Every finding on record at Orchard Valley Health and Rehabilitation

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the areas of hospice (specialized care focused on nearing the end of life) (Resident #29, Resident #62, and Resident #77) and preadmission screening and resident review (PASRR, a program ensuring residents with certain diagnoses received specialty services) (Resident #10) for 4 of 30 residents whose MDS assessments were reviewed. Findings included: 1. Resident #29 was admitted to the facility 10/20/23. Review of a hospice recertification note dated 12/15/25 revealed Resident #29 was initially admitted to hospice on 06/24/25 and was recertified to receive services from 12/21/25 through 02/18/26. Review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate she was receiving hospice services. An interview with the Regional MDS Consultant on 02/19/26 at 1:42 PM revealed Resident #29's quarterly MDS assessment should have reflected that she was receiving hospice care, and it was an oversight. An interview with the Director of Nursing (DON) on 02/20/26 at 2:39 PM revealed she expected MDS assessments to be coded accurately. An interview with the Administrator on 02/20/26 at 2:57 PM revealed he expected MDS assessments to be coded accurately. 2. Resident #62 was admitted to the facility 01/01/21. A hospice progress report dated 12/31/24 revealed Resident #62 was admitted to hospice on 09/10/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was not coded as having a condition or chronic disease that may result in a life expectancy of less than 6 months or that she was receiving hospice care. A hospice progress report dated 01/21/26 revealed Resident #62 was recertified to receive services through 03/04/26. A joint interview was conducted with the MDS Coordinator and Regional MDS Consultant on 02/19/26 at 1:42 PM. The MDS Coordinator and Regional MDS Consultant both stated that Resident #62's quarterly MDS assessment should have reflected she had a life expectancy of less than 6 months and was receiving hospice care, and it was an oversight. An interview with the Director of Nursing on 02/20/26 at 2:39 PM revealed she expected MDS assessments to be coded accurately. An interview with the Administrator on 02/20/26 at 2:57 PM revealed he expected MDS assessments to be coded accurately. 3. Resident #77 was admitted to the facility on [DATE]. A hospice agreement dated 01/28/26 revealed Resident #77 elected to receive hospice services effective 01/28/26. A significant change Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #77 was receiving hospice care. A joint interview was conducted with the MDS Coordinator and Regional MDS Consultant on 02/19/26 at 1:42 PM. The MDS Registered Nurse (RN) confirmed the significant change MDS assessment was completed due to Resident #77 electing hospice services. The MDS RN stated the MDS assessment should have reflected that he was receiving hospice care and it was an oversight. An interview with the Director of Nursing on 02/20/26 at 2:39 PM revealed she expected MDS assessments to be coded accurately. An interview with the Administrator on 02/20/26 at 2:57 PM revealed he expected MDS assessments to be coded accurately. 4. Resident #10 was admitted to the facility on [DATE]. A PASRR Level II determination notification letter dated 12/30/24 revealed Resident #10 had a Level II PASRR with no expiration date. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. An interview with the Regional MDS Consultant on 02/19/26 at 1:42 PM revealed Resident #10's annual MDS assessment dated [DATE] should have reflected she had a Level II PASRR and it was an oversight. An interview with the Director of Nursing on 02/20/26 at 2:39 PM revealed she expected MDS assessments to be coded accurately. An interview with the Administrator on 02/20/26 at 2:57 PM revealed he expected MDS assessments to be coded accurately.

Based on observations, record review, and resident and staff interviews, the facility failed to provide a bed with enough length to prevent a resident's feet from pressing against the footboard for 1 of 1 resident reviewed for accommodation of needs (Resident #48).Findings included:Resident #48 was admitted to the facility 03/26/25 with diagnoses including incomplete quadriplegia C5-C7 (spinal cord injury between the 5th cervical vertebrae and the 7th cervical vertebrae resulting in loss of some motor functions but not all), and chronic pain due to trauma. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #48 was cognitively intact. Resident #48 was dependent on staff assistance with self-care tasks, bed mobility and transfers. It was noted Resident #48 had a height of 73 inches.During an observation and interview on 02/16/26 at 11:51 AM, Resident #48 was observed sitting up in bed watching television. The head of the bed was raised approximately 30 degrees. Resident #48's head was approximately two inches below the top of the bed, while his feet were pressed against the footboard of the bed. Resident #48's legs were in a straight position. Resident #48 stated his feet hurt when they were pressed against the footboard of the bed and he asked the Nursing Assistants (NAs) to elevate his feet on pillows to keep them from pressing against the footboard of the bed. He stated he had requested a longer bed multiple times, but he could not recall the dates he made the requests for a larger bed.Follow up observation and interview conducted with Resident #48 on 02/18/26 at 10:39 AM revealed Resident #48 sitting up in bed watching television with the head of the bed raised approximately 30 degrees. The top of Resident #48's head was approximately two inches below the top of the bed. Resident #48's legs were in a straight position, and his feet were pressed against the footboard of the bed. Resident #48 stated he had activated his call light to request his feet be elevated with a pillow, so they were not pressed against the footboard.An interview was conducted with NA #11 on 02/18/26 at 10:51 AM. She stated she had just completed care for Resident #48. NA #11 stated Resident #48 requested pillows be placed under his feet because it was uncomfortable when his feet were pressed against the footboard of the bed. She recalled Resident #48 had this concern on multiple occasions but could not provide an exact number of times. NA #11 indicated she used pillows to raise Resident #48's feet up and away from the foot board.An Interview was conducted with Medical Assistant (MA) #15 on 02/18/26 at 10:58 AM. MA #15 confirmed he provided care for Resident #48 and Resident #48 spent much of the day in bed watching television with the head of the bed raised. When the head of the bed was raised Resident #48's feet pressed against the foot board, which caused discomfort for Resident #48's feet. MA #15 stated Resident #48 requested his feet be raised on pillows, which kept his feet from pressing into the bed.An observation and interview were conducted with Resident #48 on 02/20/26 at 8:08 AM in conjunction with the Director of Nursing (DON). The DON stated Resident #48 was positioned correctly in bed and his feet were pressed against the footboard of the bed. The DON asked Resident #48 if he was comfortable and Resident #48 stated the bed was too small. The DON confirmed the bed appeared to be too small for Resident #48 and he could be at risk for skin breakdown with his feet pressed against the footboard of the bed. An observation of Resident #48's feet revealed they were dry and intact with no rashes, bruising, or discoloration noted. The DON stated Resident #43 was in a longer bed before he transferred rooms on 01/29/25 but she could not explain why Resident #43 received a shorter bed after the transfer. An interview was conducted on 02/20/26 at 1:21 PM with the Maintenance Director. The Maintenance Director stated nursing staff assessed residents for proper bed size. Nursing staff would enter a work order in the TELS application (application on facility computers and facility cell phones used to manage work orders) if a resident needed a larger bed. He confirmed he received a work order for a longer bed for Resident #48 on 02/20/26. An interview was conducted with the Administrator on 02/20/26 at 1:21 PM. The Administrator confirmed nursing staff assessed residents for bed size when they were admitted to the facility. He stated the nursing assessment was a visual assessment and when a resident could express their needs nursing staff got verbal confirmation the resident was comfortable in the bed. He stated he expected residents to be in the proper sized bed.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 3 of 30 residents whose MDS assessments were reviewed (Residents #10, #47 and #108). Findings included:a. Resident #10 was admitted to the facility on [DATE].Review of Resident #10's electronic medical record revealed a quarterly Minimum Data Set (MDS) assessment with an ARD of 09/29/25 that was marked as completed on 10/22/25.b. Resident #47 was admitted to the facility on [DATE].Review of Resident #47's electronic medical record revealed a quarterly MDS assessment with an ARD of 11/15/25 that was marked as completed on 12/04/25.c. Resident #108 was admitted to the facility on [DATE].Review of Resident #108's electronic medical record revealed a quarterly MDS assessment with an ARD of 11/07/25 that was marked as completed on 12/02/25.During a joint interview on 02/19/26 at 1:42 PM, the MDS Registered Nurse (RN) and Regional MDS Consultant both verified Resident #10's quarterly MDS assessment dated [DATE], Resident #47's quarterly MDS assessment dated [DATE], and Resident #108's quarterly MDS assessment dated [DATE] were not completed within the regulatory time frame. The MDS RN explained the facility has had a lot of new admissions and they just got behind with the volume of MDS assessments to complete.During an interview on 02/20/26 at 2:57 PM with the Administrator present, the Regional Director of Clinical Operations (RDCO) revealed that while good-faith efforts had been made to address MDS issues, including completing assessments within regulatory timeframes, further improvement was still needed. The RDCO explained that a new rehabilitation company, who also had MDS resources that would provide the facility with additional MDS support, was starting at the facility on 03/01/26 which would help improve the MDS process and prevent further compliance issues.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted to the facility with mental health disorders for 1 of 6 residents reviewed for PASRR (Resident #11).The findings included:A PASRR Determination Notification letter dated 02/03/16 revealed Resident #11 had a Level I PASRR with no expiration date. Resident #11 was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder, anxiety, depression, and bipolar disorder.Review of the admission minimum data set (MDS) dated [DATE] revealed that Resident #11 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #11's active psychiatric/mood disorder diagnosis included anxiety, depression, bipolar disorder, and schizophrenia. Resident #11 took antianxiety medications. Review of a Psychiatric Nurse Practitioner (NP) note dated 05/05/25 revealed Resident #11 was being seen for an initial psychiatric evaluation and medication review at the request of facility to evaluate Resident #11's mood. Resident #11 had a past medical history of obsessive compulsive disorder (OCD), schizophrenia, and bipolar disorder, seen for evaluation of anxiety, OCD, major depressive disorder, schizoaffective disorder, and insomnia. Review of a Psychiatric NP note dated 01/09/26 revealed Resident #11 was being treated for anxiety, depression, and bipolar disorder. Resident #11's symptoms were chronic and stable and well controlled on the current regimen.There was no documentation that a request was submitted for the resident to be evaluated for an updated PASRR. During an interview on 02/18/26 at 2:00 PM, the Social Worker (SW) stated she had been the SW since August 2025. She stated that she looked at the diagnosis and medications and submits to North Carolina Medicaid Uniform Screening Tool (NCMUST). She stated that she had a lot of Level II PASRR's at this facility, and she had a person she could call to help her with questions about PASRR in the PASRR office. She stated that when a resident came in she would review their diagnosis and if the resident had a mental health diagnosis she would resubmit for a re-evaluation. She further revealed that she had completed an audit when she started the job in August of 2025, and Resident #11 was overlooked. During an interview on 02/18/26 at 2:57 PM, the Administrator revealed that if there was a new admission with a Level I PASRR, the SW would be responsible for submitting for a re-evaluation for PASRR. He stated that his expectation was that all residents who were admitted with a Level I PASRR and who have a mental health diagnosis were reviewed by the SW and then submitted for re-evaluation for a Level II.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) reevaluation after a significant change in physical or mental status was identified for residents previously determined to have a Level II PASRR. This deficient practice affected 2 of 5 sampled residents reviewed for PASRR (Residents #28 and #31).Findings included:a. Resident #28 was readmitted to the facility on [DATE]. Her cumulative diagnoses included schizoaffective disorder, bipolar type and anxiety disorder.A PASRR Level II determination notification letter dated 05/05/20 revealed Resident #28 had a Level II PASRR with no expiration date and nursing facility placement was appropriate.A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Resident #28's active psychiatric/mood disorder diagnoses included anxiety disorder and schizophrenia. She received antipsychotic and antidepressant medications during the MDS assessment period.The North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) inquiry provided by the Social Worker on 02/20/26 at 2:00 PM revealed Resident #28 received a Level II PASRR effective 05/05/20 with no expiration date. There were no PASRR reevaluation requests submitted since the significant change MDS assessment dated [DATE].b. Resident #31 was admitted to the facility on [DATE]. His cumulative diagnoses included major depressive disorder and anxiety disorder.A PASRR Level II determination notification letter dated 08/19/21 revealed Resident #31 had a Level II PASRR with no expiration date and nursing facility placement was appropriate.A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Resident #31's active psychiatric/mood disorder diagnoses included anxiety disorder and depression (other than bipolar). He received antianxiety and antidepressant medications during the MDS assessment period.The North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) inquiry provided by the Social Worker on 02/20/26 at 2:00 PM revealed Resident #31 received a Level II PASRR effective 08/19/21 with no expiration date. There were no PASRR reevaluation requests submitted since the significant change MDS assessment dated [DATE].During an interview on 02/18/26 at 2:00 PM, the Social Worker (SW) revealed she started her position in August 2025 and was still learning the PASRR process. The SW confirmed she was the person responsible for submitting requests for Level II PASRR reevaluations when needed. She explained when a resident admitted to the facility, she reviewed their diagnoses and if they had a mental health diagnosis she submitted a request for a reevaluation through NC MUST. The SW stated she was not aware a request for a Level II PASRR reevaluation needed to be submitted when a resident had a significant change in condition. During an interview on 02/18/26 at 2:55 PM, the Administrator revealed the SW was responsible for reviewing a resident's diagnoses and requesting Level II PASRR reevaluations as needed. The Administrator stated requests for Level II PASRR reevaluations should be made when a resident had a significant change in condition per the regulatory guidelines.

Based on observations, record review, and interviews with the Medical Director, Registered Dietitian and staff, the facility failed to provide nutritional supplements according to the physician's diet order for 1 of 4 residents reviewed for weight loss (Resident #90).Findings included:Resident #90 was admitted to the facility 09/24/24 with diagnoses including vascular dementia and severe protein-calorie malnutrition.Resident #90 had an order dated 06/11/25 for fortified pudding after lunch for weight stability. Resident #90 had an order dated 12/02/25 for a frozen nutritional cup two times per day for weight stability. Resident #90's weight record revealed he weighed 154.4 pounds on 12/10/25.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #90 had severely impaired cognition, was independent for eating meals, had no swallowing disorders, weighed 154 pounds, and documented weight loss of five percent or more in the last month or loss of ten percent or more in the last six months while not on a prescribed weight loss regimen.Resident #90's weight record revealed he weighed 140.2 pounds on 12/24/25.The care plan for nutrition last revised 12/27/25 revealed a risk for potential nutritional problems. Interventions included providing Resident #90's diet as ordered.Resident #90's weight record revealed he weighed 136.2 pounds 01/05/26.A summary of the Registered Dietitian (RD) note dated 01/14/26 was as follows: Resident #90 showed a significant weight loss of 11.9%) over the last three months. Resident #90 usually consumed 51% to 75% of meals. Resident #90 received fortified pudding once daily, house supplement three times a day and a frozen nutritional cup two times a day as supplements. The RD note further stated a goal of no significant weight loss through the next assessment.A telephone interview with the RD on 02/19/26 at 3:20PM revealed she worked with Resident #90 due to weight loss. She stated in December 2025 she attempted to stabilize his weight loss by adding frozen nutritional cups to his dietary order in addition to the fortified pudding that was ordered in June of 2025. She confirmed she increased his house supplement in January 2026 as a further attempt at weight stabilization for Resident #90. The RD stated she expected Resident #90 to receive dietary supplements as ordered. Resident #90 had an order dated 1/15/26 for the house supplement (fortified shake) 120 milliliters by mouth four times a day for weight stability.Resident #90's weight record revealed he weighed 133.8 pounds on 02/06/26.Resident #90's diet orders included an order revised 2/16/26 for a regular diet, with mechanical soft/ground meat texture and nectar thick liquids.An observation of Resident #90's lunch meal ticket on 02/17/26 at 11:35 AM revealed he was to receive a regular mechanical altered /ground meal with nectar thick liquids. Fortified pudding and a frozen nutritional cup were not included on the ticket. An observation of Resident #90's meal tray at the same date and time revealed he received one serving of mechanically ground chicken, one serving of spinach, one serving of egg noodles and an apple crisp. Resident #90 had just received his meal tray at the time of the observation.An interview was conducted on 2/18/26 at 10:16 AM with Nurse Aide #11. She stated Resident #90 did not receive fortified pudding or a frozen nutritional cup on his lunch meal tray. She stated Resident #90 had consumed about seventy-five percent (75%) of his meals over the past 2 weeks when she had provided care. An observation of Resident #90's lunch meal tray on 2/18/26 at 11:26 AM revealed the meal tray did not contain fortified pudding or a frozen nutritional cup.An interview with the Dietary Manager on 02/19/26 at 8:12 AM revealed that Resident #90 had a physician order for fortified pudding and a frozen nutritional cup and that Resident #90 should have received those items on his meal tray. She stated nursing staff informed her of new dietary orders via the diet requisition form. Once she received the diet requisition form with the new diet orders from the nursing staff, she would make the changes in Meal Tracker (nutrition management system used to manage dining operations), which would add the changes to the meal ticket. She stated she had no recollection that she received a diet requisition form to add fortified pudding and a frozen nutritional cup to Resident #90's meal ticket. The Dietary Manager confirmed that the fortified pudding and frozen nutritional cup were not on the meal ticket for Resident #90.An interview was conducted with Unit Manager #1 on 02/19/26 at 08:23 AM. She stated nursing staff filled out a diet requisition form when a resident received a new diet order. Nursing staff would place the diet requisition form in the Dietary Manager's inbox. The Unit Manager could not recall if diet requisition forms were provided to the Dietary Manager for the fortified pudding and frozen nutritional cup for Resident #90.An observation of the nourishment room on 02/20/26 at 2:34 PM revealed the nourishment room did not contain fortified pudding or frozen nutritional cups.An interview with the Medical Director on 02/20/26 at 11:00 AM revealed he expected residents to receive nutritional supplements as ordered. He stated if residents did not receive nutritional supplements as ordered, they would be at risk for continued weight loss. During an interview on 02/20/26 at 12:25 PM, the Director of Nursing stated she expected the residents to receive nutritional supplements as ordered.An interview with the Administrator on 02/20/26 at 2:45 PM revealed he expected residents to receive dietary supplements as ordered.

Based on observations, record review and resident and staff interviews, the facility failed to complete bed rail assessments to determine the need for bed rail use and failed to obtain informed consent prior to installation for 2 of 2 sampled residents (Resident #47 and #53).Findings Included:a. Resident #47 was admitted to the facility on [DATE]. His cumulative diagnoses included chronic respiratory failure with hypoxia (low oxygen), muscle weakness, and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition and range of motion impairment on both sides of the lower extremities. The MDS assessment noted Resident #47 required supervision or touching assistance with bed mobility, was independent with moving from a sitting-to-lying position and bed rails were not used as a physical restraint.During an observation on 02/16/26 at 2:30 PM, Resident #47 was lying in bed sleeping soundly. A bed grab bar was observed secured to the bedframe and in the upright position on the right side of Resident #47's bed.Review of Resident #47's electronic medical record on 02/16/26 revealed no evidence informed consent was obtained prior to the installation or use of the bed grab bar.Review of Resident #47's electronic medical record on 02/16/26 revealed the last completed bed rail assessment was dated 04/14/25. The bed rail assessment noted in part that Resident #47 nor his representative expressed a desire to have an assistive device to aid in mobility, safety and/or comfort, he needed assistance with rising independently from a supine (flat) position to a sitting/standing position, he had the ability to independently reposition himself in bed, and alternatives to bed rails had not been attempted due to a bed rail would promote mobility and transfers.During an observation and interview on 02/17/26 at 7:50 AM, Resident #47 was sitting up in bed eating breakfast with the head of the bed raised approximately 90 degrees. A bed grab bar was observed in the upright position on the right side of his bed. Resident #47 explained he used the bed grab bar to reposition himself when lying in bed or as an aid when pulling himself up to sit on the side of the bed.During an interview on 02/19/26 at 2:27 PM, Nurse Aide (NA) #1 revealed Resident #47 was able to use the bed grab bar to independently reposition himself in bed.During an interview on 02/19/26 at 2:38 PM, NA #2 revealed Resident #47 was able to use the bed grab bar independently for bed mobility.b. Resident #53 was admitted to the facility on [DATE]. His cumulative diagnoses included rheumatoid arthritis and intervertebral disc (cartilage between two vertebrae in the spinal column) degeneration of the lumbar region (lower back) with discogenic back pain and lower extremity pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had intact cognition and range of motion impairment on both sides of the upper and lower extremities. He was always incontinent of bladder and bowel and was dependent on staff assistance with toileting hygiene. The MDS assessment also noted Resident #53 required supervision or touching assistance with rolling left-to-right, required partial to moderate assistance with moving from a sitting-to-lying or lying-to-sitting position, and bed rails were not used a physical restraint. During an observation and interview on 02/17/26 at 3:30 PM, Resident #53 was sitting up in bed playing a game on his cellphone. Bilateral bed grab bars were observed in the upright position on each side of his bed. Resident #53 stated he used the bed grab bars only to hold onto to when staff rolled him onto his side to provide care.During an interview on 02/17/26 at 3:31 PM, Nurse Aide (NA) #11 revealed Resident #53 could hold onto the bed grab bars as staff provided care but he did not use them to independently reposition himself in bed.Review of Resident #53's electronic medical record on 02/17/26 revealed no evidence informed consent was obtained prior to the installation or use of the bed grab bars.Review of Resident #53's electronic medical record on 02/17/26 revealed the last completed bed rail assessment was dated 07/04/25. The bed rail assessment noted in part that Resident #53 nor his representative expressed a desire to have an assistive device to aid in mobility, safety and/or comfort, he was not able to rise independently from a supine (flat) position to a sitting/standing position, he did not have the ability to reposition himself in bed, he exhibited problems with balance and trunk control, and a physical therapy consult had been attempted as an alternative to bed rails.During an interview on 02/19/26 at 2:38 PM, NA #2 revealed Resident #53 would hold onto the bed grab bars to assist staff with turning during care, but he did not use them to independently reposition himself in bed.During an interview on 02/19/26 at 3:09 PM, the Director of Nursing (DON) revealed the only reason bed rails would be used for a resident was to promote independence with bed mobility. The DON explained hall nurses were responsible for completing the initial and quarterly bed rail assessments, Unit Managers were responsible for obtaining informed consent for the use of the bed rail and then maintenance was notified to install the bed rail. The DON stated she was not sure where the breakdown occurred.During an interview on 02/20/26 at 9:47 AM, the Unit Manager revealed nurses should be completing bed rail assessments upon a resident's admission, but she was not sure how often bed rail assessments should be completed thereafter. She stated nurses assessed the resident to determine the need for a bed rail, usually to promote independence with bed mobility, and then maintenance would be notified to install the bed rail. The Unit Manager was not aware that informed consent needed to be obtained from the resident or their representative prior to the installation of the bed rail.During an interview on 02/19/26 at 5:27 PM, the Administrator stated he expected nursing staff to obtain informed consent and complete bed rail assessments per the facility policy.

