Every finding on record at Oxford Health and Rehabilitation Center

Based on observations, staff interviews, a consultant pharmacist interview, and record reviews, the facility failed to have a medication error rate below 5 percent. Three medication errors were identified out of twenty-six opportunities, resulting in a medication error rate of 11.5 percent for two of the five residents observed during the medication administration observation (Resident #4 and Resident #6).Findings included:1. Resident #4 was admitted on [DATE] with a diagnosis of congestive heart failure.Resident #4 had a physician's order dated 6/9/2026 that directed the administration of two 20-milligram tablets of Torsemide by mouth twice daily for treatment of congestive heart failure.During a medication administration observation on 6/15/2026 at 8:28 AM, Nurse #2 administered one 20 milligram tablet of Torsemide to Resident #4.A review of the medication administration record showed that Nurse #2 documented that Resident #4 received two 20 milligram tablets of Torsemide on 6/15/2026 at 8:50 AM.During an interview on 6/15/2026 at 10:37 AM, Nurse #2 reviewed the physician's orders and acknowledged she had administered only one 20 milligram tablet of Torsemide when the order required two tablets. Nurse #2 stated she needed to administer an additional 20 milligram tablet to complete the ordered dose.During a telephone interview on 6/15/2026 at 1:45 PM, the consultant pharmacist stated the Torsemide order had recently changed from one tablet to two tablets and confirmed that nursing staff must follow the physician's orders by reviewing the medication administration record prior to dispensing and administering medications.2a. Resident #6 was admitted to the facility on [DATE].Resident #6 had a physician's order for one 500-milligram tablet of Vitamin C daily administered as a supplement initiated on 7/1/2024 and discontinued on 10/16/2025.During a medication administration observation on 6/15/2026 beginning at 9:09 AM, Nurse #2 administered one tablet of 500 milligrams of Vitamin C to Resident # 6.During an interview on 6/15/2026 at 10:39 AM, Nurse #2 reviewed the physician's orders in the electronic medical record and acknowledged she had administered Vitamin C without a current physician's order. Nurse #2 stated that Resident #6 previously had an order for Vitamin C and offered this as an explanation for the error.During an interview on 6/15/2026 at 12:08 PM, the Administrator stated Resident #6 had previously been ordered Vitamin C and acknowledged the administration was an error that could not be reversed.During a telephone interview on 6/15/2026 at 1:45 PM, the consultant pharmacist stated nursing staff must follow physician orders for all medications, including supplements, by reviewing the medication administration record prior to dispensing and administration.2b. Resident #6 had a physician's order initiated on 11/1/2022 for 50 micrograms of Vitamin D to be administered as 1 tablet by mouth one time a day as a supplement.During a medication administration observation on 6/15/2026 beginning at 9:09 AM, Nurse #2 administered one 25 microgram tablet of Vitamin D to Resident #6.A review of the medication administration record showed Nurse #2 documented that Resident #6 received 50 micrograms of Vitamin D on 6/15/2026 at 9:38 AM.During an interview on 6/15/2026 at 10:41 AM, Nurse #2 rechecked the house stock container of Vitamin D in the medication cart and acknowledged she had administered one 25 microgram tablet instead of the ordered 50 microgram dose. Nurse #2 stated she needed to administer an additional 25 microgram tablet to meet the ordered dose.During a telephone interview on 6/15/2026 at 1:45 PM, the consultant pharmacist stated that nursing staff must ensure the medication administration record matches the medication dose dispensed prior to administration.

Based on observations and staff interviews, the facility failed to maintain the double door oven, the stove drip pan, the steam table backsplash and rack under the steam table clean. The facility failed to label, and date opened food and failed to separate raw meat from cooked food in 1 of 1 walk-in refrigerator, and in 1 of 1 walk-in freezer. The facility also failed to label and date resident's foods, failed to discard expired food, and keep nourishment refrigerators clean for 3 of the 4 nourishment refrigerators (200, 300, 400/500 hallway nourishment refrigerators) observed. The facility failed to ensure 2 of 2 dietary staff wore hair restraints and 2 of 2 male dietary staff had all facial hair contained in a face covering. The facility also failed to hold cold food (equal to or less than 40 degrees Fahrenheit (F)) on the steam table and remove chipped plates and dirty plates from the plate warmer during tray line observation. These practices had the potential to affect food being served to residents.Findings included:1a. Initial Kitchen tour was conducted with the Certified Dietary Manager (CDM) on 11/17/25 from 9 :20 AM to 9:50 AM. Observation of the double door oven on 11/17/25 at 9:35 AM revealed black oil burnt stains inside of the oven. The floor of the oven had black layer of crust that appeared like burnt food. The oven doors had dark brown oil stains.1b. Observation of the stove drip pan on 11/17/25 at 9:38 AM revealed black burnt food crumbles on it.1 c. Observation of the steam table on 11/17/25 at 9:40 AM revealed the steam table backsplash had water and food stains on it. The rack below the steam table had dust, dirt, and water stains on it. There were a few bowls kept on the rack which also had food and water stains on them.During an interview on 11/17/25 at 9:45 AM, the Certified Dietary Manager (CDM) stated the dietary staff were scheduled to clean the equipment on Monday/ Wednesday/ Friday. Cleaning was usually done at night. She indicated the stove drip pan had aluminum foil which collected all the burnt food crumbs. The aluminum foil should be removed, and new aluminum foil should be placed on it. The CDM acknowledged that the steam table backsplash should be cleaned regularly, and the rack below should also be cleaned. The CDM indicated that the bowls on the rack below the steam table were used during activities. She further indicated the bowls would be moved to a rack in the dry storage area as these were not used frequently.2a. Observation of the walk-in freezer on 11/17/25 at 9:48 AM, revealed a brown colored open cardboard box with raw frozen chicken breast in a clear plastic bag and a opened plastic bag containing slices of garlic bread in it. There was no label on raw chicken or on the garlic bread bag.During an interview on 11/17/25 at 9:50 AM, the CDM stated the dietary cook had placed the chicken in the brown box. This was the alternate meat option for lunch for the day. She did acknowledge that the raw chicken and bread slices should not have been placed together.2b. Observation of the walk-in refrigerator on 11/17/25 at 9:50 AM, revealed a plastic container with green colored food in it with no label. Two open packages of sliced deli meat that were not labeled. Two opened packages of deli cheese slices that were not labeled.During an interview on 11/17/25 at 9:52 AM, the CDM stated the sliced deli meats were sliced turkey and sliced ham. The packages should be closed and labelled. The CDM further stated plastic container with green colored food was dietary employees' lunch. The CDM indicated dietary staff should not be placing their food in the walk-in refrigerator.3 a. Observation of the nourishment refrigerator #1 on 200 hallway on 11/17/25 at 9:55 AM revealed an opened half empty 16-ounce orange flavor soda bottle, opened 23.9-ounce mango flavored juice bottle. The freezer of the nourishment refrigerator had a frozen 16-ounce water bottle with slices of lemon in it. There were no labels on these bottles. The shelves of the nourishment refrigerator had standing water and were not clean.3b. Observation of the nourishment refrigerator #2 on 300 hallway on 11/17/25 at 9:58 AM revealed a cup of cut fruit that was not labeled. A plastic grocery bag containing a sandwich in a brown bag with no label or date, and an opened store brought pepperoni 14-ounce package containing few sliced pepperoni that was not labelled.During an interview on 11/17/25 at 9:58 AM, the CDM stated the unlabeled food in the nourishment refrigerator was employee food and not residents' food. She further stated all resident's food should be labeled with resident's name and date when the food was placed in the refrigerator. All residents' perishable food should be discarded after 3 days.3c. Observation of the nourishment refrigerator #3 on 400/500 hallway on 11/17/25 at 10:00 AM revealed an unlabeled clear plastic bag with 4 cartons of chocolate milk and a pair of gloves in them. A box of cut fruit with sell-by date 10/19/25 and a box of grapes with sell by date 10/13/25. There was also a 25-ounce grape juice bottle with no label or date on it. The nourishment room floor was dirty. There were 3 empty grocery bags, few packs of cookies and crackers and used paper towels on the floor.During an interview on 11/17/25 at 10:00 AM, the CDM indicated the nourishment refrigerators and rooms were cleaned by the housekeeping staff. The housekeeping staff were responsible for discarding any expired food when cleaning the nourishment refrigerators.During an interview on 11/18/25 at 10:30 AM, the Housekeeping Director stated that the housekeeping staff were responsible for cleaning the outside of the nourishment refrigerator and the nourishment room. Housekeeping staff were not responsible for cleaning the inside of the nourishment refrigerator or discarding any food. He indicated he did notice the nourishment rooms were not cleaned by his housekeeping staff. The staff was identified, and the rooms were cleaned. The Housekeeping Director acknowledged the housekeeping staff had not cleaned the nourishment rooms over the weekend. These rooms were to be cleaned daily.During an interview on 11/18/25 at 3:00 PM, the Director of nursing (DON) stated it was the responsibility of both nursing and dietary staff to keep the nourishment refrigerator and nourishment rooms clean. Both nursing and dietary staff should discard any expired food. DON stated the nursing staff should label and date all the food brought by visitors to the residents prior to placing resident's food in the nourishment refrigerator. All perishables' foods should be discarded after 3 days.4 a. On 11/17/25 at 9:30 AM Dietary Staff #1 was observed cleaning dishes near the dishwasher. The Dietary Staff member had facial hair that was not restrained in the facial covering.During an interview on 11/17/25 at 9:32 AM, Dietary Staff #1 stated he had forgotten to wear a facial hair covering. He indicated he was late for work and, in a hurry, forgot to wear it.4 b. On 11/18/25 at 10:50 AM Dietary Staff #2 and Dietary Staff #3 were observed assisting with dish washing. Dietary Staff #2 was handling clean dishes and Dietary Staff #3 was handling dirty dishes. Both staff members were not wearing hair coverings. Dietary Staff #3 was observed having facial hair that was not restrained in the facial covering. During an interview with Dietary Staff #2 and Dietary Staff #3 both stated they had forgotten to wear their hair nets. Dietary Staff #3 indicated he did not wear facial hair restraints.During an interview on 11/18/25 at 11:01 AM, the CDM stated all dietary staff should restrain their hair using hairnets and use facial hair restrains to cover any facial hair.5a. Tray line observation was made on n 11/18/25 from 12:00 PM to 1:20 PM. Twenty-five plates used to serve resident's food on the plate warmer were observed. Five of the 25 plates observed on the [NAME] warmer were chipped and 5 of the 25 plates had dry food particles and food stains on them.During an interview on 11/18/25 at 12:10 PM, the Assistant Dietary Manager indicated the plates may have been chipped when passed through the dishwasher. The Assistant Dietary Manager stated all chipped plates should be discarded and not used on tray line to plate resident's food.5b. The temperatures of food on the tray line were taken by the Assistant Dietary Manager using a calibrated thermometer on 11/18/25 at 12:00 PM. Tuna salad sandwich was the alternate meal option, and a bowl of tuna salad was near the steam table. Temperature of the tuna salad was 48-degree Fahrenheit (F). The tuna salad was removed from the tray line and placed in the refrigerator. The temperature of the tuna salad was rechecked at 12:30 PM using a calibrated thermometer and it read 54 degrees F. The dietary aide returned the tuna salad to the freezer and temperature was rechecked at 1:05 PM by the CDM using a calibrated thermometer. The temperature was 45 F. The tuna salad was removed from the menu and not served to the residents. During an interview on 11/18/25 at 2:30 PM, the CDM indicated the tuna salad should have been placed in smaller bowls and placed in the freezer or refrigerator so that the temperature was maintained below 40 degrees F. She said it was unfortunate that the temperature could not be maintained. The interview further revealed the tuna salad was substituted with a deli sandwich. CDM stated all food should maintain the appropriate temperature during tray line.During an interview on 11/20/25 at 2:00 PM, the Administrator stated all food should be stored at appropriate temperature, opened foods should be labeled and dated accordingly and all expired foods should be discarded appropriately. The Administrator indicated Dietary staff should wear appropriate hair covering in the kitchen and follow sanitation protocols. The Administrator stated all foods prepared for the residents should be maintained at appropriate temperature. The Administrator further stated the kitchen equipment should be cleaned as scheduled and the CDM should ensure that all equipment was clean and in good working condition. The nourishment refrigerators and rooms should be maintained clean; all residents' foods should be labeled and dated and expired food should be discarded. Employees were not allowed to place their personal food in resident's refrigerators.

Based on observations, record reviews, and staff interviews, the facility failed to follow the planned menu for renal and diabetic renal diets, and for mechanical altered and pureed diets. Failure to follow the planned menu was observed during 1 of 1 tray line observation conducted. This affected 7 residents on renal diet, 3 residents on renal diabetic diet, 17 residents on mechanically altered diet and 12 residents on pureed diet. Findings included:a. The diet spread sheet for therapeutic diets for lunch meal on 11/18/25 revealed renal and diabetic renal diets were to receive 4-ounces (oz) of carrots.The Diet Type Report revealed there were 7 residents on renal diet and 3 residents on renal diabetic diet.Tray line observation on 11/18/25 at 12:10 PM, revealed the steam table had no carrots for the renal and diabetic renal diets.On 11/18/25 at 12:22 PM the Certified Dietary Manager (CDM) entered the kitchen and stated that renal diets would be receiving sliced cucumbers. Two renal trays were observed with sliced cucumbers. During an interview on 11/18/25 at 12:25 PM, the CDM indicated carrots were on the menu for therapeutic diets. However, the product shipment had not yet arrived by lunch time. She further indicated that cucumber salad was unavailable and the renal diets would receive sliced cucumbers. She stated spinach was prepared as alternate vegetable and was not renal diet appropriate and hence had to make the decision to serve sliced cucumbers on their trays.During an interview with the Assistant Dietary Manager on 11/20/25 at 9:30 AM, she indicated carrots were supposed to be delivered earlier in the morning and the shipment had not come in until tray line time. She further stated on 11/18/25 one of dietary cooks had called out and she was assisting the cook prepare for lunch meal. The Assistant Dietary Manager stated when she came to assist on the tray line, she did not notice there was no vegetable cooked for the therapeutic diets. She further indicated she thought there was cucumber salad prepared and placed in the refrigerator and was going to use it for the lunch meal. The Assistant Dietary Manager further stated the CDM does put out the daily meal sheets and the cooks and staff review them prior to the meal and cook accordingly. She indicated she had not seen any substitutions on it for carrots. However, the the sample menu substitution sheet approved by the dietitian indicated that cucumber salad would be substitution for chips as it was renal diet friendly. She reiterated that she was stretched too thin and did not ask what the substitution was for carrots.The CDM was reinterviewed on 11/18/25 at 2:00 PM. She stated she had not communicated to the staff what the substitution for carrots were for the therapeutic diet menu. The CDM indicated carrots were on the menu for therapeutic diets. However, the product shipment had not yet arrived by lunch time. The CDM stated that chips were never on the menu for therapeutic diets and unsure who had asked for the substitution for those. CDM stated due to miscommunication no vegetable was prepared for renal and renal diabetic diets.During an interview on 11/18/25 at 1:30 PM, the Registered Dietitian (RD) stated he was approached earlier in the day by a dietary staff member (name unknown) requesting permission to substitute chips for cucumber salad. He indicated he was not aware that carrots were the planned menu item for therapeutic diets. He was only informed later that the carrot shipment had not arrived. The RD indicated there were 7 residents on renal diet and 3 residents on renal diabetic diet. The RD further indicated few of the residents on renal diet were at dialysis and did not receive a tray for lunch.b. The consistency spread sheet revealed the planned menu for mechanically altered diets was 5 oz of baked chicken leg (ground with gravy) and the planned menu for pureed textured diets was 5 oz of baked chicken leg (pureed with gravy).The Diet Type Report revealed there were 17 residents on mechanically altered diet and 12 residents on pureed textured diet.During the meal preparation observation on 11/18/25 at 11:30 AM, the Dietary [NAME] was observed cooking hamburger meat.During an interview on 11/18/25 at 11:35 AM, the Dietary [NAME] stated the hamburger meat was cooked for mechanically altered diets based on the lunch menu for that day. The Dietary [NAME] indicated the CDM places the menu spread sheet and consistency spread sheet for the meal and staff would follow them accordingly. She further indicated she does look at the menu and consistency sheets prior to prepping for any meal.During tray line observation on 11/18/25 at 12:10 PM, ground hamburger meat and pureed hamburger meat with gravy were served to residents on mechanically altered and pureed diets.During an interview on 11/20/25 at 9:30 AM, the Assistant Dietary Manager indicated one of the Dietary Cooks had called out, and she was assisting the cook. The Assistant Dietary Manager indicated that prior to the scheduled tray line, the shipment had arrived, and she was ensuring all the products had come in. She further indicated she had noticed the Dietary [NAME] taking hamburger meat for altered texture diets and cooking it. She was unsure why hamburger meat was cooked, instead of ground or pureed chicken. The Assistant Dietary Manager stated the CDM does put out the daily menu and consistency sheets and the cooks and staff were to review it and prepare the food according to the daily meal and consistency sheet. If the meal item needed to be substituted, it would be indicated on the meal spread sheet.During an interview on 11/18/25 at 1:30 PM, the Registered Dietitian (RD) stated he was unaware that hamburger meat was served for mechanically altered and pureed diets.During an interview on 11/18/25 at 2:00 PM, the Certified Dietary Manager (CDM) stated she was unsure why the Dietary [NAME] had cooked hamburger meat for altered texture diets. The CDM stated she placed the daily menu spreadsheet for the meal out for the cooks and staff to know the meal that needed to be prepared and served to the residents. The CDM indicated hamburger meat was not on the menu for mechanically altered texture diets that day.During an interview on 11/20/25 at 2:00 PM the Administrator stated all meals should be prepared as indicated in the planned menu for the day. Prior to meal preparation the menu should be reviewed, and any substitutions should be approved if needed. All efforts should be made to ensure the planned menus were followed.

Based on record review, and staff and Durable Power of Attorney interviews, the facility failed to convey (transfer) funds within 30 days of discharge from the facility to the Durable Power of Attorney for 1 of 3 residents reviewed for refund of deposit (Resident #165).Findings included:Resident #165 was admitted to the facility on [DATE]. The resident had a planned discharge to another skilled nursing facility on 4/11/25.A review of the discharge tracking MDS dated [DATE] revealed Resident #165 had a planned discharge to another facility on 4/11/25.On 11/18/25 at 1:03 PM an interview via telephone with Resident #165's Durable Power of Attorney (DPOA) occurred. The DPOA explained the resident initially paid privately for care at the facility. Resident #165 was discharged to another skilled nursing facility on 4/11/25 and was owed a refund of approximately $1700. The DPOA revealed she had been in contact with the facility's Business Office Manager (BOM) the week of 4/11/25 and was told she would receive a refund but still had not received the refund as of 11/18/25. The DPOA expressed she was mad she had to wait so long for the reimbursement. The DPOA voiced, they [the facility] were giving her the run around.The BOM was interviewed on 11/19/25 at 11:04 AM. The BOM indicated the DPOA had not yet received a refund of $1730 for two reasons. First, at the time of discharge Resident #165 had outstanding insurance claims pending and it was the facility's policy to collect all outstanding insurance payments before a refund could be issued. The pending insurance claims were completed during the week of 6/27/25 and a refund check was issued on 7/9/25. Second, the refund check was returned to the facility during the week of 8/11/25 due to an error in the mailing address. The BOM indicated she had not yet requested a new refund to be sent with the corrected address due to an oversight and she should have notified the corporate office of the mailing address error and requested another refund. On 11/19/25 at 11:27 AM a telephone interview occurred with the Director of [NAME] Office Services. The Director of [NAME] Services indicated that it was the facility policy for refunds to be provided by the 30th day of discharge and when all insurance payments had been received. The Director of [NAME] Services confirmed the last insurance payment was received by the facility on 6/27/25 and the BOM notified the corporate office on 7/9/25 of the refund request. The Director of [NAME] Services further revealed that he did not become aware that the initial refund check had been returned due to an error in the mailing address until sometime this month and had not yet received additional mailing address information from the BOM and therefore had not mailed a second refund check. An interview was conducted with the Administrator on 11/20/25 at 2:23 PM. The Administrator indicated that the resident/resident representative should have received a refund per the regulation.

Based on observations, record reviews, and resident and staff interviews, the facility failed to implement care planned interventions for fall safety for 1 of 4 residents reviewed for accidents (Resident #105). The findings included:Resident #105 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 stroke affecting the dominant right side.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #105 was severely cognitively impaired and required total assistance from staff for activities of daily living (ADL). She was assessed as having no falls since admission.A review of Resident #105's active care plan initiated on 4/17/25 revealed there was a problem area for being at risk for falls related to muscle weakness, reduced physical mobility, requiring assistive devices to walk or transfer with an intervention of a fall mat to bilateral sides of bed.On 11/17/25 at 2:51 PM an observation revealed Resident #105 lying on her bed with no fall mats present on either side of her bed.On 11/19/25 at 12:40 PM an observation revealed Resident #105 lying on her bed with no fall mats present on either side of her bed.On 11/19/25 at 12:42 PM an interview was conducted with Nursing Assistant # 5, who was assigned to Resident #105 on 11/19/25 from 7:00 AM- 3:00 PM. She indicated Resident #105 was alert but required staff to assist with all ADL needs. Nursing Assistant #5 indicated she was not aware that Resident #105 required bilateral floor mats for fall injury prevention. On 11/19/25 12:43pm an interview was conducted with Nurse # 9, who was assigned to Resident #105 on 11/19/25 from 7:00 AM-3:00 PM. She indicated she was not aware Resident #105 had been care-planned to require bilateral floor mats while in bed for fall injury prevention.An interview was conducted with the MDS Coordinator on 11/20/25 at 12:44 PM. She indicated Resident #105 was actively care-planned for the use of bilateral floor mats at the bedside for fall injury prevention and the nursing staff should have provided the floor mats for fall injury prevention.On 11/19/25 12:47 PM an interview was conducted with the Director of Nursing. She indicated nursing staff should have followed Resident #105's care plan and provided the bilateral floor mats for fall injury prevention. On 11/20/25 2:23 PM an interview was conducted with the Administrator. She indicated nursing staff should follow a resident's care plan and staff should have provided Resident #105 with bilateral floor mats at bedside as indicated in her care plan.

