Every finding on record at Mountain View of Bryson City

Based on observations and staff interviews, the facility failed to discard food with signs of spoilage and label and date food items in 1 of 1 walk-in cooler and maintain a clean and sanitary ice machine for 1 of 1 ice machine used to serve beverages to residents. These practices had the potential to affect food served to residents. Findings included: a. An observation of the walk-in cooler on 07/06/26 at 9:54 AM made with the Head [NAME] revealed the following:- A clear plastic container with a lid labeled tuna dated 6/21 with a use by date of 6/30,-A clear plastic pitcher with a lid labeled tomato soup with a use by date of 7/2,-A clear container with a lid labeled alfredo with a use by date of 6/28,-A clear plastic container with a lid labeled brown gravy with a use by date of 7/5,-A clear plastic container with an unsecured lid labeled cheezy rice with a use by date of 7/2,-A metal steam pan covered with plastic wrap with no label or date. The Head [NAME] was unable to identify the contents. It appeared to be grated cheese over pasta with a white creamy sauce on the bottom,-A clear plastic container with a lid labeled egg salad with a use by date of 7/3,-A clear plastic container with a lid labeled chicken noodle soup with no date,-An opened plastic bag labeled mozzarella cheese closed with a wire twist tie with no date,-An opened package of sliced American cheese with a received date of 05/28, with no opened on or use by date, left open to the air,-A sealed plastic bag labeled romaine dated 6/18, containing lettuce with brown discoloration and brown liquid in the bottom of the bag,-A sealed plastic bag labeled salad bag dated 6/18, containing lettuce with brown discoloration and brown liquid in the bottom of the bag.b. An observation of the ice machine in the kitchen on 07/06/26 at 10:08 AM made with the Head [NAME] revealed pink and brown substances scattered across the entire baffle (white plastic piece of the machine that helps manage ice flow) of the machine directly above the full trough of ice. An interview with the Head [NAME] on 07/06/26 during the initial observation revealed that he understood that items were not stored correctly and that the ice machine needed to be cleaned.An interview with the District Dietary Manager (filling in for the Food Service Manager) on 7/7/26 at 9:26 AM revealed that it was the Head Cook's or the Food Service Manager's responsibility to ensure all food coming in was labeled and dated, and that when packages were opened they were dated with an opened date and a use by date. The District Dietary Manager stated that all stored food should be checked daily for proper labeling and monitored for signs of spoilage. The District Dietary Manager also stated that the ice machine should be wiped down daily and the maintenance department should complete a deep clean monthly. An interview with the Administrator on 7/9/26 at 9:26 AM revealed that the Administrator expected all food to be labeled, dated, and stored correctly, and all spoiled food items to be discarded immediately. The Administrator stated that they expected the ice machine to be maintained and sanitized properly and for industry best practices to be followed.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of falls and Preadmission Screening and Resident Review (PASRR) for 7 of 22 residents reviewed for MDS accuracy (Resident #11, #20, #8, #9, #68, #10, and #76). Findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (inadequate oxygen levels) and fracture of the upper end left humerus (upper arm bone) with routine healing. The admission MDS assessment dated [DATE] coded Resident #11's fall history as having a fall in the last month and a fracture related to a fall prior to admission. Review of the nurse's progress note dated 04/22/26 revealed staff were alerted that Resident #11 was on the floor. The note indicated Resident #11 had rolled out of bed and landed on her buttocks. Resident #11 denied hitting her head or loss of consciousness and was noted to have no visible injury or complaints of pain with range of motion. Review of a nurse's progress note dated 05/13/26 revealed Resident #11 was found on the floor next to the bed. Resident #11 complained of right hip pain and was sent to the emergency room for further evaluation. A review of hospital discharge summary revealed Resident #11 was admitted on [DATE] after radiology imaging diagnosed an acute, comminuted (broken in 3 or more pieces) impacted (ends of the fractured bone are driven into each other) right intertrochanteric (involves the hip and thigh bones) fracture. A review of the discharge MDS assessment dated [DATE] coded for the number of falls since admission/entry or reentry or the prior assessment indicated Resident #11 had one fall with a major injury. During interviews on 07/07/26 at 11:55 AM and 07/09/26 at 2:39 PM, the MDS Coordinator revealed she had been in her position for approximately three months, and the discharge assessment dated [DATE] was completed by a traveling MDS Coordinator. She explained when coding the MDS assessment for falls she reviewed the resident's medical chart which included nurse progress notes. After review of the nurse progress notes dated 04/22/26 and 05/13/26, the MDS Coordinator stated Resident #11 had two falls since the prior assessment completed on 04/03/26. She stated the discharge MDS dated [DATE] should be coded to reflect one fall with no injury and one fall with major injury. During interviews on 07/07/26 at 12:15 PM and 07/09/26 at 3:07 PM, the Administrator confirmed previous MDS assessments were completed by a traveling MDS Coordinator and included Resident #11's discharge assessment dated [DATE]. She stated the discharge MDS dated [DATE] coding needed to be accurate and reflect Resident #11 had two falls since the prior assessment completed on 04/03/26. 2. Resident #20 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder. A review of Resident #20's medical record revealed a Level II PASRR Determination Notification letter dated 04/21/26 indicated nursing home placement was appropriate and to follow-up with psychiatric services by a psychiatrist. A mental health Nurse Practitioner (NP) note dated 05/06/26 revealed Resident #20 was being evaluated for cognitive impairment and bipolar disorder and management of psychiatric medications. The NP noted the medications being reviewed included brexpiprazole (antipsychotic) 1 milligram (mg) every morning, mirtazapine (antidepressant) 75 mg at bedtime, trazodone (antidepressant) 100 mg at bedtime, and divalproex sodium (anticonvulsant) 250 mg three times a day. A review of the annual MDS assessment dated [DATE] noted Resident #20 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS list of active psychiatric/mood disorder diagnoses included bipolar disorder and depression. The MDS high risk medications listed Resident #20 was taking antipsychotic, antidepressant, and anticonvulsant medications. The antipsychotic medication was noted as being received on a routine basis. A review of the significant change in status MDS assessment dated [DATE] noted Resident #20 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS list of active psychiatric/mood disorder diagnoses included bipolar disorder, anxiety disorder, and depression. The MDS high risk medications listed Resident #20 was taking antipsychotic, antidepressant, and anticonvulsant medications. The antipsychotic medication was noted as being received on a routine basis. During interviews on 07/07/26 at 11:55 AM and 07/09/26 at 2:39 PM, the MDS Coordinator revealed she had been in her position for approximately three months, and Resident #20's annual MDS assessments dated 06/02/26 and the significant change in status dated 06/18/26 were done by a traveling MDS Coordinator. She explained when coding the MDS assessment for PASRR she reviewed the resident's medical chart or asked the Social Worker (SW). The MDS Coordinator confirmed Resident #20 was considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and stated both the annual MDS assessment dated [DATE] and the significant change in status MDS assessment dated [DATE] were incorrectly coded and did not include the Level II PASRR information. During interviews on 07/07/26 at 12:15 PM and 07/09/26 at 3:07 PM, the Administrator confirmed previous MDS assessments were completed by a traveling MDS Coordinator and included Resident #20's annual MDS assessment dated [DATE] and the significant change in status MDS assessment dated [DATE]. She stated the MDS assessments dated 06/02/26 and 06/18/26 coding for PASRR needed to be accurate and reflect Resident #20's Level II PASRR information. 3. Resident #8 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, unspecified dementia, unspecified severity with psychotic disturbances. A review of Resident # 8's medical record revealed a Level II PASRR Determination Notification letter dated 10/10/2018, with no expiration date, indicated nursing home placement was appropriate. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] noted Resident #8 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS list of active psychiatric/mood disorder diagnoses included bipolar disorder. The MDS high risk medications listed for Resident #8 was taking antipsychotic medication. The antipsychotic medication was noted as being received on a routine basis. During an interview on 07/09/26 at 8:52 AM, the MDS Coordinator revealed that Resident #8's annual MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. She confirmed that Resident #8 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition and stated the annual MDS assessment dated [DATE] was incorrectly coded and did not include the Level II PASRR information. During an interview on 07/09/26 at 9:26 AM, the Administrator confirmed Resident #8's annual MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. The Administrator stated the annual MDS assessment dated [DATE] coding for PASRR needed to be accurate and reflect Resident #8's current Level II PASRR information. 4. Resident #9 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder. A review of Resident #9's medical record revealed a Level II PASRR Determination Notification Letter dated 03/05/25, with no expiration date, indicated nursing home placement was appropriate. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] noted Resident #9 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS list of active psychiatric/mood disorder diagnoses included schizoaffective disorder. The MDS high risk medications listed for Resident #9 was taking antipsychotic medication. The antipsychotic medication was noted as being received on a routine basis. During an interview on 07/09/26 at 8:52 AM, the MDS Coordinator revealed that Resident #9's annual MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. She confirmed that Resident #9 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition and stated the annual MDS assessment dated [DATE] was incorrectly coded and did not include the Level II PASRR information. During an interview on 07/09/26 at 9:26 AM, the Administrator confirmed Resident #9's annual MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. The Administrator stated the annual MDS assessment dated [DATE] coding for PASRR needed to be accurate and reflect Resident #9's current Level II PASRR information. 5. Resident #68 was admitted to the facility on [DATE]. Review of Resident #68's medical record revealed a Pre-admission Screening and Resident Review (PASRR) Level II determination notification letter dated 04/21/26 with no expiration date. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 07/07/26 at 11:55 PM, the MDS Coordinator revealed she had been in her position for approximately three months and Resident #68's annual MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. She explained when coding the MDS assessment for PASRR, she reviewed the resident's medical record to see if they had a Level II PASRR or asked the Social Worker. The MDS Coordinator reviewed Resident #68's medical record and confirmed he had a Level II PASRR determination. The MDS Coordinator stated Resident #68's annual MDS assessment dated [DATE] was incorrectly coded and should have reflected he had a Level II PASRR. During an interview on 07/07/26 at 12:15 PM, the Administrator revealed previous MDS assessments were completed by a travelling MDS Coordinator. The Administrator stated the annual MDS assessment dated [DATE] should have accurately reflected Resident #68 had a Level II PASRR. 6. Resident #10 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and major depressive disorder. A review of Resident #10's medical record revealed a Level II PASRR Determination Notification letter dated 02/09/26, which indicated Resident #10 had a Level II PASRR with an expiration date of 04/10/26, and that nursing home placement was appropriate. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS list of active psychiatric/mood disorder diagnoses included anxiety disorder, depression, schizophrenia, and post-traumatic stress disorder. The MDS listed Resident #10 as having taken the following high risk medications during the look back period: antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. The antipsychotic medication was noted as having been received on a routine basis. An interview was conducted with the Social Worker (SW) on 07/07/26 at 11:03 AM. The SW confirmed Resident #10 was issued a Level II PASRR on 02/09/26. The SW stated that she attached the Level II PASRR Determination Notification letter to the resident's Electronic Medical Record (EMR) and that the MDS Coordinator was responsible for coding the PASRR on the MDS. During an interview on 07/07/26 at 11:22 AM, the MDS Coordinator stated she had been in her position for approximately three months, and that Resident #10's admission MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. She stated that when coding the PASRR section of the MDS, she looked up the resident's Level II PASRR Determination Notification letter in the EMR and used that information to code the MDS PASRR section. The MDS Coordinator confirmed Resident #10 was not coded to have a Level II PASRR on the admission MDS dated [DATE] and after reviewing the Level II PASRR Determination Notification letter, Resident #10 was incorrectly coded and the MDS should have included the Level II PASRR information. 7. Resident #76 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder and major depressive disorder. A review of Resident #76's medical record revealed a Level II PASRR Determination Notification letter dated 03/03/25, which indicated nursing home placement was appropriate. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] noted Resident #76 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. An interview was conducted with the Social Worker (SW) on 07/07/26 at 11:03 AM. The SW confirmed Resident #76 was issued a Level II PASRR determination on 03/03/25. The SW stated that she attached the Level II PASRR Determination Notification letter to the resident's Electronic Medical Record (EMR) and that the MDS Coordinator was responsible for coding the PASRR on the MDS. During an interview on 07/07/26 at 11:22 AM, the MDS Coordinator stated she had been in her position for approximately three months, and Resident #76's annual MDS assessment dated [DATE] was completed by a traveling MDS Coordinator. The MDS Coordinator confirmed Resident #76 was not coded to have a Level II PASRR on the annual MDS assessment dated [DATE]. After reviewing the Level II PASRR Determination Notification letter she stated the MDS assessment had been incorrectly coded should have included the Level II PASRR information. During an interview on 07/07/26 at 11:43 AM, the Administrator stated MDS assessments should be accurate and correctly coded.

