Every finding on record at Oak Grove Healthcare

Based on observations, record review and staff interviews, the facility failed to post the daily nurse staffing data for 1 of 4 days of the survey (11/30/25) and maintain posted daily nurse staffing data sheets for 83 of 169 days reviewed from June 2025 through December 2025.The findings included:Observation of the daily nurse staffing sheet on 11/30/2025 at 10:30 AM, and 12:46 PM revealed a daily nurse staffing sheet dated 11/25/2025.Review of the daily nurse staffing sheets from 6/18/2025 through 12/3/2025 revealed there were 83 days of daily nurse staffing sheets missing: 6/21/25, 6/22/25, 6/28/25, 7/4/25 through 7/8/25, 7/12/25, 7/13/25, 7/16/25, 7/19/25 through 7/21/25, 7/26/25 through 7/28/25, 8/2/25, 8/3/25, 8/9/25, 8/10/25, 8/16/25, 8/17/25, 8/23/25 through 8/26/25, 8/29/25 through 8/31/25, 9/4/25, 9/6/25 through 9/9/25, 9/11/25, 9/13/25 through 9/16/25, 9/18/25, 9/20/25, 9/21/25, 9/24/25 through 9/30/25, 10/01/25 through 10/22/25, 10/31/25, 11/8/25 through 11/10/25, 11/15/25, 11/16/25, 11/22/25, 11/23/25, 11/26/25 through 11/29/25.During an interview on 12/2/2025 at 10:00 AM the Scheduler stated she had been in the scheduler position for about 2 months, and she was responsible for completing and posting the daily nurse staffing sheet. The Scheduler indicated she was trained by the [NAME] President of Operations. The Scheduler stated she knew the daily nurse staffing sheet was supposed to be posted every day. The Scheduler stated on the days she worked she posted the daily nurse staffing sheet and when she was off for holidays, or during the week and on weekends she left the daily nurse staffing sheets in the assignment book to be posted. The Scheduler verified there were multiple times when the daily nurse staffing sheet was not posted when she came back to work. The Scheduler explained there was not a weekend manager or specific nurse who was responsible for posting the daily nurse staffing sheets when the Scheduler was not working. The Scheduler stated she had not reported the daily nurse staffing sheets that were not posted when she was off to the DON or Administrator. The Scheduler stated she was unable to find the 83 days of missing daily nurse staffing sheets. During an interview on 12/3/2025 at 11:15 AM the Director of Nursing (DON) stated she expected the daily nurse staffing sheets to be posted daily. The DON was not aware that the daily nurse staffing sheets the Scheduler left to be posted when she was off had not been posted. The DON stated there was not a weekend supervisor but was aware the Scheduler left the daily nurse staffing to be posted when she was off and the facility was in the process of hiring a weekend supervisor.During an interview on 12/3/2025 at 9:15 AM the Administrator stated he expected the daily nurse staffing sheets to be posted daily. The Administrator stated the Scheduler and DON were responsible to make sure the daily nurse staffing sheets were posted. The Administrator was not aware of the missing staffing sheets. The Administrator stated the process for posting the daily nurse staffing sheets would need to be addressed.

Based on record reviews and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of Level II Pre-Admission Screening and Resident Review (PASRR) (Resident #17 and Resident #27), and anticoagulants (Resident #23). This deficient practice was identified for 3 of 3 residents reviewed for MDS accuracy. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder and bipolar disorder. Resident #17's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. The Identification Information section of the MDS assessment did not report Resident #17 had PASRR Level II determination. Further review of Resident #17's electronic medical record (EMR) revealed Resident #17's care plan included the following area of focus, in part: The resident has a Level II PASRR related to serious mental illness (Initiated 07/18/2017; Revised 03/25/2022). An interview was conducted on 09/05/2024 at 11:49 AM with the facility's Director of Social Services (DSS). Upon request, the DSS reviewed Resident #17's medical record and provided a copy of Resident 17's PASRR Level II Determination Notification letter dated 12/29/2020. The letter confirmed Resident #17 was determined to have PASRR Level II status. An interview was conducted on 09/05/2024 at 12:29 PM with the facility's MDS nurse. During the interview, the MDS nurse stated Resident #17's MDS was coded incorrectly and should have reflected a Level II PASRR. An interview was conducted with the Administrator on 09/05/2024 at 12:45 PM. The Administrator stated that she expected the PASRR information for all residents be coded accurately on the MDS. 37019 2. Resident #27 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder among others. Review of Resident #27's PASRR Level II Determination Notification letter dated 04/24/2023 confirmed Resident #27 was determined to have PASRR Level II status. Resident #27's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. The Identification Information section of the MDS assessment did not report Resident #27 had PASRR Level II determination. Further review of Resident #27's electronic medical record (EMR) revealed Resident #27's care plan included the following area of focus in part: The resident has a Level II PASRR related to bipolar disorder (Initiated 04/24/2023 and last updated 08/27/24). An interview was conducted on 09/05/2024 at 12:29 PM with the facility's MDS nurse. During the interview, the MDS nurse stated Resident #27's MDS was coded incorrectly and should have reflected a Level II PASRR. An interview was conducted on 09/05/2024 at 12:45 PM with the Administrator. The Administrator stated that she expected the PASRR information for all residents be coded accurately on the MDS. 3. Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included coronary artery disease, heart failure, hypertension and diabetes mellitus type II. Resident #23's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. The Medications section of the MDS assessment reported Resident #23 was on an Anticoagulant with Indication noted. Review of physician orders dated June 2024 through September 2024 revealed the resident was not prescribed an anticoagulant. An interview was conducted on 09/05/2024 with the facility's MDS nurse. During the interview, the MDS nurse stated Resident #23's MDS was coded incorrectly and should not have reflected the resident being on an anticoagulant. She further stated the resident was on Aspirin 81 milligrams (mg) 1 tablet by mouth daily and although it was coded correctly as an antiplatelet it must have also been coded incorrectly as an anticoagulant. The MDS nurse indicated she would need to do additional education to clarify the difference between antiplatelet and anticoagulant. An interview was conducted on 09/05/2024 at 12:45 PM with the Administrator. The Administrator stated that she expected the medications for all residents be coded accurately on the MDS.

