Every finding on record at PruittHealth- Columbia

Based on observation, record review, interview, and review of facility policy, the facility failed to assess the need for side rails, implement and document alternative measures prior to side rail use, or obtain written informed consent for 4 of 5 residents (Resident (R)149, R5, R47, and R32) reviewed for accident hazards out of a total sample of 31 residents. Failure to assess and determine hazards could lead to injury, entrapment, or death. Findings include: Review of the facility's policy titled, Bed Rails, revised on 10/20/25, indicated, Prior to installing or using beds rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the inter-disciplinary team (IDT) to determine whether the use of bedrails would constitute an enabler or a restraint for the patient . The nurse should complete the Side Rail(s) Use Assessment in determining whether the bed rails should be considered an enabler or a restraint for the patient . 1. Review of R149's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R149 was admitted to the facility on [DATE], with diagnoses including but not limited to Parkinson's disease, history of transient ischemic attack (TIA) and cerebral infarction (stroke), muscle weakness (generalized), and acquired absence of left leg above knee. Review of R149's Physician Orders, located under the Orders tab in the EMR, revealed the order for 1/4 [quarter] siderails for turning and repositioning, dated 04/05/26. Review of R149's significant change Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab of the EMR with an Assessment Reference Date (ARD) of 05/14/26, revealed R149 was dependent on staff for rolling from side to side and for transitioning from lying to sitting. The assessment showed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident was severely cognitively impaired. Review of R149's Side Rail Use and Risk Assessment, dated 05/21/26 and located in the Observations tab of the EMR, revealed the assessment was not completed prior to the implementation of bed rails. The assessment did not indicate the alternatives that were attempted prior to instillation of side rails. During an observation and interview with Unit Manager (UM)1 on 07/09/26 at 11:27 AM, revealed R149's side rails were observed on the bed. UM1 stated, The side rail assessment tool and consent were required to be completed prior to instillation of bed rails . A side rail assessment tool was not completed prior to installation on 04/05/26. An assessment should have been completed prior to instillation of side rails. There were no other alternatives attempted prior to bed rails according to the bed rail assessment on 05/21/26. Completing the assessment tool prior to instillation of side rails is important because a resident could get hurt. 2. Review of R5's Face Sheet, located under the Face Sheet tab of the EMR, revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to Alzheimer's disease, paranoid schizophrenia, unsteadiness on feet, difficulty in walking, and muscle weakness (generalized). Review of R5's Care Plan, dated 12/16/24 and located under the Care Plan tab of the EMR, revealed a focus for potential of activities of daily living (ADL) decline. Goals included using quarter side rails for turning and repositioning. Review of R5's quarterly MDS, located under the RAI tab of the EMR with an ARD of 06/05/26, revealed R5 was independent with rolling from side to side and transitioning from sitting to standing. The assessment showed a BIMS score of seven out of 15, which indicated the resident was severely cognitively impaired. Review of R5's Side Rail Use and Risk Assessment, dated 06/05/26 and located in the Observations tab of the EMR, revealed the assessment was incomplete. Under the section, Select the type of side rails(s) being evaluated for use, no side rails were selected. The rest of the form was not filled out. During an observation and interview with UM1 on 07/09/26 at 11:27 AM, R5's side rails were observed on the bed. UM1 stated, The side rail assessment tool is completed quarterly and upon a change. During an interview on 07/09/26 at 5:38 PM, the Director of Nursing (DON) confirmed, The last side rail assessment was dated 06/05/26 and was not completely filled out. 3. Review of R47's Face Sheet, located under the Face Sheet tab of the EMR, revealed R47 was admitted to the facility on [DATE], with diagnoses including but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. Review of R47's Care Plan, dated 08/06/22 and located under the Care Plan tab of the EMR, revealed a focus for potential ADL decline. Goals included using quarter side rails for turning and repositioning. Review of R47's Observations tab of the EMR revealed the most recent Side Rail Use and Risk Assessment was dated 01/21/25. Review of R47's comprehensive MDS, located under the RAI tab of the EMR with an ARD of 05/01/26, revealed R47 was dependent on staff for rolling from side to side. The assessment showed a Staff Assessment for Mental Status, which indicated the resident was severely cognitively impaired. During an observation and interview with UM1 on 07/09/26 at 11:27 AM, R47's side rails were observed on the bed. UM1 stated, The side rail assessment tool is completed quarterly and upon a change. During an interview on 07/09/26 at 5:24 PM, the Director of Nursing (DON) stated, The assessment tool for side rails is completed on admission and quarterly. Alternatives should be attempted prior to bed rails. The risks of entrapment evaluation would be indicated under the risk factors on the assessment tool. The DON confirmed the last side rail assessment was dated 01/21/25. 4. Review of R32's Face Sheet in the electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE], with diagnoses that included but was not limited to parkinsonism. Review of R32's Care Plan, located under the Care Plan tab of the EMR, dated 11/07/25, revealed R32 was care planned for bilateral quarter side rail use. Review of R32's Physician Orders, located under the Orders tab in the EMR, dated 11/07/25, revealed quarter side rail use for turning and repositioning. Review of R32's MBHC-Admission/readmission located under Assessments tab in the EMR, dated 11/07/25, revealed side rail assessments were not indicated at that time. Review of R32's admission Side Rail Use and Risk Assessment documents, located under the Assessments tab in the EMR, dated 11/07/25 and 11/20/25, revealed a side rail assessment was not completed. Further review of the Assessments tab revealed no documentation that alternates were explored prior to the installation of the bed rails or that risks and benefits were discussed and informed consent obtained. Review of R32's quarterly MDS, with an ARD of 06/01/26 and located under the MDS tab of the EMR, revealed a BIMS score of 12 out of 15, which indicated R32 was cognitively intact. During an observation on 07/09/26 at 9:14 AM, revealed R32 was in bed with the head of the bed up and side rails up on both sides of the bed. During an interview on 07/09/26 at 9:50 AM, Licensed Practical Nurse (LPN)5 stated that as a floor nurse she only completed the portion of the side rail assessment she was able to complete and that another nurse completed the other portions; she reported uncertainty as to who was responsible for completing the remainder of the assessment. LPN5 stated residents received bed rails if they wanted them and that they did not try alternatives first. She also stated that the floor nurses did not ask the residents to sign anything showing that the risks and benefits were explained to them. During an interview on 07/09/26 at 2:13 PM, the Director of Nursing (DON) stated residents were assessed on admission for side rails, and they were offered repositioning. She was unsure if alternatives were explored first or informed consent was obtained, but she expected staff to be in compliance with regulations.

Based on record review and interview, the facility failed to ensure residents were informed of the benefits, risks, and alternatives of treatment, prior to initiating or increasing psychotropic medication for 1 (Resident (R)5) of 5 residents reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of residents not knowing the potential side effects of the medications. Findings include: Review of R5's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to, dementia, Alzheimer's disease, paranoid schizophrenia, and unspecified disorder of adult personality and behavior. Review of R5's Medication Administration Record (MAR), dated September 2025, and Physician Orders, located under the Orders tab of the EMR, revealed R5 received sertraline (an antidepressant) 50 milligrams (mg) once a day, which originated on 09/20/25, and trazodone (an antidepressant) 50 mg daily at bedtime, which was increased on 06/06/25. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/26, located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated R5 was severely cognitively impaired. The MDS revealed R5 had depression and schizophrenia and took antipsychotic and antidepressant medications. Review of R5's medical records revealed no documentation that R5 or her representative were provided information, in advance, of receiving the psychotropic medications of the risks and benefits and the treatment alternatives and consented to the medications. During an interview on 07/09/26 at 3:33 PM, the Nurse Consultant stated, We have been unable to locate consents for sertraline and trazodone that were completed prior to the administration of the ordered medications. During an interview on 07/09/26 at 4:44 PM, the Director of Nursing (DON) stated, All psychotropic medications should have a consent prior to administration. New medications or dosage increases of psychotropic medications need to have a consent. Trazodone and sertraline are both psychotropic medications. I do not see a consent for trazodone or sertraline. We do not have a policy for psychotropic medications. We just follow CMS [Center for Medicare and Medicaid] guidelines.

Based on record review, observation, interview, and facility policy review, the facility failed to report an allegation of neglect by staff within twenty-four hours to the State Survey Agency (SSA) for 1 of 3 residents (Resident (R)32) reviewed for abuse out of 31 sampled residents. This had the potential to result in continued neglect of residents. Findings include: A review of the facility's policy titled Prevention of Patient Abuse, Neglect Exploitation, Mistreatment, and Misappropriation of Property, revised 10/21/25, revealed, It is the policy of [facility] and its affiliated entities . to actively preserve each patient's right to be free from . neglect . The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment . within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury . report not later than 24 hours of being notified of the allegation. Review of R32's Face Sheet, in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE], with diagnoses that included but was not limited to parkinsonism. Review of R32's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/26, and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R32 was cognitively intact. Review of Point of Care History, dated July 2026 and provided by the facility, revealed Certified Nursing Assistant (CNA) documentation that R32 received incontinent care at 1:53 AM on 07/07/26 and not again until nine hours later at 10:45 AM. Review of Grievance/Complaint Form, dated 07/07/26 and provided by the facility, revealed it was completed by UM1 and provided to the administrator or designee on 07/07/26. R32 reported a grievance about not receiving routine perineal (peri) care during the 11 PM to 7 AM shift. R32 also reported not using the call light to request assistance. Review of Nursing Home Accident/Incident, the report the facility sent to the SSA, revealed the initial neglect report was sent on 07/08/26 at 5:22 PM. During an interview and observation on 07/07/26 at 10:52 AM, R32 was in bed and Certified Nurse Aide (CNA)3 was at bedside. R32 reported he had not been provided with incontinent care at all through the 11 PM to 7 AM shift. The bedding was observed to be saturated with urine, and CNA3 verified R32 was completely saturated through his brief, pad, and bedding. CNA3 stated she reported the incident as potential neglect to a nurse. During an interview on 07/07/26 at 10:58 AM, Unit Manager/Licensed Practical Nurse (UM)1 stated CNA3 reported that R32 did not receive incontinent care through the night shift. UM1 stated it was their process to initiate the grievance process. During an interview on 07/09/26 at 2:13 PM, the Director of Nursing (DON) stated the facility did not initially report the allegation of potential neglect because they did not see it as neglect.

Based on interview, observation, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 2 of 4 residents (Resident (R)21 and R149) out of 31 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. Findings include: Review of the facility's policy titled, MDS Assessment Accuracy, revised 01/19/26, indicated, All MDS Assessments must be completed following the guidance set forth in the RAImanual as directed by the Centers for Medicare and Medicaid Services (CMS). Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025 and located at https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf, revealed, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . 1. Review of R21's Resident Face Sheet located on the dashboard of the electronic medical record (EMR) indicated that the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 04/24/26, indicated that staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The assessment further indicated that the resident was up to date on her influenza and pneumococcal vaccines. During an interview on 07/08/26 at 12:29 PM, Nurse Consultant stated that they were unable to locate documentation of an influenza vaccine from 2025 or of any pneumococcal vaccines administered to the resident. During an interview on 07/09/26 at 11:04 AM, the MDS Coordinator (MDSC)1 stated she typically asked the Infection Preventionist (IP) for vaccination status. The MDSC confirmed that R21's quarterly MDS dated [DATE] was incorrect. 2. Review of R149's Face Sheet, located under the Face Sheet tab of the EMR, indicated the resident was admitted to the facility on [DATE], with diagnoses including but not limited to, Parkinson's disease and adult failure to thrive. Review of R149's [Facility name] Hospice Notice of Election/Informed Consent, located under the Resident Documents tab of EMR, revealed an effective date of hospice was 05/05/26. Review of R149's significant change MDS, located under the RAI tab of the EMR with an ARD of 05/14/26, revealed the resident had a BIMS score of 3 out of 15, which indicated R149 was severely cognitively impaired. The assessment revealed that the box next to hospice care while a resident was blank, indicating no hospice services during the previous 14 days. Review of R149's discharge MDS, located under the RAI tab of the EMR with an ARD of 05/14/26, revealed the resident discharged to the hospital. The box next to hospice care while a resident was blank, indicating no hospice services during the previous 14 days. Review of R149's Medicaid Hospice Discharge Form, located under the Resident Documents tab of the EMR, revealed hospice services were discharged on 05/14/26. Review of R149's [Facility name] Hospice Notice of Election/Informed Consent, located under the Resident Documents tab of EMR, revealed an effective date of hospice was 05/21/26. Review of the RAI tab of the EMR revealed an MDS assessment was not completed following 05/21/26 that showed R149 received hospice services. During an interview on 07/09/26 at 12:42 PM, MDSC1 reviewed R149's EMR and stated R149 received hospice services. MDSC1 reviewed R149's significant change and discharge MDS assessments dated 05/14/26 and confirmed hospice care was not marked. MDSC1 stated, Hospice services should be marked on the MDSs. [R149]'s MDSs did not have hospice marked and should have. During an interview on 07/09/26 at 5:06 PM, the Director of Nursing (DON) reviewed R149's MDS dated [DATE] and confirmed hospice care was not marked. The DON stated, If a resident is on hospice, it should be indicated on the MDS assessment . [R149] was picked up on hospice on 05/05/26 and revoked on 05/14/26. Then [he] was picked back up on hospice when he returned from the hospital on [DATE].

Based on record review, interview, and facility policy review, the facility failed to ensure the care plan was updated to reflect current orders for 1 of 31 sample residents (Resident (R)47) reviewed for care plans. This failure had the potential to prevent facility staff from being aware of pertinent information necessary to guide the resident's care. Findings include: Review of the facility's policy titled, Care Plans, revised 10/21/25, indicated Comprehensive care plans should be reviewed not less than quarterly . following the completion of the [MDS] assessment. Care plan updates/ reviews will be performed within 7 [seven] days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay . Updates to the care plans should be made with any changes in condition at the time the change in condition occurred . Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. Review of R47's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R47 was admitted to the facility on [DATE], with diagnoses including but not limited to, gastrostomy (feeding tube) status and dysphagia (difficulty swallowing). Review of R47's Care Plan, located under the Care Plan tab of the EMR, contained the Focus area, [R47] is NPO [ingests nothing orally]. He receives tube feedings and flushes as ordered . The care plan's approach for staff included, Turn tube feeding off from 10 am -2 pm daily, dated 05/22/24. Review of R47's Orders tab in the EMR revealed an order dated 10/15/25, for Jevity 1.5 (a type of formula used for tube feeding) at 60 milliliters (ml) per hour via gastric tube with water flush at 50 ml per hour continuous. Review of R47's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/26, located in the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Staff Assessment for Mental Status which indicated R47 was severely cognitively impaired. The MDS further indicated that R47 had a feeding tube. During an interview on 07/08/26 at 3:31 PM, Licensed Practical Nurse (LPN) 3 verified R47's orders and care plan and stated, [R47]'s tube feeding runs for 24 hours and is continuous. The care plan says the tube feeding is supposed to be off from 10 AM to 2 PM. It does not match the order and should have been updated. Care plans are usually updated when the orders are updated. The nurse on the floor should have updated the care plan when the order was changed. During an interview on 07/09/26 at 4:51 PM, the Director of Nursing (DON) stated, Care plans should reflect current orders for tube feeding. [R47]'s care plan showed the tube feeding should be off from 10 AM to 2 PM. The orders for the tube feeding are continuous for 24 hours. The care plan should have been updated. Care plans should be updated as often as needed but at a minimum quarterly during care plan meetings and when there are new orders.