Based on record review and physician and staff interviews, the facility failed to have effective systems in place for entering medication orders into the electronic medical record and administering medications per the physician orders for a new admission for 1 of 6 residents whose medications were reviewed (Resident #174). The findings included:Resident #174 was admitted to the facility on [DATE] at approximately 4:45 PM with diagnoses that included Type 2 diabetes mellitus with chronic foot ulcer, hypertension, atrial fibrillation, and congestive heart failure.A review of Resident #174's physician orders dated 12/10/24 included the following: Coreg Oral Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth at bedtime for hypertension at 8:00 PM, start date 12/11/25. Hold for systolic blood pressure (SBP) below 95 and HR below 60. Gabapentin Capsule 100 MG Give 1 capsule by mouth two times a day for neuropathy at 9:00 AM & 9:00 PM, start date 12/11/25.Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia at 9:00 PM, start date 12/11/25. Atorvastatin Calcium Oral Tablet 10 MG Give 1 tablet by mouth at bedtime for hyperlipidemia at 9:00 PM, start date 12/11/25. Torsemide Oral Tablet 20 MG (Torsemide) Give 1 tablet by mouth every 12 hours for congestive heart failure (CHF) at 9:00 AM & 9:00 PM, start date 12/11/25. Resident #174's admission Minimum Date Set (MDS) assessment dated [DATE] indicated he was cognitively intact. A review of Resident #174's December Medication Administration Record (MAR) revealed all the medication orders were entered into the electronic medical record (EMR) on 12/10/24 and were scheduled to start on 12/11/24. There was no entry on the MAR for the administration of Coreg, Gabapentin, Torsemide, Flomax, or Atorvastatin at 9:00 PM for 12/10/24. Resident #174 started receiving his scheduled medications on 12/11/24 per orders. Record reviews revealed Resident #174's blood pressure on 12/11/24 was 119/50 (normal range is less than 120/80). No concerns were documented related to blood pressure on 12/11/24.An interview was conducted on 11/19/2025 at 12:30 PM with Nurse #6. She verified she worked on 12/10/25 from 7:00 AM-7:00 PM. She stated she was not the floor nurse on 12/10/24 but she did assist with Resident #174's admission. She explained that the steps she normally would take when an admission comes in was, she would call the on-call provider to clarify the medication orders and then looked to see what medications were available in the Pyxis system. Nurse #6 indicated she then sends the medication list to the pharmacy and if it was past the pharmacy cut off time for submitting orders, she would call the pharmacy to make them aware of the medications needed. However, for Resident #174's admission she only called the on-call provider to clarify the medication orders, she entered the medications into Resident #174's EMR and then sent the orders to the pharmacy. She did not check to verify if any medications were due on the evening of 12/10/24. She indicated that when she entered Resident 174's medications into the EMR the start date and time automatically scheduled the medications to start on 12/11/24 at 8:00 AM. Nurse #6 confirmed that she did not check the Pyxis system for the Coreg, Gabapentin, Torsemide, Flomax, or Atorvastatin at 9:00 PM for 12/10/24.because she did not think about the 9:00 PM medications that needed to be administered on 12/10/24, she was only trying to get the medications into the EMR. Nurse #6 continued by confirming that she did not administer Resident #174 any medications on 12/10/24. An interview was conducted on 11/19/25 at 12:59 PM with Nurse #3. She stated she was the direct care nurse for Resident #174 on 12/10/24. Nurse #3 explained that since the medications were entered to start 12/11/24 she was unaware Resident #174 had scheduled medications that should have been administered on 12/10/24 at 8:00 PM/9:00 PM. Nurse #3 continued by confirming that she did not administer Resident #174 any medications on 12/10/24. An interview was conducted on 11/19/24 at 12:12 PM with the Director of Nursing (DON). She indicated she was unaware Resident #174 did not receive his 8:00 PM/9:00 PM medications on 12/10/24. She explained the transcribing nurse should have reviewed Resident #174's medications to determine if he had any upcoming medications due. An interview was conducted on 11/19/2025 at 11:26 AM with Physician #1. He stated he did not recall Resident #174 however he wound expect medications to be administered on date of admission if they were ordered. Physician #1 explained although there was the potential for negative outcomes to occur, none resulted due to Resident #174's medications not being administered at 9:00 PM on 12/10/24.

Based on observations, record review and staff interviews, the facility failed to ensure smoking assessments were accurate and completed quarterly for 1 of 8 residents reviewed for smoking (Resident #50).The findings included:Resident #50 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was not using tobacco at the time of admission and was severely cognitively impaired. Resident #50's smoking assessment dated [DATE] completed by Nurse #4 recorded Resident #50 had cognitive loss and indicated Resident #50 needed supervision when smoking. The smoking assessment specified Resident #50 had a cognitive loss, required an occupational therapy evaluation as needed, and needed supervision when smoking. An interview was conducted on 11/20/2025 at 1:37 PM with Nurse #4, Unit Manager. Nurse #4 revealed she completed the smoking assessment for Resident #50 on 6/10/2025. She stated the process for the smoking assessments was that they are to be completed quarterly on all residents who smoke. Nurse #4 explained a smoking assessment, consisted of observing residents smoking, and speaking with the nurses and nurse aides. Nurse #4 stated she spoke with staff prior to completing any smoking assessment and did this for Resident #50's June 2025 assessment. She stated she had just started working and knew she had missed a few residents' smoking assessments and she was catching up on the smoking assessments. Nurses #4 stated she had observed Resident #50 smoke independently on 6/10/25 and verified he was a safe smoker and able to smoke independently. She further stated she thought she may have completed Resident #50's June 2025 smoking assessment inaccurately. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 was moderately cognitively impaired and required partial to moderate assistance with upper and lower dressing. The MDS revealed Resident #50 was a current tobacco user.Resident #50's care plan included a focus for smoking dated 6/10/2025, and interventions included may smoke independently and perform smoking assessments as needed. On 11/17/2025, a list of smokers was provided by the facility and Resident #50 was not listed on the facility's smoking list as an independent unsupervised or supervised smoker. Review of smoking assessment dated [DATE] for Resident #50 revealed he required supervision with smoking. This assessment was struck through, and another smoking assessment was completed on 11/18/2025 indicating Resident #50 was independent with smoking. Review of the smoking assessments dated 1/17/2025 and 11/18/2025 revealed both were completed by Nurse #4. An interview was conducted on 11/20/2025 at 1:37 PM with Nurse #4, Unit Manager. Nurse #4 stated she completed and removed the smoking assessment for Resident #50 on 11/17/2025 due to the assessment not being accurate. She stated she had coded Resident #50 as needing supervision, but that was a mistake, and she did another assessment on 11/18/2025. Nurse #4 indicated Resident #50 was independent with smoking based on her observations, interviews with staff, and her assessment based on the assessment completed on 11/18/2025. On 11/18/2025 at 11:28 AM, Resident #50 was observed smoking in the designated smoking area accompanied by other residents. Resident #50 was observed holding his cigarette in the left hand with controlled movements to and from the lips while smoking. Resident #50 was observed positioned approximately two feet from the self-closing metal container in a wheelchair and dropping ashes onto the concrete. There were no staff members observed in the smoking area. An interview was conducted on 11/19/2025 at 12:52 PM with Resident #50. He indicated he started smoking about 2 years ago out of boredom. But he was not smoking when he was first admitted to the facility. Resident #50 stated he recently started smoking out of boredom. Resident #50 stated he was aware of the designated smoking area and was able to identify the location. He further stated he would never smoke in his room and he kept his smoking materials in fear they would go missing. An interview was conducted on 11/18/2025 at 12:36 PM with Nurse #1. Nurse #1 stated she kept Resident #50's smoking materials in the nurse's medication cart and they were labeled with his name. She stated Resident #50's family members also brought him smoking material and sometimes he will have them in his possession. She further revealed Resident #50 does not need supervision when smoking. On 11/19/2025 at 12:57 PM in an interview with the Director of Nursing (DON), she explained smoking assessments were completed on admission, quarterly, and for a change in condition. She stated nurses were responsible for conducting smoking assessments, and Resident #50 should have had a smoking assessment conducted in September 2025. The DON stated interventions for a smoker were based on the assessment performed whether they are independent or supervised. If a resident needed a smoking apron, a staff member for supervision, were some of the interventions the DON was referencing. She stated the facility had staff to assist with supervised smokers and ensure interventions were followed. The DON confirmed independent residents who smoke may go out to the smoking area at their leisure. The DON could not explain why the assessment for Resident #50 was inaccurate or not completed quarterly. The DON stated the nurses were notified when a smoking assessment was due for a resident in the electronic medical record.An interview was conducted on 11/19/2025 at 10:01 AM with the Administrator. She stated the window in her office that views the smoking area and she could view all the residents who are smoking in the smoking area. She stated she had viewed Resident #50 smoking from her office and believed the smoking assessment dated [DATE] was not completed accurately for Resident #50. The Administrator stated Resident #50 was a safe smoker and she had observed him many times but had not completed a formal smoking assessment. She further stated Nurse #4 informed her she was confused with the verbiage of the smoking assessment and the smoking assessment for Resident #50 was inaccurate. The Administrator stated residents who were assessed as safe independent smokers were allowed to possess their own smoking materials. She further explained residents who required supervision with smoking, their smoking materials were kept with the nurse on their unit. The Administrator confirmed smoking assessments were completed for residents upon admission, quarterly and as needed for the purpose of a safe smoking evaluation. She further revealed the nurses were responsible for completing the assessment based on an alert in the electronic medical record for the resident.

Based on record review and physician and staff interviews, the facility failed to prevent significant medication errors when Nurse #6 did not schedule a new residents' (Resident #174) medication to start on the afternoon of admission. The medications were available in the Pyxis system (an automated, secure, and centralized system used in healthcare to manage the storage, dispensing, and tracking of medications). Resident #174 was admitted on [DATE] at approximately 4:45 PM, his medications were scheduled to start on 12/11/24 at 8:00 and 9:00 AM. This was for 1 of 6 residents whose medications were reviewed.The findings included:Based on record review and physician and staff interviews, the facility failed to have effective systems in place for obtaining and administering medications to a new admission which resulted in a significant medication error for 1 of 6 residents whose medications were reviewed (Resident #174). The findings included:Resident #174 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM) with chronic foot ulcer and atrial fibrillation. Nursing progress notes revealed Resident #174 was admitted to the facility on [DATE] at approximately 4:45 PM. A review of Resident #174's physician orders dated 12/10/24 included the following medications: - Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 24 unit subcutaneously every 12 hours for DM at 8:00 AM & 8:00 PM, start date 12/11/24. - Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for atrial fibrillation at 9:00 AM & 9:00 PM, start date 12/11/24.A review of Resident #174's December Medication Administration Record (MAR) revealed all medications orders were entered into the electronic medical record (EMR) on 12/10/24 and were scheduled to start on 12/11/24. There were no orders entered on the MAR to administer the Lantus insulin at 8:00 PM or Apixaban at 9:00 PM on 12/10/24. Record reviews revealed Resident #174's blood sugar reading on 12/11/24 was 222 (normal blood sugar is 80 to 130 mg/dL). No concerns were documented related to blood sugar results on 12/11/24.An interview was conducted on 11/19/2025 at 12:30 PM with Nurse #6. She verified she worked on 12/10/25 from 7:00 AM to 7:00 PM. She stated she was not the floor nurse on 12/10/24 but she did assist with Resident #174's admission. She explained that the steps she normally would take when an admission comes in was she would call the on call provider to clarify the medication orders and then looked to see what medications were available in the Pyxis system. Nurse #6 indicated she then sends the medication list to the pharmacy and if it was past the pharmacy cut off time for submitting orders she would call the pharmacy to make them aware of the medications needed. However, for Resident #174's admission she only called the on-call provider to clarify the medication orders, she entered the medications into Resident #174's EMR and then sent the orders to the pharmacy. She did not check to verify if any medications were due on the evening of 12/10/24. She indicated that when she entered Resident 174's medications into the EMR the start date and time automatically scheduled the medications to start on 12/11/24 at 8:00 AM. Nurse #6 confirmed that she did not check the Pyxis system for the Lantus or apixaban that were to be administered at 8:00 PM/9:00 PM. She stated, I did not think about it, I was only trying to get the medications into the EMR for Nurse #3. Nurse #6 also confirmed that she did not administer Resident #174 any medications on 12/10/24. An interview was conducted on 11/19/25 at 12:59 PM with Nurse #3. She stated she was the direct care nurse for Resident #174 for second shift 3:00 PM-11:00 PM on 12/10/24. Nurse #3 explained that since the medications were entered to start on 12/11/24 she was unaware Resident #174 had scheduled medications that should have been administered on 12/10/24 at 8:00 and 9:00 PM.An interview was conducted on 11/19/24 at 12:12 PM with the Director of Nursing (DON). She indicated she was unaware Resident #174 did not receive his 8:00 and 9:00 PM medications on 12/10/24. She explained when the orders were entered into the EMR the transcribing nurse (Nurse #6) should have verified the start date and time and changed the automatic response to begin on 12/10/24 at 8:00 PM. The EMR system scheduled the medications to begin at 8:00 AM on 12/11/24. She verified Resident #174 should have received his evening medications per the physician's orders. She stated the transcribing nurse (Nurse #6) should have reviewed Resident #174's medications to determine if he had any upcoming medications due and then obtain them from the Pyxis system if they were available. If the medications were not available, the nurse should call pharmacy to have the medications sent. The DON also stated in this case the medications were available in the Pyxis system. An interview was conducted on 11/19/2025 at 11:26 AM with Physician #1. He stated he did not recall Resident #174 however he would expect medications to be administered on date of admission if they were scheduled. Physician #1 explained although there was the potential for negative outcomes to occur, none resulted due to Resident #174's medications not being administered at 8:00 PM and 9:00 PM on 12/10/24.

Based on record review and staff interview, the facility failed to immediately notify the Responsible Party (RP) of Resident #125 being sent to the hospital following a change of condition. This was for 1 of 3 residents reviewed for notification of change (Resident #125).The findings included:Resident #125 was admitted to the facility on [DATE] with diagnoses that included nontraumatic intracerebral and intracranial hemorrhage, type 2 diabetic mellitus, dysphagia, dementia, and hemiplegia and hemiparesis.Resident #125's quarterly Minimum Date Set (MDS) assessment dated [DATE] indicated her cognition was severely impaired.The responsible party was unable to be reached for an interview.Change of condition note dated 04/26/25 revealed Resident 125 was sent to the hospital at approximately 10:30 AM related to altered level of consciousness (difficult to arouse). Resident #125 had very little reaction to sternal rub, non-verbal, and overall decreased reaction to stimuli. New order received to send Resident #125 to the hospital for evaluation.Progress note dated 04/26/25 written by Nurse #8 indicated physician was notified regarding altered mental status (AMS) and lack of responsiveness. Order provided to send out. Ems called. Resident sent to ER. Responsible party (RP) notified by House Supervisor.An interview was conducted on 11/19/25 at 1:21 PM with Nurse #8. She stated she did send resident to the hospital on [DATE]. She explained she had been off for a couple of days and when she returned she noticed Resident #125 had a change in mental status and lack of responsiveness. She stated she called the physician and received an order to send resident to the hospital for evaluation. She explained that the House Nursing Supervisor assisted with sending Resident #125 to the hospital and she told Nurse #8 she would call the Responsible Party (RP) to notify her of the transfer. An interview was conducted on 11/19/2025 at 1:33 PM with the House Nursing Supervisor. She stated she remembered assisting Nurse #8 with sending Resident #125 to the hospital for evaluation on 04/26/25. She explained she did attempt to call Resident #125's Responsible Party (RP) to notify them of the transfer. She further explained no one answered when she attempted to call the RP and she did not remember if she left a voicemail. She continued by saying she got busy with another emergency in the building and could not try to call the RP back. The next morning, she attempted to call the RP back and the RP stated the hospital had notified her the evening prior to making her aware of the transfer.An interview was conducted on 11/19/2025 at 1:45 PM with the Director of Nursing (DON). She stated Resident #125's RP should have been notified on 04/26/25 of the transfer to the hospital for change of mental status.