Based on record review, and interviews with the Speech Therapist and staff, the facility failed to revise the care plan to reflect the current diet as ordered by the physician for 1 of 1 resident reviewed for nutrition (Resident #1). The findings including: Resident #1 was admitted to the facility on [DATE] with diagnoses including vascular dementia and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. He required partial to moderate assistance with eating, and no signs or symptoms of a swallowing disorder were noted. The care plan last revised on 4/23/25 indicated Resident #1 received a regular diet with thin liquids and included the intervention to provide the diet as ordered by the physician. A review of Resident #1's active physician orders included provide a mechanical soft diet and nectar thick liquids for overt signs and symptoms of aspiration (inhaling food or fluids into the lungs) dated 05/27/25. An active physician's order dated 05/28/25 revealed pureed meats was added to the diet order. An interview was conducted with the Speech Therapist on 07/24/25 at 9:48 AM. The Speech Therapist revealed she had evaluated Resident #1's ability to safely eat and drink due to concerns of coughing during meals. The Speech Therapist revealed she identified Resident #1 as a high risk for aspiration and recommended his diet be downgraded from regular textured foods to mechanical soft with pureed meats and nectar thick liquids.During an interview on 07/24/25 at 3:36 PM, the MDS Coordinator revealed changes made to diet orders were reviewed during their morning Interdisciplinary Team meetings. She revealed she was responsible for updating the residents' care plans to reflect the current diet as ordered by the physician. She was unaware of the changes made to Resident #1's diet orders on 05/27/25 and 05/28/25 and stated the care plan should have been updated to reflect the current diet order. An interview was conducted on 07/24/25 at 3:33 PM with the Director of Nursing (DON) who explained resident care plans were updated by the MDS Coordinator. The DON stated Resident #1's care plan should have been updated to reflect the current diet as ordered by the physician on 05/27/25 and 05/28/25.

Based on record review, observations, interviews with the Speech Therapist and staff, the facility failed to provide fluids of a nectar thick consistency as ordered by the physician for 1 of 1 resident reviewed for nutrition (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including vascular dementia and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was moderately impaired. Resident #1 had upper extremity impairment on both sides, needed partial to moderate assistance with eating, and had no signs or symptoms of a swallowing disorder. The care plan dated 04/23/25 indicated Resident #1 received a regular diet with thin liquids. Interventions included provide diet as ordered. A review of the physician's diet order dated 05/27/25 revealed Resident #1 was downgraded from a regular diet to a mechanical soft consistency and nectar thick liquids for overt signs and symptoms of aspiration (inhaling food or fluids into the lungs). During an observation 07/23/25 at 12:03 PM, Resident #1 was being fed lunch while in the bed. The head of the bed was elevated approximately 90 degrees. Resident #1's meal tray included a cup of thin liquid hot tea that was covered with a lid. Resident #1 was being fed by Nurse Aide (NA) #1. The meal card on the tray included directions for nectar thick hot tea. Resident #1 was not observed to drink the hot tea and it was removed by NA #1. During an interview on 07/23/25 at 12:03 PM, NA #1 revealed she delivered the lunch tray to Resident #1. NA #1 confirmed the hot tea on the tray was a thin liquid consistency. After reading the directions on the meal card, NA #1 stated Resident #1 could not have the hot tea because it was not of a nectar thick consistency. NA #1 stated she did not notice the hot tea was not nectar thick prior to feeding Resident #1 and had not given any of the tea to drink. An interview was conducted on 07/24/25 at 9:00 AM with the Regional Dietary Manager and Dietary Manager. The Dietary Manager confirmed Resident #1's diet order was for nectar thick liquids. The Regional Dietary Manager revealed the hot tea sent on Resident #1's meal tray was an oversight by dietary staff and should have been a nectar thick consistency. The Regional Dietary Manager revealed the facility purchased pre-thickened fluids that dietary and nursing staff did not have to thicken. An interview was conducted with the Speech Therapist on 07/24/25 at 9:48 AM. The Speech Therapist revealed she had evaluated Resident #1's ability to safely eat and drink due to concerns of coughing during meals. The Speech Therapist revealed she identified Resident #1 as a high risk for aspiration and recommended liquids of a nectar thick consistency. During an interview on 7/24/25 at 10:53 AM, the Director of Nursing (DON) revealed Resident #1's diet order was for nectar thick liquids and should be served on the meal tray. During an interview, the Administrator revealed the meal card read nectar thickened liquids and should be served with Resident #1's meal as directed by the physician's order.

Based on observations of the meal service tray line, record review, and dietary staff, Registered Dietician (RD), and the Regional Director of Operations (RDO) interviews, the facility failed to provide all food items as specified by the approved menu and failed ensure residents received the correct portion sizes based on the approved menu. These practices had the potential to affect 77 residents receiving a regular diet, 18 residents receiving a mechanical soft diet (consisting of foods that are easy to swallow), and 8 residents receiving a puree diet (consisting of foods with a pudding-like texture). Findings included: 1. An observation of the lunch meal tray line on 12/02/24 at 12:32 PM revealed the shepherd's pie being served to residents receiving a regular or mechanical soft diet consisted of a layer of ground beef, a layer of mashed potatoes, and a layer of melted cheese. No additional serving of vegetables was provided. A review of the recipe with the Regional Director of Operations (RDO) and Dietary Manager on 12/02/24 at 12:33 PM revealed the recipe for 100 servings (resident census was 106 on 12/02/24) of shepherd's pie is as follows: (a). 18 pounds of 80/20 ground beef (b). one and one fourth quarts of chopped onions (c). one tablespoon of garlic powder (d). one tablespoon of black pepper (e). two and 3 fourths quarts of mashed potato flakes (f). two cups of margarine solids (g). two and a half gallons of frozen mixed vegetables In an interview with [NAME] #1 on 12/02/24 at 12:38 PM he confirmed he did not add mixed vegetables or onions to the shepherd's pie being served because they were unavailable. He stated the former RDO taught him how to make the shepherd's pie and it did not include mixed vegetables or onions. [NAME] #1 stated he did not inform the Dietary Manager he did not have mixed vegetables or onions for the recipe, and he followed guidance from the former RDO when preparing the shepherd's pie. A joint interview with the Dietary Manager and RDO on 12/02/24 at 12:41 PM reveled the shepherd's pie should have contained all the items called for in the recipe for all diet types or the Dietary Manager should have been notified so he could have obtained approval for appropriate substitutions. A telephone interview with the Registered Dietician (RD) on 12/04/24 at 4:26 PM revealed a contract company handled all aspects of food preparation, and she had nothing to do with day-to-day kitchen operations. An interview with the Administrator on 12/05/24 at 5:19 PM revealed he expected dietary staff to follow approved recipes or notify their supervisor if the ingredients were unavailable, so an appropriate substitution could be provided. 2. Review of the regular diet menu spreadsheet for breakfast on 12/03/24 is as follows: (a). two slices of French toast (b). one sausage patty (c). six ounces of oatmeal Review of the puree diet menu spreadsheet for breakfast on 12/03/24 is as follows: (a). #10 scoop (equaling 3.2 ounces) of puree French toast (b). #16 scoop (equaling 2 ounces) of puree sausage (c). #6 scoop (equaling 5.3 ounces) of puree oatmeal An observation of the steam table on 12/03/24 at 7:05 AM revealed grits, scrambled eggs, bacon, ground sausage, pureed eggs, and French toast had been prepared. Grits were served with a black spoodle (equaling 8 ounces), scrambled eggs were served with a green scoop (equaling 2.5 ounces), and bacon, sausage, and French toast were served with tongs. A continuous observation of the breakfast meal tray line from 7:10 AM through 7:37 am revealed [NAME] #2 plated regular meal trays with one piece of French toast, one sausage patty or one piece of bacon (as an alternate), scrambled eggs, and grits. [NAME] #2 plated pureed meal trays with two scoops of pureed eggs and one scoop of grits. An interview with [NAME] #2 on 12/03/24 at 9:52 AM revealed he substituted grits for oatmeal and served one piece of bacon because he added scrambled eggs, and the eggs served as the primary protein. He stated he had approval to substitute grits for oatmeal and decided to serve eggs and bacon for residents receiving regular diets without seeking approval from the Dietary Manager. [NAME] #2 did not provide a reason why he did not seek approval for menu changes. An interview with the Regional Director of Operations (RDO) on 12/03/24 at 10:40 AM revealed 2 slices of French toast, one sausage patty, and six ounces of oatmeal should have been served for residents on a regular diet, unless grits were approved as a substitute for oatmeal. She stated residents receiving a puree diet should have received pureed French toast, pureed sausage, and pureed oatmeal unless appropriate substitutions were approved. The RDO stated she was not sure why the approved menu was not followed. An email from the Dietary Manager to the Registered Dietician (RD) dated 12/03/24 at 11:51 AM revealed the RD approved the substitution of grits for oatmeal and pureed eggs doubled with cheese could substitute for pureed French toast. In a follow-up interview with [NAME] #2 on 12/04/24 at 12:28 PM he was unable to explain why only piece of French toast was served for the breakfast meal on 12/03/24 or why there was no pureed French toast or sausage. [NAME] #2 confirmed there was no cheese in the pureed eggs served in the breakfast meal on 12/03/24. An interview with the Dietary Manager on 12/04/24 at 12:38 PM revealed he was not sure why only one slice of French toast was served for the breakfast meal on 12/03/24 or why there was no pureed French toast or pureed sausage. He stated substituting grits for oatmeal had been approved as a substitute by the Registered Dietician (RD), but otherwise the menu should have been followed. A telephone interview with the Registered Dietician (RD) on 12/04/24 at 4:26 PM revealed a contract company handled all aspects of food preparation, and she had nothing to do with day-to-day kitchen operations. An interview with the Administrator on 12/05/24 at 5:19 PM revealed he expected menus to be followed, correct portion sizes to be served, and any substitutions made should be approved by the Registered Dietician (RD).

Based on observations and staff interviews the facility failed to maintain a clean floor in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, 1 of 1 dry storage rooms, and 1 of 1 kitchen; label and date open food items and discard expired food in 1 of 1 walk-in cooler and 2 of 2 reach-in coolers; cover and date open food items in 1 of 1 walk-in freezer and 1 of 1 reach-in cooler; date milkshakes to identify their use-by date in 1 of 1 reach-in cooler; maintain clean shelves on 5 prep tables in 1 of 1 kitchen; discard expired bread in 1 of 1 kitchen; and maintain clean refrigerators and freezers in 2 of 2 nourishment rooms (200 hall and 300 hall). This failure had the potential to affect food served to residents. Findings included: 1. An initial observation of the walk-in cooler, walk-in freezer, walk-in storage, and kitchen floor on [DATE] at 9:42 AM revealed multiple dried yellow and brown stains on the floor of the walk-in cooler, multiple dried black stains on the walk-in freezer floor, scattered dried brown stains on the floor of the dry storage room and surveyor's shoes stuck to the floor, and multiple dried black stains scattered across the kitchen floor. An interview with the Dietary Manager on [DATE] at 9:52 AM revealed kitchen floors were usually cleaned once a week, but 2 dietary staff members were out sick and that contributed to the floors not being clean. An additional observation of the walk-in cooler, walk-in freezer, and kitchen floor on [DATE] at 12:32 PM revealed multiple dried yellow and brown stains on the floor of the walk-in cooler, multiple dried black stains on the walk-in freezer floor, scattered dried brown stains on the floor of the dry storage room, and multiple dried black stains scattered across the kitchen floor. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected all floors in the kitchen to be clean and free of stains. 2. An initial observation of the walk-in cooler on [DATE] at 9:48 AM revealed a three quarters full box of pasteurized eggs with an expiration date of [DATE]. An interview with the Dietary Manager on [DATE] at 9:52 AM revealed the pasteurized eggs were not used and he should have removed them from the cooler before they expired. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected food to be used or discarded on or before the expiration date. 3. An initial observation of the walk-in freezer on [DATE] at 9:53 AM revealed the following: (a). a box of frozen biscuits sitting on a shelf that was open to air with an opened date of [DATE] (b). an undated 20-pound box of beef patties sitting on a shelf that was open to air (c). an opened and undated bag of diced ham sitting on a shelf An interview with the Dietary Manager on [DATE] at 9:53 AM revealed all items should be labeled, dated, and covered by the staff member placing the items in the freezer. He stated having 2 staff members out sick contributed to not having items labeled, dated, and covered. An additional observation of the walk-in freezer on [DATE] at 12:32 PM revealed a box of frozen biscuits sitting on a shelf that was open to air with an opened date of [DATE]. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected all food items to be labeled, dated, and covered appropriately. 4. An initial observation of the double door reach-in cooler on [DATE] at 9:54 AM revealed the following: (a). both doors of the cooler had dried and smeared white/brown stains to the doors and vent of the cooler (b). an unlabeled and undated bag of turkey sitting on a shelf (c). a box of 39 fully thawed 4-ounce manufactured milkshakes with no label to indicate the date they were removed from the freezer or the expiration date (d). 4 fully thawed 4-ounce manufactured milkshakes with no label to indicate the date they were removed from the freezer or the expiration date sitting on a shelf (e). an opened and undated 46-ounce box of thickened orange juice sitting on a shelf An interview with the Dietary Manager on [DATE] at 8:01 AM revealed the reach-in cooler should be clean and all items should be labeled and dated, and it was all dietary staff members' responsibility to check for labels and dates on food and beverage items. He stated thawed manufactured milkshakes should have a date indicating when they were removed from the freezer and should be discarded after 14 days. The Dietary Manager stated having 2 staff members out sick contributed to the cooler not being clean and beverage items not being dated. An additional observation of the double door reach-in cooler on 12:32 PM revealed both doors of the cooler had dried and smeared white/brown stains to the doors and vent of the cooler, and an opened and undated 46-ounce box of thickened orange was sitting on a shelf. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected all coolers to be clean, all opened food to be labeled and dated, and milkshakes to be dated when they were removed from the freezer and labeled with their expiration date. 5. An initial observation of the bottom shelves of 5 food preparation tables on [DATE] at 9:58 AM revealed the tables had scattered food crumbs and dried brown stains. An interview with the Dietary Manager on [DATE] at 8:01 AM revealed the prep tables should be clean and free of debris and he stated having 2 staff members out sick contributed to the tables not being cleaned. An additional observation of the bottom shelves of 5 food preparation tables on [DATE] at 12:32 PM revealed the tables had scattered food crumbs and dried brown stains. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected food preparation tables to be clean and free of debris. 6. An initial observation of the single door reach-in cooler on [DATE] at 10:00 AM revealed the following: (a). the outer door of the cooler had multiple dried and smeared white stains (b). an opened and undated pack of sliced ham sitting on the shelf (c). an opened and undated 5-pound bag of cheddar cheese sitting on the shelf (d). an opened and undated bag of shredded lettuce with brown spots sitting on the shelf (e). an undated 48-ounce pack of sliced ham open to air sitting on the shelf (f). an opened and undated 40-ounce bag of cheddar cheese sitting on the shelf An interview with the Dietary Manager on [DATE] at 8:01 AM revealed the cooler should be clean and all items should be labeled and dated when opened by the person placing the items in the cooler. He stated any food with signs of spoilage should be discarded and all food should be covered appropriately, and it was every staff member's responsibility to check for labeling and dating food. The Dietary Manager stated having 2 staff members out sick contributed to not having items labeled, dated, covered, and discarded when showing signs of spoilage. An additional observation of the single door reach-in cooler on [DATE] at 12:32 PM revealed the outer cooler door had multiple dried and smeared white stains. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected all coolers to be clean, all opened food to be labeled and dated, and any food with signs of spoilage to be discarded. 7. An observation of the bread rack in the kitchen on [DATE] at 10:04 AM revealed the following: (a). 5 loaves of bread with a best-by date of [DATE] (b). 6 loaves of bread with a best-by date of [DATE] (c). 7 loaves of bread with a best-by date of [DATE] (d). 8 loaves of bread with a best-by date of [DATE] An interview with the Dietary Manager on [DATE] at 8:01 AM revealed all bread should be used or discarded by the best-by date and people had not been checking dates on the bread. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected all food items to be used or discarded on or before the best-by date. 8. (a). An observation of the 200-hall nourishment room refrigerator on [DATE] at 3:02 PM revealed dried yellow stains to the bottom of the refrigerator and the lowest shelf on the refrigerator door. An interview with the Dietary Manager on [DATE] at 8:01 AM revealed it was the dietary department's responsibility to clean nourishment room refrigerators and freezers and having 2 staff members out sick contributed to the nourishment room refrigerators and freezers not being clean. An additional observation of the 200-hall nourishment room refrigerator on [DATE] at 8:38 AM and [DATE] at 7:42 AM revealed dried yellow stains to the bottom of the refrigerator and the lowest shelf on the refrigerator door. (b). An observation of the 300-hall nourishment room refrigerator on [DATE] at 12:46 PM revealed dried yellow stains to the bottom of the refrigerator and the lowest shelf on the refrigerator door. An observation of the 300-hall nourishment room freezer at the same date and time revealed dried red liquid to the bottom of the freezer. An additional observation of the 300-hall nourishment room refrigerator on [DATE] at 7:25 AM revealed dried yellow stains to the bottom of the refrigerator and the lowest shelf on the refrigerator door. An additional observation of the 300-hall freezer at the same date and time revealed dried red liquid to the bottom of the freezer. An interview with the Administrator on [DATE] at 5:19 PM revealed he expected nourishment room refrigerators and freezers to be clean and free of stains.