Based on record review and staff interviews, the facility failed to develop a discharge care plan for 1 of 2 sampled residents reviewed for discharge (Resident #83). Findings included:Resident #83 was admitted to the facility on [DATE]. Her cumulative diagnoses included obsessive-compulsive personality disorder (OCPD).A care plan meeting note dated 12/01/25 revealed a meeting was held with Resident #83's Family Member #1 and members of the facility's Interdisciplinary Team (IDT) that included the Business Office Manager, Social Worker (SW), Director of Nursing Services, and Administrator. It was noted that Resident #83 did not wish to attend. The plans discussed were for Resident #83 to remain at the facility short-term, receive psychiatric services prior to discharging home and there were no barriers to her discharge. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had intact cognition. The MDS noted Resident #83's overall goal was to discharge to the community, there was no active discharge planning currently in place and Resident #83 did not want to be asked about returning to the community on all MDS assessments.A care plan meeting note dated 01/21/26 revealed a meeting was held with Resident #83's Family Member #1 and members of the facility's IDT that included the SW, Business Office Manager and nursing. It was noted that Resident #83 did not wish to attend. Resident #83's recent inpatient psychiatric admission to an acute hospital was discussed and Family Member #1 indicated they now wished for Resident #83 to be transferred to a long-term psychiatric facility for treatment.Review of Resident #83's comprehensive care plan, last reviewed/revised on 03/03/26, revealed no discharge care plan.A discharge-return not anticipated MDS assessment dated [DATE] revealed Resident #83 discharged to an inpatient psychiatric facility.During an interview on 07/09/26 at 2:30 PM, the SW revealed the discharge planning process begins upon a resident's admission which included conducting a 72-hour care plan meeting with the resident and/or their representative to discuss the resident's needs, goals and discharge plans. She stated the MDS Coordinator was typically the one responsible for developing the discharge care plan and she was not sure why or how Resident #83's got overlooked. During an interview on 07/09/26 at 3:30 PM, the MDS Coordinator revealed she had been in her position for approximately three months and she had a list of focused care areas that should always be incorporated into a resident's comprehensive care plan which included a discharge plan. The MDS Coordinator explained she had planned on conducting an audit of resident comprehensive care plans to make sure the appropriate plans were in place but hadn't had time. The MDS Coordinator confirmed Resident #83 did not have a discharge care plan and explained there was some confusion as to whether the MDS Coordinator or SW was responsible for developing the discharge care plan.During an interview on 07/09/26 at 5:03 PM, the Administrator stated a discharge care plan should be developed as part of the resident's comprehensive care plan. The Administrator revealed the SW was responsible for starting the discharge planning process upon a resident's admission and documenting updates to the discharge plan as the resident's needs or goals changed.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents who were admitted to the facility with serious mental health disorders for 2 of 6 residents reviewed for PASRR (Resident #2 and Resident #75).Findings included:a. A North Carolina (NC) Level I PASRR screening form dated 02/23/26 for Resident #2 noted a screening type of PASRR only review. There were no mental health diagnoses documented on the NC Level I PASRR screen.A PASRR Determination Notification letter dated 02/25/26 revealed Resident #2 had a Level I PASRR with no expiration date.Resident #2 was admitted to the facility on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD), depression and anxiety disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #2's active psychiatric/mood disorder diagnoses included anxiety disorder, depression (other than bipolar) and PTSD. He received antianxiety and antidepressant medications during the MDS assessment look-back period.A psychiatric progress note dated 05/20/26 revealed Resident #2 was seen for an initial evaluation related to depression, anxiety and PTSD. The psychiatric provider noted Resident #2 currently received sertraline (antidepressant) 100 milligrams (mg) daily with good effect and lorazepam (antianxiety) 0.5 mg three times a day was restarted. The psychiatric provider noted Resident #2 appeared emotionally stable and she would hold off on making any medication changes.The facility was unable to provide documentation that a request for a Level II PASRR evaluation had been submitted for Resident #2. During an interview on 07/07/26 at 12:05 PM, the Social Worker (SW) confirmed she was responsible for submitting requests for PASRR re-evaluations as needed. The SW confirmed Resident #2 had diagnoses of PTSD, depression and anxiety when he admitted to the facility on [DATE]. The SW stated a request for a Level II PASRR evaluation should have been submitted and it was an oversight.b. A North Carolina (NC) Level 1 PASRR screening form dated 06/12/25 for Resident #75 noted a screening type of PASRR only review. There were no mental health diagnoses documented on the NC Level I PASRR screen.A PASRR Determination Notification letter dated 06/12/25 revealed Resident #75 had a Level I PASRR with no expiration date.Resident #75 was admitted to the facility on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD), major depressive disorder and anxiety disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #75's active psychiatric/mood disorder diagnoses included anxiety disorder, depression (other than bipolar) and PTSD. He received antidepressant medications during the MDS assessment look-back period.A psychiatric progress note dated 12/10/25 revealed Resident #75 was seen for an initial evaluation related to active psychiatric diagnoses of major depressive disorder, generalized anxiety disorder, PTSD, and dementia with behaviors. The psychiatric provider noted Resident #75 currently received duloxetine (antidepressant) 30 milligrams (mg) every morning with new orders provided to increase the dosage to 30 mg twice a day.A psychiatric progress note dated 05/27/26 revealed that per staff report, Resident #75's mood and behavior had been manageable but he appeared more anxious and fixated on his pain. The psychiatric provider noted Resident #75 reported anxiety and occasional depression. New orders were provided to start lorazepam 0.5 mg three times a day for anxiety.The facility was unable to provide documentation that a request for a Level II PASRR evaluation had been submitted for Resident #75. During an interview on 07/07/26 at 12:05 PM, the Social Worker (SW) confirmed she was responsible for submitting requests for PASRR re-evaluations as needed. The SW confirmed Resident #75 had diagnoses of PTSD, major depressive disorder and anxiety when he admitted to the facility on [DATE]. She stated a request for a Level II PASRR evaluation should have been submitted and it was an oversight.A continuation of the interview with the SW on 07/07/26 at 12:05 PM revealed she checked the North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) upon a resident's admission to the facility to see if the resident had a PASRR but she did not check to see if mental health diagnoses were included in the initial screening. The SW explained that she tried review the resident's admission documentation and if she noticed that the resident had mental health diagnoses with a Level 1 PASSR, she submitted a request for a Level II PASRR evaluation. During an interview on 07/07/26 at 12:15 PM, the Administrator stated she would expect for the SW to submit a request for a Level II PASRR evaluation when a resident was admitted with a Level I PASRR and had mental health diagnoses, per the regulatory guidelines.

Based on observations, record review, and staff interviews, the facility failed to prevent the administration of expired medications for 1 of 5 residents reviewed for Medication Administration (Resident #71).The findings included:Resident #71 was admitted to the facility on [DATE].Review of a physician's order dated 4/30/26 revealed Resident #71 was prescribed Vitamin B12 oral tablet. Give 500 micrograms (MCG) by mouth one time a day for supplement. During a medication storage observation conducted on 7/8/26 at 8:45 AM with the Director of Nursing Services and Medication Aide (MA) #1 on the A Hall Medication Cart, a bottle of Vitamin B 12 500 MCG with an expiration date of 1/2026 was discovered with 92 pills remaining. MA #1 stated that the expired Vitamin B-12 had been administered to one resident that morning. MA #1 reported Resident #71 had received one pill of Vitamin B 12 500 MCG that morning. She stated she became aware the medication was expired when it was discovered during the medication storage observation. The medication was removed from the A Hall Medication Cart by the Director of Nursing Services. MA #1 further indicated she should have checked the expiration date before administering the medication, stating she just didn't think to look before giving the expired dose that morning. A review conducted on 7/8/26 at 8:55 AM of the medication administration record (MAR) for the day of 7/8/26 revealed Resident #71 was administered Vitamin B12 oral tablet 500 MCG by MA #1 during the morning administration.On 7/8/26 at 8:50 AM an interview with the Director of Nursing Services revealed his expectation was for the Nurse or MA to check the expiration date before administering any medication. He stated he expected residents to be administered medications that were not expired. On 7/8/26 at 11:16 AM an interview with the Nurse Practitioner revealed she did not consider expired Vitamin B-12 being administered to a resident a major medication error. She stated she would not send a resident out to the hospital for having had expired Vitamin B-12 administered to them. She further indicated that she expected non-expired medications to be administered to residents.On 7/8/26 at 1:10 PM an interview with the Administrator revealed that her expectation was for residents to be administered medications that were not expired.

Based on observations, record review and interviews with the Nurse Practitioner (NP), a Family Member and staff, the facility failed to recognize a cognitively impaired resident had left the facility unsupervised. Staff were not aware the resident had exited the facility until a Family Member who was visiting reported a resident was wandering in the parking lot. The deficient practice occurred for 1 of 5 residents reviewed for accidents (Resident #87).Findings included:Resident #87 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, and anxiety disorder. Resident #87 was discharged from the facility on 03/01/26.A nurse's progress note dated 06/30/25 revealed Resident #87 was observed at the facility's front door, punching numbers into the keypad. The note revealed Resident #87 wanted to sit outside on the porch, and the nurse had explained a staff member needed to be with her when outside and that Resident #87 understood. An elopement evaluation dated 09/03/25 revealed Resident #87 was able to leave the building on her own, had impaired decision-making skills, had not made repetitive statements about going home, did not have a history of wandering or elopement, had not experienced a recent room change, did not wander aimlessly about the facility, and had not had a recent change in medications. Based on the evaluation Resident #87 was not at risk for elopement.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87's cognition was moderately impaired and there had been no delusional, physical, verbal, or wandering behaviors during the lookback period. Resident #87 walked and transferred independently, had no falls, and her active diagnoses included Alzheimer's disease, dementia, and anxiety disorder. The care plan dated 12/05/25 identified Resident #87 was at risk for falls related to confusion and being unaware of safety needs and had a deficit in the ability to complete self-care tasks due to impaired cognition and dementia. Interventions included to educate the resident, family, and caregivers about safety reminders and what to do if a fall occurred and the need for a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, and personal items within reach. The Nurse Aide (NA) activities of daily living task documentation dated 12/28/25 at 2:22 PM revealed Resident #87 was eating.During a telephone interview on 07/08/26 at 9:20 AM, the Family Member explained she was in a room visiting another resident when she saw Resident #87 wandering around the parking lot. She described Resident #87 had a jacket and pocketbook on her arm and was walking around from car to car looking in the windows, and it appeared as if she was looking for someone. She did not recall what time it was when she saw Resident #87 outside and did not see her walk out of the building but stated Resident #87 could not have been outside very long because she had a clear view from the window to the parking lot. The Family Member stated she saw Resident #87 in the middle area of parking lot and watched her for a couple minutes then reported it to Nurse #3 who went right away to check on Resident #87. She revealed when visiting the facility, she had to use a code to open the door when going in and out of the building and when Resident #87 got out on 12/28/25 there were a lot of visitors, and the parking lot was full. Review of Nurse #2's progress note dated 12/26/25 at 2:40 PM revealed a Family Member had alerted Nurse #3 that Resident #87 was outside in the parking lot looking in car windows and Nurse #3 returned Resident #87 back inside the building. The note included Resident #87 had stated she followed, her out.During a telephone interview on 07/09/26 at 12:55 PM, Nurse #3 stated she did not recall if she or assigned Nurse #2 brought Resident #87 back inside the building on 12/28/25. She confirmed that a Family Member who was visiting another resident on the hall she was assigned had reported to her Resident #87 was outside in the parking lot looking into car windows. She had the Family Member write a statement and stated from what she recalled, Resident #87 was found outside in the front area of parking lot and did not get far away from the building.A review of the Family Member's statement who reported Resident #87 was outside was dated 12/28/25 at 3:30 PM and read, I saw a resident walking in the parking lot. She was walking around the cars looking in the windows. I called Nurse #3's attention to this. A review of a written statement with no name or date read, why you went outside, was going out with [NAME]. Who was [NAME], she goes in with goods to see what a person does. I like to go outside a lot. A lady was going to join me. I told her it's okay I go out a lot. Where were you outside, I don't usually make to the motels. I asked were you in the parking lot. Interviews were conducted with Nurse #2 on 07/07/26 at 10:49 AM and 07/07/26 at 5:29 PM. Nurse #2 confirmed she was assigned on the hall where Resident #87 resided on 12/28/25. Nurse #2 stated Resident #87 had followed a visitor(s) outside, and she was told Resident #87 was at the front of the parking lot standing by a car and looking inside. She revealed that a Family Member visiting another resident saw Resident #87 and reported it to Nurse #3 and Nurse #3 brought Resident #87 back inside the facility. Nurse #2 revealed the last time she saw Resident #87 she was sitting in dining room eating and that was approximately 12:00 PM or 12:30 PM and stated lunch was typically finished around 1:00 PM or 2:00 PM. Nurse #2 stated she was not actively looking for Resident #87 and did not know she had got outside of the facility unsupervised. She described Resident #87 would stand at the front entrance doors, but she had not seen her attempt to exit the facility unsupervised.Telephone interviews were conducted with NA #1 on 07/08/26 at 1:17 PM and 07/09/26 at 10:27 AM. NA #1 confirmed on 12/28/25 she was the assigned to the hall where Resident #87's room was located. NA #1 stated she was providing care to another resident and when finished and back on the hall was told Resident #87 was let outside by someone and was in the parking lot looking inside cars. NA #1 stated Resident #87 was already back inside the facility, and she was not actively looking, or aware Resident #87 was missing until it was reported to her. NA #1 confirmed she had documented the activities of daily task for Resident #87 on 12/28/25 at 2:22 PM and she saw Resident #87 in dining room eating a snack and this was the last time she had seen the resident. NA #1 revealed she had not heard Resident #87 say she wanted to leave the facility or saw her trying to open a door. She described Resident #87 liked to sit in the dining room and was social and was either in dining room, walking on the hall, or in her room. An observation from the main entrance doors to the parking lot was conducted on 07/09/26 at 1:14 PM with the Administrator. According to the website Google Earth from the front entrance doors to the parking spaces located in front of the window where the Family Member saw Resident #87 was approximately 85 feet and from the front entrance doors to the middle of the parking lot was approximately 115 feet.Review of the website Wunderground revealed the outside temperature in the [NAME] City/[NAME] area on 12/28/25 from 1:55 PM through 3:55 PM was 64 degrees and there was no precipitation. An SBAR (situation/background/assessment/recommendation) dated 12/28/25 at 5:33 PM revealed Resident #87 was evaluated for altered mental status and increased confusion. Her blood pressure was 142/71, pulse 90, respirations 17, oxygen saturation level 96% on room air, and temperature 98.2.A skin check dated 12/28/25 at 5:28 PM revealed Resident #87 had no skin issues and was noted to have warm and dry skin with normal color and turgor. The previous NP progress note dated 12/30/25 revealed Resident #87 had eloped from the building but safely returned with no injury and noted she was in no acute distress.During a telephone interview on 07/09/26 at 9:35 AM, the previous NP revealed Resident #87 would pace up and down the hall and ask several times what was going on and needed constant redirection and reassurance. She stated Resident #87 had dementia and needed someone to be with her if she was outside of the facility. The NP stated she had not heard Resident #87 say she wanted to go home or leave the facility. The NP revealed if left outside alone unsupervised there was a possibility Resident #87 could wander away from the facility towards the road or woods.During an interview on 07/09/26 at 10:09 AM, the previous Director of Nursing (DON) stated she was not at the facility and did not recall specifics related to Resident #87's elopement on 12/28/25. She described Resident #87 liked to sit in the front lobby area and watch people come and go and talked about doing things and going places with her family. She had not heard Resident #87 say she wanted or needed to leave or go home.During interviews on 07/08/26 at 12:46 PM, 07/09/26 at 1:14 PM and 4:43 PM the Administrator stated she was called on 12/28/25 when Resident #87 got out of the facility and spoke with Nurse #3. Nurse #3 reported a Family Member saw Resident #87 outside in the parking lot looking in the windows of cars. The Administrator revealed Resident #87's was standing by a car that was parked in the spaces closest to the facility and in front of the window where the Family Member saw Resident #87. She explained Nurse #3 went to the front entrance door and called Resident #87 by name, and she walked back into the facility without incident. The Administrator revealed she attempted to interview Resident #87 and confirmed it was the written statement with no name or date. She revealed the information Resident #87 had provided did not make sense, so she stopped the interview. She explained that all the door locks and alarms including the entrance doors were checked and there were no issues identified and it was determined Resident #87 exited from the front entrance door. She explained that the Receptionist monitored the front entrance doors, but since April 2025 the facility no longer had a fulltime Receptionist and there was no Receptionist on 12/28/25. She stated based on her investigation she determined Resident #87 exited from the front entrance doors but did not know if she pushed the button behind the Receptionist desk to unlock the door or was let out by a visitor.