Based on record reviews and interviews with staff, residents, responsible parties, and the Medical Director (MD), the facility failed to protect resident's rights to be free of misappropriation of controlled substances for 2 of 2 residents reviewed for misappropriation of resident property (Resident #212 and Resident #49). The findings included: The facility's Abuse, Neglect, Exploitation, and Misappropriation policy, last revised on 11/16/2022, revealed in part the facility would ensure all residents were free from misappropriation of property. a. Resident #212 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, osteomyelitis of right ankle and foot, and protein-calorie malnutrition. Resident #212 was discharged from the facility on 06/05/2024. A review of the physician's order dated 05/04/2023 revealed Resident #212 had an order to receive 1 tablet of Oxycodone (an opioid that acts on the central nervous system to relieve pain) 5 milligrams (mg) every 6 hours as needed for pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #212 had moderately impaired cognition. The initial allegation report dated 10/02/2023 revealed the Administrator became aware of the misappropriation of residents' property on 10/02/2023 at 9:00 AM when the nurse medication count revealed a card of 30 tablets of Oxycodone 5 mg and the controlled medication count sheet were missing. On 10/02/2023, an internal investigation was initiated regarding the allegation of misappropriation of property for Resident #212. The investigation report (5-day) dated 10/05/2023 revealed the Director of Nursing (DON) received a phone call from Nurse #1 on 10/01/2023 at 7:10 PM. Nurse #2 verified the narcotic count was incorrect on 10/01/2023 at 7:10 PM for Resident #212. Nurse #1 and Nurse #2 stated the count on the evening of 09/30/2023 was 27 cards and 30 sheets which were the correct counts. Nurse #1 and Nurse #2 verified the count was also 27 cards and 30 sheets on 10/01/2023 during the 7:00 AM count. On 10/01/2023 new count sheets for the month of October 2023 were distributed by Unit Manager #1. The new count sheet indicated that there were 26 cards and 29 sheets that were signed in by Med Aide #1. Nurse #1 revealed at 3:00 PM on 10/01/2023 she took over the medication cart from Med Aide #1 who was being pulled to the floor to work as a Nursing Assistant (NA). Nurse #1 stated she did not count the cart with Med Aide #1. Per the facility investigation report dated 10/05/2023, a review of the narcotic receipt sheet was completed by the DON on 10/02/2023 which verified that Resident #212 was issued 30 tablets of Oxycodone 5 mg tablets on 09/14/2023 and the medication card was added to the medication cart. On 10/02/2023 the DON pulled a list from pharmacy to ensure narcotics were sent to the facility and matched the medications in medication cart revealing one card of 30 tablets of Oxycodone 5 mg issued to Resident #212 was missing from the medication cart per the pharmacy proof of delivery statement dated 09/14/2023. Multiple attempts to contact Unit Manager #1 were made and were unsuccessful. Several attempts to contact Nurse #1 and Nurse #2 were made from 09/03/2024 to 09/06/2024. The attempts were unsuccessful and there were no return calls from Nurse #1 or Nurse #2. An attempt to conduct a phone interview with Medication Aide #1 on 09/06/2024 at 8:30 AM was unsuccessful. The phone number was no longer in service. During an interview with Resident #212's responsible party (RP) on 09/06/2024 at 9:10 AM, the RP stated that facility had notified him in October of 2023 that Resident #212's Oxycodone may have been diverted by an employee working in the facility at that time. The RP also stated that the facility informed him that the facility would assume responsibility for the cost of the missing medication. An interview was conducted with the DON on 09/06/2024 at 10:20 AM. The DON stated Nurse #1 submitted to a drug test on 10/01/2023 which revealed a negative drug panel. The DON also stated Nurse #1 received written disciplinary counseling for failing to count the cart prior to accepting the cart. The DON also stated that multiple attempts were made by the facility to contact Medication Aide #1 with no success. The DON further explained that Medication Aide #1 was never heard from or seen again by the facility. The facility terminated Medication Aide #1 on 10/05/2023 and the facility notified law enforcement that they had been unable to contact or locate Medication Aide #1. Law enforcement informed the facility that a detective would be assigned to the case on 10/05/2023. Resident #212 had oxycodone available during this time frame. An interview was conducted with the MD on 09/06/2024 at 12:00 PM. The MD stated he was aware of the incident occurring on 10/02/2023. He further stated that Resident #212 was assessed and had no negative outcomes. He further explained that the facility absorbed the cost of the missing medications, and the medications were not charged to Resident #212. b. Resident #49 was admitted to the facility on [DATE] with diagnoses including dementia and fracture of left femur with surgical repair. The physician's order dated 06/02/2024 revealed Resident #49 had an order for Oxycodone 5 milligrams (mg) (an opioid that acts on the central nervous system to relieve pain); give 1/2 tablet (2.5mg) every 4 hours as needed for pain. The medication order was noted to be discontinued on 06/10/2024. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had moderately impaired cognition. A review of the initial allegation report dated 06/26/2024 revealed the facility became aware of the incident on 06/25/2024 at 11:45 AM when the Administrator was notified that Nurse #1 had signed out a narcotic several times after the medication had been discontinued by the Nurse Practitioner (NP). The 5-day investigation report dated 07/01/2024 revealed the facility completed a review of Resident #49's medication orders which revealed the Oxycodone was discontinued on 06/10/2024. Review of the narcotic sign out sheet revealed the medication had been signed out 4 times by Nurse #1 after the medication had been discontinuation. The investigation report revealed Nurse #1 had indicated that she had accidentally pulled it each time and immediately wasted it. The facility contacted Nurse #2 who countersigned the medication waste, Nurse #2 indicated that she only witnessed one pill being wasted and did not observe any other narcotic wastes for Resident #49. The allegation of diversion of residents' drugs was substantiated and Nurse #1 was terminated on 06/28/2024. The facility filed reports to the local law enforcement and the Drug Enforcement Agency (DEA) on 06/26/2024, and the North Carolina Board of Nursing (NC BON) on 06/28/2024. The MD and the Resident #49's responsible party were notified on 06/26/2024. A review of the declining narcotic sheet for Resident #49 was conducted on 09/05/2024 and revealed Nurse #1 had signed out Oxycodone 5mg and Nurse #2's signature was entered under the witnessed column. 06/13/2024 at 10:30 PM with a documented wasted amount of 1/2 tablet. 06/16/2024 at 10:08 PM with a documented wasted amount of 1/2 tablet. 06/16/2024 at 10:03 AM with a documented wasted amount of 1/2 tablet. 06/18/2024 at 8:00 PM with a documented wasted amount of 1/2 tablet. An attempt to conduct a phone interview with Nurse #1 on 09/06/2024 at 8:40 AM was unsuccessful. The phone number was no longer in service. An attempt to conduct a phone interview with Nurse #2 on 09/06/2024 at 8:55 was unsuccessful. During an interview with Resident #49 on 09/06/2024 at 10:31AM, she did not recall any concerns with her medications including her pain medication. An interview was conducted with Resident #49's Responsible Party (RP) on 09/06/2024 at 10:40 AM. The RP stated the facility had notified her in June that Resident #49's Oxycodone could have been diverted by a nurse working in the facility at that time. An interview was conducted with the Director of Nursing (DON) on 09/06/2024 at 11:30 AM. The DON stated that Nurse #1 had signed out a narcotic that had been discontinued by the (NP) four times after it had been discontinued by the NP on 06/10/2024. When Nurse #1 was interviewed she indicated she had accidentally pulled the medication each time and immediately wasted it. Nurse #2 indicated that she only witnessed one pill being wasted and did not observe any other narcotic wastes for Resident #49. The DON stated she reported the incident to the Administrator 06/25/2024 and an investigation was initiated. The DON also stated she contacted Nurse #1 on 06/26/2024 to inform her of the facility's concerns, to obtain a statement from Nurse#1, and to notify Nurse #1 that she had been placed on suspension until the investigation could be completed. The DON further explained that Nurse #1 reported to the facility on [DATE] to offer a statement and to submit to a drug test. The DON stated Nurse #1 had tested positive for the medication in question and her employment was terminated 06/28/2024. The DON stated it was determined the process to reconcile controlled medication by removing discontinued controlled medications from the medication cart was not followed by the nursing staff when Resident #49's Oxycodone was discontinued. The facility substantiated the allegation and closed the investigation on 07/01/2024. An interview was conducted with the Medical Director (MD) on 09/06/2024 at 12:00 PM. The MD stated he was aware of the incident occurring 06/25/2024. He further stated that Resident #49 was assessed and had no adverse consequences noted. He further explained that the medication in question had been discontinued and Resident #49 had not missed any doses. The MD also stated that the medications were reimbursed by the facility and not charged to Resident #49. The facility provided the following corrective action plan with a completion date of 07/01/2024. Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices: On 10/01/23, the Director of Nursing was made aware that Resident #212 had a prescription-controlled medication card containing 30 Oxycodone 5mg pills missing from the medication cart on October 1, 2023, between 7:00am - 7:10pm. On 06/26/24, the Director of Nursing was made aware that a resident had a total of 4 Oxycodone 5 mg pills signed out on the declining inventory count sheet and punched from the controlled drug card between 06/11/24 - 06/26/24 by the Charge Nurse (Nurse #1) after the Nurse Practitioner discontinued the Oxycodone 5mg on 06/10/24. The resident had no negative impact or harm as the medication was discontinued. The facility recognizes that residents prescribed controlled medication have the potential to be affected from the noncompliance of missing controlled medication. The Director of Nursing audited the named resident's-controlled medication with declining count sheet on 06/26/24. No discrepancies noted. The Director of Nursing and Administrator conducted an audit of all other medication carts to verify controlled medication count on 06/26/24. No discrepancies noted in the controlled medication count. On 06/26/24 a Root Cause Analysis was completed by the [NAME] President of Clinical Services in regard to the missing controlled medication for the resident. It was determined through root cause analysis the system / process to reconcile controlled medication by removing discontinued controlled medication (Oxycodone 5mg) from the medication cart on 06/10/24 was not followed. How will the facility identify other residents having the potential to be affected by the same deficient practice: The Administrator, Director of Nursing and Social Service Director completed a quality of review of current residents prescribed controlled medication. Identified residents prescribed controlled medications was reconciled to the declining inventory county sheet to ensure the count on the sheet and card match and that medications that were ordered were available and on med carts on 07/01/24. No discrepancies noted. Social Service Director interviewed alert and oriented residents on 06/27/24 to ensure residents are receiving medication when they are scheduled or when they ask for it and if they are experiencing an increase in pain. No issues were noted. The Director of Nursing assessed non-interviewable residents for signs and symptoms of pain to ensure pain is being managed appropriately as well. No concerns identified. The Executive Director and Director of Nursing interviewed staff members related to missing controlled medication as well. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: The Vice-President of Clinical Services re-educated the Director of Clinical Services on handling-controlled medications that have been discontinued, narcotic reconciliation and the Diversion of Drugs- Zero Tolerance on. The Director of Nursing re-educated licensed nurses and medication aides on Controlled Drugs, Drug Diversion and Pharmacy Program Management on 7/01/24. The Executive Director and Director of Nursing re-educated staff with validation of understanding on Abuse policy with emphasis on Misappropriation of Residents Property and Drug Diversion on 6/27/24. The Director of Nursing and Nurse Manager to complete quality monitoring on medication carts weekly for four weeks then monthly for two months to ensure all medications accounted for with count correct with nurses counting and documenting total cards and total count sheets beginning on 7/01/24. How will the facility monitor its corrective actions to ensure the deficient practice will not recur: On 6/26/24, when the missing controlled medications was identified the center Executive Director conveyed an ADHOC Quality Assurance Performance Improvement meeting to determine the root cause analysis of the deficient practice, put a plan of action in place to include quality improvement monitoring and the frequency of monitoring beginning on 7/1/24 to ensure all medications accounted for with count correct with nurses counting and documenting total cards and total count sheets including the Executive Director, Medical Director, Director of Nursing, the Manager of Social Services, the Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records Clerk, Central Supply Clerk, Admissions Director, Nurse Managers, Dietary Manager, and the Environmental Services Director. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement (QAPI) meeting monthly to ensure ongoing compliance times 3 months. Quality Improvement monitoring schedule will be modified based on findings of monitoring. Date of Compliance: 07/01/2024 The facility's corrective action plan with a correction date of 07/01/2024 was validated onsite by observations and interviews with the Administrator, DON, and nursing staff. An observation was conducted during a shift transition for a medication cart between 2 nurses on 09/06/2024. Nurses started with counting the total number of blister cards that contained controlled medications stored in the double-locked compartment in the medication cart and verified the balance in the narcotic count log. The nurses then counted the total number of declining narcotic sheets and verified the balance in the narcotic count log. The nurses then proceeded to count each blister card of controlled medication to ensure the quantity listing in the declining narcotic count sheets were consistent with the actual pill count. After all counts were completed and without any discrepancies, the on-coming shift nurse and the off-going shift nurse signed the narcotic count logs, and the off-going shift nurse passed the medication cart key to the on-coming shift nurse. A Medication Administration observation which consisted of 29 medications, 4 different residents, 2 different nurses and 1 medication aide was conducted on 09/04/2024 and 09/05/2024. All the medications were administered as ordered without any issues. Controlled medication was retrieved from the double-locked compartment in the medication cart during the observation. The nurse documented the removal of the controlled medication on the declining narcotic count sheet. Random samples of 3 controlled medications were pulled from each medication cart for verification of accuracy. The controlled substance counts were consistent with the records documented in the declining narcotic count sheets. Interviews with the nursing staff including medication aides (MA), Licensed Practical Nurses (LPN), and Registered Nurses (RN) confirmed they had received education related to Misappropriation of Personal Property and Narcotic Process Policy. It included the process for shift-to-shift controlled medication count, verification of on-hand controlled medications, and returning of discontinued medications to the pharmacy. The nurses and medication aides were able to describe the policy and procedures and verbalized understanding of the education. Review of audit records revealed all residents receiving controlled medications were audited by the DON weekly for 4 weeks beginning on 06/26/2024. Then monthly for 8 weeks to ensure the narcotic count was correct on each cart, shift-to-shift count was completed appropriately, and discontinued controlled medications were removed from the medication carts and returned to the pharmacy. The finding were reported by the DON to the QAPI committee monthly for 3 months for suggestions and/or recommendations; the quality improvement monitoring schedule will be modified based on finding of the monitoring. Interview with the Administrator and the DON revealed the facility launched an in-service related to controlled medication process and accountability immediately after the incident to re-educate all the licensed nurses and medication aides. The DON audited the medication carts in-person randomly to ensure all controlled medication counts were conducted appropriately and the declining narcotic count sheets were documented properly. The Administrator and the DON stated the interventions were successful as the facility did not have any similar diversion issues since then. The compliance date of 07/01/2024 was validated.

Based on record review and staff interviews, the facility failed to update care plans to reflect weight loss for 1 of 2 residents reviewed for nutrition (Resident #39) and failed to update care plans for 1 of 1 resident reviewed for pressure ulcers (Resident #17). The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact and weighed 97 pounds. Review of the facility's care plan meeting minutes dated 3/9/2022 revealed the facility was aware of Resident #39's history of permanent loss of taste and smell. Review of Resident #39's care plan dated 3/16/2022 revealed a focus area for potential for nutritional problem. Interventions included: provide supplements as ordered; provide regular no added salt diet; and Registered Dietician to evaluate and make changes as needed. The care plan did not include a focus for weight loss or information regarding her loss of taste and smell. There were no documented revisions or indications of care plan review after 4/29/2022. The quarterly MDS dated [DATE] revealed Resident #39 weighed 86 pounds with no weight loss noted. A telephone interview on 7/13/2022 at 2:18 PM with the MDS Coordinator revealed she was responsible for updating care plans following completion of quarterly and annual MDS submission. The MDS Coordinator stated she had not received notification of Resident #39's weight loss and weight loss should have been included in the care plan. Interview with the Director of Nursing (DON) on 7/13/2022 at 3:18 PM revealed she expected care plans to reflect the current status of each resident. Interview with the facility Administrator on 7/13/2022 at 3:37 PM revealed he expected care plans to correctly match the resident. 2. Resident #17 was admitted to the facility on [DATE]. Resident #17's care plan last revised on 5/16/22 indicated Resident #17 had a suspected deep tissue injury to the coccyx. Interventions included to administer treatments as ordered, monitor for effectiveness, and follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note report by the Wound Physician Assistant dated 5/27/22 indicated Resident #17's wound to coccyx: wound stage had been changed from unstageable to IV for the reason muscle was palpable and tissue depth had changed because curette debridement was completed. (Curette debridement is the surgical removal or cutting away of devitalized tissue, necrosis or slough using a curette). A phone interview with the MDS (Minimum Data Set) Coordinator on 7/13/22 at 2:09 PM revealed she didn't update Resident #17's care plan to reflect the stage 4 pressure ulcer to the coccyx because she didn't know about it. The MDS Coordinator stated whoever did wound rounds with the Wound PA should have notified her when Resident #17's pressure ulcer had advanced to a stage 4. An interview with the Director of Nursing (DON) on 7/13/22 at 2:58 PM revealed Resident #17's care plan should have been revised to reflect the current stage of her pressure ulcer.