Based on observations and interviews with residents and staff, the facility failed to secure an overbed light fixture that was positioned above a resident's head to the wall (room [ROOM NUMBER]-B); ensure the overbed light worked (room [ROOM NUMBER]-B, 327-A, and 331-B); replace the light bulbs in a fixture above the sink (room [ROOM NUMBER]); ensure the water temperature from a bathroom sink was comfortable and not too cool (room [ROOM NUMBER]); ensure the shower room air vent was clean (Hall B shower room); ensure the overbed table and dresser did not have exposed sharp edges (room [ROOM NUMBER]-B); ensure a shared bathroom toilet and floor were clean and address a strong lingering odor resembling urine (room [ROOM NUMBER]); ensure ceiling, walls, flooring, baseboards, and overbed tables were clean and in good repair (rooms 227, 229-A, 318, 319, 321, 327-A, and 330); provide a clean privacy curtain (room [ROOM NUMBER]); and ensure the toilet paper holder was in place for a shared bathroom (rooms [ROOM NUMBERS]) on 2 of 2 halls reviewed for environment (Halls A and B). Findings included: 1. a. During an observation and interview on 12/02/24 at 3:51 PM of in room [ROOM NUMBER]-B the resident was resting in bed with an overbed light positioned directly above the head of the bed. Resident #82 revealed the overbed light did not work and was unsure how long it had not. When the light switch chain was pulled the fixture moved and was not secured to wall. During an interview on 12/04/24 at 8:44 the Maintenance Manager revealed he completed weekly checks by selecting random resident rooms on each hall to identify environmental issues and he was the person responsible to fix concerns when noted. The Maintenance Manager explained environment issues were shared with him during the morning meeting, and he could be notified by staff using a computer generated or paper work order and paper work orders were kept in a binder placed at each nurse station that he checked daily. A follow-up observation and interview with the Maintenance Manager was conducted on 12/04/24 at 10:11 AM. The Maintenance Manager observed the overbed light in room [ROOM NUMBER]-B was not secured to the wall and moved when the chain was pulled and did not turn on. The Maintenance Manager revealed the fixture needed to be secured to the wall to prevent it from falling when the light switch chain was pulled and could injure the resident if they were in bed, and it fell off the wall. The Maintenance Manager revealed he was not aware the overbed light was not secured to the wall or that it did not work. b. During an observation on 12/02/24 at 3:51 PM the lights above the sink in room [ROOM NUMBER] did not work properly when turned on. The light fixture had two bulbs and when turned on only one would dimly light and flickered on and off. An observation and interview with the Maintenance Manager was conducted on 12/04/24 at 10:11 AM. The Maintenance Manager observed the lights above the sink in room [ROOM NUMBER] did not work and stated the bulbs needed replaced. The Maintenance Manager revealed he was not aware the light bulbs above the sink needed to be replaced. c. During an observation on 12/02/24 at 3:51 PM the ceiling in room [ROOM NUMBER] had approximately three areas of different sizes where the textured spackling was missing. During an interview and observation on 12/04/24 at 10:11 AM the Maintenance Manager revealed he was not aware the textured spackling needed to be repaired in room [ROOM NUMBER]. He revealed the resident would need to be out of the room for him to repair the ceiling. 2. During an observation on 12/02/24 at 10:41 AM the overbed light in room [ROOM NUMBER]-B did not work and the light switch pull chain was missing. During an interview on 12/04/24 at 9:14 AM the Maintenance Manager revealed he was aware the overbed light in room [ROOM NUMBER]-B did not work and needed replaced. He revealed the new light was ordered but he could not find the purchase order to show when and would order another one today (12/04/24). 3. a. During an interview on 12/03/24 at 9:01 AM the resident in room [ROOM NUMBER] revealed the water in the bathroom did not get warm enough. An interview and observation with Maintenance Manager was conducted on 12/04/24 at 10:03 AM. The Maintenance Manager tested the water temperature from the bathroom sink in room [ROOM NUMBER] using his thermometer. The temperature did not get above 89.6 F after approximately 5 minutes. The Maintenance Manager stated he was not aware the water temperature was not getting warm enough. b. During an observation on 12/03/24 at 9:01 AM the ceiling in room [ROOM NUMBER] had an area approximately 4 inches by 4 inches where the textured spackling had broken off. An interview and observation with Maintenance Manager was conducted on 12/04/24 at 10:03 AM. The Maintenance Manager revealed he was not aware the ceiling in room [ROOM NUMBER] had damage where the textured spackling was missing. He revealed he used spray on textured spackling and could repair the ceiling. 4. An observation and interview with the Maintenance Manager was conducted on 12/04/24 at 9:53 AM of the ceiling in room [ROOM NUMBER]. There were approximately 8 areas on the ceiling where the textured spackling was missing. The Maintenance Manger revealed he did not have a work order and was not aware of the damage. 5. An observation and interview was conducted with the Floor Technician on 12/04/24 at 9:25 AM. Two air vents located in the Hall B shower room had a significant amount of dust buildup. The Floor Technician revealed he was responsible for cleaning the air vents in the shower room and it was done daily. He stated he had not cleaned the air vent in Hall B shower room on 12/4/24. During an interview on 12/06/24 at 3:52 PM, the Administrator he expected overbed lights to work properly and staff were to notify the Maintenance Director when repairs were needed. 39037 6. An observation of the dresser of room [ROOM NUMBER]-B on 12/02/24 at 11:32 AM revealed an area of missing wood to the top of the dresser on the side closest to the bed, leaving an exposed sharp corner. Additional observations of the dresser of room [ROOM NUMBER]-B on 12/03/24 at 8:55 AM, on 12/04/23 at 7:42 AM, and 12/05/24 at 7:34 AM revealed an area of missing wood to the top of the dresser on the side closest to the bed, leaving an exposed sharp corner. An interview with the Maintenance Director on 12/04/24 at 10:57 AM revealed he was not aware of the top of the dresser in room [ROOM NUMBER]-B having missing wood resulting in a sharp corner being exposed. He stated he relied on nursing staff to notify him of rough edges on furniture since he was busy working on other projects. The Maintenance Director stated the dresser would need to be replaced. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected furniture to be in good repair or be replaced. 7. An observation of the overbed table of room [ROOM NUMBER]-B on 12/02/24 revealed an area of broken plastic on the top of the table leaving sharp edges exposed. Additional observations of the dresser of room [ROOM NUMBER]-B on 12/03/24 at 8:55 AM, 12/04/24 at 7:42 AM, and 12/05/24 at 7:34 AM revealed an area of broken plastic on the top of the table leaving sharp edges exposed. An interview with the Maintenance Director on 12/04/24 at 10:57 AM revealed he was not aware of the top of the overbed table in room [ROOM NUMBER]-B having broken plastic resulting in sharp edges being exposed. He stated he relied on nursing staff to notify him of rough edges on furniture since he was busy working on other projects. The Maintenance Director stated the overbed table would need to be replaced. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected furniture to be in good repair or be replaced. 8. a. An observation of the bedside commode placed over the toilet in the shared bathroom of room [ROOM NUMBER] on 12/02/24 at 11:11 AM revealed a large amount of brown material on the seat, dried brown stains to the outside of the toilet bowl, and brown discoloration was noted to the base of the toilet. b. An observation of the bedside commode placed over the toilet in the shared bathroom of room [ROOM NUMBER] on 12/03/24 at 2:07 PM revealed dried brown material on the seat, brown discoloration to the base of the toilet, and a dried yellow stain extending from the base of the toilet almost to the bathroom door. An overwhelming odor resembling urine was noted in the bathroom. c. An observation of the bedside commode placed over the toilet in the shared bathroom of room [ROOM NUMBER] on 12/04/24 at 7:32 AM revealed the seat was raised and multiple dried splatters were noted to the underside of the lid, brown discoloration was noted to the base of the toilet, and a dried yellow stain extended from the base of the toilet almost to the bathroom door. An overwhelming odor resembling urine was noted in the bathroom. d. An observation of the bedside commode placed over the toilet in the shared bathroom of room [ROOM NUMBER] on 12/05/24 at 7:30 AM revealed the seat was raised and dried brown material was noted to the underside of the lid, brown discoloration was noted to the base of the toilet, and a dried yellow stain extended from the base of the toilet almost to the bathroom door. An overwhelming odor resembling urine was noted in the bathroom. An interview with the Housekeeping Supervisor on 12/05/24 at 8:13 AM revealed daily room cleaning consisted of dusting, sweeping, mopping, cleaning the bathroom, and removing the trash. She stated she had instructed her housekeepers to round on this bathroom a couple of times each shift, but she could not go behind her staff and check all their work. A follow-up interview with the Housekeeping Supervisor on 12/05/24 at 2:48 PM revealed she expected bathrooms to be clean and free of odor. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected resident bathrooms to be clean and free of odor. 9. An observation of the room divider curtain in room [ROOM NUMBER] on 12/02/24 at 11:12 AM revealed a circular brown stain. Additional observations of the room divider curtain in room [ROOM NUMBER] on 12/03/24 at 2:07 PM, 12/04/24 at 7:31 AM, and 12/05/24 at 7:30 AM revealed a circular brown stain. An interview with the Housekeeping Supervisor on 12/05/24 at 2:48 PM revealed she had developed a new deep cleaning schedule which included changing room divider curtains, but she educated her staff to notify her if they noticed a stain on a room curtain before it was scheduled for deep cleaning, and she would change it. She stated she expected room divider curtains to be clean. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected room divider curtains to be clean. 10. An observation of the wall behind the bed in room [ROOM NUMBER]-A on 12/02/24 at 11:26 AM revealed multiple dried brown stains. Additional observations of the wall behind the bed in room [ROOM NUMBER]-A on 12/03/24 at 8:56 AM, 12/04/24 at 7:43 AM, and 12/05/24 at 7:33 AM revealed multiple dried brown stains. An interview with the Housekeeping Supervisor on 12/05/24 at 8:13 AM revealed she had developed a new deep cleaning schedule which included cleaning walls, but she educated her staff to go ahead and clean the wall if they noticed a stain instead of waiting for the room to be deep cleaned. She stated she expected resident room walls to be clean. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected resident room walls to be clean and free of stains. 11. An observation of the floor beside the bed in room [ROOM NUMBER]-A on 12/02/24 at 11:26 AM revealed multiple dried brown stains. Additional observations of the floor beside the bed in room [ROOM NUMBER]-A on 12/03/24 at 8:56 AM, 12/04/24 at 7:43 AM, and 12/05/24 at 7:33 AM revealed multiple dried brown stains. An interview with the Housekeeping Supervisor on 12/05/24 at 8:13 AM revealed daily room cleaning consisted of dusting, sweeping, mopping, cleaning the bathroom, and removing the trash. A follow-up interview with the Housekeeping Supervisor on 12/05/24 at 2:48 PM revealed she expected resident room floors to be clean. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected resident room floors to be clean. 12. An observation of the wall between 227-A and 227-B on 12/03/24 at 8:46 AM revealed multiple dried brown stains. Additional observations of the wall between 227-A and 227-B on 12/04/24 at 7:36 AM, and 12/05/24 at 7:38 AM revealed multiple dried stains. An interview with the Housekeeping Supervisor on 12/05/24 at 8:13 AM revealed she had developed a new deep cleaning schedule which included cleaning walls, but she educated her staff to go ahead and clean the wall if they noticed a stain instead of waiting for the room to be deep cleaned. She stated she expected resident room walls to be clean. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected resident room walls to be clean and free of stains. 13. An observation of room [ROOM NUMBER] on 12/02/24 at 11:57 AM revealed a circular hole with exposed plaster in the middle of the wall by the bathroom door. An additional observation of room [ROOM NUMBER] on 12/04/24 at 8:15 AM revealed the condition of the wall by the bathroom door remained unchanged. An interview and tour was conducted with the Maintenance Director on 12/04/24 at 10:40 AM. The Maintenance Director revealed he was in the process of going room-to-room on each hall to make a list of repairs needed but had not made it to all the rooms yet and he relied on staff to notify him when repairs were needed. He stated he was not made aware of the hole in the wall by the bathroom door of room [ROOM NUMBER] and the hole would need to be patched, sanded and painted. During an interview on 12/06/24 at 3:52 PM, the Administrator he expected overbed lights to work properly and staff were to notify the Maintenance Director when repairs were needed. 37014 14. a. An observation of room [ROOM NUMBER] on 12/03/24 at 8:49 AM revealed the overbed light fixture attached to the wall beside the A bed did not turn on when the light switch chain was pulled. Additional observations conducted on 12/04/24 at 8:18 AM and 12/5/24 at 12:33 PM revealed the overbed light fixture did not turn on when the light switch chain was pulled. During an interview on 12/06/24 at 3:52 PM, the Administrator he expected overbed lights to work properly and staff were to notify the Maintenance Director when repairs were needed. b. An observation of room [ROOM NUMBER] on 12/03/24 at 8:49 AM revealed the overbed table would not stay in a fixed position when it was raised to the maximum height and the table would lower when a minimal amount of weight was placed on top of the table surface. Additional observations conducted on 12/04/24 at 8:18 AM and 12/5/24 at 12:33 PM revealed the condition of the overbed table remained the same. An interview and tour was conducted with the Maintenance Director on 12/04/24 at 10:40 AM. The Maintenance Director revealed he was in the process of going room-to-room on each hall to make a list of repairs needed but had not made it to all the rooms yet and he relied on staff to notify him when repairs were needed. The Maintenance Director stated he was not aware the overbed light in room [ROOM NUMBER]-A did not work. He stated it was one of the older light fixtures and would need to be replaced. He revealed a new light fixture was ordered but he could not find the purchase order to show when and stated he would order another one today (12/4/24). The Maintenance Director observed the overbed table in room [ROOM NUMBER]-A and confirmed it would not stay in a fixed position when the table was raised to the maximum height. He removed the overbed table from the room and stated he would replace it with a newer one he had in storage. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected furniture to be in good repair or be replaced. 36217 15. Resident #13 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #13 with a moderately impaired cognition. During an observation conducted on 12/02/24 at 12:01 PM, the toilet roll holder mounted on the wall for the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] was dysfunctional. The rod in the middle of the toilet roll holder to hold the toilet roll was missing. Three (3) opened and used toilet rolls were seen sitting on top of the water tank at the back of the commode. An interview was conducted with Resident #13 on 12/02/24 at 12:03 PM. He stated the rod for the toilet roll holder had been missing for at least 3 months and it was very inconvenient for him. He added the opened toilet rolls sitting on top of the tank behind the commode might have fallen to the floor and been contaminated. Subsequent observation conducted on 12/03/24 at 12:11 PM revealed the rod for the toilet roll holder remained missing. During a joint observation conducted with the Housekeeper on 12/03/24 at 2:31 PM, the toilet roll holder remained dysfunctional without the toilet roll rod. Three (3) brand new unopened toilet rolls were seen sitting on top of the water tank behind the commode. An interview was conducted with the Housekeeper on 12/03/24 at 2:32 PM. He stated part of his job was to replenish the toilet rolls when cleaning the bathroom. He recalled when he brought toilet rolls to this bathroom last Friday, the rod for the toilet roll holder was still in place. He stated sometimes residents could have pulled the rod out and left it in the trash container. An interview was conducted with the Maintenance Manager on 12/03/24 at 2:40 PM. He stated he checked the entire facility including residents' room and bathroom at least once every week. He recalled when he checked this shared bathroom last Friday, the rod for the toilet roll holder was still in place. He did not know when the rod was missing but stated it was important for the residents to have a functional toilet roll holder. He added he depended on residents and staff to report repair needs either verbally or through the work order. He typically checked the work orders at least once daily to ensure all repair needs were met in a timely manner. An interview was conducted with Nurse Aide #5 (NA) on 12/03/24 at 2:51 PM. He stated he typically entered the bathroom a few times a week when he assisted residents using the toilet. He recalled the rod for the toilet roll holder was in the toilet last Friday when he assisted one of the 4 residents in this shared bathroom. He did not know when it was missing. During an interview conducted on 12/03/24 at 3:05 PM, Nurse #3 explained she rarely entered residents' bathroom as personal and incontinence cares were mostly handled by the NAs. She expected NAs to report all repair needs to her so that she would notify the maintenance staff to fix them in a timely manner. She added it was important to keep the toilet roll holder in good repair to ensure sanitary and convenience. An interview was conducted with the Director of Nursing (DON) on 12/03/24 at 4:06 PM. She expected the staff to be more attentive to residents' living environment, and to report repair needs to the maintenance department in a timely manner. She added the maintenance staff should check repair needs on a regular basis and address the issues accordingly. It was her expectation for all the toilet roll holder to be in good repair all the time.

Based on record review and staff interviews, the facility failed to notify the Regional Ombudsman when residents discharged or transferred from the facility for 6 of 6 months (April 2024, July 2024, August 2024, September 2024, October 2024, and November 2024). Findings included: Review of the facility's Admission/Discharge report for the period 04/01/24 to 04/30/24 revealed there were 25 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. Review of the facility's Admission/Discharge report for the period 07/01/24 to 11/30/24 revealed there were 125 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. During an interview on 12/06/24 at 3:52 PM, the Administrator stated he was unable to find any documentation that notifications of residents' discharges/transfers were sent to the Regional Ombudsman for the months of April 2024, July 2024, August 2024, September 2024, October 2024 or November 2024. He explained that the Admissions Director was the one who was previously responsible for sending the Regional Ombudsman monthly notification of resident discharges/transfers and they had been in the process of switching that responsibility over to the Social Worker (SW) but then both the Admissions Director and SW quit. The Administrator stated they have been actively interviewing candidates to fill the open positions and in the interim, he and the Director of Nursing had been trying to cover both positions and this process had just fell through the cracks.

