to administer intravenous (IV) medication as ordered by the physician. An interview was conducted with the Administrator on [DATE] at 3:30 PM. The Administrator stated she believed the QA process needed to be more focused on clarifying orders and reviewing all medications daily for accuracy and following the parameters. F761: Based on observations, record review, and staff interviews the facility failed to record an opened date on two insulin pens and on two opened bottles of eye drops that had shortened expiration dates. This was observed on 1 of 3 medication carts (300 hall medication cart) reviewed for medication storage. During a recertification and complaint survey of [DATE] the facility failed to: accurately label and record an opened date on a bottle of tuberculin solution and a bottle of Influenza vaccine; accurately record an opened date on a bottle of eye drops and insulin pens; dispose of expired bottles of nitroglycerin, insulin pens, and bottle of nasal spray; lock and secure a medication cart in an unattended resident care area; and to securely store medication on a medication cart. An interview was conducted with the Administrator on [DATE] at 3:30 PM. The Administrator revealed the facility including the pharmacist and the Director Nursing believed that the problems with medication storage were related to the inconsistency of the staff on the 300 and 500 halls. The Administrator stated two new nurses were hired to be consistent floor nurses for the two halls.

Based on record review, observation, and resident, staff and physician interviews, the facility failed to obtain an appointment with a retinol specialist for treatment of visual impairment for 1 of 1 residents (Resident #9) reviewed for vision. Findings included: Resident #9 was admitted to the facility on [DATE] with a diagnosis which included dry eye syndrome. Review of Resident #9's electronic health record revealed a 10/17/23 vision consult which indicated Resident #9 had gradual blurry vision with the left eye greater than the right. The plan of care indicated Resident #9 was to have a referral to a retinol specialist for treatment with an appointment to be scheduled within 2-3 weeks. Review of Resident #9's electronic health record revealed a 10/17/23 optometry order form indicated a referral to a retinol specialist was required for evaluation of left eye advanced macular degeneration, a disease that causes vision loss. Review of Resident #9's 2/13/24 quarterly Minimum Data Set assessment revealed resident had adequate vision, corrective lenses were not used, and was cognitively intact. Observation of Resident #9 on 3/4/24 at 3:25 PM revealed resident sitting on the side of the bed with mail in her hands, glasses on and her call bell was activated. An interview was conducted with Resident #9 on 3/4/24 at 3:28 PM. Resident #9 stated she needed to see a vision specialist and the appointment was supposed to have been scheduled months ago. Resident #9 revealed she had trouble with vision in her left eye and was unable to see. Resident #9 indicated she activated her call bell to request assistance with reading her mail. Review of Resident #9's progress notes as of 3/5/24 revealed no evidence that the appointment with the retinol specialist was scheduled or completed. Review of Resident #9's consult notes as of 3/5/24 revealed no evidence that the resident was evaluated by the retinol specialist. Interview on 3/6/24 at 12:10 PM with the Transporter/Appointment Scheduler revealed she was in the position since September 2023. The Transporter/Appointment Scheduler stated she was responsible for scheduling appointments for the resident after she received a referral from the nurses. The Transporter/Appointment Scheduler stated she scheduled the appointments and informed the resident and family of the date and time. The Transporter/Appointment Scheduler stated she thought she recalled the Nurse Practitioner said she was waiting for the resident to be seen by the vision clinic that visits the facility. The Transporter/Appointment Scheduler stated the vision clinic only visits the facility once per year. The Transporter/Appointment Scheduler stated she did not recall receiving a referral for an appointment with a retinol specialist. Interview on 3/6/24 at 1:15 PM with the Director of Nursing (DON) revealed Medical Records received the report from the optometry appointment in October and uploaded it to Resident #9's medical record. Medical Records had not provided the Nurse Practitioner (NP) with the report for review. The DON stated the NP or physician was not made aware of the results of Resident #9's optometry appointment in October or the recommendation for the referral to a retinol specialist. The DON stated she was not aware of the results of the appointment in October or the referral. The DON stated an appointment was made today with the retinol specialist for 4/9/24 at 12:40 PM. Interview on 3/7/24 at 10:50 AM with the physician revealed she was just made aware that the appointment with the retinal specialist had not been scheduled as ordered on the consult report. The physician stated it would not cause resident harm by not obtaining the appointment with the retinol specialist sooner, but it was a system process error.

Based on observations, record review, and staff interviews the facility failed to record an opened date on two insulin pens and on two opened bottles of eye drops that had shortened expiration dates. This was observed on 1 of 3 medication carts (300 hall medication cart) reviewed for medication storage. Findings included. Review of the manufacturer's instructions for Lantus insulin pens revealed to discard 28 days after opening. Review of the manufacturer's instructions for Brimonidine eye drops revealed to discard 4 weeks after opening. Review of the manufacturer's instructions for Latanoprost eye drops revealed to discard 6 weeks after opening. An observation of the 300-hall medication cart on 03/04/24 at 11:30 AM along with Nurse #3 revealed two Lantus insulin pens stored on the medication cart that were in use with no opened dates labeled on the insulin pens. A bottle of Brimonidine eye drops and a bottle of Latanoprost eye drops were opened with no opened dates labeled on the bottles. During an interview on 03/04/24 at 11:35 AM Nurse #3 stated she was not aware the insulin pens were not dated and indicated she did administer one of the two insulin pens to the resident it was prescribed for earlier today. She stated she was new to the facility and still getting used to procedures. She acknowledged the Lantus insulin pen was not dated and stated she failed to check for an opened date prior to administering the insulin. She indicated she had not administered either of the eye drops and had not checked the bottles for opened dates. During an interview on 03/07/24 at 12:24 PM the Director of Nursing stated insulin pens and eye drops should be labeled with opened dates when they were opened. She stated the nurse should have checked the date prior to administering the insulin. She stated education would be provided.

Based on record review and staff interview the facility failed to complete comprehensive assessments within the 14-day required timeframe for 2 of 2 residents reviewed for comprehensive Minimum Data Set (MDS) assessments (Resident #290 and Resident #291). Findings included: 1. Resident #290 was admitted to the facility on [DATE]. Resident #290's admission Minimum Data Set (MDS) dated [DATE] was noted as in progress as of 3/7/24. An interview was conducted with the MDS Nurse on 3/07/24 at 2:41 PM. The MDS Nurse stated the workload had increased with a lot of residents discharging and returning and she had more difficulty keeping up with the workload. The MDS Nurse stated she was aware of the timelines for completion of the MDS assessments and had completed assessments late recently. MDS Nurse stated she was trying to get caught up. An interview with the Administrator on 3/07/24 at 3:10 PM revealed she expected that MDS assessments be completed in a timely manner. 2. Resident #291 was admitted to the facility on [DATE]. Resident #291's 2/21/24 admission Minimum Data Set assessment was completed on 2/21/24. An interview was conducted with the MDS Nurse on 3/07/24 at 2:41 PM. The MDS Nurse stated the workload had increased with a lot of residents discharging and returning and she had more difficulty keeping up with the workload. The MDS Nurse stated she was aware of the timelines for completion of the MDS assessments and had completed assessments late recently. MDS Nurse stated she was trying to get caught up. An interview with the Administrator on 3/07/24 at 3:10 PM revealed she expected that MDS assessments be completed in a timely manner.

Based on observation, staff interviews and record review the facility failed to provide supervision to prevent a cognitively impaired resident who displayed wandering behaviors from exiting the facility unsupervised for 1 of 1 sampled residents (Resident #40) reviewed for accidents. Resident #40 was found unsupervised outside the facility by facility staff and returned inside with no injuries. Immediate Jeopardy began on 11/25/18 when Resident #40 was found outside of the facility without supervision by Nurse #4 when he was heard knocking on the outside of the facility's 700 hall door that was approximately 40 feet from the facility's front parking lot. The parking lot was not in use due to damage from a storm. Immediate Jeopardy was removed on 12/12/18 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #40 was admitted to the facility on [DATE] and had a re-entry date of 12/20/16 with [DIAGNOSES REDACTED]. The physician orders [REDACTED].#40 every shift. The current plan of care dated 11/08/18 for Resident #40 included focus areas of risk for elopement related to a history of an elopement attempt (initiated on 12/13/17) and the resident displayed exit seeking behaviors at times when he was upset or angry with increased risk for elopement. Goals were for the resident to have no elopement episodes and for the resident's exit seeking behaviors to be minimized through interventions in order to reduce the risk for injuries or elopement. Interventions included to check the wanderguard transmitter for proper functioning frequently and to replace as needed. A review of the elopement risk assessment for Resident #40 dated 11/12/18 revealed that Resident #40 had a risk score of 9 indicating that he was a moderate risk for elopement. An annual Minimum Data Set (MDS) assessment dated [DATE] documented through a staff assessment that Resident #40 had a memory problem with modified independence cognition. He had no moods or behaviors during the assessment look back period. He was independent for bed mobility, required supervision for transfers and locomotion. He utilized a wheel chair for mobility. He had a wander/elopement alarm that was used daily. A nursing note written by Nurse #3 on 11/25/18 at 1:04 PM documented that the writer noticed that resident was not in the dining room, courtyard, or bedroom at 12:00 PM (all the usual places that resident was). It was reported to the ADON (Assistant Director of Nursing) that the resident was missing. As the ADON was going to check on another unit, the 700 hall nurse, (Nurse #4), found the resident knocking on the 700 hall exit door from outside. The wander guard was active on the wheel chair. The resident was non-verbal but was laughing and aware of his actions. The ADON notified the Administrator. The resident was last seen smoking in the courtyard at 11:10 AM. The resident had been slightly agitated beforehand due to too many people being in the dining room. According to the National Weather Service computer data base the temperature in Southport, NC, where the facility is located, on 11/25/18, was 62 degrees Fahrenheit. The facility's incident investigation dated 11/26/18 of Resident #40's unsupervised exit from the facility was reviewed. It documented that the 700 hall outside exit door alarm (that Resident #40 exited) had been turned off and did not alarm when it was opened. The resident had a wanderguard on that was functioning but the door did not have a wanderguard alarm. It had a chime alarm. In an interview conducted with the ADON on 12/10/18 at 4:25 PM she stated that she was present on 11/25/18 when Resident #40 was found outside of the facility unsupervised. She said that she checked the alarm on the 700 hall door after Resident #40 was found outside of the facility on 11/25/18 and it had been turned off. The ADON stated she also checked the door leading in from the courtyard into the hallway directly across from the 700 hall exit door and found it was unlocked (approximately 16 feet between doors). She said she was not sure who turned the alarm off or who unlocked the courtyard door that allowed Resident #40 to come into the 700 hall and then exit through the hallway's outside door. She remarked that the door leading into the 700 hall from the courtyard where Resident #40 smoked was to always remain locked to prevent residents from gaining access to exit doors from the courtyard. She remembered it was a Sunday so there were no construction workers in the building but she stated that at times family members turned off the alarms. She said she immediately conducted an in-service for all staff on duty and staff coming onto the evening shift to keep door alarms on and locked. She stated that she did not know who was responsible for checking the alarms and doors on the weekends. She said that it was normal for the third shift nurses to check the doors every night. In an interview conducted with Nurse #4 on 12/10/18 at 4:50 PM she stated that on 11/25/18 (a Sunday) she heard knocking on the 700 hall door leading into the front parking lot of the facility. She said that Resident #40 was knocking on the door trying to get back into the building. Due to his cognition and language deficit he was not able to tell her what he was doing or where he had been. She reported that when she let him in the alarm on the door did not sound because she noticed that it had been turned off. She commented that the door he exited was not wanderguard alarmed but had a regular alarm that sounded if and when the door was opened. Nurse #4 also stated this door did not lock automatically from the inside when a resident wearing a wanderguard approached the door. During an additional interview on 12/12/18 at 1:50 PM with Nurse #4 she stated that she remembered that it was sunny outside and it wasn't rainy or cold when she let Resident #40 back into the building. In an interview with Nurse #3 on 12/10/18 at 4:55 PM she stated that she was the nurse for Resident #40 on 11/25/18 when he was found unsupervised outside of the facility. She said she noticed on 11/25/18 Resident #40 was not in the dining room, court yard or bedroom. She decided to check on the 700 hall for him when Nurse #4 heard the knocking. She said the resident was not able to verbalize where he had been or why he was outside due to his cognition (history of a stroke). In an interview with Physician #1 on 12/11/18 at 9:30 AM he stated he was notified when Resident #40 eloped from the building. He said the nurse who notified him informed him that the resident had been assessed and had no injuries. He commented that it was his expectation that any resident who eloped and returned be assessed for harm and then be kept safe. He would also expect to be told what measures were being done to monitor the resident. He said Resident #40 was always wandering around the facility and had communication limitations. He also noted that Resident #40 was on a high dose of pain medications for phantom limb pain and may have gotten confused that one time and went out the wrong door. He felt the elopement was an isolated incident. He said the resident usually went out to the courtyard alone to smoke and had never been an elopement risk. He had never been concerned that Resident #40 would try to elope. In an interview conducted on 12/10/18 at 8:45 AM with the Maintenance Assistant he stated that he had been employed at the facility for four years and worked from 5:30 AM to 1:00 PM Monday through Friday. He reported that he alternated on-call on the weekends with the Maintenance Director. He said maintenance personnel did not come to the facility on weekends unless they were called for an emergent situation. He reported that he checked all the door alarms and locks every morning during the week before the residents got up but he did not keep a log. He said he was not aware of who checked the alarms and doors on the weekends or holidays when maintenance staff were not on duty. An interview was conducted on 12/11/18 at 9:58 AM with the Maintenance Director. He said that maintenance checked the doors in the facility daily Monday through Friday. They checked the doors on Saturday and Sunday only if they were called in for an emergency. He was not aware of who was responsible for checking the doors on weekends. He reported that doors equipped with wanderguard were checked every Wednesday and the checks were documented in a log. He commented that doors that were not equipped with wanderguard but that had regular magnetic chiming alarms were sometimes turned off by visitors using the door. He said that on the day that Resident #40 eloped out the 700 Hall exit door he was called in. He stated that he checked the keypad on the outside of the door at approximately 3:00 PM on 11/25/18 and nothing was wrong with it but he replaced it anyway. He checked the chime alarm and it was working properly at the same time. He said he set the closer at the top of the door tighter in case the door had swollen with the weather change to make it a little heavier so that it would always latch. An interview was conducted on 12/11/18 at 10:55 AM with the Director of Nursing. She stated that it was expected and the normal practice of the third shift nurses to check the doors and alarms each night to secure the building. An interview was conducted on 12/12/18 at 2:45 PM with Nurse #5. She stated that she normally worked the 7:00 PM to 7:00 AM shift. She said that on night shift she locked the front and back doors and checked all the wanderguard doors with a wanderguard to make sure they were locking correctly. An observation made on 12/12/18 at 1:00 PM of the facility's 700 hall exit door, where Resident #40 was found on 11/25/18, revealed that it opened from the inside with a bar release and locked from the outside. It lead onto an evenly paved sidewalk that was 40 feet from the front parking lot which was not in use. The lot had been blocked off due to damage and had no activity. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 12/12/18 at 10:05 AM. On 12/12/18 at 7:05 PM the facility provided the following credible allegation of immediate jeopardy removal: Plan to correct specific deficiency and facts that led to the alleged deficient practice: Skilled Nursing Facility (SNF) Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent risk assessment was completed on 11/12/18 and Resident #40 scored a 9, indicating moderate risk for wandering. Wanderguard bracelet was in place as ordered by Medical Director (MD). Care plan and kardex included the wanderguard bracelet interventions. Resident is an independent smoker, which means he can go smoke independently in the secure courtyard, using doors on 100 hall on lobby side and door from the large dining room. Neither of these doors trigger an alarm as they open into a secured courtyard with no exits. Corrective Action for Involved Resident: On (MONTH) 25, (YEAR) at approximately 12:00 noon, SNF resident # 40 went out to smoke. It was unwitnessed which of the two doors that lead into the secure that resident exited to go smoke. Neither of these doors are alarmed as they do not lead to exit areas. Resident went into the secured courtyard area for smokers. He was alone as he had been assessed to be an independent smoker, who has the capability to light his own cigarettes and hold them using safe practices. Nurse #4 saw resident outside smoking, as well as the Activity Director. Nursing noticed that resident was not in courtyard, his room or in facility and immediately initiated resident search. Nursing unsure of approximate time that resident may have been outside, but can validate that he was seen by Nurse #4 and activity Director within 10-20 minutes outside smoking as his usual routine. Nurse #4 noted resident to be outside at 700 hall door (Door # 2) and resident was knocking on the door to return in facility. Resident has a Brief Interview for Mental Status (BIMS) of 00 due to [MEDICAL CONDITION]. However, resident is able to communicate using his unique mannerism and staff are familiar with his communication. Assistant Director of Nursing (ADON) and the Director of Nursing (DON) interviewed resident and resident denies trying to leave facility. Resident has customary routine of entering this secured smoking courtyard. It is unsure which of the two doors resident exited into the secure unit by. Resident will use door #4 from courtyard as he visits the Nursing Home Administrator. Resident normally takes a left to visit front office areas and this particular time resident went out through two other doors (doors # 2 and #4) and door #4 shut and locked behind him. Resident began knocking on the door # 2 to return. Root cause of resident exiting facility is that door #4 was not locked and door #2 had a chimer that was turned off. Resident was immediately assessed by the ADON and had no injuries or complaints of discomfort. Resident has now refused to wear wanderguard on his wrist and has been placed on 1:1. Had a wander guard bracelet placed in correct position on wheelchair as resident is a bilateral above the knee [MEDICAL CONDITION]. Wanderguard bracelet was checked by the ADON and it was functioning correctly. Update: As of 12/12/18 at 7:00 PM resident is refusing to have wander guard bracelet removed from his wheelchair and placed on his wrist. Education provided by DON and Administrator 12/12/18. 1:1 initiated. Medical Director and Responsible Party notified by Nurse #3 on 11/25/18. DON and Nursing Home Administrator (NHA) notified 11/25/18. The resident was placed on 1:1 for 24 hours. Identification of potentially affected resident and corrective actions taken: An REQ (Review to Ensure Quality) was initiated by the DON on 11/25/18 and 1:1 was immediately initiated for this resident to ensure safety for 24 hours. On 11/25/18 ADON immediately locked door # 4 and immediately activated chimer alarm on door #2. Immediately signage was posted on door #4 and door #5 stating, Keep door locked on door # 4 and #5. On 11/25/18 ADON immediately checked all other facility doors and alarms to ensure that all doors were locked and all alarm systems were activated to ensure safety. No other areas identified. On 11/25/18, the ADON printed a current SNF resident census and ensured all SNF residents listed on the census were accounted for by utilizing the list from Point Click Care. DON verified that all SNF residents at risk for wandering were in facility with functioning wanderguard bracelets. No areas of concern identified. Residents are assessed using the User Defined Assessment of Risk assessments that is an individualized resident assessment in Point Click Care. On 11/25/18, the ADON reviewed all SNF current residents at risk for elopement to ensure orders were entered for the nursing staff to document in the electronic medical record to the Electronic Medication Administration Record [REDACTED]. No areas of concern identified. On 11/25/18, Health Information Director checked the elopement risk notebooks at each nurse's station and reception desk to ensure that all SNF current residents identified as needing a wanderguard bracelet had a picture in place. No areas of concerns identified. The Health Information Manager is responsible for keeping the Elopement Risk notebooks are kept up to date. Measures put in place/Systemic changes to ensure deficient practice does not reoccur: On 12/11/18 the Director of Nursing and licensed nurses began in-servicing facility wide, all full time, all part time and all as needed (PRN) staff on the following: Elopement Prevention Training to prevent resident injury/harm or potential for injury/harm. Elopement training on what to do if residents begin to initiate exit seeking behaviors, including making verbal statements, such as I've got my bags packed, I'm going to meet my sister. Staff are instructed to redirect and provide 1:1. All staff (this includes Full time, Part time and PRN staff) to be trained by 12/12/18 or they will not be allowed to work until training is completed. All staff educated on not cutting off alarms or unlocking doors. All staff educated on what to do if there is a concern with a door lock or any type of alarming system. All staff educated on the process of providing 1:1 with a resident or 1:1 door monitoring if assigned. Staff educated on the expectation of constant visual monitoring and how to handle when the need for breaks, meals and/or any type of emergency may arise. Staff educated to report to charge nurse of any concerns or needs while providing 1:1 with a resident and/or door monitoring. Staff educated on the process of documenting the 1:1 with a resident and/or door monitoring. All nurses educated on the process of completing Risk Assessments for Assisted Living Facility (ALF) residents on admission and readmission. All nurses educated on the system process of checking all doors and alarming systems every shift 7 days per week during shift changes, including holidays and weekends. This system process will be documented on the Quality Assurance (QA) door check sheet kept in the narcotic count book. All staff educated on the different types of alarm systems and door locking systems. All staff educated on the proper placement of the wanderguard bracelets as recommended by the manufacturer. This will also be added to the facility new hire orientation. This education will be conducted facility wide, licensed nurses will educate all clinical staff and Department head will educate non-clinical staff with hand written education material provided and verbal discussions on education. Learners will be provided opportunities for discussions and/or questions for clarifications. All staff will sign an attestation document on receiving the education. On 12/12/18 NHA sent telephonic message to all families and Responsible Parties educating families regarding ensuring safety for residents and not unlocking any doors and/or turning off any alarms, including chiming alarms or squealer boxes. Families do not have codes to turn alarms off. How will the facility monitor its performance that solutions/measures are sustained? All doors, door locks and alarm systems will be checked q shift to ensure the alarm systems are working properly, all door locks are secure and all door and systems are working correctly q shift seven days per week by nursing. The checks will be documented on the Quality Assurance (QA) Door Check sheets every shift and kept in the narcotic count notebook. The DON will audit all 14 door checks daily five days per week x 2 weeks then weekly x 4 weeks and then monthly x 2 months. Maintenance Director will continue to check all doors and alarm systems weekly utilizing the TELS (Maintenance Software electronic program) system to ensure doors and alarm systems are working properly. The QA Committee, which consists of DON, NHA, MDS, Unit Manager, Therapy Director, HIM (Health Information Manager), Dietary Manager and Social Work will continue to monitor for any trends/concerns/opportunities to ensure the safety of residents with current door locking and alarming systems. Any areas of concern will be immediately addressed by the Director of nursing and/or NHA. Reports will be presented to 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, Maintenance Director and the Administrator. The NHA is responsible for implementing and ensuring this plan of correction. Completion Date: 12/12/18 The credible allegation of Immediate Jeopardy removal was validated on 12/12/18 at 8:25 PM. A sample of staff that included nurses, nurse aides, and non-clinical employees were interviewed regarding in-servicing related to the deficient practice. All interviewed staff members stated they had been in-serviced regarding elopement and the facility procedure for checking alarmed or locked doors. A review of all documents developed to correct the deficient practice was completed. All facility policies and procedures that were revised to address the deficient practice were reviewed. A review of audit forms that were developed to ensure that in-services presented to all staff were understood and allowed an opportunity for staff to interact with dialogue were also reviewed. All doors that were alarmed were checked (3 wanderguard and 6 chime alarmed) and verified to be working properly.

Based on record review, staff, resident and adult protective services interviews, the facility failed to ensure 1 (Resident #8) of 4 sampled residents was free of verbal abuse, failed to provide an environment that 1 (Resident #2) of 4 sampled residents felt safe and free of physical and verbal abuse and failed to protect 1 (Resident #1) from verbal and physical abuse. Immediate Jeopardy began on [DATE] and was identified on [DATE] at 10:00 AM. Immediate Jeopardy was removed on [DATE] at 1:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete training on abuse for 100% of the staff and to implement the monitoring of its corrective action. The findings included: 1. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] where she later expired. The Care Area Assessment (CAA) for Cognitive Status dated [DATE] revealed that the resident was alert and verbally responsive with periods of forgetfulness and was able to understand others and make her needs known. The CAA for Visual Function dated [DATE] revealed that the resident had a history of [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and vision was highly impaired. The Care Plan dated [DATE] revealed that the resident was concerned about her health and was very demanding of attention from the staff. The approach was for staff to approach the resident warmly at all times. A review of the facility ' s Grievance Log revealed an entry dated [DATE] that a NA (nursing assistant) had spoken rudely to Resident #8. A written statement by Med (medication) Aide #1 revealed on [DATE], Resident #8 rang the call bell and NA #1 entered the room and asked the resident what she wanted. According to the written statement the Resident stated that she had spilled her soda and ice and wanted some more. The statement revealed that the NA stood in front of the resident in an intimidating way and responded to the resident that when she rang her call light, she needed to tell her everything she needed right then and to stay off her call light. The statement revealed the resident was frightened and was throwing her hands in front of her to push the NA away from her. On [DATE] at 5:40 PM the Administrator stated in an interview that the incident with Resident #8 was reported by Med Aide #1 who heard the incident while standing outside the building. The Administrator stated that Resident #8 denied the incident and the resident had since expired. Review of the facility ' s investigation revealed a written complaint was made to the ADON (Assistant Director of Nursing) that a NA spoke rudely to Resident #8. The note revealed that the resident was reliable and had no complaints per the social worker. The investigation note revealed that the resident was interviewed and reported she did not feel mistreated in any way. A written statement by Med Aide #1 revealed that on [DATE] on second shift Resident #8 rang her call light and NA#1 was observed to enter the room and asked the resident what she wanted. The statement revealed that the resident stated that she had spilled her soda and ice and wanted some more. The statement read: "Name of NA #1 stood in front of resident and, in an intimidating way, told her when she rings her call light, to tell her everything she needs right then and to stay off her call light. Name of Resident #8 was frightened and was throwing her hands in front of her to push Name of NA #1 off of her and yelling get out of my face. " The Administrator stated in an interview on [DATE] at 11:35 AM that she spoke with NA #1 about the incident and the NA could not recall any unusual interactions with Resident #8. On [DATE] at 12:35 PM the facility ' s Social Worker stated in an interview that Resident #8 was generally alert and oriented and reliable with some forgetfulness. The Social Worker stated that she asked the resident if any of the girls that help her get dressed had mistreated her in any way and the resident stated: " No. " The Social Worker stated that she has had no complaints about NA #1 from other residents. NA #1 stated in a telephone interview on [DATE] at 2:01 PM that she never yelled at Resident #8 or had any problems with the resident. Med Aide #1 stated in an interview on [DATE] at 2:40 PM that Resident #8 was unable to see very well and knocked over her drink several times on the evening of [DATE]. The Med Aide stated that she went in to give the resident her medication and was on her way out of the room and NA #1 entered the room in response to the call light. The Med Aide stated that NA looked irritated. The Med Aide stated that she left the resident ' s room and went around the corner and into the courtyard to smoke. The Med Aide stated that she was standing in the courtyard outside the room of Resident #8 and could hear NA #1 yelling at the resident through the window. The Med Aide stated NA #1 stated: " I ' m going to get this up this time but next time you better tell me everything you need and stay off the call light. " The Med Aide stated that NA #1 was standing over the resident in an intimidating way and the resident was raising her arms and saying: " Get off of me." The Med Aide stated that NA#1 did not touch the resident but was raising her voice and in the resident ' s face. The Med Aide stated that she reported the incident to Nurse #3 who told her to write it up. The Med Aide stated that NA #1 usually worked the 7AM-3PM shift but that day had stayed over and worked the 3PM-11PM shift as well. A review of the payroll time sheet for NA #1 revealed the NA worked 7AM to 11PM on [DATE] and 7AM-3PM only on [DATE]. In an interview with Med Aide #1 on [DATE] at 4:40 PM, the Med Aide stated that she thought that the incident occurred on [DATE]. The Med Aide stated that on Friday ([DATE]) she reported the incident to the Assistant Director of Nursing (ADON) and was told to write it up. The Med Aide stated that she got busy and did not write up the incident until Monday [DATE]. The Med Aide stated that the incident must have occurred on [DATE]. Housekeeper #1 stated in an interview on [DATE] at 3:00 PM that he had heard NA #1 yelling at Resident #8 several times one evening. The Housekeeper stated that he heard NA #1 tell the resident that she was doing the best she could, that she was busy and to stop bothering her. The housekeeper was unable to provide the date or time this occurred.. The Housekeeper stated that he considered the way the NA was talking to the resident to be verbal abuse. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Cognitive Status dated [DATE] revealed that that resident was residing at home with her husband but he was unable to provide the amount of care needed. The CAA revealed.the resident was verbally responsive, could make her needs known and was able to understand others. The CAA for Activities of Daily Living (ADLs) revealed that the resident required assistance with ADLs and it was unsafe for the resident to transfer independently. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was severely cognitively impaired and required extensive assistance with transfers. The Care Plan dated [DATE] revealed that Resident #2 had impaired thought processes due to [DIAGNOSES REDACTED]. One of the interventions was for staff to assist with transfers and ambulation as necessary and to use the stand up lift for transfers. A psychologist consult note dated [DATE] revealed that Resident #2 reported that she did not know whether or not it really happened or if she dreamed an incident with a staff member during which she felt badly mistreated. The note revealed that the psychologist discussed his desire for the resident to be more assertive about her own needs and in cases like this to discuss with the facility staff. Review of the nurse ' s schedule revealed Nurse #1 worked from 7AM to 11PM on [DATE]. A review of the nurse ' s notes revealed an entry dated [DATE] at 7:50 PM by Nurse #1 that Resident #2 reported to her on day shift on her first medication pass that her NA (nursing assistant) was verbally inappropriate with her and that she was scared about her safety. The note revealed that the resident had also reported this very tearfully to Med (medication) Aide #2. A nurse ' s note dated [DATE] at 10:30 PM by Nurse #1 revealed that the resident was still voicing concern for her safety stating: " I ' m just so scared because she is so big and all I can do is yell. " Review of the facility ' s Grievance Log revealed an entry dated [DATE] that a NA was rough and spoke rudely to Resident #2. A review of the facility ' s investigation revealed a written statement dated [DATE] by Nurse #1 that Resident #2 complained that the NA with a ring in her lip was rough with her and spoke inappropriately to her during care this morning. The statement revealed that the resident complained that the NA was rough with her and got her leg caught in the side of the wheelchair and told her that she wasn ' t going to put up with her today. The statement revealed that the resident requested the NA no longer work with her. A written statement dated [DATE] by Med Aide #2 revealed that Resident #2 was observed in her doorway crying and stated that she was being mistreated by her NA and referred to the NA as the Mafia. Med Aide #2 wrote that the resident reported that the NA kicked her. A written statement dated [DATE] by NA #1 revealed that she and NA #2 went in to get Resident #2 up and the resident was yelling and screaming and refusing care. The NA reported that they went back in to get the resident up and the resident continued to yell as they got her up and dressed. NA #1 wrote in her statement that she did not kick the resident. A written statement by the social worker dated [DATE] revealed an interview with Resident #2 where the resident reported a nursing assistant came in her room on [DATE] around 6:00 AM and told her it was time to get up. The statement revealed that the resident stated she did not want to get up and the NA replied: " I have you all day and you are going to do what I want you to do. " The report revealed the resident began screaming and the NA told her to " shut up. " The statement revealed the resident stated that she told the NA to leave her alone and the NA continued to get her dressed and out of bed. The statement revealed that the resident stated that the same NA had worked with her before and had a similar situation with her last week but did not report the incident to the staff. The report revealed that the resident stated she did mention it to her psychologist who encouraged her to be more assertive about her care and this was why she started screaming at the NA yesterday that she did not want to get up. A note by the social worker dated [DATE] at 12:35 PM revealed Resident #2 stated in an interview that she did not feel that any other staff members had mistreated her. On [DATE] at 3:15 PM Resident #2 stated in an interview that the NAs move fast and are rough with her. The Resident stated that she had already spoken with the social worker (Adult Protective Services) and did not want to talk about the incident. During the interview the Resident was able to recall that she was from another state. The Resident stated that she was falling a lot and her husband could no longer take care of her so they moved here to be closer to family. The resident stated that her husband lived close by with a family member. On [DATE] at 1:50 PM, an interview was conducted with NA #2 who assisted NA #1 with the resident ' s care on the morning of [DATE]. The NA stated that she went in to assist NA #1 to get the resident up but had to leave the room prior to the completion of care. The NA stated that she did not witness inappropriate behavior by NA #1 while she was in the room. Med Aide #2 stated in an interview on [DATE] at 5:00 PM that on [DATE] she observed Resident #2 sitting in her wheelchair in the hall with no shoes on. The Med Aide stated that the resident was upset and reported that the girls were jerking her around and had kicked her and did not like it and did not feel safe. The Med Aide stated that after the incident, NA #1 was at the nurse ' s desk and asked the Med Aide if she had called anyone to report the abuse and stated she was glad she had a witness. Nurse #1 stated in an interview on [DATE] at 5:20 PM that when she got to Resident #2 on her med pass on the morning of [DATE], the resident was tearful and upset. The Nurse stated that the resident reported she was slung around in the bed by the NA with the ring in her lip. Nurse #1 stated that NA #1 was the only NA with a lip ring working that day and was assigned to Resident #2. Nurse #1 stated that when she asked NA #1 to get Resident #2 up that morning the NA replied that she would get the resident up when she was ready to get her up. The Nurse stated she told the NA that she did not have to yell at her and the NA stated that this was just the way she talked to people. Nurse #1 stated that she did not like the way NA #1 spoke to her. Nurse #1 stated that she did not know the resident had been kicked until bedtime when the resident told her the NA with the ring in her lip had kicked her. The Nurse stated that she looked at the resident ' s thigh where the resident pointed and did not see any sign of injury. The Nurse stated that she had already given her statement about the incident and did not know about the kick when she wrote her statement. The Nurse stated that Resident #2 had trouble getting the right word out but had always been oriented with her. The Nurse stated that when the resident did say the wrong word she knew it was the wrong word. The Nurse stated that at the time of the incident on [DATE], Resident #2 was scared of NA #1. The Nurse stated that on Saturday [DATE] the resident saw NA #1 from a distance several times and stated: " I guess they are not going to fire her. " On [DATE] at 7:15 AM, Nurse #3 stated that in report at 11:00 PM on [DATE] she was told by Nurse #1 and Med Aide #2 that Resident #2 came out in tears and stated that as soon as the door closed, NA #1 was pulling and tugging on her and kicked her and that this had been going on for a week. The Nurse stated that Resident #2 was believable. The Nurse stated that the resident responded appropriately to questions and talked like she had some sense but was not totally oriented to place and time. On [DATE] at 12:25 PM the facility ' s Social Worker stated in an interview that Resident #2 ' s level of orientation fluctuates and was not always exact in relation to time. The Social Worker stated that the resident could generally give a round about time frame but was not exact and her recall of information was not exact. The Social Worker stated that the resident told her during an interview on [DATE] that a NA came in her room around 6:00 AM to get her up and she told the NA that she did not want to get up and the NA told her that she had her all day and she would do what she told her to do. The Social Worker stated that the resident told her that she started screaming and the NA told her to shut up. The Social Worker stated that the resident told her the NA had facial piercing and was Hispanic. NA #1 stated in a telephone interview on [DATE] at 2:01 PM that on [DATE] at approximately 7:30 AM she went in and asked Resident #2 if she was going to get up for breakfast. The NA stated that the resident thought it was the middle of the night and started refusing care. The NA stated that she left the room and returned with NA #2 and the resident refused to get up so they left the room. NA #1 stated that she and NA #2 returned after breakfast and got the resident up. The NA stated that the resident told the nurse that someone kicked her. The NA stated that she did not kick Resident #2. The NA stated that she did not provide care for the resident any more that day. On [DATE] at 10:00 AM a written statement was provided by the Administrator that stated NA #1 had worked on the day and evening shifts on [DATE] and day shift on [DATE]. On [DATE] at 2:40 PM Resident #2 was observed in her room with two visitors. The Resident introduced her husband and the other visitor as a family member. An attempt was made to re-interview the resident about the incident on [DATE] and the resident ' s family encouraged her to talk about the incident. The Resident stated: " The issue has been discussed and that ' s it. " A Social Worker with Adult Protective Services stated in an interview on [DATE] at 9:50 AM that she interviewed Resident #2 on [DATE] and again on [DATE] at 10:00 AM. The Social Worker (SW) stated that the resident told her that she did not report prior incidents and that the incident on [DATE] was the first incident she had reported. The SW stated that Resident #2 had fear in her eyes when she told her that she did not want to cause a problem because she had to live there until she died and she was afraid that she would be punished. The SW stated that the resident told her that the incident on [DATE] was a nasty incident and she was scared out of her skin. The SW stated that Resident #2 reported that NA #1 kicked her and the resident described the kick as an intentional kick that just brushed her. 3a. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Cognitive Status and Communication dated [DATE] revealed that the resident was unable to be oriented due to progressive cognitive decline. The CAA revealed that the resident was alert to self but confused to time and place and unable to verbalize needs and concerns secondary to [MEDICAL CONDITION]. The CAA revealed that the resident was resistive to care, hitting, kicking and cursing at staff. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had short and long term memory problems and was severely cognitively impaired. The MDS revealed the resident was totally dependent on staff for all activities of daily living. The MDS revealed that the resident had no behaviors during the 7 day assessment period. The Care Plan dated [DATE] included a problem that the resident was resistive to care by hitting, kicking and cursing. Among the approaches was to check the resident frequently for anticipated needs and address to reduce risks for agitation, anxiety or resistive behaviors and redirect as needed. The Director of Nursing (DON) stated in an interview on [DATE] at 1:15 PM it was reported to her that NA #1 told Resident #1 that she hoped he fell out of the wheelchair.. NA (nursing assistant) #3 stated in an interview on [DATE] at 12:55 PM that she observed NA #1 push Resident #1 to the dining room in his geri-chair. The NA stated that the resident was trying to scoot out of the chair like he always did. The NA stated she heard NA #1 say to the resident: " I hope you fall out of the chair so they can send you to the hospital. " The NA stated that this happened in August or September of 2013. The NA stated that NA #1 talked very nasty to the residents and she had told the NA that this was not the kind of work for her. On [DATE] at 2:01 PM, NA #1 stated in a telephone interview that she never told Resident #1 that she hoped he fell out of his chair and had to go to the hospital. 3b. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Cognitive Status and Communication dated [DATE] revealed that the resident was unable to be oriented due to progressive cognitive decline. The CAA revealed that the resident was alert to self but confused to time and place and unable to verbalize needs and concerns secondary to [MEDICAL CONDITION]. The CAA revealed that the resident was resistive to care, hitting, kicking and cursing at staff. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems and was severely cognitively impaired. The MDS revealed that the resident was totally dependent on staff for all activities of daily living. The MDS revealed that the resident had no behaviors during the 7 day assessment period. The Care Plan dated [DATE] included a problem that the resident was resistive to care by hitting, kicking and cursing. Among the approaches was to check the resident frequently for anticipated needs and address to reduce risks for agitation, anxiety or resistive behaviors and redirect as needed. NA (nursing assistant) #2 stated in an interview on [DATE] at 1:50 PM that she walked in Resident #1 ' s room and observed NA #1 thumping the resident on the head. The NA stated that this happened awhile back but could not be specific about a date. The NA stated that this happened around the time that NA #1 was heard to tell the resident that she hoped he fell out of the wheelchair and had to go to the hospital (August/[DATE]). The Administrator stated in an interview on [DATE] at 3:45 PM that she was not aware of the allegation that NA #1 thumped Resident #1 on the head. The Administrator stated that she considered thumping the resident on the head to be abuse. On [DATE] at 2:01 PM, NA #1 stated in an interview that she never thumped Resident #1 on the head. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:00 AM. The facility provided a credible allegation of compliance on [DATE] at 1:55 PM. The allegation of compliance indicated: For Resident #1, the facility Administrator was unaware of allegation #1 against NA #1 to Resident #1. The DON was aware and failed to report the allegation to the administrator. It is undetermined when the alleged incident took place. The resident is deceased ([DATE]). A 24-hour report has been completed [DATE]. A 5-day will be completed by [DATE]. The accused NA #1 was terminated [DATE]. ? The DON has received disciplinary action by the administrator and the corporate nurse consultant for failing to report an allegation of abuse to the administrator. The DON was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. For the second allegation, the Administrator was notified on [DATE] by surveyor concerning Resident #1. The C.N.A. was aware and failed to clearly report to the nurse the alleged abuse and the employee responsible. It is undetermined when the alleged incident took place. The resident is deceased ([DATE]). A 24-hour report has been completed [DATE]. A 5-day will be completed by [DATE]. The accused NA #1 was terminated [DATE]. ? The C.N.A. has received disciplinary action by the DON and an inservice on the abuse policy with concentration on requirements for reporting all allegations. ? The Nurse has received disciplinary action by the DON and an inservice on the abuse policy with concentration on requirements for reporting all allegations. For Resident #2, remains in the facility. NA #1 was suspended [DATE] pending investigation. An investigation of the allegation was completed [DATE]. NA #1 was returned to work [DATE] after completion of the investigation but not to the care and service of Resident #2. NA #1 was suspended again [DATE] and subsequently terminated [DATE]. A 24-hour and 5-day report was completed [DATE]. ? The Administrator has received disciplinary action from the director of operations for failing to initiate and complete the 24-hour and 5-day reports on allegations. The Administrator was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. ? The DON has received disciplinary action by the administrator and the corporate nurse consultant for failing to report an allegation of abuse to the administrator. The DON was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. For Resident #8, an investigation was completed [DATE]. NA #1 was suspended [DATE] pending investigation. An investigation of the allegation was completed [DATE] pending investigation. NA #1 was returned to work [DATE] after completion of the investigation but not to the care and service of #2. Resident #3 was discharged [DATE]. On [DATE] the resident deceased in the hospital. NA #1 was suspended again [DATE] and subsequently terminated [DATE]. A 24-hour and 5-day report was completed on [DATE]. ? The Administrator has received disciplinary action from the director of operations for failing to initiate and complete the 24-hour and 5-day reports on allegations. The administrator was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. For those residents having the potential to be affected by the same alleged deficient practice: ? The Social Worker asked all residents capable of being interviewed if they had ever felt mistreated by a staff member of the facility. All residents interviewed denied feeling mistreated by any member of the staff. ? The residents of the facility had a Resident Council meeting on Thursday, [DATE]. The residents were reminded of their right to be free from abuse, different types of abuse and how and who to report it to. ? The administrative staff have been re-educated on the facility ' s Abuse Policy and Procedure by the Corporate Nurse Consultant. ? All facility employees will be re-educated on the facility ' s Abuse Policy and Procedure by the Administrator and Director of Nursing and will be mandated to attend the Abuse Policy and Procedure inservice quarterly. On [DATE] at 11:30 AM, 90% of all employees had been inserviced on the abuse policy. Employees will not be allowed to work until they have been inserviced. ? The Social Worker contacted all responsible parties of residents unable to speak for themselves to inquire of any concerns or changes in resident behavior that could indicate possible abuse. ? The nursing staff has completed a skin check for injuries of unknown origin of residents unable to speak for themselves. ? Employees who reportedly knew of resident abuse and failed to report have received disciplinary action. ? The Administrator has received disciplinary action from the Director of Operations for failing to initiate and complete the 24-hour and 5-day reports on allegations. The Administrator was retrained by the Director of Operations and the Corporate Nurse Consultant on the abuse policy with concentration on requirements for reporting all allegations. ? The DON has received disciplinary action by the administrator and the Corporate Nurse Consultant for failing to report an allegation of abuse to the administrator. The DON was retrained by the Director of Operations and the Corporate Nurse Consultant on the abuse policy with concentration on requirements for reporting all allegations. On [DATE] at 3:00 PM the credible allegation was validated by random interviews with staff showing that the staff had received inservices on the facility ' s abuse policies and procedures. Interviews revealed that the staff was knowledgeable about the definition of abuse and the different kinds of abuse. The staff voiced understanding they were to report instances of abuse immediately to their nurse or supervisor.