Based on observation, record review, and interviews, the facility failed to ensure 2 (Resident (R)147 and R11) of 3 residents who were unable to carry out activities of daily living (ADLs) received showers to maintain good personal hygiene out of a total survey sample of 31 residents. This has the potential to cause diminished dignity and skin breakdown. Findings include: Review of a document provided by the facility titled Procedure Shower, dated 2019, indicated the steps to follow when providing a shower. There was nothing in the procedure that directed staff to offer residents showers/baths twice a week or by preference. 1. Review of R147's Resident Face Sheet, located on the dashboard of the electronic medical records (EMR), indicated that the resident was admitted to the facility on [DATE], with a diagnosis including but not limited to chronic obstructive pulmonary disease (COPD). Review of R147's Care Plan, located under the Resident Assessment Instrument (RAI) tab of the EMR, dated 07/15/23, indicated that the resident required supervision from staff for ADLs. There was no evidence in the care plan that indicated R147 refused to take showers/baths. Review of R147's 5-day Medicare Minimum Data Set (MDS), located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 06/11/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which revealed the resident was cognitively intact. Further review of the MDS revealed R147 required substantial to maximum assistance with showering/bathing. Review of a document provided by the facility for R147 titled, Shower/Bath Records for the months of May 2026 and June 2026 revealed that the resident was not offered a shower during the month of May. For the month of June, the resident received a total of three showers on 06/13/26, 06/20/26, and 06/25/26. During an interview on 07/07/26 at 1:23 PM, R147 stated she did not receive routine showers/baths and would prefer a shower. During an interview on 07/08/26 at 12:36 PM, Nurse Consultant stated that the facility typically provided residents with showers twice a week or by preference. During an interview on 07/09/26 at 8:20 AM, Certified Nurse Aide (CNA)1 confirmed R147 was scheduled to take showers on Wednesdays and Saturdays during the 7:00 AM to 3:00 PM shift. CNA1 stated R147 was fairly independent but required staff to be in the shower room with her. CNA1 stated that the staff tried their best to get residents showered. During an interview on 07/09/26 at 11:14 AM, the Director of Nursing (DON) stated there were no facility policies on ADL care, just procedures on showers/baths. The DON stated that residents were to be offered a shower/bath twice a week or per preference. 2. Review of R11's Face Sheet, located under the Face Sheet tab in the EMR, revealed R11 was admitted to the facility on [DATE]. Review of R11's quarterly MDS, with an ARD of 05/26/26 and located under the RAI tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated R11 was cognitively intact. Review of R11's Care Plan, located under the RAI tab of the EMR revealed no goals or interventions related to showers or bathing. Review of R11's Point of Care History, dated May 2026, June 2026, and July 2026 and provided by the facility, revealed R11 was not given any showers during this timeframe and was provided only four bed baths. Further review revealed no documentation that R11 refused showers on scheduled shower days. During an observation and interview on 07/08/26 at 11:15 AM, R11 was sitting in bed, hair visibly greasy, and there was a small basin with water on the bedside table. R11 stated he had not received a shower in several months and that staff only provided him with a water basin for him to give himself a bed bath. He stated he wanted to get a haircut, but he had been unable to since he would like his hair washed first. During an interview 07/09/26 at 9:05 AM, CNA1 reported that all residents had a shower schedule and should be offered a shower at least two times a week. If a resident refused the shower, staff were to notify a nurse who offered the resident a shower. All refusals were supposed to be documented. She stated R11 would not be able to wash his own hair during a bed bath. CNA1 further stated that she was unaware of R11 refusing his showers and that it was inappropriate for a resident not to receive a shower in over a month. During an interview on 07/09/26 at 2:13 PM, the DON stated she expected staff to offer showers, follow care plans, and follow shower schedules. She said all refusals should be documented, and the resident's responsible party and the unit manager should be made aware.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure 1 of 2 residents (Resident (R)47) reviewed for range of motion (ROM) out of a total sample of 31 residents received the necessary equipment to prevent further decrease of motion. This failure created the potential for further decreases in motion and discomfort. Findings include: Review of the facility's policy titled, Restorative Nursing Program, revised on 11/04/21, indicated, It is the policy of this healthcare center to provide restorative nursing which actively focuses onachieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Review of R47's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE], with diagnoses including but not limited to, hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) affecting the right dominant side, contracture of the right hand, and contracture of the right wrist. Review of R47's Care Plan, located under the Care Plan tab of the EMR and dated 08/01/22, indicated the resident was at risk for pain related to contractures of both hands and legs and decreased mobility. An intervention was for the resident to be positioned for comfort with physical support, as necessary. Review of R47's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 05/01/26, revealed the resident had a Staff Assessment for Mental Status which indicated the resident was severely cognitively impaired. The assessment indicated the resident had a limitation in range of motion on one side of the upper extremities. Review of R47's Orders tab of the EMR revealed no orders for therapy, passive range of motion, a splint, or a brace for the right hand/wrist. During an observation on 07/07/26 at 11:39 AM, R47's right hand and wrist were contracted with no splint or brace in use. During an interview on 07/09/26 at 11:02 AM, Licensed Practical Nurse (LPN)4 stated R47 had contractures of both hands. LPN4 indicated R47 did not have any orders to prevent further decrease in range of motion, such as splints, braces, or passive range of motion. LPN4 stated, It would be the responsibility of the nurse on the floor to contact the nurse practitioner to obtain a referral order for physical therapy. During an interview on 07/09/26 at 12:02 PM, the Unit Manager (UM)1 stated, Physical or occupational therapy and the physician or nurse practitioner should have been contacted regarding the resident's contractures. The resident could be at risk for skin breakdown with not having adaptive equipment or passive range of motion. UM1 confirmed R47 had contractures of his right hand and did not have any interventions in place to prevent further decline. During an interview on 07/09/26 at 5:04 PM, the Director of Nursing (DON) stated, When a resident has a contracture, there should be a referral to therapy. The nurse would be responsible for obtaining the referral.

Based on observation, interview, and review of facility procedure, the facility failed to ensure 2 of 8 medication carts used for the storage of residents' medications were locked. This failure created the potential for residents and unauthorized staff to have access to medication carts, increasing the risk of medication errors and medication diversion. Findings include: Review of the facility's procedure titled Medication Storage in Healthcare Centers, with a revision date of 03/12/26, revealed that only licensed nurses, certified medication aides, and the pharmacy personnel were allowed access to medication carts. Further, medication rooms, carts, and medication supplies were to be locked or attended by persons with authorized access. During an observation on on 07/07/26 at 6:35 AM, revealed two unlocked, unattended medication carts on the facility's fourth floor. One medication cart was located at the nursing station. The second medication cart was in a residential hallway. For approximately 20 minutes the carts remained unattended and unlocked. Registered Nurse (RN)1 was observed coming out of a resident's room, which was three doors down from the nearest unlocked cart. When it was pointed out to RN1 that the two carts were unlocked, RN1 locked both carts. During an interview with RN1 on 07/07/26 at 7:12 AM, RN1 stated that once resident medications were dispensed, the medication cart must be locked. During an interview with the Director of Nursing (DON) on 07/09/26 at 1:30 PM, the DON stated that once resident medications were dispensed, the medication cart must be locked.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 2 (Resident (R)103 and R141) of 2 residents reviewed for the provision of dental services were provided with routine services out of a sample of 31 residents. The residents received no routine dental services during their admission to the facility. This had the potential for the residents to experience infections and pain associated with the lack of routine dental services. Findings include: Review of a facility policy titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, dated 12/06/22, indicated, . It shall be the responsibility of this healthcare center to obtain regular and emergency specialty services for each patient/resident to ensure the highest well-being of the residents. The healthcare center has specialty service providers who provides [sic] consultation, participates [sic] in in service education, and is [sic] available in case of emergency . 1. Review of R103's Resident Face Sheet, located on the dashboard of the electronic medical record (EMR), indicated that the resident was admitted to the facility on [DATE]. Review of R103's annual Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab of the EMR with an Assessment Reference Date (ARD) of 01/20/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R103 was cognitively intact. The assessment further indicated that the resident had no broken teeth. A review was conducted of R103's clinical record and there was no evidence that the resident was offered dental services or was seen by a dentist. During an interview on 07/08/26 at 1:06 PM, the Social Services Director (SSD) stated R103 had a history of refusing ancillary services, such as podiatry and vision. The SSD confirmed that R103 was not seen by the dentist. During an interview and observation on 07/08/27 at 1:18 PM, the SSD entered R103's room, and the resident stated she had been treated for abscesses in the past, prior to admitting to the facility. R103 opened her mouth. The resident's mouth had missing teeth, and several teeth were broken and discolored. During an interview on 07/08/26 at 1:31 PM, the Business Office Manager (BOM) stated that the facility had contracted services with a dental program that residents could opt into. The BOM explained that R103 had no income source so she would not qualify for the dental insurance program. The BOM stated she was unaware that R103 required dental services. 2. Review of R141's Resident Face Sheet, located on the dashboard of the EMR, indicated that the resident was admitted to the facility on [DATE]. Review of R141's Care Plan, located under the RAI tab of the EMR, dated 08/26/23, indicated that the resident had missing teeth. Review of R141's quarterly MDS, located under the RAI tab of the EMR with an ARD of 04/17/26, revealed the resident had a BIMS score of 15 out of 15 which indicated that the resident was cognitively intact. A review was conducted of R141's clinical record and there was no evidence that the resident was offered dental services or was seen by a dentist. During interviews and observation on 07/08/26 at 1:08 PM, the SSD stated that dental services came to the facility twice a month. The SSD confirmed that R141 was not seen by the dentist. The SSD entered R141's room, and the resident stated that he had not been seen by a dentist since his admission to the facility. R141 opened his mouth, and he had one tooth on the right side of his mouth and other missing teeth on the bottom. The SSD stated nursing notified her, and then she made a referral for a resident to be seen. The SSD confirmed the observation of R141's missing teeth. During an interview on 07/08/26 at 1:34 PM, the BOM confirmed that R141 had an income and would qualify for dental insurance. The BOM stated that R141 was not on her referral list to the dental program. During an interview on 07/09/26 at 11:14 AM, the Director of Nursing (DON) stated residents were to be offered in-house dental services and reported being unaware of the lack of routine dental services for R103 and R141.

Based on record review, interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 1 of 5 residents (Residents (R)21) reviewed for influenza and pneumococcal immunizations the opportunity to be vaccinated in accordance with nationally recognized standards out of 31 sample residents. This practice had the potential to increase the risk for this resident to contract influenza and pneumonia.Findings include: Review of the facility's policy titled Influenza (Flu) Vaccinations for Health Care Center Residents, dated 09/12/25, indicated, . All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with the vaccinations against influenza . Review of the facility's policy titled Pneumococcal Vaccinations, dated 09/02/25, indicated, . All patients/residents who reside in the healthcare center are to receive the pneumococcal vaccines(s) within the current CDC (Centers for Disease Control) guidelines unless contraindicated by their physician or refused by scoring on the MDS, the responsible party will be contacted and their wishes will be followed in this manner . Review of the CDC website titled PneumoRecs VaxAdvisor App (Application) for Vaccine Providers, dated 02/25/26 and located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, indicated, . Administer PCV [pneumococcal conjugate vaccine] 15, PCV20, or PCV21 for all adults 50 years or older . Who have never received any pneumococcal conjugate vaccine . Whose previous vaccination history is unknown . Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both . PCV13 (but not PCV15, PCV20, or PCV21) at any age and . PPSV [pneumococcal polysaccharide vaccine] 23 at or after the age of [AGE] years old . Review of R21's Resident Face Sheet located on the dashboard of the electronic medical record (EMR) indicated that the resident was admitted to the facility on [DATE] and was [AGE] years of age or older. Review of R21's quarterly Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab of the EMR with an Assessment Reference Date (ARD) of 04/24/26, revealed that staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The assessment indicated that the resident was up to date on her influenza and pneumococcal vaccines. Review of R21's Preventative Health documentation, located under the Resident tab of the EMR, revealed that it was blank and contained no information that the resident had received or refused the 2025 influenza vaccine or any pneumococcal immunizations. Review of R21's EMR revealed no evidence that R21 or the resident representative was offered the influenza and pneumococcal immunizations. During an interview on 07/08/26 at 12:29 PM, Nurse Consultant confirmed that the facility was unable to locate documentation of an influenza vaccine being offered or administered to R21 in 2025 or of any pneumococcal vaccination status for R21. The Nurse Consultant stated that each resident and/or their representative was to be approached for consent or declination of an immunization. During an interview on 07/09/26 at 11:14 AM, the Director of Nursing (DON) stated at the time of admission residents and/or their representatives were to be provided with the opportunity for consent or declination of any of the immunizations.

Based on observation, interview, and record review, the facility failed to ensure 6 rooms on 2 of 4 floors were adequately repaired and cleaned. The facility's failure to maintain sanitary resident areas and equipment in good repair had the potential to place residents at risk for injury, falls, infection, and diminished quality of life. Findings include: Review of an untitled facility document referred to as TELS (a specialized building management software program for healthcare environments), dated 06/13/26 to 06/30/26 failed to indicate the following environmental issues: 1a. Review of R67's Resident Face Sheet, located on the dashboard of the electronic medical records (EMR), indicated that the resident was admitted to the facility on [DATE]. Review of R67's quarterly Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab of the EMR with an Assessment Reference Date (ARD) of 05/18/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. During an interview on 07/07/26 at 2:55 PM, R67 stated that there was a leak in the [NAME] and [NAME] bathroom (shared bathroom connected to two rooms). An observation was immediately conducted after the interview. There was no leak, but there was an elevated toilet seat, with arms, sitting over the existing porcelain toilet. The elevated toilet seat was heavily rusted. There was a bar that was located behind the right arm rest that was broken, creating an unstable seat. b. Review of R63's Resident Face Sheet located on the dashboard of the EMR, indicated that the resident was admitted to the facility on [DATE]. Review of R63's quarterly MDS, located under the RAI tab of the EMR with an ARD of 06/01/26, indicated the resident had a BIMS score of 11 out of 15, which revealed the resident was moderately cognitively impaired. During an interview conducted on 07/08/26 at 3:40 PM, R63 stated that he used the elevated toilet seat in the bathroom he shared with R67 and reported it had been broken for a while. The Maintenance Director was present during the interview, confirmed the observation, and stated that the elevated toilet seat needed to be disposed of since it was heavily rusted, had a broken piece, and was potentially an accident hazard. 2. An observation was conducted on 07/08/26 at 2:20 PM, in room [ROOM NUMBER]. Behind the bed was a heavily dented area on the wall, approximately 18 inches in size, which was caused by the arm which hung a bed trapeze. Next to the resident's bed were pink and yellow drips/stains on the wall. In addition, the floor was sticky. During an interview and observation on 07/08/26 at 3:25 PM, the Maintenance Director and Environmental/Laundry Manager confirmed the observations. 3. An observation was conducted on 07/08/26 at 2:20 PM in room [ROOM NUMBER]. There was a corner of the bed closest to the door which was damaged and exposed a metal edge. The vent's floorboard was peeling off. Both residents' areas had fans, heavily covered with dust. During an interview and observation on 07/08/26 at 3:25 PM, the Maintenance Director verified the damage and stated that neither of the fans in the room had been evaluated by him for safe use. The Maintenance Director stated he was unaware of the two fans and that they needed to be reviewed by maintenance to ensure they were safe and functioning. During the same interview, the Environment/Laundry Manager (ELM) confirmed the observations and stated the housekeeping staff were to clean the fans. 4. During observations on 07/09/26 at 9:10 AM, the lower half of the privacy curtains in resident rooms 315, 321 and 323 were visibly dirty. The curtains touched and dragged on the floor when the curtains were pulled open or closed. During an interview on 07/09/26 at 9:30 AM, the ELM observed the privacy curtains in rooms 315, 321 and 323 and confirmed they were visibly soiled and stained. The ELM reported that there was no cleaning schedule for the privacy curtains and stated that they were only cleaned when staff requested that they be cleaned or when the cleaning staff felt they needed to be laundered. During an interview on 07/09/26 at 10:25 AM, Regional Director stated that the facility did not have a policy in place that addressed a clean/comfortable/homelike environment and that the facility followed the regulation.

Based on record review and interview, the facility failed to ensure a resident received medications scheduled during dialysis times for 1 of 1 resident (Resident (R)1) reviewed for dialysis out of sample of 31 residents. This failure had the potential to result in ineffective treatment of the resident's medical conditions, uncontrolled phosphorus levels, unmanaged pain, and adverse health outcomes associated with repeated omission of physician-ordered medications. Findings include: The facility reported they had no policy regarding medications provided on dialysis days. Review of R1's Face Sheet, located in the Face Sheet tab of the EMR, revealed R1 was admitted to the facility on [DATE], with a diagnosis including but not limited to end stage renal disease (ESRD). Review of R1's Care Plan, located under the Resident Assessment Instrument (RAI) tab of the EMR dated 08/25/25, revealed the resident needed hemodialysis related to renal failure. An intervention was that the resident required dialysis three times weekly on Tuesday, Thursday, and Saturday. Review of R1's Physician Orders, located under the Orders tab in the EMR and dated 09/08/25, revealed an order for Velphoro (medication used to treat high phosphorus levels) 500 milligrams (mg) with meals at 9 AM, 1 PM, and 5 PM, and diclofenac sodium (an anti-inflammatory medication) gel administer 4 grams (g) topically at 9 AM, 1 PM, 5 PM, and 9 PM. There were no orders to hold the medications during dialysis times. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/26 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated R1 was severely cognitively impaired. Further review revealed that R1 received dialysis while a resident. Review of R1's Medication Administration Record (MAR), located under the Orders tab in the EMR and dated June 2026, revealed that the Velphoro 500 mg and diclofenac sodium gel administer 4 g were not administered at 1:00 PM on June 2, 6, 9, 11, 13, 18, 23, 25, 27, and the 30th due to R1 being at dialysis. Review of the Progress Notes tab of the EMR revealed no documentation that the physician was notified of the missed medication doses. During an interview on 07/09/26 at 10:10 AM, Licensed Practical Nurse (LPN)6 stated R1 did not usually return from dialysis until between 2 PM and 2:30 PM. He stated if R6 was not present when medications were due and did not return within an hour of the administration time, R1 did not receive the medication. LPN6 stated R6 usually was not in the facility when the 1 PM medication was administered and so R6 did not get that dose. He stated he had never reported that to the Director of Nursing (DON) or the physician. During an interview on 07/09/26 at 2:13 PM, the Director of Nursing (DON) stated she expected nurses to follow physician's orders and that medications should not be omitted from being administered.