Based on record review and staff interviews, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, referring to the last day of the assessment period) (Residents #6, #16, #21, #28, #29, #47, #68, and #78) and failed to comprehensively complete the Care Area Assessment (CAA) for Resident #89 for 9 of 45 sampled residents. Findings included: 1. a. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's electronic medical record revealed an annual MDS assessment with an ARD of 01/20/24 that was marked as completed on 02/26/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #6's annual MDS assessment with an ARD of 01/20/24 was not completed within the regulatory time frame. b. Resident #16 was admitted to the facility on [DATE]. Review of Resident #16's electronic medical record revealed an annual MDS assessment with an ARD of 01/26/24 that was marked as completed on 02/28/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #16's annual MDS assessment with an ARD of 01/26/24 was not completed within the regulatory time frame. c. Resident #21 was admitted to the facility on [DATE]. Review of Resident #21's electronic medical record revealed an admission MDS assessment with an ARD of 06/10/24 that was marked completed 07/04/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #21's admission MDS assessment with an ARD of 06/10/24 was not completed within the regulatory time frame. d. Resident #28 was admitted [DATE]. Review of Resident #28's electronic medical record revealed an annual MDS assessment with an ARD of 07/20/24 that was marked as completed on 08/21/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #28's annual MDS assessment with an ARD of 07/20/24 was not completed within the regulatory time frame. e. Resident #29 was admitted to the facility on [DATE]. Review of Resident #29's electronic medical record revealed an annual MDS assessment with an ARD of 04/11/24 that was marked as completed on 06/16/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #29's annual MDS assessment with an ARD of 04/11/24 was not completed within the regulatory time frame. f. Resident #47 was admitted to the facility on [DATE]. Review of Resident #47's electronic medical record revealed an admission MDS assessment with an ARD of 06/14/24 that was marked as completed on 07/15/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #47's admission MDS assessment with an ARD of 06/14/24 was not completed within the regulatory time frame. g. Resident #68 was admitted to the facility on [DATE]. Review of Resident #68's electronic medical record revealed an annual MDS assessment with an ARD of 06/22/24 that was marked as completed 07/19/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #68's annual MDS assessment with an ARD of 06/22/24 was not completed within the regulatory time frame. h. Resident #78 was admitted to the facility on [DATE]. Review of Resident #78's electronic medical record revealed an admission MDS assessment with an ARD of 07/12/24 that was marked as completed on 08/12/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #78's admission MDS assessment with an ARD of 07/12/24 was not completed within the regulatory time frame. During a joint interview on 12/04/24 at 12:43 PM with MDS Nurse #2 and MDS Nurse #3 present, MDS Nurse #1 revealed both MDS Nurse #2 and MDS Nurse #3 just started at the facility in October 2024 and November 2024 respectively. MDS Nurse #1 explained that she floated between several facilities and had been working at this facility once a week to assist with completing MDS assessments. In addition, she stated MDS Nurses from other facilities had assisted when able to try and help get the MDS assessments caught up. MDS Nurse #1 stated MDS assessments fell behind primarily due to turnover in the MDS position as well as the MDS Nurses having to pick up the sections of the MDS assessment that were typically completed by other members of the Interdisciplinary Team due to turnover in those positions. MDS Nurse #1 explained they had to complete all the sections of the MDS assessment which took a lot of time. She stated they would get caught up for a month or two, then the facility would get a lot of new admissions and MDS assessments would fall behind again. She stated all the MDS Nurses were working together and slowly getting MDS assessments caught back up. During an interview on 12/04/24 at 1:06 PM, the Administrator stated MDS assessments were behind when he started his position in June 2024 and felt the breakdown was the result of a lot turnover in MDS staff. He explained since June 2024, they had a full-time MDS Nurse and a part-time MDS Nurse that both quit which put them further behind with getting MDS assessments completed. The Administrator stated with the MDS team he now had in place, he felt they would be able to get the MDS assessments caught up and stay caught up so that MDS assessments were completed within the regulatory timeframe. 36217 2. Resident #89 was admitted to the facility on [DATE] with diagnosis including depression. A review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was coded with a moderately impaired cognition. A review of Section V which consisted of care area assessment summary indicated the care area for psychotropic drug use was triggered for Resident #89. The facility did not provide any information in analysis of findings that described the nature of Resident 89's problems, possible causes and contributing factors, risk factors related to the care area, and reasons to proceed with care planning. During an interview conducted on 12/04/24 at 11:12 AM, the MDS Coordinator confirmed 1 of the 6 triggered care areas (psychotropic drug use) for Resident #89's MDS dated [DATE] were submitted without any pertinent information in analysis of findings in Section V. She explained she started her role as the MDS Coordinator about 2 months ago. Resident #89's MDS dated [DATE] was submitted by the former MDS Coordinator and she was unable to explain how it happened. She acknowledged that it was an error to submit a significant change in status MDS without the completion of analysis of findings for all the triggered areas. On 12/04/24 at 11:15 AM an interview was conducted with the Director of Nursing. She stated all the CAAs must be individualized and completed comprehensively. It was her expectation for the MDS Coordinators to complete the analysis of findings for all the triggered areas in Section V before submitting an MDS assessment. An attempt to conduct a phone interview with the former MDS Coordinator on 12/04/24 at 1:14 PM was unsuccessful. She did not return the call.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 14 of 45 sampled residents (Residents #6, #15, #16, #21, #28, #29, #42, #47, #48, #68, #78, #81, #83, and #85). Findings included: a. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 04/19/24 that was marked as completed on 06/29/24. -A quarterly MDS assessment with an ARD of 07/19/24 that was marked as completed on 08/21/24. -A quarterly MDS assessment with an ARD of 07/29/24 that was marked as completed on 08/21/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #6's quarterly MDS assessments with ARDs of 04/19/24, 07/19/24 and 07/29/24 were not completed within the regulatory time frame. b. Resident #15 was admitted to the facility on [DATE]. Review of Resident #15's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 01/22/24 that was marked as completed on 02/27/24. -A quarterly MDS assessment with an ARD of 02/23/24 that was marked as completed on 03/12/24. -A quarterly MDS assessment with an ARD of 04/05/24 that was marked as completed on 06/06/24. -A quarterly MDS assessment with an ARD of 07/06/24 that was marked as completed on 07/26/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #15's quarterly MDS assessments with ARDs of 01/22/24, 02/23/24, 04/05/24, and 07/06/24 were not completed within the regulatory time frame. c. Resident #16 was admitted to the facility on [DATE]. Review of Resident #16's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 04/26/24 that was marked as completed on 07/01/24. -A quarterly MDS assessment with an ARD of 07/27/24 that was marked as completed on 08/23/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #16's quarterly MDS assessments with ARDs of 04/26/24 and 07/27/24 were not completed within the regulatory time frame. d. Resident #21 was admitted to the facility on [DATE]. Review of Resident #21's electronic medical record revealed a quarterly MDS assessment with an ARD of 09/10/24 that was marked as completed on 11/11/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #21's quarterly MDS assessment with an ARD of 09/10/24 was not completed within the regulatory time frame. e. Resident #28 was admitted [DATE]. Review of Resident #28's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 01/19/24 that was marked as completed on 02/26/24. -A quarterly MDS assessment with an ARD of 04/19/24 that was marked as completed on 06/19/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #28's quarterly MDS assessments with ARDs of 01/19/24 and 04/19/24 were not completed within the regulatory time frame. f. Resident #29 was admitted to the facility on [DATE]. Review of Resident #29's electronic medical record revealed a quarterly MDS assessment with an ARD of 07/17/24 that was marked as completed on 08/20/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #29's quarterly MDS assessment with an ARD of 07/17/24 was not completed within the regulatory time frame. g. Resident #42 admitted to the facility on [DATE]. Review of Resident #42's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 03/22/24 that was marked as completed on 05/12/24. -A quarterly MDS assessment with an ARD of 06/05/24 that was marked as completed on 07/10/24. -A quarterly MDS assessment with an ARD of 07/09/24 that was marked as completed on 07/31/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #42's quarterly MDS assessments with ARDs of 03/22/24, 06/05/24 and 07/09/24 were not completed within the regulatory time frame. h. Resident #47 was admitted to the facility on [DATE]. Review of Resident #47's electronic medical record revealed a quarterly MDS assessment with an ARD of 07/04/24 that was marked as completed on 07/24/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #47's quarterly MDS assessment with an ARD of 07/24/24 was not completed within the regulatory time frame. i. Resident #48 was admitted to the facility on [DATE]. Review of Resident #48's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 02/22/24 that was marked as completed on 03/10/24. -A quarterly MDS assessment with an ARD of 04/12/24 that was marked as completed on 06/16/24. -A quarterly MDS assessment with an ARD of 07/09/24 that was marked as completed on 07/31/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #48's quarterly MDS assessments with ARDs of 02/22/24, 04/12/24 and 07/09/24 were not completed within the regulatory time frame. j. Resident #68 was admitted to the facility on [DATE]. Review of Resident #68's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 03/07/24 that was marked as completed on 04/08/24. -A quarterly MDS assessment with an ARD of 03/22/24 that was marked as completed on 05/15/24. -A quarterly MDS assessment with an ARD of 07/17/24 that was marked as completed on 08/20/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #68's quarterly MDS assessments with ARDs of 03/07/24, 03/22/24 and 07/17/24 were not completed within the regulatory time frame. k. Resident #78 was admitted to the facility on [DATE]. Review of Resident #78's electronic medical record revealed a quarterly MDS assessment with an ARD of 08/05/24 that was marked as completed on 09/11/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #78's admission MDS assessment with an ARD of 07/12/24 was not completed within the regulatory time frame. l. Resident #81 was admitted to the facility on [DATE]. Review of Resident #81's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 01/19/24 that was marked as completed on 02/22/24. -A quarterly MDS assessment with an ARD of 04/19/24 that was marked as completed on 06/24/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #81's quarterly MDS assessments with ARDs of 01/19/24 and 04/19/24 were not completed within the regulatory time frame. m. Resident #83 was admitted to the facility on [DATE]. Review of Resident #83's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 03/06/24 that was marked as completed on 04/03/24. -A quarterly MDS assessment with an ARD of 03/15/24 that was marked as completed on 05/09/24. -A quarterly MDS assessment with an ARD of 06/14/24 that was marked as completed on 07/14/24. -A quarterly MDS assessment with an ARD of 07/29/24 that was marked as completed on 08/23/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #83's quarterly MDS assessments with ARDs of 03/06/24, 03/15/24, 06/14/24 and 07/29/24 were not completed within the regulatory time frame. n. Resident #85 was admitted to the facility on [DATE]. Review of Resident #85's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 05/04/24 that was marked as completed on 07/03/24. -A quarterly MDS assessment with an ARD of 07/19/24 that was marked as completed on 08/21/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #85's quarterly MDS assessments with ARDs of 05/04/24 and 07/19/24 were not completed within the regulatory time frame. During a joint interview on 12/04/24 at 12:43 PM with MDS Nurse #2 and MDS Nurse #3 present, MDS Nurse #1 revealed both MDS Nurse #2 and MDS Nurse #3 just started at the facility in October 2024 and November 2024 respectively. MDS Nurse #1 explained that she floated between several facilities and had been working at this facility once a week to assist with completing MDS assessments. In addition, she stated MDS Nurses from other facilities had assisted when able to try and help get the MDS assessments caught up. MDS Nurse #1 stated MDS assessments fell behind primarily due to turnover in the MDS position as well as the MDS Nurses having to pick up the sections of the MDS assessment that were typically completed by other members of the Interdisciplinary Team due to turnover in those positions. MDS Nurse #1 explained they had to complete all the sections of the MDS assessment which took a lot of time. She stated they would get caught up for a month or two, then the facility would get a lot of new admissions and MDS assessments would fall behind again. She stated all the MDS Nurses were working together and slowly getting MDS assessments caught back up. During an interview on 12/04/24 at 1:06 PM, the Administrator stated MDS assessments were behind when he started his position in June 2024 and felt the breakdown was the result of a lot turnover in MDS staff. He explained since June 2024, they had a full-time MDS Nurse and a part-time MDS Nurse that both quit which put them further behind with getting MDS assessments completed. The Administrator stated with the MDS team he now had in place, he felt they would be able to get the MDS assessments caught up and stay caught up so that MDS assessments were completed within the regulatory timeframe.

Based on record review, and Medical Director (MD) and staff interviews, the facility failed to ensure physician visits were performed every 30 days for the first 90 days of admission for 4 of 4 sampled residents reviewed for physician visits (Residents #21, #31, #41, and #55). Findings included: a. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease (trouble breathing), heart failure, and respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #21 had moderate impairment in cognition. Review of Resident 21's Electronic Medical Record (EMR) revealed he was seen by the Medical Doctor (MD) on 06/14/24 and 08/26/24 during the first ninety (90) days of his admission to the facility. b. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes, chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues), heart failure, and chronic kidney disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #31 had intact cognition. Review of Resident #31's Electronic Medical Record (EMR) revealed he was seen by the Medical Doctor (MD) on 06/14/24 and 09/11/24 during the first ninety (90) days of his admission to the facility. c. Resident #41 was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease (trouble breathing), heart disease, diabetes, hypertension, and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #41 had moderate impairment in cognition. Review of Resident #41s Electronic Medical Record (EMR) revealed she was seen by the Medical Doctor (MD) on 08/17/24 during the first ninety (90) days of her admission to the facility. Following the MD visit on 08/17/24, Resident #41 was not seen again by the MD until 11/16/24. d. Resident #55 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke), diabetes and depression. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #55 had intact cognition. Review of Resident #55's Electronic Medical Record (EMR) revealed he was seen by the Medical Doctor (MD) on 01/19/24 and 04/17/24 during the first ninety (90) days of his admission to the facility. During an interview on 12/05/24 at 11:15 AM, the Director of Nursing (DON) revealed Medical Records and the Social Worker were keeping track of regulatory visits for the MD but due to the turnover in both those positions, she had been filling in with this process. The DON explained she provided the MD with a weekly report of all admission and discharges as well as a physician audit report for him to review to determine which residents needed to be seen. The DON stated it was not a foolproof system because if older visits were still showing up on the report as not completed, the newer admissions would not appear until the older visits were marked complete and regulatory visits would be overlooked. During a telephone interview on 12/06/24 at 11:29 AM, the MD stated the only progress notes of his visits to the facility were the ones documented in the resident's EMR. He stated that when he arrived at the facility, he was provided a list of all admissions that he reviewed to determine who was recently admitted and then saw those residents. The MD confirmed he was aware of the regulation regarding the frequency of visits and was not aware Residents #21, #31, #41, and #55 had not been seen as required following their admission to the facility. He explained the facility used to have a Medical Records staff member who kept track of when residents needed to be seen in order to remind him and it had helped him ensure regulatory visits were completed. The MD stated he tried keeping up with the regulatory visits due and if his progress notes were not documented in the resident's EMR, then there were none and the resident had not been seen.

Based on record review, resident and staff interviews, the facility failed to invite residents to participate and provide input in care planning for 2 of 3 sampled residents (Residents #50 and #11). Findings included: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic pain, chronic post-traumatic stress disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. Review of Resident #50's electronic medical record revealed no evidence she was invited to attend care plan meetings to discuss and provide input regarding her plan of care following the completion of the annual MDS assessment dated [DATE] or the quarterly MDS assessment 09/13/24. The comprehensive care plan for Resident #50 was last revised on 08/14/24. During an interview on 12/03/24 at 8:49 AM, Resident #50 stated she had not been invited to attend or had a care plan meeting scheduled since June 2024. During interviews on 12/4/24 at 2:28 PM and 12/06/24 at 3:52 PM, the Administrator revealed the Social Worker (SW) was responsible for keeping track of the care plan meeting schedule. He explained the SW left employment on 10/24/24 and since then, they had been actively interviewing candidates to fill the position. He explained that since the SW left employment, the care plan meeting schedule had not been updated and although the Interdisciplinary Team had conducted several initial 48-hour and quarterly care plan meetings with residents in their rooms, along with the resident's Responsible Party/Family Member on the phone, they had not documented the care plan meetings in the resident's medical record. The Administrator could not state for certain if a care plan meeting was held with Resident #50 following the completion of her annual MDS assessment dated [DATE] or quarterly MDS assessment dated [DATE]. The Administrator stated he would expect for care plan meetings to be completed quarterly. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, colostomy status, epilepsy (brain disorder that causes seizures), chronic post-traumatic stress disorder, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate impairment in cognition. The comprehensive care plan for Resident #11 was last revised on 11/18/24. Review of Resident #11's electronic medical record revealed no evidence she was invited to attend a care plan meeting to discuss and provide input regarding her plan of care following the completion of the quarterly MDS assessment dated [DATE]. Review of the facility's 2024 Care Plan Meeting Schedules provided by the Administrator revealed a care plan meeting was held with Resident #11's Family Member on 06/26/24 with no other scheduled meetings listed after that date. Further review revealed there were no care plan meetings listed on the schedule for any resident after 09/25/24. During an interview on 10/07/24 at 4:18 PM, Resident #11 did not recall being invited to participate in any care plan meetings. During interviews on 12/4/24 at 2:28 PM and 12/06/24 at 3:52 PM, the Administrator revealed the Social Worker (SW) was responsible for keeping track of the care plan meeting schedule. He explained the SW left employment on 10/24/24 and since then, they had been actively interviewing candidates to fill the position. He explained that since the SW left employment, the care plan meeting schedule had not been updated and although the Interdisciplinary Team had conducted several initial 48-hour and quarterly care plan meetings with residents in their rooms, along with the resident's Responsible Party/Family Member on the phone, they had not documented the care plan meetings in the resident's medical record. The Administrator could not state for certain if a care plan meeting was held with Resident #11 and/or her Responsible Party/Family Member following the completion of her quarterly MDS assessment dated [DATE]. The Administrator stated he would expect for care plan meetings to be completed quarterly.

Based on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located at the left side of her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #91). The findings included: Resident #91 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #91 had severe cognitive impairment. The MDS coded Resident #91 with impairment of one side of lower extremity and walking between locations inside the room for more than 10 feet was not attempted during the assessment period due to medical condition or safety concerns. During an observation conducted on 12/02/24 at 1:09 PM, the switch for the light fixture on the left side of Resident #91's bed 5 feet from the floor was attached with a cord 3 inches in length. Resident #91 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #91 on 12/02/24 at 1:13 PM. She stated the switch cord had been broken since she moved into her room more than a month ago. She added she was bed-bound and unable to get up from the bed without assistance. It was very inconvenient for her as she could not reach the switch cord and had to rely on the staff to control the light fixture all the time. Subsequent observation conducted on 12/03/24 at 10:46 AM revealed the switch cord for the light fixture next to Resident #91's bed remained inaccessible. An interview was conducted with Nurse Aide #5 (NA) on 12/03/24 at 2:53 PM. He noticed the switch cord for Resident #91's light fixture had been broken for a while, but he did not notify the maintenance staff to fix it. Instead, he used the switch on the wall near the entrance door to switch on the light fixture next to Resident #91's bed. He stated he should have notified the maintenance staff to fix it as it was important for Resident #91 to have full accessibility to her light fixture at all time. During an interview conducted on 12/03/24 at 2:58 PM, Nurse #3 confirmed Resident #91 was bedridden and unable to get up from her bed or stand up on her feet to switch on the light fixture next to her bed. She explained she did not notice that the switch cord was broken when she provided care for Resident #91 in the past few weeks. During a joint observation conducted with the Maintenance Manager on 12/03/24 at 2:40 PM, he acknowledged that the switch cord for the light fixture was too short and unreachable for Resident #91, and it needed to be fixed as soon as possible. An interview was conducted with the Maintenance Manager on 12/03/24 at 2:47 PM. He stated he checked the entire facility including Resident #91's room and bathroom at least once every week. He did not know when the switch cord was broken and stated it was important for Resident #91 to have accessibility to her light fixture. He added he depended on residents and staff to report repair needs either verbally or through the work order. He typically checked the work orders at least once daily to ensure all repair needs were met in a timely manner. An interview was conducted with the Director of Nursing (DON) on 12/03/24 at 4:06 PM. She expected the staff to be more attentive to residents' living environment, and to report repair needs to the maintenance department in a timely manner to accommodate residents' needs. She added the maintenance staff should check repair needs on a regular basis and address the issues accordingly. It was her expectation for all the dependent residents to have full access and control of the light fixture all the time.

Based on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 3 residents reviewed for advanced directives (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE]. Resident #65's advanced directive care plan, initiated on 07/15/21, with the most recent revision on 03/26/2024 had Resident #65 Care planned as a Full Code. Care Plan Goal listed as: Resident's advanced directives are in effect and their wishes and directions will be carried out in accordance with their advanced directives. Interventions included: Allow resident if able to discuss feelings regarding their Advanced Directives, An Advanced Directive can be revoked or changed if the resident and or appointed Health Care Representative changes their mind about the medical care they want delivered, Complete and update MOST form as needed. Honor residents and family wishes. Review advance directives at least quarterly and PRN. The appointed Health Care Representative will make all health care decisions if the resident is incapacitated. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #65 was severely cognitively impaired. Review of the Code Book revealed Resident #65's revealed a Medical Orders for Scope of Treatment (MOST) form dated 09/23/2024 that indicated his preference for a Do Not Resuscitate (DNR) status in the event he had no pulse and was not breathing. The form was signed by Resident #65's Responsible Party. On the profile page of Resident #65's electronic health record, Resident #65's code status was listed as a DNR. Review of Resident #65's Physician orders, revealed an order dated 9/23/2024 for a Medical Orders for Scope of Treatment (MOST) form dated 09/23/2024 that indicated his preference for a Do Not Resuscitate (DNR) status in the event he had no pulse and was not breathing. During an interview on 12/04/2024 at 11:44am Nurse # 1 stated a Resident's code status could be found in the Code Book located at the desk and in the resident's electronic medical record or chart. Nurse #1 stated new orders for advanced directives were received by the nurse, the social worker used to update the charts and care plan, now it was completed by nursing. During an interview on 12/04/2024 at 2:42pm Unit Manager #1 stated nurses share the responsibility to make sure new orders for advanced directives were updated in the chart, face sheet and Code Book, and the Minimum Data Set (MDS) nurse updated the care plan. During an interview on 12/04/2024 at 2:47pm, the MDS Coordinator #2 stated the social worker used to update advanced directives in the resident's care plan but was not aware who was responsible to keep them updated now. The MDS Coordinator #2 verified Resident #65's order for a DNR did not match the Care Plan for Full code in his electronic medical record. During an interview on 12/4/2024 at 3:23pm, the Director of Nursing (DON) stated the nurse who received the order would make any notifications needed to family and social work. The DON stated since the facility did not have a social worker, the DON had taken the responsibility to keep advanced directive care plans updated. The DON verified that Resident #65's care plan for a Full Code did not match the order in Resident #65's chart. The DON stated she expected for a resident's advanced directives to match throughout the medical record. During an interview 12/06/24 4:20 PM the Administrator stated he would expect a resident's advanced directive status to match across all areas of the resident's chart. The Administrator stated it had been the social worker's responsibility to update advanced directive care plans, but due to the social work position being vacant, the DON had assumed that responsibility.

Based on staff and Nurse Practitioner (NP) interviews and record review, the facility failed to notify the Physician when a urinalysis was not completed for 1 of 2 residents reviewed for notification of change (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE] with diagnosis that included bacteremia. Resident #38 had a physician's order for a urinalysis (UA) with culture and sensitivity for urinary pain one time only for one day. This was ordered on 9/24/2024 and marked completed on 9/25/2024. Review of the treatment administration record (TAR) for September 2024 revealed the UA was documented as completed on 9/25/2024. Review of the lab results revealed that there were no results for the UA ordered on 9/24/2024 for Resident #38. A phone interview on 12/06/2024 at 9:54 AM with Nurse #6 revealed revealed that she had completed and collected the UA specimen for Resident #38 on 9/25/2024 and placed it in the refrigerator for the lab to collect. She stated that if the specimen is left in refrigerator too long the lab or an employee would throw the specimen out because it is no longer useable. She stated that could be why there were no results for the UA ordered on 9/24/2024. Nurse #6 indicated she was not aware that there were no results for the UA and therefore had not notified the Physician. An interview on 12/06/2024 at 8:36 AM with the Nurse Practitioner (NP) revealed that she was not notified that the September UA did not have any results returned from the laboratory and that she would want to be notified if the staff were unable to complete the UA or if it needed to be reordered. She stated that Resident #38 had not experienced harm or a negative outcome by the UA not being completed. An interview on12/06/2024 at 12:33 PM with the Director of Nursing (DON) revealed that the breakdown was the Nurse who collected the specimen and did not fill out the requisition. She stated that if she had found the specimen sooner than today, she would have followed up with the NP to obtain a new order for the UA and she would have followed up with the Nurse as well about the specimen. She stated that her expectation was that laboratory test results, or lack thereof should be communicated to the Physician. An interview on 12/06/24 at 3:54 PM with the Administrator revealed that his expectation was if a lab order does not make it to the lab for whatever reason the NP would be notified so they could make the decision to order another lab or not.