Based on policy and record review and staff and resident interviews, the facility failed to implement their abuse policies and procedures by: 1. Failed to protect 1 (Resident #8) of 4 sampled residents from verbal abuse by failing to report an allegation of abuse to the administrator within 24 hours and failing to report other instances of verbal abuse. 2. Failed to protect 1 (Resident #2) of 4 sampled residents from verbal and physical abuse by not suspending the staff member accused of the abuse. 3. Failed to protect 1 (Resident #1) of 4 sampled residents from physical and verbal abuse by failing to report allegations of abuse to the administrator and failing to conduct a thorough investigation of the alleged abuse. The findings included: Immediate Jeopardy began on [DATE] and was identified on [DATE] at 10:00 AM. Immediate Jeopardy was removed on [DATE] at 1:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete training on abuse for 100% of the staff and for the facility to implement the monitoring of its corrective action. The facility ' s abuse policy titled Abuse and Neglect Policies and Procedures last revised on ,[DATE] on Page 4 under Reporting read: " 1. Persons witnessing an accident or incident involving a resident must report such information to their department supervisor and/or the facility Administrator. 2. Allegations of abuse shall be reported to the Administrator immediately. Immediately is defined as " as soon as possible, but ought not exceed 24 hours after discovery of the incident. " Page 4 of the policy under Protection read: " 1.This facility shall initiate measures to protect residents from harm during the investigatory process. 3. Employees of the facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty for up to ten working days until the results of the investigation have been reviewed by the Administrator. " 1. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] where she later expired. The Care Area Assessment (CAA) for Cognitive Status dated [DATE] revealed that the resident was alert and verbally responsive with periods of forgetfulness and was able to understand others and make her needs known. The CAA for Visual Function dated [DATE] revealed that the resident had a history of [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and vision was highly impaired. The Care Plan dated [DATE] revealed that the resident was concerned about her health and was very demanding of attention from the staff. The approach was for staff to approach the resident warmly at all times. A review of the facility ' s Grievance Log revealed an entry dated [DATE] that a nursing assistant (NA) had spoken rudely to Resident #8. A written statement by Med (medication) Aide #1 revealed on [DATE], Resident #8 rang the call bell and NA #1 entered the room and asked the resident what the resident wanted. According to the written statement the Resident stated that she had spilled her soda and ice and wanted some more. The statement revealed that the NA stood in front of the resident in an intimidating way and responded to the resident that when she rang her call light, she needed to tell her everything she needed right then and to stay off her call light. The statement revealed that the resident was frightened and was throwing her hands in front of her to push the NA away from her. Review of the facility ' s investigation revealed a written statement was given to the ADON that NA #1 spoke rudely to Resident #8. The note revealed that the resident was reliable and had no complaints per the social worker. The investigation note revealed that the resident was interviewed and reported she did not feel mistreated in any way. A written statement by Med Aide #1 revealed that on [DATE] on second shift Resident #8 rang her call light and NA#1 was observed to enter the room and asked the resident what she wanted. The statement revealed that the resident stated that she had spilled her soda and ice and wanted some more. The statement read: " (Name of NA #1) stood in front of resident and, in an intimidating way, told her when she rings her call light, to tell her everything she needs right then and to stay off her call light. Name of Resident #8 was frightened and was throwing her hands in front of her to push (Name of NA) #1 off of her yelling get out of my face. " The Administrator stated in an interview on [DATE] at 3:45 PM the Assistant Director of Nursing (ADON) brought statements from an incident with Resident #8 that occurred on [DATE] and an incident with Resident #2 that occurred on [DATE] while she was in the morning meeting on [DATE] (Monday). The Administrator stated that a statement regarding the incident with Resident #2 on [DATE] alleged the NA had kicked the resident. The Administrator stated that because of that statement, NA #1 was suspended pending results of the investigation. On [DATE] at 5:40 PM the Administrator stated in an interview that the incident was reported by Med Aide #1 who heard the incident while standing outside the building. The Administrator stated that Resident #8 denied the incident and the resident had since expired. The Administrator stated in an interview on [DATE] at 11:35 AM that she spoke with NA #1 about the incident dated [DATE] and the NA could not recall any unusual interactions with Resident #8. On [DATE] at 12:35 PM the facility ' s Social Worker stated in an interview that Resident #8 was generally alert and oriented and reliable with some forgetfulness. The Social Worker stated that she asked the resident if any of the girls that help her get dressed had mistreated her in any way and the resident stated: " No. " The Social Worker stated that she has had no complaints about NA #1 from other residents. Med Aide #1 stated in an interview on [DATE] at 2:40 PM that Resident #8 was unable to see very well and knocked over her drink several times on the evening of [DATE]. The Med Aide stated that she went in to give the resident her medication and was on her way out of the room and NA #1 entered the room in response to the call light. The Med Aide stated that NA #1 looked irritated. The Med Aide stated that when she left the resident ' s room she went around the corner and into the courtyard to smoke. The Med Aide stated that she was standing in the courtyard outside the room of Resident #8 and could hear NA #1 yelling at the resident through the window. The Med Aide stated NA #1 stated: " I ' m going to get this up this time but next time you better tell me everything you need and stay off the call light. " The Med Aide stated that NA #1 was standing over the resident in an intimidating way and the resident was raising her arms and saying: " Get off of me. " The Med Aide stated that NA#1 did not touch the resident but was raising her voice and in the resident ' s face. The Med Aide stated she could not remember what time the incident occurred but it was dark outside. The Med Aide stated that she reported the incident to Nurse #5 and the nurse told her to write it up. The Med Aide stated that NA #1 usually worked the 7AM-3PM shift but that day had stayed over and worked the 3PM-11PM shift as well. A review of the payroll sheet for NA #1 revealed that the NA worked from 7AM to 11PM on [DATE] and worked 7AM-3PM only on [DATE]. A payroll sheet for Med Aide #1 revealed that the Med Aide worked 3PM-11PM on [DATE], [DATE] and [DATE]. In an interview with Med Aide #1 on [DATE] at 4:40 PM, the Med Aide stated that she thought the incident occurred on Thursday ([DATE]). The Med Aide stated that on Friday ([DATE]) she reported the incident to the Assistant Director of Nursing (ADON) and was told to write it up. The Med Aide stated that she got busy and did not write up the incident until Monday morning ([DATE]). The Med Aide stated that the incident must have occurred on [DATE]. Housekeeper #1 stated in an interview on [DATE] at 3:00 PM that he had heard NA #1 yelling at Resident #8 several times one evening. The Housekeeper stated that he heard NA #1 tell the resident that she was doing the best she could, that she was busy and to stop bothering her. The housekeeper was unable to provide the date or time this occurred. The Housekeeper stated that he did not report the incident because he was focused on his work and trying to complete his assignment. The Housekeeper stated that he guessed he should have reported the incident as he considered the way the NA was talking to the resident to be verbal abuse. Nurse #5 stated in an interview on [DATE] at 4:30 PM that she did not remember Med Aide #1 telling her about NA #1 yelling at Resident #8. The Nurse stated that this would be verbal abuse and would have called the on call nurse. The Nurse stated that she remembered hearing about the incident but was on a different day. Med Aide #1 was asked to join the interview and stated that she thought she told Nurse #5 about the incident. The Med Aide stated that when she arrived at work on Friday ([DATE]) at 3:00 PM she told the ADON and was told to write it up. The Med Aide stated that she got busy and did not write up the incident. The Med Aide stated that the ADON was in the building on Sunday ([DATE]) investigating an incident with Resident #2 and NA #1 and the ADON again encouraged me to write up the incident. The Med Aide stated that she wrote up the incident and put the report under the ADON ' s door so she would have it on Monday ([DATE]) morning. On [DATE] at 4:55 PM the Administrator stated in an interview that the ADON thought they could not investigate an allegation without statements and waited until Monday [DATE] to report the incident between Resident #8 and NA #1. The Administrator stated that Resident #8 walked to her office every day and talked with her and the resident never said anything about a problem with NA #1. The Assistant Director of Nursing (ADON) stated in an interview on [DATE] at 7:40 PM that Med Aide #1 told her she was standing outside by the window of Resident #8 ' s room and observed NA #1 in the resident ' s face. The ADON stated that Med Aide #1 reported this on [DATE] (Thursday) around 3:30 PM as she was getting ready to leave for the day. The ADON stated she told the Med Aide that it needed to be in writing and would pick up her statement the next morning. The ADON stated she looked for the statement the next morning but did not find one. The ADON stated that she was in the building on Sunday ([DATE]) investigating another incident and did not see the Med Aide ' s statement and told the Med Aide that if she wanted to report the incident it would have to be put in writing. The ADON stated that conversations could be heard through the windows in the building. The ADON stated that on one occasion she was standing outside, near the dining room window and could hear conversations in the dining room. 2. The facility ' s abuse policy titled Abuse and Neglect Policies and Procedures last revised on ,[DATE] on page 4 under Protection read: " 1. This facility shall initiate measures to protect residents from harm during the investigatory process. 3. Employees of the facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty for up to ten working days until the results of the investigation have been reviewed by the Administrator. " Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Cognitive Status dated [DATE] revealed the resident was verbally responsive and could make her needs known and understand others. The CAA for Activities of Daily Living (ADLs) revealed the resident required assistance with ADLs and was unsafe to transfer independently. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance for bed mobility and transfers. The Care Plan dated [DATE] revealed that Resident #2 had impaired thought processes due to [DIAGNOSES REDACTED]. One of the interventions was for staff to assist with transfers and ambulation as necessary and to use the stand up lift for transfers. The nurse ' s schedule revealed that Nurse #1 worked 7 AM to 11 PM on [DATE]. A Nurse ' s Note by Nurse #1 dated [DATE] at 7:50 PM revealed that on the 7AM-3PM shift on the first medication (med) pass, Resident #2 reported very tearfully that her NA (nursing assistant) was verbally inappropriate with her and that she was scared about her safety. The note revealed the on-call nurse who was the Assistant Director of Nursing (ADON) was notified. The note revealed the Nurse took over care for the resident and removed reported NA from providing care for Resident #2. A Nurse ' s Note by Nurse #1 dated [DATE] at 10:30 PM revealed that upon the last med pass, Resident #2 was still voicing concern for her safety stating: " I ' m just so scared because she is so big and all I can do is yell. " The note revealed the nurse reassured the resident that the NA was not in the building. The facility' investigation file included written statements dated [DATE] by Nurse #1 and Med Aide #2 that revealed Resident #2 alleged NA #1 had kicked her and had been verbally inappropriate with her during care that morning. The investigation report included documentation of counseling for NA #1 dated [DATE] that included the following: " The employee has violated the following behavior and/or work rule standards: " 3 resident complaints. Corrective Action: Suspension pending investigation. Was offered non care but employee chose to leave. " NA #2 stated in an interview on [DATE] at 1:50 PM that on [DATE], NA #1 asked her to help get Resident #2 out of bed and the resident did not want to get up. NA #2 stated that about 30 minutes later, Nurse #1 told them that the resident was ready to get up and the resident stated she did not want to get up. NA #2 stated as she and NA #1 were leaving the room, the resident stated she would just get up. NA #2 stated when putting the side rail down she injured her finger and had to leave the room to put ice it and left NA #1 in the room with the resident. NA #2 stated a little bit later, NA #1 asked her to come in and help get the resident out of bed. NA #1 stated when she went back in the room the resident was dressed and NA #1 used the stand-up lift to get the resident out of bed. The NA stated she did not witness inappropriate behavior by NA #1 while she was in the room. The Administrator stated in an interview on [DATE] at 3:45 PM that when she was notified of the incident on [DATE] it was the end of the shift and time for NA #1 to go home. The Administrator stated that in the morning meeting on [DATE] with the Director of Nursing and the Social Worker there was discussion about whether or not NA #1 should be suspended. The Administrator stated the Social Worker had a consult note dated [DATE] by the resident ' s psychologist that the resident had relayed to him an event with similar circumstances. The Administrator stated that shortly after, the ADON brought her the employee statements and saw that Resident #2 alleged the NA had kicked her. The Administrator stated that NA #1 was suspended around 11:00 on the morning of [DATE]. Med Aide #2 stated in an interview on [DATE] at 5:00 PM that on [DATE] she observed Resident #1 sitting in her wheel chair in the hall with no shoes on and was upset. The Med Aide stated Resident #1 told her the girls were jerking her around and she did not like it and had been kicked and did not feel safe. The Med Aide stated that NA #1 came up to the desk and asked if she had called anyone to report the abuse and stated she was glad she had a witness. Med Aide #2 stated she called the Assistant Director of Nursing (ADON) and gave the phone to Nurse #1. The Med Aide stated she tried to take the resident back to her room but the resident was upset and did not want to go back to her room. The Med Aide stated later on that day the resident was in the dining room and stated she talked to the lady in the office but they probably would not do anything. The Med Aide stated that she had heard NA #1 say that as long as the (Name of Administrator) was in the building she would have a job. Nurse #1 stated in an interview on [DATE] at 5:20 PM that during her first medication pass she got to Resident #2 ' s room and the resident was tearful and upset. The Nurse stated the resident told her the aide with a ring in her lip slung her around in the bed. The Nurse stated that NA #1 was the only NA working with a lip ring. The Nurse stated that the resident had told her she wanted to go to church so she instructed NA #1 to go ahead and get the resident up and to take NA #2 with her. The Nurse stated that NA #1 stated: " I ' ll get her up when I ' m good and ready to get her up " and kept walking down the hall. The Nurse stated that NA #2 came out of the room with an injured finger and NA #1 was left in the resident ' s room by herself. Nurse #1 stated she told NA #1 she did not have to yell at her and NA #1 stated: " That is just the way I talk to people. " Nurse #1 stated that Med Aide #2 told her that the NA with the lip ring kicked her. The Nurse stated she did not learn about the kick until bedtime and assured the resident that NA #1 would not be back in her room. Nurse #1 stated that Resident #2 had trouble getting the right word out but had always been oriented with her. The Nurse stated when the resident used the wrong word, the resident was aware that it was the wrong word. The Nurse stated that on [DATE], Resident #2 saw NA #1 several times from a distance and stated: " Well, I guess they didn ' t fire her. The Nurse stated at the time of the incident on [DATE], Resident #2 was scared of NA #1. The Nurse stated she wrote NA #1 up one day and NA #1 stated: " (Name of Administrator) will not fire me. " Nurse #2 stated in an interview on [DATE] at 7:15 AM that she got to work on [DATE] at 11:00 PM and Nurse #1 and Med Aide #2 told her that Resident #2 came out in tears and told them that as soon as the door closes, NA #1 was tugging and pulling on her and kicked her and that this had been going on for a week. The Nurse stated that Resident #1 was believable and that the resident responded appropriately to questions. The Nurse stated the resident talked like she had some sense but was not completely oriented to place and time. The Nurse stated that NA #1 would be suspended and then come back to work and go around the facility saying that no matter what she did, the Administrator will not fire her because she is her daughter ' s best friend. The Administrator stated in an interview on [DATE] at 7:50 AM that NA #1 should have been suspended by the ADON (Assistant Director of Nursing) on [DATE]. On [DATE] at 9:00 AM, Nurse #6 stated in an interview that recently Nurse #5 was talking with her about an incident between NA #1 and a resident and how upset she was about it. Nurse #6 stated she asked Nurse #5 if she had reported the incident and Nurse #5 told her that she had reported NA #1. Nurse #6 stated that NA #1 had a poor attitude and was a mean spirited girl. On [DATE] at 7:40 PM the ADON stated in an interview that she was the nurse on call on [DATE]. The ADON stated she received a call on [DATE] at 10:30 in the morning and spoke with Nurse #1. The ADON stated that she went to church and then went to the facility and started taking statements. The ADON stated she pulled the abuse policy which stated that the employee could be reassigned or suspended. The ADON stated that she texted the Administrator about the incident and that the NA had been reassigned. The ADON stated that by then it was 2:30 PM and NA #1 ' s shift was almost over and assigned the NA to transport laundry. The ADON stated that she spoke with Resident #2 who was tearful and told her that her knee was pinched in the wheelchair. The ADON stated she told the resident that she would handle it with the Administrator in the morning and she left the facility at approximately 3:00 PM. The ADON stated that NA #1 reported to work the next morning. The ADON stated she put the statements under the Administrator ' s door because she had to round with the physicians. The ADON stated around lunchtime she learned that NA #1 had been suspended. The ADON stated when she was hired as ADON on [DATE] she received no orientation. The ADON stated that her first few days there she was told to go through charts and get familiar with the residents. The ADON stated that she looked through policy books and rounded with the doctors. The ADON stated that she did go through the facility computer course that included resident rights, abuse, work safety, etc. The ADON stated the social worker did the abuse training but did not go over the abuse policy. The ADON stated she thought she had to have statements from the involved staff before the allegation could be investigated. The Director of Nursing (DON) stated in an interview on [DATE] at 10:34 AM that the ADON did not get a very good orientation. The DON stated that she spoke with the ADON about tasks that had to be performed like Infection Control to make sure everything was covered and that was basically the ADON ' s orientation. The DON stated that the ADON did go through the facility ' s computer training program. The Administrator stated in an interview on [DATE] at 10:45 AM that when NA #1 came to work on the morning of [DATE] she was assigned to resident care on the 600 hall and was suspended at 11:00 AM. The Administrator stated in an interview on [DATE] at 2:00 PM that the facility ' s abuse policy stated that the accused employee could be reassigned or suspended. 3a.The facility ' s abuse policy titled Abuse and Neglect Policies and Procedures last revised on ,[DATE] on Page 4 under Reporting read: " 1. Persons witnessing an accident or incident involving a resident must report such information to their department supervisor and/or the facility Administrator. 