Based on record review and staff interviews, the facility failed to maintain accurate advance directives throughout the medical record for 1 of 18 residents reviewed for advance directives (Resident #204). The findings included: Resident #204 was admitted to the facility on [DATE]. A review of Resident #204's Electronic Medical Record (EMR) indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A document entitled, Advance Directives Discussion Document, dated [DATE] in Resident #204's paper chart indicated to withhold cardiopulmonary resuscitation (CPR) and that Resident #204 had a living will. The document was signed by Resident #204's family member and Nurse #1. A copy of a written telephone order dated [DATE] in Resident #204's paper chart indicated Do Not Resuscitate (DNR). The copy of the order was signed by the Staff Development Coordinator. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #204 was cognitively intact. An interview with Nurse #1 on [DATE] at 11:20 AM revealed she helped with Resident #204's admission on [DATE] and discussed Resident #204's advance directive with her family member. Resident #204's family member stated Resident #204 had a living will, but she had left it at home, so Nurse #1 checked the box for withholding CPR on the Advance Directives Discussion Document. Nurse #1 stated she wasn't sure why full code was on Resident #204's EMR and said she didn't enter this information into Resident #204's EMR. An interview with the Staff Development Coordinator (SDC) on [DATE] at 11:47 AM revealed she had reviewed the Advance Directives Discussion Document for Resident #204 on [DATE] and noted that CPR was to be withheld so she wrote a telephone order for DNR and had the physician sign it on his next rounds. The SDC stated she didn't check Resident #204's EMR to make sure it indicated the same advance directive as what was in Resident #204's paper chart. An interview with the Social Services Director (SSD) on [DATE] at 11:28 AM revealed she was responsible for advance directives but if she wasn't at the facility when a resident was admitted , the nurses were supposed to initiate the discussion about advance directives with the resident and/or family member if the resident was unable to make decisions. The SSD stated she wasn't aware that a MOST (Medical Orders for Scope of Treatment) form wasn't in Resident #204's medical record and that there was inconsistent information about Resident #204's advance directive in the EMR and the paper chart. The SSD stated she usually audited the new admissions on Fridays to make sure a MOST form was in place and that the advance directive information was consistent, but she must have missed Resident #204. A follow-up interview with the SSD on [DATE] at 11:59 AM revealed she spoke with Resident #204 and found out that Resident #204 wanted to be a full code. The SSD also stated she found a MOST form that had been initiated on [DATE] but it was located in the Medical Records' box. A review of Resident #204's MOST form dated [DATE] indicated to attempt CPR if person had no pulse and was not breathing and to provide full scope of treatment. The MOST form was signed by Resident #204's family member on [DATE] and by the Physician Assistant (PA) on [DATE]. An interview with the Medical Records Officer (MRO) on [DATE] at 1:25 PM revealed Resident #204's MOST form had been in her box since [DATE] because they were waiting for the physician or the PA to sign it. After it was signed by the PA on [DATE], the MRO had not had a chance to file it on Resident #204's paper chart. The MRO stated she didn't have anything to do with the advance directives except filing them in the residents' charts. A follow-up interview with Nurse #1 on [DATE] at 2:20 PM revealed she had witnessed Resident #204's family member sign both the Advance Directives Discussion Document and MOST form on [DATE] but she didn't notice that the Advance Directives Discussion Document indicated DNR, and the MOST form indicated full code. Nurse #1 stated she remembered Resident #204 stating to her to discuss her advance directive with her family member and to have her sign the necessary forms. An interview with the Director of Nursing (DON) on [DATE] at 3:32 PM revealed the SSD should have reviewed Resident #204's advance directive on [DATE] after her admission to the facility on [DATE]. The DON stated the SSD should have followed up to make sure the advance direction information in Resident #204's EMR and paper chart were consistent and were based on her preference. An interview with the Administrator on [DATE] at 3:36 PM revealed he didn't know what happened with Resident #204's advance directive but both the admitting nurses and the SSD were responsible for initiating it and making sure it reflected what Resident #204 wanted.

Based on observations, record reviews, resident and staff interviews, the facility failed to maintain a bladder catheter below the level of the bladder and failed to keep the catheter bag and tubing off the floor during transport for 1 of 1 resident (Resident #206) reviewed for catheter care. The findings included: Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #206's medical record revealed a Minimum Data Set (MDS) was not completed because the resident was admitted on ly 4 days prior. Review of the resident's 2/13/19 admission nursing assessment revealed the resident was alert and oriented to person, and place and was able to make his needs known. A review of Resident #206's baseline care plan dated 02/13/19 revealed he had a care plan for bladder elimination with goals to establish individual bowel/bladder routine and be odor free without skin breakdown. The interventions included catheter care per policy (dated 02/17/19), incontinent care as needed, monitor skin, monitor for hematuria (dated 02/18/19), catheter related to [MEDICAL CONDITION] and hematuria (dated 02/18/19), and change catheter as needed for occlusion, clot, etc. An observation and interview on 02/18/19 at 8:49 AM revealed Resident #206 lying in bed with a bladder catheter attached to the side of the bed draining amber colored urine. The resident stated he had gone to the Emergency department at the local hospital. He stated he had returned to the facility last evening with a catheter and had been told he had a urinary tract infection [MEDICAL CONDITION]. The catheter bag was clipped to the side of the bed at a level below the bladder. An observation was made on 02/19/19 at 9:35 AM of catheter care performed on Resident #206. Nurse Aid #1 performed catheter care using aseptic technique. As she completed the catheter care, the tubing was under his right leg and she brought the bag up and over his leg causing the urine in the tubing to reflux back into the bladder and when she untangled the tubing she brought the bag back over his leg to clip to the side of the bed, again resulting in the urine in the tubing refluxing back into the bladder. Nurse #1 who was also in the room to put a leg strap on Resident #206's leg to anchor his catheter was instructing NA #1 to keep the catheter bag below the level of the bladder. An interview on 02/19/19 at 10:45 AM with NA #1 revealed she was aware she was supposed to keep the catheter bag below the level of the bladder, but stated she had not kept it below the level of the bladder during Resident #206's catheter care. NA #1 stated she was trying to get the tubing from under his leg and didn't think when she raised the bag above his bladder. NA #1 stated she was aware Resident #206 had a urinary tract infection. An interview on 02/19/19 at 10:46 AM with Nurse #1 revealed she was aware NA #1 had placed the catheter bag above the level of Resident #206's bladder during catheter care and stated it should have remained below the level of the bladder. Nurse #1 stated it was her expectation that Resident #206's catheter bag remain below the level of his bladder at all times. An interview on 02/20/19 at 4:13 PM with the Director of Nursing and Administrator revealed they expected the resident's catheter bag to remain below the level of his bladder at all times. An observation on 02/19/19 at 10:55 AM revealed the resident in his wheelchair being transported out of the shower room by the occupational therapy assistant (OTA) to therapy. A swishing sound was noted while the resident was being pushed out of the shower room by the OTA. Resident #206's catheter bag and tubing were observed dragging the floor under his wheelchair as the OTA was pushing him down the hall approximately 180 feet to the therapy department. An interview on 02/19/19 at 10:58 AM with the OTA revealed she was not aware the catheter bag and tubing were dragging the floor while the resident was transported from the shower room to the therapy department. The OTA stated Resident #206's catheter and tubing should not be in contact with the floor and should have been attached below his bladder but off the floor. An interview on 02/19/19 at 2:50 PM with Nurse #1 revealed she was not aware Resident #206's catheter bag and tubing had been dragging on the floor from the shower room to the therapy department earlier in the day. Nurse #1 stated if she had seen it she would have stopped the OTA and adjusted the bag and tubing. An interview on 02/20/19 at 4:13 PM with the Director of Nursing and Administrator revealed they expected the resident's catheter bag to remain below the level of his bladder and his bag and tubing to remain off the floor during transport in his wheelchair to prevent contamination and urinary tract infection.

Based on observations, record reviews, and resident, and staff interviews, the facility failed to provide scheduled showers to maintain personal hygiene (Resident #205) and toe nail care (Resident #206) for 2 of 5 dependent residents reviewed for activities of daily living (ADL). The findings included: 1. Resident #205 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #205's medical record revealed a Minimum Data Set (MDS) was not completed because the resident was admitted on ly 8 days prior. Review of the resident's 2/12/19 nursing admission assessment revealed the resident was alert and oriented to person, and place and was able to make his needs known. A review of Resident #205's baseline care plan dated 02/12/19 revealed he had a care plan for ADL self-care deficit. The goal was for the resident to achieve maximum functional abilities. The interventions included providing resident with assistance of 1-2 persons with transfers, toileting, ambulation, grooming, hygiene, bathing and dressing. The resident was independent with bed mobility and eating. A review of Resident #205's bathing preference sheet dated 02/12/19 revealed he preferred showers twice weekly on Tuesday and Thursday. A review of the Shower Schedule for all residents revealed Resident #205 was scheduled for showers on Tuesday and Thursday during the day shift (7:00 AM to 3:00 PM). An observation and interview on 02/17/19 at 2:06 PM with the resident and family members, revealed he had not had a shower since he was admitted to the facility on [DATE]. The resident was lying in bed with clothes on and hair appeared to be greasy. The resident and family member stated he had not had a shower since he got to the facility. An observation and interview on 02/18/19 at 8:34 AM revealed Resident #205 still had not had a shower and his hair appeared greasy. The resident was dressed and sitting in his wheelchair waiting on therapy. An interview on 02/20/19 at 10:51 AM with Nurse Aid #1 revealed she had not given Resident #205 his shower on 02/14/19 as scheduled. NA #1 stated she had reported off to the NA on second shift that she had not given the resident his shower on 1st shift. An interview on 02/20/19 at 3:36 PM with NA #4 revealed she had not given Resident #205 a shower on 2nd shift and stated she was not aware that he had not been given his shower on 1st shift. NA #4 stated NA #1 had not reported to her that the resident needed a shower. An interview on 02/20/19 at 4:13 PM with the Director of Nursing and Administrator revealed they both expected residents to receive their showers as designated by the shower schedule and if residents refused, they expected it to be reported to the nurse. 2. Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #206's medical record revealed a Minimum Data Set (MDS) was not completed because the resident was admitted on ly 5 days prior. Review of the resident's 2/13/19 admission nursing assessment revealed the resident was alert and oriented to person, and place and was able to make his needs known. A review of Resident #206's baseline care plan dated 02/12/19 revealed he had a care plan for ADL self-care deficit. The goal was for the resident to achieve maximum functional abilities. The interventions included providing resident with assistance of 1 person with transfers, toileting, and bathing, and set up with grooming, hygiene, and dressing. The resident was independent with bed mobility and eating. A review of the Shower Schedule for all residents revealed Resident #206 was scheduled for showers on Tuesday and Friday during the day shift (7:00 AM to 3:00 PM). An observation and interview on 02/18/19 at 8:49 AM revealed Resident #206 lying in bed. His toenails on both feet were noted to be ¼ to ½ inch beyond the end of his toes and some of his toenails were bending downward onto the back of his toes. A review of Resident #206's shower sheet for 02/19/19 revealed Nurse Aid #2 had documented on his shower sheet for Toenails cut didn't need. An observation and interview on 02/19/19 at 2:29 PM revealed Resident #206 had his shower earlier in the day and stated he felt much better. An observation of his toenails revealed he had not had them trimmed after his shower. The resident stated he did not like for his toenails to be long and would like for them to be trimmed. Resident #206 indicated he could not cut his own toe nails because he could not reach them. An interview on 02/19/19 at 2:45 PM with Nurse #1 and observation of Resident #206's toenails revealed the resident's toenails did need to be cut. Nurse #1 reviewed the shower sheet completed by NA #2 and stated his assessment was not correct and Resident #206's toenails needed to be cut. An interview on 02/20/19 at 9:06 AM with NA #2 revealed he had given Resident #206 his shower on 02/19/19 and stated he did not pay attention to his toenails although he documented on his shower sheet they did not need to be cut. An interview on 02/20/19 at 4:13 PM with the Director of Nursing (DON) and Administrator revealed they both expected residents to have nail care after their showers and as needed. The DON stated if the resident's nails could not be cut by the staff she expected them to refer the resident for podiatry services.