Based on record review and staff, Law Enforcement Corporal, and Medical Doctor (MD) interviews, the facility failed to protect a [AGE] year old female resident with severe cognitive impairment (Resident #2) from sexual abuse by a [AGE] year old male resident with moderate impairment in cognition (Resident #1) for 1 of 4 residents reviewed for abuse. Resident #1 was observed with his shorts/boxers pulled down lying in bed next to and behind Resident #2, whose gown was pulled up exposing her breasts and her brief pulled down between her legs, with the perceived intention of engaging in sexual activity. Based upon the reasonable person concept, a person in Resident #2's position would have expected to be protected from abuse in their home environment and non-consensual sexual activity would have caused psychosocial harm and trauma such as feelings of fear, anxiety and humiliation. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinsonism, Post Traumatic Stress Disorder (PTSD), and episodic panic disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with moderate impairment in cognition. He required substantial/maximal assistance with self-care tasks and transfers and was totally dependent with ambulation using a wheelchair. The discharge MDS assessment dated [DATE] assessed Resident #1 as requiring supervision or touching assistance with wheeling 50 to 150 feet using a wheelchair and substantial/maximal assistance with chair/bed-to-chair transfer. Resident #1 was no longer at the facility and unable to be interviewed. During a telephone interview on 06/18/24 at 9:32 AM, the Law Enforcement Corporal revealed Resident #1 was arrested on 06/12/24 due to an outstanding warrant in another county. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and generalized anxiety disorder. The quarterly MDS assessment dated [DATE] assessed Resident #2 with severe impairment in cognition. She was usually able to make self-understood and sometimes understood others. She required substantial to moderate assistance with bed mobility such as rolling left to right and totally dependent with transfers and ambulation. Review of a Hospice Care Agreement revealed hospice services was elected for Resident #2 with an effective date of 06/06/24. Review of a nurse progress note dated 06/12/24 at 6:37 AM written by the Director of Nursing (DON) read in part, at approximately 1:00 AM, while walking down the hallway, nurse heard speaking in Resident #2's room and thought it was the Nurse Aide (NA) in the room. She turned and looked in the hallway and noticed the NA was sitting, so she turned on the light, went in Resident #2's room and saw Resident #1 in bed behind her. Resident #2 was lying on her right side with her arms in front of her, her night gown was pulled up exposing her breasts and her diaper was pulled down. Resident #1 was lying behind Resident #2 with his pants down. Nurse told him to get up and get out of here. Resident #1 startled, got up and left the room after pulling up his pants. Resident #2 passed away at the facility on 06/15/24. During an interview on 06/17/24 at 1:34 PM, the DON stated on the morning of 06/12/24, her phone had been acting up and she had missed 18 calls from the facility. When she spoke to Nurse #1 and the Assistant Director of Nursing (ADON) by phone, she was informed that Nurse #1 had found Resident #1 in bed with Resident #2. The DON stated both the Administrator and ADON were already at the facility when she arrived at 5:30 AM. The DON explained since there was so much going on, she assisted Nurse #1 with completing paperwork and documenting a progress note in Resident #2's medical record of the details related to the incident. The DON stated she did not speak with Resident #1 about what happened before he was taken into police custody. During a telephone interview on 06/17/24 at 9:20 PM, Nurse #1 confirmed she was Resident #2's assigned nurse during the hours of 7:00 PM to 7:00 AM on 06/11/24 to 06/12/24. Nurse #1 explained Resident #2 had been declining, not eating or drinking much for a few days, and earlier that evening Resident #1 had been walking throughout the facility and in the courtyard breezeway per his norm. She recalled around 12:45 AM the morning of 06/12/24, she was walking down the hallway toward the front lobby to get a census off the printer and when she walked by Resident #2's room, she heard a squeaking sound coming from the room. The door was half way shut and at first, Nurse #1 thought Nurse Aide (NA) #1 was in Resident #2's room providing care because Resident #2 would not be able to move around on her own for the bed to make that kind of noise but when she looked back down the hallway, NA #1 was sitting down. Nurse #1 stated when she opened the door of the room to check on Resident #2, she observed Resident #2 lying in bed on her right side facing the door and Resident #1 was lying on his right side directly behind Resident #2 also facing the door, which she described as spooning (where two people lie on their sides facing the same direction with one person's back against the other's chest). She explained since Resident #2 was unable to move on her own, Resident #1 would have had to have moved Resident #2 onto her side for them to be in that position because the last time she had checked in on Resident #2 around 9:00 PM, she was lying flat on her back. Nurse #1 recalled Resident #2's gown was pulled up exposing her breasts, her brief was pulled down between her legs and Resident #1's shorts/boxers were also pulled down. She immediately told Resident #1 to get up out of the bed and leave the room which startled him. Nurse #1 stated when Resident #1 stood up, she was so upset she did not notice if he was aroused or not but she did remember noticing that he didn't have a dressing on his coccyx wound as he walked toward the wheelchair, started pushing it out of the room and she had to tell him to pull his shorts/boxers back up. When Resident #1 left Resident #2's room, she called for NA #1 and told her to go inform Resident #1's nurse that he needed to be placed on one-to-one supervision. Nurse #1 then assessed Resident #2 who had her eyes open but was non-verbal, covered her up and then went to talk the nurse on B Hall where Resident #2 resided. Nurse #1 explained in her entire nursing career, she had never witnessed an incident like this and wanted to talk to the nurse on B Hall see what she needed to do because she was so upset. When she got to the B Hall nurses' station, NA #1 was still there, she spoke with the nurse and at 12:55 AM they called the Interim Administrator, DON, ADON, and Emergency Medical Services (EMS). Nurse #1 stated she and NA #1 then went back to Resident #2's room and cleaned her up because she had a bowel movement. Nurse #1 restated Resident #2's brief was pulled down between her legs and as they provided her care, she did not notice any bleeding or bodily fluids but her anus was open and there was stool in the rectum as if she hadn't pushed it all out. Nurse #1 stated she never asked Resident #1 what he was doing in Resident #2's room and she was not sure if sexual activity had actually occurred prior to her entering Resident #2's room but felt the intent was there based on what she observed when she turned on the light and startled Resident #1. During an interview on 06/17/24 at 3:11 PM, NA #1 could not recall the time but stated it was early in the morning on 06/12/24 when she had just come back inside from the courtyard after a taking a quick break, Nurse #1 was sitting at the nurses' station and Nurse #1 asked her to go get something from the kitchen but then told her never mind, she (Nurse #1) would go. As they both started walking up the hallway toward the front of the building, NA #1 stated she stopped to sit down in the hall like she always did to keep an eye on her resident rooms while Nurse #1 continued up the hallway. She recalled it was not very long after that when she heard Nurse #1 calling her name from the doorway of Resident #2's room. When she got to Resident #2's room, Nurse #1 was extremely upset and crying stating she had found Resident #1 with his boxers pulled down lying in bed with Resident #2 whose brief had been torn and pulled down. She stated Resident #1 had already left the room by the time she had arrived and Nurse #1 instructed her to go tell Resident #1's nurse that he needed to be placed on one-to-one supervision and when she got to the nurses' station on B Hall to inform the nurse, Resident #1 was already back on the hall. While she was at the nurses' station talking to the nurse, she recalled looking at her watch and it was 12:56 AM. NA #1 stated she had seen Resident #1 walking about the facility and in the courtyard breezeway throughout the night but never noticed him going into Resident #2's room or other residents rooms. NA #1 could not recall the time when she last checked in on Resident #2 but stated it could not have been more than 30 minutes or so before Nurse #1 found Resident #1 in Resident #2's room. Telephone attempts made on 06/17/24 at 1:08 PM and 06/18/24 at 1:50 PM for an interview with NA #2 who was assigned to provide Resident #1's care on 06/11/24 to 06/12/24 were unsuccessful. During a telephone interview on 06/17/24 at 12:43 PM, Nurse #2 revealed she was Resident #1's assigned nurse during the hours of 7:00 PM to 7:00 AM on 06/11/24 to 06/12/24. Nurse #2 stated it was her first time providing care to Resident #1 and was told in nurse report that he would pull out his Peripherally Inserted Central Catheter (abbreviated as PICC and refers to a long, flexible tube inserted into a vein in the arm that can be used to deliver fluids and/or intravenous (IV) medication), get out of bed and walk up the hallway with his IV pole. The NAs also told her that he frequently roamed the building and out into the courtyard smoking area. Nurse #3 recalled while she was doing her medication pass, Resident #1 was following her down the hall, asked for his medications and she had him go back to his room to receive his IV medication. She told him to stay in bed until the IV medication was completed which would take approximately 30 minutes. Around 11:30 PM, she noticed Resident #1 walking up the hallway with his IV pole, he then left it in the hallway and started wandering around the hall. Nurse #2 stated during the 3:00 PM to 11:00 PM shift, Resident #1's assigned NA (could not recall her name) would report she saw him out in the courtyard in the smoking area or on the other side of the facility but no one mentioned anything about him wandering in and out of other residents rooms. Nurse #2 stated at one point during the night, Resident #1 pulled out his PICC and when she went to check on him, he was lying in his room. She recalled glancing at her phone and thought it might have been around 12:50 AM or so when the nurse from the other side of the building came and told her that Resident #1 had been in Resident #2's room and sexually assaulted Resident #2. Nurse #2 stated she did not ask Resident #1 about what had been reported to her; however, he was placed on one-to-one monitoring until he was taken out of the facility by law enforcement. During an interview on 06/17/24 at 1:48 PM, the ADON recalled she received a call from Nurse #1 early in the morning of 06/12/24 informing her that she found Resident #1 exposed from the waist down lying in bed next to Resident #2 whose breasts were exposed and her brief pulled down. Nurse #1 also reported she told Resident #1 to leave the room, watched him walk out and down the hallway, she then assessed Resident #2 and Resident #1 was placed on one-to-one supervision. The ADON stated when she arrived at the facility around 2:00 AM the Administrator was already there and had contacted law enforcement. The ADON stated when she went into Resident #2's room, she was resting in bed with her eyes closed, displayed no signs of distress or pain and staff had already provided her care and placed her in a clean brief that was still dry. When she assessed Resident #2's skin, she observed a small area of redness about the size of a half dollar on her left buttock but did not observe any anal tears, bleeding or bodily fluids in Resident #2's anus (opening where stool exits the body). She also stated there was no bodily fluids on the sheets but there was a small spot of dried blood at the bottom of the bed where Resident #2's right foot was. The ADON explained Resident #2 was receiving hospice care and transitioning (stage of the dying process) and would not have realized what was going on because when they repositioned her onto the left side during her assessment, it didn't phase Resident #2. The ADON stated EMS and police officers arrived at the facility around 2:24 AM, Resident #2 was transported to the hospital by EMS and the police officers remained at the facility to talk with Resident #1. She stated she left a voicemail for Resident #2's family and then called Hospice so they could send a nurse to be with Resident #2 at the hospital since she wasn't able to get a hold of her family. The ADON recalled when she spoke to Resident #2's family later that morning, they were upset when they were informed what had happened and she provided them with the numbers to contact the police officers for more information. The ADON stated she never did talk to Resident #1 about the incident because her main focus upon arriving at the facility was to make sure Resident #2 was okay. The ADON stated after interviewing Resident #1, police officers left the facility and not even an hour later, returned to arrest Resident #1 due to an outstanding warrant. An Emergency Department (ED) Forensic consult note for Resident #2 dated 06/12/24 at 3:07 AM read in part, anogenital (referring to the anus, perianal skin and adjacent external genitalia in women) region assessed with assistance of ED nurse. No vaginal or rectal bleeding. Laceration observed 4-5 o'clock (refers to the position of the laceration in the lining of the anus) anus. An ED report for Resident #2 dated 06/12/24 at 3:18 AM read in part, [AGE] year old presenting to the ED secondary to an alleged sexual assault at her nursing facility. The alleged perpetrator was found with his underwear down, naked in bed with the patient. Sexual Assault Nurse Examiner (SANE) evaluated the patient and noted a small skin tear in the rectal area. She needs to receive permission from the patient's Power of Attorney (POA) before moving forward with any sort of assault kit. At time of sign out, patient is pending ongoing SANE evaluation. An ED Forensic Consult Note for Resident #2 dated 06/12/24 at 3:00 PM read in part, family arrived to patient's room at 11:00 AM. POA provided consent for forensic exam, photos, Sexual Assault Kit ([NAME]) evidence collection and Sexually Transmitted Infection (STI) testing. Patient tolerated exam well. Report made with the County Sheriff's office and update given to Medical Doctor. An ED physician report for Resident #2 dated 06/12/24 at 2:12 PM read in part, Resident #2 was seen by the SANE. The family did opt for a forensic exam which has been completed. They did not want any antibiotic administration but did agree with blood testing. The patient is now ready to be discharged back to the skilled nursing facility. During a telephone interview on 06/18/24 at 9:32 AM, the Law Enforcement Corporal revealed in addition to the responding police officers, she also interviewed Resident #1 about the incident involving Resident #2 on 06/12/24 and his statements were inconsistent. The Law Enforcement Corporal stated she knew Resident #1 did not reside on the same hall as Resident #2 and when she asked him why he was on Resident #2's hall, he stated he was going to the kitchen to get a snack and as he was going by Resident #2's room, he at first he stated he heard Resident #2 yell help but then changed and said he heard her yell. Resident #1 told her that he went into Resident #2's room to help her but couldn't understand her and as he was going back out of the room to get a nurse, the nurse walked in and started yelling at him. When she asked him about the nurse reporting he was in bed with Resident #2 without his shorts/boxers on and spooning her, he denied that happening and stated the nurse was trying to get him out of the facility because she did not like him. She asked Resident #1 point blank if he touched Resident #2's vagina, breasts or penetrated her and he denied it all stating he did not touch or penetrate Resident #2. The Law Enforcement Corporal pulled up the responding police officers reports which noted Resident #1 told one of the police officers at the scene that he heard Resident #2 holler for help and as soon as he entered her room a nurse came in behind him. However, Resident #1 told the other police officer at the scene that he had gone to the kitchen to get a fudge round but then decided he didn't want a snack, there was an extra wheelchair in the kitchen so he got the wheelchair and rolled down the hall and was about 10 feet from Resident #2's room when she yelled for help. Resident #1 stated when he went into Resident #2's room, he was in between the doorway and her bed, she wasn't talking very well and he couldn't understand her. Resident #1 was asked how he knew Resident #2 needed help and Resident #1 gave conflicting responses. He first stated you could just tell because she was lying on her back with her feet hanging off the side of the bed toward the door, then he said she was lying with her legs off the side of the bed toward the window and then said she was lying at the bottom of the bed and he pulled her up. Resident #1 also told the responding police officer he never touched her or tried to get her up. The Law Enforcement Corporal stated during all of the interviews, Resident #1 never would admit to being in the bed with Resident #2 or doing anything to her. She stated she never observed Resident #2's bed sheets that the responding police officers collected while on scene but they did note in their report there was blood that was brownish in color on the bed sheets; however, she stated it was possible that it was stool because Nurse #1 had indicated in her interview that Resident #2 had a bowel movement. The Law Enforcement Corporal stated Resident #2 did have a forensic examination at the hospital and the nurse examiner stated that Resident #2 had a rectal tear but the nurse examiner could not say for certain if the rectal tear was caused by penetration or a rough wipe as she was being cleaned due to her fragile skin. During a telephone interview on 06/17/24 at 5:07 PM, the facility's Medical Doctor (MD) revealed he was informed of the incident that occurred between Resident #1 and Resident #2 on 06/12/24. He stated Resident #2 was receiving hospice services due to failure to thrive. When asked about the rectal tear as noted in the ED records, the MD stated the only thing he could think of that could cause a rectal tear other than penetration, would be a very hard stool that someone was straining to pass due to constipation. The MD stated he did not think wiping someone hard/rough would cause a rectal tear. During an interview on 06/17/24 at 2:40 PM, the Administrator revealed he had only been employed approximately a week and a half when he received a call from the Interim Administrator on 06/12/24 at 1:30 AM informing him of the incident involving Resident #1 and Resident #2. He arrived at the facility around 2:00 AM, immediately notified law enforcement and police officers arrived at the facility to start their investigation. The Administrator recalled being told that Nurse #1 heard a sound coming from Resident #2's room and when she entered the room both Resident #1 and Resident #2 were lying on the bed, he had his shorts/boxers pulled down, her brief was off and Nurse #1 told Resident #1 to leave the room. The Administrator stated he did not talk with Resident #1 about what had happened, he just went down to Resident #1's room to ensure he was on one-to-one supervision, checked on Resident #2 to ensure she was ok and comfortable and then started an investigation which included completing and submitting the initial report to the Department of Health Service Regulation. The Administrator was notified of Immediate Jeopardy on 06/18/24 at 11:12 AM. The facility provided the following corrective action plan with a completion date of 6/13/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility failed to protect a resident's right to be free from alleged sexual abuse on 6/12/24 at approximately 1:00 am when Resident #1 was observed by Licensed Nurse (LN) #1 lying in bed with Resident #2. Resident #1's shorts were observed down around his knees and Resident #2's gown was raised exposing her breasts and her brief was open. Resident #1 was immediately removed from Resident #2's room and returned to his room where he was placed on 1:1 staff supervision to ensure all residents safety. Timely notifications then made to Administrator who ensured appropriate reporting requirements were made to the North Carolina Department of Health and Human Services (NC DHHS) agency, local police department and Adult Protective Services (APS). At approximately 1:00 am, Resident #2 was assessed by LN #1 for signs of injury and no concerns were noted. Stool was noted in brief and around anus and Nurse Aide (NA) #1 then assisted LN #1 with incontinence care. There was no bruising, bleeding or unusual bodily fluids noted. The Assistant Director of Nursing (ADON) completed a Psychosocial Assessment and no signs of mental anguish were identified. Emergency Medical Services (EMS) was called at 2:10 am and Resident #1 was resting quietly in bed with eyes closed at 2:24 am upon arrival and transport to the hospital for further examination. Director of Nursing (DON) and ADON report the sheets were taken by the police for further investigation. Rape kit test was performed at the emergency room (ER) after consent of family and has not yet resulted. At 2:24 am, police arrived to interview staff and Resident #1 and prior to departing the facility at 4:50 am, the officers informed the Administrator and ADON that Resident #1 denied the allegation of sexual abuse and provided four various versions of the incident and could not issue a warrant as a result. The officers instructed the Administrator and ADON to refrain from interviewing Resident #1 and to notify staff to avoid asking questions to Resident #1 pertaining to the allegation and to document word-for-word anything that Resident #1 may verbalize. Staff continued with 1:1 supervision and at 5:55 am, officers returned to the facility and transported Resident #1 to [NAME] County jail with a previous, unrelated warrant for arrest. Resident #1 did not communicate while on 1:1 supervision. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 6/12/24, the Quality Assurance Process Improvement (QAPI) Committee (Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), Social Worker (SW), [NAME] President of Operations (VPO), [NAME] President of Clinical and Quality (VPCQ) and Medical Director (MD) held an Ad Hoc meeting to discuss root cause analysis of the facility's failure to protect a resident right to be free from sexual abuse. Root cause analysis determined that LN #2 failed to respond to and recognize that the wandering behaviors of Resident #1 was a potential indication of a high-risk behavior for abuse towards others. Determination was made based on LN#2 failure to recognize and respond per the facility Abuse, Neglect and Exploitation Policy. During the meeting, current facility residents were reviewed by the QAPI Committee to identify residents exhibiting behaviors that pose a high risk for abuse to other residents to ensure residents have an appropriate plan of care in place. Effective 6/12/24, the Social Worker (SW) completed abuse questionnaires and abuse education with cognitively intact residents to ensure all other residents were free from abuse and to ensure understanding of what constitutes abuse and who to report abuse to without fear of retaliation. No additional concerns identified. Effective 6/12/24, the DON and ADON completed abuse audits on cognitively impaired residents to identify any signs physical signs of abuse such as unusual bruising, bleeding, or new skin concerns and to identify any signs of mental anguish or pain such as tearfulness, withdrawal, fear, grimacing, etc. No additional concerns observed. Effective 6/12/24, the Regional Director of Clinical Services (RDCS) and DON completed abuse questionnaires with all facility and agency staff on the Abuse, Neglect and Exploitation Policy ensure all other residents are free from abuse and to validate competency and understanding of the facility abuse policy. Address what measures the facility will put into place or systematic changes made to ensure that the deficient practice will not recur: Effective 6/12/24, all current facility staff and agency staff were in-serviced on the Abuse, Neglect and Exploitation Policy by the Regional Director of Clinical Services, Director of Nursing, Social Worker and Administrator. Training topics included 1) prohibiting, preventing and recognizing what constitutes abuse (Examples included; resident, staff or family report of abuse, physical marks such as bruises appearing as hand or belt marks, injury of unknown source, sudden unexplained changes in behavior such as withdrawal from care, fear of certain persons or expressions of guilt or shame), 2) recognizing, appropriately responding to and understanding behavioral symptoms of residents that may increase the risk of abuse such as aggressive wandering or elopement, resistance to care, outbursts, yelling, difficulty adjusting to new routines or staff and 3) that there is zero tolerance for resident abuse in the facility. Newly hired facility and agency staff and staff not receiving education by 6/12/24, will receive education prior to first worked shift by the DON, ADON, Staff Development Coordinator (SDC) or Unit Manager (UM). Effective 6/12/24, the daily schedule will be monitored for newly hired facility or agency staff to ensure completion of abuse education and validation prior to first shift worked. An orientation checklist will be completed for documentation. Education and validation will be completed by the DON, ADON, SDC or UM and monitoring of completion will be tracked by the SDC utilizing the Master Education Log. An in-service was completed by the [NAME] President of Clinical and Quality Assurance (VPCQA) on 6/12/24 with the DON, ADON, SDC and UMs on their responsibilities related the education, validation and tracking of the Abuse policy with facility and agency staff. Newly hired DON, ADON, SDC and UMs will receive education as above prior to first shift worked. Effective 6/12/24, the facility will no longer admit new residents under fifty-five (55) or those with a homeless status without Ascent Governing Body approval. Education was provided by the [NAME] President of Operations (VPO) to the Administrator, DON and Admissions Coordinator on the updated admission screening process to reduce the risk of abuse to others. Newly hired Administrators, DONs and Admissions Coordinators will receive education prior to first shift worked. Include how the facility plans to monitor its performance to make sure that the solutions are sustained: Effective 6/12/24, the DON, ADON, UM or SW will complete abuse questionnaires with facility and agency staff to validate understanding of the Abuse, Neglect and Exploitation Policy and to identify and prevent resident abuse and to ensure understanding that the facility has zero tolerance for resident abuse. Monitoring will be completed with five random staff daily for 1 week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, the Administrator or SW will complete abuse questionnaires with five cognitively intact residents to validate understanding of the Abuse, Neglect and Exploitation Policy and to residents are free from abuse. Monitoring will be completed daily for one week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, the DON, ADON, SDC or UMs will complete abuse audits with five cognitively impaired residents to ensure there are no physical or emotional signs of abuse. Monitoring will be completed daily for one week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, The Administrator, DON or SW will make rounding observations to identify high risk resident behaviors, proper staff identification and response to behaviors, and to ensure residents remain free from abuse. Monitoring will be completed daily for one week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, RDO, VPCQA or RDCS will review Abuse allegations, adherence to the updated admission screening process and the facility corrective action plan to validate compliance and to ensure the abuse policy is being followed and residents remain free abuse. Monitoring will be completed weekly for twelve weeks. Results of monitoring will be presented by the Administrator with the QAPI Committee during monthly QAPI meetings to ensure effectiveness of the facilities corrective action plan to ensure residents are free from abuse and to ensure that staff have a clear understanding of the Abuse policy which includes the prohibition, prevention, recognition, zero tolerance for and importance of the preservation of potential evidence in the event of an abuse investigation. Changes will be made to the corrective plan as necessary to ensure residents are free from abuse. Alleged date of jeopardy removal: 6/13/24 Date of Completion: 6/13/24 On 06/18/24, the facility's corrective action plan was validated by the following: Staff interviews revealed they had received education on the facility's Abuse policy and procedure which included the types of abuse, recognizing and understanding behavioral symptoms of abuse, residents' right to be free from abuse, and to immediately report any concerns of abuse to their immediate supervisor, DON, and/or Administrator. Review of the attendance sign-in sheets revealed staff education was completed on 06/12/24. Skin assessments were conducted on all cognitively impaired residents with no concerns identified. Alert and oriented residents were interviewed who all reported they felt safe at the facility, had not been touched inappropriately, were aware of their rights to be free from abuse and knew how/who to report any concerns. Staff abuse questionnaires were completed by all facility staff on 06/12/24 with no concerns reported. Audits and Monitoring tools were reviewed through 06/18/24 with no identified concerns noted and were completed as outlined in the facility's credible allegation. The completion date of 06/13/24 was validated.