2. Allegations of abuse shall be reported to the Administrator immediately. Immediately is defined as " as soon as possible, but ought not exceed 24 hours after discovery of the incident. " Page 4 of the policy under Protection read: " 1.This facility shall initiate measures to protect residents from harm during the investigatory process. 3. Employees of the facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty for up to ten working days until the results of the investigation have been reviewed by the Administrator. " Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Cognitive Status and Communication dated [DATE] revealed that the resident was unable to be oriented due to progressive cognitive decline. The CAA revealed that the resident was alert to self but confused to time and place and unable to verbalize needs and concerns secondary to [MEDICAL CONDITION]. The CAA revealed that the resident was resistive to care, hitting, kicking and cursing at staff. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had short and long term memory problems and was severely cognitively impaired. The MDS revealed that the resident was totally dependent on staff for all activities of daily living. The MDS revealed that the resident had no behaviors during the 7 day assessment period. The Care Plan dated [DATE] included a problem that the resident was resistive to care by hitting, kicking and cursing. Among the approaches was to check the resident frequently for anticipated needs and address to reduce risks for agitation, anxiety or resistive behaviors and redirect as needed. The Director of Nursing (DON) stated in an interview on [DATE] at 1:15 PM that she received a report that NA #1 told Resident #1 that she hoped he fell out of the wheelchair. The DON stated that she was told that the resident ' s family was sitting in the dining room with the resident when this occurred. The DON stated that she called the family of Resident #1 and they denied that this occurred. The DON stated that her interview with the resident ' s family revealed they did not witness the incident so she did not go any further because she did not think it happened. The DON stated that the incident occurred back in the summer of 2013, maybe August or September. The DON stated she had received training on abuse by the facility. The DON stated if she received an allegation of abuse she was supposed to fill out a concern form and interview the resident and the staff members involved and have the staff write a statement regarding the incident. The DON stated she then turned in this information to the Administrator and they discussed the findings. The DON stated the Administrator did separate interviews with the employees and the social worker talked with the resident about the incident. The DON stated that she then would get together with the Administrator and compare interviews and try to determine what actually happened. The DON stated if there was a concern about abuse the employee was suspended pending results of the investigation. The DON stated she did not document the allegation or the family interview. The DON stated she failed to report the incident to the Administrator. The DON stated at the time she was DON and doing MDS assessments and was busy. The Administrator stated in an interview on [DATE] at 3:45 PM that she was not aware of the allegation that NA #1 stated that she hoped that the resident fell out of the wheelchair until [DATE] when the social worker from Adult Protective Services entered the building and told her the incident was being investigated. Nurse #2 stated in an interview on [DATE] at 7:15 AM that she heard that NA #1 told Resident #1 she hoped he fell out of the wheelchair so he had to go to the hospital and would not have to take care of him. The Nurse stated that she did not witness the incident. The Nurse stated that NA #1 would be suspended and then come back to work and go around the facility saying that no matter what she does, the Administrator will not fire her because she is her daughter ' s best friend. NA (nursing assistant) #3 stated in an interview on [DATE] at 10:50 AM that she observed NA #1 push Resident #1 to the dining room in his geri-chair. The NA stated that the resident was trying to scoot out of the chair like he always did. The NA stated she heard NA #1 say to the resident: " I hope you fall out of the chair so they can send you to the hospital. " The NA stated that this happened in August or September of 2013. The NA stated that another resident and his spouse were sitting at the next table and the NA made the statement loud enough for them to hear but did not know if they actually heard the statement made by NA #1. NA #3 stated that she reported the incident to the weekend supervisor on duty that day and the supervisor had her write a statement about the incident. The NA stated that the weekend supervisor no longer worked at the facility. NA #3 stated that NA #1 talked very nasty to the residents and she had told the NA that this was not the kind of work for her. NA #3 stated that NA #1 gets written up and suspended with pay and she comes right back to work and nothing happens. NA #3 stated that NA #1 gets suspended and comes back and brags that they suspended her but she got paid. Nurse #5 stated in an interview of [DATE] at 3:00 PM that she had reported NA #1 multiple times and was told to write a letter to the Administrator. The Nurse stated she did not write the letter because she knew nothing would happen. The Nurse stated a NA was hired and there was an incident where a resident ' s arm was hurt and the NA was terminated. The Nurse stated NA #1 brags that she is the best friend of the administrator ' s daughter and the Administrator will not do anything to her. 3b.The facility ' s abuse policy titled Abuse and Neglect Policies and Procedures last revised on ,[DATE] on Page 4 under Reporting read: " 1. Persons witnessing an accident or incident involving a resident must report such information to their department supervisor and/or the facility Administrator. 2. Allegations of abuse shall be reported to the Administrator immediately. Immediately is defined as " as soon as possible, but ought not exceed 24 hours after discovery of the incident. " The facility ' s abuse policy titled Abuse and Neglect Policies and Procedures last revised on ,[DATE] on Page 4 under Reporting read: " 1. Persons witnessing an accident or incident involving a resident must report such information to their department supervisor and/or the facility Administrator. 2. Allegations of abuse shall be reported to the Administrator immediately. Immediately is defined as " as soon as possible, but ought not exceed 24 hours after discovery of the incident. " Page 4 of the policy under Protection read: " 1.This facility shall initiate measures to protect residents from harm during the investigatory process. 3. Employees of the facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty for up to ten working days until the results of the investigation have been reviewed by the Administrator. " Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Cognitive Status and Communication dated [DATE] revealed that the resident was unable to be oriented due to progressive cognitive decline. The CAA revealed that the resident was alert to self but confused to time and place and unable to verbalize needs and concerns secondary to [MEDICAL CONDITION]. The CAA revealed that the resident was resistive to care, hitting, kicking and cursing at staff. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had short and long term memory problems and was severely cognitively impaired. The MDS revealed that the resident was totally dependent on staff for all activities of daily living. The MDS revealed that the resident had no behaviors during the 7 day assessment period. The Care Plan dated [DATE] included a problem that the resident was resistive to care by hitting, kicking and cursing. Among the approaches was to check the resident frequently for anticipated needs and address to reduce risks for agitation, anxiety or resistive behaviors and redirect as needed. NA (nursing assistant) #2 stated in an interview on [DATE] at 1:50 PM that she walked in Resident #1 ' s room and observed NA #1 thumping the resident on the head. The NA stated that this happened awhile back but could not be specific about a date. The NA stated that this happened around the time that NA #1 was heard to tell the resident that she hoped he fell out of the wheelchair and had to go to the hospital (August/[DATE]). The NA stated that she reported the incident Nurse #3 but was never questioned about the incident. Nurse #3 stated in an interview on [DATE] at 2:55 PM that NA #2 came to her and asked her what she should do if she saw someone being thumped on the head. The Nurse stated the NA did not say who the resident was or who was thumping a resident on the head. The Nurse stated she told the NA she should report it to her nurse. NA #2 was asked to join the interview and stated that she thought she reported the incident to Nurse #3. Nurse #3 stated that she took it that NA #2 wanted information. NA #2 stated she did not report the in

Based on record review and staff and resident interviews, the facility failed to file 24 hour and 5 day reports with the Health Care Personnel Registry for allegations of abuse for 3 (Resident #8, Resident #2 and Resident #1) of 4 sampled residents reviewed for abuse. The Director of Nursing failed to notify the Administrator of alleged verbal abuse for 1 (Resident #1) of 4 sampled residents and the facility failed to complete a thorough investigation of the alleged abuse. Facility staff failed to report physical abuse to the Administrator for 1 (Resident #1) of 4 sampled residents which resulted in the resident not being protected from further abuse by the accused employee and no investigation of the alleged abuse. The findings included: Immediate Jeopardy began on [DATE] and was identified on [DATE] at 10:00 AM. Immediate Jeopardy was removed on [DATE] at 1:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete training on abuse for 100% of the staff and for the facility to implement the monitoring of its corrective action. 1. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the facility ' s investigation file revealed that Med (medication) Aide #1 reported in writing that on [DATE] Resident #8 rang her call light and told NA #1 that she had spilled her soda and ice and wanted some more. The Med Aide ' s written statement revealed that the Med Aide observed NA #1 to stand over the resident in an intimidating way and say to the resident that when she rang her call light she needed to tell her everything she needed right then and to stay off her call light. The statement revealed that the resident was frightened and was throwing her hands in front of her to push the NA away and was yelling: " Get out of my face. " The Statement revealed the incident was reported to the Assistant Director of Nursing. There was not a 24-hour or 5-day report in the file. The Administrator stated in an interview on [DATE] at 11:35 AM that she did not do a 24-hour or 5-day report because the resident denied that the incident occurred. On [DATE] at 2:45 PM the Administrator stated in an interview that she did not know she had to file the 24-hour and 5-day report to the state unless the abuse was substantiated. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A Nurse ' s Note by Nurse #1 dated [DATE] at 7:50 PM revealed that on the 7AM-3PM shift on the first medication (med) pass, Resident #2 reported very tearfully that her NA (nursing assistant) was verbally inappropriate with her and that she was scared about her safety. The note revealed the on-call nurse who was the Assistant Director of Nursing (ADON) was notified. A Nurse ' s Note by Nurse #1 dated [DATE] at 10:30 PM revealed that upon the last med pass, Resident #2 was still voicing concern for her safety stating: " I ' m just so scared because she is so big and all I can do is yell. " The facility' investigation file included written statements dated [DATE] by Nurse #1 and Med Aide #2 that revealed Resident #2 alleged NA #1 had kicked her and had been verbally inappropriate with her during care that morning. The file did not include a 24 hour or 5 day report to the state regarding the allegation of abuse. The Administrator stated in an interview on [DATE] at 10:45 AM she thought the 24 hour and 5 day reports only had to be filed with the state if the abuse allegation was substantiated. 3a. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 1:15 PM the Director of Nursing (DON) stated in an interview she had a report that a NA told the resident that she hoped he fell out of the wheelchair. The DON stated this happened back in the summer, maybe August or September of 2013. The DON stated she did not report this to the Administrator. The Administrator stated in an interview on [DATE] at 3:45 PM she was not aware of the allegation that NA #1 told Resident #1 that she hoped he fell out of the chair and had to go to the hospital until yesterday when the social worker from Adult Protective Services came in and told her the allegation was being investigated. NA #3 stated in an interview on [DATE] at 12:55 PM that she observed NA #1 roll Resident #1 to the dining room in his geri-chair and heard NA #1 say to the resident: " I hope you fall out of the chair so they will send you to the hospital. " NA #3 stated she reported the incident to the weekend supervisor and wrote a statement about the incident. The NA stated that the supervisor no longer worked at the facility. There was not a 24-hour or 5-day report filed as there was no investigation. 3b. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. NA #2 stated in an interview on [DATE] at 1:50 PM that she walked in Resident #1 ' s room and observed NA #1 thumping the resident on the head twice. The NA stated she reported this to Nurse #3. The NA stated she was never questioned about the incident or asked to write a statement regarding the incident. Nurse #3 stated in an interview on [DATE] at 2:55 PM that NA #2 asked her what she should do if she saw someone being thumped on the head but did not say who was involved in the incident. The Nurse stated she told the NA to report it to her nurse. The Nurse stated that shortly after, NA #1 was suspended so she thought the NA had reported the incident to her nurse. NA #2 was asked to join the interview and stated she thought she reported the incident to Nurse #3. The NA stated she told Nurse #3 she saw someone thumping a resident on the head. The NA stated that she did not tell anyone else. Nurse #3 stated she did not report what she was told about the incident to anyone and thought that NA #2 told her nurse. On [DATE] at 3:45 PM the Administrator stated in an interview that she was not aware of the allegation that Resident #1 was thumped on the head until yesterday when the social worker from Adult Protective Services came in and told her the allegation was being investigated. The Administrator stated that she considered thumping a resident on the head to be abuse and Nurse #3 should have reported what she was told. The Administrator stated that if the incident had been reported, she would have attempted to get a statement from NA #2. There was not a 24-hour or 5-day report done as the Administrator was not aware of the allegation. On [DATE] at 10:10 AM Nurse #3 stated in an interview that NA #2 did not tell her the name of the resident or the NA involved and she did not know what to report. The Nurse stated that it did not occur to her to report what she had heard regarding a resident being thumped on the head. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:00 AM. The facility provided a credible allegation of compliance on [DATE] at 1:55 PM. The allegation of compliance indicated: For Resident #1, the facility Administrator was unaware of allegation #1 against NA #1 to Resident #1. The DON was aware and failed to report the allegation to the administrator. It is undetermined when the alleged incident took place. The resident is deceased ([DATE]). A 24-hour report has been completed [DATE]. A 5-day will be completed by [DATE]. The accused NA #1 was terminated [DATE]. ? The DON has received disciplinary action by the administrator and the corporate nurse consultant for failing to report an allegation of abuse to the administrator. The DON was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. For the second allegation, the Administrator was notified on [DATE] by surveyor concerning Resident #1. The C.N.A. was aware and failed to clearly report to the nurse the alleged abuse and the employee responsible. It is undetermined when the alleged incident took place. The resident is deceased ([DATE]). A 24-hour report has been completed [DATE]. A 5-day will be completed by [DATE]. The accused NA #1 was terminated [DATE]. ? The C.N.A. has received disciplinary action by the DON and an inservice on the abuse policy with concentration on requirements for reporting all allegations. ? The Nurse has received disciplinary action by the DON and an inservice on the abuse policy with concentration on requirements for reporting all allegations. For Resident #2, remains in the facility. NA #1 was suspended [DATE] pending investigation. An investigation of the allegation was completed [DATE]. NA #1 was returned to work [DATE] after completion of the investigation but not to the care and service of Resident #2. NA #1 was suspended again [DATE] and subsequently terminated [DATE]. A 24-hour and 5-day report was completed [DATE]. ? The Administrator has received disciplinary action from the director of operations for failing to initiate and complete the 24-hour and 5-day reports on allegations. The Administrator was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. ? The DON has received disciplinary action by the administrator and the corporate nurse consultant for failing to report an allegation of abuse to the administrator. The DON was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. For Resident #8, an investigation was completed [DATE]. NA #1 was suspended [DATE] pending investigation. An investigation of the allegation was completed [DATE] pending investigation. NA #1 was returned to work [DATE] after completion of the investigation but not to the care and service of #2. Resident #3 was discharged [DATE]. On [DATE] the resident deceased in the hospital. NA #1 was suspended again [DATE] and subsequently terminated [DATE]. A 24-hour and 5-day report was completed on [DATE]. ? The Administrator has received disciplinary action from the director of operations for failing to initiate and complete the 24-hour and 5-day reports on allegations. The administrator was retrained by the director of operations and the corporate nurse consultant on the abuse policy with concentration on requirements for reporting all allegations. For those residents having the potential to be affected by the same alleged deficient practice: ? The Social Worker asked all residents capable of being interviewed if they had ever felt mistreated by a staff member of the facility. All residents interviewed denied feeling mistreated by any member of the staff. ? The residents of the facility had a Resident Council meeting on Thursday, [DATE]. The residents were reminded of their right to be free from abuse, different types of abuse and how and who to report it to. ? The administrative staff have been re-educated on the facility ' s Abuse Policy and Procedure by the Corporate Nurse Consultant. ? All facility employees will be re-educated on the facility ' s Abuse Policy and Procedure by the Administrator and Director of Nursing and will be mandated to attend the Abuse Policy and Procedure inservice quarterly. On [DATE] at 11:30 AM, 90% of all employees had been inserviced on the abuse policy. Employees will not be allowed to work until they have been inserviced. ? The Social Worker contacted all responsible parties of residents unable to speak for themselves to inquire of any concerns or changes in resident behavior that could indicate possible abuse. ? The nursing staff has completed a skin check for injuries of unknown origin of residents unable to speak for themselves. ? Employees who reportedly knew of resident abuse and failed to report have received disciplinary action. ? The Administrator has received disciplinary action from the Director of Operations for failing to initiate and complete the 24-hour and 5-day reports on allegations. The Administrator was retrained by the Director of Operations and the Corporate Nurse Consultant on the abuse policy with concentration on requirements for reporting all allegations. ? The DON has received disciplinary action by the administrator and the Corporate Nurse Consultant for failing to report an allegation of abuse to the administrator. The DON was retrained by the Director of Operations and the Corporate Nurse Consultant on the abuse policy with concentration on requirements for reporting all allegations. On [DATE] at 3:00 PM the credible allegation was validated by random interviews with staff showing that the staff had received inservices on the facility ' s abuse policies and procedures. Interviews revealed that the staff was knowledgeable about the definition of abuse and the different kinds of abuse. The staff voiced understanding they were to report instances of abuse immediately to their nurse or supervisor.