Based on record review, resident interview and staff interviews, the facility failed to implement a care plan interventions for 1 of 1 resident reviewed for accommodation of needs (Resident #100). The findings included: Resident # 100 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], noted Resident #100 to be moderately cognitively impaired. The MDS further revealed Resident #100 required extensive, two-person assistance with all activities of daily living (ADL). Resident #100 was coded as having an absence of spoken words and was unable to express ideas or wants. Review of a care plan dated 11/03/18 had a focus area of communication deficit related to impaired verbal communication as evidenced by expressive dysphasia. The goal for Resident #100 was to be able to make his needs known through the next review. Interventions included providing and utilizing a communication board, providing visuals, and having the resident do a return demonstration to ensure understanding. Review of Physician order [REDACTED].#100 to be evaluated and receive speech therapy as indicated 5 times per week for a duration of 4 weeks related to [MEDICAL CONDITION] and oral phase dysphagia. Review of speech therapy discharge summary dated 01/09/19 revealed Resident #100 had received speech therapy services on the dates of 11/15/18 through 1/9/19. A focus goal met on 01/09/19 included Resident #100 demonstrating basic needs and wants to caregivers by selecting an item using a communication board with 70% accuracy. Long term goals included Resident #100 utilizing a communication board to effectively comprehend and communicate basic medical and social needs during routine daily activities in functional living environment. On 02/17/19 at 3:45 PM, Resident #100 was observed sitting in his wheelchair in his room. Resident #100 was unable to communicate with the surveyor and was observed becoming increasingly agitated due to the inability to communicate. No communication board was observed in Resident #100's room. On 02/19/19 at 9:51AM an interview was conducted with Nurse Aide (NA) #1 and revealed she was responsible for Resident #100 that day. NA #1 stated Resident #100 was not able to communicate with her although he tried. NA #1 indicated she was unaware of any interventions used to aide in assisting Resident #100's communication and had never seen staff use a communication board with the resident. NA #1 further stated communication was difficult with Resident #100. On 02/19/19 at 10:02AM an interview was conducted with Nurse #1. Nurse #1 stated Resident #100 was able to point and make gestures to staff regarding his needs. She stated his communication was not clear and Resident #100 was non-verbal. Nurse #1 stated no interventions were in place to aide in communication for Resident #100. Nurse #1 was not aware of a communication board as listed on Resident #100's care plan. On 02/19/19 at 10:12 AM an interview was conducted with Speech Therapist. The Speech Therapist revealed she had worked with Resident #100 on auditory comprehension, answering yes or no basic needs and the use of a communication board which she provided. The interview revealed she did not know where the communication board went or if staff had been using it with Resident #100. On 02/19/19 at 10:27 AM an interview was conducted with Nurse #2. Nurse #2 stated she had attempted the use of a communication board with Resident#100 however the resident had refused. She stated normally if a resident refused an intervention, it would be documented on the care plan along with updates. The interview further revealed the information had not been documented for Resident #100. On 02/19/19 at 10:43 AM an interview was conducted with MDS Nurse #1. The interview revealed she had been the MDS nurse since (MONTH) (YEAR). Nurse #3 stated she updated the care plans weekly based on discussions from clinical meetings and information from nursing staff. The interview revealed if a resident refused an intervention or the intervention was discontinued she would take the intervention out of the care plan. She stated she was familiar with Resident #100 and thought staff were using the communication board as an intervention in his care. Nurse #3 stated she had never heard of Resident #100 refusing the use of a communication board. On 2/20/19 at 3:25PM an interview was conducted with the Director of Nursing (DON). The DON stated no interventions were in place to assist Resident #100 communicate with staff. The DON stated Resident #100 could clearly communicate by nodding yes or no and using gestures and a communication board was not being used. On 2/20/19 at 03:34PM an interview was conducted with the Administrator. The Administrator stated Resident #100 was able to answer yes or no questions by nodding his head. She stated no interventions were in place to aide in Resident #100's ability to communicate due to nursing staff failing to make her aware. She stated her expectation was for the care plan to directly reflect interventions in use for Resident #100.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of discharge for 1 of 3 closed records reviewed for MDS accuracy (Resident #50). The findings included: Resident #50 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #50 was discharged to acute hospital with return not anticipated. A review of the discharge summary dated 02/02/19 revealed Resident #50 was discharged to home with his family on 02/02/19. A review of a physician order [REDACTED].#50 was stable for discharge with home health. On 02/20/19 at 10:40AM an interview was conducted with MDS Nurse #1. During the interview she stated Resident #50 was not discharged to the hospital on [DATE] but was discharged to home on that date. The interview revealed the MDS dated [DATE] should have reflected Resident #50 was discharged to the community instead of acute hospital. MDS Nurse #1 stated the information was coded in error. On 02/20/19 at 3:21PM an interview was conducted with the Director of Nursing (DON). The interview revealed Resident #50 was never discharged to the hospital. The interview revealed the MDS should have shown Resident #50 had been discharged to community and was coded as being discharged to the hospital by mistake. The DON stated her expectation was for Resident #50's MDS to be coded correctly reflecting his discharge status.

Based on record review and resident and staff interviews the facility failed to communicate with the resident/family member who filed the grievance and also failed to document a summary of the investigation and resolution of the grievance for 2 of 3 residents reviewed for grievances (Resident #15 and Resident #42). Findings included: 1. Resident #15 was admitted to the facility 03/24/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was cognitively intact. Review of a grievance filed by Resident #15 dated 07/20/18 revealed she was concerned over meal portions and meal substitutions. Review of the grievance form revealed there was no documentation of an investigation or resolution. There was no evidence any corrective action was taken or that a written decision was issued. An interview with Resident #15 on 02/19/19 at 3:08 PM revealed no one followed up with her concerns regarding meal portions and meal substitutions. Resident #15 did not recall who she gave the grievance to. Resident #15 stated she still had concerns over meal portions. An interview with the Administrator on 02/19/19 at 5:21 PM revealed the grievance was filed with the previous Administrator and she was not able to provide any additional information. The Administrator stated she expected an investigation and response to all grievances. The Administrator stated grievances were forwarded to the department involved in the grievance and staff from the involved department talk with the resident or family to help resolve the grievance. 2. Resident #42 was admitted to the facility 01/07/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #42 was cognitively intact. Resident #42's family filed a grievance on 05/29/18 with a concern that Resident #42's room was too cramped related to the roommate's belongings. The Action Taken section dated 04/30/18 stated the issue was resolved to the satisfaction of the patient and a copy of the resolution was given. It was noted on the grievance form the previous Administrator initialed the form. There was no further information regarding what steps were taken to resolve the grievance. Further review of the grievance form revealed there was no mention of contact with the family member who filed the grievance. An interview with Resident #42 on 02/18/19 at 3:23 PM revealed she did not recall the former Administrator talking with her or giving her any documentation regarding a grievance about her roommate's belongings. An interview with the Administrator on 02/18/19 at 4:43 PM revealed the grievance was filed with the previous Administrator and she was not able to provide any additional information about what action was taken or why Resident #42's family had not been contacted regarding the grievance. The Administrator stated she had no explanation as to why the Action Taken on the grievance stated it was completed before the grievance was filed. The Administrator also stated she expected the grievance to be resolved with the person who filed the grievance.

Based on observation, staff interview and record review, the facility failed to provide a communication board to assist with the resident's ability to communicate for 1 of 1 resident observed with a communication deficit (Resident #100). The findings included: Resident # 100 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], noted Resident #100 to be cognitively impaired. The MDS further revealed Resident #100 was coded as having an absence of spoken words under speech clarity. Resident #100 was unable to express ideas or wants. Review of a care plan dated 11/03/18 read in part, Resident #100 had a communication deficit related to impaired verbal communication as evidenced by expressive dysphasia. The goal for Resident #100 was to be able to make his needs known through the next review. Interventions included providing and utilizing a communication board, providing visuals, and having the resident do a return demonstration to ensure understanding. Review of Physician order [REDACTED].#100 to be evaluated and receive speech therapy as indicated 5 times per week for a duration of 4 weeks related to [MEDICAL CONDITION] and oral phase dysphagia. Review of speech therapy discharge summary dated 01/09/19 revealed Resident #100 had received speech therapy services on the dates of 11/15/19 through 1/9/19. A focus goal met on 01/09/19 included Resident #100 demonstrating basic needs and wants to caregivers by selecting an item using a communication board with 70% accuracy. Long term goals included Resident #100 utilizing a communication board to effectively comprehend and communicate basic medical and social needs during routine daily activities in functional living environment. Review of a physician progress notes [REDACTED].#100 had a history of [REDACTED]. The note revealed Resident #100 was non-verbal during the physician's evaluation. Review of Resident #100's Kardex (used to communicate resident information to nurse aides) on 2/17/19 revealed Resident #100 was listed as having clear communication using signs, gestures and sounds. Review of the facility grievances dated (MONTH) (YEAR) through (MONTH) 2019 revealed two grievances for Resident #100. The first grievance dated 11/20/18 was regarding incontinence care. Resident #100 was observed with incontinence through his clothing for over an hour. Resolution included staff education on incontinence care and frequent rounding. The second grievance dated 1/29/19 was regarding food preference, stating Resident #100 needed his food seasoned and set up assistance provided with meals. Resolution to the issue included education given to nursing staff regarding meal tray set up. On 02/17/19 at 3:45 PM, Resident #100 was observed sitting in his wheelchair in his room. Resident #100 was unable to communicate with the surveyor and was observed becoming increasingly agitated due to the inability to communicate. No communication board was observed in Resident #100's room. On 02/19/19 at 9:51AM an interview was conducted with Nurse Aide (NA) #1 and revealed she was responsible for Resident #100 that day. NA #1 stated Resident #100 was not able to communicate with her although he tried. NA #1 stated she was unaware of any interventions used to aide in assisting Resident #100's communication and had never seen staff use a communication board with the resident. She stated communication was difficult with Resident #100. On 02/19/19 at 10:02AM an interview was conducted with Nurse #1. Nurse #1 stated Resident #100 was able to point and make gestures to staff regarding his needs. She stated his communication was not clear and Resident #100 was non-verbal. Nurse #1 stated no interventions were in place to aide in communication for Resident #100. Nurse #1 was not aware of a communication board as listed on Resident #100's care plan. On 02/19/19 at 10:12 AM an interview was conducted with Speech Therapist. The Speech Therapist revealed she had worked with Resident #100 on auditory comprehension, answering yes or no basic needs and the use of a communication board in which she provided. She stated Resident #100 did not have clear speech and she had considered picking the resident back up for speech services due to his inability to communicate with staff but had not done so. The interview revealed she did not know where the communication board went or if staff had been using it with Resident #100 stating she didn't know what current interventions were in place to aide in Resident #100's communication. On 02/19/19 at 10:27 AM an interview was conducted with Nurse #2. Nurse #2 stated she had attempted the use of a communication board with Resident#100 however the resident had refused. She stated normally if a resident refused an intervention, it would be documented on the care plan along with updates. The interview revealed the information regarding resident refusal of an intervention had not been documented for Resident #100. On 02/19/19 at 10:43 AM an interview was conducted with MDS Nurse #1. The interview revealed she had been the MDS nurse since (MONTH) (YEAR). Nurse #3 stated she updated the care plans weekly based on discussions from clinical meetings and information from nursing staff. The interview revealed if a resident refused an intervention or the intervention was discontinued she would take the intervention out of the care plan. She stated she was familiar with Resident #100 and thought staff were using the communication board as an intervention in his care. Nurse #3 stated she had never heard of Resident #100 refusing the use of a communication board however if he did refuse to use the communication board the intervention should have been removed and his care plan revised accordingly On 2/20/19 at 3:25PM an interview was conducted with the Director of Nursing (DON). The DON stated no interventions were in place to assist Resident #100 communicate with staff. The DON stated Resident #100 could clearly communicate by nodding yes or no and using gestures and a communication board was not being used. She stated she was not aware a communication board was listed on Resident #100's care plan and it should have been discontinued. The interview revealed Resident #100's Kardex had been changed to show he experienced [MEDICAL CONDITION] and did not have clear speech on 02/18/19. The DON stated the change had been made by nursing staff and she believed Resident #100 could clearly communicate despite his diagnosis. She stated her expectation was for nursing staff to leave the Kardex showing Resident #100 could clearly communicate and did not have [MEDICAL CONDITION]. On 2/20/19 at 03:34PM an interview was conducted with the Administrator. The Administrator stated Resident #100 was able to answer yes or no questions by nodding his head. She stated no interventions were in place to aide in Resident #100's ability to communicate due to nursing staff failing to make her aware. She stated she had received two grievances for Resident #100 regarding incontinence care and food preferences however could not say they were due to the inability to communicate with staff. She stated she had spoken to Resident #100's significant other regarding the grievances due to difficulty in communication with Resident #100 himself. The Administrator stated her expectations of nursing staff were to notify her of residents needs and to accurately update the residents Kardex with correct information pertaining to the resident's diagnosis. The interview further revealed her expectation was for nursing staff to mark on Resident #100's Kardex [MEDICAL CONDITION] instead of clear communication based on the resident's diagnosis. She stated her expectation was for the care plan to directly reflect interventions in use for Resident #100.