Based on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of a controlled substance medication (oxycodone) prescribed to treat pain. This occurred for 2 of 2 residents (Resident #177 and Resident #131) reviewed for the misappropriation of property.The findings included: a. Resident #177 was admitted to the facility on [DATE] from a hospital. His cumulative diagnosis included chronic hip pain, heart failure and non-Alzheimer's dementia. A review of Resident 177's electronic medical record (EMR) revealed his physician's orders included the following pain medications:--On 9/30/25, a physician's order was received for 500 milligrams (mg) of acetaminophen (an over-the-counter pain medication) to be administered as two tablets by mouth every 8 hours for pain. --On 10/7/25, a physician's order was written for 10 mg oxycodone to be administered as one tablet by mouth every 6 hours as needed for chronic hip pain for 14 days. A Packing Slip Proof of Delivery from the facility's contracted pharmacy was provided for review. This form was signed by Nurse #5 and confirmed 40 tablets of 10 mg oxycodone were delivered to the facility on [DATE] at 2:49 AM. Documentation on Resident #177's October 2025 Medication Administration Record (MAR) indicated the resident received one dose of 10 mg oxycodone on each of the following dates/times: --10/17/25 at 2:59 AM;--10/17/25 at 4:57 PM;--10/17/25 at 11:51 PM;--10/18/25 at 8:54 PM (documented as administered by Nurse #3).This documentation indicated that as of 10/19/25, there should have been 36 tablets of 10 mg oxycodone remaining in the bubble pack card for Resident #177. The controlled drug record for Resident #177 (a declining inventory sheet which documented when each tablet of oxycodone was withdrawn from the medication cart) was not available for review. b. Resident #131 was admitted to the facility on [DATE] with re-entry on 10/10/25 from a hospital. Her cumulative diagnosis included osteoarthritis, chronic pain, diabetes, and chronic kidney disease. A review of Resident 131's physician's orders and Medication Administration Records from July 2025 through October 2025 revealed the resident had orders to receive 5 mg oxycodone on an as needed basis throughout her stay at the facility. Two Packing Slip Proof of Delivery forms sent from the facility's contracted pharmacy were provided for review. One form was signed by Nurse #11 and confirmed 40 tablets of 5 mg oxycodone were delivered to the facility on 9/19/25 at 8:47 PM. A second Packing Slip Proof of Delivery form sent from the facility's contracted pharmacy was also provided for review. This form was signed by Nurse #7 and confirmed 15 tablets of 5 mg oxycodone were delivered to the facility on [DATE] at 11:14 PM. Resident #131's physician's orders indicated her most recent order for oxycodone was written on 10/11/25. This order indicated 5 mg oxycodone was to be administered by mouth every 6 hours as needed for pain. The resident's controlled drug record (dated 7/18/25) revealed oxycodone tablets dispensed for Resident #131 on 7/18/25 was still in use with 5 tablets remaining in that bubble pack card as of 10/19/25. On 10/19/25 at 7:36 PM, Nurse #7 signed this controlled drug record to indicate one tablet of 5 mg oxycodone was withdrawn from the medication cart to be administered to Resident #131, leaving 4 tablets of oxycodone remaining in the bubble pack card. The controlled drug records for the 9/19/25 and 10/10/25 oxycodone deliveries were not available for review. An Initial Allegation Report dated 10/22/25 and signed by the facility's Administrator revealed the facility became aware of an allegation related to the diversion of resident drugs belonging to Resident #177 and Resident #131 on 10/21/25 at 6:10 PM. The accused employee was identified as Nurse #7. An Investigation Report was submitted to the State Agency on 10/27/25. A summary of the facility's investigation reported that Nurse #3 contacted Unit Manager #1 by telephone on 10/19/25. Nurse #3 explained to the Unit Manager that she was assigned to Resident #177's medication cart on the first shift of 10/18/25. She recalled Resident #177's bubble pack card of oxycodone was on the cart during that shift and remembered that she even administered one dose of oxycodone as ordered / requested by the resident during her shift. When she came back in to work for first shift on 10/19/25, the count of controlled drug records kept on the medication cart was correct during the change of shift. However, she discovered both Resident #177's bubble pack card of oxycodone and it's corresponding controlled drug record were missing from the medication cart when she went to administer the medication to Resident #177 on this date (10/19/25). Unit Manager #1 notified the facility's Director of Nursing (DON). The facility was unable to locate Resident #177's missing medication. Nurse #7 was suspended on 10/21/25 pending investigation. The facility's Investigation Report read in part, 100% audit done 10/21/25, 2 residents [Resident #177 and Resident #131] were found to be missing narcotics. However, no residents have missed their meds [medications] to date.Total of 90 oxycodone between two residents could not be accounted for signed by this nurse [referring to Nurse #7]. Nurse #7 was identified by the facility as the alleged perpetrator for the diversion of the oxycodone discovered to be missing for both Resident #177 and Resident #131. The nurse was reported to the local law enforcement, the State Board of Nursing, County Department of Social Services, and Drug Enforcement Agency. A telephone interview could not be conducted with Nurse #7. No current contact information was available. Nurse #7 was identified as the accused employee. She worked on Resident #177's hall on 10/18/25 during both 2nd (3:00 PM - 11:00 PM) and 3rd shifts (11:00 PM - 7:00 AM). She also worked on Resident #131's hall on 10/19/25 for 2nd shift. An interview was conducted on 11/19/25 at 3:00 PM with Nurse #3. During the interview, Nurse #3 reported that she was routinely assigned to work on Resident #177's hall. She recalled working on Resident #177's hall on 1st shift the morning of 10/18/25. The resident's bubble pack card containing oxycodone tablets was available on the medication cart at that time, which allowed her to administer a dose of oxycodone upon the resident's request that morning. However, when she returned to work the next morning on 10/19/25, both the bubble pack card containing the oxycodone and it's corresponding controlled drug record were missing. Nurse #3 stated she reported the missing medication by telephone to Unit Manager #1 on 10/19/25, which prompted an investigation. The nurse stated that she was able to find an invoice from the pharmacy which documented a bubble pack card containing 40 tablets of 10 mg oxycodone that was delivered from the pharmacy for Resident #177 on 10/17/25 at 2:49 AM. The resident's October 2025 Medication Administration Record (MAR) indicated 4 tablets of the oxycodone had been administered, leaving a total of 36 missing tablets. As the interview with Nurse #3 continued on 11/19/25 at 3:00 PM, the nurse was asked if Resident #177 expressed having pain or exhibited signs of pain when his PRN oxycodone was not available. She stated he did not. The nurse reported the resident continued to receive his acetaminophen as scheduled for pain management. Nurse #3 stated that in addition to working on 10/18/25 and 10/19/25, she worked on Resident #177's hall on 1st and 2nd shifts of 10/20/25. She reiterated that the resident did not express having pain nor did he exhibit signs of pain when she worked with him. An interview was conducted on 11/18/25 at 3;15 PM with Unit Manager #1. During the interview, the Unit Manager discussed the missing oxycodone. She reported that Resident #177's oxycodone was the first medication discovered to be missing. A comprehensive search for his missing medication was conducted, but the oxycodone tablets were not found. When Resident #177's EMR was checked, it was discovered that Nurse #7 discontinued the resident's order for the oxycodone on 10/19/25. Unit Manager #1 reported she contacted the facility's Nurse Practitioner on 10/20/25 to make her aware of the missing medication and a new order was received to replace the oxycodone. When asked if Resident #177 expressed or exhibited signs of pain, the Unit Manager reported he had scheduled acetaminophen, his pain level was fine, and he was okay, Upon further inquiry about the facility's investigation, the Unit Manager reported audits were conducted on all six of the facility's medication carts. The audits identified one other resident (Resident #131) had a discrepancy in her controlled substance medication count of oxycodone. An interview was conducted on 11/18/25 at 3:45 PM with the facility's Administrator in the presence of the Regional Consultant. During the interview, the Administrator was asked to discuss the situation encountered with Resident #177's and Resident #131's missing oxycodone. The Administrator reported that the facility initiated a search for Resident #177's oxycodone when it was discovered to be missing. When the investigation was expanded, the card count sheet for Resident #131's hall didn't look right because something had been written over. When nursing checked further, it was discovered some of Resident #131's oxycodone were also missing. She noted, however, that Resident #131 did have a few tablets of oxycodone remaining in one card that was still available for her until the missing oxycodone tablets were replaced. The Administrator stated she was brought into the investigation on 10/20/25 when the missing medications weren't found and the pharmacy confirmed they were not returned. Upon inquiry, the Administrator reported that Nurse #7 never returned to the facility after she was suspended and her contact phone number was no longer working. A follow-up interview was conducted on 11/19/25 at 4:44 PM with the Administrator in the presence of the facility's Director of Nursing (DON). When the Administrator and DON were asked how many tablets of oxycodone were determined to have gone missing, they reported Resident #177 had 36 missing tablets of 10 mg oxycodone while Resident #131 had 55 tablets of 5 mg oxycodone missing (1-bubble pack card containing 15 tablets and 1-bubble pack card containing 40 tablets) for a total of 91 missing tablets of oxycodone. The facility provided the following corrective action plan with a completion date of 10/25/25: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 10/19/25 the 500-hall Unit Manager received a phone call from the 7:00 AM-3:00 PM nurse assigned to Resident #177 that he was missing his oxycodone bubble pack and the controlled drug receipt/record/disposition form for said medication. The Unit Manager questioned the nurse on the correct narcotic count sheet at shift and the nurse stated the count was correct, however she noticed the bubble pack of oxycodone was missing when she went to administer the medication to the resident. This nurse indicated she was the nurse assigned to this same medication cart on 10/18/25 and the bubble pack was present during that shift. The Unit Manager on the 500 hall called the Medical Records Director to confirm if she had collected any controlled drug receipt/record/disposition forms from the 500 hall and she stated the last time she collected any of the identified forms was on Thursday, 10/16/25. At this time, the Unit Manager notified the Director of Nursing and was instructed to look for the medication in all medication carts/units to see if it was delivered to another location and to write a statement of findings. On 10/20/25 at 9:00 AM the Director of Nursing instructed the 7:00 AM-3:00 PM Unit Manager to complete a second audit of the 500-hall medication cart and the medication room and was unable to locate the missing medication. The Unit Manager interviewed the 500-hall nurse assigned and she stated, the medication in question was present in the medication cart on Saturday during first shift as she had administered the medication as ordered/requested by the resident. She also stated that the medication was delivered on 10/17/25 and was administered on 10/18/25 on 3rd shift. At this time, the Unit Manager notified the Staff Development Coordinator, at which time they both reported the concern to the Administrator on 10/21/25 that all carts had been audited, pharmacy records were reviewed, delivery confirmation had been requested from pharmacy and/or destruction of medications. Upon audit of all medication carts/units, it was discovered that Resident #131 was missing 2 cards of oxycodone 5mg, one card of 40 tablets and one card of 15 tablets. No other residents had discrepancies noted per the completed audit findings. The two identified residents were interviewed and stated they had not missed any medications, specifically the medication in question. The medication in question for both identified residents was as needed and had not been requested prior to identifying the discrepancy. Both residents identified were not affected by the missing narcotics as Resident #177 had a replacement card delivered the same day at no charge to the resident and Resident #131 had one card remaining on hand. Neither resident was charged for the replacement of missing medications. On 10/21/25, the Staffing Agency was made aware by the Administrator of the allegations pending pharmacy confirmation for Nurse #7. Per Staffing Agency Director, Nurse #7 was advised to come in to give a formal statement and to complete a drug test. She stated she would come in on 10/22/25, however never reported to the facility. Communication was sent by the agency to Nurse #7 that she would be suspended pending investigation. An employer complaint was initiated by the Administrator to the North Carolina Board of Nursing on 10/22/25 against Nurse #7. A 24- hour report was sent in to Department of Health and Human Services on 10/22/25 by the Administrator for misappropriation of resident's property on Resident #177 and Resident #131. The local Police were notified by the Administrator on 10/22/25 to which an officer came out take a written report and information to try to reach out to Nurse #7. The Pharmacy was notified on 10/19/25, again on 10/20/25 and a third follow-up call on 10/22/25 by the Staff Development Coordinator. The pharmacy was to send the form to the Administrator for notifying the Drug Enforcement Administration once all information was finalized/obtained from the police investigation. Adult Protective Services and Ombudsman were notified by the Administrator on 10/24/25. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 10/21/25-10/22/25 the Unit Managers, Assistant Director of Nursing and Director of Nursing In-Training completed a 100% audit to include the narcotic count sheet and medication on each medication cart. There are 6 medication carts in total. During this audit, no additional residents were identified to have been affected by the deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Staff Development Coordinator initiated education on 10/22/25 for all licensed nursing staff and medication aides to include the following but not limited to narcotic count sheets, sign in/out sheet, shift to shift narcotic count, receiving and returning narcotics to/from pharmacy, reconciliation of medications prior to delivery driver leaving, misappropriation of property/drug diversion and self-reporting of legal issues per North Carolina Board of Nursing requirements. This education was completed on 10/24/25. Any licensed nurse and/or medication aide that has not received the education by 10/24/25 will be educated prior to the start of his/her next scheduled shift. The Director of Nursing, Unit Managers, Nurse Supervisors and/or Staff Development Coordinator will monitor the schedules daily to ensure all staff have completed the training prior to the start of his/her shift. All new hires will be educated during orientation by SDC or designee. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Monitoring began on 10/22/25 by the Unit Manager's, Director of Nursing and/or designee. The initial results of these audits were reviewed during an impromptu Quality Assurance and Improvement Committee meeting held during daily stand-up on 10/23/25. Medication carts and count sheets will be monitored by the Unit Manager's during the week and by the Registered Nurse supervisors on the weekends daily for 4 weeks, then three times a week for 4 weeks and then weekly for 4 weeks or until substantial compliance is achieved. The continued audits will be reviewed at the Quarterly Quality Assurance Meeting x 3 months for further problem resolution if needed. The Administrator and/or the Director of Nursing will review the results of weekly audits to ensure any issues identified are corrected. Date of Compliance: 10/25/2025 Validation of the corrective action plan was completed on 11/20/25: The validation included staff interviews and a review of the in-service education provided to the licensed nurses on the subject of Handling Narcotic Misappropriation with education on the follow-up of incidents. The in-service records confirmed that all nurses scheduled to work during the 4-day survey had completed this education. An observation was also conducted of the process employed by nursing staff to verify the narcotic count during shift change. A review of the facility's monitoring tool revealed audits were initiated on 10/20/25 and continued in accordance with the corrective action plan. The facility's completion date of 10/25/25 was validated on 11/20/25.

Based on observations, and staff interviews, the facility failed to ensure the garbage and refuse was disposed of and keep 4 of 4 dumpsters and surrounding area clean and free from debris. The findings included: During an initial tour observation on 6/30/24, at 9:54 AM, revealed 4 dumpsters located near a wooded area at the back of the facility had large amounts trash bags of garbage and refuse overflowing from the tops and loose paper products, boxes and loose food products outside of containers on the ground and surrounding areas. A follow-up observation and interview were conducted on 7/2/24 at 12:00 PM, with the Dietary Manager revealed the trash bags filled with garbage left on the ground had been removed, however the surrounding area had not been thoroughly cleaned evidence by the remaining paper and food products was still on the ground around the sides and backs of the dumpsters. The Dietary Manager stated the dietary staff were responsible for cleaning the 3 smaller dumpsters daily and the larger rental dumpster should have been emptied on 6/28/24. The rental company did not come to empty the larger rental dumpster after several calls had been made by administrator and maintenance director. An interview was conducted on 7/2/24 at 12:10 PM, the Administrator who stated the dietary manager and kitchen supervisor were responsible for ensuring the dumpsters and surrounding area were clean and maintained. She was aware the company for the rental dumpster had not emptied the dumpster by the 6/28/27 as scheduled. She had contacted the company for removal and the dumpster would be emptied immediately.

Based on record review, observations, and staff interviews, the facility failed to secure medications, date opened multi dose medications, and discard expired medications for 3 of 7 medication observations (400 hall medication cart, 500 hall medication storage/prep room, and the100 hall medication cart). Findings included: 1. On 7/03/24 at 10:43 AM the 400 hall medication cart was reviewed with Medication Aide #1. The following were discovered during the review: a. Thirty-two loose unidentifiable tablets in the bottom of the right side second and third drawers. b. One lidocaine 1% 20 milliliter (ml) multidose vial without its security cap with and no opened-on date noted. c. Two lidocaine 1% 10 ml multidose vials without security caps and with no opened-on dates noted. d. One Latanoprost 0.005% eye drops with a prescription filled on date of 4/15/24. Observed with date opened 4/12/24 and an expires 6 weeks after opening 5/22/24 notation. On 7/03/24 at 11:20 AM an interview with Nurse #2 was conducted. She stated the multidose injectable lidocaine vials should have been marked when they were opened and the eyedrops should have been discarded 6 weeks after opening according to the instructions on the prescription package. On 7/03/24 at 11:56 AM an interview with the interim Director of Nursing (DON) was conducted. She stated she expected all medications to be marked when opened and discarded when expired. 2. On 7/03/24 at 11:30 AM the 500 hall medication room was reviewed with Nurse #3. The following were discovered during the review: a. One acetaminophen 650 milligram (mg) rectal suppository with an expiration date of 12/2020 was discovered in the drawer under the medication refrigerator. b. One COVID19 mRNA vaccine with an expiration date of 4/24/2024 was discovered in the refrigerator. An interview was conducted on 7/03/24 at 11:35 AM with Nurse #3. She stated expired medications should be discarded. On 7/03/24 at 11:56 AM an interview with the interim Director of Nursing (DON) was conducted. She stated she expected all medications to be marked when opened and discarded when expired. 20906 3. An observation was conducted on 7/3/24 at 9:00 AM-9:10 AM, the medication cart on the 100 hall was left unattended with the medication (2) tablets of Renvela 800 milligrams- Sevelamer carbonate in the medication bubble card in the right corner on top of the medication cart . Nurse #4 left the medication cart to administer medication to another resident at 9:00 AM and did not return to cart until 9:10 AM. An interview was conducted on 7/3/24/24 at 9:10 AM, with Nurse #4 who stated her intentions was to discard the medication card because it was empty, and she did not see the leftover medication in the card. She further stated the medication should not have been left unsecured and she should have checked to make sure the medication card was finished. An interview was conducted on 7/3/24 at 9: 55 AM, with the Administrator who stated all medications should be secured in the medication cart or discarded properly when they are finished. The nursing staff should not leave any medication unattended at any point in time.

Based on observations and staff interviews, the facility failed to keep food preparation areas and food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. The facility failed to clean the floor and ceiling vents located over the food prep and food service area. This practice had the potential to affect food served to residents. The findings: During a kitchen tour on 6/30/24 at 9:34 AM, the following observations were made with the kitchen Cook/Dietary Aide: a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 2-compartment ovens had a heavy grease build-up, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being cooked. There was a dried grease buildup observed on the fronts of the ovens and on the walls on the inner walls of the oven or on the walls behind the oven. c. The fryer had dried brown/yellow liquid matter encrusted on edges inside and outside. The fryer had heavy grease and food build-up inside and outside, food products behind the fryer. d. The floor underneath the stove, fryer, steamer, and ovens had large amounts of dried food, grease puddles and trash. e. The 3 plate warmers had 2 rows of clean plates stored in the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around. f. The 5-compartment steam table had floating food particles in standing water, the lids of the steam table had large volumes of dried food and greasy build up around edges. g. The 2 ceiling vents and 2 air conditioning units had large volumes of black dust/debris blowing over food service and prep surfaces. An observation was conducted on 6/30/24 at 10:04 AM, the Cook/ Dietary Aide confirmed the 2 rows of clean plates in the plate warmer and 3 rows of clean plate bases into the base warmer. When asked when the last time was the plate and base warmer had been cleaned the response was I don't know, and I am not sure if there was a cleaning checklist. Dietary Aide stated there were not enough staff to clean and cook and they were doing the best they could to get things done and the meal served. An interview was conducted on 6/30/24 at 10:50 AM, the Dietary Manager and Kitchen Supervisor stated the kitchen staff were required to wipe down kitchen equipment after each meal and deep cleaned weekly in accordance with the kitchen cleaning checklist. The DM and Kitchen Supervisor further stated they were responsible for ensuring the kitchen staff kept the equipment clean and orderly. The Dietary Manager (DM) and Kitchen Supervisor acknowledged the identified kitchen equipment, the floors, ceiling fan and air condition units had not been cleaned in accordance with the checklist. The DM stated all cleaning checklists and responsibilities would be updated and available for all kitchen staff. An interview was conducted on 7/2/24 at 12:10 PM, the Administrator who stated the dietary manager and kitchen supervisor was responsible for ensuring the kitchen was cleaned and maintained. The Administrator stated the expectation would be for the Dietary Manager to ensure all kitchen cleaning protocols were in place and followed in accordance with kitchen sanitation guidelines. She further stated the Maintenance Director was responsible for ensuring the kitchen ceiling vents/fans were cleaned monthly. She indicated a kitchen and maintenance audit would be conducted to assess the environmental and dietary needs of the facility. An interview and observation were conducted 7/2/24 at 3:44 PM, the Maintenance Director who stated the fans and kitchen vents had not been cleaned in several months and confirmed that they needed to be done it was an oversight on his part.

Based on observation, resident and staff interview, the facility failed to maintain clean and sanitary resident rooms for 2 of 13 rooms on the 500 hall (rooms [ROOM NUMBERS]) observed for clean and homelike environment. The findings included: a. An observation on 6/30/24 at 10:40 AM, revealed the floor in room [ROOM NUMBER] was noted to be sticky with spilled food particles and multiple pieces of paper lying on it. On 6/30/24 at 11:06 AM, an observation and interview was conducted with the resident who resided in room [ROOM NUMBER]. The resident stated he had accidentally dropped candy and snacks on the floor last night. He further stated he left his room after breakfast with the hope that housekeeping staff would clean his room. He stated the housekeeping staff were supposed to clean his room in the morning, however, it had not yet been cleaned. b. An observation of room [ROOM NUMBER] was conducted on 6/30/24 at 11:20 AM. The floor was observed to be sticky. There were 2 empty, crumbled wipes packets (one near the side of the bed and one near the foot of the bed) and pieces of paper on the floor. The packets appeared crumbled and the trash can beside the bed was overflowing with trash. There was a biohazard bin (red color container) near the entrance of the door, which was overfilled with personal protection equipment (Gowns and gloves), which were visible coming out of the container. The couch in room was placed upside down on one side of the room. The side table appeared dusty with visible stains and sticky patches on the surface. An observation of room [ROOM NUMBER] was conducted on 6/30/24 at 1:00 PM. The floor did not appeared to be swept and mopped. The floor appeared sticky and dirty. The 2 crumpled wipes packets were still on the floor. The trash can beside the bed was emptied, but there was an empty trash bag and dirty bed linens on the floor, beside the bed. The couch was still inverted. The biohazard bin was not yet emptied. During an interview on 7/3/24 at 11:30 AM, Housekeeper #3 indicated she was usually assigned on the 500 hallway. She further indicated that she was on the schedule to work the weekend of 6/29/24 and 6/30/24 but had to call out as she had pneumonia. Housekeeper #3 stated she cleaned the resident's rooms daily and this included emptying the trash cans. She added nurse aides were responsible to remove the biohazard waste and place any soiled clothes in the plastic bag for laundry staff to pick them up. During an interview on 7/3/24 at 11:40 AM, Housekeeper #4 indicated that he was a floor tech, but was working as a housekeeping staff for 400 and 500 hallway over the weekend (6/29/24 - 6/30/24) as the assigned staff had called out sick. He further indicated he had started cleaning rooms from 400 hallway and was unable to clean the rooms on the 500 hallway till later that morning. Housekeeper #4 stated he had cleaned the room [ROOM NUMBER], as it had a lot of food on the floor. Regarding room [ROOM NUMBER], he indicated he had observed the overflowing thrash can, and the overflowing biohazard waste bin. He indicated that both were emptied, and clean bags were placed in them. Housekeeper #4 stated he did observe the furniture was inverted and not properly placed in the room. Housekeeper #4 further stated he thought that the maintenance staff were working in the room hence did not report or rearrange the furniture. Housekeeper #4 indicated he thought he had thoroughly cleaned the floor, dusted and disinfected the other furniture in the room. He indicated he did not notice any clothes on the floor. During an interview on 7/3/24 at 11:50 AM, the Maintenance Director indicated the entire 500 hallway and rooms were disinfected last week (6/27/24) as one of the Nurse aides had seen a bedbug on her shoe. The exterminator was called, and the rooms were sprayed. It was during that time that furniture was turned over. The Maintenance Director stated he had forgotten to put the furniture back properly and it was only on Monday (7/1/24) when he noticed that the resident room furniture was not arranged. He set up the furniture on Monday. During an interview on 7/03/24 at 12:23 PM, the Housekeeping Manager stated during the week there were 5 housekeeping staff (1 housekeeping staff for each hallway) and during the weekends there were only 4 housekeeping staff available to clean the resident's rooms. There was only one housekeeping staff assigned to 400 and 500 hallway over the weekend. The Housekeeping Manager further stated that the Assistant Manager was available on the weekends and did an audit over the weekend. She indicated she did not receive any report from the Assistant Manager regarding the rooms not been cleaned on Monday (7/1/24). The Housekeeping Manager stated the biohazard bin was emptied by the Maintenance Director. The housekeeping staff were responsible for emptying the trash can and removing linen on the floor. The Housekeeping Assistant Manager was unavailable to be interviewed. During an interview on 7/3/24 at 3:07 PM, the Administrator stated the 500 hallway was a rehab hallway and the residents in the hallway had different acuity levels and the rooms and hallway required more frequent cleaning. She further stated all resident rooms should be cleaned daily and trash should be disposed of as needed by the housekeeping staff. The biohazard bin should be emptied as needed. The Administrator stated there should be the same number of housekeeping staff on the weekends as there were on the weekdays. All efforts should be made to ensure all resident's rooms were clean and sanitary. The Administrator stated the pest control company had disinfected all the rooms on the 500 hallway on Thursday (6/27/24) due to a single occurrence of bed bug in a newly admitted resident's room. The entire hallway was sprayed, and all protocol followed due to this incident. The Administrator stated the furniture should have been placed back appropriately in all resident's rooms. The Administrator stated the facility Housekeeping Manager and Maintenance Director were responsible for ensuring the facility was clean and furniture properly placed for the safety of all the residents.