Based on observations, record reviews, staff and resident interviews the facility failed to update a care plan for a [MEDICAL TREATMENT] resident with an episode of spontaneous bleeding following a [MEDICAL TREATMENT] treatment. (Resident #24) and failed to update a care plan for falls interventions for a resident with falls (Resident #75). Immediate Jeopardy began for Example #1, Resident #24 on 1/21/12 following a spontaneous bleed from her [MEDICAL TREATMENT] site and was identified on 3/9/2012 at 3:15 PM. Immediate Jeopardy was removed for Example #1, Resident #24 on 3/10/12 at 7:32PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) due to example #2. The findings include: 1. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #24 ' s most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as cognitively intact. She was assessed as receiving [MEDICAL TREATMENT]. Review of the Care Plan, dated 2/27/12 entitled, "requiring [MEDICAL TREATMENT]" listed, in part, " problem: requires [MEDICAL TREATMENT]; goal: will suffer no complications due to [MEDICAL TREATMENT]; approaches: coordinate resident ' s transportation to the [MEDICAL TREATMENT] center as scheduled, monitor resident ' fluid intake, monitor resident ' s shunt for patency and all transfers require mechanical lift. " Review of the nursing note dated 1/21/12 at 2:45PM read upon return from the [MEDICAL TREATMENT] center her clothing was saturated with blood and pressure applied to site. The nurse informed the primary physician and also called the [MEDICAL TREATMENT] center. The physician informed the nurse to continue to apply pressure. Review of a nursing note dated 1/21/11 at 10:00PM read, " Pressure dressing on left antecubital site intact. Small amount of blood appears on dressing. No gross bleed this shift." Review of the nursing care guide and care plan did not reflect an update following the episode of bleeding or interventions in monitoring patency of a [MEDICAL TREATMENT]. During an interview with the treatment nurse on 3/8/12 at 9:00am she stated that there is no set individualized care plan for [MEDICAL TREATMENT] residents. Some residents have their access site checked and others do not. The treatment nurse stated that resident #24 is very alert and oriented and involved with her care. She further stated that resident #24 will tell you to leave the dressig on the shunt area and she can take it off or will ask a nurse to remove it. During an interview with the [MEDICAL TREATMENT] Center nurse #8 on 3/8/12 at 10:45 AM she stated that the facility must assess the shunt daily for bleeding, infection or any other changes or concerns. If the [MEDICAL TREATMENT] center is open, the facility can call us and if we are closed than the resident should be evaluated by the facility physician or in the emergency room . During an interview with the Director of Nursing on 3/8/12 at 2:00pm she stated the Minimum Data Set (MDS) coordinator is correcting the [MEDICAL TREATMENT] care plans and deleting "monitor resident's shunt for patency" because "we do not monitor the shunt for patency." During an interview with the Minimum Data Set (MDS) coordinator on 3/9/12 at 10:29 AM she stated that care plans are not updated unless an issue comes up. During an interview on 3/10/12 at 10:45 AM, the Administrator stated her last QAA committee meeting was held on February 15, 2012. She stated the facility had written report sheets to communicate acute care issues. The Director of Nursing monitored acute care issues by the nursing staff charting on a acute sheet. The DON reviewed the reports and brought issues to the QAA committee for review. The Administrator further stated the Director of Nursing would notify her (the Administrator) and the QAA committee and the committee would develop and implement an action plan. The Administrator stated the [MEDICAL TREATMENT] resident with the spontaneous bleed (Resident #24) was not brought to her attention and if it had been it would have been discussed during the QAA committee meeting and an action plan would have been implemented. During an interview on 3/10/12 at 11:00 am, the DON stated the report sheets were reviewed later and since the [MEDICAL TREATMENT] resident ' s issue of the spontaneous bleed had been resolved, she did not bring it to the QA meeting. She stated she did not look at the report until later. The DON further stated there was no need to develop an action plan because the issue was resolved. She stated the facility did not need to develop a care plan because they were not a specialty unit and if there were any concerns the physician or the [MEDICAL TREATMENT] unit would be notified by the nurse. The Administrator was notified of the Immediate Jeopardy on 3/9/12 at 3:15PM. The facility provided a credible allegation of compliance on 3/10/12 at 7:32PM. The allegation of compliance indicated: Credible Allegation of Compliance: For the identified resident, the [MEDICAL TREATMENT] shunt is intact without signs of redness, drainage, bleeding, or infection. At 2:45pm 01/21/2012; the licensed nurse assigned to the identified resident noted blood on the clothing covering the shunt site. The nurse also noted resident was returning with a bag of visibly bloody clothing. The nurse instructed the CNA to apply a pressure dressing to the shunt site while the nurse contacted both the [MEDICAL TREATMENT] center and the resident ' s attending physician. The [MEDICAL TREATMENT] center did not provide any additional instructions to the nurse. The resident ' s attending physician instructed the nurse to continue with the pressure dressing. The bleeding at the shunt site resolved by 10pm on 01/21/2012 . On 1/22/12 at 11 a.m. the resident ' s INR tested to be 1.9, which is within the normal therapeutic range. For those residents having the potential to affected by the same alleged deficient practice, all [MEDICAL TREATMENT] resident ' s care plans have been reviewed to ensure licensed nursing staff are 1) aware of any existing shunt/fistula and 2) the facility ' s expectation for the shunt site to be monitored for redness, drainage, infection, or bleeding. The transport company will notify the nurse of return of patient, the nurse will sign receipt of patient. An in-service has been conducted by the [MEDICAL TREATMENT] center 03/10/12 at 1:30 P.M. to the licensed nursing staff. The in-service included the care and monitoring of the [MEDICAL TREATMENT] patient including assessment of the access site for signs and symptoms of infection, bleeding and patency. In the event the licensed nurse ' s assessment does not reveal any signs of redness, drainage, infection, or bleeding; then signing the MAR indicated [REDACTED]. In the event that the licensed nurse assesses signs of redness, drainage, infection, or bleeding; the facility ' s expectation is that the nurse would document their findings in the resident ' s medical record and notify the [MEDICAL TREATMENT] center and/or the resident ' s attending physician. The MDS Coordinator, in conjunction with the facility ' s Multi-Disciplinary Team, is updating the care plans for those residents receiving [MEDICAL TREATMENT] through a shunt/fistula. (Date of Completion: March 10, 2012). The [MEDICAL TREATMENT] center will communicate with the facility through phone report acute changes and needed follow-up while at treatment center. The [MEDICAL TREATMENT] center will provide an in-service to all licensed nurses before working with residents receiving [MEDICAL TREATMENT] services. Similarly, all licensed nursing staff present during the working shifts of 03/10/12 was in-serviced by the [MEDICAL TREATMENT] center on the monitoring of residents receiving [MEDICAL TREATMENT] via shunts/fistulas to have their sites assessed for signs of infection, redness, drainage, or bleeding each shift for a 24-hour period following a [MEDICAL TREATMENT] treatment. The licensed nurse shall document the assessment on the resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility ' s expectation is that a licensed nurse shall assess a [MEDICAL TREATMENT] resident ' s fistula/shunt upon return from the [MEDICAL TREATMENT] center and each shift for twenty-four hours following a [MEDICAL TREATMENT] treatment. The MAR indicated [REDACTED]. In the event any signs of redness, drainage, bleeding or infection is noted; the licensed nurse shall notify the [MEDICAL TREATMENT] center and/or the resident ' s attending physician. Licensed nurses were in-serviced on the importance of reporting evidence of shunt/fistula abnormalities to either the [MEDICAL TREATMENT] center and/or the resident ' s attending physician by the [MEDICAL TREATMENT] center. The nurse shall follow the facility ' s standing orders; and/or in the event of an emergent situation (e.g. severe bleeding, etc.) send the resident to the Emergency Department for prompt evaluation. The remaining licensed nursing staff shall receive the referenced in-service education by the corporate nurse Consultant or the [MEDICAL TREATMENT] center R.N. by March 11, 2012; and prior to beginning patient care to ensure they possess the necessary education to properly assess a [MEDICAL TREATMENT] resident ' s shunt/fistula. The facility shall not allow any licensed nurse to report to work and perform patient care duties until they have received such in-service education. Nurse consultant will educate MDS Coordinator regarding updating of care plans and monitor updates weekly x 4 weeks. Then monthly x 3 months. The nurse educator will monitor to ensure the care plans are individualized and are revised according to the residents needs and are being followed. Weekly x 4 weeks. Then monthly x 3 months. Findings will be reported to the QA committee members. A plan of correction will be implemented as needed. To ensure compliance, the Corporate Nurse Consultant and/or MDS Coordinator shall ensure the MAR(s) for residents receiving [MEDICAL TREATMENT] services through a fistula/shunt shall include evidence demonstrative of a licensed nurse ' s assessment of the shunt/fistula for signs of redness, bleeding, infection, or drainage. Similarly, the Corporate Nurse Consultant and/or her Registered Nurse designee shall review the charts and/or MAR(s) of those residents receiving [MEDICAL TREATMENT] through a shunt/fistula daily for 2 weeks; weekly for 2 weeks; and then monthly for 3 months to ensure licensed nurses are assessing the [MEDICAL TREATMENT] resident ' s shunt/fistula for signs of redness, bleeding, infection, or drainage. [MEDICAL TREATMENT] patients will be reviewed in Patients at Risk (P.A.R.) meeting weekly. All results will be brought to the attention of QA committee members for review. A plan of correction will be implemented and reviewed as needed. Completion Date 03/10/12 The credible allegation was verified on 3/10/12 as evidenced by staff interviews and review of facility records. A [MEDICAL TREATMENT] policy has been developed and implemented. Interviews with licensed nursing staff confirmed they had received in-servicing on the monitoring of residents receiving [MEDICAL TREATMENT] via shunts/fistulas to have their shunt/fistula sites assessed for signs of infection, redness, drainage, or bleeding each shift for a 24-hour period following a [MEDICAL TREATMENT] treatment and documenting the assessment, on the importance of reporting evidence of shunt/fistula abnormalities to either the [MEDICAL TREATMENT] center and/or the resident ' s attending physician and/or in the event of an emergent situation (e.g. severe bleeding, etc.) send the resident to the Emergency Department for prompt evaluation. The care plans for the three [MEDICAL TREATMENT] residents in the facility were updated to included assessment of the fistula/shunt site. Documentation was provided showing the updated care plans and that in-servicing had begun on 3/10/12 at 1:30 PM. 2. Resident #75 was admitted to the facility on [DATE] with acute kidney failure, severe [MEDICAL CONDITION], advanced dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION], metabolic [MEDICAL CONDITION] with [MEDICAL CONDITION]. A review of Resident #75 ' s significant change Minimum Data Set ((MDS) dated [DATE] and her most recent quarterly MDS dated [DATE] revealed she scored a 15 on her Brief Interview for mental status (BIMS) with 15 being the highest score. Resident #75 ' s most recent quarterly MDS revealed she had more than 2 falls and one was a major injury. The resident had difficulty focusing her attention, but this behavior fluctuated with changes in severity. A review of the resident ' s Care Area Assessment summary (CAA) dated 9/28/11, revealed she triggered for falls and was noted she was very weak and unsteady in her gait. She required assistance with transfers and received an antidepressant. A review of the resident ' s most recent care plan dated 5/2/11 revealed the resident had poor safety awareness. Approaches were to remind the resident to ask for assistance for all ambulation, to use a tab alarm while in bed, and resident required one staff member to transfer at all times. Review of the fall risk assessment tool dated 1/26/12 revealed resident was coded as a low risk and did not use ambulation aids (not coded as using a walker) Record review of the Nurses Notes dated 2/6/12 at 10:30 PM the resident was found on the floor beside her bed. She complained of pain of her right hip. Emergency Medical Transport (EMT) was notified and the resident was transferred to hospital for evaluation. There was no fracture and resident was returned back to the facility. During an interview on 3/9/12 at 10:00 am with the Nurse that wrote the 2/6/12 Note, Nurse # 1 stated she found the resident on the floor next to her bed. Nurse #1 further stated the resident complained of right side pain and she called EMT. Nurse #1 stated the resident had a history of [REDACTED]. The resident was very unstable. She did not use her call bell but she would yell out for staff to help her get up. Staff did not mention if the tab alarm was on while the resident was in bed. A review of the incident report dated 2/6/12 revealed the cause of the accident was due to an unstable gait. The fall was not witnessed. A review of the measures to prevent reoccurrence was left blank. The facility did not document if the resident ' s tab alarm was on while in bed. During an interview on 3/8/12 at 9:58 Am the Director of Nursing (DON) stated on 2/6/12 the resident was sent to the hospital and the X-ray was negative for a fracture. The resident came back to the facility and there were no interventions. The DON did not mention if the tab alarm was on or working after the fall. A review of the Nurses Notes dated 2/9/12 at 11:00 AM revealed Resident #75 was observed sitting on the floor with no injuries. No one assessed if the tab alarm was on the resident. A review of the incident/accident report dated 2/9/12 revealed the cause of the accident was wet socks. The description of the occurrence revealed the resident was observed sitting upright on the floor beside her bed. She denied any pain and stated she was on her way to the trashcan to dispose of her wet pull up. A review of the measures to prevent reoccurrence was to place the resident ' s walker and trashcan at the bedside. There was no intervention for the wet socks and there was no documentation concerning the resident ' s tab alarm on the resident ' s bed. During an interview on 3/8/12 at 9:58 AM the DON stated that the resident knew when she had to go to the bathroom. She did wear briefs and if she urinated in her brief, she could not stand to keep a wet brief on. The resident would take the wet brief off and discard it. The resident would let you know by yelling out and if you did not come quickly enough, would remove the wet brief herself. The DON did not address the tab alarm intervention. The facility decided to put the trashcan and her walker by her bedside to help her feel more independent. The DON stated the facility did not update the care plan due to she did not feel there was a need to write it down. When the DON was asked how staff knew the trashcan and walker were to be placed beside the bed, the DON stated that staff just knew where to place the trashcan and the walker. A review of the resident ' s care plan last updated on 5/2/11 revealed there was no documentation for the walker or her trashcan by her bedside. The care plan did have as an intervention a tab alarm while in bed. During an observation on 3/8/12 at 10:10 AM, the trashcan and walker were not in the resident's reach. The trashcan and walker were observed across the room by the sink. During an interview on 3/8/12 at 10:21 PM, Nurse #3 stated the trashcan and walker should be placed away from the resident because of her safety unawareness. She should not get up unassisted. Sometimes she was not clear and even on her good days she was unsteady. During an interview on 3/8/12 at 10:24 pm, Nursing Assistant (NA#7) when asked how she cared for Resident #75 stated she asked the resident what she needed and looked at the care plan. Stated she thought her walker should be closer to the resident but was not sure and the trashcan was supposed to be under the sink. NA#7 did not mention the resident was suppose to have a tab alarm attached. During a follow up interview, on 3/8/12 at 11:28 AM, NA#7 stated she looked at the care plan and there was no mention of where the trashcan or where the walker should be placed. NA #7 stated she thought the walker and trashcan should be placed where the resident wanted them placed. During an interview with the MDS coordinator on 3/9/12 at 10:29 AM revealed weekly all falls were discussed and her documentation was placed on a Patients at Risk (PAR) sheet. The sheets were reviewed and the QAA committee looked at the sheets to develop a plan of action. Stated the first intervention would be for the resident ' s falls to be referred to therapy for review. The MDS coordinator was observed reviewing the Resident #75 ' s chart and she stated that therapy had not reviewed the falls of 2/6/12 or 2/9/12. The MDS coordinator after reviewing her PAR documentation dated 2/7/12 revealed the incident of 2/6/12 was not discussed and there had been no plan of action. The MDS coordinator further stated the incident on 2/9/12 was discussed and Resident #75 already had alarms and there was no injury so no interventions were put into place. The MDS Coordinator stated the walker and trashcan being placed by the resident ' s bed had not been discussed. The MDS coordinator further stated the resident ' s falls seemed to come from her getting up and going to the bathroom and a toileting program would been more appropriate. During an observation on 3/9/12 at 10:00 AM, the resident was observed lying in her bed. The trashcan and the walker were observed across the room by the resident's sink. During an interview on 3/9/12 at 10:00 AM Resident #75 stated she did not remember her February falls and was not sure if she wanted her walker or the trashcan at her bed side. During an interview on 3/9/12 at 11:14 AM, the hospice NA #8 stated the trashcan was kept under the sink and the walker was by the sink away from the resident. She stated she remembered when the resident fell in February 2012, and the resident told her she was on her way to the bathroom. NA #8 further stated the resident had several falls during February and they all seemed to relate to the resident getting up to go to the bathroom. NA #8 stated the resident told her she wet her briefs and was trying to go to the bathroom. She stated the resident was able to let her know when she had to go to the bathroom and NA #8 would assist her to the toilet. NA#8 stated the resident was a hospice resident and was too weak to get up by herself. She stated there had not been any updates on the hospice care plan to indicate the resident needed her walker or trashcan beside her bed.

