Every finding on record at Pavilion Health Center at Brightmore

Based on record review and resident, staff and Law Enforcement Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of property when Housekeeper #1 used a resident's credit card to buy personal items for herself. This deficient practice affected 1 of 3 residents reviewed for misappropriation of property (Resident #30).The findings included:The facility Abuse Prohibition Policy dated 9/2022 and last approved on 10/2025 read in part, Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings, or money without the resident's consent. The policy stated, it is the policy of this facility not to employee or otherwise engage individuals found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law. If any problems are identified that could lead to a potential abuse threat, the applicant should not be hired or if already hired, will be terminated from employment.Resident #30 was admitted to the facility on [DATE]. Resident #30 was his own Responsible Party (RP).A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #30 was cognitively intact.A review of the Initial Allegation Report dated 8/21/2026 at 12:38 PM indicated the facility became aware of the misappropriation of Resident #30 funds on 8/21/2026 at 11:04 AM when Resident #30 notified the facility that he had received an email from his financial institution's fraud unit on 8/21/2026 stating there were possible fraudulent charges on his account totaling $500. Resident #30 indicated he received a credit on 8/21/2026 to his account for the unauthorized charges due to reporting fraud. There was no accused staff. Local law enforcement was contacted 8/21/2026 at 11:56 AM. The facility immediately initiated an investigation. Resident #30 was immediately provided with a lockbox. The Initial Allegation Report was completed and signed by the Administrator.A review of the Investigation Report dated 8/28/2026 at 1:08 PM revealed the facility Administrator had contacted one of the stores on 8/21/2026 where Resident #30's card had been used, and the store was able to match the transaction number, date and amount of the purchase to Housekeeper #1's store rewards account. Housekeeper #1 was immediately suspended on 8/21/2026 pending the investigation. The facility had contacted local law enforcement but no charges were filed. Adult Protective Services (APS) was notified but did not open a case. The facility interviewed all current residents who were cognitively intact and asked if there were any concerns with misappropriation of property. Interviews were completed with the Responsible Parties (RPs) for all residents who were cognitively impaired. No other residents or RPs identified any issues with misappropriation of resident property. All staff education regarding abuse, neglect and misappropriation was initiated by the facility on 8/21/2026. The Investigation Report was completed and signed by the Administrator.A review of the Law Enforcement report dated 8/21/2026 at 12:16 PM indicated the case was closed as Resident #30 chose not to prosecute.A telephone interview on 9/2/2026 at 3:55 PM with the Law Enforcement Officer who responded to the facility on 8/21/2026 revealed no investigation was conducted and the case was closed because Resident #30 chose not to prosecute.A review of Resident #30's credit card statement for 8/2026 revealed that Resident #30 had identified six unauthorized charges made on 8/21/2026: a food purchase of $25.32; a sporting goods purchase of $270.64; a tobacco/vape purchase of $5.56; a gasoline purchase of $30.01; a grocery purchase of $85.93; and a liquor store purchase of $23.49. The charges totaled $440.95. The credit card statement indicated all unauthorized charges had been listed as a purchase adjustment and fully credited to Resident #30's account by 8/22/2026.An interview conducted with Resident #30 on 9/1/2026 at 10:08 AM revealed Resident #30 received an email on 8/21/2026 from his financial institution which indicated there were possible fraudulent charges on his credit card account. Resident #30 stated he reviewed his online statement and the unauthorized charges were approximately $500 dollars. Resident #30 reported he identified the fraudulent charges and his credit card account was credited for those amounts. Resident #30 stated the credit card was cancelled and a new card was sent by overnight mail. Resident #30 stated he believed his credit card was taken on 8/20/2026 when he was asleep or in the bathroom as he chose to stay in his room most of the time. Resident #30 stated he had heard a housekeeper took his credit card, but he was unsure of the person's name. Resident #30 stated he had never given his credit card to any staff member to use. Resident #30 indicated he always left his wallet out on his bedside table and never had an issue with missing property. Resident #30 reported no other credit cards were missing from his wallet and no items were missing from his room. Resident #30 stated local law enforcement had come to his room on 8/21/2026 but Resident #30 chose not to press charges as Resident #30 reported he had done some stupid things when he was younger, had been granted some forgiveness and felt he needed to pass that along. Resident #30 indicated the facility provided a lockbox for him but he did not see the need for it and had placed it under his bed. Resident #30 stated he got his money back so he wasn't too concerned about the incident. Resident #30 indicated he was not sure why the facility thought it was a big deal.An interview with the Housekeeping Manager on 9/2/2026 at 3:00 PM revealed she had heard a rumor that a resident's credit card had been stolen but she was not involved in the investigation for Resident #30. The Housekeeping Manager stated Housekeeper #1 was off on 8/21/2026 and never came back to work. The Housekeeping Manager indicated all staff received abuse, neglect and misappropriation education recently and were also educated regarding abuse, neglect and misappropriation upon hire and yearly through online modules. The Housekeeping Manager stated the education included that staff was not to take money or gifts from residents.A telephone interview conducted on 9/2/2026 at 3:30 PM with Housekeeper #1 stated Resident #30 gave her his credit card on 8/20/2026 to use for items she needed such as shoes and school supplies for her child in exchange for making a purchase for him as he only had $10 cash. Housekeeper #1 indicated she was off on 8/21/2026 and received a call on that date from the Administrator asking Housekeeper #1 if she knew anything about Resident #30's missing credit card. Housekeeper #1 indicated the Administrator suspended her on 8/21/2026 pending the investigation. Housekeeper #1 stated she was not sure why Resident #30 reported the charges as fraud as he gave her the credit card to use. Housekeeper #1 stated the Administrator had asked her to write a statement which she was in the process of writing during the week of 9/1/2026. Housekeeper #1 reported her last working day was 8/20/2026 and she had not returned to the facility. Housekeeper #1 stated she remained under a suspended status and had not heard anything further from the facility.An interview on 9/2/2026 at 4:00PM with the Administrator revealed the facility was told by Resident #30 that he had been notified that he had fraudulent charges on his credit card and his credit card was missing from his wallet. The Administrator stated the facility called law enforcement, Adult Protective Services (APS) and the State Agency. The Administrator reported that law enforcement interviewed Resident #30 but Resident #30 did not want to press charges. The Administrator indicated the facility investigated and she found out who had taken the credit card as the Administrator had called the sporting goods store where an unauthorized charge was made. The Administrator stated the store matched the transaction number, date and amount of the purchase to Housekeeper #1's rewards account. The Administrator reported she contacted Housekeeper #1 on 8/21/2026 who denied the allegation. The Administrator stated she spoke again with Housekeeper #1 but could not recall the date and Housekeeper #1 told her that Resident #30 had given her the credit card to use. The Administrator revealed Resident #30 denied giving Housekeeper #1 the credit card and stated he did not give permission for her to use the card. The Administrator stated she did not know what Housekeeper #1 had done with Resident #30's card. The Administrator indicated Housekeeper #1 was still suspended and the facility had attempted to contact Housekeeper #1 for her statement but the facility has not been able to reach her. The Administrator stated the facility did not have enough evidence to substantiate the allegation. The Administrator stated Housekeeper #1 broke facility policy by using Resident #30's credit card.A follow up interview with Resident #30 on 9/2/2026 at 4:30 PM indicated he thought it might have been [Housekeeper #1] as she was in and out of the room a lot on 8/20/2026. Resident #30 stated he had not agreed to pay for any of Housekeeper #1's purchases and had not given her his credit card to use. Resident #30 reported he still did not want to press charges and considered the matter closed.The facility submitted a plan of correction for past non-compliance consideration. The plan of correction was not accepted as it did not identify those residents with credit cards or valuables in room, the education provided to residents regarding securing credit cards or valuables in room, what residents were to report and how residents that were admitted prior to 8/24/26 were to know they could request a lock box for credit cards or valuables. The plan of correction did not address who would review background checks for agency staff and did not identify how the education provided to staff was different from previous and other required training about abuse.

Based on record review and staff interviews, the facility failed to submit a request for a Preadmission Screening and Resident Review (PASRR) evaluation for a resident with increased behavior for 1 of 5 residents reviewed for coordination of PASRR assessments (Resident #9). The findings included:A review of the medical record revealed that Resident #9 was considered by the State of North Carolina to have a Level II PASRR Halted, dated 9/5/25 with no expiration date. The notification letter indicated no further PASRR screening was required unless a significant change occurred with the individual's mental status which suggested a psychiatric disorder that is not dementia.Resident #9 was admitted to facility on 9/5/25 with diagnoses that included paranoid schizophrenia, depression, and anxiety disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated an active diagnosis of schizophrenia and use of antipsychotic medication. The MDS indicated Resident #9 was currently considered by the state Level II PASRR process to have a serious mental illness. A review of Resident #9's care plan last revised on 8/19/26 revealed Resident #9 had a Level II PASRR Halted related to severe mental illness. Interventions included reporting severe changes in cognitive functioning and an increase in behaviors to the state PASRR department. The care plan also indicated a focus area dated 8/12/26 which revealed Resident #9 verbalized suicidal ideation with a plan for suicide and/or injuries as evidenced by saying he didn't want to live and he would try and save some pills to add up to multiple doses and it would be enough to take him out. Resident #9 had diagnoses of quadriplegia and anxiety and required total care by staff and was seen by a Psych NP (Psychiatric Nurse Practitioner). Interventions included reporting any suicidal ideations, threats to Medical Director if noted, reporting to nurse and Psych NP immediately if Resident #9 verbalized suicidal thoughts, and administering medication as ordered.A review of Nurse Practitioner (NP) #2's progress note dated 8/12/26 revealed last night staff overheard Resident #9 stating he wanted to end his life. Per the report, Resident #9 reported he was going to save his medications for a couple of days and take them all at once. The progress note indicated Resident #9 denied all suicidal statements. No documentation was discovered in Resident #9's medical record that a referral was made for an updated PASRR evaluation when Resident #9 vocalized a suicidal ideation with a plan to nursing staff on the 7:00 PM to 7:00 AM shift on 8/11/26-8/12/26. An interview with the Social Worker (SW) conducted on 9/2/26 at 5:04 PM revealed she was responsible for completing the PASRR referrals but was not aware of Resident #9's suicidal ideation statement on the 7:00 PM to 7:00 AM shift on 8/11/26-8/12/26 and was on vacation during that time. The SW stated the Social Work Assistant was covering for her during that time but had not made her aware of Resident #9's statements to nursing staff. The SW stated the suicidal ideation statement would have warranted a PASRR referral. An interview with the Social Work Assistant occurred on 9/2/26 at 5:34 PM. She revealed when she arrived at work on 8/12/26, she was given a note passed on from a night shift Nurse Aide about Resident #9 having suicidal statements. She stated she made NP #2 aware of the note. The Social Work Assistant was not aware she needed to request a PASRR evaluation. An interview with the Administrator was conducted on 9/3/26 at 4:19 PM. She stated the PASRR screen should have been discussed in the clinical meeting after the suicidal ideation statements were made and a referral for a PASRR evaluation should have been completed for Resident #9.

Based on record review and staff interviews, the facility failed to submit a request for an updated Preadmission Screening Resident Review (PASRR) evaluation for a resident who was admitted to the facility with a diagnosis of bipolar disorder for 1 of 4 residents reviewed for PASRR (Resident #96).The findings included: A review of the medical record revealed a Level I PASRR completed for Resident #96 on 6/04/26 indicated she had no mental health diagnoses and did not include her active diagnosis of bipolar disorder. The Level I PASRR determination letter noted Resident #96 did not to meet the federal definition for mental illness and was assigned a PASRR number with no expiration. Resident #96 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. A review of the medical record revealed no evidence that an updated PASRR evaluation was requested for Resident #96. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 was cognitively intact, exhibited no behaviors or rejections of care, had an active diagnosis of bipolar disorder, and was receiving anti-anxiety and anti-depressant medications. The MDS indicated Resident #96 was not currently considered by the state Level II PASRR authority to have a serious mental illness or intellectual disability. An interview conducted with Social Worker #1 on 9/02/26 at 4:56 PM revealed she was responsible for ensuring a Level I PASRR was completed for all residents prior to admission. She indicated the hospital case managers usually completed the Level I PASRR however she reviewed the Level I screen in the North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) to ensure it included any active diagnoses of serious mental illness. Social Worker #1 stated a Level 1 PASRR was completed for Resident #96 prior to admission, however she must have overlooked that the Level 1 PASSR screen submitted by the hospital case manager did not include Resident #96's active diagnosis of bipolar disorder. Social Worker #1 revealed she should have requested a new Level 1 PASRR screen for Resident #96 including the diagnosis of bipolar disorder and submitted it for review. An interview conducted with the Administrator on 9/02/26 at 5:00 PM indicated Social Worker #1 was responsible for ensuring a Level I PASRR was completed for all residents prior to admission and reviewing the Level I PASRR screens submitted by the hospital case managers to ensure they included the resident's diagnoses of mental illness. The Administrator stated Social Worker #1 should have completed a new Level I PASRR screen for Resident #96 which included the diagnosis of bipolar disorder and submitted it for review.

Based on record review, staff, Nurse Practitioner (NP) #2, On-Call NP, Medical Director, and Family Member #1 interviews, the facility failed to immediately implement a comprehensive plan to ensure highest practicable mental health and psychosocial well-being and failed to immediately notify Family Member #1 when Resident #9 voiced a suicidal ideation with a plan to Nurse Aide (NA) #1 on the 7:00 PM to 7:00 AM shift of 8/11/26-8/12/26. Resident #9 was seen by the Psychiatric NP on 8/11/26 due to his significant anxiety and depressive symptoms, his refusal of his anti-depressant medication and his request to have the medication discontinued. This deficient practice was for 1 of 1 resident reviewed for mental health services (Resident #9). The findings included:Resident #9 was admitted to facility on 9/5/25 with diagnoses that included quadriplegia, paranoid schizophrenia, depression, and anxiety disorder.Resident #9's annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and did not exhibit any hallucinations or delusions. He was coded for verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others which both occurred one to three days a week. Resident #9 was coded for behaviors which significantly interfered with his care and significantly disrupted care or living environment. The MDS further revealed Resident #9 did not exhibit having little interest or pleasure in doing things and did not feel down, depressed, or hopeless. Resident #9 utilized a wheelchair and was coded for functional limitation in range of motion for both upper and lower extremities. The MDS indicated Resident #9 was dependent on staff for all activities of daily living (ADL). Resident #9's Mood Interview indicated no presence and no frequency of having little interest or pleasure in doing things or feeling down, depressed, or hopeless. Resident #9's care plan dated 7/22/26 revealed a focus area for an ADL self-care performance deficit due to his diagnosis of quadriplegia and interventions included total dependence on staff for ADL, utilization of mechanical lift and two staff members for all transfers, and skin inspections with daily and reporting changes to the nurse on duty. Resident #9's care plan also revealed a focus area for verbally aggressive behavior and poor impulse control. Interventions included administering medications as ordered, monitor and document for side effects and effectiveness, approaching Resident #9 in a calm manner, providing positive feedback for good behavior, and psychiatric consult as indicated. Resident #9 had an additional focus area for a halted Level II Preadmission Screening and Resident Review (PASRR) related to severe mental illness and interventions included reporting an increase in behaviors or severe changes in cognitive functioning to the state PASRR department. The care plan also revealed Resident #9 had an additional focus area for behaviors indicating he was resistive to care, chose not to follow treatment plan, refused medication, refused to allow staff to change drinking straw and refused incontinence care. Interventions included education of the possible outcomes of not complying with treatment or care and giving clear explanations of all care activities prior to and as they occur during each contact. A review of a Psychiatric (Psych) NP progress note dated 8/11/26 revealed Resident #9 was seen related to nursing reports that he has been noted with significant anxiety and depressive symptoms. The note indicated Resident #9 had been refusing his antidepressant medication and requested sertraline (an anti-depressant) to be discontinued. The Psych NP note revealed Resident #9 was taking 3 milligrams (mg) of melatonin (an over-the-counter dietary supplement used to help with trouble sleeping) at bedtime for sleep and he was noted to be fidgeting during the visit and appeared restless. The note further indicated Resident #9 had a sad affect at times during the visit and they discussed some non-pharmacological interventions for anxiety and depressive thoughts, as he was not agreeable to medications. Resident #9 reported he felt disconnected and sad because he had not been able to get in touch with his family as easily over the previous two weeks. The Psych NP noted Resident #9's family brought him a new phone set up to use voice commands to make calls. The note indicated to continue the 3mg of melatonin at night for insomnia and the plan was to attempt to build rapport and continue discussion of potential medication management. An attempt for a phone interview with the Psych NP occurred on 9/3/26 at 2:30 PM but she was out of the office for the week and was not reachable by phone.A review of Resident #9's August 2026 Medication admission Record (MAR) revealed the following medications were documented as given by Nurse #1 at 9:00 PM on 8/11/26: 3mg of melatonin, 81mg of Aspirin, 20mg of baclofen (a muscle relaxer), 300mg of gabapentin (to treat nerve pain), and 5mg of oxybutynin (to treat overactive bladder). The MAR also revealed Resident #9 was documented as receiving a 7.5mg-325mg tablet of hydrocodone-acetaminophen (narcotic pain reliever) at 10:38 PM by Nurse #1.A review of the nursing staffing schedules revealed Nurse #1 and NA #1 worked the 7:00 PM to 7:00 AM shift on 8/11/26-8/12/26.An interview with Nurse Aide (NA) #1 occurred on 9/2/26 at 7:25 PM. She stated Resident #9 voiced the suicidal ideation and plan to her on the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26. NA #1 could not recall exactly what time he stated he would save up his pills to hopefully be able to take himself out, but she immediately reported it to Nurse #1. She stated he told her that no one liked him or cared for him, and he may as well be dead. NA #1 stated she tried to calm him and gave him support. She also revealed she sat with him and watched television and tried to be encouraging to him. NA #1 stated Nurse #1 came in and checked on him, and NA #1 was told to keep an eye on him. NA #1 indicated she sat in the hallway at various times through her shift to monitor him and Nurse #1 told her to alert her immediately if Resident #9 said anything else concerning. NA #1 stated she was not aware of any documentation showing how often Resident #9 was checked or monitored. A telephone interview with Nurse #1 on 9/2/26 at 6:08 PM revealed she worked at the facility as needed. She could not recall if Resident #9 had voiced any suicidal statements, but if he had, she would have him monitored by staff. Nurse #1 stated a nurse aide might have told her about Resident #9 making a suicidal statement but could not really remember. She stated she did recall Resident #9 being depressed. Nurse #1 could also not recall if any monitoring was completed or if monitoring was documented anywhere in the Electronic Medical Record (EMR) but stated there could be a piece of paper somewhere if 15-minute checks were completed, but she could not recall if any checks were implemented during the 7:00 PM to 7:00 AM sift on 8/11/26 to 8/12/26. She revealed the on-call provider would have a record if she called them, but she could not remember if she called them. Nurse #1 indicated she would have written a progress note in Resident #9's EMR if he had made any suicidal statements. There were no nursing progress notes in Resident #9's EMR for the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26 by nursing staff detailing any suicidal statements made by Resident #9, monitoring plan, notification to the provider, or notification to Family Member #1 regarding Resident #9's status. An interview with the Social Work Assistant occurred on 9/2/26 at 5:34 PM. She revealed when she arrived at work on 8/12/26, she was given a note passed on from a night shift NA about Resident #9 having suicidal statements. She stated she made NP #2 aware of the note. A review of a Nurse Practitioner (NP) progress note written by NP #2 dated 8/12/26 revealed last night staff overheard Resident #9 stating he wanted to end his life. Per the report, Resident #9 reported he was going to save his medications for a couple of days and take them all at once. The progress note indicated Resident #9 denied all suicidal statements and reported the NA made everything up. The progress note revealed Resident #9 exhibited anxiety and she had a difficult time redirecting the conversation and Resident #9 wanted to discuss how he didn't like his NA. NP #2 further indicated in her note she spoke to Family Member #1 about the reported suicidal statement Resident #9 made to staff and Family Member #1 indicated Resident #9 would make statements when he's mad that he later regrets.A phone interview with NP #2 on 9/2/26 at 6:44 PM revealed she was the primary care NP for Resident #9 and she knew him well. She stated she was notified by the Social Work Assistant and nursing staff on the morning of 8/12/26 when she arrived at the facility that Resident #9 had made a suicidal statement with a plan the previous night. NP #2 stated she met with Resident #9 on the morning of 8/12/26 and he denied everything and accused the nursing staff of lying about what he said. She explained she was not notified by nursing staff on the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26 and stated generally when any resident has made a suicidal statement with a plan, she would send them to the hospital for evaluation. NP #2 indicated Resident #9 did not have the use of his hands due to his quadriplegia and would have expected staff to have a monitoring plan for him. NP #2 stated she would have wanted nursing staff to call her immediately to notify her when he made the statement and added she would have liked to speak to Resident #9 over the phone that night and worked with staff to come up with a plan for monitoring. A phone interview with Family Member #1 on 9/3/26 at 9:21 AM revealed she was told the following morning on 8/12/26 that Resident #9 made a suicidal statement to staff. She could not recall which staff member informed her and stated it could have been the Administrator, but she wasn't sure. Family Member #1 stated it was not like him to make a statement like that, and she thought something that day did not go his way, and he made the statement to staff. She stated Resident #9 was not a suicidal person by nature and did not like to take medications that he felt would drug him. She stated this was the first time ever that Resident #9 had made a suicidal statement and wanted to be notified of it by staff. Family Member #1 indicated Resident #9 was anxious and depressed and she felt he needed to be back on his medication but stated typically when Resident #9 thought about the medications he was taking, he would stop taking it. She also explained Resident #9 could not pick up his right arm to his mouth, but his left arm was able to reach his mouth, although he was not able to utilize his hands or fingers to adequately feed himself. An interview with Nurse #2 on 9/3/26 at 12:29 PM revealed Resident #9 took his pills whole, not crushed and she would feed a few at a time to him on a spoon each morning. She stated she worked with Resident #9 often and she was on duty on 8/12/26 for the 7:00 AM to 7:00 PM shift. Nurse #2 stated she was made aware at some point during the morning of 8/12/26 that Resident #9 made a suicidal statement the night before but did not receive any communication from the previous shift about monitoring Resident #9 for safety, making sure he took all of his medications, or checking his room for any medications. A combined interview with Unit Manager and the Regional Nurse Consultant on 9/3/26 at 4:30 PM revealed Resident #9, the night he made the suicidal ideation comment, had nothing in his room that could have harmed him. The Unit Manager noted that the provider saw Resident #9 the following morning. The Unit Manager revealed the On-Call NP was the provider on duty after hours and on the weekends. The Unit Manager stated she was called by Nurse #1 during the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26 about the suicidal statement voiced to staff by Resident #9. She stated she then called the On-Call NP, and she told the Unit Manager that since Resident #9 was not physically able to do anything such as manually hold onto pills with his fingers, staff would keep him safe by monitoring him. A telephone interview with the On-Call NP on 9/3/26 at 5:11 PM occurred. She stated she was on call every weekend and every night after hours including the night of the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26. The On-Call NP explained that one of the nurses at the facility called her and explained Resident #9 stated he planned to save up his pills and hopefully, someday it would be enough to take himself out and she didn't think Resident #9 could take any action on his suicidal statement as it was reported to her that Resident #9 had quadriplegia. She stated she never had access to the EMR to write any progress notes or view any resident information and relied on the nurses to write a note that they contacted her. The On-Call NP stated all the orders she gave to the nursing staff were verbal orders. She explained she had the expectation nursing staff would be documenting in the EMR that they notified the provider of any updates or changes to Resident #9 or any other resident. The On-Call NP stated she told a nurse the night she was contacted about Resident #9's suicidal statements to put Resident #9 on suicide precautions per the facility's Suicide Prevention protocol. She was not sure of the exact protocol, but she believed it involved 15-minute checks and to have Resident #9 follow up with the Psych NP. She also stated she expected nursing staff to check Resident #9's room to make sure there wasn't anything that Resident #9 could harm himself with. The On-Call NP stated her order to the nurse who called her that night was to follow the facility Suicide Prevention procedure and that the order for monitoring and follow-up should have been entered into the EMR to be checked off by the nurse. The On-Call NP was not sure if the Medical Director signed off on the order. An additional review of Resident #9's EMR revealed no telephone order written by nursing staff or the On-Call NP for the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26.A follow-up interview with the Unit Manager and the Regional Nurse Consultant on 9/3/26 at 5:31 PM occurred. The Unit Manager stated the On-Call NP gave her a verbal order that night when she alerted her regarding Resident #9's suicidal statement. She stated since it was in the middle of the night and she was home without her laptop, and she did not enter the order or a progress note into the EMR to monitor Resident #9 for safety. The Unit Manager stated she called Nurse #1 back during the 7:00 PM to 7:00 AM shift on 8/11/26 to 8/12/26 and told her that she should monitor Resident #9 and Nurse #1 made sure his room didn't have any medications laying around. The Unit Manager reiterated that typically the nurse on duty would take the verbal order from the On-Call NP and put it in the EMR as a verbal order and the Medical Director would sign off on it. An additional review of Resident #9's care plan revealed a focus area dated 8/12/26 indicating Resident #9 verbalized suicidal ideation with a plan for suicide and/or injuries as evidenced by saying he didn't want to live and he would try and save some pills to add up to multiple doses and it would be enough to take him out. Resident #9 had diagnoses of quadriplegia and anxiety and required total care by staff and was seen by Psych NP. Interventions included reporting any suicidal ideations, threats to the physician if noted, reporting to nurse and Psych NP immediately if Resident #9 verbalized suicidal thoughts, and administering medication as ordered. An interview with the Medical Director on 9/3/26 at 1:13 PM revealed he was not made aware of Resident #9's suicidal ideation statement with a plan in August 2026 by nursing staff and did not know about it until discussing it with the state surveyor. He stated he was well-acquainted with Resident #9, and they spoke quite often when he was in the building. The Medical Director explained Resident #9 has never said anything before about suicide. An interview with the Director of Nursing (DON) occurred on 9/3/26 at 4:05 PM. He stated Resident #9 was unable to use his hands even to feed himself and could only take the pills given to him by the nurse. The DON had the expectation, in this specific case regarding Resident #9, for nursing to wait and monitor him and based on his physical abilities, nursing staff could alert the provider the following morning. An interview with the Administrator on 9/3/26 at 6:15 PM revealed she had the expectation nursing staff would put a progress note in Resident #9's EMR following his suicidal statement and would follow the provider's order.