Based on record review and interviews with staff and resident, the facility failed to maintain a resident's dignity when Housekeeper #1 spoke to Resident #13 in a demeaning manner regarding the cleanliness of his room and cursed at the resident. This deficient practice affected 1 of 3 residents reviewed for dignity. Findings included: Resident #13 was admitted on [DATE]. A witness statement written by Housekeeper #2 indicated on 3/03/24 at 2:20 PM she had been making rounds on the hall when she heard and saw Housekeeper #1 in Resident #13's room, cursing him. On 07/03/24 at 8:51 AM an interview with Housekeeper #2 was conducted. She stated on 3/03/24 she had been in the hallway talking with Housekeeper #1 who was talking directly to Resident #13 who was in his room. Housekeeper #1 cursed at Resident #13 and said things about his lack of cleanliness. She explained after Housekeeper #1 had said curse words, he (Housekeeper #1) left the hall, and she did not see him again and thought he had may have been sent home. She stated she immediately reported the incident to Minimum Data Set (MDS) Nurse #1 and wrote up a statement about what happened. She stated the incident happened quickly and she did not understand what had triggered Housekeeper #1. Housekeeper #1 was unable to be contacted for an interview. On 7/03/24 at 9:44 AM an interview with MDS Nurse #1 was conducted. She stated on 3/03/24 when she arrived at the facility, Resident #13 was sitting in the dining room, and he told her the housekeeper (Housekeeper #1) just cursed at him. After talking with Resident #13, he went back to his room. MDS Nurse #1 stated she verified Housekeeper #1 had left the building before she arrived. She stated Housekeeper #2 reported to her she had witnessed the event and wrote a statement. Resident #13's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. An interview with Resident #13 was conducted on 06/30/24 at 11:32 AM. Resident #13 explained a while ago a staff member had cursed at him. He stated he had no idea what the staff member had been upset about and had not experienced anything like that before or since. He stated the Administrator had spoken with him about what happened, and he had no further concerns regarding this incident. He stated he had not seen that staff member since then and was not afraid of anyone. Resident #13 stated his roommate (Resident #43) had been present when the incident occurred. An interview with Resident #43 was conducted on 06/30/24 at 11:42 AM. He stated he did not recall anyone cursing at his roommate and had not had anyone speak inappropriately to him. An interview with the Administrator was conducted on 7/03/24 at 4:31 PM. She stated on 3/03/24 staff had ensured Housekeeper #1 had left the facility and Resident #13 was safe.

Based on observations and staff interviews, the facility failed to post the daily nurse staffing information to residents and visitors for 1 of the 4 days (6/30/24) of the survey period. Finding included: On 6/30/24 during facility initial tour and multiple observations throughout the day including at 9:20 AM and at 1:30 PM, the daily nurse staffing sheet posted near the facility lobby was dated 6/28/24. The posting was not updated to reflect the current date, census, and staffing information. During an interview on 7/3/24 at 2:17 PM, the Scheduler stated she was responsible for completing the staffing information for the week. On Friday, she completed the staff postings from Friday to Monday. These forms were given to the Administrator. The Administrator was responsible for posting the information in the front lobby daily. During an interview on 7/3/24 at 4:00 PM, the Administrator stated the nurse staff posting should be posted daily. The Administrator indicated the Staff Development Coordinator was responsible for ensuring that the daily nurse staffing sheet was accurately completed and was posted in the lobby during the weekend. The Administrator indicated she oversaw the process and ensured the daily nurse staffing sheet was posted and was clearly visible for residents and visitors. The Staff Development Coordinator was unavailable to be interviewed.

Based on observations, staff interviews and record review, the facility failed to: 1) Discard expired medications and/or medications without a legible expiration date on 3 of 3 medication (med) carts observed (the 200 Hall Med Cart, the 400 Hall Med Cart and the 500 Hall Med Cart); 2) Label medications with the minimum information required, including the name of the resident, on 1 of 3 med carts observed (the 400 Hall Med Cart); 3) Store medications in accordance with the manufacturer's storage instructions in 1 of 3 Medication Storage Rooms (230-300 Hall Med Cart); and 4) Secure a medication cart when not in use for 1 of 6 med carts observed to be unlocked and unattended by nursing staff (300 Hall Med Cart). The findings included: 1. An observation was conducted on 5/17/23 at 2:12 PM of the 200 Hall medication cart in the presence of Medication (Med) Aide #1. The observation revealed 6 - 12.5 milligram (mg) promethazine (an antinausea medication) suppositories with an expiration date of February 2023, and 1 - 650 mg acetaminophen suppository with an expiration date of March 2023 were stored on the med cart. Upon review of the suppositories, Med Aide #1 confirmed the suppositories were past their expiration date. An interview was conducted on 5/18/23 at 12:05 PM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated third shift nursing staff were typically responsible to check the expiration dates on the medications stored on the med carts to be sure none were expired. However, she also reported she would expect a nurse (or Med Aide) to review the labeling of a medication prior to administering it to a resident. 2-a. An observation was conducted on 5/17/23 at 1:45 PM of the 400 Hall medication cart in the presence of Nurse #1. The observation revealed 1 - expired vial of 25 milligrams (mg) / milliliter (ml) promethazine dispensed for Resident #360 was stored on the med cart. The vial had the manufacturer's expiration date of April 2023 imprinted on its label. Upon review of the vial, Nurse #1 confirmed the promethazine was expired. A review of Resident #360's medication orders revealed the resident had a current order for 25 mg/ml promethazine to be injected as 25 mg intramuscularly every 6 hours as needed for nausea/vomiting. 2-b. An observation was conducted on 5/17/23 at 1:45 PM of the 400 Hall medication cart in the presence of Nurse #1. The observation revealed a stock bottle of 81 milligram (mg) delayed release aspirin with approximately 30 tablets remaining in the bottle was stored on the med cart. The expiration date of the stock bottle of aspirin was not legible. 2-c. An observation was conducted on 5/17/23 at 1:45 PM of the 400 Hall medication cart in the presence of Nurse #1. The observation revealed 3 - unlabeled vials of 25 mg/ml promethazine were stored on the med cart. The vials were not labeled with the minimum required information, including a resident's name. During an interview conducted on 5/17/23 at 1:50 PM with Nurse #1, the nurse confirmed the promethazine vials were not labeled with a resident identifier. She reported both the unlabeled vials of promethazine and the expired promethazine vial needed to be sent back to the pharmacy. The nurse also acknowledged the expiration date on the label of the aspirin tablets could no longer be read. Nurse #1 reported the stock bottle of aspirin needed to be removed from the med cart. An interview was conducted on 5/18/23 at 12:05 PM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated third shift nursing staff were typically responsible to check the expiration dates on the medications stored on the med carts to be sure none were expired. However, she also reported she would expect a nurse (or Med Aide) to review the labeling of a medication prior to administering it to a resident. 3. An observation was conducted on 5/17/23 at 2:05 PM of the 500 Hall medication cart in the presence of Nurse #1. The observation revealed a stock bottle of 81 milligram (mg) delayed release aspirin with 4 tablets remaining in the bottle was stored on the med cart. The expiration date of the stock bottle of aspirin was not legible. During an interview conducted on 5/17/23 at 2:10 PM with Nurse #1, the nurse confirmed the expiration date on the label of the stock bottle of aspirin could no longer be read. She reported the stock bottle of aspirin needed to be removed from the med cart and added, I'm going to tell them to take this out of the stock room. An interview was conducted on 5/18/23 at 12:05 PM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated third shift nursing staff were typically responsible to check the expiration dates on the medications stored on the med carts to be sure none were expired. However, she also reported she would expect a nurse (or Med Aide) to review the labeling of a medication prior to administering it to a resident. 4. Accompanied by Nurse #2, an observation was conducted on 5/17/23 at 2:30 PM of the 230/300 Hall Medication (Med) Storage Room. The observation revealed one - unopened bottle of 0.2% brimonidine / 0.5% timolol eye drops (a combination medication used to treat glaucoma) dispensed for Resident #87 was stored in the Med Storage Room's refrigerator. A thermometer placed in the refrigerator indicated the refrigerator's temperature was 36 degrees Fahrenheit. The thermometer reading was confirmed by Nurse #2 at the time of the observation. The manufacturer's storage instructions for 0.2% brimonidine / 0.5% timolol eye drops indicated the bottle should be stored at 59 - 77 degrees Fahrenheit. An interview was conducted with Nurse #2 on 5/17/23 at 2:50 PM. During the interview, the nurse stated she thought the eye drops were likely put in the refrigerator because another type of eye drop was supposed to be refrigerated until opened. Upon inquiry, the nurse reported she was not sure if the brimonidine / timolol eye drops should have been stored in the refrigerator. An interview was conducted on 5/18/23 at 12:05 PM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect medications to be stored in accordance with the manufacturer's instructions. 35122 5. On 5/17/23 at 10:28 AM an observation was made of a medication cart parked outside of room [ROOM NUMBER]. The lock mechanism was observed in the unlocked position. No staff were observed in the hall. Resident #14 was sitting in a wheelchair near the cart. A few moments later Nurse #1 exited room [ROOM NUMBER] and walked to the nurses' station and used the phone before returning to the medication cart. An interview was conducted with Nurse #2 on 5/17/23 at 10:32 AM. She explained she had been in room [ROOM NUMBER] and out of view of the medication cart. She demonstrated the lock was not engaged by opening a top drawer. She stated the cart should have been locked when she stepped away. On 5/18/23 at 2:40 PM an interview with the Director of Nursing (DON) was conducted. She stated the medication cart should be secured when out of the nurse's line of sight.

Based on record review and staff interviews, the facility failed to develop a care plan which addressed the use of an antipsychotic and antianxiety medication for 1 of 5 residents (Resident #21) reviewed for unnecessary medications. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses which included manic depression (bipolar disorder) and anxiety disorder. The resident's admission orders dated 2/15/23 included the following medications, in part: 25 milligrams (mg) sertraline (an antidepressant) to be given as three tablets by mouth every day (for a total dose of 75 mg) and 0.5 mg risperidone (an antipsychotic medication) to be given as one tablet by mouth twice daily. Lorazepam (an antianxiety medication) was added to the resident's medication regimen on 2/20/23 as 2 mg / milliliter (ml) injected intramuscularly twice daily. Review of Resident #21's admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had moderately impaired cognition. The MDS assessment also reported the resident received an antidepressant, antipsychotic, and antianxiety medication during the 7-day look back period. On 2/21/23, the resident's lorazepam was discontinued and replaced with 1 mg clonazepam (also an antianxiety medication) initiated as one tablet to be given by mouth twice daily. Resident #21's current medications (as of the date of review on 5/17/23) continued to include 25 mg sertraline to be given as three tablets by mouth every day, 0.5 mg risperidone to be given as one tablet by mouth twice daily, and 1 mg clonazepam to be given as one tablet by mouth twice daily. A review of Resident #21's current care plan revealed it included an area of focus (dated 2/20/23) which indicated the resident was at risk for side effects from the use of an antidepressant medication. Further review of the resident's comprehensive care plan revealed it was last revised on 5/1/23. However, the care plan did not address Resident #21's use of an antipsychotic or antianxiety medication as of 5/17/23. An interview was conducted on 5/17/23 at 11:55 AM with MDS Nurse #1. Upon request, the nurse reviewed Resident #21's current care plan. When asked, the MDS nurse confirmed the resident's current care plan only addressed her use of an antidepressant medication (not an antipsychotic or antianxiety medication). MDS Nurse #1 reported the facility usually implemented a care plan to address psychotropic medications (any drug capable of affecting the mind, emotions, and/or behavior), which would have included the antidepressant, antipsychotic, and antianxiety medications. An interview was conducted on 5/18/23 at 11:45 AM with the facility's Director of Nursing (DON). During the interview, the DON reported all of Resident #21's psychotropic medications should have been addressed in the resident's care plan.

Based on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect the number of falls sustained for 1 of 6 residents (Resident #210) reviewed for accidents. The findings included: Resident #210 was admitted to the facility on [DATE] with a cumulative diagnoses which included a history of cerebrovascular accident (stroke) with hemiplegia/hemiparesis (complete paralysis to partial weakness on one side of the body). Review of the resident's electronic medical record (EMR) revealed an admission Minimum Data Set (MDS) assessment was completed for Resident #210 on 10/3/22 Documentation in Resident #210's EMR reported the resident sustained a fall without injury on 10/13/22 and 10/23/22. The resident was also reported to have one fall with injury on 10/26/22. Resident #210's most recent MDS was a quarterly assessment dated [DATE]. The MDS section on Health Conditions reported the resident had only one fall with injury since her last MDS assessment dated [DATE]. An interview was conducted on 5/17/23 at 11:55 AM with MDS Nurse #1. During the interview, the MDS nurse was asked to review the Health Conditions section from Resident #210's MDS dated [DATE]. Upon review, MDS Nurse #1 confirmed the resident's quarterly MDS reported only one fall with injury. During a follow-up interview conducted on 5/17/23 at 12:27 PM, MDS Nurse #1 reported she reviewed Resident #210's EMR. She stated the resident's 11/16/22 quarterly MDS should have indicated the resident sustained two falls without injury and one fall with injury. An interview was conducted on 5/18/23 at 11:45 AM with the facility's Director of Nursing (DON). During the interview, the DON reported she would expect the MDS assessments to be accurately completed.

Based on observations, staff and resident interviews, and record review, the facility failed to maintain accurate advance directive information throughout the medical record for 3 of 8 residents reviewed for formulation of advance directives (Resident #29, Resident #38, Resident #85). The findings included: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29's annual minimum data set (MDS) dated [DATE] revealed she was cognitively intact. A review of Resident #29's hard copy chart revealed a Medical Orders for Scope of Treatment (MOST) form dated [DATE]. The form stated Resident #29 should have full scope of treatment and cardiopulmonary resuscitation (CPR) should be initiated. Resident #29's hard copy chart had a signed Full Code Agreement form dated [DATE]. A review of the electronic health record (EHR) revealed Resident #29's information bar (referred to as Bed Board by facility staff) listed resident specific information. It indicated Resident #29 was a Do Not Resuscitate (DNR). The DNR status was added [DATE]. Review of Resident #29's EHR revealed an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:05 AM, a review of Resident #29's medical records revealed there was no care plan for code status. In an interview with the resident on [DATE] at 10:12 AM, she stated she had spoken with facility staff regarding her advance directives. Resident #29 wanted to be a full code and stated, I told them they better perform CPR if needed. An interview was conducted with Nurse #1 on [DATE] at 11:50 AM. Nurse #1 stated when a nurse needed to know a resident's code status, they can look in the hard copy chart and in the EHR. Nurse #1 reviewed Resident #29's code status in the EHR. She indicated the resident's information bar revealed a DNR status and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 stated she was unsure of why there was a discrepancy, but it was a good reason why nurses should look in a resident's hard copy chart for advance directive information. An interview with MDS Nurse #1 and MDS Nurse #2, on [DATE] at 2:04 PM revealed they were responsible for care planning advance directives. Code statuses and MOST forms were verified at every care plan meeting. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Nurse #1 and MDS Nurse #2 reviewed Resident #29's care plan and stated there was no care plan for code status, indicating she fell through the cracks. 2. Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's EHR revealed an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's hard copy chart revealed a MOST form dated [DATE]. The form stated Resident #38 should not be resuscitated and was indicated as a DNR with limited additional interventions. Resident #38's hard copy chart had a signed No Code Agreement form dated [DATE] as well as a physician signed DNR form dated [DATE]. A review of Resident #38's EHR revealed the resident's information bar indicated he was a DNR. The DNR status was added on [DATE]. On [DATE] at 10:48 AM, a review of Resident #38's care plan dated [DATE] revealed a care plan for DNR status. The care plan indicated the resident wished to be honored as a DNR through the next review. Resident #38's quarterly MDS dated [DATE] revealed his cognition was not assessed due to him being rarely understood. In an interview with Nurse #1 on [DATE] at 11:50 AM, she reviewed the code status documentation for Resident #38. She stated the resident's information bar indicated he was a DNR, and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the resident's representative on [DATE] at 1:56 PM. She stated she did not remember if staff spoke with her regarding the resident's wishes. She further explained the last time she discussed advance directives with Resident #38, he stated he didn't want life sustaining measures. 3. Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #85's hard copy chart revealed a MOST form dated [DATE]. The form stated Resident #85 should not be resuscitated and was indicated as a DNR with limited additional interventions. Resident #85's hard copy chart had a signed No Code Agreement form dated [DATE] as well as two physician signed DNR forms dated [DATE] and [DATE]. A review of Resident #85's EHR revealed an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EHR revealed Resident #85's information bar indicated CPR should be attempted for the resident. The CPR status was added on [DATE]. On [DATE] at 1:52 PM, a review of Resident #85's care plan dated [DATE] and reviewed on [DATE] revealed the resident wished to be a Full Code. Resident #85's quarterly MDS dated [DATE] revealed she was cognitively intact. An interview was conducted with Nurse #1 on [DATE] at 11:50 AM. She reviewed Resident #85's medical record and stated CPR was indicated in the resident information bar and there was an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview with Resident #85 on [DATE] at 3:45 PM, the resident stated she had spoken with her daughter regarding her wishes and did not want to discuss the issue further. An interview was conducted with Nurse #2 on [DATE] at 11:16 AM. Nurse #2 stated she looked in a resident's hard copy chart when she was unfamiliar with the code status. She did not look in the EHR for code status information. An interview was conducted with the social work coordinator on [DATE] at 12:35 PM. She stated she did not have a role in code status documentation. In an interview with the admissions coordinator on [DATE] at 12:40 PM, she stated advance directive paperwork was completed upon a resident's admission. Nurses wrote orders for code statuses and completed updates when there was a change in status. In an interview with the director of nursing (DON) on [DATE] at 4:01 PM, she stated MDS nurses entered and updated care plans for code status as they received copies of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This information included MOST forms and DNR forms. The DON stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further indicated education had been provided to staff to look in the hard copy chart for the most current advance directive information. An interview was conducted with the Administrator on [DATE] at 9:30 AM. She stated nurses and the admissions coordinator updated code status information in the EHR. All residents should have a care plan for code status and code status information should be the same in all areas that it was documented.