Based on observations, record review, staff and resident interviews and review of facility standing orders, the facility failed to put interventions in place after a spontaneous bleed for one (1) of one (1) sampled resident on [MEDICAL TREATMENT] (resident #24, example 1), failed to ensure monitoring of bowel records for one (1) of (1) one sampled resident with a history of fecal impaction (resident # 95), failed to monitor bowel records for five (5) of twenty-two (22) sampled residents whose bowel records were reviewed (resident # ' s 24, 7, 28, 37 and 49) and failed to assess one (1) of one (1) resident with pain (resident #95). Immediate Jeopardy began on 1/21/12 for Resident # 24, example 1, and was identified on 3/9/2012 at 3:15 PM. Immediate Jeopardy was removed on 3/10/12 at 7:32 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level E for example 2 Resident # 95, example 3 resident # 24, example 4 resident #28, example 5 resident #7, example 6 resident #37, example 7 resident #49 and example #8 resident #95 and also for the facility to implement monitoring their credible allegation implementation (no actual harm with potential for more than Minimal harm that is not Immediate Jeopardy). The findings include: 1. Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #24 was cognitively intact, needed extensive, two person assistance with bed mobility, was totally dependent on two persons for transferring, needed extensive assistance with dressing, toilet use, hygiene and was totally dependent for bathing. Section O, Special treatments, was incomplete. Review of the Care Plan, dated 2/27/12 entitled, "requiring [MEDICAL TREATMENT]" listed, in part, under approaches to monitor resident's shunt for patency. Review of the resident ' s January 2012 through February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also received Aspirin 81milligrams daily. The March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [MEDICAL TREATMENT] care plan did not address medications that could cause possible bleeding. Review of the nursing note dated 1/21/12 at 2:45PM read, "Resident return from (name of [MEDICAL TREATMENT] facility), clothing saturated with blood. Pressure applied to site. Writer informed primary physician, (name of [MEDICAL TREATMENT] center) called, also. Physician informed writer to continue to apply pressure. " No other interventions were documented. Review of a nursing note dated 1/21/11 at 10:00PM read, " Pressure dressing on left antecubital site intact. Small amount of blood appears on dressing. No gross bleed this shift." This was the last documentation regarding the bleeding at the [MEDICAL TREATMENT] site. Review of the nursing care guide and care plan did not reflect an update following the episode of bleeding or interventions in monitoring patency of a [MEDICAL TREATMENT]. During an interview with Nurse #5 on 3/8/12 at 8:55 AM she stated that vital signs are not taken upon return from [MEDICAL TREATMENT]. During an interview with the treatment nurse on 3/8/12 at 9:00 AM she stated that there is no set care plan for [MEDICAL TREATMENT] residents. Some residents have their access site checked and others do not. She stated that resident #24 is very alert and oriented and involved with her care and she will tell you to leave the dressing on the shunt area and she can take it off or will ask a nurse to remove it. During an interview with Nurse #3 on 3/8/12 at 9:25 AM she stated that the [MEDICAL TREATMENT] residents have so many hours that their dressing will stay on and then the dressing removed. She continued by stating that either the evening shift or the next day shift will take the dressing off and [MEDICAL TREATMENT] will send information back with the resident if there is a change in condition or change in orders. She stated that she usually will check the site when the resident returns. She stated that there is no formal documentation in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Director of Nursing (DON) on 3/8/12 at 10:40 AM she stated that only one resident has specific orders for care post [MEDICAL TREATMENT] because he has a different doctor and the residents who go to (name of center) [MEDICAL TREATMENT] have no orders related to their access sites from their physician. She stated that these residents leave the dressing on and it is removed after several hours by the nursing staff or the resident. She said that the nurses probably look at the sites during medication pass. She stated that the facility " charts by exception " and unless something was unusual with the site there would be no documentation regarding the site. She continued by saying that " Our understanding of the expectation of us is that the dressing should come off later that night, at the earliest, or early the next morning. [MEDICAL TREATMENT] will send a form back to us with the resident's vital signs and labs that were done at [MEDICAL TREATMENT] and any recommendations. " She stated that she thought the [MEDICAL TREATMENT] center had done an in-service with the nursing staff related to how to care for a [MEDICAL TREATMENT] site, looking for signs/symptoms of problems and infection control, but was not sure. " We don't monitor the shunt for patency. " During an interview with the [MEDICAL TREATMENT] Center nurse #8 on 3/8/12 at 10:45 AM she stated that the [MEDICAL TREATMENT] center sends paperwork with the resident, post [MEDICAL TREATMENT], to the facility documenting any problems, changes in orders, or areas of concern. This documentation is given to the contract transport company. Nurse #8 also stated if there are areas of concerns or changes in orders these changes are also faxed to the facility. She continued by saying that the nursing home must assess the shunt daily for bleeding, infection or any other changes or concerns. She continued by saying that if the [MEDICAL TREATMENT] center is open, the nursing home can call the [MEDICAL TREATMENT] center with concerns; however, if the [MEDICAL TREATMENT] center is closed then the resident should be evaluated by the nursing home physician or in the emergency room . During an interview on 3/8/12 at 11:00 AM with the Assistant Director of Nursing (ADON), she stated that the [MEDICAL TREATMENT] center has not in serviced the staff. During a follow up interview with the DON on 3/8/12 at 2:00pm she stated the Minimum Data Set (MDS) Coordinator is correcting the [MEDICAL TREATMENT] care plans and lining through "monitor resident's shunt for patency" because "we do not monitor the shunt for patency." During an interview with resident #24 and observation on 3/9/12 at 10:25am she stated that nobody comes in and looks at her shunt after she returns from [MEDICAL TREATMENT], unless she is bleeding. She stated that she is on [MEDICATION NAME] and sometimes bleeds longer after [MEDICAL TREATMENT]. She stated that she use to return from [MEDICAL TREATMENT] around 1pm but now it ' s sometimes 3pm because she bleeds longer. She stated on the day she returned with blood everywhere she was in the transport vehicle when she started bleeding. The transport folks were supposed to tell the nurses when they checked me back in. The nursing assistant came to my room after they finished feeding folks and said, " What happened to you? " She said she had blood everywhere. The nursing assistant instructed her to call for the nurse when she is bleeding. She thought the transport folks told the nurse. She stated she didn ' t remember the nursing assistant ' s name. During a follow up interview with the resident she stated that the transport folks said they would let the aide know so my clothes could be changed because my shirt and my sweater was just saturated. She stated that it could have been a nurse that came in first, but the aide did come in and change here clothes. Resident #24 was observed in bed, she had a dressing on her [MEDICAL TREATMENT] site and no bleeding was observed. During an interview with Nurse #1 on 3/9/12 at 11:30AM she stated that she went in to see how resident #24 was when she returned from [MEDICAL TREATMENT] and her clothes were saturated with blood. She stated that the blood was in the area of her shunt and it was still wet and that is why she was concerned. She stated that she did not know what to do so she called the physician. She continued by saying that the aide followed her into the room a few minutes after she went in and she had the aide stay with the resident while she called the doctor. She stated that she checked on resident #24 because usually when she returns from [MEDICAL TREATMENT] she wants a pain medication. She continued by saying that she didn ' t know whether to send her back to the [MEDICAL TREATMENT] or to the emergency room . She said that the physician said to apply pressure. She also stated that neither the transport folks nor the [MEDICAL TREATMENT] center informed her that the resident was bleeding and that she was not sure if she took any vital signs. Review of the acute nursing report dated 1/21/12 revealed that the resident was returned from [MEDICAL TREATMENT] and her clothing was saturated with blood. During an interview with the DON and Administrator on 3/9/12 at 12:00 PM the Administrator stated that the facility does not have a policy to monitor shunts. She continued by saying that all residents are monitored in the facility. She further stated that [MEDICAL TREATMENT] is a specialty and the facility is not a specialty facility. The [MEDICAL TREATMENT] center monitors the [MEDICAL TREATMENT] residents. If there is a problem in the facility that we cannot resolve, then we can send the [MEDICAL TREATMENT] residents to the hospital. During this same interview the DON stated that Resident #24 is alert and oriented and knows how to use her call bell and express her needs. During an interview with the Medical Director on 3/9/12 at 3:25 PM he stated that the staff has had no specific training related to [MEDICAL TREATMENT] care of the nursing home resident. He stated that if the staff has a problem with a [MEDICAL TREATMENT] resident bleeding they can call him or the [MEDICAL TREATMENT] center. When asked if a residents ' care plan should be updated to include interventions to monitor [MEDICAL TREATMENT] shunts following a bleed and what to do in the event of a bleed, he stated he did not think there was anything specific that needed to be put into place. He stated that at this time, he does not know what the facility currently has in place for [MEDICAL TREATMENT] residents. During an interview with the [MEDICAL TREATMENT] center on 3/9/12 at 3:45 PM with Nurse #10, she stated that resident #24 finished her treatment at 11:43 AM on 1/21/12. She stated usually the patients are here an additional 30 minutes to have pressure applied to the area. When resident #24 completed her treatment that day she did not have high blood pressure, no notes of bleeding and no complications. There would have been no calls or faxes made to the facility because there were no complications. Resident #24 was brought to the facility by (name of transport), a contracted transport, and that ' s who would have picked her up. Nurse #10 stated that she was not sure what time the transport vehicle would have arrived. She also stated that she remembered that someone made a call from the facility regarding this resident and bleeding and they did not know what to do. She told them that they needed to apply pressure and telephone their physician. She stated that the [MEDICAL TREATMENT] center ' s protocol is that if we cannot control the bleeding within 10 minutes then we call 911 for transport to the hospital. During an interview on 3/10/12 at 10:45 AM, the Administrator stated her last QAA (Quality Assessment and Assurance) committee meeting was held on February 15, 2012. She stated the facility had written report sheets to communicate acute care issues. The Director of Nursing monitored acute care issues by the nursing staff charting on a acute sheet. The DON reviewed the reports and brought issues to the QAA committee for review. The Administrator further stated the Director of Nursing would notify her (the Administrator) and the QAA committee and the committee would develop and implement an action plan. The Administrator stated the [MEDICAL TREATMENT] resident with the spontaneous bleed (Resident #24) was not brought to her attention and if it had been it would have been discussed during the QAA committee meeting and an action plan would have been implemented. During an interview on 3/10/12 at 11:00 am, the DON stated the report sheets were reviewed later and since the [MEDICAL TREATMENT] resident ' s issue of the spontaneous bleed had been resolved, she did not bring it to the QA meeting. She stated she did not look at the report until later. The DON further stated there was no need to develop an action plan because the issue was resolved. She stated the facility did not need to develop a care plan because they were not a specialty unit and if there were any concerns the physician or the [MEDICAL TREATMENT] unit would be notified by the nurse. The facility had a Nursing Home [MEDICAL TREATMENT] Transfer Agreement, dated 2/10/10, that specified only the responsibilities of the [MEDICAL TREATMENT] center. The Administrator was notified of the Immediate Jeopardy on 3/9/12 at 3:15 PM. The facility provided a credible allegation of compliance on 3/10/12 at 7:32PM. The allegation of compliance indicated: Credible Allegation of Compliance: For the identified resident, the [MEDICAL TREATMENT] shunt is intact without signs of redness, drainage, bleeding, or infection. At 2:45 PM 01/21/2012; the licensed nurse assigned to the identified resident noted blood on the clothing covering the shunt site. The nurse also noted resident was returning with a bag of visibly bloody clothing. The nurse instructed the CNA to apply a pressure dressing to the shunt site while the nurse contacted both the [MEDICAL TREATMENT] center and the resident ' s attending physician. The [MEDICAL TREATMENT] center did not provide any additional instructions to the nurse. The resident ' s attending physician instructed the nurse to continue with the pressure dressing. The bleeding at the shunt site resolved by 10pm on 01/21/2012. On 01/22/2012 the resident ' s INR tested to be 1.9, which is within the normal therapeutic range. A policy has been developed and implemented. For those residents having the potential to be affected by the same alleged deficient practice, all [MEDICAL TREATMENT] resident ' s care plans (three currently in the facility) have been reviewed to ensure licensed nursing staff are 1) aware of any existing shunt/fistula and 2) the facility ' s expectation for the shunt site to be monitored for redness, drainage, infection, or bleeding. The transport company will notify the nurse of return of patient, the nurse will sign receipt of patient. An inservice has been conducted by the [MEDICAL TREATMENT] center on 03/10/12 at 1:30 P.M. to the licensed nursing staff. The inservice included the care and monitoring of the [MEDICAL TREATMENT] patient including assessment of the access site for signs and symptoms of infection, bleeding and patency. In the event the licensed nurse ' s assessment does not reveal any signs of redness, drainage, infection, or bleeding; then signing the MAR indicated [REDACTED]. In the event that the licensed nurse assesses signs of redness, drainage, infection, or bleeding; the facility ' s expectation is that the nurse would document their findings in the resident ' s medical record and notify the [MEDICAL TREATMENT] center and/or the resident ' s attending physician. The MDS Coordinator, in conjunction with the facility ' s Multi-Disciplinary