Based on record review, video footage, observations, and interviews with family members, staff, the Medical Director, Police Officer, and Fire Captain, the facility failed to supervise a severely cognitively impaired resident (Resident #1) from exiting the facility without staff knowledge on 11/22/25 (Saturday) at approximately 10:28 AM on foot for 1 of 3 residents reviewed for supervision to prevent accidents. Resident #1 who had a primary diagnosis of toxic encephalopathy (neurological disorder caused by exposure to toxic substances, leading to diffuse brain dysfunction) exited from the facility without staff's knowledge for over two hours on the morning of 11/22/25. Resident #1 walked on the sidewalk on Providence Road (Providence Road is a heavily trafficked road in the city of [NAME]), fell and was assisted by strangers who placed the resident into their private vehicle and drove across town where the strangers dropped Resident #1 off at a fire department 20 miles away from the facility. The fire department called medics who transported Resident #1 to the hospital. Resident #1 was noted to have an abrasion and mild swelling over the right maxilla (upper jawbone) and abrasions on posterior aspect of bilateral hands from a reported fall on Providence Road where the facility was located. This had the high likelihood of causing serious harm and/or injury.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy, cardiac arrest, atherosclerotic heart disease (coronary artery disease caused by the buildup of fats, cholesterol and other substances in and on the walls of the heart arteries) and chronic kidney disease.A review of the Interdisciplinary Risk Assessment (this assessment is completed during admission to determine a resident's risk factors in the areas of pressure ulcer, wandering, falls, malnutrition and dehydration) for Resident #1 dated 11/8/25 and completed by the admitting nurse indicated Resident #1 did not have a history of wandering per family or other medical notes, did not have a history of elopement, had not been noted to wander, and did not have a diagnosis of dementia. The assessment also indicated Resident #1 had the following risk factors for fall: confusion/disorientation/impulsivity and altered elimination which meant he was frequently incontinent of both urine and bowel.Resident #1's care plan initiated on 11/10/25 indicated Resident #1 was at increased risk for falls due to confusion, poor balance and poor communication/comprehension and that he had impaired cognitive function or impaired thought processes. Interventions included to anticipate and meet needs as much as possible, to check on the resident frequently throughout the shift and to cue, reorient and supervise the resident as needed. Resident #1 did not have a care plan for wandering behaviors or risk for elopement.The admission Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and did not exhibit wandering behaviors during the assessment period. Resident #1 did not have any range of motion impairments, used a wheelchair, and required partial/moderate assistance with most activities of daily living including walking 10 feet. Resident #1 did not have any falls since admission.A nursing progress note dated 11/21/25 at 6:36 AM documented by Nurse #2 indicated Resident #1 was resistive to personal care per staff. Nurse with nurse aide encouraged Resident #1 to allow staff to change soiled brief. Resident #1 showed confusion with understanding the need for changing and his ability to do it himself. The nurse explained to Resident #1 several times that they were there to help him due to his weakness displayed and unsteady gait. Resident #1 allowed staff to change him. Confusion noted throughout the personal care. Resident #1 placed legs into brief and attempted to ambulate alone. Nurse had to keep Resident #1 from falling while ambulating.A review of an Incident Report dated 11/22/25 prepared by the Director of Nursing indicated at approximately 11:30 AM, staff suspected that Resident #1 was missing from the building after they were unable to locate him when his (family member) came to visit. The Weekend Supervisor initiated the Code Pink protocol for missing residents. (Code Pink protocol meant a resident was missing and was used by the facility to alert staff to start searching for the missing resident.) Before the incident, staff interaction with the resident included a Nurse Aide who served him breakfast at approximately 8:15 AM, and his assigned Nurse Aide who picked up his tray at approximately 9:30 AM and observed him still lying in bed. Staff conducted an extensive search of the facility and surrounding areas, including neighboring buildings, the street, nearby bushes and drainage ditches but could not locate the resident. The Weekend Supervisor reported the incident to the Director of Nursing and Administrator and notified law enforcement. Upon arrival at the facility, staff provided the police with all relevant identifying information of the resident. The Weekend Supervisor notified the resident's listed family members of Resident #1 missing. At approximately 12:55 PM, law enforcement notified the facility that they had located the resident and contacted Emergency Medical Services to transport the resident to the Emergency Department for medical evaluation as precautionary measure. A phone interview with Family Member #2 on 12/4/25 at 5:11 PM revealed he tried to get in touch with Resident #1 on 11/22/25 at 10:30 AM by calling the phone that was in his room at the facility but Resident #1 did not pick up the phone. Family Member #2 stated he decided to go ahead and come to the facility and he arrived around 11:00 AM. He stated that when he got there, Resident #1 wasn't in the room, so he asked the nurse aide where Resident #1 was. He said the nurse aide thought Resident #1 was in his room but when she saw he wasn't in his room, she searched for Resident #1 in the rehabilitation room, but he wasn't there either. Family Member #2 further stated that the nurse aide told the nurse that she couldn't find Resident #1, so they started looking in other rooms. When they didn't find Resident #1, the nurse told the Weekend Supervisor who called a code pink over the intercom. Family Member #2 stated that at that point, he got in his car and drove around the block searching for Resident #1, and then he called Family Member #1. Shortly after, police arrived and they wanted to know what time Family Member #2 arrived at the facility. After about 2 hours and 15 minutes, police told them that Resident #1 was at the fire station across town and that he was picked up by somebody down the street from the facility where he fell and they took him to the fire station. He also stated that Resident #1 was sent to the hospital when the medics arrived at the fire station because he couldn't answer questions. Family Member #2 further stated that he either visited or called Resident #1 almost every day and Resident #1 had always been confused ever since his last hospitalization. Whenever Family Member #2 visited Resident #1 at the facility, he assisted him with walking and sitting up front and outside, but Resident #1 never talked to him about going home or leaving. Family Member #2 stated that he did not think Resident #1 should be left to walk by himself because he wasn't steady walking and he could not make decisions on his own.A phone interview with Nurse Aide (NA) #1 on 12/4/25 at 1:01 PM revealed she last saw Resident #1 on 11/22/25 around 9:30 AM when she picked up his breakfast tray. NA #1 stated that Resident #1 was still in bed at that time, and he did not want to get up. NA #1 stated that Resident #1 was lying in bed underneath his blankets, so she didn't see what he was wearing that day. NA #1 stated Resident #1 never left his room by himself, and he did not usually walk unassisted because he was not steady whenever he walked. NA #1 further stated that Resident #1 was confused per baseline, and he usually needed help with putting his shoes on. NA #1 stated that when Family Member #2 arrived at around 11:00 AM and asked her where Resident #1 was, she looked in his room, and he was not there. They looked in the therapy gym, but he wasn't there either. They then began searching for Resident #1. NA #1 stated that she did not know how Resident #1 got out of the facility, but she heard that a housekeeper saw him walking in the hallway right before he got out. NA #1 also stated that she remembered it being warm that day because she went outside to search for Resident #1. NA #1 stated that the Weekend Supervisor called the police who told them eventually that Resident #1 had been found. A phone interview with Housekeeper #1 on 12/4/25 at 2:40 PM revealed she saw Resident #1 in the middle of the hallway in front of the dining area on 11/22/25, but she did not remember the time. Housekeeper #1 stated that Resident #1 was walking towards the main entrance without any assistive device, and that he was wearing a white shirt, pants and shoes. Housekeeper #1 stated that she remembered asking Resident #1 where he was going and Resident #1 told her that he was going to the porch. Housekeeper #1 stated Resident #1 was normally in his room and that this was the first time she saw him walking out in the hallway.A phone interview with Nurse #1 on 12/4/25 at 11:16 AM revealed she was assigned to Resident #1 on 11/22/25 from 7:00 AM to 3:00 PM. Nurse #1 stated she saw Resident #1 on 11/22/25 when she gave him his morning medications, but she could not recall the exact time. Nurse #1 stated that Resident #1 was lying in bed, and that she had to wake him up to take his medications. Nurse #1 stated that she didn't recall what Resident #1 was wearing that day. Nurse #1 further stated that Resident #1 did not do well with ambulating on his own, and that he walked with assistance from staff. Nurse #1 stated that NA #1 told her around 11:15 AM that Resident #1 was not in his room, so they started looking for him in all the rooms on her hall. When they could not locate Resident #1, Nurse #1 spoke with the Weekend Supervisor, and they started a more thorough search including the surrounding area outside the facility. Nurse #1 stated that they continued to look for Resident #1 even when the police came. Later on, Nurse #1 heard from the police that Resident #1 was found and that he was safe. Nurse #1 shared that they had cameras inside the facility, all the other doors were kept locked and that the only way to go in and out was through the front door where there should be a receptionist even on the weekends. Nurse #1 stated there was a receptionist on 11/22/25. Nurse #1 further reported that she hadn't seen Resident #1 ambulate by himself, and that Resident #1 was confused and was not able to communicate his specific needs. A phone interview with the Weekend Supervisor on 12/4/25 at 11:31 AM revealed she did not see Resident #1 on 11/22/25. The Weekend Supervisor stated that Nurse #1 told her around 11:15 AM that they were looking for Resident #1 and could not find him inside the facility. She stated that she called a code pink over the intercom which alerted all staff that a resident was missing and that all staff members should start looking for the missing resident. She stated that they started searching for Resident #1 from both inside and outside the facility. At 11:25 AM, the Weekend Supervisor called the Administrator and the DON and notified them of Resident #1's elopement and that search was in progress. The Weekend Supervisor informed them that staff had been searching every single area inside the building, the grounds, buildings next door, by the street, bushes and ditches close by. At 11:25 AM, the Weekend Supervisor called the police and the police arrived at 11:30 AM. The Weekend Supervisor gave the police information about Resident #1 and provided details and his face sheet. The Weekend Supervisor also called Resident #1's family members listed on his face sheet to inform them of Resident #1 being missing. Around 12:50 PM, she was notified that police found Resident #1. She stated that she couldn't remember who told her that Resident #1 had been located. A review of the Emergency Department Provider Notes dated 11/22/25 for Resident #1 indicated a chief complaint of altered mental status. Resident #1 was found walking on street and was taken to the firehouse. He was also reported missing two hours ago per family. Abrasion and mild swelling over the right maxilla (jawbone) and inferior to the right orbit (bony socket in the skull that houses and protects the eyeball). CT (computed tomography) scan of the head was negative for acute bleeds. Abrasions present on the posterior aspect of bilateral hands. Resident #1 was unsteady on his feet and unable to walk without assistance. Resident #1 was alert and oriented to person and date of birth . He was not oriented to time, place or recent events. Resident #1 was admitted and remained in the hospital while waiting for another skilled nursing facility placement.A phone interview with Receptionist #1 on 12/4/25 at 1:09 PM revealed she worked as the receptionist on 11/22/25 from 8:00 AM to 8:00 PM. Receptionist #1 stated that she did not remember Resident #1 going out through the front door on 11/22/25, but she did not know what Resident #1 looked like. Receptionist #1 stated that if she needed to step away from her desk, she usually got coverage but if she couldn't, she would run quickly and come back as soon as she could. She stated that she did not remember if she left her reception desk unattended on 11/22/25. Receptionist #1 further stated that she knew the long-term residents well and also recognized the short-term residents. However, if the resident did not have a walking device, she stated that she would not think they would be a resident at the facility. Receptionist #1 stated that if she was uncertain, she was supposed to verify whether the person was a visitor or a resident by asking for their name and checking the sign-in sheet. A phone interview with Family Member #1 on 12/4/25 at 10:13 AM revealed she saw Resident #1 at the hospital looking scratched up with a pump knot (a lump or swelling usually from a blow) on his cheek. Family Member #1 reported that when she asked facility staff how Resident #1 got out of the building, they told her that they didn't know how he got out, and that nobody knew what happened or how it happened. She also reported that she asked Resident #1 what happened to him while he was away from the facility, but he did not remember anything and could not tell her what happened to him. Family Member #1 stated that Resident #1 has had some memory loss after he had a heart attack the last time he was hospitalized , and that she did not think it was safe for him to be walking by himself especially on the sidewalk outside the facility. Family Member #1 stated that she visited Resident #1 often and she assisted him to walk and sit outside, but Resident #1 had never mentioned to her about wanting to leave the facility or go home.An observation was made with the Administrator on 12/4/25 at 2:21 PM of the lobby and front area of the facility where Resident #1 walked. The Administrator stated Resident #1 walked out of the lobby and out the front door towards a chair on the left side right outside the therapy gym. The distance from the front door to the chair was approximately 150 feet. It was another 125 feet from the chair to the sidewalk outside the facility. Right outside the facility was Providence Road which was a 2-lane road with a posted speed limit of 35 miles per hour. The sidewalk was along Providence Road where the facility was located.A review of the weather conditions per the Weather Underground website revealed the following data for [NAME], North Carolina on 11/22/25 at 10:33 AM: 70 degrees Fahrenheit with no precipitation, Southeast wind speed at 13 miles per hour (mph) with a gust of 20 mph. The video footage was viewed with the Administrator and the Quality Assurance Nurse Consultant on 12/4/25 at 2:25 PM, and it revealed the following caught on camera on 11/22/25:10:28 AM - Resident #1 walked into the lobby and straight out through the front door. Receptionist #1 was at her desk, but she was observed talking to a visitor. Resident #1 was observed walking with a limp and an exaggerated swaying of both arms alternatively. He kept on walking out the front door and almost stumbled against the curb from an island right outside the door. Resident #1 regained his balance and started walking to a chair on the left side right outside the therapy gym.10:29 AM - Resident #1 sat at a chair outside the therapy gym while a car was observed driving in through the facility's driveway.10:36 AM - Resident #1 stood up and started walking towards the sidewalk outside the facility.10:37 AM - Resident #1 stopped on the left side of the driveway and stood there for a minute.10:38 AM - Resident #1 resumed walking and crossed the driveway to the brick wall at the facility entrance and towards the right sidewalk while walking with an ataxic gait (uncoordinated, clumsy, staggering walk with poor balance, characterized by wide-based steps, irregular foot placement, and a tendency to [NAME] or fall, often resembling drunkenness).10:39 AM - Resident #1 went out of view of the camera/video footage.An interview with the Director of Nursing (DON) on 12/4/25 at 1:38 PM revealed after he was notified by the Weekend Supervisor at around 11:25 AM about Resident #1's elopement on 11/22/25, he came to the facility. The DON stated by the time he got to the facility, the police had already left. He stated that he received report from the Weekend Supervisor that the police told her that they had located Resident #1, that they called the medics and then sent Resident #1 to the hospital. He further stated that he had not seen Resident #1 ambulate by himself at the facility, and that most of his interaction with him was while he was lying in bed, so he did not know if he had balance or gait issues. The DON shared that Resident #1 might have walked out of the building through the front door, but he was not aware if there was a camera at the front lobby. The DON stated that he would not say that it would be safe for Resident #1 to be walking unsupervised outside the facility.An interview with the Administrator on 12/4/25 at 2:12 PM revealed she was on leave during Resident #1's elopement incident on 11/22/25, but she found out that Resident #1 walked out of the facility through the front door. The Administrator stated that the front doors were unlocked, and they were usually unlocked because there was a receptionist at the front desk. However, the receptionist did not know that Resident #1 was a resident. She also stated that Resident #1 did not have safety awareness and for some reason, he wanted to get out of the door that day. She shared that prior to the incident, Resident #1 had only stayed in his room, and had not demonstrated any signs that he would attempt to get out of the facility unassisted. An interview with the Rehabilitation Manager on 12/4/25 at 12:31 PM revealed Resident #1 needed supervision when ambulating by himself because of balance and gait issues. The Rehabilitation Manager stated that it was safe for Resident #1 to walk with a family member or a staff member, but she would not recommend for him to be walking by himself. She stated that somebody needed to keep an eye on him because it was not safe for him to walk by himself, and he could fall or get hurt especially with his confusion.A phone interview with the Medical Director on 12/4/25 at 1:18 PM revealed a severely cognitively impaired resident like Resident #1 should not be outside without supervision. The Medical Director stated that if Resident #1 was just sitting outside, it would not have been a problem but if he got out to the main road, he could get lost, and that it was definitely a problem especially with him being gone for over two hours.A phone interview with the Police Officer on 12/4/25 at 12:20 PM revealed Resident #1 was located walking along the road on the sidewalk by some folks driving by in a car, and Resident #1 asked for a ride to a location that was supposed to be his friend's house. The Police Officer stated that when they arrived at the address, Resident #1 said it did not look familiar, so they decided to drop him off at the fire station. He stated that they did not have information about the people who picked Resident #1 up, and that he did not know what road Resident #1 was walking on before he got picked up. He also stated that from what he could remember, there was no report of any medical emergencies, but they called the medics to come and check him out and an ambulance took Resident #1 to the hospital. The Police Officer further stated that he was not sure what time Resident #1 was located walking on the road, but he knew that from the time he was last seen at the facility to the time he was located was within a two to two and a half hour period. He also shared that they did not file a police report because there was no crime but only filed a missing person report to document about Resident #1 being missing from the facility. A phone interview with the Fire Captain on 12/4/25 at 4:41 PM revealed they had no information regarding the people who dropped Resident #1 off at the fire station. The Fire Captain stated that the people who dropped him off said that they saw him fall while he was walking down on Providence road where the facility was located and so they picked him up, but the address Resident #1 gave them was not familiar to him, so they decided to drop him off at the fire station which was 20 miles away from the facility per GPS (global positioning system). The Fire Captain stated that he saw Resident #1, but he couldn't remember what he was wearing and all he could remember was that he was confused and unable to answer any questions. The Administrator was notified of immediate jeopardy on 12/4/25 at 5:44 PM.The facility provided the following corrective action plan:How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 11/22/25 at approximately 10:30 AM, Resident#1 was observed by Visitor#1 walking out of facility and then walking to chair in front of therapy gym and sitting down. Approximately 5 minutes later, Resident #1 was observed by Visitor #1 getting up from chair and walking up sidewalk towards brick wall at facility front entrance driveway. Visitor #1 observed resident speaking to persons in a white [NAME] who instructed Resident #1 to walk down to stoplight where they would pick him up. Resident #1 observed by Visitor #1 getting into a white [NAME]. Staff were unaware that Resident #1 had exited the facility. Visitor #1 was standing outside on sidewalk at facility entrance driveway and noted Resident #1 walking towards a white [NAME] occupied by a male and a female who instructed Resident #1 to walk down the sidewalk towards stoplight and they would pick him up. Visitor #1 stated he was unaware that Resident #1 was a resident of the facility. On 11/22/25, at approximately 11:00 AM, Resident #1's cousin arrived at the facility to visit Resident #1 and notified staff that resident was not in his room. Resident #1 was seen by Housekeeper #1 at 10:20 AM walking up 400 hall towards dining room. Staff immediately began initial search in the facility and parking lot for Resident #1. On 11/22/25, at approximately 11:10 AM Nurse Supervisor #1 instructed Receptionist #1 to initiate a Code Pink (Missing Resident Search) via overhead paging system and staff continued to search in and on facility grounds, Assistant Living Facility next door, and local streets, and surrounding areas including wooded areas behind the facility. On 11/22/25, at approximately 11:25 AM, police were notified. Police arrived at the facility at approximately 11:30 AM and were provided with a detailed description of Resident #1 (resident wearing white shirt, jeans and white sneakers) and information provided by Visitor #1 who observed resident getting into white a vehicle. Face sheet with resident's picture was also provided. Temperature outside at time of incident was 67 degrees. On 11/22/25, at approximately 11:25 AM, Nurse Supervisor #1 notified the Director of Nursing and Administrator. On 11/22/25, at approximately 11:30 AM, Responsible Party and Medical Director were notified of the incident by the nurse supervisor. On 11/22/25, at approximately 12:55 PM, Resident #1 was located and transported to the hospital for evaluation and treatment as a safety precaution. Regional Director of Operations and police notified Resident #1's family who were on site that Resident #1 had been located by a bystander near North Lake mall who witnessed resident fall and assisted him to a nearby fire station who then notified police and Emergency Medical System. On 11/22/25, Quality Assurance (QA) Nurse Consultant reviewed Resident #1's care plan with no updates at this time. Care plan to be updated related to exit seeking behaviors upon readmission. On 11/22/25, at approximately 1:45 PM, family notified staff that they would be packing up residents' belongings and that he would not be returning to facility. Staff assisted family with gathering resident's belongings. On 11/25/25, video footage of the front entrance was reviewed by the Administrator. At approximately 10:30 AM, Resident #1 who walked with a limp was noted walking out the front entrance door and walked towards the therapy gym and sat down in a chair. Resident #1 sat in the chair for approximately 5 minutes and then Resident #1 was noted walking with unsteady gait up the sidewalk towards a brick wall in front of the facility entrance and then turned right and went out of view. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 11/22/25, a head count was completed by Nurse Supervisor #1 for 100% of residents. All residents in facility were accounted for with no issues identified. On 11/22/25, the Director of Nursing reviewed clinical alerts dashboard and nursing notes for all residents for the past 30 days to identify any exit seeking behaviors. No issues identified. On 11/22/25, the Director of Nursing audited 100 % of residents wandering risk assessments. All resident with low wandering risk were reviewed for changes in condition/function that may put them at risk to exit the facility. No issues identified. Risk assessments are completed upon admission by the admitting nurse, quarterly and any time a change of condition is noted by staff nurse or nurse manager. Additionally, on 11/22/25, all residents at high-risk for wandering charts were reviewed by the Director of Nursing to ensure that they had appropriate wander prevention strategies in place to include wander guard bracelet in place and functioning properly, daily battery checks and every shift placement checks were present on the MAR and that care plan was current and appropriate interventions were on the care plan. The results of the audit revealed all residents that were assessed as high risk for wandering were noted to have elopement prevention measures in place and up to date care plans. On 11/22/25, the Nurse Supervisor checked 100% of current residents with wander guards for placement and function by observing that wander guard was on resident's person and utilized the wander guard checker device to ensure proper function. No issues were noted. On 11/22/25, all exit doors were checked by the Director of Nursing and Nurse Supervisor #1 to ensure they were functioning properly. On 11/22/25, staff interviews were initiated for all staff by the Director of Nursing to identify any exit seeking behaviors. Interviews identified no other new onset of exit seeking behaviors. On 11/22/25, the QA Nurse Consultant rechecked all entrance/exit doors to include door with wander guard system, squealer boxes and on/off switches for mag lock doors (doors with keypad entry/exit) and all were functioning properly. No issues were identified. On 11/22/25, a Quality Assurance Performance Improvement meeting held with the Interdisciplinary Team members which included the Director of Nursing, Regional Director of Operations, Social Worker, Nurse Supervisor, Business Office Assistant, Unit Manager, QA Nurse Consultant and Human Resources Director to discuss incident findings and plan to correct.What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? On 11/22/25, the Director of Nursing began education of all full time, part time, and as needed staff including agency on the following topics: Elopement Prevention and Missing Person Policy. Education included what to do if resident was exhibiting wandering/exit seeking behaviors especially for those residents who normally stayed in their rooms. Staff educated to stop and communicate with the resident and redirect, ensure safety of the resident and immediately notify the nurse. As of 11/25/25, 25% of staff had not attended the Elopement Prevention and Missing Person Policy in-service. The Administrator will ensure that any of the above identified staff who did not complete the in-service training by 11/25/25 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation for the above identified staff and will be provided by the Staff Development Coordinator during orientation and prior to working in patient care areas. On 11/25/25, the Administrator educated all receptionists that all visitors will need to sign in and out and wear a badge to identify them as a visitor when entering the facility through main entrance designated for visitor entry. All other exit doors are locked with signage above directing visitors to go to the main entrance to enter and exit the facility. Additionally, all receptionists and nurses were educated by the Administrator that receptionists are to lock the main entrance door upon leaving front desk for any reason and nurses are to let visitors into and out of facility in receptionist's absence from receptionist area. Receptionists were educated to have all persons exiting facility to be identified prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility to ensure they are not a resident displaying exit seeking behaviors. If the person is noted to be a resident, receptionist is to maintain resident safety and immediately notify nurse assigned to resident to come assist resident. The Administrator will ensure that any newly hired receptionist or nurse will receive this education prior to working and this in-service was incorporated into the new employee facility orientation for the above identified staff. As of 11/25/25, the following changes were put in place to correct the deficient practice. Visitors will be required to sign in and out and wear visitor badge while in the facility. Additionally, receptionists were educated that they are to lock the main entrance door upon leaving front desk area for any reason and if no one is available to provide coverage until they return, they are to notify nursing staff via phone that they will be leaving front desk area prior to leaving. Upon hearing doorbell ringing, nurses are to go to front entrance area and let visitor into the facility, have visitor sign in and provide them with a visitor's badge. For visitors leaving facility, nurse is to identify person prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility. A receptionist is scheduled to work 7 days a week. In the event that there is no receptionist available, facility front entrance doors will be locked and nurses on duty will be responsible for allowing visitors entry or exit to facility. On 11/25/25, to alert visitor of need to si[TRUNCATED]