Based on observation, staff interviews, physician interviews and review of the facility ' s Communicable Disease Outbreak Preparedness Plan, COVID19 Unit Best Practices policy and COVID19 Hand Hygiene and Donning and Doffing Personal Protective Equipment (PPE) policy the facility failed to prevent an infection control systems failure by 1. Failing to implement the facility ' s Communicable Disease Outbreak Preparedness plan and the facility ' s COVID19 Unit Best Practices policy by not providing housekeeping services to maintain a sanitary and clean environment to prevent the spread of the COVID19 virus in the facility ' s COVID positive unit which included; 30 of 30 resident rooms, 2 of 2 shower rooms, hallways, the unit ' s COVID screening station area and the unit ' s entrance and exit areas and 2. Failing to implement the facility ' s policies and procedures on hand hygiene and PPE when staff failed to perform hand hygiene and remove their PPE after they provided resident care and exited resident rooms for 2 of 2 staff members (Nursing Assistants #4 and #5), who worked on the facility ' s COVID positive unit. As of 08/26/20, 73 of 118 the facility ' s residents tested positive for the COVID19 virus. These failures occurred during a COVID-19 pandemic. Immediate Jeopardy began on 08/17/20 when the facility failed to provide housekeeping services to maintain a sanitary and clean environment to prevent the spread of the COVID 19 virus in the facility ' s COVID positive unit. Immediate Jeopardy was removed 8-28-20 when the facility implemented an acceptable creditable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E that is not Immediate Jeopardy to ensure monitoring systems put in place are effective. The findings included: 1. The facility ' s Communicable Disease Outbreak Preparedness Plan dated March 2020 , read in part; Environmental Service: would ensure the availability of alcohol-based gels, tissues and waste receptables at the facility. Make sure every sink is well-stocked with soap and paper towels for hand washing. Increased environmental cleaning using disinfectants approved to kill the Communicable disease. Laundry services-community staff will bag the transport and wash clothes following the manufactures instructions to determine the appropriate method and amounts of chemicals to produce a hygienically clean linen. Community plan operations would increase environmental cleaning using disinfectants approved to kill Communicable Disease. Ensure a trash can is near the exit inside every resident room to make it easy for employees to discard PPE. The facility ' s COVID19 Units Best Practices Policy dated June 3, 2020, read in part: laundry within the COVID unit was to be put into water-soluble bag, when picking up laundry within the unit, all water-soluble bags will be placed in a larger receptacle and taken out of the end hall COVID unit door outside and then around to the back door to the laundry area. Trash pickup included all smaller bags of trash from resident rooms when being picked up are to be placed into a larger receptacle and taken out the end hall COVID outside door around back to the dumpsters. Any items that are in red bags are to be boxed and taken (like trash) out the end of the hall door to the designated area. Observations on 08/17/20 from 11:20 AM to 1:45 PM of the facility ' s COVID positive unit, which was located on the facility ' s 400 and 500 hallways, revealed the following: A. On 8/17/20 at 11:20 AM, of the entrance to the COVID positive unit on the 400 and 500 hallways, revealed the unit was sealed behind zipper enclosures. At the unit ' s entrance there were several boxes of supplies stacked against the wall, barrels filled with soiled linen and trash and soiled gloves and a mask on the floor. B. Observations on 08/17/20 near the COVID unit ' s exit door revealed there was a COVID screening station in this area. There were used gloves, tissues and paper on top of the screening station ' s table. Wheelchairs, clothing, boxes of supplies, opened briefs, used juice cups, food wrappers and leftover meal trays were observed around or under the screening station ' s table. The floor under the screening station ' s table was stained with red and brown colored substances, dried fluids and food. Two barrels filled with soiled linen and trash were at the unit ' s exit door. C. Observations on 08/17/20 of the unit ' s hallway, where rooms 401 to 501 were located, revealed there were multiple bags of soiled linen and trash in the hallway. Observations inside each of the six resident rooms on this hallway revealed there were used gloves, used masks, dried fluid spills, food and resident clothing on the floors. Also, the side tables in these rooms were not clean with dried substances. D. Observations on 08/17/20 of the unit ' s hallway, where rooms 502 to 512 were located revealed there were barrels filled with trash and soiled linens, old bedding, wheel chairs and boxes of unopened supplies and cleaning products in the hallway. Observation inside the eleven resident rooms on this hallway revealed the floors in these rooms were unclean with dried fluids, brown matter, used gloves, briefs and food. Observations of the shower room on this hallway, revealed there was black mold in the tiles, a heavy build of soap residue in the two shower stalls, and the bathtub was unclean with a large volume of a brown sand like substance and rust. There were used towels, washcloths, gloves and trash on the floor of the shower room. There were used gloves, wipes, brown matter and areas of rust in the shower room ' s sink. The floor under the sink had a heavy buildup of mold and soap residue. E. Observations on 08/17/20 of the unit ' s short hallway, where rooms 513 to 515 were located, revealed in the hallway there were used nursing supplies in bags, trash and beds stored along the walls. Observations of the three resident rooms on this hallway revealed gloves, dried fluid spills, paper products and food on the floors, tray tables with dried substances, and trash cans filled with trash. Observations of this hallway ' s nurse ' s station revealed used gloves, used masks, and opened nursing supplies on the desk and on the floor. F. Observations on 08/17/20 of the area near the COVID unit ' s exit door revealed five yellow barrels that were full of trash and two grey barrels that were full of used PPE and other used items. A total of eighteen plastic bags that contained soiled linen and resident laundry were piled up against the wall. Additionally, opened and uncovered packs of briefs and gloves were observed in the handrails and on tray tables in the hallway. G. Observations on 08/17/20 of the unit ' s hallway, where rooms 406 to 415 were located, revealed there were used gloves and a mask in the hallway ' s hand rails and barrels were overflowing with trash. Observations of the ten resident rooms on this hallway revealed the floors were unclean with soiled linen, used cups, dried fluids, food, and paper products. Used gauze and medication cups were on the floors near unemptied trash cans in resident rooms. Plastic bags that contained resident clothing were on the floor in resident rooms and in the hallway outside of resident rooms. H. Observations on 08/17/20 of a shower room on the hallway, where rooms 406 to 415 were located, revealed mold growth was on the wall tiles and floor tiles. Also, wheelchairs, bedding and resident equipment were stored in the shower stalls. On 08/17/20 at 11:55 AM an interview was conducted with NA #4, who was an agency NA and worked on the facility ' s COVID unit. NA #4 stated this was her first day working in the facility ' s COVID unit and she received brief training on the transmission of COVID 19 infection and unit requirements. NA#4 stated she had not received any direct training on the cleaning or disinfecting procedures for the facility ' s COVID19 positive unit. NA #4 stated, I just wipe things down with the wipes located in the resident ' s rooms. There was no specific place where the disinfectant was kept, as you can see everything is all over the unit and disorganized. I was asked to come to work at this facility and placed on the COVID19 positive unit, and I am trying to keep the residents clean, fed to the best of my ability. On 8/17/20 at 11:58 AM, an interview was conducted with NA #5, who was an agency NA and was working on the facility ' s COVID unit. NA #5 stated that he received a very brief training on the transmission of COVID19, infection control practices and handwashing and sanitizing. NA #5 stated he had worked several back to back shifts in the facility ' s COVID unit and it was getting very frustrating trying to keep residents clean and cared for and keeping the unit clean. NA #5 further stated, it was too much to care for residents and clean an entire unit by the end of the shift. NA #5 specified the trash and linen barrels would get full because there was no housekeeping staff working on the unit and when you needed to clean things off you had to go through boxes on the hall to find things. NA #5 explained, that he did not receive any specific training on the cleaning or disinfecting procedures for the unit. He stated, that he was asked to come to the facility, and was placed on the COVID19 positive unit and did his best to clean in between caring for the residents. During an interview on 8/17/20 at 12:10 PM, Nurse #3 stated the facility ' s COVID positive unit had several call outs due to illness or not returning to the unit. Therefore, the current aides and nurses had to pitch in and do their best to clean the unit after all the resident care was provided. Nurse #3 stated, the cleaning can get difficult at times. During an interview on 8/17/20 at 12:30 PM, Nurse #4 stated prior to staff working on the facility ' s COVID19 positive unit they were educated and informed on the infection control policy and procedures for COVID 19 positive unit, which included; handwashing and sanitizing practices and disinfecting surfaces. Nurse #4 explained, the unit ' s nursing staff were required to maintain and clean the unit due to no housekeeping staff being assigned to work on the unit. She explained, the housekeeping staff provided the supplies and were expected to pick up trash and soiled linen at the unit ' s back door. But, at times the trash was not picked up for a few days, so things were stored at unit ' s back door and at other locations on the unit until the housekeeping staff came to pick them up. Nurse #4 stated, with the increase of COVID positive residents at one time it became very challenging for the unit ' s nursing staff to provide the medical care to the residents and to properly clean and disinfect the unit. An interview was conducted with the facility ' s contracted Housekeeping Supervisor (HKS) and Housekeeping District Manager (DM) on 08/17/20 at 1:45 PM. The HKS stated the facility ' s contracted housekeeping staff were only responsible for cleaning the non-COVID area and the nursing staff assigned to the COVID19 positive unit were responsible for cleaning the unit. The HKS added that he was responsible for providing the COVID positive unit with cleaning and disinfectant supplies and picking up trash and linen to prevent the spread of the infection. He added there was no housekeeping staff assigned to the COVID positive unit. The HKS further stated the nursing staff, who worked on the unit, were in-serviced on environmental cleaning checklist for isolation rooms for the COVID19 unit, but he was not sure if they were provided with other training on how to clean the unit. The Housekeeping District Manager stated he was informed by the corporate manager that the nursing staff working on the facility ' s COVID unit would be responsible for cleaning and disinfect the unit, therefore contracted housekeeping staff were not assigned to work on the COVID unit. The District Manager further stated that he was uncertain what kind of cleaning and disinfection training the nursing staff that worked on the COVID unit was provided. The DM explained the expectation was for the COVID unit nursing staff to place all trash and soiled linen in the designated barrels and to place the barrels at the designated door for housekeeping staff to pick up, to prevent the housekeeping staff from walking through the unit. The DM further explained, the housekeepers were expected to pick up these items daily in accordance to the facility best practice policy and procedures. During an interview on 8/17/20 at 12:15 PM, the facility ' s Regional Nurse Consultant (RNC) stated, all nursing staff were educated on the COVID19 policies and procedures and required to perform return demonstration of handwashing and sanitizing practices, infection control practices for cleaning and disinfecting rooms and surfaces, before they were assigned to the unit. The RNC did not specify what cleaning and disinfection training the nursing staff working on the unit was provided in the absence of housekeeping staff working on the unit. She indicated supplies for cleaning were available, but it had been difficult for unit ' s nursing staff to perform resident care and to clean and disinfect the unit thoroughly as required by the facility ' s infection control policies and procedures. During an interview on 8/17/20 at 2:15 PM, the Director of Nursing (DON) stated the facility ' s Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC) were responsible for monitoring the COVID19 unit and checked the condition of the unit and the residents on the unit, but they both became sick and were unable to work. The DON explained the staff that worked on the unit should use bleach, which was the designated disinfect to clean frequently touched surfaces. The DON stated, there should be no soiled linen, resident clothing, trash, used supplies or leftover food on the floor in the COVID unit. The DON stated the COVID unit previously had a designated housekeeper, but she walked off the job a few weeks ago and no replacement was provided by the housekeeping department. The DON specified the unit ' s nursing staff struggled to keep the unit as clean as possible. The cleaning supplies were provided and available, but the nursing staff did not have much time to maintain the cleanliness of the unit. Several residents were moved to the unit at one time and things became dysfunctional when the ADON and SDC became sick and there was no management monitoring of the unit. The DON stated the administrator and housekeeping supervisor were aware of the situation. During an interview on 8/17/20 at 2:00 PM, the Administrator stated weekly discussions via Quality Assurance Meetings were held to determine the cause of the facility ' s COVID outbreak and the action plan. The continued source of the infection among staff had not been determined, but issues with the cleanliness of the environment became an issue as the facility did not have staff available to do the proper cleaning. The administrator explained the facility ' s current housekeeping contract was terminated at the end of July 2020, but they were working out their contract through the end of August 2020. The Administrator stated the expectation was for the housekeeping department to supply the COVID19 positive unit with designated cleaning supplies and follow the Best Practice Policy and Resident Placement Policy to pick up trash and laundry from the unit. The Administrator confirmed there were no housekeeping staff assigned to the COVID19 positive unit since the end of July 2020 and the expectation was for the unit ' s nursing staff to clean and maintain the environment of the facility ' s COVID positive unit. During a telephone interview on 8/24/20 at 3:49 PM, with a member of facility ' s Department of Operation (DO) and Director of Nursing (DON) reported the ADON/infection preventionist had been doing the monitoring and surveillance tracking of the COVID unit, but she was out sick. The housekeeping staff were affected, therefore, the responsibility for cleaning and maintaining the environment had been impacted. The DO stated the new housekeeping contract service would start at the end of the month (August 2020), and housekeeping staffing was now being covered by agency staff, staff from sister facilities, and the facility was offering staff overtime and bonus pay to ensure coverage was available. The agency staff were provided basic infection control training practices prior to accepting a position at the facility. During the survey, no in-service or orientation checklist for the agency staff was provided. Additionally, no infection control, cleaning/disinfection training documents were provided for the staff working on the COVID19 positive unit or new hires. During a telephone interview on 8/27/20 at 2:48 PM, the Chief of Nursing Officer for the facility ' s contracted staffing agency stated, the staffing contract with the facility was established on 7/16/20 with the agreement the facility was responsible onsite training of the facility requirements in infection control prior to placement and to determine the adequacy of each employees ' job performance. During a telephone interview on 8/25/20 at 9:44 AM, the Medical Director stated he was unable to pinpoint a specific cause for the outbreak of the COVID infection in the facility. However, the Medical Director speculated the outbreak was potentially due to lack of adequate housekeeping cleaning and disinfecting procedures, poor ventilation in the facility and limited staff. He further stated to control the rapid spread at a short period of time was difficult to manage when resources were limited and reporting of symptoms when staff were asymptomatic. The facility had enough PPE and cleaning supplies available, however, due to the contracted housekeeping service company ' s practice, the facility staff and residents were impacted by the poor cleaning practice of the company. The Medical Director stated, I had been informed by the administrator and the director of nursing that due to the housekeeping contract services, the quality of cleaning throughout the facility had a significant impact on the spread of [MEDICAL CONDITION]. The staff attempted to do their best to provide care and maintain a clean environment for the residents. The contracted housekeeping staff did not work in accordance to the professional standards. The Medical Director stated, I had been made aware the current housekeeping company had been terminated the end of July and the new company would start on end of August, therefore, unit staff had the extra burden of trying to clean and maintain the environment. The Medical Director indicated the contract cleaning standards were poor which may have had a direct impact on the spread of [MEDICAL CONDITION]. The Medical Director specified, the timeliness of the returned COVID19 test results revealed an increase of positive cases each week. He continued to review the cases each week and currently 51 residents who had been on the COVID 19 unit for the past 15 or more days have been moved to the step-down unit and there are only 23 current active cases. Review of the facility ' s weekly tracking information on the number of residents who tested positive for the COVID19 virus revealed the following: week of 7/15/20- 2 residents, week of 7/22/20- 4 residents, week of 07/29/20- 10 residents, week of 08/06/20- 12 residents, week of 08/12/20- 35 residents and the week of 08/19/20- 23 residents. 2. The facility ' s Communicable Disease Outbreak Preparedness plan dated March 2020, read in part; Prevention section read in part all staff should practice good hygiene and handwashing techniques and would be educated to conduct frequent washing of hands and to avoid touching the eyes/face area. Healthcare workers should wear appropriate Personal Protective Equipment (PPE) masks, gloves, and gowns while working with suspected cases. Nursing would ensure on-going education and training of staff. Ensure employees clean their hands according to CDC guidelines, including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment (PPE). The facility ' s revised COVID19 Hand Hygiene and Donning and Doffing PPE competency infection control checklist for nurse aide in training policy and procedure dated 8/7/20, revealed in part; put 3 to 5 milliliters of antiseptic soap in the palm of your hands. Rub your hands together to distribute it. After you complete your care for the individual and if your hands are chapped or dry, apply lotion or a barrier cream that is dispensed by an individual-use dispenser and approved by your organization. Wears and/or uses safety equipment and supplies when indicated and properly trained to use. The facility ' s COVID 19 unit special airborne/contact precaution signage revealed a reminder: HAND HYGIENE must be performed before entering the room and following removal of PPE and leaving the patient ' s room. Observation on the facility ' s COVID19 positive unit on 8/17/20 from 11:40 AM to 11:45 AM, revealed NA#4 entered and exited two different resident rooms on the unit ' s 400 hall to assist residents with water and snacks touching bed side trays and tables, and picked up soiled linen from the floor. NA#4 was observed to exit the first resident ' s room and did not remove her PPE, gloves or wash her hands or use sanitizer before entering the second resident ' s room. NA #4 entered the second resident ' s room wearing the same PPE, gloves in place and wiped off a resident with the provided wipes. NA#4 was observed exit the second resident ' s room wearing the same PPE and did not wash or sanitize her hands. NA #4 carried soiled linen from the resident ' s room and stacked it in already filled barrels at the end of hall. On 8/17/20 at 11:55 AM, an interview was conducted with NA #4, who was an agency NA and worked on the facility ' s COVID unit. NA #4 stated this was her first day working the unit and she was provided brief training on the transmission of COVID 19 infection and unit requirements for handwashing and sanitizing, donning and doffing PPE when entering and exiting resident rooms. NA#4 confirmed there were occasions she had not removed the PPE or washed her hands as required because she was trying to respond to resident call lights and clean up the unit. NA #4 stated, I got in a hurry trying to do everything and did not remove my PPE after entering or exiting every resident room where I had either provided care or touched surfaces. NA #4 explained, things have gotten so overwhelming on the unit with two aides and so many residents to look after. NA #4 stated, that she was asked to come to work at this facility and placed on the COVID19 positive unit, and that she was trying to keep the residents clean, fed to the best of her ability. Observation on 8/17/20 from 11:45 AM to 11:50 AM, revealed Agency NA #5 was observed in a resident ' s room cleaning up the soiled linen and trash and placed the items in plastic bags and placed the bags outside of the resident ' s room in the 500 hallway. NA #5 exited this resident ' s room, but did not remove the PPE, gloves or perform hand hygiene. NA #5 then entered a second resident ' s room wearing the same PPE and gloves and provided this resident with requested fluids. NA#5 was observed to exit the second resident ' s room without removing PPE, gloves or performing hand hygiene. NA #5 then entered a third resident ' s room wearing the same PPE and gloves. While in the third resident ' s room NA#5 was observed to touch unclean surfaces including tray tables and remote control without cleaning them. On 8/17/20 at 11:58 AM, an interview was conducted with NA #5, who was an agency NA and worked on the facility ' s COVID unit. NA #5 stated he had received very brief training on the transmission of COVID19, infection control practices, handwashing and sanitizing and donning and doffing PPE. NA#5 stated he had worked several shifts back to back and things were getting very frustrating trying to keep residents clean and cared for as well as keeping the unit clean. NA #5 stated that he knew if he was providing care and handling soiled linens, he should remove his PPE and wash his hands between each resident. NA #5 explained, Things have gotten so busy with so many residents and trying to keep up with care and cleaning and he may have walked in and out of resident rooms and not changed his PPE in between each resident. NA#5 further stated it was too much to care for residents and clean an entire unit by the end of shift. During an interview on 8/17/20 at 12:10 PM, Nurse #3 stated the expectation for the staff assigned to the facility ' s COVID19 positive unit was to provide care for each resident while wearing with full PPE, which included gloves, gown, K95 mask or surgical mask, and face shield or goggles. and proper handwashing when staff entered and exited resident rooms. Nurse #3 explained, all staff have been informed of the unit policy and procedures for donning and doffing PPE and washing and sanitizing hands to prevent the spread of [MEDICAL CONDITION]. During an interview on 8/17/20 at 12:15 PM, the facility ' s Regional Nurse Consultant (RNC) stated all staff were educated on the COVID19 policies and procedures, required to perform return demonstration of handwashing and sanitizing practices, infection control practices for the unit and donning and doffing PPE before they were assigned to work on the unit. The nurse explained there were signs posted throughout the unit and in front of resident rooms that specified hand hygiene must be performed before entering the resident ' s room and following the removal of PPE when exiting the resident ' s room. The RNC stated all staff assigned to the COVID19 positive unit were expected to follow and perform infection control practices of hand hygiene and proper use of PPE when they performed resident care and when they touched potentially infected surfaces. The RNC indicated staff should wash their hands in resident rooms when sinks were available and use the provided hand sanitizer in areas where direct handwashing was not available. During an interview on 8/17/20 at 12:30 PM, Nurse #4 stated prior to any staff working the COVID19 positive unit they would have been educated and informed of the infection control policy and procedures for COVID 19 positive unit, handwashing and sanitizing practices, donning and doffing PPE. Nurse #4 further stated there were infection control and contact precaution signs posted throughout the unit as a reminder to perform proper hand hygiene and about donning and doffing PPE when staff entered and exited resident rooms. During an interview on 8/17/20 at 2:15 PM, the Director of Nursing stated all staff assigned to the COVID19 positive unit were required to wear full PPE (gloves, gown, K95 mask or surgical mask, and face shield or goggles) when providing care or physical contact with the resident. The entire unit had signage posted to remind staff to perform hand hygiene, proper donning and doffing of PPE and discarding procedures of used PPE. The DON explained, staff should wash and sanitize hands prior to placement of full PPE and mask before entering resident rooms. When staff exited resident rooms they were expected to wash hands in room and/or sanitize hands before exiting and discarded items in the designated yellow barrels for trash and grey barrel for PPE. The DON stated, staff should wash and sanitize their hands when all PPE was removed. The DON explained staff should not enter any other resident room or common areas wearing the same PPE after they provided care or assistance to a resident. The DON stated every resident room on the facility ' s COVID unit had a full PPE cart in front of the room ' s doorway which included full covering PPE and hand sanitizer. During a telephone interview on 8/27/20 at 2:48 PM, the Chief of Nursing Officer for the facility ' s contracted staffing agency stated the staffing contract with the facility was established on 7/16/20 with the agreement the facility was responsible for onsite training of the facility requirements in infection control prior to the staff member ' s placement and to determine the adequacy of each employees ' job performance. The administrator was notified of immediate jeopardy on 08/28/20 at 11:39 AM. The facility provided the following credible allegation of immediate jeopardy removal: F 880 INFECTION PREVENTION AND CONTROL 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The Facility failed to follow its Infection Prevention and Control policies as evidence by a quarantined COVID-19 positive unit with (23) residents having soiled floors, uncontained/uncovered soiled linen and trash on floor in hallways and/or resident rooms, staff not performing hand hygiene between residents and a shower room with black substance noted on wall on quarantine unit. The facility failed to ensure infection control training for (2) two agency staff members (NA #4 and NA#5). These (2) agency staff did not have a [DIAGNOSES REDACTED]. The first positive staff member (Hospice CNA) reported to the facility that she was positive on 7/16/2020, the facility immediately excluded her from work. The facility resident placement policy was implemented and any resident who has exposure to this positive staff member was moved to a quarantined person under investigation (PUI) room and tested for COVID-19. The second positive staff (RN Supervisor) member was screened for signs and symptoms of COVID-19 upon reporting to work on 7/14/2020. Mid-shift, she stated she did not feel well. This employee was sent home after being tested by facility staff. Her COVID-19 results on 7/16/2020, was positive. Both employees were excluded from work and quarantined for 14 days. The facility implemented mass testing of all residents and staff on 7/14/2020 - 7/15/2020. The facility routinely monitored residents for signs and symptoms of COVID-19. The facility continued to utilize our resident placement policy and relocated all suspected residents with signs and symptoms of COVID-19 to a dedicated unit called persons under investigation (PUI) and immediately tested and quarantined a minimum of 14 days. These residents ' symptoms were monitored routinely by the Licensed Nurse. Despite these efforts, from 07/15/2020 to 7/29/2020 the facility increased COVID-19 positive residents from two (2) to sixteen (16) after mass testing was completed. From 08/06/2020 to 08/12/2020 after mass testing was completed, the facility increased COVID-19 residents from (16) sixteen to (47) forty-seven positive COVID-19 residents. From 08/19/2020 to 08/26/2020 the facility increased positive COVID-19 residents from (47) forty-seven to (73) positive COVID-19 residents. Total facility census on 8/26/2020 was 118 residents. The facility failed to follow its Infection Prevention and Control policies and training of the (2) two agency staff in infection control which potentially lead to the increase in COVID-19 positive residents and staff in the facility. This is evident by observations of the quarantined /COVID-19 unit positive with 23 residents. This unit upon observations revealed soiled floors, uncontained/uncovered soiled linen and trash on floor in hallways and/or resident rooms and a shower room with black substance noted on wall on quarantine unit. Additionally, the (2) two agency staff were not performing hand hygiene between residents and inappropriately donning/doffing personal protective equipment. On 8/28/2020, the entire quarantine unit including resident rooms, hallways, shower room and the doors to enter and exit the quarantine unit were cleaned by Housekeeping and Nursing Staff. After cleaning completed, this area was inspected by the Assistant Director of Nursing and Housekeeping Supervisor to ensure a clean, sanitary orderly environment. No issues were identified. (TRUNCATED)