Based on observations, record review, review of manufacturer's instructions, and Medical Doctor, Nurse Practitioner (NP, Psychiatric NP and staff interviews, the facility: 1) failed to prevent a resident, who had been deemed incompetent by the North Carolina Clerk of Superior Court and had a history of wandering and exit seeking behaviors, from exiting the facility unsupervised and without staff knowledge (Resident #1). Resident #1 was located by the police department at a 2-lane highway intersection approximately 8 miles from the facility; and 2) failed to ensure securement was according to manufacturer recommendations for providing a safe facility van transport when a resident slid partially out of the wheelchair, underneath the lap belt, causing her knees to hit the floor of the van resulting in minor bruising to her hand and knees (Resident #2) for 2 of 4 residents reviewed for accidents. The findings included: 1. The Emergency Department (ED) Physician's progress note dated 04/01/22 for Resident #1 read in part, .suffers from dementia. He has had 24/7 home health. Will lose weekend care beginning 6:00 PM today, 04/01/22, and will only have caregivers Monday through Friday from 9:00 AM to 6:00 PM. He is unable to cook, has to be reminded to eat and take medications and has walked away from residence on multiple occasions and had to be located by caregivers and brought back home. The State of North Carolina Letter of Appointment for Guardian of the Person dated 04/11/22 revealed Resident #1 was deemed an incompetent person and the Department of Social Services was appointed as his guardian. Resident #1 admitted to the facility on [DATE] with diagnoses that included an infection of the central nervous system, confusional arousals (a form of sleep disorder wherein a sleeping person wakes up but seems disoriented or acts strangely), and dementia with behavioral disturbance. A care plan initiated on 05/18/22 noted Resident #1 had impaired cognitive function and impaired thought processes related to a diagnosis of dementia. Interventions included: share with Resident #1 when it is time for care/routine related activity, use simple statements and give him time to process them. A care plan initiated on 05/23/22 noted Resident #1 was an elopement risk/wanderer related to impaired safety awareness and history of wandering. The initial goal initiated on 05/23/22 indicated he would not leave the facility unattended through the next review date. Interventions initiated on 05/23/22 2-lane included: address wandering behavior by walking with Resident #1, redirect him from inappropriate areas, engage in diversional activity, distract Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book, and wanderguard (alarm) device to right ankle. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with intact cognition. He required supervision with locomotion on and off the unit, had no wandering episodes during the 7-day MDS assessment period and used a wanderguard device daily. A Nurse Practitioner (NP) #1 progress note dated 08/30/22 revealed Resident #1 was a poor historian due to cognitive and psychiatric impairment. The FNP noted Resident #1 had poor judgement, impaired insight, disordered thinking, and was confused, forgetful and oriented only to self. A staff progress note dated 09/27/22 at 10:47 AM written by Nurse #2 read, Wanderguard applied to right ankle. During an interview on 10/11/22 at 2:04 PM, Nurse #2 explained Resident #1 was alert and oriented to self and often stood in a military stance (which she described as standing straight with his arms behind his back) staring out the windows or doors but not really trying to exit the facility. Nurse #2 recalled on 09/27/22, between 2:30 PM and 3:00 PM, Resident #1 was hovering at the front entrance door while a vender was trying to exit the facility. Nurse #2 stated she was able to get Resident #1 redirected away from the front entrance door and back to his room. Nurse #2 added once he was assisted back to his room, she did not recall noticing him leave his room or going back to the front lobby. A police report dated 09/27/22 revealed Resident #1 was found at 6:11 PM along a highway intersection located approximately 8 miles from the facility. He was observed walking alone and appeared disoriented. He was taken by police to the local hospital for evaluation. Resident #1's hospital records from 09/27/22 were unable to be obtained at the time of this investigation. An online website named Google Maps was used to obtain the walking distance from the facility to the location where Resident #1 was found as indicated on the police report. The highway intersection was 2-lanes with a posted speed limit of 35 miles per hour. Depending on the route Resident #1 walked, the distance from the facility to the highway intersection where he was found was 8.2 miles to 9.0 miles. An online website named Time and Date was used to obtain the outside weather in the Hendersonville area on 09/27/22 and noted at 2:54 PM the temperature was 67 degrees Fahrenheit with wind speeds of 10 miles per hour. A staff progress note dated 09/27/22 at 11:00 PM written by Nurse #1 read in part, this nurse was informed that Resident #1 was brought to the Emergency Department (ED) after being found wandering. This nurse immediately placed calls to the Director of Nursing (DON) and the Administrator. Resident #1's family member was notified. Attempts made to reach Resident #1's Guardian were unsuccessful. Resident #1's wanderguard bracelet was found torn off in his nightstand. Upon returning to the facility, Resident #1 was placed on 15 minute safety checks and a one-to-one sitter. Denies any pain or discomfort. No new skin issues observed. Vital signs within normal limits. This nurse placed a new wanderguard to Resident #1's right ankle and it's functioning properly. During an interview on 10/11/22 at 2:22 PM, Nurse Aide (NA) #3 confirmed she worked during the hours of 7:00 AM to 3:00 PM on 09/27/22. NA #3 recalled she saw Resident #1 in his room around lunchtime and then again at 1:00 PM when she went back into his room to pick up the lunch trays. NA #3 explained Resident #1 was confused at baseline and around 2:00 PM to 3:00 PM he wandered around the facility trying to find a way out. She stated staff would provide him with as much redirection as he would allow, until he eventually got tired and went back to his room. NA #3 stated it wasn't until just recently (she could not recall an exact date) Resident #1 tried to get staff to cut the wanderguard off for him and they explained they couldn't because it was needed to keep him safe. During an interview on 10/11/22 an 2:40 PM, Nurse #3 confirmed she worked during the hours of 7:00 AM to 7:00 PM on 09/27/22 but was not assigned to provide Resident #1's care. Nurse #3 stated she remembered seeing Resident #1 during the day but couldn't recall the exact time(s). Nurse #3 also stated sometime during the morning of 09/27/22, Resident #1 had removed his wanderguard device and a new one was placed back on. Nurse #3 explained Resident #1's baseline was to pace the halls, checking the doors and stating he needed to go home, and staff would try and redirect him with various techniques that usually worked. During an interview on 10/11/22 at 3:02 PM, NA #1 confirmed she worked during the hours of 2:00 PM to 11:00 PM on 09/27/22 when Resident #1 exited the facility unsupervised and was assigned to provide his care. NA #1 recalled when she arrived to work at approximately 2:05 PM, she noticed Resident #1 walking toward the dining room, he turned and followed her to the employee time clock area. After clocking in, NA #1 stated as she walked down the hall to the nurses' station to review her assignment, she told Resident #1 where his room was located. NA #1 was not sure if Resident #1 went into his room or if he turned and went back to the front lobby. NA #1 stated after her initial encounter with Resident #1, her afternoon was busy as she started her initial incontinence rounds, assisted one or two residents with a shower, completed another general round of her assigned residents, assisted residents outside to smoke at 4:00 PM, assisted another NA with resident care, and then at approximately 4:45 PM to 5:00 PM, supper trays were delivered to the hall and they all began passing the meal trays out to the residents. NA #1 stated NA #2 had delivered Resident #1's supper tray to his room and did not recall NA #2 mentioning whether or not Resident #1 was in his room at the time. NA #1 stated while she and NA #4 were in a room feeding two residents, NA #2 started picking up supper trays which would have included Resident #1's. NA #1 explained Resident #1 was alert and oriented to self and there were days he would sit in his room and other days, he would walk up and down the halls, at times asking how to get out of the facility. She added, some days he was easily redirected and other times he would become angry, raising his voice and/or cursing. NA #1 stated she could not recall seeing Resident #1 after first arriving to work and it just didn't register with her that she hadn't seen him out in the halls like normal the evening of 09/27/22. NA #1 stated it wasn't until after supper that she was notified by Nurse #1 Resident #1 had exited the building and was taken to the hospital. NA #1 also stated she remembered Nurse #1 telling her earlier that day, Resident #1 had removed his wanderguard device and a new one was placed back on and then after they had discovered he had exited the building, they found his wanderguard device in a drawer in his room. During an interview on 10/12/22 at 6:44 AM, NA #2 confirmed he worked during the hours of 1:00 PM to 7:00 AM on 09/27/22. NA #2 stated he remembered seeing Resident #1 during his shift but not specific times. NA #2 stated Resident #1 was not in his room when he delivered his supper tray and explained that was not unusual as Resident #1 would typically wander the halls, go back to his room and eat a little, get up and walk around some more, go back to his room to eat a little more, and then leave the room again. NA #1 stated he did not pay attention to whether or not anything had been eaten when the meal tray was removed from Resident #1's room or if he had even been the one who picked up Resident #1's supper tray that evening. NA #2 stated Resident #1 was always making comments that he was going to escape and wore a wanderguard device on his wrist that was later placed on his ankle due to him removing the device. NA #2 stated he never mentioned Resident #1's comments about leaving to facility Administration and explained given Resident #1's dementia, he just took his comments as part of the disease process. NA #2 stated after they had been notified Resident #1 had exited the building, he searched Resident #1's room and found his wanderguard device in a drawer in his room. NA #2 added, prior to 09/27/22, he had not known Resident #1 to attempt or remove his wanderguard device. During an interview on 10/12/22 at 6:31 AM, Nurse #1 confirmed she worked during the hours of 7:00 PM to 7:00 AM on 09/27/22 when Resident #1 exited the facility unsupervised and was assigned to provide Resident #1's care. Nurse #1 stated when she first arrived at work, she remembered looking into the residents' rooms as she walked down the hall toward the nurses' station but she did not recall seeing Resident #1 in his room or on the hall. Nurse #1 stated she didn't think anything of it because he typically wandered the facility, she would have to locate him to give him his evening medications and when he was ready to go to bed, he went back to his room. Nurse #1 couldn't recall the exact time but stated she was doing the evening medication pass and was 2 rooms ahead of his when the Nurse from A Hall notified her she had just received a call from the hospital that Resident #1 was brought there by the police. Nurse #1 stated it took her by surprise and she immediately notified the DON and Administrator. Nurse #1 stated when she spoke to staff who were present that evening, no one remembered seeing him during supper and when they had picked up his meal tray, he hadn't eaten which wasn't unusual. When they looked in his room, Nurse #1 reported they found his wanderguard device placed in his drawer where he had removed it. Nurse #1 explained Resident #1 was alert and oriented to self with extreme confusion, his cognition would come and go as sometimes he would say something clear and then not make sense the next second. Nurse #1 stated he would sundown (state of confusion occurring and [MEDICATION(S)] into the night) during the afternoon/evenings, sometimes he would push on the exit doors but most times he just asked staff to let him out and they were usually able to redirect him with a snack. Once Resident #1 returned from the hospital on 09/27/22, Nurse #1 stated she took his vitals, completed a skin assessment, initiated 15-minute safety checks, and staff were assigned to provide one-to-one supervision. During a telephone interview on 10/13/22 at 1:30 PM, NA# 4 revealed she worked at the facility per diem through a staffing agency. NA #4 stated on 09/28/22 she was notified by the DON that Resident #1 had exited the facility on 09/27/22 after she had opened the front door to report to work. NA #3 recalled when she arrived to work on 09/27/22, there were visitors waiting at the door and when she entered the code to open the door, the visitors all walked out. NA #4 explained she did not recognize Resident #1 as he was not one of her assigned residents and she thought he was part of the group of visitors who left. During an interview on 10/13/22 at 1:02 PM, the DON revealed Resident #1 was alert and oriented at times with periods of confusion and typically wandered around the facility looking out the windows and doors but had never noticed him trying to get out. The DON could not recall the time but states she was already at home the evening of 09/27/22 when she was notified by Nurse #1 that Resident #1 was found by the police outside the facility. The DON stated she instructed Nurse #1 to do an immediate head count to make sure all other residents were accounted for while she called to notify the Administrator what had happened. The DON stated she then went to the facility and assisted the Administrator with starting the investigation which included obtaining staff statements, checking the functioning of other residents' wanderguard devices, conducting an elopement drill, and providing staff education. The DON stated when she talked with staff, they couldn't recall the last time they had seen Resident #1 in the facility and wasn't aware that he had exited the building until notified by the police. During interviews on 10/11/22 at 4:35 PM and 10/12/22 at 4:44 PM, the Administrator confirmed she was notified of Resident #1's elopement on 09/27/22 by the DON but could not recall the exact time. The Administrator did recall the facility was notified around 7:00 PM that Resident #1 was at the hospital and she picked him at 10:30 PM to bring him back to the facility. The Administrator explained once Resident #1 returned to the facility, he received a new wanderguard device and was placed on one-to-one staff supervision. The Administrator stated when she was first notified of Resident #1's elopement, she wasn't sure how he had exited the facility since he wore a wanderguard device and it wasn't until she started investigating the incident she learned he had been removing them. She added, had Resident #1 been wearing his wanderguard device at the time he exited the building on 09/27/22, the door would have alarmed to notify staff. The Administrator stated when she reviewed the video footage, Resident #1 was seen on the video around 3:00 PM, wearing a hat and coat, standing by the front entrance door with visitors of other residents and walked out of the facility when the door was opened by NA #4 who was reporting to work. The Administrator confirmed staff were unaware Resident #1 had exited the facility on 09/27/22 until notified by hospital staff at approximately 7:00 PM. She added the time frame from when Resident #1 exited the building and staff were notified he was at the hospital was too long for staff not to realize someone was not in the facility and staff should be aware of where their assigned residents were not only during mealtimes but throughout their shifts. The Administrator explained during her investigation, she realized staff weren't really familiar with the residents' who wandered and staff needed to familiarize themselves with the residents at risk, not just depend on the wanderguard device to alert them. As part of the investigation, the Administrator stated new pictures were taken of the residents identified as an elopement risk, to better represent what the resident currently looked like, elopement books were updated, and staff were educated. In addition, she explained staff were instructed to immediately report any new behaviors, such as a resident removing a wanderguard device, so that new interventions could be put into place and a sign was placed on the front doors to alert visitors to be more conscientious of residents in the area when entering and exiting the facility. During a telephone interview on 10/12/22 at 1:48 PM, the Psychiatric Nurse Practitioner explained Resident #1 was not alert and oriented and often wandered throughout the facility. He explained Resident #1's mentation came and went, sometimes he was more with it and able to repeat things said but not able to remember other details. He added Resident #1 could also be threatening and combative at times. The Psychiatric Nurse Practitioner stated he did not feel Resident #1 would be safe outside the facility unsupervised. During a telephone interview on 10/12/22 at 11:00, NP #1 revealed she treated Resident #1 from the time of his admission until September 2022 when NP #2 took over his care. NP #1 stated Resident #1 was alert and oriented to self and did not feel Resident #1 was someone who would be safe outside unsupervised. During a telephone interview on 10/12/22 at 9:54 AM, NP #2 revealed when she took over Resident #1's care in September 2022, he was not alert and oriented but after some medication adjustments, he became more alert. NP #2 stated she tried to conduct a Brief Interview of Mental Status (BIMS) assessment with Resident #1 but when she asked questions about his cognition, he became angry and she wasn't able to complete the BIMS assessment. NP #2 further stated Resident #1 did not have good judgement and given his level of cognition, he would not be safe unsupervised when out of the facility. During an interview on 10/12/22 at 11:58 AM, the facility's Medical Doctor (MD) revealed Resident #1 was very confused, he could hold a conversation but didn't always make sense. The MD stated given Resident #1's level of cognition, he would not be safe outside unsupervised and/or wandering alone alongside a busy road. On 10/13/22 at 12:07 PM, the Administrator, Regional Director of Operations, and Regional Director of Clinical Services were notified of Immediate Jeopardy. The facility provided the following Allegation of Compliance with the correction date of 09/28/22: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Based on record review, staff interview and observation, the facility failed to prevent a Resident from exiting the facility and walking down a main road unsupervised. Resident #1 was admitted to the facility for long-term care on 05/09/22 with a diagnosis of [CONDITION(S)], unspecified dementia with behaviors, mood disorder, anxiety disorder, abnormal gait and mobility, confusional arousals, muscle weakness, and lack of coordination. Resident #1 was assessed upon admission at risk for elopement and care plan in place with intervention of wanderguard to ankle. Resident #1 has periods of cognitive clarity and sever confusion with the most recent BIMS score assessed as a 13 (cognitively intact) on 08/11/22. On 09/27/22 at approximately 10:30 AM, the licensed nurse noted his wanderguard was not in place to the right ankle and reapplied a new device. Per the Medication Administration Record (MAR) review, the device was assessed as in place and properly functioning during previous routine monitoring. At 8:20 PM, the facility licensed nurse received a c all from police that Resident #1 had been brought to the ED after being observed walking alone along a main road. The DON, Administrator and Medical Provider were immediately notified and multiple attempts were made to contact the Guardian and family member who were both made aware of the incident. Resident #1 returned to the facility at 10:45 PM and was assessed by the licensed nurse without injury or pain and vitals at baseline. Updated wandering risk assessment completed, wanderguard replaced to ankle and continuous one-to-one staff supervision initiated. Care plan, Kardex and orders updated accordingly. Effective 09/27/22 at 10:45 PM, Resident #1 will remain on one-to-one supervision until further determined by the Interdisciplinary team. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Residents who exhibit exit-seeking behaviors wand who are assessed as an elopement risk are at risk of exiting the facility without supervision. The following plan has been formulated to address this issue and updates to the facility risk assessment made accordingly: On 09/27/22 at 8:25 PM, the facility initiated a 100 percent census verification an all residents accounted for and safe. On 09/27/22 at 8:30 PM, all facility doors and windows and wanderguard system doors verified as secure and properly functioning. No concerns identified. On 09/27/22 at 8:45 PM, licensed nurses verified placement and proper functioning of wanderguard devices for all other residents as per plan of care. Residents also reviewed for known behaviors or removing or attempting to remove wanderguard device. No additional concerns identified. On 09/27/22 at 9:00 PM, the licensed nurses completed an elopement audit by updating wandering risk assessments for all current facility residents to identify those at risk for elopement and to ensure appropriate care plan and Kardex in place and current wanderguard orders with monitoring for placement and function. Elopement risk binders verified for accuracy, completeness and placement at nurse stations and reception desk with copy of resident profile, phot and care plan by the Director of Nursing (DON). Residents also reviewed for any behavior of removing and/or attempting to remove wanderguard device. No additional residents identified as current risk. On 09/27/22 at 9:15 PM, the DON conducted an elopement drill with current facility staff and initiated elopement education with all current facility and agency staff. Education included: 1) review of the elopement policy, 2) response in the event of a missing resident, 3) recognizing residents exhibiting exit-seeking behaviors such as pushing on exit doors, removing, or attempting to remove wanderguard devices, verbalizing desire to go home, purposeless wandering, etc., 4)responding to exit-seeing behaviors by providing redirection or distraction and reporting to supervisor when attempts are unsuccessful, 5) reporting to supervisor in the event a wanderguard device is improperly functioning or not in place per resident plan of care and immediate implementation of additional intervention to ensure safety, 6) ensuing staff awareness of residents identified at risk for elopement and location of elopement binders at the nurse stations and reception desk, 7) ensuing staff heightened awareness when entering or exiting facility doors that residents are clear from doorway, 8) providing routine care rounds every two hours for residents with wandering and exit-seeking behaviors to ensure supervision to prevent exit from the facility, 9) licensed nurses to complete wandering risk assessment (admission, quarterly and with all changes) and document proper function and placement of wanderguard devices as ordered don the MAR, and 10) IDT review of residents at risk for elopement during Monday-Friday morning meeting for effective plan of care and/or need for revision with communication to nursing staff with any changes. Facility and agency staff not receiving initial education will not be permitted to work until education completed. The Staff Development Coordinator (SDC) will be responsible for ensuing education completion. On 09/27/22 at 9:45 PM, the Administrator conducted an Ad-Hoc QA meeting via telephone conference with the DON, Unit Manager, Regional Director of Clinical Operations (RDCS), Regional Director of Operations (RDO, VP Risk Management, and Medical Director to discuss incident, review facility elopement policy and to initiate an immediate performance improvement plan based on root cause analysis. Root cause analysis determined that the facility failed to prevent a resident from exiting the facility by 1) failure to ensure a staff member recognized and prevented an at risk resident from exiting the lobby door with visitors as staff member entered from break and 2) failure to ensure staff properly responded to, report and implement a new intervention when a resident knowingly removes a wanderguard device. On 09/27/22 at 10:00 PM, the RDCS provided education to the Administrator and DON on the elopement policy and facility responsibility of maintaining an effective process to prevent residents from exiting the facility without supervision to ensure safety. Education included 1) strategies to ensure staff understanding and compliance of the elopement policy and ongoing monitoring, 2) interventions to prevent an unsupervised exit from the facility of an at-risk resident and ongoing monitoring, 3) interventions to enhance staff awareness of residents identified at risk and ongoing monitoring, and 4) maintaining an effective QAPI program whereby the Interdisciplinary Team (IDT) monitors the effectiveness of the corrective action plan of the elopement prevention program and makes changes to the plan as necessary to maintain compliance with preventing residents from unsupervised exits of the facility. Newly hired Administrators and DON will receive education during the orientation process. Effective 09/27/22, the facility will conduct elopement drills on all shifts bi-monthly to ensure continued staff understanding of the elopement policy and procedures in the event of a missing resident. The IDT will monitor for ongoing compliance during monthly QAPI meeting. Effective 09/27/22, the IDT will monitor residents at risk for elopement during the monthly meeting process Monday-Friday utilizing the Elopement Huddle Tool to evaluate ongoing effectiveness of care plan and will make revisions to the plan as necessary to maintain resident safety. The IDT will communicate with nursing staff any concerns or changes to residents at risk. Monitoring will be documented on the Elopement Huddle tool and maintained by the Administrator. Effective 09/27/22, the Maintenance Director or Administrator will complete daily door, window and wanderguard system checks for proper function. Any concerns will be addressed immediately through QAPI to ensure continued resident safety. Effective 09/27/22, the facility will conduct questionnaires with five (5) facility or agency staff to ensure understanding of providing care and supervision for residents at risk for elopement to prevent unsupervised exits from the facility. Monitoring will be completed by the Administrator or DON five times weekly for four weeks, then 3 times weekly for four weeks and then weekly for 4 weeks. Effective 09/27/22, residents identified at risk for elopement will be audited for a current, accurate wandering risk assessment, effective care plan, monitoring of wanderguard devices for propre placement and functioning, accurate and updated elopement risk binders at the nurse stations and reception desk, documentation of daily door, window and wanderguard system checks for proper function, bi-monthly elopement drills and daily review by the IDT per review of the Elopement Huddle Tool. Monitoring will be completed by the Administrator or DON five times weekly for four weeks, then 3 times weekly for four weeks, then weekly for four weeks. Effective 09/27/22, the Administrator will be ultimately responsible to ensure implementation of this corrective plan. Alleged date of compliance: 09/28/22. 2. Review of the manufacturer's instructions for the QRT-1 Series, which is the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport, specified in part: B. Secure Passenger: 1. Attach lap belts by using integrated stiffeners to feed belts through opening between seat backs and bottoms and/or armrests to ensure proper belt fit around occupant. 2) Attach shoulder belt by extending the belt over the passenger's shoulder, across upper torso and fasten pin connector onto the lap belt. 3) Ensure belts are adjusted as firmly as possible but consistent with user comfort. Warning: Lap and shoulder belt should not be held away from the passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels, or frame. Belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with the junction between lap and should belts located near the passenger's hip. The manufacturer's instructions provided no guidance regarding occupants sitting on cushions or mechanical lift slings while they were seated in their wheelchair during transport. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included intellectual disabilities, pervasive developmental disorder (delays in the development of socialization and communication skills), and age-related physical debility. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #2 with severe impairment in cognition and was nonverbal with communication. She required total staff assistance with all activities of daily living and had impairment on both sides of the upper and lower extremities. The MDS indicated Resident #2's height was 67 inches and she weighed 181 pounds. The Resident Incident Report dated 08/02/22 at 4:26 PM noted Resident #2 slid out of the wheelchair while in the facility van during transport and was taken to the Emergency Department (ED) for evaluation. The ED hospital records for Resident #2 dated 08/02/22 read in part, Resident #2 presents with family for fall out of wheelchair while being transported inside of a van prior to arrival. Resident #2 is nonverbal and reportedly fell forward out of the wheelchair injuring her left knee and ankle. Also has superficial wounds to left hand. Upon physical exam it was noted Resident #2 had abrasions to the left knee, ankle, and hand with no rash, pruritus (itching), or wounds. It was further noted x-rays conducted on 08/02/22 of Resident #2's left fingers, knee and ankle were negative for acute fractures. A staff progress note dated 08/02/22 at 11:00 PM and written by Nurse #1 read in part, Resident #2 returned from the Emergency Department (ED) via stretcher, returned to bed, skin assessment done. A skin assessment dated [DATE] completed by Nurse #1 revealed Resident #2 had a new open area to the center of her top lip that was not bleeding and new bruising to the left fingers, right hip, front of the right thigh and lower leg, front of the left thigh and lower leg, right toe(s) and ankle, and left toe(s) and ankle. The facility's investigation into the van incident involving Resident #2, completed and signed by the [TRUNCATED]