Based on record review and staff interviews the facility failed to develop a comprehensive care plan within 7 days of completing a comprehensive assessment for 1 of 21 residents (Resident #56) reviewed for care plans. The findings included: Resident #56 was admitted to the facility on [DATE] with diagnoses that included fracture of the left humerus (upper arm bone), falls, and urinary tract infection. The admission minimum data set (MDS) assessment dated [DATE] indicated Resident #56 had upper extremity impairment to one side, required partial to moderate assistance with activities of daily living (ADL), was frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers and coded for falls. The MDS assessment was signed on 6/17/25 verifying it was completed. Resident #56's Care Area Assessment (CAA) Summary dated 6/10/25 revealed the triggered care areas included ADL functional/rehabilitation potential, urinary incontinence, falls, pressure ulcers and nutritional status. The care plan decision completion date for all the care areas was 6/11/25. A review of Resident #56's medical record revealed the care plan dated 6/05/25 included focus areas and interventions related to discharge planning, mood disorder and activities. The care plan did not include focus areas or interventions related to the triggered care areas on the CAA related to ADL function, falls, urinary incontinence, pressure ulcers and nutrition. An interview conducted with MDS Coordinator #1 on 6/26/25 at 11:02 AM MDS Coordinator #1 stated the day after admission, or if on a weekend, the following Monday she developed and completed the resident's comprehensive care plan. She revealed the comprehensive care plan was revised after the admission MDS was completed to include any additional care areas triggered on the CAA. MDS Coordinator #1 indicated Resident #56 was admitted to the facility due to a fall with a fracture, was incontinent and requiring assistance with ADL and her admission MDS assessment was completed on 6/10/25. MDS Coordinator #1 revealed she was unaware that Resident #56's comprehensive care plan had not been completed and it was an oversight on her part. During an interview with the Administrator on 6/26/25 at 11:40 AM she stated the MDS Coordinators were responsible for developing and completing the residents' comprehensive care plans and a comprehensive care plan should have been completed for Resident #56.

Based on record review and staff interviews, the facility failed to develop personalized comprehensive care plans in the areas of oxygen therapy (Resident #16) and include accurate interventions in a care plan (Resident #41) for 2 of 21 residents reviewed for comprehensive care plans. The findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, pneumonia, and dependence on supplemental oxygen. A review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #16 was coded for oxygen therapy. A review of Resident #16's medical record revealed a current physician order dated 6/13/25 for two liters of continuous oxygen via nasal cannula. A review of Resident #16's June 2025 Medication Administration Record (MAR), for the period of 6/1/25 through 6/30/25, revealed she had been receiving the oxygen as ordered. An observation on 6/23/25 at 2:44 PM revealed Resident #16 in her room receiving oxygen via nasal cannula from concentrator. A review of Resident #16's care plan as of 5/30/25 revealed there was no care area in place for continuous oxygen use. An interview with MDS Coordinator #1 on 6/25/25 at 3:54 PM revealed the information in each care plan was gathered in their interdisciplinary meetings and from nurse and clinical notes and nurse aide charting. The MDS nurses complete each resident care plan. MDS Coordinator #1 stated Resident #16 used continuous oxygen since she was admitted , and it was an oversight oxygen use was not included in her care plan. An interview with the Director of Nursing (DON) on 6/26/25 at 11:39 AM revealed the MDS Coordinators were tasked with completing the comprehensive care plans. He had the expectation Resident #16's care plan would include oxygen therapy. An interview with the Administrator on 6/26/25 at 11:43 AM revealed she had the expectation all care plans should be updated. 2. Resident #41 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia, diabetes and epilepsy. A review of Resident #41's medical record revealed a current physician order dated 6/2/25 for wearing an abdominal binder for protection due to pulling at feeding tube. May remove for care and replace when finished. Assess skin integrity every shift. There were no other current or discontinued orders for hand mitts for Resident #41 in his medical record. A review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #41 was not coded for restraints. A review of Resident #41's June 2025 Medication Administration Record (MAR), for the period of 6/1/25 through 6/30/25, revealed the abdominal binder was in place each shift. Resident #41's current care plan dated 6/23/25 revealed there was a care problem area use of bilateral mitts to hands and abdominal binder due to pulling at feeding tube with increased risk for associated complication and injuries. Interventions included administering abdominal binder as ordered and monitor and document for side effects and effectiveness, ensuring there is a physician's order for device, and ensuring correct positioning with proper body alignment while using device. An interview was completed with Nurse #2 on 6/25/25 at 2:20 PM and revealed Resident #41 never used bilateral mitts on his hands. She stated the abdominal binder was in place to keep him from pulling at his feeding tube. An interview with MDS Coordinator #1 on 6/25/25 at 3:57 PM revealed Resident #41 never used hand mitts, just the abdominal binder and the hand mitts were included in the care plan by mistake. An interview with the DON on 6/26/25 at 11:43 AM revealed the Unit Managers complete the baseline care plans when residents were admitted and the MDS Coordinators were tasked with completing the comprehensive care plans. He noted when Resident #41 came to the facility he was in and out of the hospital and he kept taking out his feeding tube. The hand mitts were never used, and the abdominal binder had been sufficient. An interview with the Administrator on 6/26/25 at 11:45 AM revealed she had the expectation the hand mitts would be taken off the care plan for Resident #41.

2. Resident #92 was admitted to the facility on [DATE]. A review of a social service progress note dated 05/07/2025 at 10:11 AM stated Resident #92 had a planned discharge to an assisted living facility. A review of the discharge MDS assessment dated [DATE] revealed that the discharge status had been coded as discharge to hospital. An interview on 06/25/2025 at 11:15 AM with the MDS Coordinator indicated she received a resident's discharge information through progress notes, discussions with the Social Worker or weekly utilization review meetings. The interview revealed she was newer to the role of MDS Coordinator and had just coded Resident #92 went to the hospital by mistake. She stated it should have reflected the resident was discharged to an assisted living facility. An interview on 06/25/2025 at 3:41 PM with the Director of Nursing (DON) indicated the MDS should be coded accurately. She was not sure why Resident #92's discharge MDS had been coded incorrectly. An interview conducted with the Administrator on 6/26/25 at 11:39 AM revealed the resident MDS assessments should be coded accurately. Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of hospice (Resident #345), discharge status (Resident #92), and oxygen use and functional abilities (Resident #49). This deficient practice occurred for 3 of 21 residents reviewed for accuracy of assessments. The findings included: 1. A review of Resident #345's medical record indicated she was admitted to hospice services on 5/29/25. Resident #345 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] revealed Resident #345 was not coded for receiving hospice services. During an interview with MDS Coordinator #1 on 6/26/25 at 10:56 AM she revealed Resident #345 was receiving hospice services prior to being admitted to the facility. MDS Coordinator #1 stated Resident #345 was not coded for receiving hospice services on the admission MDS due to an oversight on her part. An interview with the Director of Nursing on 6/26/25 at 11:37 AM indicated Resident #345 was receiving hospice services and the MDS assessment should have been coded accurately. An interview conducted with the Administrator on 6/26/25 at 11:39 AM revealed the resident MDS assessments should be coded accurately. 3. Resident #49 was originally admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (CVA), hemiplegia, left hip contracture, and dependence on supplemental oxygen. Resident #49 physician orders dated 6/7/25 included to administer oxygen at 2 liters continuously via nasal cannula at bedtime for oxygen supplement for hypoxia at bedtime. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 rarely made herself understood and had severely impaired cognitive skills for daily decision making. She was coded as needing functional assistance for less than half of each care activity. The MDS assessment was not coded for oxygen use. Resident #49 was observed with oxygen at 2 liters via nasal cannula on 6/24/25 at 8:15 AM and 6/25/25 at 8:40 AM. An interview on 6/25/25 at 11:38 with Nurse Aide (NA) #1 revealed that she had never observed Resident #49 move on her own or assist with any of her care. NA #1 stated that Resident #49 was dependent in all care areas and required at least 2 people to provide total care. NA #1 reported that Resident #49 used oxygen when in bed sleeping. An interview on 6/25/25 at 9:10 AM with the Unit Manager revealed that Resident #49 was total care and dependent in all areas of activities for daily living (ADLs) and required oxygen at bedtime. The MDS Coordinator was interviewed on 6/25/25 at 4:01 PM. The MDS Coordinator stated she collected resident status information from medical records and clinical staff in the daily team meetings which she used to code the MDS assessment. The MDS Coordinator confirmed that Resident #49 used oxygen. She stated Resident #49's oxygen usage was coded in error and the functional status for Resident #49 was coded incorrectly. The Administrator was interviewed on 6/26/25 at10:42 AM. The Administrator stated the MDS Coordinator should collect information regarding a resident from therapy and clinical nursing, and orders should be reviewed for MDS coding. The Administrator reported she would have expected the coding to accurately represent the resident and orders for treatment.

Based on record review and staff interviews, the facility failed to ensure a resident had an indication and a diagnosis for the use of an antipsychotic medication. This was for 1 of 5 residents for chemical restraints (Resident #49). The findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a medical emergency where blood flow to a part of the brain is interrupted, causing brain tissue damage due to lack of oxygen and nutrients), hemiplegia and hemiparesis of the left arm and leg (inability to move/use the left arm and leg), aphasia (a disorder that limits the ability to communicate) following cerebral infarction, benign neoplasm of cerebral meninges (a slow-growing tumor that originates surrounding the brain and spinal cord), adult failure to thrive, and vascular dementia/unspecified severity/with mood disturbance and anxiety. Resident #49's Physician orders included: -Seroquel 25 milligrams (MG) (Quetiapine Fumarate) dated 9/11/24 to give via gastric tube. - Seroquel tablet 25 milligrams (MG) (Quetiapine Fumarate) dated 4/3/25, to give via gastric tube. Resident #49's care plan was revised on 4/3/25 included that she received antipsychotic medication related to her diagnosis of dementia with behavioral disturbances with risk for adverse side effects. The interventions for taking an antipsychotic included consulting a pharmacist to review my psychotropic medications quarterly and as needed for possible changes or reductions. The care plan also included discussing possible side effects of medication with me and my responsible party (RP). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 rarely made herself understood and had severely impaired cognitive skills for daily decision making. She was not coded for potential indicators of psychosis. Resident #49 was coded for diagnosis that included Alzheimer's Disease, cerebrovascular accident/stroke and Non-Alzheimer's Dementia. Resident #49 was coded as currently taking an antipsychotic (high risk medication) on a routine basis and an indication for use was noted. She was coded with impaired extremities on one side and needing functional assistance for less than half of each care activity. Resident #49 had contractures of the left extremities and was unable to use the right extremities. On 6/23/25 at 10:12 AM, Resident #49 was observed asleep in bed and did not respond to verbal stimuli. Observations on 6/24/25 at 11:00 AM and 1:18 PM were completed. The resident was asleep sitting in a chair. She did not awake with her name or voice commands. Observed Resident #49 on 6/25/25 at 9:00 AM while Nurse Aide (NA) #1 provided a bed bath. The resident did not have control of her body and began to lean to the right side. NA #1 had to ask for assistance to complete Resident #49's bed bath. The pharmacy recommendation dated 5/2/25 addressed Seroquel tablet 25 milligrams (MG) order dated 4/3/25 stated that Resident #49 was receiving antipsychotic agent Quetiapine 25 daily but lacks an allowable diagnosis to support its use. The pharmacy recommendation stated the Seroquel 4/3/25 order stated Seroquel use was for squirming. The pharmacist recommended the following diagnosis: Schizophrenia, Delusional disorder, Mood Disorder, Psychosis in the absence of dementia, Tourette's disorder, Hiccups (not induced by other medications), Nausea and vomiting associated with cancer and chemotherapy, Behavioral or psychological symptoms of dementia and Medical illness/delirium with psychotic symptoms. The provider selected the agree with pharmacist indication box. The recommendation form was signed by provider on 5/6/25 with hiccups and nausea associated with cancer circled. Resident #49's Seroquel (Quetiapine Fumarate) orders included: - Seroquel tablet 25 milligrams (MG) dated 6/7/25 included, to give 1 tablet via gastric tube one time a day for nausea and vomiting, hiccups. - Seroquel tablet 25 milligrams (MG) dated 6/13/25 to give Seroquel tablet 25 milligrams (MG) 1 tablet via percutaneous endoscopic gastrostomy (PEG) tube one time a day for dementia with behavioral disturbance. An interview on 6/25/25 at 11:38 AM with Nurse Aide (NA) #1 revealed she had not observed Resident #49 speak or have any movement of her extremities. She stated that she had observed Resident #49 grind her teeth and had not observed hiccups. The NA could not confirm that Resident #49 exhibited behavioral disturbances. The Unit Manager stated on 6/25/25 at 8:37 AM that she had not observed Resident #49 move her extremities. The Unit Manager reported she had observed Resident #49 grind her teeth and had not observed Resident #49 with hiccups. The Unit Manager stated she had not observed Resident #49 exhibit behaviors such as yelling, hitting or pulling PEG-tube. The Unit Manager could not confirm that Resident #49 exhibited behavioral disturbances. Phone interview with Nurse Consultant on 7/3/25 at 4:43 PM revealed that Resident #49 original Seroquel order was dated 9/11/24. The Nurse Consultant stated that Seroquel was reordered every time Resident #49 was readmitted to the facility. She stated that the admitting nurse would select the medications in the electronic medical record (EMR) and the providers would review and make changes as needed.

Based on observations, record reviews, and staff interviews, the facility failed to use sterile gloves and failed to perform hand hygiene while providing tracheostomy care to Resident #62. This deficient practice occurred for 1 of 1 resident observed for tracheostomy care (Resident #62). The findings included: Resident #62 was originally admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia and tracheostomy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was coded for tracheostomy and tracheostomy care. The care plan dated 2/7/24 included Resident #62 had a tracheostomy with risk for complications including decreased oxygenation, infection, nutritional imbalance, anxiety, and decreased ability to communicate. The interventions included providing trach care as ordered and observing tracheostomy site for redness, drainage, signs of infection each shift and report to nurse or provider. Resident #62's physician orders included: - Change the disposable inner cannula every shift and as needed every shift. (8/15/24) - Respiratory therapist to change tracheostomy tube every month. (8/15/24) Nurse #1 was observed on 6/25/25 at 10:49 AM performing trach care for Resident #62. Nurse #1 set up a table with a white paper barrier on top of table. Next, Nurse #1 placed tracheostomy care supplies on the barrier which included: one trach drainage gauze, one trach inner cannula, and six pairs of gloves. She did not use a tracheostomy kit. Nurse #1 donned a clean gown and 2 pairs of non-sterile clean gloves. She then removed the dirty dressing and placed the dirty dressing in the trash. Nurse #1 doffed her gloves and without sanitizing her hands, donned 2 pairs of non-sterile gloves and applied a clean gauze to Resident #62's trach site. Using the same gloves, Nurse #1 removed the trach inner cannula and disposed of the inner cannula in the trash. Nurse #1 removed her gloves, then donned a new pair of non-sterile gloves without sanitizing her hands and inserted a new inner cannula in Resident #62's trach site. Nurse #1 doffed her gloves and gown and washed her hands at the sink in Resident #62's room. An interview conducted on 6/25/25 at 2:10 PM with Nurse #1 revealed she was aware that she had not sanitized her hands each time she had doffed her gloves. She stated she should have had hand sanitizer with her supplies or should have washed her hands at the sink before donning a new pair of gloves. Nurse #1 stated that a respiratory therapist used sterile trach kits when providing trach care. She was not aware that she needed sterile gloves for trach care. An interview conducted on 6/25/25 at 2:43 PM with the Infection Preventionist/ Assistant Director of Nursing (ADON) revealed her expectation was that every nurse would sanitize their hands every time that they removed their gloves and before putting on clean gloves during wound and trach care. The ADON further stated staff received education on infection control annually and multiple times during the year. An interview on 6/26/25 at 12:23 AM with the Director of Nursing (DON) revealed he was not aware of Nurse #1's errors during trach care. The DON stated it was his expectation that Nurse #1 followed the best practices infection control to avoid introducing microorganisms into the trach site. The DON stated that the respiratory therapist visited Resident #62 to complete sterile trach care the previous day.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 5 medication errors out of 27 opportunities, resulting in a medication error rate of 18.52% for 1 of 4 residents (Resident #49) observed during the medication administration observation. The findings included: Resident #49 was originally admitted to the facility on [DATE]. Her diagnosis included presence of a percutaneous endoscopic gastrostomy (PEG) tube. A PEG-tube is a feeding tube inserted through the skin and the stomach wall to provide nutrition and a route for medication administration. A review of Resident #49's active physician orders included an order dated 6/7/25: -Enteral Feed Order every shift flush with 30ml (milliliters) of water then administer each medication separately. Dissolve each medication in 10-15 ml of water and flush with 5 ml water after each medication. Flush with 30ml water as final flush. On 6/25/25 at 8:37 AM, the Unit Manager was observed as she began to prepare medications for administration to Resident #49 via PEG-tube. The medications included: 81mg (milligrams) aspirin (used for stroke prevention)- 1 tablet, 25 mg metoprolol (used blood pressure management) - 1 tablet, 25mg Seroquel (used for hiccups) -1 tab, and 4 mg silodosin (used relax urethra to prevent urine retention)- 1 capsule. All four medications were placed in a 30 ml medication cup. The Unit Manager poured the medication tablets in a clear plastic sleeved and crushed the medication. Next, she opened the medication capsule and emptied the medication in the mix of crushed medications. Then the Unit Manager poured 5mg/ml of Metoclopramide (used for nausea) into a medication cup for a total of 10 ml. Next, she poured 30 ml of ProStat (protein supplement) into a medication cup. The Unit Manager was observed on 6/25/25 at 8:48 AM as she [NAME] the medications for administration into Resident #49's room. After the nurse connected a syringe to the resident's PEG- tube, she flushed the tube with 30 ml of water. The crushed medications were mixed with 60 ml of water in a cup and the solution was poured into the syringe connected to Resident #49's PEG-tube. The Unit Manager then combined the Metoclopramide and Prostate with 20 ml of water for a total of 60 ml of solution. She then administered the solution into the syringe and then the PEG-tube. The Unit Manager completed the medication administration by flushing the resident PEG-tube with 60 ml of water. An interview was conducted with the Unit Manager on 6/25/25 at 2:11 PM. The Unit Manager reported she was nervous and did not routinely work with Resident #49. The Nurse Manager stated that her normal practice was to combine all medications and administer in the PEG- tube at once as a cocktail. The Unit Manager stated that she had not reviewed the medication administration order for Resident #49 prior to administering the medications. An interview was conducted on 6/26/25 at 10:29 AM with the facility's Director of Nursing (DON). During the interview, the DON stated he would expect that orders are followed for all medications administered to a resident.