Based on record review, observation, interview, and facility policy review, the facility failed to develop and implement a comprehensive care plan that included instructions needed to provide effective and person-centered care for 1 (Resident (R)149) of 31 sampled residents. Failure to develop and implement a comprehensive person-centered care plan could place residents at risk for unmet care needs. Findings include: Review of the facility's policy titled, Care Plans, revised on 10/21/25, indicated, The comprehensive care plan should describe the following- The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s). Review of R149's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE], with diagnoses including but not limited to, Parkinson's disease, history of transient ischemic attack (TIA) and cerebral infarction (stroke), muscle weakness (generalized), and acquired absence of left leg above knee. Review of R149's Physician Orders, located under the Orders tab in the EMR, revealed an order for 1/4 [quarter] siderails for turning and repositioning, dated 04/05/26. Review of R149's Side Rail Use and Risk Assessment, dated 05/21/26 and located in the Observations tab of the EMR, revealed R149 was assessed for the use of side rails. Review of R149's Comprehensive Care Plan, located under the Care Plan tab in the EMR, dated 06/02/26, revealed R149 had decreased mobility. There was no care plan for use of side rails. During an observation on 07/07/26 at 11:34 AM, R149's bed had bilateral upper side rails in use. During an interview on 07/09/26 at 11:27 AM, Unit Manager (UM)1 confirmed R149 had side rails in use and stated, There should be a care plan for the use of side rails. [R149] does not have a care plan for side rails and should have. During an interview on 07/09/26 at 5:24 PM, the Director of Nursing (DON) stated, The documentation requirements for side rail use includes the side rail use assessment, consent, an order, and a care plan. There should be a care plan for side rail use. [R149] does not have a care plan for side rails.

Based on a review of the facility's dietary policies, observations, and staff interviews, the facility failed to ensure proper sanitation of kitchen equipment, maintain overall cleanliness of the main kitchen, and properly label and discard expired foods in the 1/1 main kitchen. This deficiency posed a potential risk to the health and safety of the 140 residents who reside in the facility and consume food prepared in the kitchen.Review of facility policy titled Labeling, Dating, and Storage with a revision date of 11/11/2022 states, 1. Food and beverage items will have an identifying label as well as a received date and opening date, as applicable; for items prepared on site, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc.Review of facility policy titled Foodborne Illnesses with a revision date of 10/18/2017 states, 3. It is the responsibility of the Dietary Manager to see that dietary employees practice safe and sanitary methods when preparing foods to prevent cross-contamination and the spread of bacteria. 4. It is the responsibility of the Dietary Manager to see that food is properly stored to reduce the chance of foodborne illness. 6. Hands, equipment, utensils, and work areas must be cleaned and properly sanitized to prevent cross-contamination of foods. All equipment must be dismantled, cleaned, and sanitized between uses.During the initial walk-through of the facility kitchen on 07/15/25, starting at 10:30 AM, with the Dietary Manager (DM), revealed the following:1. In the Freezer: An aluminum pan approximately 9x13 inches (in) size, covered with aluminum foil, was labeled Dressing with a handwritten date of 6/26/25. No use-by or discard date was present.2. In the Cooler: A stainless-steel pan containing three heads of cabbage, not stored in their original packaging or box, was labeled Cabbage with a date of 07/01/25. No use-by or discard date was included on the label. Approximately 18 croissants were observed stored in a cardboard-like packaging box, wrapped in plastic. Visible gray spots were present on the tops of the croissants. The label on the plastic stated Croissants with a prep date of 07/07/25, but no use-by or discard date was observed.3. The industrial stove was found to be filthy. The backsplash, originally stainless steel, was completely blackened with buildup. Significant accumulation of grime was observed on the side backsplash, and the stove burners appeared rusted.4. The exhaust hood was tested and found to not be functioning at full capacity. The lighting inside the hood was dim, with only 4 of the 8 lights were operational. Additionally, the hood exhibited visible rust on both the exterior and interior surfaces, and the paint was observed to be chipping.During a follow up kitchen observation on 07/16/25 at 11:31 AM, the exit door leading to outside was observed with a heavy accumulation of dark brown grime and debris running down its surface. A lime green fly trap was hanging near the exit sign with multiple visible flies stuck to it. These findings were confirmed by the DM.Review of a facility invoice from Southeast Restaurant Cleaning, LLC dated 01/11/25, documented a quarterly inspection under NFAA Code 96 standards for the hood exhaust system. The description also noted that some pilot lights on the stove were out at the time of inspection.Review of a facility invoice from Southeast Restaurant Cleaning, LLC dated 06/14/25, documented that cleaning services were performed on the hood, ductwork, and exhaust system. However, the invoice specifically stated that no equipment was replaced during this service.During an interview on 07/15/25 at 11:07 AM, the DM stated dietary staff are expected to check the coolers daily to ensure all items are properly labeled and stored. DM noted maintaining proper labeling and storage is the responsibility of all dietary staff. She reported that kitchen cleanings are performed daily after each meal, and deep cleanings-which include wiping down equipment-are conducted weekly. The DM explained that dietary staff are assigned specific duties, and upon completion, they are to initial a duty checklist and submit it to her or the Dietary Supervisor. A visual inspection is then performed to verify that the assigned tasks were completed appropriately. Regarding the overall kitchen cleanliness, she acknowledged that she and her staff do their best to maintain standards despite being short-staffed. The DM also agreed that the stove's backsplash is in poor condition and needs to be fully replaced. During an interview on 07/17/25 at 10:30 AM, the Facility Interim Administrator (FIA) revealed the kitchen remains an ongoing area of focus. She stated that her expectation is for dietary staff to properly label all food items, include accurate dates, and promptly discard any visibly expired food. She also acknowledged that some of the kitchen equipment is outdated and in need of replacement.During an interview on 07/18/25 at 10:45 AM, with the [NAME] President (VP) and Nurse Consultant (NC1), both individuals are in agreement regarding the dietary and environmental concerns observed in the facility. They acknowledged that the current conditions are unacceptable and confirmed that the issues will be addressed. The VP stated that he is actively working with vendors and has contracts in place to resolve the identified concerns.

Based on review of facility policy, direct observations, and staff interviews, the facility failed to ensure resident meals were served and distributed in a timely manner. This failure to adhere to established meal service protocols had the potential to impact residents' nutritional intake, satisfaction, and overall quality of care.Review of facility policy titled Mealtimes with a revision date of 10/18/2017 revealed: .2. Meals must be established at regular intervals comparable to those in the community.Review of designated mealtimes revealed the following schedule: Breakfast is served from 7:45 AM to 8:45 AM, Lunch from 11:40 AM to 1:00 PM, and Supper from 5:00 PM to 6:15 PM.An observation on 07/16/25 at 9:17 AM revealed a resident in room [ROOM NUMBER] yelling out, Give me something to eat. At the time of the observation, no meal carts or trays were present on the floor.An interview with the Dietary Manager (DM) on 07/16/2025 at 10:24 AM revealed that food preparation is completed and temperatures are to be taken by 11:30 AM. Following this, tray line service begins immediately, and hotbox carts are dispatched to the units in 30-minute intervals.An observation conducted on 07/16/2025 at 11:30 AM, 11:45 AM, and 11:50 AM revealed that food temperatures had not been taken and the tray line had not yet started during any of these times. Kitchen staff were observed engaging in non-dietary-related conversations, washing dishes, and completing other non-tray line-related duties. An interview with a Dietary Aide (DA) on 07/16/2025 at 11:53 AM revealed that the tray line had not started due to staffing issues, including staff arriving late and others calling out. She stated that these delays push the entire meal service schedule behind. The aide further noted that this is not the first time such delays have occurred and expressed concern that the issue will likely continue if staffing shortages persist.An observation on 7/16/2025 at 12:06 PM noted staff beginning to take temperatures of the lunch meal and start plating the meals. On 07/17/2025 at 9:15 AM, the first hotbox for breakfast arrived on Unit 3. At that time, ten residents were present in the Unit 3 dining area, waiting to be served. Residents were observed asking for breakfast, and staff responded by informing them that they were waiting for the second hotbox to arrive before they could begin service. The second hotbox arrived at 9:20 AM, and the first breakfast tray was served at 9:22 AM. On 07/17/2025 at 12:30 PM, no lunch trays were observed on the 100 Hall. Residents were seated in the dining area waiting for their meals. Although no concerns were voiced by the residents at that time, the delay in meal service was evident. At 12:52 PM, tray carts were brought in by the dietary aide, and the first resident was served at 12:55 PM. On 07/17/2025 at 1:09 PM, meal trays were delivered to Unit 4 while residents were seated in the dayroom. The first tray was served to a resident at 1:12 PM. On 07/17/2025 at 2:04 PM, the lunch hotboxes arrived on Unit 200. At that time, residents were observed sitting in the main dining area of Unit 200, waiting for their lunch to be served. On 07/18/2025 at 9:26 AM, breakfast for Hall 200 arrived on the floor while residents were seated in the dayroom waiting to be served.A follow-up interview with the Dietary Manager (DM) on 07/18/2025 at 10:47 AM, confirmed the delays in meal service times. She explained that these delays are primarily due to staffing shortages. The DM stated that there was a time when she would overstaff as a precaution to ensure adequate coverage; however, she was subsequently instructed not to overstaff due to budget constraints. As a result, she has experienced increased staff callouts and late arrivals. Additionally, she noted that the majority of dietary staff are new and still in training, which further contributes to the delays in meal preparation and service.An interview with Nurse Consultant (NC1) on 07/18/2025 at 10:45 AM, conducted in the presence of the [NAME] President (VP), revealed that NC1 was aware that meal trays had been extremely late over several days. She was informed that the dietary department had been experiencing staff callouts and that many employees were still new and in training. In addition, the VP stated that the facility is fully staffed overall and expressed the opinion that the dietary staff are not taking accountability for the delays in meal service.An interview on 07/18/2025 at 1:29 PM with the Facility Interim Administrator (FIA) revealed that she is aware of ongoing staffing concerns affecting non-clinical departments, including Housekeeping and Dietary. She confirmed that additional staff are needed and acknowledged the facility is experiencing a high turnover rate. The FIA stated that within the past 100 days, there have been 35 new hires, with a new hire retention rate of 71 percent. She noted that she has been actively working with [NAME] Health Recruiters and participates in weekly calls to discuss current staffing levels, new hires, and potential candidates. She emphasized that staffing for non-clinical departments remains a work in progress.

Based on review of facility policy, observations and interviews, the facility failed to ensure that the medication refrigerator temperature logs were checked daily in 1 of 4 medication storage rooms. Review of the facility's policy titled Medication Storage in the Healthcare Centers states Medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier . Procedure #8, the temperature will be logged daily on the refrigerator and room temperature log.During an observation on 07/16/25 at 03:29 PM, the 200 hall refrigerator revealed a large amount of ice pooled in the freezer. The ice is dripping on the medication. A pool of water is resting at the bottom of the refrigerator in the container with the new insulin.During an observation on 07/17/25 at 08:33 AM, the staff moved the 200 hall refrigerated medications to the 300 hall refrigerator.During an observation on 07/17/25 at 08:40 AM, the 300 hall refrigerator logs revealed that 3 out of 4 months observed were not checked daily.During an interview on 7/17/25 at 9:23 AM, DON stated, We moved the medications to hall 300 hall refrigerator. The 200-hall refrigerator is inoperable. We ordered another refrigerator. It is the responsibility of the day and night nurses to record the refrigerator temperatures daily.

Based on review of facility procedures, observation and interviews, the facility failed to ensure that appropriate infection control procedures related to wound care were implemented for 1 of 1 Residents (R)6 reviewed. Specifically, during a dressing change Registered Nurse (RN)4 was observed removing a soiled dressing from R6's wound and replacing it with a clean dressing, without changing gloves and performing appropriate hand hygiene.Review of the facility's clinical procedure titled, Clinical Procedure: Infection Control-Wound Dressings copyrighted 2025, revealed, Pre-Procedure, Infection control during a dressing change is important to wound care management. By following a standardized protocol, healthcare professionals ensure safety and compliance with evidence-based practices. Procedure.apply clean gloves to remove the soiled dressing, placing it directly into the waste bag to avoid contaminating surrounding surfaces. Remove gloves and perform hand hygiene. Apply a new pair of gloves.Apply clean or sterile gloves to apply the new dressing.Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including but not limited to: unspecified, pressure ulcer of left upper back, unstageable (history of), pressure ulcer of left hip, unstageable (history of) and unspecified wound of left shoulder.Review of R6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 06 indicating severe cognitive impairment.Review of R6's Medication Administration Record (MAR) dated July 1-17, 2025, revealed the following orders: 1. Enhanced Barrier Precaution with a start date of 09/17/242. Dakin's Solution 0.25 percent % as needed (PRN) with a start date of 07/10/25 and special instructions to: Cleanse wound to coccyx with Dakins Solution, pat dry. Skin prep peri wound, allow to air dry. Lightly fill the wound cavity with Calcium Alginate Ag to the wound bed and cover with dry gauze. Secure with foam border dressing every day and as needed. Monitor for signs and symptoms of infection.Review of (R) Progress Note dated 07/09/25 revealed wound location at the coccyx, with a volume of 18.625 cc, an area of 18.75 square centimeters, a length of 7.5 cm, a width of 2.5 cm, and a depth of 1.1 cm. Granulation tissue is 80% present, with a soft texture and pink color. Necrotic tissue accounts for 10%, yellow in color. Drainage is serous, with a moderate amount. The primary dressing is calcium alginate with silver, and the secondary dressing is zinc-based barrier cream applied to the periwound area, covered by bordered gauze dressing. Dressing is changed daily.During an observation of wound care on 07/17/25 at 1:38 PM, RN4 sanitized their hands, then placed a gown and gloves on. RN4 then removed the dirty wound dressing and placed on clean gloves. RN4 took a bag of chips from the resident and placed it in the trash can. RN4 labeled the dressing with a black marker with the date and R4's initials. During an observation of wound care on 07/17/25 at 1:48 PM, RN4 sanitized hands and donned gloves. RN4 then removed the soiled dressing. RN4 proceeded to remove the Dakin's solutions from the cup and cleaned the wound using circular motion. RN4 proceeded to dry the wound with a 4x4 gauze, afterward, RN4 removed gloves. RN4 sanitized hands and placed on a new pair of gloves and placed on the clean dressing.During an interview on 07/17/25 at 2:03 PM, RN4 stated, I do have a certification in wound care. I go by the policy and procedures on how to change wound dressings. I realized I should have changed gloves before cleaning with the Dakins' solution. I receive additional education through attending in-services, if they introduce new products.During an interview on 07/17/25 at 3:49 PM, the Director of Nursing (DON) stated, The wound nurse gets her continuing education from Relias. She came in knowing her information. She was a wound care nurse from a different agency. We will continue doing Relias training and competencies. The Relias walks them through on how to change a dressing, and then I will check her off for competency. During an interview on 07/17/25 at 3:54 PM, the Administrator stated, We also have a wound boot camp that we send the wound care nurses to. The additional training is given by Medline services. The [NAME] teams will conduct education calls, or sometimes the wound nurse can go in person to the trainings.

Based on observations, interviews, and record review, the facility failed to ensure that Resident (R)90 was provided with a functioning television, compromising the resident's right to a homelike environment. This failure affected 1 of 1 residents reviewed for a homelike environment.Review of R90's Face Sheet revealed R90 was admitted on [DATE] with diagnoses that included but not limited to: displaced fracture of the fifth cervical vertebra, unsteadiness on the feet, difficulty in walking, and central cord syndrome at the specified level of the cervical spinal cord.Review of R90's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/25, showed R90 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Under Section F0400, Interview for Daily Preferences, R90 indicated that doing his/her favorite activities was very important, with the resident serving as the primary respondent. The MDS also documented that R90 is dependent on staff for transfers and is wheelchair-bound.Review of R90's Care Plan with the last conference date 07/02/25 revealed Category: Activities R90 prefers activities that identify with prior lifestyle. Goal- R90 will express satisfaction with daily routine and leisure activities. Approach- Encourage R90 to become involved with activities: R90 prefers staying in room, games on iPad, watching TV, Ladies group social with food, Bible study on iPad, and eating popcorn. Provide a setting in which activities are preferred: own room, day room.Review of a Maintenance handwritten log dated May-June 2025 revealed R90's room [ROOM NUMBER](1) Needs a new TV.Review of a work order dated 05/30/25 entered by the Maintenance Department revealed Some channels don't play, but TV still works.During an observation and interview on 07/15/25 at 12:15 PM, with resident R90 in her room. She was found lying in bed with the head of bed elevated approximately 45 degrees and appeared visibly frustrated while attempting to change the channel on her television using the remote control. R90 shared that she considers herself antisocial and prefers to remain alone in her room, with watching television (TV) being her favorite activity. She expressed ongoing frustration regarding her TV not functioning properly, stating that it frequently freezes when she tries to change the channel, turns off by itself, and that about half of the channels-many of which are her favorites-have no audio. She noted that as a result, she ends up watching the same programs repeatedly. R90 emphasized that she is bed-bound and dependent on staff for assistance with the TV. She reported that she has been experiencing these issues for several months and has informed staff daily, including members of the maintenance team, yet no corrective action has been taken. R90 stated that she has been a resident at the facility for approximately one year and expressed disappointment and concern that her repeated requests for help with the television have not been addressed. During an interview on 07/18/25 at 8:48 AM, Licensed Practical Nurse (LPN)1 stated he was unaware of any current issues involving R90's television not functioning. He recalled that the resident had previously voiced complaints about her TV a few months ago, at which time Maintenance was notified of the issue. He further stated that R90 prefers to remain in her room and is dependent on staff for assistance with activities of daily living (ADLs) and transfers.During an interview on 07/18/25 at 8:57 AM, the Maintenance Director revealed that he is aware of R90's ongoing issues with her television not working. He stated that he has a replacement TV available to install in her room but has not yet had the opportunity to do so. He confirmed that R90 has been experiencing TV problems since approximately May 2025. The Maintenance Director assured that a working television would be placed in her room by the end of the day.During an interview on 07/18/25 at 10:13 AM, with the Facility Interim Administrator (FIA), Nurse Consultant (NC1), and [NAME] President (VP) revealed that they were previously unaware that Resident R90 did not have a functional television. Upon learning of the situation, all three agreed that it is unacceptable for the issue to have remained unresolved for such an extended period. They collectively assured that R90 would have a fully functioning TV by the end of the day. Furthermore, they expressed a clear expectation that the Maintenance Department is to follow up promptly and ensure R90 is provided with a new television. NC1 revealed there is no policy for a homelike environment.