Based on observations and staff interviews, the facility failed to remove expired medications and secure an unattended medication cart for 2 of 4 medication carts reviewed for medication storage (A hall cart and C hall cart).Findings included: a. On 7/8/26 at 8:17 AM, during an observation of the C Hall Medication Cart with the Director of Nursing Services, the medication cart was found unlocked, unattended, and located inside the C and D Hall Nursing Station. The nursing station had two points of entry: one entrance with a door that was unlocked, and a second entrance that had no door at all, leaving the area completely open. Both entrances were accessible to residents and visitors. On 7/8/26 at 8:18 AM an interview with the Director of Nursing Services revealed that the cart belonged to Nurse #1. He stated that his expectation was that the Nurse or the Medication Aide (MA) locked the Medication Cart when it was unattended by a Nurse or an MA.On 7/8/26 at 8:21 AM an interview with Nurse #1 revealed that she had checked the C Hall Medication Cart in morning during handoff with the night shift Nurse. She stated that she had locked the C Hall Medication Cart upon finishing hand off with the night shift Nurse. She further indicated that she was unsure why the C Hall Medication Cart was unlocked. She stated that she was the only one that had a key to the C Hall Medication Cart. She further indicated that she always locked her Medication Cart when she walked away from it.b. An observation of the A Hall Medication Cart on 7/8/26 at 8:45 AM with the Director of Nursing Services and Medication Aide #1 (MA) revealed a bottle of Vitamin B-12 500 micrograms (mcg) with an expiration date of 1/2026 with 92 pills available for use. On 7/8/26 at 8:46 AM an interview with MA #1 revealed that she did not normally work on A Hall. She stated that she had administered the Vitamin B-12 500 mcg to a resident. She further indicated that she should have checked the expiration date before she administered the medication. She stated that she just didn't think to look at the medication expiration date before she administered the expired medication this morning. On 7/8/26 at 8:50 AM an interview with the Director of Nursing Services revealed that his expectation was that the Nurse or MA checked the expiration date before administering any medication. He further revealed all Nurses or MAs were to check the Medication cart at the beginning of each shift for expired medications and remove any expired medications and return them to the pharmacy. He stated he expected that residents were administered medication that were not expired. c. An observation of the A Hall Medication Cart on 7/8/26 at 8:52 AM with the Director of Nursing Services and Medication Aide #1 (MA) revealed a bottle of Vitamin B-12 1000 mcg with an expiration date of 6/2026 with 11 pills was available for use. On 7/8/26 at 8 52 AM an interview with Medication Aide #1 (MA) revealed that she checked expiration dates on all medications and restocked her medication cart once a week. She stated that all expired medications are removed from the cart and returned to pharmacy. She stated that this medication had not been used today. On 7/8/26 at 8:53 AM an interview with the Director of Nursing Services revealed that his expectation was that the Nurse who took over the Medication carts checked all expiration dates on all medications before the start of each shift. He further indicated that all expired medications were to be removed from the medication cart and returned to pharmacyOn 7/8/26 at 1:10 PM an interview with the Administrator revealed that her expectation was that expired medications should be removed from the medication carts and replaced with non-expired medications. She stated she expected that residents were administered medication that were not expired. The Administrator further revealed that her expectation was that all medication carts were to be locked by the Nurse or MA when the medication carts were unattended

Based on observations, test tray and Speech Language Pathologist (SLP), Registered Dietitian (RD) and staff interviews, the facility failed to serve pureed food items with an applesauce or pudding-like consistency. This failure had the potential to affect 2 of 2 residents who had orders for an advanced dysphagia (difficulty swallowing) diet with pureed-texture foods (smooth, moist pudding-like foods that require no chewing).The findings included:During an observation of the lunch meal service in the main dining room on 07/06/26 at 1:26 PM, the SLP reported residents who had orders for a pureed diet could not eat the food due to the food items being too thick for the residents to swallow. She explained the pureed food items sent out from the kitchen were a paste-like consistency but should be more of an applesauce-like consistency and when she noticed residents received pureed food that was too thick, she took the food back to the kitchen to have dietary staff add more liquid. The SLP revealed she felt the inconsistency in the preparation of pureed food was due to high turnover in dietary and dietary staff not being well-trained.A test tray of a lunch meal was conducted with the District Dietary Manager on 07/08/26 at 1:34 PM which consisted of pureed chicken with gravy, pureed collard greens, mashed potatoes, pureed bread, and a pureed brownie for dessert. The chicken, collard greens, mashed potatoes and bread were all pureed to a smooth, pudding-like consistency; however, the brownie puree was thick and sticky, similar to a peanut butter consistency, and was unable to be shaken off the spoon. During an interview on 07/08/26 at 1:36 PM, the District Dietary Manager agreed the pureed brownie was too thick and stated the longer it sat, the thicker it got. She stated the pureed brownie needed more milk added in order for it to be the correct pudding-like consistency.During a follow-up interview on 07/09/26 at 8:11 AM, the SLP revealed that for the past year, 90% of the time the pureed food sent out from the kitchen was the consistency of paste or peanut butter which was hard for residents with dysphagia to swallow. The SLP explained when she noticed the pureed texture was not at the correct consistency she provided education to dietary staff. She stated she would and get the dietary staff trained so that they were pureeing food at the right consistency but then the dietary staff would leave and she had to start all over. The SLP stated she had voiced her concerns to the Administrator who tried to get the issue addressed but the inconsistency in the preparation of the pureed food continued to be an issue.During a phone interview on 07/09/26 at 10:22 AM, the RD revealed she was aware of the concerns regarding the consistency of the pureed food items served to residents. She explained pureed texture should not be thick or stick to the spoon and should be more of a pudding-like consistency that easily slides off the spoon. The RD reported that the SLP had educated dietary staff regarding pureed texture food items but dietary staff continued to struggle with preparing pureed food at the correct consistency.During a follow-up interview on 07/09/26 at 10:57 AM, the District Dietary Manager revealed there had been a lapse between Dietary Managers at the facility for about three weeks, with support staff filling in to help the facility dietary staff, and a new Dietary Manager had just been hired. She confirmed the inconsistency of the pureed-texture foods served to residents had been an issue. She explained the SLP had brought concerns to her attention on several occasions regarding the consistency of the pureed food items and conducted in-services with dietary staff. The District Dietary Manager explained pureed texture should be a pudding-like consistency, not diced or chopped, and slide off the utensil. She stated there was no recipe for pureeing the food items which made it hard to be consistent. The Dietary Manager explained that as far as ensuring the correct consistency of pureed food, staff would need more in-servicing on how to properly prepare pureed foods by using liquid to reach the desired consistency and having a Dietary Manager on the line for monitoring meal service.During an interview on 07/09/26 at 5:03 PM, the Administrator revealed she was aware of concerns with the inconsistency of pureed food items and after multiple conversations with the District Dietary Manager, the inconsistency of pureed items remained an ongoing issue. The Administrator explained pureed food items should be thin enough to slide through the prongs of a fork and during her observations, the meat and vegetables were usually okay, but food items such as bread and desserts were usually too thick. The Administrator stated it was her expectation for residents to receive the correct diet consistency as per their diet order.

Based on record review and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary concerns voiced by residents during Resident Council meetings for 6 of 12 months reviewed (January 2026, February 2026, March 2026, April 2026, May 2026, and July 2026).Findings included:The Resident Council minutes for the period August 2025 through July 2026 were reviewed and revealed the following:Resident Council minutes dated 01/09/26 noted in part, old business was noted as read and approved and any issues not resolved were moved to new business. Under new business, residents voiced food was the main concern, menus have been reviewed with food managers, and the diet doesn't reflect residents' likes or dislikes. Snacks were not being passed. Resident Council minutes dated 02/06/26 noted in part, old business was noted as resident council had not received a reply from administration in regard to January concerns. Under new business, residents voiced food was the main concern, meats were processed meats and not real meat. Resident Council minutes dated 03/06/26 noted in part, old business was noted as responses from administration were discussed and food continued to be an ongoing issue. Under new business, residents voiced snacks were not offered. Residents waited in the dining room for meals to be served. Resident Council minutes dated 04/03/26 noted in part, old business was noted as no follow up from administration from March concerns. Under new business, residents voiced food was still a concern. Residents' preferences were not being honored. Staff were not asking residents' preference for meals. Meals were late. Breakfast at 9:00 AM and lunch at 1:45PM. Resident Council minutes dated 05/01/26 noted in part, old business noted as responses from administration were discussed and food continued to be a concern. Under new business, residents voiced food still the main concern. Mealtimes were off schedule. Only one staff member delivered meal trays. Resident Council minutes dated 07/03/26 noted in part, old business was noted as reviewed. Under new business, residents voiced food dislikes were still an issue. When a resident was out with family, they did not get a dinner tray.The facility's grievance logs for the period August 2025 through July 2026 were reviewed. Grievances filed on behalf of the Resident Council related to the concerns voiced during the monthly meetings were all noted as resolved.A Resident Council group interview was conducted on 07/07/26 at 1:50 PM with Resident #30, Resident #36, Resident #40, Resident #71, and Resident #78 in attendance. All residents reported ongoing dietary concerns, specifically that food preferences were not being followed. The residents agreed that menu choices provided to staff were not what was being served to the residents. Residents reported there was inconsistency between what they had ordered for lunch or dinner and what they received.During an interview on 07/09/26 at 6:18 PM, the Dietary Manager revealed she attended Food Committee meetings, which took place immediately after Resident Council and included the same residents as Resident Council. She stated the Food Committee discussed similar food issues each month, and she was aware of the food concerns voiced by residents. The Dietary Manager confirmed she had worked with the Corporate Registered Dietitian to develop a more culturally appropriate menu that still met the nutritional needs of the residents. She expressed it is an ongoing process that will take some time to make changes.During an interview on 07/09/26 at 09:58 AM, the Activity Director revealed she did not attend the Resident Council meeting at the request of the residents. She stated the Resident Council President documented the meeting minutes and provided her the minutes after the meeting. The Activity Director reviewed the Resident Council minutes with the Administrator and Social Worker (SW). The Activity Director stated that grievances from the meeting minutes were transferred to a grievance form by the SW and dispersed to the appropriate department for resolution. Resolved grievances were returned to the Resident Council President to be presented to the Resident Council. The Activity Director stated the food issues were reoccurring concerns for Resident Council. She also confirmed the facility had a Food Council that met after Resident Council.During an interview on 07/09/26 at 10:19 AM, the SW revealed she met with the Resident Council President and Administrator the day after the Resident Council meeting to review the new grievances and communicate progress on past grievances. She stated she transferred all new grievances from the Resident Council minutes to a grievance form and provided the appropriate department with the form. Once the grievances were resolved, she gave a copy of the resolved grievance form to the Resident Council president and placed another copy in the grievance log.During an interview on 07/09/26 at 10:31 AM, the Administrator stated she met, or the SW met, with the Resident Council President to review Resident Council grievances. She was aware there had been repeated dietary concerns voiced during Resident Council meetings. The Administrator explained she continued to meet with the Dietary Manager to improve and resolve the residents' dietary concerns.

Based on observations and staff interviews, the facility failed to discard expired food from 1 of 1 walk-in cooler, date food items in 1 of 1 walk-in freezer, cover food items in 1 of 1 walk-in cooler, and remove expired food available for use from 1 of 1 dry storage room. This deficient practice had the potential to affect food served to residents. Findings included: 1. An initial observation of the walk-in cooler on [DATE] at 10:02 AM revealed a box of thawed premade peanut butter and honey sandwiches with a date of [DATE]. An interview with the Dietary Manager on [DATE] at 10:05 AM revealed the date of [DATE] indicated that was the date the sandwiches were placed in the cooler, and she was not sure how long they were good for after they were thawed but she would check. A follow-up interview with the Dietary Manager on [DATE] at 11:00 AM revealed she was unable to locate the manufacturer's information on how long the premade sandwiches were good for after being thawed, so she discarded the sandwiches. An interview with the Administrator on [DATE] at 3:13 PM revealed he expected food to be stored according to manufacturer's guidelines. 2. An initial observation of the walk-in freezer on [DATE] at 10:07 AM revealed 2 undated bags of french toast sitting on a shelf in the freezer and a box of frozen pizzas open to air. An interview with the Dietary Manager on [DATE] at 10:10 AM revealed the french toast should have had a date written on it when it was placed in the freezer by the staff member. She stated the pizzas should have been covered and not left open to air by the staff member who opened the box. An interview with the Administrator on [DATE] at 3:13 PM revealed he expected all food in the walk-in freezer to be dated and covered appropriately. 3. An initial observation of the dry storage room on [DATE] at 10:15 AM revealed two and a half cases of canned pureed turkey sitting on a shelf with a best-by date of [DATE]. An interview with the Dietary Manager on [DATE] at 10:18 AM revealed the turkey should have been used or discarded on or before the best-by date. An interview with the Administrator on [DATE] at 3:13 PM revealed he expected food to be used or discarded on or before the best-by date.