Based on record review, resident interviews, family interviews and staff interviews the facility failed to protect Resident #28 from neglect when he was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis of chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. In addition, Resident #28 stated during the day shift on 3/9/24 when he requested a dietary supplement he was told there were not any. No vital signs were documented on the day shift on 3/9/24. Resident #28 reported he experienced chest pain on 3/9/24, felt belittled and that staff were retaliating against him because he had filed a complaint about care. In addition, on 3/10/24 the facility neglected to provide incontinence care and assistance with activities of daily living for Resident #17 when requested by a family member. Resident #17 had severe cognitive impairment and when the family member arrived had a wet brief, was wearing a t-shirt and was partially covered by a blanket. Care was not provided until later in the afternoon when a second family member arrived and requested assistance. This deficient practice occurred for 2 of 3 residents reviewed for neglect (Resident #28 and Resident #17). Immediate jeopardy began on 3/9/24 when the facility neglected to provide necessary care and services for Resident #28. Immediate jeopardy was removed on 3/19/24 when the facility provided and implemented an acceptable credible allegation of Immediately Jeopardy removal. The facility remains out of compliance at a lower scope and severity of G (actual harm that is not Immediate Jeopardy) for example # 2 and to complete education and ensure monitoring systems put into place are effective related to neglect. The findings included: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), heart failure, hypertension, and anxiety. An admission MDS assessment dated [DATE] indicated Resident #28 was cognitively intact, was receiving hospice care and required maximal assistance with toileting, showering, and dressing. The assessment further indicated rejection of care 1-3 times and use of oxygen. A care plan dated 2/26/24 indicated Resident #28 was care planned for the following: -altered respiratory status/ difficulty breathing related to anxiety, COPD history of respiratory failure with intervention to provide oxygen as ordered. -continuous oxygen therapy for CHF and COPD with interventions to give medications as ordered, monitor/ document side effects and effectiveness, observe for symptoms of respiratory distress and report to physician as needed (restlessness, pulse oximetry, increased heart rate, headaches, lethargy, confusion, cough, accessory muscle usage and skin color. -altered cardiovascular status, arrythmia, CHF and hypertension with interventions to assess shortness of breath and cyanosis, diet consult as necessary, oxygen as ordered, monitor/document/report changes in lung sounds (crackles), edema, and changes in weight; vital signs as ordered/as needed and report abnormal readings to physician. -acid reflux with an intervention for medications to be given as ordered, monitor/ document side effects and effectiveness. -hospice services related to COPD, with an intervention to administer pain medications as prescribed, assess frequently and provide additional pain relief as necessary; coordinate care with hospice team; invite hospice staff to participate in resident care planning conferences; promote comfort by repositioning, adding more pillows, massage, reading, and aromatherapy. A review of the March 2024 Medication Administration Record revealed Resident #28 was to receive the following during the 7am- 7pm shift: -Omeprazole- give one tablet in evening for GERD (4pm) -Prostat- (Protein supplement) 30 milliliters one time a day for additional protein (9am) -Budesonide inhalation suspension (nebulizer treatment)- 2 times a day for COPD (9am) -Formoterol fumerate inhalation solution 2 times a day (every 12 hours) for COPD (1pm) -Tamsulosin- one capsule by mouth 2 times a day (Flomax) (9am) -Ensure (dietary supplement)- 3 times a day (10am, 2pm) -Oxgyen 3 liters continuous nasal canular for shortness of breath- every shift O2 -Vital signs every shift -Ipratropium-albuterol inhalation solution #60 vial-(nebulizer) inhale 4 times a day for COPD (11am, 5pm) -Fluticasone propionate suspension- spray each nostril one time a day for allergies (9am) -Observe or ask resident if shortness of breath (SOB) occurs when lying flat down or is resident avoiding lying flat due to SOB; every shift signs of SOB: interrupted speech pattern (only able to say a few words before taking a breath); increased respiratory rate During an interview on 3/11/24 at 11:10 AM Resident #28 revealed he received a nebulizer treatment once on Saturday 3/9/24 and once on Sunday 3/10/24 during the 7:00 am to 7:00 pm shift (day shift), although he was supposed to receive nebulizer treatments four times during the day shift. He also stated he did not receive any of his other medications that were in pill form. Resident #28 stated he had chest difficulty on 3/9/24 and requested a breathing (nebulizer) treatment on several occasions but did not receive it until late afternoon. He revealed he told Nurse Aide (NA) #1 he needed a breathing treatment each time she came into his room to check on him or answer his call bell throughout the day and NA #1 told him that she informed Nurse #10 of his requests. Resident #28 indicated on 3/9/24 he called his daughter to complain of chest pain and that he had been asking for a breathing treatment for 3 hours. The Resident explained NA #1 was trying to be helpful when she spoke with his daughter on the phone while she was in the room and stated she was doing all she could by reporting the Resident's need for a breathing treatment. The Resident stated when the Medication Aide (later identified by the Resident as Med Aide #1) finally came in to give him his breathing treatment later in the day, she stated in a hostile manner here is your breathing treatment. The Resident stated he had not reported his concerns that occurred over the weekend to nursing management. During a follow up interview on 3/14/24 at 12:42 pm Resident #28 revealed he did not receive any medications by mouth, and he received one breathing treatment during the day shifts on 3/9/24 and 3/10/24. He stated on 3/9/24, Med Aide #1 stated in a hostile manner you push your bell every 5 minutes, then she activated his call bell so that he could not use it and it stayed on for the remainder of the shift. The Resident further explained since Med Aide #1 pressed the call bell, there was no way for him to press it if he needed something. Resident #28 also revealed he felt belittled when he asked Med Aide #1 for his scheduled dietary supplement, and she stated in a hostile tone there is none! The Resident did not state if this occurred on 3/9/24 or 3/10/24. He further revealed he asked Nurse #11 on the next shift (7:00 pm- 7:00 am) for the dietary supplement and he received it. The interview further revealed Resident #28 stated he felt two staff, including Med Aide #1, were retaliating against him by acting mean, because he filed a complaint about not receiving care a few weeks prior, when he was first admitted to the facility. The Resident stated management handled the issue and that he had not seen that staff person since then. A review of video footage from camera #14 on 3/9/24 from 7:00 am to 7:00 pm and the Medication Administration Audit (indicates the date and time medications were initialed as administered on the Medication Administration Record) report for 3/9/24 revealed following: -8:05 am- NA #1 entered Resident #28's room and exited at 8:08 am. -8:12 am to 8:13 am- two unidentified NAs deliver breakfast trays to Resident #28 and his roommate. -8:35 am- Nurse #10 (supervised Med Aide #1 on 3/9/24) arrived on 200- hall with med cart and begins med pass. -8:40 am- NA #1 approached Nurse #10 at med cart and they had a conversation then NA #1 leaves the hall. -8:44 am- 9:00 am Nurse #10 continued with med pass in other resident rooms but never entered Resident #28's during this time. -9:06 am- NA #1entered Resident #28's room, collected one breakfast tray and exited the room. -9:14 am- Nurse #10 relocated med cart to the end of 200-hall and continued med pass. -9:33 am- Nurse #10 left 200-hall without the med cart -9:44 am- Nurse #10 returned to the med cart on 200-hall. -10:00 am- NA #1 entered Resident #28's room -10:01 am- NA #1 exited Resident #28's room, spoke to Nurse #10 who was at the other end of the hall and performed a hand motion as she was speaking. Nurse #10 then turned around and left the hall. -10:19 am- NA #1 entered Resident #28's room. NA #1 exited Resident #28's room at 10:24 am and walked across the hall to enter another resident's room. -10:22 am- Med Aide #1 entered Resident #28's room with what appeared to be a small plastic cup. It was not clear if Med Aide #1 medicated Resident #28 or his roommate. Med Aide #1 exited Resident #28's room at 10:25 am with something in her hand. -10:22 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension (nebulizer) and Fluticasone propionate suspension (nasal spray) to Resident #28. -10:23 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ensure and Tamsulosin to Resident #28. -10:24 am Per Med Administration Audit report, Med Aide #1 signed that she administered Prostat to Resident #28. -10:25 am- Per the Med Administration Audit report, Med Aide #1 signed that she conducted a pain assessment (0 of 10 scale), obtained vital signs, checked oxygen at 3 liters continuous nasal canular for shortness of breath for Resident #28. -10:25 am- Per the Medication Administration Audit report, Med Aide #1 signed that she observed or asked Resident #28 if shortness of breath (SOB) occurred when lying flat down or was resident avoiding lying flat due to SOB; monitored for signs of shortness of breath such as interrupted speech pattern (only able to say a few words before taking a breath) and increased respiratory rate. -10:31 am- NA #1 entered Resident #28's room. -10:32 am- NA #1 exited Resident #28's room with water pitcher and box of gloves. -10:33 am- NA #1 entered Resident #28's room with water pitcher the exits a few seconds later at 10:33 am. -10:33 am- Nurse #10 moved medication cart near middle of hallway/ closer to Resident #28's room and had a conversation with NA #1. -10:34 am- Med Aide #1 went to Nurse #10's cart while Nurse #10 was still talking to NA#1. -10:35 am- Med Aide #1 and Nurse #10 conversing at med cart and they both leave 200-hall with the med cart. -10:35 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -11:03 am- Med Aide #1 returns to 200-hall with med cart. -11:15 am- NA #1 entered Resident #28's room. -11:16 am- NA #1 exited Resident #28's room and takes linen cart from linen closet and leaves the hallway. -11:18 am- NA #1 returned to hall and entered Resident #28's room. -11:19 am- NA #1 exited Resident #28's room and walked past Med Aide #1 at the med cart. -11:19 am- Med Aide #1 entered Resident #28's room with a small plastic cup in hand. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -11:20 am- Med Aide #1 exited Resident #28's room and returned to med cart. -11:28 am- NA #1 returned to 200-hall, removed something from the hallway floor, said something in Med Aide #1's direction and Med Aide #1 looked at NA #1 then NA #1 left the hall. -11:55 am- Med Aide #1 left med cart, exited the hall and returned to the med cart at 11:56 am. -12:13 pm- Resident # 28's roommate left the room. -12:34 pm- Per the Medication Administration Audit report, Med Aide #1 signed that she administered Formoterol fumerate inhalation solution to Resident #28. -12:55 pm- Med Aide #1 entered Resident #28's room with a lunch tray and immediately exited with lunch tray. -1:11 pm- Resident #28's roommate returned to their room. -1:51 pm- Per the Medication Administration Audit report, Med Aide #1 signed that she administered Ensure Plus to Resident #28. -1:33 pm- NA #1 entered Resident #28's room and exited at 1:36 pm then converses with another Aide in the hall. -1:52 pm- NA #1 entered Resident #28's room and exited at 1:53 pm. -2:00 pm- Med Aide #1 in hall talking with another NA. -2:03 pm- Unit Manager #1 entered Resident #28's room and exited at 2:04 pm. -2:09 pm- Unit Manager #1 re-entered Resident #28's room with a 4-ounce plastic cup in her hand and exited at 2:10 pm. During an interview on 3/17/24 Unit Manager #1 indicated she answered Resident # 28's call bell and he requested acid reflux medication. She stated Resident #28 did not appear short of breath and he did not request a nebulizer treatment. She left the Resident's room then returned and administered the acid reflux medication, which was a standing order. -2:21 pm NA #1 returns to 200-hall, removes her coat, places it out of camera shot and leaves hall. -2:22 pm NA #1 entered Resident #28's room and exited at 2:22 pm. -2:58 pm- Med Aide #1 returns to 200-hall with no cart and entered another resident's room. -3:08 pm- Nurse #10 arrived on 200-hall with dirty linen bag and placed in dirty linen closet next to Resident #28's room but does not go into his room and leaves 200-hall. -3:20 pm Nurse #10 returned to 200-hall with med cart. -3:59 pm NA #1 entered Resident #28's room and exited at 3:59 pm with blue gloves in hand and spoke with someone out of camera footage then left 200-hall. -4:30 pm NA #1 entered Resident #28's room and exited at 4:31 pm. -4:34 pm Med Aide #1 arrived on 200-hall with med cart and started med pass. -4:48 pm NA #1 returned to 200 hall and entered Resident #28's room and exited at 4:48 pm with dirty linen bag. -4:49 pm NA #1 entered Resident #28's room. -4:50 pm NA #1 exited Resident #28's room and spoke to Med Aide #1 at the med cart as she was pointing toward Resident #28's room, then walked to med cart and continued to speak with Med Aide #1. NA #1 walked away from Med Aide #1, put her hands up in the air and re-entered Resident #28's room. -4:51 pm NA #1 exited Resident #28's room. -4:51 pm Med Aide #1 left med cart with something in hand and walked past Resident #28's room as she left 200-hall. -4:53 pm Med Aide #1 returned to 200-hall. -4:54 pm NA #1 entered Resident #28's room with incontinence supplies and exited at 4:54 pm. -5:00 pm- Med Aide #1 on the 200-hall with med cart. -5:01 pm- Med Aide #1 entered Resident #28's room (something in hand) and exited at 5:03 pm. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -5:03 pm- Med Aide #1 exited Resident #28's room and left 200-hall. -5:04 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -5:12 pm NA #1 in hall with Med Aide #1 for brief conversation. -5:16 pm Med Aide #1 entered Resident #28's room with a small plastic cup in hand and exited at 5:16 pm. It was unclear if Med Aide #1 if she medicated Resident #28 or his roommate. - 5:42 pm Med Aide #1 placed med cart trash bag in dirty linen closet and exited at 5:43 pm. -5:46 pm- Med Aide #1 entered Resident #28's room after leaving dirty linen closet and exited Resident #28's room at 5:46 pm. -5:47 pm- Med Aide #1 exited 200-hall with med cart. -6:00 pm- Med Aide #1 returned to 200-hall without the med cart. A review of video footage from camera #14 on 3/10/24 from 7:00 am to 7:00 pm and the Medication Administration Audit report for 3/10/24 revealed following: -7:02 am Med Aide #1 entered Resident #28's room with the mobile vitals machine and exited at 7:04 am. -7:55 am- NA #1 entered Resident #28's room and exited at 7:57 am. -8:00 am- NA #1 entered Resident 28's room, exited at 8:02 and left 200-hall. -8:18 am- NA #1 and NA #14 entered Resident #28's room with breakfast trays and exited at 8:19 am. -8:18 am- Med Aide #1 entered Resident #28's room with a small plastic cup, unwrapped straw, and another item in hand and exited at 8:21 am with an unwrapped straw and a plastic bottle. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -8:32 am- Nurse #13 (supervised Med Aide #1 on 3/10/24) arrived on the 200-hall with med cart. -9:03 am- NA #14 re-entered Resident #28's room with a cup of coffee and exited with another breakfast tray. -9:57 am Nurse #13 left hall with med cart laptop. -10:01 am Nurse #13 returned to hall and resumed med pass. -10:46 am- Med Aide #1 arrived on the hall without med cart and went to Nurse #13's med cart and exited hall at 10:52 am. -11:27 am Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension and Fluticasone propionate suspension (nasal spray), Ipratropium-albuterol inhalation solution (nebulizer) and Prostat to Resident #28. -11:28 am Per the Med Administration Audit report, Med Aide #1 signed that she administered Tamsulosin to Resident #28. -11:29 am Per the Med Administration Audit report, Med Aide #1 signed that she administered Ensure Plus, conducted a pain assessment (0 of 10 scale), obtained vitals, checked oxygen, and asked/ assessed for shortness of breath of Resident #28. -11:52 am- Med Aide #1 returned briefly to the med cart, picked up a small plastic cup, entered Resident #28's room and exited at 11:52 am. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -12:13 pm- Resident #28's roommate (Resident #60) in bed A leaves the room via wheelchair, with a family member. -12:23 pm- Med Aide #1 transported/ parked the med cart to dirty linen closet outside of Resident #28's room, discarded a bag of trash in the dirty linen closet, exited the dirty linen closet, returned to med cart and picked up a small plastic cup with spoon and entered Resident #28's room with the plastic cup in hand. Med Aide #1 then exited the room with cup in hand, placed it on med cart at 12:24 pm and exited 200-hall with the med cart. -12:29 pm- Med Aide #1 returned to 200-hall without med cart, stood outside Resident #28's room then left the hall. -12:32 pm- NA #14 and unidentified unknown NA entered Resident #28's room with lunch trays. -12:56 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered formoterol fumerate inhalation solution to Resident #28. -1:02 pm- Med Aide #1 arrived on 200-hall and left the hall at 1:05 pm. -from 2:00 pm to 4:26 pm- No staff entered Resident #28's room. -4:24 pm- Med Aide#1 arrived on 200-hall with medication cart and began med pass. -4:26 pm- NA #14 entered linen closet, retrieved linen, and entered Resident #28's room. -4:27 pm- NA #14 exited Resident #28's room and into one of the rooms across the hall from Resident #28, then leaves the hall a few minutes later. -4:53 pm- Med Aide #1 entered Resident #28's room with something in hand. It was not clear if Med Aide #1 medicated Resident #28 or his roommate. -4:54 pm Med Aide #1 exited Resident #28's room. -4:57 pm Med Aide #1 re-entered Resident #28's room. -4:58 pm Med Aide #1 exited Resident #28's room. -4:59 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered omeprazole and Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -5:00 pm- Med Aide #1 at med cart and Nurse #13 at med cart on opposite end of hall. -5:05 pm- NA #14 and an unknown NA delivered dinner trays to Resident #28's room and exited at 5:06 pm. -5:08 pm- Med Aide #1 entered Resident #28's room and exited a few seconds later then left the hall. -5:09 pm- Med Aide #1 returned to 200-hall and the med cart. -5:51 pm- Med Aide #1 left 200-hall with med cart. -6:31 pm- NA #14 entered Resident #28's room with a bag of linens, left the room seconds later and placed bag in dirty linen closet. Attempts to interview Nurse #13 were not successful. Attempts to interview NA #14 were not successful. A review of video footage from camera #7 on 3/09/24 from 7:00 am to 7:00 pm showed a hall's length view but did not show a view of the Resident #28's room. The view shows blurry parts of Med Aide #1 standing at the med cart, sometimes showing only the bottom half of her legs, leaving the med cart, returning to the med cart around similar or the same footage times that were viewed on camera #14. During a phone interview on 3/14/24 at 11:21 am Resident #28's family member, indicated she resided out of state and received several phone calls from the Resident on 3/9/24. She stated she was a nurse and was working when the Resident left her a voice mail message about 1:58 pm about how he pressed his call bell, NA #1 responded, and he told her he needed a breathing treatment and he had not received it. She returned his call about 5:15 pm to see if the Resident received his treatment. Resident #28 told her that he was experiencing chest pains and had been requesting his scheduled breathing treatments for at least 3 hours. The family member further indicated at one point during the day (about 5:15 pm) when she spoke to the Resident, she also spoke with the NA #1, on the Resident's cell phone when the NA went in to check on the Resident. The family member stated NA #1 told her she had reported to Nurse #10 on several occasions the Resident needed a breathing treatment and at one point Nurse #10 stated she was on break and that the NA needed to find someone else. The family member stated she was so upset, she demanded to know what was going on and NA #1 attempted to have a nurse who was out in the hall come into the Resident's room to talk to her, but the nurse would not come to the phone. The family member further indicated every time she spoke with the Resident, he seemed out of breath as evidenced by speaking in a reserved manner to preserve his breath and she could tell he was short of breath. The family stated she was so upset she called the hospice phone number and left a voice mail message for the Hospice Administrator at 5:05 pm and left messages about the Resident's report of difficulty breathing. When the family member called the Resident about 6:00 pm, the Resident stated he had just received a nebulizer treatment from the nurse and that he was feeling better. The family member also stated the Resident was only confused when he needed breathing treatment, and she truly believed him when he stated he was having difficulty. The family member stated she spoke with the Resident on 3/10/24 after she came from church, and he stated he was ok. She stated when she spoke with the Resident on Tuesday 3/12/24, he stated Sunday was a little rough, but he did not go into detail, then said it was ok. During an interview on 3/14/24 at 12:21 pm Med Aide #1 stated she was assigned to Resident #28 on the 7:00 am- 7:00 pm shift on 3/9/24 and 3/10/24 and was responsible for administering his medications and breathing treatments. She further stated on 3/9/24 NA #1 did not inform her that Resident #28 needed a breathing (nebulizer) treatment on 3/9/24 during the 7am- 7pm shift. Med Aide #1 indicated she administered a breathing treatment to Resident #28 three times during her shift (morning, afternoon, and before evening) on 3/9/24 and 3/10/24. Med Aide #1 denied being hostile towards Resident #28, activating his call bell so he could not use it, or telling him there was no dietary supplement to give him when he asked for one during her shift on 3/9/24. During a phone interview on 3/14/24 at 4:36 pm NA #1 revealed she was assigned to Resident #28 on day shift on 3/9/24 and each time she answered his call bell or checked on him from the morning through the afternoon, the Resident requested a breathing treatment. She further revealed she informed Nurse #10 on at least three occasions that the Resident was requesting his breathing treatment. The third time she informed Nurse #10 of the Resident's request for his breathing treatment, Nurse #1 stated she was on break and that NA #1 should ask Med Aide #1. NA #1 stated she located Med Aide #1 in another resident's room watching a soccer game and informed her of the Resident's request for medication. NA #1 stated Med Aide #1 replied ok. NA #1 further revealed when she went to check on the Resident during the afternoon, the Resident was on his cell phone with a family member and gave NA #1 the phone. NA #1 spoke with the family member on the phone and apologized that there was nothing else she could do but keep telling the nurse that the Resident was requesting a nebulizer treatment. NA #1 stated she returned to the Resident's room later in the afternoon and the Resident stated he still had not received his breathing treatment, then asked her did you see the nurse? when is the nurse coming. The NA further stated the Resident was not gasping for air and she could not determine whether he was short of breath because he seemed frustrated and was trying to maintain his composure. NA #1 stated her assignment kept changing on 3/9/24, the communication was horrible, and the attitudes and disposition of the nurses were awful. A follow-up call to NA #1 was placed on 3/17/24 at 4:09 pm and the voice mail box was full. During a follow-up interview on 3/17/24 at 1:53 pm Unit Manager #1 indicated she was the Unit Manager for the entire building on Saturday 3/9/24 and Sunday 3/10/24 and that Nurse #1 oversaw the Med Aide #1. She further indicated she was not aware that the Resident did not receive nebulizer treatments and medications as ordered and scheduled. During an interview on 3/14/24 at 12:02 pm Nurse #10 revealed she supervised Med Aide #1 on 3/9/24 who was assigned to Resident #28, and she was never informed the Resident reported chest pains or difficulty breathing and requested a breathing treatment. She further revealed she had no conversations with NA #1 about Resident #28 during the day shift on 3/9/24. During an interview on 3/14/24 at 10:44 am Nurse #11 indicated he worked 7:00 pm to 7:00 am on 3/9/24 and 3/10/24 and was assigned to Resident #28. Nurse #11 stated Resident #28 did not complain about being mistreated by staff or not receiving his medication as scheduled on 3/9/24 or 3/10/24 during the 7:00 am to 7:00 pm shift. Nurse #11 further indicated he administered breathing treatments as ordered to Resident #28's, on both nights that he worked, and the off-going staff did not mention any concerns with the Resident. A hospice nurse progress note dated 3/11/24 revealed the Resident #28 reported to the hospice social worker that he was not administered breathing treatments as ordered over the weekend and specifically complained about treatment from an evening nurse or med aide. He further reported that facility staff activated his call light so that he could not press it. The note further read that the hospice administrator was contacted by Resident #28's family member about the Resident receiving medications on 3/9/24. During a phone interview on 3/15/24 at 8:16 pm the Hospice Nurse revealed she visits Resident #28 on Monday/Friday every week and that the Resident was very upset when he reported to her on 3/11/24 that his scheduled nebulizer treatments were not given on time on 3/9/24 and 3/10/24. She stated that the Resident did not give specific times he did not receive his nebulizer treatments but that he only received one treatment during 7am to 7pm shifts and should have received 4 treatments during those shifts. She stated the Resident had high anxiety and she believed what he was telling her because the hospice nurse heard similar stories from other patients related to not receiving their medications. She also stated the Resident should have received scheduled breathing treatments 4 times per day and not receiving those treatments could cause psychological stress which would affect his breathing, cardiac status, and increase his heart rate. The Hospice Nurse stated over the weekend, she received a voice mail from the Resident's family member stating the Resident was having chest pains and that the family member also contacted the hospice administrator and left a message about the Resident's unanswered requests for breathing treatments. She also stated his symptoms would have resolved faster than they did, had the Med Aide administered the medications and nebulizer treatments as ordered. The nebulizer treatments should have been spread throughout the day so he could avoid the spikes in anxiety, since he was already nervous due to the albuterol which could cause the heart rate to increase. During an interview on 3/12/24 at 2:35 pm Unit Manager #2 agreed to follow-up with Resident #28 after the Surveyor informed Unit Manager #2 the Resident had concerns from the weekend (3/9/24 and 3/10/24) regarding the call bell incident, Med Aide #1 interactions related to not getting his medications, and dietary concerns. During an interview on 3/14/24 at 1:10 pm Unit Manager #2 revealed she spoke with Resident #28 on Monday or Tuesday (3/11/24 or 3/12/24), after the [State Surveyor] informed her Resident #28 had concerns about incidents that occurred over the weekend (3/9/24 and 3/10/24), related to not receiving his nebulizer treatments, call bell being activated so the Resident could not activate it and wanting to speak with the dietician about menu concerns. Unit Manager #2 further revealed the Resident did not mention he did not receive his breathing treatments but that he did not get his medications on time over the weekend and his call bell was not being answered in a timely manner. Unit Manager #2 stated she informed the Director of Nursing (DON) of the concerns after she spoke to the resident. During an interview on 3/14/24 at 1:00 pm the DON indicated he was not made aware of Resident #28's concerns until 3/14/24 related to not receiving medications or that Med Aide #1 activated the Resident's call bell so that the Resident could not use it. The DON further indicated he expected all residents to receive their medications as prescribed and call bells to be answered in a timely manner. During an interview on 3/14/23 at 1:10 pm, with the Corporate Nurse, Unit Manager #2 and the DON present, the Corporate Nurse spoke on behalf of Unit Manager #2 and stated Resident #28 did not report to Unit Manager #2 that he did not receive his nebulizer treatment or that the Med Aide #1 pressed his call bell so he couldn't use it. The DON indicated Unit Manager #2 made him aware of the call bell concerns on 3/14/24. During a phone interview on 3/14/24 at 5:00 pm the facility Nurse Practitioner (NP) indicated scheduled breathing treatments could have helped Resident #28's symptoms if he received them. She further indicated the Resident was probably upset and became more air hungry, anxious, and bronchioles constricted despite receiving oxygen at 3 liters. The NP indicated her expectation was for Resident #28 to receive all his scheduled medications as ordered. During a phone interview on 3/14/24 at 5:27 pm the Medical Director revealed he took over as Medical Director in January 2024 and was not yet familiar with Resident #28. He further revealed the Resident could have had a significant decline when he did not receive his breathing treatments as ordered and not receiving breathing treatments may have caused the symptoms that included: i