Based on interview and review of the Facility Assessment, the facility failed to include the use of an elevator as part of the Facility Assessment, as it is utilized to transport residents during daily operations. Findings include: Facility Policy was requested on 01/29/25 from the Administrator. The Administrator indicated that the facility did not have a policy pertaining to the operation of the elevator or the completion of the Facility Assessment. Review of a facility document titled, Code Black: Utility Outage, documented that the Maintenance Director (MD) notified [NAME] Elevator of the outage and inquired about the projected duration on 01/15/25 and 01/25/25. Review of the Facility Assessment, with a revision date of July 2024, Section III. Physical Environment, Technology, and Equipment did not document information in reference to occupying an elevator in the facility. During an interview on 01/29/25 at 10:24 AM, Licensed Practical Nurse (LPN)2 revealed that the elevator has been down over the weekend and was back in operation on the afternoon of 01/27/25. During an interview on 01/29/25 at 10:43 AM, Registered Nurse (RN)1 revealed she works on the third floor, and she confirmed the elevator was down when she returned to work on 01/27/25. During an interview on 01/29/25 at 11:18 AM, LPN1 states the elevator has been going in and out lately. LPN1 states the elevator was inoperable this week 01/27/25, but started back working that evening. During an interview on 01/29/25 at 11:40 AM, the Maintenance Director (MD) revealed that the elevator has been giving them issues for over a week. The MD states the elevators are contracted with [NAME] Elevator, and he will contact them if there is an issue, so they can come out for service. The MD states that when the elevators are inoperable, he must open all doors and cut the alarms off during that time. During an interview on 01/29/25 at 1:56 PM, the Administrator states that the Senior President of the facility stated that it wasn't a requirement to list the elevator as a piece of physical equipment in the Facility Assessment. During an interview on 01/29/25 at 2:40 PM, the Director of Nursing (DON) states that the elevator has been inoperable for hours in the past, but this time it has been down for days. The DON further stated that she is not sure if there is a standard policy. The DON's expectations are for staff to follow emergency preparedness training, but there is not one specific to the elevator. During an interview on 01/29/25 at 3:50 PM, the Administrator states that his job is to ensure the residents are safe and secure. The Administrator further stated the elevator was not included in the Facility Assessment because he received communication from upper management that it didn't need to be included. He understands that the elevator is a part of the facility, but since the facility doesn't provide maintenance, quarterly inspections or repairs to it, it didn't need to be incorporated in the Facility Assessment.

Based on interviews and record reviews, the facility failed to provide an environment free from potential accident hazards. Specifically, the facility used a mattress to transport Resident (R)1 down the stairwell, when the facility elevators were not working, for 1 of 3 residents reviewed. Furthermore, the facility failed to provide training and documentation related to the safe transportation of resident when the facility's elevator is not working. Findings include: The Facility Policy was requested on 01/29/25 from the Administrator. The Administrator indicated that the facility did not have a policy pertaining to the operation of the elevator or an emergency plan. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute embolism and thrombosis of unspecified deep veins, paroxysmal tachycardia, Type 2 Diabetes mellitus, generalized anxiety disorder, dizziness and giddiness and cognitive communication deficit. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/24, revealed R1's Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R1 was moderately cognitively impaired. Further review of the MDS revealed R1 uses a wheelchair for mobility. Review of a facility document titled, Code Black: Utility Outage, documented that the Maintenance Director (MD) notified [NAME] Elevator of the outage and inquired about the projected duration on 01/15/25 and 01/25/25. Review of the MD's emails dated 01/15/25 at 11:12 AM and 01/25/25 at 8:40 AM, revealed that [NAME] Elevator was dispatched for service request. Review of the Maintenance Activity Logs from 11/01/24 through 01/29/25, revealed no documentation of maintenance records about the elevator being inoperable. During an interview on 01/29/25 at 10:24 AM, Licensed Practical Nurse (LPN)2 revealed that the elevator has been down over the weekend and was back in operation on the afternoon of 01/27/25. LPN2 states, in case of an emergency, staff calls 911 if they need to move a resident from upper floors. She also states, staff reschedules appointments for the dependent residents if the elevator is down. During an interview on 01/29/25 at 10:43 AM, Registered Nurse (RN)1 revealed she works on the third floor, and she confirmed the elevator was down when she returned to work on 01/27/25. RN1 states in the case of an emergency, staff transfers the residents via the stairwell in wheelchairs, or they call 911 if they are unable to transfer the resident from upstairs. RN1 further stated that in the past they have transported a dialysis patient on a mattress down the stairwell. She has only seen that technique done at this facility but hasn't been trained on it. RN1 states dependent residents that have outside appointments, are rescheduled when the elevator is inoperable. During an interview on 01/29/25 at 11:18 AM, LPN1 states the elevator has been going in and out lately. LPN1 states the elevator was inoperable this week 01/27/25, but started back working that evening. LPN1 states he hasn't been provided training or directives on what to do if the elevator isn't working for dependent residents on second, third or fourth floors. He states that if a dependent resident has an appointment and the elevator is inoperable, staff will reschedule the resident's appointment. LPN1 states he's never heard of, nor has he ever used the mattress technique for transporting residents. In case of an emergency LPN1 states that he will get the residents downstairs by any means necessary. During an interview on 01/29/25 at 11:40 AM, the MD revealed that the elevator has been giving them issues for over a week. The MD states the elevators are contracted with [NAME] Elevator, and he will contact them if there is an issue, so they can come out for service. The MD further stated on Monday 01/27/25, the MD assisted with bringing a dialysis resident from the fourth floor down the stairwell on a mattress with a cover under and over the resident for safety and security. The MD further stated that on the same day he assisted another resident from the third floor down the stairwell with the mattress technique as well. The MD states that when the elevators are inoperable, he must open all doors and cut the alarms off during that time. The MD states he had training on the mattress technique by the previous Administrator. During an interview on 01/29/25 at 12:30 PM, R1 revealed she was placed on a mattress by two men and transported down the stairwell for a Radiology appointment outside the facility. During an interview on 01/29/25 at 12:55 PM, RN1 stated that R1 went out for an appointment on Monday 01/27/25. RN1 states the resident was transported down the stairwell via wheelchair by LPN1, and a male therapist. R1 was transferred from the third floor to first floor. During an interview on 01/29/25 at 1:13 PM, LPN1 stated he transferred R1 from the third floor, by putting a blanket underneath a mattress and slowly assisting her down to the first floor, with the assistance of other staff. R1 was not apprehensive about the transfer and there were not any injuries or mishaps during the transfer. LPN1 confirmed that he never received any formal training on the mattress technique or what to do in an emergency situation. During an interview on 01/29/25 at 2:40 PM, the Director of Nursing (DON) states that the elevator has been inoperable for hours in the past, but this time it has been down for days. The DON states that all hands are on deck in situations when residents need to get downstairs, or the staff will call Emergency Medical Services (EMS) for assistance. She is not sure if there is a standard policy. The DON's expectations are for staff to follow emergency preparedness training, but there is not one specific to the elevator. In the case of an emergency, staff would use a mattress, in which she thinks is the safest measure for the resident. The DON doesn't recall any formal education on the mattress technique or what to do in case of an emergency in the facility when the elevator is out of service. During an interview on 01/29/25 at 3:50 PM, the Administrator states that his job is to ensure the residents are safe and secure. The Administrator includes they transfer residents down the stairs with the use of a stretcher from transportation, with their supervision, or by placing a resident on a mattress, if the mattress has handles. He feels this is the least hazardous way to transport the resident's downstairs, when the elevator is not working. The Administrator stated that there were no falls or injuries for the residents that were transported down the stairwell. The Administrator states the previous Administrator provided communication of best practices to staff to use when the elevator is not working, but there is no documentation. He also states the facility doesn't have an Emergency Plan in place to use when the elevator is out of service. He states that they need to properly train and educate staff on all shifts about an Emergency Plan.