Based on record review and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when Nurse Aide #1 raised her voice, yelled and argued with a resident causing the resident to become upset for 1 of 3 residents reviewed for dignity (Resident #122). A reasonable person would not want to be yelled at and could feel belittled, scared or threatened when spoken to in such an undignified manner. Findings included: Resident #122 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #122 had moderate impairment in cognition. He had no behaviors and required assistance with toileting hygiene and transfers. Review of the facility's investigation documentation revealed on 08/28/24, Nurse #2 and Nurse Aide (NA) #2 reported they witnessed NA #1 display verbal aggression toward Resident #122 by yelling and arguing with him after he had fallen while attempting to go to the bathroom unassisted. When NA #2 continued arguing back and forth with Resident #122, Nurse #2 intervened and removed NA #1 from the room. Corrective actions included mandatory inservice for all staff on residents rights, neglect, abuse and exploitation. In addition, NA #1 was immediately suspended and her employment subsequently terminated on 09/02/24 following the completion of the facility's investigation. Resident #122 discharged from the facility on 11/26/24 and was unable to be interviewed. An undated witness statement written by NA #1 revealed in part that on 08/28/24 after Resident #122 had fallen in the bathroom she asked him why he had attempted to go to the bathroom unassisted and Resident #122 started shouting at NA #1 stating that was what she told him to do. NA #1 noted in the statement that she denied telling that to Resident #122 and in an attempt to defend myself, I did raise my voice. NA #1 further noted in the statement, I admit I shouldn't have spoken loudly to any resident, I feel that it could have been handled better by all parties involved. During a phone interview on 04/16/25 at 4:54 PM, NA #1 recalled on the evening of 08/28/24, NA #2 called her to the room because Resident #122 had fallen on the bathroom floor and the door wouldn't open. NA #1 stated she managed to wedge herself through the door to get it open for Nurse #2 and NA #2 to come in. When Nurse #2 asked Resident #122 what happened, Resident #122 started yelling and screaming at her (NA #1) stating that she had told him to go to the bathroom. NA #1 stated she responded by telling Resident #122 that what he was saying was not true and she never told him to take himself to the bathroom. NA #1 stated she never cursed or yelled at Resident #122 but did disagree with what he was telling Nurse #2. NA #1 stated she was asked to leave the room by Nurse #1, was sent home that night and a few days later she was notified her employment was terminated. During a phone interview on 04/16/25 at 4:28 PM, Nurse #2 confirmed she had worked at the facility on 08/28/24 during the hours of 7:00 PM to 7:00 AM and recalled being notified that Resident #122 had fallen on the bathroom floor. Nurse #2 stated she couldn't recall the exact specifics of what happened but did remember as she entered Resident #122's bathroom, NA #1 came in behind her and stood over Resident #122 with one leg on each side of him. Nurse #2 stated when she asked Resident #122 what happened, he looked at NA #1 and stated he only did what she (NA #1) told him to do, which was to get up off his butt and go to the bathroom. Nurse #2 recalled NA #1 then started screaming and cursing stating she never said anything like that to Resident #122. Nurse #2 stated Resident #122 was upset, so she intervened instructing NA #1 to leave the room and called the Nurse Supervisor to let her know what had happened. Nurse #2 stated after NA #1 left the room and staff assisted Resident #122 up off the floor and back to bed, he calmed down and returned back to his baseline. During a phone interview on 04/17/25 at 9:48 AM, NA #2 revealed she witnessed the incident involving Resident #122 and NA #1 on 08/28/24. NA #2 stated at the time, she was a Personal Care Assistant (PCA) and was going room-to-room with NA #1 helping with what she could. NA #2 recalled early in the shift on 08/28/24 around 5:00 PM, she went into Resident #122's room with NA #1 because he had wet the bed. She recalled Resident #122 had recently returned from the hospital and wasn't feeling well. NA #2 stated NA #1 started getting snippy (irritable) with Resident #122 and asking him various questions such why he hadn't used the urinal like he used to and why he didn't just get up and go to the bathroom. NA #2 couldn't recall the exact time but stated it was sometime later in the shift when she had checked in on Resident #122 and found him lying on the bathroom floor and called for NA #1 to come to the room. NA #2 stated she and Nurse #2 were both present when NA #1 raised her voice when asking Resident #122 why he was in the bathroom. NA #2 stated when Resident #122 told NA #1 that he was just doing what she had told him to do, NA #1 started yelling at Resident #122 stating she never told him to do that. NA #2 stated Resident #122 was upset that he had fallen and NA #1 talking and arguing with him the way she did just upset him further. NA #2 stated NA #1 never cursed at Resident #122 but she was being very disrespectful and argumentative toward Resident #122. During an interview on 04/17/25 at 3:22 PM, the Administrator revealed it was never appropriate for staff to speak to residents disrespectfully. He explained if residents were resistive or upset, staff were instructed to walk away from the situation and get another staff member to try and provide the resident's care. The Administrator explained at the time of the incident with Resident #122, NA #1 was going through a lot of personal issues which he felt likely contributed to her losing control of her behavior and speaking disrespectfully to Resident #122 but it should have never escalated to the point that it did. The Administrator stated he did not feel that NA #1 was verbally abusive to Resident #122 but she was definitely disrespectful, which was never acceptable.

Based on record review and interviews with staff, the facility failed to protect resident rights to be free from misappropriation of controlled medication for 1 of 7 residents reviewed for misappropriation of resident property (Resident #276). The findings included: Review of the facilities Abuse, Neglect and Exploitation policy and procedure which was last reviewed on 4/4/25 revealed that the facility stated residents had the right to be free from misappropriation of property. Resident #276 was admitted to the facility on [DATE] with diagnosis that included depression, anxiety disorder and dementia. Review of the quarterly minimum data set (MDS) dated [DATE] revealed that Resident #276 was severely cognitively impaired. Review of the physician's order dated 10/16/24 revealed Resident #276 had an order to receive 0.5 milligrams (MG) of lorazepam (a medication used to treat anxiety) every 6 hours as needed for anxiety for 14 Days. Review of the facilities investigation dated 10/26/24 revealed at 9:00 PM on 10/25/45 the Administrator in Training (AIT) was comforting Resident #275. Upon leaving the resident's room the AIT discovered 2 white pills. The AIT took the lorazepam pills to the nurse on the hall Nurse #6. At around 10:00 PM to 10:15 PM the AIT asked Nurse #6 if she had solved the issue with the pills found in Resident #275's room. Nurse #6 stated she was going to waste the pills with another nurse, Nurse #3. Nurse #6 then confirmed the medication did not belong to Resident #275. At 10:15 PM on 10/25/24 Nurse #3 was asked to count narcotics with Nurse #6. The count was completed and there were two narcotics that needed to be fixed/ corrected. The pills were punched out and Nurse #6 stated that she was going to take the pills to the resident that needed them. At 4:50 AM Nurse #7 was reviewing the narcotic count sheet. Nurse #7 found that a controlled medication was marked as wasted and another medication was signed out, but no one was documented as having witnessed the waste. Nurse #7 reached out to Nurse #6 who was still in the building catching up on charting from her shift. Nurse #7 had noted suspicious activity for Resident #276 controlled medication. Nurse #7 then informed the AIT of the suspicious activity. At 5:00 AM on 10/26/24 Nurse #3 was asked to sign for 2 pills that were wasted by Nurse #6. Nurse #3 signed off on the narcotic sheet that the 2 white pills were wasted. The AIT then suspended Nurse #6 pending an investigation. The facility then interviewed Nurse #3, Nurse #6, and Nurse #7 and sent Nurse #6 for a drug test on 10/28/24. Resident # 276's medication administration record (MAR) was reviewed, and it was documented that the controlled medication was as needed and last administered in August 2024. The allegation of diversion of residents' drugs was substantiated and Nurse #6 was terminated on 10/29/24. The facility filed a report to the North Carolina Board of Nursing (NC BON) on 10/29/24. The investigation was documented by the AIT. Review of the controlled medication count sheet revealed that Nurse #6 had signed out one tablet of lorazepam 0.5 MG for Resident #276 on 10/25/24 at 9:00 PM and then documented it as a wasted punch and another tablet of lorazepam at 9:00 PM and then documented it as a wasted punch. Nurse #3 signed off as having witnessed the wasting of both tablets of lorazepam. Review of Resident #276's October 2024 Medication Administration Record (MAR) revealed the prn lorazepam was not initialed administered. A phone interview with Nurse #3 was attempted several times without success. This Nurse no longer worked at the facility. A phone interview with Nurse #6 was attempted several times without success. This Nurse no longer worked at the facility. A phone interview with Nurse #7 was attempted several times without success. This Nurse no longer worked at the facility. An interview with the AIT on 4/17/25 at 10:24 AM revealed she arrived at the facility at 9:00 PM on 10/25/24 to sit and meet with Resident #275. She sat with Resident #275 for 45 minutes to an hour. She got up and spoke to Nurse #6 to tell her she calmed Resident #275 down. She went back into Resident #275's room and found a little white pill with EP904 on it in his bed. She took the pill to Nurse #6, and Nurse #6 snatched it out of the AIT's hand and placed it in a little plastic medication cup and placed that in the top drawer of Nurse #6's medication cart. The AIT stated that she went back into Resident #275's room and saw a second little white pill with EP904 on it on the ground next to Resident #275's shoe. She took that second pill to Nurse #6 and asked her what it was. She stated that Nurse #6 told the AIT she wasn't supposed to see that and took the pill from her. Nurse #6 then stated that she would waste the medication after she finished her medication pass. The AIT stated that she googled EP904 and discovered the medication was lorazepam. She stated that when Nurse #7 came in between 10:00 PM to 10:30 PM the AIT asked Nurse #7 to verify if Resident #275 had an order for lorazepam. Nurse #7 informed the AIT that Resident #275 did not have an order for lorazepam. Nurse #7 looked at the controlled medication count sheet for Resident #275 and stated that the documentation was incomplete and asked if Nurse #6 was still at the facility. The AIT told Nurse #7 that Nurse #6 was still there. Nurse #7 stated that she was going to go take care of it with Nurse #6. The AIT stated that Nurse #7 confronted Nurse #6 about correcting the controlled medication count sheet. She stated that Nurse #7 said Nurse #6 had first asked her to sign the witness section for the two wasted lorazepam tablets. Nurse #7 stated that she had refused as she was not present during the wasting of the lorazepam. The AIT explained Nurse #6 then took the controlled medication count sheet to Nurse #3 and asked her to sign the witness for the lorazepam waste that Nurse #6 stated she had completed earlier in the night. Nurse #3 signed off the witness signature for the 2 lorazepam tablets Nurse #6 stated she had wasted. The AIT the called the Administrator and the former Director of Nursing (DON) immediately. The AIT stated that she then asked Nurse #3 if she had witnessed Nurse #6 wasting the 2 lorazepam tablets earlier. Nurse #3 stated no she didn't see the pills get wasted and she knew she shouldn't have signed off on the controlled medication count sheet. The AIT revealed that Nurse #6 had already left at this point and the former DON called Nurse #6 to let her know she was suspended pending an investigation. On Monday 10/28/24 she sent Nurse #6 to get a drug test, and they terminated Nurse #6 on 10/29/24 after their investigation was completed. A phone interview with the former Director of Nursing (DON) on 4/17/25 at 2:03 PM revealed that the AIT informed her that she had found lorazepam in Resident #275's room and gave it to Nurse #6. She stated that she was partially involved in the investigation, and she had confirmed that Resident #276 had the orders for the lorazepam. She and the AIT called Nurse #6 together to interview her during the facilities investigation and asked her to take a drug test on 10/28/24. An interview with the Administrator on 4/17/25 at 2:58 PM revealed that 2 of Resident #276's lorazepam pills were found in Resident #275's room on his bed and on the floor beside his shoe and Resident #275 did not have an order for lorazepam. He stated that the facility opened an investigation, reported Nurse #6 to the Board of Nursing, and suspended Nurse #6. He stated that ultimately, they ended up terminating Nurse #6. He indicated that was all the information he had about that investigation.

Based on record review and staff interviews, the facility failed to implement their abuse policy and procedure by not maintaining evidence of an investigation into misappropriation of property and not immediately reporting an allegation of abuse to the Administrator/designee and not notifying local law enforcement or Adult Protective Services of allegations of abuse or misappropriation of property for 3 of 5 abuse investigations reviewed (Residents #12, #24, #27, #43, #223, #222). The findings included: Review of the facilities Abuse, Neglect and Exploitation policy and procedure which was last reviewed on [DATE]. The administrator will be immediately notified by staff if abuse, neglect, mistreatment, misappropriation and or exploitation is alleged or suspected. Staff will document the investigation findings including any recommendations of corrective action and such documentation will be retained as part of the investigation file. a. Review of the initial allegation report submitted by the facility to the State Agency noted an allegation type of misappropriation of resident property that the facility was made aware of on [DATE] at 4:52 PM that noted the medications of Resident #12, Resident #24, Resident #27, and Resident #43 were found in Nurse #8's personal bag at the nurse's station. The facility attempted to notify Nurse #8 of her suspension and local law enforcement were notified of misappropriation of resident property. A review of the facility's investigation documentation revealed that Nurse #8 had removed the medications from the cart because the residents no longer used the medications or they were expired. The investigation consisted of a statement from Nurse #8 and interviews conducted with alert and oriented residents asking if they were happy with their care, if staff was treating them with dignity and respect, and if the nurses provided care including medications in a professional manner. There was no additional information included in the facility's investigation such as the names of the medications or amount of medications for each resident that was found in Nurse #8's personal bag. Several attempts were made to interview Nuse #8 with no success. She no longer worked at the facility. A phone interview with the former Director of Nursing (DON) on [DATE] at 2:03 PM revealed that she had been the DON for approximately 2 months when this incident occurred. She stated that she saw a bag at the nursing station and when she checked the bag, there were resident medications inside. She stated that she started the initial report to submit to the State Agency and notified the Social Worker, Administrator and Corporate. The former DON explained as part of the investigation, she got a statement from Nurse #8, notified the physician, monitored the residents for adverse reactions, got a list of medications that were found, and initiated a plan of correction. In addition, she obtained drug screen from Nurse #8, notified local authorities, notified the resident's responsible parties and or the residents. She stated that she had completed a thorough investigation and was unsure why none of the documentation for all the things she completed was gone. An interview with the Administrator on [DATE] at 3:01 PM revealed that the former DON stated that some staff brought the bag with the resident medications in them to her. He stated that the investigation was a reportable to the State Agency and there was an attempt to interview Nurse #8. He stated that he was uncertain of what steps were completed as part of this investigation and had no idea where the missing documentation for the investigation might be. A phone interview with the former Corporate Nurse on [DATE] at 3:41 PM revealed that as part of the investigation, all she did was ask the alert and oriented residents about their care and medication administration and no residents had reported any issues. She stated that she was normally the one who returned medications to pharmacy for destruction but she could not recall if she returned the medications that were found in Nurse #8's bag. The Corporate Nurse stated she was unsure where any additional documentation related to the investigation would be located. 39037 b. Review of the initial allegation report submitted by the facility to Division of Health Service Regulation (DHSR) via fax transmission on [DATE] at 5:40 PM noted an allegation of diversion of resident drugs that the facility was made aware of on [DATE] 3:30 PM. It was alleged that a possible diversion of medication had occurred due to Resident #223's liquid Morphine being an abnormal color. The allegation was not reported to law enforcement. Review of the 5-day investigative report submitted by the facility to DHSR via fax transmission on [DATE] at 9:25 AM noted Adult Protective Services (APS) was not notified of the allegation. Further review revealed the allegation of diversion of resident drugs was unsubstantiated. An interview with the Social Worker (SW) on [DATE] at 3:02 PM revealed she completed the 24-hour/5-day report for the allegation of possible diversion of Resident #223's liquid Morphine. She stated she did not notify law enforcement or APS because she wasn't instructed to by the Administrator. The SW stated the Director of Nursing (DON) and Administrator were also involved in the investigation and she only completed the reports and faxed them to DHSR. A telephone interview with the former DON on [DATE] at 4:37 PM revealed she completed interviews with nurses working on Resident #223's hall when the liquid Morphine was noted to be clear in color instead of blue and sent the Morphine back to the pharmacy. She stated that was all she could recall regarding the allegation and the SW and Administrator would probably have more information. An interview with the Administrator on [DATE] at 2:04 PM revealed the SW completed the 24-hour report and the department involved with the allegation completed the 5-day investigation. He stated once the information was collected for the 24-hour/5-day reports, he reviewed the information and consulted with the former Compliance Officer to see if any additional actions should be taken, and if not the report was sent to DHSR. The Administrator stated the former Compliance Officer did not instruct him to notify law enforcement or APS. c. Review of the initial allegation report submitted by the facility to Division of Health Service Regulation (DHSR) via fax transmission on [DATE] at 4:48 PM noted an allegation type of resident abuse that the facility was made aware of on [DATE] at 8:30 AM. Nurse #3 alleged that Nurse #4 was unable to focus when caring for Resident #222 the night of [DATE], went to his car for long periods of time and was sleepy when he returned, drew up liquid Morphine for Resident #222 and placed the syringe behind his ear and had to be told to administer the medication, and gave the liquid Morphine too rapidly, causing the resident to get strangled. Law enforcement was not notified of the allegation. Review of the 5-day investigative report submitted by the facility to DHSR via fax transmission on [DATE] at 12:33 PM noted Adult Protective Services (APS) was not notified of the allegation on [DATE]. Further review revealed the allegation of resident abuse was unsubstantiated. Nurse #3 and Nurse #4 were unavailable for interview during the investigation. An interview with the Social Worker (SW) on [DATE] at 3:02 PM revealed she was unsure if the allegation for Resident #222 needed to be reported to DHSR and did not complete the 24-hour/5-day report until she was instructed to by the Administrator. She further stated she did not notify law enforcement or APS because she wasn't instructed to by the Administrator. The SW stated the Director of Nursing (DON) and Administrator were also involved in the investigation and she only completed the reports and faxed them to DHSR. A telephone interview with the former DON on [DATE] at 4:37 PM revealed she could not recall any further details about the allegation of resident neglect for Resident #222 and the SW and Administrator would have more information about the allegation. An interview with the Administrator on [DATE] at 2:04 PM revealed he was unsure why Nurse #3 waited so long to report the allegation of abuse for Resident #222 since she had received education multiple times on immediately reporting abuse or neglect concerns to him or the SW. He was unable to explain why the initial report was not submitted within the 2-hour time frame. The Administrator explained the SW completed the 24-hour report and the department involved with the allegation completed the 5-day investigation. He stated once the information was collected for the 24-hour/5-day reports, he reviewed the information and consulted with the former Compliance Officer to see if any additional actions should be taken, and if not the report was sent to DHSR. The Administrator stated the former Compliance Officer did not instruct him to notify law enforcement or APS.