Based on record review and resident, family member, staff interviews, Hospice Nurse, Nurse Practitioner (NP), and Medical Director interviews the facility failed to prevent a significant medication error when Resident #28 was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. This had the high likelihood of a serious adverse outcome including psychological stress which would affect his breathing, cardiac status, and increase his heart rate. The deficient practice occurred for 1 of 1 resident reviewed for significant medication errors. Immediate jeopardy began on 3/9/24 when Resident #28 was not administered scheduled nebulizer treatments despite repeated requests. The immediate jeopardy was removed on 3/19/24 when the facility provided and implemented an acceptable credible allegation of Immediately Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective related to preventing a significant medication error. The findings included: Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of chronic obstructive pulmonary disease (COPD), heart failure, hypertension, and anxiety. An admission MDS assessment dated [DATE] indicated Resident #28 was cognitively intact, was receiving hospice care and required maximal assistance with toileting, showering, and dressing. The assessment further indicated rejection of care 1-3 times and use of oxygen. A care plan dated 2/26/24 indicated Resident #28 was care planned for the following: -altered respiratory status/ difficulty breathing related to anxiety, COPD history of respiratory failure with intervention to provide oxygen as ordered. -continuous oxygen therapy for CHF and COPD with interventions to give medications as ordered, monitor/ document side effects and effectiveness, observe for symptoms of respiratory distress and report to physician as needed (restlessness, pulse oximetry, increased heart rate, headaches, lethargy, confusion, cough, accessory muscle usage and skin color. -altered cardiovascular status arrythmia, CHF and hypertension with interventions to assess shortness of breath and cyanosis, diet consult as necessary, oxygen as ordered, monitor/document/report changes in lung sounds (crackles), edema, and changes in weight; vital signs as ordered/as needed and report abnormal readings to physician. -hospice services related to COPD, with an intervention to administer pain medications as prescribed, assess frequently and provide additional pain relief as necessary; coordinate care with hospice team; invite hospice staff to participate in resident care planning conferences; promote comfort by repositioning, adding more pillows, massage, reading, and aromatherapy. A review of the March 2024 Medication Administration Record revealed Resident #28 was to receive the following during the 7am- 7pm shift: -Budesonide inhalation suspension- 2 times a day for COPD (9am) -Formoterol fumerate inhalation solution 2 times a day (every 12 hours) for COPD (1pm) -Oxgyen 3 liters continuous nasal canular for shortness of breath- every shift O2 -Ipratropium-albuterol inhalation solution #60 vial-(nebulizer) inhale 4 times a day for COPD (11am, 5pm) During an interview on 3/11/24 at 11:10 AM Resident #28 revealed he received a nebulizer treatment once on Saturday 3/9/24 and once on Sunday 3/10/24 during the 7:00 am to 7:00 pm shift (day shift), although he was supposed to receive nebulizer treatments four times during the day shift. Resident #28 stated he had chest difficulty on 3/9/24 and requested a breathing (nebulizer) treatment on several occasions but did not receive it until late afternoon. He revealed he told Nurse Aide (NA) #1 he needed a breathing treatment each time she came into his room to check on him or answer his call bell throughout the day and NA #1 told him that she informed Nurse #10 of his requests. Resident #28 indicated on 3/9/24 he called his daughter to complain of chest pain and that he had been asking for a breathing treatment for 3 hours. The Resident explained NA #1 was trying to be helpful when she spoke with his daughter on the phone while she was in the room and stated she was doing all she could by reporting the Resident's need for a breathing treatment. The Resident stated when the Medication Aide (later identified by the Resident as Med Aide #1) finally came in to give him his breathing treatment later in the day, she stated in a hostile manner here is your breathing treatment. The Resident stated he had not reported his concerns that occurred over the weekend to nursing management. A review of video footage from camera #14 on 3/9/24 from 7:00 am to 7:00 pm and the Medication Administration Audit (indicates the date and time medications were initialed as administered on the Medication Administration Record) report for 3/9/24 revealed following: -8:05 am- NA #1 entered Resident #28's room and exited at 8:08 am. -8:35 am- Nurse #10 (supervised Med Aide #1 on 3/9/24) arrived on 200- hall with med cart and begins med pass. -8:40 am- NA #1 approached Nurse #10 at med cart and they had a conversation then NA #1 leaves the hall. -8:44 am- 9:00 am Nurse #10 continued with med pass in other resident rooms but never entered Resident #28's during this time. -9:14 am- Nurse #10 relocated med cart to the end of 200-hall and continued med pass. -9:33 am- Nurse #10 left 200-hall without the med cart -9:44 am- Nurse #10 returned to the med cart on 200-hall. -10:00 am- NA #1 entered Resident #28's room -10:01 am- NA #1 exited Resident #28's room, spoke to Nurse #10 who was at the other end of the hall and performed a hand motion as she was speaking. Nurse #10 then turned around and left the hall. -10:19 am- NA #1 entered Resident #28's room. NA #1 exited Resident #28's room at 10:24 am and walked across the hall to enter another resident's room. -10:22 am- Med Aide #1 entered Resident #28's room with what appeared to be a small plastic cup. It was not clear if Med Aide #1 medicated Resident #28 or his roommate. Med Aide #1 exited Resident #28's room at 10:25 am with something in her hand. -10:22 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension (nebulizer) to Resident #28. -10:23 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ensure and Tamsulosin to Resident #28. -10:24 am Per Med Administration Audit report, Med Aide #1 signed that she administered Prostat to Resident #28. -10:31 am- NA #1 entered Resident #28's room. -10:32 am- NA #1 exited Resident #28's room with water pitcher and box of gloves. -10:33 am- Nurse #10 moved medication cart near middle of hallway/ closer to Resident #28's room and had a conversation with NA #1. -10:34 am- Med Aide #1 went to Nurse #10's cart while Nurse #10 was still talking to NA#1. -10:35 am- Med Aide #1 and Nurse #10 conversing at med cart and they both leave 200-hall with the med cart. -10:35 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -11:03 am- Med Aide #1 returns to 200-hall with med cart. -11:18 am- NA #1 returned to hall and entered Resident #28's room. -11:19 am- NA #1 exited Resident #28's room and walked past Med Aide #1 at the med cart. -11:19 am- Med Aide #1 entered Resident #28's room with a small plastic cup in hand. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -11:20 am- Med Aide #1 exited Resident #28's room and returned to med cart. -11:28 am- NA #1 returned to 200-hall, removed something from the hallway floor, said something in Med Aide #1's direction and Med Aide #1 looked at NA #1 then NA #1 left the hall. -11:55 am- Med Aide #1 left med cart, exited the hall and returned to the med cart at 11:56 am. -12:13 pm- Resident # 28's roommate left the room. -12:34 pm- Per the Medication Administration Audit report, Med Aide #1 signed that she administered Formoterol fumerate inhalation solution to Resident #28. -12:55 pm- Med Aide #1 entered Resident #28's room with a lunch tray and immediately exited with lunch tray. -1:52 pm- NA #1 entered Resident #28's room and exited at 1:53 pm. -2:00 pm- Med Aide #1 in hall talking with another NA. -2:22 pm NA #1 entered Resident #28's room and exited at 2:22 pm. -2:58 pm- Med Aide #1 returns to 200-hall with no cart and entered another resident's room. -3:20 pm Nurse #10 returned to 200-hall with med cart. -3:59 pm NA #1 entered Resident #28's room and exited at 3:59 pm with blue gloves in hand and spoke with someone out of camera footage then left 200-hall. -4:30 pm NA #1 entered Resident #28's room and exited at 4:31 pm. -4:34 pm Med Aide #1 arrived on 200-hall with med cart and started med pass. -4:50 pm NA #1 exited Resident #28's room and spoke to Med Aide #1 at the med cart as she was pointing toward Resident #28's room, then walked to med cart and continued to speak with Med Aide #1. NA #1 walked away from Med Aide #1, put her hands up in the air and re-entered Resident #28's room. -4:51 pm NA #1 exited Resident #28's room. -4:51 pm Med Aide #1 left med cart with something in hand and walked past Resident #28's room as she left 200-hall. -4:53 pm Med Aide #1 returned to 200-hall. -5:00 pm Med Aide #1 on the 200-hall with med cart. -5:01 pm- Med Aide #1 entered Resident #28's room (something in hand) and exited at 5:03 pm. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -5:03 pm- Med Aide #1 exited Resident #28's room and left 200-hall. -5:04 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -5:12 pm NA #1 in hall with Med Aide #1 for brief conversation. -5:16 pm Med Aide #1 entered Resident #28's room with a small plastic cup in hand and exited at 5:16 pm. It was unclear if Med Aide #1 if she medicated Resident #28 or his roommate. -5:46 pm- Med Aide #1 entered Resident #28's room after leaving dirty linen closet and exited Resident #28's room at 5:46 pm. -5:47 pm- Med Aide #1 exited 200-hall with med cart. -6:00 pm- Med Aide #1 returned to 200-hall without the med cart. A review of video footage from camera #14 on 3/10/24 from 7:00 am to 7:00 pm and the Medication Administration Audit report for 3/10/24 revealed following: -8:18 am- Med Aide #1 entered Resident #28's room with a small plastic cup, unwrapped straw, and another item in hand and exited at 8:21 am- with an unwrapped straw and a plastic bottle. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -8:32 am- Nurse #13 (supervised Med Aide #1 on 3/10/24) arrived on the 200-hall with med cart. -9:57 am- Nurse #13 left hall with med cart laptop. -10:01 am- Nurse #13 returned to hall and resumed med pass. -10:46 am- Med Aide #1 arrived on the hall without med cart and went to Nurse #13's med cart and exited hall at 10:52 am. -11:27 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension and Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -11:52 am- Med Aide #1 returned briefly to the med cart, picked up a small plastic cup, entered Resident #28's room and exited at 11:52 am. It was unclear if Med Aide #1 medicated Resident #28 or his roommate. -12:13 pm- Resident #28's roommate (Resident #60) in bed A leaves the room via wheelchair, with a family member. -12:23 pm- Med Aide #1 transported/parked the med cart to dirty linen closet outside of Resident #28's room, discarded a bag of trash in the dirty linen closet, exited the dirty linen closet, returned to med cart and picked up a small plastic cup with spoon and entered Resident #28's room with the plastic cup in hand. Med Aide #1 then exited the room with cup in hand, placed it on med cart at 12:24 pm and exited 200-hall with the med cart. -12:29 pm- Med Aide #1 returned to 200-hall without med cart, stood outside Resident #28's room then left the hall. -12:56 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered formoterol fumerate inhalation solution to Resident #28. -from 2:00 pm to 4:26 pm- No staff entered Resident #28's room. -4:24 pm- Med Aide#1 arrived on 200-hall with medication cart and began med pass. -4:53 pm- Med Aide #1 entered Resident #28's room with something in hand. It was not clear if Med Aide #1 medicated Resident #28 or his roommate. -4:54 pm- Med Aide #1 exited Resident #28's room. -4:57 pm- Med Aide #1 re-entered Resident #28's room. -4:58 pm- Med Aide #1 exited Resident #28's room. -4:59 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28. -5:00 pm- Med Aide #1 on the 200- hall with med cart and Nurse #13 at med cart on opposite end of hall. -5:08 pm- Med Aide #1 entered Resident #28's room and exited a few seconds later then left the hall. -5:51 pm- Med Aide #1 left 200-hall with med cart and was not observed returning with the med cart before 7:00 pm. A review of video footage from camera #7 on 3/09/24 from 7:00 am to 7:00 pm showed a hall's length view but did not show a view of the Resident #28's room. The view shows blurry parts of Med Aide #1 standing at the med cart, sometimes showing only the bottom half of her legs, leaving the med cart, returning to the med cart around similar or the same footage times that were viewed on camera #14. During a phone interview on 3/14/24 at 4:36 pm NA #1 revealed she was assigned to Resident #28 on day shift on 3/9/24 and each time she answered his call bell or checked on him from the morning through the afternoon, the Resident requested a breathing treatment. She further revealed she informed Nurse #10 on at least three occasions that the Resident was requesting his breathing treatment. The third time she informed Nurse #10 of the Resident's request for his breathing treatment, Nurse #1 stated she was on break and that NA #1 should ask Med Aide #1. NA #1 stated she located Med Aide #1 in another resident's room watching a soccer game and informed her of the Resident's request for medication. NA #1 stated Med Aide #1 replied ok. NA #1 further revealed when she went to check on the Resident during the afternoon, the Resident was on his cell phone with a family member and gave NA #1 the phone. NA #1 spoke with the family member on the phone and apologized that there was nothing else she could do but keep telling the nurse that the Resident was requesting a nebulizer treatment. NA #1 stated she returned to the Resident's room later in the afternoon and the Resident stated he still had not received his breathing treatment, then asked her did you see the nurse? when is the nurse coming. The NA further stated the Resident was not gasping for air and she could not determine whether he was short of breath because he seemed frustrated and was trying to maintain his composure. During an interview on 3/14/24 at 12:21 pm Med Aide #1 stated she was assigned to Resident #28 on the 7:00 am- 7:00 pm shift on 3/9/24 and 3/10/24 and was responsible for administering his medications and breathing treatments. She further stated on 3/9/24 NA #1 did not inform her that Resident #28 needed a breathing (nebulizer) treatment on 3/9/24 during the 7am- 7pm shift. Med Aide #1 indicated she administered a breathing treatment to Resident #28 three times during her shift (morning, afternoon, and before evening) on 3/9/24 and 3/10/24. During an interview on 3/14/24 at 12:02 pm Nurse #10 revealed she supervised Med Aide #1 on 3/9/24 who was assigned to Resident #28, and she was never informed the Resident reported chest pains or difficulty breathing and requested a breathing treatment. She further revealed she had no conversations with NA #1 about Resident #28 during the day shift on 3/9/24. During a phone interview on 3/14/24 at 11:21 am Resident #28's Family Member, indicated she resided out of state and received several phone calls from the Resident on 3/9/24. She stated she was a nurse and was working when the Resident left her a voice mail message about 1:58 pm about how he pressed his call bell, NA #1 responded, and he told her he needed a breathing treatment and he had not received it. She returned his call at about 5:15 pm to see if the Resident received his treatment. Resident #28 told her that he was experiencing chest pains and had been requesting his scheduled breathing treatments for at least 3 hours. The family member further indicated at one point during the day (about 5:15 pm) when she spoke to the Resident, she also spoke with the NA #1, on the Resident's cell phone when the NA went in to check on the Resident. The family member stated NA #1 told her she had reported to Nurse #10 on several occasions the Resident needed a breathing treatment and at one point Nurse #10 stated she was on break and that the NA needed to find someone else. The family member stated she was so upset, she demanded to know what was going on and NA #1 attempted to have a nurse who was out in the hall come into the Resident's room to talk to her, but the nurse would not come to the phone. The family member further indicated every time she spoke with the Resident, he seemed out of breath as evidenced by speaking in a reserved manner to preserve his breath and she could tell he was short of breath. The family stated she was so upset she called the hospice phone number and left a voice mail message for the Hospice Administrator at 5:05 pm and left messages about the Resident's report of difficulty breathing. When the family member called the Resident about 6:00 pm, the Resident stated he had just received a nebulizer treatment from the nurse and that he was feeling better. The family member also stated the Resident was only confused when he needed breathing treatment, and she truly believed him when he stated he was having difficulty. The family member stated she spoke with the Resident on 3/10/24 after she came from church, and he stated he was ok. She stated when she spoke with the Resident on Tuesday 3/12/24, he stated Sunday was a little rough, but he did not go into detail, then said it was ok. During a phone interview on 3/15/24 at 8:16 pm the Hospice Nurse revealed she visits Resident #28 on Monday/Friday every week and that the Resident was very upset when he reported to her on 3/11/24 that his scheduled nebulizer treatments were not given on time on 3/9/24 and 3/10/24. She stated that the Resident did not give specific times he did not receive his nebulizer treatments but that he only received one treatment during 7:00 am to 7:00 pm shifts and should have received four nebulizer treatments each day during those shifts. The Hospice Nurse stated the Resident had high anxiety and she believed what he was telling her because she had heard similar stories from other residents related to not receiving their medications. During an interview on 3/14/24 at 1:10 pm Unit Manager #2 revealed she spoke with the Resident #28 on Monday or Tuesday (3/11/24 or 3/12/24), after the State Surveyor informed her Resident #28 had concerns about incidents that occurred over the weekend (3/9/24 and 3/10/24), related to not receiving his nebulizer treatments. Unit Manager #2 further revealed the Resident did not mention he did not receive his breathing treatments but that he did not get his medications on time over the weekend. Unit Manager #2 stated she informed the Director of Nursing (DON) of the concerns after she spoke to the resident. During an interview on 3/14/24 at 1:00 pm the DON indicated he was not made aware of Resident #28's concerns until 3/14/24 related to not receiving medications over the weekend (3/9/24 and 3/10/24). The DON further indicated he expected all residents to receive their medications as prescribed and call bells to be answered in a timely manner. During a phone interview on 3/14/24 at 5:00 pm the facility Nurse Practitioner (NP) indicated scheduled breathing treatments could have helped Resident #28's symptoms if he received them. She further indicated the Resident was probably upset and became more air hungry, anxious, and bronchioles constricted despite receiving oxygen at 3 liters. The NP indicated her expectation was for Resident #28 to receive all his scheduled medications as ordered. During a phone interview on 3/14/24 at 5:27 pm the Medical Director revealed he took over as Medical Director in January 2024 and was not yet familiar with Resident #28. He further revealed the Resident could have had a significant decline when he did not receive his breathing treatments as ordered and not receiving breathing treatments may have caused the symptoms that included: increased shortness of breath, wheezing and increased stress. The Medical Director stated the Resident's symptoms caused him to contact his family member who called hospice when he could not get assistance from the facility. The Medical Director indicated his expectation was for staff members to administer medications as ordered. The Administrator was notified of immediate jeopardy on 3/16/24 at 6:00 pm. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 3/9/24 and 3/10/24 the facility failed to prevent a significant medication error when Resident # 28, who has diagnoses including COPD with respiratory failure and CHF, was not administered scheduled nebulizer treatments as ordered by the physician at 9 AM (Budesonide), 11 AM (Ipratropium-Albuterol), 1 PM (Formoterol Fumarate) and 5 PM (Ipratropium-Albuterol) despite repeated requests. On 3/11/2024, Resident #28 was seen by the Nurse Practitioner at the request of Hospice nurse for shortness of breath and chest pain. He reported these symptoms to the Hospice Nurse on 3/11/24. Per Nurse Practitioner, Resident #28 to continue Morphine for pain and restlessness and new order for Hydromet Syrup 5-1.5 MG/5ML (Hydrocodone-Homatropine) 5ml every 6 hrs. for cough/congestion. Resident #28 reported to the Hospice Nurse on 3/11/24 that he only received one nebulizer treatment for the 7am to 7pm shifts on 3/9/24 and 3/10/24 was having shortness of breath and chest pain. Hospice nurse reports resident does have anxiety regarding not receiving medications and a combination of the anxiety and trouble breathing is triggering his PTSD per the hospice progress note. The resident was interviewed by the Administrator on 3/14/24 about 3/9/24 and 3/10/24 and not receiving nebulizer treatments. The resident reported he suffered from chest pain as a result of not receiving the scheduled nebulizer medication. The resident continues to have assessments (respiratory, pain assessments) to assess for any serious adverse outcome including any significant decline or respiratory distress. Resident # 28 is receiving routine vital signs every shift including pulse ox (documented in the medical record) and daily nursing assessments of his respiratory status. On 3/14/2024, Medication Aide #1 was immediately suspended pending investigation. On 03/14/2024, the Director of Nursing notified the provider of the significant medication error when Resident #28 was not administered his scheduled nebulizer treatments as ordered by the physician which included the 9 AM (Budesonide), 11 AM (Ipratropium-Albuterol), 1 PM (Formoterol Fumarate) and 5 PM (Ipratropium-Albuterol) despite repeated requests. On 3/14/2024, the Director of Nursing and Unit Managers completed medication administration audit by reviewing the electronic record for 3/9/2024 to 3/10/2024 for all shifts. The results were: All scheduled medications documented as administered. On 03/14/2024, the DON and the ADON conducted interviews that were completed on current residents with BIMs of 13 or higher indicating no cognitive impairment and they were asked if they have any concerns with medication administration and if they had received all of their scheduled medications. This included residents on the 200 halls where Resident #28 resides. The results included that there were no residents who reported any concerns with their medications being administered and they had no significant decline or respiratory distress and reported receiving their scheduled medications. All residents with a BIMs of 12 or below with cognitive impairment were assessed observing for any acute distress (shortness of breath verbal/nonverbal indicators of pain) by Unit Managers for any significant decline or respiratory distress. This included residents on the 200 halls. The results were no other residents identified with any significant decline or respiratory distress. The Director of Nursing determined on 3/15/24 that no other residents were impacted by the medication error when no other current alert residents with a Brief Interview of Mental Status (BIMs) of 13 or greater reported any concerns with having received their medications and when all other current residents with a BIMs of 12 or less indicating cognitive impairment were assessed for any change in condition including any significant decline, pain or respiratory distress with none noted and all vital signs were at baseline. On 03/15/2024 the Director of Nursing (DON) and Assistant Director of Nursing initiated random medication observations of the licensed nurses and the medication aides to ensure that all residents received their scheduled medication and that the 6 rights of medication administration were followed including documenting administration of medications that were administered. This was completed on 03/15/2024 and there were no negative findings. Director of Nursing, and /or Assistant Director of Nursing and/or Unit Managers and /or Nurse Managers completed Medication Pass Observations using a Medication Observation Tool, on 5 licensed nurses, and 1 medication aid with no concerns identified. This was completed on 03/15/2024. 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. On 03/15/2024, the Administrator and Director of Nursing conducted a root cause analysis and determined that the root cause of the alleged error was that Medication Aide #1 failed to follow facility policy related to medication administration and 6 rights of medication administration and disregard of resident's rights by ignoring request by Nurse Aide #1 for administration of Resident #28's nebulizer treatment. Video footage revealed Medication Aide #1 did not administer nebulizer treatments as ordered. The video was reviewed for the 7a-7p shifts on 3/9/24 and 3/10/24. All Full Time and Part Time and as needed (PRN) Nursing (Registered Nurses, Licensed Practical Nurses) and Medication aides will be educated on the following preventing medication errors, the 6 rights of medication administration (right medication right patient, right dose, right time, right route, and right documentation) and following medication safety practices by the Director of Nursing, Nurse Managers and Staff Development Nurse. Education began on 03/14/2024. In person training was completed and the in-service topics included preventing medication errors, the 6 rights of medication administration (right medication right patient, right dose, right time, right route, and right documentation-signing MAR after administering medication). The Director of Nursing will review staffing schedules daily to ensure that anyone that did not receive the in-service training by 03/15/2024 will not be allowed to work until the training is complete. This training will be incorporated into the general orientation program and education for agency staff. The education was provided in person both days on 3/14/24 and 3/15/24 by the Assistant Director of Nursing in the facility. The Administrator and Director of Nursing will communicate with all nursing staff beginning 3/18/24 via meeting, phone, and nursing huddles to reiterate that Resident #28 and all other residents, are not to be neglected, retaliated against and all residents receive the ordered care and services. The Director of Nursing will ensure any staff not communicated with will not be able to work until communication is complete. All new staff will be trained during orientation by nursing leadership. The Interdisciplinary Team (Administrator, Director of Nursing, Nurse Managers, Minimum Data Set Coordinators, Unit Manager, Support nurse, Therapy, Health Information Management, Dietary Manager, Medical Director, Pharmacist), were notified of the significant medication error by 03/15/2024 and were involved in the removal plan. DON will be responsible for ensuring the removal plan is implemented. Immediate Jeopardy Removal Date: 03/19/2024 F760 - Date of immediate jeopardy removal: 03/19/2024. On 03/26/24, the facility's immediate jeopardy removal plan effective 03/19/24 was validated by the following: Nursing staff interviews revealed they had received education on the 6 rights of medication administration. Administrative staff interviews revealed they had completed audits of nurses and medication aides during medication pass. The facilities medication error rate was 0% during the medication pass facility task completed by the survey team. The immediate jeopardy removal date of 3/19/24 was validated.