Based on record review and staff interviews, the facility's Quality Assessment an Assurance Committee failed to effectively maintain implemented procedures and effectively monitor these interventions that the committee put into place in December of 2016. This was for one recited deficiency which was cited in December of 2016 on a recertification survey, cited on a complaint survey in May of 2017 and cited during the current recertification survey. The deficiencies were in the area of professional standards. The continued failure of the facility during three federal surveys of record show an isolated pattern of the facilities inability to sustain an effective quality assurance Program. The Findings included: This tag is cross referred to: 483.21 Services meet Professional Standards: Based on record review and staff interviews, the facility failed to clarify physician orders [REDACTED].#111). The facility was recited for 483.21 for failure to clarify physician orders [REDACTED]. 483.21 Services Meet Professional Standards was originally cited during the December 15, 2016 recertification survey for failure to implement physician orders [REDACTED]. 483.21 was also cited on a complaint survey of May 11, 2017 for failure to transcribe a physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) on 02/08/18 at 5:38 PM, the DON stated that she was still continuing with the quality assurance program established which included auditing a sample of new admissions and the physician orders [REDACTED]. DON further stated that Resident#111's record was not reviewed when she completed her monthly audit on 11/05/17 and he was discharged by the December audit. She also indicated there were no identified concerns with the audits completed.

Based on record review and staff interviews, the facility failed to complete the Treatment Administration Records (TAR) for 1 of 8 sampled residents reviewed for treatments. Resident #111's TAR had blanks where staff were to indicate if a treatment was administered or an indication that the treatment was not administered with an explanation on the reverse side. The findings included: Resident #111 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The admission physician orders were written by the unit manager nurse (UM) on the Treatment Administration Record (TAR) on 11/16/17. These included: *[MEDICATION NAME] 1% apply topically twice a day; and *[MEDICAL CONDITION] (Continuous Positive Airway Pressure) to be applied at night and removed in the morning. A telephone order written 11/16/17 at 11:40 PM was for Triad cream to the left and right posterior /upper thigh buttocks region every shift to skin tears and to the excoriation to the groin and periarea until resolved. Review of the completed TAR for November 2017 revealed the [MEDICATION NAME] cream was administered only on 11/17/17 by Nurse #1. Review of the medical record revealed no physician orders which discontinued this ordered [MEDICATION NAME] treatment. In addition, the TAR was blank related to the application of the [MEDICAL CONDITION] to Resident #111 on the nights of 11/16/17, 11/17/17 or 11/18/17 (no initials to indicate the [MEDICAL CONDITION] was applied to the resident). The TAR also was blank for the second shift for the application of Triad cream on 11/18/17. Resident #111 was discharged to the hospital on [DATE]. A telephone interview was conducted on 02/08/18 at 9:20 AM with Nurse #2 who worked the night of 11/16/17. She was unable to recall details regarding Resident #111. Nurse Aide (NA) #2, who worked 2:00 PM to 10:00 PM on 11/18/17 was interviewed on 02/07/18 at 2:03 PM and could not recall this resident. NA #1, who worked 2:00 PM to 10:00 PM on 11/17/17, was interviewed on 02/07/18 at 2:18 PM. She could not recall details of this resident's care. NA #3, who worked on 11/19/17 starting at 6:00 AM, was interviewed via phone on 02/08/18 at 6:10 PM. He stated he barely recalled this resident and thought he wore a [MEDICAL CONDITION] at night. Unreturned voice messages were left for Nurse #1 who cared for Resident #111 from 7:00 AM to 7:00 PM on 11/17/17, 11/18,17 and 11/19/17 until he discharged on [DATE]. A telephone interview on 02/08/18 at 3:29 PM with Nurse #4 who worked 7:00 PM to 7:00 AM on the nights of 11/17/17 and 11/18/17 revealed she was unable to recall details of Resident #111's [MEDICAL CONDITION]. She recalled speaking to the family about it but could not recall if he had a [MEDICAL CONDITION]. The Assistant Director of Nursing was interviewed on 02/08/18 at 4:54 PM. The ADON stated the TAR should have been completed with initials to indicate the [MEDICATION NAME] and the [MEDICAL CONDITION] was applied or indicated the reason they were not. The DON stated during interview on 02/08/18 at 5:11 PM that the TAR should have been completed with initials to indicate the [MEDICATION NAME] and the [MEDICAL CONDITION] was applied or indicated the reason they were not applied.

Based on observations and staff interviews, the facility failed to remove expired medications from 1 of 1 medication room and failed to date an opened multi-dose vial in 1 of 1 medication refrigerator. The findings included: The pharmacy policy, last revised 10/31/16, was reviewed relating to the storage and expiration dates of medications and biologicals which indicated the facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 1. An observation of the medication room on 2/7/18 at 4:00 pm revealed (1) unopened bottle of Calcium Supplement, (1) unopened bottle of [MEDICATION NAME]' Yeast, and (1) unopened bottle of Vitamin B-12, available for use, all with expiration dates of 01/18. During an interview with the Assistant Director of Nursing (ADON) at the time of the observation, she verified the medications were expired and should have been removed. She explained the central supply person is responsible for reordering, restocking, and rotating the stock medications. In the process, if any expired medications are found they are to be removed from the medication room and given to her or the Director of Nursing (DON). She stated the expired medications must have been overlooked as the central supply person only works three days per week. The central supply person was unavailable for an interview. 2. An observation of the medication refrigerator on 2/7/18 at 4:20 pm revealed an opened, undated multi-dose vial of [MEDICATION NAME] Solution. During an interview with the ADON at the time of the observation, she verified the vial was opened and not dated. She explained she would date the vial for the date it was received in the facility, which was 1/29/18. During an interview with the DON on 2/7/18 at 5:00 pm she stated she was unsure of why the bottles of expired medications were in the medication room. She explained the central supply person restocks the stock medications and is expected to remove any expired items and give them to her or the ADON. She expected all nursing staff should check stock medications for expiration dates and any expired stock medications should be removed from the medication room and returned to the pharmacy. The DON also stated any multi-dose vial should be dated when opened and any vials found opened and undated should be discarded. She expected vials of [MEDICATION NAME] Solution to be dated when opened and discarded after 28 days.

Based on record review and staff interviews, the facility failed to clarify physician orders [REDACTED].#111). The findings included: Resident #111 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The hospital discharge medication list dated 11/16/17 included the treatment orders of: *SSD (Silver [MEDICATION NAME]) cream 1% apply daily; and *[MEDICATION NAME] 1% apply topically BID (twice a day). There was no indication as to where these creams were to be applied on Resident #111's body. The admission physician orders, which included skin treatments were written by the unit manager nurse (UM) on the Treatment Administration Record (TAR) on 11/16/17. These included: *SSD (Silver [MEDICATION NAME]) cream 1% apply daily to; and *[MEDICATION NAME] 1% apply topically BID (twice a day). These orders were also written on the admission physician orders [REDACTED]. Neither the SSD nor the [MEDICATION NAME] creams included placement of the creams on Resident #111's body on either the physician signed admission orders [REDACTED] The admission nursing assessment dated [DATE] at 5:10 PM was completed by Nurse #2 and Nurse #3. In the narrative section of this assessment, Nurse #2 wrote on 11/16/17 at 6:40 PM Resident #111's groin was red, excoriation was noted on both buttocks, there were open areas on the back of his thighs and the right lower leg had a surgical area, and the right lower leg had open areas around the leg. This note indicated an order clarification was received for the wound to the right lower leg. Telephone orders dated 11/16/17 at 11:40 PM included Triad cream to the left and right posterior and upper thigh buttocks region for skin tears and shears and groin and pericare excoriation. On 11/16/17 at 11:40 PM, Nurse #3's narrative notes on the admission nursing assessment stated the skin assessment was completed. He had a skin tear to the right posterior upper thigh/buttocks region measuring 0.2 centimeters (cm) by 2 cm by 0.1 cm. Also on this left posterior/upper thigh buttocks region was a skin tear measuring 0.4 cm by 2 cm by 0.1 cm and a sheared are to the left posterior thigh measuring 2 cm by 1 cm by 0.1 cm. The note revealed that Triad paste would be applied to these areas and to his excoriated groin and periarea. Review of the Nurse Practitioner's initial progress note dated 11/17/17 for Resident #111 indicated that the medication list was reviewed during this encounter, however no clarification for the SSD or [MEDICATION NAME] treatments were noted in the progress note. Review of the completed TAR for November 2017 revealed the SSD cream was administered daily on 11/17/17, 11/18/17 and 11/19/17 by Nurse #1. The [MEDICATION NAME] cream was administered on 11/17/17 by Nurse #1. There was no indication as to where the creams were applied on the body. A telephone interview on 02/08/18 at 6:00 AM was conducted with Nurse #3 who completed the initial skin assessment. Nurse #3 stated she could not recall this resident enough to clarify information. A telephone interview was conducted on 02/08/18 at 9:20 AM with Nurse #2. She was unable to recall details regarding Resident #111. Interview with the UM occurred on 02/08/18 at 2:43 PM confirmed she had transcribed the physician orders [REDACTED]. She stated these orders came from the hospital discharge sheet and clarified with the physician. She stated the treatments should have been clarified as to the location for application. She stated she did not personally care for Resident #111. Unreturned voice messages were left for Nurse #1 who cared for Resident #111 from 7:00 AM to 7:00 PM on 11/17/17, 11/18,17 and 11/19/17 until he discharged on [DATE]. The Assistant Director of Nursing was interviewed on 02/08/18 at 4:54 PM. The ADON stated the location of the SSD and [MEDICATION NAME] creams should have been clarified. The DON stated during interview on 02/08/18 at 5:11 PM that the orders for the SSD and [MEDICATION NAME] creams should have been clarified to include the location for application on Resident #111's body.

Based on observations, record review, staff interviews and resident interview, the facility failed to assess a pressure ulcer upon admission, measure it, obtain physician orders, and track its progression for 1 of 4 sampled residents reviewed for pressure ulcers (Resident #4). The findings included: Resident #4 was admitted to the facility from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Review of the hospital records dated 04/05/17 and sent to the facility upon discharge revealed under the skin notation that she had a stage 2 pressure ulcer which was present on admission. This was included in the list of discharge diagnoses. The accompanying FL 2 (a form which determines need for skilled nursing care placement) dated 04/05/17 included under the skin section that she had a sacral stage 2 (pressure ulcer) and discolored legs. Review of the Admission Data Collection form, dated 04/05/17 at 1:05 PM by Nurse #1, included a skin section with a body form which indicated a skin issue on Resident #4's sacrum. This area was hand noted to be a stage 2 (pressure ulcer). The narrative written on this form by Nurse #1 included a statement that a skin assessment was done and there was a stage 2 ulcer noted to sacrum (symbol for with) cream on it. Unit Manager aware. Review of the admission orders [REDACTED]. Review of the initial dietary assessment dated [DATE] identified a stage 2 (pressure ulcer) on her sacrum with recommendations to add Prostat (protein supplement) for wound healing. Review of the History and Physical completed by the physician on 04/06/17 revealed the only mention of skin issues under the area of the physical exam was that her skin was warm and moist, color was normal and she had a double lumen (Percutaneously Inserted Central Catheter) PICC line in place to her right upper arm without redness or [MEDICAL CONDITION]. There was nothing about the sacral pressure ulcer mentioned including under the past medical history section. The admission Minimum (MDS) data set [DATE] coded Resident #4 with intact cognition, requiring extensive assistance with bed mobility, transfers and toileting, being frequently incontinent of bladder and always incontinent of bowel, and being nonambulatory. She was coded as having a stage 2 pressure ulcer, which was present on admission. Review of the Care Area Assessment (CAA) or pressure ulcers dated 04/17/17 stated that pressure ulcers triggered secondary to potential for pressure ulcers and a current Stage 2 (pressure ulcer) to the sacrum. The CAA stated weekly skin checks continued with daily checks by aides when administering post incontinence care as needed. Pressure ulcer care was given daily and as needed. The CAA stated a care plan would be initiated to improve current status of Stage 2 pressure ulcer to sacral area. No care plan related to pressure ulcers was found. Review of physician telephone orders dated 04/21/17 revealed that Prostat 30 milliliters was ordered to be administered every day for 30 days per the registered dietician's recommendation. Review of the Medication Administration Record [REDACTED]. Review of the medical record revealed that the only skin evaluations completed for Resident #4 after the initial assessment dated [DATE] had two entries. The first was dated 04/15/17 with picture notes but nothing about a sacrum pressure ulcer and the second was dated 04/22/17 which indicated her skin was intact. In addition there were no indications in the nursing notes about the sacral pressure ulcer or on the Treatment record indicating any treatment was being provided beginning the day of admission. During an interview with Resident #4 on 05/09/17 at 10:41 AM, she stated that she had a very small open place on her bottom but staff put cream on it daily. An interview with Nurse #1 on 05/10/17 at 11:13 AM revealed that because she was not a registered nurse, the Unit Manger would have been responsible for assessing and measuring the sacral stage 2 pressure ulcer. She stated she was unaware of any treatment orders. She further stated then the Unit Manager would place the area on the weekly wound worksheet which were reviewed every Tuesday and measured to show healing progress. Review of these worksheets revealed Resident #4 was never listed on them for measurement, staging or for progression of healing. Follow up interview with Nurse #1 revealed that she recalled the area looking like an opened blister and therefore she marked it as a stage 2. The Unit Manager was interviewed on 05/10/17 at 11:28 AM and revealed the admitting nurse completed the initial data collection tool and if someone was identified with a pressure ulcer, she as Unit Manager was responsible for assessing and staging the area. The admitting nurse was not a registered nurse, that nurse could measure the area. The Unit Manager stated she could not recall if she was aware of this area or not. She further stated that the area should have been written on the weekly wound worksheet for tracking purposes. Upon follow up interview on 05/10/17 at 11:47 AM she stated there would not have been an order if barrier cream was the cream being used on Resident #4's sacral pressure ulcer. At this interview, the Unit Manager stated she had never observed the pressure ulcer upon admission and could not recall if she knew about it. Interview with Resident #4 on 05/10/17 at 12:04 PM revealed Resident #4 stated she was admitted with a pressure ulcer that started in the hospital. She stated staff treated it with cream every day. She then stated it hurt when she was first admitted but has no pain now. On 05/10/17 at 12:25 PM, an observations of Resident #4's sacral area was observed with Nurse #1. Nurse #1 pointed to a healed area. On 05/11/17 at 9:44 AM, an interview with the Director of Nursing revealed she expected that the Unit Manager would look at a wound if the admitting nurse was not a registered nurse so that the wound would be staged and documented and if necessary call the physician for wound orders and begin the tracking system. She stated the facility had no standing orders to refer to in relation to treatment of [REDACTED].