Based on record review and staff interviews, the facility failed to follow manufacturer ' s recommendations to use two people for safe bed to chair transfer of a dependent resident and cross the sling straps before transferring the resident. This resulted in the resident ' s fall during transfer, causing the resident to have severe head trauma, hospitalization and death. This occurred for 1 of 3 sampled residents reviewed for accidents (Resident #50). Immediate Jeopardy (IJ) began on 11/22/19, when Nurse Aide #1 operated the mechanical lift without assistance of another staff member, transferred Resident #50 from the bed to the chair and did not cross the lift sling straps, which resulted in the resident' s fall during the transfer with severe head trauma, hospitalization and death. The IJ was removed on 12/5/19, when the facility provided and implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put into place are effective to prevent accidents. The findings included: The manufacturer ' s manual, dated 2010, for the lift, which was used for Resident 50 ' s transfer, included a warning: Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. The manual recommended to place the sling straps around, crossed between or underneath the patient ' legs. Resident #50 was admitted to the facility on [DATE]. Resident 50 ' s lift assessment, dated 2/23/19, revealed that she required mechanical lift for transfer. The Quarterly Minimum Data Set assessment, dated 10/15/19, revealed she had severely impaired cognition. Resident #50 ' s [DIAGNOSES REDACTED]. She required total assistance with activities of daily living (ADL), including two people assistance for transfer. She did not have steady balance during transitions. Resident #50 ' s plan of care, dated 10/15/19, revealed she was at risk for falls, due to muscle weakness and impaired mobility. The goal was to prevent serious injury. The interventions were to provide total ADL care, including transfer via mechanical lift. The Nurse Aide Information Sheet for Resident #50 revealed she required mechanical lift for bed to chair/recliner transfer. The skills checklist of Nurse Aide #1 for 11/7/19 – 11/19/19, indicated review and return demonstration for Hoyer, Sit-to-Stand lifts and two-person transfer on 11/19/19 were observed by the nurse-trainer. The checklist did not specify the lift sling/strap application procedure. The Skill Checklist Resident Lift, completed by Nurse Aide #1 on 11/19/19, indicated all lift transfers require assistance of two staff members. The incident report, dated 11/22/19, indicated that on 11/22/19 at 1:00 PM, Nurse #1 was called by the staff to Resident 50 ' s room. She observed Resident #50 on the floor, next to the mechanical lift, with blood around her head. Nurse Aide #1 stated that during the transfer, she was lifting the resident to place her in her chair via mechanical lift, when the resident slipped out the lift on the floor, hitting her head. The assessment revealed about 1.6 inches laceration on the back of resident ' s head. A dressing was applied. The resident was transferred to bed via mechanical lift by three assistants and prepared for transfer to emergency room (ER). Hospital records revealed that Resident #50 arrived to theER on [DATE] at 1:45 PM after witnessed fall in the nursing home. Per EMS (Emergency Medical Service) report, patient slid out of the mechanical lift and fell , hitting her head. Upon assessment, patient ' s mental status was at baseline and there was 1.5 inches laceration on her posterior scalp. Per family report, the patient slid forward from the lift, fell out of the sling and hit her head on the lift. Review of the CT (Computer [NAME]ography) scan, dated 11/22/19 at 4:00 PM, revealed the multicompartmental acute intracranial bleeding (massive brain bleeding). The scalp laceration was repaired with staples. The resident was admitted for observation. On 12/2/19 at 9:50 AM, during the phone interview, Resident 50 ' s family member indicated that the resident passed away on 11/28/19. On 12/2/19 at 3:15 PM, during an interview, Nurse Aide #1 indicated that on 11/22/19 at 1:00 PM, she came into Resident 50 ' s room on 300 hall to provide bed to chair transfer. Nurse Aide #1 stated that she was aware of the requirements to use the mechanical lift by two assistants. The other staff members were not available at the time. Nurse Aide #1 began to transfer Resident #50 from bed to chair via mechanical lift alone. During the transfer, Resident #50 slid out of mechanical lift sling, hit her head on the lift leg and fell to the floor. The nurse aide called for help. The floor nurse came immediately, assessed the resident, notified the physician, family and within one hour after the incident sent the resident to the hospital evaluation. Nurse Aide #1 confirmed she did not cross the straps during the lift sling application. On 12/4/19 at 2:40 PM, during an interview, Nurse Aide #1 indicated she was aware that on 11/22/19, two other nurse aides worked on 300 hall, but at 1:00 PM, she did not see them. She was not comfortable to use mechanical lift, because she did not receive enough training in the facility. No staff members offered help to her with resident ' s transfer on 11/22/19 at 1:00 PM. On 12/2/19 at 12:40 PM, during an interview, Nurse Aide #3 indicated that on 11/22/19, she worked on 300 hall and was not assigned for Resident #50. She remembered that approximately at lunchtime, she was called to Resident 50 ' s room for help. Nurse Aide #3 observed the Resident #50 on the floor near lift, with small amount of blood around the head. The aide confirmed that the staff completed competency training annually, including the lift/transfer, and always have two people for mechanical lift operation. On 12/2/19 at 1:10 PM, during the phone interview, Nurse #1 indicated that on 11/22/19 after 1:00 PM, she was called to Resident 50 ' s room. In resident ' s room, she observed Nurse Aide #1 near the mechanical lift and Resident #50 on the floor, with small amount of blood around her head. Upon assessment, the resident had 1-1.5 inches laceration on the back of her head with small amount of blood. The nurse notified the physician, the DON and sent the resident to the hospital evaluation within one hour. The nurse aide reported she operated the lift alone. Nurse #1 completed the incident report and re-educated the nurse aide about requirements of two people for lift transfer. On 11/22/19, there were two more nurse aides, Nurse Aide #2 and Nurse Aide #3, on the floor and Nurse #1 did not know why Nurse Aide #1 used the mechanical lift without other nurse aides. The nurse continued that it was part of the training for all the staff to have two assistants for lift transfer. On 12/4/19 at 2:45 PM, during an interview, Nurse #2, Staff Development Coordinator, indicated that she provided the training for the staff, including the training for lift/transfer. During the education/training, she discussed with staff the policy requirements of two assistants for transfer, different kind of lifts and slings, available in facility. The practical, demonstration part, was separately provided by experienced nurse aides on the floor, which included the appropriate sling application, with placing straps crossed between legs. On 12/2/19 at 12:30 PM, during an interview, the Director of Nursing (DON), indicated that on 11/22/19 after 1:00 PM, she was notified by the staff that Resident #50 was dropped from mechanical lift to the floor during bed to chair transfer, provided by Nurse Aide #1 alone, and hit her head. Nurse Aide #1 confirmed she used the mechanical lift without assistance. The DON stated that Nurse Aide #1 successfully completed the lift/transfer training few weeks ago as part of her orientation process. The DON completed the investigation, which revealed that Nurse Aide #1 did not follow the lift/transfer procedure: she did not have second assistant for mechanical lift and did not cross the sling strap during the transfer. Nurse Aide #1 was returned to the orientation/training to receive re-education about the lift transfer safety. The DON and administration completed mandatory in-service training with return demonstration for all the staff in regard to lift transfer, and re-assessed all the resident, received lift assistance for transfer. On 12/5/19 at 8:00 AM, during an interview, the Administrator indicated that the facility provided training, education, re-education and in-services in different aspects of care, included the lift/transfer. It was mandatory for the staff to have completed skills checklist prior to provide care. The Administrator and DON were notified of Immediate Jeopardy on 12/4/19 at 3:10 PM. On 12/5/19 at 5:00 PM, the facility provided the following credible allegation of Immediate Jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Beginning on 11/22/19, Nurse Aide #1 was not allowed to work with residents in the skilled unit or residents requiring transfer with a mechanical lift until she was retrained on lift sling selection by weight and girth as included in the Owner ' s Operators Maintenance Manual for Patient Slings, the proper technique for transferring the resident and the need to use two staff members to transfer a resident. Nurse Aide #1 was able to verbalize expectations in following the care card, how to select the proper lift sling and provided a return demonstration to the administrative nursing team starting on 11/22/19 and ended on 12/4/19. The Community ' s Maintenance Director inspected both the sling and mechanical lift that had been used to transfer Resident #50. Residents requiring the use of a mechanical lift are at risk. On 11/25/19, the DON, Assistant DON (ADON), and other administrative nurses compiled a list of residents that required a mechanical lift for transfers. Return demonstrations of all nursing assistants performing mechanical lifts were completed on 11/25/19 and will again be required of all staff to be completed by 12/5/19. Care cards were reviewed by the DON, the Assistant DON and other administrative nurses by 12/5/19 to assure the proper information. 2. 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. The non-compliance resulted from failure to maintain safety for resident ' s lift transfer by Nurse Aide #1. Staff that includes nurse aides, licensed staff, physical therapists (PT) and occupational therapists (OT) will receive re-education, with completion on 12/5/19, on choosing the correct lift pad by the instructions in the Owner ' s Operators Maintenance Manual for Patient Slings. The slings will be kept in the Community Spas, and a size chart of the lift slings will be posted above the rack holding the slings. The re-education and return demonstration will be documented on individual Lift Assessment Sheets and on Community In-Service sheets. Education on where to find the lift slings, how to choose the correct size of sling, correct technique for applying the sling to the resident and following the community ' s policy will be included in orientation for all new nursing assistants, licensed staff, PTs and OTs. The SDC will maintain a skills checklist for all newly hired nursing assistants and licensed staff. The nurse aides were instructed that under no circumstance was a transfer to be completed by one staff person. The Administrator, DON, ADON and other Administrative nurses are responsible for the implementation of the credible allegation of immediate jeopardy removal. The date of the community ' s alleged removal of the immediate jeopardy is 12/5/19. The credible allegation was verified on 12/6/19 as evidenced by licensed and non-licensed nursing staff interviews on each of the halls. The staff had been re-educated on the implementation of appropriate procedure of residents ' lift transfer by two staff members at all the time, completed in-service/training in regards to location of residents ' care cards and lift slings and proper technique of the lift sling application. Interviews with the licensed and unlicensed staff confirmed they were in-serviced prior to working on the floor. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented as of 12/5/19.

Based on record review, staff interviews and observation, the facility failed to train staff on safe transfer of residents using the mechanical lift per manufacturer's recommendation and the facility's lift/transfer training procedure, specifically, to use two people during transfer, to correctly use the straps to secure the resident during transfer and to use the correct sling. Five of 12 of nurse aides interviewed revealed they had insufficient training with using the lift, sling sizes and type of lift for residents' transfer (Nurse Aide #1, Nurse Aide #2, Nurse Aide #4, Nurse Aide #5 and Nurse Aide #6). This resulted in the resident's fall during the transfer, causing the resident to have severe head trauma, hospitalization and death. Immediate Jeopardy (IJ) began on 11/22/19, when Resident #50 was transferred from the bed to the chair with a mechanical lift using a technique that was not in line with the manufacturer's recommendation and the facility's lift/transfer training procedure. The nurse aide operated the mechanical lift without assistance of another staff member and did not cross the lift sling straps, which resulted in the resident's fall during the transfer with severe head trauma, hospitalization and death. Other aides were not clear about the training on the sling sizes and color-coding and indicated other staff were not always available to participate in the mechanical lift transfer and had to perform the transfer alone, even though they were aware of the policy on lifting with two people. The IJ was removed on 12/5/19, when the facility provided and implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance at a lower scope and severity of [NAME] (pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put into place are effective to prevent accidents. The findings included: The manufacturer ' s manual, dated 2010, for the lift, which was used for Resident 50 ' s transfer, included a warning: Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. The manual recommended to place the sling straps around, crossed between or underneath the patient ' legs. The manufacturer recommended to use the Lift Sling Sizing Chart, indicated five different sizes of the lift slings, from small to extra-extra-large, corresponding to color codes. Resident #50 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, dated 10/15/19, revealed she had severely impaired cognition. Resident #50 required total assistance with activities of daily living (ADL), including two people assistance for transfer. She did not have steady balance during transitions. The Nurse Aide Information Sheet for Resident #50 revealed she required mechanical lift for bed to chair/recliner transfer. This document did not specify the size or color of the lift sling to use for the resident. The skills checklist of Nurse Aide #1 for 11/7/19 – 11/19/19, indicated review and return demonstration for mechanical lift, Sit-to-Stand lifts and two-person transfer on 11/19/19 were observed by the nurse-trainer. The checklist did not specify the lift sling/strap application procedure. This skills checklist was signed by the nurse. The Skill Checklist Resident Lift, completed by Nurse Aide #1 on 11/19/19, indicated multiple steps of transfer from bed, transfer to chair procedures, including correct sling position and straps application. The checklist did not specify the way to place the straps around, crossed between or underneath the resident ' s legs. The checklist showed the warning: all lift transfers require assistance of two staff members! This checklist was signed by the Nurse Aide #3. The incident report, dated 11/22/19, indicated that on 11/22/19 at 1:00 PM, Nurse #1 was called by the staff to Resident 50 ' s room. She observed Resident #50 on the floor, next to the mechanical lift, with blood around her head. Nurse Aide #1 stated that during the transfer, she was lifting the resident to place her in her chair via mechanical lift, when the resident slipped out the lift on the floor, hitting her head. The assessment revealed about 1.6 inches laceration on the back of resident ' s head. A dressing was applied. The resident was transferred to bed via mechanical lift by three assistants and prepared for transfer to emergency room (ER). Hospital records revealed that Resident #50 arrived to theER on [DATE] at 1:45 PM after witnessed fall in the nursing home. Per EMS (Emergency Medical Service) report, patient slid out of the mechanical lift and fell , hitting her head. The CT (Computer [NAME]ography) scan, dated 11/22/19 at 4:00 PM, revealed massive brain bleeding. The resident was admitted for observation. Review of the Certificate of Death, dated 11/28/19, revealed Resident 50 ' s immediate cause of death was multicompartmental intracranial bleeding (massive brain bleeding). The condition, leading to the cause of death was the fall from the lift. On 12/2/19 at 3:15 PM, during an interview, Nurse Aide #1 indicated that on 11/22/19 at 1:00 PM, she came into Resident 50 ' s room on 300 hall to provide bed to chair transfer. Nurse Aide #1 stated that she was aware of the requirements to use the mechanical lift by two assistants. The other staff members were not available at the time. Nurse Aide #1 began to transfer Resident #50 from bed to chair via mechanical lift alone. During the transfer, Resident #50 slid out of mechanical lift sling, hit her head on the lift leg and fell to the floor. The nurse aide called for help. The floor nurse came immediately, assessed the resident, notified the physician, family and within one hour after the incident sent the resident to the hospital evaluation. Nurse Aide #1 confirmed she did not cross the straps during the lift sling application. On 12/4/19 at 2:40 PM, during an interview, Nurse Aide #1 indicated she was aware that on 11/22/19, two other nurse aides worked on 300 hall, but at 1:00 PM, she did not see them and did not have other staff members to help. Nurse Aide #1 mentioned that she worked with the Resident #50 first time and did not read the Nurse Aide ' s Information Sheet for Resident #50 prior to resident ' s transfer. She was not comfortable to use mechanical lift, because she did not receive enough training in the facility. No staff members offered help to her with resident ' s transfer on 11/22/19 at 1:00 PM. On 12/2/19 at 12:40 PM, during an interview, Nurse Aide #3 indicated that she provided the training for lift transfer procedures, completed and signed the Skill Checklist Resident Lift for nurse aides on the floor. She trained Nurse Aide #1 for lift transfer during her orientation. The training included discussion, demonstration and return demonstration of sling placement and straps application. Nurse Aide #3 mentioned that she always taught to cross the straps to increase the safety of transfer. On 12/2/19 at 1:10 PM, during the phone interview, Nurse #1 indicated that on 11/22/19 after 1:00 PM, she was called to Resident 50 ' s room. In resident ' s room, she observed Nurse Aide #1 near the mechanical lift and Resident #50 on the floor. The nurse aide reported she operated the total lift alone. Nurse #1 completed the incident report and re-educated the nurse aide about requirements of two people for lift transfer. On 11/22/19, there were two more nurse aides, Nurse Aide #2 and Nurse Aide #3, on the floor and Nurse #1 did not know why Nurse Aide #1 used the total lift without other nurse aides. The nurse continued that it was part of the training for all the staff to have two assistants for lift transfer. On 12/3/19 at 9:10 AM, during an interview, Nurse Aide #2 indicated that she worked in this facility three months and received training with lift transfer during the orientation. She remembered that the lift transfer required two staff members. Nurse Aide #2 used the lift slings, which were available in the resident ' s room at the time of transfer. For residents of different weight and height, she could use the same size of the lift slings. She did not know if the lift slings were color-coded. On 12/3/19 at 10:10 AM, during an interview, Nurse Aide #8 indicated that she had many years of experience as nurse aide and provided the training for other nurse aides on the floor in the lift transfer. During the training, she demonstrated the position of the straps crossed between resident ' s legs and the application of the sling, according to the Nurse Aide Information Sheet, available at the nurses ' station. She stressed it one more time that she always demonstrated the crossed between legs straps position to promote safety of transfer. Nurse Aide #8 did not provide practical lift transfer training for Nurse Aide #1. On 12/3/19 at 10:15 AM, during an interview, Nurse Aide #4 indicated that she used long sling for mechanical lift and short sling for Sit-to-Stand lift transfer. She was not aware of different sizes of the slings for mechanical lift and used what was available in the residents ' room at the time of transfer. On 12/3/19 at 12:00 PM, during an interview, Nurse Aide #5 indicated that she worked about one year in the facility. She could not recall the lift transfer training during her orientation period and learned how to use the lift from other employees. Nurse Aide #5 was aware of two people requirements to operate the lift for transfer. At times, the second assistant was not available on the floor for transfer and the nurse aide had to operate mechanical lift alone. After the incident on 11/22/19, Nurse Aide #5 worked three shifts per week and tried to participate in mandatory re-education in the area of lift transfer. She did not have an opportunity to demonstrate how she used the lift because the supervisor was not available. On 12/3/19 at 3:10 PM, during an interview, Nurse Aide #6 indicated that for resident ' s lift transfer, there was only large size of the lift sling available in the facility. In order to transfer the resident with the lift, Nurse Aide #6 looked on resident ' s approximate size, mobility and chose to use mechanical or Sit-to-Stand lift. If the resident already had the lift sling on the bed, Nurse Aide #6 would use it for lift transfer. He was not aware of documentation about the type of the lift or size of the lift sling for each resident. On 12/4/19 at 2:45 PM, during an interview, the Staff Development Coordinator indicated that she provided the training for the staff, including the training for lift transfer. During the education/training, she discussed with staff the policy requirements of two assistants for transfer, different kind of lifts and slings, available in facility. The practical, demonstration part, was separately provided by experienced nurse aides on the floor, which included the appropriate sling application, with placing straps crossed between legs. The Staff Development Coordinator mentioned that the facility did not require additional certification/training for experienced nurse aides to be a preceptor for other nurse aides. On 12/2/19 at 12:30 PM, during an interview, the Director of Nursing (DON), indicated that on 11/22/19 after 1:00 PM, she was notified by the staff that Resident #50 was dropped from mechanical lift to the floor during bed to chair transfer, provided by Nurse Aide #1 alone, and hit her head. Nurse Aide #1 confirmed she used the mechanical lift without assistance. The DON stated that Nurse Aide #1 successfully completed the lift/transfer training few weeks ago as part of her orientation process. The DON completed the investigation, which revealed that Nurse Aide #1 did not follow the lift/transfer procedure. She did not have second person to assist her in using the mechanical lift and did not cross the sling strap during the transfer. Nurse Aide #1 was returned to the orientation/training to receive re-education about the lift transfer safety. After the incident on 11/22/19, the DON and administration completed mandatory in-service training with return demonstration for all the staff in regard to lift transfer, and re-assessed all the residents, received lift assistance for transfer. On 12/5/19 at 8:00 AM, during an interview, the Administrator indicated that the facility provided training, education, re-education and in-services in different aspects of care, included the lift/transfer. It was mandatory for the staff to have completed skills checklist prior to provide care. The Administrator and DON were notified of Immediate Jeopardy on 12/4/19 at 3:10 PM. On 12/5/19 at 5:00 PM, the facility provided the following credible allegation of Immediate Jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: In the written statements, Nurse Aide #1, who had transferred the resident, acknowledged that when she placed the resident in the lift sling, she had not placed the lift sling under the resident ' s legs or between her legs and had transferred the resident without the help of another staff member. Resident #50 slid out of the sling, hitting her head on the legs of the mechanical lift. Beginning on 11/22/19, Nurse Aide #1 was not allowed to work with residents in the skilled unit or residents requiring transfer with a mechanical lift until she was retrained on lift sling selection by weight and girth as included in the Owner ' s Operators Maintenance Manual for Patient Slings, the proper technique for transferring the resident and the need to use two staff members to transfer a resident. Nurse Aide #1 was able to verbalize expectations in following the care card, how to select the proper lift sling and provided a return demonstration to the administrative nursing team starting on 11/22/19 and ended on 12/4/19. The Community ' s Maintenance Director inspected both the sling and mechanical lift that had been used to transfer Resident #50. 2. 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. Staff that includes nurse aides, licensed staff, physical therapists (PT) and occupational therapists (OT) will receive re-education, with completion on 12/5/19, on choosing the correct lift pad by the instructions in the Owner ' s Operators Maintenance Manual for Patient Slings. The slings will be kept in the Community Spas, and a size chart of the lift slings will be posted above the rack holding the slings. The re-education and return demonstration will be documented on individual Lift Assessment Sheets and on Community In-Service sheets. Education on where to find the lift slings, how to choose the correct size of sling, correct technique for applying the sling to the resident and following the community ' s policy will be included in orientation for all new nursing assistants, licensed staff, PTs and OTs. The SDC will maintain a skills checklist for all newly hired nursing assistants and licensed staff. The nurse aides were instructed that under no circumstance was a transfer to be completed by one staff person. Education on where to find the lift slings, how to choose the correct size of sling, correct technique for applying the sling to the resident and following the community ' s policy will be included in orientation for all new nursing assistants, licensed staff, PTs and OTs. This initial training will be provided by the Staff Development Coordinator, DON or another licensed nurse designated by the DON. Prior to working with residents that require transfer via mechanical lift, the nurse aides, licensed staff, PT or OT in orientation will demonstrate to the Staff Development Coordinator (SDC), DON or another licensed nurse appointed by the DON that he/she is capable of safely transferring residents via mechanical lift, using the correct sling, correctly applying the sling prior to transferring the resident and with the assistance of another staff member. The Administrator, DON, ADON and other Administrative nurses are responsible for the implementation of the credible allegation of immediate jeopardy removal. The date of the community ' s alleged removal of the immediate jeopardy is 12/5/19. On 12/3/19 at 10:20 AM, during an observation of the bed to chair lift transfer, provided by Nurse Aide #8 and Nurse Aide #7. They explained the procedure to the resident, took the large sling, correct size for the resident, and put it under the resident on the bed. The total lift was ready in resident ' s room. Nurse Aide #8 gently crossed the straps between resident ' s legs and hooked up the sling to the lift. Both nurse aides transferred the resident to the chair, repositioned the resident in the chair and disconnected the lift from the sling. During the procedure, the resident did not show signs of discomfort or pain. The credible allegation was verified on 12/6/19 at 1:25 PM as evidenced by licensed and non-licensed nursing staff interviews on each of the halls. The staff had been re-educated on the implementation of appropriate procedure of residents ' lift transfer by two staff members at all the time, completed in-service/training in regards to location of residents ' care cards and lift slings and proper technique of the lift sling application. Interviews with the licensed and unlicensed staff confirmed they were in-serviced prior to working on the floor. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented as of 12/5/19.