Based on interviews, record review, and facility policy the facility failed to ensure Resident (R)5 and R6 were free from sexual abuse. Additionally, the facility failed to give report to another Licensed Nurse to ensure residents needs were met before leaving the facility for break. Specifically, R10 On 1/23/23 at 7:45 PM, a staff member observed R5 lying on top of R6 with his genitals exposed. After separating the residents and body audits completed, the facility conducted interviews with both residents. The investigation revealed R5 stated that R6 was a woman and that he knew her from the past. R6 was interviewed and made sexual references that occurred by showing with happened with his hands. Both residents were fully clothed at the time of the incident. R5 had on a shirt and pants, and R6 had a nightgown and brief that was intact, neither resident's clothing was noted to be off or pulled down. Families were notified of this incident, and during the notification R5's Resident Representative stated that R5 has a history of wandering and was found in the past at a neighbor's house in their bathroom. On 6/8/23 at 5:52 PM, the Administrator and Director of Nursing (DON) were provided with a copy of the Centers for Medicare and Medicaid (CMS) Immediate Jeopardy (IJ) template, notifying the IJ existed at F600 due to the facility failure to prevent sexual abuse and notify law enforcement as required by federal regulations. On 6/9/23 at 2:27 PM, the DON provided an acceptable IJ removal plan relate to F600. The immediacy of the IJ was removed as of 6/9/23. The IJ was lowered to the scope of severity of E. Implementation of the removal plan was verified by interviews and record reviews. Upon implementation verification, the DON was notified the IJ was removed as of 6/9/23 at 2:27 PM. Upon QA Review by the SA, the survey team returned to the facility on [DATE] with additional concerns. From this review, IJ was found related to a new incident at F600. R21 was observed via a cell phone recording to have been verbally abused by CNA2, in the presence of LPN2, with no interventions. On 6/24/23 video evidenced recorded around 8:30 AM - 9:00 AM revealed CNA2 being verbally abusive toward R21. CNA2 was observed speaking loudly and aggressively while pointing their finger toward R21 in an aggressive manner. During the video, R21 stated that he was in pain and needed help with getting his urinal. CNA2 stated that How am I supposed to know that you are in pain in an aggressive manner while standing over the resident and pointing in a demeaning manner. CNA2 also made statements such as Touch me again, and it's going to be a problem in an aggressive manner. In the video, CNA2 was explaining to Licensed Practical Nurse (LPN)2 that R21 grabbed them while their back was turned. LPN2 was observed telling R21 You can use your hands (grab your own urinal), you can roll over and do that without help. During the video, LPN2 was observed allowing CNA2 to verbally abuse R21 without de-escalating the situation. The IJ template was presented to the Director of Health Services/DON on 06/30/23 with an effective date of 06/24/23. On 6/30/23 at 5:44 PM the DON provided an acceptable IJ removal plan related to F 600. The immediacy of the IJ was removed as of 6/30/23. The IJ was lowered to the scope of severity of E. Findings include: The facility's policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission statement, revised on 11/21/2016 indicated, It is the mission of [NAME] Health and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. R5 was admitted to the facility on [DATE] with diagnoses including but not limited to heart failure, Alzheimer's disease, legal blindness, and schizophrenia. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/24/23, R5 has a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicates they are cognitively intact. Further review of the MDS revealed R5 has a history of wandering and had this behavior 1 -3 days a week during this assessment period. R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to; cerebral palsy, seizures, dementia without behavioral disturbance, and communication deficit. Review of the Discharge MDS with an ARD of 3/15/23, revealed R6 has a BIMS score of 5 out of 15, which indicated cognitive impairment. An interview on 6/7/23 at 2:21 PM with Certified Nursing Assistant (CNA)1 revealed While I was passing trays, I noticed R5 in his room on top of his roommate (R6). I called the charge nurse to the room and we assisted R5 back to his bed and noticed that his penis was out of his pants. The resident kept saying that he knew that woman (R6). We kept explaining to R5 that R6 was a man and his roommate and that he should not be in bed with other residents without their consent. R5 was later moved into a private room and was put on one-to-one supervision for about a month. R5 at times still wanders but he is legally blind, so staff have to look to make sure he does not wander into other residents' rooms. An interview on 6/7/23 at 2:27 PM with Licensed Practical Nurse (LPN)1 revealed I was called to the room by CNA1 and told that R5 was lying on top of R6. R5 was assisted to his bed. When we moved R5, we saw that his penis was outside his pants, R6 was still clothed, and his brief was intact. When we spoke with R5, he believed that he was in bed with a woman that he knew, we explained to him that R6 was a man and his behavior was not appropriate. We notified the DON and R5 was moved into a private room with a sitter. I spoke with R6 he made a motion with his hands signaling that R5 was attempting to touch his private areas. R5 was later put on one-to-one supervision for a few weeks, he wanders at times but not as much as he used to. Record review on 6/8/23 of R5 Social Services Progress Notes with a Late- Entry on 2/14/23 at 4:19 for 1/23/23 revealed On 1/23/23 R5 was physically inappropriate with his peer (R6). Resident (R5) was placed on 1:1, moved to a private room, and a referral was made to psychiatric services. Social Worker (SW) visited the resident, and he was in his room watching. SW explained to R5 the limits of physical sexual aggression towards others. SW informed the resident representative and educated R5 on behavior and referral to psychiatric services. Resident representative acknowledged and gave consent for psychiatric services, staff will monitor for any potential mood/behavior changes. Record review on 6/8/23 of R5's Nurses Progress Note dated 1/23/23 at 9:02 AM revealed Nurse was called to the room by the CNA. The resident was inappropriately touching another resident. Assisted the resident back to his bed and notified the Director of Nursing. The resident was moved to another room and a sitter for one on one was placed at his bedside. The nurse practitioner and resident representative notified. Record review on 6/8/23 of R5 Nurses Progress Note dated 1/26/23 at 7:45 AM revealed C.N.A. reports resident noted wandering into neighbors' room through bathroom. The resident was noted sitting on another resident's bed. The resident was reoriented by the nurse through conversation. Resident placed back in bed where he remained throughout the night. Review of R5's Care Plan revealed Behavioral symptoms follow up with psychiatric services intervention for sexual disinhibition. Interventions include redirect resident and monitor behavior; document behaviors daily twice a day. Review of R5's care Plan revealed Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety. Interventions include maintain a calm environment and approach to the resident; move to a private room due to wandering into another resident's room one-to-one was initiated for 24 hours 1/23/23-1/24/23; remove resident from other resident's rooms and unsafe situations. Record review on 6/8/23 of R6 Social Services Progress Notes with a Late- Entry on 2/23/23 at 4:18 PM for 1/23/23 revealed R6 roommate (R5) was sexually inappropriate towards R6. Social Worker (SW) asked R6 to explain the incident that occurred with his roommate and R6 stated that R5 touched him. R5 was moved to another room, the family was notified and requested a referral for psychiatric services for R6. R6 was also informed of psychiatric referral and roommate transferred. Record review on 6/8/23 of R6 Nurses Progress Notes dated 2/1/23 at 3:13 AM revealed resident resting in bed with eyes closed easily aroused with verbal stimuli. Patient with multiple episodes of crying throughout the shift, when asked what is wrong and why is crying, he shakes his head no and stated, 'Please don't leave me.' Denies pain and discomfort, assistance provided with all phases of Activities of Daily Living (ADLs), so signs or symptoms of distress. Record review on 6/8/23 of R6 Progress Notes dated 2/2/23 at 2:05 PM revealed Resident tolerated all his medications crushed without complaints. His niece came to visit and expressed some concern about his demeanor. She stated that he just seems a bit off. A staff member went to check on him and will continue to monitor. Record review of a Nurses Progress Note dated 2/4/23 at 1:08 AM revealed resident lying in bed watching television, able to communicate wants and needs to staff. Resident in a sad tearful mood, resident oriented with one-on-one with nurse and conversation. An interview on 6/8/23 at 11:01 AM with the DON revealed they were not working on the evening the incident occurred but instructed the Unit Manger to complete body audits and interview both residents related to the incident. R5 believed that R6 was a woman, R5 is legally blind and has a history of wandering but this was the first time an incident of this nature has ever occurred with him. After the incident and body audits were completed, R6 was observed with his brief still intact and with no signs of physical harm so we didn ' t send him to the hospital or call law enforcement. The policy for the facility is when a resident shows signs of harm or displaced clothing/ underwear is to transfer residents to the hospital and call law enforcement. Interventions for R5 after this incident included one-to-one supervision for 24 hours and relocation into a private room where the resident is still placed. Interventions for R6 included monitoring for mood changes, a body audit after the incident, and obtaining a psychiatric consult. A phone interview on 6/8/23 at 11:43 AM with the Psychiatrist Consult for the facility revealed that R5 was followed by psych services from 2/1/23-4/12/23 and was discharged due to being put on hospice. Further revealed that R6 was not followed by psych because, during the initial consult, the resident was not exhibiting any signs or harm/distress, further stated that the resident's insurance would not cover psychiatric services but if the resident was in distress during their assessment they would have referred R6 to a psych service that insurance and would cover. Mutiple attempts were made to contact R6 during the survey 6/7/23 - 6/9/23 with no success. The facility's removal plan for F600 included: 1) R6 received a psychiatric consult and was not referred for further services as no signs of harm/distress were exhibited post event. R5 was transferred to a private room and placed on one-to-one supervision. R5 was removed from one-to-one after exhibiting no indication that he would repeat a similar incident. R5 will remain in a private room for the duration of his stay at the facility. 2) R5 will be placed on one-to-one-supervision to prevent any further occurrences due to R5 cognitive impairment, blindness, and wandering at times. 3) All staff will receive education by the Director of Health Services/ DON, Clinical Competency Coordinator, and/or licensed nurse designee on the facility Abuse policies to include: Abuse Identification; Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, and Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Any staff who are currently out on personal leave and/or Family Medical Leave Act (FMLA) will receive education prior to the next scheduled shift. Education was initiated on 6/8/23, we have currently completed approximately 45% of all partner in-services and have a 100 % completion date of 6/16/23. Any alleged and/or witnessed abuse, neglect, exploitation, mistreatment, and/or misappropriation of funds will be reported and investigated per regulation and facility policy, by the Administrator and/or Director of Health Services/DON and logged on a tool. The Administrator and/or DON will review each investigation once the investigation is completed to ensure that appropriate interventions are put in place to prevent reoccurrence. 4) The DON and/or Administrator will present results of reviews to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months and/or substantial compliance achieved. 48448 Findings include: Review of R10's medical record revealed the facility admitted the resident with diagnoses which included Acute and Chronic respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, presence of aorotocoronary bypass graft, acute pulmonary edema, acute on chronic systolic heart failure, personal history of transient ischemic attack, diabetes mellitus type two, dyslipidemia, and cerebral infarction. Review of the discharge MDS with an ARD of 02/05/23 revealed R10 had a BIMS score of 15, indicating the resident was cognitively intact. Review of R10's Care Plan, initiated on 02/05/23, revealed that the resident had a care plan for altered mental status (AMS) with an intervention to send the emergency room for evaluation and treatment. Review of R10's progress notes entered late on 02/06/2023 at 09:03 AM for 02/05/2023 at 12:58 PM stated CNA came to get nurse. Assessed resident at 11:10 AM. Noted AMS. Resident presented with swollen lips, pale tongue, slowed response to questions posed to resident. Resident speech was more slurred than usual. Baseline for resident is A+Ox4. Resident had family at bedside. Family requested resident be sent to MUSC Downtown. Called DHS 11:14 AM who agreed. Called On-call for order at 11:15 AM. 911 called and gave report to MUSC Downtown. EMS arrived and family left to meet resident at hospital. EMS assessed resident. Reported to nurse that was possible stroke and will take the Prisma Health Richland. Nurse notified family of change of location. Resident left facility at 1200 PM. During an interview on 06/07/23 at 1:59 PM, CNA2 stated she has been employed with the facility for over [AGE] years. CNA2 stated she had provided care for R10 that morning and R10 was her usual self. CNA2 went back into the room and tried to get the R10 to eat her meal, but R10 stated she did not want to eat at that time. R10's family came out of the resident's room later and asked to see the nurse. CNA2 tried to find the nurse but was unable to find LPN 3. She was able to locate LPN2 and LPN2 assessed the resident. LPN2 decided to send R10 to the hospital. R10's family was extremely upset and continued to scream, yell, curse, became belligerent until the LPN2 had to tell them the police would have to be called if they didn't calm down. The family eventually calmed down. EMS took R10 to the hospital. During an interview on 06/07/23 at 2:10 PM, LPN2 stated she has been employed at the facility for 2 years. LPN2 stated she was working on the first floor. A CNA stated that there was a family on the fourth floor that was upset and wanted their family member sent to the hospital. She was unsure who the CNA was at this time. LPN2 assessed R10 and found she was lethargic, but not unresponsive. LPN2 decided to send R10 to the hospital. LPN2 called the Emergency Medical Services (EMS) and stayed with R10 until they arrived. R10's family wanted R10 to be sent to Medical University of South Carolina (MUSC) of [NAME], but EMS decided to send the R10 to the nearest hospital because she was exhibiting signs of a stroke. She was not given report by the nurse who was taking care of R10. LPN2 stated she does not leave the building when going on break, especially if it's only one nurse working on the floor. Anything could happen to the residents and the nurse would not know. LPN2 also stated that she was unaware of LPN3 leaving the building to go on break. During an interview on 06/07/23 at 2:30 PM, LPN3 stated has been employed with the facility since September 2022. LPN3 stated she was working with R10 all morning and R10 was fine and was in no distress. LPN3 stated right before 11:00 AM she checked the R10's fingerstick blood sugar (FSBS) and it wasn't either high or low. LPN3 proceeded to tell CNA2 that she was going on break and LPN3 left the building to go on break. About 10 minutes after LPN3 left the building she received a call from CNA2 that something was wrong with R10. She stated she told CNA2 to call LPN2 because she was not in the building. LPN3 spoke with R10's daughter and told R10's daughter that she just left R10 and R10 was fine. LPN3 repeated R10's FSBS to R10's daughter. The facility only had one nurse on the floor that day. When it's only one nurse on the floor LPN3 stated she doesn't give report to another nurse when LPN3 goes to lunch. On 06/07/23 at 2:45 PM during an interview with the DON, she stated she received a call from the facility stating R10 was unresponsive. R10's daughter was upset that she found R10 that way and she could not find anyone to help her. DON stated she spoke with LPN2 and was told LPN3 was on break. LPN2 assessed R10 and decided to send R10 to the hospital. DON reviewed footage and CNAs and nurses were in and out of R10's room during the morning. Around 11:00 AM, LPN3 went on break and CNA2 was left on the floor. R10's daughter walked into the R10's room right after LPN3 left the floor. That's when R10's daughter found R10 and went to look for nurse. R10's daughter could not find the nurse, so CNA2 went to look. CNA2 found LPN2 and R10 was assessed. LPN2 stayed with the resident until the resident was sent out of facility. LPN3 was educated on giving report to another before leaving the floor. DON stated notifying the CNAs is not enough because anything can happen. During a review on 06/07/2023 at 3:30 PM of the SBAR Communication form completed by LPN2 on 2/5/23. The change in condition, symptoms, or signs observed and evaluated is/are AMS. This started on 2/5/23. Since this started it has gotten worse. The question of if this condition, symptom, or sign has occurred before was answered no. Vital signs were as followed: blood pressure was 116/64, Pulse 48, Respirations 20, Temperature 98.6, Pulse oximetry 83% on room air. During an interview on 06/08/2023 at 09:41 AM R10's daughter stated on 02/05/2023 she was calling her mom to check on her that morning with no answer. Since we could not get her mom on the phone, she took an Uber to the facility. Once she arrived at the facility, she found her mom unresponsive with her tongue hanging out of her mouth. She went into the hallway to get help but couldn't find anyone. When she did find the CNA, they went to look for the nurse and could not find her. She stated it took her 2 hours to find a nurse. When a nurse was found she had to ask the nurse to send her mom to the hospital. Additional findings include: Review of facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised on 07/29/2019, states- The state survey agency and the state agency for adult protected services should be notified in accordance with state law through established procedures of any allegations of Abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the event upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. On 6/24/23 video evidenced recorded around 8:30 AM - 9:00 AM revealed CNA2 being verbally abusive toward R21. CNA2 was observed speaking loudly and aggressively while pointing her finger towards R21 in an aggressive manner. During the video, R21 stated that he was in pain and needed help with getting his urinal. CNA2 stated How am I supposed to know that you are in pain in an aggressive manner while standing over the resident and pointing in a demeaning manner. CNA2 also made statements such as Touch me again, and it's going to be a problem in an aggressive manner. In the video, CNA2 was explaining to Licensed Practical Nurse (LPN)2 that R21 grabbed them while their back was turned. LPN2 was observed telling R21 You can use your hands (grab your own urinal), you can roll over and do that without help. During the video, LPN2 was observed allowing CNA2 to verbally abuse R21 without de-escalating the situation. R21 was admitted to the facility on [DATE] with the diagnoses including but not limited to; intellectual disabilities, muscle weakness, blindness in right eye, conductive hearing loss (bilateral) and unsteadiness on feet. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 06/05/23 revealed R21 has the Brief Interview of Mental Status (BIMS) score of 99, which indicates that R21 is cognitively impaired. Further review of the MDS revealed R21 requires one-person physical assistance with transfers and bed mobility. An observation and attempted interview on 6/30/23 with R21 revealed that he was non-interviewable and had difficulty discussing the alleged verbal abuse. A phone interview on 6/30/23 at 10:38 AM with R21's Resident Representative (RR)1 revealed I was sent the video on Saturday (6/24/23) by my brother, R21. In the video I saw CNA2 being verbally aggressive towards R21. She (CNA)2 was upset because R21 touched her and was trying to get her attention to use his urinal that was out of reach. Further in the video, I saw CNA2 waving her finger and getting close to R21 in an aggressive manner. I came to the facility on the day of the incident (6/24/23) and spoke with R21, CNA2, and two other nurses, but I can't recall their names. I asked for CNA2 to not work with the resident any longer after this incident, because R21 had told me he had issues with this CNA previously, but he could not remember her name. On Monday (6/26/23), I came back to the facility and spoke with the Unit Manager Licensed Practical Nurse (LPN)1 and someone from the Business Office about the incident and filed a grievance against CNA2. A phone interview on 6/30/23 at 10:48 AM with R21's RR2 revealed I came to the facility on the day R21 sent us the video of CNA2 being verbally aggressive towards him. When I got to the facility, I spoke with CNA2 and another nurse about CNA2 being verbally abusive to R21. When I watched the video, I feel like the other nurse in the video (LPN2) did not attempt to de-escalate the situation. In the latter part of the video, CNA2 yelled at the resident If you touch me again we are going to have some problems. I was unsure what she meant by that statement, but to me, it sounded threatening and like she would hit him (R21) if he touched or grabbed her again. R21 told me that he meant no harm when he grabbed her arm, but he was trying to tell CNA2 that he needed to use his urinal. I am unsure if the resident is safe at the facility because I fear that someone might try to get back at him because he recorded the incident. An interview with the Director of Nursing (DON) on 6/30/23 at 11:37AM revealed that CNA2 was currently at the facility and working today. During an interview on 6/30/23 at 11:42 AM, CNA2 revealed I was working on Saturday (6/24/23) with R21. While I was in his room and bending over to reach for something, R21 grabbed me hard on the shoulder. I went and told LPN2 and the Unit Manager LPN1 about the incident. R21 is a bigger man, so when he grabbed me, it was rough, because he is strong. I have been working with R21 since he was admitted and had no idea that he was hard of hearing and had a vision impairment. Later that day, his family came to the facility and spoke with me because R21 had recorded the incident on his phone. After this incident, I received an in-service by the Clinical Coordinator and continued to work as normal the rest of the day and week and was not placed on suspension during the investigation. CNA2 further stated that she has not received any abuse or neglect training from the facility because I previously worked at this facility a few years ago and have been a CNA for many years. A phone interview on 6/30/23 at 12:39 PM with LPN2 revealed I was working on Saturday (6/24/23) when CNA2 came to the nurse's station upset because R21 had grabbed her on her shoulder. We went down to the room together and that's when CNA2 and R21 started going back and forth (arguing) with each other about the incident. CNA2 was yelling at the resident that the way that he grabbed her shoulder was assault and that she was going to press charges and call law enforcement if he did that again. I was trying to understand what was going on during this time when they were yelling at each other. I told LPN1 about this incident, but I am not sure what happened afterward or if it was reported to the state agency/DHEC and investigated as verbal abuse by the facility. LPN2 further stated that they were unsure if CNA2 had worked with R21 after this incident but on the day of the incident (6/24/23), had switched CNA2's assignment with another staff member. An interview on 06/30/23 at 12:52 PM with R21 revealed I have seen CNA2 on the unit since the incident, however, CNA2 has not worked with him since last weekend 6/24/23. When asking the resident if he felt safe, R21 replied No, I don't feel safe right now. An interview with the DON on 6/30/23 at 1:45 PM revealed that they were unaware of the verbal abuse between CNA2 and R21 that occurred on 6/24/23. She stated,If I would have heard about this incident, I would have pulled them all in and gotten interviews. The DON further stated that they spoke to R21's family, but not about this incident and only discussed a room change. The Infection Preventionist handled R21's RR's grievance and spoke with the family in a meeting on Monday (6/26/23). An interview on 6/30/23 at 2:00 PM with the DON and Infection Preventionist (IP) revealed I was not working on Saturday (6/24/23) when this incident between R21 and CNA2 occurred. On Monday this week (6/26/23), staff informed them that R21 and their family had concerns and needed a follow-up meeting. I spoke to the Unit Manger/LPN1 on Monday and the family discussed the issue regarding CNA2 and R21 wanting a room change. The resident stated that he didn't want to be in a nursing home due to old people and he switched rooms with a newer roommate with a similar diagnosis. After the meeting, I completed a grievance for R21 and his family and provided re-education to CNA2 related to communicating with individuals with hearing or vision issues. I spoke with CNA2 about what happened, and she said that the resident grabbed her on her shoulder and that she was not being ugly with him. The ICP further stated that she did not speak to the other nurse (LPN2) who was a witness, and this incident was not investigated or reported. An attempted phone interview with the Unit Manager/LPN1 on 6/30/23 at 2:08 PM was unsuccessful, a voicemail message was left with contact information. A phone interview on 6/30/23 at 2:13 PM with R21's RR3 revealed I was sent the video by R #21 on Saturday 6/24/23 and was very upset by this incident. R #21 has communication issues because of his hearing and will often touch others when he needs help. I do not think he meant to hurt C.N.A #2 that day but he told me he needed his urinal. When my family went to see the resident later that day on Saturday (6/24/23) I was on speaker phone when my family spoke to C.N.A #2. Even though I was on the phone I heard C.N.A #2 being disrespectful towards my family. I did not speak with anyone at the facility related to the incident, but I sent the video to the local Ombudsman's office and spoke with their staff about the incident. Record review of Grievance/Complaint Form dated 6/26/23 revealed Family of R21 wanted to speak to Unit Manager regarding an issue with CNA2 and R21. CNA2 told resident not to grab her like that, resident got upset. CNA2 was provided education on caring for residents with intellectual disabilities and hearing loss. The facility's removal plan on 06/30/23 for F 600 included: 1) R21 was referred to psychiatric services on 6/30/23 for psycho-social support to determine if there are any lasting effects from this event. 2) All staff will receive education by the DON, Clinical Competency Coordinator and/or licensed nurse designee on providing care to residents with intellectual disabilities as well as the facilities Abuse policies to include: Abuse Identification, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Any staff who are currently out on leave will receive education prior to the next scheduled shift. Education was initiated on 6/30/23 and we will have a 100 % completion dated of 7/3/23. 3) Any alleged and/or witnessed abuse, neglect, exploitation, mistreatment, and/or misappropriation of funds will be reported and investigated per regulation and facility policy by the Administrator and or DON and logged on a tool. The Administrator and /or DON will review each investigation to ensure that appropriate interventions are put in place to prevent reoccurrence. The Administrator and/or DON will review each grievance to ensure no reportable event was captured as a grievance as opposed to a reportable incident to the state agency and appropriate persons/ agencies. 4)The DON and or Administrator will present results of reviews to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months and/ or until substantial compliance is achieved.