Based on observation and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of oxygen use for 1 of 3 residents reviewed for respiratory care (Resident #272). The findings included: Resident #272 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #272's physician orders revealed an order dated 04/13/25 for oxygen to be administered continuously via nasal cannula at 3 liters per minute, may titrate to keep oxygen (O2) saturation greater than 90%. A review of the admission Minimum Data Set, dated dated dated [DATE] revealed Resident #272 was not coded for oxygen use. An observation on 04/14/25 at 11:56 AM revealed Resident #272 sitting in his wheelchair by his bed with oxygen being administered via nasal cannula by an oxygen concentrator.

Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of a resident's admission (Resident #272) and ensure a baseline care plan addressed insulin use for a resident with diabetes (Resident #73) for 2 of 4 residents reviewed for respiratory care and self-administration of medications. The findings included: 1. Resident #272 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #272's medical record revealed no baseline care plan had been developed for him within 48 hours of admission. On 04/17/25 at 9:16 AM an interview with the Admission/Discharge Nurse revealed she was responsible for completing baseline care plans, but if a resident was admitted over the weekend the nurse on the hall admitting the resident was responsible for completing it. An interview on 04/17/25 at 10:14 AM with the MDS Coordinator revealed the nurse on the hall who admitted a resident was responsible for completing the baseline care plan. An observation of Resident # 272's electronic medical record with the MDS Coordinator showed no baseline care plan. An interview on 04/17/25 at 12:32 PM with the Director of Nursing (DON) revealed the facility computers were not working over the past weekend as the facility had been acquired by another company and the computers were being changed over. She indicated the admitting nurse was responsible for completing the baseline care plan, and that it was important for a baseline care plan to be completed for resident care needs and preferences to be known. On 04/17/25 at 3:38 PM an interview with the Administrator revealed baseline care plans should be completed timely and accurately by the admitting nurse. 39037 2. Resident #73 was admitted to the facility 04/07/25 with a diagnosis including diabetes. Review of Resident #73's Physician orders revealed orders dated 04/07/25 for Insulin Glargine 100 units per milliliter inject 30 units subcutaneously (under the skin) at bedtime and Insulin Lispro 100 units per milliliter per sliding scale before meals and at bedtime. A review of Resident #73's baseline care plan dated 04/08/25 revealed in the Medications/Treatments there was no indication she received Insulin and in the Medical Conditions section there was no indication she had a diagnosis of diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed it was in progress. In an interview with the Admission/Discharge Nurse on 04/17/25 at 9:15 AM she confirmed she completed Resident #73's baseline care plan. She stated Resident #73's baseline care plan should have reflected that she had a diagnosis of diabetes and received Insulin, and it was overlooked. An interview with the Director of Nursing (DON) on 04/17/25 at 2:02 PM revealed she expected a baseline care plan to accurately reflect a resident's diagnosis and medications. She stated Resident #73's baseline care plan should have reflected she was a diabetic and received Insulin and, the person completing the baseline care plan was responsible for ensuring it was accurate. An interview with the Administrator on 04/17/25 at 3:32 PM revealed he expected baseline care plans to be accurate.

Based on observations, record review, and resident and staff interviews, the facility failed to provide showers as scheduled to a resident dependent on staff assistance for bathing for 1 of 4 residents reviewed for activities of daily living (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (trouble breathing), heart failure, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #2 with intact cognition and was dependent on staff assistance with showering/bathing and transfers. She displayed no behaviors and did not reject care during the MDS assessment period. A review of Resident #2's comprehensive care plans last reviewed/revised on 03/13/25 revealed she had an activities of daily living self-care performance deficit related to deconditioning, COPD and heart failure. Interventions included dependence on staff with showering twice weekly and as necessary. Review of the master shower schedule revealed Resident #2 was scheduled to receive a shower on Wednesday and Saturday during the hours of 7:00 AM to 3:00 PM. Review of the Nurse Aide (NA) point of care documentation report for April 2025 revealed no evidence Resident #2 received her showers on Saturday as scheduled. During an observation and interview on 04/14/25 at 3:45 PM, Resident #2 was lying in bed with the head of bed slightly elevated. Resident #2's hair was uncombed and appeared greasy. Resident #2 stated she was supposed to receive two showers per week on Wednesday and Saturday but for the past 3 weeks she had not been receiving her scheduled shower on Saturday. Resident #2 could not recall the name of the staff she spoke with but stated when she asked if she was going to get her shower, their response was we'll see. Resident #2 revealed staff did not offer to give her a bed bath when a shower wasn't given nor was her hair washed until she received her scheduled shower on Wednesday. Resident #2 expressed when she didn't get a shower, she felt like she smelled and it made her feel nasty. During an interview on 04/17/25 at 10:41 AM, Nurse Aide (NA) #3 revealed she was routinely assigned to provide Resident #2's care. NA #3 stated Resident #2 was scheduled to receive showers on Wednesday and Saturday each week and had mentioned to her in the past that she did not always receive her scheduled shower on Saturdays. NA #3 explained she frequently provided Resident #2 her scheduled shower on Wednesdays and she never refused when offered. NA #4 who provided Resident #2's care on 04/05/25 (Saturday) and NA #5 who provided Resident #2's care on 04/12/25 (Saturday) were unable to be reached for an interview. During an interview on 04/17/25 at 11:09 AM, the Administrator in Training (AIT) revealed she was also a NA and had provided Resident #2 with a shower in the past. The AIT could not recall the date but stated it was one weekend when she was at the facility, Resident #2 had stated she didn't get her scheduled shower that Saturday. The AIT stated she reviewed the NA point of care documentation for April 2025 and confirmed there was no documentation to indicate Resident #2 was provided her showers on Saturdays as scheduled. During an interview on 04/17/25 at 3:22 PM, the Administrator stated he would expect for staff to provided residents their showers as scheduled.

Based on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside a resident's room that indicated the use of oxygen for 1 of 3 residents reviewed for respiratory care (Resident #272). The findings included: Resident #272 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #272's physician orders revealed an order dated 04/13/25 for oxygen to be administered continuously via nasal cannula at 3 liters per minute, may titrate to keep oxygen (O2) saturation greater than 90%. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #272 exhibited no behavior or rejection of care and was not coded for oxygen use. An observation on 04/14/25 at 11:56 AM revealed Resident #272 sitting in his wheelchair by his bed with oxygen being administered via nasal cannula by an oxygen concentrator. There was no cautionary or safety signage posted outside his room indicating supplemental oxygen was in use. An observation on 04/15/25 9:22 AM revealed Resident #272 lying in bed with oxygen being administered via nasal cannula by an oxygen concentrator. There was no cautionary or safety signage posted outside his room indicating supplemental oxygen was in use. An interview with Nurse #1 on 04/16/25 at 3:19 PM revealed the nurse assigned to the hallway was responsible for placing the oxygen in use signage but she was not aware where the signage was kept. On 04/16/25 at 2:12 PM an interview was held with the Director of Nursing (DON). She indicated the nurse who admitted a new resident was responsible for placing the oxygen signage on the resident's door, but any nurse could place the signage. The DON continued to voice the oxygen in use signage should have been placed on Resident #272's door and was not certain why it was not in place. An interview with the Administrator on 04/17/25 at 3:38 PM revealed the signage should have been placed on the resident's door and he did not know why it was not in place.

Based on observations, record review, and staff interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #73). Findings included: Resident #73 was admitted to the facility 04/07/25 with a diagnosis including costochondritis (inflammation of the cartilage that connects a rib to the breastbone). Review of the baseline care plan dated 04/08/25 revealed Resident #73 was cognitively intact. Review of the medical record revealed Resident #73 was assessed for self-administration of medication on 04/08/25. The assessment indicated Resident #73 was not approved for self-administration of medications and may not keep medications at the bedside. Review of Resident #73's Physician orders revealed an order dated 04/09/25 for Diclofenac Sodium gel 1% (anti-inflammatory medication) apply to left chest wall twice a day for 14 days. Resident #73's admission Minimum Data Set (MDS) assessment dated [DATE] was in progress. An observation of Resident #73's room on 04/16/25 at 8:08 AM revealed a tube of Hydrocortisone (anti-inflammatory) cream 1% sitting on top of her overbed table and a medication cup containing a whitish gel-like substance sitting on the dresser beside her bed. An interview with Resident #73 on 04/16/25 at 8:08 AM revealed the substance in the medication cup was medication provided by the facility that she applied daily to her chest for pain. She stated she was not aware of the name of the substance in the medication cup. Resident #73 further stated her family brought her the Hydrocortisone cream for itchy skin and she applied it when she needed it. She stated she could not recall when she last applied the Hydrocortisone cream. An interview with the Director of Nursing (DON) on 04/16/25 at 8:17 AM revealed she was unable to identify the whitish substance in the medication cup but stated it should not be left in Resident #73's room. An interview with Nurse #1 on 04/16/25 at 3:42 PM revealed she was caring for Resident #73 on the 7:00 AM to 7:00 PM shift. She stated she didn't leave the medication cup with the whitish substance on Resident #73's dresser and if she had seen the cup she would have removed it. An observation of Resident #73's overbed table on 04/17/25 at 8:32 AM revealed a tube of Hydrocortisone cream 1% sitting on top of the table. A follow-up interview with the DON on 04/17/25 at 2:02 PM revealed the whitish substance in the medication cup on 04/16/25 was most likely Diclofenac Sodium. She stated no medications should be left in a resident's room unless they had been assessed as safe to self-administer the medication and if the resident was not safe to administer their medication, the medication should be stored in the medication or treatment cart. An interview with Nurse #5 on 04/17/25 at 3:32 PM revealed she was caring for Resident #73 on the 7:00 AM to 3:00 PM shift. She stated she did not see the Hydrocortisone cream on Resident #73's overbed table and if she had she would have removed it from the room. An interview with the Administrator on 04/17/25 at 3:19 PM revealed he expected staff to store medications appropriately.

Based on observations, record review, staff interviews, and review of the facility's policies and procedures, the facility staff failed to follow infection control procedures when Nurse #1 did not don a gown while administering Resident #51's tube feeding for 1 of 5 staff members observed for infection control practices. The findings included: Review of the facility's undated policy for Enhanced Barrier Precautions revealed that gowns and gloves should be worn when performing high contact resident care activities such as device care or use with central lines, urinary catheters, feeding tubes, tracheostomies or ventilators. An observation on 04/16/25 at 11:59 AM of Nurse #1 entering Resident #51's room that had a sign on the door for Enhanced Barrier Precautions which instructed staff to don gloves and gown. Nurse #1 entered the room and informed Resident #51 she was going administer his tube feed, washed her hands, and applied clean gloves. Nurse #1 proceeded to attach the tube extension set to the gastrostomy tube (feeding tube surgically inserted into the stomach) and administered the bolus tube feeding. An interview with Nurse #1 on 04/16/25 12:01 PM revealed that she did not need to put on a gown for the administration of a tube feed. She stated that she thought the sign was for Resident #51's roommate and that she wasn't sure. A phone interview on 04/16/25 at 1:05 PM with the Infection Preventionist revealed that the Enhanced Barrier Precaution sign was for Resident #51. She stated that Nurse #1 should have worn gown and gloves for the administration of the tube feeding. She stated that Nurse #1 had been educated on what Enhanced Barrier Precautions were and when they needed to be implemented. She stated that if a staff member was unsure who was on Enhanced Barrier Precautions there was an A or B on the sign on the door or on the back of the door indicating which bed was on precautions. She further stated that there was a list posted at the nurse's station letting staff know which residents were on precautions. A joint interview on 04/16/25 at 12:24 PM with the Administrator and the Administrator in Training (AIT) revealed Enhanced Barrier Precautions were for Resident #51 because of his feeding tube. The AIT stated that during education it was explained that if staff entered a room to provide care in a room that had Enhanced Barrier Precautions sign, and the staff were unsure which resident the signs were for then the staff should assume it applied to both residents and put on the appropriate personal protective equipment (PPE). The Administrator stated that his expectations were that if Enhanced Barrier Precaution signage was present that staff put on the appropriate PPE when providing direct patient care.