Based on observations, record review and physician and staff interviews, the facility failed to conduct a thorough search in response to an alarm alerting staff that an exit door was opened and failed to determine if a resident had exited the building unsupervised. This affected 1 of 3 residents reviewed for accidents (Resident #3). On 09/13/21 between the hours of 6:30 AM and 6:50 AM, Resident #3, who had severe cognitive impairment, exited the building through the emergency exit doors located at the end of the resident hall and remained outside the building unsupervised. When the alarm at the nurses' station sounded, staff checked all the exit doors but did not search outside the building or conduct a head count to confirm all residents were accounted for. While Resident #3 was outside unattended, there was a high likelihood for serious harm. The findings included: Resident #3 admitted to the facility on [DATE] with diagnoses that included dementia with Lewy Bodies (disease associated with abnormal deposits of protein that lead to problems with thinking, movement, behavior, and mood), [CONDITION(S)] with delusions, and anxiety. A care plan initiated on 03/18/21 noted Resident #3 had a wanderguard order in place. The goal was for him to maintain optimal quality of life while living in the skilled nursing facility setting and the intervention was for wanderguard placement. The care plan was noted as resolved on 06/11/21. A staff progress note written on 06/11/21 by the Administrator read, Resident #3 is not exit-seeking. Discontinue the wanderguard. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #3 with severe impairment in cognition for daily decision making. He was independent with walking and locomotion, used a cane and displayed wandering episodes one to three days during the MDS assessment period. A staff progress note written by Nurse #2 on 09/13/21 at 7:51 PM read in part, Resident exited out facility door and wandered approximately 100 feet into a residential yard near facility. He was observed on his hands and knees in the yard. Resident #3 denies pain, all limbs moveable without complaints of pain. No abrasion or laceration noted. Resident #3 able to ambulate self-back into facility. Resident #3's Responsible Party and physician notified of incident. Intervention in place as follows: 1) wanderguard placed on left lower leg and 2) skin check administered. Resident #3 resting in room with no distress noted. During interviews on 01/18/22 at 12:24 PM and 5:02 PM, Nurse Aide (NA) #1 confirmed he worked during the hours of 11:00 PM to 7:00 AM on 09/12/21 to 09/13/21 when Resident #3 exited the facility unsupervised. NA #1 could not recall the exact time he heard the alarm sounding at the nurses' station on 09/13/21 but stated it was somewhere around shift change and he immediately went to check the panel which showed the exit door at the end of the hall had opened. He opened the exit door at the end of the hall to see if anyone had gone outside and when he didn't see anyone, he started checking all the other exit doors throughout the facility but never saw any resident outside the facility doors. NA #1 stated it was still dark when he opened the exit doors to look outside and confirmed he did not go outside to check around the perimeter of the building. NA #1 added he did not do a head count of the residents. NA #1 recalled last seeing Resident #3 somewhere between 6:30 AM and 6:45 AM as Resident #3 was walking the hallway as normal and he had displayed no abnormal or exit-seeking behaviors at the time or during the shift. NA #1 added although Resident #3 wandered the halls, prior to the incident on 09/13/21 he had never tried to exit the facility. NA #1 stated when checked the panel at the nurses' station to see what door triggered the alarm, he did not reset the panel and left the alarm on while he checked the exit doors. He was not sure who ended up resetting the alarm. NA #1 confirmed he was trained on elopement procedures which included responding to the alarm, checking the door(s) that triggered and outside perimeter, and completing a head count to ensure no resident had exited the building. During an interview on 01/13/22 at 3:50 PM, Nurse #1 recalled it was early in the morning on 09/13/21, just before shift change at 7:00 AM, when the alarm at the nurses' station sounded alerting them an exit door was opened. Nurse #1 did not recall checking the alarm panel herself and explained NA #1 checked the exit and front entrance doors and reported to her he did not see anyone other than staff entering the building. Nurse #1 could not recall the exact time she last saw Resident #3 but stated she typically checked his sugar every morning between 6:00 AM and 6:30 AM. Nurse #1 confirmed she was trained on elopement procedures which included what to do when an alarm triggered such as check the exit doors and outside perimeter of the building, conduct a head count of residents if not sure how the alarm was activated, and if unable to locate a resident, call 911. Nurse #1 explained when they heard the alarm at the nurses' station sound that morning and staff did not see any residents outside when they checked the exit doors, they did not do a head count because at the time they weren't aware Resident #3 had exited the facility and thought the alarm likely sounded due to staff entering the building during shift change. Nurse #1 added Resident #3 typically wandered the halls but did not recall him displaying decreased confusion, agitation, or exit seeking behaviors during the shift. During interviews, on 01/12/22 at 4:36 PM and 01/18/22 at 10:42 AM, the Administrator explained on the morning of 09/13/21, at approximately 7:15 AM, she responded to a knock at the entrance doors of the facility and was informed by a police officer a resident was found in the front yard of a residential home located up behind the building. The Administrator went to the location where Resident #3 was found and recalled he was sitting down in the front yard. Emergency Medical Services (EMS) arrived, assessed Resident #3, stated he was fine and she brought him back to the facility without incident which she recalled was approximately 7:45 AM. She added, after Resident #3 was returned to the facility, a wanderguard was placed on his ankle and all exit doors were checked. The Administrator confirmed they were unaware Resident #3 had exited the facility until notified by the police officer and when they reviewed the video footage, she seemed to recall he went out the exit door at 6:50 AM. She stated the alarm at the nurses' station was functioning at the time of the incident on 09/13/21 to alert staff if any of the exit doors were opened. The Administrator explained staff were re-educated to pay attention to the alarms when sounding, check the area where the alarm triggered and if unable to determine how the alarm was activated, they were to conduct a head count, perimeter check and notify management. During an interview on 01/13/22 at 10:55 AM, Nurse #2 stated when she arrived to work on 09/13/21 she was informed Resident #3 had exited the building just before 7:00 AM shift change. She added the Administrator was already at the facility when notified by police Resident #3 was found at one of the residential houses located behind the facility. Nurse #2 stated they reviewed the video footage to determine which door Resident #3 exited and could not recall the exact time he exited the building or when he was brought back to the facility but stated it was only a couple of minutes, maybe 5 minutes or so. Nurse #2 added once Resident #3 was back in the facility, he was assessed with no injuries noted and a wanderguard was put in place. An online website named Time and Date was used to obtain the outside weather in the Hendersonville area on 09/13/21 and noted at 6:54 AM the temperature was 61 degrees Fahrenheit with no wind. It was further noted, sunrise was 7:06 AM. An observation with the Administrator was conducted of the facility property on 01/14/22 at 9:05 AM. At the front entrance of the facility, to the left, was a road leading up to a memory care facility and several residential houses. Behind and to the side of the facility, there were steps leading up to the memory care parking lot which was located across from the side road leading to the residential homes. Trees and wooded areas were also along the perimeter of the facility and the back of the residential homes. Per the Administrator, Resident #3 was found in the front yard of the first home. She was not sure what route Resident #3 walked to arrive at the residential home. The distance from the front entrance of the facility to the residential home was approximately 0.1 miles or 528 feet. Observations of the alarm panel located at the nurses' station and exit doors was conducted with the Maintenance Director on 01/14/22 at 1:14 PM. The emergency exit used by Resident #3 when he exited the facility was located at the end of A Hall and when the Maintenance Director pushed down on the door handle for 15 seconds, the door opened, and an alarm sounded at the door and nurses' station. The Maintenance Director then entered the code into the keypad panel located at the exit door and the alarm turned off. The alarm at the nurses' station continued to beep rapidly until the panel was reset and identified the exit door that was opened. During a telephone interview on 01/12/22 at 2:15 PM, the facility's Medical Doctor (MD) stated he did not recall being notified of the incident on 09/13/21 when Resident #3 exited the facility. The MD explained Resident #3 was pretty stable when ambulating; however, was not appropriate to be outside the facility unattended. The MD added he would be concerned that when outside unattended, Resident #3 could have easily wandered down the road to the main highway. On 01/18/22 at 6:45 PM, the Administrator was notified of Immediate Jeopardy. The facility provided the following Corrective Action Plan with the correction date of 09/15/21: On 9/13/2021 Resident #3 left the facility unattended. Resident #3 was found in the yard of a residential house beside the facility. Resident #3 was reassessed for potential to elopement on 9/13/2021 by the Director of Nursing. Body audit completed for Resident #3 by the Director of Nursing on 9/13/2021. Psychosocial assessment was completed by the Social Worker on 9/13/2021. Wanderguard bracelet placed on Resident #3 on 9/13/2021. Resident #3's care plan was reviewed and updated by Minimum Data Set (MDS) Nurse on 9/13/2021. All residents with dementia or dementia related diagnosis and low BIMS score are at risk for elopement. Regional Clinical Nurse and Director of Nursing audited all at risk and high-risk residents for potential elopement and updated assessments as needed on 9/13/2021. Regional Clinical Nurse and Director of Nursing updated Care Plans for all resident at risk for elopement on 9/13/2021. Director of Nursing and Maintenance Director audited all wanderguard bracelets on 9/13/2021 for function. Nursing updated all Elopement Binders for nursing stations and lobby desk on 9/13/2021. Elopement binders will be updated as needed with admissions and discharges by the Director of Nursing. All new at-risk residents will be reviewed upon admission by IDT team and all others quarterly during care plan review. Maintenance Director audited all doors for alarm function on 9/13/2021. Maintenance Director found no issues. Maintenance Director will continue to check all doors daily for alarm function. Elopement Drill was completed on 9/13/2021 with all staff to ensure proper response to door alarms by the Maintenance Director. Maintenance Director to complete elopement drills quarterly and during orientation of any new staff. Maintenance Director completed a 2nd elopement drill on 01/06/2022. Maintenance Director will continue to complete elopement drills quarterly. Administrator/Director of Nursing in-serviced all staff on elopement procedures on 9/13/2021 for proper response. Education included: · The door monitoring device at A wing nurses station only has 3 exit doors labeled to leave on. One is A-wing end of hall door, one is main dining room door, and the final is B-wing end of hall door. These doors do not have wanderguard functionality installed on them and the end of hall doors do not have mag lock or locking capabilities. They are emergency egress corridors which must exit without key service. The exterior access of these doors are locked, hence once outside you will not be able to re-enter without being allowed entry from the interior. · If any three of these sounds, you must identify who opened the door. You should be able to identify which door opened by reviewing the monitoring device located to the left of the medication room to the right of the Emergency Generator panel. If the panel indicates A-wing door for example the end of hall door should still be alarming if the door device is functioning properly. The codes are 1234, do not tamper with these devices. They are in place for your safety and the safety of the residents. If you do not see anyone near the door and are not aware of who may have triggered the annunciator you must do an exterior perimeter check. If you do not know the length of time it has been alarming a census count must be completed by the nurses. If it is identified that a resident is missing the Director of Nursing or Administrator is to be contacted immediately to implement the emergency procedures. To reset the device at the nurses station you depress the button at which the door is alarming and press it again to reactivate for monitoring. · The codes should not be given to family or residents at any time. · Do not disregard any alarm · Do not block or prop open exits at any time. · Do not shut off any alarms until you have investigated the reason for the alarm to annunciate and have eliminated any potential risk. · If you are unsure or it is unsafe to leave your position you can page for a census count. Staff were re-educated to check the facility for missing residents and conduct a head count when alarm has sounded. Staff were also instructed to search outside facility for any residents. Instruction on who to call such as Administrator, Director of Nursing for further direction. Education included the use of the elopement binders for high-risk residents. Any new hires or new agency staff will be in-serviced on the elopement process prior to starting a shift going forward. All residents listed in elopement books are reviewed monthly in Risk meetings which includes Director of Nursing, MDS Nurse, Social Worker and Dietary Manager. Quality Assurance Performance Improvement meeting was completed on 9/14/2021 by Administrator, Director of Nursing, Social Worker and Business office manager. Medical Director was informed of the incident and facility changes on 9/14/2021. All findings will be reviewed by the Interdisciplinary Team during Quality Assurance Performance Improvement meetings and quarterly thereafter. All recommendations will be implemented as needed by the Administrator. Completion Date: 9/15/2021 The Corrective Action Plan was validated on 01/31/22 and concluded the facility implemented an acceptable corrective action plan on 09/15/21 once staff education was provided on the elopement process and the elopement plan was reviewed during a QAPI meeting held on 09/14/21. The daily monitoring schedule of the facility exit doors alarms for September 2021 to January 2022 were reviewed with no concerns identified. Elopement books were observed at each nurses' station and reception desk. The elopement books contained information and pictures for each resident identified as high risk. Multiple staff on various shifts were interviewed and verified they received re-education related to elopement and were able to describe facility processes for: what to do when a resident demonstrated elopement/exit seeking behaviors, where the elopement books were located and what information they contained, responding to door alarms, checking the exit doors and outside perimeter of the building, conduct a head count of all residents, and who to notify in the event of an elopement.