Based on review of the facility policy, interviews and record reviews, the facility failed to ensure that Advanced Directives were correctly documented and/or implemented for 3 of 3 residents reviewed, Resident (R)5, R9, and R20. On [DATE] at 5:52 PM, the Interim Administrator (IA) was notified that the facility's failure to maintain and implement written policies and procedures regarding advanced directives caused a resident to not receive Cardiopulmonary Resuscitation, the IA was then notified that the allegation constituted Immediate Jeopardy (IJ) at F 578, with an effective date of [DATE] and the IJ template was presented. On [DATE] at 2:27 PM, the Director of Nursing (DON) provided an acceptable IJ removal plan for F 578. On [DATE], the immediacy of the IJ was removed and the IJ was lowered to the scope of severity of E, no actual harm with potential for more than minimal harm that is not IJ. Findings Include: Review of facility policy titled, Advance Directives: South Carolina with a review date of [DATE] revealed This healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advance Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advance Directives executed in accordance with state law will be honored by the healthcare center.The healthcare center shall enter in the patient/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center. Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Record review of R20's Hospice notes titled Skilled Nursing Visit Note dated [DATE] revealed that R20 stated that she wanted Cardiopulmonary Resuscitation (CPR) if her heart or lungs stop working which was evidenced/reaffirmed by patient/ responsible party. R20 also stated that they would like life-sustaining treatments other than CPR. Review of Skilled Nursing Visit Note under section titled Clinical Record Items- Advance Directive stated that the Document type/Instruction was Full resuscitation and a copy was supplied. A Physician's Order for R20 dated [DATE] revealed R20's was a Full Code. Review of R20's Care Plan with a last review date of [DATE] revealed that If the patient/ resident's heart stops, or if patient/ resident stops breathing, CPR WILL be initiated in honor of the wishes through the next review period. With Approaches listed as: All staff to be made aware of patient/ resident's wishes and Review Advance Directive with patient/ resident and/ or appointed health care representative quarterly. Notify MD of any changes Review of R20's Progress Notes dated [DATE] revealed Resident expired at 1430. DHS and Hospice made aware. Review of R20's medical record revealed no documentation of resuscitation or CPR occurring. During an interview with the DON on [DATE] at 12:15 PM, she confirmed CPR was not performed. Review of R9's quarterly MDS with an ARD of [DATE] revealed R9 scored 12 on a BIMS, indicating the resident has moderate cognitive impairment. Review of R9'S Face Sheet under section titled Advance Directives revealed that R9 is a Full Code. Review of R9's Hospice Notes titled, DNR dated [DATE] revealed a DNR Order stating that no resuscitative efforts be made in the event of cardiopulmonary arrest. Review also revealed a DNR authorization for Patient /Resident Without Decision-Making Capacity: Florida, North Carolina & South Carolina. Review of R5's quarterly MDS with an ARD of [DATE] revealed R5 scored 11 on a BIMS, indicating the resident has moderate cognitive impairment. Review of R5'S Face Sheet revealed that R5 is a Full Code. Review of R5's Hospice Notes titled, DNR dated [DATE] revealed a DNR Order stating that no resuscitative efforts be made in the event of cardiopulmonary arrest. Review also revealed a DNR authorization for Patient /Resident Without Decision-Making Capacity: Florida, North Carolina & South Carolina. Review of R5's Care Plan with a last revised date of [DATE] revealed Problem: Advanced Directive; Full Code with a goal of: If the patient/ resident's heart stops, or if patient/ resident stops breathing, CPR WILL be initiated in honor of the wishes through the next review period. Approaches listed as All staff to be made aware of patient/ resident's wishes and Review Advance Directive with patient/ resident and/ or appointed health care representative quarterly. Notify MD of any changes. Review of R5's Hospice Note titled, Skilled Nursing Visit Note dated [DATE], revealed that R5 expressed his wishes to be a DNR and did not want any resuscitative efforts made and was reaffirmed by resident representative. During an interview on [DATE] at 10:32 AM, R9's Representative stated that he told the facility that he wishes for the R9 not to be resuscitated in the event of an emergency. During an interview on [DATE], time unspecified, the Director of Nursing (DON) stated that the unit manager, MDS coordinator and the social worker all work together as a team when discussing resident advance directives. She also stated that it was the responsibility of the nurse to ensure that advance directive orders are placed. Attempted to contact Social Worker on [DATE] at 10:30 AM for an interview, no answer voicemail left. The removal plan for F 578 included: 1. R9 and R5 advance directives, orders and face sheet were reviewed and revised to reflect accurately the wishes of the resident(s)/resident representative(s) on [DATE]. R20 no longer resides in the facility. 2. An audit of all current residing residents advance directives by a licensed nurse will be conducted to ensure the residents) and/or resident representative(s) wishes are reflective accurately in the resident's medical record, MatrixCare. This includes verifying the resident's order, advance directive wishes and the residents face sheet to ensure all areas are accurate and reflective without discrepancies. The facility appointed staff to include the Director of Health Services, Clinical Care Coordinator and/or the Infection Preventionist will in-service all licensed nurses on code status recognition in MatrixCare and to follow the desired wishes of each individual resident. Any licensed nurses currently out due to vacation and/or personal leave will receive education prior to next scheduled shift. All new hire licensed nurses will receive the same in-service information in orientation. The facility social worker will also receive the same education, as well as the process to verify advance directives are reflective accurately without discrepancy in the resident's medical record, according to the resident and/or resident representative wishes. Weekly the Social worker, Director of Health Services and/or Clinical Competency Coordinator will meet to review any resident who admitted that week and any current residing resident record where changes were made to advance directives wishes to validate the medical record reflects accurately without discrepancies. This review will be recorded on a monitoring tool. 3. The Director of Health and/or Administrator will present results of reviews to the QAPI Committee monthly x 3 months and/or until substantial compliance achieved.

Based on record reviews and staff interviews, the facility failed to ensure 1 of 3 residents' environment was free of accident hazards/supervision/devices. Specifically, Resident (R) 1 left the facility unattended on 12/26/21. Staff were unaware of R1's whereabouts or condition until he was found by Emergency Medical Staff (EMS) at a nearby hospital. This failure had the potential to place R1's health and safety at risk for serious injury, harm, impairment, or death. The facility's failure substituted substandard quality of care. Resident (R)1 had a successful elopement from the facility on 12/26/21. A nurse's note on 12/26/21 by the Licensed Practical Nurse on duty, indicated on 12/26/21 at 10 PM, resident was not in his room. According to the facility investigation report, a un-staffed camera recorded the resident exiting the facility through the main entrance at 10:28 PM. At 11:14 PM, the video camera recorded a police officer arriving to the facility however, R1 was not observed with the officer. At 11:23 PM, Emergency Medical Services (EMS) personnel arrived at the facility with R1. There was no police report or EMS report indicating R1 sustained any injuries or was treated by EMS during the incident. Several staff interviews revealed the facility was unaware of R1's whereabouts and condition until he was returned to the facility by law enforcement and EMS personnel. During an interview with the Administrator on 01/06/22 at 11:34 AM, he stated R1 was found by EMS at the corner of Laurel St and [NAME] Ave, 1.5 miles away from the facility. The Administrator further stated R1 was wearing long sleeve thermal shirt, a pair of jeans and black footwear. The temperatures were between 55 - 60 degrees Fahrenheit (F). On 1/07/22 at 10:44 AM, the facility Administrator was provided with a copy of the Centers for Medicare and Medicaid (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F600 and F689 due to the facility's neglect to adequately monitor R1, who had a diagnosis of dementia, with an effective date of 12/26/21. On 1/07/22 at approximately 1:50 PM, the facility provided an acceptable IJ Removal Plans related to F689. The immediacy of the IJ's were removed as of 1/07/22. The IJ was lowered to scope and severity of D, no actual harm with the potential for more than minimal harm this is not IJ. The facility's removal plan included for F689: 1. On 1/07/22 the facility purchased door alarms for all exits as mean of an additional monitoring system for anyone who were to exit the facility with or without a wander guard device. 2. Daily checks for functionality of all alarmed exit doors will be educated by the Maintenance Director and/or designee and findings documented on the door alarm device daily testing report form. 3. Functionality will include checking for an alarm sound and door locking. 4. Daily checks for functionality of wander guard bracelets will be conducted by the assigned nurses and/or designee and findings documented in the resident electronic medical record. 5. Functionality will be checked using the tag/device for activation and/or taking resident to door and listening for alarm sound and door locking. 6. Daily checks for doors alarms functioning, to include new alarming devices at all exit doors will conducted by the Maintenance Director. 7. Education/In-Servicing imitated 12/27/21 will continue until all partners have been educated. 8. The education will include instruction on the door alarm devices and daily testing, including the checking placement and functioning of devices. 9. The facility will continue to complete elopement risk assessments upon admission, quarterly, annually and with significant change to identify high risk residents. The above plan was implemented by the facility and verified. Implementation of the removal plan was verified through observations, staff interviews, and records reviews. Observation verified that all door alarms were functioning successfully. Documentation review revealed that staff was educated on Abuse, Neglect, and Exploitation policies and procedures, immediacy on responding to door alarms, and following the wandering/elopement procedures. The training were conducted on 12/27/21. Findings include: The facility admitted R1 on 3/18/16 and readmitted on [DATE] Dementia Without Behavioral Disturbances, Seizures, [CONDITION(S)] and [CONDITION(S)] Disorders. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview Mental Status (BIMS) score of 7, indicating R1 was mildly cognitively impaired for decision making. A late entry nurse's note on 12/28/21 by LPN 1 revealed on 12/26/21 at 10 PM, This nurse arrived at the facility and received a report from day shift nurses. I then started med pass. I started at the end of the elevators. I worked [MEDICATION(S)] around to R1 room and when I opened the door he was not in there and I immediately notified the CNAs. They began to look for him and he was later returned to his room. During an interview on 1/06/22 at 9:45 AM, the Director of Nursing (DON) revealed the facility's video camera observed R1 getting on the elevator on the 200 unit and exiting the facility through the main entrance. The DON stated she received a call on 12/26/21 at 10:50 PM stating R1 was not in his room. When asked, who called to report R1 was not in his room, The DON stated Registered Nurse (RN) 1. The DON further stated RN 1 did not know the whereabouts of R1 but stated he (R1) was not gone for more than 20 minutes. During an interview on 1/06/22 at approximately 11:11 AM with Registered Nurse (RN) 1 revealed he did not know how R1 exited the facility and did not hear any alarms. RN 1 stated he went to the first floor to get a cup of ice and saw the ambulance and police at the front door with the resident. RN 1 further stated he did not know how long R1 was away from the facility. When asked did he report the incident to the DON, RN 1 did not confirm he reported R1 leaving the premises to the DON. During an interview on 1/06/22 at 12:23 PM with Security Guard (SG) 1 revealed on 12/26/21, a nurse approached him and asked if he had seen a resident exit the facility. He informed the nurse no. The SG stated a few minutes later, a police officer arrived in front of the facility and asked were they missing a resident. The SG revealed he was unsure, but stated a nurse asked him earlier did a resident exit the facility. The SG further stated the police officer informed him that a resident was picked up by EMS. During an interview on 1/06/22 at 12:55 PM with the Facility Consultant (FC)1 revealed on 12/26/21 LPN 1 was passing out medications on the 200 unit. At 10:06 PM, LPN 1 noticed R1 was not in his room. The FC stated she reviewed the video camera footage and R1 was observed getting on the elevator at 10:26 PM and exiting the facility through the main entrance at 10:28 PM. The FC stated a staff member went outside to look for R1 at 11:14 PM. Lastly, the FC stated the video camera footage revealed a police officer arrived with EMS and R1 was returned at 11:23 PM. FC1 further stated there was no police report of the incident and that R1 was found near the hospital on approximately 1.5 miles from the facility. When asked, did R1 receive medical intervention during his time away from the facility? The FC stated, No. He was returned and did not require any medical attention. A telephone interview on 1/06/22 at 1:30 PM with LPN 1 revealed on 12/26/21 around 10 PM, she was passing out medications and noted R1 was not in his room. LPN 1 stated she immediately informed staff R1 was not in his room and they began searching the premises. LPN 1 revealed she did not hear any alarms sound to alert staff a resident exited the facility. LPN 1 further stated R1 was returned to the facility, but she could not recall the time. On 1/07/22 at 9:50 PM, the Administrator revealed per the video camera footage, R1 was wearing a long sleeve thermal shirt, a pair of jeans and black footwear on 12/26/21. Reportedly, the temperature was between 55-60 degrees F. The Administrator further stated the cameras in the facility are not manned to have staff monitoring them at all times.

On the day of the complaint inspection, based on record reviews, observations, and interviews, the facility failed to ensure residents received regular position changes to prevent and treat pressure ulcers for 2 of 11 residents reviewed who had pressure ulcers (#1 and #2). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident had an inherited Stage II sacral pressure ulcer. In addition to wound dressings, the physician ordered turning every two hours and limiting sitting to 1-2 hours at a time. The resident, who was thin and frail looking, was observed sitting in a Broda chair, with a thick seat cushion, at 12:30 PM. He was in the dining area at that time. Another observation of the resident, at 3:15 PM, revealed he was still sitting in the Broda chair. He was in his room by the bed. A Certified Nursing Assistant (CNA), overheard the resident being questioned about if he was tired. She stated she was going to put him to bed and did not know why he had been left sitting up. At 3:40 PM, the resident was still sitting up in the chair. The Unit Manager was consulted about the observations made of the resident sitting up for a long period. She stated that when the staff attempted to put him to bed that afternoon, he requested to stay up. When she went to the resident and asked him about lying down, he said he preferred to sit up but would lie down if she wanted him too. At that point, two CNAs entered the room to put the resident to bed. Review of the pressure ulcer tracking records showed the resident's pressure ulcer measured 6 centimeters (cm.) by 4 cm. by 0.1 cm. on 5/3/12, 5/11/12, and 5/18/12. The ulcer showed an increased size on 5/25/12, measuring 7 cm. by 5 cm. by 0.1 cm. Review of the weekly pressure ulcer report dated 6/11/12 showed the sacral ulcer measured 10.5 cm. by 7.3 cm. by 3.5 cm. Resident #2 with [DIAGNOSES REDACTED]. The resident had an inherited Stage IV pressure ulcer on each trochanter and three ischemic ulcers on his left leg and foot. The right trochanter ulcer measured 5 cm. by 7.5 cm by 3.5 cm. The left trochanter ulcer measured 5.5 cm. by 7.5 cm by 4.5 cm. He had had the trochanter ulcers debrided at the hospital and was a wound treatment center patient. The resident was lean and received nutrition and hydration via tube feedings. An observation of the resident at 1:05 PM revealed he was sitting upright in a reclining geriatric chair in his room. At 3:05 PM, he was observed in the same position. There was a thick seat cushion in the chair. At 3:50 PM, the resident was still sitting up. These observations were shared with the Unit Manager who stated that the resident sat up so long because he had a haircut that day and his daughter visited. She stated the CNAs were about to put him back to bed.