Based on observation, record review and Responsible Party, staff, and Medical Doctor interviews, the facility failed to safely transfer a resident from the bed to the chair when one staff member used a mechanical lift resulting in the resident falling to the floor for 1 of 6 sampled residents reviewed for accidents (Resident #30). On 05/17/23, while being transferred one of the clasps attaching the sling to the mechanical lift malfunctioned resulting in Resident #30 falling out of the sling onto the floor. Upon initial nurse assessment, Resident #30 complained of no pain and had no obvious injuries but later that same day he complained of hip pain, was sent out to the hospital for evaluation, x-rays obtained revealed no hip fracture and he returned to the facility on [DATE]. On 05/22/23 additional x-rays were obtained due to complaints of neck pain that revealed Resident #30 had sustained a C7 (one of the cervical vertebrae that support the head and connect it to the shoulders and body) and T1 (vertebrae that make up the spine and located in the upper part of the back) fracture. Findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included progressive neurological conditions (refers to a progressive deterioration in function that can be gradual over time or rapid), Parkinson's disease, and dementia with Lewy Bodies. The annual Minimum Data Set (MDS) dated [DATE] assessed Resident #30 with moderate impairment in cognition and had impairment on both sides of the upper and lower extremities. Resident #30 required substantial/maximal staff assistance for bed mobility (roll left and right) and total staff assistance with transfers. An Activity of Daily Living (ADL) care plan, last revised 05/18/23, revealed Resident #30 had an ADL self-care performance deficit related to Lewy Body dementia, fatigue, impaired balance, limited mobility, and Parkinson's disease. Included was an intervention initiated on 08/09/22 that noted Resident #30 required a mechanical lift with a sling and two-person assistance for all transfers. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #30 with moderate impairment in cognition. Resident #30 had impairment on both sides of the upper and lower extremities and was totally dependent on staff for self-care and mobility. During a telephone interview on 01/25/24 at 10:13 AM, Resident #30's Responsible Party (RP) revealed on 05/17/23 Resident #30 was dropped from the mechanical lift during a transfer due to a malfunction of the machine. The RP stated she learned of the incident when she arrived at the facility on 05/17/23 around lunchtime and recalled Resident #30 was in pain and that afternoon he was sent out to the hospital for evaluation. The RP stated he was first sent to the county hospital and was informed the x-rays obtained revealed a hip fracture. Resident #30 was then transferred to another hospital where the x-ray results were reviewed again and this time she was informed there was no hip fracture, and he returned back to the facility. The RP recalled two days later, Resident #30 was sent back out to the hospital for evaluation due to complaints of neck pain, a Computed Tomography (abbreviated as CT and defined as a scan that uses x-rays to create pictures) was done that showed a spinal fracture and he was placed in a neck collar. The RP stated Resident #30 was later evaluated by the Neurosurgeon who recommended surgery but Resident #30 refused. The RP stated the neck collar Resident #30 was given at the hospital was uncomfortable for him and the Neurosurgeon ordered him a new one but even then, she as well the facility staff had a hard time getting him to wear it. The RP stated Resident #30's fractures just took time to heal and he did not suffer a decline from his baseline as a result. The RP stated she understood accidents happened, the staff involved in the incident were no longer employed at the facility and she felt the facility was taking good care of Resident #30. During a telephone interview on 01/26/24 at 2:22 PM, Nurse Aide (NA) #6 confirmed she attempted to transfer Resident #30 using a mechanical lift without additional staff assistance on 05/17/23 and he had fallen to the floor during the transfer. NA #6 recalled Resident #30 asked to get up in his recliner, which he did from time-to-time, and she asked the other NA working with her on the hall to assist with the transfer because they had been instructed to always have 2-person assist when using the mechanical lift. NA #6 stated the other NA was busy and she had waited for her as long as she could but Resident #30 was getting anxious so she made the decision to go ahead and transfer him by herself. NA #6 explained after she had gotten Resident #30 positioned in the sling, she made sure the sling straps were all positioned correctly and the clasps locked in place and then proceeded with the transfer. She recalled his bed was already in a high position so she didn't have to lift him any higher and used the lift to move him horizontally off the bed. He was suspended approximately 2 to 3 feet from the floor and as she moved the lift toward his chair, she held on to the sling with one hand. When she let go of the sling to push the feet open on the mechanical lift so that it would go around the chair, Resident #30 fell out of the sling onto his back on the floor. NA #6 stated she told Resident #30 not to move and she immediately informed Nurse #5 who came to the room to assess Resident #30. NA #6 stated the only thing she could figure happened prior to transferring Resident #30 was when she connected the sling clasps to the mechanical lift all but one made a 'click' sound when the top of the clasp was locked into place. NA #6 restated she was instructed to always have 2-person assist when using the mechanical lift and she made the wrong decision to go ahead and transfer Resident #30 without waiting for help. A nurse progress note dated 05/17/23 at 1:00 PM and written by Nurse #5 revealed in part, called to Resident #30's room by staff. Upon entering the room, Resident #30 was observed on the floor in front the bed with the lift sling underneath him. NA #6 stated she was transferring Resident #30 to the chair with the mechanical lift when his weight shifted and the sling came out of the hook. Upon assessment, no obvious injuries were observed, Resident #30 denied pain and stated he was fine. The Medical Doctor (MD) and family were notified of Resident #30's fall. Resident #30 was secured back into the sling and placed back into bed by staff. When securing the sling to the mechanical lift, three of the hooks were noted to be snapping into place but the fourth one did not snap. The mechanical lift was taken to maintenance for repair and the hook was replaced. The Administrator and Director of Nursing (DON) were also made aware of Resident #30's fall, lift issue and replacement of hook. A second nurse progress note dated 05/17/23 at 4:10 PM and written by Nurse #5 revealed Resident #30 was sent to the hospital for evaluation due to a fall via Emergency Medical Services (EMS) transport. During a telephone interview on 01/26/24 at 9:01 AM, Nurse #5 revealed she was no longer employed at the facility and confirmed she was Resident #30's assigned nurse on 05/17/23 when she notified by the NA (could not recall her name) that Resident #30 had fallen during a transfer. When she asked the NA what had happened, the NA told her Resident #30 was on the mechanical lift when one of the clasps for the sling malfunctioned and he fell to the floor. The NA also stated she knew she shouldn't have but she had tried to transfer Resident #30 independently using the mechanical lift. Nurse #5 seemed to recall when she arrived at the room, Resident #30 was lying on his right side on the floor and he wasn't complaining of any pain. She did a full body assessment which included checking Resident #30's hips, completed a neuro assessment and there were no signs of any obvious injuries identified. She and the NA assisted Resident #30 back up into bed, she checked him thoroughly again and he voiced no complaints of pain or displayed any non-verbal indicators such as moaning or grimacing. Nurse #5 was not sure how Resident #30 fell out of the sling and stated she seemed to recall the NA had showed her how one of the sling clasps wouldn't snap closed properly. Nurse #5 immediately notified the Administrator and DON of the incident and they came to Resident #30's room to assess the situation, had maintenance inspect the lift, and pretty much took things over from there. Nurse #5 stated later that afternoon (05/17/23), the Administrator and DON made the decision to send Resident #30 out to the hospital for evaluation, even though he still was not complaining of any pain, just for precautionary measures. Nurse #5 could not recall what time Resident #30 returned from the hospital but stated a few days after his fall, he was sent back to the hospital for a full CT scan because he had started to complain of pain in his neck and being sore all over. She didn't remember what the x-rays revealed but he had returned wearing a neck collar. Nurse #5 stated prior to the fall on 05/17/23, Resident #30 required total staff assistance with ADL and when he returned to the facility after his second hospital evaluation, he was pretty much at his normal baseline. Nurse #5 stated she never noticed any change in his physical or mental condition as a result of the fall. He rarely complained of pain other than soreness in his neck and did not like wearing the neck collar because it was uncomfortable. During a telephone interview on 01/26/24 at 3:44 PM, the Director of Nursing (DON) stated on 05/17/23 she was informed by a staff member, could not recall whom, that Resident #30 had fallen during a transfer. The DON immediately informed the Administrator and they both went to Resident #30's room to assess the situation. By the time they arrived at the room, Resident #30 had already been placed back into bed. The DON stated she had maintenance inspect the mechanical lift and it did have a faulty sling clasp that was immediately replaced. The DON stated upon initial assessment following the fall Resident #30 was ok but then he started complaining of a headache, was given Tylenol and monitored. She explained anytime you asked him how he was feeling he stated he was ok but just for precautions, she and the Administrator decided to send him out to the hospital for evaluation. The DON stated when she talked with NA #6 on 05/17/23 about what had happened she seemed to recall NA #6 stating she had asked another NA to help assist her with transferring Resident #30 and they had told her they would but if would be a little bit before they could assist and then for whatever reason, she chose not to wait. The DON stated NA #6 was immediately suspended and her contract with the staffing agency was terminated. The DON stated it was an unfortunate, isolated event and while she did not feel NA #6 had any malicious intent when she attempted to transfer Resident #30 independently, NA #6 made the bad decision not to follow facility protocol. The DON stated she started immediate re-education of nursing staff on 05/17/23 regarding mechanical lift transfers with an emphasis on always having 2-person assist when using a mechanical lift. During telephone interviews on 01/25/24 at 11:47 AM and 01/26/24 at 3:06 PM, the Administrator confirmed he was notified of the incident involving Resident #30 and immediately went with the DON to Resident #30's room to assess. He stated the DON took NA #6 out in the hall to discuss what happened while he stayed in the room to talk with Resident #30. The Administrator stated although Resident #30 wasn't complaining of any pain at the time of the fall, he and the DON decided to go ahead and send Resident #30 out to the hospital for an evaluation just as a precaution. The Administrator stated the hospital initially thought he had a hip fracture but then determined he did not and Resident #30 returned to the facility. A few days later, Resident #30 started complaining of a headache and was sent back to the hospital for CT scan which revealed spinal fractures. The Administrator stated it was facility protocol for staff to always have 2-person assist for mechanical lift transfers and felt it was neglectful on NA #6's part because she attempted to transfer Resident #30 without additional staff assistance. NA #6 was immediately suspended due to her not following facility protocol and her contract with the staffing agency was terminated. The Administrator stated he felt the incident involving Resident #30 was an isolated event, they implemented an internal plan of correction and put measures in place that included audits and monitoring with no further concerns identified. As part of the monitoring process, the Administrator stated he visited with Resident #30 daily to ask him if he was having any pain and Resident #30 had no complaints nor did he decline from his baseline as a result of the injury he sustained from the fall. A Hospital Discharge Summary dated 05/18/23 for Resident #30 read in part, was reported he was being transferred at the skilled nursing facility using a mechanical lift when it broke and Resident #30 landed on his hip. Reports of hip pain. Original x-ray was read as negative and CT scan of the hip was ordered which was read as equivocal (result could not be interpreted as positive or negative) and correlate clinically. CT scan showed no visible fracture of proximal right femur (hip) or right pelvis, there was reported posterior angulation of the intertrochanteric (point where the muscles of the thigh and hip attach) right femur as well as advanced osteoarthropathy (disease of the joints or bones) of the right hip. Pelvic and right hip x-rays were read as negative for fracture by Radiology. Resident #30 was evaluated today with his relative at bedside and is reporting no pain. His baseline is bed-bound and usually does not ambulate. He was discharged in stable medical condition back to the skilled nursing facility. A nurse progress note written on 05/19/23 at 6:54 AM revealed in part, Resident #30 was complaining of discomfort to the right hip and lumbar region. The MD was contacted and pain medication requested. Review of Resident #30's May 2023 Medication Administration Record (MAR) revealed a physician's order dated 05/19/23 for Tylenol 325 milligrams (mg) two tablets every 6 hours as needed for pain. Resident #30 received doses on 05/19/23 at 7:35 AM, 1:08 PM with a pain level of 05/10 (numerical pain rating scale with 10 being the worst level of pain), and 8:25 PM with a pain level of 05/10; 05/20/23 at 8:15 PM with a pain level 08/10; 05/21/23 at 11:46 PM with a pain level 07/10; and 05/22/23 at 7:59 AM with a pain level 05/10. All doses administered were noted to be effective. A nurse progress note written on 05/21/23 at 11:06 AM revealed in part, Resident #30 was displaying pain to the left upper back, neck and shoulder which made it hard for him to turn. The nurse contacted the hospital to have the x-rays sent to the skilled nursing facility and was informed x-rays were only taken on the lower body, none were completed of the shoulder or back. The MD was notified and orders were obtained for x-rays of the neck, back and rib area. A nurse progress note written on 05/21/23 at 6:38 PM revealed in part, the mobile X-ray Tech arrived at the facility to take Resident #30's x-rays and was unable to obtain views. The MD was notified and orders received to send Resident #30 for outpatient x-rays. A message was left with outpatient radiology for an appointment. A nurse progress note written on 05/22/23 at 8:35 AM revealed in part, x-ray orders were clarified and the MD will fax the order to outpatient radiology for the appointment to be scheduled. A nurse progress note written on 05/22/23 at 10:10 AM written by Nurse #5 revealed in part, outpatient radiology confirmed receipt of the faxed physician's order for x-rays and an appointment was made for 2:00 PM. RP was notified. Resident #30 received Tylenol this morning per physician order and reported good results. A Hospital Discharge Summary dated 05/22/23 for Resident #30 read in part, fell from a mechanical lift 3 days ago and was evaluated here with complaints of hip pain on the right side. Imaging studies were equivocal and hip fracture was suspected and he was transferred to another hospital for further evaluation by orthopedics. Hip fracture was not confirmed and he was sent back to the skilled nursing facility that day. Since then, he has complained of posterior neck and bilateral posterior shoulder pain. He is bed-bound with dementia, Parkinson's disease and rheumatoid arthritis. Because of ongoing complaints of pain, the patient was sent by the skilled nursing facility for CT scans of the cervical spine, chest, abdomen and pelvis today. The Radiologist read the study showing acute fractures at C7 and T1. Case discussed with the Neurosurgeon who recommends placement of a cervical collar. He expects these injuries to heal completely without surgical intervention. Resident #30 returned to the skilled nursing facility on 05/22/23. During an interview on 01/26/24 at 1:13 PM, the facility's Maintenance Director revealed on 05/17/23 he was called down to Resident #30's room after the incident to inspect the mechanical lift. He checked the hydraulics, hooks and all the components to make sure everything was working properly. He stated the mechanical lifts had four hooks which he described as U-shaped with a safety clasp across the top to ensure the sling straps stayed in place when attached to the lift. Upon inspecting the mechanical lift used to transfer Resident #30, he discovered the safety clasp on one of the lift hooks had malfunctioned, it had either collapsed or broke completely, which was how the sling strap came loose from the hook on the mechanical lift. The Maintenance Director explained when a person was suspended in the sling, the weight of the person caused the string straps to pull down and tighten but when the mechanical lift was lowered, the sling straps loosen and rise up and when functioning properly, the safety clasps prevented the sling straps from coming out of the top of the hook. The Maintenance Director stated either he or the Maintenance Assistant checked the mechanical lifts daily and when the lifts were inspected on 05/17/23 the hooks all appeared fine. He stated he kept a supply of replacement hooks in stock and the hook on the lift used to transfer Resident #30 was immediately replaced. During a telephone interview on 01/26/24 at 4:03 PM, the Medical Director (MD) stated he recalled being informed Resident #30 had a fall from a mechanical lift but did not remember all the exact details of the incident. The MD stated prior to his fall on 05/17/23 Resident #30 required total staff assistance with ADL. The MD stated he would expect there be some sort of decline for anyone who fell from a mechanical lift but did not recall anyone mentioning Resident #30 experiencing increased pain or further decline from his normal baseline as a result of the fall. The facility provided the following Corrective Action Plan with a completion date of 05/29/23: On 05/17/23, Resident #30 was lowered to the floor by a Nurse Aide during a transfer using a Hoyer lift. The Nurse Aide reported Resident #30's weight shifted and the sling came out of the clip that holds the sling in place. Resident #30 did not initially complain of pain but did later in the shift. The physician was notified of the incident by the Charge Nurse on 05/17/23 and received an order for Resident #30 to be evaluated in the emergency room (ER) due to the new complaints of pain. Resident #30 was evaluated at the hospital on 05/17/23 and returned to the facility on [DATE]. On 05/22/23, additional x-rays were completed on an outpatient basis and revealed a C7/T1 fracture. He had a referral to see a neurosurgeon and is to wear a neck collar until released by the neurosurgeon. Resident #30 was seen on 06/08/23 by Spine and Neurosurgery. Resident #30 remains at the facility and has pain medication ordered with effective results noted. Maintenance replaced the clip on the lift on 05/17/23 that was used by Resident #30. The Nurse Aide was working under a contract with an agency and her contract was terminated on 05/18/23. The Nurse Aide had completed competency training on mechanical lifts on 03/07/23 that was competed by a Registered Nurse. All residents that are transferred with a mechanical lift have the potential to be affected by the same practice. The clips had been checked by the maintenance assistant at the beginning of the shift on 05/17/23. The clips on the other mechanical lifts were checked again on 05/17/23 by the Maintenance Assistant and no issues were found upon visual inspection after the incident. The Medical Records/Central Supply Clerk performed a visual inspection of the slings and all slings were in good condition on 05/17/23. The Director of Nursing initiated staff education on 05/17/23 on mechanical lifts with the staff on duty. Education was continued by a Registered Nurse with additional nursing staff on the proper use of mechanical lifts by 05/18/23. Nursing staff members not present during the initial training had education completed on the first day back to work. Education with the nursing staff was completed by 05/29/23. Mechanical lift education was added to new employee orientation by the Human Resources Director on 05/18/23. A visual cue (laminated sign) was added to the mechanical lifts as a reminder to staff that two staff members must be present to use the mechanical lift. Written reminders were posed in different areas of the building stating that two staff members are required to use mechanical lifts. The visual cue and written reminders were added to the mechanical lift by the Director of Nursing on 05/18/23. The Maintenance Director and/or Maintenance Assistant will perform a visual inspection of the mechanical lifts, focusing on the clips, daily for two weeks, then three times a week, then reducing to weekly. Maintenance will repair/replace any issues noted on the inspection or will remove the lift from use if necessary. The inspections were initiated by the maintenance department on 05/18/23. The Director of Nursing, Assistant Director of Nursing or other Registered Nurse will perform mechanical lift transfer audit weekly for a minimum of 4 weeks then monthly until the QAPI committee changes the frequency of the audits. The assigned Registered Nurse will review at least 4 transfers per week for the audit. The mechanical lift audits will be documented on the mechanical lift audit form and will review that the sign is present on the lift and that two Nurse Aides are using the lift during the transfers properly. Re-education and/or return demonstration will be completed as needed based on the transfer observations. Any deficient practice will have corrective action taken at the time of discovery by the Registered Nurse. The mechanical lift audits were initiated on 05/26/23 by the Director of Nursing and will continue until substantial compliance has been achieved as deemed by the QAPI committee. The facility held an ad-hoc QAPI meeting on 05/29/23 with the Medical Director in attendance by phone. The topic of the meeting was a review of the mechanical lift issue and further development of the performance improvement plan. The Director of Nursing reviewed the results of the audits with the QAPI committed on July 31, 2023 when the facility held the quarterly meeting. No trends, patterns or issues were identified during the audits. The audit will continue at a minimum of monthly per recommendation of the committee. Date of compliance: 05/29/23 The Corrective Action plan was validated on 01/26/24 and concluded the facility had implemented an acceptable corrective action plan on 05/29/23. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on use of mechanical lift transfers that included requiring two-person assistance for all transfers, proper positioning in the sling and checking the security of the sling hooks and clasps to the mechanical lift. Staff interviewed all verbalized they were observed performing a mechanical lift transfer after receiving reeducation. Review of the monitoring tools of mechanical lift transfers that began on 05/26/23 and continued weekly through 09/26/23 were completed as outlined in the corrective action plan with no concerns identified. Review of the mechanical lift inspection audits 05/18/23 through 01/24/24 revealed inspections were completed daily and any issues identified were immediately repaired.