Based on observations, record reviews, staff, Resident, Respiratory Therapist, Nurse Practitioner and Physicians interviews the facility failed to implement an effective pest control program to control the presence of flies in the rooms of 1 of 3 sampled residents (Resident #2) reviewed for pest control. Resident #2 had live maggots develop in his [CONDITION(S)] site and was transferred to the Emergency Department for removal of 3 maggots from his [CONDITION(S)] site which resulted in bacterial tracheitis and was treated with intravenous antibiotics. Immediate Jeopardy (IJ) began on 08/03/21 when Resident #2 was found to have live maggots in his [CONDITION(S)] site. The facility failed to implement an effective pest control program to prevent flies in the facility which caused the development of maggots in Resident #2's [CONDITION(S)] site. The Immediate Jeopardy was removed on 08/08/21 when the facility implemented a Credible Allegation of IJ removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not IJ) to ensure monitoring of systems were effective and to complete employee inservice. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], respiratory failure and [CONDITION(S)]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and required total assistance with his activities of daily living. The MDS also indicated he required a [CONDITION(S)], suctioning, and a feeding tube. An interview was conducted with Nurse #2 on 08/05/21 at 3:00 PM who explained that she and the Respiratory Therapist (RT) went into Resident #2's room on the afternoon of 08/03/21 to perform his [CONDITION(S)] care and she noticed the Resident's [CONDITION(S)] site had redness, more so than normal but knew that the Nurse Practitioner (NP) had been notified of the redness earlier that day and had ordered an antibiotic ointment to be applied for 10 days. The Nurse continued to explain that when the RT lifted the Resident's [CONDITION(S)] dressing up, they observed a small white worm peep its head out from the right side of the [CONDITION(S)] then went back in. She stated it happened a second time but went back into the stoma (an artificial opening) before the RT could catch it. The Nurse explained that she went to find the NP but was told she had already left the facility, so she notified the Director of Nursing (DON) of their observations of the worm in Resident #2's [CONDITION(S)] site. Nurse #2 reported that Resident #2's [CONDITION(S)] did not have a lot of drainage that required suctioning and his [CONDITION(S)] site was usually clean and dry. The Nurse also reported that she had noticed flies in Resident #2's room prior to the sighting of the worm but the flies were not on the Resident, just in his room. During an interview with the Respiratory Therapist (RT) on 08/05/21 at 5:45 PM he explained that during a weekly visit with Resident #2 on the afternoon of 08/03/21, he noticed a sweet smell similar to the Resident's enteral formula coming from the Resident's [CONDITION(S)] which he had never smelled before that day. The RT also stated that Resident #2's [CONDITION(S)] site was red which he thought that was unusual because Resident #2 normally did not have a lot of drainage from his [CONDITION(S)] to cause the redness. The RT stated he observed a worm or maggot in the Resident's [CONDITION(S)] site and tried to catch the maggot but could not get it because the maggot was too fast and disappeared down into the [CONDITION(S)] site. The RT stated he applied an antibiotic ointment that had been ordered for the redness around his [CONDITION(S)] and finished the [CONDITION(S)] care. The Director of Nursing was notified of the maggot sighting in Resident #2's [CONDITION(S)] site. The RT continued to explain that he knew that the only way maggots could have gotten into Resident #2's [CONDITION(S)] site was by flies and that he had never seen flies in the Resident's room or in the facility. A progress note dated 08/03/21 2:16 PM written by the Director of Nursing revealed Resident #2 was noted to have redness around his stoma opening to his [CONDITION(S)]. When the Respiratory Therapist was cleaning his [CONDITION(S)], a small grey moving foreign object was noted moving into the Resident's stoma. The Medical Director was called, and an order was received to transfer Resident #2 to the hospital. The Resident had no fever, no cough or other respiratory difficulty. During an interview with the Director of Nursing (DON) on 08/05/21 at 4:00 PM she explained that Nurse #2 informed her that she and the Respiratory Therapist observed a small wiggly thing go down inside Resident #2's [CONDITION(S)] site and the RT tried to grab it but he could not get it. The DON continued to explain that when she got to Resident #2's room the RT repeated his observation and stated it was a larva that went down into the side of the Resident's [CONDITION(S)]. The DON stated she called the Nurse Practitioner to notify her of the observations and the NP gave her an order to obtain an ultrasound but the X-ray company could not perform ultrasounds on [CONDITION(S)] sites so the Medical Director was notified and he gave an order to send Resident #2 to the Emergency Department for treatment. The DON continued to explain that she only knew of one way that maggots could have gotten into Resident #2's [CONDITION(S)] site and it was through flies. She stated that Resident #2 was not mobile and therefore could not swat the flies away that landed on his [CONDITION(S)] site. She stated that the facility was in the process of remodeling and she had observed the construction workers had propped the doors open in order for them to bring materials into the facility and that could have been how the flies came into the facility. The DON continued to explain that the maintenance staff checked all of the window screens in the resident rooms for a tight fitting seal and discovered some of the screens did not have a tight fitting seal so the screens were repaired or replaced. A progress note dated 08/03/21 5:46 PM written by the Nurse Practitioner revealed he presented with foul smelling sputum. It was described as acute and worsening. This is a/an exacerbation. The problem was reported by the nursing staff. The symptom is gradual in onset and ongoing. The frequency of episodes is increasing. Pertinent findings include denies fever and nasal congestion. Redness at [CONDITION(S)] site and report from Respiratory Therapist of larval infection. The progress note continued to reveal the plan was [CONDITION(S)] status chronic and ongoing and now with infection. Red with Respiratory Therapist reporting sighting of larval activity. Transferred to hospital as they have the most advanced resources in the area. An interview with the Nurse Practitioner (NP) on 08/05/21 at 11:45 AM revealed on 08/03/21 during her visit with Resident #2 she noted he had redness around his [CONDITION(S)] site which she ordered an antibiotic ointment to be applied for 10 days. The NP explained that later in the day on 08/03/21 she was notified that the Respiratory Therapist observed larva in Resident #2's [CONDITION(S)] site and the NP ordered an ultrasound to see if there was damage to the soft tissue. The NP stated the X-ray mobile company was unable to perform the ultrasound, so the decision was made to send the Resident to the Emergency Department. The NP explained that she could not comment on whether the larva caused Resident #2's [CONDITION(S)] site to become red because it was not uncommon for redness to occur around a [CONDITION(S)] site. A review of the hospital Emergency Department report dated 08/03/21 revealed Resident #2 presented with maggots in his [CONDITION(S)] site. Three (3) maggots were removed from the [CONDITION(S)] site and a bronchoscopy was conducted with no signs of maggots further down the [MEDICATION(S)] tree. The examination was concerning for bacterial tracheitis. The Resident was admitted for treatment with intravenous antibiotics for bacterial tracheitis and maggot infestation. An interview was conducted with the Emergency Department Medical Director on 08/05/21 at 3:45 PM who explained that Resident #2 presented at the Emergency Department on 08/03/21 with maggots in his [CONDITION(S)] site. The Physician explained that the Resident had 3 maggots removed from his [CONDITION(S)] site and a bronchoscopy was performed to determine if the maggots had invaded the Resident's lungs, but no maggots were found in his lungs. The Physician stated that if the maggots had not been removed, they could have crawled into his respiratory tract and into Resident's lungs which could have caused an [CONDITION(S)] response and respiratory distress. The Physician also stated death was a possibility but not probable. An observation made of Resident #2's private room on 08/5/21 at 10:15 AM while the Resident remained in the hospital, revealed it was cool, neat, clean and orderly. No signs of fly activity were observed in the room or in the windowsill. A review of Resident #2's Treatment Administration Record (TAR) indicated [CONDITION(S)] care was to be performed every shift and as needed. During an interview with Nurse #5 on 08/09/21 at 11:15 AM the Nurse confirmed she worked on 08/02/21 7:00 PM to 7:00 AM and performed [CONDITION(S)] care for Resident #2. The Nurse explained that she did not notice anything unusual about the Resident and that he acted in his normal manner. The Nurse stated the Resident's [CONDITION(S)] site was a little red but not excoriated and there was very little drainage from his [CONDITION(S)] which was normal as well. The Nurse indicated she did not notice flies in the Resident's room. The TAR also indicated Nurse #4 worked on 08/02/21 on the 3:00 PM to 11:00 PM. During an interview with Nurse #4 on 08/09/21 at 9:20 AM she confirmed she performed [CONDITION(S)] care on Resident #2 and explained she noticed a little redness around the Resident's [CONDITION(S)] site but contributed the redness to the recent reduction in the [CONDITION(S)] tube because Resident #2 was being weaned from the [CONDITION(S)]. The Nurse stated the Resident had very little phlegm that evening and did not have to be suctioned which was not unusual for him. The Nurse also added that she did not notice any fly activity in the Resident's room that evening or any other evening. An interview was conducted with the Medication Aide (MA) on 08/05/21 at 9:45 AM. The MA explained that there was fly activity on the 300 hallway and in the room across from Resident #2's room. She continued to explain that Resident #1 kept all kinds of open food in her room and she would not allow you to remove the food from her room. The MA stated she had not reported the fly activity in Resident #1's room but that the staff were aware of the flies in the Resident's room and even discussed it among themselves. An interview and observation of Resident #1's room across the hall was made with Nurse #1 on 08/05/21 at 9:50 AM. The Nurse explained that the flies were all over the building and especially in Resident #1's room. While standing at the open door to the Resident's room the Nurse acknowledged a fly circling around an approximately quarter sized brownish yellow liquid in the floor beside Resident #1's bed. On 08/05/21 at 10:08 AM an interview and observation were made of Resident #1's room with the Unit Manager (UM) during which the Resident was out of the facility for a Doctor's appointment. The UM explained she had noticed flies in the hallway outside the Resident's room every now and then and felt the reason for the flies was because the facility had recently undergone remodeling and the fly lights had to be taken down in order to accommodate the remodeling. The UM stated that they had started to put the fly lights back up since they were finished with remodeling the walls. During the interview an observation was made of Resident #1's room with the UM. She acknowledged a fly that circled around Resident #1's side of the room. The UM pointed out various food products that were stored on tables on Resident #1's side of the room. The food consisted of open containers of cream cheese, open variety pack of cheeses with a label that stated it should be refrigerated, open chip bag, open vegetable juice and salsa dip. The UM reported that the management team had a discussion in the morning meeting the day before (08/04/21) about the fly activity in the Resident's room and in the facility and what could be done about it but did not elaborate on what that was. On 08/05/21 at 10:33 AM an interview was conducted with Resident #1's roommate Resident #4 who was cognitively intact. During the interview a fly landed on Resident 4's left wrist and the Resident stated she had noticed the flies in the last two days but that she had not reported them to anyone. A review of the facility's receipts provided by the Pest Control Company indicated onsite services of inspections and chemical applications were conducted on 05/15/21, 06/24/21 and 07/28/21. The receipts indicated insecticide and gel bait was applied in the kitchen area for cockroaches, traps for mice in the kitchen areas and traps for rats around the exterior area. An interview was conducted with the Maintenance Supervisor (MS) on 08/05/21 at 1:10 PM. The MS explained that when maggots were discovered in Resident #2's [CONDITION(S)] site he knew they could have only gotten there by fly activity so he toured the facility and discovered that the construction workers had removed the electrocution traps (fly lights) from the walls in order to remodel so he ordered more fly lights and was in the process of mounting them in the areas where the remodeling had been completed. The MS stated he checked the fly fan in the kitchen to make sure it was working properly as well. The MS also explained that the facility had pest control services conducted once a month and as needed for cockroaches, mice and rats and that there had been no indications of the need for an extra visit for extermination to be made by the pest control company. An interview was conducted with Housekeeper #1 on 08/05/21 at 1:45 PM. She explained that she had especially noticed the flies in Resident #1's room in the last couple of days. The Housekeeper stated the Resident kept food in her room and would not allow them to throw the food away. The Housekeeper explained that they cleaned Resident #1's room every day and deep cleaned the room once a month but they would perform extra deep cleaning when she was out of the room and when the opportunity presented itself. During an interview with Nurse Aide (NA) #1 on 08/05/21 at 2:00 PM the NA stated that it was common knowledge that Resident #1 had flies in her room and that she had not reported it because she thought management was aware of the flies in the Resident's room. During an interview with Nurse Aide (NA) #2 on 08/05/21 at 2:20 PM she explained that she took care of Resident #2 on 08/01/21 and did not notice a fly on the Resident but did notice a fly in the window of the Resident's room. The NA continued to explain that by the time she finished with Resident #2's care, the fly was gone, and she did not think to report it to anyone. The NA also explained that she normally was not assigned to Resident #1 but that she observed 2 flies in the Resident's room that morning when they were getting the Resident's roommate out of the bed. During an observation of Resident #1's room on 08/05/21 at 2:34 PM Resident #1 was not in her room, but a fly was noted to be on the Resident's bed. An interview was conducted with Nurse Aide #3 on 08/05/21 at 2:45 PM. The NA explained that she assisted with getting Resident #2 up in the recliner on 08/01/21 and observed flies in the Resident's room but that the flies did not land on the Resident. The NA stated that she saw flies in Resident #1's room all the time and that she had not reported the fly activity because she knew it was common knowledge that there were flies in the facility and in some resident's rooms and assumed the management knew it as well. An interview was conducted with the Director of Nursing (DON) on 08/05/21 at 4:00 PM. The DON stated the open food and the recent remodeling the facility was currently undergoing was the reason for the increase fly activity in the facility. The DON explained that she had recently observed a construction worker had propped a door open to the outside in order to bring materials into the facility and she explained to the workers why they could not prop the doors open. The DON also stated she discovered that the families had pushed some of the window screens in the residents' rooms open and had the maintenance department check all the window screens to make sure they were tight fitting. On 08/05/21 at 5:35 PM this writer accompanied the Director of Nursing (DON) to Resident #1's room to interview the Resident. At that time a fly flew in front of the DON's face and the DON swatted at the fly and stated, there's a fly. Resident #1 stated it's been in here all day and I can't get rid of it. I need a fly catcher in here. The DON replied that they could not have a fly catcher in the resident rooms. During an interview with the Administrator on 08/05/21 at 6:05 PM she reported she had not noticed an increase amount of fly activity in the facility but that when the maggots were discovered in Resident #2's [CONDITION(S)] site she had maintenance audit the window screens in the all residents' rooms and found that some of the screens were pushed away from the tight fitting seal and had them repaired. She continued to explain that the facility was in the process of remodeling and they realized the construction workers had removed the fly lights from the walls throughout the facility and that could be a possibility as to why they had an increase in fly activity. She stated the Maintenance Supervisor ordered fly lights on 08/03/21 and had received them on 08/04/21 and had started mounting them throughout the facility. On 08/06/21 at 3:03 PM a telephone interview with Resident #2's Physician revealed he was made aware of the maggots in the Resident's [CONDITION(S)] site by the Director of Nursing on 08/03/21 and he ordered the Resident to be transferred to the Emergency Department. The Physician explained that the maggots could only have gotten into Resident #2's [CONDITION(S)] site through flies and that the facility was undergoing remodeling which could have been how the flies had gotten into the facility and to the Resident. The Physician stated he could not determine if the maggots caused the redness around Resident #2's [CONDITION(S)] site but that if the maggots had not been discovered by the facility staff the maggots could have traveled further down into the Resident's lungs and cause respiratory difficulty. On 08/07/21 at 6:05 PM during a telephone interview with Nurse #3 she explained that on 08/01/21 she noticed an unusual smell and redness around Resident #2's [CONDITION(S)] site and reported it to the Nurse Practitioner who ordered an antibiotic ointment to be applied to his [CONDITION(S)] site. The Nurse added that Resident #2 normally did not have a lot of drainage from his [CONDITION(S)] site and that he did not require a lot of suctioning as other residents with tracheostomies required. The Nurse stated she did not notice any flies when she last worked with Resident #2 but have noticed flies in his room and in the windowsill but have not seen flies on the Resident himself. The Nurse continued to explain that she had noticed an increase amount of fly activity in the facility since the facility had undergone remodeling and contributed it to the fact that the construction workers had to prop the doors open to bring materials into the facility. The Nurse also stated that the construction workers had taken the fly lights down in order to remodel the walls. The Nurse also explained that she noticed flies in Resident #1's room all the time. The Nurse continued to explain that Resident #1 kept food in her room like unsealed snacks and food left over from her meal trays and was resistant to having the food removed from her room. The Nurse stated she also felt the reasons for the increase fly activity in the facility was because the construction workers would open the windows and pass materials through them and forget the close the windows when they are finished for the day. She also stated that she knew the families would push the window screens out in the residents' rooms during their visitation time. Nurse #3 explained she had not reported the increase activity because she knew it was common knowledge. On 08/06/21 at 6:25 PM during an second interview with the Maintenance Supervisor (MS) he stated that he felt the increase in fly activity happened because of the frequent opening and closing of doors by the construction workers during the recent remodeling of the facility and the fly lights had to be taken down to accommodate the process. The MS stated that on 08/03/21 he ordered 3 new fly lights and mounted them on 08/04/21. On 08/09/21 at 12:15 PM the Administrator was notified of the Immediate Jeopardy. The facility submitted the following credible allegation of Immediate Jeopardy removal. Allegation of Compliance F 925 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance All residents with wounds, dressings and or tracheostomies were at risk from the failure to adhere to correct and adequate pest control polices. The facility had in place a pest control process for employees to follow prior to 8/03/20. The facility's pest control included: fly fan in kitchen area, fly lights throughout the facility, reporting system through maintenance work orders, contracted pest control company servicing facility monthly and as needed for any problems that arise between services. The facility's policies also included management room rounds as well as Maintenance Assistant daily rounds of grounds to remove any trash throughout the parking lot around facility as well as the dumpster area. The facility failed to keep fly or flies from Resident #2's [CONDITION(S)] site causing 3 maggots on [CONDITION(S)] site. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. The Accordius Health at Hendersonville's policy on pest control has been and will continue to be followed to include fly control. On 8/4/2021 the Regional Director of Operations reviewed the pest control policy with the Administrator to ensure compliance. This includes but not limited to the procedures for fly prevention to include the use of fly lights, and window screens. The facility's pest control included fly fan in kitchen area, fly lights throughout the facility, reporting system through maintenance work orders, contracted pest control company servicing facility monthly and as needed for any problems that arise between services. The facility's policies also included management room rounds to include signs of pest or food items laying around, as well as Maintenance Assistant daily rounds of grounds to remove any trash throughout parking lot around facility as well as the dumpster area. On 8/3/2021 the Administrator in-serviced the Maintenance Director on procedures for pest prevention, to include checking all windows to ensure window screens were in place and in good working order, and fly lights were in place, all doors were checked for proper closing and sealing. The Maintenance Director also checked the kitchen fly fan to ensure proper operation. On 8/4/2021 the Administrator educated the Contractor of the need to limit door openings for potential fly problems. On 8/4/2021 the Maintenance Director contacted the pest control company for assistance with fly reduction measures and visit to facility for further input. The Administrator had spoken with the family of Resident #2 as of 8/6/2021 about the observation of flies around Resident #2's [CONDITION(S)] area. The Regional Director of Clinical Services on 8/3/2021 instructed the Director of Nursing to assess all residents with wounds, tracheostomies, and stomas to ensure no maggots were present. On 8/3/2021 the Director of Nursing completed an assessment of all residents with stomas, wounds, and/or tracheostomies to ensure there were no signs of maggots or other pests. As of 8/7/2021 the Administrator/Designee provided remediation education and continued with awareness of policy and procedures to prevent and report any signs of pest, staff were also educated to kill or remove pest, if possible. Education also included the process of flies laying eggs and eggs transition to maggots. The Administrator will provide fly swats for staff. The facility has at all times had system for reporting pest. In review of work orders no pest have been reported as of 8/7/ . All interviewable residents have been educated on food storage in resident rooms on 8/7/2021 by the Director of Nursing. Room rounds will be completed 5 times per week by all department managers with areas of observation to include rooms were clean, residents were clean, and there were no signs of pests, or food debris in resident rooms. Staff should correct or report areas of concern to the appropriate person for correction. The facility alleges immediate jeopardy removal as of 8/8/2021. The Administrator is responsible for implementing the acceptable immediate jeopardy removal plan. On 08/13/21 at 10:15 AM a review of the facility's receipt provided by the Pest Control Company indicated onsite services of inspections and chemical applications were conducted on 08/09/21 for flies in various areas throughout the facility. An interview was conducted with the Maintenance Supervisor (MS) on 08/13/21 at 10:15 AM. The MS explained that the Pest Control Company conducted an extermination treatment on 08/09/21 to spray a chemical specifically to target flies since flies were not one of the pests targeted on the monthly treatments. The MS stated that the chemical would be included in the routine monthly treatments provided by the Pest Control Company. On 08/13/21 the facility's credible allegation of Immediate Jeopardy removal date of 08/08/21 was validated by the following: resident interviews indicate the fly activity in rooms had decreased, multiple staff from all departments of the facility were interviewed and acknowledged inservice training had been completed as well as through inservice attendance records, department managers indication of room rounds vigilance had been increased, observations of resident rooms and areas throughout the facility and dumpster areas showed no signs of fly activity, multiple fly lights had been mounted throughout the facility and the fly fan in the kitchen was functioning properly, pest control records reviewed to indicate an extra pest control treatment on 08/09/21 had been provided to specifically target flies, a new system of reporting and documenting pest control sightings had been initiated and lastly observations of window screens throughout the facility were appropriately fitted to prevent flies into the facility.