On the days of the survey based on observations, record review, interviews, review of the facility's policy and procedures for [MEDICAL CONDITION] Care and the Nurse Practice Act Section 40-33-20, the facility's Nursing staff failed to provide the appropriate and necessary treatment to 3 of 5 sampled resident with tracheostomies. Resident #1's [MEDICAL CONDITION] was not changed every 28 days per the physician's orders [REDACTED]. Resident #2's inner cannula was replaced with a size smaller due to the nursing staff's failure to obtain the correct size prior to performing [MEDICAL CONDITION] care. Resident #2 also had the [MEDICAL CONDITION] appliance changed out by a nurse that was not educated or trained. Facility staff failed to act when Resident #3's [MEDICAL CONDITION] came out and failed to follow up on the Pulmonologist's recommendations for a possible decannulation. The findings included: The facility admitted Resident #1 on 11/30/2010 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] coded the resident as alert and oriented and coded the resident as having no behaviors during the assessment period. Review of the nurses notes revealed an entry dated 3/8/2011 at 0545 AM that documented "trach care began - Resident began to cough up blood out [MEDICAL CONDITION] red in color. Resident inner cannula removed and cleaned - Resident began to vomit large amount of thick emesis, noted no milk. Cleaned mouth c (with) wash cloth. Resident began to make choking noises. Suction machine set up. Suctioned mouth small amount of frothy sputum obtained. [MEDICAL CONDITION]- bloody sputum obtained. HOB (head of bed) up O2 (oxygen) continued at 5 L (liters)/28%[MEDICAL CONDITION]. Sats (saturations) 97%. Supervisor notified and present. Doctor notified and new order obtained and noted. Regional called for transportation to ER at 6:40 AM." Further review of the nurse's notes revealed documentation [MEDICAL CONDITION] was performed however, there was no documentation of the [MEDICAL CONDITION] appliance change out. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Change #6 [MEDICAL CONDITION] (every) 28 days and prn (as needed) resident was receiving [MEDICAL CONDITION] every day. However, there was no documentation Resident #1'[MEDICAL CONDITION] changed every 28 days per the physician's orders [REDACTED]. Review of the Transfer Summary dated 3/8/2011, revealed the primary [DIAGNOSES REDACTED]." Review of the Physician's readmission orders Trach care q (every) day and PRN (as needed), #6 Shiley clean inner cannula [MEDICAL CONDITION] q day and PRN, #6 [MEDICAL CONDITION] q 28 Days and PRN." During an interview with the surveyor on 3/28/2011, Resident #1 (who is unable to speak but communicates through writing) was asked what caused the bleeding to her [MEDICAL CONDITION] on 3/8 that resulted in her going to the hospital. Resident #1 wrote, "Cause for bleeding was they took out my permanent piece that came [MEDICAL CONDITION] put some red piece which was not a replacement piece for my kind of trach." During an observation of the Unit 700, Supply Room, Licensed Practical Nurse #1 stated that there were no #6 [MEDICAL CONDITION] parts in the supply room. LPN #1 confirmed that Resident #1 only had a #4 Shiley complete appliance at the bedside and again stated that the facility had been out of #6 Shiley trachs and stated that they had been ordered. LPN #1 was asked what she used for Resident #1 [MEDICAL CONDITION]. LPN #1 picked up a size 4 "spare inner cannula." Visible on the size 4 packaging, was a Caution note that read "Caution Temporary, Single Use Only. Ten (10) minutes is suggested as the time limit for continual usage. This inner cannula is shorter than the original custom fitted inner cannula and secretions may build up on the inside of the outer cannula if ten (10) minutes is exceeded. WARNING: Use only in Shiley [MEDICAL CONDITION] of the same size number." LPN #1 stated that she used the "spare inner cannula" on Resident #1. LPN #1 stated that Resident #1 had a size 6 Shiley but stated again that there were no #6 Shiley [MEDICAL CONDITION] parts available. LPN #1 was again asked if she used the temporary spare inner cannula on Resident #1, LPN #1 stated, "Yes." LPN #1 then stated that she used the spare inner cannula for longer than ten minutes and stated that she knew the spare inner cannula was a size smaller than the resident's #6 Shiley. Observation of the other three units supply rooms revealed one partial box of #6 [MEDICAL CONDITION] inner cannulas. Observation of the Main Supply Room revealed 2, #6 Shiley [MEDICAL CONDITION] complete appliances. During an interview with the surveyor on 3/28/2011 at 3:15 PM, the Director of Nurses, confirmed the #4 [MEDICAL CONDITION] bedside. During another interview at 4:30 PM, the DON presented a bag with Resident #1's name written on the outside that contained a #6 [MEDICAL CONDITION]. During an interview with the surveyor on 3/28/2011, LPN #1 and the DON confirmed the spare inner cannula warning and LPN #1 again stated that she used the spare inner cannula on Resident #1 and used it incorrectly. The DON also confirmed there was no documentation that Resident #1'[MEDICAL CONDITION] was changed every 28 days. The DON stated, "If its not documented then it wasn't done." The DON also stated that the nurses should initial on the MAR/TAR when any treatment was given. She stated that there was not an "acceptable reason" as to why there was no documentation. During an interview with the surveyor on 3/28/2011, the Medical Director and Attending Physician for Resident #1 stated that he expected that [MEDICAL CONDITION] care should be performed sterilely. The Physician also stated that if a resident has a #6 [MEDICAL CONDITION] only #6 Shiley parts should be used. He further stated that he did would expect the nursing staff to not use different sizes for the trachs and not to use a temporary inner cannula. The Physician stated that he would expect the staff to call him and the pulmonologist if a smaller [MEDICAL CONDITION] or a temporary part needed to be used. During an interview with the surveyor on 3/29/2011, the Director of Respiratory Services stated that the Spare Inner Cannulas were only to be used if a resident was mechanically ventilated. The Spare Inner Cannulas should not be used on a resident that can spontaneously breath. During an interview with the surveyor on 3/29/2011, the Administrator confirmed the presence of 2 size 6 Shiley trachs in the facility. One of which was at Resident #1's bedside and the other was temporarily in the administrator's office. Review of the General Ledger Spending Detail revealed on 3/24/2011, two Fenestrated Cuffless Size 6 Shiley trachs were ordered. No other entries for Size 6 Shiley trachs were located. During an interview with the surveyor on 3/29/2011, the Speech Therapist stated that Resident #1 did not tolerate occlusion of [MEDICAL CONDITION] long periods of time. She stated that she attempted "finger occlusion" to allow the resident to speak but if the resident needed to be suctioned or was congested, she could not tolerate any type of treatment. The Speech Therapist stated that a "Decannulation Plug" was never used on the resident, as she was not a candidate for decannulation due to her progressive disease process. During observation of [MEDICAL CONDITION] Care on 3/29/2011, LPN #2 washed her hands and applied disposable gloves. LPN #2 then placed her supplies on the bedside table where a urine filled bedpan had been placed. Liquid was observed on the bedside table. LPN #2 then placed a saturation monitor on the resident and auscultated the resident. LPN #2 opened the sterile gloves and proceeded to don them over the now soiled disposable gloves. LPN #2 then suctioned the resident again repeatedly touching the resident'[MEDICAL CONDITION] and outside of the cannula with her "sterile" hand. LPN #2 then removed the sterile gloves and proceeded to don another pair of sterile gloves without washing her hands or removing the other pair of disposable gloves. LPN #2 was observed to touch the resident's left bed rail. LPN #2 removed the inner cannula and placed it in the tray of sterile water, LPN #2 was observed to touch the underneath side of the tray that was not sterile with her right hand. LPN #2 picked up the inner cannula and touched the sterile portion of the cannula with her left hand. LPN #2 used her right hand to clean the inside portion. LPN #2 then used sterile gauze and cleaned the right and left side of the flange and under [MEDICAL CONDITION]. LPN #2 was not observed to clean around the stoma site. LPN #2 removed the sterile gloves and still with the disposable gloves applied [MEDICAL CONDITION] and put a new piece of gauze under the appliance. LPN #2 removed her gloves, ausculted, gathered the dirty supplies and then washed her hands and proceeded to the soiled utility room. LPN #2 returned to the resident room and was going to pour the liquid down the sink and stopped. She left the room and obtained a biohazard bag, she returned to the room, donned disposable gloves and disposed of the liquid in the biohazard bag. LPN #2 removed her gloves, set up the resident's bedside table and left the room with the biohazard bag. She picked up the phone and made a phone call with the bag in hand, and was observed to change hands multiple times. LPN #2 proceeded to the basement to dispose of the bag. LPN #2 returned to Unit 700 and was observed to rub the back of another resident and then began to chart. LPN #2 was asked if she was finished and she stated, "Yes." During an interview with the surveyor on 3/29/2011 LPN #2 and the DON were informed of the multiple breaks in sterile technique. Review of the facility's policy on [MEDICAL CONDITION] Care revealed the following: "1. wash hands and assemble all supplies...4. Establish a sterile field near the resident's bed and place equipment and supplies on it...Procedure: Using sterile technique, suction the entire length of the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation. To clean a Stoma: 1. Put on sterile gloves...with dominate hand, saturate a sterile gauze pad with the cleaning solution... wipe the resident's neck under the [MEDICAL CONDITION] flanges and [MEDICATION NAME] tape...use additional pads or cotton tipped applicators to clean the stoma site and the tube's flanges. Remove and discard gloves. To clean a Non Disposable Inner Cannula: Put on Sterile Gloves, working quickly, use dominant hand to scrub the cannula with the sterile nylon brush..." Further review of the policy revealed the following: [MEDICAL CONDITION] Change outs: "[MEDICAL CONDITION] change outs will be performed Q 29 Days and PRN unless otherwise ordered by the physician. Manufacturers guidelines are every 29 days and PRN." The following complications can occur within the first 48 hours [MEDICAL CONDITION] insertion/change out: Hemorrhage, bleeding causing airway obstruction, aspiration..." Nursing Considerations: "Keep appropriate equipment at the patient's bedside for immediate use in an emergency. Consult the physician about first aid measures you can use for your [MEDICAL CONDITION] should an emergency occur. Use extreme caution when attempting to insert an expelled [MEDICAL CONDITION] because of the risk of tracheal trauma, perforation, compression and asphyxiation." The facility admitted Resident #2 on 12/22/2009 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#6 [MEDICAL CONDITION] a disposable inner cannula that was to be changed every day. Size 6 [MEDICAL CONDITION] out to be done every 28 days and PRN. Review of the nurses notes revealed on 3/7/2011 at 10 PM, "Resident pulled out his outer cannula... reinserted cannula..." On 3/8/2011 at 12 PM, "Resident'[MEDICAL CONDITION] given, #4 inner cannula placed." On 3/8/2011 at 5 PM, "received order form Dr. to [MEDICAL CONDITION] #8 Shiley now." At 5:10 PM, "Trach #8 Shiley replaced without difficulty." During an interview with the surveyor, LPN #3 stated that she [MEDICAL CONDITION] on Resident #2 and placed a size 4 inner cannula into a size 6 Shiley Trach. She stated that she did not have all of her supplies when she went into the room. LPN #3 stated that she realized she did not have a #6 disposable inner cannula after she had removed the old inner cannula. LPN #3 stated that she called for her supervisor to bring her a new disposable #6 Shiley inner cannula. The supervisor brought a Size 4 Disposable Inner Cannula and informed LPN #3 that there were not any #6 available. LPN #3 confirmed again that she did not have all the necessary supplies available prior to [MEDICAL CONDITION] for Resident #2. During an interview with the surveyor on 3/29/2011, LPN #4 stated that she changed out Resident #2'[MEDICAL CONDITION] the evening of 3/8/2011. LPN #4 stated that the doctor was in the room with her and stated that "he was not comfortable doing it" and told LPN #4 to go ahead and change out [MEDICAL CONDITION] a size 8 Shiley. The DON and the Director of Respiratory Care Services confirmed that LPN #4 did not have the required education and training in place. Review of the Inservice Records revealed on 3/17/2011, the facility conducted a "Skills Fair" and [MEDICAL CONDITION] care was one of the topics taught; 31 nurses attended. The DON stated the inservice was not in relation to any event related to [MEDICAL CONDITION] care that occurred but was related to the annual skills fair. Review of the Competencies for [MEDICAL CONDITION] Change Outs revealed 12 nurses completed the required training. All of the nurses were nurses that worked the 7-3 shift. LPN #4 did not have documentation of the necessary education and training required for [MEDICAL CONDITION] change outs. The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation from the night shift. On 3/8/2011 at 11:45 AM, the nurse supervisor documented that the "nurse reported to writer that pt (patient)[MEDICAL CONDITION] out. Upon entering the room noted [MEDICAL CONDITION] on napkin on bedside table. Immediately assessed respiratory status, O2 sats 98-100% on RA (room air) resps even and unlabored, lungs clear to auscultation and greater than 10. Pt husband at bedside stated that pt was talking to him. Husband denies [MEDICAL CONDITION] stated that pt has decannulated herself "several" times in the past. Notified Dr. and pt pulmonologist that [MEDICAL CONDITION] noted on bedside table, pt O2 sat were 98-100% on RA, resps (respirations) 16 even and unlabored, lips and mucous membranes pink. Per Dr. Jones, pt to remain decannulated O2 sats every shift and PRN, O2 2 L per minute via NC (nasal cannula) for shortness of breath/O2 sats less than 92%, schedule follow up with pulmonology. Per pulmonologist, place dry gauze over stoma site, pt to come to Pulmonology Clinic 3/9/2011. ST (speech therapy) at bedside worked with pt for swallowing. Pt swallowing pudding and honey thick liquids. Husband at bedside, who was notified of new orders and appt in AM. Verbalized appreciation of our care and stated that he was happy [MEDICAL CONDITION] out." Review of the Pulmonology Note dated 2/7/2011 revealed recommendations were as follows: "1. Nighttime Pulse Ox on Room Air, 2. Wean O2 during day to room air-check pulse ox over 1-2 hours, 3. Cap [MEDICAL CONDITION] during day if room air pulse ox is >92%, 4. Possible decannulation next visit." The next visit was scheduled for 3/7/2011. There was no documentation that the facility staff had followed up with the pulmonologist to clarify if he wanted his recommendations to be written as orders. None of the recommendations were acted upon. Review of the physician's orders [REDACTED]. There was no documentation that Speech Therapy began working with the resident on 2/22/2011. On 3/7/2011 an order was written for Speech Therapy to evaluate and treat 5 x/week for decannulation. Further review revealed Resident #3 ' s 3/7/2011 pulmonology appointment, was cancelled due to not having received the appropriate preparation for decannulation. During an interview with the surveyor on 4/4/2011, the Nurse Supervisor stated that LPN #5 reported to her that Resident #3'[MEDICAL CONDITION] out. The Nurse Supervisor stated that she immediately assessed the resident and noted there was no respiratory distress. She then notified the Physician and the Pulmonologist. The Nurse Supervisor stated that the husband was at the bedside and was questioned to see if he pulled [MEDICAL CONDITION]. The husband told the Nurse Supervisor that he did not pull [MEDICAL CONDITION]. During an interview with the surveyor, Resident #3's husband stated he arrived to the facility on [DATE] at 10 AM and noticed the resident'[MEDICAL CONDITION] on the bedside table wrapped [MEDICAL CONDITION]. During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011. She was told that Resident #3's "trach was out." She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that during walking rounds she did not see [MEDICAL CONDITION] the resident's room. She also stated that the CNA performed AM care on the resident and did not notice [MEDICAL CONDITION] the resident's room. LPN #5 stated that she knew the resident was to be decannulated and assumed that it was done "medically" and not accidentally. LPN #5 returned to the resident's room and the husband asked her when [MEDICAL CONDITION] been removed. LPN #5 checked the chart and noted that there was no documentation of the decannulation. LPN #5 stated that she immediately notified the Supervisor. During a telephone interview with the surveyor on 4/7/2011, CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). She stated that the night shift of March 7th was the first and only time she had cared for the resident and stated that she did not know the resident. CNA #1 stated that she did not think the resident pulling out [MEDICAL CONDITION] an emergency situation. During a telephone interview with the surveyor on 4/12/2011, LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that the resident did not have [MEDICAL CONDITION] during his shift. He stated that he was aware the resident was to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident's trach. LPN #6 stated that he did not believe the situation was an emergency. LPN #6 stated that the resident's oxygen saturations were normal and she was not in any distress. He further stated that he did not think the resident accidentally decannulated herself because if she had then it would an emergency situation. On 03/28/2011 at 3:40 PM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-328 with a scope and severity level of "K" and existed in the facility as of 03/08/2011 due to the facility failure to provide proper treatment and care for 3 of 5 residents with tracheostomies. On 03/08/2011 a nurse without the appropriate education and training changed Resident #2's [MEDICAL CONDITION]. On the 11-7 shift on 3/7-3/8/2011 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube. Resident #1's [MEDICAL CONDITION] was not changed as ordered. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Substandard Quality of Care and Immediate Jeopardy was removed and citation F-328 was lowered to a scope and severity level of "E" as of 03/29/2011 at 4:20 PM.