Based on record review and staff interviews the facility failed to meet the staff vaccination requirement when the Director of Housekeeping and Laundry, Laundry Aide #1, and Dietary Aide #1 worked without being fully vaccinated and without an exemption. The facility also failed to implement an effective process for tracking COVID-19 Vaccination Status for 3 of 3 facility staff. The facility went into outbreak status during survey on 07/13/22 when two facility staff and one contract staff and three residents (Residents #46, 45, and 36) tested positive for COVID-19 on 07/13/22. The findings included: The facility's *COVID-19 Vaccine* policy with no reviewed date, read in part: It is the policy that all persons be offered the COVID-19 vaccine. This facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless received religious or medical exemptions. Staff includes all fulltime, part-time, as needed employees, and contract staff. The facility COVID- 19 staffs vaccination spreadsheet 92provided by the Administrator on 07/12/22 was reviewed and included in-house staff and contract staff. Director of Housekeeping and Laundry, Dietary Aide #1 and Laundry Aide #1 who were all listed as facility staff were listed as partially vaccinated and had only received one dose of a two-dose vaccine. A review of on 05/13/22 of the National Healthcare Safety Network (NHSN) data for the week ending 06/26/22 revealed the following staff and resident vaccination information: Recent Percentage of Staff who are Fully Vaccinated = 81.8% Recent Percentage of Resident's who are Fully Vaccinated = 92.2% Review of medical records and facility vaccination documents revealed Resident #46 and Resident #36 were not vaccinated and tested positive for COVID-19 on 07/13/22. Resident #45 was partially vaccinated and tested positive for COVID-19 on 07/13/22. An interview was conducted with Director of Housekeeping and Laundry on 07/13/22 at 2:15 PM revealed she had received the first shot of the COVID-19 vaccine in November 2021 and was planning to receive the second shot of the vaccine. She stated each time she planned to go and receive the second shot something would come up at home or at work and she was not able to go. She revealed she was planning to go within the next week and receive the second shot of the vaccine. The Director of Housekeeping and Laundry was observed wearing an N95 mask and stated because she is not fully vaccinated, she always wears an N95 mask in the facility and is tested bi-weekly. An interview was conducted with Laundry Aide #1 on 07/13/22 at 2:17 PM revealed she had received the first shot of the COVID-19 vaccine in March 2022 and was then diagnosed with [CONDITION(S)]. She stated she was going to discuss receiving the second shot with her physician at her next appointment. Laundry Aide #1 was observed wearing an N95 mask and stated she wears an N95 mask while in the facility and is tested bi-weekly. Dietary Aide #1 was not available for interview. An interview was conducted with the Administrator on 07/13/22 at 11:02 AM revealed Dietary Aide #1 received her first does of the vaccine in December 2021 and had not received second dose of vaccine due to her [CONDITION(S)] diagnosis. She stated Dietary Aide #1 was supposed to discuss a medical exemption with her physician. A telephone interview was conducted with Infection Preventionist (IP) on 07/13/22 at 1:13 PM revealed she was responsible for COVID-19 testing, tracking staff and resident vaccinations, weekly NHSN reporting, and updating tracking reports weekly. She also revealed she reports staff vaccination status to the Administrator and Human Resources. She stated she was aware of the three staff members not being fully vaccinated. The IP stated she realized the seriousness of the tracking of the vaccination status of the employees and indicated she had reminded the three staff not fully vaccinated weekly they needed to receive their second vaccine. She also stated she reported to the Administrator and Human Resources multiple times of the three staff not being fully vaccinated and needing to receive their second vaccine. She further indicated the three staff members not fully vaccinated had not requested exemptions. She stated the facility has held initial vaccine and first booster clinics for staff and residents and will be scheduling a second booster clinic for staff and residents as soon as vaccine arrives. An interview was conducted with Director of Nursing (DON) on 07/15/22 at 1:30 PM revealed IP handled all of staff vaccination. The DON stated staff that were not fully vaccinated were required to wear an N95 mask. She revealed she was not aware staff were employed at facility and worked who were not fully vaccinated and had no exemption. She stated staff should follow vaccination policy and be vaccinated or wear an N95 mask if not vaccinated. An interview was conducted with Administrator on 07/15/22 at 2:04 PM revealed according to staff vaccination policy, staff should be fully vaccinated or have an approved exemption. She stated she was aware of staff not having received their 2nd doses of vaccine. She also stated she had reached out to staff who had not received their second doses of vaccine and discussed with IP about those staff receiving their second dose of vaccine and or an exemption. The Administrator revealed all staff should be vaccinated according to policy and the facility should have followed up more closely to make sure the policy was being followed.