Based on record review, observation, staff, and resident interview the facility failed to provide supervision of 1 (Resident #1) of 3 sampled residents reviewed for wandering behavior resulting in unwanted advancement into the personal space of Resident #2 and the sexually aggressive behavior exhibited toward Resident #3. Immediate Jeopardy began on 5/19/18 and was removed on 10/6/18 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level grid position (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. Findings included: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The documentation on the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as severely cognitively impaired with trouble concentrating two to six days of the assessment period. Resident #1 was also assessed as having no behaviors and ambulatory with no assistance. Resident #1 was not coded as having wandering behaviors that would affect others. The documentation in the care plan initiated on 1/31/18 for Resident #1 had problem areas for his inability to express emotion, listen and share information due to auditory and verbal deficits. The documentation in a nursing note dated 5/19/18 at 10:25 PM for Resident #1 stated, Resident observed in another female resident's room on 300 hall. He had gotten in females room and was sitting in her (Resident #2) room in the wheel chair, had his hands under her covers and was attempting to touch her inappropriately without (her) consent. Resident (#2) had yelled out and had turned her call bell on to call for help. Resident (#1) was removed from her room and returned to his room and asked to go to bed for the night. Resident #2 had [DIAGNOSES REDACTED]. The documentation on the most recent quarterly MDS assessment dated [DATE] coded Resident #2 as having moderately impaired cognition and requiring extensive assistance of one person with bed mobility. Resident #2 was interviewed on 10/5/18 at 11:13 AM. Resident #2 revealed Resident #1 came in her room at night and put his hand under her bed covers. She stated she hollered and rang the call bell for help until they came and got Resident #1 out of her room. When asked how this made her feel at that time, she revealed it was upsetting. She indicated she still saw Resident #1 walking in the halls but he had not come into her room after that incident. The care plan for Resident #1 was updated on 5/19/18 with the problem area that stated, I demonstrate inappropriate behavior towards a female resident. The documentation of the approach on the care plan stated, Place resident in area where constant observation is possible. Nurse #1, a nursing supervisor, was interviewed on 10/5/18 at 4:12 PM. Nurse #1 revealed that she was the nurse on the hall where Resident #1 resided on the evening of 5/19/18 but she usually worked on the first shift (7:00 AM to 3:00 PM). She indicated Resident #1 was removed from the room of Resident #2, redirected to his own room, and went to sleep on the evening of 5/19/18. She stated she called the facility Administrator to notify him of the incident with Resident #1 and Resident #2. Nurse #1 indicated she was directed by the Administrator to keep an eye on him (Resident #1). Nurse #1 revealed Resident #1 was checked on every 15 minutes by the nursing staff for a couple of days after the 5/19/18 incident. Nurse #2, a nursing supervisor, was interviewed on 10/6/18 at 8:41 AM. Nurse #2 indicated she worked on the second shift (3:00 PM to 11:00 PM) and sometimes third shift (11:00 PM to 7:00 AM) for the hallway where Resident #1 resided in (MONTH) (YEAR). Nurse #2 indicated that the first time Resident #1 demonstrated the concerning behavior of going into female resident rooms was on 5/19/18. She said he did have a tendency to wander but was easily redirected. Nurse #2 revealed the nursing staff kept an eye on him for a few days after the 5/19/18 incident but after a while the staff felt like he was okay. Nurse #2 revealed she did not think he would hurt anybody so the nursing staff were watching him. Documentation in the nursing notes from 5/20/18 to 5/26/18 revealed the resident was not noted to have any inappropriate behaviors at night but did ambulate in the hallways of the facility. There was no documentation in the nursing notes to indicate the resident was wandering into other resident's rooms between 5/20/18 to 5/26/18. Documentation in a nursing note dated 5/27/18 at 10:39 PM stated in part, Resident has been wandering in and out of residents rooms. Resident has been easily redirected this shift. Documentation in a nursing note dated 5/28/18 at 8:52 AM stated in part, Resident did have behaviors noted this shift 11PM -7AM. Patient was combative with writer and staff trying to keep him out of ladies bedrooms while asleep. Eventually able to redirect resident to his room and continued to monitor him throughout the shift. Supervisor and management made aware. Nurse #3, the nurse who wrote the nursing note dated 5/27/18 at 10:39 PM and 5/28/18 at 8:52 AM, did not respond to requests for an interview. An interview was conducted Nurse #2 (second shift supervisor) on 10/6/18 at 8:41 AM. Nurse #2 revealed she was not aware of the combative behavior and attempts to get into the female residents rooms of Resident #1 on 5/28/18. An interview was conducted with Nurse #1 (first shift supervisor) on 10/6/18 at 9:32 AM. Nurse #1 revealed she was not aware of the combative behavior and attempts to get into the female residents rooms of Resident #1 on 5/28/18. The DON (Director of Nursing) was interviewed on 10/5/18 at 4:15 PM. The DON indicated she was not made aware of the 5/28/18 behavior of Resident #1. An interview was conducted with the DON on 10/6/18 at 11:31 AM. She indicated that after the 5/19/18 wandering behavior of Resident #1 the care plan was updated with the intervention of 15 minute checks as needed. She indicated that after the 5/28/18 behavior of Resident #1 documented in the nursing notes the resident's care plan was updated with the interventions of frequent monitoring as needed and redirection with rest as needed. Review of the medical record for Resident #1 did not reveal any documentation to indicate any behavior or wandering problems in June, July, or (MONTH) of (YEAR). Documentation on the care plan for Resident #1 was updated on 8/1/18 for the problem of a risk for unsupervised exits from the facility related to cognitive impairment and restlessness. Some of the interventions included encouraging socialization with other peers as appropriate, at risk wandering protocol, and allow to ventilate feelings related to stay at the facility. There was also no documentation of wandering into residents' rooms in the nursing notes for Resident #1 from 9/7/18 to 9/23/18. The documentation in an incident report, written by Nurse #1, regarding Resident #1 dated 9/19/18 at 10:15 PM stated, Resident (#1) was observed in another resident's room (female Resident #3) by 2 staff member, leaning over resident kissing her on the mouth and had his right hand in her (incontinence) brief and his left hand on his penis. When staff entered room, he was removed from her room, placed on another hall and 15 minute checks were started on resident. The documentation on the incident report indicated the family of Resident #1 was notified at 11:30 PM, no injuries were noted as well as notification of the physician, DON, and Administrator. Resident #3 had [DIAGNOSES REDACTED]. Documentation in an annual MDS assessment dated [DATE] coded Resident #3 as severely cognitively impaired with cognitive decision making skills and she was totally dependent on one or two people for all activities of daily living. Resident #3 was observed on 10/5/18 at 11:28 AM to be lying on her back in a low bed. The resident made moaning sounds but did not communicate verbally. The documentation in an incident report regarding Resident #3 dated 9/19/18 at 10:15 PM stated, Resident (#3) was observed lying in her bed, another resident was standing over her kissing her in the mouth and had his hand in her brief. Resident was not yelling out for help, was lying there calmly. The documentation in the incident report indicated there were no injuries noted as well as notification of the physician, DON and Administrator. Nurse #1, a nursing supervisor, was interviewed on 10/5/18 at 4:12 PM. Nurse #1 confirmed she was the nurse on the hall when Resident #1 was found in the room of Resident #3 on 9/19/18. Nurse #1 indicated she was notified by two nurse aides that Resident #1 was inappropriately touching Resident #3. She said Resident #1 was immediately returned to his room, Resident #3 was assessed for any injuries, and the Administrator was notified of the incident. Nurse #1 revealed the Administrator instructed her to move Resident #1 to another room on another hallway. Nurse #1 revealed she moved the resident to another hallway immediately and 15 minute checks were initiated for Resident #1. Nurse #1 stated she asked the two nurse aides on the hall to write statements regarding the incident. Nurse #1 stated the facility social worker was notified the next day of the events on the evening of 9/19/18. The documentation of the incident from NA (Nurse Aide) #1 stated, At 10:15 PM call light was on in Room (Number) and noticed there was a wheelchair by bed A. As I entered the room (I) saw (Resident #1) bent over kissing (Resident #3) in her mouth, his right hand was in her brief, his left hand was putting his private part back in his pants, after asked him what he was doing, I called for the nurse he then exited the room. The documentation of the incident from NA #2 stated, I was in hallway after CNA (certified nursing assistant) asked (Resident #3 what he was doing.) He was over (Resident #3's) bed and he had his private part out and then he put (it) back in his pants. An interview was conducted with the social worker on 10/5/18 at 4:56 PM. The social worker indicated that she was notified of the behavior of Resident #1 on the morning of 9/20/18. The social worker indicated the nursing staff were assessing the well-being of Resident #3 and that she did not assess Resident #3 on 9/20/18. Nurse #2, the second shift nursing supervisor, was interviewed on 10/6/18 at 8:41 AM. She stated the behavior on the evening of 9/19/18 was not the usual behavior for Resident #1. She indicated he did not usually have problematic behavior but would wander in the hallways. The DON was interviewed on 10/5/18 at 4:15 PM. The DON indicated she was notified of the behavior of Resident #1 on the morning of 9/20/18. She stated that the intervention put in place after the incident was the removal of the resident to another hallway, every 15 minutes a documented check of the resident, a mental health consult, checking of the urine for possible urinary tract infections as needed, redirection, and the encouragement of facility activities. The DON provided documentation of the 15 minute monitoring of the resident initiated on 9/19/18 and indicated that the monitoring time interval varied as the concern for the behavior of Resident #1 varied. The DON indicated the nurses staff varied the monitoring interval for the resident based on the amount of wandering he was doing. The DON stated if Resident #1 was walking around more the interval was every 15 minutes to check on him. A review of the documentation on the location and behavior monitoring for Resident #1 indicated that various time intervals were used to monitor the resident. The documentation shows that on 9/19/18 beginning at 10:15 PM Resident #1 was monitored every 15 minutes until 6:45 AM on 9/20/18. There was no location/behavior log documentation for 9/20/18 from 7:00 AM to 9/21/18 at 2:30 PM. An interview was conducted with NA #3 on 10/6/18 at 8:04 AM. NA #3 stated that on 9/20/18 -9/21/18 she was assigned to Resident #1 on the first shift and part of the second shift. NA #3 indicated she monitored the resident every 15 minutes or 30 minutes depending what was on written on the behavior log on the clip board. NA# 3 indicted the nursing assistants did not determine the monitoring interval for Resident #1. NA #3 stated Resident #1 has been monitored every day since he arrived on the hallway. NA #3 stated she was told Resident #1 had been in a ladies room, had done something inappropriate and had to be moved to another hall. NA#1 stated that Resident #1 was being monitored so he did not go into female resident rooms. An interview was conducted with NA #4 on 10/6/18 at 7:45 AM. NA #4 indicated she was assigned to Resident #1 on 9/20/18 on the second shift and monitored the resident every 15 minutes. NA #5 was interviewed on 10/6/18 at 8:10 AM. NA #5 indicated Resident #1 was being monitored so he did not go into other people's rooms. NA #5 indicated she would monitor the resident every 15 to 30 minutes based on what was on the monitoring sheet at the nurses station. NA #5 indicated she was assigned to Resident #1 on 9/20/18-9/21/18 for the third shift. She stated she monitored the resident every 15 or 30 minutes on 9/20/18. NA #5 stated once or twice Resident #1 got up to use the bathroom but the majority of the time she went in to check on him he was still sleeping. The documentation on the location and behavior monitoring for Resident #1 for 9/21/18-9/25/18 indicated the resident was monitored every half hour. The documentation for the location and behavior monitoring for Resident #1 for 9/26/18-9/27/18 changed to every hour. Documentation indicated on 9/28/18 Resident #1 was monitored every half hour. There was no documentation for monitoring of Resident #1 for 9/29/18-9/30/18. The documentation indicated the behavior monitoring resumed for every 15 minutes from 10/1/18 to 10/6/18. Documentation in a physician's progress note dated 10/1/18 stated, (Patient) has been moved to 100 Hall because he was caught sexually molesting another resident. Because adequate communication with him is impossible, we felt that the only way to help was to remove him from the hall he was on. There have been no incidents since then. The physician was interviewed on 10/6/18 at 10:45 AM. The physician indicated Resident #1 can't communicate due to a [MEDICAL CONDITION] which left him unable to hear and speak clearly. He stated he was notified of both the incident Resident #1 had with Resident #2 and Resident #3. He stated Resident #2 was scared a little bit by Resident #1 coming in her room but he did not touch her. He stated he was not aware of any other additional incidents since Resident #1 was moved to another hallway. The Administrator was interviewed on 10/5/18 at 4:15 PM. The Administrator confirmed he was notified of the 9/19/18 incident by a phone call from Nurse #1 late that night. He stated he did not recall sending a report to the state regarding the 9/19/18 incident with Resident #1 and acknowledged it was the facility policy to do so. The DON was interviewed on 10/6/18 at 4:24 PM. She indicated it was her expectations that for the safety of the residents Resident #1 should have been and was removed from the situation. The DON said the priority was to keep the residents safe. She stated it was her expectation that residents be assessed, family notified, proper reporting, care planning, staff in-services as needed, and incident reports filled out after an allegation of sexual misconduct by a resident. On 10/6/18 at 12:27 PM the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 10/7/18 at 8:27 AM. The credible allegation of compliance indicated: Credible Allegation of Compliance: The creation of this Letter of Credible allegation constitutes a written allegation of compliance. Preparation and submission of this letter does not constitute an admission or agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth by the surveyor agency. This letter is solely prepared because of requirement under state and federal law, and to demonstrate the good faith attempts by the provider to improve the quality of life of each resident. Date: 10/06/2018 Corrective action accomplished for those residents found to have been affected by the deficient practice. On 5/19/2018 at 10:00 pm, Resident #1 was observed in the room by the licensed nurse #1. Resident #1 was attempting to put his hands under resident #2's cover while resident #2 was in bed. Resident #1 was removed from the room by licensed nurse #1. Head to toe skin assessment for resident #2 completed by licensed nurse #1 on 5/19/2018 no injuries noted. Resident #1 was placed on every 15 minutes watch check for 3 days and was discontinued as resident was noted to show no behaviors of wondering. Resident #1 & #2 attending physician and responsible party notified. On 9/19/18 at 10:15 pm, Resident # 1, was observed in the room of resident # 3. Resident # 1 was leaning over resident #3. Resident #1 observed kissing resident #3 on her mouth by certified nursing assistant #1. Resident #1 right hand was observed in resident #3 brief and left hand was observed putting his P . back in his pants. Two Nurse Aides, #1 and #2, saw resident # 1 and immediately removed him from the room. The CNAs reported it to licensed nurse #1 who completed head to toe skin assessment resident # 3 and found no signs of injury. Charge nurse #1 called the administrator at @11:30pm to inform of the incident. He advised the nurse to move patient #1 to the 100 hall which is away from Resident #3. Resident # 1 was immediately moved to another room and placed on 15 minute checks by licensed nurse #1 to ensure he did not go in any room other than his own, effective 9/19/18 at 10:45 pm for 3 days until 9/22/18 at 7:00am then was reduced to 30 minutes check as resident exhibited no wandering behavior for 3 days. 30 minutes check was continued for 5 days until 9/26/2018 at 3pm when it was reduced to hourly as resident exhibited no wandering behavior for 5 days. On 9/28/18 Resident was observed walking up and down the hall more often than usual. Licensed nurse #2 increased the monitoring to every 30 minutes completed by certified nurse aides on duty continue until 10/1/18 at 7am when resident was noted ambulating more on hallways. Every 15 minutes checks continue until today. Every 15 minute checks will continue until resident #1 is noted to wander safely on the hallway and exhibited no signs of wandering to other residents' rooms. Licensed nurse on duty will monitor to ensure the completion of 15 minutes check. Resident #1 & #3 family members were notified at the time by nurse #1. Both resident's physicians were notified at the time and no new orders by licensed nurse #1. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. 100% of wandering risk assessments for all current residents with wandering behavior completed by the Director of Nursing on 10/6/18 to identify if any resident exhibited wandering behaviors in the past 7 days, no other resident identified with wandering attempt in the last 7 days. 100% interview of all current alert and oriented resident was completed on 10/6/2018 by Assistant Director of Nursing, Director of Social services, Registered nurse supervisor and/or Central Supplies supervisor to identify any resident to include Resident #1 has wandered in their room uninvited and exhibited any inappropriate behavior. No other resident voiced any concern regarding resident #1 or any other resident related to wandering behaviors 100% interview of all current employees on duty interviewed by the Executive Director, Director of Nursing and/or Director of Social Services on 10/5/2018 and 10/6/2018 to identify if any wandering behaviors for resident #1 was noted to any resident to include residents with cognitive deficit. No other staff member voiced concerns for any additional residents beside, resident #2, and #3. Any staff member not interviewed by 10/6/2018 at 11:59pm will be not be allowed to work until interviewed. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective 10/6/2018, and moving forward, licensed nurses will complete Wandering risk assessments for all residents on admission/re-admission, quarterly, with any significant changes of resident's condition, and/or whenever a resident is noted to exhibit wandering behaviors/attempts. Any noted concerns will be addressed and corrected by licensed nurses immediately; interventions will be implemented and resident's care plan will be revised and updated immediately by licensed nurses. Direct care staff will be notified of new interventions put forth by a licensed nurse through resident's care guide which are located in each nursing station. Effective 10/6/2018, the center interdisciplinary team, which includes Director of Nursing, MDS nurse #1, MDS number #2, Registered nurse, Social worker #1, and Activity Coordinator #1, Executive director initiated a process for reviewing any resident who is noted with inappropriate wondering behaviors to identify the root cause of the behavior exhibited and put forth an appropriate intervention to prevent the reoccurrence. Intervention to include but not limited to prompt psychiatric evaluation, social service consultation, one on one care, and/or medication evaluation will be implemented when appropriate. Any identified issues will be addressed promptly and plan of care developed as indicated. This review will take Monday through Friday effective 10/6/18 Effective 10/6/2018, week end RN supervisor and/or designated licensed nurse reviewing any resident who is noted with inappropriate wandering behaviors to identify the root cause of the behavior exhibited and put forth an appropriate intervention to prevent the reoccurrence. Intervention to include but not limited to prompt psychiatric evaluation, social service consultation, one on one care, and/or medication evaluation will be implemented when appropriate. Any identified issues will be addressed promptly and plan of care developed as indicated. This review will take Saturday and Sunday through Friday effective 10/6/18. Executive Director, Director of Nursing, Certified Dietary Manager, Director of Social Services and/or Staff Development Coordinator conducted re-education for current scheduled staff, full time, part time and as needed employee for all departments started on 10/5/2016. This education included identifying wandering residents, abuse policy and procedures, proper reporting, appropriate actions to be taken for residents with wandering behaviors, wandering assessment completion requirements per protocol and provision of safety for all residents. This education will be completed by 10/6/2018, any employee not educated by 10/6/18 will not be allowed to work until educated on this requirement. Effective 10/6/2018. This education will be added on new hires orientation education for all new facility employees. This education will also be provided annually for all staff. The facility plans to monitor its performance to make sure that solutions are sustained. Effective 10/07/2018 the Director of Nursing, Assistant Director or Nursing, RN supervisors will review daily documentation and 24 hours reports to identify any indication of wandering behaviors. Any issues identified during this monitoring process will be addressed promptly. Findings from this monitoring process will be documented on a daily clinical report form and filed in clinical meeting binder after proper follow ups are done. This monitoring process will take place daily (M-F) for 2weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 10/6/2018, Executive Director and/or Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for three months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. The title of the person responsible for implementing the acceptable plan of correction Effective 10/06/2018 the facility executive Director and the Director of Nursing will be ultimately responsible for the implementation of this plan of correction to ensure the facility attains and maintains substantial compliance. Compliance Date 10/06/2018 The credible allegation was verified on 10/7/18 at 10:00 AM as evidenced by record review, observation, staff and resident interviews. Interviews were conducted with a sample of staff members from all three shifts to verify re-education was conducted for all employees regarding identifying wandering residents, abuse policies and procedures, proper reporting, appropriate actions to be taken for residents with wandering behaviors, wandering assessment completion requirements per protocol and provision of safety for all residents. The same sample of staff members were interviewed to assure the facility interviewed them regarding additional residents effected by the wandering behavior of Resident #1. Interviews were conducted with a sample of alert and oriented residents on all of the halls of the facility to verify they had been interviewed regarding wandering residents coming in their room uninvited and exhibiting inappropriate behavior. Observations were made to confirm the wandering residents were doing so safely. Documentation of wandering risk assessments, in-service records, and the current behavior/wandering log for Resident #1 were reviewed. All of the evidence indicated the facility had completed the corrective action by 10/6/18.