Team, is updating the care plans for those residents receiving [MEDICAL TREATMENT] through a shunt/fistula. (Date of Completion: March 10, 2012). The [MEDICAL TREATMENT] center will communicate with the facility through phone report acute changes and needed follow-up while at treatment center. Similarly, all licensed nursing staff present during the working shifts of 03/10/12 was inserviced by the [MEDICAL TREATMENT] center on the monitoring of residents receiving [MEDICAL TREATMENT] via shunts/fistulas to have their shunt/fistula sites assessed for signs of infection, redness, drainage, or bleeding each shift for a 24-hour period following a [MEDICAL TREATMENT] treatment. The licensed nurse shall document the assessment on the resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility ' s expectation is that a licensed nurse shall assess a [MEDICAL TREATMENT] resident ' s fistula/shunt upon return from [MEDICAL TREATMENT] and each shift for twenty-four hours following a [MEDICAL TREATMENT] treatment. The MAR indicated [REDACTED]. In the event any signs of redness, drainage, bleeding or infection is noted; the licensed nurse shall notify the [MEDICAL TREATMENT] center and/or the resident ' s attending physician. In the event of excessive bleeding apply pressure for 10 minutes, if bleeding continues call 911. Licensed nurses were inserviced by the [MEDICAL TREATMENT] center on the importance of reporting evidence of shunt/fistula abnormalities to either the [MEDICAL TREATMENT] center and/or the resident ' s attending physician. The nurse shall follow the facility ' s standing orders; and/or in the event of an emergent situation (e.g. severe bleeding, etc.) send the resident to the Emergency Department for prompt evaluation. The remaining licensed nursing staff shall receive the referenced in-service education by March 11, 2012; and prior to beginning patient care to ensure they possess the necessary education to properly assess a [MEDICAL TREATMENT] resident ' s shunt/fistula. The facility shall not allow any licensed nurse to report to work and perform patient care duties until they have received such in-service education. The Corporate Nurse consultant or an R.N. from [MEDICAL TREATMENT] center will in-service the licensed staff nurses upon hire and twice annually. To ensure compliance, the Corporate Nurse Consultant and/or MDS Coordinator shall ensure the MAR(s) for residents receiving [MEDICAL TREATMENT] services through a fistula/shunt shall include evidence demonstrative of a licensed nurse ' s assessment of the shunt/fistula for signs of redness, bleeding, infection, or drainage. Similarly, the Corporate Nurse Consultant and/or her Registered Nurse designee shall review the charts and/or MAR(s) of those residents receiving [MEDICAL TREATMENT] through a shunt/fistula daily for 2 weeks; weekly for 2 weeks; and then monthly for 3 months to ensure licensed nurses are assessing the [MEDICAL TREATMENT] resident ' s shunt/fistula for signs of redness, bleeding, infection, or drainage. Negative outcomes will be presented to the (Patients At Risk) P. A. R. committee and Quality Assurance (QA) committee via facility monitoring tool. Steps to prevent reoccurrence will be initiated. Staff demonstrating lack of assessment will be educated and disciplined per progressive discipline policy. [MEDICAL TREATMENT] education with return demonstration will be added to the in-service calendar twice annually. Licensed staff will not work with [MEDICAL TREATMENT] patients before receiving in-service training. [MEDICAL TREATMENT] patients will be reviewed in P.A.R. meeting weekly. All results will be brought to the attention of QA committee members for review. A plan of correction will be implemented and reviewed as needed. Completion date 03/10/12 The credible allegation was verified on 3/10/12 as evidenced by staff interviews and review of facility records. A [MEDICAL TREATMENT] policy has been developed and implemented. Interviews with licensed nursing staff confirmed they had received in-servicing on the monitoring of residents receiving [MEDICAL TREATMENT] via shunts/fistulas to have their shunt/fistula sites assessed for signs of infection, redness, drainage, or bleeding each shift for a 24-hour period following a [MEDICAL TREATMENT] treatment and documenting the assessment, on the importance of reporting evidence of shunt/fistula abnormalities to either the [MEDICAL TREATMENT] center and/or the resident ' s attending physician and/or in the event of an emergent situation (e.g. severe bleeding, etc.) send the resident to the Emergency Department for prompt evaluation. The care plans for the three [MEDICAL TREATMENT] residents in the facility were updated to included assessment of the fistula/shunt site. Documentation was provided showing the updated care plans and that in-servicing had begun on 3/10/12 at 1:30 PM. 2. The Facility Physician Standing Orders, undated, read, " *Milk of Magnesium 30cc (cubic centimeters) PO (by mouth) QD (everyday) PRN (as needed) for constipation if no bowel movement in 3 days. *[MEDICATION NAME] Suppository QD PRN constipation and *Soap Suds or Fleets Enema QD PRN constipation. " Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #95 ' s most Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed using the Brief Interview for Mental Status as scoring a 15, which is cognitively intact. She needed extensive assistance in toileting. She was assessed as being continent of bowel and bladder. She was further assessed as having impairment on both sides of her upper and lower extremities. She was assessed as having no constipation. During an interview with the MDS nurse on 3/7/12 at 10:30am she stated that the resident ' s admission labs showed the dehydration was resolved and therefore a care plan for dehydration was not done. She stated there was also not a care plan in place after the resident ' s impaction because she was unaware of the impaction. A review of the resident ' s medications was performed. She was not receiving medications to help promote bowel movements or given stool softeners during the month of February 2012. She was not on any diuretics. Review of the February bowel records indicated that the resident had a medium bowel movement on 2/21/12 and no bowel movement on 2/22/12. According to the documentation of her bowel records in February the resident would routinely have a bowel movement every other day. Review of the Acute nursing report, dated 2/22/12 for the 7am-7pm shift, revealed that Nurse #2 documented that resident #95 " c/o (complained of) abdominal discomfort, self disimpacted. " During an interview with Nursing Assistant #2 on 3/8/12 at 2:15pm she stated that on 2/22/12 she worked both day and evening shift. She stated that on the evening of 2/22/12 she helped the resident to the bathroom where the resident stated she was having problems with having a bowel movement. She left the resident and came back and the resident was observed to be manually trying to remove the stool while in the bathroom. At this time, NA #2 stated she went and told Nurse # 2. During an interview with Nurse #4 by telephone on 3/8/12 at 10:30am, she stated that on the evening of 2/22/12 the resident complained of being constipated. She said that the resident told her she had told the nurse during the day. Nurse # 4 helped the resident from the bathroom back to her bed. The nurse then assessed the resident and found hard stool in her rectum. She stated that she tried to give a suppository but there was " so much hard stool it would not work. " The nurse stated that the resident ' s rectal area was swollen from the large amount of stool that was present. She stated that she digitally removed hard stool and then gave a Fleet ' s enema and then the resident had a bowel movement. She stated that she did not notify the physician but did pass on the information to the oncoming day nurse on 2/23/12. Review of the Acute nursing report, dated 2/22/12 7pm-7am (2/23/12), revealed that Nurse #4 documented that resident #95 had " severe impaction, disimpacted some, then gave [MEDICATION NAME] Suppository with little effect then continue to complain of several constipation. Had to disimpact more then gave fleets enema with positive effects. This resident said she told (Nurse #2) all day she was constipated and nothing was done until I did above as written. " During an interview with Nurse # 2 on 3/8/12 at 3:50pm by telephone, she stated she honestly did not recall the resident talking to her about having any bowel problems on 2/22/12. She stated that she just could not remember anything from that date. Review of the Nursing Note, dated 2/23/12, documented that the resident complained of " severe constipation. " A [MEDICATION NAME] suppository was given, " had to disimpact was severely impacted, " and after given the resident the suppository she was still constipated and a Fleets enema was given with results. Review of the March bowel records indicated that the resident had no documented bowel movements for the days of 3/3, 3/4, 3/5 and 3/6. During a resident interview on 3/7/12 at 3:50pm she stated that she uses her walker in getting to the toilet. She stated that the nursing assistants help her and they usually want to know if she has had a bowel movement. She stated that she has always had problems being constipated. She stated, " I went today and the stool was hard. " She further stated that she let ' s the staff know if she is having problems. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the nurse #1, on 3/7/12 at 2:10pm she stated that she was not aware that the resident had not had a bowel movement from 3/3/12-3/6/12. Nurse #1 had not worked all of these days with this resident. She stated that the resident had had 3 bowel movements (BM) today. She stated that the protocol states that on the third day if there has been no BM to give standing PRN orders and if after standing orders the resident has not had a BM to notify the physician. The Nursing Assistants should let us know if a resident has not had a bowel movement. During an interview with Nursing Assistant #3 on 3/7/12 at 11:00am she stated that when a resident does not have a bowel movement the nurse is to be informed. NA #3 had not worked with this resident during these days. During an interview with Assistant Director of Nursing on 3/7/12 at 3:00pm she stated that our protocol is that after three days of no bowel movements the standing orders are started. During an interview with the Director of Nursing on 3/7/12 at 3:05pm she stated that it is her expectation that the bowel records would be monitored daily and if a resident has not had a BM by day 3 that the facility's standing orders would be started. She further stated that she use to have a PCA (personal care assistant) that would monitor the bowel records weekly and she said, "I guess i need to start that again." During an interview with the Administrator on 3/9/12 at 12:00pm she stated that bowel records should be monitored and if a resident has not had a bowel movement in three days then the standing orders should be put into place. 3. The Facility Physician Standing Orders, undated, read, " *Milk of Magnesium 30cc (cubic centimeters) PO (by mouth) QD (everyday) PRN (as needed) for constipation if no bowel movement in 3 days. *[MEDICATION NAME] Suppository QD PRN constipation and *Soap Suds or Fleets Enema QD PRN constipation. " Resident #24 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #24 was cognitively intact, needed extensive, two person assistance with bed mobility, was totally dependent on two persons for transferring, needed extensive assistance with dressing, toilet use, hygiene and was totally dependent for bathing. During a review of the December 2011 bowel records for the dates of 12/5/11-12/8/11 and 12/13/11-12/21/11 there were no recorded bowel movements. During a review of the January 2012 bowel records for the dates of 1/15/12-1/20/12 there were no recorded bowel movements. During a review of the February 2012 bowel records for the dates of 2/16/12-2/19/1 there were no recorded bowel movements. During a review of the March 2012 bowel records for the dates of 3/4/12-3/7/12 there were no recorded bowel movements. Review of the Medication Administration records from December 2011 through March 2012 revealed no documentation that the bowel standing orders were implemented during the above dates. During an interview with Assistant Director of Nursing on 3/7/12 at 3:00pm she stated that our protocol is that after three days of no bowel movements the standing orders are started. During an interview with the Director of Nursing on 3/7/12 at 3:05pm she stated that it is her expectation that the bowel records would be monitored daily and if a resident has not had a BM by day 3 that the facility's standing orders would be started. She further stated that she use to have a PCA (personal care assistant) that would monitor the bowel records weekly and she said, "I guess I need to start that again." During an interview with the Administrator on 3/9/12 at 12:00pm she stated that bowel records should be documented and monitored and if a resident has not had a bowel movement in three days then the standing orders should be put into place. 4. Resident #28 was readmitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment completed on 2/3/12 coded her as severely impaired in decision making skills for tasks of daily living and impaired in short and long term memory. The resident was totally dependent on staff for all areas of daily living. She was documented as always incontinent of both bladder and bowel. The Facility Standing orders for this resident indicated if the resident had no bowel movement in 3 days the resident was to received Milk of Magnesium 30 cc (cubic centimeters) PO (by mouth) QD (every day) PRN (as needed) for constipation. Resident #7 was to receive a [MEDICATION NAME] Suppository QD PRN or a Soap Suds of Fleets Enema QD PRN if no stool resulted from the Milk of Magnesium. A review of the December Resident Plan of Care for bowel movements revealed Resident #28 had zero stools documented for December 16, 17, 18, 19, 2011 with 6 spaces left blank. A review of nursing notes for Resident #7 did not document any bowel movements for December 16 - 19, 2011. An interview with the MDS nurse was conducted on 3/8/12 at 3:00 PM. The nurse stated their protocol was to start constipation standing orders when the resident had no stool for three days. She indicated nursing staff documented the Facility Standing Order medications on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was not interviewable. An interview with Staff Nurse #3 was conducted on 3/8/12 at 2:30 PM. Nurse #3 reported Nursing Assistants (NA) were required to complete the Resident Plan of Care Documentation stools on their shifts. The Nurse stated she did not check the bowel records herself. The nurse stated she was not aware Resident #28 had gone more than 3 days without a stool. During an interview with Nursing Assistant #3 on 3/8/12 at 2:40 PM she revealed she always filled in her assigned resident spaces to indicate the bowel movements for each resident. She stated she asked alert and oriented or continent residents each day if they had a stool. The NA stated the nurse was supposed to look at the Resident Plan of Care to see if the resident needed medication for stools. During an interview with the facility Administrator on 3/9/12 she indicated it was her expectation nursing staff would monitor bowel records and initiate constipation Standing Orders for residents who did not stool in 3 days. 5. Resident #7 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. [MEDICAL CONDITIO