Based on record review and staff interviews, the facility's Quality Assessment and Assurance Committee failed to develop and implement interventions and procedures to maintain compliance for 1 deficiency cited during the recertification survey of 12/15/16 and cited again during the complaint survey of 05/11/17. The repeated deficiency was in the area of services provided that meet professional standards of quality. The current deficiency involved the failure to transcribe treatment orders at the time of admission. This repeated deficiency during two federal surveys of record show an isolated pattern of the facility's inability to implement an effective Quality Assurance Program. The findings included: This tag is crossed referred to: F281: Based on record review and staff interviews, the facility failed to transcribe physician orders for wound care for 1 of 4 residents sampled with wounds upon admission (Resident #2). The facility was originally cited during a recertification survey on 12/15/16 for failure to implement physician orders for medication administration and failure to follow a physician's order for laboratory work. During an interview on 05/11/17 at 1:10 PM, the Administrator stated the facility had concentrated on the facility's transcription from month to month and did not check transcriptions on new admission orders [REDACTED]

Based on record review and staff interview, the facility failed to develop a care plan for pressure ulcers for 1 of 4 residents sampled for pressure ulcers (Resident #4). The findings included: Resident #4 was admitted to the facility from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Review of the hospital records dated 04/05/17 and sent to the facility upon discharge revealed under the skin notation that she had a stage 2 pressure ulcer which was present on admission. This was included in the list of discharge diagnoses. The accompanying FL 2 (a form which determines need for skilled nursing care placement) dated 04/05/17 included under the skin section that she had a sacral stage 2 (pressure ulcer) and discolored legs. Review of the Admission Data Collection form, dated 04/05/17 at 1:05 PM by Nurse #1, included a skin section with a body form which indicated a skin issue on Resident #4's sacrum. This area was hand noted to be a stage 2 (pressure ulcer). The narrative written on this form by Nurse #1 included a statement that a skin assessment was done and there was a stage 2 ulcer noted to sacrum (symbol for with) cream on it. Unit Manager aware. Review of the admission orders [REDACTED]. Review of the initial dietary assessment dated [DATE] identified a stage 2 (pressure ulcer) on her sacrum with recommendations to add Prostat (protein supplement) for wound healing. Review of the History and Physical completed by the physician on 04/06/17 revealed the only mention of skin issues under the area of the physical exam was that her skin was warm and moist, color was normal and she had a double lumen (Percutaneously Inserted Central Catheter) PICC line in place to her right upper arm without redness or [MEDICAL CONDITION]. There was nothing about the sacral pressure ulcer mentioned including under the past medical history section. The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #4 with intact cognition, requiring extensive assistance with bed mobility, transfers and toileting, being frequently incontinent of bladder and always incontinent of bowel, and being nonambulatory. She was coded as having a stage 2 pressure ulcer, which was present on admission. Review of the Care Area Assessment (CAA) or pressure ulcers dated 04/17/17 stated that pressure ulcers triggered secondary to potential for pressure ulcers and a current Stage 2 (pressure ulcer) to the sacrum. The CAA stated weekly skin checks continued with daily checks by aides when administering post incontinence care as needed. Pressure ulcer care was given daily and as needed. The CAA stated a care plan would be initiated to improve current status of Stage 2 pressure ulcer to sacral area. No care plan related to pressure ulcers was found. During an interview conducted on 05/11/17 at 10:27 AM , the MDS nurse who completed the CAA stated she missed developing a pressure ulcer care plan for Resident #4.

Based on record review and staff interviews, the facility failed to transcribe physician orders for wound care for 1 of 4 residents sampled with wounds upon admission (Resident #2). The findings included: Resident #2 was admitted to the facility from the hospital on [DATE]. His [DIAGNOSES REDACTED]. Review of the FL 2 (a form that screened the level of care needed) included physician orders. This form included medications. Under additional information was information that a dressing was changed to the right scrotal incision wound. The information stated rt (right) scrotal wound>>Wound Dressing Activity: Changed Incision, Wound Dressing: Foam, Other: removed (1) piece Mesalt rope, repacked with (1) piece Mesalt rope, covered with 4x4 border foam. [MEDICATION NAME], Silver Impregnated, Other: removed (1) sheet [MEDICATION NAME]-Ag, replaced with (1) [MEDICATION NAME]-Ag sheet and interdry cloth. Review of the admission physician orders transcribed by Nurse #3 on 04/08/17 included the medications as stated on the FL 2. There were no transcribed treatment orders of any kind on the order form. The physician signed this form acknowledging the orders were in effect on 04/10/17. The Admission Data Collection tool dated 04/08/17 identified Resident #2 via hand written pictures with a stage 3 area 2 centimeters (cm) x 5 cm on right lower abdomen, a stage 3 area 3 cm x 7 in front abdomen, a stage 2 area 4 cm x 6 cm on right buttocks and an open area on the right area of his scrotum. There was no staging or description of these areas. Under current treatment was checked: surgical wound care, application of dressing, and application of ointments/medications. The narrative on this form written 04/08/17 at 6:00 PM stated that he arrived with a [DIAGNOSES REDACTED]. Review of the history and physical written by the physician on 04/10/17 revealed his history of his present illness included he had a chronic sacral wound at home and developed redness at the wound site. He underwent debridement of necrotic tissue and was debrided to about 3 cm deep, 3 cm wide and 2 cm long. Mesalt dressing was placed and he was treated with routine dressings with [MEDICATION NAME]. Under the Review of Systems the physician noted he was recently treated for [REDACTED]. Under Physical Exam the physician noted a left inguinal wound, maceration of wound beneath skin folds, chronic skin changes with thickening of the skin. Under Plan the physician addressed the skin with He will continue w/ (with) routine wound care of his lower abdominal, injuinal and scrotal wounds. Review of the Treatment Record revealed the following wound care provided to Resident #2 during his stay in the facility on 04/09/17 and 04/10/17: 1. Scrotum wound - cleanse with normal saline pack with alginate silver, cover with 4x4 border foam dressing. There was no number of times this was to be completed other than during the hour 7a-7p. 2. Abdomen fold wounds - cleanse with normal saline, place alginate silver in fold. There was no number of times this was to be completed other than during the hour 7a-7p. 3. Apply barrier cream to coccyx every shift. This was to be done during the hours of 7a-7p and 7p-7a. The only nursing note that described the areas or treatment was dated 04/09/17 at 7a-7p stating dressing changed to surgical site on right side of scrotum. Silver alginate rope placed in abdominal folds, and covered with pillow cases to decrease drainage. Review of the Minimum Data Set, dated dated [DATE] stated he was independent for daily decision making, required extensive to total assistance with most activities of daily living skills, had 1 stage 2 pressure and 2 stage 3 pressure ulcers all present on admission. Review of telephone orders revealed there were no telephone orders for treatment for [REDACTED]. An interview with Nurse #3 who transcribed Resident #2's admission orders [REDACTED]. Nurse #3 stated that when she did an admission she verified the hospital medications with the physician upon admission. After she transcribes the orders, a second nurse double checks the orders for accuracy. Interview with the Unit Manger on 05/11/17 at 8:39 AM revealed that the medication and wound orders from the hospital were to be verified with the facility physician then transcribed to the order sheet and medication and treatment administration records. She further stated that if there were no wound orders then the physician would be notified and orders obtained. The Unit Manager went through the medical record and verified there were no wound orders documented. A phone interview on 05/11/17 at 9:18 AM with Nurse #4 who rechecked the admission orders [REDACTED]. Nurse 4 was unable to recall anything about the orders or Resident #2's wounds. Nurse #3 was interviewed a second time on 05/11/17 at 9:27 AM. Nurse #3 stated she verified the wound orders with the physician and should have transcribed them to the order form. She stated she just put them on the treatment administration record. She stated she started the admission, and because he arrived at shift change, Nurse #4 completed the admission. The Director of Nursing stated during interview on 05/11/17 at 9:44 AM that she observed the abdominal and buttocks wound and stage them. She did not observe the scrotum area. She expected that nurses would obtain physician orders for each wound and write those orders on the order sheet. She further stated that the Unit Manager was responsible for rechecking to ensure orders for new admissions were in place on the order sheet. On 05/11/17 at 9:54 AM, the Unit Manager stated during interview that she saw Resident #2's wounds on Monday after admission (04/10/17) and she should have transcribed the observation on the Weekly Wound Worksheet. The DON was present at this interview and stated that the lack of physician orders for Resident 2's wounds should have been identified and clarified on Monday.