Based on record review, resident, responsible party (RP) and staff interviews, the facility failed to ensure group activities were planned for rehabilitation residents to meet the needs of the residents who expressed that it was important to them to attend group activities for 3 of 3 residents reviewed for activities (Resident #37, Resident #85 and Resident #88). The findings included: A review of the March 2024 activity calendar revealed activities for inside of the facility during the week and on the weekends. Activities were scheduled daily at 11:00 AM and 2:00 PM for the duration of the month. The calendar revealed an ice cream social dated 03/01/24 and bingo twice a week on Tuesdays and Thursdays. On 03/13/24 at 10:25 AM an interview was conducted with the Activities Assistant. During the interview she stated the activities were planned by the residents during a meeting held each month. The interview revealed most activities were held in the activity room on the long-term side of the building and events were usually held at 2:00 PM daily. She stated she would normally remind residents the day before the event and on the day of the event 30 minutes prior to start time would go to the rooms of the residents that she knew would want to participate and assist them to the activity. The interview revealed she and the Activities Director would typically split the building meaning she would ask the residents on the long-term care side of the building and the Activities Director would ask residents on the rehabilitation side of the building. She stated the Activities Director had been out of the facility since the beginning of March on leave. The Activities Assistant stated she had not gone to the rehabilitation side of the facility and asked residents if they wanted to attend activities scheduled. She stated she also assisted with resident admissions into the facility as part of her job duties assigned by the Administrator. She stated she only had 30 minutes to gather residents to attend activities and did not have time to go room to room to ask residents if they wanted to attend. The interview revealed she assisted the residents that needed to be pushed via wheelchair to the activities and if there was a large activity the Nurse Aides (NA) on the hall would assist. She stated she would ask the NA's on the hall for assistance getting the residents to the activity room. 1. Resident #37 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #37 felt that it was very important to have activities that included doing things in a group setting. The assessment further indicated Resident #37 was moderately cognitively impaired. A care plan dated 02/06/24 revealed a focus area for Resident #37's interest in group bingo events. The goal was for Resident #37 to participate in group bingo events when offered. Interventions included providing reminders and assistance to group activity of interest. On 03/11/23 at 11:39 AM an interview was conducted with Resident #37's Responsible Party (RP) #1. During the interview she stated Resident #37 had been discharged to the hospital and recently readmitted back to the facility (2/22/24). She stated since he had returned, he was moved to the 400 hall on the rehabilitation side of the facility. The interview revealed no staff members had come to the room and asked Resident #37 if he wanted to attend the bingo activity that the facility had twice a week. She stated on 03/01/24 the facility had an ice cream social; the interview revealed the resident had observed a staff member walk down the hall with a bowl of ice cream and told her he would like to have some ice cream. RP #1 stated she had to push the resident in his wheelchair and go find where the facility was having the ice cream social event for him to attend. She stated activities were very important to the resident and sometimes she wasn't in the building to take him. RP #1 stated all residents should be included in the activities not just the residents on the long-term side of the building. On 03/13/24 at 10:13 AM a follow up interview was conducted with RP #1. During the interview she stated according to the March activity Calendar the facility had bingo at 2:00 PM on 03/12/24. She stated she was in the resident's room on the afternoon of 3/21/24 and no one had come to the room and asked Resident #37 if he wanted to attend the activity. On 03/13/24 at 10:50 AM an interview was conducted with Nurse Aide (NA) #2. During the interview NA #2 stated she had taken care of Resident #37 on a regular basis. NA#2 stated she had never asked Resident #37 if he wanted to attend any of the activities in the facility. NA#2 stated she thought she had seen someone from activities ask the residents if they wanted to attend. On 03/13/24 at 10:59 AM an interview was conducted with Nurse #2. During the interview she stated she was regularly assigned to Resident #37. She indicated typically she observed someone from the Activities Department come to the hall and ask the residents if they would like to attend activities during the first week of their admission. She stated if the residents said no, then sometimes they were not asked again. She stated she had not seen anyone ask Resident #37 if he wanted to attend an activity. On 03/13/24 at 10:35 AM an interview was conducted with the Director of Nursing (DON). During the interview he stated the Activities Director had been out of the facility on leave since the beginning of March. He stated he had not received any complaints of residents not being asked to attend activities. The interview revealed he felt the nursing staff were assisting residents to attend the activities that were scheduled. On 03/13/24 at 11:48 AM an interview was conducted with the Administrator. During the interview she stated Resident #37's RP had never voiced any concerns to her of staff not asking if he wanted to attend activities. She stated the Activities Director had been out of the facility since the beginning of March and she was not aware of the arrangement between the Activities Director and her Assistant. The interview revealed she did not know why Resident #37 had not been asked to attend the activities in the facility. 40197 2. Resident # 85 was admitted to the facility on [DATE] with diagnoses that included diabetes and a history of a stroke. She resided on the 300 hall, which was one of the two rehab halls. An Activity Assessment completed by the Activity Director and dated 1/3/24 indicated the assessment was completed with Resident #85 who indicated she wanted to be invited to out of room activities. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 had severe cognitive impairment and displayed no behaviors. She was able to make herself understood and usually understood others. Preferences for Customary Routine and Activities (section F) indicated group activities were very important to her. A wheelchair was used for mobility. On 3/13/24 at 10:25 AM, the Activities Assistant was interviewed. She explained that on a typical day when an activity is scheduled at 2:00 PM, she would remind residents the day prior and an hour before the activity by going to the rooms of the residents that she knew would participate. She added that the Activity Director normally went to the rehab side to do this task. The Activities Assistant stated that the Activity Director had been out of the facility since 3/5/24 and she had not been going to the rehab side of the building to inquire if residents wanted to go to any group activities because she didn't have enough time. An observation and interview were conducted with Resident #85 on 3/13/24 at 1:33 PM. She was sitting in her wheelchair watching television (TV) in her room and stated she couldn't recall being asked to go to activities but, I love being around people and it would be nice to be asked. A review of Resident #85's medical record from 12/28/23 to 3/14/24 didn't reveal any activity notes. Activity logs for resident #85's participation in activities were not available for review. On 3/14/24 at 8:32 AM, an interview occurred with Nurse Aide #13 who was assigned to care for Resident #85. She stated the activity calendars were in resident rooms and that sometimes activities will come and ask residents if they wanted to go to whatever was scheduled. She could not recall if Resident #85 was asked or assisted to attend group activities. The Administrator was interviewed on 3/14/24 at 12:31 PM and stated she was not aware Resident #85 was not being included in group activities. The Administrator stated she didn't know the arrangement that was made by the Activity Director and Activities Assistant prior to the Activities Director leaving the facility on 3/5/24 regarding resident activity participation. She added it was her expectation that Resident #85 be invited and assisted as desired to group activities. 3. Resident #88 was admitted to the facility on [DATE] with recent left shoulder fracture. She resided on the 300 hall, which was one of the two rehab halls. An Activity Assessment completed by the Activity Director and dated 2/1/24 indicated the assessment was completed with Resident #88 who indicated she wanted to be invited to out of room activities. The Admission MDS assessment dated [DATE] indicated Resident #88 had moderately impaired cognition and displayed no behaviors. Preferences for Customary Routine and Activities (section F) indicated group activities were very important to her. Resident #88's care plan included a focus area for an interest in group activities and a willingness to participate. One of the interventions included to provide reminders and assistance to group activities of interest before they start. On 3/13/24 at 10:25 AM, the Activities Assistant was interviewed. She explained that on a typical day when an activity was scheduled at 2:00 PM, she would remind residents the day prior and an hour before the activity by going to the rooms of the residents that she knew would participate. She added that the Activity Director normally went to the rehab side to do this task. The Activities Assistant stated that the Activity Director had been out of the facility since 3/5/24 and she had not been going to the rehab side of the building to inquire if residents wanted to go to any group activities because she didn't have enough time. An observation and interview were conducted with Resident #88 on 3/13/24 at 1:39 PM. She was sitting in her wheelchair watching television (TV) and stated she hadn't been asked or told anything about the activities going on for the day but would like to be given a choice of attending or not. A review of Resident #88's medical record from 1/25/24 to 3/14/24 did not include any activity notes. Activity logs for resident #88's participation in activities were not available for review. On 3/14/24 at 8:32 AM, an interview occurred with Nurse Aide #13 who was assigned to care for Resident #88. She stated activity calendars were in resident rooms and that sometimes activities will come and ask residents if they wanted to go to whatever was scheduled. She could not recall if Resident #88 was asked or assisted to attend group activities. The Administrator was interviewed on 3/14/24 at 12:31 PM and stated she was not aware Resident #88 was not being included in group activities. The Administrator stated she didn't know the arrangements that were made by the Activity Director and Activities Assistant prior to her leaving the facility on 3/5/24 regarding resident activity participation. She added it was her expectation that Resident #88 was invited and assisted as desired to group activities.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 9/29/22. This failure occurred for four repeat deficiencies cited for resident's rights, accuracy of assessments, maintenance of nutrition and hydration status, and infection prevention and control that was subsequently recited on the current recertification and complaint investigation survey of 3/26/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F550 (Resident's Rights): Based on record review, observations, resident, and staff interviews, the facility failed to treat a resident (Resident #198) with dignity and respect when Nurse Aide #12 treated her roughly during personal care, causing her to cry. Resident #198 was observed to have pinkened areas at the creases of the thighs where the brief comes up between the legs. The facility also failed to provide care for 1 of 1 resident (Resident #17) in a dignified manner by leaving her uncovered in bed, in a soiled brief after being made aware of care needs. This was for 2 of 13 residents reviewed for dignity. During the recertification and complaint survey of 9/29/22, the facility failed to provide incontinence care when requested to 1 of 6 sampled residents reviewed for dignity. This failure caused the resident to cry, expressing she felt worthless, horrible, bad and did not deserve this treatment. F641 (Accuracy of Assessments): Based on observations, staff interviews, and record reviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #399), hospice services (Resident #22), range of motion (Resident #11), and tube feeding (Resident #57). This deficient practice was identified for 4 of 18 sampled residents. During the recertification and complaint survey of 9/29/22, the facility failed to code range of motion status accurately on the MDS for 1 of 19 residents reviewed for accuracy of assessments. F692 (Maintenance of Nutrition and Hydration Status): Based on observations, interviews with the Registered Dietitian (RD), the Nurse Practitioner (NP) #1 and NP #2, staff, and record review, the facility failed to follow a recommendation from the RD to reweigh Resident #36 for further evaluation after an assessment of significant weight loss. Additionally, the facility failed to implement a plan from NP #2 in response to subtherapeutic total protein lab results for Resident #11. This failure occurred for 2 of 7 sampled residents reviewed for nutritional status. During the recertification and complaint survey of 9/29/22, the facility failed to follow the recommendation of the Registered Dietitian to reweigh a resident with significant weight loss to determine the accuracy of the weight status. This failure occurred for 1 of 6 sampled residents reviewed for maintenance of nutrition status. F880 (Infection Prevention and Control): Based on observations, staff interviews and record reviews the facility failed to implement their infection control policy when Nurse Aide (NA #4) did not perform hand hygiene between residents during meal delivery and meal assistance and Nurse Aide (NA #12) failed to doff soiled gloves and perform hand hygiene before exiting Resident #57's room to obtain incontinence care supplies. This deficient practice was observed for 2 of 2 nursing assistants observed for hand hygiene and had the potential to result in the cross contamination of microorganisms between residents and environmental surfaces. During the recertification and complaint survey of 9/29/22, the facility failed to follow manufacturer guidelines for cleaning and disinfection of a glucose meter, stored in the medication cart that was used for a resident but was not designated for individual resident use. The Administrator and the Regional QAA Nurse Consultant were interviewed by phone on 3/16/24 at 5:01 PM. During the interview, the Administrator stated that repeat deficiencies were reviewed during quarterly QA meetings which included a review of the QA plan to ensure that monitoring of the deficiency continued to prevent a reoccurrence of the same deficient practice. The Administrator also stated that during monitoring, if QAA committee identified that the deficiency was ongoing, staff received re-education and the concern was discussed during QAA meetings to identify any trends for continued monitoring. The Administrator stated that she was aware of the deficiencies from the 9/29/22 survey. The Regional QAA Nurse Consultant stated that the repeat deficiencies were related to staff taking shortcuts, the use of agency staff, MDS staffing changes and staff oversight despite continued efforts to re-educate staff.

Based on observations, staff interviews and record reviews the facility failed to implement their infection control policy when Nurse Aide (NA #4)) did not perform hand hygiene between residents during meal delivery and meal assistance and Nurse Aide (NA #12) failed to doff soiled gloves and perform hand hygiene before exiting Resident #57's room. This deficient practice was observed for 2 of 2 nursing assistants observed for hand hygiene and had the potential to result in the cross contamination of microorganisms between residents and environmental surfaces. The findings included: 1. Review of the facility's policy titled Hand Hygiene dated July 2002 and last revised on July 2023, stated in part, It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. 1. Specific Indications for hand hygiene included before resident contact, and after direct contact with the resident's skin and touching equipment or furniture near a resident. On 03/11/2024 from 1:08 PM to 1:14 PM a continuous observation of the lunch tray meal delivery service was conducted in the facility on the 300 hall. Hand sanitizing dispensers were observed in place at intervals on the wall of the 300 hall. During this continuous observation, NA #4 removed a meal tray from the meal cart, entered Resident #88's room, placed the meal tray on Resident #88's overbed table and repositioned the resident's overbed table in front of the resident. NA #4 was then observed to exit the room and returned to the meal cart without performing hand hygiene. NA #4 pushed the meal cart further down the 300 hall and removed Resident #404's meal tray from the cart. NA #4 served the lunch tray to Resident #404 and assisted the Resident #404 with tray set up. NA #4 exited Resident #404's room and returned to the meal cart without performing hand hygiene. NA #4 removed Resident #405's meal tray from the cart. NA #4 served the lunch tray to Resident #405. NA#4 exited Resident #405's room without performing hand hygiene. An interview was conducted with the Assistant Director of Nursing (ADON) on 03/11/2024 at 1:15 PM who was also serving lunch trays on the 300 Hall. The ADON stopped NA #4 and asked NA #4 to perform hand hygiene after NA #4 served Resident 405's meal tray. The ADON also provided hand hygiene education to NA #4 specific to meal delivery and entering and exiting resident rooms. The ADON further stated that all staff should clean their hands between each resident. She also revealed that NA #4 had been educated in proper hand hygiene. An interview was conducted with NA #4 on 03/13/2024 at 10:45 AM. NA#4 stated that he thought he performed hand hygiene after serving meal trays and exiting resident's rooms. He also stated that he had received hand hygiene education specific to meal delivery and when entering and exiting resident rooms. An interview was conducted with the ADON on 03/13/2024 at 11:23 AM. The ADON stated that she was the facility's Infection Preventionist and was responsible for the Infection Prevention Program for the facility. She further stated that all staff had received hand hygiene education on hire and yearly thereafter. She also stated that throughout the year there are several Infection Control educational sessions for employees including hand hygiene. She also stated that NA #4 had received hand hygiene education and was aware of the indications for hand hygiene during meal delivery. On 03/13/2024 at 9:15 AM an interview was conducted with the Director of Nursing (DON). The DON revealed that staff were expected to perform hand hygiene after caring for each resident including during meal delivery. On 03/13/2024 at 2:25 PM an interview was conducted with the Administrator. The Administrator indicated NA #4 should have performed hand hygiene in accordance with the facility's policy. She also revealed that all staff had received hand hygiene education. 20934 2. Review of the facility policy, Hand Hygiene, revised October 2022, recorded in part, Specific Indications for Hand Hygiene, after contact with bodily fluids, excretions, urine, or feces. Review of the facility policy, Perineal Care, revised October 2011, recorded in part, if gloves become soiled anytime during the care, change gloves and perform hand hygiene. Resident #57 was observed on 3/14/24 at 6:50 AM in bed alert, awake, nonverbal and lying on her back. Nurse Aide (NA) #12 donned gloves pulled the covers back and rolled Resident #57 onto her right side to observe Resident #57 for signs of incontinence. Resident #57 was observed wearing a night gown and a disposable brief. NA #12 was asked by the surveyor if she saw any signs of incontinence, NA #12 stated, No, but I don't usually check like that. NA #12 then rolled Resident #57 onto her back, unfastened the disposable brief, placed both gloved hands inside the opened brief and reached toward the Resident's buttocks until both gloved hands were observed to contact bowel movement. NA #12 then asked Resident #57 if she could change her brief and Resident #57 smiled. NA #12 said to the resident, Ok, I am going to go get some wipes and change your brief. NA #12 exited the Resident's room but did not remove the gloves that had contacted bowel movement in the Resident's disposable brief. NA #12 then walked to the clean linen closet that was to the right of the Resident's room, opened the closet door, removed a package of disposable wipes, and opened the lid of the disposable wipes while wearing the same soiled glove. NA #12 was interviewed prior to going back into the Resident's room and asked if she realized that she still had on the same gloves she used to check Resident #57 for incontinence? NA #12 sighed and stated that she did have on the same gloves she used to check Resident #57 for incontinence, and that she received infection control and hand hygiene in-services often. NA #12 stated that according to the training she received, she should have removed the soiled gloves and washed her hands before exiting the Resident's room. She further stated, I know that. Unit Manager (UM) #2 was interviewed on 3/14/24 at 11:44 AM. UM #2 stated NA #12 did not follow infection control practices and would need re-education on incontinence care and hand hygiene. UM #2 further stated that NA #12 should have removed the soiled gloves, and performed hand hygiene before she left the Residents' room. The Assistant Director of Nursing (ADON)/Infection Preventionist (IP), was interviewed on 3/14/24 at 11:20 AM and stated once the gloves become soiled, staff should remove the soiled gloves in the room, and perform hand hygiene before exiting the room. The ADON/IP also stated staff should not exit a resident's room with soiled gloves and then use the same soiled gloves to contact other items or surfaces. The ADON/IP stated NA #12 and other nursing staff would need re-education regarding the proper way to provide incontinence care and when to perform hand hygiene. A phone interview with the Administrator and Regional Quality Assessment and Assurance Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Administrator stated that when NA #12 assessed Resident #57 to see if she needed incontinence care, NA #12 should have removed the soiled gloves, performed hand hygiene, obtained the needed supplies, and then put on new gloves.