Based on medical record review, observations and interviews with staff the facility failed to supervise one of one residents during transport in the facility van. Van Driver #5 left Resident #1 unattended in the facility van with the engine running while Van Driver #5 went into the facility. The vehicle rolled down an embankment, across a road and into a wooded area stopping against a tree. Immediate jeopardy began on 4/17/11 at 2:00 PM when Resident #1 was left unsupervised inside the van with the engine running. Immediate jeopardy was removed on 4/28/11 at 6:45 PM. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings are: Review of the facility transportation policy dated 9/15/2008 revealed: "It is the policy of Mountain View Manor Nursing Center to transfer residents to their medical appointments utilizing the facility's van. The Van Driver will transport and assist the resident to his/her appointment and will remain with the resident until appointment is completed, then will return to the Facility via the Facility Van." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS), a quarterly assessment dated [DATE], revealed the resident had severe memory and cognitive impairment. It further revealed the resident was ambulatory with the limited assistance of one staff member and was independent with transfers with set-up help or supervision. A review of Resident #1's medical record revealed a nurse's note dated 4/17/11 at 12:45 p.m. which indicated Resident #1 was to be transported to the hospital emergency department in the facility van for complaints of a headache. A later nurse's note dated 4/17/11 at 2:00 P.M. read: "Resident involved in motor vehicle incident while in process of being taken to emergency room via facility van. EMS (Emergency Medical Services) called and transported resident to hospital". A review of Resident #1's hospital medical record revealed that she arrived at the Hospital Emergency Department on 4/17/11 at 2:29 P.M. A physician's progress note dated 4/17/11 at 2:34 P.M. revealed: "She denies any complaints currently but she had a headache earlier. Head CT (Computerized Tomography) shows no abnormalities." A review of the findings from the physical examination did not reveal any injuries sustained in the motor vehicle accident. Resident # 1 was released from the Emergency Department on 04/17/11 at 5:28 P.M. and transported back to the facility. Review of the facility's written investigation of the incident dated 4/19/11, included the following: the police investigation report, the facility incident/accident report, a statement by Van Driver #5 who was transporting Resident #1 on 4/17/11 and a statement by Van Driver #2 who assisted Van Driver #5 with positioning Resident #1 in the facility van prior to transport on 4/17/11. Review of the facility Incident/Accident report related to the accident on 4/17/11 revealed: "Resident loaded into van to go to emergency room . Van had malfunction and rolled over bank. 911 called and first aid given. Resident complained of arm, neck and chest pain. Aide applied C-spine hold until EMS arrived. No visible injuries to resident. Resident alert and oriented and talking to staff. Refused C-spine collar when EMS arrived. Resident taken to emergency room . Resident was securely strapped in van". The undated statement by Van Driver #5 read, "Driver got in van, driver's seat, reached to put seat belt on and pressed the brake pedal, pedal went all the way to the floor. Driver had not taken van out of gear prior to attempting to press the brake. Driver got out of van and came to tell (name of Van Driver #2)". The statement by Van Driver #2 dated 4/17/11 read, "Around 2:00 PM (name of Van Driver #5) came and got me to help him load a resident in the van to take her to the emergency room . (name of Van Driver #5) and I loaded and secured resident in van. All tie downs were tight and seat belt in place. Van was in park and the emergency brake was applied. After securing resident I returned inside the building. About one minute later (name of Van Driver #5) returned to get me and stated 'there's something wrong with the brakes'. I was returning to the van with (name of Van Driver #5) and when we got to the door I noticed the van was rolling. (Name of Van Driver #5) and I started running toward the van in an attempt to stop the van. 911 called immediately." Review of the police investigation dated 4/17/11 at 2:59 PM included: Upon my arrival, I noticed a vehicle sitting in the woods. The vehicle had front end and rear end damage. The driver side door was open. They (staff) advised no one was hurt but that a female was being transported to the (name of hospital) due to other problems. The staff stated that the van rolled off the hill. I asked who had been driving it, they advised (name of Van Driver #5). I asked him (Van Driver #5) what happened, he stated that they had loaded up (name of Resident #1) to take her to the E.R. and when he got in to drive, he noticed that the brakes were soft. He (Van Driver #5) stated, "I do the same thing every time I get into a car to drive. I put on my seat belt and as I'm doing that I always mash the brake pedal and pull it into gear. But I noticed that the brake pedal was soft so I took off my seat belt and walked inside to let them know that the brakes were soft and as I walked back out the door I saw the van rolling off the hill." (Name of Van Driver #5) stated that he left the van in park with the parking brake set. The only person that was reported being in the van was (name of Resident #1) and she remained secured in the back of the van. I called for a wrecker. Upon their arrival, I explained to them what I had been told what had happened. I asked if they would test the brakes and transmission out when they got the van back into the road. When they started to move the van I noticed that the back tires were just sliding in the leaves. They had to stop and put the van out of gear and take off the parking brake to get the van to roll. When the van was sitting in the road the wrecker driver tested out the parking brake. The van would not move with the brake set. The wrecker driver even put the van into drive and gave it gas and the van did not move. At that point he put the van in park and let off the parking brake. The van held itself with the vehicle being in just park. The area where the van was tested was steeper than the area the van rolled off of. The wrecker driver stated there was no problem with the brakes or transmission. The drive shift was OK. If the van was in park and parking brake was used the van should not have rolled off. It appears that the van had been left in neutral or drive and brake left off. No reported injuries. Interview on 4/26/11 at 9:30 AM with the Administrator revealed Van Driver #5 had been hired 4/11/11 with job duties to include van transport. The Administrator stated the van was taken to the mechanic's garage after the incident on 4/17/11 and remained there. The Administrator stated that since the incident on 4/17/11 the mechanic had verbally told him the vehicle was tested and no mechanical problems were found. The Administrator stated that in the interim a staff member's personal vehicle was being used to transport ambulatory residents. The Administrator stated no re-training of van drivers had been done and he had not yet met with the drivers to discuss the incident. The Administrator provided service records from the garage where the facility van was serviced which indicated the last time the van was in for service was 3/8/11 for an oil change. On 4/26/11 at 10:30 AM the facility Director of Nursing (DON) stated there were six van drivers but most resident transports were done by Van Driver #1, the primary driver. On 4/26/11 at 10:45 AM the Administrator provided a copy of the Daily Van Safety Checklist and indicated the identified items on the sheet were checked every time the van was driven. The items indicated on the sheet included: directional signs, head lights, brake lights, windshield wipers, horn, backup alarm, tires and stop lights. These sheets indicated a safety check had been done on the facility van 4/11/11-4/17/11. Staff were unable to identify who completed the safety check on 4/17/11. An interview was conducted with the facility Administrator on 04/26/11 from 12:10 P.M. through 12:25 P.M. and the accident scene was observed. The Administrator was unaware of the exact position of the parked van on 4/17/11 when Resident #1 was left unsupervised by Van Driver #5. The Administrator stated Van Driver #5 could provide that information. The Administrator demonstrated the direction the van rolled on the day of the accident. The van rolled approximately 57 feet from the front walkway before rolling up and over an 8 inch curb. It then rolled over an azalea bush and partially knocked it down as well as two sections of wooden fence before rolling down another 8 inch curb. It then rolled approximately 25 feet across the facility drive and up another 8 inch curb. The van then rolled another 72 feet down a steep embankment with an approximate 70 degree slope. At the bottom of the embankment was a shallow drainage ditch at the edge of a two-lane highway. The van travelled across a two-lane highway and approximately 43 feet into a wooded area before coming to rest against a tree. The posted speed limit for the highway was 35 miles per hour and there was a sharp curve on each side of the section of highway the van crossed. The Administrator described the highway as a "busy road". On 4/26/11 at 11:45 AM the DON stated Van Driver #5 had been trained on 4/11/11 by Van Driver #1 and on 4/13/11 by Van Driver #2. On 4/26/11 at 1:00 PM and 4/27/11 at 11:40 AM Van Driver #1 stated he was the primary driver of the facility van. Van Driver #1 stated that Van Driver #5 was the first driver he ever trained. Van Driver #1 stated he had Van Driver #5 travel with him on 4/13/11 during a van transport as part of the training. Van Driver #1 stated he reviewed all items on the Skilled Sheet For The Van Driver which included the following skills: How to Sign Resident Out of Facility, Obtaining Paperwork From Charge Nurse, Letting Lift Down on the Van for Resident entrance/dismount, How to get Resident into and out of van safely, Locking wheelchair/geri-chair down, Putting seat belt around resident, Hooking tie downs/safety belts to chair, Write starting mileage-resident name-destination, Getting resident out of van at destination, Getting resident into appointment building, Checking resident in at the check-in desk, Returning resident to Facility, Giving paperwork to Charge Nurse and Write ending mileage. The Skilled Sheet For The Van Driver for Van Driver #5 was signed and initialed on 4/13/11 to indicate all skills had been reviewed. Van Driver #1 stated he knew a van driver should be observed driving the facility van prior to transporting a resident independently although it wasn't included as a skill on the Skilled Sheet for the Van Driver. Van Driver #1 stated that events of the day on 4/13/11 prevented him from observing Van Driver #5 driving the facility van before he was allowed to drive it alone. Van Driver #1 stated that he did not know if there was a policy on leaving residents unsupervised in the van and he did not review anything regarding this when training Van Driver #5. Van Driver #1 stated there had been times when he had to leave a resident in the van after securing them to pick up paperwork in the facility. Van Driver #1 stated that since the accident he had not met with the administrator to discuss any changes that would be put into place. On 4/26/11 at 1:55 PM Van Driver #2 stated she had trained Van Driver #5 on 4/11/11 during a transport of a resident. Van Driver #2 stated during the training she was driving the van but went over all the details of transporting a resident including how to secure a resident in the van, the daily safety checklist, how to operate the lift and to use the emergency brake whenever the van was not in motion. Van Driver #2 stated she was working on 4/17/11 when Van Driver #5 was called in to transport Resident #1 to the hospital. Van Driver #2 stated she knew it was his first time driving the van so she offered to assist with securing the resident in the van. Van Driver #2 stated the van had been brought to the front entrance of the facility and was facing the driveway entrance. Van Driver #2 stated the van was in park and the engine was running while she was assisting Van Driver #5 with getting the resident secured in the van. After securing the resident in the van, Van Driver #2 stated she went back into the building. She stated she did not get very far into the facility when Van Driver #5 came in and told her there were no brakes on the van. Van Driver #2 stated they walked toward the entrance doors and noticed the van was moving. Van Driver #2 stated the van made a slight turn and they ran to try and catch it. Van Driver #2 stated the van went up a curb, knocked down a fence, went up another curb, down the hill, across the road and stopped in the woods. Van Driver #2 stated they were not able to catch up with the van to stop it. Van Driver #2 stated she went inside to have someone call 911 while Van Driver #5 went to the scene of the accident. Van Driver #2 stated after informing staff to call 911 she went to the scene of the accident. Van Driver #2 stated she saw Van Driver #5 turn off the engine of the van when she arrived at the scene of the accident. Van Driver #2 stated that since the accident she had not transported any residents and that she had not met with the administrator to discuss any changes that would go into effect as a result of the accident. In a follow-up interview on 4/27/11 at 1:40 PM Van Driver #2 stated she was not aware that part of training a new driver included observing them drive the van because it was not a part of the Skilled Sheet For The Van Driver. Van Driver #2 also stated she was not aware if there was a policy about supervision of residents. On 4/27/11 at 9:20 AM Van Driver #5 stated prior to 4/17/11 he rode in the van a couple times with Van Driver #1. Van Driver #5 stated he was shown all the safety features, how to perform the Daily Van Safety Checklist prior to use and how to secure a resident in the facility van. Van Driver #5 stated he had not driven the van prior to 4/17/11. Van Driver #5 stated about 1:30 PM on 4/17/11 he was asked if he could transport a resident to the emergency room . Van Driver #5 stated he moved the facility van to the front entrance and Van Driver #2 assisted him to secure Resident #1 in the van. Van Driver #5 stated Van Driver #2 went back into the facility after Resident #1 was secured in the van. Van Driver #5 stated he got in the van and pushed the brake pedal down to check the brakes. Van Driver #5 specified that the two times he pushed the brake pedal it felt "mushy" and "went to the floor". Van Driver #5 stated he got out of the van and went into the facility to find Van Driver #2 to have her look at the brakes. Van Driver #5 stated he was in the building at the most, for a minute and a half. Van Driver #5 stated when he left the van it was running and it was in park with the emergency brake engaged. Van Driver #5 stated when he and Van Driver #2 got to the front door they could see the van was moving and ran to try and stop it as they could see it was headed for the hill at the front of the facility. Van Driver #5 stated when he got to the van he checked to see that the resident was okay and turned the engine off. Van Driver #5 stated he checked the emergency brake and it was still engaged and the gear shift was in park. Van Driver #5 could not explain what happened to cause the van to roll from the parking lot approximately 230 feet. Van Driver #5 stated he had been told in training to never leave a resident unsupervised. He stated he had been told to call 911 if something happened to the resident during transport and to call the mechanic shop if mechanical problems were suspected. On 4/27/11 at 9:50 AM the Administrator stated he still didn't know what the problem was that caused the accident because he was waiting to receive the findings from the insurance company but the insurance company had not yet sent out an adjustor. Upon further questioning, the Administrator acknowledged that the owner of the garage had checked out the brakes and was unable to find anything wrong with them. The Administrator further stated that typically the senior van driver, Van Driver #1, would do all the training. The Administrator stated there was not a written protocol on what would be included in training other than what is on the Skilled Sheet for the Van Driver. He stated it was his expectation that the new van driver should drive the van in the presence of the trainer even though it was not included on the Skilled Sheet for the Van Driver. The Administrator stated that a resident should never be left alone in a vehicle and that the drivers should use their mobile phone to call for assistance, even if they are in the facility parking lot. The Administrator stated he did not speak to Van Driver #5 about specific details of the accident. On 4/27/11 at 10:30 AM the Administrator acknowledged that he had not implemented corrective actions for two of the contributing factors of the 4/17/11 van accident which included; the van driver leaving a resident unsupervised and unattended while the resident was in the vehicle and not including supervised driving as part of the orientation for new van drivers. The Administrator was notified of the immediate Jeopardy on 4/27/11 at 10:30 a.m. The facility provided a credible allegation of compliance on 4/28/11 at 4:59 p.m. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Resident #1 was assessed by the RN Supervisor and monitored by staff until Emergency Management Services arrived. EMS transported Resident #1 to the hospital for evaluation. Later the same day the resident returned with no new orders and no apparent injuries. Resident #1 will receive continual supervision with all transports by the van driver. On April 28, 2011 the Administrator conducted an audit of all other interviewable residents transported via the facility van since January 01, 2011. The audit included interviews with residents to determine if any other resident was affected by the deficient practice. The findings from this audit revealed that no other resident was affected by the deficient practice. Facility residents will receive continual supervision by the van driver during transports. The van was immediately taken out of service and sent to a local garage for inspection and has not been driven since April 17, 2011. On April 27, 2011 and April 28, 2011 all van drivers were inserviced by the Safety Director, the Administrator, and the Director of Nursing on the importance of not leaving a resident unattended in the van. They are to use a cell phone after bringing the van to a complete stop in a safe area. Also, van drivers were instructed that prior to exiting the van the driver will place the van in park, engage the emergency brake and turn the van off. Wheel chocks are to be used under the front and back of a tire the minute the van driver exits the vehicle. On April 27, 2011 the Van Transfer Policy was updated to reflect that the resident is not to be left unattended in the van; if the van driver requires assistance they are to stop in a safe area and use a cell phone to call the facility or to call 911. Wheel chocks are to be used under the front and back of a tire as soon as the van driver exits the vehicle. Three permanent signs will be posted in the van that state "Never leave resident unattended" in large bold letters. These signs will be posted on the dash, on the right inside of the rear door, and on the back of the lift. New van drivers will have orientation on the safe operation of the van by the senior driver and skills will be checked off. The skills checklist has been updated to reflect that new van drivers will drive the van to a minimum of five appointments under the supervision of an experienced van driver. The skills check list now includes to never leave a resident unattended, to use a cell phone to call for assistance, and to use wheel chocks immediately upon exiting the van. All current drivers were retested on the skills checklist on April 28, 2011 by the Safety Director. All current drivers passed the test. On April 27, 2011 all van drivers were inserviced by the Safety Director, the Administrator, and the Director of Nursing on the importance of never leaving a resident unattended in the van. They are to use a cell phone after bringing the van to a complete stop in a safe area. Also, van drivers were instructed that prior to exiting the van the driver will place the van in park, engage the emergency brake and turn the van off. Wheel chocks are to be used under the front and back of a tire the minute the van driver exits the vehicle. Three permanent signs will be posted in the van that state, "Never leave resident unattended" in large bold letters. These signs will be posted on the dash, on the right inside of the rear door, and on the back of the lift. Wheel chocks will be placed under the front and back of a tire any time the van is parked to load or unload a resident. Monthly Q/A of the van preventative maintenance safety checklist will be review by the senior van driver, the Safety Director, and Administrator for compliance. The Director of Nursing or the Safety Director will do a weekly ride-along audit of van/personal vehicle safety, that a resident is never unattended, the experience of the driver, the signs are in the van, and chocks are used under the front and back of a tire when loading or unloading residents. During these audits the van drivers will also be observed to ensure that they place the van into park, set the emergency brake and turn the van off prior to exiting the vehicle. The Administrator will monitor the audit for compliance and provide a monthly report to the QA committee for review and appropriate follow-up action if indicated. On April 27th, 2011 the Van Transfer Policy was updated to reflect that the resident is never to be left unattended in the van; if the van driver requires assistance they are to stop in a safe area and use a cell phone to call the facility or to call 911. Wheel chocks are to be used under a front and back tire immediately when the van driver exits the vehicle. In interim until the van is back in service residents with outside facility appointments will be transported to appointment by: 1. If resident is ambulatory, transport will be by a designated van driver in their personal vehicle. The ambulatory resident's family members can transport if they are willing to transport in their personal vehicle. 2. If resident is non-ambulatory, transport will be by non-emergency transport (name of local county EMS). For the associate that transports with their personal vehicle, a vehicle safety check and a skill sheet for that driver will be reviewed by the Safety Director before they are allowed to transport residents in their personal vehicle. The same policy as the van policy will be followed. The one personal vehicle that has the possibility of transporting residents was inspected by the facility's Safety Director to verify the safety of the personal vehicle used for resident transport. This inspection included reviewing and obtaining a copy of the registration card, the vehicle inspection statement, and all maintenance records for the personal vehicle used for resident transport. Copies of these records will be kept on file in the Safety Director's office. The Safety Director checked the vehicle with the Personal Vehicle Safety Checklist that includes directional signals, functioning seat belts, functionality of the brake pedal, headlights, brake lights, windshield wipers, horn, tires, and emergency flashers on the personal vehicle used for resident transport. Skills check list has been updated to reflect that new van drivers will drive the van to a minimum of five appointments under the supervision of an experienced van driver. The skills check list now includes to not leave a resident unattended, to use a cell phone to call for assistance, and to use wheel chocks immediately upon exiting the van. Three permanent signs will be posted in the van that state "Never leave resident unattended" in large bold letters. These signs will be posted on the dash, on the right inside of the rear door, and on the back of the lift. All van drivers will be inserviced every six months by the Safety Director, the Administrator, and the Director of Nursing on the importance of never leaving a resident unattended in the van. They are to use a cell phone after bringing the van to a complete stop in a safe area. Wheel chocks are to be used under the front and back of a tire as soon as the van driver exits the vehicle. The Director of Nursing or Safety Director will do random weekly checks of van safety for three months or until substantial compliance is achieved then monthly. Any areas of concern will be addressed immediately and reported to the QA Committee. The Director of Nursing or Safety Director will do random weekly ride-along checks on residents in the van for three months, then monthly for three months or longer until discontinuation approved by the QA Committee. Any areas of concern will be addressed immediately and reported to the QA Committee for review. The Director of Nursing or Safety Director will check new van drivers' orientation before releasing a driver to transport residents without an experienced van driver. The Administrator will monitor the random checks for compliance and provide a monthly report to the QA committee for review and appropriate follow-up action if indicated. The Immediate Jeopardy was removed on 4/28/11 at 6:45 PM. The audit of all interviewable residents had been completed and determined no other residents had ever been left unsupervised or felt unsafe during transport. The facility had revised the van policy and included supervising residents at all times during transport, the use of wheel chocks and procedures to take if there are suspected mechanical problems with a vehicle. The safety sheet for the one personal vehicle used in the interim for ambulatory resident transport included the registration card, inspection statement, all maintenance records and the personal vehicle safety checklist. The revised Skilled Sheet For The Van Driver included a new driver must be observed driving the van five separate times before driving independently, supervision of residents and procedures to take if there are suspected mechanical problems with a vehicle. The records were reviewed to ensure all drivers had been retested on the skill sheet. Inservice records were reviewed and all drivers were in attendance for review of the new policies and procedures. The signs to be placed in the facility van were available for immediate use. Wheel chocks had been purchased and all van drivers were interviewed and were aware to use them whenever a vehicle was not in motion. Van drivers were able to verbalize understanding of the new policies and procedures including changes to training, supervision of residents and procedures to take if there were suspected mechanical problems with a vehicle.