Based on record review and staff interviews, the facility failed to investigate grievances for 1 of 3 sampled residents (Resident #2) and failed to provide in writing a summary of the grievance investigation and provide in writing the results of the investigations the for 3 of 3 sampled residents with grievances (Residents #2, #3 and #6). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. Resident #2 was admitted with pressure ulcers. Review of the grievances revealed Resident #2's responsible party (RP) filed a complaint/Grievance Report through the social worker on 04/10/17. The concern description included that Resident #2's dressing was very wet when it was supposed to be dry. The second concern was that the resident reported that he did not receive lunch yesterday or today and also did not receive dinner last night. The form listed the responsible parties for investigating these concerns included the Director of Nursing (DON) and the Dietary Manager (DM). This form was a two part form so that a copy was maintained. The copy was still attached. Under the findings of the investigation revealed that per interview the dressing change was delayed as the nurse was waiting for visitors to leave in order to change it and the RP voiced understanding. This was signed by the DON dated 04/11/17. There was no evidence of any investigation of the dietary concerns. Interview with the DM on 05/10/17 at 4:04 PM revealed she had not received any grievance to investigate relating to Resident #2's missed meals. Interview with the DON on 05/11/17 at 10:07 AM revealed that the social worker who took this concern was no longer employed. DON stated that once she returned the grievance relating to the nursing issues, the social worker was supposed to then pass it to the DM for her investigation. She did not do so per the DON. In addition, the DON stated she reviewed the nursing issue with the RP verbally but was not aware the RP should have gotten a copy of the investigation and findings. Interview with the Administrator on 05/11/17 at 1:10 PM that he was unaware the findings were to be provided in writing after a grievance was investigated. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility grievances revealed Resident #6 filed a grievance on 02/07/17 regarding a Nurse Aide (NA) who answered her call light and didn't believe her when the resident told her she was wet. The grievance stated Resident #6 was told by the NA that she wasn't wet and she had just changed her and pulled the cover back up over her. The findings of the investigation on the facility report revealed the NA went into Resident #6's room, checked the resident for incontinence and found the resident was dry and attempted to explain that to the resident. The plan to resolve the grievance was for the NAs to take another NA or staff member into Resident #6's room when providing care. The complainants remarks were, ok then. The results communicated section on the facility form revealed the results were verbally communicated without a written copy of the grievance investigation given to the resident. An interview conducted on 05/11/17 at 10:07 AM with the Director of Nursing (DON) revealed she investigated Resident #6's grievance and reviewed the investigation and results with Resident #6 but was not aware she should have received a written copy of the investigation and findings. An interview conducted on 05/11/17 at 1:10 PM with the Administrator revealed he was unaware the findings of grievance investigations were to be provided in writing after the investigation was completed. 3. Resident #3 was readmitted to the facility on [DATE]. Review of a grievance dated 03/13/17 filed by a staff member revealed Resident #3's family member had requested for Resident #3's clinical information to be faxed to another facility. The staff member called Resident #3's family member to see if they had concerns about Resident #3. The family member stated that they were upset because a nurse asked if they just wanted comfort medication when Resident #3 was sent out to the hospital in January. The family member stated they felt like some staff were tired of taking care of Resident #3. Under Action Taken on the grievance form, the information read: the staff member asked the family member if they would like to speak with the Director of Nursing (DON) and offered Resident #3 a private room. The family member stated they would speak with another family member and get back with her. The form also noted that both the Nurse Practitioner and Unit Manager spoke with Resident #3's family member on the day in January about her decline and the decision to keep Resident #3 comfortable or to transfer her to the Emergency Department (ED). Resident #3 was transferred to the ED. Under Status on the grievance form, the information read: Resident #3 was moved to a private room and the Resident's family member did not want to speak with the DON. The form was signed by the DON and dated 03/14/17. Interview with the DON on 05/10/17 at 1:45 PM revealed she investigated Resident #3's family's concern but the family member refused to speak with her therefore she could not explain the investigation to the family member nor did she provide the family member with a written copy of the investigation and the findings. Interview with the Administrator on 05/11/17 at 1:10 PM revealed he was unaware that a written copy of the grievance investigation and findings were to be provided to the complainant.