Based on observations, staff interviews, and record reviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #399), hospice services (Resident #22), range of motion (Resident #11), and tube feeding (Resident #57). This deficient practice was identified for 4 of 18 sampled residents. The findings included: 1. Resident #399 was admitted to the facility on [DATE] with diagnoses that included a periprosthetic fracture of the left hip, chronic embolism (a block in the artery), and thrombosis (blood clot) of deep veins of the lower extremities, and dementia. Resident #399 was discharged from the facility on 1/2/2023. Review of the admission nursing assessment completed on 12/20/2023 by Nurse #4 revealed no alterations in skin integrity including skin conditions or wounds. Review of NP #1 visit on 12/26/2023 at 12:03 PM revealed NP #1 evaluated and noted a right heel wound with skin coming off and the right great toe with a necrotic wound with right great toe and second toe crossed. NP #1 ordered a wound physician consult for right heel and right great toe and to paint right great toe with betadine twice a day. A review of Resident #399's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #399 had severe cognitive impairment. The MDS revealed no presence of wounds. An interview was conducted with NP #1 on 03/14/2024 at 11:14 AM. NP #1 revealed Resident #339 presented to the facility with a wound on his right great toe. She further stated that when she evaluated Resident #399, his right great toe was necrotic, and the right great toe and the second toe were crossed. She also stated Resident #399 also had a wound on his right heel which was opened. NP #1 also stated that wound care was ordered and a consult for the wound care doctor was made on 12/26/2023. An interview was conducted with the MDS Nurse #1 on 03/14/2024 at 12:39 PM. MDS Nurse #1 revealed he reviewed the admission nursing assessment to complete Section M (Skin Conditions) on the MDS. MDS Nurse #1 also stated that there was no nursing documentation in Resident #399 medical record related to wounds or skin conditions. An interview was conducted with the DON on 03/14/2024 at 1:20 PM. The DON stated that he expected all MDS's be completely accurately based on the resident's clinical status. An interview was conducted with the Administrator on 03/14/2023 at 2:00 PM. The administrator stated that her expectation was for the MDS to be reflective of the resident's clinical condition and completed accurately. 40197 2. Resident #22 was originally admitted to the facility on [DATE] with diagnoses that included venous insufficiency and type 2 diabetes. A care plan was initiated on 3/28/23, indicating Resident #22 was to receive palliative care, no terminal diagnosis was noted. A physician's order dated 6/23/23 indicated Resident #22 received palliative care services. Review of Resident #22's medical record did not reveal hospice service documentation. A modified Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was coded with hospice care. During an interview with the MDS Nurse #1 on 3/14/24 at 2:23 PM, he reviewed Resident #22's MDS assessment dated [DATE] as well as her medical record information and stated hospice care was marked in error. The Administrator was interviewed on 3/14/24 at 12:31 PM and stated it was her expectation for the MDS assessments to be coded accurately. 3. Resident #11 was admitted to the facility on [DATE] and had diagnoses that included contractures to the right and left knee and dementia. A Physical Therapy (PT) discharge summary dated 1/19/24 indicated Resident #11 received therapy for limited range of motion to her bilateral knees. She was discharged to nursing to don/doff bilateral knee braces when in bed. A review of Resident #11's active care plan, last reviewed 2/21/24, included a focus area for limited physical mobility related to contractures. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment and was not coded for any limited range of motion to the lower extremities. On 3/14/24 at 2:53 PM, an interview occurred with the Rehab Director who explained that Resident #11 had decreased range of motion to her knees and was unable to fully straighten them out. An observation of Resident #11 was conducted on 3/14/24 at 3:45 PM while she was lying in bed. She was unable to fully straighten out her legs when asked to do so. During an interview with MDS Nurse #1 on 3/15/24 at 9:22 AM, he reviewed Resident #11's MDS assessment dated [DATE] as well as her medical record information and stated limited range of motion should have been marked for the lower extremities. The Administrator was interviewed on 3/14/24 at 12:31 PM and stated it was her expectation for the MDS assessments to be coded accurately. 20934 4. Resident #57 was admitted to the facility 5/20/22. Diagnoses included nothing by mouth and attention to percutaneous endoscopic gastrostomy (PEG) tube, among others. A physician (MD) order dated 7/13/23, recorded NPO (nothing by mouth) diet, and NPO texture. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #57 required extensive staff assistance with eating and received 51% or more of her calories from a tube feeding. The MDS Coordinator was interviewed on 3/18/24 at 9:21 AM and reviewed Resident #57's quarterly MDS dated [DATE]. He stated that he did not complete this MDS, and that the MDS Coordinator who completed it no longer worked at the facility. In review of the MDS, he stated that Resident #57 had a NPO MD order dated 7/13/23 and that the 10/18/23 quarterly MDS should have assessed Resident #57 required total staff assistance for eating. He stated that the MDS was assessed incorrectly. The Administrator and Regional Quality Assessment & Assurance (QAA) Nurse were interviewed together via phone on 3/16/24 at 5:01 PM. During the interview, the Regional QAA Nurse stated that the quarterly MDS assessment dated [DATE] for Resident #57 stated that the assessment of extensive assistance with eating was inaccurate because Resident #57 was totally dependent on staff to provide all her nutrition from an enteral product via a PEG tube. The QAA Nurse stated the MDS should have been coded as requiring total staff assistance. The QAA Nurse stated that the MDS was completed by prn (as needed) MDS staff who no longer worked at the facility.

Based on observations, resident and staff interviews and record review, the facility failed to honor a resident's right to keep personal equipment in his room per his preference. This failure occurred for 1 of 2 sampled residents reviewed for personal property (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE]. Resident #36 was his own responsible party. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #36 with intact cognition, adequate hearing, adequate vision, clear speech, understood by others and able to understand others. Resident #36 was interviewed and observed on 3/11/24 at 11:48 AM. He stated that he ordered an ice cream maker online about one to two months ago and that he used it to make ice and ice cream for himself and his roommate. During the interview, an ice cream maker was observed in his room available for use. Nurse #8 documented in a progress note dated 3/11/24 that around 11:30 PM, she responded to a call for help from Resident #36 after a fall. The NP was contacted, and Resident #36 was sent to the emergency room (ER) for further evaluation. Unit Manager #2 recorded a progress note dated 3/12/24 at 2:23 PM that Resident #26 returned to the facility from the ER with no new orders. During a follow up interview with Resident #36 on 3/13/24 at 1:10 PM, Resident #36 stated that he returned from theER on [DATE] and when he got back to his room, his ice cream maker was gone. Resident #36 further stated They just took it, no one told me, and I don't know why they took it and stated that he wanted his ice cream maker back. An interview with the Maintenance Director occurred on 3/13/24 at 2:00 PM and revealed that Resident #36 had an ice cream maker in his room that he used for about 1 month. The Maintenance Director stated he checked the ice cream maker before it was used to make sure it was safe to operate in the facility. The Maintenance Director further stated that Resident #36 went to the ER and returned to the facility on [DATE]. While Resident #36 was gone, the Maintenance Director stated that he removed the ice cream maker from his room as part of a decluttering plan the Resident agreed to and placed it in storage. The Maintenance Director stated that Resident #36 did not identify the ice cream maker as an item he wanted removed from his room as part of the declutter plan, and that he did not ask his permission before it was removed. The Maintenance Director further stated that he thought it was best to remove the ice cream maker while Resident #36 was gone. The Maintenance Director stated that he should have asked Resident #36 first before removing the ice maker from his room while he was away from the facility. A phone interview with the Administrator and Regional Quality Assessment and Assurance Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Administrator stated that Resident #36 had a conversation with staff about organizing his room and that she thought that while he was in the ER recently that staff should remove it to determine if the ice cream maker was a fire hazard. She stated that she was not aware that the Maintenance Director had already assessed the ice cream maker before it was used and determined that it was not a fire hazard. After further thought, the Administrator stated that she was not in support of removing the ice cream maker from Resident #36's room without his permission. The Administrator further stated that staff should have given Resident #36 a call to notify him that the ice cream maker was being removed since it was removed from his room while he was in the ER.

Based on observation and staff interviews, the facility failed to ensure residents wheelchairs were in good repair for 2 of 2 residents reviewed for environmental concerns (Residents #54 and #94). The findings included: A. An observation was made on 3/11/24 at 11:30 AM of Resident #54 seated in her wheelchair in her room. The right armrest of the wheelchair had a two inch piece of orange tape with 1 inch of yellow foam exposed. B. An observation was made on 3/11/24 at 10:15 AM of Resident #94 while she was lying in bed. Her wheelchair was observed pulled up next to her bed. The left armrest of the wheelchair had two inches of exposed yellow foam. On 3/13/24 at 8:31 AM, an interview occurred with the Maintenance Director, who stated he was responsible for the maintenance of wheelchairs. If staff found a problem, they were to fill out the maintenance work orders, and he addressed it. He observed Resident #54 and #94's wheelchair armrests with the exposed foam. The Maintenance Director stated if he had been aware of the condition of the armrests, he would have switched them out. The Administrator was interviewed on 3/14/24 at 12:31 PM and stated it was her expectation for wheelchairs to be in good repair.

Based on record review, family interview, staff interviews and video observation, the facility failed to protect a resident's right to be free from misappropriation of resident property when a housekeeper staff member#1 (floor tech) used a resident's credit card and made multiple unauthorized purchases that included, the facility vending machine, grocery stores, gas stations, vape stores, shopping stores, restaurants and liquor stores. This occurred for 1 of 4 residents (Resident #98) reviewed for misappropriation of resident property. The findings included: Resident #98 was admitted to the facility on [DATE] and discharged on [DATE] at 5:45am. Resident #98 passed away later the same day in the hospital. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #98 was cognitively intact. Review of the initial report to the state read in part incident date was 12/28/23, The facility became aware of the incident on 01/02/2024 at 12:45pm when Resident #98's family member called the facility and reported Resident #98's missing credit card and driver's license. An interview was conducted with the Administrator on 03/14/24 at 8:15am, she indicated she received a call from Resident #98's family member on 01/02/24 and the family stated Resident #98's credit card and driver's license had been stolen at the facility. The Administrator indicated that she informed the family that she would be following the facility's abuse protocol for the allegation of the missing items. The Administrator also indicated she called the family back on 01/03/24 and provided an update on the investigation about what was observed on the video camera of the housekeeping staff member #1 observed to enter Resident #98's room and then go to the vending machine after exiting the Resident's room. The administrator indicated she had informed the family member the police were notified of this information, and they informed her they would escalate the information to the fraud department. On 03/14/23 at 8:30am a review of the bank credit transaction forms received from the bank was received by the facility on 01/02/24 from Resident #98's family member. The bank credit transaction forms revealed several unauthorized purchases made on 12/28/23 through 12/31/23 that included multiple charges from the facility vending machine, grocery store, gas stations, vape stores, food restaurants, shopping stores, and liquor stores. Attempted to contact Resident #98's family was made on 03/14/24 at 8:45am and was unsuccessful. Attempted to contact housekeeping staff member #1 on 03/14/24 at 8:55am, however voice mail indicated it was not a working number. Attempted to contact the Police officer was made on 03/14/23 at 9:00am and again on 03/15/24 and was unsuccessful. An interview was conducted with the Social Worker (SW) on 03/14/24 at 9:30am and she indicated the Housekeeping Supervisor came to her on 12/28/23, (she was unsure of the time) with Resident #98's purse. The SW indicated she directed the Housekeeping Supervisor to give the purse to the Administrator or to the Business Office. SW indicated she never touched the purse, but she knew Resident #98 had been sent out to the hospital earlier that morning. An observation of the facility's video camera was done on 3/14/24 at 11:12am, and the video camera revealed on 12/28/23 at 12:30pm the housekeeping staff member #1 entered Resident #98 room. He left the room around 12:35pm and was observed going to the facility's vending machine near the 300 and 400 halls around 12:37pm. Housekeeping staff member #1 was observed to make two purchases from the vending machine. An interview was conducted with Resident #98's family member on 03/15/24 at 9:00am, and he indicated they canceled the credit card, contacted the police department, and called the facility once they reviewed Resident #98's accounts. The family member indicated the police had not reached out to him since he made the report, but stated he was informed it could take 3 to 6 months or longer before the case would be closed. The family member indicated the Administrator had reached out to the family and explained the process of the investigation. An interview was conducted with housekeeping staff member #2 on 03/15/24 at 9:30am. Housekeeping staff member #2 indicated she did not see Resident #98's purse in her room on 12/28/23. She indicated she had been informed to clean up Resident #98's room because she had left to go to the hospital early that morning. Housekeeping staff member #2 indicated the room was clean, and she only mopped over the floor because there were footprints on the floor. Housekeeping staff member #2 indicated she had no knowledge of any missing items at the time. An interview with the Housekeeping Supervisor on 03/15/24 at 9:45am occurred and she indicated she retrieved Resident #98's purse from her room and was informed by the SW to take it to the Business Office. The Housekeeping Supervisor indicated that she gave the purse to the Business Office Manager on 12/28/23. She indicated she never opened the purse. Review of statement from the Business Office Manager dated 01/08/24 read in part To Whom It May Concern, Regarding Resident #98's personal belongings (purse). Upon Resident #98's discharge to the hospital, the Housekeeping Supervisor came to the business office and gave her Resident #98's purse. The Business Office Manager indicated she locked the purse in the closet in the business office until the family picked up the purse. A review of the investigation report dated 01/09/24 read in part, Resident # 98 's family member reported on 01/02/24 Resident #98's credit card and driver's license were missing out of her purse. The facility contacted the police and Adult Protective Services (APS). The facility interviewed alert and oriented residents regarding misappropriation of resident property with no concerns. They audited grievances made of missing monies/items and found no issues. They collected statements from staff members who were also in the room on the day of the incident, and no one had observed the credit card or driver's license. The facility reviewed the cameras from 12/28/23 the day Resident #98 went to the hospital and the cameras showed the housekeeping staff member #1 entering the Resident's room, after the Resident had discharged and was showed to leave the Resident's room and go to the vending machine at 12:37pm. The family provided a charge of five dollars on 12/28/23 at 12:39pm from the facility's vending machine. The police were in contact with the family and informed them an investigation was ongoing. The video footage determined a reason to substantiate. An interview was conducted with the Director of Nursing (DON) on 03/15/24 at 12:42pm and he revealed he had not been made aware of Resident #98's missing property until the family called the facility on 01/02/24. The DON indicated the facility had a zero tolerance of abuse, neglect, and misappropriation of resident's property. An interview was conducted with the Administrator on 03/15/24 at 1:15pm, she indicated she followed the facility's abuse policies and procedures for the investigation for Resident #98's missing credit card and driver's license and the facility had zero tolerance of misappropriation of resident's property. She also indicated that the facility completed a full plan of correction. The facility provided the following corrective action plan with a completion date of 01/06/24. Corrective action for resident involved: On 1/2/2024, Resident #98 son notified facility of charges made to resident's credit card following discharge from facility on 12/28/2023 to hospital. On 1/2/2024, Administrator submitted an initial allegation report for misappropriation of resident property and notified police and APS. On 1/2/2024, the Administrator suspended interviewed Housekeeper#1 pending investigation. On 1/2/2024, Administrator reviewed video footage for 12/28/2023 and noted housekeeper#1 entering and exiting resident#1 room following discharge to hospital on 12/28/2023 and using card to purchase items from vending machine in dining room between 300 and 400 halls. On 1/2/2024, Administrator provided [[NAME]] police department with investigation findings and completed report of incident. On 1/2/24, Resident's son notified Administrator that Citi Bank would be reimbursing resident's account for fraudulent charges. On 1/5/2024, Administrator concluded investigation and substantiated allegation related to misappropriation and based on investigation findings the root cause of incident was due to housekeeper#1 failing to follow facility policy related to abuse to include misappropriation. On 1/5/2024, a Quality Assurance and Performance Improvement meeting was held with the Interdisciplinary Team to review findings of investigation with no additional findings. On 1/9/2024, the Administrator completed an investigation report and submitted an investigation report to the Department of Health and Human Services. Corrective action for potentially impacted residents: Beginning 1/2/2024, the Administrator and Director of Nursing identified residents that would be potentially impacted by the alleged deficient practice by completing resident interviews for all current resident with BIMS of 13 or higher and asked if they had any concerns with misappropriation of property. Grievances/concerns were reviewed for the last 30 days to identify any concerns related to misappropriation of property for residents with BIMS of 12 or less. This was completed by 1/3/2024. Results included: No other residents identified with issues related to misappropriation of property. On 1/5/2024, after concluding investigation, the Quality Assurance Committee convened to discuss the misappropriation of resident property and the status of the investigation. There were no additional findings at that time. Systemic Changes: On 1/2/2024, the Administrator began servicing all full-time, part-time and PRN (as needed) staff (including agency) on ABUSE (Misappropriation of Resident Property) policy. This training will include all current staff including the agency. This training included: ABUSE (Misappropriation of Resident Property). On 1/3/2024, the Administrator and Director of Nursing verbally reeducated residents and family regarding policy related to Inventory List, Resident Personal Items. As of 1/4/2024, 20 % of staff members have not attended the in-service. The Administrator will ensure that any of the above-identified staff who do not complete the in-service training by 1/5/2024 will not be allowed to work until the training is completed. Quality Assurance: Beginning the week of 1/8/2024, The Administrator or designee will monitor misappropriation of resident property using the QA Tool for Misappropriation. The Administrator will monitor Misappropriation of Residents Property using the QA Tool for Misappropriation by interviewing 4 residents weekly regarding missing money or personal items and monitor any concerns daily for 4 weeks. This will be completed weekly for 4 weeks and 8 Residents monthly for 2 months and all newly admitted Residents. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and the ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Social Worker, Therapy Manager, Health Information Manager, and the Dietary Manager. Compliance date: 1/06/2024 The facility's corrective action plan was validated on 03/15/24 when staff interviews revealed they received education on the Abuse policy and procedures, residents' rights to be free from physical abuse, neglect, and misappropriation of resident property . The education included documentation and reporting to management immediately when they become aware of reported, suspected abuse, misappropriation and/or injury. Nurse's Aides must submit the reports of misappropriation of resident property, and/or abuse issues daily to the Nurse/Unit Manager immediately. The Unit Manager will review information and submit it to the Director of Nursing and the Administrator. Facility documentation revealed staff were trained on the following topics and additional training: abuse policy and procedures, residents' rights education, misappropriation of resident property and interviewing for abuse, nurse notification and assessment, the residents. Attestations related to the abuse training were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working their next shifts. Newly hired staff received an in-service service prior to working and this was verified by the facility trainers and orientation form. The completion/compliance date of 01/06/24 was validated.

Based on observations, record review, staff interviews, and Registered Dietician (RD) interview, the facility failed to follow the RD's recommendation to reweigh a resident identified with significant weight loss to determine if the change in weight status was accurate for 1 of 5 residents reviewed for nutrition (Resident #26). The findings included: Resident #26 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderate cognitive impairment with no behaviors or rejection of care. Resident #26 weighed 210 pounds (lbs) on admission and had no or unknown significant weight loss. He had a mechanically altered diet and supplemental tube feedings. Resident #26's care plan initiated on 7/26/22 revealed he had a potential nutritional problem related to receiving mechanically altered diet and tube feedings. The interventions included, in part: RD to evaluate and make diet change recommendations as needed. Weigh the resident at same time of day, using the same scale and record the weight. The care plan further revealed Resident #26 required tube feeding to assist in maintaining or improving his nutritional status. The interventions included, in part: consult the RD as needed and weigh as ordered. Resident #26's electronic medical record (EMR) revealed the following recorded weights: -On 08/15/2022 Resident #26's weight was recorded as 208 lbs. -On 09/19/2022 Resident #26's weight was recorded as 186 lbs (10.58% weight loss). Review of the RD note dated 9/21/22 revealed Resident #26 was noted to have a weight discrepancy of 22 lbs less than his previous weight. The RD recommended staff reweigh Resident #26. During an interview on 9/29/22 at 2:06 PM the RD revealed Resident #26 was weighed monthly per facility protocol. When there was a weight discrepancy, she created a reweigh list and emailed it to the Unit Manager. The DON and the Administrator were also copied in this e-mail. The RD further revealed she sent two emails requesting that Resident #26 be reweighed, but it was not done. The RD stated reweighs should be done as soon as possible so she could add the appropriate interventions for the resident. An interview was conducted with the Director of Nursing (DON) on 9/28/22 at 12:30 PM which revealed he was unaware of Resident #26's weight loss and would have him reweighed. During an interview with Nurse Aide (NA) #7 on 9/28/22 at 3:45 PM she revealed she had been asked by the Director of Nursing to reweigh Resident #26 on that day and his reweigh was 186 lbs. She further revealed when she weighed residents, she reported the weights to the nurse and the Unit Manager. An interview was conducted with Nurse #3 on 9/29/22 at 11:45 AM that revealed weights were completed for residents on admission then monthly. If there was an issue with weight/nutrition the resident would have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/29/22 at 2:52 PM the Unit Manager indicated she thought she had reweighed Resident #26 but explained she had been very busy and she may have overlooked it. During an interview on 9/29/22 at 4:07 PM the Administrator explained resident weights were recorded in the electronic medical record and the RD then reviewed those weights. A list of residents that needed reweighed were communicated by e-mail. The Administrator revealed she was included in those emails, and she thought the Unit Manager or DON had ensured Resident #26 was reweighed. She further revealed reweighs should occur on the same day.