Based on record review, observation, staff, and resident interview the facility failed to prevent abuse for 2 (Resident's #2 and #3) of 3 sampled residents reviewed for abuse. Resident #1, a cognitively impaired resident, made an unwanted advancement into the personal space of Resident #2 and exhibited sexually aggressive behavior toward Resident #3, a cognitively impaired resident. Residents #2 specified the unwanted advancement was upsetting to her and Resident #3 was assessed by facility staff and found to have no physical injuries. Immediate Jeopardy began on 5/19/18 when Resident #1 made an unwanted advancement into the personal space of Resident #2. Immediate Jeopardy was removed on 10/6/18 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level grid position D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. Findings included: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The documentation on the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as severely cognitively impaired with trouble concentrating two to six days of the assessment period. Resident #1 was also assessed as having no behaviors and ambulatory with no assistance. The documentation in the care plan initiated on 1/31/18 for Resident #1 had problem areas for his inability to express emotion, listen and share information due to auditory and verbal deficits. The care plan for Resident #1 was updated on 5/19/18 with the problem area that stated, I demonstrate inappropriate behavior towards a female resident. The documentation of the approach on the care plan stated, Place resident in area where constant observation is possible. a. The documentation in a nursing note, written by Nurse #1, dated 5/19/18 at 10:25 PM for Resident #1 stated, Resident observed in another female resident's room on 300 hall. He had gotten in females room and was sitting in her (Resident #2) room in the wheel chair, had his hands under her covers and was attempting to touch her inappropriately without (her) consent. Resident (#2) had yelled out and had turned her call bell on to call for help. Resident (#1) was removed from her room and returned to his room and asked to go to bed for the night. Resident #2 had [DIAGNOSES REDACTED]. The documentation on the most recent quarterly MDS assessment dated [DATE] coded Resident #2 as having moderately impaired cognition and requiring extensive assistance of one person with bed mobility. Resident #2 was interviewed on 10/5/18 at 11:13 AM. Resident #2 revealed Resident #1 came in her room at night and put his hand under her bed covers. She stated she hollered and rang the call bell for help until they came and got Resident #1 out of her room. When asked how this made her feel at that time, she revealed it was upsetting. She indicated she still saw Resident #1 walking in the halls but he had not come into her room after that incident. Nurse #1, a nursing supervisor, was interviewed on 10/5/18 at 4:12 PM. Nurse #1 revealed that she was the nurse on the hall where Resident #1 resided on the evening of 5/19/18 but she usually worked on the first shift (7:00 AM to 3:00 PM). She indicated Resident #1 was removed from the room of Resident #2, redirected to his own room, and went to sleep on the evening of 5/19/18. She stated she called the facility Administrator to notify him of the incident with Resident #1 and Resident #2. Nurse #1 indicated she was directed by the Administrator to keep an eye on him (Resident #1). Nurse #1 revealed Resident #1 was checked on every 15 minutes by the nursing staff for a couple of days after the 5/19/18 incident. Nurse #2, a nursing supervisor, was interviewed on 10/6/18 at 8:41 AM. Nurse #2 indicated she worked on the second shift (3:00 PM to 11:00 PM) and sometimes third shift (11:00 PM to 7:00 AM) for the hallway where Resident #1 resided in (MONTH) (YEAR). Nurse #2 indicated that the first time Resident #1 demonstrated the concerning behavior of going into female resident rooms was on 5/19/18. She said he did have a tendency to wander but was easily redirected. Nurse #2 revealed the nursing staff kept an eye on him for a few days after the 5/19/18 incident but after a while the staff felt like he was okay. Nurse #2 revealed she did not think he would hurt anybody so the nursing staff were watching him. Documentation in a nursing note dated 5/27/18 at 10:39 PM, written by Nurse #3, stated in part, Resident has been wandering in and out of residents rooms. Resident has been easily redirected this shift. Documentation in a nursing note dated 5/28/18 at 8:52 AM, written by Nurse #3, stated in part, Resident did have behaviors noted this shift 11 PM -7 AM. Patient was combative with writer and staff trying to keep him out of ladies bedrooms while asleep. Eventually able to redirect resident to his room and continued to monitor him throughout the shift. Supervisor and management made aware. Nurse #3, the nurse who wrote the nursing notes dated 5/27/18 at 10:39 PM and 5/28/18 at 8:52 AM, did not respond to requests for an interview. An interview was conducted Nurse #2 (second shift supervisor) on 10/6/18 at 8:41 AM. Nurse #2 revealed she was not aware of the combative behavior and attempts to get into the female residents rooms of Resident #1 on 5/28/18. An interview was conducted with Nurse #1 (first shift supervisor) on 10/6/18 at 9:32 AM. Nurse #1 revealed she was not aware of the combative behavior and attempts to get into the female residents rooms of Resident #1 on 5/28/18. The DON (Director of Nursing) was interviewed on 10/5/18 at 4:15 PM. The DON indicated she was not made aware of the 5/28/18 behavior of Resident #1. An interview was conducted with the DON on 10/6/18 at 11:31 AM. She indicated that after the 5/19/18 wandering behavior of Resident #1 the care plan was updated with the intervention of 15 minute checks as needed. She indicated that after the 5/28/18 behavior of Resident #1 documented in the nursing notes the resident's care plan was updated with the interventions of frequent monitoring as needed and redirection with rest as needed. b. The documentation in an incident report regarding Resident #1 dated 9/19/18 at 10:15 PM stated, Resident (#1) was observed in another resident's room (female Resident #3) by 2 staff member, leaning over resident kissing her on the mouth and had his right hand in her (incontinence) brief and his left hand on his penis. When staff entered room, he was removed from her room, placed on another hall and 15 minute checks were started on resident. The documentation on the incident report indicated the family of Resident #1 was notified at 11:30 PM, no injuries were noted as well as notification of the physician, DON, and Administrator. Resident #3 had [DIAGNOSES REDACTED]. Documentation in an annual MDS assessment dated [DATE] coded Resident #3 as severely cognitively impaired with cognitive decision making skills and she was totally dependent on one or two people for all activities of daily living. Resident #3 was observed on 10/5/18 at 11:28 AM to be lying on her back in a low bed. The resident made moaning sounds but did not communicate verbally. The documentation in an incident report, written by Nurse #1, regarding Resident #3 dated 9/19/18 at 10:15 PM stated, Resident (#3) was observed lying in her bed, another resident was standing over her kissing her in the mouth and had his hand in her brief. Resident was not yelling out for help, was lying there calmly. The documentation in the incident report indicated there were no injuries noted as well as notification of the physician, DON and Administrator. Nurse #1, a nursing supervisor, was interviewed on 10/5/18 at 4:12 PM. Nurse #1 confirmed she was the nurse on the hall when Resident #1 was found in the room of Resident #3 on 9/19/18. Nurse #1 indicated she was notified by two nurse aides that Resident #1 was inappropriately touching Resident #3. She said Resident #1 was immediately returned to his room, Resident #3 was assessed for any injuries, and the Administrator was notified of the incident. Nurse #1 revealed the Administrator instructed her to move Resident #1 to another room on another hallway. Nurse #1 revealed she moved the resident to another hallway immediately and 15 minute checks were initiated for Resident #1. Nurse #1 stated she asked the two nurse aides on the hall to write statements regarding the incident. Nurse #1 stated the facility social worker was notified the next day of the events on the evening of 9/19/18. The documentation of the incident from NA (Nurse Aide) #1 stated, At 10:15 PM call light was on in Room (Number) and noticed there was a wheelchair by bed A. As I entered the room (I) saw (Resident #1) bent over kissing (Resident #3) in her mouth, his right hand was in her brief, his left hand was putting his private part back in his pants, after asked him what he was doing, I called for the nurse he then exited the room. The documentation of the incident from NA #2 stated, I was in hallway after CNA (certified nursing assistant) asked (Resident #3 what he was doing.) He was over (Resident #3's) bed and he had his private part out and then he put (it) back in his pants. An interview was conducted with the social worker on 10/5/18 at 4:56 PM. The social worker indicated that she was notified of the behavior of Resident #1 on the morning of 9/20/18. The social worker indicated the nursing staff were assessing the well-being of Resident #3 and that she did not assess Resident #3 on 9/20/18. Nurse #2, the second shift nursing supervisor, was interviewed on 10/6/18 at 8:41 AM. She stated the behavior on the evening of 9/19/18 was not the usual behavior for Resident #1. She indicated he did not usually have problematic behavior but would wander in the hallways. The DON was interviewed on 10/5/18 at 4:15 PM. The DON indicated she was notified of the behavior of Resident #1 on the morning of 9/20/18. She stated that the intervention put in place after the incident was the removal of the resident to another hallway, every 15 minutes a documented check of the resident, a mental health consult, checking of the urine for possible urinary tract infections as needed, redirection, and the encouragement of facility activities. The DON provided documentation of the 15 minute monitoring of the resident initiated on 9/19/18 and indicated that the monitoring time interval varied as the concern for the behavior of Resident #1 varied. The DON indicated the nurses staff varied the monitoring interval for the resident based on the amount of wandering he was doing. The DON stated if Resident #1 was walking around more the interval was every 15 minutes to check on him. A review of the documentation on the location and behavior monitoring for Resident #1 indicated that various time intervals were used to monitor the resident. The documentation shows that on 9/19/18 beginning at 10:15 PM Resident #1 was monitored every 15 minutes until 6:45 AM on 9/20/18. There was no location/behavior log documentation for 9/20/18 from 7:00 AM to 9/21/18 at 2:30 PM. An interview was conducted with NA #3 on 10/6/18 at 8:04 AM. NA #3 stated that on 9/20/18 -9/21/18 she was assigned to Resident #1 on the first shift and part of the second shift. NA #3 indicated she monitored the resident every 15 minutes or 30 minutes depending what was on written on the behavior log on the clip board. NA# 3 indicted the nursing assistants did not determine the monitoring interval for Resident #1. NA #3 stated Resident #1 has been monitored every day since he arrived on the hallway. NA #3 stated she was told Resident #1 had been in a ladies room, had done something inappropriate and had to be moved to another hall. NA#3 stated that Resident #1 was being monitored so he did not go into female resident rooms. An interview was conducted with NA #4 on 10/6/18 at 7:45 AM. NA #4 indicated she was assigned to Resident #1 on 9/20/18 on the second shift and monitored the resident every 15 minutes. NA #5 was interviewed on 10/6/18 at 8:10 AM. NA #5 indicated Resident #1 was being monitored so he did not go into other people's rooms. NA #5 indicated she would monitor the resident every 15 to 30 minutes based on what was on the monitoring sheet at the nurses station. NA #5 indicated she was assigned to Resident #1 on 9/20/18-9/21/18 for the third shift. She stated she monitored the resident every 15 or 30 minutes on 9/20/18. NA #5 stated once or twice Resident #1 got up to use the bathroom but the majority of the time she went in to check on him he was still sleeping. The documentation on the location and behavior monitoring for Resident #1 for 9/21/18-9/25/18 indicated the resident was monitored every half hour. The documentation for the location and behavior monitoring for Resident #1 for 9/26/18-9/27/18 changed to every hour. Documentation indicated on 9/28/18 Resident #1 was monitored every half hour. There was no documentation for monitoring of Resident #1 for 9/29/18-9/30/18. The documentation indicated the behavior monitoring resumed for every 15 minutes from 10/1/18 to 10/6/18. Documentation in a physician's progress note dated 10/1/18 stated, (Patient) has been moved to 100 Hall because he was caught sexually molesting another resident. Because adequate communication with him is impossible, we felt that the only way to help was to remove him from the hall he was on. There have been no incidents since then. The physician was interviewed on 10/6/18 at 10:45 AM. The physician indicated Resident #1 can't communicate due to a [MEDICAL CONDITION] which left him unable to hear and speak clearly. He stated he was notified of both the incident Resident #1 had with Resident #2 and Resident #3. He stated Resident #2 was scared a little bit by Resident #1 coming in her room but he did not touch her. He stated he was not aware of any other additional incidents since Resident #1 was moved to another hallway. The Administrator was interviewed on 10/5/18 at 4:15 PM. The Administrator confirmed he was notified of the 9/19/18 incident by a phone call from Nurse #1 late that night. He stated he did not recall sending a report to the state regarding the 9/19/18 incident with Resident #1 and acknowledged it was the facility policy to do so. The DON was interviewed on 10/6/18 at 4:24 PM. She indicated it was her expectations that for the safety of the residents Resident #1 should have been and was removed from the situation. The DON said the priority was to keep the residents safe. She stated it was her expectation that residents be assessed, family notified, proper reporting, care planning, staff in-services as needed, and incident reports filled out after an allegation of sexual abuse. On 10/15/18 at 6:00 PM the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation of immediate jeopardy removal on 10/17/18. The credible allegation of immediate jeopardy removal indicated: The creation of this Letter of Credible allegation constitutes a written allegation of compliance. Preparation and submission of this letter does not constitute an admission or agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth by the surveyor agency. This letter is solely prepared because of requirement under state and federal law, and to demonstrate the good faith attempts by the provider to improve the quality of life of each resident. Date: 10/06/2018 Corrective action accomplished for those residents found to have been affected by the deficient practice. On 5/19/2018 at 10:00 pm, Resident #1 was observed in the room by the licensed nurse #1. Resident #1 was attempting to put his hands under resident #2's cover while resident #2 was in bed. Resident #1 was removed from the room by licensed nurse #1. Head to toe skin assessment for resident #2 completed by licensed nurse #1 on 5/19/2018 no injuries noted. Resident #1 was placed on every 15 minutes watch check for 3 days and was discontinued as resident was noted to show no behaviors of wondering, or sexual inappropriate abusive behaviors. Resident #1 & #2 attending physician and responsible party notified. On 9/19/18 at 10:15 pm, Resident # 1, was observed in the room of resident # 3. Resident # 1 was leaning over resident #3 and was observed kissing resident #3 on her mouth by certified nursing assistant #1. Resident #1 right hand was observed in resident #3 brief and left hand was observed putting his P . back in his pants. Two Nurse Aides, #1 and #2, saw resident # 1 and immediately removed him from the room. The CNAs reported it to licensed nurse #1 who completed head to toe skin assessment resident # 3 and found no signs of injury. Charge nurse #1 called the administrator at @11:30pm to inform of the incident. He advised the nurse to move patient #1 to the 100 hall which is away from Resident #3. Resident # 1 was immediately moved to another room and placed on 15 minute checks by licensed nurse #1 to ensure he did not go in any room other than his own, effective 9/19/18 at 10:45 pm for 3 days until 9/22/18 at 7:00am then was reduced to 30 minutes check as resident exhibited no wandering behavior for 3 days. 30 minutes check was continued for 5 days until 9/26/2018 at 3 PM when it was reduced to hourly as resident exhibited no wandering behavior for 5 days. On 9/28/18 Resident was observed walking up and down the hall more often than usual. Licensed nurse #2 increased the monitoring to every 30 minutes completed by certified nurse aides on duty continue until 10/1/18 at 7 AM when resident was noted ambulating more on hallways. Every 15 minutes checks continue until today. Every 15 minute checks will continue until resident #1 is noted to wander safely on the hallway and exhibited no signs of wandering to other resident's room. Licensed nurse on duty will monitor to ensure the completion of 15 minutes check. Resident #1 & #3 family members were notified at the time by nurse #1. Both resident's physicians were notified at the time and no new orders by licensed nurse #1. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. On 10/06/2018, 100% interviews was completed by Assistant Director of Nursing, Director of Social services, Registered nurse supervisor and/or Central Supplies supervisor for all current alert and oriented residents in the facility to identify any other resident with an allegation of Abuse and/or Neglect. No other resident, voiced allegation of abuse and/or neglect, or sexual inappropriate behaviors. On 10/06/2018 100% interviews was completed by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Nurse Manager for all employees on site on 10/6/2018 to identify any awareness of any resident with an allegation of Abuse and/or Neglect. No concerns related to abuse, neglect or sexual misappropriate behavior were voiced. This interview was completed for all staff, to include full time, part time and as needed staff. Any employee not interviewed by 10/06/2018 will not be allowed to work until interviewed. 100% interview of all current alert and oriented residents was completed on 10/6/2018 by Assistant Director of Nursing, Director of Social services, Registered nurse supervisor and/or Central Supplies supervisor to identify any resident which includes Resident #1 who has wandered into their room uninvited and exhibited any inappropriate behavior. No other resident voiced any concern regarding resident #1 or any other resident related to wandering behaviors 100% of all current employees on duty was interviewed by the Executive Director, Director of Nursing, Director of Social Services and Nursing Supervisor on 10/5/2018 and 10/6/2018 to identify if any wandering behaviors for resident #1 was noted to any resident to include residents with cognitive deficit. No other staff member voiced concerns for any additional residents beside, resident #2, and #3. Any staff member not interviewed by 10/6/2018 at 11:59 PM will be not be allowed to work until interviewed. Family members for residents that are not alert and oriented were interviewed by the DON and ADON on 10/06/18 to identify any residents which includes Resident #1 who has wandered into their family member's room uninvited and exhibited any inappropriate behavior. No family members voiced any concern regarding resident #1 or any other resident related to wandering behaviors. 100% of non interviewable residents had head to toe assessments completed by the RN Supervisor, SDC and hall nurses on 10/5/2018 and 10/6/2018 to look for any signs of abuse or signs of sexual abuse. No signs of abuse or sexual abuse were noted. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective 10/06/2018 the ADON, Nurse supervisors, and/or SDC, initiated a process for reviewing clinical documentation for the last 24 hours. This review will include completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. before it happened. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly, and appropriate actions will be implemented by the DON, ADON, SDC and/or Registered Nurse supervisor. Any negative findings will be documented on the daily clinical meeting form and maintained in the daily clinical meeting binder. Effective 10/06/2018, week end Registered Nurse supervisor and/or designated licensed nurse will review reviewing clinical documentation for the last 24 hours. Then this review will include completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. before it happened. This systemic process will take place every Saturday and Sunday. Any negative findings will be documented on the week end supervisor report form and maintained in the daily clinical meeting binder. Effective 10/6/2018, the center interdisciplinary team, which includes Director of Nursing, MDS nurse #1, MDS number #2, Registered nurse, Social worker #1, and Activity Coordinator #1, Executive director initiated a process for reviewing any resident who is noted with inappropriate wandering behaviors to identify the root cause of the behavior exhibited and put forth an appropriate intervention to prevent escalation of the behaviors and hence prevent abuse before it happened. Intervention to include but not limited to prompt psychiatric evaluation, social service consultation, one on one care, and/or medication evaluation will be implemented when appropriate to prevent possibility of abuse. Any identified issues will be addressed promptly and plan of care developed as indicated. This review will take Monday through Friday effective 10/06/2018 Effective 10/06/2018, week end RN supervisor and/or designated licensed nurse reviewing any resident who is noted with inappropriate wandering behaviors to identify the root cause of the behavior exhibited and put forth an appropriate intervention to prevent escalation of the behaviors and hence prevent abuse before it happened. Intervention to include but not limited to prompt psychiatric evaluation, social service consultation, one on one care, and/or medication evaluation will be implemented when appropriate. Intervention to include but not limited to prompt psychiatric evaluation, social service consultation, one on one care, and/or medication evaluation will be implemented when appropriate to prevent possibility of abuse. Any identified issues will be addressed promptly and plan of care developed as indicated. This review will take Saturday and Sunday through Friday effective 10/06/18. Executive Director, Director of Nursing, Certified Dietary Manager, Director of Social Services and/or Staff Development Coordinator conducted re-education for current scheduled staff, full time, part time and as needed employee for all departments started on 10/5/2016. This education included identifying wandering residents, the facility's abuse and neglect prohibition policy including prevention, protection, investigation, and notification, as well as, appropriate actions to be taken to prevent abuse from happening by early identification of warning signs from wandering residents. This education will be completed by 10/6/2018, any employee not educated by 10/06/2018 will not be allowed to work until educated on this requirement. Effective 10/6/2018, this education will be added on new hires orientation for all new facility employees. This education will also be provided annually for all staff effective 10/06/2018. The facility plans to monitor its performance to make sure that solutions are sustained. Effective 10/07/2018 the Administrator, Director of Nursing, and/or Director of Social Services will review clinical documentation for the last 24 hours. This review will include, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. before it happened. Any issues identified during this monitoring process will be addressed promptly by the DON, ADON, SDC and/or Registered Nurse supervisor. Findings from this monitoring process will be documented on a daily clinical report form and filed in clinical meeting binder after proper follow ups are done. This monitoring process will take place daily (Monday - Friday) for 2 weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 10/7/2018, Executive Director and/or Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for three months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. The title of the person responsible for implementing the acceptable plan of correction Effective 10/06/2018 the facility executive Director and the Director of Nursing will be ultimately responsible for the implementation of this plan of correction to ensure the facility attains and maintains substantial compliance. Compliance Date 10/06/2018 The credible allegation was verified on 10/18/18 at 5:30 PM as evidenced by record review, observation, staff and resident interviews. Interviews were conducted with a sample of staff members from all three shifts to verify re-education was conducted for all employees regarding identifying wandering residents, abuse policies and procedures, proper reporting, appropriate actions to be taken for residents with wandering behaviors, wandering assessment completion requirements per protocol and provision of safety for all residents. The same sample of staff members were interviewed to assure the facility interviewed them regarding additional residents effected by the wandering behavior of Resident #1. Interviews were conducted with a sample of alert and oriented residents on all of the halls of the facility to verify they had been interviewed regarding wandering residents coming in their room uninvited and exhibiting inappropriate behavior. Family members for residents who were not alert and oriented were interviewed to verify they were contacted by the facility regarding any concerns for abuse or inappropriate behavior by wandering residents. Three residents that were at risk for wandering/behaviors were reviewed and all had care plans in place to address wandering behaviors and appropriate interventions in place. Observations were made of the wandering residents with no concerns noted regarding inappropriate behavior. Documentation of wandering risk assessments, in-service records, and the current behavior/wandering log for Resident #1, skin assessments of non-interviewable residents, audit tools, and clinical round checklists were reviewed. All of the evidence indicated the facility had completed the corrective action by 10/6/18.