Based on staff interviews and record reviews the facility staff failed to protect residents on four (4) of four (4) hallways by not notifying facility administration and law enforcement of a staff member who was carrying a firearm in the facility. Immediate Jeopardy began on 4/7/12 when Transporter #1 was observed by nursing staff while he carried a gun in the facility. Immediate jeopardy was removed on 4/13/12 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place. The findings are: A review of a facility document titled "Facility Employee Handbook" with a revised date of 12/06 indicated in part "Zero Violence." "The Facility prohibits any workplace conduct that could be interpreted as threatening, confrontational, offensive or violent. This expectation applies to employees, visitors, residents, resident's family members, vendors, suppliers and other parties with whom you have business contact. Some specific examples of behavior that will not be tolerated include: Possession of weapons or firearms, including those licensed to carry concealed weapons, on Facility premises or in personal or Facility vehicles, or while performing in any job related capacity." The Employee Handbook also had a cover page titled "Employee Handbook Acknowledgement Form," with an area for date and employee signature and a statement at the bottom of the page "This receipt must be placed in the personnel file." A review of the personnel file for Transporter #1 revealed he was hired on 3/21/12 in a part-time position for four (4) hours each day Monday through Friday to transport residents from their rooms to physical therapy. The file also contained the document "Employee Handbook Acknowledgement Form" and was signed and dated 3/21/12 by Transporter #1. A review of a facility document titled "Employee Coaching Plan - Level 2" revealed "On Saturday 4/7/12 at 7:00 PM Transporter #1 brought in a pistol into the facility. The gun was unloaded and in a case but he did show it around." An employee statement indicated Transporter #1 "stated he was just visiting the facility and had just purchased the gun. He didn't realize he could not bring in the weapon because it was unloaded and had never been fired. He also stated the facility did not have a sign restricting firearms." The document dated 4/9/12 and signed by the Administrator revealed a violation of possession of weapons, dangerous device or substance on company property by Transporter #1 and he was suspended on 4/9/12 "until notified." A "brief description of violation and investigation" revealed Transporter #1 was responsible for transferring residents to and from therapy. His work days were Monday through Friday. During an interview on 4/11/12 at 12:20 PM the Human Resources Director stated Transporter #1 worked Monday through Friday each week and was last clocked in to work on Friday 4/6/12. She explained she was not aware of any policies and procedures regarding staff response if someone brought a gun into the facility but verified the employee handbook clearly stated firearms were not allowed in the facility. During an interview on 4/12/12 at 6:40 AM Licensed Nurse (LN) #1 stated she worked on Friday night 4/6/12 and Transporter #1 was in the facility and told her he would be working third shift on weekends as a security guard. She further stated he made various comments that only women worked in the facility and they had all those medications and he was going to keep them safe. She explained she did not think they needed a security guard because they had never had one before but she didn't ask anyone in administration about it. During an interview on 4/11/12 at 10:55 AM with NA #2 she stated she worked from 2:00 PM until 8:00 PM on Saturday 4/7/12. She explained she first saw Transporter #1 in the facility between 5:00 PM and 6:00 PM. She stated he walked up to the nurse's station and she saw the grip of a small gun sticking out of a pocket of his pants. She explained she did not know if the gun was loaded because she did not ask him. She further stated Transporter #1 told her he had a permit to carry it and he had permission from the Administrator to have it. NA #2 explained nursing staff took his word for it that he had permission to have the gun and they did not call the police or Administrator or Director of Nurses. She stated she saw Transporter #1 walk up and down each of the resident hallways, in and out of resident rooms and he talked with residents and asked them how they were doing. She further stated Transporter #1 took the charge keys (master keys) out of a desk drawer at the nurse's station and carried them in his pocket Saturday evening. She explained the keys opened and locked the outside doors to the facility and opened the medication room. During an interview on 4/11/12 at 3:48 PM with NA #3 she stated she worked Saturday 4/7/12 and Sunday 4/8/12 from 2:00 PM until 10:00 PM. She explained Transporter # walked up and down the resident's hallways with a gun in a holster on his right side around 6:30 PM or 7:00 PM on Saturday 4/7/12. She stated she did not know if the gun was loaded because she did not ask. She further stated she saw him go in the resident's rooms and come back out. She explained he told her he was a security guard for the facility at night. She stated she had not been informed by anyone in administration they had security and they had never seen a security guard in the facility before that night. NA #3 explained she thought something had happened so he was there for a reason. She stated she knew there was a facility policy that firearms weren't allowed. She further stated she was not aware of anyone calling administration about Transporter #1 and the gun on Saturday 4/7/12. A review of a handwritten document titled "Grievance from 3rd Shift" and dated 4/7/12 revealed Transporter #1 "was carrying a gun on premises, nurse asked him to lock it up because it's a safety issue. Sat in car at 2 AM, at 3:15 AM car gone, was not here (Don't know if he was still on the clock). Left for 2 hours on a "fire" call. Made comment he can do whatever and the Administrator will not get rid of him. Kept going in resident's room with gun in holster on side, while families were here. He said if we had issues with the gun to take it up with the Administrator. Nurse said to have Administrator or Unit Manager call but he was not going to carry the gun." During an interview on 4/12/12 at 10:00 AM with NA #4 she stated she worked Saturday 4/7/12 from 10:00 PM until 6:00 AM and saw Transporter #1 with the gun. She explained she saw him from 11:00 PM until midnight as he walked down each of the hallways and walked in and out of resident rooms. She further explained Transporter #1 had no purpose to walk in and out of resident rooms and she was not sure why he did it. She stated at approximately 12:15 AM Transporter #1 walked up to the nurse's station with the gun in his hand and told her he had a concealed weapons permit to carry it. She explained he was wearing dark pants "with a lot of pockets like the police wear." She stated she did not know if the gun was loaded because it didn't matter if it was or wasn't because she was afraid of it. NA #4 stated Transporter #1 told her he had told the Administrator he was going to do security from 10:00 PM until 6:00 AM on the weekends and it was okay for him to carry the gun in the facility. She further stated the licensed nurses told him he needed to lock the gun up but he didn't. She explained Transporter #1 told her she didn't understand because there were people who did crazy things and there were drugs in the facility. She further explained he walked away and she did not see him again until she saw him sitting in his vehicle at between 2:15 AM and 3:00 AM. She stated "we kept our eye on the residents and facility for our safety" and we made sure every door and window was locked and the alarms were all on. She explained after Transporter #1 left the facility nursing staff looked for the employee handbook to verify there were no guns allowed in the facility. She stated they wrote by hand the document "Grievance from 3rd Shift" and left a copy under the Administrator's door, on the Director of Nurses' desk and on the Unit Manager's desk. She verified she did not call the Police, Administrator, Director of Nurses or Unit Manager during her shift on 4/7/12 through 4/8/12. She stated there was also a Manager on Duty on the weekends but they did not call them when Transporter #1 had the gun in the facility. NA#4 explained she did not receive any concerns from residents or family members about Transporter #1 or the gun. During an interview on 4/12/12 at 5:07 PM with NA #5 she stated she worked Saturday night 4/7/12 from 6:00 PM until 6:00 AM. She explained Transporter #1 walked around with a gun on his hip and told her he was security for the night. She verified she volunteered and wrote the document by hand titled "Grievance from 3rd Shift" because she and her co-workers were concerned that Transporter #1 had a gun in the facility. She stated she told him she felt unsafe and he told her nobody would take the gun from him. She further stated she did not know if the gun was loaded because she didn't ask. She explained she saw him as he walked in an out of resident's rooms and he answered call lights. She stated she did not hear any concerns from residents or family members while Transporter #1 had the gun in the facility. She further explained she was not aware that any staff called the police or anyone in administration to report Transporter #1 had a gun in the facility. During an interview on 4/12/12 at 11:04 AM the Business Office Manager verified she was the Manager on Duty on Saturday 4/7/12 and was on call for a twenty-four hour period until Sunday morning 4/8/12. She stated she did not receive any calls from staff reporting Transporter #1 was in the facility with a gun. On 4/12/12 at 12:47 PM surveyor left a message for Transporter #1 to return call . Transporter #1 did not return the phone call. During an interview on 4/12/12 at 12:54 PM with LN #2 she stated she worked Saturday night 4/7/12 from 7:00 PM until 7:00 AM. She explained Transporter #1 was dressed in dark pants and had a gun in a holster on his right hip. She further explained after she got her shift report she started her medication pass and was in a resident's room giving medication when somebody came up behind her and scared her. She stated it was Transporter #1 and he did not knock on the resident's door before entering the resident's room. She explained he told her he had to go on a "fire call" and would be back in a couple of hours and he was doing security in the facility. She stated Transporter #1 came back to the facility later that evening when she went outside to take a break and she saw him with a flashlight walking around the facility property, was shining the light into the woods and inside and around the outside of two (2) storage buildings behind the facility. She explained he walked over to a table where she was sitting and sat down and stated "you all just don't understand what kind of neighborhood we're in and what if somebody breaks a window." She stated he further said "what if somebody breaks into a medication cart" and "all I need is this" and held his right fist up into the air. LN #2 explained she went back into the facility and was sitting at the nurse's station with other nursing staff when Transporter #1 walked up and said he had a gun and pointed to it on his right hip. She further explained he said he was doing security because the Administrator wanted him to do that. She stated she told him it didn't matter if he was doing security but he couldn't have a gun in the facility. She further stated he said he had all the equipment he needed to do security but he finally admitted the Administrator did not know he had a gun in the facility. She explained she told him he had to lock the gun up and he walked down the hallway with it toward the administrative offices and she did not see the gun again. She stated she wished she had called 911 but didn't because Transporter #1 finally took the gun away. She also stated she did not call the Administrator, Director of Nurses or Unit Manager and she was not aware that any staff called anyone in Administration when Transporter #1 had the gun in the facility. During an interview on 4/13/12 at 12:11 PM with LN #3 she stated she worked every weekend and worked on Saturday 4/7/12 from 7:00 PM until 7:00 AM. She explained when she got to work Transporter #1 was already in the facility. She stated she did not see him at first and someone told her he was a security guard that night. She further stated she did not think much about it at first because "we've had a couple of things get gone lately." She explained she saw Transporter #1 at the nurse's station between 7:30 PM and 8:00 PM and told him, "I heard you have a gun" and he said "yes I do." She stated she did not ask if the gun was loaded because she didn't want to know and she didn't hear if any staff said the gun was loaded or unloaded. She further stated Transporter #1 got a little attitude when she questioned him about the gun. He told her he had the proper paperwork and if she had a problem with it to take it up with the Administrator. She explained Transporter #1 left the facility for a couple of hours because he told them he was going on a "fire call" and while he was gone the nursing staff did a search of the policy book and found there were to be no weapons on the premises. LN #3 stated when Transporter #1 came back to the facility between 10:00 PM to 11:00 PM the nursing staff confronted him about the gun and "I was a little bit afraid of him." She further stated she did not think he would pull the gun out but he did make a comment, "I don't really need a gun, all I need is this right here and held up his fist" She explained Transporter #1 took the gun away after 11:00 PM but she was not sure where he put it. She stated came back to the nurses station and said he put it up, went outside to his car and he was gone after 2:00 AM. LN #3 further stated she worked on Sunday 4/8/12 from 7:00 PM to 7:00 AM and Transporter #1 was there when she arrived at the facility. She explained NA #1 had been confronted by Transporter #1 and was in tears. She stated she went to check on NA #1 in the conference room and a law enforcement officer was standing in the room and she believed he had a sheriffs' badge on his shirt sleeve. She explained she went back to the nurses station and approximately 30 minutes later NA #1 came to the nurses station and Transporter #1 left the facility. She stated she did not see Transporter #1 with a gun on Sunday 4/8/12. LN #3 stated she was not aware that any staff had called anyone in administration on Saturday 4/7/12 about the gun. She explained if Transporter #1 had not taken the gun away they would have called the Administrator. She further explained there was no reason he should have had a gun in the building and she thought the staff were shocked that he had a gun and was showing it to anyone who would look at it. She explained the staff were not comfortable at all that Transporter #1 had a gun and he was a little frightening at times. She stated she was concerned if a resident had gotten out of control Transporter #1 might have shot someone. She explained they had residents who were confused and she was worried that a resident might get the gun because Transporter #1 had the gun tucked in his pants with a black holster around it and the handle was sticking out. She stated she had not been told by anyone in administration they would have a security guard but took Transporter #1's word for it that the Administrator had approved for him to be there as a security guard. During an interview on 4/11/12 at 10:14 AM Nursing Assistant (NA) #1 stated she did not work on Saturday 4/7/12 but worked the 7:00 AM to 7:00 PM shift on Sunday 4/8/12. She explained when she got to work NA #2 told her Transporter #1 had a gun in the facility on Saturday 4/7/12 and he was showing it to the nursing staff in the nursing station. She stated NA #2 also told her Transporter #1 walked around the facility with the gun in his hand and told them he would use it if he had to. She explained NA #2 told her they didn't think about calling the police because Transporter #1 told them the Administrator said it was okay to have the gun in the facility. NA #1 further explained NA #2 told her Transporter #1 took the charge keys out of the desk at the nursing station and carried them around Saturday night. She stated the keys opened various doors in the building including the medication room but not the narcotic cabinet. NA #1 further stated she called the facility Administrator on Sunday evening because she was concerned about the gun, was afraid and requested for her fiancee to stay in the building until she finished her shift. She further explained after she talked with the Administrator, Transporter #1 told her fiancee he had to leave and the police arrived shortly thereafter. She stated the police told Transporter #1 it was not permissible for him to have a gun on the premises and if he had a gun he would be arrested and then the police left the facility. During an interview on 4/11/12 at 1:30 PM the Director of Nurses stated she was not informed that Transporter #1 was in the facility with a gun until Sunday afternoon 4/8/12 at approximately 8:30 PM. She explained she received a call from LN #3 about the incident and she asked if the Administrator had been notified and was told staff had called him earlier on Sunday evening. She stated it was her expectation staff should have asked Transporter #1 to leave the facility immediately and they should have contacted law enforcement. She also explained the facility had a manager on duty assigned for a twenty-four hour period on Saturday and Sunday and they were expected to report any concerns to the Administrator. She stated she was not aware if the manager on duty had been notified. She further stated she thought Transporter #1 took it upon himself to perform the role of security guard without correct guidance and he should have been removed from the facility. During an interview on 4/11/12 at 2:12 PM the Administrator stated Transporter #1 was hired as a rehabilitation transport person and before he was hired he did work as a volunteer. He stated he received a phone call from NA #1 on Sunday evening 4/8/12 at approximately 6:00 PM. He explained NA #1 told him she didn't feel comfortable with Transporter #1 and was afraid and wanted her boyfriend who was at the facility to stay there with her. He explained Transporter #1 got upset with the boyfriend because he didn't like where the boyfriend was standing and called the Administrator and during this call Transporter #1 admitted he brought a gun into the facility on Saturday 4/7/12. He further stated Transporter #1 told him he had called a friend at the police department and the officer was presently at the facility. The Administrator stated he talked to the police officer and told Transporter #1 to go home. He explained Transporter #1 came to his office on Monday morning 4/9/12 and said he wasn't aware he couldn't have a gun in the facility. The Administrator verified he did not receive any phone calls from the facility staff on Saturday 4/7/12 but it was his expectation staff should have immediately called the police and Administrator. The Administrator was informed of Immediate Jeopardy on 4/12/12 at 4:10 PM. The facility provided a credible allegation of compliance which included: Allegation of Substantial Compliance 1. Area police officer responded to a call from the facility on Sunday, April 8, 2012 at approximately 6:30 PM. The call was initiated by Transporter #1 in regards to a verbal confrontation with a guest in the facility. During the course of the officer ' s visit, Nursing Assistant #1 reported to the responding officer that Transporter #1 allegedly had a gun on the facility premises on the evening of Saturday, April 7, 2012. The officer spoke with the facility Administrator via telephone and as a result of this conversation, Transporter #1 was asked by the facility Administrator to leave the facility on Sunday, April 8, 2012 at approximately 6:45 PM. Transporter #1 was instructed to report to the facility Administrator's office on Monday, April 9, 2012 at 9:00 A.M., was suspended and subsequently terminated from employment. 2. As of Thursday, April 12, 2012 at 7:00 PM, the facility Administrator and Regional Human Resources Director have interviewed all staff on duty on Thursday, April 12, 2012 at 7:00 PM to ask of any knowledge regarding firearms and/or weapons brought on to the facility premises. No other reports of firearms in the facility have been made as of this time, Thursday, April 12, 2012 at 7:00 PM. Facility Administrator and Regional Human Resources Director reiterated during the course of staff interviews that if there is a report of firearms and/or weapons on the facility premises, employee will immediately dial 911 and then notify the facility Administrator and/or Director of Clinical Services. In addition, a posting of the "Zero Violence" policy has been placed in the employee break room on Thursday, April 12, 2012 at 7:30 PM. 3. The following steps were taken: a. Administrator/Human Resources Coordinator initiated re-education to full-time, part-time and PRN employees on Wednesday, April 11, 2012 at approximately 1:00 PM on "Zero Violence" policy which includes that "Possession of weapons or firearms, including those licensed to carry concealed weapons, on facility premises or in personal or facility vehicles, or while performing in any job related capacity" is prohibited and will not be tolerated. In-service will be completed by Friday, April 13, 2012 by 9 AM. After 9 AM on Friday, April 13, 2012, employees who have not completed the in-service will not be permitted to work until the education is completed. b. Administrator/Human Resources Coordinator/Director of Clinical Services further educated full-time, part-time and PRN employees on Wednesday, April 11, 2012 at approximately 1:00 PM that if they observe, or are made aware of or have been subjected to firearms and/or weapons on the facility premises, they should immediately dial 911 and then immediately inform the Administrator and/or Director of Clinical Services. In-service will be completed by Friday, April 13, 2012 by 9 AM. After 9 AM on Friday, April 13, 2012, employees who have not completed the in-service will not be permitted to work until the education is completed. c. Any violations of the "Zero Violence" policy will be thoroughly investigated and where warranted disciplinary action taken, up to and including immediate termination of the offending employees. If non-employees are involved, full-time, part-time and PRN employees should immediately dial 911 and then inform the Administrator and/or Director of Clinical Services. In certain matters having criminal implications, violations may be reported to the police or other law enforcement personnel. d. Employees will not be retaliated against for making good faith reports under this policy. e. A 24 hour initial report was filed with the North Carolina Department of Health and Human Services Division of Health Service Regulation-Healthcare Personnel Registry on Thursday, April 12, 2012 at approximately 9:00 AM. A 5 day report to follow upon completion of facility investigation. f. Social Worker initiated interviews on Wednesday, April 12, 2012 at approximately 2:00 PM with 57 interviewable residents to ensure that they feel safe while residing in the facility. The resident interviews were completed on Thursday, April 12, 2012 at approximately 11:00 AM. The results indicated that the residents feel safe while residing in the facility. The Administrator investigated one non-related concern which was resolved with a grievance on Wednesday, April 11, 2012. g. Assistant Activity Director informed residents during resident council meeting of the "Zero Violence" policy as it relates to firearms on the facility premises on Thursday, April 12, 2012 at approximately 10:00 AM. He advised residents that the facility strives to ensure residents are always safe and that should they have any concerns related to their safety, they can notify any member of the staff. h. Residents' families to be reminded via mail of the "Zero Violence" policy. Letters will be mailed out by Friday, April 13, 2012 by 12:00 PM. i. Signage was posted on all exterior facility doors on Wednesday, April 11, 2012 at approximately 8:00 PM to alert visitors that weapons/firearms are not permitted on the premises. j. Corporate Human Resources Director re-educated Administrator and facility Human Resources Coordinator on Thursday, April 12, 2012 at approximately 4:00 PM on background check results for potential hires. Administrator and facility Human Resources Coordinator fully understand that the Corporate Human Resources Director must be notified prior to hire for any backgrounds revealing more than a minor traffic violation. 4. The following steps have been taken and monitoring will be ongoing: a. Administrator/Human Resources Coordinator/Director of Clinical Services will conduct Quality Improvement (QI) monitoring of the "Zero Violence" policy as it relates to firearms on the premises of the facility. He/She will interview 6 staff members (equating to approximately 18% of the total employee population per week) about the "Zero Violence" policy as it relates to firearms on the facility premises and to whom and when to report any instances. QI monitoring initiated on Wednesday, April 11 at approximately 4:00 PM and will continue to be conducted 3 x weekly for 3 months and 1 x weekly for 9 months. b. Social Worker/Director of Clinical Services will interview residents to ensure that they feel safe while residing in the facility. She will interview 6 residents (equating to 30 % of the total resident population per week). QI monitoring initiated on Wednesday, April 11 at approximately 2:00 PM and will continue to be conducted 3 x weekly for 3 months and 1 x weekly for 9 months. c. Administrator/Human Resources Director/Social Worker/Director of Clinical Services will report results of QI monitoring to the Risk Management/Quality Improvement Committee monthly x 12 months for continued compliance and/or revision. The next meeting will be on Friday, April 13, 2012 at 9:00 AM. Immediate Jeopardy was removed on 4/13/12 at 3:20 PM with interviews of nursing assistants, licensed nursing staff and administrative staff who worked as Managers on Duty confirmed they received inservice training on 4/11/12, 4/12/12 and 4/13/12 prior to reporting on duty regarding the "Zero Violence" policy. Interviews with nursing assistants, licensed nurses and administrative staff who worked as Managers on Duty revealed awareness of expectations of the "Zero Violence" policy they would immediately call 911, then the facility Administrator and/or Director of Nurses if there was a report or observation of anyone with a firearm or weapon in the facility. Interviews with residents and family members revealed they were pleased with the "Zero Violence" policy and they had not had and concerns about violations of the policy. Review of the inservice documents and sign in sheets confirmed the inservice training had been done on 4/11/12, 4/12/12 and 4/13/12 and signage was verified on all exterior facility doors to alert visitors that weapons/firearms were not permitted on the premises.