On the days of the survey based on observations, record review, interviews, review of the facility's policy and procedures for [MEDICAL CONDITION] Care and the Nurse Practice Act Section 40-33-20, the facility's Nursing staff failed to provide the appropriate and necessary treatment to 3 of 5 sampled resident with tracheostomies. Resident #1's [MEDICAL CONDITION] was not changed every 28 days per the physician's orders [REDACTED]. Resident #2's inner cannula was replaced with a size smaller due to the nursing staff's failure to obtain the correct size prior to performing [MEDICAL CONDITION] care. Resident #2 also had the [MEDICAL CONDITION] appliance changed out by a nurse that was not educated or trained. Facility staff failed to act when Resident #3's [MEDICAL CONDITION] came out and failed to follow up on the Pulmonologist's recommendations for a possible decannulation. The findings included: The facility admitted Resident #1 on 11/30/2010 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] coded the resident as alert and oriented and coded the resident as having no behaviors during the assessment period. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Change #6 [MEDICAL CONDITION] (every) 28 days and prn (as needed) resident was receiving [MEDICAL CONDITION] every day. However, there was no documentation Resident #1'[MEDICAL CONDITION] changed every 28 days per the physician's orders [REDACTED]. Review of the nurses notes revealed an entry dated 3/8/2011 at 0545 AM that documented Resident #1 experienced problems [MEDICAL CONDITION] was completed and was transported to the ER. Review of the Transfer Summary dated 3/8/2011, revealed the primary [DIAGNOSES REDACTED]." Review of the Physician's readmission orders Trach care q (every) day and PRN (as needed), #6 Shiley clean inner cannula [MEDICAL CONDITION] q day and PRN, #6 [MEDICAL CONDITION] q 28 Days and PRN." During an observation of the Unit 700, Supply Room, Licensed Practical Nurse #1 stated that there were no #6 [MEDICAL CONDITION] parts in the supply room. LPN #1 confirmed that Resident #1 only had a #4 Shiley complete appliance at the bedside and again stated that the facility had been out of #6 Shiley trachs and stated that they had been ordered. LPN #1 was asked what she used for Resident #1 [MEDICAL CONDITION]. LPN #1 picked up a size 4 "spare inner cannula." Visible on the size 4 packaging, was a Caution note that read "Caution Temporary, Single Use Only. Ten (10) minutes is suggested as the time limit for continual usage. This inner cannula is shorter than the original custom fitted inner cannula and secretions may build up on the inside of the outer cannula if ten (10) minutes is exceeded. WARNING: Use only in Shiley [MEDICAL CONDITION] of the same size number." LPN #1 stated that she used the "spare inner cannula" on Resident #1. LPN #1 stated that Resident #1 had a size 6 Shiley but stated again that there were no #6 Shiley [MEDICAL CONDITION] parts available. LPN #1 was again asked if she used the temporary spare inner cannula on Resident #1, LPN #1 stated, "Yes." LPN #1 then stated that she used the spare inner cannula for longer than ten minutes and stated that she knew the spare inner cannula was a size smaller than the resident's #6 Shiley. During an interview with the surveyor on 3/28/2011, LPN #1 and the DON confirmed the spare inner cannula warning and LPN #1 again stated that she used the spare inner cannula on Resident #1 and used it incorrectly. The DON also confirmed there was no documentation that Resident #1'[MEDICAL CONDITION] was changed every 28 days. The DON stated, "If its not documented then it wasn't done." The DON also stated that the nurses should initial on the MAR/TAR when any treatment was given. She stated that there was not an "acceptable reason" as to why there was no documentation. During an interview with the surveyor on 3/28/2011, the Medical Director and Attending Physician for Resident #1 stated that if a resident has a #6 [MEDICAL CONDITION] only #6 Shiley parts should be used. He further stated that he did would expect the nursing staff to not use different sizes for the trachs and not to use a temporary inner cannula. The Physician stated that he would expect the staff to call him and the pulmonologist if a smaller [MEDICAL CONDITION] or a temporary part needed to be used. During an interview with the surveyor on 3/29/2011, the Director of Respiratory Services stated that the Spare Inner Cannulas were only to be used if a resident was mechanically ventilated. The Spare Inner Cannulas should not be used on a resident that can spontaneously breath. Review of the [MEDICAL CONDITION] Care policy revealed the following: [MEDICAL CONDITION] Change outs: "[MEDICAL CONDITION] change outs will be performed Q 29 Days and PRN unless otherwise ordered by the physician. Manufacturers guidelines are every 29 days and PRN... The following complications can occur within the first 48 hours [MEDICAL CONDITION] insertion/change out: Hemorrhage, bleeding causing airway obstruction, aspiration... Nursing Considerations: Keep appropriate equipment at the patient's bedside for immediate use in an emergency. Consult the physician about first aid measures you can use for your [MEDICAL CONDITION] should an emergency occur. Use extreme caution when attempting to insert an expelled [MEDICAL CONDITION] because of the risk of tracheal trauma, perforation, compression and asphyxiation..." The facility admitted Resident #2 on 12/22/2009 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#6 [MEDICAL CONDITION] a disposable inner cannula that was to be changed every day. Size 6 [MEDICAL CONDITION] out to be done every 28 days and PRN. Review of the nurses notes revealed on 3/7/2011 at 10 PM, "Resident pulled out his outer cannula... reinserted cannula..." On 3/8/2011 at 12 PM, "Resident'[MEDICAL CONDITION] given, #4 inner cannula placed... Dr. called NNO (no new orders) thus far..." On 3/8/2011 at 5 PM, "received order form Dr. to [MEDICAL CONDITION] #8 Shiley now..." At 5:10 PM, "...Trach #8 Shiley replaced without difficulty." During an interview with the surveyor, LPN #3 stated that she [MEDICAL CONDITION] on Resident #2 and placed a size 4 inner cannula into a size 6 Shiley Trach. She stated that she did not have all of her supplies when she went into the room. LPN #3 stated that she realized she did not have a #6 disposable inner cannula after she removed the old inner cannula. LPN #3 stated that she called for her supervisor to bring her a new disposable #6 Shiley inner cannula. The supervisor brought a Size 4 Disposable Inner Cannula and informed LPN #3 that there were no #6 Shiley's available. LPN #3 confirmed again that she did not have all the necessary supplies available prior to [MEDICAL CONDITION] for Resident #2. During an interview with the surveyor on 3/29/2011, LPN #4 stated that she changed out Resident #2'[MEDICAL CONDITION] the evening of 3/8/2011. Review of the Competencies for [MEDICAL CONDITION] Change Outs revealed 12 nurses completed the required training. All of the nurses were nurses that worked the 7-3 shift. LPN #4 did not have documentation of the necessary education and training required for [MEDICAL CONDITION] change outs. The DON and the Director of Respiratory Care Services confirmed that LPN #4 did not have the required education and training in place. Review of the Nurse Practice Act Section 40-33-20 revealed: "Special Training. A nurse must successfully complete a course of "special education and training" acceptable to the board to perform additional acts." The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Pulmonology Note dated 2/7/2011 revealed recommendations were as follows: "1. Nighttime Pulse Ox on Room Air, 2. Wean O2 during day to room air-check pulse ox over 1-2 hours, 3. Cap [MEDICAL CONDITION] during day if room air pulse ox is >92%, 4. Possible decannulation next visit." The next visit was scheduled for 3/7/2011. There was no documentation that the facility staff had followed up with the pulmonologist to clarify if he wanted his recommendations to be written as orders. None of the recommendations were acted upon. Review of the physician's orders [REDACTED]. There was no documentation that Speech Therapy began working with the resident on 2/22/2011. On 3/7/2011 an order was written for Speech Therapy to evaluate and treat 5 x/week for decannulation. Further review revealed Resident #3 ' s 3/7/2011 pulmonology appointment, was cancelled due to not having received the appropriate preparation for decannulation. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation from the night shift. During an interview with the surveyor, Resident #3's husband stated he arrived to the facility on [DATE] at 10 AM and noticed the resident'[MEDICAL CONDITION] on the bedside table wrapped [MEDICAL CONDITION]. During a telephone interview with the surveyor on 4/7/2011, CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). She stated that the night shift of March 7th was the first and only time she had cared for the resident and stated that she did not know the resident. CNA #1 stated that she did not think the resident pulling out [MEDICAL CONDITION] an emergency situation. During a telephone interview with the surveyor on 4/12/2011, LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that the resident did not have [MEDICAL CONDITION] during his shift. He stated that he was aware the resident was to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident's trach. LPN #6 stated that he did not believe the situation was an emergency. LPN #6 stated that the resident's oxygen saturations were normal and she was not in any distress. He further stated that he did not think the resident accidentally decannulated herself because if she had then it would an emergency situation. During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011. She was told that Resident #3's "trach was out." She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that during walking rounds she did not see [MEDICAL CONDITION] the resident's room. She also stated that the CNA performed AM care on the resident and did not notice [MEDICAL CONDITION] the resident's room. LPN #5 stated that she knew the resident was to be decannulated and assumed that it was done "medically" and not accidentally. LPN #5 returned to the resident's room and the husband asked her when [MEDICAL CONDITION] been removed. LPN #5 checked the chart and noted that there was no documentation of the decannulation. LPN #5 stated that she immediately notified the Supervisor. During an interview with the surveyor on 4/4/2011, the Nurse Supervisor stated that LPN #5 reported to her that Resident #3'[MEDICAL CONDITION] out. The Nurse Supervisor stated that she immediately assessed the resident and noted there was no respiratory distress. She then notified the Physician and the Pulmonologist. Cross Refer to F328 related to the facility failure to provide services according to acceptable standards of clinical practice. On the days of the inspection, based on limited record reviews, observations, interviews, and review of the [MEDICAL CONDITION] Care policy the facility failed to provide services, which met professional standards of quality. The facility staff failed to follow professional standards of practice related to the care of residents with tracheostomies. On 03/08/2001 Resident #2's [MEDICAL CONDITION] was changed by a nurse without the appropriate education and training; Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube; Resident #1's [MEDICAL CONDITION] was not changed as ordered. On 03/28/2011 at 3:40 PM the Administrator was notified that Immediate Jeopardy was identified at F-281 and cited at a scope and severity level of "K" due to the facility failure to provide proper treatment and care for 3 of 5 residents with tracheostomies. On 03/08/2011 Resident #2's [MEDICAL CONDITION] was changed by a nurse without the appropriate education and training; Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube; Resident #1's [MEDICAL CONDITION] was not changed as ordered. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Immediate Jeopardy was removed and citation F-281 was lowered to a scope and severity level of "E" as of 03/29/2011 at 4:20 PM.

On the days of the survey based on record review and interviews, the facility failed to ensure Resident #3, 1 of 5 sampled residents with tracheostomies, was not neglected when she did not receive the necessary care and services (assessment and physician notification) that would have been appropriate at the time decannulization was first identified. Resident #3 accidentally decannulated on the 11-7 shift, 3/7-3/8/2011. The Certified Nurse Aide and the Licensed Practical Nurse providing care to Resident #3 on the 11-7 shift failed to notify the physician or provide the necessary care in a timely manner. The findings included: The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation of any resident concerns related to [MEDICAL CONDITION] the 11-7 shift (3/7-3/8/2011) staff. On 3/8/2011 at 11:45 AM, the nurse supervisor documented that the "nurse reported to writer that pt (patient)[MEDICAL CONDITION] out. Upon entering the room noted [MEDICAL CONDITION] on napkin on bedside table." During an interview with the surveyor on 4/4/2011, the Nurse Supervisor stated that LPN #5, working the morning shift 3/8/11, reported to her that Resident #3'[MEDICAL CONDITION] out. The Nurse Supervisor stated that she immediately went and assessed the resident and noted there was no respiratory distress. She then notified the physician and the pulmonologist. During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011 and it was reported that Resident #3's "trach was out." She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that she knew the resident was scheduled to be decannulated and assumed that it was done "medically" and not accidentally. LPN #5 became concerned when questioned about [MEDICAL CONDITION] Resident #3's husband and could not find any evidence in the clinical record that the Resident was decannulated as scheduled. CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that he was aware the resident was scheduled to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident'[MEDICAL CONDITION] stated that he did not believe the situation was an emergency. Cross refer to F-157 Related to the facility failure to promptly notify the physician and/or family related to a change in the resident's condition. Cross refer to F-281 Related to the facility failure to provide services according to acceptable standards of clinical practice. On 03/08/2001 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube Cross refer to F-328 Related to the facility failure to provide timely treatment and care for residents requiring [MEDICAL CONDITION] care. On 03/08/2001 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube. On 03/28/2011 at 3:40 PM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-224 at a scope and severity level of "J" and existed in the facility as of 03/08/2011 due to the facility failure to provide appropriate and timely treatment and care for 3 of 5 residents with tracheostomies. Resident #3's [MEDICAL CONDITION] came out on the 11-7 shift, 3/7-3/8/2011 and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Substandard Quality of Care and Immediate Jeopardy was removed and citation F-224 was lowered to a scope and severity level of "D" as of 03/29/2011 at 4:20 PM.

On the days of the survey based on record review and interviews, the facility failed to ensure that the Physician was notified of a change in condition for 1 of 5 sampled residents with tracheostomies. Resident #3's physician was not notified of the resident's decannulation on the 11-7 shift until the later the following morning. The findings included: The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation from the night shift (3/7-3/8/2011). On 3/8/2011 at 11:45 AM, the nurse supervisor documented that the "nurse reported to writer that pt (patient)[MEDICAL CONDITION] out. Upon entering the room noted [MEDICAL CONDITION] on napkin on bedside table........Notified physician and pt pulmonologist that [MEDICAL CONDITION] noted on bedside table,....... ." During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011. She was told that Resident #3's "trach was out." She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that during walking rounds she did not see [MEDICAL CONDITION] the resident's room. She also stated that the CNA performed AM care on the resident and did not notice [MEDICAL CONDITION] the resident's room. LPN #5 stated that she knew the resident was to be decannulated and assumed that it was done "medically" and not accidentally. LPN #5 returned to the resident's room and the husband asked her when [MEDICAL CONDITION] been removed. LPN #5 checked the chart and noted that there was no documentation of the decannulation. LPN #5 stated that she immediately notified the Supervisor. During a telephone interview with the surveyor on 4/7/2011, CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). She stated that the night shift of March 7th was the first and only time she had cared for the resident and stated that she did not know the resident. CNA #1 stated that she did not think the resident pulling out [MEDICAL CONDITION] an emergency situation. During a telephone interview with the surveyor on 4/12/2011, LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that the resident did not have [MEDICAL CONDITION] during his shift. He stated that he was aware the resident was to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident's trach. LPN #6 stated that he did not believe the situation was an emergency. He further stated that he did not think the resident accidentally decannulated herself because if she had then it would an emergency situation. Cross Refer to F328 related to the facility failure to promptly notify the physician and/or family related to a change in the resident's condition. On the days of the inspection, based on limited record reviews, observations, and interviews the facility failed to promptly notify Resident #3's physician and family when her [MEDICAL CONDITION] came out. On 03/28/2011 at 3:40 PM the Administrator was notified that Immediate Jeopardy was identified at F-157 and cited at a scope and severity level of "J" due to the facility failure to provide proper treatment and care for 1 of 5 residents with tracheostomies. On 03/08/2011 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube and the physician/family were not notified timely. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Immediate Jeopardy was removed and citation F-157 was lowered to a scope and severity level of "D" as of 03/29/2011 at 4:20 PM.

On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey and the facility administrative staff was aware of problems with the call lights. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light for room [ROOM NUMBER] was blinking on and off with no sounds. The call light for room [ROOM NUMBER] was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights for rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room [ROOM NUMBER] to turn off the call light for room [ROOM NUMBER]. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms [ROOM NUMBERS], located in a corner, not readily visible to the staff from the halls. When asked how long problems with the call lights had existed on the unit CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observed near room [ROOM NUMBER] called for a CNA to go to room [ROOM NUMBER] due to the call light being on over the door, in the hallway. Observation of the call light panel at the nurse's station revealed the light for room [ROOM NUMBER] was not lit. In an interview with the surveyor on 12/06/2010 at approximately 8:45 PM the Administrator confirmed she was aware the call lights were not working and that the Maintenance Manager received a report regarding call lights not functioning properly on 11/25/2010. The Administrator showed the surveyor a maintenance log dated 11/25/2010 that documented the concern that the call light system on Unit 700 was not working. In an interview with the surveyor on 12/06/2010 at approximately 9:05 PM the Maintenance Manager stated that some work was performed on the call lights 2 months ago. He stated he was not aware of the recent concerns but showed the survey a log dated 11/25/2010 that addressed concerns that the call light was not working on Unit 700. The Maintenance Manager stated that because the concerns were documented in the log did not mean anyone knew about the problems. Cross Refer to F-463, as it relates to a nonfunctioning nurse call panel at the Unit 700 nursing station during the first day of the survey On 12/06/2010 at approximately 9:15 PM, Immediate Jeopardy was identified related to F463 at a scope and severity level of J. An acceptable plan of correction was submitted at 2:03 PM on 12/07/2010; at 2:30 PM, the Immediate Jeopardy was removed. However, the citations remained at a lower scope and severity level of D.

On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to ensure that all components of the nurse call system were operational. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light to room 712 was blinking on and off with no sounds. The call light to room 715 was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights to rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room 715 to turn off the call light for room 701. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms 718 and 719, located in a corner, not readily visible to the staff from the halls. When asked how long problems existed on the unit with the call lights CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observed near room 701 called for a CNA to go to room 717 due to the call light being on over the door, in the hallway. Observation of the call light panel at the nurse's station revealed the light for room 717 was not lit. In an interview with the surveyor on 12/06/2010 at approximately 8:25 PM Licensed Practical Nurse (LPN) #1 revealed she was aware of the problems with the call lights a few weeks ago and so was the Maintenance Manager. LPN #1 stated the call lights for rooms 701 and 715 would just "come on". In an interview with the surveyor on 12/06/2010 at 8:30 PM the Director of Nursing (DON) and LPN#1 revealed the call light system used by the facility was both audible and visual. When a resident pushed the call light button in the room a sound was heard and the light came on over the resident's doorway and at the panel at the nurse's station. In an interview with the surveyor on 12/06/2010 at approximately 8:45 PM the Administrator confirmed she was aware the call lights were not working and that the Maintenance Manager received a report regarding call lights not functioning properly on 11/25/2010. The Administrator showed the surveyor a maintenance log dated 11/25/2010 that documented the concern that the call light system on Unit 700 was not working. In an interview with the surveyor on 12/06/2010 at approximately 9:05 PM the Maintenance Manager stated that some work was performed on the call lights 2 months ago. He stated he was not aware of the recent concerns but showed the survey a log dated 11/25/2010 that addressed concerns that the call light was not working on Unit 700. The Maintenance Manager stated that because the concerns were documented in the log did not mean anyone knew about the problems. Cross Refer to F-490, as it relates to the facilities administrator being aware of the call lights no working prior to the survey. No interventions were in place to prevent further concerns with the call lights. On 12/06/2010 at approximately 9:15 PM, Immediate Jeopardy was identified related to F463 at a scope and severity level of J. An acceptable plan of correction was submitted at 2:03 PM on 12/07/2010; at 2:30 PM, the Immediate Jeopardy was removed. However, the citations remained at a lower scope and severity level of D.