Based on record review, observations, resident and staff interviews, the facility failed to provide sufficient staff to ensure 1 of 6 residents (Resident #37) received incontinence care when requested which resulted in the resident stating it made her feel worthless, horrible, and bad and she didn't deserve to be treated that way. Findings included: This tag is cross referred to: 1. F550: Based on observation, resident and staff interviews and record review, the facility failed to provide care in a manner to maintain the resident's dignity by not providing incontinent care when requested. This resulted in Resident #37 crying while waiting for incontinent care and she reported it made her feel worthless, horrible, bad and didn't deserve to be treated that way. This was evident for 1 of 6 residents who were reviewed for dignity and respect. 2. F677: Based on observations, resident and staff interviews, and record review, the facility failed to provide incontinence care when requested for 1 of 6 residents (Resident #37) reviewed for activities of daily living (ADL). Resident #37 indicated she activated her call light at 7:00 am on 09/26/22 to request incontinence care and was not provided with care until 11:37 am. During an interview with Nursing Assistant (NA) #1 on 09/26/22 at 11:50am, NA #1 indicated that the facility needed more nursing assistants and more staff in the kitchen. She stated she felt this would help with the residents waiting so long to be cared for. NA #1 indicated she does the best she can with the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Director of Nursing (DON) on 09/28/22 at 7:47 am, and he indicated the Nursing Department was staffing challenged and he had knowledge of staff doing double work at the facility. DON indicated that they also had a lot of agency staffing to help in the facility. An interview was conducted with the Administrator on 09/29/22 at 3:15 pm. She indicated that staffing was a challenge in the facility. However, her expectation was for staff to provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record review and staff, family, Nurse Practitioner (NP) and Wound MD interviews, the facility failed to provide the necessary care and services to prevent/treat pressure ulcers. The facility also failed to apply a wound dressing as ordered by the physician for 1of 5 residents reviewed for pressure ulcers (Resident #26). The findings included: Resident #26 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderate cognitive impairment with no behaviors or rejection of care. The resident required extensive assistance with bed mobility, toileting, personal hygiene, was always incontinent of bladder and occasionally incontinent of bowel. The resident had 2 stage 3 pressure ulcers present on admission and was receiving pressure ulcer care. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Remedy Nutrashield cream to buttocks every shift and as needed for wound healing/prevention. 7/25/22 -Pressure relieving mattress 7/25/22 -Prostat, supplement, one time a day for additional protein/wound healing 30 milliliters (ml) via gastric tube (a tube place directly into the stomach for feeding) mixed with 60ml of water 8/1/22 -Unstageable wound of the right buttock- cleanse area with normal saline/wound cleanser, pat dry, apply [MEDICATION(S)] dressing three times per week on every Tuesday Thursday and Saturday. 9/20/22 Resident #26's Care Plan initiated on 7/26/22 revealed: Resident #26 was incontinent of bladder with increased risk of skin breakdown and infections. The interventions included check the resident frequently throughout shift for incontinence. Wash, rinse, and dry perineum and change clothing as needed after incontinence episodes. Report any open areas, rash or irritation to skin to nurse if noted. The resident used incontinence briefs and needed assistance with all incontinence care. Resident #26 had a pressure ulcer and was at risk for development of additional pressure ulcers due to decreased ability to re-position, incontinence, and immobility. The interventions included observe the residents dressing each shift to ensure it was intact and adhering. Report loose dressings to the nurse. Observe/document/report to MD changes in skin status, administer treatments as ordered and monitor for effectiveness. Apply moisture barrier with each brief change. Resident #26 had an ADL Self Care Performance Deficit related to impaired mobility. The interventions included staff assistance to re-position and turn in bed and report any redness, broken areas or irritation noted on skin to the nurse. Resident #26 had actual impairment to his skin integrity. The interventions included encourage good nutrition and hydration to promote healthier skin. Review of Resident #26's wound notes revealed the following: On 8/9/22 the 2 stage 3 pressure ulcers noted on admission were resolved and barrier cream was recommended. On 8/23/22 a new left buttock non pressure related, moisture associated wound was noted. The treatment plan included [MEDICATION(S)] dressing 3 times a week, barrier cream 3 times a day, reposition resident and offload wound. On 8/30/22 the left buttock non pressure related, moisture associated wound was resolved. On 9/20/22 a new right buttock pressure related unstageable deep tissue injury (DTI) with intact skin was noted. The area was 6.5 x 4 centimeters (cm). The treatment plan included [MEDICATION(S)] dressing 3 times a week, reposition resident every 1 to 2 hours and offload wound. On 9/27/22 the right buttock pressure related unstageable DTI had deteriorated and the skin was no longer intact. The area was 7.5 x 3.5 x 0.1cm with light serous exudate. This area was debrided on that date. In addition, there was a new left buttock pressure related unstageable DTI with intact skin and the area was 6 x 3cm. The treatment plan included [MEDICATION(S)] dressing 3 times a week, reposition resident every 1 to 2 hours and offload wound. During an interview on 09/26/22 at 11:05 AM Resident #26's family member stated he had 2 small wounds on his buttocks before he came to the facility, but his bottom looked much worse now. She did not think the facility was doing enough for his wounds. She revealed the facility did not have the proper size condom catheter for the resident. The condom catheters were being used to ensure the resident stayed dry so the wound could heal but the catheters provided by the facility did not fit properly. The condom catheters the facility provided were too big and would either come off easily or would leak. She further revealed because of the leakage she was afraid the wounds would continue to get worse. An interview with Nurse Aide (NA) #4 on 09/27/22 at 4:32 PM revealed the facility did not have the proper size condom catheters for Resident #26, because they did not have the condom catheters and indwelling catheter was placed on that day. She further revealed when the facility was out of condom catheters supply staff was notified and would reorder. An observation of the supply room was conducted on 9/27/22 at 4:35 PM with NA#4 revealed there were 3 small boxes of size 36mm (large) condom catheters in the supply room. There were no other sizes observed. An observation of Resident #26's wound care was made on 09/28/22 at 11:20 AM. NA# 5 removed the old dressing. Nurse #2 was at the resident's bedside with dressing change supplies ready. He had created a clean area on the resident's bedside table. Nurse #2 performed hand hygiene and donned clean gloves. Resident #26's left and right buttock had large reddened areas. The wounds were close together and created a butterfly shape. In addition to the large, reddened area the left buttock the was a pea sized purple area that was open with a yellow center. The right buttock wound was open and had a small amount of clear drainage. The Nurse #2 cleansed the entire wound with dermal wound cleanser and patted the area dry. Nurse #2 performed hand hygiene and donned clean gloves. He opened the [MEDICATION(S)] dressing and cut it to fit the residents wound. The dressing was applied to the wound, a clean brief was put on Resident #26, he was then repositioned and covered. During an interview with Nurse #3 on 9/29/22at 11:45 AM the NAs would report if the resident had a new or worsening area on their skin. She would then assess and report changes to the Unit Manager and MD. She stated she followed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with NA #6 on 9/29/22 at 12:20 PM she revealed she made rounds on residents every 2 hours. During rounds she would check the incontinent resident and dry them if needed. She stated when Resident #26 had a condom catheter it would leak because it was too big. When staff would check or move him, they had to be very careful because the catheter would come off easily. If a resident had a new area of concern or a worsening area, she let the nurse know. She further revealed Resident # 26's wound looked like it was getting worse, sometimes the dressing was soiled and had to be removed. If she had to remove the dressing, she notified the nurse to reapply the dressing. She stated the nurses don't always put the dressing back on. There were times when she would provide incontinence care to the resident and the dressing would not be in place. During an interview with the NP on 09/29/22 at 3:38 PM she revealed she was aware the wounds on Resident #26's buttocks and wound care should be provided as ordered. She further revealed they used condom catheters to keep the resident's skin dry and to assist with wound healing. Resident #26's condom catheter would frequently come off, she had tried to place condom catheters on the resident herself. On 9/27/22 she ordered an indwelling catheter to better keep the wound dry. The NP indicated Resident #26 being wet or soiled will negatively impact the residents wound healing. During a follow up interview on 09/29/22 at 4:17 PM Resident #26's family member revealed staff placed an indwelling catheter on 9/27/22 because there were still no condom catheters his size. She stated she had been asking for a smaller condom catheter for more than a week, but the facility had been out. This was not the first time the facility had ran out of condom catheters that fit Resident #26. The family member stated when she arrived that morning there was a lot of blood in the catheter tubing and the resident complained that it hurt. She asked staff to remove the indwelling catheter. Staff removed the indwelling catheter and placed a brief on Resident #26 because there were still no condom catheters that fit him. An interview with the Administrator on 09/29/22 at 4:07 PM she revealed if staff notice supplies were low or out, it should be requested from supply or the DON. She stated the condom catheters should have been ordered and staff should communicate needs. An observation and interview were made on 09/29/22 at 4:19 PM NA #6 was preparing to perform incontinence care. When the residents brief was removed, there was no [MEDICATION(S)] dressing on Resident #26's wound and stool was observed on the wound bed. NA #6 stated she did not know why the dressing wasn't in place and she did not remove it. She stated the nurse was on break and she would notify her about the dressing when she returned During an interview on 09/29/22 at 4:23 PM this surveyor made the DON and Nurse Consultant aware that Resident#26 did not have the ordered dressing on his wound, NA #6 was at the bedside and needed someone to replace the dressing. The DON stated the resident should have had the dressing in place and wound care orders should be followed. The Nurse Consultant stated she would replace the dressing for Resident #26. On 09/29/22 at 04:40 PM The Nurse Consultant revealed the nurse was aware Resident #26's dressing was off but had not had time to reapply it. The Nurse Consultant stated she applied Resident #26's dressing. On 09/29/22 at 4:28 PM an interview was conducted with the Wound MD that revealed, Resident #26 had 2 pressure related DTIs. The DTI on the right buttock had deteriorated and required debridement. The DTI on the left buttock was newly acquired. The Wound MD stated he expected wound orders to be completed as ordered. He further stated if the resident was wet or soiled this would facilitate further skin breakdown and possible infection. He revealed that Resident #26 was almost always wet when he came in to provide wound care.

Based on observations, resident and staff interviews, and record review, the facility failed to provide incontinence care when requested for 1 of 6 residents (Resident #37) reviewed for activities of daily living (ADL). Findings included: Resident #37 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #37 was cognitively intact. Resident #37 needed extensive assisted with all activities of daily living with the exception of eating. No issues of refusals of care noted. A review of an ADL care plan dated 09/02/22 revealed Resident #37 required assistance with ADL care and was incontinent of bowel and bladder. Interventions included instructions to check on her frequently and provide incontinence care as needed. An observation on 09/26/22 at 11:00 am revealed Resident #37's call light was activated. On 09/26/22 at 11:15 am, Resident #37 was observed call out verbally for staff's assistance and the call light was activated. Resident #37's room had a noticeable odor of urine. Resident #37 indicated she was wet and had not been changed since the night shift. Resident #37 indicated that she had informed Nursing Assistant (NA) #1 that she needed to be changed when she came in to deliver the breakfast meal between 8:30 am and 8:45 am. Resident #37 indicated that NA #1 told her she would be back, turned her call light off, and never returned. Resident #37 voiced she had to eat her breakfast while she was soaked and wet and it was not a good feeling. While in the room it was observed Resident #37's breakfast was still in front of her during at 11:15 am. Resident #37 indicated that she had been waiting for assistance for over 3 to 4 hours. Resident #37 stated that this made her feel horrible, worthless, and bad. Resident #37 indicated she knew what time it was because she used her phone call to call her daughter for help. During an observation at 11:37 am on 09/26/22 care was provided to Resident #37 by NA #1. It was observed Resident #37 was double briefed and both briefs were saturated with urine. During care Resident #37 started to cry and stated, I know I'm fat and I'm hard to move but I don't deserve to be treated this way. NA #1 indicated she was working in the kitchen from 7:00 am until she passed the trays on the hall around 8:45 am, and she had not provided care for Resident #37 since she got to work at 7:00 am. NA #1 also indicated that she turned the call light off at 8:45 am. NA #1 stated this was because the kitchen needed help. During an interview with Nurse #1 on 09/27/22 at 9:00 am she revealed she had no knowledge of Resident #37 not receiving care on 09/26/22 until 11:30 am. Nurse #1 also indicated that sometimes the NAs had to work in the kitchen during the morning and they tried to cover the hall to meet the needs of the residents. A phone interview was attempted on 09/27/22 at 10:00 am with NA #11 who worked with Resident #37 on the third shift that began on 09/25/22 and ended on 09/26/22. An interview was conducted with the Director of Nursing (DON) on 09/28/22 at 7:47 am, and he indicated the Nursing Department was staffing challenged and he had knowledge of staff doing double work at the facility. The DON indicated that all resident's incontinence care needed to be done during the morning round when first shift staff came on duty. The DON indicated his expectation was for all residents in the facility to be assisted with incontinence care every 2 hours and whenever needed. He also indicated no residents in the facility should wait over 15 to 20 minutes for care to be provided. The DON indicated he was not aware a resident had to wait 3 to 4 hours for incontinence care to be provided. An interview was conducted with the Administrator on 09/29/22 at 3:15 pm. She indicated that her expectation was for staff to provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, resident and staff interviews and record review, the facility failed to provide care in a manner to maintain the resident's dignity by not providing incontinence care when requested. This resulted in Resident #37 crying while waiting for incontinence care and she reported it made her feel worthless, horrible, bad and didn't deserve to be treated that way. This was evident for 1 of 6 residents who were reviewed for dignity and respect (Resident #37). Findings included: Resident #37 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #37 was cognitively intact. Resident #37 needed extensive assisted with all activities of daily living with the exception of eating. While touring the 100 hall on 09/26/22 at 11:00 am Resident #37 was observed to call out for assistance and the call light was activated, upon entering Resident's room, the room had a noticeable odor of urine. Resident #37 indicated she was wet and had not been changed since the night shift. Resident #37 indicated that she had informed Nursing Assistant (NA) #1 that she needed to be changed when she came in to deliver the breakfast meal between 8:30 am and 8:45 am. Resident #37 indicated that NA #1 told her she would be back, and she never returned. Resident #37 voiced she had to eat her breakfast while she was soaked and wet and it was not a good feeling. While in the room it was observed Resident #37's breakfast was still in front of her during this tour at 11:15 am. Resident #37 indicated that she had been waiting for assistance for over 3 to 4 hours. Resident #37 stated that this made her feel horrible, worthless, and bad. Resident #37 knew what time it was because she had called her daughter her family for help. During an observation at 11:37 am on 09/26/22, it was observed Resident #37 was double briefed and both briefs were saturated with urine. During care Resident #37 started to cry and stated, I know I'm fat and I'm hard to move but I don't deserve to be treated this way. NA #1 indicated she was working in the kitchen from 7:00 am until she passed the trays on the hall around 8:45 am, and she had not provided care for Resident #37 since she got to work at 7:00 am. NA #1 stated that this was because the kitchen needed help. A phone interview was attempted on 09/27/22 at 10:00 am with NA #11 who worked with Resident #37 on the third shift that began on 09/25/22 and ended on 09/26/22. An interview was conducted with the Director of Nursing on 09/28/22 at 7:47 am, and he indicated the Nursing Department was staffing challenged and he had knowledge of staff doing double work at the facility. The DON indicated his expectation was for all residents in the facility to be treated with dignity and respect and no resident should have to wait over 30 minutes for care and treatment. An interview was conducted with the Administrator on 09/29/22 at 3:15pm. She indicated that her expectation was for staff to always treat residents with respect and dignity.

Based on interviews and record review the facility failed to administer medication as ordered to 2 of 3 sampled residents. (Resident #1, Resident #2). Resident #1 had nausea, vomiting and diarrhea, and Resident #2 had an elevated blood pressure as a result of these medication admininstration failures. Findings included: 1. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed Resident #1 as being cognitively intact for daily decision making. Review of the Nurse Practitioner's (NP) progress note dated 09/06/2016 revealed she was asked by nursing to see Resident #1 since he had received another resident's medication in error. She documented a medication error had occurred and the resident received wrong medication. He had received [MEDICATION NAME] 17 micrograms, [MEDICATION NAME] 220 milligrams (mg), aspirin 81mg, [MEDICATION NAME], biscacoyl 10 mg, [MEDICATION NAME] 6.25 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME]/APAP 5/325 mg. losartan 25 mg, [MEDICATION NAME] 75 mg, and Senna 2 tabs. Further documentation review revealed the resident was aware of the medication error. Vital Signs were recorded as blood pressure 140/60, pulse 76, respirations 18, and temperature 97.2. The medication error was found directly after receiving the medication. The resident denied any headache, vision changes, lightheadedness, nausea, vomiting, and diarrhea. He does feel sleepy. He denied pain. Reviewed the medication error report completed for this error and signed by the Director of Nursing (DON) on 09/08/16. It stated Nurse #2 was a new employee who had worked two days at the facility. Resident #1 was given the wrong medication. The nurse on duty was notified on 09/06/2016 at 10 AM and the doctor was notified. The DON and nurse on call were notified on 09/06/2016. The administrator and pharmacy were notified of the medication error on 09/06/2016. Vital signs were checked. Documentation of this was made in the nurses' notes. An interview on 01/30/2017 at 1:36 PM with the NP revealed the nurse who gave the wrong medication reported it to her immediately. I saw the resident immediately and put extras checks in place. The medicine he received was not a big deal. Two were blood pressure meds, others were stool softeners and pain meds. I saw him again the next day. The error was 09/06/2016. He was having nausea, vomiting and diarrhea. I thought that it was likely due to the medications he had had the day before. At that point I gave him meds as needed for nausea and encouraged a bland foods and fluids to drink. He was not unstable at any time. I saw him within 20 minutes of the medication error occurring. Other residents in the facility were also having nausea and vomiting so it may have been due to something other than the medications. Durning an interview on 01/30/2016 at 2:56 PM the DON stated that Nurse #1 was on the med cart and was orienting a new nurse, Nurse #2, the day the medication error occurred. Nurse #1 gave Nurse #2 the medication she had poured to give Resident #1. Nurse #2 gave the medications to the wrong resident. An interview with the Pharmacist on 01/30/2017 at 3:16 PM revealed that the [MEDICATION NAME] and aspirin could have potentiated or enhanced the effect of the [MEDICATION NAME] that Resident #1 was on. The losartan could have lowered his BP. A phone interview on 01/30/2017 at 3:43 PM with Nurse #2 revealed she had worked the day of the med error that occurred with Resident #1. She was orienting with Nurse #1. She stated there were lots of residents so Nurse #1 said she would pour the medications and Nurse #2 could give the medications to the residents. I went to the wrong room. I told the nurse. The NP was there in the building and she came and saw the resident. The NP told me to make a list of everything he got that was not his medication and the side effects. She told me to go to the resident and explain it to him. A phone interview on 01/30/2017 at 4:01 PM with Nurse #1 revealed she did not remember Resident #1 or med error that occurred on 09/06/2016 with him. An additional interview on 01/30/2017 at 4:15 PM with the NP revealed her expectation was that correct medications are given to the correct resident. She stated Resident #1 did ok after receiving another resident's medications since he had received only one dose. He had diarrhea one day and it resolved. An additional interview with the DON on 01/31/2017 at 1:03 PM revealed her expectation was that medications were to be administered correctly per their facility policies and procedures. 2. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed she was cognitively intact for daily decision making. Review of Resident #2's physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. She had not been administered 13 doses of this medication. Other medications she had received daily included [MEDICATION NAME] (used to control blood pressure) and [MEDICATION NAME] (a medication used to control blood pressure by reducing excess body fluid). Review of Resident #2's blood pressures 11/30/2016-12/13/2016 revealed a range of 115/58-186/108. The high blood pressure reading of 186/108 occurred once. Review of the pharmacy receipts revealed all of Resident #2's medications except [MEDICATION NAME] were delivered on 11/30/2016. Review of the progress note by the NP dated 12/14/2016 revealed Resident #2 had requested to be sent and went to the hospital for hypertension. She had had a blood pressure of 186/108. The resident stated her blood pressure had been creeping up for a while. She noted headache and weakness as well during that time but no vision changes. Per the resident she had an electrocardiogram and blood work done. She was found not to have received her [MEDICATION NAME] at our facility. Once she received the [MEDICATION NAME] at the hospital her blood pressure normalized and she was sent back to the facility. An interview on 01/30/2016 at 1:36 PM with the NP revealed that Resident #2 went to the emergency room (ER) one night per her request for her blood pressure. She came back the same day. The NP stated she saw her the next day. Per the resident she stated the hospital found she was not on her [MEDICATION NAME] and so they put her back on it. We continue what the hospital had the resident on when they are admitted . It was ordered on admission and got missed. So she was not getting her [MEDICATION NAME] until she went out to the ER and they discovered it. I had ordered it for her. In the process of her admission it got missed. An interview on 01/30/2016 at 3:16 PM with the Pharmacist revealed Resident #2 had [MEDICATION NAME] started on 12/14/2016 and her blood pressure was 126/84 that day. The Pharmacist also stated Resident #2 had received [MEDICATION NAME] which helped to maintain her blood pressure. An interview on 01/30/2016 at 4:25 PM with the Physician revealed her expectation was that the provider would be notified of high or low blood pressures. She stated she expected orders to be picked up and implemented. She said if everyone did what was expected in reviewing orders no orders would will fall through the cracks or get missed. An interview on 01/30/2016 at 5:45 PM with Nurse #4 revealed the physician wrote the order in the system and she checked it and confirmed it. She stated she then faxed it to the pharmacy just to make sure nothing fell through the cracks. She stated for a new admission the orders were signed off by the provider if they come with orders and the supervisor put them in the system. The doctor signed off on the new orders. Most of the time the supervisor did the orders for us and we checked it and the night shift checked them. An interview on 01/31/2017 at 8:32 AM with Nurse #5 revealed that the nurses had put the orders in the computer when she started to work there but now the doctor put them in. If the nurse was working the floor she would have checked for new orders every two hours. An interview on 01/31/2016 at 1 PM with the Pharmacy Technician revealed there were two sets of orders received on 11/30/2016. The first set of orders was the discharge orders for Resident #2 from the hospital discharge summary. The second set was through the facility's computer system and did not have [MEDICATION NAME] listed. She called the facility and spoke with the nurse at 3:30 PM to get clarification. The nurse stated she'd check and get back to the Pharmacy Technician. She did not get back to her so the medication was not filled. She stated the medication was in the building for use if needed. She stated no one at the facility picked up on that until 12/13/2016. It was filled and sent on 12/13/2016 by the pharmacy for Resident #2. An interview on 01/31/2017 at 1:03 PM with the DON revealed that the process for orders was they were received on admission from the hospital discharge summary. They were reviewed by the provider and then faxed to the pharmacy. The unit manager or supervisor put the orders in the computer system and the next check was the nurse on the hall who confirmed the orders by checking the discharge summary against what went on the MAR. They made changes or clarified orders if needed. She and the unit managers look at all meds every morning. She stated her expectation was that all order transcription was accurate.